Radiology on a Trip to the Zoo

Poster No.: C-1470

Congress: ECR 2017
Type: Educational Exhibit
Authors: 1 2
A. S. Linhares Moreira , M. O. E. Castro , P. Grande-Pérez , J.
2

2 1 1 2 1
Brito , A. R. Ventosa , H. Patricio , B. M. Q. Santos , G. Afonso ,
1 1 2
M. Diniz ; Faro/PT, Portimão/PT
Keywords: Education and training, Education, Ultrasound, MR, CT,
Neuroradiology brain, Musculoskeletal system, Abdomen
DOI: 10.1594/ecr2017/C-1470

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Learning objectives

To present a pictographic review of radiological signs named after or related to animals.

Background

There are numerous signs in radiology, both for pathological and normal anatomical
structures.

Some of these signs, patterns or radiological appearances are animal related, so, on a
trip to the zoo, we propose to do a revision of animal related radiologic signs.

Since some of these animal-related radiologic signs are linked to certain diagnosis and
are more easily recognizable, they allow for a more confident diagnosis when reporting.

Findings and procedure details

We performed a search on animal related radiological signs and appearances in the

literature and then performed an exhaustive search to find exemplificative cases from
our practice.

We discuss, illustrate and correlate with the animal that originated the associated
radiologic manifestations, of all the cases we could find in our practice.

Various radiological modalities were included from plain radiograph, contrast radiograph,
computed tomography (CT) to magnetic ressonance imaging (MRI).

For a more comprehensive analysis of these animal signs, we have divided them as
follows:

• Mammals
• Fish, Mollusk, Crustacean and Cnidarian
• Birds
• Insects and Reptiles

Mammals

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• Rat Tail Sign

The rat tail sign, also known as bird's beak sign, is associated with the appearance of
the terminal esophagus on barium swallows on patients with achalasia (Fig. 1 on page
9). The terminal esophagus appears gradually tapering, with regular borders, for 1-3
cm, and only small amounts of barium pass through the inferior esophageal sphincter,
because it is hypertonic and unable to relax in achalasia [1].

• Bunny Waveform Pattern

The spectral Doppler wave appearance of the vertebral artery in early subclavian steal
syndrome resembles a bunny (Fig. 2 on page 9). This appearance occurs when the
vertebral artery maintains a continuous antegrade flow with an initial narrow systolic peak
with sharp upstroke followed by a prominent midsystolic deceleration, which represent
the bunny ears and their separation from the bunny's body [2].

• Dural Tail

The appearance of a tail arising from a mass in continuity with the dura mater on MR
images, represents the thickened and enhancing dura mater (Fig. 3 on page 10). This
sign is frequently observed in meningiomas, though it is not specific as it may be present
in other types of lesions [3].

• Feline Esophagus

This aspect is thus named because it resembles the folds in the normal folds of
the distal esophagus of a cat. The feline esophagus is viewed in double-contrast
esophagography and consists of fine transverse folds which cross the entire esophageal
lumen (Fig. 4 on page 10). These findings are transient and are usually associated
with gastroesophageal reflux [1, 4].

• Whiskering

The term whiskering refers to the aspect of enthesopathy due to the bone proliferation that
occurs in the marginal bone creating a "fuzzy" appearance associated with the irregularity
and indistinctiveness of this finding (Fig. 5 on page 11) [5].

• Scottie Dog Appearance

The scottie dog appearance is seen on normal oblique views of the spine (Fig. 6 on page
11). The transverse process represents the head, the pedicle is the eye, the pars
interarticularis the neck and the lamina the body. This sign is important because it aids

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in the accurate diagnosis of spondylolysis when there is a lucent area through the neck
of the scottie dog [6].

• Bear Paw Sign

Xantogranulomatous pyelonephritis usually presents as an enlarged, non-excreting

kidney with an obstructing stone. In the diffuse form the renal parenchyma is replaced by
the indolent infectious process producing hypoattenuating masses, which are arranged
with a "hydronephrotic" pattern and have peripheral enhancement after contrast material
administration, resembling a bear paw (Fig. 7 on page 12) [7].

• Staghorn Calculus

Staghorn calculi are large and usually form a cast of the renal calyces and pelvis, giving
the impression of branching and resembling a stag's antlers (Fig. 8 on page 13).
Staghorn calculi are usually composed of struvite and are commonly associated with
recurrent infections [7].

• Panda Sign

The panda sign consists of changes in the signal intensity at the level of the midbrain in
T2W MRI sequences, with hyperintensity of the tegumentum, except for the red nucleus,
with normal signal intensity of the lateral portion of the pars reticulata of the substantia
nigra, and decreased signal intensity of the superior colliculus (Fig. 9 on page 13).
This appearance is due to the accumulation of heavy metals and is classically associated
with Wilson's disease, though it may be seen whenever there are diffuse changes in the
white matter of the midbrain [8].

• Ivory Vertebra

The term ivory vertebra refers to a diffuse homogeneous increase in density of one
vertebral body (Fig. 10 on page 14). This aspect may be associated with osteopetrosis,
Paget's disease, osteoblastic metastasis, myelosclerosis, lymphoma and fluorosis [9].

• Dromedary Hump

This aspect is a normal anatomical variant which is associated with a pseudo mass of
the left kidney due to molding by the adjacent spleen (Fig. 11 on page 15) [7].

• Zebra Pattern

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The zebra pattern on ultrasound may be seen in patients with necrotizing enterocolitis. In
necrotizing enterocolitis the small bowel may show thickening and increased echogenicity
of the valvulae conniventes with a zebra pattern on gray scale ultrasound (Fig. 12 on
page 15), though not a specific finding, as the zebra pattern may also be present with
other causes of diffuse edema. The zebra pattern may as well be identified in necrotizing
enterocolitis with color Doppler sonography with multiple parallel lines of hyperemic
valvulae [10].

• Zebra Spleen

Zebra spleen is a term used to describe the archiform heterogeneity of the enhancing
spleen in the arterial phase (Fig. 13 on page 15), which is normal in this phase. Other
possible descriptors are ring-like, curvilinear, concentric or bizarre pattern [11].

• Zebra Stripes

The zebra stripes are one of the artifacts that may be seen on MRI studies (Fig. 14
on page 16). This artifact is a type of 3D aliasing and is more severe when field
inhomogeneity is present [12].

• Anteater Nose Sign

The anteater nose sign is associated with calcaneonavicular tarsal coalition and
calcaneonavicular bar and is thus named due to the elongation of the anterior process of
the calcaneus in a tubular shape towards the navicular as viewed on a lateral radiograph
of the foot or ankle (Fig. 15 on page 16). This is a congenital malformation that should
be remembered in patients with foot pain and deformity as it is easily identifiable with this
animal sign in plain radiograph [13].

Fish, mollusk, crustacean and cnidarian

• Fish Vertebra and Fishmouthing

Fish have biconcave vertebras with superior and inferior concavity and sparing of the
anterior and posterior margins. This same aspect in humans has been named fish
vertebra (Fig. 16 on page 17).

Fishmouthing is the term sometimes used to describe the disc space between these fish
vertebras (Fig. 17 on page 18). Fish vertebras characteristically are associated with
pathologies that have diffuse weakening of the bone, such as osteopenia/osteoporosis,
sickle cell anemia, renal osteodystrophy or homocystinuria [6, 9].

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• Caput Medusa Sign

The caput medusa sign, also known as palm tree sign, is associated with developmental
venous anomalies of the brain, such as venous angiomas, and it can be identified in
contrast enhanced CT and MRI. Venous angiomas are seen in imaging as tributary veins
radially arranged and draining centrally towards a single drain vein (Fig. 18 on page
19), resembling the ancient greek mythological character Medusa, but also medusae
(jelly fishes) [8].

• Manta Ray Sign

The manta ray sign is generally associated with bladder exstrophy, due to wide pubic
diastasis which resembles a manta ray swimming in your direction (Fig. 19 on page 20)
[14].

• Endosteal Scalloping

Endosteal scalloping refers to the aspect of cortical erosions usually associated with slow
growing medullary lesions, with focal resorption of the inner margin of cortical bone (Fig.
20 on page 21). This type of erosions can be seen in multiple diseases, such as fibrous
dysplasia, eosinophilic granuloma or multiple myeloma, just to name a few [15].

• Vertebral Scalloping

Vertebral scalloping most commonly affects the posterior half of the vertebral bodies due
to increased intraspinal pressure, dural ectasia (Fig. 21 on page 21), bone resorption
and in some cases of congenital syndromes. Vertebral scalloping less frequently affects
the anterior half of the vertebral bodies, and when this happens it is usually associated
with an aortal aneurysm or changes in the lombo-aortic lymph nodes [6, 16].

Birds

• Eggshell Calcifications

Eggshell calcifications may be present in various organs and consist of rim calcifications
with a radiolucent center.

In association with lung disease, this type of calcifications may be seen in radiographs or
CT scans, usually appearing in the hilar and mediastinal lymph nodes (Fig. 22 on page
22) and most frequently being associated with silicosis and sarcoidosis [16, 17].

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In the breast these rim calcifications are seen on mammography and are virtually always
benign. They may be associated with fat necrosis, also known as oil cysts (Fig. 23 on
page 23), but also with skin calcifications [18].

• Egg on a String

The egg on a string sign refers to the classic appearance of a chest radiograph in
newborns with transposition of the great arteries, which show an apparent narrowing of
the superior mediastinum and a globular and enlarged cardiac silhouette (Fig. 24 on page
23) [19].

• Crow's Feet Appearance

Mostly related to asbestos pleural disease rounded atelectasis may be associated with
fibrous stranding that extend towards the atelectasis from the thickened pleura, having a
crow's feet appearance (Fig. 25 on page 23) [20].

• Gull Wing Sign

In erosive osteoarthritis the interphalangeal joints acquire a gullwing shape (Fig. 26 on

page 24) largely due to the destruction of the articular cartilage. This aspect is due to
more marked bone erosions in the periphery of the distal subchondral cortex and more
marked central erosions in the proximal side of the joint. It is essential to note that this
gull wing sign is nonspecific and may be seen in late stages of psoriatic or rheumatoid
arthritis [21].

• Hummingbird Sign

The hummingbird sign, also known as penguin sign, is associated with midbrain atrophy
in the sagittal plane and it has been linked to progressive supranuclear palsy. This
midbrain atrophy translates into imaging as a beak-like structure at the level of the
cerebral peduncle with the pons representing the hummingbird's body (Fig. 27 on page
24) [22].

• Owl Eyes Sign

The presence of bilateral, symmetric, well-circumscribed circular foci of hypersignal on

T2W axial MRI provide the name for this sign (Fig. 28 on page 25). This appearance
relates to intramedullary gliosis and was initially associated with spinal cord infarction due
to occlusion of the anterior spinal arteries, though now we know that this is a nonspecific
sign that may be associated with cord contusion, compressive myelopathy, infection and
inflammation [23].

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• Swan Neck Deformity

The hyperextension of the proximal interphalangeal joint and flexion of the distal
interphalangeal joint gives the fingers a characteristic swan neck appearance (Fig. 29 on
page 25), seen on physical evaluation as well as on plain radiographs. This finding is
present most commonly in patients with rheumatoid arthritis [6, 9].

• Beak Sign

The beak sign is associated with tapering of the contrast column at the level of obstruction
in volvulus in a barium enema study. The beak sign can also be seen in CT scans in
volvulus as the rectal contrast does not progress or as the distended upstream colon
tapers at the transition point (Fig. 30 on page 26) [24].

• Claw Sign

The claw sign aids in determining the origin of a mass, classically in the proximity of the
kidneys. The claw sign is seen in tumors of renal origin that cause the normal parenchyma
to splay around the tumor (Fig. 31 on page 26), indicating their renal origin [25].

Insects, reptiles and bugs

• Butterfly Appearance

The normal appearance of the medullary spine on the axial plane has a typical gray matter
with a butterfly or H-shape (Fig. 32 on page 27), with thicker anterior motor columns
and thinner posterior sensitive columns [26].

• Butterfly Vertebra

Congenital anomaly in which there is a symmetric fusion defect of a vertebral body that
can lead to sagittal clefts in the vertebral bodies, giving them a distinctive configuration
(Fig. 33 on page 27). Butterfly vertebras may be isolated or associated with other
spinal anomalies [6, 9].

• Moth-Eaten Appearance

The moth-eaten appearance of bone lesions, also known as permeative pattern, is

linked to confluent small, patchy osteolytic lesions with poorly demarcated margins and
broad transition zones (Fig. 34 on page 27). This appearance is associated with

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bone destruction and is suggestive of aggressiveness, though not always malignancy.
Moth-eaten appearance can be present in Langerhans cell histiocytosis, osteomyelitis,
osteosarcoma, lymphoma or myeloma [9, 15].

• Cobra Head Sign

The cobra head sign is associated with adult-type ureteroceles, seen as a bulge of the
distal ureter surrounded by a thin lucent line in a bladder filled with contrast material (Fig.
35 on page 28) [7].

• Turtle Sign

The turtle sign refers to the external genitalia of a male fetus as seen in the second
trimester ultrasound, with the penis being represented by the head of the turtle and the
scrotal sac by the turtle's body (Fig. 36 on page 29) [27].

Images for this section:

Fig. 1: Rat Tail Sign. Frontal view of a barium swallow displaying a distended distal
esophagus with tapering at the level of the inferior esophageal sphincter and only a small
amount of contrast material passing into the stomach in a patient with achalasia

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

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Fig. 2: Bunny Waveform Pattern. Spectral and color Doppler image with a bunny
appearance from a patient with early subclavian steal (courtesy of Dr Bruno Santos)

© Dr Bruno Santos, Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

Fig. 3: Dural Tail Sign. T1W RM of the brain depicting a hyperintense lesion in relation
to a meningioma that induces hyperintensity of the adjacent dural mater known as dural
tail sign (courtesy of Dr Sofia Freitas)

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

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Fig. 4: Feline Esophagus. Frontal view of double contrast barium swallow showing
transverse bands in the mid and lower esophagus, thus named because it resembles
the normal folds of the feline esophagus, this aspect is most commonly associated with
gastroesophageal reflux (courtesy of Dr Miguel Oliveira e Castro)

© Radiology Department, Unidade Local de Saúde do Baixo Alentejo - Beja/PT

Fig. 5: Whiskering. Frontal pelvic radiograph displaying slight enthesopathy, also known
as whiskering, most evident in the superior and inferior iliac spines bilaterally and the
right greater femoral trochanter

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

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Fig. 6: Scottie Dog Appearance. Two radiographs of the lumbar spine, in right oblique
views, demonstrating the normal appearance of the vertebrae, resembling a scottie
dog, with the transverse process representing the head, the pedicle the eye, the pars
interarticularis the neck and the lamina the body of the dog, best depicted in the second
image with a superimposed drawing

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

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Fig. 7: Bear Paw Sign. Contrast enhanced CT of the abdomen, on an axial plane through
the kidneys, showing a staghorn calculus, associated with dilated renal calyces, in a case
of xanthogranulomatous pyelonephritis (courtesy of Dr Miguel Oliveira e Castro)

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

Fig. 8: Staghorn Calculus. Frontal abdominal radiogram depicting calcifications that

produce a cast of the renal calyces and pelvis, giving the impression of the branching
stag's antlers

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

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Fig. 9: Panda Sign. T2W axial RMI demonstrating hypersignal of the tegumentum, except
for the red nucleus that represent the panda's eyes, normal signal intensity of the lateral
portion of the pars reticulata of the substantia nigra representing the panda's ears, and
decreased signal intensity of the superior colliculus in the place of the panda's cheeks,
in a patient with Leigh syndrome (courtesy of Dr Ana André)

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

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Fig. 10: Ivory Vertebra. Lateral radiograph of the lumbar spine depicting a homogeneous
increase in density of one vertebral body in a patient with Paget's disease (courtesy of
Dr Miguel Oliveira e Castro)

© Radiology Department, Hospital Mãe de Deus - Porto Alegre/BR

Fig. 11: Dromedary Hump. Abdominal ultrasound showing the lower pole of the spleen
that appears to be molding the left kidney, creating a hump which is a normal anatomical
variant (courtesy of Dr Ana Rita Ventosa)

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

Fig. 12: Zebra Pattern. B mode ultrasound image of the bowel in a neonate with
necrotizing enterocolitis showing hyperechoic valvulae conniventes with a zebra pattern
(arrows) (courtesy of Dr Henrique Patrício)

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

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Fig. 13: Zebra Spleen. Contrast enhanced axial abdominal CT on arterial phase depicting
the characteristic archiform heterogeneity of the spleen with a zebra stripe pattern

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

Fig. 14: Zebra Stripes. Zebra stripe artifact in a coronal MRI localizer image (courtesy
of Radiographer Nuno Pinto)

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

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Fig. 15: Anteater Nose Sign. Oblique radiograph of the foot showing a tubular elongation
of the anterior process of the calcaneus towards the navicular resembling an anteater's
nose in a case of calcaneonavicular bar (courtesy of Dr Miguel Oliveira e Castro)

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

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Fig. 16: Fish vertebra. Lateral radiograph of the dorso-lumbar spine with a biconcave
appearance in a patient with osteoporosis

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

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Fig. 17: Fishmouthing. Lumbar sagittal CT, in bone window, shows fish vertebras in
a patient with marked osteoporosis with an increase in disc space height giving the
appearance of an open fish mouth

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

Page 19 of 31
Fig. 18: Caput Medusa Sign. Contrast enhanced T2W RMI of the cerebellum shows
multiple tributary veins radially oriented and draining towards a single central drainage
vein in the right cerebellar hemisphere in relation to a developmental venous anomaly
(courtesy of Dr Pablo Grande)

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

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Fig. 19: Manta Ray Sign. VRT of pelvic CT, in bone window, shows a wide pubic diastasis
that resembles a manta ray (courtesy of Dr Luis Silva)

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

Fig. 20: Endosteal Scalloping. Frontal femoral radiograph showing a metaphyseal

medullary lesion with focal resorption of the inner margin of cortical bone in a patient with
fibrous dysplasia (courtesy of Dr Miguel Oliveira e Castro)

© Radiology Department, Hospital Mãe de Deus - Porto Alegre/BR

Page 21 of 31
Fig. 21: Vertebral Scalloping. T2W sagittal MRI of the cervical and dorsal spine showing
an accentuated posterior concavity of C5 through D3 vertebral bodies, most prominent
in D3, due to dural ectasia in a neurofibromatosis type 1 patient (courtesy of Dr Pablo
Grande)

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

Fig. 22: Eggshell Calcifications. Chest CT on the axial plane in a mediastinal window
shows a peripherally calcified mediastinal lymph node in a patient with silicosis

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© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

Fig. 23: Eggshell Calcifications. Craniocaudal mammogram of the left breast shows
a peripheral calcification with a radiolucent center most frequently associated with fat
necrosis, virtually always benign (courtesy of Dr Graça Afonso)

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

Fig. 24: Egg on a String Sign. Thoracic anteroposterior radiograph of a newborn showing
an enlarged cardiac silhouette with an apparent narrowing of the superior mediastinum,
in a patient with transposition of the great arteries

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

Page 23 of 31
Fig. 25: Crow's Feet Appearance. Axial thoracic CT in lung window showing a round
atelectasis on the postero-basal segment of the inferior left lobe with fibrous stranding
known as crow's feet (courtesy of Dr Miguel Oliveira e Castro)

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

Fig. 26: Gull Wing Sign. Radiograph of the hands show erosions in the interphalangeal
joints resembling gull wings because of the marked peripheral bone erosions in the distal
subchondral cortex and marked central erosions in the proximal side of the joint, aspect
usually associated with erosive osteoarthritis (courtesy of Dr Miguel Oliveira e Castro)

© Radiology Department, Hospital Mãe de Deus - Porto Alegre/BR

Page 24 of 31
Fig. 27: Hummingbird Sign. T1W weighted sagittal MRI of the brain trough the brainstem
showing atrophy of the midbrain with a preserved pons, usually associated with
progressive supranuclear palsy (courtesy of Dr Pablo Grande)

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

Fig. 28: Owl Eyes Sign. T2W axial MRI of the dorsal spine depicting bilateral, symmetric,
well-circumscribes circular foci of increased signal intensity resembling an owl's eyes
(courtesy of Dr Pablo Grande)

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

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Fig. 29: Swan Neck Deformity. Hand radiograph depicting hyperextension of the proximal
interphalangeal joints and flexion of the distal interphalangeal joints of the third and fourth
fingers in a patient with gout (courtesy of Dr Jorge Brito)

© Dr Jorge Brito, Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

Fig. 30: Beak Sign. CT images of volvulus in different patients, the first non-enhanced in
the axial plane and the second contrast enhanced in the coronal plane, both depicting the
beak sign, seen as tapering of the distended upstream colon at the level of the transition
point

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

Page 26 of 31
Fig. 31: Claw Sign. Contrast enhanced axial abdominal CT images from two different
patients showing the claw sign as slaying of the normal parenchyma as a means to
determine the origin of a lesion, which on the first image is a renal cell carcinoma and
on the second a simple renal cyst

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

Fig. 32: Butterfly Appearance. T2*W axial MRI depicting the normal appearance of the
medullary spine, with the anterior motor columns inferiorly and the thinner posterior
sensitive columns superiorly (courtesy of Dr Pablo Grande)

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

Fig. 33: Butterfly Vertebra. Coronal CT of the lumbar spine on bone window shows an
incomplete vertebral fusion of L4 in relation to a congenital butterfly vertebra (courtesy
of Dr Ana Rita Gameiro)

© Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

Page 27 of 31
Fig. 34: Moth-Eaten Appearance. Humeral radiograph showing a permeative pattern of
patchy confluent osteolytic lesions in a case of multiple myeloma (courtesy of Dr Miguel
Oliveira e Castro)

© Radiology Department, Hospital Mãe de Deus - Porto Alegre/BR

Page 28 of 31
Fig. 35: Cobra Head Sign. Frontal view of intravenous urography showing a bulging of
the left distal ureter into the bladder surrounded by a thin lucent line in a bladder filled
with contrast material, in relation to a ureterocele (courtesy of Dr Jorge Brito)

© Dr Jorge Brito, Radiology Department, Centro Hospitalar do Algarve - Algarve/PT

Fig. 36: Turtle Sign. Ultrasound of male fetus showing the external genitalia resembling
a turtle (courtesy of Dr Ana Franco)

© Obstetrics Department, Centro Hospitalar do Algarve, Faro Unit - Faro/PT

Page 29 of 31
Conclusion

Knowing radiological signs is important to be able to recognize normal anatomy as well

as disease.

The multitude of signs in current day radiology makes it difficult to keep up to date, so
on a trip to the zoo, we present some of the animal related signs that we encountered
in our practice.

Personal information

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