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Sllavko K. Kallfa





Prmbledhje Artikujsh nga
Radiopaedia.org
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food inspired X-Ray sign




cervical hamburger sign.f.30
head cheese sign................................................ f.3
honeycomb lung............................................... f.6
licked candy stick appearance...... f.13
mesenteric hamburger sign.............. f.18
omental cake..........................................................f.22
oreo cookie............................................................... f.25
sausage digit...........................................................f.29





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Head cheese sign
Dr Frank Gaillard et al.
Head cheese, believe it or not, is not a cheese and is often not made of head. It is in fact a type of
terrine, with bits of meat scavenged from various parts of various animals (including the head)
usually from a calf or pig. It has a heterogeneous mosaic pattern, ranging from light to dark.
The appearance of the cut surface of this dubious delicacy has been likened to that
hypersensitivity pneumonitis, where there is a combination of :
lung consolidation
ground glass opacities
normal lung
hyperinflated / air trapped lung (mosaic attenuation)

References
1. High-resolution CT of the lung. W. Richard Webb, Nestor L. Muller, David P.
Naidich. Philadelphia : Lippincott Williams & Wilkins, c2001. ISBN:0781722780 (find it
at amazon.com)
2. Webb WR. Thin-section CT of the secondary pulmonary lobule: anatomy and the
image-the 2004 Fleischner lecture. Radiology. 2006;239 (2): 322-38.
doi:10.1148/radiol.2392041968 - Pubmed citation
Synonyms & Alternative Spellings
Synonyms or Alternative Spelling Include in Listings?
Head cheese sign - chest

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Head cheese Image courtesy of Tamorlan. Please see case description page for licence and original file
information. From the case: Head cheese - photo
Modality: Photo
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From the case: Hypersensitivity pneumonitis - probable sub acute to chronic
Modality: CT




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Honeycombing
Dr Andrew Dixon and Dr Behrang Amini et al.
Honeycombing refers to the computed tomographic (CT) manifestation of diffuse pulmonary
fibrosis (usual interstitial pneumonia). CT demonstrates clustered cystic air spaces (between 0.3-
1.0 cm in diameter), which are usually subpleural and basal in distribution. The walls of the cysts
are well-defined and often thick (1-3 mm
4
). Honeycombing is an irreversible finding
in interstitial lung disease and associated with a poor prognosis.
Differential diagnosis
air-space consolidation in the presence of pulmonary emphysema can mimic this
appearance.
in some situations, paraseptal emphysema and paracicatrical emphysema can also mimic
honeycombing
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Etymology
The term honeycomb lung is thought to have originated in the 19
th
century in Germany and is
thought to have first appeared in 1949 in a study by N Oswald and T Parkinson
5
.

References
1. Austin JH, Mller NL, Friedman PJ et-al. Glossary of terms for CT of the lungs:
recommendations of the Nomenclature Committee of the Fleischner Society. Radiology.
1996;200 (2): 327-31. Radiology (citation) - Pubmed citation
2. Mueller-mang C, Grosse C, Schmid K et-al. What every radiologist should know about
idiopathic interstitial pneumonias. Radiographics. 27 (3): 595-615.
doi:10.1148/rg.273065130 - Pubmed citation
3. Arakawa H, Honma K. Honeycomb lung: history and current concepts. AJR Am J
Roentgenol. 2011;196 (4): 773-82. doi:10.2214/AJR.10.4873 - Pubmed citation
4. Watadani T, Sakai F, Johkoh T et-al. Interobserver variability in the CT assessment of
honeycombing in the lungs. Radiology. 2013;266 (3): 936-44.
doi:10.1148/radiol.12112516 - Pubmed citation
5. Johkoh T, Sakai F, Noma S et-al. Honeycombing on CT; its definition, pathologic
correlation, and future direction of its diagnosis. Eur J Radiol. 2013; .
doi:10.1016/j.ejrad.2013.05.012 - Pubmed citation
Synonyms & Alternative Spellings
Synonyms or Alternative Spelling Include in Listings?
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Synonyms or Alternative Spelling Include in Listings?
Honeycomb lung
Honeycombed lung
Honeycomb lungs
Honeycombed lungs
Honey combing

Photograph - Bee honeycomb
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pulmonary fibrosis with
prominent honeycombing. Image courtesy of Dr Frank Gaillard .
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From the case: Honeycomb lung - gross pathology
Modality: Photo
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non-contrast
Predominantly basal and peripheral reticular opacities with honeycombing and traction bronchiectasis.
From the case: Honeycombing in an usual interstitial pneumonia (UIP) pattern
Modality: CT
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Axial non-contrast
Predominantly basal and peripheral reticular opacities with honeycombing and traction bronchiectasis.
From the case: Usual interstitial pneumonia
Modality: CT
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From the case: Rheumatoid interstitial lung disease
Modality: CT



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Licked candy stick appearance
Dr Henry Knipe and Dr MT Niknejad et al.
The term licked candy stick appearance refers to tapering of the tips of the metacarpal bones,
metatarsal bones, phalanges or clavicles and is usually associated with:
psoriatic arthropathy
rheumatoid arthritis
leprosy
neuropathic joint

References
1. Roche CJ, O'Keeffe DP, Lee WK et-al. Selections from the buffet of food signs in
radiology. Radiographics. 2002;22 (6): 1369-84. Radiographics (full text) -
doi:10.1148/rg.226025521 - Pubmed citation
2. Brant WE, Helms CA. Fundamentals of diagnostic radiology. Lippincott Williams &
Wilkins. (2007) ISBN:0781765188. Read it at Google Books - Find it at Amazon
3. Davies SG. Aids to Radiological Differential Diagnosis. Saunders Ltd. (2009)
ISBN:0702029793. Read it at Google Books - Find it at Amazon
Synonyms & Alternative Spellings
Synonyms or Alternative Spelling Include in Listings?
Licked candy stick sign

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From the case: Rheumatoid arthritis
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From the case:
Leprosy
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From the case: Leprosy

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From the case:
Leprosy
Modality: X-ray



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Sandwich sign
Dr Frank Gaillard et al.
A sandwich sign (sometimes known as a hamburger sign) refers to a mesenteric +/- para-aortic
nodal mass giving an appearance of a hamburger. Confluent lymphadenopathy on both sides of
the mesenteric vessels gives rise to an appearance described as the sandwich sign.
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The sign is specific for mesenteric lymphoma (typically non-Hodgkins) unless the patient has
had a transplant. If so, posttransplant lymphoproliferative disorder should be considered.
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References
1. Hardy SM. The sandwich sign. Radiology. 2003;226 (3): 651-2.
doi:10.1148/radiol.2263020109 - Pubmed citation
2. Haaga JR, Boll D. CT and MRI of the whole body. Mosby. (2009) ISBN:0323053750.
Read it at Google Books - Find it at Amazon
Synonyms & Alternative Spellings
Synonyms or Alternative Spelling Include in Listings?
hamburger sign

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From the case: Hamburger sign
Modality: CT
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From the case: Sandwich sign
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From the case: Hamburger sign in patient with CLL
Modality: CT



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Omental cake
Dr Frank Gaillard et al.
An omental cake refers to infiltration of the omental fat by material of soft-tissue density.
The most common cause is metastases from ovarian, gastric or colon cancer. Tuberculous
peritonitis may also give this appearance. Masses on the peritoneal surfaces may also be present.
Malignant ascites may be present. Lymphoma can present as omental caking, diffuse peritoneal
thickening, and ascites, the best clue is significant lymphadenopathy.
A core biopsy may be helpful if the primary tumour is unknown.

References
1. Weissleder R, Wittenberg J, Harisinghani MG. Primer of diagnostic imaging. Mosby
Inc. (2003) ISBN:0323023282. Read it at Google Books - Find it at Amazon
2. Roche CJ, O'keeffe DP, Lee WK et-al. Selections from the buffet of food signs in
radiology. Radiographics. 22 (6): 1369-84. doi:10.1148/rg.226025521 - Pubmed citation
Toma P, Granata C, Rossi A et-al. Multimodality imaging of Hodgkin disease and non-
Hodgkin lymphomas in children. Radiographics. 2007;27 (5): 1335-54. Radiographics
(full text) - doi:10.1148/rg.275065157 - Pubmed citation
Synonyms & Alternative Spellings
Synonyms or Alternative Spelling Include in Listings?
Omental caking

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From the case: Omental
cake
Modality: CT
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From the case: Omental cake
Modality: CT



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Oreo cookie sign
Dr Frank Gaillard et al.
The oreo cookie sign refers to the appearance of a pericardial effusion on lateral radiographs of
the chest. A vertical opaque line (pericardial fluid) separating a vertical lucent line directly
behind sternum (epicardial fat) anteriorly from a similar lucent vertical lucent line (pericardial
fat) posteriorly.
It should not be confused with the double oreo cookie sign of SLAP tears
2
.

References
1. Weissman NJ, Adelmann GA. Cardiac imaging secrets. Elsevier Health Sciences.
(2004) ISBN:1560535156. Read it at Google Books - Find it at Amazon
2. Tuite MJ, Cirillo RL, De smet AA et-al. Superior labrum anterior-posterior (SLAP)
tears: evaluation of three MR signs on T2-weighted images. Radiology. 2000;215 (3):
841-5. Radiology (full text) - Pubmed citation
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Oreo Cakesters cookies, made by Nabisco. Photo by Evan-Amos. Original file:
http://commons.wikimedia.org/wiki/File:Oreo-Cakesters.jpg
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From the case: Pericardial effusion
Modality: Annotated image
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From the case: Pericardial effusion
Modality: Annotated image



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Sausage digit
Dr Jeremy Jones and Dr MT Niknejad et al.
The term sausage digit refers to the clinical and radiologic appearance of diffuse fusiform
swelling of a digit due to soft-tissue inflammation from underlying arthritis or dactylitis.
The common causes of sausage digit are :
psoriatic arthropathy
osteomyelitis
sickle cell anemia
sarcoidosis
tuberculous dactylitis (spina ventosa)
leukemia
syphilitic dactylitis
gout

References
1. Roche CJ, O'Keeffe DP, Lee WK et-al. Selections from the buffet of food signs in
radiology. Radiographics. 2002;22 (6): 1369-84. Radiographics (full text) -
doi:10.1148/rg.226025521 - Pubmed citation
2. Davies SG. Aids to Radiological Differential Diagnosis. Saunders Ltd. (2009)
ISBN:0702029793. Read it at Google Books - Find it at Amazon
3. Longo D, Fauci AS, Kasper D et-al. Harrison's Principles of Internal Medicine.
McGraw-Hill Professional Pub. (2011) ISBN:007174889X. Read it at Google Books -
Find it at Amazon
Synonyms & Alternative Spellings
Synonyms or Alternative Spelling Include in Listings?
Sausage digit sign
Sausage digit appearance
Sausage sign



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Unilateral and Bilateral Locked Facets



General Considerations
Normal relationships of facet joints: Inferior articulating facet of body above (blue arrow) lies
posterior to superior facet of body below (red arrow)




Ligamentous Injuries
Mechanism is flexion/distraction
Injury is to the posterior spinal ligamentous complex
Unstable in flexion; stable in extension
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If unrecognized, can lead to progressive neurologic damage
Imaging Findings
Widening of the interspinous distance
Slight anterior subluxation of one vertebral body on another
Widening of the facet joint
Usually the posterior aspect
Disk space narrower anteriorly than posteriorly
Sharp angle kyphosis


From Seminars in Roentgenology, Jan 1978 John H. Harris, Jr.
Posterior ligamentous structures involved in flexion injury
are (a)supraspinous ligament (b) interspinous ligament (c) facet joint capsule (d) posterior longitudinal ligament

Degrees of ligamentous injury
o Subluxation of vertebral body
o Perched facet
o Locked facets
At least 50% subluxation
Unilateral Locked Facet
Mechanism is flexion/distraction and rotation
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o Only 30% associated with neurologic defect
Most often occurs at C4-5 and C5-6
Inferior articular facet of superior vertebral body is locked in front of the superior facet of the more
inferior vertebral body but only on one side
Imaging Findings
o Subtle
o Slight anterior subluxation of one vertebral body on the one below
Usually less than 25% of the width
o On lateral view of cervical spine, some bodies appear true lateral below level of injury and
oblique above level of injury
Bow-tie sign
o Spinous processes do not align on frontal film
Spinous processes of inferior vertebrae displaced toward the locked side
Bilateral Facet Dislocation
Severe flexion injury
Both anterior and posterior ligamentous structures are disrupted at site of injury
More superior vertebra subluxes forward by 50% or more of the body below
Usually occurs in lower cervical spine

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Locked facets. Body of C4 is subluxed anteriorly on C5.
The inferior facet of C4(blue arrow) lies anterior to the superior facet of C5 (red arrow) below it.
The normal relationship has the inferior facet posterior to the superior fact below it.


May have associated fractures of the laminae and vertebral arch
Quadriplegia frequently develops
If there is a fracture through posterior elements, less chance of neurologic injury as cord can
decompress
85% neurologic deficits with locked facets



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Unilateral Locked Facet. Top. On frontal view of cervical spine, at level of the locked facet (C5), the spinous process is
displaced towards the right (black arrow), out of alignment with those below it (white arrows). The lateral view
demonstrates the "bow-tie" sign at the level of the locked facet. The superior facet of C6 (yellow arrow) is posterior to the
inferior facet of C5 (blue arrow).Bottom: Axial CT at the level of C% shows the normal facet relationship on the left
(hamburger on a bun) (white arrow) while the locked facet is seen on the right (reverse hamburger on a bun) (yellow
arrow).

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