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APID REVIEW

SHAHID HUSSAIN
SHERIF A. A. LATIF
ADRIAN D. HALL
Rapid Review of
Radiology
Shahid Hussain
MA, MB, BChir, MRCP, FRCR
Consultant Radiologist
Heart of England NHS Foundation Trust, Birmingham) UK
Sherif Aaron Abdel Latif
MB, ChB, MRCS, FRCR
Consul tant
Dudley Group of Hospitals NHS Foundation Trust, West Midl ands, UK
Adrian David Hall
MB, ChB, MRCP, FRCR
Consultant Radiologist
Dudley Group of Hospitals NHS Foundation Trust, West Midlands, UK
MANSON
PUBLI SHING ----------
Dedications
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Contents
!'rdJ.cc
Contri butors
,\bb,n; .I;o",
G,'nnJI Imrodllcl ion
Ch'l'tcr I - ChC51 1"'.ginS
CI,.ptcr 2 - ,\bdomin.1 I""sing
Ch'l'tcr 3 - Centr.] :-l"<ry"". Sr.t""" He,d .10<1 I Ill.g; 11\;
ell'plcr'; - Inug;nll
CII'I"'-' 5 - I"cd; .,,;, Imag;ng
GII.!,"-' 6 - 1I,.,.j, l",agi"l1 b.y /trill l .. ,/",n,
Furth,',lk.ding
I min of ])illl:,,,,,,i.1 ]); ')\"""'$
Gener.1 ]n, kx
5
o
,
II
71
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205
2H9
331
3H
3
3<6

Preface
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Abbreviations

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,
GENERAL
INTRODUCTION
This book has been written primarily for senior radiology
ITJinces preparing for final radiology exams and in particular
for trainees studying for the Fellowship of [he Royal
College of R3diology. With Ihis in mind, the cases
presented herewith have been presented in the exact
manner that the cases are presented in the Ro}'al College
of Radiology FRCR 2B exam. In the exam, long cases and
viva cases are presented wit h a very minimal bur hi ghly
relevant hi story and the required response is expected to
be presented in a particular way. This format of reporting
'
involves giving a Description/ Interpretation of the images;
Diagnosis; Differential Diagnosis; and advice on Furrhcr
Management. We have laid Ollt the answers here in exactly
this manner and have included a Discussion [Q give in-
depth further information about each condition which wi ll
enable the sntdent to answer any qucstions directed to him
or her in the viva situation, By tollowing the RCR exam
formal , thc candidate should be ideally prepared for t his
e.l:am and for [he future as a Consultant Radiologist.
FILM TECHNIQUE
Whatever the imaging modality, the radiologist interprets
images using all the infonnation and clues available, to
produce a differential diagnosis and/or advise on further
investigation and management. Above all else, this mUSt be
done in a SAFE manner, and this often requi res one [Q be
systematic in approach. Secondly, this process must be done
in a SENSIBLE manner - it is easy to quote endless li sts of
differential diagnoses but if these are not refined for each
individual case, the r.:tdiologisr's input is of little value.1l1e
following discussion concentrates in particular on
performing these tasks in the examination viva scenario.
However, much of the advice is applicable to everyday
practice [Qo, in particular the emphasis on a safe and
sensible approach.
TYPES OF FILM
The rypes of film one may enCounter in an exam/viva arc as
follows:
The ' Aunt Minnie'
There arc certain disorders that have a characteri stic
appearance on imaging that allows one to make an instant
'Spot diagnosis'. It \ \ ~ I l be assumed the candidate has come
across it before, and thus t he best preparation here is
exposure to as many ofthese cases as Ix>ssible. Radiological
atl ases and film libraries provide ready access ro many of
these classic cases, which can then be committed to
memory. You can prepare a ready-made description of
these cases for rhe viva. Ifro\! arc sure of the diagnosis,
dispatch the film promptly with your preprepared 'speech'
so that you can progress to the next case as soon as
possible. Of course there may be 'Aunt Minnie' cases that
yOll haven't secn and rhis may present a problem, Such
cases arc often not amenable to working out the diagnosis
- you either know it or you don' t . The only thing ro do is
be methodical in your analysis and description of the
findings so that at the very least you can suggest whether
you feci an abnormali ty is li kely 10 be lo ngstanding and
benign or orhenvise, and make appropriate suggestions on
how you would proceed.
The 'test of observation'
Here, there is an abnormality prescnt that once seen, may
wclllcad to an easy diagnosis. The abnormality is subtle or
hidden however, such that it tests the candidate's
perception and approach [Q a case. Perceptual abi lity,
however, is variabl e, not only between people bur also in
the same obscn'er on diflcrcllt days (this is particularly [rue
in examinat:ions where anxiety levels arc high). You must
therefore be systematic in analysing each film if there is no
ob\'ious abnormality [ 0 sec on firsr inspection. There arc
mall Y diflerent s}'srcmatic approaches and it is beyond [he
scope of this discussion to be morc prescriptive. Howcver,
make sure you haye a system and usc it. Moreover, describe
the process you are going through aloud in the viva so that
the examiner knows that you arc practising safe radiology.
The 'jigsaw puzzle'
This type of case presents several findings that once
identified and considered together, lead to a specific or
differential diagnosis. This nOt only tCSts perceptual skill
and systematic approach, but also the abili ty ro mentall y
'cross-reference' se\'eral diflcrential diagnosis lists for the
various abnormalities identified, to find thc 'best fit'
diagnosis. Whenever producing a differential diagnosis in
an exami nation or real life, it is \'ital to produce a sensible
list, not just a recital oflong lists learnt from books. To do
this, you must use all clues available from the clinical
histOry and film, and combine this information with
knowledge of the incidence of each possibility in a given
patient population.

Generalln1rodueti on
Th. ' di.<u .. ion
In , I .. ,,,I ..,><1.1. '""", "" m,nr
"00,"" '"" "m nn ,,,,,,,,IK ' 1><" ,,, ' d"S" "'" bu' ,,'h<,
,.I,ffim"".1 ,h .. h< n,,,,, ... 1
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,oo.l "" ho" , WI "1"''''' in
1"><'"'' A, ,Iw.), t< ""I <"I',,,,,h!o tUm
" " I),i, .. " .. I. '1'1'" .. ,10 II,
Mfr",;, 1 ,',,'""''', S""h ""<'. in 1'''';''''''' .".,,,
,I>< "'h,, , n., "f'"" ,><Iiol",'" _ "" ru" h"
in,,,,,Vt"'" ,nJ """'S' ...... ",.
ANALYSING THE CASE
A, ,1, .. Jy 'mph,,",d. 'p" " of . 11
')1"" uf MOl< .... ,." ><I , ;,:, on '<'r""""'"
I>< '''nl><, '"'r'"
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""" of, ", 'lI< ' oJ ,." ,,(,h, P'"' ''' 0';"5
,;'1.", i<I, n,"k",,", .I", "" 'M ' ilm 0' , n""",,,,1
'.OOn." .... _ O''''N<'' "'" I>< <I'm'"",O '"
from th< JiII<",.,i.J hot on th< b"iouf
""" """"" ;0 "'. S,..,,'IK fr.m", .. , ,", t; h. ." ')'
.I..., ",Ir "' ...... ""'"'" ,I" Jifi,,,,,,, ili _ 'h'
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in, m<Ju.dy ...Jk.", ,,,,,",,,,,y , I r"'"'' b ''''"I,k,
F,,,m;,,,,,, .iI oft,n ''I' , ., 1>< 11' " ... """'rk. 'h<)'
01"', fi ",I", 0'); ""''''''. "ro"" I""' ' " ... ,". ,"
r,,,h,1" ' '' M''')'''' m't " I .. , ' 0 ",,,,,""ms
I"" h", ...... II .. """r"" m _ ''''' ' ''''' . ..., 0<" ' 'l''"3
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'h<" h.", l,oJ ", ",,,",'k, r".'''' """' "''''
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,k" I"" ..
PRESENTING THE CASE
W",," r"""""'s "")' , .. 1""1"" in ,n.,,,,,, ,-..,,'
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Answer 1 Chest Imaging
ANSWER 1
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ANSWER 3
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ANSWER 7
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ANSWER 8
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Answer 9 Chest Imll ging
ANSWER 9
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ANSWER 10
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Answe,12 Chest Imaging
ANSWER 12
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Answer 14 Chest Imaging
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Answer 14 Chest Imaging
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CASE 15
ory
68-year-old male presented with
progrcssi\'c dyspnoca.
CASE 16
ory
--H)-year-old male presented with a
g progrcssi\'c history of dyspnoca
_more reecn! onset cyallosis.
Chest Imaging Cases 15, 16
37
38
Answer 15 Chest Imaging
ANSWER 15
Observations (15al
This chest TJdiograph demonstrates bilateral lower zone
imerstirial rcricular opacity with evidence of basal volume
loss demonstrated b ~ ' descent of bath hila. The interstitial
opacit), gives the heart an irregular 'shaggy' border. These.
appearances arc in keeping with basal fibrosi6. There is a
calcified pleural plaque rcbred to the right hemidiaphragm.
The combination of basal tibrosis with pleural disease
would suggest asbestos exposure with pulmonal)' asbestosis
and pleural plaques.
Diagnosis
PulmonarY;lsbcstosis.
Discussion
Pulmonary asbestosis is a chronic progressive fibrotic
condition secondary to chronic asbestos exposure.
eroeidol itc (blue) asbestos fibres arc mOst commonly
associated with malignant disease and pleural disease.
Radiological features are of a fibrosing alveolitis that
predominantly affects the bases and is indistinguishable
from other causes. Fibrosis can progress to result in
progressive massive fibrosis, but this again predominates
at the lung bases. Pulmon:u), asbestosis has a latency period
of -40 years and therdore pleural changes are usually seen
prior to lung parenchymal changes.
Othcr features of asbestos exposure include:
Pleural efli.tsion - this is the earliest pleural
abnormality, with a latency of - 10 years.
Focal pleural plaques - have a btenc}' of 20-40 years.
DitTuse pleural thickening
Pleural calcification.
Rounded atelectasis - this is also known as folded
lung and :uises due to infolding of thickened plcurtl.
with associated subscgmental atelectasis.oMost
commonly seen in the lower lobes, it has the
appearance of a rounded subpleural mass abutting
15b CT image of the chest demonstrating a large
intra parenchymal lung lesion that is abutti ng
thickened pl eura. Vessels appear to be radiating
towards the lesion as though pulled towards it.
thickened pleura, with linear bands extending from
the mass into the lung (craw's feet ) ( I Sb ).
Malignant mesothelioma - - 90% arc related to
previous asbestos exposure
Lung carcinoma - there is a brency of -30 years and
occurrence is related to the dose of asbestos exposure
and to cigarette smoking - which can increase risk by
100-fold.
Practical tips
Multiple pleur.l.l plaques arc characteristic tor previous
asbestos exposure ( I Sc).
Look for signs of m:llignancy in patiems with asbestos
exposure - remember the increased risk of pleural and
pulmonary malignancy. Pulmonary masses should be
investigated with CT - ch:lfacteristic findings may
permit a confident diagnosis of folded lung in some
cases.
Asbestosis is the 'odd one out' among the inorganic
dusts causing pulmonary fibrosis. Thl: other
fibrogenic dusts cause upper ZQlle fibr06is.
Further management
Systemic sympwms, e.g. weight loss, should be
carditlly investigated to exclude mesothelioma or
bronchogenic carcinoma, for which t hese patients are
at increased risk.
In cases where there is still clinical concern abom an
area of possible tolded lung despitl: imaging,
percutaneous biopsy may be required to exclude a
malignancy.
Further reading
Akira M, Yamamoto S, Yokoyama K, etal. (1990 ).
Asbeswsis: high-resolution CT-pathologic
correlation. Radiolog'l 176: 389- 394.
15c Axial image shows a ri ght anterior calcified
pleural 'plaque consistent with previous asbestos
exposure. There is also subpleural reticulation
representi ng fitirosis and appearances would be of
asbestosis.
Answer 16 Chest Imaging Case 17
ANSWER 16
Observations (16)
This frontal chest rJdiograph shows extreme
There is marked dilatation of the central and main plll -
.anary arteries with 'pmning' of peripheral pulmonary
meri cs. No diffuse lung abnormality is seen
The findings arc indicative ofpuhnonary hypertension.
Gj,.-cn the gross cardiomegaly, a kft to right shunt is the
alIOS! likely cause. Howe\'er, cyanosis should not occur and
lIS presence suggests the shunt has rc\-crscd, that is, the
p;1[ienr has developed Eisenmenger's syndrome.
Diagnosis
Pul monary arterial hypertension from an undiagnosed
,"cntricular septal defect (VSD) progressing to
Eisenmenger's syndrome,
Discussion
Pul monary arterial hypertension is dilgnoscd by a sustained
mean pressure >20 mml-l g (systolic >30 ITlITlHg, diasTOlic
>1 5 ITlmHg). Radiological fe:Hllfes on a plain chest
r.tdiograph that suggest the diagnosis arc:
Increase in size orthe main pulmonary artery.
Reduction in size of peripheral pulmonary arteries
known as 'peripheral pruning'.
Right heart enlargement
Calcification ofthe central pulmonary arteries - a late
but characteristk sign.
Parenchymal mosaic attenuation pattern seen on
HRCT.
Pri mary pulmonary hypertension is idiopathic. The
condition can also arise secondary to pulmon:lTY disease or
CASE 17
History
.. \ 50-year-old female presented
with progressi,'e dyspnoea and
intermittelH cyanosis of the
fi ngcl1l.
cardiovascular disease, either from an increase in overall
pulmonary arterial resistance or from :In increase in the
o' erall circulatory ' olume going through the pulmonary
circulation.
Increased resistance - pulmonary veno-occlusil"e
dise:lse, chronic pulmonal)' thrombocmbolism, any
chronic I'emil:ltory disorder leading to chroni c
hypoxi:l and resulting vasoconstriction in the
puJmonal)' arteri:ll bed
Increased flow - left to right shunts, i.e. ASO (atrial
septal defect ), VSO (vemricubr septJ.J defect ), rOA
(patent ductusarreriosus).
In Eisenmenger's syndrome the pulmonary arterial
pressure climbs until it c,"elltually exceeds the pressure in
the left heart and the shunt re'crscs. It is seen in those with
pulmonary hypertension from :I left to right shunt.
Practical tips
On a pl:lin chest radiograph, hilar
can mimic pulmonar), aTlerial hypertension. Clinical
history here is vital and cr should be subsequentl)'
undertaken in the right clinical sening.
The diameter of the m:lin pulmonal)' artery should bo
less than that of the ascending thoracic aorta. Rcvcrsal
of this ratio is a sign of pulmonary hypertension.
Further management
Primary pulmonary hypertension has 110 cure :md a dism:ll
prognosis. It is a diagnosis of exclusion so all underl ying
causes of secondal)' pulmonary hypertension must be
investigated. Cardiology referral with a I'icw to echo-
cardiography would be required initially.
39
40
Answer 17 Chest Imaging
ANSWER 17
Observations (17a)
This frontal chest film shows abnormal rcticuhr interstitial
op:Kiry at both lung bases, though there arc no features to
indicate significant volume loss at the present time. A large
area of calcinosis is noted in the soft t issues around the
upper right hUlllerus. The combination of find ings and
clinical history suggests a diagnosis of systemic sclerosis
with lower zone pulmonary fibrosis and Raynaud's
phenomenon
Diagnosis
Lower zone pulmonary fibrosis due to systemic sclerosis.
Differential diagnosis
For lower zone pulmonary fibrosis:
Idiopathic pulmonary fibrosis (I PF) (cryptogenic
fibrosing alvcolitis - CFA).
Connective tissue disorders - systemic sclerosis,
rheumatoid
Asbestosis.
Drugs - especially certain cytotoxic;, e.g.
cyclophosphamide, bleomycin, busulphan, etc.
Discussion
This autoimmune disease has also been known as
scleroderma, a subgroup known as CREST syndrome
Current nomenclature is systemic sclerosis wiTh diffuse or
limited scleroderma, the latter being The equivalent of
CREST syndrome. The condition is three times as
common in females and typically presents in the 4th- 5th
decades. A variety of autOantibodies may be present
including ANA and rheumatoid Factor. Clinical features
are many and varied bur include:
Musculoskeletal - thickened skin, soft tissue
calcinosis, Raynaud's, erosi,e arthritis (sec Case 152).
Lungs -loll"er zone pulmonary fibrosis, aspiration.
Oesophagus - hypotonia results in dilatation and
dysphagia. lncompetence of the gastfo-ocsophageal
sphincter results in reflux and consequent peptic
stricture, aspiration, etc.
Small bowel - dilatation and slow transit result in
bacterial overgrowth and malabsorption. Barium
studies show 'hidebound' appearance due to fibrosis
pulling the vah>ulae closer together.
Pscudosacculatiolls and pneumatosis in small and
large bowel.
The CREST syndrome represents Calcinosis, Raynaud's,
oEsophageal dysmotility, Sclerodactyly, Telangiectasia.
Practical tips
Once lower zone pulmonary fibrosis has been noted
on the chest radiograph, examine the film for the
following features that may indicaTe a specific
diagnosis:
Dilated oesophagus - systemic sclerosis (sec Case
152).
Erosions of the lateral ends of clavicles -
rheumatOid.
Pleural plaqucs - asbestOsis.
Soft tissue calcification - systemic sclerosis.
Signs of malignancy including bony sclerosis from
myeloproliferative disorders - cyTOtoxic induced
Sympathectomy cl ips - systemic sclerosis ( 17 b).
Remember which disorders cause upper and lower
zone fibrosis ( reler to the differential diagnosis abovc,
and also that in Case 18 for npper zone fibrosis ):
sarcoid is rhe classical upper zone disease, much as
IPF is the classical lower zone Thereafter,
remember that the upper zones arc better aerated and
the lower zones better perfused. So, diseases caused
by inhaled dust (inorganic or organic, e.g. silicosis
and extrinsic allergic akeolitis [EAA] respectively)
I ,,'" atlect the upper zones, while the lower zones will be
'0"1 afkcted by blood disorders, i.e. drugs and
autoimmune conditions. Unfortunately, asbestos is an
exception and docs not obey this logic.
As with many fibrotic lung conditions, theft; is an
increased incidence of pulmonary malignancy in
systemic sclerosis associated pulmonary fibrosis -
check for focalnodulcs/masses on the chest
radiograph. Alternatively, tOcal airspace opacities may
represent aspiration.
Further management
HRCT is the imaging choice in diagnosis and follow- up
ofinrcrstitiallung disease. cr imaging findings of fibrosis
include lung volume reduction, subpleural reticulation,
interlobular septal thickening and tJ":."letion bronchiect.1sis.
CASE1S
.... istory
r.:ar "Id 111J.1c I'n:scn1\:,j \\11h hol.:k
Jnd p"('grc"'I"c
:;'SE 19

Chest Imaging
Cases 18, 19
4'
42
Answer 18 Chest Imaging
ANSWER 18
Observations (18a)
Plain radiograph of the chest shows changes of upper zone
fibrosis with elevation of both hila and upper zone reticular
opacit ies. In addition, there is a cavilY in the left uppe r
zone containing a soft ti ssue density mass with surrounding
air crescent. These appearances would be consistent with
a mycetoma. The patieTlt also has a marked kyphosis with
the head obscuring the lung ::apices. Moreover, on close
inspection. there is a hint of syndcsmoph),tc formation
along the right lateral aspeCT ofrhOr:lcic spine.
The combination of findings is consistent upper
zone fibrosis associated \\ith ankylosing spondylitis. There
is myceroma formation in the fibrotic C:IVil}, in the left
upper zone.
Diagnosis
Ankylosing spondylitis.
Differential diagnosis
For uplX'r zone fibrosis (mnemonic - 'STRAD'):
Sarcoidosis.
TB.
R.1diation.
Ankylosing spondylitis.
Dust inha13tion - inorganic (e.g. si lica) and organic
(i.e. chronic extrinsic allergic aheolitis).
Discussion
Ankylosing spondylitis is an autoimmune disease that most
manifests as a seronegative ;lfthropathy,
predominantly affecting the axia l skeleton (ini ti all y
sacroiliac joints then thoracic and lumbar spine). It usually
presents in the 2nd-4th decade and more fTcquently affects
men (sex mtio of - 5: I ). As wel l as bone involvement, there
arc respiratOry and cardiac m:llliteslations. Respi ralo!)'
manitestations arc seen in - I % of cases and features
include:
UPlX'r lobe pulmonary tibrosis.
Relicular/ reticul onodular opacities in lUllg apices.
Apical bullae and cavit"Jtioli .
Paraseptal emphysema.
Bronchiectasis .
Cardiac fC:ltll res include aorti tif; involving the ascending
aona with aortic \alve insutlicielll'Y.
P13ill radiographic features of upper zone fibrosis
include:
EIc\':Ition of the hila.
Tenting of the hemidiaphragms.
Ele\':Ition of the horizontal fissure on the right (a
good indicator).
Increased lucency of the lower zone due to
hyperexpansion.
Reticular opacilies ill the upper zones.
Practical tips
Clues to help limit the diOercntial diagnosis for upper
zone fibrosis include:
Kyphosi' and 'bamboo spine' indicate ankylosing
spondylitis.
Egg shell nodal caldficalion suggests silicosis or
S:trcoid.
Associated calcified grJnulomatn suggest TB.
look for signs of secondary
infection/ mycetoma in fibrot ic cavities ( ISb).
Whcn pulmona!), fi brosis due to ankylosing
spondylit is is suspected, look for signs of
complications of dmg treatmcnt on the film:
Ihascular necrosis of humeral heads secondary to
steroids.
Atypical dist ri bution of fibrosis may be secondary
10 drug treatment.
Further management
Multidiscipl inary management is required in this
ll1ult isystem disease .
18b CT image in the same pati ent shows a cavitating
lesion in the left upper lobe api cal segment
containing an Aspergill us fungus bait.
Answer 19 Chest Imaging Case 20
ANSWER 19
Observations (19)
Two Spot images from an angiogram ;11I<cstigation at the
Ie ... el of the aortic arch lre prcscnt'cd. Both images show the
left shoulder joinr in an alxlucTcd position. The left hand
image shows contn st filling of the aortic arch with filling
of the brachioccphalic tru nk and left common CUQ[id
m ay. There is filli ng of the; proximal artery but
them there is a complete occlusion with no filling beyond
it. The right hand image shows a slightly delayed film \\;th
.:omr:ast seen in the left vcncbral artery (best seen at the
k\'d of the C3/ 4 ) providing filling of the distal left
wlxb.v;an anery.
Di agnosis
Subclavian steal syndrome.
Discussion
This is a condition that is usually acquired and caused by
ahcrosdcrotic disc:!$!:. Stenosis of the su\xla,i3.n artery
results in stcaling of blood [Q the arm via rctrogradc flow
m the ipsilateral "crlcbral artery. Othcr acquired causcs
-:Iudc "asculiti (Takarasu), cmbolism, aortic disscction,
radi ation fibrosis and chest trauma. Congenital causes arc
ancommon. Clinical features include:
lefT arm is more commonly im'oked than thc right.
Reduced BP up to 40 mmHg in the aflccted arm.
Delayed/wcak pulse in the aflccted arm.
CASE 20
History
\ -I4' ye:lT-old male having a pre -
cmplo)'mcnt chest radiograph.
SubcJa"ian insufficicncy - pai n, numbness and
weakness in the arm that is brought on by cxercising
thc limb. Necrosis ofthc fingertips.
Vertebrobasilar insuflicicncy - syncope can be
prccipitatcd by exercising the arm due to the stealing
of blood. Headaches, ataxia, vertigo, diplopia,
homonymous hcmianopi::a ::and hemiparcsis have ::all
been reported.
Practical tips
Di::agnosis can be m::ade by US by
reversal of Doppler flow in the "cnebral artery.
Further management
CT can be useful to identify/characrcrizc c::alcificd
atheroscl erotic plaque in the subcl:lvian artcry
(uncontrasted CT) and also the site/ degree of
stenosis (arterial phase CT).
Surgical referral is required for treatment wi l h either
balloon :mgioplast}' (+/ - stem insenion) or surgical
bypass (common carotid to subclavian artery).
Further reading
Chung ]W, Park JH, 1m JG, etnl. ( 1996). Spiral CT
angiography ofthc thoracic aort:l. /{adioGmplJiCJ 16:
81 1- 824 .
43
44
Answer 20 Chest Imaging
ANSWER 20
Observations (20a)
This chest radiograph shows multiple fine, sand-like, tillY
calcified lesions measuring Jess than I mill in diameter,
spread throughout both lungs. Both lungs arc of normal
\'olul11(. No olher abnormality is seen.
Di agnosis
Ain:ol:lf microlithiasis.
Oifferential diagnosis
With pin-poinr high-density nodules, rhe possibilities afC
Girl}' limited, as follows:
Inhaled illO%'3nic dusts such as si licosis. Nodules tend
ro be a linle larger and arc predominantly in rhe
Illiddle and upper zones. CoaicscclKc \0 torm larger
lesions with cavir,uian and fibrosis occurs. Egg shell
calcification of nodes.
Other inoTbranic inhaled dust s such as tin oxide,
limestone and marble.
Slightly larger high-density opacities lead [0 a largcr
ditlercntial in addition to the above:
Varicclla pneumonia - inlection can appear
radiologicall y with multiple calcified nodules
measuring 1- 2 mm in size. No lymph node
calcification isscen.
Hist9plasmosis - hcaled inlection Gill also result in
multiple tiny calcifications throughom rhe lungs.
Associated mediastinal lymph node, liver and
spleen calcification.
Metasr:.uic calcinosis - focal calcification within the
alveolar septae due to elevated senun calcium and
phosphate b 'ds in conditions such as
h}'PCrparathyroidism, multiple myeloma, sarcoidosis,
milk-alkali syndrome or hypervitaminosis D. There is
upper zone prcdominancc and di sease can progress to
fOrtn airsp;lCc opaci ties, consolidatil'c appcarances and
fibrosis (20b).
Pulmonary haemosidcrosis due to mitral vall-e disease.
Barium aspiration - hyperdense opacities in the lowcr
zoncs morc common on the right (20c).
Discussion
This is a rare condition that aflccts adults in the 4th- 6th
decades, resulting in calcification within the all'eoli. Usually
these paticnts arc asymptomatic, howcI'er thcy can prcsent
with dyspnoca on exenion. R.1diological appearances call
be quite striking with diffuse tiny calcit1ed nodules < I mm
in diamcter spread throughout borh lungs. The middle and
lowcr zoncs arc preferentially aHee!ed. Serum GI1cium and
phosphatc arc normal. DiAcrentiation from the causes
below is usually made by thc normal biochemistry,
charact eriSlic radiological appearances and the p3.ucity of
clinical symptoms rci3.1il'c to the lll3.rked radiological
changes.
Practical tips
Clinical history is of vital imponance when down
3. li st of ditlCrcnt i3.1 diagnoses. Alveolar microlithiasis is 3.
good cX:1mple of where markcd r:ldio[ogical changes :1re
associatcd with a relative lack of symptoms. A simple
question to the clinician such as 'how unwell is this
patient?' can be most helpful.
Further management
No further m;lIlagement is required in this benign
condition.
Further reading
Brown K, j\'l und OF, Aberle DR, Batra P, tt (I/. ( 1994).
Intrathoracic calcific3.tions; radiographic features and
di ffe rential diagnoscs. RadioGraphiu 14; 1247-1261 .
20b Chest radi ograph showing bilateral upper zone
airspace opacities of metastatic calcinosis.
20c Chest radiograph showing hyperdense airspace
opacities in the lower zones predominating on the
right in a patient who aspirated during a barium
swall ow examination.
CASE 21
History
.\ 28-year-old pariem prcscnlcd with
oXrcriorating chronic d)'Spnoca.
CASE 22
History
A 45-year-old 1n3ic presented with
':,udiac arrhythmia and shortness of
breath.
Chest Imaging Cases 21, 22
45
"
Answer 21 Chest Imaging
ANSWER 21
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I_a .>f ,,'hm"'" .oJ m .... "'mm,,,,ly 11 ""1 "'
r"""" ""h ,)"i, 'ib",,". rU',. ,,",,)' f<'M" of 'h<
d;"_ ,..-
l'ul."",,,! ",fih,,,ion ,,,,.><>ph Wo. "
r"" "" .. , mif..-'t<><y/ ' ]ittins p","mQft"" of r'''h)'
." .. .. , .. """ .. ",," .. ,,,.

I .... ,h""'''' I,,, ,. " 1' 1"" k""
p"'do..,,",....,< ,h" b ",U, U,' ... ",,,..,,
,hodo. ,.. "" ph" ,oJ.W."""
M ",,,,,I "'r"""" i" dil",,1 "," 'll """"h ;lk"
f""'I""'S ,t-.. ""'S" in 'rl'<"" .'" '1'1", <on
""'." ; , "S" "",oI/'"b" ,on.po<
LoN. "",,.,,;J,,,,,",
... ,,., c r of . "'m'" r,,;"n, wrth ABI'''' '"
"""'" 21b. 1 ' ,,_ 2 1b .h .... J ;r ,,<J ." " " ,". _
f.U,d/plul'l',J up,,,, lob< "",,"'hi. "" I" 1>< ..
..," " " ., "",. ,,1 '" f",," .. 1'""," ", 11 < .1< .. """",
,IK .' " t" J iI.>!,J ''''''''hi ith fu 1110,,, "f

Prlt1lc. ' l ip.
... 'I'''' O\J ,,,to"" ,,, Th. ,,".I, rl ,;"" < ..... "r ""--'n .-I>"", "l-
'''' '" m,J, f""" i" .1",,,10,,,,,,,, ' Od 1)'1'<'
... _ ",,,I . . .,...""";"""'r;" ,,.,
10",,_
c ) "'" _ 1"'" """' ffi"" ,Ix urr")Qb"
mo", ,h." 100<. (2 1dl
in"""," -'l"i<. ;" i, i,N,
.tl;',,,J
HI - 1,.-.. H><
I""J"mi.,,,,,,
Furth r
Rd"u' <0 ,,, .. , .. with fu<t o"
""-""'. ur HRCr.
Furth. reading
Will;"., S_\ I. I,",,, f.T (1 9971- .. '" J'I'
""k"",' (," ...... 'l'
J!U;'''",/,hi<, 11, I
Answer 22 Chest Imagi ng Case 23
ANSWER 22
Ob" ,"'lions (22)
...... .. "" .. ,; '<n1";"-;' "dol ..... !
."I" .",m"" 1'/"'" Th< ,m",&, """,, .kl.)<d
<"h m," .. ' " ' ,,( 'h' ""," .. I. ' r "" I .".! "..,,,1 "')'" onl"""
.ith oporin. of tl>< , ...oo.., .. 1b;'I"," m of
.. " .... yu<..w .. <nh ..... ,"""" .... ;.,'"
.. .., inm, .. P""'<O .
Di.ynosis
"", .. I.
Discussion
.. "' .... r < .. 01;..- "",;'1 .... n .. In_H" "f ",,;"n,
ith _cu...._ HOH"", ,. t, ..... 5" .. h>Nt ' ''!' d ... ..
,iV' . CIi " "," r""'"' ''"' " of ,,=id ;. ,..,-JI"
.,myth", i ... wdk-ru!"I''''ky..-.l hu" f,, ",,_
CASE 23
HillOry
A 50. )< ... ,.,k !'''.''''
p,.,,,,,,,,J n """",,'k><"
"",ling. of <>,.1 ... _001 .. dud"
, Cmll " ",m"h ,,.. ,t.. '",n,n,,"'"I ..
"P'""' o. 1'1 .... S'.).
" 1,,,, .... i.1 '" h.q"'"",.' "" ,ld.)",01 g'""-"io;' '"
,nhID"'",'" """'I""id". ' 0 ".". of6bruoio.
"I' .... .,ftlK ,.oo< .-.Ii" m . ....... .,.
ditf",nt;""q [.urn , J-,., " f"""J '"lo<.ru;um .of
it< 10 ... ",", "" "" d;""K,
_ "' .. "f "f '"" ,n),,,,.-.I ; , I II .
P,.ctIClllllps
SI''''''S ,"-rt>< '"11&"''' " " ''''',"''''' """'l'
,I.,., ,... "n, 'n, ",,,, .. I);" ,I,'S"''';''
Furthe, mln_gem.nl
lo.M " CXIl M of .omoiJ .
"
48
Answer 23 Chest Imaging
ANSWER 23
Observations (23a)
This chest radiograph shows evidence of previous surgery
- there arc sternotomy wires and :l metallic mitr:!l v,ll\'e
replace ment . The heart is enlarged with a cardiothor.lcic
ratio of 2 1 :32. There is a ' double density' seen through
the right hean - a sign a flert atrial enlargement . Mul tiple,
small ( 1- 5 mill ) calcium density nodules arc seen in both
lungs with mid and lower zone predominance. Upper ZOne
venous diversion and a tiny light pleur:!] cffilsion suggest
pulmonal)' venous hypertension.
Appearances indicate that the patient has had surgical
lllitr:ll val ve rcpi3cemcllt, but there arc persisting Icaturcs of
mitral vake disease and signs of left heart failure. He
should undergo furt her asscssmcnr o f "ake and lefr heart
function. The highdensity pulllloll3ry nodules indi cu c
pulmonary haemosidcrosis, a consequence of elevated
pulmon3ry venous pressure over many ye3rs.
Diagnosi s
Mitral ,'al\'e di scasc.
Discussion
The most comlllOIl GUIse of mirral valve di se:lse is
rheumatic h<.:arr disease, widl presentati on most cumnlonl y
seen in middk ,Igcd fcm;\ks. It results in kll ,ltriJI
cnbrgemcnt J.nd pulmonary Vl!1l0US hypertension/heart
f-ailure
Radiographic SigllS of mitral \'al"c disease arc:
' Double density' behind the ri ght heart border due to
left atrial enlargement.
Splaying o rlhe carina by the large kft atrium.
Oesophagus di splaced to the ri ght.
23b Chest radi ograph shows enl argement of the left
atrial appendage in a pati ent with mitral stenosis.
ldt .anal "'PfICnd.agc CII\,U"ge lllenr. The norm;11 kIt
mcdu!brul comour hJ.s tWO convcxities above th<.:
\'C:IIUldC - rhc X>nK: arell 3nd the main pulmonal)'
MttT\ Enbrgcmc::nt of the k ft 3tri313ppend3ge
produ.:cs.amlrd "bump' below the pulmon3ry
23b n..s IS sometimes calk d the ' third mogul
[he term mogul is one uscd by skiers to describe
bumps In [he snow!).
Caktfiarioo of thrOlll bus in lile !cll: 3trium ( 23c).
Right "'cntricular hypertrophy,
Pulmoru.n hypertension, intcrstitial and
pulnlOrUJ)" oedema.
Pulfl"lOfUry h.lemosi d<.:rosis - longstanding clev3tion
of pulmonary "'enous prl!ssure results in oozing of
serum into the incerstitium. Blood products withi n
this wi ll ultimately be broken down to ,.
Practical tips
h is diAicult to distinguish trom plain lilm
is mitrJ.1 "3[\"e stenosis or n:gurgi tation -
eonscqu<.: ncC$ and signs arc t he S3111e and
Howe"er, if there is gross kfl atrial '
rhcrc must he a component of stenosis prescnt.
Further management
Cardiac !'efen al with a "iew [(l
assessment is required. Tr<.:a lmen il1\'ol\'es
for arrh ythmi as (3rial t"lbrillati o ll - AF) and
cardiac funnion. Surgical intervcntion
pCrelltall COllS v,llvc balloon dil at3tion (high
r.lrcs), valvotomy and v:llv<.: repbc<.:mcllt.
23c lateral chest radiograph shows curvilinear
calcificati on of the left atrial wall.
u r old f1ule W:I,S rdured for
m"cstiguiofl rollowing m;!;:!.l
g showing a right lower lobe
k-I.iofl .
Chest Imaging
I,.,.'
.'
Case 24
49
50
Answer 24 Chest Imaging
ANSWER 24
Observations (24)
These PET scan images from 3. PET CT dcmonsnatc a
1;lrgc right lower lobe highly FDG ( 18 fluoro-2-dcoxy-
glucose) avid lesion. There is a smaller lett upper lobe FDG
avid lesion. Thc.rc is also rigln hilar uptake as well as uptake
in the subcarinal region. Uptake in the region of the
oesophagus is also dcmonsu ;ucd. There is 110 FDG avid
lesion in li"cr or adrcnals. No bony lesions arc
demonstrated.
Diagnosis
l\'lct3static right lower lobe bronchogenic carcinoma.
Differential diagnosis
The left upper lobe lesion represent's either metastases or a
synchronous lesion.
Di scussion
PET scanning rdics on increased upl3kc of FDG in cell
populations with higher metabolic turno\'cr. The main
application is oncological imaging; other, less utilized
applications include CNS and cardiac imaging. h is essemial
that PET scans arc compared with cross-sectional imaging
if no PET CT scan has been performed. Assessing only
PC:f illl;lges alone can lead to diagnostic crrors, mainly
incorrect st:lging of malignant disease, The cr images (not
shown) of this PET/CT scan demonstrated a right sided
pleural effusion that turned out to be malignant. Pleural
cffilsions do nOt demonstrate increased FDG activity.
Among Other areas, normal FDG uptake is
demonstrated in the brain, heart, sal ivary glands, liver,
spleen as well as upper renal tracr and it is also excreted in
the urine, Nomlal bowel uptake is also often demonstrated.
Pirfulls include increascd FDG uptake in fut (brown f.my
tissuc); this can simulatc malignant nodal diseasc. In the
current study, the increased oesophageal uptake is due to
a coexisting reflux ocsophagitis.
rET scans can be false negative for small lung
metaStases or solitary lung nodules, False positivc diagnosis
o n PET scanning also occurs due to infection and
intlammation - conditions that arc associated wid1 in-
creased glucose turnover.
Practical tips
In the UK, PET scanning is used mainly as a staging
tool. Neurological and cardiac applications arc not
utilized widely. Among others, PET is used for initial
rcstaging of bronchogenic or oesophageal
Cancer networks arc increasingly utilizing PET prior
[Q planning for curati\'c surgel)', A growing
application is the assessment of sol itary nodules. This
is particularly useful in centrallesiolls tor which
histological confirmation is more challenging and the
complication rate is increased.
A well documcmed pitfull is a fulsc negative scan for
small IUllg nodules or mcmsmscs. Lesions measuring
less than 7-8 mm do ha,'c a higher fillse negati,'c rate.
Lymphoma staging is also widely undertaken. This is
\'el)' useful for assessment of activity in residual
lymphoma masses and also for assessment of early
rcsponse to chemotherapy. Inflammatol)' or infected
nodal mediastinal masses (histoplasmosis) can also
give rise to false positive Corrclation with cross
sectional imaging is importallt in all cases where FDG
imaging is undertakcn.
Further management
PET CT resulrs should be discussed within a multi-
disciplinary team \,ith the purpose of deciding whether the
patient would be a candidate for surgical disease clearance.
248 Right lower lobe bronchogenic
carcinoma (left) and likely metastasis (right).
25
fe male, prc\'iollsly
- the USA, presented for a
t chest mdiograph.
E 26
ry
:+-year-old male presented with
gia.
51
52
Answer 25 Chest Imaging
ANSWER 25
Observations (25a)
This iron tal chest rndiograph demonstrates widespread 1- 3
nUll diarnclcr miliary nodules seen Ihroughom barh lungs
with no zonal predominance. The miliary nodules arc of
cakifk density. Popcorn calcification ofthc kIt hilar lymph
nodes is $Cen. In addition, there is amorphous calcification
$Cen under the lell: hcmidiaphragm, which is likely to be in
the $plccn.
Diagnosis
Histoplasmosis.
Differe ntial diagnosis
For increased density miliary opacities:
MiliarYlllcrastascs
Pneumoconiosis - silicosis, si.dcrosis, baritosis.
Varicclb-zostcr (25b).
H:lcmosidcrosis - due to chronic pulmonary venous
hypertension, pu]mon:,uy haemorrhage, or idiopathic.
Histoplasmosis.
For popcorn calcification oflymph nodes:
Sarcoidosis.
Silicosis.
Hisropbsmosis.
Coal workcr's pncumoconiosis (,,,\VP).
L}'lllphoma - post radiotherapy.
Forsplcnic calcification:
Tuberculosis.
Histoplasmosis.
In F.lrcts secondary to sickle cell discase.
Hrd:nidcysts,
Haematoma.
Discussion
Histoplasma cnpSlllnwm is a fungus usually found in
temperate clim:tres and most commonly in thc northern
USA. Infection is by inhalation of air bornc fungal sporcs.
These g..:rmin:ltc in the :l1vcoli and then spre;ld via the
pulmonary Iymph:llics [0 the hilar/Illediastinallymph nodes
25b Multiple calcified tiny nodules at
the left lung base in a patient with old
varicella pneumonia,
and haematogenously to the spleen. Acme infection usually
presents with few nonspecific symptoms, and radiological
findings include gencralizcd lymphadenopathy, flitting
nonscglllental bronchopneumoni:l, multiplc miliary
nodules, popcorn calcification ofhihlr/mediastinallymph
nodes and splcnic calcification. Chronic hislOpiasrnosis is
seen in patienrs with chronic obstructi\'c airways disease
and has r:l.diological features of peripheral consolidation
and apical fibrosis, Disseminated infcction can occur in
immunocompromised patients.
Nonpulmonary features of hisroplasmosis include
pericarditis (5- 10%) and rheumatologic syndromes (-6%),
c.g. arrhrnlgia, erythcma nodosum.
Practical tips
In cases whcre there arc multiple radiolosical findings,
consider the diflcrential diagnosis liST for each finding and
idemi!)' an ovcrlapping diagnosis (easier said than done in
a \'h'asilllalion! ).
Further management
Clinicll/occupational history and I-IRCf can be useful to
dillcrcntiate the possible undcrlying d!;\gnoscs. Respiratory
referral with a \'icw to antifunSll trcatmcnt would be
required ill the acute infcction.
Further reading
Brown K, Mund OF, Aberle DR, ct at. (1994 ).
Imrathor;lcie calcifications: radiographic fcatures and
diflCrential diagnoses. RndioGrnpIJies 14: 1247-1261.
Whelt LJ, Wass J, Norton J ( 1984). Cavitary
histoplasmosis occurring during tWO large urban
outbrcaks, Analysis of elinical, epidemiologic,
roentgcnographic, and Jaboratot) fe:ltures. Mtdici"t
( Baltimore ) 63(4 ): 20 1-209.
'Vilear LJ, Connolly-Stringfield PA, Bakcr RL ( 1990),
Disseminated histoplasmosis in the acquircd immune
ddiciellC)' syndrome: clinical findings, diagnosis and
trcat'lllcllI,and rcvlcwof\hclil'erarurc. Mcdicim
(Baltimore) 69( 6 ): 361.
er 26 Chest Imaging Case 27
ations (26a)
IIOntal chest radiogr-aph dcmons[r.ltcs a right sided
.arch. No left sided aortic knuckle is seen. The hean
enlarged. No IOcal1ung parenchymal abnonnaliry is
_ is can be contirmed wirh arterial phase contrast
-ed CT chest (26b). Right sided aortic arch can be
ed with scveral congenital cardiac abnormalities but
.I.lso be see n in p:nicms without cardiac abnor-
The lauer group of p:l.IiclHS usually h:l\'c :J. right
.Ionic arch with :In aberrant Jeft subclavian artery
g as the most distal branch ort he aorti c arch), which
behi nd the This can be seen on a
swallow examination as a posterior indcmation in
t:wium column of the mid oesophagus. Patients with
sided aortic arch with mirror i1ll3gC branching, such
the leti: subclavian arises as a branch of the first ,"esse!
dlc Jortic arch, arc the group usuall y associated with
tic heart disease. The aorta descends in the right
crior mediastinum (although in a small proportion,
.;; this is 011 the lett).
eASE 27
tory
34-year-old smoker presents with
ressivel)' worsening shortness of
ath.
Practical tips
Right sided aortic arch call gin: a notch in the posterior
aspect of the upper oesophagus on COntr:lSt swallow
examination.
Further management
No further managemem is required in thi s condition.
26b Axial CT image demonstrates the right sided
aortic arch.
53
Answer 27 Chest Imil ging
ANSWER 27
ObH rvllions l 27"1
Th, ,h,,' , .. I"5''I'h !oi 1"",1 'hkl .",1 'hm ",1,,1
'l'" ' ""'. S""U' ""'h I. "S' P"''''''''''' afl.,,!
,,-,jo,,,<,, s,.,.,,, ' on.1I ",.jo'n.", .,,,, .. ," p .... "ull'
wi,h .. ,I .. .PI'" zoo ... ),'a pi, . .. , ,nu.;.," "'
f"'<""""m. "" w,n. :<u """r .... ..,fi ,;,,"'
n, .. "' .. ,,, '"UO" ' 0 'f'il< af 'h,
''', '"' ..... '" J;"rih,,,,,," ",d "''').''' ''1
w<o. 1J " II ,I" "M'" Iii-d)'

Oi.gnosl.
,,,,,,>;<',,,,", "u
Oiff".nti., dllgno.ls
F", 'Y"" ";0<," "",,,,.1 0> ;n", ... J I.nt
'''' ' m<''
.. ,), .. ", ... _ "1<,.,, .... ""'" in
l nd---<>, ' , n,,< ." m"l<;rk ')'" ""'''
,,, .... """', ' "' h.' 3' "f ",1"", 1)' ,,,,;i,,,,, " "
" " .) ' "" -.II.,...., "', "oJLlk fv<on,,;'-.. ,
O".'""y _on rI'.'" ,Ib,""
.00 ",."'''' pn<U""" ..... ,,'"',
),;"'00';00-"",,,,,,,, - r ....Jomin."tlj 'r"" 'lV>.
Tu"'''''''."k" ....
C)""
Oi..,u .. ion
I .. " II " , mul';'I"" "
'" ",.Ie n,,"m, ,I . ",,,, . _. "" h 0 un ""-'''' """"on I,' .,
p,J-..f," J " ,,k>1 oJ." m l" . .okl h" ,n
... 1'11""' '''' '1' ,,'
C;H in, ,-,j,,,, , "q"'"" inHW "S"' '" <ti
""",uk' 'hn 1""&',,,;,, ly e .... ' ''' ..... 0" ., ,h" ....J
,n." then fiKm"""" u. ",", Uy
"""" .. , .. "",,,,,,1 in uP"' .'''''' . r""umn',"""", .. '"
""",""" ""I <0" I'< ","""", \'1",,,1 .1Ii,,'." "" , .... Ir
...... .. "d. H "l'f""'''''''' '"" of .oouk.
' orl ''''"el., , hin '\'" 'h" ... ,0/",,..,..... ."" .....
on" .00.' .. I"", <of , he "1' '''' mJ
,,<c ... , (1 71)1 .
P OIic.llip.
On CU, <)"'''' ""'I' J .. ..., .. .... V""",.,.,j 1un3
,,,h.,,, "" he ,,,11<,,,,,, \>y " 1",,,,,, ', ""'
"" I ",. Ok"'Wj'in, .","" ,,,I."',,,,"
1.\ "'p" \ """""" ,."",, '" I "

)';,",,>fobmrn""'6 .h'"'8" on eXk ""Iuok rih/-.on
.n; , ..... m . .... ( """,,,f,brom,,) ," in
1'''''<00, ...t .... o,.'" and ,,;,,_
TO'",,,,,,, "k",,;, ;, ,..ill' o.kn,;tKJ lor ,n. hi>tu<y _
,h ...... " d"J lor ,\" ,Oi.OJ .. rm,,,'" ",,"' ......
""""', .",1 "'k ...... "1'J,,,n.
IImo,h.",.,;, 1"'''''''''' , h" l ... -. II , J ')'" ",.j '",
'"'\' . bo , '" ,n."
k '" '"..,., ""'inS'
managemlnt
HKCT "" '" .';"1;" 'h, or ,,", ,, r"'"""
_n.n r.,. 1"","6.01 "'"'pi ;''' .. ", of
... "'.' , .... / ... )"',,,,,,, ''';' .' ' 'g ... .Iuk, .. .I
r 0 ,.""""","",,,,
, .. ding
.'1""" ,,,,,) ... 'I>, .II"!" SL." oJ .
''''''I'''''.' "r
.00 cr find;"S' . 17),

CASE 28
History
A m.l, p" ... n""
""'m" ... t r'" '' oc.h 1m"&,,
lAh,.,.. llk _.,., .. ..,,,;..,, I "' .. " ..
'p'" _ . h" h .. h'rp<n<J "'.u.
,I,,,,n'
CASE 29
History
A ""I, I""""" J .;'h
.""".i ..... "'.,{
,," .... h
Chest Imaging Cases 28, 29
Answers 28, 29 Chest Imaging
ANSWER 28
OI>& .. ".lIono i2b. b._I
><k"," ;",'s" "" .. ,n "'''''N.m '1'1,,' fi", ;",,",'
P "") P"'-'""'''''' .. "" d.mo",,,,',,
,,,",,.; 1h< W,,' o" ... ,.,. p .... ) ,)",_., p,g"i'
",h"" io , ... "",h . hh "',",," ... """J . nJ
'r""""." uf ,I" ,.,rt;" , n" , ... P'o,,,,,' m.;"
... Th. ,hWol ""1'< {1&) .00_" ""'",.; ""d",","
..... , ... ,,,lxl",10 ./t,,,",, " ,I>< k .. l ,,(,1>< .. ,-""k,.
G;,," , ... ,...,w,'" of ';"', 'h" ,I",
,", .. I ' h' .. ", ""' ,I><
,hi,.! 1m , 'h, ..... , .k.',",,!.
1'" h,.,Ik""", ""'"
Dll g"".I .
Tho,.,;" "",II" 'p.Jrom ,,,onJ,,), '0 1kJ,t<," ""';',1
,;b>
Diff er.nti, 1 di . gno."
0, """" "I tI ... "';, ".,k, . It, :
_ 'mi.-" rh, .. , NoJ "
I" "b.
""'"",,,,,1 _ r"" ",.,,";.. , w ""-",,rr.
>,r".u'.
ANSWER 29
ObSflrv lon.12So, 29bl
'1".'" "" I cr ... "' ,h. ,h,,' .h",, ">1,,, or
'''!'' .. ,1\tl," .... ",,'
j<I .. , or><"' ... h .n",,"' " "1"01
,0. , ,,,1'; ... ;. .. "f r, ,, J"'i\> ."uIJ fi, . ;o h
oJf 1"""""'0<)'..00.,""
Oi.gno. l.
,,,,\fm, ,t,,, to, '''''IT f, ,,'" ,
Diff. ,entlll dilgno.ls
............ ,' """-")'
l'ulmoooM)",J.m.,
1"(.,,".,, ,
H
'''''un'' ......
E'.>,rin,., oIk,." ,[",,!;,"-

.... """"' ..
f",," .... " nf s"x .. ' gI .... -
, ..... "" '/I)mph"' .. ,
Di ...... lon
., .... ,,, ..... "",,",,m. ", ... ",
""". "'''1' '" ,<in <Omf"<""'" .. tI" mot of, ... n"k
"f"'" <,...,'" .., "I d" 'n.. ,',,, "" , _ ,,(
"i>< Ju. to """ ",<UP"''''''' .. d ",,,,,,I,, ')'UP""''' >
.... .. l'" or' ')mp' .... ""' r";'''!>' Th.
",1><1.0,,," .. ,,<r....v ... n", ""' <r .... '-"<IuJ<J ;,h
, nb """" "' '''' ' "' "' ",,,,,,,, rrobk,n,
< .. , ."'" Ju< ,,, , ... "",,,<J "'"",, "1'0""1"'-..... ., _
""""",1"-"""""';' ,iii .. ,,"," _, ''''"'pm ';''''''''',",
11>< "",I, ,,[ d,;, "r",' 'rmr"'""
r'''" ,,,"" ,,,,,,,.oJ ....... ""'n"". '""h"
"I fu.m"",n '''''
"""' ,m too';"" "',. ,
Prictioalllp'
ri b> "w .... .. _J-I'" 0'''''' .......,I,,"," but "'" onil'
')"'1''''''' ''''"' I II"! ,of , ..... ,
Further managemenl
US .>eM " , ,\\'" ..... , ' "'' .>.><";n, .n,ml
I "'I'rk, , 'S".I ." n , Iv ''''' o. ,,", I ",I ,." ',,,.1

cr/MRI .. """ ""lUi ;' , ..... , ... of
"""r"""'" ;; ,.,. "I'I'""n' on rI>o. ,od"w ' I'"r,
.""" .... "". "'1".1 ..
I.., I """""r oro,,,, .
"h-wl., """' ..
1"1""",,,, 6Ioro,;"
F", ""J"I " ' ""k>bul ..
I. p.!'" < U< , ... "" _
.
Di.cu .. iDn
lA'""" " il.,;'. .""11,, m.J. ,hnblly "'"
'''nro,m." en , rio, f'""'"5' ,,",I '"
r "'s" '" in "'l, .. n .. ,h. ok"""'>!,,.oo
""'''' "..,," '" ...... _-" (0,,,,,,,,
UPI'" WR< ,-",",,, I", Jom;'m
1.,,,,,,,,,1 ,,,,J,,,, ,,;,10 .. ;,.,,
1<1<)' R to,."
,,,,km. , l"<IIIil..- (10,,',
",' '1'1'< ...... "" \.
11>< ... ,,""" 1"''''Ok ,,,
"'I'<"''' ,h.
",.,11 "',, >." ""-
, l"m" ,!lin""
Answer 29 Chest Imaging Case 30
Tbcsc same lindings 3fe visible all CT. Alveolar Ollid often
~ n r s as 'ground glass' opacity, which is an increased
::u.zi ncss/ attc.nuation in the lling - and which can be
chy in distribution. 'Ground glass' opacity is a relatively
..onspccifi c imaging finding due [0 many conditions that
.::aISC an overall increase in density within the segmellt of
g displayed as a pixel on the CT image. There is a long
( remia! diagnosis including any cause of alveolar
. j collsolidation.
CASE 30
iistory
~ 65-vear-old male was referred tor :l
ardiac MRJ to assess cardiac viability.
Practical tips
A combination of cardiomegaly, pleural clTusion and
airspace opacity suggests cardiac f."tiluTe with pulmonary
oedema.
Further management
Medica! management with eXR radiological tollow-up as
appropriate .
57
58
Answer 30 Chest Imaging
ANSWER 30
Observations (3Da, 30b)
The first image (30a ) is;t shorr <l.\:is scan through the left
\'cmriclc during the firs t pass of contrast. There is no
contrast enhancement orlhc thinned IeH \'cmricular septal
:md anterior walls. The visualized posterior, lateral and
inferior walls show 110mlal enhancement and arc of nOnllal
thickness . The second im:agc (30b) is a delayed lour
chamber ,-jew showing delayed, prolonged cnhanccmcm
of the septal, apical and 3lHcrohncr;11 wall of the left
ventricle. These appearances :HC of an extensive left
"cnrricular infurct wit h no evidence that inl"olved areas arc
viable.
Diagnosis
Left \'cntricubr inrnrct involving Ihe septal/apical!
amcrolatcralwalls.
Discussion
Cardiac MRJ has 311 expanding rolc and current uses
include asscssmentof:
Cardiac viability prior to re\'ascubrization.
Cardiac congenital heart detect
Cardiac tumours.
Perieardialdiscasc.
Canliomyopathics.
Assessing cardiac viability post infarction is
important since re\'ascularization of li\'e tissue reduces
morbidity and morraliry. Previously cardiac pcrfilsion was
assessed cardiac nuclear medicine (lIHBG - Illeta-
iooobenzylguanidinc [scintiscan}) stress resting but there is
now an increased role for cardiac M ItI.
Shorl a.'(is cine images arc acquired at first of a
bolus injection of gadoli nium to determine perfusion,
Infurcted myocardium shows no enhalll::ement on lint-pass
imagin! (as demonst rated in this case), In addi t ion, first -
pass imaging can show:
Whether the infarct is transmural or subendocardiaL
Degrce of hypo/akinesi a.
Delllycn..cnhancel1lenr sequences al approximately 5 min
show enhancement in infarcted tisslle sillce clear:lllce of
contrast from fibrotic tiSSlle is slower lh:lll from normal
nH'ocardium.
Ifthere is :lny uncert.linty regarding ditlercntiation of
ischaemic from inf.ucted mnxardi um then cardiac MRI
stress testing is per!armed images acquired
at stress with adenosine and then repeated afTer 20 min al
rest. Areas of hypocnhancement at st ress that show
recove!)' at rest represent areas of ischaemia rather than
in&rcti on. .,\
Practical tips
Cardiac MR.I is a test that requires assessment of
cine inllges to make a subjecti\'e and objecti\'e assessment
of1cfi \'enlricular function (ejection frnction).
Further management
Coronary artery atherosclerotic disease is ch:lr,lCterized
using coronary angiography or corona!)' artery CT
Patients with isehaemic but \'iable mYOi:ardiulll may be
suitable for re\':lscularization with angioplasty or bypass
gl'Jfiing,
:.ASE 31
Iis:ory
female patient prcscmcd
.:best pain.
tASE 32
ry
':'i-ycar-oJd Illale presented with

Chest Imaging Cases 31,32
59
60
Answer 31 Chest Imaging
ANSWER 31
Observations (31a)
This chest radiograph shows e\'idence of a pn:,'ious rigln
llIastcctonw. !-lean :lIld mediastinal conrours are normal.
No lung 3.b'llormaliry is seen. There is ditnlsc sclerosis of all
visible bones, mOSt evident in Ihe ribs, Appearances arc of
difli.Isc sclerotic mct:lSI":lSCS from a breast carcinoma primary.
Diagnosis
"hstcctomy and sclerotic bone metastases,
Differential diagnosis
For causcs of unibtcraJ hypcrtr.lllsr.1dbncy:
Chest wall abnormality - mastectomy, pecroral muscle
atrophy (polio) or absence (Pobnd's syndrome).
Pleur-l1 almorm:tlit), - pncu1l1othor:lx,
Lung abnormality - Swyer-James syndrome
(consequence of bronchiolitis as a child resulting in a
hypoplastic lung with air tT:lpping on expiration),
emphyscma, bulb!.', pulmon:ll)' embolus (3 I b ),
For causes of unilater:tl hyperdensity:
Chest wall :lbnormalil)' - gynaecomastia (unilater:tl in
40% of cases), breast impl:\l1I.
Pleural abnorm:llity - pleurJ.1 dfusion on supine film,
pleural thickening.
LUl\g - ul\ilatera\ pu\mom.\}' oedema
from lying on one si de (3 I c), consolidation, lobar
collapse (especi:llly left upper lobe ).
31b There is a large central pulmonary embolus on
the right with marked reduction in vascular markings
on thi s side.
Discussion
'''ith breast cancer being such a common
complications will present frequemly on plain radiographs
so it is important to note :I mastectomy. Another 'tell tak'
sign of pre\iolts bre:lst cancer is the presence of a:;:illaTT
clips from node sampling.
The mastectomy may first be percei\'ed as a disparity
between the o"eral1 densities of the tWO hemithoraces..
There arc many other causes for this, though sometimes
may not be e:ls), deciding which side is norm:ll.
Practical tips
In :lny c:lse with a history of breast cancer, the chcsr
radiograph should be scrutinized for features of recurrence.
These classical "iva films for exams :lnd also presc
frequently in e"el)'ciay practice. Features to look fi
include:
Sclerotic/lytic bone metastases (31d).
Lung
Lymph:lngitis C;J.rdnomafQsa.
Pleural effusion.
A-.;illary lymphadenopathy.
Ri ght hemidiaphragm ele":ltion secondary to li,er
metastases.
PUilllOnal)' pnelllllonitis/ ilbrosis from
Further management
In cases where clinical hi story and examin:ltion do
revcal an olwious cause lor the rdati,"c diftcrenccs
chest lucency - CT chest would be appropriate.
Isotope bone SCJn may ident"if)r distant bone
metastases.
31c Unilateral pulmonary oedema with pleural
effusi on and ai rspace opacity on the right.
Answers 31, 32 Chest Imaging
d Multiple poorly defined lytic lesions are seen
;;:TOughout the ribs bilaterally.
SWER32
Observations (32a)
chest radiograph shows no ti.xallung abnormality and
rib fracture or pneumothorax from the recent trauma.
"e\"er, there is bilateral inferior rib notching involving
3rd- 8th ribs. The aortic knuckle is not well seen bllt
is no other mediastinal contour abnormality. The
..art is not cnl:lrgcd. There is no evidence of previous
surgery. No other specific bOlly or soft tissue

The most likel y diagnosis is coarctation of the aorta -
p:nicnr's blood pressure should be checked in both
and compared with that in the legs for confirmatory
:Jiagnosis
- 'or rib notching due to coarctation of the aorta.
- erential diagnosis
inferior rib notching:

Coarctation of the aorta .
Subclavian obstruction after Blalock- Taussig shunt
for tetralogy of Fallot .
\cnous: SVC obstmction.
Arteriovenous malformations (AVlvl ).
:S-curogcnic, neurofibromatosis.
superior rib notching:
Rheumatoid arthritis, sckrodenna and SYSTemic lupus
crythcmarosus (SLE).

:S-curofibromatosis.
syndrome.
IUllg disease.
Discussion
The most common cause of inferior rib notching is
coarctation of the aorta. This can be of [\vo types:
Preductal - the hypoplastic segment is long
These patients present in inf3ncy and early childhood
with congestive fJilurc. Prognosis is worse
than lor those who present with t. he postduct"al type .
I'ostductal - this Ilsuallv consists of a short narrowed
segment, immediatel y distal to the site of the
ligamentum artenosulll (32b). Presentation is llsllally
in latef childhood, and is with hypertension,
diftcrential blood pressures in the upper and lower
limbs and/ or a heart IllUfmur.
( COIlt.)
32b Single angiographic image shows postductal
stenosis of the descending thoracic aorta, with
poststenotic dilatation.
62
Answer 32 Chest Imaging
On chest radiographs, the focal Il:J.ITowing of the aorta is
cbssically made more (vident because of pre- and
posl'Stcnoric dilatation producing a classic ' tigure of 3' sign.
Obscuration orthe arch, as in this case, is also recognized.
Ri b 1l00ching on the inferior surfucc of the 3rd-8th ribs can
ll suall}, be seen in untrc:ltcd patients by 8 years. Rib
notching occurs due [0 dilatation of the posterior
imcrcostal arteries, which act as collateral vessels. Since the
1st and 2nd posterior intercostal arteries arise from the
COsfoccl"l'ical trunk of subcbvian artery rather than
descendi ng aorta, they do nOt form a collateral path and
hence do not cause rib erosion.
Coarctation of the :10m is associated with sc\'eral orher
congenital anomalies such as bicuspid aortic valve, patent
ductus arteriosus (PDA), \'ctHricular septal dcfcC[ (VSD),
tricuspid atrcsia and transposition of the gre;lt \csscls. There
is also an association with Turner's syndrome.
Practical t ips
When suspected from plain fi lms and clinical findings,
t.'IR or CT has now largel y replaced
com'emional as the next im'cstigatioll of
choice (32c).
When inferior rib nmchi ng is noted check:
The aortic comour for the 'figure of 3' sign.
Is therc evidence of previous repai r, e.g.
thoracotonw scar?
The hcart for e\'idence ofldi: ventricular
hypertrophy, i.c. elevation of the apex.
Arc there features to indicate neurofibromatosis,
e.g. cutaneous soft tisslle nodules?
When rib Ilmching is unilateral, suspect an aberrant
$ulxla\'ian artery origin on the unaflected side.
Further management
Surgical treatment for coarctation of the aorta in\,oh'es
resection and end to end anastomosis, prosthetic patch
graft, sulxlavian fbp aOrToplasry or balloon angioplasty.
32c A maximum intensity projection (MIP) image from an
MRA examination of the thoracic aorta.
SE 33
ory
38-year-old man was Ixing
tigatcd for transient neurological
".
CASE 34
ory
51-year-old woman with oesophageal
er presented complaining of chest
Chest Imaging
Cases 33, 34
63
64
Answers 33, 34 Chest Imaging
ANSWER 33
Observations (33a)
There 3TC some incrc3.scd tubular sofi: tisslie dcnsitv
opJCitics in the right lower zone, suggcstiyc of abnormal
vessels, leading TO a faim pulmonary nodule. There is a
funhcr nodular opacity in the right lIplXT zone, again \Iith
Ihe suspicion of vessels running to it from the right hilum.
The left lung is CicJT and the mediastinal outline normal.
Given the clinical details, pulmonary ancrion:nous
mallormations giving rise to paradoxical emboli and TIAs
l1msr be presumed. Contrast cllh:lllccd CT would confirm.
Diagnosis
Pulmonary :lrtcrio\'cnOllS m3ltonm.tion (AVM).
Differential diagnosis
Single or multiple pulmon;uy nodules frOIll other causes.
Discussion
Pulmonary AVMs arc abnormal \'Jscular communications
between pulmonary arteries and \eins (95%) or systemic
arteries and pulmon:lry veins. 1\10st they arc of
the simple type, with :I single artery feeding :I focal
aneurysmal segment and a single dn)ining vein. Compkx
lesions ha\"e more than one artery and/or vein. Figure 33b
is a single angiographic image tll;lt demonstrates the large
feeding vessel to a solitary AVl'vl
Multiple pulmoll:lr)' AVMs may be associated with
Osler-Weber- Rcndu syndrome. They arc asymp-
tomatic until the 3rd-4th decade when they can present
with local effects - haellloptysis, d)'spnoca on exertion and
cyanosis with clubbing (due to right LO lefi: shunt ); or
distal eflects - cerebrovascular accident (CVA) or brain
abscess due TO paradoxical emboli. Lesions enlarge with
age.
Practical tips
The 'finger in glme' appearance from mucoid impaction
of cemfal ;lirways in allergic bronchopulmonary asper-
gillosis can look similar in some ways to the vessels
supplying an AVM. However, there is a nodule at the end
of these \cssels in AVI'.,.\
ANSWER 34
Observations (34)
This chc:st radiograph shows a normal sized heart and clear
lungs. There is, however, c\idcnce of air within the
mediastinum - best seen aTOund the leli heart border and
aortic arch. Helow the medialldi: di;lphragm, a stent is just
about visibic across the gastro-ocsophageal junction.
It is likely that there has been oesophageal perforation
from the stemed oesophageal tumour
Diagnosis
Pneumomediastinum from perforation of stented
oesophageal cancer.
Further management
Angiographic assessment and treatment with embolization
or balloon occlusion is now the preferred management.
Further reading
Coley SC, Jackson JE ( 1998). Pulmonary arteriovenous
maltormations. C/jIJicn/ Radi%gy 53(6): 396-404.
Pick A, Deschamps C, $tallSOIl AW ( 1999). Pulmonar)'
arteriovenous tistula: presentation, diagnosis, alld
treatment. World journal ofSllrgery 23( 11 ):
IIIS- II22.
33b Single image from an angiographic
investigation demonstrating a large feeding
vessel to the pulmonary AVM.
Differential diagnosis
For causes of pneumomediastinul\J:
Al,'eolar rupture in acute asthma.
Oesophageal rupture due to malignancy, trauma,
l"iolent vomiting ( Boerhaa\..:>s syndrome - usually
associated with a left sided pleural effusion).
Extension from peritoneum - pneumoperitoneum.
Iatrogenic - following oesophageal balloon
dilatatioJl/stenting, bronchoscopy, ll1cdiastinoscopv.
positile pressure \'emiJalion. .
Chest Imeging Case 35
nnum is an uncommon condition that is
m.nic but can present \I'ilh ncdcor ches!'
11 rarely leads to any complications bur it can
dUgnostic sign for an underlying medical
th.u does need trcarmen!. Although a ['an::
_ it is see n in children and masa
ti ps
rlx' ribs for any sign of trauma.
lAX lung fields for a lesion that might halC
bronchoscopic/ surgical investigation.
4fr under the diaphragm to indicate
toneum .
.old male presented to A& E
1'a:Urrenr acute-on-chronic
Look for an cffilsion to suggest oesophageal injury, or
oesophageal stem, as in this case.
Further management
Chcst CT after the patient has drunk some water-soluble
contraSt , or a water-soluble contrast swallow, can confirm
an oesoph:ageal tear and leak and help to idcntif}' the si te.
Further readi ng
Gcrazounis 1\.\, Arhanassiadi K, Kalantzi N, Mousr:mias
M (2003). Spontaneous pneumomediastinum: a rare
benign entity. J01I'-"(I/ of711omcic alld Cnrdiol'aJw/flT
Surgery 126(3):
65
66
Answer 35 Chest Imaging
ANSWER 35
Observations (3Sa)
There is a large area of increased lucency in the right mid
and upper zone with no visible.:: lung markings. There is no
visible lung edge, however, to suggest this is a pneumo-
thorax. Moreover, there is crowding of"csscls in the lower
zone. The appearances arc likely ro indicate a large upper
lobe bulla. There arc no focal pulmol131")' opacities to
indicate superadded infcClion. ComparisOI;I with an}'
;l\>;lilable old films should help confirm this interpretation.
A general reduction in density in the left upper zone
suggcSlS rhal similar pathology is del'doping here tOO
Diagnosis
Large right sided bulla.
Discussion
A bulla is a large dilated airspace within the hmg Witll a \\"JJl
less than I mill thick. They arc usuallY' produced byah'colar
dcst ruction in "'mphyscUlII, Impaired ventilation ofrhe rest
of the lung can result in dyspnoea, as well as that due to
rhe background chronic lung disease.
Confusion Cln lrise when the absence oflung mukings
leads to the erroneous diagnosis of pneumothorax. This
35b Image demonstrates a small pneumothorax
wi th no lung markings lateral to the lung edge.
can have dire conscquences if an intercostal chest drain is
then placed in the bulla! An expiratory fi lUl
makes a pneumothorax easier to detect ( because it en-
hances the cont rast di ffe remial between pleural air and
lung parenchyma) but probably won't hel p resolve di ag-
nostic confusion with a bulla. Patients with chronic lung
disease may well ha\'e pre\'ious filrns that show a bulla TO
be longstanding.
Practi cal tips
A pneumothorax leads to two findings: a visible lung edge
and hypodensity with absent lung markings il teral to this
(35b). A bulla has absent lung markings but not t he
discrete lung edge. COIlI'ersciy, skin folds (seen mOST
in babies and the elderly) can produce a pseudo
lung edge but there be lung markings lateral to iT
(35,).
Further management
If diagnostic uncertainty continues after expert review of
the films, then occasionllly CT of the thorax may be
needed to diflerentiate bullae from pneumothorax.
35c Chest radiograph demonstrates a skin fold
giving an apparent lung edge but lung markings are
visible lateral to it.
Chest Imaging Case 36
... lib Sequential chest radiographs taken 4 months apart.
36c HRCT thorax of the same patient at a later dale.
6i
68
Answer 36 Chest Imaging
ANSWER 36
Observat ions (36a, 36b, 36c)
This frontal chest rldiograph (36a) demonstrates wide -
spreld, fairly symmetTicll lung plrcnchymll abnormality
that is central in distribution and chnr.lo.:terized bv bronchial
\\'all thickening and cysti c bronchiectatic chl;'ge, Some
larger soft tissue density nodules arc seen in the lower
zones, which likely represent mucous plugs. Bibteral
lobull!ed hibr enbrgement is seen with the right si ded
R:adiological features ofCF on a chest r.ldiograph arc:
Cystic/cylindrical bronchiectasis.
Peribronchial cuffing/thickening.
Mucous plugging with secondlry lte1cctlsis due to
obstruction.
I-lil ar lymphadenopafhy.
Allergic bronchopul"lonaryilslX'rgil losis (ARPA).
Ir mphadenopathy being more evident. Appearances arc of Respiratory complications or CF include pneumothorax.
cystic fibrosis. haemopt)'sis and cor pulmonale. Chronic pulmonary
Chest radiogrlph (36b) from the same plticnr t:l.ken at infecrion can lead to hypertrophic pulmonary osteo-
a lat cr date demonSlrat"es more ad\'anced disease with more arthropathy ( H POA).
mucous plugging and hyperinfbtcd lungs secondary to air Cystic fibrosis is a multisystem disease: as wdl as causing
trapping. Peribronehill culling and thickencd 1.1Ontapering ~ meconium ileus (i n, chi ldren) and meconium ileus
bronchi arc e\'idem. A right subclal'i;lIl central hne is noted, e(luivalent (in adults), It Clll also callse pancreatic insuffici-
presumabl}' for the administration of IV antibiotics, eney, biliary cirrhosis, portal hypel'lension, malabsorption
A c r image (36e) of the chest on lung windows shows due to gallbladder disease, cholelithiasis lnd dubbing
typical reatures of CF with cylindrical brollchie([asis and a (36d).
central distribution, peribronchial euni ng. mucous plugging
:and lOCal :nclectasis. It also shows the most common
compl ic:ation of:a pneumothorax on the lci't side.
Di agnosis
Cystic fibrosis (CF).
Di scussion
Cystic fibrosis is an :autosolll:ll recessi\'e Illultisystem
condition that is chlrl(terized by exocrinr gbnd
dysrunction due to mucous plugging arising sccondlry to a
fuull in rell chloride transport. The condition aHects whites
with a geographi cal distribution :affecting Europeans and
Ashken:azi Jews. Di:agnosis is usually made in children, \\;th
the majority being diagnosed within the first year of life
with the clinical presentation of meconium ileus and
respiratory symptoms. Pulmonary compli c:ations are the
predominant cause of de:ath and sun'ival is limited to
-30-40 rears.
36c HRCT thorax of the same patient at a later
date.
Practical tips
Typical presentation is of\\;despread pulmonary
disease in a young patient.
Tunnelled cenrrallines in patient's arc used for long
term drllg treatment with antibiotics or ":i-
chemotherapy. Again thi s is a clue 1'0 the underlying
diagnosis,
Look for complicltions ofCF - pneumothoraces and
secondary infections.
Though nor a common site, I-I POA Clll occur in the
humerus and may thus be visible on the edge ofthr
film.
Furt her manage me nt
Follow-up in these patients is bc5t lX'rformed wit h HRCf
which can answer the important quest ions when lunf
transplant is considered - is there coexistent Aspergill
infection? Arc there complicating felttlTeS, e.g. pneurrx
thomces?
36d Single axial CT image
demonstrates significant splenomegaly
due to portal hypertension and
pancreatic calcification secondary to
recurrent bouts of acute pancreatitis.
Chest Imaging
- rar-old IV drug user presented with cough and
rtncss ofbrcarh. He is nored to be signific:lOtly
- on prescluation. This series of chest radiographs
n at presentation, day 3 and day 7.
Case 37
69
70
Answer 37 Chest Imaging
ANSWER 37
Observations (37a, 37b, 37e)
The firs t chest film taken at presentation (373) shows no
obvious radiologic:tl 3bnorm3lity. The next radiograph
from 3 days later (37b) shows bilateral mid and lower zone
rcricu!ar/gr:lIlular inrcrstitial infiltrate with no evidence of
volume loss. The third film trom 7 days after presentation
(37c) shows bilateral consolidarjvc change affecting both
lungs. There is :J. pneumothorax on the left with subtotal
collapse of the left lung. Surgical emphysema is noted.
It is notable that the patiellt was initially vcry
symptomatic wit h a relatively normal chest film and then
showed rapid pulmonary changes over several days. The
history of IV dmg abuse raises the possibility of background
HIV infection and the sequence of radiological appearances
is typical for Pllwllloeystis e""illii pneumonia.
Diagnosis
Pncumocystis carinii pneumonia (PCP).
Discussion
P. carillii pneumonia is the mOSt common cause of
interstitial pneumonia in immullocompromised patients
Radiological findings can be very variable but the typical
pattern of development is as follows:
Normal chest radiograph is seen in up to 40% of
patients, especially carlyon in the infection.
Bilateral diffuse perihilar airspace/granular/reticular
opacities is the typical appearance.
Progression to diffuse airspace consolidation with air
bronchograms.
Pleural effusions arc seen in -20% of cases.
Response to treatment occurs over a period of - 1
week
Atypical features (seen in - 5%) include upper lobe thin
and thick walled cysts, IUllg nodules, mediastinal and
hilar lymphadenopathy.
Treatment with aerosolized pentamidine alone results
in the disease af1ccting upper lobes.
Complications of PCP arc common, e.g- pneumothorax
and superimposed TB/fungal infections.
Appearances on CT include a patchy mosaic/'ground
glass' pattern with subsegmental sparing and coexistent
thin walled cyStS and pneumatoceles. Appearance of
nodules on CT imaging is suggestive of a second disease
process being involved - metastases, l)'mphoma, septic
emboli or Kaposi's sarcoma.
Bilateral gallium uptake is seen prior to radiological
changes being evident.
Practical tips
A strong index of suspicion for PCP should be maintained
when an immunocompromised patient presents with
dyspnoea. As in this case, symptoms can be OLit of
proportion to the initial radiographic changes.
Further management
Diagnosis is confirmed with sputum cytology or
bronchoscopy and lavage. Treatment is with IV co-
trimoxazole.
Further reading
Kuhlman JE, Kavum M, Fishman EK, Siegelman $S
( 1990 ). PIIClllI/oeystis carinii pnellmonia: spectrum of
parenchymal CT findings. Radiology 175: 7 11 -714.
Chapter 2
ABDOMINAL IMAGING
IN ABDOMINAL RADIOGRAPHS
ays, a s)'Stcmltic approach is required to be able to
:t lhc mOSt information from a radiograph. The order
led is a guide and should be adapted to your own
lliettnccs and adjusted for each individual case.
- eral assessment
r assess the qu:..ti t)' or the film, ensuri ng that there
.kquarc cQ\'cragc - arc the hernial orifices cQ\'cred in
p.uicm who appears to h:wc small bowel oOOmtetian?
..dtition, make a quick assessment of the film to exclude
important di:tgnoses that arc surgical emergencies and
rt'qui rc immediate management:
PtttOration.
Tone Illcgacolol.l ,
es
ufy any lines that arc present, e.g. postsurgi cal dnins,
tubes, urill:!r)' catheters and peritoneal dialysis
ters. The pre$Cnce of peritOnea! dialysis catheters or
rgical drains may offer a simple explanation for free
.a.pcriwneal gas.
Gas pattern
erentiating sma ll from large bowel is \'ery difficult in
ng chi ldren and one can usually only say whedler a
k m is in dll: or distal bowel. In adults,
raures uscd to distinguish the two include position in the
omen; diameter (I:uge bowel <5 cm, small bowel <3
; \'alvube conni\'t: ntcs travcrse the whole of small
1::1 but t his is nor so with the colonic haustralions; solid
es onl\' scen in colon.
The of ' nor mal' bowd gas pattems is rather wide,
t from experi ence, one should quickly know whether
amount and di st ribution of bowel gas arc. \cry
ormal. Unusually shaped collections of g:liS (e.g.
should raise suspicion of gas outside the GI
:no- and lead rou to examine thc area very dosely. Check
.:Mefully for gas in areas of the abdomen where it is not
wormall y seen, e.g. o\'er the liver (either as pockets of g3S
'JI"\\; thin the biliary tree ) or in the relroperiwncum. Don't
forget 10 check for bowel loops extending be low the < '-\
inguinal ligament indicative of hernia.
Exclude bowel dilatation and wallthiekening. If there
is dilatation, decide whether it is small or large bowel and
then try to cst:l.blish the 'cut oW point. wter ClSCS ill ustrate
specific features to check for when one suspeCtS small or
large bowel obstruction.
Soft ti ssue organs
Check the size and outline of the liver, spleen and kidnq'S.
Also check the psoas outlines which be obscured by
retroperitoneal pathology .
Calcification
Look at the rest of the film for calcified densities such as
gall stones 5- 10% visible on plain radiographs) and
renal tract calculi (80-85% "isiblc on plain radiographs).
Common incidental calciftc opacit ics include mesenteric
nodes, phleboliths , ,ascul ar calcifi cation and uterine
fibroids. Calcification within the solid Ofb':lns may be more
significant however. Unusual calcified opacities may allow
fOf a specific diagnosis such as a pelvic dermoid.
Bones
Assess thc bones of the vertebral column and pe lvis for
incidental pathology or findings that might be rclc\'ant to
intra abdominal di sease such as sacroiliac joint changes
associated with inflammatory bowel disease.
Periphery of the film
Conclude by looking at peripheral stmcmrcs. For example,
patholog), at the lung bases that might mimic abdominal
patholoID', incident:l.llcsions in the abdominal wall.
ABDOMINAL CT
The first qucstion to ask yourself when looking at all
abdominal cr is what type of comrasr has the patient been
gh'en, i.e. oral/IV/ both and during what phase has
imaging been carried Out. The typical phase for abdominal
71
72
Abc!ominal Imaging
imaging is portal-\'enous (60-70 seconds delay) bur other
phases, e.g. pre-contrast, :mcrial, delayed, arc useful in
characterizing spedfic lesions.
Axial im::agcs will commonly be presented and you can
proceed in one of two ways - either :lSSCSS all stmctures on
each axial image then proceed to the next image, or,
alternatively, assess each org:m in mm o\'er a series of slices
before moving on to the next organ. in rcalit ... , a
combination of the tWO is often used but the J:mcr ensures
nothing is missed.
As well as searching for tOcal lcsions within the organs,
other features to check include the foll owing:
Li\'cr:
Overall attenuation (e.g. reduced in fatty change)
and enhancement homogeneity.
Size :Illd comour (e.g. irregular contour in
cirrhosis).
Patency of normal vascul::lrstrucrures.
$mte of intrahepatic bile ductS.
Gallbladder - check for stolles, the density ofbilc,
wall thickening and perieholecystic fluid. Carefully
assess the extrahepatic bile ducts.
Pancreas - check lor calcification; the state of the
pancreatic duct, pcripancreatic collections and
infl:lnlmatofY changes.
Spleen - check sizc and adjacent \'::Irices.
Kidneys - is the :menuation orthe kidneys correct for
that phase of scan? Is there:: collecting s ~ ' S t e m
dilamti on? Check the adrenals abo\'e.
Then systematicall y eval uate the nonsolid organs:
Aorta - as well as o\'erall size, du:ck for dissection and
patency of main branches. Check major venous
patency at the same time, excluding deep vein
thrombus.
Bladder, ovaries/ ut erus.
Lymphadenopathy.
Intra-abdomi nal fat - peritoneal soft ti sslle deposits
arc easily overlooked unl ess the abdominal fur is
careful! vscrulinized.
Colon, 'ileum and stomach.
Free gas/flui d.
Bones and lung bases.
- :car-old male presented with a
of gradually progressive
.,.
SE 39
ory
- -year-old female presellted with
bkcding.
Abdominal Imaging Cases 38, 39
73
GENERAL
INTRODUCTION
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74
Answer 38 Abdominal Imaging
ANSWER 38
Observations 138a)
Single AP image from a double cammst barium swallow
examination shows a short, smoothl y i.lpcrcd narrowing
in rhe lower ocsoph<lgus juSt superior to the gastro-
oesophageal junction and a small hiatus hernia. The
OCsoph3guS proximal to rhis h:l.S delicate tr,Ulswrse mucosal
folds, the so-called fcline oesophagus. This 3.ppe31"311CC is
35S0Ciatcd with gastro-ocsophagcal rdlux and leads to the
conclusion that the shon stricrun: is a peptic stricmrc.
Di agnosis
Peptic stricture fcline oesophagus.
Differential diagnosi s
For oesophageal strictures:
Lower oesophagus:
Peptic stricture secondary to gastro-oesophageal
renux,
Scleroderma - aflccted patients have an
incompetent lower oesophageal sphincter and
reduced pcrisl::Ilsis resulting in marked gastro-
oesophageal reflux.
NG intubation - pre\'cnrs'closure orthc lower
oesophageal sphincter.
Zollinger-Ellison syndrome_
Upper and mid oesophagus:
Harrett oesophagus - acquired condition
characterized b)' col umnar Illel::lplasia secondary to
chronic gasrro-oesophageal rcflux/ oesophagitis.
Prcmalignam condition with an increased risk of
adenoearcinoma of the oesophagus.
Caustic ingestion - usually long, smoot h
narrowing forms 1-3 months l)Osl ingestion.
Mediastinal rJdiOtherap), - usuaJJy long, smooth
narrowing forms 4-8 momhs post radiotherapy.
Skin diseases - epidermolysis bullosa, pemphigoid,
ery thema multi forme.
Other less common causes of strictures include Crohn's
disease, Candidn oesophagitis and Behr;el's disease.
Discussion
Pepti c strictures have this typical appearance of short (1-4
cm), smooth, tapered, concentric narrowing in the IOll'er
oesophagus. Associated radiologi cal findings include
intramural pscudodi\'eniculosis (38b) and feline oesopha-
gus (so called occause this is the normal appearance in
cats). Longitudinal scarring can cause fixed [ranS\'ersc folds
but these can be diflerentiatcd from fcline oesophagus
sincc lhe), arc only seen in the region of the strictur;: and
do not extend more than half way across the oesophagus,
giving a 'step bddcr' appearance.
Practical tips
Previous CXRs call ~ useful in identifying a cause for a
stricture - look for a tlll110UT that might have been
irradiated or fratures of aspiration pneumonia/hiatus
hernia.
Further management
GastrOenterology referral \ \ ~ t h a view to direct \;sualization
and confirmation of diagnosis with endoscopy,
Furt her reading
Luedtke P, Lc\-illc MS, Rubcsin SE, tt nl. (2003).
R.,diologic diagnosis ofbcnign esophageal strictures:
a paltern approach. RadioGrnplJics 23: 897-909.
38b Contrast barium swall ow shows flask shaped
outpouchings with a narrow neck of intramural
pseudodiverticulosis.
swer 39 Abdominal Imaging Case 40
rvations (39)
image from a mesenteric angiogram examination
an abnormal duster ofvcssds and contrast 'blush'
_ ysplasia is the most common cause of occult
"ng in the large bowd, predominantly aflCcting the
y population. The condition is characterized by
ar ectasia of the colonic circulation, most commonl y
- :ring rhe caecum and ascending colon. The condition
to chronic low-gr3dc blood loss but can also lead to
cs of severe lower GI bleeding. There is an associa-
\\it h valvular heart disease, specifically aortic stenosis
SE 40
ory
35-year-old farmer presented with
ache in the right upper abdomen
sc ... cralmonths.
Di agnosis can be made with selective mesenteric
angiography or CT angiography. Both arc :a ble to idcnrif)'
bleeding when the rate is as little as I mljmin. Three levels
of abnormalit\, afC identified:
In carly disease, a densel)' contrast filled dilated \'ein is
seen within the bowel wall.
As the disease progresses, a vascular tuft can be seen
at the lesion site.
Fmther progression shows an early filling vein during
the arterial phase of scanning.
;vlcsenteric angiography has the adv,lntage of proceeding
directly to treatment with embolization. '1. ,
Practical tips y-r ; J
CT is exce.Hem at the bleeding point when "\V;
there is actIve GI blcedll1g. Always perform a pre-contrast f
scan prior to the arterial phase scan so that high-
contrast intraluminal blood can be diftcrentiated from
high-contrasT bowel tOad content/debris.
Further management
Surgical resection is the definitive treatment when
endoscopic treatments have not controlled bleeding.
75
76
Answer 40 Abdominal Imaging
ANSWER 40
Observations (40a)
There is a large, well defined lesion in the right upper
quadr:l!ll, which has thin, curvilinear calcification of its wall.
This is projected over the li,'cr and is probably inrrahcp3tic,
though a calcified gallbladder cannot be excluded from this
film. This is a solitary lesion with no orher abnormality
seen. Gi\'cn the appearances and paticnI's young 19C and
occupation, a hydatid q'Sl of the li\'cr is most likely. Funhcr
imaging with CT would help confirm the location of the
lesion and the diagnosis. Serological tests for hydatid
disease should also be undertaken.
Diagnosis
Hydatid disease.
Differential diagnosis
Ofca1citicd Ji\'crlcsion:
Metastasis - especially colorcctal cancer.
Primaryli\'crlUmOl1T.
Infection - hydatid, TB.
Discussion
disease is through infection by the
parasitic tapeworm EcJllllO,o'CIIsgr(lllllloSlls. Dogs are the
definite host with the human acting as an accidental host
following lcddental ingestion of eggs from canine faeces.
The li,er is the mOSt commonly imoln:d organ and
presentation is with abdominal pain, jllllldice, colic
with eosinophilia in 20-50%.
In the lil'er, inlection results in the fomlltion ofa cyst,
which is more commonly found in thc right lobe; the size
of the cyst ranges up to 50 Clll bur is - 5 em on average and
mult iple in 20% of cases. The cyst is composed of three
layers - the Outer pericyst, middle laminated ectocyst and
the inner endocyst.
Radiological features ;lfe:
Variable appearance ranging frOIll a simple unilocular
cyst to a complex hct"Cfogclleolls cystic mass.
D:lIlghtcr cysts arc char;lCterislic bllt arc a r;1re finding
Their presence is noted by a 'racemose' appearance.
Initially <hmghter cyStS arc \\'ell defined and round and
aTe seen at tile periphery of the mother cystS. They
progress to !orm large, irregular shaped cysts filling
the Illother cysl.
Can also contain debris (hyd.1tid sand), internal
septations and wall calcification.
Calcification is seen in 20- 30% of hydatid cyStS and is
cUrIilinear or ring like. Dense calcification is
seen as the e,st Start.s to heal.
On cr, the appearance is of a \\'ith a high
attenuation wall on Ilncnhanccd CT cvcn without
calcification.
,\IRI appearance is of a cyst with a low signal rim.
On C f /MRI!, thc wall and septac enhance with
contrast, which can aid in the diflercntiation betwecn
hydatid cyst and a simple liver cyst.
Complications arc of cySt rupture (50- 90% of cases) and
infection.
The lungs arc the second most common site of
involvement in adult s and the mOSt common in children.
There is a predilection lor the lower lobes and disease is
Illore cOlllmonly seen on the ri ght. CySts arc multiple in
and bilateral in of cases. Figure 40b shows several
left sided, well defined round intrapulmonary lesions.
Calcification is rare. When ai r infiltrates between the layers
of the cySt wall it can give the appearance of:a 'meniscus'
sign, 'onion peel' sign and fin:atly thc 'watcr lily' sign, when
there is complete separation of the endocyst from the
pericysr. Rupture of the cySt can resul t in surrounding
consolidation.
Practical tips
Benign liver cysts afe common, but all cySts should be
closely inspected lor atypical features, e.g.
h)'l)cTattenllating wall Of wall calcification suggestive
of abscess/hydatid; poorly dcfined edgcs, which may
suggest the lesion is in fact a metastasis.
Cystic lesions involving lil"Cr and lungs should suggest
infectivc/malignant underlying diagnosis until proven
otherl\"ise.
Further management
)\bnagement can be cither medical (t\\"o benzimidazoles
arc commonly used, albcndazole and mcbend:azolc) or
surgical (cystectomy or partial organ resection).
Further reading
Pedrosa I, Saiz A, Arrazola 1, It nl. (2000). Hydatid
disease: radiologic and pathologic features and
complications. RndioGrnphics 20: 795-817.
Polat P, Kantard M, Alper F, It nl. (2003). Hydatid
disease frolll head to toc. R..ndioGrnplJicJ 23:
475-494.
40b Patient with pulmonary hydati d presented with
several large. well defined nodules in the left lung
with no calcification.
Abdominal Imaging
CASE 41
History
.\ 67-year-old, o\'crwcight female
p,nicnt, with no past medi cal history,
pr('scnrcd with \'ague abdominal pain,
nausea and \ol1li[lng.
Case 41
77
78
Answer 41 Abdominal Imaging
ANSWER 41
Observations (41a, 41b)
AI' :abdominal radiograph shows distended loops of gas-
filled small bowd but absent colonic gas. TogClhcr with
the clinical history, appearances 3fC consistent with small
bowel obstruction. There is no evidence of free gas on
these films but on the second image there is an abnormal
collection of air o\'er the ce!Urnl liver that has a somewhat
li near/branching configuration. This is consistent with air
in the biliary tree. In the right side of pelvis, there is a
round opacity showing peripheral calcification - this is likely
to indicate an obstructing gJ.llstone.
Di agnosis
Gallstone ilcus.
Discussion
Gallstolle ileus is rchlti\'el y rare, accounting for 1-2% of all
mcch;mic;ll obstructions (though more in the elderly). The
most common scenario is of a stone eroding through from
gall bladder to duodenum - the cholecysroduodenal fistula
leads to pneumobi lia and the Stone then impacts in the
Slllall bowel. The fistula can also be !Tom the comOlon duct,
and can enend to thc colon or stomach instead of the small
bowel.
Occasionally, the diagnosis can be made on plain films
\\;th Rigler's triad t>f small bowcl obstruction, pneumobilia
and ectopic gallstOnes. Oncn, however, the gallstone is nor
seen on plain film since rhe stoncs frequently have a
predominant composition of cholcsterol with little
calcilication. An axial CT scan of the abdomen (41 e
conlimled a gallstone ilcus \\;th a 5 em diameter laminated
gallstone found in the distal ileum. The bowel was
collapsed disral to rhe site of stone impaClion. At
laparotomy, the stonc was milked back to thc jcjunum and
rcmo\cd.
Practical tips
Always check for air in the biliary tree on the small
bowd obstruction :lbdominal film .
Till y loculcs of air in the biliary tree tend to be
ccntl':llly located in the li\'(r (4Id) compared with
porral \'ein gas, which is seen in the periphery.
Bili::!')' tree gas can also be seen as a normal finding in
p a t i c l l l ~ who hal'l.: had a previous sphincterotomy or
[allowing a recent ERe I' (endoscopic rctrogrndc
cholangiopancrcatography),
Further management
1\ lcchanic;rl Sl11all bowel obstruclion is a smgic&..
emergency.
Further reading
Gurlcrik G, Gurlcyik E (2001 ). GallstOne ilclls:
demographic and clinical criteria sllpponing
preopcrati\'e diagnosis. UJI/S TrnJ'lIIn Derg 7( 1):
32- 34.
Pangan JC, Estrada R, Rosales R ( 1984).
Cholecystoduodenocolic fistula with recurrent
gallstone ilcus. ArciJjJ'eJo/Surgery 11 9: 1201- 1203.
ry
n;: ar-old male is admitted with
-encephalopathy.
- SE43
ory
llymptomatic 22-),c;1r-old male
nrcd with deTerioraTing renal
:rion
Abdominal Imaging Cases 42, 43
79
80
Answers 42, 43 Abdominal Imaging
ANSWER 42
Observations 142)
Image from a double contrast barium meal examination
shows multiple serpiginous filling defects in the lower
oesophagus. Normal appearances of the g,tstric nmdus arc
observed. Appcar:lllccs arc consistent with oesophageal
varices and the distribution suggests that these arc 'uphill'.
Diagnosis
Ocsoph:agcal varices.
Differential diagnosis
For ocsophagcal ,ariees:
Varicoid carcinoma of oesophagus.
For gastric variccs (i.c. CJUSCS of thickened gastric folds):
Hypenrophie gastritis.
Mcnctrier'sdiseasc.
Lymphoma.
Splenic \'cin thrombosi s,
Discussion
Oesophageal ,'a rices ha,'e a ,'cry typical appearancc on
contr;lst sw:tllow examination of dilated, smooth,
se rpiginous filling defects. Varices collapse in the creer
position and are beSt imaged with the patient pronto Thcre
arc two types:
Uphill "arices (found in the lower oesophagus); these
are charanerizcd by collatcral blood flow from the
portal vein vb the azygous "ein to the superior \"ena
cava (SVC). These arise due to liver cirrhosis and duc
ANSWER 43
Observations (43)
This pl:lin abdominal radiograph shows multiple small foci
of calcification over both renal areas in thc region of the
rCIl:J1 medulla rather than ren:J1 cortex. No stones arc seen
elsewhere along the course of the renal tracrs.
Diagnosis
Rell:J1 medullary llephrocalci nosis.
Discussion
Mcdullary nephroc:Jlcinosis represcnrs calcific:Jrion in the
distal con\'oluted tubules, i.e. in the renal pyramids, There
arc m:Jny causcs :tnd the underlying pathology can rarely
be determined on a plain rndiograph - clinical history is fur
more important here.
Tlte C:J lISCS arc:
Renal tubular :Jcidosis ( RTA),
Endocrine causes - hyperparathyroidism,
hyperthyroidism, Cushing's.
Medulla!) sponge
Idiopathic hypercalcuna,
to IVC/hcp;uic vein/splenic vein thrombosis or
obstruction.
Downhill \'ariccs (found in the mid and upper
oesophagus); these arc characterized by coll:ncral
blood flow from the SVC \'ia the :azygous vei n into
the IVe, and arise due to SVC obstruction from
conditions such as IUllg tumour, lymphoma and
rc[rasternal goi tre.
Gastric varices arc secn in combination with oesophageal
"arices in patients with portal hypertension. When seen.tn
the absence of oesophageal "arices, splenic vein thrombosis
should be suspected. Again, appearances arc of smooth.
serpiginous or grape -like filling defects; most
seen in the gastric fundus.
Practical tips
Best images arc obtained with thc patient in a prone
position,
Further investigation with an ultrasound of the
abdomen should be advised to look for cirrhosis and
portal hypcrtension.
Further management
Treatment is aimed at controlling poml hrpcrtension \Vim
medi cal and surgical (transjugular intrahcp:ttic
shunt - T IPS) means. Treatment of bleeding
":trices and preemptive treatment of non bleeding varices is
achie,-cd with endoscopic bandi ng and sclerotherapy.
Renal papill:t!), necrosis.
Hypelyir:Jminosis D,
Milk-alkali syndrome,
M:Jlignancy - bone metastases, multiple myeloma,
p:trnneopiastic syndrome.
Primary hypcroxaluria,
Practi cal tips
The most common causcs of symmetrical medullary
nephrocalcinosis are hyperparathyroidism and RTl'..
The most common cause of asymmetrical medullary
nephrocalci nosis is medulla!)' sponge kidney".
Further management
Underlying causc must be identified - particubrly tre:ttJbk
Further readi ng
Dyer RB, Chen MY, Zagona RJ ( 1998). Abnorm:t l
calcifications in the urina!)' trnct. RadioGraphies 18:

E 45
ry
n=Jr-old male presented with
dial bloating.
Abdominal Imaging Cases 44, 45
81
82
Answers 44, 45 Abdominal Imaging
ANSWER 44
Observations (44)
This is a single AI' image from a double contrast small
bowel barium examination. T here is focal, eccentric
n:lrrowing of the second part of the duodenum, with
predominant notching of rhe latc",! wall. Appearances of
the duodell um superior and inferior to this arc completely
normal.
Diagnosis
Annular pancreas.
Differential diagnosis
For 3.nnubr pancreas:
Sphincter orOddi oedema (secondary to impacted
none or pall crc3tili s)/carcinoma - usually produces an
eccentric lesion but thi s is medially
located.
Duodenal adenocarcinoma - usually presems with an
annular concemric I<:sion \\;th shoulderi ng and
utccr:ltion. There is an association
syndrome and coeliac
Discussion
Annular pancreas is a disOrder characterized by fuilure of
rotation of the ventral bud of the pancreas resulting in
pancreatic tissue encircl ing the duodenum. TIll: sccond pan
of the duodenum is inmh'ed in 85% of cases, Usually
patients are asymptomatic, but the condi tion can preSCn!
at any age , wi t h 48% of cases present ing in adulthood.
There is an association wi th other congenital abnormalities
when the condition presents in chi ldhood - tracheo-
oesophageal atrcsi:l, duodenal atresia, irnperfor:ne anus,
Down's syndrome.
ANSWER 45
Observations (45a)
Single image from a percutaneous chol3ngiogram is shol\1l.
The percutaneous needle is seen with the tip in a proximal
intrahepatic bili3ry duct. There is clcar abnormalit), of the
common duct, which has several strictures with duc t
dilatation and beading. No filling defects arc seen to
indic3te gallstones. Contrast is scen in the duodenum with
no obstnl cting lesion scen at the lel'cI ofthc sphincter of
Oddi.
Diagnosis
Primary sclerosing cholangitis ( PSC).
Differential diagnosis '
For PSC:
Sclerosing cholangiocarcinoma.
Acute ascending cholangi tis.
Bile duet carci noma - thi s G ill ran:I)' inl'oll'e the bili;u)'
system in a difruse maImer producing multiple 1l1mour
stric1l1res.

Clinical presentat ion can be with:
Pol )'hydramnios - i'l utero.
Persistent vomiting, "double bubble' - in neonates.
,'omiting and abdominal pain - in adults.
The condition is complicated by 311 increased incidence 01
acute and chronic p3ncreatitis 3nd periampullary I"P';; ' J
ulcer.
Practical tips
Crtrcfully examine the fi lm for g:lllstones or sma ll
fe;)tures of cocli3c di sease (small bowel
flocculation of contrast , featureless smooth small
IUlllen/ folds, jejunization of ileal loops and
peristal sis) to suggest :lI101her diagnosis.
Further management
cr \\ill confiml pancreatic tissue encircling the
duodenum.
ERCP (endoscopic retrograde
cholangiopanereatography) or I'vt RCP (magnetic
resonance cholangi opancre3togr:lphy) shows a
nomlally located main pancre3tic duct in the body 01
the pancreas, :lIld 3 small duct in the head or t he
pancreas encircling the duodenum.
Further reading
Rizzo RJ, Szucs RA, Turner MA ( 1995). Congenital
abnormalities of the pancreas and biliary t ree in
adul ts. l{nnioGmplJiu 15( 1): 49-68.
Di scussion
Prim3!,)' sclerosing cholangi tis is a progressile fibr", ...
inflammatory condition 3fTecting both intrahepalic
enrahepatic bile ducts. The condition is strongly as""",,,_
with inflammatory bowel dise3se (ulecratilc coli tis [l"
round in 70%, Crohn's in 15%). Other assocbtions i'",""K
ret roperitoncal and mediastinal fibrosis, chronic a
hepatitis, Riedel's thyroiditis, p3ncrcarit is and Sjogn=fl
s)'ndrome.frescntal"ion is Wilh progressive fatigue, ,,"".
and jaundice. Biochemical changes :tn: round wi th clC"I
SCrulll bilinrbin and alkaline phosphatase.
Im3ging feat\rres on cholangiogi.lphy
(MRCP/ ERCP): there arc mtrhifocal strictures
aflccting intra- and ext rahepati c bile ducts wilh
lesions. The classic p311em is or 3 'beaded' appe"" ...
with alternating segments of stenosis and dilat":ltia.
( 45b),
Im3ging features on CT: ducts have the 3ppcaran.x
strictures, dilat;ltion, belding 3nd pruning.
Imaging on US: usually normal but may show dua
1\';111 thickening,
Abdominal Imaging Case 46
of PSC include:
management
curative treatment for this condition is Ih'cr
rion. Medical palliath'c care in\,oh'cs treatment
toms of cirrhosis, parmi hypcrtension, chronic
(pruritus and malabsorption ) and ductal
ns such as strictures and ascending cholangitis.
'pHnary approach is therefore adopted requiring
"'gists, transplant surgeons and inrcn'cntional
- euoold male presented with
..n.aJ pain and vomiting.
45b Single image from an ERCP examination
showing multiple stri ctures with poststenotic
dilatation gi ... ing a beaded appearance.
83
84
Answer 46 Abdominal Imaging
ANSWER 46
Observations (46a)
This plain abdominal radiogr.lph shows a large, ahaustral
viscus arising fi-om the left side of the pelvis :llld
extending into the upper abdolllen. The loop is projected
OWf the left side of pelvis and descending colon with its
apex under the left hcmidiaphragm. The medial walls of
rhe loop form a sumrmuion line. There arc sc\'cral dilated
loops of descending colol1 cvidem with absence of g.ts in
the rectum. The features an: typical of sigmoid volvulus and
there is no frc.c intflpcritoncal gas seen to indic,Hc
pcrfor:uion.
Diagnosis
Sigmoid volvulus.
Differential diagnosis
For brgc bowel obstruction:
Colonic malignancy.
Inflammatory strictures: Crohn's, ischaemia,
divcnicujiris.
Voll'lllus.
Infectious processes; TB, amocbiasis.
Extrinsic lesions: abscqs, bJadder/prostate/merine
endometriosis.
Discussion
Volvulus account for - 10% of Jarge bowel obstructions in
the UK, the most common type being sigmoid volvulus
This occurs more commonl)' in the elderly. The twisting of
the sigmoid colon on its mesenteric axis is USU;\t!y a chronic
problem with supcrimposed acute episodes, and represents
a closed loop obstruction. Radiologically, the features arc
of large bowel obstruction with a markedly dilared loop of
colon seen arising from the left iliac fossa. The I'okulus is
characterized by an ahaustral inverted V-shaped loop of
colon. The media] walls produce a summ;uion line and
together with the lines ofthc lateral walls create the classic
'coffee bean' appearance. Se\'cral radiological features have
been doculllented as typical , though the most specific arc:
Apex of the loop under the left hemidiaphragm.
Inferior convergence of the loop in the left side of the
pelvis - the main axis of the loop therefore eXTends
from left iliac fossa towards right upper quadrant.
'Left flank O\erlap' sign - loop overlaps descending
colon,
Medial wall summation line.
Other features described include 'li\'er ovcrlap' and 'pckic
overlap' signs (where the loop overlaps li\'er and lefT iliac
bone, respectively); apex ofloop above T! 0; an air to fluid
ratio >2: 1.
Diagnostic confusion can be resolved with a barium
enema examinati on. This demonstrates a smooth, Tapered
beak-like end of the barium column termed the 'bini's
beak' sign. Treatment in\'olves the placing ofa rectal!latlls
tube.
Practical tips
Caecal volvul us (46b) can someti mes be a confusing
ditlerential. It represents twisting JUST above the ileocaecal
vake and call usually be differentiated from sigmoid
volvulus bvsc\'eral teatures:
Caecal usually occurs in a younger
group: 30- 50 years
Dilated obstructed caecum often dilates to fill the left
upper quadrant (although in many cases \'ertical
rotation occurs with caecum still filling the right iliac
fossa). The main axis will be opposite that of sigmoid
\'oh'ulus howe\'er, eXTending from the right iliac fossa
towards the left upper quadranL
Some haustral markings arc still el'ident, un!ike
sigmoid \'okulus .
There mav well be small bowel dilatation bUT lhe rcst
of the colon will be undilated, unlike sigmoid
\'okulus,
Further management
Urgent surgical referral with a \'iew to insertion of a !latus
tube to decompress the bowel.
Further reading
Burrel! HC, Baker OM, Wardrop P, EvansAJ ( 1994).
Signiticant plain tilm findings in sigmoid \'olvulus.
CiiJlicnl Rndiolo,9.1' 49 : 317- 319.
46b CaecaLvolvulus with a dilated caecum
extending up into the right upper quadrant. Small
bowel is dilated' secondary to this obstruction but
large bowel is collapsed helping to differentiate
caecal from sigmoid volvulus.
E 47
ry
::; '-car-old female presented with
nal pain and vomiting.
SE 48
ory
38-\'car-old woman underwent
ruSt enhanced CT for further
uarion of a lesion noted
Ulld.
page 88forcnsc answer)
Abdominal Imaging Cases 47, 48
85
86
Answer 47 Abdominal Imaging
ANSWER 47
Observations (47a)
Multiple dilated loops of g3s-fillcd small bowel that
measure morc than 3 em in diameter arc seen within the
central abdomen. No gas is seen within the large bowel and
appearances arc consistent with small bowel obstnlcrion.
Surgical clips arc noted in the right side of pelvis along with
choicc),stcClomy clips in the ri ght upper quad ram.
Adhesions a TC therefore the most likely cause of the
obstnlction.
Di agnosis
Small bowel obstmction from adhesions.
Differential diagnosis
For small bowel obstruction;
Adl1(:sions - account for up to 60% of s1l1:l11 bowel
obstructions.
Hcrni::a.
Gallstone ileus.
Small bowel or caecal malignancy.
Intussusception.
Malrotation and volvulus.
Discussion
Small bowel obstruction can have a varied prcsenr:uion on
plain :abdominal The classical appeaf3nce is of
central abdominal small bowel loops dilated to :>3 em in
diameter with :a paucity of gas in the large bowel. Other
appe:af3nces C:all be of:
'String of beads' sign due to small:airfluid b 'c!s in
fluid filled obstructed loops of small bowel (47b).
Absence of gas in the small bowel due to compleTe
obstruction and complete fluid filling ofJoops (47e).
47b Plain abdominal radiograph
demonstrating the 'string of
beads' sign.
Small bowd can be differemi:ated from large bowcJ using:
the following fe:afUTes:
Presence of"al"ulae conni\'entes which extend :across
the width of the bowel. Colonic haustf3 do not
tran:rse the whole lumen.
Dilated bowc! located in the centf31 abdomen f3ther
than the peripher)' (47d).
Diameter of loops is <5 em.
Absence of solid leees.
Practical tips
Alw:ays check the film to tTy to identify the underl ying:
cause of the obstruction:
Check herni:al orifices at the groin - there should Ix
no bowcJ gas extending below the position of the
inguin'llligamcnt (3 line from public tubercle to
anteriorsuperior ili ac spine ) (47e, 47f, 47g, 47h).
Look for evidence of previous surgery, as in this
Look for air in the biliary tree and radioopaque
gall stOnes outside the TerritOry of the gallbladder as
indicators of gallstOne ileus.
Examine bones for metastatic lesions, which can poim
to malignancy.
Alw:l.)'$ remember ro check for free gas secondary to
perforation!
Further management
CT is the inl'estigation of choice for small bowd
obstruction and it can identify both the site and c:ause 011
obstmction and also the complications. Mcchanical sm
bowel obstmetion is a surgical cmcrgency.
47c Plain abdominal radiograph
demonstrating complete absence of
small bowel gas due to fluid filling.
Abdominal Imaging
47e Axial CT image shows that there has been a
previous attempted hernia repair with a mesh
noted in situ. There has, however. been a
recurrence with dilated bowel going into the
hernia and completely collapsed bowel emerging
from it. This shows that this is the level of
obstruction.
479 Coronal CT ref ormatted image in
the same patient demonstrates a right
sided inguinal hernia.
47h Axial CT image of a patient with small
bowel obstruction.
87
88
Answer 48 Abdominal Imaging
ANSWER 48
Observations (48a)
A l;ngc c(mral mass lesion is demonstraTed in th!.: left
kidney. This is slightly hctcrog..:ncous but hlS 3. prcdomi -
lllmly 6tty density. Appearances arc consistent with left
renal angiomyolipoma.
Diagnosis
Angiomyolipom3.
Discussion
Angiom}"olipoma is a benign lesion containing fur, blood
\'csscls and smooth muscle. They Tend to present in two
groups of patients'
Women in their 4th-7th decades where lesions arise
spontaneously and tend to be iolitary allri I/J/I'/nfcml.
Young paricms wirh TUberous sclerosis II'here lIIultiple
nlld bilateral lesions an: seen in up to 75% of patients
(48b),
They arc also seen rarely in autosomal dominant polycystic
kidney disease (ADPKD) and neurofibromatosis.
Appearance 011 US: typical appearance is of a we!!
ddined edlObright lesion due to a high fin content
(48c). There 'can be a variable degree ofredm:ed
echogenicity depending on the ,unOUlH of smooth
muscle and/or haemorrhage
Appearance on CT: again, appeaT"J.nce is of a weI!
ddined fat -collt:l.ining lesion with some areas of
higher attenuation tissue. Identifi c ltion off.1t (He
<-20) within a renal lesion is highly specific for an
angiol1l)olipoma.
Appearances on ~ I R I : a En suppression sequence CaD
be very liseful in confirming intralesional fu t conrenl
The main complication of these lesions is haemorrhage
the risk is rdated to size. Lesions greater than 4 cm
diameter ha'e a risk of spontaneous bleeding
approximately 50%.
Practical tips
hkntification of f.Jt in a renal lesion is very specific
angiom),olipoma.
Further management
Smail lesions 4 cm) arc usually asymptomatic but I
>4 cm arc almost always sympromatic with pain and ..
of haemorrhage. Lesion resection or nephrectomy s
be consid<:Ted in these patients. Transcatheter art
embolization is;ll1alrernarive.
Abdominal Imaging Case 49
89
90
Answer 49 Abdominal Imaging
ANSWER 49
Observations (49a, 4gb)
The twO CT images (493. ) demonstrate a large, well
defined soft ti ssue mass in the central abdomen. This
displaces 3djaccm bowcl loops and most likely originates in
the mescntery.
The si ngle imlgc (49b) from a double contrast barium
enema examination shows multiple small , well defined
mucosal filli ng defecTS throughoUT the colon consistent
with widespread colonic polyposis. Mul tiple polyps
throughout the colo n suggest an underlyi ng genetic
condition.
Diagnosis
Familial adenomalOus po lyposis ( FAP) wi t h mesenteric
desrnoid tumour.
Discussion
Famil ial adcnomatous polyposis is an autosomal dominant
disease (chromosome 5) characterized by multiple colonic
adenol1latous polyps that inc\'it3bly progress to colorectal
cancer within 20 years of diagnosis. Treatment invoh'es
prophylactic 1000al coleCTomy in carl)' adult life and genetic
screening of r. "lIllil y memocrs from the second decade with
a \'iew to prophylactic surgery. All patients ha\'e colonic
polyps but small bowel and gastric adenomas arc also found
(pcriampullaty cancer is the nltolsr COllllUOtl caliSC o(llcath
once..coltOftlY has-bccl1..pcrfunncd).
Other associated features include:
Desmoid tUlllours.
Mesenteric fibrosis.
Gastric harnano mas.
Hypenrophy of rctinal pigment epithelium.
Gardner and Tun:ol.$),ndrollles arc \'Miants of-fAP.
Gardncr syndrome also includes:
Osteomas of the skull and
Dental abnormalities - dentigerous cySts, odontoma,
hyperce mentollla, supernumerary teet h.
Soft tissue tlImours stich as fibroma, lipoma,
leiom)'oma, neurofibroma.
Epidermal cysts.
Associat ion with lh)'roid canccr.
49b Multiple
polyps.
TurcOt syndromc is FAP with assocbted CNS malignan..-,
stich as medulloblastoma.
Other polyposis conditio ns arc :
Peutz-Jeghers - autosomal dominant (AD)
hamartomatous polyposis condition with features
of mucQeulaneous pigmentation (usually brown
pigmented freckling on the mucous membranes
oflips and gums) and multiple polyps found
prl!dominamly in the stomach and small bowel, \\ith
lew also seen in rhe large bowel. Hamartomas ha\"e
malignant potential but the condition is associated
with all increased risk of lip per Gl tract malignancies..
Complieal'ions of the cOll (lition incl ude:
o\hbbsorprion.
Transient intussusception
Carcinoma of the GI tract.
Carcinoma of breast , pancreas, ovary, endome
and Testes.
Cowden's s\'ndromc - AD condition char.lctcriud
multiple ha;113rtOm:uous polyps, breast and thyroid
mali gnancy and skin lesions.
Cronkhit e-Carmda syndrome - hamanomatous
colonic arc a.ssoci:ltcd with alo(>l!cia., skin
piglllcOI'3.tion and nail atrophy.
Practical t ips
Images should oc carefull y inspected for a coexist
colo nic tumour as well as cxtr:acolonic mali gnan .
Intussusceprion in adults indi cates an underhing.
bowel pathology, whereas in children if can be
idiopathi c.
Further management
Surgical referral is required for prophylact ic cokcr
is referr.tl for genetic screening of rclati\es.
Further reading
Galiatsatos P, Foulkes WD (2006). Familial
adcnOmatOllS polyposis. AmeriCfm jOllrnnl of
Gnstrotllurology 101(2): 385-398.
Abdominal Imaging Cases 50, 51
91
92
Answers 50, 51 Abdominal Imaging
ANSWER 50
Observations (50a)
This single TI weighted coronal image shows a striking
reduction in signal intensity throughout the H"cr
parenchyma. This is likely 10 indicate iron overload. II is
notable t hat the spkcn retains normal signal intensity so
the li\'(:r is most likely due to hacmo-
chromatosis.
Diagnosis
i-Iacmochromarosis.
Discussion
Pri mary hacmochrOlTl3[Qsis is an aurosomal recessive
condition characterized by increased absorption and
ckposition of iron within several organs illCluding [iva,
pancreas, heart and pituitary gland. Patients arc usuall)'
lsymptom:ttic until the 2nd dCC3dc, then they present with
a varied clinical picture due [0 iron deposition in:
Skin - h)'PCrpiglllcllt:ttion.
U\'er - cirrhosis. lu:p:uomegaly.
l)allcrc3S - diabetes.
Heart - arrhythmias. dilated cardiomyopathy.
Ml1sculoskclet31 - arthralgi:t.
Pituira.ry - piruir-J.ry r.,ildrc with signs of impotence,
atrophr. hair loss.
Radiologically, imaging of the abdomen shows marked
abllormality oCthe livcr. Accumulation of iron rcsults in the
liver being of ditl'usel)' reduced signal on ;vIRl. The degree
of iron deposition has been shown to correlate with the
l\oIlU appearances. Uncnh:lIlced CT of the li\'cr
demonstrates increascd :lUenuation ( >75 HU). Follow-up
in these patients is important due to the hepatic
complicati on" of cirrhosis :tnd the ;nc.rc;eed risk. Oh
hepatocellular carcinoma.
Art.hropatAy of haemochromatosis is similar to that of
calcium pyrophosphate deposition disease.
calcinosis is a tcamre. T}VicaJl)', appearances arc of squaring
of the mctacarpal he.lds due TO flatTening and peripheral
small, hook-like SpUTS ( SOb). Osteopenia is also common.
ANSWER 51
Observations (51 a, 51b)
1111:1ges arc control and delayed prone abdominal
radiographs fro111 an [VU series. The control fi lm shows
medi all y located appearance ofbolh kidneys and although
the superior poles of both arc identifiable, inft:rior poles
are not. The delayed IVU image (S ib) shows Illedial
location of the pell'icalyeeal systems, which are anteriorly
orientated. No filling defects arc identified.
Di agnosis
Horseshoe kidney,
Practical tips
l\'l ultiplc transfusions for chronic haematological disordCG
C:lnlead to iron overload, i.e. transfusion siderosis. j\IRJ
wi ll show hypointensity in the liver find spleen in t
condition. This helps diflerenti:lle it from haemo.
eh romatosis where the spleen shows normal signal
MIU.
Further management
In thc course offollow-up, ultl'J.sound monitoring may
useful due to [he high risk of dC\'cloping cirrhosis
hepatocellularcarcin0111a.
SOb Radiograph of both hands shows fl atteni ng of
the 2nd and 3rd metacarpal heads with loss of joint
space, giving a squared appearance. Early spur
formation is seen on the lateral aspect of the 2nd
metacarpal of left hand.
Discussion
This is t he most COlllmon fusion abnormality of
kidneys. It is 1110re cOIll111only found in male patients
has an incidence of I in 300. The kidneys arc joined
tht:ir lower poles in 90% of Ca$CS, by a parcnehymal/fi
isthmus band ( SI c). The long axis of the
medially oricntated with anterior rotation, such th.;n
renal pclvisesi are anteriorly located. Thc condiri
complicated by urinar), stasis with renal stone fornua.
infection and reflux. Vesieoureteric reflux
hydronephrosis sd:ondary to ureteropelvic jlln
obstruction arc common. There is :I reported
Abdominal Imaging Case 52
enec of rCIl::ai adenocarcinoma, transitional cell
m ~ and Wilms' rumour. In :I.ddition the kidnc" is
cptib1c to injury following abdominal traUffi3.
oc kidney is associated with:
ourin:u)' ab'normaJitics: hypospadia,
hidism, urctcr,ll duplication, bicornuate
'Jscular abnormalities .
. al tips
.an IVU, check for filling defeCTs, which could
nt a retl;11 calculus or transi tional cell
- ~ o l d male willI weight loss.
51c Axial CT image demonstrates the horseshoe
kidney with a narrow isthmus of tissue extending
anterior to the aorta and IVC.
93
94
Answer 52 Abdominal Imaging
ANSWER 52
Observations (S2a)
Single AI' radiograph of the abdomen shows a metallic
stem within the (cmtal pel\'is, which presumably lies inlhc
rectum or distal sigmoid colon. [t is likel y thaI Ihis stent
has been inserted to rdicve symptolllS from a (olarectal
1'lI1l1our. The rest of the bowd gas pattern is unremarkable
wi t h no ("vidence of obslnlction.
There arc, however, amorpholl s, poorly marginated
areas of calcification seen in the region of the liver and thc.:sc
likely rcpn:scm calcified liver Illct:mascs. Ultrasound or cr
should be undcrt3kcn, and a contrast cnl13nccd CT (52b)
of this patient docs confirm the presence of calcified liver
Diagnosis
Stcntcd rcct:l[ tumour with calcified liver mctast:tscs.
Differential diagnosis
For calcified [h'cr mctast:J.scs:
Muci nous adenocarcinomas - colon, rectum, ovarian,
brc:l5[ and s[Omach.
Osteosarcoma.
Endocrine pancreatic carcinoma.
Medul lal)' carcinoma ofthr roid.
LUllgcancer.
Discussion
Colorcct:ll carcinoma is the third most COlllmon cancer
diagnosed in the de"eloped world. Rectum and sigmoid arc
the most common si tes of1csions. When' surgical resection
is not possible or appropriate, stems can provide
symptomatic relief and prel'ent obstruction.
The liver is the most common site for metastatic spread
after regional lymph nodes,
Practical tips
As with all radiographs that show e\'idence of likel y
primal)' malignancy. once thi s has been noted, look
carefull y for metastat ic disease elsewhere on the film,
coloreetal cancers metastasize to the li\'er
due [0 the ,"enous drainage of bowel l"i a the portal
\'enous system. Howe\,er, t he \'enOliS drainage of the-
rectum interfuces with the systemic venous drainage- .
the 3nal canal and thus pulmonary metastases are said
10 be more likely in rectal cancer than other colonic
tumours. In reality, pullnonal)' metastases arc nOt :m
uncommon finding in colon or rectal cancer.
Further management
TNi\'1 ( tumour- node- met astases) staging lllust be
accomplished as lor most tumours. Tumour staging
rectal cancer is done with MR.I (52c) (along with loc.ll
nodal staging). The primary reason for MRl is ro as
proximity of nUll our to the llle$Oreetal fuscia - this is thr.
plane along which the surgeon dissects in a [ot"J.imcsorc
excision (TME) procedure. This boundary is rhus referm.
10 as the eireumfercmial resection margin (CRM), Ifloc..
tumour spread extends close to it, the surgical margin Il\.Io
well be contaminated with tumour wi th the attendant .
oflocal recurrence. ldent if)'ing patients where the CR.:\!
threatened in thi s way means they can be selected
preoperati\'e radiotherapy or chemotherapy to reduce r
risk. Di stal nodal disease and metastases can be ass!:
with CT or MRI but if the chest is al so to be imaged
exclude pulmonary metastases, CT is required for 1
component at least.
52c Thin T2 weighted image shows a
circumferential rectallumour with wall breach at
the left anterolateral wall (12-2 o'clock) consistent
with this being a T3 tumour.
SE 53
c ry
35-year-old female presented \ \ ~ t h
inal pain and per rectal bleeding
.3 months.
Abdominal Imaging Case 53
95
96
Answer 53 Abdominal Imaging
ANSWER 53
Observations (53a, 53b)
Plain abdominal film of adult patielll shows marked wall
thickening of the transverse colon wi th thlllllb-printing.
The sigmoid loops show no such abnormalities and the
rc(mlll contains fucccs. The double contr:lSt b:lIium enema
film confirms extensive mucosal ulccrmion and a somewhat
cobblestone "ppcaranee rhat extends from caecum 10 the
descending colon. The colon distal to this is 1l0fllllL The
appearances :Ire in keeping with colitis, and sparing or the
more distal colon makes Crohn's disease morc likely than
ulcerative colilis. It is not:lblc that the sacroiliac joints arc
normal.
Diagnosis
Crohn'sdiscasc.
Differential diagnosis
For [emlina] ileal disease:
TB - uSlIllly has morc severe il\\'olvement of the
caecum ( 53c). Thnc is oHen evidence of pulmonary
TB.
Radiation ileitis.
Ycrsinia.
53c T8 can also affect the bowel and appearances
can mimic those of Crohn's disease. Caecal
involvement with features of stri ctu ring and
ulceration is more common than terminal ileal
involvement.
For thumb printing:
Inflammatol)' colitis - Crohn's, uJccl""Jtive colitis
( UC).
Ischaemiccolitis.
Infectious colitis/pseudomembranous colitis
Divcrticulitis.
Othcr causcs: cndometriosis, am)'loidosis, hereditary
angioncurotic ocdcma, lymphoma.
Discussion
Crohn's disease is a chronic, inflammatory, granulomatOUl
disease that can aflcct any part of thc bowel trona
oesophagus to recrum. Small bowel is most
imolved and the tcrminal ileum is iJwolvcd in ovcr 95%
cases (531). I'rcscnt:ltion is usually in the 2nd-4th decldo
with s)'ml)\ollls uf abdominal pain, diarrhoea, pcr ren
bleeding, weight loss and fearurcs ofmabbsorption
Radiological fcatures arc:
Aphthous ulccrs - shallow ulccrs with surrounding
oedema.
Fissures, and fistulae - Crohn's is the third
most (0111111011 cause offisrulae aftcr idiopathic causa
and di\crticulitis. Thc tistulae can be bctwcen loops
Ner 53 Abdominal Imaging
I, between inflamed bowel loops and otntcr
nal "iscera, c.g. colo\'cskal or from bowel to
tone mucosa - longirudinal and transverse
Sl!'par.ttcd by ocdematous mucosa,
ning of small bowcllolds.
lion of small bowclloops due to inflammation
or:dcmaofwalL
gr:lIl ubrity with < I 111m rounded mucosal
'yps - inflammatory or mucosa.
- often multiple.
Jc:sjons willI discontinuous disease 3TC seen in
of eases.
g fea tures (53e) are dcmollstr:ltcd in this case of
_ male patient who has had a pre\'ious Terminal ileal
C- image shows recurrence of disease in the
ina I ileum post surgical resect ion. There is
bowel wall thickening and oedema with
alery change in the surroundi ng ti ssues.
resection for Crohn's disease. There is noll' recurrence of
disease in the ncotcrminal ileum with features of:
Thickening of the bowel wall.
M3rkcd stranding of the surrounding (,1[ due to
inflammation.
Engorged and dilated mesenteric \'csscls rclerrcd to as
the 'comb sign' due 10 the similarity in appear:lllce to
the teeth of a comb.
Skip lesions with tWO imoked segments shown on this
single axial image.
MR imaging (small bowel emerograph}') fearures arc
demonstrated in Figures 53f- 53i . The fat suppressed
coronal/axial images ( 53f, 53g) show bowd wal l
lhickening in the proximal ileum.
(eOlu. )
53f (coronal ), 53g (axial) fat suppressed images
showing bowel wall thickening of a loop of proximal
ileum. Dynamic images are obtained and viewed in
cine mode to see how this focus of bowel contracts.
97
98
Answer 53 Abdominal Imaging
The pre- :md post-contrast TI weighted corOlll! images
(S3h, 53i) show cnhancmlcnt of an involvc.d loop of small
bowel in the central lower abdomen.
Treatment is both medical and surgical, with a high rate
of fCCllTrcncc cI'cn alter resection (almost 40%), p;'1rticubrly
in the ncotCfminal ileum following distal ileal resections
Practical tips
Terminal ileal involvement, skip lesions and multiple
strictures arc the best signs for Crohn's disease. When
assessing colonic disease, rememocr that UC aimosl
always involves the rectum and has a continuou'
distribmion withom skip lesions. Ho\\"cler, if a UC
patient has had steroid enemas, the rectum may look
nonmtl.
Always look for signs of complications of Crohn's, i.e
adenocarcinoma ( risk increased up to 20-lold),
lymphoma, toxic meg:lcolon, pertoration, abscess,
fistulae.
Always look for signs of extrailltestinal manifestations
53h (pre-contrast), 53i (post-contrast) coronal
images of the colon showing enhancement in the
thickened small bowel loops in the lower abdomen.
of disease all the film. Check lor sacroiliac joint
disease, gallstones, hypcnrophic osteoarthropathy.
Always look for signs of drug rfcatmcnr of disease on
the film. Check femoral heads lor evidence of
;t,,:tscuhr necrosis from steroid trcatmclH.
Further management
Initial diagnosis in suspecTed cases is often confirmed
with a Slllall oo\\'d barium study (iollow through Of
emerod)'sis). Sometimes a more aCUTe presentation
with abdominal pains mal' lcad to the diagnosis fi m
being suggested by CT. Capsule is a !1!:'1
illl"estigationllm Illay also first identify disease. OIKt"
the diagnosis is made, follow-up imaging with MRI
idea}.as this iucurs no rndiation risk oin what afC
trequcntly young patients. CT imaging remains
equally useful, howelcr, when complications stich A
abscess arc suspccll:d.
Trealllll:m includes medical and surgical discipli nes..
SE 55
Dry
'::9-year-old male presented with
ivc d}'sphagia.
Abdominal Imaging Cases 54, 55
99
100
Answers 54, 55 Abdominal Imaging
ANSWER 54
Observations (541
Single image from a double conrr3st barium meal
examination shows multiple, small dense foci ofconlr:J.$t
wit hin t he aIHrulll and bod\' of the slOmach. These are
surrounded by a lucent halo' rcprc.scming oedema. There
is some irregular thickening of the gastric folds, with thc
target lesions appearing to be orientated along these.
Diagnosis
Erosive gastritis.
Different ial diagnosis
For aphthous ulccr:Hion:
Erosi l'C gastritis.
Crohn's di sc;lSC.
Ihriurnprccipiralcancf.ICts .
For gastric fold thickening:
Erosil'c S;lstritis.
Zollinger- Elli son syndrome.
Crohn'sdisease.
Malign:lIlc), - lymphoma, carci noma.
Benign rcani,'e lymphoid hyperplasia,
Mcncuier'sdiseasc,
ANSWER 55
Observations (55)
Si ngle image trom a barium swall ow examination shows a
lesion in the lower oesophagus, just superior to the gastro-
ocsophageal junction, The lesion is well defined with ;1
smooth edge, indenting lhe oesophageal IUlllen, No
ulceration Of infiltration is seen. Appearances suggest a
benign intramural mass, most likely a leiomyoma.
Diagnosis
Lciomroma orthe oesophagus.
Differential diagnosis
For smomh ocsophagel1 mass lesion:
Neurofibroma.
Li poma.
Hacmatoma, e.g. from instmmemation.
Dupl ication q'5t - can simulate an intramur::J.I mass,
Di scussion
This is dIe mOst common benign tumour of the
oesophagus. It is usuall y fou nd in young adul ts, being
slightl y more common in males. Growth is slow and
Discussion
Gastritis often has t his apht hoid appearance ,,;da
":lriolirorm ulcers, consisting or a tin)' dense focus
barium surrounded by a radiolucent halo or oedema
a ;rnrget lesion' appearance. Lesions arc usually multiple.
The lntrum is preferentially affected wit h spread towarQ.
the fundus, lesions appearing (Q be longitudin
oriemated along the rugal rolds,
Causes:
In 50% or cases, no caus.ati,'e abnormality is identi fi
Peptic discasc,
Dmgs - aspirin, NSAIDs, steroids,
Alcohol.
Infenion - herpes simplex, cytomcgalO\'irus (CM\' .
C(mdidn,
Crohn's disease - lI slIall )' there arc signs ofCrohn's
disease in other locations, most commonly the
terminal ileum.
Practi cal tips
On the cont raSt examination look for features in
oesophagus of an infecti,'c cause for the gamic appca
or for oesophageal varices pointing TO alcohol as
undcrlringcause.
Further management
Gastroemerology referral with a ,'iew (Q endoscopy.
presentation is with dysphagia, odynophagia and pos..
haematelllesis.
Radiol ogical features are:
Well defined, large, smooth intramural mass
extending into the oesophageallulllcn.
Forms an obtuse angle wilh lhe adjacent mucosa-
good sign ofa benign lesion.
Usuall), found in the mid and lowef oesophagus,
Calcification is sometimes seen and is vi rruall v
diagnostic si nce it is the only oesophageal
ealcif)' .
Ukerationisrarc.
May be multiple in -3%.
Uniform contraSt enhancement on CT,
Practical tips
Smooth, wdl defined, slow growi ng oesophageal
afC likely 10 be benign.
Further management
Gastroenterology referral \\;th a I';ew to direct ,;su
wi th endoscopy.
Abdominal Imaging Case 56
101
Answer 56 Abdominal Imaging
ANSWER 56
Observations 156a, 56b)
The All postmicturition imlge (56b) from 3n rvu series
shows billteral dilat3tion of the disra.1 ureter with 3 cobra.
held' lppelrlnce. There is a surrounding thick I1llo of
lucency within the bbdder, represcnting oedema. These
3ppeara.nces are of bilatera.l ureterocelcs. The control film
(56a ) demonsnates bilateral calculi in the peh'is that lie
within these ureteroceles.
Diagnosi s
Bilatcra.l ureterocdes.
Differential diagnosis
I:or radiolucent bladder filling defects on lVU:
Ureterocele.
Hiaddertllmour.
Radiolucent calculus.
102
Sloughed renal plpilla.
Gas secondary to fistula, cystitis, idiopathic causes and
trauml.
Island prostate - enl3rged central zone Cln appear as ~
ccntra.l bladder lucency.
Di scussion
A simple or ort horopic ureterocele is a congenira.1 prolapse
of the dist;!l ureter lnd its orifice into the bbddcr. It
usu311y an incidental ti nding in adu\[s and is bilatera.l in
third of C3ses. Figure 56c shows how a ureterocele c
produce l less spedfk type of filling defect when t.b.:.
bladder is full and Figure 56d shows the typical ultra.sound.
3ppelra.nce. The main complication is of obstructi
which can cause collecting system dibtatian and rc
failure. There is also an increased risk of stone forma '
and it is therefore imperative to check the control film
e,"ery patient-as in this case!
56d US image of the bladder s hows protrusi on of
the distal ureter int o the bladder, indi cating that
these are orthotopic ureteroceles and not
pseudoureteroceles.
Abdominal Imaging Case 57
urcrcrocclcs can haxc a similar appearance and
d bv obslrucl;on of:l normal ufetef. Dificrcll-
bcn\:ccn the tWO types can be made using
or oblique films, which show no prmnlsion of
into t he bladder lumen with pscudourc[crocelcs.
of pscudourcfcrocclcs include:
.Jana ahhe distal ureter secondary to impacted
infection,
r tumour (56c:) ,
to check the comrol film of an IVU.
management
I asymptomatic ureterocele Ill;l}' not require
recurrent urinary tract infcnion ( UTI ), calculi,
obsrruct;vc uropathy arc indi cations for surgical
56e Single axial T2 weighted image of the pelvis
shows a pseudoureterocele secondary to a large
bladder tumour.
103
104
Answer 57 Abdominal Imaging
ANSWER 57
Observations 157a)
This frorHa] chest radiograph of an adult patient shows an
added com'ex soft tissue density along the right mediastinal
border and behind the heart. There is no normal gastric
:ti l' bubble beneath the left hcmidiapllf:l.grn. The findings
suggest dilatation of the ocsoph:agus secondary to chronic
distal ohstrunion, most likely due to achalasia. A barium
swallow would confirm.
Diagnosis
Achalasia.
Differential diagnosis
Secondary achalasia due to a stricture at the gastro-
oesophageal junction, There will be normal pcristalsis
however.
Chagas' disease is esselltially the same as achalasia but
the neurenteric plexus damage is due 10 Trypmlosomfl
cYII::.iinfcction.
Discussion
Achalasia is a lllmilily disorder that is idiopathic in
aetiology, characterized br degeneration of Auerbach' s
plexus. This results in a fai lure of relaxation of the caudal
oesoph:lgus at the g:lstro-oesophageal sphincter.
Presentation is with progressivc dysphagia. investi gat:ioe.
is with a contrast swallow examination (57b), which mat"
show featufes of:
'Vigorous achalasia' - multiplc tert iary contractions in
the distal oesophagus Gill be the earliest sign.
'Bird's beak' deformity - symmetrical sLenotic
segment of oesophagus at the gastro-ocsophageal
junction. Imaging the patient erect allows best
demonstration with contraSt forcing its way through
the gastro-oesophageal sphincter when the
hydrostatic pressure of the barium column in the
oesophagus is sufiiciemly high.
l'vlcga-oesophagus - dilatation of the oesophagus ttui
call involve its emire length.
Relaxation ofthe lo\\"er oesophageal sphinCler can be
induced with amyl niTraTe inhalation.
Achabsia is complicated by an increased risk of d e v c l ~
an oesophageal squamous cell carcinoma.
Practical tips
Check lungs for pulmonary changes of previous
aspiration.
Check for evidence of pulmonary metastases from
secondary oesophageal malignancy (or indeed if the
di!:ncd oesophagus is due to a primary malignancy
rather than achalasia).
Further management
The condition is fi.lrther im'estigated with pressure
measurements (manomet!)') and endoscopy.
Treatment is most commonly by pneumatic di latalil:
of the gastro-ocsophageal sphincter. Surgical
mrotomy is considered where there is disease
57b Two images from a barium swall ow
examination show a dilated oesophagus contai
food debris, which 'narrows down to form the
classical ' bird's bea'k' appearance at the gastro-
oesophageal junction.
Abdominal Imaging Case 58
105
106
Answer 58 Abdominal Imaging
ANSWER 58
Observations (58a, 58b, SSc)
Three im;lgcs from an JVU se ries arc provided bur no
control film (which would normally be assessed prior 10
interpretation of the post -contrast films ). [Illages show
uni lateral increasingly dense and persistent ncphrogr:un on
the right'. The right kidney shows uniform smooth
reduction in size when compared to the lefr. There is
delayed excretion of comrasr by t he right kidney on the 10
minute fi lm ( 58e). These appcar:lI1ccs suggest unibtcTll
right renal :trtcry stenosis. The young age of the patient
makes fibromuscuhr dysplasia more likely than
atherosclerosis as the underlying pathology.
Diagnosis
Renal artery stenosis.
Differential diagnosis
For persistent dense ncphrogram:
UnilaTeral:
Obstruction - acute obstruction is the most
common cause of this sign.
Renal artery stenosis/ ischaemia.
Renal vein thrombosis.
Acutc bacterial pyelonephritis.
Acute papillary necrosis.
Bi lateral:
H}'potension/shock.
Aelile tubular necrosis.
Acute glomerulonephritis .
Causes of un ilatera I change involving both kidneys.
Discussion
'Illere arc two main causes of renal artery stenosis:
Atherosclerosis (80- 90%) - usually in the proximal
2 cm of the renal artery; afrects older population >50
years; more common in men; bibteral in one-third.
Fibromuscular dysplasia ( 10-20%) - usually in the
mid and distal renal arter)'; allccts young adults and
.::hildrcn; more common in women; bilateral in two-
thirds.
Less common causes include vasculiti s, arterial dissection
and thromboembolic disease.
Hypertension in neurofibromatosis is a consequence 01
phaeochromocytoma and/ or renal artery stenosis, .11
smooth stenosis seen in proxim:al ren:al :arter)'.
In this p:arielU, a renal angiogram was performed and
showed a smooth n:arrow stenosis in the mid portion of
rhe right rena! artery (58d) and this would be in keeping
with the underl ying diagnosis of fibromuscular dysplasia
of the renal ;lrter'\' .
The of renal artCr)' stenosis is systemic
hypertension as a result of o\'er;lCtivit}, of the renin-
angiotensin system. Treatment is aimed :at medically
controlling hypertension and with renal arter)'
Practical tips
If there is bilateral delayed persistent nephrogram
with absent or decreased excretion, then the patient
t..... needs to be immediatclv checked to ensure that
contrast anaphylactic sh"ock has not occurred.
Magnetic resonance or CT is the
prcli:rred ilwesrig;lti on tor thi s condition in the
moc\ernera.
Further management
Attempted renal arter)' angiography and angioplasry arc
usually
S8d Single image from a renal angiogram showing a
stenosis in the mid portion of the right renal artery.
Abdominal Imaging Case 59
107
108
Answer 59 Abdominal Imaging
ANSWER 59
Observations (59a, 59b)
Single image from a barium follow-through examination
shows smooth thickelled small bowel folds. Selected axial
images from an IV comrast enhanced CT scm of the
abdomen again dcmonsrr.l1cs smooth thickening ofbowcl
folds in dilated loops offluid-fillcd small bowel. In addition,
there is thrombus seen in the mid superior mesenteric vcill.
Diagnosis
Small bowel ischaemia secondary to superior mesenteric
vein (SMV) thrombosis.
Differential diagnosis
For smooth thickened folds'
Haemorrhage.
Ischaemia:
Acute - embolus, Hcnoch-Schonlcin purpura
( HSP).
Chronic - vasculitis, thromboangiitis obliterans,
radiother.lPY
Oedema
cirrhosis, nephrotic syndrome,
protein-losing enteropathy.
Angioneurotic oedem,\.
Lymphatic obstruction lymphoma, mesenn:ric
fibrosis, intestinallymphangiecrasia.
Discussion
Small bowel/mesenteric ischaemia can present very acutdy
with symptoms of acute abdominal pain, ,'omiling,
diarrhoea and recral blecding. This is usually due ro arterial
thrombus, dissection or acute ,"enous Obstruction. Chronic
ischaemia usually due to chronic arterial thrombus has a
more indolent symptomatology with longstandi ng
grumbling abdominal cramps, postprandial pain, wei ght
loss and malabsorption. Other causes of ischaemia include
\"asculitis, bowel obstruction, radiotherapy and aCUle:
abdominal inflammation, e.g. pancreatitis, appendicitis.
Radiologi cal features of acure small bowel ischaema
include:
Bowel \\'all thickening/oedema.
Enhancement pattern of the bowel wall can be
incre3sed or decreased (5ge).
Stranding of the surrounding f.1L
Pneuillatosis intestinal is, which is a late sign and
indicati\'e of necrotic bowel.
Free imra-abdominal gas due to perforation of
necrosed bowel.
Portal venous gas is seen in preillorbid patients.
In chronic ischacmia, there call be additional complicati
of strictures (which tend to be long, smooth a
symmetrical), ulceration and atrophic valvulae connivenro.
The splenic flexure and the proximal descending colon
most cOlllmonly affected due to the transition fr
superior to inferior mesenteric arterial suppl y at this poiIIL
Practical tips
Look careftilly for linear gas shadows within the
bowel wall indi cative ofinrramllfal gas.
Portal vein gas is usually seen in the pcriphery of the
liYcr as well as centrally, in contrast to biliary gas,
which is usually only central. This is a prcmorbid sip
in adults.
Further management
hll'cstigation with CT C:tll both diagnose and
complications of ischaemia.
59c Axial CT image of the abdomen shows
dilated fluid-fi ll ed loops of non-enhancing
ischaemic small bowel.
SE 61
- tory
57 -year-old m:alc prcscillcd with
'Cr abdomi nal pain.
Abdominal Imaging
Cases 60, 61
109
110
Answers 60, 61 Abdominal Imaging
ANSWER 60
Observations (60)
Single oblique radiograph of the pelvis from an IVU shows
a small, shrunken, spastic trabeculated bladder with
multiple diverticula, with a superiorly pointed dome. This
is the so called 'pinc trce' appearance of a neurogenic
bladder.
Diagnosis
Neurogenic bladder.
Differential diagnosis
For Slllall bladder:
Infection - schistosoilliasis/TB.
Iatrogenic - postsurgery/ radiotherapy.
Neurogenic.
Transitional cell carcinoma (TCC) - awmilletric
bladder contraction with thick wall and filling defects.
Extrinsic compression - usually gi\'es a pear shaped
bladder appearunee.
ANSWER 61
Observations (61)
Single image from a barium enema examination
demonstrates a well defined, Sillooth, eccentric filling deft."(;t
in the distal sigmoid colon. This appears to be extraluminal
in origin and lies on the mesenteric aspect of the bowcl A
similar lesion is seen in the pouch of Douglas. Multiple
lesions centred in an intrJperitone3110carion suggest the
diagnosis ofimraperitone31 metaS[3Ses.
Diagnosis
Colonic mctastascs.
Discussion
Tumours to the mesentcry via four rolltcs:
Direct invasion along thc mesenteric \'essels and fut -
scen wi th gastric, pancreatic, colonic and biliary
cancers; 40% of patients with adenocarcinoma of the
pancreas have tumour cxtending along the mcscntcric
root at diagnosis
Extension mesenteric 1}'mph3tics - colonic,
ovarian, breast, lung, c3rcinoid and melanoma cancers
C3n spread to mesenteric lymph nodes, though
lymphomJ is morc common.
Haematogenolls spread - commonly from melanoma,
hrCJS! :lild lung prim3ries, met3st'3ses invoke lhe
anti mesenteric bordcr of the bowd via sm311 arteries.
They can act as the lead point tor intussusception. Up
to 7.5% ofmehnoma paticnts show st1l311 bowel
involvcment
Discussion
Bladder innervation is by the parasympathetic nervC$
52-54. Injury to these nerves causes denervation oftbc
detrusor muscle, giving this appearance of a shrunken.
heavily trabeculated bladder, with an irregular thicken
wall and multiple diverticula. Causes include:
Congenital anomalies - myelomeningocele, spina
bifida.
Spin:!1 trauilla.
Diabetes mellitus.
Infection - syphilis, herpes.
.Spinal neoplasm
Practical tips
Inspect IVU films carefully to look for asp'
abnormality, which can help to determine the
cause of the bladder abnormality.
Further management
In the absence of an easily identifiable cause, lumbo
spine MIU can be useful.
Intraperitoneal seeding - brc:lst, 0\'3rian, panctc:lOi:
and gastric tumours arc the most common primaries
responsible for intraperitone31 'drop' seeding. "Thot
lesions involve the mesenteric borders. Appcaranas
arc of a focal mass or ditfuse stellate appearance 011
CT, but on double contrast barium im3ging,
Jppcarances arc of a foc31 extrinsic indentation of
bowel. This involves the pouch of Dougl3s (50'\
commonly the superior/anterior border of the
sigmoid. Thc distal ileum and mediJI border ofd:.:
caecum arc also often invoked
Practical tips
The most common underlying calise lor
malignant diseJse is ovarian cancer.
Further management
Clinical review of patient to tty and loc3lize a likely
tumour. CT sC3nning will confirm peritone31
Illay well reycal the primary tumour.
Further reading
Shcth S, Horton KNt, Garland [\tR, Fishman EK _
l'vlcsenteric neopl3sms; CT appe3rances of priffiX"l
and secondary tumors and diffcrcntial
RndioGmphics 23: 457-473.
SE 62
ory
46-year-old Icmalc , recentl y
ted to the UK from Africa,
- med with symptoms of urinary
ncy and urgency.
E 63
ry
diabetic presented with
and abdominal pain.
Abdominal Imaging Cases 62, 63
111
11 2
Answer 62 Abdominal Imaging
ANSWER 62
Observations (62a)
This single coned view of the pekis shows curvilinear wall
calcifi catio n of a relatively normal capaci ty bladder, No
calcifiGlrion of the lower ureter.; is seen. No discontinuity in
thc calcifi cation is.scen.
TIle history of residence in Africa raises the possibilities
of bladder TB and schistOsomiasis. The absence of gross
bladder contraction makes the laner more likcl}" but it
would also be helpful to re,;ew a full length alxlominal film
Practical tips
Schistosomiasis il1\'ol\'("s bbdder and lower ureters
and results in a calcified, nonshrunken bladder. Tn
involves rhe kidneys and spreads via the ureters ro
involve rhe bl:ldder. It is very unusual to have isolated
bladder involvcment with TB and the degree of
bladder contraction is more marked than in
schistosomi:lsis
Transitional cell ::r
Discontinuity of calcitic at ion in the bladder wall
should arouse suspicion of bladder cancer,
Diagnosis
SchistOsomiasis.
Different ial diagnosi s
For calcified bladder wall:
Cancer - prirnaril}' transitional cdl carcinoma (TCC)
but also other rarer bladder tlImour.;.
Radi otherapy.
Inlection - Tn and schistosomiasis.
, . . .
SChlstOSOlmaSIS IS one of the mOSt common paraslilc
infcctions, affecting 8% of the global population.
Schistosolllff l)(Illllntobi lllll is the female parasitc whi ch
aflccts the genitourinary system. Unlike TB, which tends
to affect thc kidneys first and then spreads caudally,
schistosomiasis has a re,'erse involvement and uSlIall}' is
confined to bladder and lower ureters. (Another case of
bladder schi stOsomiasis [62b] is shown - note the absence
of upper tract calci fication that one might sec in TB.)
Classically, the patient presents wi th urinary frequenc)"
urgency and dysuria. Imaging findings arc of:
Calcification of the bladder - which results in reduced
bladder filling capaci ty and increased posnnicturi tion
residual volume.
Calcitlcation of the lower uret ers.
Lower ureteric strictures.
Ureteritiscystica.
Complications of disease aAccting the genitourinary system
incl ude:
Cystitis.
Vesicourelerie reflux and subsequent pyelonephritis.
Increased risk of squamous cell carci noma of the
bladder.
Other systems can be affected:
Li\'er - oval mi gration results in portal hypertension
and subsequent oesophageal varices.
Respiratory system - diffuse granulomatous lung
lesions.
Further management
Followup in these patients is required since the latency fw
development of squamous cel l carcinoma of the bladder
can be lip to 30- 35 rears.
62b Calcification of the bladder is seen in
schistosomiasis wi th absence of upper tract
calcification to help differentiate from TB.
Abdominal Imaging Case 64
R 63
tions (63)
biominal radiograph demonstrates gas within the
~ . i l y c c a l system and upper ureter. No intra-
a1 renal gas is seen. No gas is seen in the right
or in the bladder.
_ nie - uri nary diversion procedures .
.' tract fistula to bowel due to innalllillation,
Crohn's, diverticulitis or spreadi ng malignancy.
mamU5 pyelitis is a condition in which infective
produce gas, which is confined within the renal
:cc,aI system. In emphysematous pyelonephritis, gas
\\ithin the renal parenchyma - a lifcthrcatcnirrg
JII'l that requi res prompt di:agnosis and tn:amlcnt.
E 64
;uold female presented with
lIUlCty and epigastric pain.
There is an increased incidence of these conditions in
patients with diabetes mellitus and women arc three times
more: cOlllmonly affected than men. Esc/)ericbia coli is the
causative organism in 70% of cascs with Klehsiell", Proteus,
Candida and PseudomOllflsorganisms also being found. In
emphysematous pyelonephritis, small gas bubbles arc
initially seen on plain radiographs in\"ol\'ing lhe renal
parenchyma; this progresses to give a di ffuse mottling in
morc ad,'anced disease and then progresses to produce a
crescent of perinephric gas when there is extension into
the perirenal fill.
Practical tips
CT is the best imaging modality for assessing extent and
location of gas.
Further management
Depends on ca use but obviously infective causes require
prompt, appropriate antibiotic treatment.
Further reading
Joseph RC, Amendola MA, Artze ME, et al. (1996 ).
Genitourinary tract gas: imaging evaluation.
RadioGrapbies 16: 295-308.
113
11 4
Answer 64 Abdominal Imaging
ANSWER 64
Observations (64a)
Single image from :t double contrast barium meal
cx:ulIi nati on shows :t lI'ell defined smooth walled ovoid
mass lesion in l he gastric JllIfIlm. A central smooth ulcer
is present and no calcification is seen.
Diagnosis
Leiomyoma of the stomlcn.
Differential diagnosis
Fortargc! lesions:
Ncurofibrolll3.
Lipoma (64b).
Ectopic pancreatic rest.
MCl'3stascs - cOlll mon ly breast, IUll g, renal and
mali gnant melanoma.
Hacm3ngioma
Di scussion
This is the second mOST common benign gastric tumour
after gastric Ukc ocsophagcallciomyoma, these aTC
slow growing lesions and arc usually asymptomatic umil
they incn:asc in size, when there may be epigastric p:lin and.
bleedi ng. The gastric antrum and pylorus arc l he m
common si tes "flected. The majority of these lesio
extend imraluminally (60%) and form well defi ned 0\'
defects. They arc more likely ('Q ulcerate than ocsophag
leiomyoma with ulcerat ion scen in up to 50%. Calcifica .
is rare.
Complications include:
Bleeding.
Obstmction.
Intussusception - tumour can act as a lead point.
Malignant degeneration - in up to 15-20% m
cases.
Practical tips
Smooth, well defined, slow growing gastric lesions
likely to be benign.
Further management
Although radiological appcarances suggest this to be
benign lesion, referral for +/- biopsy should
made.
64b Axi al CT image demonstrating a well defined,
smooth, rounded lesion in the stomach, which has
clearly the same attenuation as intra/extraabominal
fat. This has appearances of a gastric lipoma.
Abdominal Imaging Cases 65, 66
IJ8jorcnsenllsUler)
11 5
11 6
Answer 65 Abdominal Imaging
ANSWER 65
Observations (65a)
Single image from a double contrast bariulll enema
exami nation shows :abnormalitv of the colon that extends
from the rectum [0 the mid rrans\'crsc colon. There aTe
(C3IUTes ofJuminal narrowing with mucosal irregularity,
granulari t y ;1 11(\ shallow ukcr:ltion. The disease process
appears cOll tinuous along the 3.flcctcd segment's with no
fil rthcr lesions seen. Noml:!l appearances of the ikocacc:L1
region. Normal sacroiliac joints. T hc appearanccs arc in
keeping with a colitis, most likely ulccrntive colitis.
Diagnosi s
Ulcc:rnti,'c colitis ( UC).
Di scussion
Ulcerat ivc coli ti s is an idiopathic bowel
disease \Iith invokemcnt predominamly of the mucosa and
su bmucosa or thc l:t rge bowel. There arc tWO peaks of
prcscntltion - 3rd-5th dccades and 7th- 8th dccldes. The
most commo n presentation is with blood)' diarrhoel and
abdominal plin.
The rectum is almost always involved (96% of cases)
with continuous, and of
the colon more proxlillally. The tcrmlllalrku1l1 IS 111I"01\'ed
in 10- 25% due 10 backwash ileitis. In acute infl ammation
there arc findings of:
65b Single axial CT image shows continuous
thickening of the colonic wall invol ving sigmOid
colon. The surrounding fat is 'dirty' !i ncreased
attenuation) due to inflammatory change.
Appearances are of an acute active colitis though
the appearances here are not specifi c for an
underlying cause.
of bowd W:I!l (65b).
Significant bowel wall thickening can 1c3d to tht:
classical 'thumb-printing' appearance.
Widening ar t hc presacral space.
Fine ll1uc<>S.11 granularity.
Superficial ulceration.
I'scudopolyps - islands of oedematous mucosa.
Collar button ulcers (65c).
Appcal'Jnces in the chronic stage:
Colon becomes ri gid with llllllinainarrowing due [(
chronic inilamm:ltion, and loss or haustrations -
'le3clpipc' colon.
Coorsc grnnul:tr mucosa.
Inflam1l13tory polyps.
Ibck\\'ashilcitis.
Abdominal Imaging
n is complicated by:
n from toxic in 5- 10% - thc
..:ommon cause of death (65d).
.ldCIlOCarcinQm3 - this complicates Lip to 5%
with risk highest when there is
or onsct at a young age( <15 years) and
\\;th chronicity of disease. The rectosigmoid
'TIOSI common location for ncopbstic
[lOtlJlion.
strictures - usually a single, shon, smomh
is found, most cOlllmonly in the
si gmoid.
.lS with Crohn's disease, there arc a variety of
..u.: complications which include iritis, pyoderma
chronic acrivc hepatitis, sclerosing
and seronegative arrhriti s ( Figure 65c
;l Ies s;lcl'oiliiris with carly sclerosis of both
oi nts).
I tips
riJtion ofCrohn's from UC is often possible
the imaging tindings:
thn' s characteristically has multiple, eccent ric,
transmur:ll , skip lesions; preferential in\'ol\'ement
of terminal ileum. FiStulae and deep ulcers afe
common features .
UC characteristicall \' has a continuous, concentric,
symmetric i1l\'ol\,eniclH that eXl'ends proximally
from the rectum :lIld only occasionally ilwokes the
terminal ileum. Fistulae, fissures and deep
ulceration arc nOt fcatures.
Remember that although the recnUll is always
involved in UC, it Illa}, appear spared if steroid
enemas have been used.
Look for intestinal complicJtions of UC incl uding
malignancy, toxic megacolon, pneumatosis intestinal is
and perforation .
Look for exrJ";li mestinal complicat ions of UC such as
sacroiliitis.
Look lor compl ications oftreaUllellt, e,g. steroids
causing avascular Ilecrosis (AVN) Of osteoporosis.
Further management
A combined medical/surgical approach to disease !lIanage
ment should be taken.
117
118
Answer 66 Abdominal Imaging
ANSWER 66
Observations (66a)
Single image from a double contrast barium examination
is shown. There arc multiple slIb1l1LlCOS:l ] lesions seell
scattered throughout the (olon with no regional
predominance. Close inspection shows that these aTC due
to gas-filled cysts in the bowel wall. No free intra-
abdominal gas is seell to suggesT perforation. No linear gas
collections ;\rc seen. No portal vein gas is seell.
Diagnosi s
Pnc1I1l1arosis cysroi(ics intcstinalis.
Discussion
Pneumatosis cystoidcs imcsrillalis is usually a benign
condiriori of middle aged people who tend to be
asymptomatic but elll present with symptoms of vaguc
abdominal pain, diarrhoea and lllUCOUS discharge.
R.adiological findings arc of multi pic small \ - 5 mm gas
ti ll ed cysts in a subserosal!sublllucosal distribution. They
are more cOlllmonly found on t he mescnteric rather than
anti mesenteric sidc of the colon. The cysts can rupturc
leading to pneumoperitoneum but with no symptorm
peritonitis. This cystic pneumatosis is usually a bem_
innocuolls condition and is associated with ch
obstructivc pulmonary disease, perhaps dl,le to air t
from ruptured alvcoli and along the mescntery \"i.l
retropcritoncum. There is also an association with m
disruption elsewherc in . the GI tract, e.g. peptic
disease
Practical tips
Air in tht: bowel wall due to infarction typically
more linear (66b) and may be associated with
gas in pre morbid cases.
Further management
Pncumatosis of the colon is usuallv not <i" '''''',,,' ..........
- the importance here is to trcat the patielll,
Further reading
Pear BL ( \998). Pnnllllatosis intcstinalis: :l review.
/{nnio/Qgy 207: 13- 19.
66b Abdominal radiograph shows linear gas
opacity withi n the wall of the transverse coler
a pati ent with ul cerati ve colitis.
Abdominal Imaging Cases 67, 68
119
120
Answers 67, 68 Abdominal Imaging
ANSWER 67
Observations (67)
Selected 'in and ou[ ofphasc' T1 weighted axial images of
the abdomen arc provided, the ou[ ofphasc image lying to
the right. There is enlargement of tile left adrenal gland
which appears of intermediate signal imcllsiry all Tl in
phase and shows signal 'drop out' 011 the TI Out of phase
image. Appearances on this chemical shift MRl art:
consistent with fatty content and indicative of a benign
adenoma.
Diagnosis
Adrenal adenoma.
Discussion
Adrcnal1csions arc found in - 9% ohhe general population.
Adrenal ldenomas arc the most common adrenal lesiol1.
Imaging feamres can be used to ditTcrcntiatc benign
adenomas from primary malignant (carcinoma, phaeo-
chromocytoma) or metastatic adrenal lesions.
Imaging features for differentiation of an adenoma from
metastasis are:
Adenomas are mostly <2.5 em in size; lesions >4 em in
likely to be or adrenal
Lesions showing no growth over 6 months arc usually
benign.
On unenhanced cr - adenomas often contain
intracellular f.1t", lowering the overall density on CT.
When <10 Hounsficld units (HU), this is highly
specific for adenoma (96% specificity). Some
adenomas contain less fat and so a lesion with H U
> I 0 may represent adenoma or malignant lesion.
On IV contrast enhanced cr - both adenomas and
metaStases enhance, but adenomas washoUT more
rapidly. After a plain scan, acquire postcomrast scans
at 60 s (early) and 10 min (ddayed).
ANSWER 68
Observations (68)
Single image from an JVU study is provided without a
control film. It shows renal ectopia with both kidneys being
located on the right side. This is crossed fused renal ectopia.
There is no associated hydronephrosis.
Diagnosis
Crossed fused renal ectopia.
Discussion
Crossed renal ectopia involves a kidney being located on
the opposite side ofthe midline from its ureteral orifice. It
is more common for the left kidne}' to have migrated to the
right , with the crossed kidney lying inferior to the normal
kidney. Usually the kidneys are fused and arc associated
with aberrant renal ancries.
(
early-delayed )
% washOllt .. x 100
carly-ullcnhanced
Washout >60% has sensitivity and specificity - 9m.
the diagnosis of adenoma.
On chemical shift M JU - signal drop Oul on the OIl[
of phase imaging is seen with adenomas. Lesions
without significant intracellular fut (e.g. metastases
don't show any signal difference on in/our of phase:
imaging. The sensitivity and specificity arc similar
if nOt bener than, those of cOntrast enhanced CT.
PET may be useful when CT and M lU fail to
characterize an adrenal mass. Mali gnant lesions s
increased uptake of FDG ( 18 fhroro-2-deoxyglue
(>Ii,'er activity) while benign lesions do not (<li\er
activity).
Practical tips
An incidcmal enlarged adrenal picked up on US/ CT
should be further irwestigated with a chest radiograpit.
look for a lung neoplasm.
Further management
Adrenal adenoma should be followed up after 6 m
Lesions that grow by over I ern in this time or those
measure over 4 ern should be considered for su
Hormonally active lesions may also be considered
surgery.
Further reading
Mayo-Smith WW, Boland GW, Nota RB, Lee MJ
(2001 ). State-of-the-art adrenal imaging.
RndioGrnplJics 21: 995- 1012
It is associated with:
Renal calculi.
Infection
Reflux.
Megaureter.
Cryptorchidism.
Urethral valves.
Multi cystic dysplasia
Practical tips
Try to identify complications of the condition such as
scarring from recurrent infections, or hydronephrosis
to obstnrction from stones/urethral valves.
Further management
No active management is required.
fC1ll::J.1c prcscnlcd with
Sfc::J.torrhoc::J. for 12 months.
ur-old 1l1::J.Ic W::J.$ involvcd in ::J.
accident.
Abdominal Imaging
Cases 69, 70
121
122
Answers 69, 70 Abdominal Imaging
ANSWER 69
Observations (69)
Single image from a small bowel enema examination is
shown. The tip of the small bowd enema catheter is seen
in the proximal duodenum. The examination dcmonstfltcs
a reversal of fold pattern with an increased Ilumbcroffolds
seell ill The ileum and a reduction in the number of smalJ
bowel folds seen in the proximal jejunum. These features
suggest malabsorption in dlC proximal s111311 bowel such as
coeliac disease.
Diagnosis
Cocli3cdiscasc.
Discussion
Coeliac disease is a gluten-sensitive clltt:fopathy
charaClt::rized histologically by villous atrophy. The
duodenum and jejunum arc afl:ectcd more than the ileum
because some proximal gluten digestion means that less
reaches t he disul small bowel. It classically presents with
steatorrhoea and diarrhoea, but more commonly presellts
in less specific ways such as fatigue, weight loss and
abdominal pain. Malabsorption can also n::sult in anaemia,
osteomalacia, neuropathy and oedema. Age at presentation
call vary from early childhood to late middle age.
lmagiog features of coeliac disease include
Smlll bowd dilatation (due to reduced motility) is the
most common imaging finding.
Reduced number of folds in the jejunum.
'Jejunalization' of the ileum - an increased number of
ileal folds. This is a response to the reduced mucosal
arca in thcjcjullum.
ANSWER 70
Observations PO)
Single image from an IVU series shows contrast in the
collecting systcms and in the bladder. The bladde.r has an
abnomlal elongated configuration eXTcnding up om ohhe
pelvis. There arc bilateral pelvic fractures through the
acetabulum. No free COl11rast is seen leaking from the
bladder.
Diagnosis
Pe;lr shaped urinary bladder secondary to pelvic
hlematoma.
Differential diagnosis
For pear shalX'd bladdcr ( mnemonic - 'HELP' ):
}-hematoma
External iliac artery aneurysms.
Lymphadenopathy.
Pelvic lipomatosis.
'Moulage' sign - dilated smalJ bowel loops with
d&ccmcnt, particularly in the jejunum and
duodenum.
T ransicm intussusception - the cause of abdom'
pains.
Floccubtion of the barium contrast due to
Autoantibodies (e.g. antiendom),sial )
but diagnosis is made by demonstration
on jejunal biopsy. This abnormality
remo\ed from the diet and recurs when it is
condition is complicated by an inerea!iCd .risk
adenocarcinoma of the small bowel,
carcinoma and pharyngeal carcinoma) (;1
Practical tips
Folds in the jejunum arc normally thicker and
numerous than the ileum. Expect to sec seven fi
per inch in the jejunum lnd thrce to tour folds I:G
inch in the ileum. A reversal of this pattern shaul..
raise suspicion of coeliac disease.
If the radiological features deteriorate while on J
glutcn-frce diet, raise the possibility Ii
such aslymphoml
Further management
Confirmation of diagnosis is made with
bowel biopsy.
Practical tips
Look for an underlying cause lor the abnormal
bladder lppearance - pclvic fractures, i
calcification in the walls of aneurysms, i
ch;\nges in bone/small bowel to suggest un
malignancy and l)'mphadcnopathy.
Further management
Further treatment will depend on the underlying
this is a secondary finding pointing towards an
problem.
Abdominal Imaging Case 71
E 71
'"
rear-old ICl1lllc with 3.n incidental
kgon deteCTed on ul t rJsound.
71 a T2 weighted MRI scans wi th a normal and extended TE.
11b T1 weighted scans, in and out of phase.
123
124
Answer 71 Abdominal Imaging
ANSWER 71
Observations (71a, 71b, 71c)
T2 weighted im:ages demonstJ"3.te :a well defined, sligluly
lobulated m:ass in the right lobe of liver, which is of
increased signal on dIe normal T2 and UI[r.I-T2 weighted
seans (7 13). This is the so-c:llled 'light bulb' sign. Axi:ll TI
weighted images (7 Ib) show thc lesion to be of reduced
sign:al wit h no signal change in the Jj\er on out of ph:asc
sc:allS to indicate that the lesion represents focal t:-arty
sparing. D}'namic post-contrast images (7 1c) show
peripheral nodular enhancement with centripetal filling in
o\er time. These appearances arc diagnostic of cavernous
haemangioma.
Diagnosis
Cavcrnous haem:tngiom:l.
Differential diagnosis
For hn>erechoic hepatic lesions on US:
Haemangioma.
Focal nodular hypcrpl:asia (FNH).
!\dcnollla.
t\' \craSt:isis.
Hep:atocell ular carcinolna.
Lipom:l.
Discussion
Hepatic haemangioma is the most common benign tumour
of tile liver, anccting up to 20% oCthe population.
:arc usually :asymptom:atic, being incidental findings 011
imaging studies, however large lesions c:an present with
:acure haemorrhage and abdominal pain; 90% arc solitary
and 90% measure less than 4 em in diameter. Mul
hacm:lIlgiorna may be associated ,\;th OsIcr-Wcbcr-
syndrome. Some enlargement can be seen du
pregnancy.
Imaging findings on ultrasound: well defined,
uniform, lesion is the Iypical ulmsou
3ppcar:lI1cc (71d). No Doppler signal is seen widUl'
the lesion due [Q the low-,"c!ocity flow (7 1c). La
lesions (;lll appear hn>occhoic and show flow
ho\\'c,cr.
Imaging findings all cr: lobubtcd lowattcl1uati
lesion, which is frequently peripheral in location.
Calcification is not common. Following comr.m
injection, there is peripheral nodubr cnhancelllcm
with centripetal tilling. The lesion lIsuallj' fills in
completely o\'(:r 3-30 min to become isodcnsc \\;
II\'cr, though larger lesions show persisting
central noncnhanccmcnt/ scar and small lesions Il\lII
show immediate unitoml enhancement.
Inllging findings on haem:lIlgiomas show
signal on T2 weighted images [hat persist on mort"
heavily T2 weighted scans. This is called the 'light
bulb' sign and is indicative of cyst or haemangior-.
The enhancemelU pattern with gadolinium is as
described lor CT.
Imaging sulphm colloid lItan: cold
Usually imaging is sufliciclit to make thc di agnosi.)
where :uypical features :afe present, biopsy CnI
undertaken prO\ided therc is normal livcr between
lesion and li\cr capsule to pre\ent haemorrhage.
71 Abdominal Imaging Case 72
tips
the illvcstig;ltion archaicc 10 characterize
:ted hlcm:mgioma. A positive ' \ight bulb' sign
cs that the lesion is either a cyst or a
gioma. However, depending on the specific
allccS,I)()SI-contraSI SGI1lS rnaysti11 be
iraj as necrotic or cystic neoplasms can yield a
"t' ' light bulb' sign.
)If TV CQnlr.IS( - obtlin pre -conTrast scans, then
. n 30 s (arrcrial phase ), 60 s (ponal phase ) and
min (equilibrium ph:lsc ).
centripetal enhancement is intense and nodular,
h i ~ h J y specific for the di:lgnosis of
gl01113.
Further management
These arc essentially benign lesions and don't require any
furrhcr follow-up.
Further reading
VihnO\'3 Je, Bl fccl6 J, Smimiotopoulos }G, ct fli.
(2004). Hemangioma from head [0 toc: MR imaging
WiTh pathologic correlation. RadioGraphies 24:
367- 385 .
125
Answer 72 Abdominal Imaging
ANSWER 72
Observations (72a, 72b, 72c, 72d)
Several axial cr images of the abdomen with IV contraSt
cnhancctm:nt in the portal venous phase arc shown. There
is significant stranding of the fat indicatil'e
ofacutc inflammation, which is prcdominamly around the
pancrc:Hic tail. \Virhill the pancreatic tail , there is a
moderate sized fluid-filled C)'stic lesion, which would be
consistent with a pancreatic pseudocyst in a patient with
pancreatitis. The local inflammatory change appears to
extend to involn! the distal transvcrsc colon at the splenic
f1exurc. In addition, there is central low atlclU13tion within
the panal ,'ein extending into the proximal spleni c vein in
\ ,.,' 'r' keeping with I.'Ortaljsplcnic vein thrombosis. The
1 pancreatic duct IS dilated al 4 mOl diameter. While the
whole b"<l llbladdcr h.\s not been im<lged - no g<lllsrones <Ire
seen on Ihese im<lges. The visualized liver edge is smooth
and liver has normal attenuation.
\\
126
Di agnosis
Pancreatitis.
Di scussi on
Pancreatitis is an aCllte inflatnmatorv condition. There arc
tWO main types of pancreatitis - oe<icmatOus and necrotic.
Oedem<ltous pancreatitis is the much morc common form,
eh;lr;ICtcrized by gland oedema, whereas necrotic panerea
t:itis is rarer and is compliclted b)' pancreatic haemorrh<lge
and necrosis.
Appearances of the panercas in pancreatitis can therefore
be variable, wi th the pancreas appearing normal, having
areas of nonenhancemcnt due to necrosis, ha"ing areas of
increased attenuation due to haemorrhage, or appearing
enlarged and oedematous. Uni versally, Streaking into the
surrounding fut due ro inflammation is obselyed.
Causes of pancreatitis include:
Alcoholism and g:lllstones :Ire the two most common
c:luses of acute pancreatitis. Assess for signs of alcohol
excess by looking for funy change in the li\'er (ditlilsc
low attenuation on cr, raised echogenicity on US),
cirrhosis (irregular nodular surfuce to the Ih'er whi ch is
atrophic ) and portal hypertension (splenomegaly and
varices). Assess for gallstones with US initially, then
Mltep ifthere is still uncertainty.
Infections - hepatitis, IllUlllpS.
Trnuma.
Hypercalcaemia from multiple myeloma, sarcoidosis,
:lmyloidosis.
Drugs, e.g. steroids, diuretics (fruscmide, thiazides),
azathioprine.
Malignancy.
P,Hlcrearitis can be complicated by pseudocyst formation;
abscess formation (usuall y develops 2 weeks after acute
infl:J.mlllarion onset); spread of local inflammation to
in\'olvc bowel loops resulting in strictures, colitis and
pe rforation; portal ,"ei n, splenic \'cin, Sl-'IV thrombosis;
ascites and chest complications - pleural effusion (usually
kft sided), empyema, unilateral pulmormry oedema.
In chronic pancrc:uitis (following sc\'CrJl bouts of 3(
episodes ), the pancreas becomes atrophic, there
llluldtOcal calcificltion, the pancreatic duct becomes dilJt
and chronic pscudocysts can form (72c).
Practical tips
Look for the two main C:lUSCS ofpancre:ltitis - alco'"
and gallstones. US is required to look for b"<lllstoncs
and can be used to look for complications, e.g.
pseudocyst formatioll and portal "cin thrombosis.
Look for the maill complications of pancreatitis .
Assessing the pancreas is beSt done by three phase
irn:lging \\'ith a pre('ontT:lSt and 'pancrcatie' phase
s) scan of the pancreas, followed by portal
venous phase scans of the abdomen and pelvis. The:
precontrast scan will allow lor assessment of
calcification in the pancreas to determine whether
is an acuteonchronic episode. Pancreatic phase sc
best assess for areas of necrosis and tixal mass ksi
Portal "enous imaging allo\\'s for assessment oflOQ(
disease and compli cations.
Further management
Treatment is usually conservati ve although necrori
pancreatitis may well need more aggressive manage
involving surgery or percutaneous r:rdiologically gu
drainage.
M-old male presented with
-J. and chronic rcnal fuilurc_
Abdominal Imaging
Cases 73, 74
127
Answers 73, 74
Abdominal Imaging
ANSWER 73
Observations (73)
Ultrasound longitudinal image of the right testicle
demonstrates multiple sma!) hypcrcchoic foci, with no
posttriar acoustic shadowing, disrribmed
throughout the. testicle. The testicle is otherwise of normal
size and shape. No other focal mass lesion is identified.
Diagnosis
Testicular microlithiasis.
Di scussion
Testicular microlithiasis is a (ondition characterized by
failure of clearance of degenerated rubular epi thelium from
the scminiferous tubules, which subscqucmly calcif)'. This
is an asymptomatic condition and is an uncommon
incidental finding. [mage findings on US arc of multi pic
small \ - 2 nlm hypc:rcchok foci with no acoustic sh:ad-
owing, disuiblilcd throughout both teSles. Atypical
appearances of asymmetrical and unilateral foci arc also
seen. There is an increased risk of testicular gcrm cell
tumour in 40% and therefore follow-up 6 monthly-US
is of len ath<iS'ctl.
ANSWER 74
Observati ons (74)
Single AI' r:ldiograph delllonstrntes amorphous,
putty-like calcification within a shrunken right k.idney.
128
Diagnosis
Reml tuberculosis with autonephrectomy.
Discussion
The urogenital tract is the second most common site to be
affcrted by TB, after the lungs. Renal TB is found in 5-1O'X.
of patients with pulmonary TB, bur there is only
rndiographic e"idence of pulmonary TB in fewer than 50%.
The kidney is usually affected first, via haematogenolls
spread from a lung/bone/GI focus. There can then be
contiguous spread of to im'ol\'e the ureters and
bladder. Renal TB is unilateral in 75% of cases and the most
common appearance is of a small, shnmken, scarred,
non functioning kidney.
Less common appearances arc of:
Cortical scarring.
Rcnal pelvis/infundibular strictures rcsulting in
hrdrocalycosis and amputated calyx.
Ncphrolithiasis.
Dystrophic parenchymal calcification.
Associations include:
Cryptorchidism.
Infertility.
Klinefc!ter's.
Down's syndrome.
Male pseudohermaphrodism.
Al"eolar microlithiasis.
Practical t ips
Identifying the disrriburion of calcific foci is im
since a cluster of calcification within a hypocchOl"::
suggests nunour or chronic testicular infarction. I
can be due to [Onion, trauma or sc,'cre cpididymim..
Furt her management
Urological referral with follow-up testicular US
monthly intervals to screen for malignancy.
Uretcral TB is found in 50% of gcnitourinary TB
Radiographic features of involvement include
filling defccts, calcificati on and strictures. Bladdtt
presents with a shrunken, scarred, calcified bladder
thick.ened wall and/or filling defects. Clinical p
is with frequency, urgency, dysuria, mic
haemaruria a.nd 'srcrilc' pyuria.
Practical ti ps
Urin;u)' tract TB spreads in an ante grade fashion.
Check chest radiograph for signs of pulmonary
but t hi s is only seen in about 50% of cascio
Further management
Medical dmg therapy for TB should be initiated.
Abdominal Imaging Cases 75, 76
cAr- old female presented with
129
130
Answers 75, 76 Abdominal Imaging
ANSWER 75
Observations (75)
Supine abdominal radiograph shows a positiyc 'Rigler sign'
suggest ive OfpnClItllOpcrironclim. There is also outlining
of the falciform ligamcm and the left lateral umbilical
lig:amcnt wilh a large aTca of free gas seen overlying the
liver. These findings arc consistent with pneumo-
peritoneum.
Diagnosis
Pncumopcriwilcum.
Differential diagnosis
Of causes ofpncumopcritoncum:
Tr:lUllla.
l:nTogcnic ClUSCS, e.g. laparotomy - usually gas should
hal'e resolved within 3 da)'s and its presence is
suspicious after this; although it can take up to 3
weeks [0 resolve in some cases. Faster absorption
occurs with CO
2
:lIId in obese p:l.ticms.
Perforation of abdominal \iscus.
Rupmrcd pneumatosis intcstinalis.
Rupture of an abscess.
Exrcnsion from chest, i.e. pneumomediastinum,
broncnoplcural fistula,
Through femalc gcnital tract, e.g. intercourse,
waterskiing.
Discussion
There :lfe a variety of signs th:lt aid in the detection of free
int raperitoneal gas.
ANSWER 76
Observations (76)
Single image from a barium me:\l cxamination shows there
is poor distension of the entire stomach, which is most
evident in the bod}' and :lIltrum, with relative sparing of
the cardia. Irregular gastric mucosa is seen within t he
fundus and bod}'. The duodenum is normal. The
appearances arc {hose of linitis plastica :and a gastric tumour
must be excluded in the first inst3.nce.
Diagnosis
Linitis plastica due to brasrric carcinOllla.
Differential diagnosis
For linit is plastica appearance (mnemonic - 'CALM
RAGE' ),
Cancer.

Lymphoma - usuall y non-Hodgkin'S type, most
common pan ofGI tract ancCled.
Metasmscs - from lung, breast and melanoma.
Radiation.
Alkalis and other corrosivcs.
Granulomatous disorders, e.g. Crohn's, TB.
Eosinophilic enteritis.
Signs of free gas within the peritoneal ca"ity on a
radiograph arc:
'rootb:l]] sign' - large round lucency in central
abdomen.
'Rigler sign' - air on both sides of the bowel w
makes it unusually visible.
'Triangle sign' - gas within bowd doesn't no
foml edges thercfore such unusuall}' shaped
collections of air should arouse suspicion of ITtt _
'Unchus sign' - olllline of median umbilical
li gament.
Outlining off.:tlciform ligament as well as the IDe
and lateral umbilicallig-aments.
Practical tips
If therc is an)' doubt about the diagnosis thcn m
chest radiograph or a left knera] decubitus film
abdomen should be acquired.
Further management
Free intraperitoneal gas is suggestive of:a perforated
and is a surgical emergency - inform the surgiCJI

Further reading
Lc\'ine MS, Scheiner 10, Rubesin SE, n (II. (1991
Diagnosis of pneumoperitoneum on supine
abdominal radiographs. Amc";wn jOIIrlJII! of
Radiology 156: 731-735.
Discussion
Gastric carcinoma
lll:alignanc}' and shows an incre:lsed pre\'alcnce ill
The scirrhous type of the tumour, which produco.
plastica, accounts for 5- 10% of gastric cancer._
infiltration of tumour causes fibrosis and ri gi
reduction/ absence of peristalsis in affected area.
fundus and body of the slOmach arc most
in\'olved.
on CT is often \'cry
due to poor distension; however, contrast
afe much better due TO their d}'llamic nature.
Further management
Referral to a gastroenterologist for endoscopy.
isappropriarc.
Further reading
B:a-Ssalam:ah A, Prokop M, U!'tinann!\i, tt (I/.
Dedicated multide[eetor cr of rhe sromach:
spectrum of diseases. RadioGraphies 23: 62-
131
Answer 77 Abdominal Imaging
ANSWER 77
Observations (77a, 77b)
This fulllcngth film taken at 15 minutes in ;m JVU series
shows multiple small, well defined, smooth rounded tilling
defects within both ureters.
Diagnosis
Pyclonreteritis cystica.
Differential diagnosis
For radiolucent tilling defects in the ufeters:
Radiolucent calculi .
Transitional cdl carcinoma (Tee).
Pycloufcrcritiscystica
Blood dots.
Ureteric polyps
Sloughed renal papillae.
Discussion
This is ;\ condition characterized by multiple
subepithelial ftuid-nllcd CYSts in the wall of the renal
and ureters extending into the ureteric lumen. Theft'
association with recurrent urinary tract infections
obstmction, with a predisposition in diabetic patients..
condition is asymptomatic and the lesions arc
premalignant. Occasionally it presents with haema
Practical tips
Although any part of t.he ureter n1JY be invoked,
slight prcdilcction for the upper third.
Further management
ChJrJctcristic IVU JppeJrances may well p e ~
confidcnt diagnosis. However, if there is diJgDI
uncertainty then ureteroscopy with biopsy may so
be required. Antibiotic treatment may be unde
though the response is variable.
77b Multiple round filling defects.
132
E 78
ry
fnr-ol d fe male with diabetes
trd \\1m renal failure.
Abdominal Imaging
Case 78
133
C'
"
134
Answer 78 Abdominal Imaging
ANSWER 78
Observations (78a, 78b)
Two images from an IVU series arc shown. There is
evidence of renal papillary swelling and enlargement. The
intcrpoJar calyces on the right have a 'ball on ICC'
appearance with 3 collection of contrast in the
cemre of the papilla. A partial duplex system is also
dcmonstr.ltcd on the right. There is a well defined
intr:aluminal non-opaque filling defect in the upper ureter
on the right, which repre$Cnts a sloughed papilla.
Diagnosis
Renal papillary necrosis.
Differential diagnosis
Of causes ofrcnall':lpi ll ary necrosis (mnemonic - 'SAD
ROPE'),
Sickle cell disease.
Analgesics.
Diabetes.
Renal ,-cin thrombosis.
Obstructive uropathy.
Pyelonephritis.
Ethanol abuse.
Discussion
Renal papillary necrosis is caused by a variet), of disease
processes that rcsuh in ischaemia of the papillary portion
of the renal pyramids. There is a progression in
appearances as disease progresses. Phases of de\'cl
Papillary swelling/enlargement .
Panial papilla')' sloughing - tract fomlation
communicating with an irregular ca\ity. On an I\
this is shown by the 'ball on tee' appearance \\itb
contrast extending into a cavitated pa
Total papillary sloughing - which gives a 'signet
appearance 011 IVU the nonopacified slou_
papilla being surrounded by contrast in the
calyx/ ureter.
Practical tips
To diflerentiate between the various causes, ide
whether the involvement is unilater-al (renal \'ein
thrombosis, obSITucri"e uropadly) or bilateral
(s}'sterniecauses) .
Diabetes is the most frequent cause (50%) .
A classic 'cx;lm type film' to be aware of is the 1\1.:
showing renal ,"'pillal)' necrosis and background
abnormalities ofa condi tion that has been treated
with NSAlDs, e.g. ankylosing spondylitis, or boo!
changes of sickle cell disease.
Further management
Trcatmem ofthe condition requires identification (X
underlying cause and control of this disease process
7ab Sloughed papilla (left) and ' ball on tee' appearance (right).
Abdominal Imaging
Cases 79, 80
CASE 80
History
A 28-year-old female presented \\;th tipper
abdominal pain, pyrexia and jaundice.
135
136
Answers 79, 80 Abdominal Imaging
ANSWER 79
Observations (79)
Single image from;} barium swallow examination shows a
shaggy, ulcerated Illllcosal pattern in the thoracic
oesophagus typical of candidiasis.
Di agnosis
Calldidn ocsophagitis.
Discussion
Cnlldidn ocsophagitis is the mOst COllllllon cause ot'
infectious ocsophagitis with C. (I/bicfllIS being the most
commonly ilWol\"cd org:lIlism. Immunocompromiscd
pariems have a predisposition to infection. Prcscmarion is
with gradual d)'Sphagia, odYllophagia and rCl.rostcrnal pain
Association with oral infection is seen in up to 80%,
characterized by SlTcral pltchy, white plaques cOI"cring the
mucosa. In the oesophagus there is predilection for the
IIpper 1J(f/f Q!tlJe oesopllflg/IJ with the appear-Jllcc of multiple,
shaggy, longitudinal mucosal plaques. There is reduction
in primary [Xrisf"Jlsis and some narroll;ng oCthe lumen due
to spasm and oedema. Stricture formation is a rare
complication.
Other infecti\e causes of ocsophagitis include:
Herpes ocsophagitis - the second most C0111mon cause
of infectious ocsophagitis. Caused by herpes simplex
virus ( HSV) type I and most commonly presenting in
males in 2nd-4th decades. Usuall)' involving the mid
oesophagus, there arc multiple small discrete
superficial punctate ulcers. The intervening mucos.:J. is
usually of normal appearance.
ANSWER 80
Observations (80a, 80b)
Axial CT image and coronal reformats ofthc liver with IV
contrast in portal ,cnolls phase are shOll'n. There arc
multiple, well defined low attcnuation cystic structures seen
throughout the liver. These appear to be communicating
lI'ith the bile ducts and are better demonstrated on the
coronal reformatted imagcs (SOb), No calculi are scen in
the ducts. The CT appearances arc highly suggcstil'e of
Caroli's disease and the clinical detJils suggest cholangitis
has de\'clopcd.
Diagnosis
Caroli'sdisease.
Discussion
Caroli's disease is a rare autosomal recessive disorder
characterized by multifocal, cystic dilatation of the
intrahepatic bile ducts. The differential diagnosis for this
condition is polycystic li\er disease, however the two can
be discriminated by identif)'ing the communication
betwcen 'cysts' and bile ducts in Caroli's.
CytOmegaloli rus (CMV) <>esophagitis - presenrs
radiologicall)' with a single or multiple giant flat
superfici;llulcer{s) ncar the gastro-ocsophageal
junction. Less commonly, it can present as discret e
small superficial ulcers as arc seen in herpes
oesophagitis.
HIV ocsophagiris - chamcterized by giam
oesophageal ulcers, difficult to differentiate from
O .'IV <>esophagitis.
All affect imlllunocompromiscd patientS :lIld arc mrcly
in immunocompctents.
Practical tips
Do 1l0tmistJke pseudodil'erticulosis of the oesophagus
deep ulceration. This is a benign condition II
oesophageal mucous glands become dilated and torm
shaped outpouchings rrom the lumen. It is associated
any $CIere ocsophagitis (sec Case 38).
Further management
Always consider if not
alreadyapparenr.
Oropharyngeal candidiasis ma)' be a pointer to
nature of oesophageal ulceration but upper Gl
endoscopy is still often needed to confirm via bi
and brushings.
Antifungal or amiviml drugs tor treatment as
appropriate.
Associations orCaroli's disease:
Medullary sponge kidney (80'it).
Polycystic kidney disease.
Congenit;ll hepatic fibrosis.
Choledochal cyst.
Complications include biliary stasis, stoncs,
hepatic abscess. There is an increased risk
carcinoma in patients ,,;th Droli's disease. Biliary .
and porral h)'I>Crtension arc 1/{Jf;complications.
Practical tips
Diagnosis is dependent on showing that the
communicate lI'ith the biliary tree - coronal and
reformats call be essential for this.
Further management
If there is anI' concern as to whclhcr the
communiCating, MRCP (magnetic resonance
pancreatography) is a noninvasive method I
Abdominal Imaging Cases 81, 82
137
138
Answers 81, 82 Abdominal Imaging
ANSWER 81
Observation (81a, 81b)
Two MIU images are presented - T2 weighted sagittal and
axial images through the pelvis. TheS(: images show bulky
enlargement offhc uterus. The junctional zone is widened
and poorly defined and there aTC l11ultipk high signal fixi
within the myometrium in keeping with ccropic
endometrial tissue These appearances arc typical of
adenomyosis.
Diagnosis
Adenomyosis.
Di scussion
Adenomyosis is a chronic condition affecting women
during the reproductive years. There is III incrclscd
incidence in multiparous women, suggesting that uterine
trauma plays a role in the development of this disease. The
disease is characterized by ectopic endomerrial tissue
spreading into the myometrium resulting in myometrial
hyperplasia. The condition is benign and although it is
associated with endometriosis, there is no increased risk of
de"cloping endometrial/utcrine malignancies. The disease
can be either fOCal or difli.tsc. It can sometimes be difficult
ANSWER 82
Observations (82a)
Single AP radiograph of the abdomen demonstrates a large
mass lesion in t he right upper quadrant, which shows
clllyilinear calcification of the wall. Appearances would best
fit with this being a calcified wall of the gallbladder. No
discontinuous areas in calcification jre seell.
Diagnosis
Porcelain gallbladder.
Differential diagnosis
Similar appearalll.:es on US can be due to:
Emphysematoll s cholecystitis.
Gallbbdder filled with stones
Normal gas-filled bowel
Discussion
This is an idiopathic condition that was coined to describe
the blue discolouration and brittle naUlre of the gallbladder
at surgery. The condition is associated with gallstones in
90% of cases and is more frequently seen in women (sex
ratio of 5: 1). Pat ients are usually asymptomatic and
diagnosis is made incidentjlly on plain films or US
imaging. Radiographic appearances mirror the histological
findings of dystrophic calcification in a chronically inflamed
gallbladder. The caleification can be of twO types:
Curvilinear calcifi cjtion in the muscularis (82b).
Punctate calcification in the mucosa/glandular spaces.
on US to differentiate focal forms of the condition fr
uterine fibroids.
US appearances afe of poorly defined hypoechoic area
within the myometrium with multiple small, 2-4 nu:a,
ectopic endometrial cysts seen withill the myometriu
There is thickening of the anteriof and posterill
nwometrialwaiJs .
. Ivl Rl appearances arc \'ery similar - myometrial \\
thickening; high signal (on T2 weighted images) ect
endomctrial cySts in the myometrium and focal/di
thickening of the innermost layer of myometrium kn
as the junctional zone.
Symptomatically pjticnts present with menorrhap.;..
pelvic pain and dysmenorrhoea and the condition can
to infertility.
Practical tips
Widening of the junctional zone with eCTopic cndom
cysts arc the best MRI features for diagnosis.
Further management
Hysterectomy is the only management option to rc
symptoms.
Imaging features on US arc of curvilinear/pun
calcification in the lhickened wall oflhe gallbbdder, \\
can be local or affecting the whole wall , wi t h Illi
jcoustic shadowing. On oral cholecystography_ -
gallbbdder is found to be 1l0nh.lIlctioning. The illl
of identiF,'ing the condi t ion is the risk of den'l
gj!lbladdcr carcinollla, which occurs in 10-20% of
Appearances of galibladder carcinoma in this simation
be of a luminal tilling defect, infiltration cjusi ng focal
thickening or a localized filllgating mass. Cholecyst
is therefore recommended e\"en if the paticlU
asymptomatic.
Practical tips
Ultrasound and CT scans should be scrutinized far
secondary gallbladder malignancy when porcelain
gallbbdder is noted
A discontinuity in the calcification whcn the whole
gallbladder wall appears to be calcified may be a
to gallbladder carcinoma.
Further management
CholeeystectolllY is advised due to the high risk of tuml
Further reading
Kane R, Jacobs R, Katz], Costello P ( 1984). Pore
gallbladder: ultrasound jnd cr jppearances
Radi%gy 152: 1" 37- 141.
Abdominal Imaging Case 83
139
140
Answer 83 Abdominal Imaging
ANSWER 83
Observations (83a, 83b, 83cl
Three MIU images arc shown - a sagittal T2 weighted
image (833), axial Tl (83b ) and axial Tl weighted lilt
suppressed image (8 3c). There is a large 4 em lesion
idcnti licd within the left ol'ary, which is of high signal 011
both T I and T2 weighted images and shows no fut
suppression. On the sagittal T2 weighted image, there is
el'idence of layering of the contents of lhis mlSS. These
appearances would be entirely consistent with blood
produC[s and the lesion represents an cndomeniorna.
Diagnosi s
Endonletrioma.
Di scussion
Endometriosis is a chronic condition characterized by
ectopic deposits of endometrium outside the uterine cavity.
It aflccts women in the 4th-6th decades and is
characterized by chronic pe!\'k pain, dysmenorrhoea,
menorrhagia and dyspareunia. Common sites for
endometrial deposits arc the ovaries, fallopian rubes, pouch
of Douglas and uterosacralligarnents, however more dist'Jl
spread can occur to the bladder/bowel wall with even
further distal spread to the lungs and plcur.l. Spread to the
G I tract most commonly occurs TO the distal sigmoid :llld
t he rect'osigmoid wall and deposits can result in peritoneal
adhesion and subsequent obstruction. Repeated bkeding
of the ectopic endomet.rial deposits results in fibrosis and
pain.
Endometrial deposit s can be focal or diffuse. In
case, the cbssical appear:mcc of an endometrioma
'chocolate cyst' is shown with a 1- 5 em cyst contai
layered blood products of high signal on T l and _
weighted images. There is no signal loss on fut supprl!SSl(
sequences. The diffuse form is more common, how("l
with multiple smaller scattered cysts seen in se\
locations.
Complications depend on the site of the deposin
can result in:
InfertiliTY (due to involvement of the fallopian tubes
causing adhesions/fibrosis ).
Bowel obstruction (due to fibrosis/stricturing oflbt:
bo\\'clwall).
Pneurnothor.lx (due to spread to the pleura ).
Practical tips
Endometriomas can be diOcrcnriat'cd from dermoid
by using 3. fur suppressed MRj sequence. Both will
hi gh signal on TI and T2 weighted images
endometriomas will still be high signal on fa t supp
sequences.
Further management
This wndition can be difliculr 10 COntrol.
management with hormonal suppression of menst
is often attempted but surgical excision may be req
S3e l esion remai ns high signal on the T1 fat
suppressed image suggesting that it represents bl ood.
-old female presenlcd
.tbdominal pain.
Abdominal Imaging Case 84
141
142
Answer 84 Abdominal Imaging
ANSWER 84
Observations (84a)
This single image from a double contrast barium enema
shows abnormality of the sigmoi d colon with poor
distension and apparent e:\ternal compression of the bowcl
loops inferiorly. Thn:e well (Idined eakifie densities an: seen
adjacent to the affected segment and ha,'e the appearance of
teeth.
Diagnosis
Ovarian dermoid.
Discussion
Ovarian dermoid cyStS arc benign lesions, which arc
relali,'cly common, accounting for -20% of all o"arian
neoplasms. These mostly present during the reproductive
years, with a mean age of presentation of 30 years. They
contain tissue from all three germ cciliayers - ectodermal
(ski n, brain), meso<icrmai (muscle, f.lt ) and endodermal
(mucinous/ciliated epithelium). TUlllours arc bilateral in
- 10%.
Trpi cal appearance is of a unilocular cyst, lined by
squamous epithelium and containing sebaceous, fatty
material hair follicles and skin glands arising from the
wall . A proruocrance into thl: Cl.vit), known as a Rokitansky
nodule is usually the site ofbone/teelh material.
Appearances on plain radiograph: teeth occur in 56
of cases and arc readily identifiable. Mass effect \\i th
bowel loop displacement is otten seen (84b). The
image shows a cemral lucent demit}' rcprcscntati n'
f:tt in the right side of the pelvis, which is dispbcing
sigmoid colotl.
Appearances on us/crjf\'lIu::t well delincd high
cchogcniciry lcsion is identified in the o\'ary due to
high fur content (84c). Again teeth arc easily
identified with posterior acoustic shadowing, \\idUII
the solid Rokit3nsky nodule. Fat is readily iclcntifiUo
011 CT and J\'I RJ virtue of its low density :lIld hi_
signal.
Complications arc of torsion, rupture and
degeneration (seen in 2% of cases).
Practical tips
Some films uscd in radiological exams rely on the can
nOling an incidental lesion at the edge of the film.
in ovarian dermoids arc a classical example of an
the film'case!
84 Abdominal Imaging
management
there is still clinical concern after l.lltrasound,
~ useful in completely characterizing these
Figures 84d-f arc axial T2 weighted (84d),
ghted (84c) and fut satur.llcd (84f) axial
_ of the pelvis showing dermoid cysts in both
. The right most cyst shows signal voi d
rly on all image sequences in keeping with
--,nion :l1ld complete f.1 t suppression confirms the
inam fat coment ofthcsc lesions.
ani to gynaecologist for surgical excision.
Furt her reading
OutW3tcr EK., Siegelman ES, HllIlI JL ( 2001 ). Ovarian
teratomas: tumor I)'pes and imaging characteristics.
RndioGrnp/)jcs 2 1: 475- 490.
84d-84f Axial T2 weighted (84d), T1
weighted (84e) and fat saturated (84f)
axial images of the pelvis showing
dermoid cysts in both ovaries. Loss of
signal on the fat saturated image
confirms the high fat content.
143
CASE 85
History
Incidental li'"cr lesion W,\S nOfcd on
abdominal ul trasound scan ora 26-ycar-
old female
Abdominal Imaging Case 85
Abdominal Imaging Case 85
145
146
Answer 85 Abdominal Imaging
ANSWER 85
Observations (85a. 85b)
Selected prc- and post-contrast l'vIlU images of the liver.
Prc-contr:lSt images (853) demonstrate:l brge, well defined
lesion in segment 4 of the liver, which is of slightly reduced
signal on Tl weighted images. Out of phase Tl weighted
images show 110 significant alteration of liver signal [0
suggest the area is due to focal f.ltty sparing. The lesion is
slightly hyperintense on T2 weighted scans.
On dynamic postconrrast imaging (85b), the lesion
ShOII'S marked enhancemem during early arterial (25 s)
phase with a central hypointcnse scar ,isible at this stage.
There is subsequent wash out of contrast in the portal (60
s) and equilibrium ( 3 min) phases to become isointense
with liver. The central scar shows enhancement in the
equili brium phase.
The contrast agent used is gadolinium BOPTA (Gd-
BOIYfA) and the image taken at 90 min shows persisting
contrast uptake within the lesion indicative of hepatocyte
content. These appearances and pattern of enhancement
would best fit wi t h the diagnosis of focal nodular
hyperplasia.
Diagnosis
Focal nodular hyperplasia (FNH).
DiHe;ential diagnosis
For hepatic lesion with central scar:
FNH.
Adenoma.
Hepatocellular carcinoma
Haemangioma.
Fibrolamellar carcinoma.
Di scussion
Focal nodular hyperplasia is a benign hepatic lesion that
occurs mOst commonly in young/ middle aged \\"omen
Usually these patients arc asymptomatic, with diagnosis
made as an incidental finding, although some patients can
present with vague abdominal pain. They are solitary
(85-95%) vascular lesions containing normal hepatic
elements - Kupffer cells, hepatocytes and bile ducts
Imaging features arc very similar to those of hepatic
adcnomas. Unlikc hepatic adenomas, development is not
associated with the oral contraceptive pill, though
ocstrogens can exert trophic ctlccrs
Focal nodular hyperplasia is dil'ided into typical and
atypical groups, with approximately 50% in each. Typical
lesions show the signal characteristics, enhancement pattern
and central scar as described below. Atypical lesions may
show signal heterogeneity, with more marked '1'1 and T2
hyperintensity, and no centr.ll scar .
Imaging Icatures on cr and J\HU: classical FNH is
isodense on CT, while MRJ shows mild Tl
hypointensity and mild '1'2 hyperintensity. There is
prominenr enhancemellt in the arterial phase
following IV contrast, the central s..::ar being
conspicuous at this point due to nonenhancement.
Contrast washes out rapidl). in the portal and
equilibrium phases to become similar to normalli,er,
though there may be scar enhancement in the
equilibrium phase.
Liver specific MRI contrast agents can help further..
In this case, a gadolinium agent with additional li,
specific properties (Gd-BOPTA) has been used.,\[
gadolinium chclates in current usc arc cxtraecll
agents that arc excreted \ia the kidneys. Gd-BOPT.
and Gd-EOB-DTPA arc tll"O agents cUTrently in
that ;1]SO show a proportion ofhepatie excretion. Tbn-
beha'e the same as conventional extracellular age
during the arterial, portal and equilibrium phases of&.
MRI, but also ilhlS[rate funcrioning hepatocyte ti
on delayed illl;lges. Since FNH contains hepal 00
and abnormal bile ductules, such agents arc rctai
within FNH on delayed images {20 min to 2
depending on the agent}. Other nongadolinium
liver specific MRI contrast agents can similarly
characterize FNH on the basis of the fu nctio
hepatic tissue elements it contains.
Imaging features on angiography: these lesions
usually ha'e a central supplying artery with
filling giving a ' spoke wheel' appearance; this can
difl"crcntiation from an adenoma, which has several
peripheral supply vessels.
Imaging features on sulphur colloid scan: usuall y
these lesions show normal activity due to the pre
ofKllpflercclls.
Practi cal tips
Sulphur colloid SC:lllS h:w(' Tr:lditionally been used'
help confirm FNI-I suspected on CT and MIU by
virtue of the pn:scncc of Kuptler cells. Liver spccili.:
contrast agcnts ,.1s described above lllaY.1l0W 0
this in many cases.
Hepatic adenoma is a cOlllmon ditlcrcntial when
FNH is considered and there is evidence that
such as Gd-BOPTA can help ditfcrcnti:J.tc FNH .
hepatic adenoma h), dClllonstr:lting the presence at
functioning liver tissue in rhe fonner.
Further management
Difl""erentiation frolll adenoma and hepatocC"
carcinoma can sometimes be difiicult elen Ilith histol
inlormation. Excision is then carried out.
Further reading
Schneider G, Grazioli L, Sai ni S (2005 ). MRI oftlJ(
Liller. Springer, Nell' York
Chapter 3
CENTRAL NERVOUS
SYSTEM, HEAD AND
NECK IMAGING
D MRI HEAD
imaging, if:ln abnormality is nOT obvious at first
..Deck all arcassyst'cmatically:
h if IV contrast has been given.
les - check the configuration and size, ensuring
is appropri ate for the other CXf!.l-3.xi:J.1 CSF
such as the sulci.
hemispheres, brainstclll and cerebellum - on
in particular, there is a lot of information to
tc for focal masses, signal abnormalities and
ral abnormali ties! In examination \ ' iVa5, it may
lIIlrC'alistic to expect the candidate TO quickly detect
.lhnormalitics so you may well be gi,"cn some
cc or JUSt presented with selected images. A
of FU\JR (fluid anenuatcd inversion
:) or PD (proton density) sequences may
.' lead you to pathology on M RI .
-axi al spaces - carefully check for normal size,
c of blood or other collections.
is - chcck for enhancemenr on cr and normal
\Xtids on i\'IIU {including vessels at the skull
periphery - assess orbits, sinuses, temporal
Iskull base and skull vault.
e has their own blind spots bur here arc some
ed areas 1'0 check when all else seems normal:
temporal lobes and posterior fossa 011 cr -
ges of the teml>oral loocs arc often degraded by
artefucr and pathology easily missed. The same
to a lesser extent ill the posterior fossa.
base and petrous bone - pathology GI.Il be easily
JUiooked, especially on M Itl where there is a lot to
- si gns of stroke - the changes ofinfurction
be \'ery subtle. Carefully check for subtle focal
'ng and reduced grey-white matter
rcntiation. The Imer is beSt detected by using
I11II:I'\' 'narrow windows' on cr.
c:Oous sinus thrombosis and subdurnl empyema arc
disorders with significant morbidity and mortality
t can Ix easily overlooked. When presented with an
normal cr of a patient with a history of
cDminci ng acute imracrnnial pathology, always double
.:Deck for increased density in the venous sinuses and
mbtle subdural collections. Administrntion of IV
may help confirm either.
- Hxmorrhage - subtle subarachnoid or subdural
tiood. must not be missed. Check for small
amounts ofsubarachlloid blood layering in the
occipital horns or around the medulla close [0 the
fornmen magnum.
Pituitary - this is well sccn 011 sagittal MRI scallS, so
do not forget to chcck it.
A notc on mass lesions:
\Vhen confronted an intracr:lIlial mass lesion, assess
the following:
Location - cemin tumours a predilection for
certain areas of the brain .
Age - this has a strong influence on the differential
diagnosis. Certain rumours are common in the
paediatric age group while metaS[;lses always have to
be considered in the older adult population.
Is the mass intra- or eur.t-axial - that is, does it
originate within brnin substance or nOt? The
distinction is very important in fomling a differential
diagnosis and though it seems obvious, can
sometimes be difficult to establish on cr in
particular. An eurn-axial mass causes crowding ofthc
subcortical white matter fronds that extend between
gyri. Com'erscly, an intrn-axi31 mass stretches the grey
matter around it and consequently displaces the
fronds of white maHer 3parr.
Mass eflcer and oedema - check ror midline shift and
effacement of normal CSF sp3ces such as sulci and
cisterns. If extra-axial CSF spaces arc obliterated,
there is risk or death due to br:lin herniation through
dural al>crt ures. !f rou see such features, then indic3te
the degree of urgency required in seeking
neurosurgical evaluation and intervention.
Assess the enhancement pattern of the lesion. This is
often nonspecific but certai n patterns such as the
intense, homogeneous enhancement of meningioma
allow a confident di agnosis.
CT AND MRI NECK
Cross-sectional imaging of the neck requires excellent
an3tomical knowledge! Familiarize with the
anatomical divisions of the upper aerodigesth'e traer, the
fascial Sp3Ces ofthe neck along which tumour and infection
track, and the nodal stations of the neck. With this
knowledge, you can make a meaningful interpretation for
the E?-..TT surgeon. T2 weighted scans with fu! suppression
arc particularly useful to eV31uate at first inspection if these
arc avail3ble, for detecting both primary pathologr and
147
eNS, Head and Neck Imaging
nodal disease. Thereali-cr, sinmltaneous examination of the
Tl weighted scans can help to better delineate the precise
anatomical location of disease.
Look at the sofi- tissues of the anterior cen'ical space.
which should be no greater than a third of the width
ofa vertebral bod" for C I- 3 and no more than the
width ofa \'ertebr:al body for C4-7. Check the
imen'al between the anterior arch of atlas and the
RADIOGRAPHS greater
There arc a very limited number of pathologies that arc On the AP film :J]ook for misalignment of the
likely to be shown on a skull radiograph: vertebral spinous processes in a \'Crtical plane, which
Trauma
As well as skull fractures, check for indirect signs of fixture
such as fluid leyels in sinuses and intracranial air. Remember
10 look at all the bones on the film - the fracture of
would suggest a flcet joint dislocation. Ensure that
the AP 'peg' view adequately excludes a C2 peg
fracture.
odontoid peg at the edge of the lateral skull film is a basic
exam type of case.
When you arc suspicious of an unstable fracture, nak
this clear so that adequate steps arc taken to prote ... ,
the cervical spine until such time as this has been
confirmed or excluded with CT.
Calcification
Know the normal intracranial calcifications such as pineal
and choroid plexus so that you can ditlerentiatc from
pathological calcification such as that associated with
meningioma.
When assessing thoracic and lumbar films, carefully chco.
alignment and \'ertebral body height. On the AP fil m
the thoracic spine, look for widening of the paravcrte
stripe suggestive ofhaematoma.
Mali gnancy
Pi tuitary Bony involvement is one of the most common sites
Size and shape of the pituitarr fossa should be assessed. metasratic tumour spread along with the lungs and Ihu
Vaul t
Several diffuse processes have characteristic changes on the spinous process for lytic deposits. As ever, pay attention
skull radiograph and make for 'spot diagnoses', e.g. the soft tissues - a paravertebral soft tissue mass may
acromegaly, fibrous dysplasi;l, th3lassacmia, you to a subtle bony lesion. Do not lorget that \\
hyperparathyroidism ;md myelon13. mrcloma classically produces focal bony lucencies
Spine
As always, there arc many potential pathologies to sec on
plain fi lms of the spine but trauma, infection and neoplasia
arc particularl y common.
Tra uma
possible resulting vertebral collapse, a significant nu .
of cases show only diffuse oSleopenia, which can III
osteoporOSIs.
Infection
When ;lssessing cen'ical spine films'
-0. First ensure that the complete cervical spine has been
imaged down to C7- Tl level
Spinal infection is usually centred on the disc and the
there will be a reduction in disc height with i1l\'olvc
of the superior endplate of the vertebral body belo\\
inyohement of the inferior endplate of the vertebral
above. Added sofi- tissue d\le to abscess is likely to be
and in the cervical spine will be seen as a preyertebral
tisslle Im.SS on the lateral cervical spine film; in the [h
spine this will be seen as a widening of the paravert
stripe; and in the IUl11b::lf region there may be a
148
On the lateral film, look at the anterior spinal,
posterior spinal and spinolalllinar lines to ensure
continuity (I.e. imaginary lines drawn along the
anterior and posterior vertebral body cortices and
along the anterior limits of the spinous processes). abscess
eNS, Head and Neck Imaging
~ d presented with bilateral
dcafilcss.
Cases 86, 87
149
150
ANSWER 86
Observations (86a)
Single high-resolution axial CT image of the skull at the
level of the petrous bone. There is bilateral enlargement of
t he vestibular aqueduct. Preci se measurements have not
been documented but the aqueducts afC dearly signifi cantly
wider than the horizontal semici rcular canal seen on the
right.
Diagnosis
Enlarged vestibular aqueduct syndrome.
Discussion
Enlarged vestibubr aqueduct syndrome presents clinicall)'
with sensorineural hearing loss. Hearing is usuall y prescnt
:\f birth and then deteriorates from age of -3 years.
Deterioration is often in a manner, associated with
episodes of minor head trauma. There is a suggestion of an
inherited recessive genetic link and 50% of cases arc
bilateral. A degree of cochlear dysplasia is present in 75%
of cases.
The normal endolymphatic duct ori ginates from the
vestibule, via the common crus and extends posterolaterally
in the bony vestibular aqueduct to t he endolymphatic S.1C.
The endolymphatic sac on the posterior aspect of the
petrous temporal bone. Enl arged vestibular aqueduct
syndrome is diagnosed when the diameter at irs midpoint
exceeds 1.5 mm. Figure 86b indicates the dil:J.ted aqu
in rhiscase.
Diagnosis of the condition is important due to the _
results achie\'cd with cochlear implantation.
Practical tips
A quick assessment of the vestibular aqueducts can
made by comparing the diameter at midpoint to thc=
diameter of the adjacent posterior semicircular
the aqueduct should not be larger.
When identified, check the cochlea for e"idence of
dysplasia.
Further management
Advise on a\'oiding head trauma where possible,
no contact sports.
Hearing can be improved with cochlear implants.
Further reading
Dahlen RT, Harnsberger HR, Gray SD etal. ( 1997).
Overlapping thin-section f.1st spin-echo MR oftht
large \'estibular aqueduct syndrome. American
jOltrlml of Neuroradiology 18: 67- 75.
Valvassori GE ( 1983). The I:J.rge vcstibul:J.r aqueduct
associated anomalies of the inner car. Otola171lgo _
C/illicsofNortbAmeriCll 16: 95- 101 .
86b Axial CT image demonstrating an enlarged
vestibular aqueduct.
eNS, Head and Neck Imaging Case 88
187)
que image from a parotid sialogr-anl with no
iiIm provided for comparison, The parotid duct is
calibre with no obstructing stones or stricture.
florid pUllerate dilatation of the
___ ""'I" ",,,,,,,,1,, and acini in keeping with punctate
recurrent sialadcnitis is llSU;\lIy associated with
,[rietll Tc causing duct obstruction. These causes,
Me rare in children and chronic infhlmmation is
JlTl monJy idiopathic in nature. The parotid is
more than the submandibular gland, perhaps due
par.l tivcly smaller salivary Olltput. Clinically,
present with repeated artacks of swelling of tile
associated fevcr. Age of onset is typically 3- 6
symptoms usually rcsoh'ing sponranl"Ously after
Althollgh sialography is the primary method of
diagnosis, US is useful for tollow-up as it avoids thc
radiation burden and invasive nature of sialography. At US,
the gland is swollen with :I hettrogencous appearance and
multiple hypo<:choic tOci within it. lntraglandular reaerivc
lymph nodcs may be noted
Practical tips
lnrraglandular lymph nodes arc seen in the parotid but not
the submandibubr gland, which becomes encapsulated
before lymph node de,"dopmellT occurs embryologically.
Further management
Although sia1cctasis most commonly idiop;\thic, Sjogren's
syndrome can also cause this appearance and should be
excluded with laboratory investigations. I'/J ?
Further reading
Yam KL, L1U C, Li CK ( 1997). Primary Sjogren
syndrome prescnring as rccurrclll parmitis. HOllg
KOIIDJolmlal ofPaediarriu (Ncw Series) 2: 47-50.
151
152
Answer 88 eNS, Head and Neck Imaging
ANSWER 88
Observations (88a)
CorOIl:ll Tl weighted MR il11agcsofthc orbit show llllrkcd
bilateral swelling of the muscle bellies of the interior, medial
and superior rc([Us muscles with sparing of the tendinous
insertions. This disrribution of extraocular Illuscle swelling
is typical ophth:tlmoplthy.
Diagnosis
Thyroid ophthalmopatlw.
Differential diagnosis
Orbital pSCudotlllllOur - usually ilwokcs both muscic
belly and tendillo/ls jmcrtioll; is pnillflll compared (0
painless thyroid opluhalmopathy and is morc commonly
IIlIilateral.
Discussion
Thyroid ophthalmopathy is a disease of the orbit
characterized by deposition ofmucopolys:tCcharidcs \\ithin
the muscle bellies of the intraorbital muscles. [t tlsu:tll y
presents in adults and is more common in \\omel1. Thc
paticllt is usually hyperthyroid (although 10% of cases arc
found in cut hyroid patients) with ocular presentation
within I year ofhypcrthyroid symptom onset. Se"erity of
the cye disease, howcver, is not related to thc sC"crity of
thc thyroid hormonc imbalancc.
Radiological fcatures arc as follows
Majority of cases arc bilateral although therc is often
asymilletrical diseasc. About 10% arc unilateral
and medial rectus arc most coml11only
affected, with the lateral rectus being lc,\st likel y to be
affected.
Musele bellies arc with swollen appearance
and relative sparing of the tendinous insertions. Axix
CT images (88b) show swollen medial recti with
t)'pical sp:lring of the tendinous insertions
Proptosis, lid retr:lctiOIl and reduced eye mo'"eIllCnlS
are features.
Usually rhe disease resolves spontaneously but ste
trcatmCnt is prescribed to treat the swelling :lnd [0 red
intraorbit:ll pressure, which can otherwise cause optic n
and ophthalmic "ein compression. Surgical decompressil
is sometimes required when there is acute swel ling
threatellcd visual loss.
Practical tips
The order of muscles involved in thyroid
ophthalmopathy is ( from most to least frequent )
IntCrior>]\kdial>Supcrior>LaterabOblique - Mllen
- I'M SLO(w).
Further management
Thyroid ophthalmopath)' with visual disturbance req
prompt evaluation and treatmcnt gi"cn the potential
to visual function.
Further reading
Hosten N, Sander B, Cordes M, etn/. (1989). Gr.JXCS
ophthalmopathy: Mit imaging ofthc orbits.
RfldiologJ' I72: 759- 762.
88b Selected axial CT images through the orbi ts show thickening of tbe medial rectus muscles with
their tendons.
eNS, Head and Neck Imaging
89
\-car-old lll ale presented with
al headaches.
Case 89
89a Axial PO (top left), axial and sagittal T1 weight ed (left), axial and coronal T2 weighted
(right) MR images.
153
154
Answer 89 eNS, Head and Neck Imaging
ANSWER 89
Observations (8ga)
Select ed MIU images demonstrate a round lesion in the
amcrosupcrior aspect of the 3rd ventricle. The lesion is
mildl y hypcrimcnse on Tl weighted images, with variable
signal on T2 weighted images and a graduated fluid !clod
appearance. It is likely that the COntents are proteinaceous
fluid and the findings arc consistent wi th a colloid cyst of
rhe 3rd vcnrriclc
Diagnosis
Colloid C)'SL
Differential diagnosis
For 3rd vcntricular lcsion:
lvleningioma - these arc not usually hyperintense on
T I . Meningiomas commonly caJcit)r and show diffuse
enhancement with cOntraSL
Ar.lchnoid cyst - these arc usually isodense on CT and
isoimense with CSF 011 MRi
Dermoid cyst - usually found in the midline. These
contain fut and arc therefore hypode115e on CT
and have mixed signal on J'vllU.
Ependymoma of the 3rd ventricle - these arc "ery
r.lre. Imaging featllres i'nclude cystic areas, necrosis
and calcification and they show diffuse uniform
enhancement.
Basilar tip aneurysm.
Discussion
Colloid cysts account for approximately 0.5-1 % ofCNS
'tll11l0urs' . They usuall y present in young adults and arc
more commonly seen in males. The cysts arise from the
interior aspect of the septum pellucidulll and extend into
the 3rd vCllIricle. Presentation is usually secondary to
obstructed CSF flow at the leld of the 3rd ventricle with
features of positional headache due to tr.lnSielll obstruction,
distllrb:lIlces of gait, reduced consciousness lcl'el and
papilloedcma. The lllajority of cysts ( 80%) contain
mucinous material while 20% contain fluid similar to CSF.
Typical features on CT: well defined thin walled cyst
in the 3rd veillride of slightly increased attenuation
with no enhancement (89b). Can cause erosion of the
sella
Typical features on MRI : mucinous material contained
within the cyst produces a well defined lesion of
increased signal intensity on TI and T2 weighted
images.
Practical tips
A large basilar tip aneurysm can be mist:J.kcn for a
colloid cyst on uncnhanccd CT scan Jnd this rcq
carly identification and treatment.
Need to assess whether or nor there is hydroccp
- look at the degree ofdilarariotl of the temporal
horns oCthe lateral ,cntriclcs and look lor depT
ofthc brainstcm
Further management
Although these arc benign lesions they can present
wi th CSF flow obstruction resulting in headache, k
consciousness al1d death, so a clinical review tor evi
elevated intracranial pressure and neurosurgical
appropriate.
eNS, Head and Neck Imaging
- '"Car-old male presented with
\isual field blurring.
Cases 90, 91
155
156
Answer 90 eNS, Head and Neck Imaging
ANSWER 90
Observations (90a)
This contrast enhanced CT image of the brain
demo!lStr;ncs mul tiple ring enhancing lesions with
surrounding ":lsagellic oedema in the left frontal lobe.
Though no lesions arc seen in the right hemisphere on this
single image, JPparcnt vasagenic oedema in the right
frontal lobe suggests that there may be further lesions on
this side that arc not visualized. The diHcrcntial di:tgnosis
for ring enhancing lesions is long, but the history of pyrexi:t
points towards cerebral abscesses being most likely.
Diagnosis
Cerebml abscesses.
Differential diagnosis
For ring enhancing CNS lesions:
Cerebral abscess.
Metastases.
Toxoplasmosis.
Demyelination.
Lymphoma.
Multicentric glioma
l'vl ultip.le inrnrcts .
Resolv1ng haematomas
Discussion
(I
Patients who arc immullocompromised, on steroids or have
dbbctes aTC more susceptible to CNS abscess formation.
The most common SOU Tee of infection is haematogenous
spread, though direct spread trom intected paranasal sinuses
can also occur. Clinical presentation is with headache,
seizure and pyrexia. Focal infect ion pre..:eding abscess
tormation is ceTcbritis, and appears as foeallow-density
change on CT or high T2 signal on MRJ (90b, 90c). This
proceeds to capsulation/abscess lormation at 10-13
with the ring enhancement illustr:Hed. When arising
hacmatogenous spread, the classic3l location is at
grC)'-whire nlltter interflce, and most commonly in
middle ..:erebral artery territory. The me.di l l wlll is -
thinnest (due to better perfusion of the grey m
laterally than the white matter medially) and resul ts .
tendency to rupture on this 3spect into the "cntricle
Practical tips
Dif'tcremiation ofthc above list call be difficult and
history is "ery important to identify immune statm...
foreign travel and clini..:al presentation
Look for complications of absces$Cs such as rnpflln"
causing meningitis Of ventriculitis, radiologicall y
identified bv enhancement of these structures or
sigl1,\1 in thi: sulci on FLAJ R MR images.
Wall enhanccmcnt of cerebral abscess is typicall y
unifOfm - thick, im:gubr wall enhancement sho
raise suspicion of ..:erebral metastases.
A peripheral ring on the unenhanced scan is more
common in metastasis than glioma
Assess paranas;"ll sinuses for a primary source of
infection and ensure a chest radiograph has been
10 look for sourccs ofinfcct'ion and potential ri gb;:
left shunts.
Further management
J'vI!U with diffusion weighted imaging can solllcri mo
ditlcrcntiate tumour/metastases from abscess. Rest11'
ditfusion of pus in an abscess cavity meJns that an
is high signal Oll OWl Jnd low signal on ADC
diffusion coefficient ) mapping. Opposite findings
with llccrorictlllllours.
90b, 90c Axial T1 weighted postcont rast a nd coronal T2 images
of left temporal lobe abs cesses . The axial T1 postContrast image s hows a n
e nha ncing rim with s ur rounding low s ignal oede ma. The coronal image s hows
a high signal abscess with s ignificant high signal s urro undi ng oedema causing
a mode rate degree of mas s effect a nd midl ine shift.
eNS, Head and Neck Imaging Case 92
91
\.omcg:a]ovirus (CMV).
Herpes simplex.
'lpticdruscn.
_ rhisis bulbi.
lninal detachment
of prematurity.
thpcrcalcacmic states - hyperparathyroidism,
..an:oidosis, chronic renal failure.
g adult m:lle prescnted with
and panlysis of upward b'"lZC.
Di scussion
Optic drusen arc focal accumulations of hyali ne material
in the region of the optic nerve head, which commonly
calcify. Aetiology is thought to be either a dc\'clopmcnral
abnor!ll;llit)' or a degenerat ive process and it is
histopathologically separate from retinal drusen deposits
that call be a nOTmallinding or associated with age related
macular degeneration. Clinically. patients arc usually
asymptomatk bur can present with reduced \'isu:al acuity,
migraine-like headaches and pscudopapill ocdema. Di:ag-
nosis is made by the absence of ad\ersc imaging features
such as abnormal cnhanccmcnt, optic nen'C thickening,
mass dlcCI or postcrior globe solid lesions. Ocular ultra-
sound can be particularly useful in evaluating, and
confirming this is not anuall). papilloedema. Optic disk
haemorrhage is a very rare complication. The majoriry of
cases (75%) arc bilateral.
Practical tips
Bilateral calcification docs not necessarily suggest a
benign disc::lsc process. The nonherirable form of
retinoblastoma (66") presents at - 24 months \\irh
usually unilatcnl disease; but the heritable form (33%)
presents ::II - 12 months with often (66%) bil::atenl
disease.
Further management
Ophthalmologica l assessment is required 10 confi rm the
diagnosis and check viSllal fields and acuity.
157
158
Answer 92 eNS, Head and Neck Imaging
ANSWER 92
Observations (92)
This midline saginal Tl post-contrast ,'vIR image
demonstrates a large, slightly lobulated but well defined
mass in the pineal region. The mass enhances homo-
geneously, compresses the superior colliculus and causes
dilatation of the 3rd velUride. The most likely diagnosis is
a pineal germinoma causing Parinaud's syndrome and
obstructive hydrocephalus
Diagnosis
Pineal germinoma.
Differential diagnosis
Of pineal region masses:
Germ cdl tumours ( >50%):
Germinoma
Teratoma - extremely heterogeneous mass. Occurs
in young children
Choriocarcinoma.
Embryonal cell tumour.
Pineal parenchymal tumours (25%):
Pineoeytoma - well demarcated, calcified, slow
growing tumour in1middle ,'ged adults.
. Pineoblastoma - si milar to medull oblastoma.
Allects young children. Enhances avidly :llld is nOl
usually well circumscribed.
Others:
J'vlcningioma
Epidermoid or dermoid.
Arachnoid cyst - CSF density/signal
Pineal cySt - common; fluid density or signal
though contents can be proteinaceous on MlU.
Lipoma
Discussion
The pineal gland is a midline structure situated behind the
3rd ventricle and responsible for biorhythm. It is calcified in
most people over the age of 15 years and in almost all
elderly. Germ cell tumours arc the most common tum
ofthe pineal region, accounting for over 50% of all p.
masses. The most common subtype is germinoma, which
histological1y similar to testicular seminoma. Pi
germinomas arc well defined midline masses that arc
more common in m3les than females. They afe norma
seen in children and young adults. The lesion enh
avidly. Oue to the anatomical location of the pineal
these lesions compress the aqueduct ofSylvius produ
hydrocephalus. The superior col1iculus of the brain
also be compressed producing Parinaud's synd
paralysis of upward gaze. Less common germ cd! ttl
of the pineal gland include teratOmas, which are m
seen in young children. Choriocarcinomas and
cell tumours arc even less common and arc hi_

Practical tips
The pineal region is in the midline and masses in
region may compress the aqueduct ofSyivius, so
gland
exceeds I em in diameter a pathological pineal p
should be suspected.
Calcification in germinoma when present is ccntnIL.
pincobbst'Oma pniphaal.
In children think of teratoma (which are \-
heterogeneous masses), pineoblastoma and a vein
Galcnancurysm
In young adults, the most common solid lesion is
germinoma.
Further management
Surgery is difiicult due to the central location in
The main rolc for surgery is in obtaining a
possibly debulkins of tumour to relieve
symptoms. However, serminomas arc
radiosensitive and therefore radiotherapy is the
of treatment.
92 Pineal germinoma.
eNS, Head and Neck Imaging
Case 93
na PO and T2 weighted axial (top), T2 weighted coronal and T1 weighted sagittal (bottom) images.
159
160
Answer 93 eNS, Head and Neck Imaging
ANSWER 93
Observations (93a)
Selected J\Ht images of Ihe brain demonstrate
hyperintel1sity in the righr trans\'ersc sinus on the T I and
T2 weighted images \\lrh an absence oCthe nomlal \'enOliS
si nus flow \'aids. There is high-signal abnormality seen
withi n the right mastoid air cells on T2 weighred images,
which is intermediate signal on Tl imaging - this is likely to
indicate change, Appearances arc
consistenr wirh a diagnosis of \'enous sinus thrombosis
secondary to mastoiditis. No imracerebral/ccrcbellar
or inlarer is demonstrated on these images.
Di agnosi s
Venous sinus t hrombosis.
Di scussion
There arc a variet), of underl )'ing ellises of \'enous si nus
thrombosis, which include trauma, in/ccrion, idiopathic and
h)'percoagulablc states, i.e. oral contracepti\'e pill,
anti phospholipid syndrome, parancoplastic tumour
s)'ndromes, antithrombin III deficiency. Presenting
srmptoms can often be \'ery nonspecific, meaning that
diagnosis is often OI}ly made radiologically. Symptoms
include headache, nausea, vomi ting and drowsiness, The
superior sagit tal sinus is most commonly aflccted, followed
by trans\'ersc and sigmoid sinuses
IUdiological appearances :ITC:
Uncontrastcd CT may show a hypcrdcnsc \ '(nOllS
sinus due to thrombus (Figure 93b shows a
thrombosed superior sagitt:J.J si nus). Contrast
enhanced CT shows a filling delcct withi n the
triangular lumen outlined by a sillall rim of (oml"$
the 'empty delta' sign.
MRI demonstrates :lIlabscncc afOaw \oid within
vcnous sinus, with local eflects of oedema, subcom
infurction, suteal effacement and haemorrhage.
[n the acute phase, thrombus can appear as
isoinrcnsc on Tl weighted imaging and
hypointcnsc on 1'2 weighted imaging. TIlis
hypointcnsity on T2 can sometimes be mistna.
tor flow \'oid and thcn::forc phase-contrast MR.o\.
which shows /low, is beneT at identification.
I n a chronic thrombosis, the venous sinus appea
hypcrimcnsc on T I and '1'2 weighted images
w extracellular methaemoglobin.
Venous infarcts arc idenrifiablc by their
nonconformity \\ltb arterial territories and
haemorrhagic tendency, Figure 93b demOIlstr.u
a \'enous inf.,rct that docs nOt conform to the
anatomical area sl1pplied by the vessels of posta.
circulation,
93b Selected axial CT images demonstrate a focal area of low attenuation invol ving grey and
with appearances consistent wit h an infarct. The distribution, however, does nol conform to arteria
since this represents a venous infarct.
eNS, Head and Neck Imaging Case 94
sinus thrombosis call present in a '"cry
manner and has signific3m morbidity and
umrC31cd. When assessing scans of acutely
_-call)' unwell' palicnts, alwa)'S keep it in mind
the scan carefully. Similarly, beware of
g infan':t$ that show features as described
:itham questioning the possibility of an
rutg wnous sinus thrombosis.
J.ranccs oflhrombus on MRl are complex
~ \\;th the age o[[hrombus. Moreover, patent
sinuses can show absence of tlow \'oid when
in certain planes. Making the diagnosis of
smus thrombosis from MRI can therefore be
1('d. Modern Illultidctcctor CT scanners h3YC
t speed and spatial rcso]urion to image the
Sinuses and provide an allcrnari"c that (an be
interpret, thrombus appearing as a filling
Ul the lumen Oflhc otherwise enhanced '"CnOllS
Figure 93c is a coronal reformat of a CT
~ l showing thrombus in rhe lefi- tranS\'crsc
~ an ;cmpty dclt.l' sign.
93c Coronal reformat CT image shows thrombus in
the left transverse sinus.
162
Answer 94 eNS. Head and Neck Imaging
ANSWER 94
Observations 194a)
Single T2 weighted Mit image of [he brain at the kycl of
the internal ;ludirol)' Illcarus. There is a large , well defined
soft ti ssue mass lesion in the Tight ccrcbcllopontinc (CP)
angle with extension intO the internal auditory canal.
Widening of the canal is seen. No dural tai l is c\'idclH.
Acoustic neuroma is m OST likely.
Di agnosis
Acousticncuroma.
Differential diagnosis
orer angle lesions:
Acoustic neuroma accounts tor 75% orcp angle
masses.
Meningioma is the mosllikdy diHi.:rclltial at 10%
(94b). Lesions arc extra-axial and tend 10 be
cxtracanalicular and commonl y calci!},. Dunl rails arc
seen in up [0 6O'X.oftumours on MRJ.
Epidermoid 5% ofCP angle lesions.
Arachnoid CYST.
Posteri or circulation aneurysm.
Metastases.
Di scussion
Acoustic neuromas arc the most common tumours of
CP angle and internal auditory (anal. They
from the \'estibular di\'ision of the 8th nefl,c and sh.
perhaps be morc accurately termed \'cstibular sc
llomas. These lesions prescll! in the 4th-7th decades
arc more frequently seen in females. Prescntation
at a rounger age in patients \lith type 2 neurofibro
with prescntation in thc 2nd decade. Bilateral aCf'
neuromas arc virtually pathognomonic of
fibromatosis typc 2, whilc solimry tUlllours arc seen
to 25% of cases. Presentation is with sympl
scnsorincural hearing loss, tinnitus, vertigo and
94b Axial PO, T2 and T1 weig
images with three post-contras:
coronal images demonstrate a
defined, extracanalicular,
enhanci ng lesion in the
angle representing a
swer 94 eNS. Head and Neck Imaging Case 95
ging features:
arise ill the internal auditOry canal (lAC).
cause oftlte lAC.
LCSions extend imo rhe CP angle.
L.olt'gcr tumours (>3 em) have central areas of necrosis
md haemorrhage.
is llOt a feature.
cr lesions arc usually imensc with uniform
anccmcnt.
MRI, lesions arc low sigmll on TI, high signal on
n <lnd show uniform enhancement with gadolinium.
ieal tips
'nguishing the main CP angle masses from each
Ilhcr:
Bmh acoustic neuroma and meningioma show
uniform enhancement so this is unhclphLI.
Acoustic neuroma - expands the lAC, causing
flaring of the poms acousricus. May be bright 011
T2 unlike meningioma. Makes an acute angle \\ith
petrous bone.
Mcningiolll::l - dural rail of enhancement, obtuse!
anglCJwith petrOlls bone. Relatin:ly linle tissuc in
the lAC compared to acoustic neuroma.
Epidermoid vs arnchnoid cyst - both appear to
follow the density and signal ofCSF on CT and T I
md T2 weighted j\'IRJ. Howc\"er, the epidermoid
shows increased signal on PO, FLAIR and diffusionfl
weightedMI{:l .
SE 95
ory
30-ycar-old male:
-opanlomogram
) done for denral
Detection of acoustic neuroma is largely done with
M RJ when possible - thin section T2 weighted
sequences are used in the main, with COntrast reserved
for difficult cases. When contT:l indicated, use contrast
enhanced CT.
A subgroup of acoustic neuroma show rel ;llively rapid
growtb that necessit3tes treat ment while others show
extremely slow growth and can be managed morc
conservatively, Follo\\;ng initial diagnosis, a repeat
*
that can be managed more conservatively.
Neurofibromatosis type 2: bil:lteral acoustic neuroma
is a recognized diagnostic criterion for this condition.
also known as the MlSME srndrome ( multiple
inherited schwan noma, meningioma and
ependymoma), In the 'real world' most acoustic
neuromas arc unrelated to neurofibromatosis typc 2.
However, in exam "i\'as (and when bilateral),
hal'e a high index of suspicion for the meningioma
elsewhere on the scan.
Further management
Therapeutic options involve surgical excision, stereotactic
radiation and conservative management. Which one
depends on the particubr circumstances of each patient,
but also whether the tumour is fast growing or not. A
repeat sean a few months after the first can help ident it}'
the group of f.1Ster growing lesions that require a more
aggressivc approach.
163
164
Answer 95 eNS, Head and Neck Imaging
ANSWER 95
Observations (95a)
The OPG shows multiple missing teeth in the upper jaw
and to a lesser extent the lower jaw LOO. In the riglu body
of the mandible, there is a well cin:ulllsuibcd, thin walled,
unilocular lucency measuring sen:ral ccmimclrcs in
diameter. 111crc is no associated bon}' dC$truClion. The Ll'St
is 3ssociatcd with the crown of an unerupted molar and
appcar:lIlccs afC consistent WiTh a dentigerous cyst.
Diagnosis
Dentigerous cyst.
Differenti al diagnosis
Of cYStic mandibular lesion:
cyst.
Dentigerous cySt.
OdonlOgenic kcratocyst.
AmcloblaSIOlll:l.
Aneurysmal bone cyst.
Simple bone cyst.
Metastasis/ myeloma.
Brown tulllour.
Fibrous dysplasia.
Man}' orher 'small print' lesions - nasopalatine cySt,
Pindborg' s tumour, Statile's bone cyst, medi:tn
mandibular cyst, etc.
Discussion
Dentigerous cysts arise from the ctown of an unerupted
tooth. The typicall}' aftccted age group is 10-30 years, with
a male predominance. The cysts arc slow growing and
usually an incidental finding, but occasionally cause pain,
swelling or becomc secondaril y infected. The maj ority
occur in the posterior mandible. They arc \'ariable in size,
and ha\'c a t hin walled, unilocular appearance. TIlt
associatio" ",ilh all ll1uyupud CYOII"1 is lilt key to diaguosis.
The diAcrential diagnosis of cystic lesions of the
mandible is vcry long bl![ most of the causes arc so r;tfe that
t hey can be dismissed most of the time. The emphasis will
consequently be on common lesions and important rare
ones. It is Ixst to assess lesions according to visible
association wi th demition, unilocular \"$ multilocular nature
and age of the patient. Note that although not visibly
dentition related, lesions such as ameloblastOllla and
odoll togenic keratocysr do arise from dental -related tissue.
Dentition-associated cysts:
Periapical/radicular cyst - secondary to pulp necrosis
of a carious tooth. V"i/ow/ay cyst associaud with thr
Toot of a tooth. Can Ix when large:, but noc
expansile. Most common lesion seen, Likely to be
painful.
Dentigerous cySt - IIlIilow/aT cyst associaud Il'ith lIlt
cyon", of all murllpted tooth
No visible association with teeth:
Ameloblastoma/ adamantinoma - rare, locally
aggrcssh'e (but non-merast:l.sizing) lytic [Umour
is slow growi ng and often painless. This is all
t.'<pnmi/t, multi/ow/aud cyst witiJ 'bubbly' appenrn".,
(though 20% uni locular). Can be associated with
unerupted molar tooth. Thinned cortex and no
matrix mineralization. Contrast enhanced cr
ma}' show enhancement of soft tissue elements and
possibly an enhancing mural nodule. Five times m
common in mandible than maxil!:t. age
3(}-SO ,yeaYl. Figure 95b is an OPG in an adult pa
with ameloblastoma sho\\ing a lytic expansile lcsioa
of the right side of the mandiblc with arcas ofinte
septation producing a 'soap bubble' appearancc,
lesion is locally aggressi\"e and has destroycd sevcral
right lower teeth roots.
Odontogenic keratocyst (OKC) - "'Illti/ow/aud
lllli/owlay C,yst oftw 1ltay sitt of3rd lower /IIolar;
expallsilt extending along the mandible; sclerotic
may displace teeth. Same age and sex group as
dentigerous cySt; 50% arc symptomatic wi t h swd
growth rate is rapid and recurrence rate after
curemgc is high. Multiple OKCs arc a feature of
Gorlin- Goltz (basal cell nac"tls) syndrome, an
autosomal dominant condition characteri zed b,'
multiple cutaneous basal cell carcinomas. .
Aneurysmal bone cySt (ABC) - ","Itilow/ar c.m
'soap bubble' appcnYIIllu i" polttrior mlllldible.
Appearances arc therefore very similar to
ameloblastoma but ABC occurs primarily in those
under 20 years of age.
Fibrous dysplasia - 'ground glass' lIlatrix wirlJ
calcijicarioll.
Met:l.stas<:s and myeloma - don't forget t hese in
older patienr.
95b OPG s hows large lytic ameloblastoma in the
right mandible with areas of int ernal septation
producing a 'soap bubble' appearance.
eNS, Head and Neck Imaging Case 96
l. ... 'St with demal associ,uian:
tCd \Iith toot h apcx :md pain . I>crbpical cyst.
tcd with unerupted tooth _ dentigerous cyst
\'Can and associated with crown) or
JStOlll3 (>30 years).
C\ost wit h no dcnral association:
_ OKC, simple bone cysr.
- - ameloblastoma, mct3stases or myeloma.
<Y
year-old patient presented with
-hes and suspected sinusitis.
If brown tumour is suspected look. for other signs of
hypcrpar:uhyroidism such as resorption ofthc lamina dura
orthe teeth producing 'floating teeth' and generali zed
dcmincmlization ofrhc mandible and ll1;uilb.
Further management
Though often dentigeroll s cyst can cause
pain and swelling and may predispose to pathological
merure. Surgical excision (including the uncruprcd tooth)
may therefore be undertaken.
Further reading
Scholl R., Kcllw H, Neumann D, Lurie A ( 1999). Cysts
and c"sric lesions of the mandible: clinical and
radioiogk-histopathologic review. RndioGrnplJics 19:
1107- 11 24.
165
166
Answer 96 eNS. Head and Neck Imaging
ANSWER 96
Observations (96a)
This occipiwn1cnral radiograph shows a large calcified
lesion in the right fromal sinus. The lesion has \'cry well
defined margins and a slightly lower density cemre. No
fluid is seen within the sinus and there is no evidence of
local bony destruction. The appearances arc those of a
frontal si nus 'iYory Ostt-oma',
Diagno'sis
h'ol)' osteoma.
Di scussion
Osteomas an:: benign tumours of membranous bone. These
arc round, well defined lesions of bony density that arc
usuall y found incidentally. They arc commonly found in
the paranasal sinuses, p:l1"ticularly the frontal and et hmoid
sinuses. Other coml11on si tes include the calvarium and
mandible. A CT coronal reconstruction (96b) in the same
patient confiml s t hat the lesion lies within the right frontal
sinus.
96b Coronal CT reconstruction demonstrating a right
frontal sinus osteoma.
Practical tips
"Yhen multiple osteomas arc seen always consider
Gardner's syndrome and irwcsligarc the fami ly hist
and tor the presence of colonic polyposis.
Paran:lsal sinus osteomas may cause local pressure
erosion. A coronal CT rcconsmlCtion (96c)
dcmonstrJtcs a left cdulloid sinus osteoma eroding:
the lamina papyracc;l and extending into the left
orbit. Background sinus inOammatory changes 3
present.
Further management
Incidental finding requiring no further management
eNS. Head and Neck Imaging
lid female presented with
w.l loss; and an episode of
mthsago.
Case 97
167
168
Answer 97 eNS, Head and Neck Imaging
ANSWER 97
Observations (97a. 97b)
Selected MR images ofrhc brain - FLAIR axial and T2
weighted sag;!!al - arc presented. These scans show
multiple foc:!] O\'oid signal abnormalities in the
pcri\'ctltricubr white matter, which 3rc orientated
perpendicular to the long ax is of dIe ventricles. Further
lesions invoke the corpus callosum. No associated oedema.
No evidence of hydroccph:tlus. Given the clinical derails, it
is likely that the patient has multiple sclerosis and is
currentl y experiencing optic
Diagnosis
Multiple sclerosis (MS).
Differential diagnosis
Of white matt er lesions on MR];
Acute disseminated cnccphalolll),clitis (ADEM).
Vasculi t is.
Ischaemic disease (97c).
Migraine.
Ncurosarcoid.
Di scussion
This is the mOSt common chronic demyelinating disease
and' is characterized by multiple lesions spread in tilll e and
space. Typically, it has a remitting /rdapsi ng course. The
onset of symptOms is usually in the 3rd-4th decades and
thcre is a sli ghtl y increased predominance in remales.
I ncrcascd prevalence is nOTed in areas of temperate cl imate.
Clinkal presentation is with focal neurologi cal signs,
commonly including optic neuritis.
Imagingfcaruresare:
Lesions arc ]x:ri\'entricular in location, O\'al
in shape, with their long axis perpendicular to the
lateral ventri cle wall s - 'Dawson's fingers'.
Common locations for plaques include peri\'entricular
white matter, corpus callosum, internal capsule,
centrum scmiovale, optic ner'I'C/ tracts, cerebellum.
Lesions on the inferior aspect ofrhe corpus ca ll osulll
arc characteristic.
Acute lesions can ha,'c mild surrounding oedema and
can enhance with comraSt.
Chronic lesions ha"e no mass effect / oedema and
don'tcnhancc.
Lesions arc hyperintense on T2, hypo/ isointense on
Tl.
Mull'ip1c sclerosis is also the most common demyelinating
process aflccting the spine - the cervical spine being most
frequently affected. It is characteri zed by plaques orientated
along the axis or the spinal cord.
Funher clinical e\'3lua[i on im'ol\'es:
Lumbar punctme with CSF analysis for ol igoclon:tI
bands.
Electrophysiologic;).1 studies.
Practical tips
Focal while matter signal ;).bnorm;).lities in cerebral
white marter (sometimes referred to as unidentified
bright objects - UBOs) are common incidental
fi ndings on MRl with se\'eral aetiologies. Maki ng a
specific diagnosis of dem),clination is often nor
possible from imaging alone though multiple IcsiOOl.
il1\'ol\;ng lhe corpus callosum arc characteristic for
1.'15. Coexisting lesions in the brainsl'cm, cerebell um
and spinal cord also increase specificity.
Be wary of making a conclusive diagnosis of M5
M RI unless feat ures arc highly specific and t here is J.
supporting history - the consequences for the pa
arc significant. Often , one can only offer a ditlcrcn
diagnosis for ' UBOs' that incl udes ,'v15.
Further management
M RI of the spi nal cord is frequentl y also undertak
complete assessment. Though MRl findings may be _
suggesti\"e , careful neurological assessment is req uira.
correlate the imaging findings clinical and Jahora.
findings before making the diagnosis.
Further reading
Runge VM, Price AC, Kirshner H5, ct at. ( 1986). n.
evaluation of multiple sclerosis by magnetic reso
imaging. RfldioGrnpbiC!6: 203- 212.
97c Sing(e axial MRI FLAIR image shows
periventricular high signal with scattered high
signal white matter foci. Appearances are of
related small vessel disease.
eNS, Head and Neck Imaging
Case 98
169
170
ANSWER 98
Observations 198a, 98b)
This later:)l image of the skull (98a) shows elongation of
the jaw (prognathism), frontal bossing, cnlargcl1lt:nr of the
frontal sinuses and t hickening of the calvaria. There is
marked enlargement of the pituitary fOssa with e,idcncc of
expansion bur no erosion.
Selected sagitt;'l] 1' 1 weighted illlages (98b) of the br.l.in
connml the plain IiIIll findings of enlargement of the lTontal
sinuses, frontal bossing ;'ind thickening of the c;l]"aria.
There is a mass lesion within the pituitary fossa with
appearances consistent wit h pituitary macroadcllol1la.
Enlargement of the tongue is also noted.
Diagnosis

Discussion
Excess growth hormone secretion by the anterior lobe of
the pituitary gland results in a variety of nlllsculoskclet;ll
abnOfm:l.litics.
g8e Magnified image from plain skull radiograph
shows enlargement of the sella.
Plain radiogr:tphic image findings :l.rc:
Enlargement of the sella (98c).
Mandibular enlargemcnt.
Increase in sizc ofrhe frontal sinuses with promin
afthc supraorbital ridge.
Enlarged hands with spade-like appearances of the
terminal phalanges (98d).
Thickening of the calvaria.
Dur:t l ect:l.sia :l.nd posterior \"crtebr:l.1 body scall apln:-
Increased heel pad thickness( >25 tllm) (98c).
Prcm:lture ostcO:lrthritis (OA).
Pract ical tips
Normal dimcnsions of thc pituitary fossa on lateral
films arc a length of < 15 mill and height of < 12 mm.
Further management
!\'ianagcmcnr of this condition is both medical (soma
statin/brolllocriptine ) and surgical ( trallssphe n
hypophysectomy).
98d Radiogra
of the hand
shows marked
soft tissue
enlargement
givi ng it a sp
like appearanc:e.
In addition th
is widening of
terminal tufts.
98e Soft tissue lateral radiograph demonstrates
thickening of the heel pad, which measures >25 mm
in thickness. .
eNS. Head and Neck Imaging Case 99
-. weighted axial (top left). thin section T2 weighted axial orbits (top right), axial and coronal T2 weighted
I MR images.
171
172
Answer 99 eNS. Head and Neck Imaging
ANSWER 99
Observations (99)
The axial images of the orbit show fusitorm enlargement
of the posterior right optic l1en'e, which also il1\"okes both
sidcs of the optic chiasm. The coronal scan confirms
thickening of the posTerior aspect of bOTh optic nen'es.
Axial T2 weighted images also show a round tixus of high
signal in The right cerebellar hemisphere and a second lesion
in the posterior aspen of right midbrain that produces
convexity to the margins of the cerebral peduncle. The
appearances arc likely to indicate optic nerTe glioma
involving the chiasm and both opril": nen'es along with
hamartomas in the cerebellum and midbrain due to
neurofibromatosis type I. No cutaneous neurofibromas arc
seen on these images.
Diagnosis
OpTic chiasm/nen'e glioma due LO neurofibromatosis type
1 ( NFl ).
Differenti al diagnosis
ror optic nerve thickening:
Optic nen'e glioma - 80% under 20 yean, variable
enhancement, calcifjcation I""Olre, buckling of nen"e,
of len asymptomatic.
'Meningioma of optic nem: - middlc aged women,
'tramtrack' enhancemelll, calcification in 20- 50%,
st raight nen"e, visual impairment early.
Sarcoidosis.
Multiplcsclcrosis
Lymphoma, kukaemia and metastatic disease.
Intracranial hypertension - enlarges the perineural
CSFspace.
Discussion
Opt ic nen'e glioma typically presents in childhood, only
20% manifesting beyond the age of 20. Rclati\"cly slow
growing and benign ill children, lesions presenting in adults
often show morc rapid malignant growth with intracranial
spread. Though often asymptom:uic, prescntaTion can bc
with visual loss and strabismus. BHater:!1 tumours herald
NF l . The tumour causes fusiform or tubular cnlargement
of the optic nen"e sheaTh complex and shows variable
enhancement with IV contrasT. The majority of lesions
occurring in the orbital portion of the nene do not extend
intracranillly. Some optic nen'c gliomas haxc ext!:
associated thickening of rhe surrounding meninges, Ie
ar.lchnoidal hyperplasia, which is often seen in patients 'Il
NF - on T2W MIU, Ihis is seen as:I ccntrallow-si
tumour surrounded a higher-signal rim that call M
like a dilated perineural CSF space. p.
Approximately 25% of paticlHs with optic glioma
NFl and it is one of the diagnostic critcri:l listcd for
condition, of which two or more arc required: six or IDI
'cafe-au-lait' patches; twO or morc Lisch nodules; rn
more neurofibromas or one plexiform ncurofibr
axillary freckling; optic glioma; bone
pseudarthrosis; fint degree relati,'c with NFl} In this
the coexisting lesions in the cerebell um and midbrJin
one to the overall diagnosis of NF l . These high T2
toci arc seen in the brainsl'em, basal gangl ia, cerci
peduncles, cerebellum and the stLprarenrorb.1 whi Te
They arc usually thought of lS I
lnd often decrease in size with .
to in the cerebmm,
and telling the difference be i
enlarges O\'er time or shows
possibility of astrocytoma must be considered.
choroid plexus calcification and hydrocephalus
aqucduct stenosis arc other intrncranial features .
NFl is sporadic in 50% and autosomal dominant'
(chromosome 17).
Practical tips
Tl weighted post-contraSt scans of the orbit sh
be performed with fut suppression in view of the
adjacemorbitai fur.
Meningioma is the main differential diagnosis for
optic ncn'e thickening and the features liSTed abo-
may help distinguish the tWO.
Whenever NFl enters t he diflcrential for anv
I""Oldiological study, al\\':lYs check for evidence of
cutaneous nodules that 'clinch t hc diagnosis'.
Further management
Treatment depcnds on the size ofnrl1lour along \\
age and gener:!] condition ofthc patient. Options
surgcry, radiotherapy and chemotherapy.
eNS. Head and Neck Imaging Case 100
173
174
Answer lOa eNS, Head and Neck Imaging
ANSWER 100
Observations 1 11008)
Axial T2 weighted image demonstrates high signal in the
lateral aspect of right medulla. This is bright on dIe DWI
indicating restricted water molecule: diffusion probably from
cell swell ing due to leutc inf:lfction. Together with the
clinical details, findings arc consistent with
syndrome due to infurction in the territory of the right
posterior inferior cerebellar artery ( PICA).
Observations 2 (100b)
These axial and coronal 1'2 weighted images show a focus
ofincrcascd signal in the right side of the midbr:l.in. Then:
is no associated mass dice! and the lesion lies in the region
of the red nucleus. The clinical symptoms arc compatible
with 3n infurct affecting the red nucleus and causing
Claude's syndrome.
Diagnosis'
Right PICA infarction (Wallenberg's syndrome).
Diagnosis 2
Ri ght midbrain infarction :lflccting the red nucleus
(Claude's syndrome ),
Di scussion
There arc various specific panems ofbrainstem infarction,
oftell having unusual eponyms. Othe rs include Weber's,
Nodlnagel's, "<lillard-Gubler and Foville's syndromes.
Wallenberg's syndrome is due to PICA occlusion and
presents with ipsilateral ataxia, d)'sphagia, fucial pain and
temperanlre sensory impairment and Homer's syndrome,
wi th contralateral irnpairrncnL of pain and tcmpcrature
scnsation in the bod)' and limbs. The PICA is the first
major intracranial branch of the vertebrobasilar system :lIld
supplies the dorsolateral medulla, cerebellar ,'ermis and
posterolatcral cerebellar hemisphere. It arises from the distal
"ertebral :lrtery just below the basilar artery origin. As well
100a High signal in lateral aspect of
ri ght medulla.
as thrombosis, infuretion can result from dissection of
,'crt ebral artery,
Claude's syndrome is due TO a lesion of the red nu
of which inF.lrction is one example. The consequences
ipsil:tteral oculomotor pals}' and contralateral tremor
araxia,
Practical tips
These arc examples of comparati\'el y rare and
specific infarcts but they do make for an interestin ....
test ofneuroonatomy understanding!
OWl depicts reduction in Brownian motion of\\
molecules, Cytotoxic oedema in acute infarction
produce this and present high signal on the 0\\1
scan. It is ,'cry sensitive, depicti ng infurclS JUSt 30
or SO from onset.
The DWI image also has inherent T2 weighting
'shine through' ), that is, thc signal is a combin.lD
ofT2 weighted and reduced diffilsion, As such.
not distinguish an older infurcr (T2 hyperi
from a recent one (reduced diffusion) as both \\
appear bright. An alternati\'e that can
diflcrentiate acute and nonacute infurcts is the
apparent diffusion coefficient (ADC) map.
no T2 component and shows reduccd diffusion
acute infurct) as low signaL An older infarct th.Jl:
also bright on DWI b}' virt ue of T2 'shine th
will be bright on AOC.
Ischaemia is not the cause of reduced di
Others include seizurc, trauma, h}'\>oglycaemi..l.
abscess.
Further management
DWI is !\lore scnsiti"e in thc carl}' detection of '
when compared to CT. However, when throm
being considered, cr is more than adequate to
haemorrhage alone.
100b Right midbrain high signal.
eNS. Head and Neck Imaging
101
C1r-old male presented with
_lIlrrollcd epilepsy_
Case 101
175
176
Answer 101 eNS, Head and Neck Imaging
ANSWER 101
Observations 1101a. 101b)
The axial CT image of the [)",in ( lOla) showsscvcliIl small
calcified lesions in the subepcndymaJ region of the txxIy of
the lateral \cntricks. The T2 wciglucd MR im:agc of the
brain ( 10 I b) conlirms sc\'cml small subcpcndYlllalnodulcs
with associated low signal representing calcification. These
appearances arc consisTcm with slIbcpcndymal hamartomas.
There arc abnormal widened gyri in the left paricml lobe
and right frontallobc seen on Ihe MR image, which arc
likel y to indicate cortical h:lI11lrtom3S.
Diagnosis
Tuberous sclerosis.
Discussion
TuberOLis sclerosis is an inheri ted autosomal domin:llll
disorder of the neuroectoderm that is characterized bv
mul[isystem abnormalities. The classical triad of features
arc mental retardation, seizures and adenoma scbaceum.
CNSfcarures:
Subepcndymal hamartomas - most commonfy seen
along the ventricular surfuce of the caudate nucleus.
r ... l ultiple small sy.bependymallcsions which calcify in
80%. Figure I Ol c shows another case where nodules
have not calcified, but produce :I 'w:lI'y' border to the
,entriclcw:llls.
Corric:ll t ubers - appearances arc of large widened
:ltypical gyri with reduced attenuation ce!lues on CT.
The)' :Ire usuall}' multiple and can show rim
calcification in 50%.
Heterotopi c grey matter is13nds - these :lppcar as 13rge
hypodcnsc focal islands of tissue \\ithin the cerebral
whiremattcr.
Giant cell astrocytOlll:ls - occur around the foramcn of
J" lonro, and can cause hydrocephalus. J\-blign:l11t
potential is low.
Multisystem illvokement:
Ocular - ocular phakomas, oplic nerve gliomas.
Renal - angiomyolipoma, cysts, incre:lsed risk of ren:ll
ccllcarcinoma.
Respiratory - Iymphangiomyom:ltosis-like features
with cystic lung disease, spontaneous pneumothoraces
chylothorax.
Cardio,"asctdar - rhabdomyoma, aonic aneurysms.
Skin - :ldenoma sebaceum ( red/ brown small flat skin
lesions distribUled o\"er nose and
checks), sh:lgreen p:ltches, ash lcaflcsiolls, subungual
fibromas.
Practical tips
The phakornatoses ( neurocutaneous disorders), of
which tuberous sclerosis is an example, make great
eX:l111 G1SCS because of the multitude of radiological
signs to 'piece together' - know them well!
Distinguishing lubcrs/ h:lrnarto111as from giant c
astrocytomas: tubers and subependymal hamar!
C:lll show some enhancement on MRI but CT is
usually sensithe enough to show this. Because
cell astrocytom3S show more enh:lllcement, this
be :lppreeiable on CT a.nd should a.rouse suspici
Further management
Tuberous sclerosis has a high mortality with 70
before the :lgc of 24 A multidisciplinan
approach is required with follow-up imaging im
Mltl brain, renal ultr3Sonography ( monitoring
myolipom:ls :lnd looking for renal cell c:lTcino
cchocardiography (50% of patients ha\c
Further reading
AJtman Nit, Purser RK, Post MJ ( 1988). Tuberou.
sclerosis: characteristics:l t CT and J\' IR imaging.
Radi%gy 167: 527-532.
.... 101c ./ ,_

--
i, ! _,
. ,.., , ,
f f:-
'. ', .",.
eNS, Head and Neck Imaging Case 102
177
178
Answer 102 eNS, Head and Neck Imaging
ANSWER 102
Observations (102a)
Axial 1'2 (left ) and gradient echo T2 (right ) images
dcrnonstr,nc a lesion in the lllcdi:ll right Icmporallobc with
a vcry low signal rim representing hacmosidcrin. This is
ch:u :lctcristkally more prominent on the gradicm echo T2
sequence with 'blooming' artcf.tcr. The cenlre of the k-sion
shows T2 hypcrimcnsity and the o\'crall shape is round.
The fcamrcs are consislcnr with a C:l\'crnoma.
Diagnosis
Ca\'crnoma (ca\"ernous angioma or ca'"crnous mal -
formation)"
Discussion
Vascular malformations arc a common cause of
parenchymal brain haemorrhage and should be excluded
when young patients present with spontaneous
haemorrhage. They de,"elop from congenitally abnormal
\'ascular connections, whieh may incrcasc in size. with rimc.
R .. 1diological features of\'ascular malformations arc:
Arteriovenous malformations (AVMs) afe the most
common type and arc eucntially an abnormal
collection of an cries connected dircctlv to ' "cins with
no imen'ening capillaries ( I 02b). Thc' vast majority
afe supratentorial. On CT thc)' arc of mixed density
and mav have calcifications. Enhancement is also secn.
!-Iowcver, the classical appearance is found on MRl
102b Large right cerebral AVM
demonstrated on a CT cerebral angiogram.
where flow ,ooids with complcx flow patterns aTe
Figurc I 02c demonstr.ltes an example on an axi al _
weightcd image with an AVM in the right frontal
producing the characteristic (';l1lglc of now voids.
C:wernous malformations (ca,"ernomas) arc thin
walled sinusoidal vessels representing congenital
hamartomas. Unlike other vascular
then: is no brain parenchyma Ixtwecn the \"3sculM
spaces. The appearancC$ on CT arc rather nons
but i\'IIU shows vcn' characteristic features, as
illustrated. The celltral high signal represent's
lllcthaemogiobin and the outer low signal rim
haemosiderin. They presem with focal seizures (W
small parenchymal haemorrhages.
Venous angiomas arc asymptomatic and
anomalous ,"eins that dmin rhe normal brain.
Classically, an enhancing stellate venous mallo
is seen extending TO t he ventricular or conical
Practical tips
AVMs typically h;1\'c ;t tangle oflow-signal flo\\
":\ on ,\-IRI best seen on T2 and PD weighted ima_
10% of AVMs develop an :lssod:J.tcd :lllclll)'Sm OJ(
alw:l\'S look. for this.
Gradient ccho T2 is an excellent technique for
idcntif)'ing haclllosidcrin 011 MIU, which is oltca
in vascular llultOrm:uions.
102 eNS. Head and Neck Imaging Case 103
idcrin will also be seen in an old haemorrhage
itwoking an underlying vascular
ation. Figure l02d dcmonSlrarts an old
age in the kft imernal capsule/thalamus
.. would be cas}' to confuse this with c;;wcrnoma
the axial image. Howe"er, all old haemorrhage
to form ::I slit-like cavity unlike the rounded
of cavernoma, and the coronal scan illustr.n cs
difference. NOte also the local \'olume loss due to
gliosis resulting in some enlargemen t orlhe adjacent
[cft [atcra] vcntridc.
Further management
Often these arc aSYffipromatic and call be monitored with
imaging to 3SSCSS change in growth. There is, however, an
up to 2% risk of bleeding and surgcry/slcrcoractic
radiosurgery arc treatment options.
03 Axial and coronal T2 weighted scans of orbits (left/middle) and a 'time of flight' MR angiogram of the
rluacranial ci rculation !right),
179
180
Answer 103 eNS, Head and Neck Imaging
ANSWER 103
Observations (103)
T2 weighted images demonstrate dilatation of the left
superior ophthalmic vein \\'ith presence of flow \'oid and
no focal compressi\'e mass lesion. The "time of flight' MRA
demonstrates normal arteri:!l intracranial anatOIlW \\'ith
signal in the dilated left ophthalmic \"cin indicatil;g f.m
flow. The find ings arc in keeping with a kft carorico-
C;ll'crnousfisrub.
Diagnosis
CaroriCOC3'I'CrIlOUS fistub.
Differenti a l diagnosis
For superior ophthalmic rein distension:
Ca"ernous sinus thrombosis.
Superior ophthalmic "ein thrombosis.
Pseudotllmour.
Graves' disease.
Obstructi,'c orbital mass.
Discu ssion
Fistulous communication betweell the internal carotid
artery and the ca"ern?us can ariS<,' secondary to head
trauma or rupture 01 an mternal caroud artery aneurysm,
The condition olien occurs spontaneously, however, due
[0 atherosclerosis. In addition, fisllllae can occur \\ith dural
branches of the external carotid artery. Orbital bruit is
found in - 50% of patients due to turbulent arterial blood
flow, The increased arterial pressure in the l'e!lOllS system
and orbiral "cin congestion result in the symptoms of:
Pulsatik proptosis.
Chemosis.
Reduced visual acuity due to impaired retinal
perfusion - scvere/ rapid visual loss requires
angiographic im'cstigation and listula closure as an
emergency (0 preserve function.
103 Dilated left superior ophthalmic vein.
Cranial nerve palsies - most commonly 6th and 3rd
nervcs. This is thought to be due to either impaired
\"cnous drainage of the ncn"c or direct compression
Ilcr'I'CS bv distended ' "cins.
srmptoms arc secn in - 10% duc to
presence of conllcniOtls between the two GI\"ernous
sinuses.
Imaging features on h'IRI arc:
Dilated superior ophthalmic vcin with flow ,oid.
Enlargement of the ea,'ernous sinus.
Swelling of the extraocular muscles, which can rcsuli
in limited ere mo,ements.
shows c;\fly opacification of the supe
ophthalmic rein when contrast is injected into intc
carotid artery. opacification of the veins C011llTI
eating with cavcrnous sinus may also be noted.
Practical tips
Early radiological changes arc of enlarged ocdemat
extraocular muscles and dilatation of the superior
ophthalmic Icin.
More chronic changes arc of eniargeillent of the
superior orbital tissure and scll:ar erosion.
Clinically, pulsatile exophthalmos susgeslS this
condition.
Further management
When imaging features of a caroticQCa"ernous fistu.b
associated with decreased "isua! acuit,)" cmergency
mcnt is required to relieve intraoclllar pressure.
eNS, Head and Neck Imaging Case 104
181
182
Answer 104 eNS, Head and Neck Imaging
ANSWER 104
Observations (104)
SeleCTed '\'IR images ofthe brain show a large lesion in the
cerebellum, which is predominantly cystic in narure
(hn>erimcnsc on T2 and hypoimensc on Tl weighted
images). Following IV colltrnsr there is cnhancemcm oftlle
\\':1.11 of the cystic component and an associan:d solid nodule
posteriorly. S.1gittal image shows some filllncss of the btcral
"cmridcs and ObStTUcri\'c hydrocephalus is likely with
compression at thc level of the 4th '(lUride.
Diagnosis
Hacmangioblastoma.
Differential diagnosis
Juvcnilc pilocytic ;lstrocytoma - can be "cry difficult to
diflcrentiatc from a haeillangioblastonll. This is the
mOSt COlllnlon infratentorialtulllour in children.
There is an association wi th ncurofibromatosis typc I ,
Lesions arc of an ident ical appearance, with a
predominant cystic component and enhancing solid
peripheral nodule.
Metastasis.
Arypical mcdulloblastoma,
Di scussion
Haemangioblastoma is a benign vascular rumoull aflccting
the CNS. It is the most common primary infratemorial
nUllour in adults. The majority (80%) present in adults in
the 3rd-6th decades, although there is an association '\ith
"on Hippel- Lindau (VHL), which sees these tumours
presenting in childhood and in this case may be multiple.
Typical appearance is of a well defined cystic I
containing fluid of CSF density with a solid perip
nodule, showing uniform a"id enhancement.
commonly haemorrhage or necrosis in the solid n
but it rarely calcifies. In up to 30% of cases the lesions
be emird)' solid wilh no cystic component.
Practical tips
When forming a differential for the posterior fossa
mass with enhancing peripheral nodule, the foil
general izations apply:
Chi ldren - piloc)'tic astrocytoma>
hacmangioblutoma.
Younger adults - hacmangioblasroma most com
Older adults - consider cystic mctaS[3sis
Further management
When haemangioblastoma is suspected, don't forg:...
raise the possibility o f VH L (4-20% of haemangiob
occur in the COllleXI of VHL and multiple lesi
diagnostic ofVI-IL). VHL is an autosomal dominant
inherited condition characterized
develop a
blastomas, cardiac
pheochromocytomas, pancreatic I
cell mmours and haemangioblaslomas, li"er
and retinal angiomas.
104 Enhancement of the solid posterior nodule on post-gadolinium images.
eNS. Head and Neck Imaging Case 105
183
184
Answer 105 eNS. Head and Neck Imaging
ANSWER 105
Observations (105)
The selected images demonstrate diffuse cerebral atrophy
exceeding that cxptctcd for the patient's young age. There
is:I large focal area of signal abnonm.liry in the central pons
Ih:1I is hyperintense on T2 weighted and hypointcnsc on
TI wei glued sc:ms. 111crc is no associated mass effect. The
signal changes would fil with central pontine myelinol ysis
and the clinical dCt3i1S and cerebral atrophy suggest that
chronic alcohol abuse may Ix the underlying cause.
Di agnosi s
Central pontine myelinolysis.
Differenti al diagnosi s
Pondnc glioma.
Inf.,rcrion.
Di scussion
Central ponline myelinolysis results from the destrllction
of sheaths, in patients with rapidly
corrected hypon:t tracmia. Cases are reported in patients
with:
Chronic alcohol abuse.
Chronic liver disease. '
$c"ere m::alnutrition.
Wilson's disease, chronic rell::al fitilure, diabetes, acute
m)'clogcnous leukaemia.
In the c::ase demonstrated there is diffilse glob::al (erebral
::atrophic ch::ange suggestive of chronic alcohol abuse.
Clinically this results in pseudobulbar palsy,
cOll\'uisioIlS, acute confusion and progression to comL
is mOSt commonly confined to the pons but changes
also be secn in the basal b>;lnglia, caudate, thalamus
suocortkal white matter. Radiological presentation is
fairly wdl defined low attenuation lesions on CT in
central pons. On MIU, lesions aTe oflo\\' intensity on
and high signal imensity on T2 imaging.
Practical tips
Standard MR/CT im::aging (::an be normal for up to
days after symptolll onset, lagging considerably behi nd
clinical presentation. Rest ricted diffusion on D
however, is found wirhin 24 hours.
Further management
Early MIU appearances can be similar for a b::asibr
inElrcr and M RA (::an be useful to look for :lrteri,;d
thrombus.
Sc::arch for underlying cause if not readily app::arcOL
Further reading
Ruzek KA, Campe::all NG, Miller GM (2003). Earf!;
diagnosis of central pontine myelinolysis with
diffusion-weighted imaging. American JOllnHlJ
Nmrorndiolo!JY25: 210-213.
Stadnik nv, Demaerd P, Lurpaert RR., It nl. ( 200.;
Imaging tutori::al: differemi::al di::agnosis of bright
lesions on diffusion-weighted MR images.
RadioGraphies 23(1): e7.
105 Focal area of reduced Signal on T1 weighted (left) and increased signal on T2
weighted (right) images.
eNS, Head and Neck Imaging
-old fCIll:a1c patient prescnted
clles.
Cases 106, 107
185
186
Answer 106 eNS, Head and Neck Imaging
ANSWER 106
Observations (106a )
Thi s non contrast enhanced cr image demonstrates a large
midli ne mass extending into t he 3rd ventricle, which hlS
both solid :lIld cystic compOllcnrs with central calcitication.
There is dibtation orthe temporal and anterior horns of
the "cntridcs but normal :tppcarancc to the 4th ventricle -
findi ngs arc in keeping with obstructive hydrocephalus at
the lc,"el of the. 3rd ventricle secondary to a mass lesion.
The mixed density and calcification arc \ ' (1)' suggcstive of
a craniopharyngioma and MIU is suggested to further
e"aluate.
Diagnos is
Craniopharyngioma.
Differential diagnos is
or suprascllar/intrascllar mass lesion:
Pituitary macroadcnoma.
Craniopharyngioma
R.1thke cleft cysr.
Other masst:s in the sell ar region include meningioma,
metastases, chordoma and intenla!l'arOlid mer)' aneurysm.
Pituitary macroadenor{KI is the most common lesion
involving the sellar and suprasellar regions. Microadenol1las
(20%) an: defined as being less [han 10 mm in size and
usu:llly present with sympl"Oms due to hormonal secretion.
Macroadcnoll1as (80%) measure over 10 mill in size and
arc usually endocrinologieally inaeri,'e. T h e ~ ' present with
symptoms secondary to mass effeer such as hydrocephalus,
bitemporal hemianopia from optic chiasm compression,
involvement of cranial nerves tr:wdling in the adjacent
c,wcrnolls sinus ( 3, 4, 53 and 6) and hypopitui
resulting from compression of normal pituitary tissue
Compared to craniopharyngioma, pituitary
adenomas arc predominantl y solid and show morc i
uniform enhancement. Calcification is rare,
craniopharyngioma. Suprasellar extension produca
'snowman' configuration due to w:lining at the I
the diaphragm sellae. Figure I 06b shows prc- and
contrast Tl weighted images of a pituitary macroa
with such features.
lbthkc deft cyst is the other main diAcrcntiai di.a_
wi th 70% in\"olving sellar and suprasellar regions.
benign cySt arising from remnants of Rathke's pouu
can be differentiated by the following features'
regular and ovoid shape, smaller size ( <2 !TIl ), cystio;:
110, or minimll cnh:lllccmcnt ofthe thin wall.
Di scussion
Craniopharyngioma account for - 4% of int
neoplasms, with a slight predominance in males,
peaks ofincrcascd incidence:
Firstl y in children in 1st-2nd decades, Wh("fC
account for 50% of suprasellar turnouTS.
Secondl y in adults in 5th - 6th decades.
These arc benign tumours arising fro m rem
111thke's pouch. They grow from a suprasellar ori_
the base of the 3rd vemricle. lmr:lsel lar extension
in 2 1%. Involvement of the bon)' sella can be seen
radiographs and o n CT bOlle window imag("S
demonstrate appearances or J-shaped sell a, enl
and then ultimatel y erosion and destnJcrion.
106b Pre- and post-contrast T1 weighted MR sagittal images demonstrate a large pituitary
adenoma with uniform enhancement with contrast and with no cystic elements or signal
voids to suggest calcification.
106
eNS, Head and Neck Imaging
IT appcar,lIlccs arc 5ho'l\'11 in this casc \\;th
,,:ystic clements and calci fi cuion (which is
-90% of cases). Following comrasl there is
amen! of the solid compOllcnrs and the CYSt
.\tRI findings reflect CT features with a cystic
InCn! following fluid signal (although high
>my be seen on Tl weighted images depending
Jttin/ blood content). The solid componcm is
on T 1 and shows cnhancclllcllI with
106c shows '1'1 sagittal pre- and post-IV contrast
d T2 axial and 53gitt.l l images (left). These
.I Lu-gc suprasellar lesion with intnsclb.r extension.
solid and C}'stic clements wj th enhancement of
component'S and cyst wall. Complications of
'C hydrocephalus, pituitary st;}lk and optic chiasm
n can be appreciated.
Practical tips
Look for the complications of masslcsions in this area:
Hydrocephalus :lIld optic chiasm compression.
Lateral extension to invoke thc cavcrnous sinus ( seen
in up to 10% of pituitary which can
lead to thrombosis :lIld cranial nervc palsy. Lateral
extension beyond the lateral wall of the internal
carotid is rare wilh Rathke eleft cySt :lnd may help
diflcremi:lte it frolll the other two conditions listed.
Further management
Treatment is surgical +/- posropcrath'e radiotherapy.
Furt her reading
Choi SH, Kwon 81, Na DG, ct al. (2007). i'imitary
adenoma, craniopharyngioma, and Rathke cleft cyst
ilwolving both intr.tsell ar :lIld suprasellar regions:
ditlcrcntiation llsing 1-Ht!. CIi"icn! Radio!ogy62:
453-462.
106c T1 sagittal pre and post -IV contrast and T2 axial and sagittal images demonstrate a
large suprasellar lesion with solid and cystic elements with enhancement of the solid
component s and cyst wall. The lesion is causing obstructive hydrocephalus, pit uitary stalk
and optic chi asm compression.
187
188
Answer 107
eNS. Head and Neck Imaging
ANSWER 107
Observat ions (107a)
T1 sagi ttal and T2 axial and coronal images of the brain
dcmonsu':uc: complete :agenesis of the corpus callosum \\ith
no callosal [issue identified. There is increased separation
of the 13tcral \'cmodes on the a.xial images crc;uing a 'b:J.t's
wing' appear-uKe. Coronal image demonstrates clc\'3tion
of the 3rd ventricle.
Di agnosis
Agenesis ofthc corpus callosum.
Di scussion
The corpus callosum usually develops by 20 \\'ccks'
gestation. The genu and the body of the. corpus callosum
develop first and the posterior bod)' and spleniulll develop
b ter. The rostrum is the last part of the corpus callosum TO
develop. Idcntil}'i ng the parts of the corpus callosuill
present call help to diflcrcntiatc octwccn dysgenesis (absent
genu/splenium) and destruction, most commonly 10
ischaemia (genu present but may be atrophic ). Corpus
callosal agenesis is usually associated with reduced
intellectual function and can be associated with a varier\' of
c;NS abnormalities
itpoma, Oandy- 'Valker cySts, mterheilltsphenc arachnOId
cysts, neuronal migration disorders and Arnold- Chiari
malformation.
Classical imaging appearances on CT/MIU arc with:
' Bat 's wing' appcar""Jnce of the lateral ,'entriclcs due to
parallel lateral "entricles with marked separation
( 107b).
' High riding' 3rd ventricle - can be seen at the b 'd of
the Jateml ventrieles.
Enlarged foramen of t-.'ionro.
Prenatal detection can be made by US investigatic..
Diagnosis cannot usually be made before 22 wee
gestation. Equivalelu image findings arc of:
Absence ofthe septum pdlucidum.
Dilated/elevated 3rd ,cnrricle.
Enlargement of the occipitJI horns of the lateral
,cntrides.
Practical t ips
Ditlcrentiating bcrween dysgenesis and ischacmie da
is done de("ermining which parts of the corpus call
arc abnormal. With ischaemie injury the rostrum nill
present but :ltrophic.
Furt her management
Somctimcs this fin ding is made incidentally on
imaging in later lire and no fu rther in\estigatiOD
required.
Further reading
Babcock OS ( 1984). The normal, absent, and abno
corpus callosum: sonographic findings. Rndioio..!!!
15 1: 449-453.
Oa\'idson HO, Abraham R, Steiner RE ( 1985).
of the corVllS callosum: magnetic resonance
Rndiolog., 155: 371 - 373.
107b Axial CT images of the brain demonstrating 'bat's wing' appearance of the lateral ventricles in a
with agenesis of the corpus callosum.
eNS, Head and Neck Imaging Case 108
189
190
Answer 108 eNS, Head and Neck Imaging
ANSWER 108
Observations (108a. 108b)
Axial CT images ( 1 08a - axial CT scaJl at skull base with
IV contrast, seen on bone and soft tissue windows) oflbe
brain demonstrate a poorl}' defined enhancing lesion in the
jugular foramen, which is extending superiorly to in\'ol\'e
rhe middle car and is causing permeative erosion aflbe
pClrous temporal bone at the juguhlf foramen. The T2
weighted MR image ( l OSb) confi rms this mass lesion,
which appears hrpcrintcnsc with serpiginous flow ,ooids
indicati ng vascular flow.
Diagnos is
Glomus jugulorymp::lIlicum tumour.
Description
Glolll us jugulare rulll OUrs afC paragangliomas :lIld afC rhe
most common jugular foramen lesion. Trpically, these
lesions arc soliury with a peak incidence in the 5th-6th
decades and increased incidence in females. There are
fumi lial associations in which multiple paragangliomas
present in conditions such as multiple endocrine neoplasia
( MEN).
Glomus jugubre rumours usually extend imracranially
and can inl"ohe the middle car, as demonstrated here.
Clinifal presentation ma), be related to illloll'cment oCthe
9t h, 10th and 11 th cranialnervcs. When there is extension
to im"oh"e the middle ear (glomus jugu10tympanicum) then
pulsatile tinnitus is the classical presentation.
These tumours arc highly vascular and enhance alidly
wi t h cont rast on CT and MRI. On CT , permeati\"(: bone
erosion is classical, differing from the coarser lytic
destruction seen wi t h skull base metasuses. Vasculu
,ooi ds and foci of haemorrhage are beller demonstnt
MRI - flow produces black signal I"oids and haem
produces hyperintensc foci on T I weighted images
combination of black holes and white dots leads to
called 'salt and pepper' aplXlrance commonly dcscril
Angiography is sometimes required for smaller
that don't demonstrate the classical imaging appe
and rel"eals a hypcr\'ascular lesion with a dense
mmourstain.
The re is a small risk of maligna nt transformaci
in -2% of cases.
Practical tips
When suspected on MRI , cr can still help make.a
conclusive diagnosis in many cases by demonstra
classical permeat i,", pattern of erosion at the
foramen.
Further management
Depending on the size of the tumour and t he in
extension, a combined ENT / neurosurgieal proc
pcrfomled.
Further reading
Caldemeyer KS, l'-' lathews vr, AzzarclJi B, Smith
( 1997). The jugular foramen: a rC\"1cwofan;a[
masses, and imaging ch:aracteristics. RadinG,..
17: 11 23- 1139.
108b Hyperi ntense mass lesion with flow voids"
eNS, Head and Neck Imaging Case 109
191
192
Answer 109 eNS, Head and Neck Imaging
ANSWER 109
Observations (109)
These sclcclcd MR im3gcs show an expanded sphenoid
sinus filled with abnormal signal rather th:a11 air. The
(amelUS show mild uniform hyperintcnsiry on Tl weighted
and T2 weighted images. The wall s of the sinus :appear
slllomh and intJct with no ob\iou$ evidence of dcstmctiOIl.
The findings arc consistent with a mucocele of the
sphenoid si nus, the signal indicative ofprotcinaccolls fluid
contents. Sagin;)'l Tl and coronll 1'2 inl:lgcs dcmonstr:I\C
displacement of the optic nerves br the expanded sinus,
presumably causing compression of the atHl:rior optic
pathway gi\'en the hiSTOry of\'isuaJ disrurbance.
Diagnosis
Sphenoid sinus mucocele
Discussion
A mucocele arises due to chronic obstruction of a sinus,
which then becomes filled with mucus. This collection acts
like a slow growing mass c:lUsing expansion of sinus bony
walls withom frank bOil\' dl:slruction. Vessels and other
srmcrures arc displaced ";ther than being encased, as with
a tumour. Usually these lesions are asyrnptomaric untillhcy
becomc large when the}' can cause optic nel""\'C compression,
proprosis and headache. Secondary infection of the
mucocele can supen'ene, but this is a rare complication.
Ninet), per cent of lesions arc found in rhe frontal and
ethmoid sinuses with sphenoid sinus rnucocdes being anI}'
rarely seen.
Appc:ar.mccs on MRJ :lrC \'3rbbk depending 011
fluid/ protein CQrHcnt of the mucocele but impo
imaging findings arc of a nondcstructi\c, slow gra ...
lesion.
Practical tips
CT is good lor showing bony expansion with the
absellce of bone erosion.
is good for identil)'ing the exrelll/size of tile
lesion and looking for complications of optic nel'\ c
compression ( usually from postcrior ethmoid lesi<-
and proptosis from frontal and anterior
ethmoid sinuses).
Tl hypcrintensity \\ithin a lesion on MRI s
often helps to rnpid1r limit the diAcrential diagn
there are;\ limited number of things that arc brig.I:K
on TI imaging, i. e. fat, blood, proteinaceous f1uiQ.
paramagnetic contrast agents.
Further management
Referral to ENT for consideration of endoscopic
surgery.
109 Superior displacement of opti c nerve (left); lateral displacement of cavernous sinus
by large sinus mucocele (right).
eNS. Head and Neck Imaging Case 110
193
194
Answer 110 eNS, Head and Neck Imaging
ANSWER 110
Observations (110a, 110b)
The selected plain CT images ( iIOa) show a poorly
defined, hypcrdcnsc midline lesion eXTendi ng across the
body of the corpus callosum. There is no significant
surrounding oedema.
Pre- and politcontrast Tl weighted MRimagcs ( 1IOb)
from the same patient show a multilobulatcd lesion with
uniform cnhanccrncnr crossing the midline in the body of
the corpus callosum. No further lesions lre seen the
brain Incidental note is made of cavum
sepnull pcllucidum. lllc findings arc of a 'buuerfly' tumour
in t.hc corpus callosum.
Diagnosis
HutTcrfly gliobhlSloma multiformc (GBM).
Differential diagnosis
For lesions crossing the midline in the corpus callosum:
GBi\1.
Lymphoma.
Dcmyclimuing disease - multiple selerosis.
Discussion
This is the mOSf common :ind the most mali gnant primary
brain (Umour. [\ accounts for >50% of brain tumours \\;th
:I :lge distriburion pc:alcing :It the 7lh-8th decades. The
most common location is within the white muter of
centrum scmiovalc with increased incidence in the frontal
lobes. Other patterns of di stribmion include callosal
extension giving this appearance of a butterfly gHom:l,
postcrior fossa lesions and multifocal distribution (seen in
2-4%).
Tumours sprcad b), direct extension imohing white
maller traClS, such as the corpus callosum and cerebral
peduncles or vi:l the CSF 2% of C:ISes). Haematogenous
spread can also very rnrcly occur.
Typical imaging appcarnnces of a butterfly gIl
of a poorly defined lesion that enhances uniformly
fomlation, necrosis and haemorrhage are seen in a
of C:1SCS and c:1kilication is rare and usu:llly :1SSOCiatcd
chemo/ r.ldiOlher.lpy. The corpus callosum is mack
dense, tightly packed white matter tr.lcrs and th
mass efleet and vasogenic oedema arc m
Hemispheric glioblastomas conversely have quite
mass eHect and surrounding oedema.
Practical tips
GBM and lymphoma arc the two likeliest diagnose..
bUrTerfl)' lesions ill\'olving the corpus callosum. Al
diflicult to differemiate radiologically, cavit:\tiOll
necrosis arc rcl:ltivcl y uncommon in lymphoma (ex
AIDS patients).
Further management
T2 hypoilltensiry is sometimes present with C:"S
lympholl1:1 and thereforc this imagc sequencc CD
sometimes hclp to diffcrentiatc lymphoma from
glioblastoma.
Ncurosurgical c\alu:ltion.
Further reading
BOllrekas EC, Varakis K, Bnms D, et nf. (2002 ).
of the corpus callosum: illl:lging and di!fe
considcrations in :ldults and children. Alllerimll
JOlln1n1 ofRndiology 179: 25 1- 257.
Rees JI-I, Smirniotopollios JG, Jones RV, Wong K
( 1996). Glioblastoma multitormc: radiologic
pathologic correlation. RadioGrnphies 16: 6.
110a lobulated lesion crossing the mi d line in the body of the corpus callosum.
eNS, Head and Neck Imaging
Case 11 1
lllb
present ed with
-
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, '.' .
. .
. ,

! .
. f.\.'=t
...... '



e

,-
.,
.'\,
0
-
;.
',-\'
-
195
196
Answer 111 eNS. Head and Neck Imaging
ANSWER 111
Observations (111a, 111b. 111c)
These STiRsagitt:l1 ( l il a), STIR coronal ( illb) and T2
weighted axial ( i l le) images of the spine demonstrate
posterior vertebral scalloping, particularly at the T il , TI2
and L2 b'ds. There is also a thoracic scoliosis. AI
approximately no le"el , coronal images show a right sided
highsignallesion projecting laterally from the spinal canal,
presumably through the intervertebral foramen. This
follows CSF signal and is probably a lateral thoracic
meningocele. The axial 1'2 weighted image shows a second
lateral thoracic meningocele on the Jeft side, in a similar
region ofthe spine. The combination of findings is strongly
suggestive of neurofibromatosis type I and multiple high-
signal cutaneous nodules on the sagittal images confinn this
diagnosis.
Diagnosis
Neurofibromatosis type I (NFl ).
Discussion
Neurofibromatosis Iypc I is a neurocutaneous disorder, of
which 50% is inherited in an autosomal dominant manner
and 50% is sporadic. Classical features in the spine include:
L.1teral thoraci c meningocele (dysplasia ohhe
meninges resulting in di\"enicula of the thecal sac,
whieh extends through the neural foramina ).
Posterior vertebral scalloping - also due to dural
ectasia.
1118 Posterior
vertebral
scalloping.
Neurofibromas - enhancing dumbbell -shaped lesi
Scoliosis and kyphosis.
Enlarged vertebral foraminae - due to neurofibrOI1ll
or lateral meningocele.
Hypoplasia of the pedicles, Irans\'erse and spinous
processes.
Practical tips
Alwars look for the presence of subcutaneous nod
on the image when NF l is suspectcd.
It Illa}' be difficult to diflCre.ntiate between a lateral
thoracic meningocele and a 'dumbbell' neurofib
However, on MRI the former will be ofCSF de
on all sequences, Le . high signal on T2, whe.reas
latter wi ll have a hyperintense periphery on T2 mQ
hypointense core.
In a case such as this, one might also comment rn..
there arc no obvious adrenal Illasses or renal
as)'mmetry (impl ying association with
phaeochromocytollla and renal artery stenosi s,
respectively).
Further management
Neurofibromas can undergo malignant tr:l.Ilsform;!.tli
2-3%; therefore a rapid rone of growth or new onset
should be thoroughly investigated.
111b l ateral thoracic meningocel e.
eNS, Head and Neck Imaging Case 112
197
198
Answer 112 eNS, Head and Neck Imaging
ANSWER 112
Observations (112a)
Selected uncnhanccd axial cr images ofrhc bi.lin show a
well defined low attenuation lesion in the left fronrallobc
causing minimal mass effect. The contents arc oflowcr
attenuation than CSF but gh'en the absence oftrauma it is
that thi s is due to intr.lcr:lnial air. It is likely that
instead, it represents fur, which could be easily confirmed
by adjusting the CT windows or taking a direct
measurement. A calcified nodule is seen at the posterior
aspect of the lesion with further mural c:l.lcific:l.Iions
elsewhere. Further small loculcs of f'at arc seen in the
:Interior hom of the left lateral ventricle and sc\'cr:al sulci.
Diagnosis
Ruptured dermoid cyst
Discussion
Dermoid cYstS arc fairly Ullcommon CNS lesions, usu:ally
presenting before the 4th decade. They arise due to
inclusion of epithdial elements :at the time of closure of the:
neural rube and therefore contain ectodermal and
mesodermal components, i.e. hair, sebaceous glands and
skin. Derrnoi ds arc usually locpted ncar the midline and C:all
be found within hrain parench}'m:a , vcntricles, CSF sp:aces
or within hom:. Dc\'elopmem :and g.rowth arc \'ery slow and
presentat ion is therefoTt: late.
Typical appearances on Cf: low-densit), lesions
containi ng fat with no contrast enhancemem. j\l ural
or focal ccntral calcification can be seen.
Typical appearances on MR.I: well defined lesion
which is high signal imensit),on T I weighted il1lagi
\\ith signal \'oid at points of calcifi cation. No
enhancement with comrast.
CySt rupture leading TO chemical meningitis is
occasional complication, as in this c:ase. Release of
globules can produce f.u-Iluid levels WiTh CSF. Fi
112b demonstrates typlc:al appcar.mce of:a dcmlOid II;
6t-containing lesion of high signal on TI weight
im:aging. Some strands of mesodermal tissue arc n
within it. A f.lI -fluid level is seen in the [:ateral \emrick
to rupture into the subarachnoid space.
Practical t ips
Posterior fossa dcrmoids arc usually found in the
midline and show no contrast enhanccmem on
CT/MIU.
On TI weighted MRI high signal is produced
Fat.
Blood products ( methaemoglobin).
Proteinaceous fluid.
Contrast.
Further management
MRI is bencr than cr for nlprurc of a
CYSt and the consequent chemical meningitis.
eNS, Head and Neck Imaging Case 11 3
199
200
Answer 11 3 eNS, Head and Neck Imaging
ANSWER 113
Observations (113a)
These T2 weighted axial brain images show :J. diffuse
increase in signal affecting the right Icmporallobc. This
in\'o!\'cs grey and wll ite maner, eXTending to the cortical
surncc. Sulci in the aAcctcd aTea arc dfuccd. Similar signal
changes extend along the cingulate gyrus ,md also affect
the contralateral temporal lobe to a lesser extem. The
duration of the history and distribudoll ofillvoil'cmcnt :lfe
in keeping wi t h encephalitis, mos\ likel y due to herpes
simpkxvims.
Diagnosis
Herpes simplex (HSV) encephalitis.
Differential diagnosis
Ri ght middle cerebral territory infilTct.
Di scussion
Encephalitis is the term generally u.sed to describe a diffuse
cerebral inflammatory process of \'iral aetiology. Clinical
presentation is with confusion, headache and seizures
progressing to coma. Fe\'er is almost always prcsem. The
most common organism is HSV. infection being either
primary or due to vinls The resulting cytotoxic
oedema manifests as high signal on T2 weighted, FLAIR
and DWI t.'IRI. The temporal lobe is typically affected,
often with the inferior frontal lobe and cingulate gyrus.
Unl ike other viral infections, the basal g:mgli:!. arc usually
spared.
Practical t ips
HSV encephalitis has hi gh Illonalit}, and morbidity
rates bur is treatable with acyclovir SO a high index of
suspicion is needed, especially on cr, which may well
be the first imaging done - signs of oedema and
swelling arc likely to be comparati\'cI}' subtle
compared to MRI (if prcscllt at all).
Bilateral temporal lobe im'okement is virtually
pathognomonic of HSV infection. Features that
atypical and should arouse suspicion of other
organisms include basal ganglia i1l\'ol\'ement and
isolated im'oh-ement of other lobes withom
lobe ilwolvemellr.
Cytotoxic oedema (seen in stroke and encephali

atlects\\"hite matter only,
Without clinical history, one might mistake the :\
changes of HSV encephalitis for a middle ccrebr.JI
artery (MeA) infarct. Howevcr, notc that the
posteromedial temporal lobe affecTed by HSV is
spared in an MCA infurct as this lerritory is sup
by the posterior cerebral arIel)' ( PCA). Figure II
shows a typical MCA infJrct wilh lowanenuatioo
change in the right [emporallobe but sparing the
described posteromedially (this scan also happem
show a hypcrdense MCA due to lhrombus). FOf"
compari son, Figure 113c shows a PCA infurct \\
the posteromedial rempomllobc affected.
Neonatal herpes-related encephalitis is due to H
type 2, probably acquired via the genital tract
perinatally. The imaging features arc different fnr
those due to HSV type I described above.
Further management
Urgent treatment with alHiviral drugs - mort
untreated I-ISV encephali tis can be as high as 65%,
11 3b Axial plain C7
brain shows a ri
middle cerebral a:
territory infarct
hyperde nse art ery
sign.
eNS. Head and Neck Imaging Case 114
201
202
Answer 11 4 eNS, Head and Neck Imaging
ANSWER 114
Observations (114al
This single CT im::agc shows diflusc low-attenuation change
in the frontJl and tcmponl lobes and br:linstem with loss
of the grey-white matter diflcrcllliation. The cerebellum is
bener preserved. Generalized sulcal cff.1ccmcm indicates
ccrebr.tl swelling.
This widespread reduction in brain density makes the
normal ccrcbr:tl vessels and dural rcflccrions appear
conspicuous. Close inspection confirms thal this
is a pcrccplUal 'abnormality' - rhe basal cisterns arc of
normal CSF density so there is not acute subarachnoid
haemorrhage. The ffndings arc suggcstil'c of global ccrcbr:l.l
ischaemia and oedema.
Diagnosis
Global cerebral anoxia.
This particular casc turned out to be secondary to
asthma induced cardiorespiratory arrest.
Di scussion
Global ischaemia can occur following prolonged hypoxia,
which may be sccondary to litting, aspiration, smothering,
strangulation, etc. The CT,findings arc distinni\'e, with loss
of grey- white matter differcnriation and changes due to
cercbr:al oedcllla includi ng sulcal eflaccment. Generalized
low density of the cerebral COrTex de\"elops. The cerebellum
is more resistant to hypoxia and therefore appears of hi_
densit), in comparison with the low-density cerebral cona:
the socalled 'rC\"ersal sign' (sec also Case 163).
The conspicuity of the vessels and dura may lead
to the erroneous diagnosis of acute subarachn
haemorrhage (SAH) on first inspection. An example or"_
real SAH is shown ( 1l4b ) - note high density in
suprasellar cistern representing acute haemorrhage and
nornlal density cerebral cortex wi th preserved grey-\\
marter differentiation. There is also dilatation of
temporal horns of the lateral ventricles indicati ng e
obstructive Trauma is the most COIllrn.
cause of SAH. cr is 90% sensith'c in the detection of ;'\!..
in the first 24 hours following prcsentuion. Howcvcr.
decreases to 50% at I week and continues to fall ther
Small SAH may not" be seen on CT and will
deTected on lumbar puncture (LP) as xanthochromia. r.-
cause of75% of spontaneous SAH is berry ancurysms
these arc mostly found sprouting from the circle of\\
An exam pic of a large SAH in :I patient with :I rup
aneurysm is shown ( 1 14c). Note the cxtcnsi\'c amoWl[
blood filling the sulci and Sylvian fissures. Blood has
entered dlC vemricuiar svstcm and C.lIl be seen in the- '
and 4th ventricles. The'large ;lIleurYSlll appears to
from the origi n of lhe left middle cerebral artery.
' 14b Axial plain CT of brain showing SAH with
blood in suprasellar and basal cisterns.
A nswer 114 eNS, Head and Neck Imaging
Pro<li",,1 t ips
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History
A j "'.., fN<" ""J
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MU$culoskelelallmaging Case 115
'"
Answer 115 MuSculoskel et al Imagi ng
ANSWER 11 5
Observatio ns II I !NIl
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(l IShI

wolghtod MAllm.go
.how _ II
high .ign" <VO';,
It.;"". in tn.
prox;moll.f1 1.mu"
Musculoskeletal Imaging
_ p and show benign features with
expansion, cortical thinning and fluid levels
)(R.I, However, the SBC has a more centra1
\\i thin the aRectcd bone, is less cxpansilc and
.bow a p:llhognomonic 'ful1cn fragment'.
_ in the !llscd skeletOn is subarticular and
'c wit h no marginal sclerosis - when all these
aTC presem in the correct age group, the
is is clear.
can look aggrcssi\'c or benign so is 3.1wars
bearing in mind depending on clinical history .
.'. fibrous dysplasia has such ' -:tried appc3!,;II1CeS
frequently enters the diflcrt;ntial diagnosis lor
. cal benign !>one lesion!
11 Sd AP pelvis in a female with
widespread lytic metastases and a
pathological fracture of the left femoral
neck. Note the cortical destruction and
the wide zone of transition of the
majority of the lesions.
Case 116
209
""
Answer 116 MuScul oskelet al Imagi ng
ANSWER 116
ObservatlonS II I"'1
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a.ion. ond scl. ,o. i .
Answer 11 6 MuSculoskeletal Imaging Case 117
mm, "",I ,t"" 'K'
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CASE 117
HiSlOI"1
13_)" .. ,_,,1& ""I,
p.oo in kit hip.
11 6<1 AI' pol";, of potiom ";th "Ice .. ,;,.. ooi';,.
Tho,. i. M. , . .. 1 .. w;!h *" o.d.m. 'ou>
,0"" .... IIed 'i9mokl 0010".
Answer 117 MuSculoskeletal Imaging
ANSWER 117
ObH fVlti ons ll l1,1
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Discus.ion
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, 17. Fr"," lot ... 1 '" tho " .. " ...,ion, ..o'U ....
.Ii ppod left femor.1 opi phy. i .
CASE 11 8
History
~ m.l. Pol;'"! p", .. "I<d . ';!h p';";"
.m!"'","" <lUmp .
MuSculos keletal Imaging Case 118
214
Answer 118 Musculoskeletal Imaging
ANSWER 118
Observations (118a)
A below knee has previously been performed.
lllcrc is a pcrmcati\'c lucency with a ,\ide zone of transition
affecting the tibial stump. Periosteal reaction is visible along
the posterior cortex ;lIld there is llso a hint of this along
the fibub. runhc:mlOTc, fuint luccncics arc suspected along
the :anterior cOrtex of the distal femur. These arc rhe
appearances of an aggrcssi\'c lesion.
The reason for :Imputation and the time: inrerval since
ha\'e nor been stared - this would help dari/)' the likel y
diagnosis. From the radiological findings alone, the main
possibilities arc that rhe amputation was for a distal
malignancy such as bone lymphoma that has now recurred,
or that rhe current findings arc due 10 osteomyelitis in the
stump following amputation to r an unrelatcd reason.
However, suspectcd im'olvcment of the di stJI femur
without joint destmction f"lxOUI"S the former option.
Diagnosis
Lymphoma recurrence following amputation.
Differential diagnosis
Of permc:ui)'c bone lesions:
Metastases.
Myeloma.
Lymphoma.
Leukaemia.
Osteomyelitis
118b AP and lateral images of the tibia show a
permeative lesion is present wi th evidence of cortical
destruction.
Discussion
Another example of a lymphoma is seen
tibia of a parielH in Figure 118b; a peTmeariH:
present with e\idence of cortkal destruction.
Permeative bone dest"mnion on
the presence of aggressive p;nhology with fa
potential. The pcrmcath'c lesion has a ditfusc:
eaten' appearance (l i Se). The zone oftransi
in other words the lesion is poorly dcmu.-
impaceptibly merges with uninvolved bone,
lesions where the zone of transition to no
narrow. PeriOStcal reaction rna)' or may not Ix
finding of a lesion on imaging usu.ll.
mal ignant pathology; however. infection can
s,1me appearallce.
Practical tips
This is an example of a \'i\"3 type film whel"("
definite or 'spot' diagnosis 10 be made - it is
of preseming a reasoned approach to;1 sensible
diagnosis, thcn st"ating how [[lis could be natTC"
using dinkal inlormation or fi.lnher investig:n-r
Further management
Recurrence of lymphoma may entail
and/or radiotherapy. MRI rna)' be helpful
local extent more accurately.
presented with :I
infection.
Musculoskeletal Imaging Cases 119, 120
215
Answer 119 MuScul oskel et al Imaging
ANSWER 11 9
Ob ..
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o
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di_" phyols, l,e.

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' bo.on, """" . rr .... n<' ..... n' '"
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o".o I.ro. i.
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wi'"
pyknoOyoo",o.i. ,
119,120 Musculoskeletal Imaging
.... ith pyknodysostosis (11 9d ) demonstrates
!iClcrosis with classicJ.] 'pointed chalk' tcrm;Jlli
cycrflaskddormity:
sclerosis indicat cs osteopetrosis.
. disease w;]I dcmOnStr.Hc sclerosis of the
is and lucency orlhc widened metaphysis.
r's disease will be associnlcd wi t h generalized
nil and pencil-thin cortices. There may also be
of avascular necrosis of IIle femoral or hUllleral
md massh'C hepatospleno megal y m:l)' be seen
.oibdominal radiographs.
emia is associated with coarsened
brion producing a 'cobweb' appearance.
poisoning causes dense rnct;lphyscal bands.
management
treatment 'l\'ailab1c tor osteopet rosis is bone
transplamation. Patients arc morc prone to
than the normal popul.uion.
rvations (120a)
Aexi on and extension views of the spine arc
m. On flexion there is significant adanlOaxial joint
.ation. The odolHoid peg is not clearly demarcated
likel y to be eroded. The remainder of the
- -..a.I spine is quitc wcll prcscncd. The most likely
is in a patiem of this age is rheumatoid arthritis.
toaxial subluxation in a patient \\"ith rheumatoid
tis ( RA).
erential diagnosis
mJ.moaxial subluxation:
.. Jt.-\.
.. Psoriatic arthropathy .
.. U'cnilc idiopathic anhritis.
119d
Pyknodysostosis
hand showing
osteosclerosis with
pOinting of the
distal phalanges
producing a
'pointed chalk'
appearance.
11ge Forearm of a
patient with
fluorosis showing
diffuse
osteosclerosis and
prominent
ligamentous
insertion
calcification.
Ankylosing spo ndyli tis.
Systemic lupus erythematosus (SLE).
Down's syndrome .
J"lorquio's syndrome.
Retropharyngeal abscess in a child.
Discussion
Atlamo.uial subluxation occurs when the dist-lIlcc octween
the posterior aspect ohhe arch of the alias and the ;lIltcrior
aspect of the odontoid peg exceeds 3 mill in adultS and 5
mm in children. Erosion and destmction of the OOomoid
peg may also be seen, particularl y when the process is
caused by an inflammatol)' arthropathy. Several causts arc
described in the differential diagnosis list but RA is the
most common cause in adults. Synovitis with pannus
format ion causes erosion of the odontoid peg and
atlantoaxial ligamentS and consequcnt subluxation. This
(CO/ It. )
217
Answer 120 MuSculoskeletal Imaging
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CASE 121
HiSlary
~ Y ' ' ' ' " ~ """C,ri"',,,," r""'"'
p .... m,d .-i," k h kn<, p.i"_
MuSculoskeletal Imaging Case 121
220
Answer 121 Musculoskeletal Imaging
ANSWER 121
Observations (121a, 121b)
AI' and l:ltem1 r.ldiographs of the left- knee show lobulated
calcified masses in the soft tissues anterior to the left knee.
Taking into consideration the age and cthnicity of the
paticm, ru!l1or.ll calcinosis is the most likely diagnosis.
cause pain and limitation of mo\"ement, with .::
ulcer:nion and the de\clopmelH of a sinus tract d
nuid. In fuct, the masses m3y contain fluid
lel"cls on imaging that ha\"e a milk of eakiulll (on
The periarticular region orlhe hip is the most COlllla
aHccted site. The masses can grow to 3 ,"cry large sill:
there is a tendency tor recurrence if the lesions
complctelyexciscd.
Diagnosis
Tumoral calcinosis.
Differential diagnosis
Ofpcriarticular soft tissue calcification:
Hacmatoma.
Myositisossificans.
Crystal arthropathy.
Practical tips
The radiological appearances of the ,'arying CJ
periarticular calcification can be quitc different:
Tumoral calcinosis - lobulated dense tl13sseS,
fluid le\"els.
Sclcrodcm13 ( I 21c - note the characteristic dist:ll tutt
resorption in the index tinger).
Myositis ossific3llS and synovial sa rcoma may I
similar but withom fluid Ic\"els.
Dermatomyositis. DefmatOll1l"0sitis - shects OfC:lkificatioll.
SyIlO\'ilJ osteochondromatosis.
Tumornl calcinosis.
SYIl0\;alurcom:t ( 121d, 121 e, 121f, 121g).
S)'no\'ial oSTeochondromatosis - se\"eral foci of
calcification with lucent centres that 3fe essen
loose bodies within the joim.
Discussion Further management
Tumonl calcinosis is a rare, 1x:nign condition characterized
b}' the presence of progressively enlarging perianieular
calcified soft t issue masses. It usually affects roung black
patients and there is a fumilial tendency. The masses Illay
Patients with tumor31 calcinosis arc usuallv treat
phosphate depiction. Surgical excision is 3150 a
option but needs to be meticulous as recurrena:
OCCLIrs with incomplete excision.
121c Radiograph of the
hand in a female adult
with scleroderma shows
the typical soh tissue
calcifi cation. Note the
distal tuh resorption
affecting the index
finger, which is
characteristicall y seen in
this conditi on.
121e, 1211, 121g Axial n , T2 and fat saturated images of the synovial sarcoma shows a fairly well de
soft ti ssue lesion which is of tow signal on T1 and in homogeneously high signal on T2.
Musculoskeletal Imaging Cases 122, 123
-_m p,,,,,,,,d with rigidity and
221
222
Answer 122 Musculoskeletal Imaging
ANSWER 122
Observations (122a)
All and latCr:l1 radiographs of the right knee and upper tibia
and fibula demonstrate marked cortical thickening of the
diaphyses ohlle tibia and tibula, which has the appcarnncc
of'dripping candle wax', This is typical ofmclorhcostosis.
There arc also multiple small sclerotic lOCi within thc
mctJdi:tphysis of the distal femur and the proximal libi:! ,
which h:1I"c thc appearance of oSlcopoikilosis.
Diagnosis
Mclorhcostosis and ostcopoikilosis.
Differential diagnosis
$dcrQ[ic metastases in a paricllI with mclorhcostosis; this
is much less likely. Howt:I'cr in patients with multiple
sclerotic foci alone, sclerotic metastases must always be
considered.
Di scussion
Melorheostosis is a nonhereditary disease of unknown
aetiology that often presents as an incident-al finding. II is
usuall y discovered in childhood where it has a rapid
progression, but it occasionally presents in adults where it
has a slow c.hronic course. The limb ill\"oked often
demonstrates joint pain, swelling and limitation of
movement. Males and fem:lles arc equally aficcted.
Radiological signs ofmclorheoslOsis arc as follows:
Conical hyperostosis in one or multiple tubular bones
with streaks of sclerosis beginning at the proximal end
of the bone and extending distally, This produces the
chamcteristic 'dripping candle wax' appearance. This is
shown particularly well in Fi gure 122b, where the
right humerus and scapula arc aficcted in allother
patient.
Predominantly aflccts the diaph)'Sis of the bone,
The lower extremities arc more commonl \' aficcted
than the upper. .
Although a single bone may be involved, contiguous
bones of an extremity afe mOTe often aflccted.
Hilateral signs arc cxtremcly rare and should prompt
consideration of other causcs of sclerosis.
Limb length discrepancy is also a feature and the
sclerosis may cross the joint and result in joint nLsion.
The skull , spine and ribs arc rarely invoh'ed. !\klorheostosis
is associated with osteopoikilosis, osteopathia stri ata
(asymptomatic disease consisting of longitudinal striations
along the metaphyses of long bones ) and arteriovenous
malformations,
OSleopoikilosis is an autosomal dominant disorder that
is more common in II is asymptomatic and consists
of multiple o\'oid bone islands parallel to the h;:lJlg axis of
the bone. These bone islands normall y measure 2- 10 mm
and arc found at the metaphysis and epiphysis, rarely
extending into the midshaft. It usually aficcts rhe peh'is,
wrist and ankle and Tarely affects the skull , ribs and
mandible. The differelltial diagnosis or this condition,
which often leads to clinical confusion and concern, is
disseminated sclerotic metaStases.
Practical tips
Ostcopoikilosis tends to be distriburcd around
whereas multiple sclerolic !l\Clastlscs will not
confin<.!d.
Further management
No further mallagement is normall y necessary.
conditions arc usuall y found incidenrall) . The
is to ensure thai a patielU with multiple sclerotic
has osteopoikilosis and not sclerotic metastases.
Further readi ng
Levine S, Lambiasc It, Petchprapa C (2003). G::rT
lesions of the tibia: characteristic appearances.
coLII'entional r.ldiograph)' . RndioGmphics 23:
157- 177.
122b AP radiograph of
melorheostosis affecting the
humerus scapula
demonstrating the typical
'drippi ng candle wax' appearance,
Answer 123 MuSculoskeletal Imaging Case 124
ANSWER 123
Olao,."ations 1123)
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CASE 124
History
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224
Answer 124 Musculoskeletal Imaging
ANSWER 124
Observations (124a)
There is difruse, coarse trabeculation of the visible bones
causing a 'cobweb-l ike' appcar.:lllCC. Erlenmeyer flask
deformity of the distal femurs is presen!. The features arc
in keeping with thalassacmia major.
Diagnosis
Thalassacmia major.
Discussion
Thabssacmia is an inherited disorder of haemoglobin
synthesis charncfcristically seen in Mediterranean patients.
The homozygous form, thalassacmia major, is mOTC sncrc.
The radiological signs result from marrow hypcrpl:J.sia and
expansion due [Q cnramcdullary h:u: rnatopoicsis. Evcry part
of the skeleton may be aflcctcd in patients with untreated
disease. R.1diologicaJ fcamrcs of the complications of
treatment such as recurrent transfusions and iron chel ation
thcrapy may also be seen. In fuet, abnormalitit:s secondary
to iron chelation therapy arc now more common than
those due to lllarrow hyperplasia.
The radiological signs to look for depend on the site of
the imaged'
Peripheral skelerun:
Coarse trabeculation e3using 'cobweb' appearance
( 124a).
Loss of conca\'ity ofwbular bones ( 124a).
Er1cnmerer flask deformity of metaphyses of long
bones ( 124a).
Arthropathy and chondroca1cinosis as a result of
haemochromarosis secondary to hypertral\sfllsion.
Fraying of metaphyscs and dense metaphyseal
bands secondary ro iron chel3tion therapy.
Skull:
'Hair on cnd' appearance.
Frontal bossing (124b) due to diploic expansion.
Obliteration of paranasal sinuses (except for
ethmoid sinuscs) due to marro\\' h)'pcrplasia
( 124b).
A-.;i:tlskekton:
Co3rsc trnbeculation causing 'cobweb' 3ppe3rance
( 124<).
Bi conC3\'C "ertebr.lc.
'Bone within bone' appearance of spine and ribs.
Paraspinal masses (due to extramedullary
hacmatopoiesis).
Expansion of the ribs posteriorly, panicularly at the
costochondral junctions, due to marrow hyperplasia
( 124c).
Practical tips
T he only sign may be a difruse but subtle coarsening
ofthe bony trabeculae.
On an AX It look for evidence of hepatosplenomegaly
(a resul t of extramedullary haematopoiesis) and
gallstones.
On a exit look for cardiomcgaly secondary to
an3emia, 3S well as a paraspinal mass due to
eMr.lmedullary haematopoiesis.
Further management
Death usu311y occurs within the first decade-.
b)' multiple transfusions, howe\'cr as exp
discussion this tOO leads to skeletal abnorrn
Further reading
Tyler P, Madani G, Chaudhuri R, ct (I/. (2006
radiological appearances ofth:llassnemia,
Rndiology 6 1( 1):
CASE 125
History
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MuSculoskeletal Imaging Case 125
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125
Musculoskelet';l Imaging Case 126
benig.n or aggressive?
ysis, metaphysis or epiphysis?
old is the patient?
"olmg patient with an aggressive lesion such as
m[cd, the twO main primary tumours to
Me Ewing's and osteOsarcoma. The tWO can
:ult to differentiate radiologically, and can also
1Ullilar clinical features such as fevcr and
'fosis. The features shown in Table 2 may help,
_ none arc pathognomonic .
Further management
i':lRI is helpful in assessing local spread :llld :lids planning
of surgical resection.
Further reading
M, Robbin M, i\kRac G, tt al. ( 1997). The
many fuees of osteosarcoma. RadioGraphies 17:
1205':' 1231.
.able: 2 Dljji:YC1Iti(ltillgfCfl/IlYn of Ewillg'r S(lYCOIIJ(l lid ortcosnYCOIII(l
Ewing's sarcoma
Children
Osteosarcoma
More common in diaphysis
Older children and young adults
1\-10T": common in metaphysis
More conHllOnl}' sclerotic More commonly lucent or permeative
To bone To lung
227
228
Answer 126 Musculoskeletal Imaging
ANSWER 126
Observations (126a)
There is a tnllswrsc fracture at the medial third of the
clavicle. which is li kcl\' to be an insufficienc\' fracturc as
Ihere arc Looser at the b \cral aspect oCthe cl:J.I'iclc
:tnd the b tcr.tl border of the body ofth, scapula. The bones
arc generally oSlcopcnic with marked thinning of the
coniccs. The findings arc consistem with a diagnosis of
osteomalacia
Diagnosis
Osteomalacia.
Discussion
Ostcomabcia is a disorder of insuHkicnt osteoid
mineralization causing bone softening. Aetiology can be
due to dictary deficiency, dccrclscd absorption or deficient
metabolism of vitamin D.
Radiological fc;trurcs of ostcomalacia include.:
Generalized ostcopcni:t.
Cortical thinning.
Bowing of long bones.
Protmsio acetabuli.
Coarse trabecular patrc.rn ( 126 b).
Looser zones:
_ Pseudofra([ures that consist of tranS\'erse luct':nt
clefts \Iith sclerotic margins .
These arc mostly seen in the pekis, femoral necks
( 126c) and scapula.
Insutlicicncy fraCTUres.
Practical tips
Osteomalacia is related TO renal failure and
hyperparathyroidism therefore:
On an abdominal radiograph look for a perit
dialysis catheter or a Hillnelled femoral haem
line.
On a chest radiogr.lph look for a centr.ll
line and eroded lateral cla"icles.
Promincnr vascular and soft tissue calcification
secn.
Brown TUmours be present and appear as
lesions, which mal' also be associated with
pathological
Further management
Treatment involves rCI'ersing t he cause of Ii
deficiency.
prcsclHcd with
ing dcformit), of right leg.
Musculoskeletal Imaging Cases 127, 128
229
230
Answer 127 Musculoskeletal Imaging
ANSWER 127
Observations (127a)
There is marked angulation deformity of the diaphyses of
the lower tibia and fibula with the formation of
pseudarthroses. The bones aTe also generally ostcopcnic.
The most diagnoses arc nonunion of prc\'ious
fractures, ncurotibromatosis or osteogenesis impcrfccta.
Di agnosis
Neurofibrom:ltosis.
Differential diagnosis
Nonunion of a fracture.
Osteogenesis imperfecra.
Fibrous d}'spbsil.
Congeniral.
Discussion
Congenit:ll - :lllcCls the middle to lower third ofthc tibia
and tibula. Half of congenital pseudarthroses present in the
first }'c:ar of life and later on there ma}, be cupping of thc
proximal bone end and pointing ofthe distal bone end.
Neurofibromatosis rype I (NF l ) is a common genetic
disorder ;1I\d in addition 10 cutaneous and neurological
:abnormalities, osseous lesidns :are also seen. There rnav be
an terolateral bowing of the ribi:a with or a
hypoplastic fibula. Focal n:lrrowing and intramedullary
sclerosis or cystic change:at the :apex of the angulation is
due to hanlarlOnlatOus fibrous tissue, typically at the
junction of the middle and distal third of tibia. Pathological
fracture with nonunion often results in pseudarthrosis of
the tibia and fibu la, with 'pencil pointing' of the bone
fragments. Prophylactic bracing of limbs with bowing
deformit), may pre"ent the de\clopment of pseudarthrosis.
OSleommy with bone grafting and pinning ( 127b) is the
treatment of choice if the pseudarthrosis has
occurred.
Osteogenesis imperfecta - all four types can r
bowing of ,he long bones due to bone softening
multipte fractures. Bowing typically involvC$ all the
bones and can resull in pseudarthroses. Again OSt
and pinning arc the preferred treatment alth:
bisphosphonalcs n:l\'C been shown to produce
success.
Cleidocranial dysplasia is associated with (on_
pseudarthrosis of the femur.
Ankylosing spondylitis can lead to pseudarthrosis
spine.
Practical tips
Severe osteopenia and multiple fractures ofdi
;lges that hale exuberant callus format ion su&.. cIII
osteogenesis imperfecta. Remember that SOIlK
osteopenia may result trom disuse, howe"er, c!"
fracture nonunion.
Look for soft tissue nodules indicative of
neurofibromatosis.
A 'ground glass' density lesion associated \\ith
pscudarthrosis is suggestive offibrous dyspl.lSi.l.
Furthe r management
As in this case, osreotomy with bone """-....
is the treatment of choice.
Further reading
Cheema 1, Grissom L, Harckc H (2003).
characteristics of lowerexrrcmit")' bowing in
RndioGrnpbics 23: 871 - 880.
127b Radi ograph of t he same patie nt pos
wit h pins.
Musculoskeletal Imaging Case 129
'Aunt Minnie'. Fong's discasc, also known as
and ostco-onychodysplasia, is a nTC
[ di sorder characterized by symlllcrric:ll
and mesodermal anomalies. Patients lend to
abnorrn31i ties of nai l dysplasia that Gill
spooning and splitting of the fingernails or ("\' ell
or aplasia. This particularl}' aflccts the thumb
finge rnail s. Pat ient s lll;lY al so h:1.\"c lbnorm:tl
of [he iris.
ofbilatcrnl poSTerior ili ac horns is seen in
and is diagnostic ofdlC condition. Hypoplasia
JDtc:rior half of the ilia can result in drooping of the
. The other major finding is aplasia or hypoplasia
d bc, whi ch results in recurrent lateral
dislocations. Hypoplasia orthe capitellum and !';ldial head
may also be pn::scm and this can kad to all increase in the
carrying angle: at the dbow. Similarly, genu valgus can
<x:eur due ro asymmetrical den:lopmcnt of the femoral
condyles. Some patients may ha\'e a short 5th metacarpal.
Practical tips
Look for a peri roneal dialysis eMheler or femoral
runnelled dial ysis line on the pcl vic radiograph, :ls
Ihese palients have rcnal failure.
If the knecs arc included on the radiograph, look for
hypoplastic or absent patellae and genu valgus
deformity.
Further management
The mOSI serious association of thi s condition is renal
dysfunction, which occurs secondary to abnormality of the
glome rular basemenr membrane leading ro protei nuria,
hacm3ruria and renal f.lil urc. The mechanism for this
is unknown , bur renal f.1ilure tends to <x:ellr in later life,
This is an important poim ro note when diagnosis of this
condi tion is made, often incidentally.
231
232
Answer 129 Musculoskeletal Imaging
ANSWER 129
Observations (129a)
There is a 'hair on end' appcarnncc to the skull vault and
the diploic space is widened. This docs not aHe" the
calvaria below the lel'el of the imcrnal occipital protuber-
ance. The mlxilbry sinuses arc oblitcr.ttcd. The most likely
C:IllSC is thabSS3cmia major.
Diagnosis
TIIl13.ssacmi:J.major.
Differential diagnosis
Of'hair on end' appcar;111CC of skull:
The mnemonic is 'STAN' and is c:\sy to remember when
VOli think of Sun Laurc! 's hair!
. Sickle cell disease.
Thalassacmia major.
Anaemia (other an3cmias ):
Hereditary spherocytosis.
Glucose-6-phosphatc dehydrogenase deficiency.
Severe iron deficienc}' anaemia.
Neoplastic:
Hacm:lIlgioma (J29b).
Neuroblastoma metastases in children.
Di scussion
The 'hair on end' sign is a finding that can be seen in the
diploic space ofthe skull on r:tdiogr:tphs, cr and MIU, and
has thc appearancc oflong, thin, venical striations. On plain
radiogl'.)phs and cr the appearance is caused by alternating
thickened tr:abecul ae and radiolucent marrow hyperplasia.
On 1'\-\ RI, the alternating bands of h}'POintense tr:abe..:uiae
and h}'pcrimense marrow producc the distillct striated
p;\ttem. Es.scmially the effect is due to marrow hyperplasia.
The diploic space widens and the outer table thins and can
become obliterated. With regard TO anaemic causes, the
marrow hyperplasia begins in the frolHal region and can
aflcct the entire calvaria excluding that which is below the
internal occipital prolllbcr:tllce, since there is no marrow in
this area. Marrow hyperplasia in thalassaemia major is more
marked than in any other anaemia and may cause
hyperplasia of the fucial bones resulting in obliteration of
thc paranasal sinuses. Howc"cr the ethmoid sinuses arc
spared as they do not contain marrow. Thc 'hair on cnd'
appearance can also be seen in se"ere childhood cases of
iron deficiencyanacmia.
The medical literature is split as TO whethcr the 'hai r on
end' appearance may be re"ersed following treatment of
the anaemia. Some authors have reported that resolution
of the appearance occurs with rrCatmelH, although the
diploic space may remain wider than normal. Howe\'er
others h:we reported that the appearances persist without
regression e\'en O\'cr a follow-up period of approximately
20 years.
Practical tips
Thalassacmia major and sickle cell disease arc the
most common causes of'hair 011 end' skull. To
diflcrentiate the twO look at the maxillary sinuso-
they arc obliterated this suggests thalassaemia.
docs not occur in sickle cel l disease.
Is {he appearance diffuse or localized? Ifl ocaJizo:.
consider neoplastic causes such as haemangiolll.l
( 129b).
Haemangioma [ends to have a 'corduroy' ap
i.e. thickened and coarsened rather than thin \
trabeculation due t'O \'ascubr channels. This is
demonstrated in Figure 129b.
Further management
Thal:tssacmia major has a poor prognosis with
aHccted children not surviving past the first
Treatment is by repeated transfusions.
Further reading
Hollar 1"1 ( 2001 ). The hair-onend sign. Rndi
347-348.
auk presented wil It left
forsc\"crnlwccks. He
Musculoskeletal Imaging Cases 130, 131
233
234
Answer 130 Musculoskeletal Imaging
ANSWER 130
Observations (130a)
,"Iultipk bony C.\ostoscs arc secn arising from the ribs on
both sides of the chest. 011 the lett, there is a large
associated soli tissue mass projected O\"er the btcr:tl thor.lx
Gi"cn the history of chest pain, sarcomatous tf:msformation
must be suspected. Mon:oyer, there is a small leti: pleural
rc:tetion, a large pulmon:lI)' nodule in the left upper zone
and possible pulmonary nodules ill the leti: lower zone and
rightcostophrenic recess.
The combination of findings suggests sarcomatous
tr.J.t1sformarion ill diaphyseal aclasis wirh pulmonary
Diagnosis
Diaphyseal aclasis with sarcomatous transformation.
Discussion
Diaphyseal aclasis is an 3urosomal dominant condition
ch:!racterized by multiple exostoscs (osteochondromas).
Osteochondromas 3fe benign cartilaginous tumours.
Diaphyseal aclasis is usuall y discovered in childhood and
short stature may occur due to the development of
exostoses :It the expense of nornul bone growth. The
exostoses arc usually multiple and bilater.:ll and mostly afii:cT
the li nlbs though ribs can be atli:CTed, as in this case. The
130b AP and lateral radiographs of the ulna
demonstrate multiple exostoses. Note how
they point away from the joint.
exostoses poillt away trom the nearest joint, as illustr;J..tel
image 130b. A pscudo-Madclung ddormity may de\'
( 130b), where there is ulnar shortening with bo\\ _
the radius, and ulnar tilt of the distal radial articular
[n tcwcr than 5% ofpatknts, malign:llll transform.m
into chondrosarcoma or ostcos:m:oma call occur. A
example is shown ( 130( ) where a patient with d i a ~
acbsis developed a chondrosarcoma aHccting the fi
The exostoses may also cause neurological comp
due to ncrve compression or entrapment.
Practical tips
'Diaph)"scaJ' aclasis is a misnomer as the exostoso
;lTise from the metaphyses.
They are otten multiple and bilateral and point
from the nearest joint.
Thc carrilagc cap of the cxostosis Ill:!}' be calcificu.
Further management
In cases of neTye entrapmenr, surgical excision
possible. The crucial f..1ctor is to f
degeneration when iT occurs; sllspiciol1s signs i
and growth of an exostosis :lfter physcal closun.
thickening of the cartibginotlS cap by greatcr than I :;.
This is best delincated 011 MRL
130c AP of rlght femur demonstrates
extensive flocculent calci fication in a
huge chondrosarcoma, which arose
from the exostosis at the medial
femoral condyle.
Musculoskeletal Imaging Case 132
131
.... ""atii,' ns (1 31a,
lateral radiographs of the [cfi knee re"cal a well
in the l:lIcral aspect orthe medial femoral
. A scpantc bony fragment lies within the defect.
_1"-"'""" rhose of osteochondritis dissccans.
KOChondritis dissccans is svnon"mous with
hondrosis dissccans and fracture
The cardinal fcaHirc is fragmentation ora portion
the articular cartilage and underlying bone, which may
Ie to fonn a loose body \\ithin the joint. It is thought
o.:cur due to subchondral btiguc fr:tcturc as 3. result of
lUri ng from rotatory impacrion torees. Though
times asymplOmatic, presentation is often with p:lin
<J.\"Jtcd by movement and/ or limited movement.
r,uients are mOSt cOlllmon!\, aficctl-d in adolescence with
aficctcd morc than The of
uochondriti s dissecans at t he knee is the Lateral Aspect
fcmoral Epicondyle (usefully remembered by the
... \.\1' mnemonic). The condition can be bilateral in up
30% of cases. Other commonly aflcctcd sites include the
eral head, capitellum and talus. ,vllU is useful in
cmlining whether the osteochondral fragment is loose
("\; denced a rim of fluid around it on T2 weighted
_ or a rim of contrast around it on i'lIRl anhrography.
CASE 132
istory
middle aged female prcselllcd lI'i[h
nful hands.
Practical tips
In the adolescent knee with symptoms bur no obvious
abnormality on first inspccrion, check for the subtle
osteochondl""J.l defec!. The' LAM E' mnemonic
identities the classical location.
When idemitied, check for radiological evidcncc of
joinr eflllsion and loose bodies.
Suggest MRI forfurthere' "aluation.
Furt her management
Identification and trcannent arc important to prevent the
dc\"eloprnem of osteoarthritis. Arthroscopy and remolal
or pinning of the detached fragment is the treatment of
choice when conservative management with reST and
NSAIDs!:lils.
. f 131b

131b T1 and T2 weighted sagittal MRI images
of the knee show a traumatic osteochondral
fracture in the anterior aspect of the lateral
femoral condyl e
235
236
Answer 132 Musculoskeletal Imaging
ANSWER 132
Observations {132aj
This radiograph of both hands re\'eals soft tissue swelling
at the meracarpopha!:mgeal joints bilarerally and to a lesser
extent at the proximal interphalangeal joints, This is not
associated with any erosions, ho\\'e\'cr there is subluxation
of sc\'eral joints including the metacarpophalangeal joint of
the right index li nger and the right first carpometacarpal
joint. Degencrati\'e ch'lll ges arc also noted at both wrists.
In summary, there is a bibtcralnollcrosi\'c anhropathy \\i th
evidence of joint subluxation, The differential diagnosis
incl udes coll agen \'ascular disease, Early rheumatoid anhritis
sholl id also be considered.
Diagnosis
Systemic lupus erythematosus (SLE).
Differential diagnosis
Of nonerosi\'c deforming arthropathy:
Coll agen "ascuhl f disease.
SLE.
Ehlers-Danlos syndrome.
Scleroderma.
Jan:oud's arthropathy.
H}<pOsammaglobulinaemia.
Discussion
O\'cr 90% of paticnts with SLE dc\'clop arth ralgia,
Nonerosi\'c arthropathy is characteristically present, the
main fcatures ofwhieh arc soft tissue swelling and joint
subluxation. In particular, the subluxation aftects the first
carpometacarpal joi nts and ;llso the metacarpophalangeal
joints leading to ulnar de"iation of the fingers. The
distribution is olien bikuel'JI and symmetrical but t:bc
f.tctor excluding rheumatoid arthritis is of co
absence of erosions. Se\'eral difterent diseases
similar appcal":lIlces as outlined in the differential _
Soft tissue calcification Illa\' be seen \\'ith sclerod
Ehlcrs-Danlos sHldrome: )accoud's arthritis is
nonerosi\'e aflccting the hands and
patients lollowing rheumatic \'ah'e disease. Figurt
shows an example of this demonstrating cha
subluxation at the metacarpophalangeal joints
ulnar de\'i.uion orthe digits. There is also subl
the first carpometacarpal joint, Note the a
erosions.
Practical tips
The only finding lI'it h the lIonerosi\'e arthr
Illay be periartkub r soli tissue swelling in the
stages.
Subluxation of joints is the major li nding and
Illostly ;IAcCIS the metacarpophalangcal and
carpometacarpal joints bi b tcrall}' .
The appearances tend to be bilateral and
Scleroderma ( 132c) and EhJcrs- Danlos syn
may be associated with soli. tissue calcificatioo.
hand radiograph,
Further manageme nt
SLE is, as its name suggests, a systemic
although patiems can CXpeCi a long lifc death
occurs frOIll renal failurc or cardiomyopathy.
supporti\'e with the aim of suppressi ng the .1.
element oftlte discase.
Musculoskeletal Imaging
Case 133
male prcS(:ntcd \\;rh left
237
238
Answer 133 Musculoskeletal Imaging
ANSWER 133
Observations (133al
AP and axial radiographs ofthc left shoulder demonstrate
a well defined lesion ill the upper hUllleral epiphysis. This
has a thick sclerotic borda and central lucency. The lesion
has nonaggrcssi\'c features including a narrow zone of
transition and the likely diagnosis consideri ng the agc of
the patiellt and the loc1tion of the lesion is
chondroblastom:t.
Diagnosis
Chondroblastom:l.
Differential diagnosis
Of epiphyseal lesions'
Chondroblastorna - well defined sclerotic border,
calcification in 50%, may have periosteal re;letion.
Giant cell tumour (GCT) - closed epiphyses, abuts
articular surfuce, eccentric, no marginal sclerosis. No
periosteal reaction unless fracturc present
Geode - will be other signs of older
patients
Metastases and myeloma
Infection - llSUllI), :netaphyseal rather than epiphyseal.
Discussion
Chondrobbstoma is a rare, cartilage contlining tumour
that llmost always occurs in the epiphyses of long bones.
Patients aflccted arc under 30 years of age and tend to
present with localized plin. The lesion is usu311y well
defilled with" sclerotic border and occurs most commonl"
about the knee joinT. Calcification within the lesion is see;l
in approximately 50%. The tumour rardy metastasizes but
m3Y be locally aggressive ( 133b, 133c).
As with all focal bone lesions, an 3ssessment of benign
\"s aggressive tClTures, the patiem's age and the location of
the lesion within the bone arc criticli in forming a
meaningful differential diagnosis. Fortunately, the
dilferenti31 for epiphyseal lesions is fairi)' short! One
condition that deserves brief discussion is GCT as this can
somet.imes look similar. The \ast majority occur in long
bones, most commonly ar the knee. Age at presentation is
20-40 years, often with pain. Classical features ofGCT arc
presence in a fused skeleton, epiphyseal subanicular
location, ecee.ntric position and absence of margin31
sclerosis. Onl y when III these features are present can one
confidently predict GeT from rhe plain r.lciiogr.lph. What
is impossible to sa)', ho\\e\er, is whether the lesion is
benign or malignant.
Figure 133d is a radiograph of the knee in a patienr with
a GeL Note how tht lesion 3buts the articular surfuce but
has no marginal sclerosis unlike the ehondroblastoma
illustrlted ( 133a). The distinction l11;ly not always be this
clear howe\'er, and further 3.(h-ice is ollercd in rhe practical
tips section.
Practical tips
With regard to epiphyseal lesions in yOllng p;nients,
the two main possibilities lre chondroblastoma and
GCT. However, man}' ehondroblastomas will not have
the prominent internal calcifications and sclerotic
border seen in Figure 133a. In such ClseS it is
importam to check whuher the paticm has unfuso:l.
epiphyses 35 GeT will not normally be seen in this
group.
If doubt still as to the nature of an cpiphya
lesion, MR.! tl1J)' help. There is typiclll)' lTIarked
oedema seen surrounding a chondroblastoma bUi
rarclyaroundaGCT
Further management
Chondroblastoma is a benign tumour that m3Y bco:
loc3H), aggressive. Treatment is by curettage and bone
grafting.
133b, 133c Plain radiograph of a lucent tibial
epiphyseal lesion and axial T2 weighted MRI'
of the same case, which shows a well defi ned
hypointense lesion in the tibial epiphysis co
with a chondroblastoma. The high signal th
the tibial plateau is in keeping with marrow
This reactive oedema is a common feature d
chondrobfastoma and can lead to overesti
the aggressiveness of the lesion.
133d Radiograph of knee
demonstrating a lucent subarticular
lesion typical of a GeT.
Musculoskeletal Imaging Cases 134, 135
239
'"
Answers 134, 135 MusculoskeletlOllmllglng
ANSWER 134
Obsarvllions l1341
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ANSWER 135
Obsarvalionsl1351
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Answer 135 MU$culoskel etallmaglng Case 136
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CASE 136
HISlOIY
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Answer 136 Musculoskeletal Imaging
ANSWER 136
Observations illaal
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Musculoskeletal Imaging
Conventional osteosarcoma affecting the meta-
of the femur in a child.
ory
- -year-old female presented wilh
pain.
Case 137
243
244
Answer 137 Musculoskeletal Imaging
ANSWER 137
Observat ions (137a)
There is homogeneous sclerosis of the L4 \"Crlchral body
producing the appearance of an i\"ory vertebra. No
significam expansion or trabeculation of the \"crtebral body
is seen. The remaining and bony skeleton 3TC
nonnal in appearance. 111C most likely diagnosis in a female
patient is SclCfOlic metastases from a breast carcinoma
primary. The diHcrcntial di:lgnosis includes lymphoma.
Diagnosi s
Sclerotic metastases from breast carCin01ll3.
Different ial diagnosi s
(J\'l ncmonic - 'Mc:ts ... LP HI M' ):
Lymphoma.
l'agct'sdiscasc,
Hacmangiorna.
infection.
M3StOCYlosis.
Di scussi on
The iI'o!)' \"(;rn:hrn sign refers to 311 increase in opacity of;)
\'enchral body that rcrai ns its size and (amours.
In adults:
disease is more frequent t han the mher ret icu
Howewr lymphoma is generally morc likely to
in destructi\'e IVlic lesions than osteosclerosis,
Paget's disease' tends to cause expansion of the
vcrtebral bod)' with coarsening oft hc venical
trabeculae, In fuct, the sclcrosis of Paget's tencb-
mostly at the periphery with relative lucency of
centre owing to atrophy orthc spongiosa, This
produce a 'picture frame' or windowed double
cOntour appearance,
As \\i th PagcI's disease, haemangioma callses
increased vertcbral trabccubtions and expansioa
sclerotic venebral body, The younger age groun
help to diflcremiate il from Paget's,
Infection in the healing phase 1ll;IY calise
,'enebra, ho\\'c\'cr this ra.rcly ilwok es a single \
and endplatc destruction with decrease in disc
height will point to the correct diagnosis,
Mastocytosis is a svstemie disease eharJcleriud
mast cdl prolifera.tion in skin and the
n:ticulocndot hclial system, Release of histamine
mast cells in bone promotes osteoblastic aCO\l:-
leading to sclerotic skeletal foci part icularly in
spinc,
0steoblastic metastases eli ci t a sclerotic response that
results in patchy replacement of the \'ertebra.l body
spongi0S3 with dense new bone that may be confluent
( 137b, 137c), Sclermic metastases from prostate
carcinoma in men and breast carcinoma in women arc
the most common primaries, Occasionally
osteosarcoma and carcinoid are responsible,
Lymphomatous deposi ts can also elicit a marked
osteoblastic response resulting in diffuse sclerosis,
When considering lymphoma as a cause, Hodgkin's
Vcnebroplasty, the introduction of cement int
collapsed \cnebra.l body under imaging gui
results in high density within the vencbra. '
137b Sagittal fat
saturated MAl image
shows a sclerotic
metastasis in the T5
vertebral body.
137c Sagittal fat
saturated MAl
image shows
multiple
scleroti c and
lytic metastases
throughout the
vi suallized
spine,
an i\'o!,)' \'enebra, This procedure is pcrformed
patients with vertebral collapsc who ha"e snc:n:
unresponsil'c 10 mcdication, and is highly dfi
An example is shown (l 37d ) of an elderl)'
who had painful osteoporotic collapse at two
le\'cls and was successfiilly [realed with resol u
pain,
Musculoskeletal Imaging Case 138
\'crtcbra sign is less cOlll mon in children and
. the result oflymphollll,
nunonly, oslcobbslol1la, ncuroblaslOm:l,
rna or medulloblastoma deposits can cause
nee.
tips
vertical lr;abccubtion and expansion suggeS[
or- hJcm:lI1gioma. The kuter :lAcels a younger
,whereas the former is seen in the
b<
mass 111:1}' be seen with lymphoma due to
thy, which may also cause alllenor scalloping
bodies.
tocyrosis, look for involvement of SCH:ral
:lIld bKkgrolllld small bowel
thickcningjdil:muiorl and hepatosplenomegaly, which
may be sccn on the spine r.ldiogr.lph.
Decreased disc Sp:lCC height and cndplatc changes
point 10 infection.
Further management
The underlying Clllse G ill be dClcmlillcd from the age of
the patient, ancillary signs on the radiograph (as described
abovc) and thc history and cxamination. An isotope bonc
scan may be required to loc:tre further dqx>sits in a p:tticllt
with mct"ast"ascs.
Further reading
Graham TS (2005). rhe ivory vertebra sign. R.adiology
235: 614-615.
245
246
Answer 138 Musculoskeletal Imaging
ANSWER 138
Observations (138a)
There is marked abnormality at the midtarsal joint with
dislocation. sclerosis and debris formation. Prominent
vascular calcification is noted. The appearances arc those of
a Charcot joint and the most likely cause in \'lew of the
\'ascubr ca1cillc:ltion is diabetes mellitus.
Diagnosis
Diabetic ncurop:llhic 100L
Differential diagnosis
Of causes of neuropathic joint:
Shoulder and upper limb joints:
Syringomyelia.
Congcnit:ll insensitivity to p'lin
uprosy.
Syphilis.
Spine'
Trauma.
Tabes dorsalis.
Hip and knee:
Tabes dorsalis.
Steroids.
Ankle and foot:
Di:lbctcsmcllitus.
Alcoholism.
j\'lyclolllcningocdc.
Congenital inscnsiri\"ity to pain.
Discussion
Neuropathic arthropathy is a traumatic arthritis associated
with loss of sensation ;lnd proprioception of an affected
limb. When encoun tered clinicall y it is also known as a
Charcot joillt. The decreased pain sensation produces
repetitil'e trauma leading to eventual destruction of the
joint. There is olien no history of trlullll and the patient
Ill l}' present with a swollen Wl rrll joint with normll
inflammatory markers. A third h:we pain at presentation
although there is ustll ll y a decreased response to deep pain
and proprioception at t his stage. Because the patient is still
using the limb there is no juxta-articular osteoporosis, in
fJct the bones arc sclerotic. The exccption to this rule is in
patients with superadded infection, which is not
uncommon in diabetics. Repeti tivc trauma leads to
destmction, dislocation and dcfomli ty \\irh multiple loose
bodies within the joint. The likely underlying pathology
depends upon the site of the joint and the age of the
patient. When considering the ankle and foot, thc most
common causes in adults arc diabetes mellitus and
alcoholism, whereas in children the most common causes
arc myelomeningocele and congenital insensi tivity to pain.
Examples arc shown of a Charcot joint secondary to
diabetes mellitus ( 138b ) and a Charcot elbow in a patient
with syringomyelia ( 138e).
Radiological features of a Charcot joint include:
Dense (i.e. sclerotic) bones.
Destmction and fragmentation of articular
Degeneration.
Debris (loose bodies).
Di slocation.
Deformity.
Joint cffitsion.
Exeessin:callus formation.
Practical tips
Look for vascular calcificati on on the radiograpr
will otten be present in patients with diabetes
hence point to the underlying eausc.
Further management
Trcatment is stl.pporril'e. Ampurat ion may be
severe progress101l.
Musculoskeletal Imaging Case 139
247
248
Answer 139 Musculoskeletal Imaging
ANSWER 139
Observations (139al
Irregularity, sclerosis and loss ofhcight of the right femoral
head arc seen on the pelvic radiograph. There is no
signitic:l!lt abnormality ohhc acetabulum and the lefi: hip is
unremarkable. The findings arc consistent with avascular
necrosis of the right hip. Bilateral sacroiliac joint fusion is
also present, though more prominclH 011 the riglH side.
This suggests a background seronegative arrhropathy. It is
therefore likely that the avascular necrosis is drug induced
by treatment for the seronegative arthropathy, or perhaps
associated inflanllllawrv bowel di sease. No bowel
abnormality is seen on tl;is plain film [0 confirm the latter
hypothesis
Diagnosis
Avascular necrosis (AVN) in a patient on steroids for
seronegative arthropathy.
Differential diagnosis
For causes of avascular necrosis (mnemonic - ' DRIED
HI P' )'
Diaoctes and other metabolic conditions, e.g.
hypedipidaemia, gout, pancreatitis.
R.adiotherapy. '
l;l tl ammatory disorders, e.g. rheumatoid, SLE,
scleroderma.
Endocrine disorders, e.g. Cushing'S.
Drugs, e.g. steroids, anti-inflammatory and
immunosuppressi\'e drugs, alcohol.
Haematological disorders, e.g. sickle cell, hacmophilia,
polycythaemia, Gaucher's.
Infection and injury, e.g. fractures, burns and f.1t
emboli sm.
Penhe's disease (idiopathic AVN in children).
Discussion
Avascular necrosis is a consequence of interrupted blood
su pply [Q bone with death of cellular c1cmclHs. The many
causcs arc listed in the difierential diagnosis and folloll" the
mnemonic 'DRIED HIP'. The femor.tl head is the most
common site at'tected. Other common locations include the
humeral head and femoral condyles . The earliest
radiological sign is subtle relative sclerosis seCOnd;H)' to
resorption of surrounding bone. A radiolucent crescent
par.tllel to the articular surface may appear. Flattening,
fr.tgmentation and sclerosis then ensue. Subchondr.tl cysts
and collapse lead to early osteoarthritis of the aflccred joint.
An AP afthe pel vis ( 139b ) shows the subtle crescent sign
in the !cft hip of a child with early avaseubr necrosis. This
is more clearly seen on the frog lateral vicw of the sallle
patient ( 13ge).
Musculoskeletal Imaging Case 140
tips
eOlia] for A \TN is long and,.of course,
toe- idiopathic Penhe's disease in children. The
IblUres arc worth checking for in
J. CJuse , but clinic31 history may be required
For example, the child with AVN shown in
leukaemia, and steroid trc:atmcnt was the
with steroid theral')'. e.g. thumb-printing
presence ofa SrDm3 or sacroiliitis
Rhcutlllloid-typc arthropathy or changes of
sdcrodcml:l.
Vascular calcification, which may point to
di:abctcs.
Associations \\;Ih immunosupprcssh'cs, e.g. pelvic
transplant kidney.
Further management
The underlying cause should be sought and treated.
patients will de\'elop debilitating secondary arthritis and
go on to require replacement of the affected joint.
249
250
Answer 140 Musculoskeletal Imaging
ANSWER 140
Observations 1140a)
There is diffilSC osteosclerosis 3Hccting the \'isibk skeleton.
There is also ll1:tssivc splcllot1ll!galy making the likdy
(iiagnosis That of myelofibrosis. Lymphoma is another
possibility and less !ikcly, m:lslCX:YlOsis.
Diagnosis
r.lyclofibrosis.
Differential diagnosis
Of dimISI: bony sclerosis and splenomegaly:
Lymphoma.
M:lStocyrosis.
Of generalized osteosclerosis in ;Idults:
Sclerotic metastases (especially breiS! or prostate
carcinoma).
Lymphoma.
A'lyclo/ibrosis.
Paget's disease (140b).
Renal osteodystrophy.
Sickle (ell disease.
M;lstocrtosis.
Osteopetrosis.

Fluorosis
Osteopetrosis and pyknodysosTOsis have onset in the
paediatric age group.
140b Axial CT image of the
pelvis shows sclerosis of the
right hemipelvis with cortical
thickening and thickened internal
trabeculations typical for Paget's
disease.
Discussion
This rnrc1oprolifcrativc disorder results in progfC'1ll
marrow n:placcmcm by tibmsis ;lIld consequent an
extramedullary h3cm:lTop0ics;s and
massi,'c). age ofansc! is O\"er 50 )cars.
Practical t i ps
Osteosclerosis is on-en missed when the appcaranct
blamed on the qU31ity orthe film, i.e. when it is
thought to be due to the I';1diograph being
underpellCrrJted. Assessment of the intervertebra
discs should be made - if the" arc visible then the:
:lppearanee is to be real. This is well
demonstrated in Figure 140e: there is diffuse
osteosclerosis aflccting all the bones on this exit
patiellt with osteopetrosis. Note how the
intervertebral discs arc clearly seen, reinforcing:
f.let that the radiograph is Ilot underpcnelratcd.
P.lticnrs with renal osteodrsrrophy may ha\'e a
haemodialysis line on CXR or peritoneal
on A.XR. There may be evidence of subpcrioslcM
bone resorption, soft tissue and vascular calci
and 'nigger jersq" spine.
When sclerotic met"JstJses 3Te suspected on a
cheek rhe bre;lsr shadows: in female patienl5
may be 3 mastectomy, while in males enlarge
breast tisslie Illay be seen due 10 hormone th
prostatic carcinoma, Figure 140d shows sueh-:-
- sclerotic prostate lllet3St:lses and gynaeco
140c CXR of an adult with
osteopetrosis demonstrates
diffuse dense osteosclerosi s.
Musculoskeletal Imaging Case 141
c splenomegal y on the AXR suggests
-brosis
atrophy (possibly with calcification) sli ggest's
cd] disease, and there may be mher signs of this
~ gallstones, avascular necrosis of the femoral
.Ind cndphuc inf:lfClions causing H-shapcd
I bodies.
megal), and small bowel thickening suggest
' osis.
the" AXR of a patient with osteopetrosis a
izcd 'bone within bone' lppcar.mcc Illay be
md the \'encbral bodies may h;1\'( densely
'c cndplatcs producing 'sandwich \'crtcbr:J.c'.
(,"cr flask dcfarmin' of the femurs should also
cd for. Figure 140c is an orthopamomogr.un
adult patient with osteopetrosis demonstrating
osteosclerosi s and supernumerary teeth
'5 disease c;m also produce a 'bone within bone'
nee, howe"er coarse trabeculation and cortkal
ning normall y diflcrcnti:lle this from other
is is associated with ligamentous insertion
management
is no specifi c rreatillem for myelofibrosis.
omy is not routinely performed, but is indi cated
for spleni I.' enlargement that causes rC\:llrrc nt painful
episodes, SC\'\:re thromlxxytopeni3 or an llnaccepmbl y high
red bl ood ce ll transfusion requirement. Median survival
from time of diagnosis is approximatel y 5 years. End stage
myelofibrosis is a wast ing illness characterizcd by gencral
di sability, Ii,'cr failure and bleeding from thrombo-
cytopeni a.
140e OPG of an adult with osteopetrosis; this
demonstrates diffuse osteosclerosis and
supernumerary teeth, which is an associated finding.
251
252
ANSWER 141
Observations (141a)
There is a large, cxpansilc, mixed lytic/sclerotic destruct!,'C
lesion involving t he right anterior hcmipclvis. There is
marked cortical destruction wit h a soft tissue component.
The lesion has a wide zone of transition. This is an
aggn.:ssi"c lesion and the most li kel y diagnosis in a patient
of this age is a primary malignancy such as lymphoma or
chondrosarcoma. Metastasis should also be considered.
Diagnosis
Chondrosarcoma.
Differential diagnosis
Lymphoma
Metastasis.
Discussion
Chondrosarcoma is the third most common primary bone
malignancy with multiple myeloma being the mOSt
common and osteosarcoma following second. Chondro-
sarcoma ca n be primary, or secondary following malignant
translorrnation in ;1 pre-existing skeletal lesion such as an
osteochondroma, enchondroma or a parosteal chondroma.
Chondrosarcoma most commonl y presents in the 4th or
5th decade of lite with a male predilection of 2: I.
Radiographs typically re\cal a mixed lytic and sclerotic
appcarance. The scleroric areas represent chondroid matrix
mineralization and arc seen in 60- 78% of lesions. The
characteristic appearance of mineralized chondroid matrix
is a 'ring and arc' pattern of calcific:uion that can co..11esce to
form 'snowflake- type' calcification. This characteristic
chondroid calcification usually ;\lIows confident radiological
di;\gnosis of a cartilaginous lesion.
R.,diological signs
Mi xed lytic/sclerotic lesion.
Wide z:onc of transition.
'Ring and arc' and 'snowflake' calcification.
Cortical destructi on.
Soft tissue mass.
Chondrosarcomas arc also characterized as central or
peripheral. Central chondrosarcomas make up the majority
and arc intramedullary in origin, although they may erode
through the cortex into the soft tissues . Central
chondrosa rcomas lIsuall y arise in the pelvis or lemur and
arc often expansile with the characteristic calcification
described. Endosteal scalloping is often seen and call help
diflcrcntiate low-gr;\de chondrosarcomas from enchond-
romas. Clinical sympwll1s arc nonspecific, with pain being
the most frequent symptom. Peripheral chondrosarcoma is
also termed exostotic chondrosarcoma and refers to
malignant degeneration in an cxostosis (i.e. is a secondary
chondrosarcoma). An cxample is shown in Figurc 141 b-
note the flocculent calcification of the chondrosarcoma,
which had arisen from the exostosis at the lateral femoral
condyle. This should always be suspected when there is
growth of an exostosis after skeletal maturity or if an
exostosis becomes painful. The cartilage cap of a suspicious
exostosis can be measured 011 M lU, and if the thickness is
greater than I.S cm then malignant transformation
be suspected. Again, flocculent chondroid cakificao
characteristic tor malignant degeneration.
Practical tips
It call otten be diflicult to diflcrentiate an encho
from an intr;\medullary chondrosarcoma, howc'a"
larrer is more likely to present with pain and
enchondroma will often demonstrate periosteal
and cortical bre.\kthrough.
Further management
As with most primary bone t umours, a su
chondrosarcoma should only be biopsied in a
bone tumour centrc so as nOt to seed tll
contaminate the surgical field.
Further reading
Murphey lvi , Walker E, Wilsoll A, et at. (2003).
of prim.\!)' chondrosarcoma: radiologic-pat h
correlation. /{ndioGmpbics 23: 1245- 1278.
141b Flocculent calcif ication
from a chonrlrosarcoma that has
arisen from the exostosis at the
lateral femoral condyle.
Case 142
A 45-year-old male presented with severe back pain for several weeks.
253
254
Answer 142 Musculoskeletal Imaging
ANSWER 142
Observations (142a, 142b)
AP and hlteral images ( 1423) ofthc thoracolumbar spine
shol\' marked deformity at the TI2/ LI level with erosive
destruction of the opposing ,"enebral endplates. There is
anterior slip at this level with anterior angulation (gibbus
deformity)_ Appearances arc in keeping \'ith a discitis.
Axial and coronal T2 weighted MR images ( 142b)
demonstrate high signal in the TI2/ Ll intel"Yertebral disc.
Signal change extends throughout the adjacent ,ertebrae,
and there is endplate destruction and partial vertebral
col l:tpse at T12. Til ,ertebra has increased marrow signal
suggesting it is also in\"ol\"ed. The axial image demonstrntes
high-signal fluid collections in both psoas muscles
consistent with bi lateral psoas abscesses.
Diagnosis
Tuberculous ( Pan's disease ) with associated
psoas abscess.
Di scussion
The spi ne is the most common bony location to be
in,'olved in TH. Presentation is often late since initial
sympl"oms :are of ,"aguc back pain and stiffness. The most
common location IS the upper lumbar/ lower thor:acic
region, particularly around LI leyel. The anterior aspect of
the venebral body is mOSt typically aftectcd. The disk spacc
thcn becomes involved via cxtension along the anterior or
posterior longitudinalligamelll or directly through the
endplatc.
R:adiological features of disci tis include:
Reduction in height of the intervertebral disc,
is the first sign of a disciris.
Erosion of the "ertcbral endplates.
Involvement of the vcrtebrallxxlies leads to
and resulting gibbus deformity.
Spread of infection into adjacent soft tissues
in psoas/ paraspinal abscesses.
Neurological im'ol\-ement arises due to intraspim.
spread of infection and vertebral body
occurs much more commonly when the infecri"fo_
organism is TH.
Practical tips
Discitis will cause bon)' abnormali ty of the su
and inferior endplates of the adj:acent ,enebral
i.e. abnormalitv will be centred at" the level of
Thc vertebral disc space is m:aintained longer ill.
spondylitis than in pyogenic discilis.
Look at the paraspinal regions to look for s
infection. Infection can present as leg pain/s--
duc 10 rracking of collections dOWI1 the iIi
muscle.
Look at, and around the spinal cord for ex
collcctions :and spinal in\"olvemem.
Further ma nagement
Treatment is with antituberculous medication.
of associated psoas or epidural abscesses may be
142b (left) Vertebral body collapse with abnormal marrow signal
in the vertebral bodies above and below it. Bilateral psoas
abscesses (right ).
male presented with
hand following :J.
Musculoskeletal Imaging Cases 143, 144
255
256
Answer 143 Musculoskeletal Imaging
ANSWER 143
Observations (143a)
There is a bilaterul symmetrical erosive arthropathy ltlecting
the distal interphabngell joints. BOlle density is preserved
and there is 'pencil in cup' ddormity with bony
proliferation. At the left little finger there arc signs of
ankylosis of the distal interphalangell joint. The
appearul1ces lre consistent with psoriatic arthroplthy.
Diagnosis
Psoriltic arthropathy.
Differential diagnosis
Ankylosing spondylitis.
Rheumatoid arthritis (RAJ.
Discussion
This is a seronegative arthropathy aflecting synovium and
ligal11entous attachmcnts, and aflects fewer than 5% of
psoriasis pltients. In approximately 15%, the
Cln predate de\"clopmem of skin changes by SCI'aal years
The pattern of disease is \'arilble, though the case illustruted
is classical, i.e. asymmetric erosive oligoart hritis aflccting
the distal joints of hands and feet. New bone formation is
charucteristic, and Illay i"esult in ankylosis of interphalangcal
jOllHs, as in this case. Resorption of the distal phalangcal
tufts nu y Ix seen with accompln)'ing nlil changcs.
Spondylolrthrop;lthy is another pattern of disease, often
with sacroiliitis and parul"ertcbrul Other disease
paTtefllS include symmetrical pol\'arthritis mimicking
rheulllatoid, lllotloarthriris and arthritis mlltilans, a grossly
destructivc pattcrn that may progress to forlll 'opera glass
hand'
143b Radiograph of bot h hands of a patient with
rheumatoi d arthritis. Bilateral symmetrical erosive
destruction is present affecting the
metacarpophalangeal joints and the wrists. Note the
telescoping of bone ends and the periarticular
osteoporosis.
Practical tips
When presented with a hand radiograph with C'\
of erosil'l' arthropathy, certain
can help identify the most likcly aetiology. The
mdiological differentiating learures of the more
common crosive arthroplthies arc as tallows:
Psoriatic arthropathy:
- Usually (/IyJllmctrical aosh"e.
- lntaphalangeal joints, particularly the dist:a.
interphalangeal joints, aTe a!lecred.
- ROilY prolijcrfltioJl/ periostcal reactioll ani
prcsCJ1'cd bom dCllsit'ycharacrerisric.
- 'Pencil in cup' ddormity
- Ankvlosis .
It'
- Bilateral symmetrical crorlJ'e arthropathy.
- Metacarpophalangeal and proximal
interphalangeal joi!HS affected, Le. prOD
JIIlfll/joj'ltsojdigilJ.
- Margillal erosions.
- Subluxation with ulnar deviation of digiD.
- Decreased bone demity.
- Ankvlosis. .
- Figure 143b is a rudiograph of both
patient with rheumatoid arthritis
bilateral synllnetrical crosil'c dcstructX..
llletacarpophabngeal joints. There is
genemlized decreased bone density and
arthropathy at rhe carpal joints and rail.
joints. Figure 143c sholl'S similar ch _
feet of a rheumatoid patient with
erosions and symmetrical subluxation ..
metara.rsophalangeal joints
143 Musculoskeletal Imaging
Gomy arthropathy:
- .\symmetrical crosh'c arthrop:llhy.
- Erosions arc juxta-articular with DVttiJnllgj"g
("gu.
- Preserved bone density and joint space.
- Bony proliferation/periosTc:ll reaction.
- Goltr) tophi causing sort tissue masses in 50%.
- Figures 143d and 143c arc radiographs of goU[
demonstrating an asymmetrical eros;ve
arthropathy with 'punched out' erosions. These
have o\'crhanging edges, which arc best
seen at the proximal imerphalangeal joints orthe
index fingers bilaterally and the
mcucarpophlbngcal joint of the right thumb.
Furt her hrgc 'punched out' juna-articular
erosions with associated tophi arc seen around
the base of the right big toe in particular. Note
the preservation of bone density.
Radiog ra ph of both ha nds de monstrates
, ' punched out' e rosions with overhangi ng
and associated soft tissue swelling in a patient
gout.
It is impossi ble to distinguish thc
sponrlyloonhropathy of psoriasis from Reiter's
syndrome though it is notable that in psoriasis the
hand is most affected and in Reiter's, the foot.
Spond)'lo.1.rthropathy of psoriasis is diflcrcnt
from ankylosing Sl)()nd)'litis - thc
paravcrtebral ossification is asymmetrical and nOT duc
to true s)'ndesrnophytes.
Further management
Givcn thc inflammatory nature of the di sease, treatment
consists of anti -inflammatory and immunosuppressive
drugs as for other infl3mmatory anhrop:lthic.::s.
'43e Radiograph i gout
with characteristic 'punched out' erosions aff ecting
t he big toes.
257
258
Answer 144 Musculoskeletal Imaging
ANSWER 144
Observations (144a)
Il:adiogr.:tphs of the lett hand fCveal ::I lucent cxp:msik lesion
ofthc diaphysis ofthc 5th Illcrac:upal. There is thinning of
the cortex but no conical breakthrough or periosteal
reaction. No pathological fracture hlS occurred and no
fraCl11rc is seen elsewhere. The lesion has a narrow zone of
tr:l.l1sition and nonaggrcssivc fcamrcs and is consistent \\ith
an enchondroll1a.
Diagnosis
Enchondroma.
Differential di agnosis
For lytic lesion in the digits (mllemonic - 'SEGA GAME
1"),
Simple bone cyst - r;uc in the hand.
Enchondroma is by fur the most likel y lesion with this
appcar;l1Iccat this site.
<.Ibnt cell ttlrnQUT of tendon sheath.
Ancun'smaJ bone C"Sf - mrc in the hand.
GIOllll'IS tumour -I)ainful.
Abscess/ osteomyelitis.
Mcmstascsalldllwc!oma.
Epidermal inclusion cyst (imr:l.Osseous) - distal
ph3.bnx; history oftr:luma, e/,\tlu:m3. 3.nd swelling m3.\'
be prescnt. . .
Fibrous - r:'Lre in the h3.nd.
Di scussion
Enchondroma is a common benign eartibginous tumour
most collllllonly seen in the tububr bones (50% in hands
and feet ) ofpatiellIs under the age of 30 years.
The C:J.Tdinal radiologicallCalmes arc listed below:
Centr:'Lllesion within the medullary canal.
LueelH expansion of bone.
Narrow zone oftr:l nsition.
Thinning of the cortex but no cortical breakthrough.
No periosteal reaction unkss pathological fr:'Leture.
St ippic(] calcific;ltion llKI)' be presem
Cortical endoste;\1 scalloping.
Alleets small tububr bones.
Oilier' s disease occurs when multiple enchondromas arc
present ( l 44b). The enchondromas arc most commonly
see n in the (emur, tibia and hands in an asymmetrical
distribution. In the long bones, presentation is with
asymmetric limb shortening due 10 impairment of epi-
physeal fusion. The lesions do nor incre3.se in size after
ccss.l rion of normal growth. Malignant rr:'Lnslormarion to
chondrosarcoma can occur in up to 25% of patients with
Oilier's disease by the age of 40. Malignant change is more
common in centr:'Llicsions and should be suspected when
there is abnormal comi nued growth wi th pain 3.nd swelling
and/or imaging findings of growth in a pre\'iously stable
lesion, bony erosion and new or increasing calcification
"Ialli.lcd's s)'ndrome describes multiple enchondromas
wi t h multiple soft tissue haemangiolll3.s, which presem on
imaging as multiple phlebolilhs in the soft tissues. It
prescnts bl"cr, usuall y after puberty, and has a much higher
incidence ofmalignalll tr:'Lllsfonmuion.
Pract ical tips
Chondroid pattern calcification, onen seen in
enchondroma, is howe,"er frequelllly absent in
of the tubular bones of the hands and feet.
A painful enchondroml without pathological -
should be suspected of having undergone m
tr:lnsformation IIntil pro\'en otherwise
Further management
There is no specilic treaTment for enchondronu ..
benign bony That is of len picked up inci
when a pathological fr:lCture occurs.
144b Multiple lucent expansile
lesions of the tubular bones of the
hand represent e nc hondromas in
this patient wi th Oilier's disease.
Note that the absence of phlebolit hs
excludes the main differential
diagnosis, Maffucc i's syndrome.
Musculoskeletal Imaging
Cases 145, 146
presented wilh heel pai n.
259
260
Answers 145, 146
Musculoskeletal Imaging
ANSWER 145
Observations (145)
Tllerc: diflllsc- osteoscicr(>sis wit h J 'bOlle wi {hiLl hOll e'
,1Pl'C.'1rJL1ce, The most likel y cii.lgnosis is ostt'opelrosis,
Diagnosis
Osteopetrosis causing a 'bone wit hin hellle'
Different ial di agnosis
Of ' bone wit hin bOll e' appcJr;lIJcc (mJ1C'lll o nic ,- 'SHA RPS
POOL') :
<) SicklC' cdl ,iiscasc,
.. H ypervi Lllinosis D,
/\cromegaly,
'" Rickets,
'" r;lget' s
Q Scnrvy-
'" Post- radi,llioJl tberapY/ Lh ol'Ouast/hell'Y metal
poisoning,
G C)!'ieopetfosis ;md 0\;]105i5,
'" Osteol11 vc lit i.s,
'" LeL1kaemid,
Di scussion
' Bone \vithin bOll e' clcscribcs til,' r.ldi o logi cal
",hell' one bone w within al1orh<:r , lL Cc\1l be
seell ,IS P;UT ofnofnd dn'c lor11l C\1t, espeCi ;llly in thc spinc,
GI' c>wth ,\I:r esr may ;ll so C;HISt' xb e ,lppnr:1I1ci:: hlll' tile re ;He
5('\,('['.11 p,ltholos,iul ,all SCS as lislt:Ll , The di(Tll sc
os teosclerosi s ;md :lgC ol'the pClticllt in rhi s 114;; ) ],oilll
to t llC correct
ANSWER 146
Observations (146)
"Vithin the bu,iv oC lhe C;t!c'1J1 t ll S thne 'J \\'dl ' LlcJll1cd
JesioL1 Ilarrnw 'Z,(lne nl lTansi l iOll , Th e lesion
h,1S ::t vcr y rhill scleroti c bo rdt' l' ,1 11ci celllrJ ll v w itiJin the
lesi,oll i , a ( lu mp of Therc is 110 l'cri osLc.ll
l' e;1Crion ur o verlying soft m;lSS, T he lesion ,1
:tppeJl'<1l1ce dnd rile findillgs .liT n "p ical o t
;lll iniLlOSStC1l1s
Diagnosis
In traosscous iipolll J,
Differenti al diagnosis
e l1ni ca l1lnal hone c"st
POsL -tfa Ulllari c CIf<;\' ,
Gia11l ce ll fl 1111 0 11i' \ GeT) ,
" Des moplastic Ii brOIll ,oL
Di scussion
The CJ IC lll CliS is t il e lli OSC COlllDl ClLl IOCl rioll l() r all
iiltI;lOSSCOlI S lipomJ Ori1n sire' S ot inl' o lw:menr include
rhe proximal te lllUL' , tib ia, pelvis, 1ll.1l1,li bl. c alld
vend,]'c , \Nhcn in\' o h' illg tllbllLtr bo nes, ir i s Il <; l\.11 1\,
loca ted at rhe P,lli" lltS L,f any ag,c ill.1\' dn 'eioi,
Pract ical tips
The di ltcrt'11ti ,11 di agnosis el 'bOI K \l' il' hin hOl K' <1lll),',d l-ancc
is 1;1]-ge blll rh ere MC fe ,llllrcs or l il e Llilderkin ..
that poim 10 tile specitic Cduse:
l1uy 11;1\' (: ErknnKyn' ihsk ddnnnit\' oj
the (' nds of long bones and sclerotic vULL' bral '
endplalt' s producing \;llJci" ieh vcrl' c brJt",
., T here lllay he ;mciJl,llY Sigll<; (e lJ C\i:'e,lse Oil
the radi ugr:lp h sll ch as ;\\',lSC\t! ;lr nt'crmis of Ie men,)"
and hLimera l he.1ds, gdlbtollCS, H -slupcd vc:nehrac
due rn endphtc: intar([i o l\ ,111d sl,lcnic arropliy Ol'
,
e Acromq;'l ly is ,w:;oci;1tcd WiLh rCClangular-s h<l l' eci
venehrae and ci1ondl'OcakilJosis
. 0 I n children, cOll sici n I'ickn;; ;1l1d luok for siliavill g and
fl;l)i Ilg of rbt JlJCLlp lwscs,
o It th e p:ui enr is deledv, ,'(lilsid er Paget ' s ,met look t(x
inc:rl';1sed trJlxculariol1 Jild COI' t iCl llhi ckcni ll g:,
Further management
The o lll v t reaimelli ,\\':lihble Jor oqeopetfosis is bone
Jl1.\lTOW .1re ))lore prone rn
Tr ;lctl1reS rhdll the nonn.lll)(>PL1LHitllL
Further reading
VVi lli ams H , Da\ies l\ , Chap man S (2004), HOll c wiThin
J hone', CIiIi1I:t7! }{,:r-iiirJ/ogr S9: 132- 1.44,
:\11 illtraoss(ouS li poma, "irh llO genrln I)lcdilcni oll , Thert'
is an assoc iari l)n wich TIle: n'pi("i
radi o logic,ll Je-arllr,s are ;1/1 eXI'3nsiJe , nOll aggl- cssiYe
r;)diolu,'(L1r Icsioll \I,il l! <l Lhill , \wll dt'i lncd sclemric bor,ieL
The re is no pcrio:;lc;l l 1'(, ;l( [i 011 or conica l ricsl rUCliOI1 ,
Somcril11cs rh e Icsio ll Jl\,l)' he scpr.m"d, A ('J Hr,, 1 CIUlllp 01
calciticari on is virru,l llv di;lgl1osti c dnd rq'!'(:.5eJ1lS
c'l icitit'.J tiOI1 ti'om Ln necrosis,' l'atiCrl15 be
ur h;l ve lo c l1i zecl bone pJin. The 1"Jciio'
gr.1phic .1ppClr.llh'cS Me, [() a lllJi cJIll Cr:l1 bone
Orher dine l'('llti ,li ;ll't' listed ti) l cOlllplett' ness ht1f
the L'C1Hl;11 (,lic ifiCll'i o ll and ci1;1L';Kteri , ri, ,11)t'Ca l' ,1I1CCS or
th e lesioll m;lkc ir vinuJll y tii,lg11 0Slic of ;lJl
intraosseom lipo \Jl;l
Pract ical tips
,. Iq,o lll c\ ( ' lir' ol11'-l of bOllc ') ,' .\11 occ ur J [
.:l gc.
A dUJll I,' i.e, virm:dl )' di,lf:':llosric
Further management
T his ,\ 1X: llig ll bt' ll )' Inil)ll and I l l) lll nil,r rn ,ll);l gern
fnt
i, n
CASE 147
History
"'m.I< F"'",,",,01
... 1 O"ro "",,,,,,,h<J 0.00.
MuSculoskeletal Imaging Case 147
'"
'"
Answer 147 MuSculoskeletal Imaging
ANSWER 147
ObsefVali"nsI147'1
' )'h"" """" 4,h m" .. '<pOI, ",01< "',""
'";.')' 'n_ Tk' 'ruin& '" m_ l.klr 'n b< . I"'r"h"
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"",,h "To"",', .)"d"",,,,. 1"'0000)I"f'>'"h),,,;.!.m mJ
,],,,.Id ,100 b<
.""";&,,.1 .
Dilllneai.
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Oifh nt l. 1 dl'U"",I,
.. "" .. 4, h m<'><"'"1',l/m"., "',I ,
..... tio_
r""inf"",;"" (. !rom ."kIo "u rl .... ><),
To,""', ')'nJ"",,,_
r .. u.loh)J'OI' ..... hp";'J .... ,,.
r""..J.'I'""u.J..,l' lM'"'' h)T<r..l
Discussian
,;,t,,,,.,, ,,( , I" 'h '" "'" .",01 <>" n" U I. " ""' W' . '",
".um,. 1 . h" ",,,. , ... '"" rh pi'" ,h,""S
,h'"' ........ , r""d.,hn"' r""h)'", ... "",, i X-
I ...... 00m,""" ..... of",".1 md ... 1<,,", ",,;-,,,,,,
'0 r .... hrroiJ ho,mon< .I"" to ",J'''''t'" "',;.,...." mJ
hQn".,,,,,. '",,"kwo h,," j)", ......
" ;'" h) .. b", "M'
"'on Ob<K """". '0' "" f., """"I "",J,,>O".
.... ""' .. ,l.,," .. .I h) "i._ ""'." ninj; ur ,10.
.w " ",II'''''''' """"" .... , irh 0(,11< trio .....
5,h .... 1 ""'" .. "r ", 75'); ( I<Th)_
l'wud""",..w.) T"'!''' "h) h" ........ -..
,n<! b". "" k" """"" "",m" <rh,,..
')".1"""" >,,1 .. """'
"', " "''"' ''''''''' 'i" .fi'".-rl ""'",, h.,';"g 4'; X()
d "orno. o", ... r .. ", " " 10m .bo,n' ... ",nd"l' ""'u"
, h ... ",,,,;,,io .ith ,""" ""U" ""k .oJ >mill
,;.. . ,,,,,",,,,ion i> .."n ., 10'" vf
"""",,nO< , i,l",y <"",""'" (""hn. ,
", ..... iry ... .1 "f , .. 4110 m" .. "J"l ."
""". """" " ''''' oh """"'I"")"" ,h"",,"in,; ohl><
'<N .n<! 5,h m<"''''T', I, .
p Cllcal tips
"1"1", "",,' .,., """.'''''1',1 n "" .11 nn", ' '''''
.Jon', b< I'u, off .), ,10. .. '"" .... i
""'" JI_;,h .u"",""" in ,10.
""'" .... "";,, 10Th
hYJ" , .... "h)",i.li ... .
If, II< . ;" n . 1-<, , i"" I i,[, ,111 .. ,II< """''''' '"
w,,,,01 '"111\' '' T ... ".,-,
,)'''.1"""" ,n"" li"ly.
I ,," .. m."' uf ","I'irk ",,,,,,.,,,,,-, .. " '1""'11,: ",
'''Y or ,..., ifl<", ,, ,i., . "l\'''''''' "", flr
". h ...J ;,h r""i",IMlr
,h" ,,'" ri,,,", of l"' ud"h),rop""hrroi.J"",_
Funho. m.". s.m."t
T""" n ow t""",,, ",,,In,,,,,. i, "","
'''.'''''"1)- ,. ",1 .. ,.1 ,,, I"." ... , ',,"m. ,nJ
;. ><;&,,,. 1.
147b Ha"d , a d;og .. ph of a pa,;"", with
p.eudohypopor .,hy!oidi 1m dom o".tr." I
<"""e"i.,.. of , 10. J.d '0 5,h """ .'''pal"
Answer 147 MuSculoskeletal Imaging
107< Rod;"g"ph ollne 1001 io 11>0 .. me po,;enl os in
Figu,. 147b demon"""" ,"",'. n"", 01 ,h. 3""0
511> me'.'., .. ".
CASE 148
HISlory
" 00)- I""'ntN _ . ..,
... """" dU""8 'h< "OS"'-
Case 148
264
ANSWER 148
Observations (148a)
There is an area of dense sclerosis aflccting the shaft or the
femur with associated cOrtical thickening. Within this is an
area of ccmral111cency. This likely represents a nidus and
the tcatufcs arc therefore consistent with all osteoid
osteoma. Depending 011 other clinical features, infection
might be considered as a diHcrential diagnosis.
Diagnosis
Osteoid osteoma.
Differential diagnosis
Infixtion.
Eosinophilic granuloma.
Discussion
Osteoid osteoma is a rclati\'cly common, benign skeletal
neoplasm composed of woven and osteoid bone, with loose
intervening fibrovascular tissue. The lesion itself rarely
exceeds 1.5 em in maximum dimension and there arc three
main types: cortical, cancelloll s and subperiosteal.
Cortical lesions arc the most common and have
characteriseic findings. Radiographs show dense reactive
sclerosis that aHccts the sha'ft of a long bone, especially the
tibia alld femur. The lesion itself, howc"er, is a radiolucent
area within this area of osteosclerosis known as the nidus.
This is more clearly set::n on tht:: CT images of the same
patit::nt (148b).
Cancellous osteoid osteomas have a sitc predilection for
the femoral neck, posterior clements of the spine and the
small bones of the hands and feet. By comparison, the
sclerosis associated with a cancellolls lesion is usually mild
or moderate and may be distant from t he lesion. C
the classical cortical osteoid osteoma, the cancellous
may not necessarily be situated at the centrc oj
sclerosis, making treatment more diflicult.
The subperiosteal type is rarest, and typically I
the medial aspect of the femoral neck or in the
feet. It produces a soft tissue mass immediately adjao:::a
the affected bone rather than osteosclerosis. Can ...
and subperiosteal osteoid osteonl<1S typically arise
intra-articular or juxta-articular location.
Osteoid osteomas most commonly occur in efl(-
and tibia, where they arc usually diaphysci
metadiaphyseal. The most commonly affected area
spine is the neural arch of the lumbar spine .. \;:
locations include the skull, ribs, mandible and
Intra-articular lesions arc most commonly found in
The affected population is young, with abol..
presenting between the ages of 10 and 20 years._
all patients arc Caucasian with a male prcdominaocc
is the ll sualmode of presentation and is worse at
is thought to be related to the vascularity of the
Symptoms may be present before the lesion is
ica11), visible and approximately 75% of patients repm-
of pain after salicylates. CT can aid plain radio_
identifying tht: nidus. When the history is
location unusual or radiographs
bone scinrigrapby can be very helpful. The
finding is a 'double dmsit}" sign, in which I
area of intense radionuclide activit), w'","'on,1inr
nidus, superimposed on a second larger area
tracer accumulation due to reactive sclerosis.
148b CT reconstruction in the same patient clearly
shows the lucent lesion with surrounding sclerosis
and central nidus.
Musculoskeletal Imaging Case 149
suggest 3. cr scan to confirm and
J the nidus.
pat'icnt's::J.gc arc strongly
__ ~ .. '00.""" an isotope bone scan if
and CT arc unrc\caling.
of com pi ere rClllO\,:t1 of the nidus.
treatment is surgic31, however lllany cases 3rc
ted radiologically wi rh CTsuidcd laser
ubl ion. Greater than 90% Sllccess rates arc
";;th this technique.
Furt her reading
Gangi A, Guth S, Dictclllanll j, Roy C ( 2001 ).
Interventional Illuscu[oskclctll procedures.
RndioGrnplJics 21(3): I.
Knnsdorf ,\>I, Stull M, Gilkey F, Moser R (199 1).
Osteoid osteoma. RndioGrnpbjCJ 11 (4): 67 1- 696.
265
266
Answer 149 Musculoskeletal Imaging
ANSWER 149
Observations (149a)
There is all extensive, cxpansik [liceill lesion involving the
length orlhe lett humerus, pn:dominJntl)' the mctlphyscs
and diJphysis. RClllo<klling orlhe bone is cI"idcl1l and the
lesion has 'ground glass' density in some places. There is,
however, no cortical break or perjosle:.l reaction 3nd
lesion has nonaggrcssiw fcamrcs. The most likely diagnosi s
is librous dysplasia.
Diagnosis
Fibrous dysplasia.
Discussion
Fibrous dyspbsia is a benign tiura-osseous dc\-c!opmcllt'al
:l1lolll.l1y of bone whereby the medullary cavity becomes
replaced by an iml11atlll'c mat rix of .:ollagcn and \\"OI'CI1
bOllc. Males and females arc equally affected and 75% of
patients develop the disease belore Ihe age of 30 years. The
monostotic form, which mOSI commonly lflects rhe ribs,
proximal femur and craniofacial bones, accoullIs lor 80%
ofcascs.
Thc polyostotic fonn (i.e. in\'ohing more than one sire)
is seen n:mai.ning the
femur, tibia, pelvIS and 1;1clal boncs_ A subtyiX 01 the
pol)'oSlolic form is McCune- Albright syndrome , where
polyostotic unil:tleral fibrous dysplasia is associlted with
'catc au-lait' SPOtS and precociollS puocrty in young girls.
a 'ground gbss' density !csion in the
medullary cavity is the characteristic fcaturc_ Thc 111ct;Jphysis
14gb Occipitomental radiograph of skull in a
pat ient wit h leontiasis ossea demonstrating
hemicrania I sclerosis and expansion.
is thc primary site of in\'ol\'ement with extension into
diaphysis and the lesion may undergo calcitication_
The crlniofucial torm is termed leontiasis ossel
hcmicranial, unlikc Paget's discase. Thc frontal
sphenoid bones arc most commonl y invohed. Sclet"
overgrowth of the fucial bones and cllvari:t results in
deformity, cxophthalmos lnd visul l implirmenl
obliteration ofthe si nuses. Sclcrosis of the skull bast
nlrrow thc neurll toraminl clusi ng cranial
Frontal and lateral skull radiographs 1
149c) of l paticm \\;th leontiasis ossca show these Ii
Complications of fibrous dppiasia includc pat
frncmre, and malignant transformation into osteos.t!i
fibrosarC01l1l or malignant fibrous hisliocytoml in
1% of cases.
Osteotibrous dysplasia is ;111 cmity that was Illis
the past lor fibrOllS dyspJasi:t. It is almost cxcl
conlincd to thc diaphysis of the tibia and is seen in
children. The are vcry simillr to
dysplasia with a nonaggressi\<e
glass'lcsion. Enlargcmcnt ofthc tibia occurs \\ith
bowing. As with fibrous dyspllsil, pathologic:t.l rn...
c0111monly occur. The lesion often rcgresses spon
with age. An eXl1llpic is shown ( 149d ) that illus
typical appearances ;11ld mid-di:lphyscallocation in",
child.
radiological featurcs of fibrous dysplasia
Lucent/'ground glass' lesion in medullary CJ.\
Expansilc.
Answer 149 Musculoskeletal Imaging
;\ lctadiaphyscallocation.
Remodelling/alteration in bone architcaurc.
Endosteal scalloping.
'Shepherd's crook' deformity when :aflCcting proximal
femur.
Li mb length discrepancy.
Pathological fractun:.
No cortical destruction.
Nonaggrcssivc features.
Practical t ips
The appearances of fibrous dysphsia on' rlap with those of
many benign bone lesions and it is reasonable to include it
on rhe differential diagnosis list in many cases. As a result,
is often the firsl differential prmidcd by r:ldiolog)' trainees
In a viva even when the lesion in question hlS characteristic
katurcs of something c l s c ~ Only if a lesion has the
cturaCfcrisric features should fibrous dysplasia be the tirsl
Jiagnosis mentioned - morc often, il should be further
down the list.
Further management
There is no specific tre;lImelll for fibrous dysplasia.
uhologi eal fracUlres often occur and may necessitate
urgieal fixation.
149d Radiographs
of the leg in a child
demonstrate a
lucenV'ground
glass' lesion in the
diaphysis, which
has nonaggressive
f eatures and is
typical of
osteofibrous
dysplasia.
Case 150
267
268
Answer 150 Musculoskeletal Imaging
ANSWER 150
Observations (150a, 150b)
A'\:ial images oflhc wriSt with Tl weighting ( 1503) and T2
fur saruration ( l SOb) arc shown. Inflamed tcndon sheaths
an: of high signal on T2 &t sattlr;lfCd images and low signal
on Tl weighted images. In addition, there is palm:!f
bowing of the flexor retinaculum. The median ncryc is of
increased signal on the T2 weighted imlge. This
combination of features is consistent with a diagnosis of
carpal tunnel syndrome.
Diagnosis
Carpal tunnel syndrome.
Discussion
Carpal WHile! syndrome is a disease that arises due to
chronic pressure on the median ncrve as it passl"S the
carpal tunnel, usually associ:ttcd with repetiti ve wrist
Illovelllents. It is lllorc commonly seen in females with a
ratio of 4:1 and is bi lat eral in 50% of cases . Ustla]])'
diagnosis is Ill ade by cli nicians with positi\e findings on
clinical examination, electromyelography and nerye
conduction studies. lt1diological ex;;ullina[ions havc a roll.'
in the few cases where these ilwestigations are inconclusi\"c.
Ult rasou nd is usually the first examination undertaken
although M IU has been shown to bc morc specific and
sensitive. US findings arc of:
Akdian nervc swelling in the proximal mnncljlc\"cl of
the distal radius.
Nervc flattening in the distal nlllncl .
Bowing of the flexor retinaculum.
On M RJ thcse same findings can be appreciated:
Median nervc swelling proximal to the
termed pscudoncuroma.
Palmar bowing of t he flcxor retinaculum.
Featurcs of tcnosyno\"itis - which appear as
signal on 1'2 wcightcd images around the fI
tcndons.
Increased signal in thc median nelYC on TI
imaging.
Median nervc enhancemcnt following contra
injection is vari able and thcre can be marked
enhancement due to oedema or absence of
enhancemcmdue to ischae mia.
Practical tips
Assessment of nerve swelling can be made
the size of the 111edbn nervI.' :It the level
radius and at the ham:lte.
Further management
Methods to decrease oedema and swelling \\i
c:lrpal tIInnel such as treatment of hypo thy "
restriction of fluid illlakc can help rel ieve sy
Howeyer the gold standard treatment for carpoa
syndromc is surgical decompression.
150b High signal of median nerve on T2
weighted image (upper arrow); palmar
bowing of flexor retinaculum (lower arro,;",).
Musculoskeletal Imaging Case 151
269
270
Answer 151 Musculoskeletal Imaging
ANSWER 151
Observations (151a, 151b)
AI' and lateral Tadiogr;\phs of dlC lumbar spine show
posterior \'cttcbr.tl sGllloping of the lower lumbar vertebrae
\\'ith a narrowed anteroposterior canal diameter. The AI'
film ( 151a) shows th:Jt the inrcrpcdicular dist:lIlcc is
abnormally narrowed at L5 level and there is squaring of
the iliac wings. The features arc consistent wit h
achondroplasia.
Diagnosis
Acl1ondroplasia.
Differential diagnosis
Of posterior \'crtcbr:J.] scalloping:
Prcssurt" dlccr - tUIllOurS in spinal c:l nal ,
syringomyel ia and cOllllll unicating hydrocephalus.
Dural cctasil. This occurs in ncurofibrolll:atosis.
Mar/;IIl 's and Ehlcrs- Danlos.
Acromegaly.
Achondroplasia.
Congenital disorders sllch as Illucopolysaccharidoscs,
e.g. Morquio' s syndrome.
Discussion
Achondropbsia is an autosomal dominant disease of
defcctive enchondr.tl bone formation relatcd to advanced
151c Macrocephaly and bulging forehead on lateral
skull radiograph.
p;uemal agc. Those \\1th thc homozygous form
still born or die in thc neonatal pcriod. Tho
hcterozygolls :tchondroplasia can h;l\"e a long we
normalill1elligcnce.
R.1diologicll fc:tturcs to look lor includc the
Macroccphlly with bulging forehead ( 151c
narrow foramen nt lgnum m a ~ ' be associ.uc-d
hydrocephllus.
Small J-shlpcd sella due to flarrcning ofru
sellae.
Short flared ribs.
llc)stcrior vertebrnl scalloping.
Anterior-inferior \enebr.tl body beaks.
Short pcdiclcs and caudal narrowing ofintc
distance (this should normally increasc in the
dircction). These abnormali ti es can Icad to
stenosis.
Squared ilbc wings.
'Champagne glass' pchic inlet ( 15 Id).
Horizontal sacrum.
Shortening and bowinS of long bones with.l
'trumpet' appearance due to di sproporti onate
mel"Jphyseal flaring ( 15 1e).
Brachydactyly leading to short smbb), fingers I ~
151d AP pelvis in an achondroplastic
typical 'champagne glass' pelvis with
iliac wings. The int erpedicular distance nar
caudally and the sacrum is horizontal in orien
and difficul t to visualize.
Answer 151 Muscutosketetallmaging
P"<li""llip.
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CASE 152
History
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Case 152
m
Answer 152 MusculoskeletlOllmllglng
ANSWER 152
Obso",atlonsI 15h)
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Musculoskeletal Imaging
Cases 153, 154
CASE 154
History
An 15-yc3r-old male presented with
back pain.
273
'"
Answers 153, 154 MusculoskeletlOllmllglng
ANSWER 153
Obsorvatlonsl153)
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ANSWER 154
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Musculoskeletal Imaging
Case 155
tips
ttncbral body affected has a uniformly flat 'coin
edge' 3ppcarancc.
;-encbral discs arc typically spared with normal
~ c c s .
posterior clements arc spared.
generalized Os[copcnia suggests osteogenesis
\'ertcbra plana is the term used to describe
of a previously normal vertebral body,
refers to flattening of the venehral bodies
from binh. Pbtyspondyl)' may be generalized, aflixting all
the \'crlcbral bodies, multiple, affecting some but not all
the vcrtcbrnl bodies, or localized, in\"o]ving just one
\crtcbn.l body.
Further management
The underlying caUSe should be determined ifpossibk.
Eosinophilic granuloma is the most common cause in
children and usually n:sokes spontaneously wilh age.
275
276
Answer 155 Musculoskeletal Imaging
ANSWER 155
Observations (155al
Three well defined densities in the right uppcr quadrant 3TC
projected outside the comour of the right kidney and arc
likely to represent gallstones. There is mild, diffuse
osteosclerosis and increased trabeculation of the bony
skeleton with I'encbral cndplate infarctions causing H-
shaped lumbar vertebrae. Sclerosis and flancning ofthc left
femoral head suggest avascular necrosis. The spleen is noted
to be atrophic :md calcificd. Ol-crall the features arc
consistcm with a diagnosis of sickle cell disease.
Diagnosis
Sickle cell disease.
Discussion
Sickle cell disease is an inherited disorder mostly seen in
Afro-Caribbcans. The sickling arthc red blood cells leads to
increased blood viscosity, occlusion of small I'essels and
bone infarction leading to necrosis. Chronic
anaemia also ensues. Marrow hyperplasia leads to
coarsening of the trabeculae and may cause diffuse
osteosclerosis. A CXR in a l7-year-old female with sickle
cell disease is shown ( I 55b). This demonstrates diffuse
osteosclerosis with H-shaped thoracic vertcbrae (due to
endplate. infarctions) and cardiomegaly (secondary to
chronic anaemia ).
155b CXA in a patient with sickle cell
disease demonstrating diff use
osteosclerosis with cardiomegaly and H-
shaped thoracic vertebrae.
Practical tips
Ancillary signs of sickle cell disease on the radiogt2l'
depend on the area ofrhe body imaged:
Abdominal radiograph:
H -shaped vertebrae due to endplate infurctiom..
Avascular necrosis ofthe femoral heads causim!:
flattening and fragmentation. -
Gallstones (secondary to haemolytic anaemia
Splenic arroph)' and calcification.
Renal papillary necrosis may be caused by siekk-
cell disease due to sloughing of papillae from
infurcrion; a sloughed papilla mal' be seen widm:
the renal calyx (on an IVU) ( I SSc).
Chest radiograph:
H-shaped vertebrae due to endplate infurniom.
Avascular necrosis of the humeral heads
Cardiomegaly (due to chronic anaemia).
Skull radiograph:
'Hair on end' appearance of skull vault due [0
marrow h)'perplasia.
Widening of diploic space.
Further management
Treatment is generally supportive with m
transfusions bei ng necessary. There is a high ineid
infection of bone and lung. Skeletal pain can occur
only from osteomyelitis but also from bone
inf..1rction
CASE 156
History
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1,,'; ';PH "t p..>tn .


MuSculoskeletal Imaging Case 156

m
Answer 156 MusculoskeletlOllmaglng
ANSWER 156
Ob" fYlli ons l l 561
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CASE 157
History
An r""'"' f"<",",1 1<5
p . ....
MuSculoskeletal Imaging Case \57
Answer 157 MuSculoskeletal Imaging
ANSWER 157
Ob ..
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CASE 158
History
.\ 14-ycar-oJd male presented with
.mll pain.
Musculoskeletal Imaging
Case 158
281
282
Answer 158 Musculoskeletal Imaging
ANSWER 158
Observations (158)
Within the midshaft or the diaphysis of the humcms there
is a rdativciy well defined Irtic lesion that has a narrow zone
of transition. There is endosteal scall oping and smooth
J:uncl lalcd periosteal reaction. The lesion has nonaggrcssi\'c
features and in this age group eosinophilic granuloma or
infcclion is the most likely diagnosis.
Diagnosis
Eosinophilic
Differential diagnosis
Osteomyelitis.
Fibrous drsplasia.
Leukaemia
Lymphoma.
Discussion
Langcrhans cell hisriocytosis is a spectrum of disease
characterized by idiopathic proliferation of hist ioc),tcs
producing focal or systemic manifestations. Eosinophilic
granuloma is the term used [0 describe the disease when
limited ro bone and is mostly seen in patients aged octween
;; and 30 years, The elinical 'and radiological fC:Hurcs may
mimic infecrion as well as mher benign and malignam
diseases. The cause and pathogenesis of the condition arc
unknown. Clinicli m:mitCSl'ations relate to thc atfected
bone with local pain, tenderness and masses COlli manly
observed . Patients may ha\'c low'grade fe"er or ele"ated
inflammatory markers, which eonnlscs the clinical picture
wit h infection, The may occur in any bone,
although there is a predilection for the flat bones widl more
t han half occurring in the skull, mandible, ribs and pelvis.
Lesions arc solitary in 50- 75% of cases. Approximately one,
third oflesions occur in the long bones, most commonly
the femur followed bv the humerus and tibia. Most lesions
occur in the diaphysis, and in general the growth plan: acts
as a barrier to extension.
Radiographic aplX'aranccs arc \'aried. Lesions typi
appear lytic but may have reacti"e sclerosis. l"largins '
oc well demarcated or poorly defined and they may C"
ha\"e a pcnneati\'c appearance. A lamcllated periost
reaction is often seen. i lwasioll of overlying soft tissue
result if rhe lesion penetrates through the In
skull, the lesion is often round with a punched
appearance and une\'en destruction of the inner and
skull tables results in a 'double contour' or 'ocvelled c
appearance. If there is more than one lesion, these
coalesce producing 'geographical skull'. In the spine,
\'crtebral bod,' is thc most common site of lm'oke
Lung occurs in 10%. Treatmcnt of the
lesions consists of conscn'ati,'e therapy
treatment such as curettage or excision .
Practical tips
AJways keep this condition in mind when fo
diflcrential diagnoses for lytic bone lesions in the
patient - the appearances are varied and the clinical '
may be confusing.
Further management
The prognosis of eosi nophilic granuloma is excellent
spontaneous resolution lesions occurring in b-1
months.
Further reading
Lc\'inc S, Lambiase R, Pelchpr:tpa C (2003), ConiQ1
lesions of the tibia: characteristic appearances at
conventional radiograph}', RtJdioGrnplJitJ 23:
157- 177.
Stull M, Kransdorf M, O,,'aney K( 1992 ). L1ngerhm
cell histiocytosis of bone. RndioGrnphitJ 12( 4);
801-823.
Musculoskeletal Imaging
CASE 159
story
:!4-ycar-oJd male prcscms with knee inst:lbiJity
ing a football injury 2 l110mhs previously.
Case 159
283
284
Answer 159 Musculoskeletal Imaging
ANSWER 159
Observations (159a)
S:lgillal T2 weighted imagcs or the knee demonstrate a
rupture orrhe anterior cruciate ligament, no imact fibres
being demonstrated. In keeping with this, there is mild
anterior tibial translocation. The posterior cmciate ligamcnr
(PCL)is intacr.
There is loss ohhc normal 'bow tic' appearance ohhe
laterll meniscus with non-visualization or the bodv and
much orthe posterior horn. Funhcrmore, abnorm;llow
signal tissue is present in the intercondylar region just lateral
10 the PCL. These findings are indicative or a 'bucket
handle' tcar of the lateral mcniseus with a fragment of
mcniscus displaced A joint emLsion is also present.
Diagnosis
Anterior cruciate ligament (ACL) rupture with 'bucket
h;mdle' tear of the lateral meniscus.
Differenti al diagnosis
Nonc.
Discussion
The ACL is best evaluated on Tl weighted images and
fibres should run parallel to the roof of the intercondylar
notch (159b). ACL tears most commonly leave no nonm.l
residuallibres visible on MIt! . Sometimes, residual fibres
of the ACL arc seen, but following a more horizontal
course than normal.
Sagittal images of normal menisci show a 'bow tic'
lPI>carlrlce on at least two contiguous slices (159c). This
is because the normal meniscus is approximatel y 9 mill in
width and the sagi nal images arc 3-4 mill in thickness.
Thus, at least two sagittal slices should pass through a
contiguous section of meniscus.
'Hucket handle' tears constinHe about 10% of Illeniscal
tears. The vert ical tear through the inner edge produces a
mobile fragment that flips through approximately 18
much like a handle flipping from one side of a bucket
the other. In such circumstances, the residual pan:
meniscus will be reduced in thickness and will not be Stta
on the usuaillumbcr ofsagirral scans. If the 'bow tic'
seen on less than two contiguous SJgirral images, a 'bu
handle' tear must be excluded. The mobile fragmalll'
should then be sought elsewhere in the joim, c.g. me
in the intercondylar region; anterior to the postCfl"
entdatc ligament ( peL) producing the 'double pel'
(I 59d); in the anterior joim, in from of the anterior
of the meniscus.
Other t}'PCS of mcniscal tear include:
Oblique and horizontal - linear signal change \\1m.
the meniscus th:lt extends to the inferior or superior
surf.,cc.
R.1dial (also known as 'parrot beak' tear) - a vcrrial
(ear through the rrcc edge will produce an absent
'bow lie' sign similar to a 'bucker handle' tcar.
Howcn:r, the derect is only small and so the ddea
the 'bow tie' is much smaller.
As an aside, if the 'bow tic' appeamnce of the m
is seen on more than two saginll images this C.Do
indicative of a discoid Illeniscus. This is prob
congenital abnormality where the meniscus has J
disc -like sh3pe than the normal 'e-shape' due to II
thll1 nomlal body. They arc mon: prone to rcaring 3.IlIr.i
be symptomatic e\'en without being torn.
Further management
A complete ACL tcar causes instability that is
by surgical repair with a prost hetic or tendon grwo..
Menisclltears often require arthroscopic
debridement.
CASE 160
istory
kmalc patient presented with joinr
n,.
Musculoskeletal Imaging Case 160
285
286
Answer 160 Musculoskeletal Imaging
ANSWER 160
Observations 1160a)
There is subperiosteal resorption of the r:ldial aspect ofthc
middle phalanges of the index and middle fingers. No
c\'idcncc of marginal erosions or brown tUllIours is seen
though the trabecular pattern is coarsened. The findings
arc consistent with h)'perparathyroidism.
Diagnosis
Hyperparathyroidism.
Discussion
The uneOnlrollcd production of parathyroid hormone in
h)'Pcflxtr:lthyroidism is primary, secondary or tertbry.
Primary hyperparathyroidism is causcd by a parathyroid
adenoma. Thc raiscd parathyroid hormone lelcls lead to
resorption of bone and hypercalcaemia. Secondary
h)'perp:Hathyroidism is usually a consequencc of renal
insuflicienc)" where chronic hypocalcaemia leads to
parathyroid hyperplasia. Some patients with secondary
hnxrp:lrathyroidisrn then go on to delclop the tertiary
form, whereby a parathyroid adenoma :Irises within :I
chronicall y ol'erstinllliated hyperplastic parathyroid gbnd.
The cardinal radiological feature is subperiosteal bone
resorption. The dillerent sHes aflccted arc shown l>elow,
the d:lssical location being the radial aSlxct of the middle
phalanx of the index and middle fingers. Figure 160b
shows :lnothcr pattern of erosion - band-like zones in the
middle orthe terminal rults. Bone soltening mal' result in
wedged vertebrae, kyphoscoliosis :lnd bowing of long
bones. Parathyroid hormone-stinllllated focal osteoclastic
activit)' can cause brown tumours, which arc characteris-
tieall)' expallsile, lytic, wdl demarcated lesions. These can
be the solit:I.TY sign ofhYlxfl>arathyroidism in 3% ofc:lscs.
Figure 160c a pathological fracture through a bro\\TI
160b Left hand
radi ograph
demonstrating
lucent bands of
resorption across
the mid-portions
of the distal
phalanges of the
first three digits.
Radiological features of h),pcrparathyroidism arc
10110ws:
BOlle resorption:
Radial aspect middle ph,)Janx of211d and 3rd
fingers ( 160 .. ).
Terminal phalangeal tufts ( 160b).
Disral end of cla\"idcs and superior aspect of ribs
onCXIL
"ledial aspect proxill1:l1 tibia ( 160c).
I'Ikdial tcmorll and humeral necks.
La.mina dura of skull :Illd teeth producing 'fl
teeth' ,
'Pepper-pot' skull due to trabecular n:sorplion
( 160d).
Pseudo-widening of joillls, e.g. sacroiliac jointi..
cro5ions of the h;lIlds.
Bone softening:
Wedged Iertebrae.
Kyphoscoliosis.
Bowing of long bones.
Brown tumour ( 160e).
Osteosclerosis (marc common in seconda/"}'
h)"l>erp;lralhrroidism).
'Rugger jersey' spine.
Soft tissuc calei/ication:
Periarticular.
Chondroc:llcinosis.
Anerial.
Ren:ll c:llculi.
1\ ledullary nephrocalcinosis.
""'l t

160c AP radiograph of both knees
demonstrates subperiosteal resorption at
the medial aspect of both tibial metaphyses.
Answer 160 MuSculoskeletal Imaging
Pro.li"", lip
On CXk .. '"Or<';""'" .. , ...
'"I"ri", "r" , Ob, - Yi! " 1< 1",""k .. , ",,,,,,,
", ", I< " , ... '"r<,;, w <>f, h,
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.. "";,"'" .ith n" f, o" ", ""
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'"""". 'rin< m,,' I>< "n
.-.f 'h' ,'"' , ... " J", ,fl
160<1 OiIfu bon. , orption 01 tho
O, ' n. 'pop","pOf okull
._"-' flC4.
Further men.yemenl
j" ."'f}' h,l'<,p .... io I .. . "J I>y "''11",,1
If>"'" of 'h< r""hl",id tl .. J . """ d in"," .nJ
'"'" ......... di,I<"''''' "rh'l"''f .... US
.. " "ubi ."W'pn, m'''' "'" i, I",""ml,o
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"'Uf>O< p"''''!'roid ,<I",om . MRI 0< .dnt't;<'phr "a)' I><
to Iox , I< ,IK """'""'I.
1601 CXR in potie nt wOh
hypo,po"thy""di.m with "b,l
,o.ionI of th o .u".rio' .,,'.011 0( tt>e
I<flpooto,ior 7th on " 8 th lib .
1600;1 AP 01 l;got
,lIoold .. domom" oting . , ,,,ion 01
, h. I.te, ol ond of tho ctoviolo.
1601> S.otomibi . con wi t h im. g ot 10
min.od 90 "'"' po" injection._
let. i ... d tr.ce, in ri ght p ...
od."""".
'"
Chapter 5
PAEDIATRIC IMAGING
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CASE 161
History

CASE 162
History
A" I.), .... ,"h'd I"""""" . j,h

Paediatric Imaging Cases 161, 162
'"
Answers 161, 162 Paedi a tric Ima g ing
ANSWER 161
ObSflfYlli<>n' II&11
,.o"'\O"' rh ,,(, e, e,' " , I>< .. "" '<'0
tI>< Iungo_ 11>< "" 00hl "",n, ,,,,,",m, ,s
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Olillnosi.
T h .. "' ...... d)-.pI .. i"
Oiffo, ontlll dl19naois
O(k,h.1 .. on"'" Jpr]"'"
0. .. "",,,,,,, , nl''''''''
Th. ",,"I'OOri< J" r I,, ;',
I" .,,', ,t. .... " d,'i'I ..... ,_
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h,," b", ko", Hu k n o .. h , .. 11,,,,, '"
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ANSWER 162
ObSflovltions l 1621
' I'h.", ... " of,'. """,n,1 ,","IT Th.
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,j;",,,,,, ,' ," ,,, ,,"'" . "",n"", 1"''''''',
Oiffl , u t!11 dilgno.l.
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'TK! M' ,
T , .. ,",.,;"
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'nfik . ...... ''' n.-.')'

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th"" " ",,1-.oric Jw,,,,,",. ,,...., of , t-", roo """mon
' ''''''. "" .",,1 d"rl"i' Tt-", m"'" ' ''' mm'' ''
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P,ootlc.' tip.
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In,"" " ""'" ,I i "I<,o) " pi<, on ,,( d<,'",J i " " """0 I
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CASE 163
History
r.m<'l<"'''''-rl,'" cr "f ,t.. ... ,
... o!d ..... , "iz ...... ,00
hH''' ''
CASE 164
Hi. tory
.\ r ""n"J w;,t. b" .. h;n
.. 10 .. , 1,_
Paediatric Imaging Cases 163, 164
'"
Answers 163, 164 Paediatric Imaging
ANSWER 163
ObH rv&lions ll&l1
" h, cr "''" .h.T." ",,+,., 1
,ou", """" of ,,", .. ki...J tl"i, TI>< "...y.oo ... h m, rt"
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"'''''' .. to .... ""'')'_
Dllgnosl.
hIT'''''' ... ;';U'y ' h,
"on'
OIKUlSlon
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hi".' ''' ... '" 'hIT ,I", ,,,,btu",;' lit,.- .fk",J, (;T "
ANSWER 164
ObseovI,ions 11641
An 'ul>< rI' ";'' ' .. ,."l'
Th, rill'" h,mi!""'" r.n,4 I'r' ,-",,,,,.11"<0"'
m ... , "",,nt m,J","", 1 "'ift ' 0 ,I>< """""",01
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t,;''"t'"''' ' ,ti'rh"s"'''"' h,m;. ""u'" f"on, i, il u ... ,,/
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m'''' '''mm''" '''''''''';'' .. ,.01 ",,,,,,,.Iy. I .. 15""
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frono CHI,
CASE 165
History
F", m""" ""''''''
. ith ..... , ......
h"u" h;"h.
Paediatric Imaging Case 165
'"
Answer 165 Paediatric Imaglng
ANSWER 165
ObH <v, l l"ns . HIs..1
An 1<G ",I>< I;', On , ,,,I 'h", ... MI ... I
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f,,,, I"",m '""" hh
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Di1llnosi.
ti y.lin< m<m\><'", ,1..,,"><
Discuu lo n
ti r , li., m<"' ""'" d;"'.", '" On< "f,h .... ,,' ..-.-. m"n
,'"U"" of '''I,i"',,,!, in I, i, ' ''''''
rom""", in p"m"",,, in.:.n" bu' .no <>Un
in ' "m inf..,,, uf JW><,;" " "', "" .. , " Ju< '0 t.., k of
",,-f,,,,,"," , , m "',," ,,,,., .... ,;t,k IQ, "',,'" 'h< ,u,'."
n ., ;" .t. ", oJ I'" oJ 0 J 1.1' , I", ')I'" : "',,,J .. " I "-
\\"i,I"",,, i, , I", """,I)' ,'i",",;I>I, .,,01 ' '''''in
wll'p",J ".u,int '" 'p;, '''''Y f'" h,
, .... ,0< "". 11 In 'irh"
'5""''''' l'i"" "r ..... ,' '"" 'II'"'" "I" "","m .00
... .... " , ,,><lin! "'" m ,"" )"ng 1'<"."",,'1",
1'" <tm, " ' ,on, .. " "h"of ",ton' ,h",I'l' ",d
1'<""""" H",,,,,,., oJ.. ,1<""," wo )'
1"'''''' '''' ." r k..J ,,, .r in,,, 'h,
165b Ch"1 ,odiog .. ph 01 <Md"iln HMO one! 'of,
Q" "'OIhO,'" oond .. y to ve",il.lio" ,h.,Opy.
NO,,'he 1. l t ,_ .1,
( rulmon"r in,,,,,itW ,mr h,...m. - 1'1 f.j ,
" " 1< .. 1 to . ,,"IJ,n ;" inf.n,,
,,,,,.if.,,, "'" 'n ,ho: ... ,,.,irl>I , ....... ot..m",'ion
fh< en' ",,>n .,' '" ;n' , . f h" ""xl< ,;"i,,.'I)" -"1""'" ..
dong"' " bu"I<, to ,ho: lung 1"'. ;pI"'l""
bil.",,,]. 'rmm,,,,,. 1 r,",m, P",""""",di."inum "'"
P"' " mot ..... '" "'" otl". """ P li< " """ of J""ifh r""'"
,'<" ,iI,,""'. fi O" " d,",o""'"'' "", .....
.. " in . n i.f.", " ,,,,,d bplin'
""".1>< ..... """."'. tl>< of,..., ' 0
th< ns"' . n.! ' f>< ;" 'f>< I<f! 1,,",
" ... " in , .. , , ,, , I", r< ' '''''''1". I "" " .up!<
"f In in"", . 'itb r" lmnn' <l ' ;""",. <>l <mph.,,,,,., .. "I
kf! . i,j,d "n."", rn,"","""""" ,b,
<nJw.inum ' 0 'h< IOIo..p1<d 1<>""" , du< ro ....
,b, in""'''''m m.J I)'mph"'''' ... "'".
m".' ,I< '''r in ,IK I<fi I. " 0.
P,"o:licel , ip.
s;g,,, ,of I"', m"u, ;,)" '"' 'f>< f,lm '" ",du,,"
."""."',, ..... ," ,i, >oJ ....... ,> ,,..;1 .,. .,
""'''' .
Sima" lung .'" '" ",on""
I""umon;" '" .""' ,, ... .. "inoJ Auk! 'rOO''''''''
!>o.m unlik HMll, 'h< lung ',""m<' i" ,h< ..
b< nom .. 1 '" """", .. J,
1&50 Ch .. , ,0<11011'0"" 0' ohikl wi'h flMO who
d ... IoPOd pulm"",rv InW .. itioi empl>vum ""
101. p""ufnO' ho," ... ",.-.lO,V '0 ""nlilotion ""' .. py.
No" the bubbly i" .. , odioting ro
"'" lung 0<190,
Answer 165 Paediatric Imaging
II;, I>o"",h.",,,,,, m t<."", ofH,\1 P
.oJ ," no" .. ,,,,,;,, ... ""h .. ",,"",",0'
... '" 'f"""""'"
C .... , .. 1"..;, .... ,,(.11 10",,, ,,,,I , ..... , , .. 'h,
"""""oJ t""
"""1 <., .. ' .. 116 .... 1 _ .. ,h.,.,M. ri,,",
'U b<oJ' .. ;, p ..... ;"kriot/), IT"", tho u bJ", ...
;n ,IK umb'"'' ""''I' ,IK. "",oJ, .. ,IK ;,,"' m"
,n" "'m .. ",, "'<t." on<l thu, ;"'0 ........ , Th,
t'" #o"oioJ <;,1\" ",n,. ,I>< "",>I "",." "
H - Il , .. '''m .. U-+
Umh'K, 1 '<;n , .. h"" - " .. \II>. ..,i,K,
IT"", urn..., .... p,,,,n$ in .onh ........... inw
,,,.,,", 0' ,nJ i\'e ." ""n;". ;., d>< 'OIh,
" nn m l l.'d).
managoment
T,,,,,,,,,", .. ,,,j,,. .. <nt il ...... ....J
1m;" .. ' ...... of
C .. .. ;,;'" "f II Mn ",","'"' ,h,,"1J I",
" .... '1)' .. y .. "",;';.1 ".rh)"" ....
p .. u"" ....... anJ pn,u"""",",,,, ,,, u,"
CASE 166
History
U"<OO1"' ..... hot"
" 'n,...

Aodiograph
demo"",.';"g
1>0';""" 01 on

"oh.,.,.,
Case 166
298
Answer 166 Paediatric Imaging
ANSWER 166
Observations (166a)
This axial comrast enhanced CT image shows bilarcrnl and
symmetrical low density in the b::lsal g:lIlglia, in\'Oh-ing thc
putamina and thalami. There arc scveral possible causcs for
this appearance. Hypoxia and hypotension should be self-
evident. If not present, le\'l.'ls of glucose and carbon
monoxide should be checked urgcllIly.
Diagnosis
Low-density basal gangli3 secondary
hypoxia/ ischaemia.
Differential diagnosis
Of low-density bas:tl g:l.Ilglil
Hypoxia
Hypotension
HypogJycacmi:l
Carbon monoxide poisoning
WiJson'sdiscasc
Of basal g:lI1glia ca1cificltion (mnemonic 'PIE MAPS' ):
Physiological - rhe most common calise and
so with agc, .
InfectIon - c)'to1l1cgalOVlnlS (CMV), toxopl asma,
rubdla, HI V.
Endocrine - hypoparathryroidism (and
pscudoj pseudopscudohypoparathyroi dism),
hypcrparatllyroidism, hypothyroidism.
lI'lceabolic - Leigh discase, Fain disease, Wilson's
disease.
Anoxia - at birth, ccrebro"ascular accidcnt (eVA).
Poisoning - Clrbon 1I10noxide, lead.
Syndromes - Down's, Cocbyne's syndrome,
ncurofibromatosis.
Discussion
Apan from \Vilson's disease, the listed ditlrrcnti:J.I diagnoses
lor this :tppe:n:l1Ice afe of :tWIC disorders t hat ul t imatcl}'
result in reduced cerebral oxygenation or glucosc provision.
T he dlcct of hypoxi:tj h)'potension on the infant brain
dcpends on whcthcr t he infant is tefm or prem3ture, and
whether the insuh is mild or scvere. In thc prem:tUlrc infant
up to about 34 "'cch, it is thc dccp whitc martel" Thai is
most vulnerable and hypoxie-ischacmie injury rcsults in
peri,"cnrricular Icukomalada ( PVL) with sparing of sub-
cortical white maner and cortex. Since the cOfTicospinal
t r:\Ct fibres pass t hrough this area, there is usually rcsulting
1Il0torimpairmcnt.
I n t he term inf:tn t , the pattern of susceptibility is
diftcrelH. A mild insult results in isch:tcmia of the
'watcrshed' :treas oftlie cerebrum where blood supply is
most tenuous_ These arc the boundaries OCfwcen the areas
supplied by the anterior, middle and postcrior cerebral
arteries. Vit:11 ;Ifeas of the brain arc protected by redistri -
buti on of blood flow. Aftc r a sc,'cre insult, howc"cr, "ieal
arcas of the brain can no longer be protcctt.'d, and it t hc
most met.lbolicall)' actirt.' areas at this timt.' of lift.' that arc
aHccted. Thus, ischacmic damage occurs in the deep grcy
matter (thalami, putullin:t and br:tinstclll nuclei), the pcn
rolandic and conicospinal tr.tc[S. This case illustrate
such a pattern.
In oldcr childrt.'n, $t.',-erc hypoxic-ischaemic injury fill"
produce a diflcrent pattern, that of global cerebral injun-
T he resulting cercbral oedcma :lIld loss of grcy-whl
marta diflcrcnti:ttion with sparing of tht.' brainstem
ccrcbdlulll GIll produce the acute rCl'crs:t1 sign on cr
descriocd elsewhcrc (sec Case 163).
As a comparatil-c aside, high-dcnsity b:tsal ganglia d
to calcification arc illustrated (l 66b ) and the diffcren
diagnosis listed.
Practical tips
Comparativc dcnsities of grey and whi tc matter in tlr
infJnt brain arc variablc on CT dcpcnding on stage
myelill3lion. Norrnaliry ofthc basal g:mgli:t
can oc confirmcd by comp:trison wit h othcr grey
matterstntcturcs.
MRI is thc most sensitivt.' mod:tlity for dctecti ng
hypoxic-ischaemic injury but may be logistically
difficult in the acutclr unwcll inf.mt. Ultrasound llUO
be practically the casiest imaging option bm has
reduccd scnsiti,"ity.
Further management
Urgent correction of hypoxia, h)"potcnsion
hypoglycaemia is required followcd exclusion of
ory
mature neonat e prcscllIcd with
ina! distension and sepsis.
CASE 168
History
.\0 adolescent mate presented with a
hiswl)' oftralima.
Paediatric Imaging
Cases 167,168
299
300
Answer 167 Paediatric Imaging
ANSWER 167
Observations 1167a )
A cord c!:i mp is noted indicating that the neonate is no
morc than a few davs old. The bowel is abnormal with
gaseous distension and a bubbly appearance to the bowe!
wall indicating lllllrll gas. A brgc pneumoperitolleum is
present with most of the gas adjacent to the li\'cr. The
features arc consistclH with necrotizing enterocolitis and
perforation. No gas is seen within the portal veins.
Diagnosis
Necrotizing enterocolitis (NEe).
Discussion
up to 80% of cases arc n:latcd to prematurity and NEe is
the most COlllmon gastrointestinal emergency seen in
premature blbics, lIsllaIly occurring in the tirst 2 weeks of
life. Ischaemia of the bowel is thought to occur secondary
to perinatal stress, hypoxia or infection. Presentation is
diarrhoea or bloody stools. Radiographic features consist
of distended thick walled bowd which has a bubbly
:lppearance due to submucosal gas, i.e. pneumatosis
intestinalis. Gas mar track from the bowd into the portal
ve no us and can be ,seen on
(branchlllg gas extends tow:lfds the penphery of the h\'er
unlike air in the biliary tre!,;, which is central ). Such a
finding in adults is an ominous and usually premorbid sign,
bur in NEe, this is nOt the case at all. Bowd strictures arc
a potemial long term complication.
Pneumoperitoneum should be carefull y looked for, as.
this necessitates immediate surgery. In the supine position.
free gas often collects anteriorly as a large rounded lucency
in the central abdomen producing the 'football' sign.
When perforation occurs ill utero, meconium within the
peritoneal cavity calcifies and can be seen on pl ain
radiography. An example is shown in a neonate ( 167b
where there is peritoneal calcification (best seen over the
inferior tip of liver ) with a pneumoperitoneum causing
positive Rigler sign, i.e. visualization of both walls of tbc
bowel.
Practical tips
The earliest radiological sign on plain film is bowel
di[,ltation (due to ileus).
If a cOntrast enema is required to exclude obstructioa
then watersoluble contrast should be used - barium
is contraindicated.
Further management
Mortality rates arc dependent on the degree
prematurity, with rates quoted at 5% in term infunrs
12% in premature newborns. Initial treatment is supportJ\"
with bowel rcst bm if serial radiographs or clinical fea
show progression or per/ofation then surgical resecti on
nccrotic bowel is required.
167b Abdominal radi ograph in a newborn
de mo nst rates visibility of both sides of the bowel
wall, i.e. a positi ve Rigl e r s ign indi cating
pneumoperitoneum. Flecks of calcifi cation in the
right abdo men confirm the diagnosis of ante natal
meconium pe ri to nitis .
swer 168
Paediatric Imaging
Case 169
ervations (168)
bonr injul)' is $Cen on this skull r.ldiogr:lph. There arc
pie wormian bones, which at thi s age is abnormal.
is a large differential di:agnosis but the most likely
is idiopathic.
- erential diagnosis
worrnian bones, with common causes underlined
cOlonic ' PORKCHOPSI'):
Pyknodysoslosis.
Osteogenesis imprrtccrJ
Rickets in healing.
Kinky hair syndrome ( Menkes).
CleidOCranial dysostosis
HmOIhyroidjsm/hypophosphatasia.
OLOpalatodigital syndrome ,
Pachydcrmopcriostosis.
Syndrome of Down's.
Idiopathic - norma] in first \'Car of Hti;
Discussion
'onni:an bones arc essentially small bones occurring in the
rures of the calvaria. These intrasururJ.1 ossic1cs arc usually
CASE 169
History
.l,. child with a hi st0'1' of partial seizures.
found in the lambdoid, posterior sagill3l :md tcmporo-
squ:lITIosal suturC$. The), arc consi d ered abnormal when
seen after 1 rear or large ;\Ild numerous (> 10 ;n number
and larger than 6 x 4 01111).
Practical tips
Because oflhc wide di lTcrential diagnosis, il is diilicult
to idemify a specific cause wilhout Ihe aid of a good
dinic:al hisrory.
Diffuse ostcopeni:a will be present on the skull
radiograph in cases o f rickets and ostcogenesis
impcrlccta.
Pyknodysostosis, o n the other hand, will be 3ssociated
with diffuse osteosclerosis on rhe film.
Further management
t.hnagcmelll is dependcllI on the underlying causc.
Further reading
Cremin B, Goodman H, SprJll ger j, Bei ghton P ( 1982).
Wormian bones in osteogenesis iml>crfccta and other
disorders. Skeletnl Rndi%g:v 8( I ): 35-38.
301
302
ANSWER 169
Observations (169a)
Axial T2 weighted MR image at the level of thc latera]
vcnrric1cs. This demonstrates ;1 large cleft extending
through the full thickness of the left cerebral hemisphere
from thc surface of the to the left lateral ventricle.
The cleft is lined by grey matter and is filled with CSF. The
findings arc consistent with schizcnccphaly.
Diagnosis
Schizcncephaly.
Discussion
During gestation, Il('uranes migr3tc out\v,lrds from the
pcrivcntricular germinal matrix to form the norma] cerebral
cortices. This migration can be interfered with by several
causes including chromosomal abnormalities, but mostl y
the reason is unknown. The result is brain tisSLle lying in
the wrong place, typically grey maner.
Schizcnccphaly is a cleft extending through tbc full
thickness of cerebral hemisphere from the ependyma-lined
wall of ventricle to the brain surtaee. It is lined by pia ;md
grey matter that usually shows polymicrogyria, and is often
located around tile $ylvian fissure. The lateral end of tile
cleft may be open and readily apparellt (open lip type ) but
can sometimes be closely opposed ;md easy to miss (dosed
lip type ). However, even the closed lip type will show a
small irregularity in the wall of the "entricle at the site of
16gb Axial T2 MRI of the brain shows a small area of
subependymal heterotopic grey matter adjacent to
the left occipital horn. Note how it is isointense to
the cortical grey matter.
the cleft. It is not certain whether this condition is due -
an ischaemic insult leading to germinal matrix infarcno.
or whether it represents a focal cortical dysplasia.
There arc diHcrent manitcstations of the conge
neuronal migration anomalies which result in - _
degrees of mental retardation and/or seizures. 11It
following further patterns are recognized:
Heterotopic grey matter - when small collections of
the neurones arrest on their way to t he cortex the\'
can be seell as discrete nodules '( most commonly in
subependyrnal location ) or as a subcortical band.
Thus there arc nodular and band heterotopias. Thor:
are isointense to grey matter and show no
enhancement. \-Vbile so metimes asymptomatic,
seizures and developmental delay can ensue, espe .
with band heterotopia. An example of nodular
heterotopic grey matter is shown in an axial T2 MR
image of the brain ( 169b), where a small area of
heTerOtopic maner is seCl1 in a subependymal
location adjacent to the occipiral horn ofrhe left
lateral ventricle.
P01Ylllicrogyria - sometimes neurolles may migrate
the cortex but arc abnorm,\lly distributed, produ . _
a bumpy appearance to the cortical gyri termed
polymicrogyria. An example is shown in a coronal
weighted MRI ( 16ge), where polymicrogyria
atlccting the right temporal lobe produces a burnp:r
Answer 169 Paediatric Imaging Case 170
In lI}";, :-;or, ,h, oorm" ,,"' ...... .ol
"" J,,,...,, ,nJ
r",h),3),TI' - On """ .... ' , .. "'r" roony
(1''' h no I, ... '1""'" m "' 'h,
'""" "", .. 10m. 'h, ,",r",", "rthr ..... '1'1'''''
;. ( l<Wdl, Oli""
, .... 1'''"'"'' ><"'< """, oJ ,,'mb,ion '""
w"n.J ,",,;,'01.
P'"Clicallip.
SU""f'<oJ,Tft.1 .od, .... ,. '""n,", <'" ..... ,
, .. Iu''f"r ..... g ' l>< '" "., ... "'" H' ... '''',
",,"ul<,;,, ,hi; ',n,l l" "1",,1 ",
""'''' " ' "" ,h.., ,.., 8" )' "' ... ,.,. ""'" '"
Funhl r managl ment
,",d;'.ol "".'5''''''.' o" r;l<l"r,
CASE 170
History
"'m" -I I
f'",,,,",,J h),.,..""
169d C",""'" TI MAi o. on. 010 <hitd w;'"
h ncopl>oly: II>< lX>t1;co ' 0 .mooth with .Imoo.
ne "",mol ly 10,m,<I gyrI.
",
304
Answer 170 Paediatric Imaging
ANSWER 170
Observations (170a)
An cndotr.lchcal rube has been pllecd juSt above the carina.
There is also all NG tube passing inro the stOffilCh. There
arc bilateral diffi.1SC patchy opacities in both lungs indican,'c
of widespread atelectasis and patchy consolidation.
However, thc lungs appe3T hypcrinflatcd and there arc
5111311 pleural cnusions. In vicw of the history, the
:appearances arc likel y 10 be due to meconium aspiration
syndrome.
Diagnosis
Meconium aspiration syndrome.
Discussion
A'\cconiulll aspiration syndrome is the most common cause
of respirator}' distress in ncwborns bom at 1'11][ or post reml.
The brgc size oflhc fetus makes ddive,)' diAinLit. Perinatal
hypoxia and feral distress lead 10 meconium defecation ill
lIlero. Aspiration of the meconium into the
tracheobronchial tree then causes obstruction of small
peripheral bronchioles (though only a minority of fetuses
exposed to meconium stained amniotic fluid develop
respiratory symptoms). This resuhs in une\'enly distributed
areas of subsegmental ateledasis with alternating areas of
air trappi.ng. The chest radiograph usually begins dearing
within a few days with no long teml radiographic sequelae
in the lungs.
The radiological features on CXR are:
Bilateral patchy atelectasis and consolidation.
No air bronchograms.
Hypcrinllation with areas of air trapping.
Small pleural effusions.
Spontaneous pneumothorax and
pneumomediastinum result from the air trapping
( 170b).
Practical tips
Most common cause ofrespiratory distress in term
babies: meconium aspiration.
Most common cause of respiratory distress in preterm
babies: hyaline membrane disease.
Further management
Almost all neonates with meconium aspiL.ltion
make a full recovery of their pulmonary function. Upper
ainl'ay suction may be employed and vcntilatory suppon
may be required in more scvere cases of rcspiL.ltory distress...
HOb CXR in a neonate with a large
pneumomediasti num. Air outlines the
thymus producing an 'angel's wi ngs'
appearance.
CASE 171
History
",,"""m r",,,",<>1
'<&''S''''''' of;.,.,.j,
CASE 172
History
,\1'''"'"''"'8 ,!",,,,,,,h,,'11'''.
.'" ,,\'" in m>k
; ,fon itt. fM"" .",,1)' "",""""d
", .. ,')' ,,,,,' .. ht .....
Paediatric imaging Cases 171, 172
'"'
Answer 171 Imuglng
ANSWER 171

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f"">'h "'f""'"nmg d>< "''''I'"'llUL A ... no"" b<1=- , ....
, ..... " ,.-, "" .. " .... ," '>ri,-.'"'"
1"""'''''''- Th, ",,""" "" ",mi",",
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f",u l,("I'Ofl
Oi",u$, lon
f.mt..y.-,lnS".nf ,h. ' un. "'-r " "" " ,
"', m tIO< n""h< ..,.j Ili",,"' .. of ,hi,
"rm'"," ;" ;"r,n' r ,,,.1, in ,-.m",
oomb .... ion. of .. ,., ... TOf _ I' .. n"' '''''
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'm'I''' ""' "f ,," 'h, ')'I" " I
f""'''' "'.
I" of c,,,,, 'h,,,, """f',",n' , ,,-
''''';', ""I "f ,1\<<< ""-< '"
",,,d . S., n. Ii,,,d. <on n. r",,",I,
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"""f'h.pc. 1 "sm,n', '", d i,,01 "'V"'"' "' both). Tni,
.... , "'"."",,,,,,,!h, ""'" <ommon 'U"'l"J'< ( ><'" '"
"""00 "I>< .. ,"'''' ''''''''I'h'F'' "'''' .. ...J Jri, oI
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. i,,,1 ,-" .. k, .. 1"""'" ""'h"
int" "'"H",h ..,.j ,10,,, tn. n:_,", uf , ", ,,",.-d_
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An ,umri' i< ,00"",, {17 LbJ .... '" """,,,,,
h .. """" "j<mJ ,;. '" SG ,"b< in ,,,. """f'h'S"' ,..J i<
"'" '" I"'" ;"to ' "' "","" ' " th, ;;'tul.

""' ..... - ,h,,", ",,,,,,,,I>,.oL
J",,,,kJ ....... h of p""im>L '"""Ph"", ,nJ ,
k<d .. '""' n. ".kJ ""loin it .It"
p"".' .
gI<" ""-l< .. ," "",-",,"0> , .. '"
' ''1,,10.
(;" "' '"' ."'Iom," inJ" " " uf.
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Look fo.. ronooL;J"kon "'w-" .. s """;,,,J
"";"""'" p''''"'''''"''.
""' ..... ,", J TOF " " '" rut or.
., ,,.,,,"'" .I,,, , <I" en t<,.

\'"",,,,",1 '" .. 0"1 .....
... ,,'-<, .. .. " ....
<;",t .. , ""'" I.v "","".Il<!-
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... 'm>l;",.
Furth ,
S"'1Ii<, 1 "'P';' .... ". TIt ... '" I"" ' "mri"",,1
hr , .. ,,,amofi< k'k, """'Ph'S,,1 " ,;.,,,'" '"
"""il;'1" ,,,.I, i, g .. ' nJ/"" "r""""
P"'""""';"
Answer 172 Paediatric Imaging Case 173
ANSWER 172
Observations (172)
This MCUG study shows a transverse filli ng defca at the
_ terior urcthr:l. with distension of the proximal posterior
;arcthra. The findings arc collsisrcnr \ \ ~ t h posterior urethral
lQhcs.
Diagnosis
Posterior urethral vakes.
Discussion
Congenital presence of thick folds of mucous membrane
in the posterior urethra is the most common cause of
uri nary tract obstrunion in boys. The condition is often
suspected on prenatal US where it can lead to
oiigoh)'clramnios, hydronephrosis, prune belly and urine
lSCitcs or urinoma due 10 leak. I f obstruction occurs carlv
in IItero then multicysti c dysplastic kidney may result. Aftc"r
birth, MCUG is the investigation of choice to outline the
tr:Insvcrse fi lli ng defect caused by the thick mucosal folds.
Distension and elongation of the proximal part of the
CASE 173
History
A newborn presented with abdominal
distension and failure to pass
meconium.
posterior urethra may be seen during voiding and
vesieouretera! reflux is present in 50%. Bladder
trabeculation and a significant post void residual volume
may be noted. Prognosis depends on the duration of
obstruction prior to corrective surgery and is worse if
associated with \'esicoureteral reflux. Approximately rhrce-
quarters of cases will have been discO\'ered in the first year
of life, though occasionally it call be first noted in
adulthood.
Practical tips
Note how diagnosis is still possible when the catheter is ill
sim during the. voiding phase of the MCUG ( 172).
Further management
Urological surgical intervention is required with initial
treatment aimed at relieving bladder outlet obstntction and
abl:tting the valves. Secondary trcatment may be required
for vcsicoureteral reflux, urinary tract infections, urinary
incontinence and renal dyshlilctioll.
307
308
Answer 173 Paediatric Imaging
ANSWER 173
Observations (173a)
An NG tube is in the stomach. There arc multiple dilated
loops of bowel in the abdomen. No fluid lc,"cls arc seen
within the bowel suggesting that the ;lppcaranccs be
dlle to meconium ileus. However, mher p:uhoiogics such as
Hirsc hsprung's discasl: ;lIld impcrfor:llc anliS should be
considered.
Di agnosis
,\.tcconiulll ileus.
Differential diagnosis
Hi rschspnlllg's disease.
Impcrlor:uc3.nlls.
Ilcatatrcsia
Inguinal hernia.
Di scussion
Meconium ileus is the term used to describe small bowel
obsmu.:rion in neonat .. :s secondary to inspiSS:J.tcd meconium
pellets impacted in the disnl ileum. The \'35t majority prm"c
to [m"e cystic fibrosis and this is the earliest manifcstation of
the disease. The diagnosis is confirmed by performing a
contrast enema, which demonstrates multiple round filling
defects (the inspissated meconium) in the distal ileum and
proximal colon ( 173b). The colon may be very narrow on
the contraST STUdy if it has been unused due to antenatal
ubsrnleTion, whereby it is Termed a microcolon. The enema
should be performed using Gastrograffin as t his has a
therapeutic eflect, helping to cle:tr the meconium
drawing water into the gut.
With Hirsehsprung's dise:tse, the cont r:tst enema will
demonstrate dilated bowel with :t transition zone to a dist1l.
aganglionic segment.
Practical tips
On all A...,{R of:t baby it is almost impossible TO tell if
dil:tled loops ofbowcl arc l:uge or small bowel. The
presence or absence of ,omirins/passage of
meconium are more helpful to know with regard to
assessing if there is high or low bowel obstruction.
The hernial orifices should be checked for :tir
suggesting an inguin:tl hernia.
A 'soap bubble' appeamnce be seen on AXR in
llIeconium ileus due to the mixlllre of gas with
meconium.
Fluid levels arc not usually presem in meconium ileus
because the bowel COntentS arc ,ery viscous.
Look at the sacrum on the AXR, as imperforate anlU
is associated with sacral agenesis.
Further management
'V:tter-soluble contrast enema can be useful for both
diagnosis and treatnletH.
All patients with meconium ileus should have a 'SIl"CZ
test' to exclude underl ying cystic fibrosis.
173b Gastrograffin enema in a newborn shows
multiple filling defects in the ascending colon and
terminal ileum, which represent inspissated
meconium. Note the dilated small bowel loops.
CASE 174
Hist ory
_\ 4-yur-old child presenred with
~ ' c r and abdominal pain.
CASE 175
History
.\ 4-month old child presented
",lil pcr,;islent irri t'Jbilit)'.
Paediatric Imaging
Cases 174,175
309
310
Answer 174 Paediatric Imaging
ANSWER 174
Observations (174a)
Axial cr of the :abdomen with oral canTmst and IV contrast
in poml phase. There is a large slightly hcrcrogcl1wlls mass
arising from the. right kidney. The mass docs not enhance as
much as the rellal parenchyma. There is local mass effect
with displacement, but no 100';'\siol1 ofthc right lobe ofli\'cr
or encasement of"csseJs. A small mass of similar density is
seen ncar the hilum of the left kidney. The appearances
suggest bitateral Wilms' tumours.
Di agnosis
Bilateral Wilms' [Umours.
Differe nti al diagnosis
Neuroblastoma.
Discussion
Wilms' tumour (ncphroblastoma) is the most common
abdominal malignancy in young children, mOSt commonly
prc.scming at ase 3-4 years. The most frequent presentation
is with abdominal mass, though hypertension, pain, IC\'er
and h:u:maturia also occur. The tumour grows to a
large size, often over 10 cm. Radiological
fcatures includc:
Exophytic mass displacing rather than encasing
adjacent structures.
Less contrast enhancement than norlllal rella]
parenchyma.
Cystic/necrotic areas give it a heterogeneous
appearance.
111\':1sion ofthc ren:1l \'ein and inferior ,'c na ca\':1 may
occur in up 1'0 10%.
Tumours arc bilateral in 10% and this indicates background
nephroblastomatosis, a state of persistent nephrogenic
blastema that is a precursor to Wilms'. Wilms' tumour is
associated with the Beckwith- Wiedem:lnn s}'ndromc
(macroglossia, visceromegaly and omphalocclc). Other
associations include aniridia and hemihypcrtroph}'.
The main differential diagnosis is neuroblastoma, a
comlllon malignant tumour of the neural crest that presents
in a similar way to Wilms' tumour ,lith a painful abdominal
mass and fe'er. Typical age of present'alion is slightly earlier
howe\'er (under 2 years). Hormone secretion from the
tumour (such as catecholamines) may cause other signs,
including hypertension and opsoclonus (chaotic jerky eye
mo\'eme[1[s). It can arise in lhe sympathC[ic
ncural chai n including the adrenal gland and the abdominal
s}'lllpathetic chain.
Practical tips
Always check for bilateral tumours when Wilms' is
suspected.
Differentiating between neuroblaStollla and Wilms'
tumour can be difficult radiologically but then: are
some specific features that can help:
Almost all neuroblastomas contain calcification
whereas 'Only up ro 10% of Wilms' rumours calcify.
Both tumours call cross the midline and look
similar on imaging, appearing illsep3.fablc from the
kidney; howcver, neuroblastoma rends to encase
surrounding ,esscls such as the aorta whilc Wilms'
tumours tend to displace surrounding tissucs and
stmcrures. An examplc of a neuroblastoma is
shown ( 174b) cncasing the aom and coeli ac axis
vessels. Neuroblastoma may also extend into the
spinal canal through the neural f'Or."tmina.
Look for evidence of 1l1e[3static spread; 70% of
neuroblastomas have malignant spread at presentation
c'Ompared to just 10% of Wilms' tUlllOUrs. Also,
\-Vi!ms' tumours spread to lung, whereas
neuroblastoma sprcads to bone.
Further management
Treatment is ,lith radical nephrectomy and
I'reopcrath'c chemotherapy is advocated in cases ofbilarer.al
Wilms' tumours and whcn therc is IVe extension at
tumour (occurs in - 5%).
174b CT of a neuroblastoma. The huge mass
displaces the spleen and left kidney and shows
typical encasement of vessels, in this case the aOt:i
and coeliac axis.
Answer 175 Paediatric Imaging Case 176
ANSWER 175
Observations (175)
There is bilateral symmetricll thick, smooth periosteal
reaction aAccting the diaphyses of the long bones. There
is no fraying or splaying of rhe metaphyses to suggeSt
rickets. The most likely diagnosis at this age is Cail'{fs
disease, ho\\'c\'cr other possibilities such as lcuk:".cmia need
to be considered.
Diagnosis
Caftcy's disc:lSC.
Differential diagnosis
Of bilateral dinusc periosteal rcacrion in childhood:
Norni:ll variant belare the age of 4 months_
Clflcy'sdiscasc.
Leukaemia.
Scurvy.
Rickets.
Hypcn"irami nosis A.
Non accidcnt:ll injury ( NAI ).
Discussion
Inf.l.Iltilc conic:J.l hypcrostosis (Caffey's disease ) is a
prol ifcrJtivc bone disease seen in patients under the age of
CASE 176
History
None available.
6 months. Irritability and fcn:r arc thc prcscnring
symptoms and are associated with soft tissue swelling O\'cr
thc bones. Bilateral synll11ctri cal thick periosteal reaction
is t he cardinal radiological feature and most commonly
alleets the m,mdible, elal'icle and the long boIlCS. It usually
involvcs thc diaphysis ofthc bone. In t he majority ofe:lSCS,
[here is spontaneous complete reeon:ry by t he age of 3
years.
Practical tips
If there is ditfusc periOSTeal reaction with tractures of
<liBering ages, NAI must be considered .
With rickcts, splaying and fraying ofthe mctaphrscs
will besccn.
Further management
Whcn NAI is considered then a (.-arcnli analrsis ofpn.:vious
radiographs, the clinical presentation and consult":nion with
a specialist paedi3trie radiologist must be carried our
because of the repercussions of a misdiagnosis.
311
312
Answer 176 Paediatric Imaging
ANSWER 176
Observations (176a)
There is widespread bilateral decreased bone density with
healing insuflicicncy fractures of the r:tdius lnd ulna
bilaterally. These arc associated thick smooth periosteal
rC;lcri oll and there is !Taying and of the mCl.lphyscs.
The fcarurcsarc char.tctcristic ofrickclS.
Diagnosis
Rickers.
Differential diagnosis
Hypophosph3t:J.sil.
Discussion
Ri ckets is mOST commonly due to insuflicicnt biologically
actil'c I'iumin D, though impaired calciulll absorption or
excessive phosphate excretion call occasionally be to blame.
In the western world, pure dicta!)' deficiency ofl'itamin 0
is the sole cause; morc ofren it is due to
malabsorption or impaired vitami n 0 mct:J.bolism in the
Ih'cr or kidney.
RickelS is 'essc: ntially osteomalacia during enchondral
bone growth, Portions of the skeleton that ha"e already
matured show features of osteomalacia, but loss of normal
maturation and mineralization of cartilage cells at the
176b AP radiograph of both legs shows typical
features of rickets with fraying of the metaphyses.
growth plate lead to the additional distinctive radiological
featmes of rickelS. Osteomalacia is discussed elsewhere in
the book but the radiologieallcatuTes arc due to excessive
unminel"".llized osteoid producing Looser's zones,
osteopenia, cortical tunnelling, indistinct trabeculae and
finally bowing and fl"".letures due to softened bones.
In addition, the following features arc seen in rickets:
Widened growth plate - loss of normal chondrocyte
maturation and minel"".llization result in cdl build up
here.
Metaphysc:s arc irregular/ frayed, splayed and cupped
- impaired miner.1lizarion causes the frayed irregular
appear.1nce while build up of chondrocytes at the
physis indems the metaphysis producing cupping and
splaying.
Epiphysis oSleopcnic and irrcgubr.
I\:riarticularsofttissue. swelling.
Apparent periostcal reaction due to subperiostcal
ullminer.1lized osteoid.
Delayed maturation and growth.
Figure 176b demonstrates ricketS of the lower limbs -
note the typical changes around the in the tiw
and also bowing of the fibula, Figure ] 76e is a CXR of.a
child with rickets showing spla)'ing of the anterior ends 01
Answer 176 Paediatric Imaging Case 177
the ribs and the metaphysis of the right humerus. The
~ a r a n c c of the anterior rib ends is due to changes at the
cOSlochondr.d junction growth "blcs :and is tcnncd rhe
' rachitic rosa')",
Practical tips
The earliest sign of rickets on the plain film is a
widening of the growth plate.
i..,(X)ser's zones aTC .. ire in rickets compared 10
ostcom:tbci:t in the filscd skeleton.
CASE 177
History
~ o n c ;lvai b blc.
Further management
Rickers is now usuall y idcllIificd early :llld treated with
Iiramin D supplements. Significant pch'is deformity and
gait disturbances arc now rarel y seen in the dC\'ciop<!d
world.
313
314
Answer 177 Paediatric Imaging
ANSWER 177
Observations (177a) Discussion
There is panial nlsion of an extra digit with the mct:lClrpal
of the IinJc finger. This represents
polys)'lldact)'ly, the possible causes of which include
idiopathic, Ellis- van Crc\'c1d syndrome and C:arpcntcr
syndrome.
There arc scveral causes ofsrndactyly (filsion of digits) and
pol ydactyly (supernumerary digits ), which arc bot h
congcnit:ll abnonnalitics. Ellis- van Crcvcld syndrome is
also assOCiated with carpal fusion, as is Apcrr's syndrome.
This is characterized bv features in the skull: notabk
craniosynostosis of the sutures, hypoplastic mi d
filee and enlargement of the sclb. . All of these features arc
in the lateral skull radiogl':lph in a child with
Apert's syndrome ( 177b ).
Diagnosis
Ellis-van Crcn:ld syndrome.
Differential diagnosis
or causes of polydactyly:
Idiopathic.
Ellis- van Crevcld syndrome.
Carpenter syndrome.
Pol ysynd:lCtyly syndrome.
Ofcallscsof s),ndaCfyly:
Idiopathi c.
Apcrr's syndrome.
Carpemer syndrome,
Down's syndrome.
Poland's syndrome.
NCli rofibrolllarosis.
Practi cal tips
Some exam cases will have an obvious abnormali ty as part
of a syndrome that you don' t know - Slating that you
would seek help from a te.ubook or specialist colleague is
a reasonable answer. You ca n't know everything!
Further management
Poly/syndactyly wi ll be parr of a syndrome with multiple

177b Lateral skull radiograph of a child with Apert's
syndrome demonstrating craniosynostosis of the
coronal sutures, hypoplasia of the midface and
enlargement of the sell a.
CASE 178
History

Paediatric Imaging Case 178
315
316
Answer 178 Paediatric Imaging
ANSWER 178
Observations (178a, 178b)
There is bowing deformity ohhc tibia, fibula and humcms
The metaphyses of the bones arc widened producing an
Erlenmeyer flask deformity. The metaphyses arc also
rclati\'cly lucent when compared with the diaphysis, which
is sclerotic. There 3fC no specific leatures 10 indicate lead
poisoning, ostcopo.!tTOsis or thalassacmia, so the diflcrcnti:ll
diagnosis lies between Pyle'S disease and lipidoses such 35
Gaucher's or Niemann- Pick disease.
Diagnosis
Pyle's discasc.
Differential diagnosis
[11 rhiscasc:
Craniomct'aphyscai dysplasia.
Niemann-Pick disease.
Gauchcr'sdiscasc.
Of Erlellmeyer flask deformity (mnemonic - 'Lead
GNOME' ):
Lead.
G3uchcr's.
Niemann- Pick disease - looks like Gaucher's but
withouJ avascular necrosis.
Osteopetrosis
Mctaphyse;11 dyspbsia ( Pyle's) and craniollletaphyseal
dysplasia (same as Pyle's discase: but there is a history
of cranial nelyepalsies).
'E'malOlogical!! - thalassaemia.
Discussion
Pyle's disease is also known as metaphyseal dyspbsia. It is
a rare autosomal reccssi,"c disordcr characterized by flaring
of the ends of long bones with relative constriction and
sclerosis of the ce mral ponion of the shafts. Affected
patients arc usually and genu valgus
deformity is often a featu re:. The expanded metaphyses
tend to be lucent and have the appearance of an
Erlenmeyer flask (narned after the wide necked laboratory
flask bearing the name of thi s German chemist).
Craniometaphyseal dysplasia essentially has the samc
features but in addition there arc cranial nCIYe palsies due
to sclerosis of the skull base.
Gaucher's disease is a hereditary disorder oflipid st.oragc
common among Ashkenazi Jews. It is characterized by
hepatosplenomegaly with flask-shaped long bones and
generalized osteopenia with strikingly thin corticcs.
Avascular necrosis is also a feature.
Practical tips
Erlenmeyer flask deformity, the metaphyseal expansion of
long bones, is also discussed in Chapter 5. AdditionaJ
differentiating ICaturl..""S can be found on [he r:ldiograpn as
to the specific underlying cause of Erlenmeyer flask.
deformity:
Diftllsc sclerosis and sclerotic vertebr:ll endplates
producing 'sandwich vcrtebrae' indicate osteopetrosis.
With Pyle's disease, there will be relative sclerosis at
the diaphysis and lucenc)' of tne metaphysis.
Gaucher's disease will also be associated wit h lucency
and osteopenia but there may be signs of anscular -
necrosis of the femoml or humeral hcads (loss of
height and Ii-agmentation) and on an AXR massi,"e
hepatosplenomegaly may be seen.
Thalassaemia is associated with coarsened
trabeculation producing a 'cobweb' appearance.
Lead poisoning causes dense metaphyseal bands as
well as Erlenmeyer flask deformity.
Further management
This condition is usuall y asympromatic and requircs n...
direct management.
1788 Metaphyseal wi dening wi th
increased lucency.
Paediatric Imaging Case 179
CASE 179
Hist ory
_ 'onc3vailabk,
318
Answer 179 Paediatric Imaging
ANSWER 179
Observations (179a, 179b)
The lateral skull radiograph ( 179b) demonstrates thinning
of the calvaria with multiple wormian bones. Bowing
dctormirics afC seen w atTcC[ the li mbs (1 79a) and there
Ut several frlcturcs of diHcring ages, mostly seen at the
metaphyses of the long bOlles. Thac is geller,\iized
oSTcopcnia of the skeleton wi th marked thinning of the
con ices. The fcanm::s arc consistent with osteogenesis
irnpcrfccT:t
Diagnosis
Osteogenesis impcdccta
Differential diagnosis
Of lI'oTmian bones with common causes underlined
( mnemonic - 'PORKCHOPSI' ):
P),knodysostosis
Ostcogcm:sisinmcrfccra.
Rickets in healing.
Kinky hair s)'lldromc (I'''knkcs).
Cleidocranial dysostosis.
Hypothyroidism/hypophosphatasia.
Otopalatodigital syndrome.
Pach),dermoperioslosis.
Syndrome of Down.
nOrllwl in first ,"car of life.
Di scussion
Osteogenesis imperfecta is a connective tissue disorder
characterized by fi.lgile bones and blue sc1eme. Type I is
comp:ltiblc with life. Type 2 is the lethal form associated
with perinatal death.
The principal radiological features include:
Diffuse osteopcnia with thinning of cortices.
Multiple fractures of differing ages with
pseudarthroses and bowi ng deformity.
Fractures arc associated with exubcmllt callus
fOfmation.
Biconcave yerrebi.ll bodies.
Multiple wOTmian bones in the skull
POOf dentition.
Practical tips
Multiple fractures in children should i.lise suspicion of non
accidental injury (NAI) and sometimes diflcrentiating this
from osteogenesis imperfecta can be difficult. Predomi-
n:lJ1t1y osteogenesis fractures are diaphyseal compared with
metaphyseal NAI fractures but this is nOt always the casco
Further management
Early medical inteIyention to increase bone mineral density
and surgical intcrvention to treat/correct scoliosis and treat
fractures mean that a multidisciplinary approach to the
ongoing treatment is required
CASE 180
Hist ory
A child presented with
vomiti ng and .uaxi:!.
CASE 181
Hist ory
A 2-l11omh-old baby presented with
cyanosis.
(Ste pnge 322 [01- e(lse (lllslI'cr)
Paediatric Imaging Cases 180, 181
320
Answer 180 Paediatric Imaging
ANSWER 180
Observations (180a)
A series of axial MRI images of skull show a well defined
hypcrdcnsc mass in the cerebellar ycrmis causing
compression and anterior displacement of the 4th ventricle
with obstmctil'c hydrocephalus. A small alllount ofocdcma
surrounds t he mass. The teatures arc typical of a
medulloblastoma
Diagnosis
Medulloblastoma.
Differential diagnosis
Of posterior fossa tumour in children:
Medulloblastoma:
Predominantly midline posterior to 4th vcmriclc.
Hypcrdcnsc on CT with oedema.
Avid cnh:I.llCCl11CllL
20% calc;!)', 50% necrose.
Juvenile pilocytic astrocytoma:
Typically paracentral, posterior to 4th ,'cntriclc
Majority arc cystic with an enhancing mural
nodule, the remainder arc solid.
20% calci!)'; oedema is rare.
Epend)'llloma:
Arises within 4th ve ntricle.
Heterogeneous appearance and enhancemem
SO%c;\lcify.
Hydrocephalus is otten communicating type due
to protein exudate obstructing CSF resorption
Spreads through the exit foramen of fourth
\"emride and wraps around brainstern (' plastic
growth'). Sagittal and axial T2 weighted MR
images (l 80b) demonstrate a high signal lesion
arising within the 4th Yemricle, wrapping around
the brainstem and spreading via the foramina of
Luschka and Magendie. Hydroceph.llus is present
and a syrinx orthe upper cervical cord has
de,-doped.
Hrainstem glioma:
Within pons, possibly causing pontine expansion
or 4th 'Tntride displacement posteriorly_
Iso or hypodense to brain so may be easily missed.
Sagittal TI weighted MIl! with contrast ( i SOc)
dcmonstrates a large pontine glioma. Note how
the lesion is nonenhancing and almost the same
signal as surroundi ng brain. Smaller such lesions
can easily be missed due to such imaging
characteristics.
Enhancement often absent or minimal
H),droccphalus uncommon (because present with
focal neurology before this occurs).
Discussion
,\kdulloblastoma is the second most common paediatric
brain tumour and the most common in the posterior fossa.
It is a tl'pe ofprimiti\"e neuroectodermal tumour ( PNET)
180b Sagittal and axial T2 MRI of
the brain demonstrating an
ependymoma in the 4t h ventricle,
which extends into the foramina of
l uschka and Magendie and causes
obst ructi ve hydrocephalus. A syrinx
of the upper cervical cord has
developed.
Answer 180 Paediatric Imaging
arising from the roofofthe 4th,\cntriclc. The majority of
patients affected are under the age of 15 years, with 80% of
lesions arising from the cerebellar vem}is, and the rest lying
more laterally in the cerebellum. This lateral location is
marc C01111110n in older children. They arc typically
hyperdensc on CT due to dense cellularit)" and show avid,
homogeneous enhancement. There is usuall y surrounding
oedema, 20% show calcification and up to 50% show
necrosis/cystic change. They arc malignant and
spread occurs via the CSF in up to a third. Medulla
blastoma is rardy associated wi th Gorlin's syndrome - an
autosomal dominant disorder cha racterized by multiple
Cluaneous basal cell carci nomas during childhood with
mandibular ker:l.tocvsts and enensin: intracranial
Gllcificarion of the and tentorium.
At least 50% of primary brain IllmOUfS in children occur
in the posterior fossa. Brainstem glioma tends to present
with focal neurology due to invoh'ement oflhe long tr:J.cts
and cr:J.nial nerve nuclei, while the olher three differential
diagnoses listed present br way of mass effect and
obstructive hydrocephalus with headache, vomiti ng and
at3xia. The salient imaging reatures of each arc listed. Ir is
important when staging paedi,lIric posterior fossa tumours
to remember the potential ror CSF spread with medullo-
blastoma in particular, but sometimes with ependymoma
too. POSt gadolinium scans should therefore include the
whole spine as well as brain to pick up such deposits ('drop
180e Sagittal T1 weighted MRI post IV contrast that
shows a large pontine glioma.
metastases' ). A sagi nal TI MlU post-contrast ( l SOd)
demonstrates an enhancing medulloblastOma in the
posterior fossa causing obstructi"e hydrocephalus. CSF
spread of tumour has occurred with a metastasis in the
prepontine cistern.
Practical tips
Make sure the post COntr:J.St scan looking for drop
metastases is done preopcrarh'dy as postoper:J.ti\'e
haemorrhage and granulation tissue can cause
connlsion.
Haemangioblastoma is primarily a tumour of adul ts
but can be seen in adolescents in the posterior rossa
when part of\'on Hippcl- Lindau syndrome. It is
typically a cystic mass enhancing mUr:J.1 nodule,
SO has si milarities with pi lacy t ic astrocytoma.
Further management
MRJ of the spine with intr:J.venous contrast enhancement
should be undertaken to look ror 'drop metastases'.
Neurosurgical assessment is then dearly appropriate.
Further reading
Koeller K, Rushing E (2003). From the archives of the
AFIP: medulloblastoma: a comprehensive review
radiologic-pathologic correlation. RadioGraphies 23:
1613- 1637.
180d Sagittal T1 MRI of the brain with gadolinium
showing an enhancing posterior fossa mass, which
causes obstructive hydrocephalus. A metastasis is
seen in the prepontine cistern. This proved to be a
medulloblastoma.
321
322
Answer 181 Paediatric Imaging
ANSWER 181
Observations (181a)
There is a right sided aortic arch, The heart is boot shaped
indicating right ventricular hypertrophy. The lungs are not
plet horic, in fun there is a reduction in the calibre of the
pullllOnary vessels. Ol"crall, the !caturcs Jre suggestive of
Ell10r'S Tetralogy
Diagnosis
Tetralogy of FalJot.
Differential diagnosis
Of conditions associated with a right sided aortic arch:
Truncus arteriosus.
Tetralogy of Failor.
Transposition of great vessels.
Pulrnonarvatrcsia
septal delcct (VSO).
Discussion
Tctralob'Y of Failor is Olle afthc most common causes of
c)lanotic congenital hean disease and is composed of the
following: obstruction of right \"cntricular outflow, brgc
VSD, right ventricular hypcnrophy and an o"erriding aorta.
Radiological features on CXR arc
Conca"ity in tIle region of the pulmonary anery,
which is small.
Enlarged aona
Normal sized hean.
Boot shaped hean due to right ventricular
hypertrophy.
Right sided aortic arch in 25% of cases
Decreased calibre of pulmonary ,"essels.
Right sided aortic :lfch may also be seen in paticnts with
another cause of neonatal cyanotic congenital hean disease
- transposition of the great ,essels. However unlike Fallot's
there is increased pulmonary vaseularity and the heart has
an 'egg on its side' appearance on the CXR due 10 Ihe f::lct
that the mediastinum is narrow because of the abnormal
relationship of the great vessels. An example is shown
( 18 1 b), though in this particular casc the aortic arch is left
sided.
Practical tips
Fallot's tetralogy, pulmonary stcnosis and tricuspi d
atresia cause cyanosis with oligaemic lungs.
Transposition ofthe great vessels, tmncus arteriosus
and lotal anomalous pulmonary venous drainage
cause cyanosis with plethoric lungs.
Further management
referral for echocardiography and consideraTion
for a palliati,c shunt or complete surgical repair.
181b CXR in a child with transposition of the great
vessels. There is pulmonary vascular congestion and
the heart has an 'egg on its side' appearance.
CASE 182
History
,\n II m, .. , " ,"1 "" .. I 1"1'"
.... J ,b,,,,,," . 1
Pae diatric Imaging Case 182
324
Answer 182 Paediatric Imaging
ANSWER 182
Observations (182)
The posterior fossa is enlarged with absence of the
cerebellar vermis, hypoplasia oCtile cerebellar hemispheres
and the presence of a large posTerior fossa cySt, which is in
continuity with the 4th ventricle. A vcntriculopcritoncal
shunt is seen in the right l:trcral ventricle. There is
\'cntriculomcgaly but the sulci arc. not clfJccd. The features
arc consistent with Dandy- Walker malformation
Diagnosis
Dand).-Walkcr malformation
Discussion
The Dandy-Walker malformation is a congenital
malformation whcreb}' the posterior fossa is enlarged and
the tentorium ((rcbelli is elevated, howc"cr the cercbcll;u'
hemispheres arc hypoplastic. Absence or hypoplasia of the
cerebellar vermis is present with a posterior fossa cyst
directly connecTed to the 4Th ventricle. Ventriculomegaly
and dysgenesis of the corpus callosum arc associated
findings. Most affected patients die in infancy. The less
severe form, Dandy- \Valker variant , is more common and
is not associated with enlargemelH of the posterior fossa.
T he associaTed posterior fossa cySt is smaller and the
cerebellar vermis is hypopl;lStic rJther thJn ;lbsent.
There Jre numerous associated eNS anomalies, for
example corpus callosum dysgenesis, holoproseneephaly,
gyral dysplasia , grey matter migration anomalies and
encephalocele. Associated anomalies outside the eNS
include cleft palate, polydactyly and cardiac defe([s.
Practical tips
A mega cisterna magna may mimic Dandy- Walker
malformation, howe\'er there is no cerebellar vermis
abnormality, continuity with or abnormality of the
4th I"entricle.
A posterior fossa arachnoid cySt may also mimic these
appearances.
If the posterior fossa is not enlarged and the
cerebellar vermis is rather than absent,
consider Dandy- Walker variant rather than
malformaTion.
Further management
The associated eNS abnormalities can be better identified
on i\.j RI. T rearment often involves inscnion of a ventricular
shunt, as in this case, to relieve hydrocephalus. Genetic
counselling may be appropriaTe for the f.1mil)'.
182 Absence of cerebellar vermis (left): sulci are not effaced (bottom
left); ventriculomegaly (right); hypoplasia of cerebellar hemispheres
(top right).
Pllediat,ic Imaging Case 183
CASE 183
History
mmmo&.
326
Answer 183 Paediatric Imaging
ANSWER 183
Observations (183)
Dextrocardia is present with situs solitus. A right femoral
line is noted. An NG tube is present in Ihe stomach, which
is dilated with air. There is a 'double bubble' appearance
of the dilated stomach and duodenal cap with no gas seen
distally. The findings afC consistent with duodenal atresia
Diagnosis
Duodenal :nrcsi3, possibly pan ofVACTERL syndrome.
Differential diagnosis
Of ' double bubble' on abdominal radiograph:
AnnuJarpancreas.
Duodenal diaphragm.
Peritoneal band.
Choledochal cyst.
Discussion
Duodenal atresia is due to failure of rccamllizatiOIl of the
duodenum at around 10 weeks and is the most common
cause of congenital duodenal obstmction. The other major
cause is an nular pancreas, and both arc associated with
Down's The is just beyond the
ampulla in the majority of cases and the 'double bubble'
results from gas-fluid levels in the first part of duodenum
and stomach. Gas may be seen more distally in the bowel
if there is duodenal stenosis rather than complete atresia
(though atresia is twice as common).
Duodenal atresia is associated with the VACTERL
syndrome, a non-random association of congenital
abnormalities aftccting multiple systems, summarized by
the mnemonic 'VACTERL'. Three or more of the
associated defects arc required to make the diagnosis. The
mnemonic is as follows
Vertebral anomalies
Anorectal anomalies - imperforate anus.
Cardiovascular :momalics - most commonly
endocardial cushion ddects.
Tracheo- Esophageal fistula
Renal anomalies - ma}' be associated with a single
umbilical artery.
Limb anomalies - e.g. radial dysplasia, polydactyly,
syndactyly.
The characteristic cardiac abnormality is a septal defect but
dextrocardia, as in this case, has been described.
Practical tips
Always check the 'double bubble' radiograph for
VACTERL associations, e.g. vertebral anomalies on the
film
Further management
Fluid and electrolyte imbalance must be corrected along
with decompression of the stomach NG tube insertion.
Surgical correction is then required, usually with good
Paediatric Imaging Case 184
CASE 184
Hist ory
~ ,hdJ ~ " h , I ~ " " " " " .
328
Answer 184 Paediatric Imaging
ANSWER 184
Observat ions (184a)
Lateral spinal radiograph shows vert ebral bodies arc
fla ttened with ccnll':li bcaking anteriorl y. There is also
wi dening of the intcrvcrt cbr.l! disc spaces and posterior
,'ertcbral scalloping_ The findings arc suggestive of
Morqui a's syndrome.
Diagnosis
Morquia's
Differential diagnosis
Hurler's syndrome.
Achondroplasia.
Discussion
Morquia' s syndrome is a rare metabolic disorder cl assified
as one of the rnucopol ys3C(ha ridoscs. It is autosomal
recessive and presents in childhood wi th characteristic
skeletal dcfonnity and dwarfism. Patients also ha\'c deafness
and cardiac dysfunction, howc"cr Ihey may well Ii"c [Q
adul thood. Atlantoaxial subluxation is a feature and there
may be absence of thc odontoid peg. Radi ograph of the
184b Lat eral cervical spine demons trat ing
absence of the peg with flattening and
posterior scalloping of the vertebral
bodies.
cervical spinc in the same p;]tienr (I 84b) shows mul t iple
flattened vertebral bodies and abscnce of the peg.
Hurler's syndromc (another of the mucopol y-
S3ccharidoscs) and achondroplasia can have similar radio-
logical features; in particular, both may causc posterior
,'enebral bod)' scalloping and anterior venebral body
bcaking
The radiol ogic;l l fca nlres of Morquio's s)'l1drome arc
described below:
Spine:
Posterior ,crtebral sc;]lIoping.
\ Videning of intervene bra I disc spaecs.
Congenital flattening of the ,enebral bodies
( plar)"spond)"l)').
Anteri or bcaking of ,crtebral bodies.
Atlantoaxi;ll sublux;]lion.

Pelvis:
Fragmem";]tion and flattening offemoml hcads
( 1.4<).
Flared ili;]c wings ( 184c).
184c AP radiograph of pelvis showing fragmentation
and flanening of the femoral heads wi th fl aring of
the iliac wings.
Answer 184 Paediatric Imaging
Lower limbs:
Sloping of superior margin of tibial plateau laterally
( 184d).
Genu I'algus deformity ( 184d ).
Hands and feet"
Proxirm.l tapering of the metacarpal bones
producing 'bullet-shaped' tllcrac3.rpJls ( 184e).
Short \\;dcncd mbular bones with metaphyseal
irregularity ( 184e).
Practical tips
It may be vcry difficult on imaging to diAcrcntiatc
Morquio's from achondroplasia or dle olher
sacchl ridoscs. Some featu res may help radiological
diflcrentiation:
Cau(bl narrowi ng of the spinal callal is not a Icarmc of
the mucopolysaccharidoscs however it is present in
achondroplasia; therefore assess the intcrpcdicubr
distance on the All of the spine .
The 31ltcrior vertebral body beaks in 1\1orquio's tend
to be in the Middle of the "enthral body whereas in
Achondroplasia and Hurler's syndrome they arc
Ameroinfcrior.
184d AP radiograph of both knees shows
genu valgum wi th sloping of the superior
margins of the tibial plateau.
If the spine radiograph includes the craniocer\'ical
junction always assess the peg as this be absent in
and there may be atlantoaxial subluxation.
On a peh'ic radiograph flaring oflhe ili ac wings "iJJ
be seen in achondroplasb and the
mucopolysaceharidoses, howC\'er in achondroplasia
the sacrum may be hori zontal in orient-J.tion therefore
appearing abscnt (see Case 15 1).
Further management
Mortality/ morbidity arc related to atlantoaxial instability
due to odonlOid peg hyperplasia. In additi on, respirarory
complications arc common due to chest wall deformity.
Further reading
\Vakely S (2006). The posterior vertebral scalloping sign.
R.ndiology 239: 607- 609.
329
Chapter 6
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CASE 185
History
';':""oj, . m.mm" ..... m' ;n , . 1,-",
old ~ " " " n
Breast Imaging Case 185
'"
Answer 185
ANSWER 185
ObSflrvllions IIB51
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CASE 186
History
A woman with a firm mass
in the ccmrallcft breast.
Breast Imaging Case 186
336
ANSWER 186
Observations (186a, 18Gb)
Bilateral mammograms show that in the upper central and
hucral aspects of the left breast there is extensive
pleomorphic microcalcification. Within the left axi ll a there
is a 21 mill diameter rounded node. The right breast
appears normal. Ultrasound of the superior central left
breast demonstraTes an irregular solid mass.
The extensive microcalcification is of a configur:ltion
suspicious for malignancy in the central left breast. There
is possible metastatic spread ro the large axillary node. The
ultrasound demonsrrates a probable malignancy. Furrhcr
investigation with urgent biopsy of the lesion is required.
Diagnosis
Ductal carcinoma ill situ ( DCIS) with involved axillary
nodes.
Differential diagnosis
For pleomorphic calcification on mammograms:
DCIS.
Atypical ductal hyperplasia.
Fat necrosis.
Fibrocystic change.
For enlarged axillary nodes:
Ipsilateral breast malignancy.
Infection/inflammation of ipsilateral breast or arm.
Collagen vascular discase/rheumatoid arthritis.
Lymphoproliferative diseases: lymphoma and
leukaemia.
Metastases (melanoma, lung, contralateral breast).
HIVadenopathy.
Discussi on
Pleomorphic microcalcification may be defined as irregular
calcifications of varying sizes and shapes, usuall y <: 0.5 mm
in size. Orthogonal mammographic views may darif)' the
characteristics - for instance, lilH.:ar and segmental
distributions suggest that the calcification is ductal in
origin, whereas regional or diflilsc multiple bi!ater.ll groups
are less li kely to represent a ductal process.
A small percentage of mllignant lesions arise from the
stromal elements of the brelst. Ninety per cent of breaSt
cancers have cellular features thlt arc similar to ductal
epithelium and arc consequently classified as ductal cancers.
When confined ro the duct thev arc te rmcd ductal
carcinOllll ill sitll ( DCIS). When the cells have breached
the basemenr membrane around the duct and invaded the
surrounding tissues, they arc termed invasivc ductal
carcinoma ( IDC).
The diagnosis of DCIS is associated with the possibility
of associated invasi ve disease. If no invasive focus is
identified on mammography further assessmenr with
ultrasound and possibly J\lR imaging with a view to
potentially finding an invasive component may be
performed.
Practical tips
Not infiequently, microcaJcification is ofequi\ocal
configuration - if there is doubt there is a low
threshold to proceed to biopsy.
Look carefully for signs of an invasive focLis within the
ca1cifieltion - search for a spiculate mass or stromal
deformity. If not identified, assess further with
ultrasound and possibly MR imlging.
Further management
Further imaging assessment is suggested: mammographic
magnification orthogonal views (typically craniocaudal and
mediolateral ) may evaluate morphology and distribut ion
of the microca1cification. Ultrasound guided biopsy of the
solid lesion lnd mlmmographic stereotactic biopsics to
Obtain a sample containing calcification should be
performed. The sllspicious node should be sampled under
ultr;l.sound guidance. In this case, the biopsies showed:
ultrasound solid lesion - invasive carcinoma; stereotactic
carl'S - DClS; axillary node - malignant cells.
Once a diagnosis of malignancy has been established,
surgical rcferral is required. In this case the pltienr
underwent a mastecromy and axilbry lymph node
clearance. Histological findings ,,ere of a 12 mm I DC in
thc superior ccntral breast with extensive (7 cm)
intermedi,He grade DCIS; 4 Ollt of 15 axillary nodes were
involved with tumour.
186a Left MlO: axi l lary lymph
node (upper arrow) and
extensive microcalcification
(lower arrow).
CASE 187
Hi st ory
A 33-year-old woman with a soft
mobile smooth left breast lump.
Breast Imaging
Cases 187, 188
CASE 188
Hi story
A 64-\'car-old wom:all with a swollen
CI)1:hC;'l\:UOllSright breast.
33j
338
Answers 187, 188 Breast Imaging
ANSWER 187
Observations (187a. 187b)
The breasts arc heterogeneously dense. There arc scmi-
ovoid low-density opacities in bmh breasts. There is a large
dominant lesion in the upper Oll ter left breast.
Ultrasound of the left breast lump demonstrates:I wel!
defined smooth margined anechoic mass with through
transmission. The appearance of the lesion assessed with
ultrasound is in keeping with a benign simple cyst.
Diagnosis
Benign simple cySts.
Differential diagnosis
Of:l smooth low-densi ty lesion on mammography:
Simple cyst.
Oiteyst.
Fibroadenoma.
- 1.5% of circumscribed round lesions Illay be
malignancies.
Of an echoic lesion on ultrasound:
Simple cyst.
Complicated (proteinaceous) cyst.
Duct ectasia.
illtr:J.dl!craljintracysric papilloma - look carefully on
ultrasou nd for a mural lesion.
Discussion
Cyst's arc asymptomatic in many women. Presentation is
l'ariable. A palpable mass or masses may develop rapidly and
is/arc associated with tenderness. They del'elop
ANSWER 188
Observations (188)
There is diffilsc tr.lbecular prominence throughout the right
breast which is or generalized increased density. The skin
is thickened. There arc enlarged nodes in the right
The left breast is normal.
Di agnosis
Probable inflammatory right breast cancer axillary
nodal illl'oll'emcm.
Differential diagnosis
For diffusc trabecular/skin thickening:
Post radiotherapy change.
Progressive systemic sclerosis.
Obstruction ortht' superior I'ena cava.
Lymphoma.
infection/ inflammatol)' mastitis - most common in
lactating women.
Tr:lllma.
Generalized oedema due to causes such as congesu"e
hean f.l ilure or nephritic syndrome.
Di scussion
Uhr:lsound or MR imaging may be used to find a discrete
pc:rimc:nopausally in many women, but can be found in
women of all ages. Cysts may develop after commencing
oestrogen (hormone ) replacement
On mammography, cysts appear as semi-ovoid masses
with variable margins and density. There may be a
peripheral halo and/or rim egg shell calcification. On
ultrasound, cyStS usuall)' appear as well defined, anechoic
masses posterior acoustic enhanccmem. In some, hi gh
specular echoes shift in position as gain is increased
('gurgling' cysts) . Posterior enhancement is not always
demonstrable, particularly if the cyst is small or dose to the
chest wall. If there is any question as to the cysti c narure
of a lesion, aspiration is recommended. On occasion lesions
appear cystic on ultrasound, but aspiration is unsuccessful
- thick prOTeinaceoUs fluid may be tOO gelatinous to be
aspirated.
Practi cal tips
Avoid satisfaction ofsul"\'ey: look for other, more
suspicious lesions.
CyStS often recur after aspiration.
If the lesion is dearly a simple: cyst, aspiration is not
required unless the symptoms of the mass arc
distressing.
Irlhere is any doubt as to the nature or the cystic
lesion, core bioI'S), is suggested.
Further management
Ir there is any doubt about the mammographi c
appearances, further el'aluation with ultrasound should be
undenaken.
invasive focus which could be biopsied. The diagnosis
could also be obtai ned from skin punch biopsy or rrom
image guided core biopsy of an axillary node.
Inflammatol)' breast cancer may be defined by clinical
di agnosis dependent on findings of oedema, el)'lhema and
'pcau d'orange' or on histological findings of metastatic
breast cancer in dermal lymphatics. The definition is
debatable: not all women with clinical findings suggcsti,'c
or inflammatory breast cancer have iOl'olved dermal
lymphatics and all patientS with tumour cells in the
dermal lymphatics present wi th signs of inflammation .
Inflammatory malignancies account for 1% of all breast
cancers and up to 40% of locally adl'anced breast cancers.
The diflcrentiation between mastitis and inflammatol)'
carcinoma may be ditlicult.
Practical t ips
Patients often undergo neoadjuvam chemothcrapy
prior to mastectomy.
Consider infla!J1matory breast cancer when an
inflamed breast fui ls to respond to a brief course of
antibiotics.
CASE 189
History
A 42-rear-old mail wi th a soft mobile
tender Icft breast lump.
Breast Imaging
Cases 189, 190
CASE 190
History
Screening mammograms in a 57-rear-
old womall.
339
340
Answers 189, 190 Breast Imaging
ANSWER 189
Observations 1189)
In the left brC:lst there is l full shaped density emanating
from the nipple which gradually blends into surrounding
lany tissue. The right breast appears normal
Diagnosis
Gynaccornasria.
Differential diagnosis
Of a breast lump in a male:
Gvnaccomastia.
!\Ialc breast cancer (circuillscribed or spiculate mass
usually evident; often eccentric to the nipple ).
Pscudog}'naccomasria (f.1rty cnbrgcmctlt with no
ductal or stromal prolitcration; secondary to obesity).
Di:lbctic mastopathy (firm mass in patient with
longstanding type I diabetes mellitus ).
Abscess (cITthcma; acute histOry).
Discussion
Gynaccomastia usually appears as a fan shaped density
emanating from the nipple, gradually blending into
surrounding fat. Three mammographic patterns of
gynaecomastia have bce.n described: nodular, dendritic and
dirfuse. Tllere may be prominent extensions into the
surrounding fu t and, in some cases, an appearance similar
to that ofa hetemgeneollsly dense tcmalc breast. Although
ANSWER 190
Observations (190)
1n the antelior aspects of both breasts there arc smooth \\"ell
defined spherical calcifications with lucent centres. No
abnormal masses or distortion arc seen.
Diagnosis
Bilateral calcification of benign configuration.
Differential diagnosis
For benign calcification:
Vascular - usually secondary to medial atherosclerosis .
Mav be. associated with diabetes and
hYl;erparathyroidism. Often demonstrates a
characteristic 'train track' configuration.
Fat necrosis - peripheral calcification in a lucent mass;
histOry oftraullla or surgery.
Fibroadenoma involution -
calcifications usually beginning at the periphery and
the n ill\'olvi ng the central portion.
'Milk of calcium' - a benign process that call be
diagnosed with magnification views of orthogonal
projections: on the CC view, calcifications appear
poorly defi ned and sllludgy; when imaged on the
MLO view, rhe calcifications are seen as sharply
defined and cresccnt shaped or linear.
Plasma cell mastitis and duct ectasia - large rod-like
calcifications orienled along the axes of the duct:al
there arc characteristic mammographic features that ailow
breast cancer in men to be recognized (round/spiculate
subareolar mass typically eccenTric to the nipple), there is
substantial overbp between these features and the
mammographic appearance ofbcnign lesions. Male breast
cancer is rare, accounting lor < I % of all male cancers.
Gynaecomastia is characterized by hyperplasia of ductal
and stromal clements of the male breast . It manifests
clinically as a soft, mobile, tender mass in the retroareolar
region. Gynaecomastia has been associated with an
increased semm bcI of oestradiol and a decreased level of
teSTOsterone - this may occur with physiological changes
at puberty and senescence and be caused by endocrine
disordcrs, systcmic diseases, neoplasms and certain drugs
including anabolic steroids, cimetidine, spironolactone and
marijuana
Further management
On the diagnosis of gynaecomastia it is important to
corrdate the imaging findings with the clinical histOry.
Many cases of gynaecomastia are idiopathic bur
underlying causes should be investigated - senUll hormone
b cls should be taken. Ask for a drug history and the
presence of signs of chronic renal insufficiency, cirrhosis
and a testicular mass; other imaging imestigations
perr:a ining to the patient may raise one of these
possibilities.
system. These calcifications h:nd to be coarser and
larger (usually >1 mill in diameter) than malignant
calcifications.
Skin or dermal - usually spherical and lucent-centn:
calcifications at the periphery of the breast.
Suture - usually seen :at a known surgical site. The
calcifications be linear or tubular.
Discussion
Calcification is a frequent finding on mammograms. The
arrangement of calcification aids categorization as to
whether it is benign or malign.ult. Clustered (occupying a
,olume <I pI oftisstle), linear and segmental calcification
may be secondary to benign or malignant processes.
Regionally and diffusely distributed calcifications arc most
likely due to benign processes. These calcifications arc
scattered in a la rge volume of the breast and do not
necessarily conform to a ductal distribution.
Practical tips
If calcification is of equivocal configuration, there is a low
threshold to proceed to biopsy_
Further management
No intervention required. Routine recall lor screening.
CASE 191
History
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Breast Imaging Case 191
'"
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Answer 191
ANSWER 191
Obu.vlli .. 191b. 19101
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Further Reading
AidJ to Radiological Diffirmtia/ Dif/gllosis
Stephen Chapman, Ri ch:ml Nakidny
\VB S;1UllrlCrs, 4th edn, 2003
Clillicnllmngillg: An Arlal of J)ijfirwtiai Diagnosis
Ronald L Eisenberg
Lippincott Williams and Wilkins, 4th cdn, 2002
Diagnostic lI"aging Head fllld Nuk
lti c Harnsbcrgcr
Amirsys, 2004
FlIlIdfllll Clltnls o/Dif/gIlMt;, Radi%!J.Y
William E Brant , CI),de A Helms
Lippincott Williams and Wilkins, 3rd cdn, 2006
Grail/oer (Illd AlliJon's Diagllostic Radiology: A Textbook
of Medical /lIJflgjllB
Ronald G Grainger, David J Alli son, Adrian K Dixon
Churchill Li vingstone, 4th edn, 2001
lmagill!] of DisenJeJ of tile Chest
D ~ l \ ' i d M H:mscll , Peter Armst rong, David A Lynch, H
Page McAdams
j\'losby, 4[h cdn, 2004
Mnglltlic Resoll flll 'e IlIIng;II9 o/the Brf/ill and Spille
SconWAtias
Uppincorr-R.wen, 2nd edn, 1996
NtIITOTfl di%m- TIJe ReqlliIiteJ
Robert I Grossman, D:a\'id M Youscm
Mosby, 2nd edn, 2003
Pfledifltrit NtllTOiwflgi"g
A Barko\'ich
Lippincott Willi:ams and Wilkins, 4th edn, 2005
Radi%m Rtl'itw Mall lla/
Wotfg:ang Dahncrt
Lippincott WitlianlS and Wilkins, 6th (dn, 2007
Sc/f-Al!Cl!JIICllt C% m- Rtl!iew of NtIITOilll(Jgillg
Ki rsten Forbes, Sanjay Shetty, Mi chael Lev, Joseph
Hcis(rll1:an
J\'lanson Publishing Ltd, 2008.
Sdf-Al!el!lIItI" CO/OIIT Rel'iell' oj 'nJorfl cie Imflging
Sue Copley, DJvid M. Hansell, Nestor L. Muller
Manson Publishing Ltd, 2005
Textbook of Rfldi%g:y fllld Imflging
David Sutton, Rodney Reznck, Janet Murfitt
Churchill Livingstone, 7th (dn, 2002
343
".
Index of Differential Diagnoses
" ' h,I",;, !7
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, ..
l;l
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..
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H i t'! 110
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b,>,.1
I ..
iow-J",,,,y I ..
.l.II.
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bl
..... of,'{'<dI Hf.!.P) 70
, .. limnS J"'", "" IVU
;.
..... U ""
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h ';9
t.,...I . '""' n".'" ..... o.z
..... .. . 97
1><",,,,
... "",", I".,,, '"7
,akmc" .... 190
,,"ws,J .. 'koJ... 187
lump"""'" 189
"''" '"''''1''' i< I ."
186
<i. ;" 103
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.........
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.. """ .. Il+
,ok""' .... tu..-.n'l"k"' .. I
,,1<;(., .. , ..
I ..
bI .. !d<,
"",," bon;"" 190
r, " t' rtir 1.1/
11 N.JJ.', 12
.l
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I;'" ,"","'..." 51
0 '
,,, ,,,, ... ... III
b"".
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<pI<," l.5.
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II
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90
""" "'''''.\< 105
",>.I"." l..
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....
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,,,,,,,,, ,tt. "'''"'' Ilu
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27
,')">1" 1<>;'" " 9,
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103
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f,,,,,,,,,,.,,, .. ,,,, .. ,,( 117
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41
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I'"
119
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.... ... c -, i W". _ " '" "
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JooJ""J "",... ", I
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Jpl"''''''
,," ' h .. u<)t ...... 17
"1'1'" ' nn ........ h
n >I,. w<"""" """ II
' it-h' ,>kJ ",,110 ,'5
t',oio' "''"'$_'/o''' ."
,)"J"",", III
E"" nm<nt.<''')...Jrom< lit
... , ... L",,,,IJ '\"""""" 177
,m bol.", ;"". , .. """,, ""'"
............ "..." .n
,,""hi"" """'" r,<h,;, .J
,mrh,,,,,.,,,.,, n.'
",.h,I;, ;,. "",,k' ,In,,
I J.>
""I,,,,,,""", H-I
,nodom,,,,,,,,", U
,nodom" ........ 81.0.1
''''''p..x

... n, tu f"'K'''' ..
,.. .... 'Y ' h
" ,""".d,,'" '"'" ",,,it;',n l.i
<"iI,,,,'J ,',,, ;"'d,, kju.:J ,,"
"b
15i. I"
""'""'"rh' .. 1'"1""",.,,. .. , lon

'1"""),'"00" 89 _ UO
"J,,,,,,,OI
<pOC!")'
1<1-1
,"I""" ><I< .... 101
f.rl<n"",)<r

" ,n, ,,,,),, .. ,,""'
hJ
115
,"" ,0"".,,1
( .:CMOI 1M
,-" ,i o>" .'k,." ( A.\) II
<)<>
"",.,J""," 9 1
, h)""" .",,, h . lm"I' '' lor 88
111 .. < (H' G )
"
f.lkn
,,1
f,mili. 1 ...... ..,."" ... " ....... ..,.,...
(HP) ."
k Ii,,, .IS.
f,mor'" 'p;pl')'b. "1'1'"
'"
.",,,,,ol h .. J
" .... ul .. 117. I ,'.I. 139
mult;',n' "" ""iI\,,,.,,,
,,;
Gene.al Index
,;,,,,,,,
Il7
ol "''''''"''''''''' I ,'.
,ibro<] )'.'",, ""i'""" F""f."";'"
III
,lbroo,u"",., J,,,, .. i, 58
'''''',",J)'1''''''' Ii.
'io\l! ..... J -C<> .u
f ... ,Jk I.,
';,wl", ... ",.,', .1",.", '.l
""o .... I IY.W' .1!7
h .. ..-.l.I" h)'f'<'pI,,;, (fSH I.
"'r""
""" S'. J ..""
"'"' ..... 1I<."'n>< 161
",,,.1,,11 . ;" , n. 167
" ":,"K. urI"" k,.",.t
117
r""" ,I "",, ,'" " "". 9.
""<t.,o,
(;PJJ . 1. N
,.., . .. " ."" r'''"mon ..
u
'" .Is . .... ,Vc bronchopu lmon.,,-
... .... AI,<
0;
.... """' 81
, . ..., . .... "1
.... '",,,'" .,., " , i.Z
11" "'0<>'"
.,,,,.1 .. "" k" ... __
Cw",', J""", OJ
" " "".-
P""'''' ;';' 71
(j",I,,,, ..
V"'" .oJ,,,,,,,,, 09
.... " '" """".'. I .. i';, pl.".,.
,.
!!'''"., k' ) ",)"<.O", M
,."""'i"",, h,
11'''''' .'.r." <1
""""'''. .IJI.
'--''''''''S',tlin 17.>
"""'''''''''' 'n''
" ... ""..".""",,,,,,.1 .l.II.
1"""" "' '''''''1'''''' 'ph""",.
... >7
G."""',, J ... .,., 119,1 78
g"", "n n
8"" , ,, 1\,,,,",, ..
slOobl." om, mult;'bm" . burtffil y
""
V"""' i" r"""''" '" "'"."
, ..
t<i ""O'';-'" Ji<, ""
!O"""'",noi';" ,n" """.rthr ""
,......, "",h"" .. ," )' I H
"'. ".Ion, ""'" J ... '"
C .. "'n\ J .... " 5,'
" II
" W<".""'" ",_,,,,,',,,,,,,. i. i
S"l" " . .. "
0 .... 1 I ...
h.'"""",,", I""
Oorn'" iZ
",o';'y k,... 109
. ,."o<",m.>t;. HO.I89
10'1. '"0
h"""o,,",m, 119.1!7
sa
,,">t"' Ii lb.
h ... ru''''''''''y II
h 119.1
"''';"5 k_
aoow'" "'"""'"
<", .. ",J ,"",J""
.ynJ"",,,, M
gI ... u" " r.n",,,,,, ,.,.,,",
,.
"',,'
"0
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'" p''''''' "'' '' c>r< " ""'"
fo..1 ,oJu!. h)'f'<'1' J..o"

"" , ';,h h"""",hw.,,""" 50
h' I' ''''''''', ,.",u' ...
! ;
7'!
"''I'''' ' .... " ( Hoi,")
","""".11,;, II.'
h"" """.'"" ""'1"",,1
"""'W"P"Y I H RC1' )
l"oS ,I"",,,' II
rrim.,,- ,"",""""i. .l.
""''"''"..,..,,,.''' ..... 1-
hip ,, '''' .'"""1" .l.
... _ 17l
... '"f,.b.",
II
HI" ;"1,;.,
7.
1'0" ... ".", , . ... ;; i""' ". '"' ''
U
"",;"..,,,1 ".. I W
h""", .. 1 "'..J. " '",,,ul .... """";. t..
lll.. \J,6i
11",1"",'00"""" 18.
hy,h" .",,, 'w,, .. J"' ... (II Mil l
16,. 170
hr'"'' """"" i"
hy<l" .... rh>I", "",.1.0
hy<l """ r" """
"''''''"' ''' ! I
,,,,,,,,,.,,",,, I .. ,Iv.h,,, 172
"'0.1"""",,,..., 68
hll""'.ok"". " . 71
15l.l 60
",n.1 mcJulJ...y no """".k .. "."
"
hll" rt" ,.;.,
17;
,..-" ... *"' ...
50
"
'
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.. f - ,';klH
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- .
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;" 0
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- ,-" -

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1!- ... -"'--
;;

iI'!-. 50
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, 1'"
. d
. -
.;
' "
q
, .
,
,.
,
,- " ,-
H Hj" P f'n .... HHi

.'.-" ,- .. ,-3"M ' "3 . .., ""

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. . .... !, ",-.
.. - , -.., -: "i';v ,. .;
"" .",_ .,,"j ;:..
.J ,'.-. _ r j; .
i,t. [i;!
i' i-
_"" "l' ," !
_,' .... i::. "A , .-.
'i < ,!!, "
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- ,- "
l = ...
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q
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,
... ,"., .. "_:: : :: "- ,' ,-.6' -.... ...... ,
d _ ' pH t,;: 1- h1 1 rg p: ,', g '" t; ,i' -H
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..... =- ,! """
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.... i .'"' i2. ,
.. "i.. ; '" "-;
"J Q

.,'" .. ".r - ",'. .. -. _ ... ,AE -_ " s'- S 5 ..
.... *- --. $.. .. -. " - .-'" - ,.
it;: - ...
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c .. N ........ t;', .. I;; .... "'ill f:.. ::- i
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- ,' . ,
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.. - .'

'!:' 41
r ,
, -

, .
1 t
1c ..
33:1 :; 333 3<1 ;:l; 3 :l;;::;::: .. .... ,="
-".,.,"' 0 - "" i' -"" . .... .. ',.. "-"-', .. .., .-' _ . ... -,. <--.
. .. ,."-'-i<,;,
. !"! "" ' ' il "

,,;,.' _ -";3",_ ,..
.. tdH-pI:;8 h -H
g-' :q
, Ie '",. .. J :::.,'
';,. f' '"']- ':. no." ,
< ...... -'-' ',, ' ''-'-! .=; ;;; - - - o::..j; .. i,l-:;:"-
... ;;-:l .. '- ;: .. 5 i" --;. -,"
0.. ... ", ,. .,." _ ....
,. .... .... - , ..
... '" . _0 -:;;: . > ...
.. .... .. -
,. Q", - .., -

,-,,:;0:;3"''';
.-"
... " ," .- ..... - 3 ..
J
.,.,! ... . _<
0-
""!'r i".
..
'"?-'!'[" ":-'- , a
.'
_ ...
.'" t"' >- , '
. "
.- .-"

"
'"
"''' ..... ", ...
... sn
iJ"'I'''hk .... 1. 7
,J",,>l ,J, ... " . ...
.-
"'''''<0'''''' 115. 1.;
lJ
b l
'"k"""",m ... " .. ,1
,Iml' I ""
k.,S iI.
""r hroN .. ,on" 17.
... Il7
p<k;' II.
r"""" <;>;',,,"_ H"
pub",,",,)' 130
III
,, 1m'" t. ... '""" to .. "", <"""
l L 137. ""
'''1''''''''''
m"''''' .. "kno.;. 111
13;
17.'
... 71
mOJ ........ fOK' .... 100
,",IJI< ""'l' (.\lCA)
"",",,,m It.
.,f"". II,
,"iiMy ..... "k, .!.>
'" [5M ,""I .... "'" 9.
,""r,1 '''w J,."", II
mrtnl,oI""""'r II
I ""I" io' , ."",1,,, IT>< Il 0, Il,.
18 .
"')
," """"k. ' p"" .,id ,in", Ill',
'' I M<
"oh: ,;", "." ........
'"
'"""'rk .-,irh)". ... d,'rl..... I."
... 97
I ...
m)"Kanl,a1 ",J"" """,,"
.. i. 81
.. " III
P"'l"",i," I H
",;I ... ""II",,tJ ...... , 118
"",1 ",g'''. \\"" ''''(.
.!.
""' .... 'i,,'S """",,,,it.. ,,,7
"'...,,, ..
J",,.k,,, j ", .. " I .l
... ...... iom "'";''' 00 ')"0""",,
""
.." .... n.m ",u. 17J
,,,.Js' I',,,m",, .. itr
"''-'', " ... .01 ;1",, ". C"-",,, ' , J '" '"
" ""ph"""",,,,,, 17,.
"'p""".k .. ,,;'. ",".1 m...JuU")"
"
General Index
""Un,","''''''' 17,
III
,,"""',""' .. a1,.... lJl
127
. 8
exit. 27
I.
'!,p< 1 11I.ll7
..... , 'J"}
.... ;" ..... Iuk,
')'p< l
,,,, .. M .. W" ""
"""",,,I m;Y""'" . ""'S,"i1.d
.. """.dit, I oW
lOOt . .I" ... ,,, 118
.."-'" ,,,;.], ",.1 17_; ,
m
"0<"..,>1 ''', I.'"
Qd<' ''''1:'"",I""",)" ',S
........ " ..... r<s IlO
''''''';'.
f .... "" 171
'''''''' ..
"'rt"" M
","" H
.ll!
' um,,",. kri k,""
.. '" ,0> i''' ",
),u l .. ,,,, ,,,, "0<'"'''''' Lt
,.".'" <1
id.
"''''rh' 8;n. 7<J
'-""'r h
"'h ... .,; 7
", ... .ll!
I<iom)"'-"'H' ;;
01"" >I",,,,,,.. " iot" """ I" ...
, 01,., 171
011.,(, ""'.,., IH
, .. om ,.,,1 '''" .0
'" u,,,"' .. ,,,'". I 7.
"f<o-d,,,,m ""
"""1"'..;0" ] 06
91
""'< gl"'''. 'N
'-""Ph "l "" .01 <."J , .. ,,;, 7Y
' l'''''''' ''< 33
ho"".n.;."" 71
" .... 11.
... 'hnl"'h,
(' .mho, J"'", 53
h)1"'rt""",k .... ,;7
"' ....... I J I
",,,,,,,t..,,,,, ... 1.10
'-"t<'-"' .... ,p ..... ,,1 Ill
Il;
"''''"' .... .. 1 1 i.
""","1 ..... , J, -rI.... ..9
"'p<,,,,,,. 117. Ihl.
'"
1"<><",
,""'..,m. I .... ".
"""""" 1 .. ,, Ilb,176
'I"
"'''' '!''.";. 1"", 17
119, ] 10, 105
III
,,"' .... " .. __"'n' 12;, I J 4
,,,,,, ,,,, .. , >1 130
lu"g""""''''''' !
IJIi
14"
,j;Ij\,,, I"
"'.,,;," " " '" hi
","i """,,,.-.oJ ")'"
157
p"hrl'l'" 1.9
J i",." 1:17. 11<'
P'""'"
H ,IM.'
"m";., 12
r''''''' ;'' ."uilkit",,)'.
.lb.
71
J, -'so L
p"""",I"""",,,=<o. 96
.. ''',. ,,'""",, ' .7
pm'" "",). ""
,.,""",1
P""" JoK' '''' ",,,.,,", II
p<",,, .. 1 ",,,,,I< """"'r/ ''''''"
II
r<kk " ,",",,'0." 70
cI.4
p<r';" ""'tm, 0;,11"
M
p<""""""'" b .. 1oon
II
p<,"'"J;,;'. h .. " pio;"k"'" !i
p<,.0",,1 <4;W"". ", ' 07
I",;""",""ul" k ........ I...... I ..
1'<",,-1'><1><" Jow" i9
ph,I"""",,,, 101
r""f'"' '"''''f''''''' , ....
r ..... g<""i.o", . 91
.. ,,"""\''''''''. 106
rk",,1 ,,10.;/;""00. " ...
<>1"""" li
"""".1 <lTu ..... ,
....... ',.n"""'" 1..5:
,",wn;o," .""" ... , ')'>.1""",
170
l'fim'f)' '" i' l
F""'"'''''''' ,,,d.-m, J,,,, to "".rt
" . "" 10
""'"", 11"",, "blkj"' II
""'",,' 1 ..... , ,"""
,
pk"'.d 1'1"1"'"
,,"",,'" """"'"' J..i
" , l
rk""I."oo",","",,, II
rt"um .. ,,,,k, _ ... "'".;;
II
rt" " m ..
" "". M
pncumalOsis (tontinlled)
cystoides intestinalis 66
intestinalis 65, 167
pneumobilia 41
pneumoconiosis 6, 7
PlIelfmotystis tan"ii pneumonia
( PCP) 37
pneumomediastinum 34,165
meconium aspiration syndrome
170
pneumonia, aspiration 171
pneumoperitoneum 34,75
necrotizing emerocolitis 167
pneumothorax 3 1
bulla diflerential diagnosis 35
cystic fibrosis 36
endometrioma 83
Langerhans cell histiocytosis 27
meconium aspiration syndrome
170
PllwmotyJtis tnrjlljj pneumonia
37
positive pressure \entilation
complication 165
polycystic kidney diS(:asc 48
polydactyly 177
polyhydramnios, annular pancreas
44
polymicrOb .. yria 169
portal hypertension, oesophageal
varices 42
positive pressure ventilation 165
positron emission tomography
(PET), merasl';nic bronchogenic
carcinoma 24
posterior cnlciate ligament 159
double PCL sign 159
postcrior inferior cerebellar artery
infarction 100
posterior urethra! vahes 172
Pou 's disease 142
prematurity
hyaline membrane disease 165,
170
necrotizing enterocolitis 167
primary sclerosing cholangitis 45
primitive neuroectodermal tumour
( PNET) 180
progressive massive fibrosis 7
prostate carcinoma, metastascs 140
Protws, emphysematous pyelitis 63
pmne belly, posterior urethral vahes
172
pscudodi\erticulosis, intr.lmural 38
pseudohyperparathyroidism 147
pS(:udo-Maddung deformity 130,
153
PsclldomollaJ, emphysematous
pyelitis 63
pseudoureteroceles 56
psoas abseess 142
psoriasis 11 6
psoriatic arthropathy 143, 152
pulmonary arterial hypertension 16
General Index
pulmonaryarterimenolls
malform:uion 33
pulmonary asbestosis 3, 15
,.. pulmonary embolus 31
pulmonary fibrosis
dmg-induced 18
lowcrzone 15, 17
upper zone 15,17, 18
pulmonary haemosiderosis 23
pulmonary interstitial emphysema
(PIE) 165
pulmona!)' malignancy
asbestosis 15
systemic sckrosis 17
pulmona!)' metastases, cavitating
14
pulmona!)' nodules
follow-up 6
mitral vah'e disease 23
oesophageal tumour 14
rhcumatoid lung 6
sarcoidosis I
pulmona!)' oedema 3 1
heart failure 29
pUlmOlla!)' opacity
barium aspiration 20
ground glass 29
Icft upper lobe tumour
lrmphangitis carcinomatosa 12
lung lobe collapS(: 14
metastatic calcinosis 20
pleural pscudotumour II
puhnona!)' sarcoidosis 1
pulmonary \cnous hypertension
mi tral \'alvediscasc 23
pulmona!)' oedema due to heart
failure 29
pyelitis, emphyscmatous 63
pycloureteritiscystica 77
pyknodysostosis ! 19, 168
Pyle's disease 119, 178
Rathke cleft cyst 106
Raynaud's phenomeno n 17
thoracic Outlet syndrome 28
rectum
st'ent'ed tumour with calcified liver
metastases 52
ulcerative colitis 65
Rdter's syndrome 116, 143
renal adenocarcinoma 51
renal arte!)' stenosis 58
renal ectopia, crossed nlsed 68
renal lesions, fat 48
renal medull ary nephrocalcinosis 43
renal obstmction, hydronephrosis
68
renal osteodystrophy 119, 140
renal papilla!) necrosis 78
renal scarring, infections 68
renal stones, horseshoe kidney 5 1
renal lUberculosis with
autonephrecromy 74
renal tubular acidosis 43
renin-angiotensin system,
o\'eracrivity 58
rcspirarory distress, meconium
aspiration syndrome 170
reversal sign 114, 163
rheumatic heart disease 23
rheumatoid arthritis 120,143
rheumatoid factor 17
rheumatoid lung 6
rheumarologic syndromes,
histoplasmosis 25
rib.
bilateral cervical 28
eXOStoses 130
lesions 9
notching 32
rickets 168, 175, 176
fight vent ricular hypertrophy, mitral
valve disease 23
Rigler sign 75, 167
Rigler's triad 41
Rokitansky nodule 84
S sign of Golden 14
sacral agenesis 173
sacroiliac joint disease
Crohn's disease 53
ulcerative colitis 65
sacroiliac joint fusion 139
sacroiliitis 116,143
sandwich ,enebrae 140
sarcoidosis
cardiac sarcoid 22
pUinlOna!)' 1
schistosomiasis 62
schizcncephaly 169
sclerpdcrma 132, 152
sclerosis
Charcot joint 138
dilYuS(: 119
thickening, interlobular
29
sialectasis, juveni le punctate 87
sicklccclidisease 129, 140, 155
siderosis, transfusion 50
sigmoid colon, displacement 84
sigmoid mlvulus 46
silicosis 18
simple bone cySt 115
Sj6grcn's syndrome 87
skin folds, lung edge art:efuct 35
skin nodules, neurofibromatosis type
I 8
slipped upper femoral epiphysis
(SUFE) 117
small bowel
adenoma 49
ischaemia 59
loop dilatation 69
strictures 59
thickening in Crohn's disease 53
small bowel obstrucdon 4 1
adhesions 47
mechanical 4 1,47
351
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