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Part 2 book “Review of radiolog” has contents: Musculoskeletal radiology, radiotherapy and nuclear scans (radiotherapy and chemotherapy, nuclear scans), few thumb rules in radiology, image based questions.
om c e m ks oo eb m fre ks oo eb m m co m co e e fre ks oo eb m co m m co m e fre e m Age Neuroblastoma – < yrs SBC – 0–10 and 10–20 FCD – 10–20 ABC – 10–20 Ewing’s sarcoma – 0–10 and 10–20 Osteosarcoma – 10–20 GCT – 20–30 and 30–40 Chondrosarcoma – > 30–70 MM – > 50 Metastasis – > 50 eb om e c fre m co e fre ks oo ks oo eb m m co e co m re oo ks f eb m I ee om m c o c ee ee co m e m re m e co m om co e c e fre fre sf oo k eb m ks oo eb m ks oo eb m co m e m m co e ks fre m e co m co m e co Musculoskeletal Radiology oo eb m fre fre oo ks eb m ks eb oo m e m e m e m e m oo m m e co re sf m om e c fre co m e fre ks oo e eb om c ee ee c om m m m m c o ee e oo k eb m eb eb oo oo ks ks • Single lamella –– Healing fracture, Osteomyelitis • Solid periosteal –– Osteoid osteoma (smooth) Undulating –– O.M pulmonary osteoarthropathy fre fre e e co co Periosteal Reaction m e eb m m m eb • Flecks, punctate, flocculated calcified foci • Punctate—When disruption is in zone of provi sional calcification • Ring and arc—Disrupted enchondral bone formation • Enchondroma, osteochondroma m oo Cartilage Matrix I Benign tumor—sharp inner and outer margin Benign inflammatory condition— sharp inner but fuzzy outer margin oo ks ks oo ks f fre re e • Bony trabeculae, radiodense struts (pathognomonic) • Osteosarcoma, parosteal osteosarcoma, osteoblastoma, FD, fat necrosis I (**-FD-shows thick sclerotic rim—Rind of orange) eb m co Osseous Matrix m eb m e co m m Matrix Pattern I NCCT—most valuable modality in detection of subtle matrix calcifications m oo • Ewing’s, reticulum cell sarcoma, high grade chondrosarcoma fibrosarcoma, angiosarcoma, leukemia and metastasis eb m ks fre fre ks oo III Permeative Bone Destruction co e eb m m co e e c GCT [no marginal sclerosis] • Reticulum cell sarcoma, osteosarcoma, chondrosarcoma, fibrosarcoma, round cell tumor (Ewing’s), osteomyelitis Continuous e e ks fre fre oo ks m eb • With sclerotic margin—SBC, enchondroma, CMF, FD, Brodie’s • No marginal sclerosis—GCT (Figure), also-SBC • Ill defined margins—osteosarcoma, chondrosarcoma, ABC, osteomyelitis om co e co m m m m m m e co fre ks eb oo m co m I II Moth-eaten Bone Destruction–Wide Zone of Transition—Malignant co m co m e e e m co m Patterns of Bone Destruction I Geographic Musculoskeletal Radiology 171 e co e ks fre oo e eb m m m m e co co e sf re fre oo k ks oo m m e eb eb om m e c co oo ks fre e fre ks oo m e e fre ks ks • MC-malignant bone tumor-Skeletal metastasis • IOC for bone metastasis is bone scintigraphy except in spine, where MRI is preferred MRI is also IOC for extent of primary bony tumor eb m c om om c ee ee c o m m eb I oo oo oo Bone Scan ee ks fre fre • Ewing’s Sarcoma • Metastasis e e Saucerization Osteomyelitis—shows increased activity on all three phases of bone scan e eb m co co m m co ABC CMF (thick coarse septations) GCT NOF m eb m m • • • • m m e co m re oo ks f eb Lytic Expansile Lesions with Septations (Septations are Residual (N) Bone) Soft tissue lesion—Hyperintenseboth on T1W & T2W images Lipoma eb m m e co fre oo ks om e c fre ks oo eb m m waning Interrupted/discontinuous (Aggressive) • Codman’s Angle/Triangle –– Due to tumor, blood, edema, pus –– Both malignant and benign • Buttress –– Slow growing tumor • Truncated lamella –– Neoplasm, virulent infection I m • Multilamellated/onion peel (Waxing course) (Figure) –– OM –– ABC –– Ewing’s –– Osteosarcoma • Spiculated –– Parallel spiculation—hair on end Thalassemia Metastasis Ewing’s Osteosarcoma –– Divergent/Sunburst spicules Osteosarcoma Hemangioma Osteoblastic metastasis –– Various directions Ewing’s sarcoma eb m m co m Onion peel periosteal reaction—Ewing co m m m m e co fre ks eb oo I co m co m e e e m co m 172 Review of Radiology e e m m e m om e c e m oo ks ks oo I e eb om c ee ee c om m m m eb KeiL – (Keinbock-lunate) KoNa – (Kohler-navicular) m c o co m e fre fre ks • MRI-IOC –– Bisphosphonate Therapy—Jaw –– Keinbock’s—lunate –– Kohler’s—Navicular oo e co co e • Superscan with absent UB activity (due to renal failure) Benign lesions showing uptake on SPECT • Osteoid osteoma • Eosinophilic granuloma • ABC • Chondroblastoma • Enchondroma fre m m I Renal Osteodystrophy ee eb m • Super scan (most common) • Pseudofracture → focal eb m m co e e co re fre oo ks ks eb Hyperparathyroidism m m eb oo • ‘V’ shape advanced edge • Clover, heart and micky mouse signs of uptake in vertebral bodies m oo k e fre re oo ks f Paget’s Disease AVN ks fre m Bone scan remains positive for months even after treatment of acute osteomyelitis—cannot differentiate between healing from chronic active disease co m I eb oo eb m e co m FDG-PETCT is IOC-for Assessing Treatment Response for Metastasis • Decrease in standard uptake value (SUV) suggests response to treatment m ks ks oo (Shows uptake also on blood phases with delayed phases) • Fatigue → Repeated stress (normal bones)-Fusiform increased radiotracer uptake • Insufficiency—Normal stress on abnormal bone • Sacral stress fracture → Honda sign-/‘H’ sign • Shin splints → Exercise induced pain/tenderness in posteromedial aspect of tibia → Linear uptake on delayed phases-Oriented longitudinally ((n) blood pool and blood flow unlike stress fractures) eb I sf fre fre e e c co m om m eb IOC for stress fracture of tibia → MRI IOC for B/C stress fracture → Bone scan oo oo ks ks eb oo m m m co I eb fre fre e co e co m m m m e e e m co m co m Stress Fractures co m co m –– Most common-pattern-hot lesions scattered diffusely • Causes of False-negative bone scintigraphy in a patient of bone metastasis –– Avascular lesions –– Rapidly growing pure osteoclastic lesions with no osteoblastic activity –– Lesions with low bone turnover (MM and thyroid cancer) • Causes of false positive results –– Increase blood flow in osteoarthritis, trauma and inflammation Musculoskeletal Radiology 173 e co e ks fre e e m e fre fre ks ks ee c om om c ee e m m eb oo oo eb m • m c o ee co m co e e fre ks oo • e fre oo ks eb m m m co m • m om e c e fre oo eb eb I Tuberculosis of hip joint—mortar and pestle m oo k eb m m co –– Inflammatory edema and exudates –– Necrosis and cavitation –– Destruction and deformation –– Healing and repair Hip tubercular arthritis can arise in acetabulum, synovium, femoral epiphysis and metaphysis (Babcock’s triangle) –– Wandering acetabulum –– Bird’s beak appearance of femur –– Mortar and pestle appearance (figure) –– Breaking of Shenton’s line Knee TB –– Triple deformity in advanced cases, i.e lateral, posterior and superior displacement of tibia on femur –– Shoulder TB synovial lesions are rare in shoulder joint T.B atrophic type without pus- carries sica Frontal bone TB –– Button sequestrum Pelvis TB –– Weaver’s bottom ks re oo ks f • m m sf re fre ks oo eb m e co m Four Stages Wandering acetabulum—TB m e co co • Sequestration and periostitis are not common and usually no sclerosis • Very small sequestrum • Marginal erosions in weight bearing joints • Kissing sequestra • Rice bodies –– Synovial joints –– Tendon sheaths –– Bursae e e c fre ks oo m I m oo TUBERCULOSIS OF BONES Dense circumscribed blush in early arterial phase of angiography → osteoid-osteoma eb eb m m I eb • Reduced blood flow and blood pool phase, increased on delayed • Periarticular uptake of radiotracer om co m m m e co fre oo ks eb Reflex-Sympathetic Dystrophy m m Bone scan may be (normal) in 85% of cases in first 48 hours but then reduced activity (cold) for a variable period co m m m m e co fre ks But bone scan (BS) detects AVN earlier than MRI (72 hours vs days) eb oo I co m co m e e e m co m 174 Review of Radiology e co m I om c ee m e oo • Sickle cell disease –– Prone to salmonella infection (cortical fissuring and tunneling) eb I ks fre e Cellulitis and OM show similar soft tissue changes, however in cellulitis, the bone is (n) om c ee m m eb Soft tissue swelling is the Ist radiographic sign of pyogenic arthritis/OM Earliest bone change 8-10 day after infection e oo ks I m e fre ks oo eb m m c o e fre e c However in all cases of shoulder/hip joints due to periosteal spread into synovium due to metaphysical attachment of synovium or joint capsule m co co e fre ks oo ee m om I ks oo m m eb eb m m e co m m co e fre re oo ks f re sf eb oo k fre ks oo eb Acute pyogenic arthritis is a complication of O.M in infants (< year) and in adults In rest the physis block spread of infection to joint m e co m • Osteomyelitis is most frequent at end plates d/t greater no arteries at this location • Ist ordered investigation—X-ray –– Cortical irregularity –– Periosteal reaction –– Deep soft tissue swelling –– Demineralization –– X-Ray-Earliest bone changes (7–10 days) • USG –– Deep soft tissue swelling is the earliest sign (2–3 days) –– Periosteal elevation (hyperechoic line) –– Subperiosteal fluid collection –– Cortical breach • MRI –– Investigation of choice for bone infection suns –– Most sensitive investigation as it can pickup marrow edema within six hours • Bone scintigraphy –– Can be positive (1–3 day) earliest –– Uptake on all three phases: Blood flow (angiography), Blood pool (capillary), Delayed (2–4 hours) uptake in bone eb e m m co e oo m m co e e c fre ks oo eb I BONE AND JOINT INFECTION m m m eb eb om m m eb oo oo ks ks • TB dactylitis –– Cystic expansion of short bones –– Spina ventosa (spina-short, ventosa-expanded with air) –– Plain radiography is the modality of choice for evaluation and follow-up –– Differential diagnosis—syphilitic dactylitis→ Bilateral involvement Symmetric involvement Seen in More periosteitis Syphilitic Less soft tissue swelling dactylitis Less sequestrations • TB of Tendon Sheath/Bursae –– Dumbbell-shaped swelling –– Melon seed bodies –– Rice bodies (serofibrinous stage) ks fre fre fre e co e co m m m m e e e m co m co m m co co m co m Musculoskeletal Radiology 175 e e m om e c fre m co m co e e fre fre ks ks e om c ee ee c om m m • Celery stalk appearance eb oo oo eb Rubella OM m m e oo ks eb m Earliest change is in metaphysis with widening of zone of provisional calcification • Congenital Syphilis –– Bilateral symmetrical destruction of medial end of proximal tibial metaphysis (Wimberger’s sign) Pathognomonic • Late Congenital Syphilis –– Hutchinson teeth, mulberry molar –– Hot cross bun skull –– Thickening of upper half of tibia anteriorly → sabre tibia d/t periosteitis (MC feature) m m co e fre c o m sf oo k eb m m co e fre ks oo m eb Syphilis ks Flowing wax appearance – melorrheosteosis m e co re fre ks • Serpiginous tract/channel having sclerosed margin which marks the tract of infection • Finger like extension in adjacent normal bone pathognomonic oo I ee e co e ks fre oo eb m m co e e co m Brodie’s Abscess—Lytic Bone Lesion with Sclerosed Margin re • Celery stalk appearance also seen in mucoid degeneration of anterior cruciate ligament on T2W /STIR images m eb Chronic OM of Garre • Children (endosteal expansion of bone) False Positive on Scintigraphy oo ks f eb m Cloacae Involucrum-3-week Sequestrum-4-week (dead dense bone) (Figure) Bony thickening and deformity No sclerosis however seen in skull OM oo m eb eb oo ks • • • • Chronic osteomyelitis (dead dense bone) m co m m e co fre oo ks om e c fre Chronic Osteomyelitis • Degenerative disease • Healing fracture • Loose prosthesis But not show uptake on early phases (I and IInd) I • Gallium scan –– 67Ga (gallium) bind to leukocyte and go to sites of inflammation –– If gallium scan is congruent or hotter than Tc99 MDP infection is implied –– If gallium scan is noncongruent or colder-no infection –– Labeled leukocytes not useful for spinal infection as 50% or more of spinal osteomyelitis present as nonspecific areas of decreased or absent activity eb m m co m m I m m m m e co fre ks eb oo I co m co m e e e m co m 176 Review of Radiology m e co re sf co fre ks I om c ee e m m eb oo In posterior elements T.B has predilection for → Pedicle and lamina Pyogenic disease-predilection for–facet joints om c ee e e e fre ks oo c o m m eb eb • Better to detect calcification • Epidural extent can be missed on plain CT due to beam hardening artifact m co m m m co e fre ks oo CT m om fre eb • Dot and Dash appearance also seen in cases of Multiple sclerosis on FLAIR images of MRI m • Standard uptake values (SUV) > 2.5 for malignant but up to ‘21’ can be seen in tubercular infections • However uptake peaks at 60 minutes than decrease in infective/inflammatory lesions while does not decrease in malignant diseases • FDG-PET + C-11 acetate → latter accumulates only in malignant lesions ee oo ks ks oo I m FDG-PET e oo k On X-ray > 30–50% mineral must be lost before a radiolucent lesion becomes conspicuous e c m co e I eb eb m • Spinal vertebral hydatidUsually unilocular with diverticulated cysts • Subarachnoid neurocysticerosis is MC type of spinal cysticerci fre re oo ks f • IOC—Better detection of skip lesions • Earliest detection of Pott’s spine on STIR/T1W images m I eb eb m e co m m m eb oo oo • Begins in cancellous area • Paradiscal region–MC site (less commonly in centrum or at anterior surface) • Anterior wedging common in dorsal spine • Disc avascular–hence involvement of disc is via direct spread from subchondral bone or beneath anterior or post longitudinal ligaments • Skip lesions *Pyogenic infection on contrary causes more disk destruction m ks ks TB SPINE (POTT’S SPINE) co e m m m co fre fre e e c • Licked candy appearance MRI e oo eb eb m om Leprosy m m co e oo ks ks No pain No sequestrum No osteopenia Shaggy periostitis, reactive sclerosis/melting snow appearance • Dot and Dash appearance on MRI (Actinomycosis) • • • • eb oo m co m ks fre fre fre e co e co m m m m e e e m co m Maduromycosis OM co m co m Musculoskeletal Radiology 177 e m e m om e c fre e co m e e eb oo ks fre fre om c ee ee c om m m eb m m m eb m m e co Distribution of affected joints Presence of soft tissue swelling Bone density Cartilage space narrowing Reactive bone formation Site and character of erosions Subarticular cystic lesions Presence of soft tissue calcification Joint deformities oo • • • • • • • • • ks m co e fre ks c o m e co re sf oo k oo ks oo eb m NONINFECTIVE INFLAMMATORY ARTHRITIS Described Under Gas within disk – Brucellosis discitis (Hallmark) – Clostridial – Streptococcal Gas in degenerative disk vacuum phenomenon ee e co e ks fre oo eb eb ks • Ivory vertebra • Fusion of contiguous vertebrae considered surest sign of healing oo eb m m co e fre Healing TB oo ks f eb m m m m co e fre ks oo eb m e co m re – T2W hyperintensity without T1W hypointensity in the cord → cord edema – with T1W hypointensity → myelomalacia I m m e co fre oo ks m om e c fre ks oo eb m m co • Paradiscal/marginal/intervertebral/subarticular/ metaphyseal lesions • Disease process usually begins in anterior part of vertebral body • In dorsal spine the paraspinal abscess has fusiform appearance (Bird’s Nest appearance) • Abscess at the dorsolumbar junction has an indis tinct converging lower border (Petering abscess”) • Calcification: Pathognomonic of tubercular abscess (tear drop shaped calcification) • Four Patterns of Destruction on CT –– Fragmentry (47%)-exploded vertebral bodiesMC –– Osteolytic (33%) –– Subperiosteal (10%) –– Well defined lytic with sclerotic margins (10%) • Thick nodular rim of increased attenuation due to increase vascularity and hypercellular wall of the inflammatory cavity–Rind sign • Preserved disk space despite extensive bone destruction–Floating disk sign eb eb oo Pyogenic spondylitis shows multiple small erosions like a ‘Pepper Pot’ with no calcification I m m m m e co fre ks Most Common Variety m co m I co m co m e e e m co m 178 Review of Radiology oo ks oo m e eb eb m e e co co m m om e c oo oo k ks sf re fre eb eb m m m e fre ks oo eb m m ks • Early changes → (Nonosseous) → USG and MRI • Late changes → (osseous) • Earliest –– Joint space widening and soft tissue swelling (due to edema and swelling of synovium) and effusion –– Best detected at 5th MCP joint • Fusiform soft tissue swelling at-PIP and IInd to 5th MCP • Swelling over ulnar styloid—due to involvement of extensor carpi ulnaris sheath • Blurring and obliteration of pre-Achilles fat pad • Blurring and thickening of the Achilles tendon • Osteopenia –– Juxta articular—due to synovial inflammation –– Generalized → Limitation of movement due pain eb oo m co m e m m co e ks fre fre fre e co e co m m m m e e e m co m Rheumatoid Arthritis-MC Inflammatory Arthritis e c e fre fre m e oo ks MRI is IOC for early RA, as treatment is more effective if administered early eb eb m I m oo ks oo ks f eb m om m co • Juxta articular osteopenia • Uniform narrowing of: –– Distal radioulnar –– Radiocarpal –– Intercarpal joints • Subluxations at Ist MCP and IP (Hitchhiker’s deformity) • Terminal phalangeal sclerosis • Lack of periosteal reaction—Hallmark of disease • Marrow edema re co e co m m Early X-Ray Change DIP joints are spared in RA e ee c om om c ee m No uniform joint space narrowing–Osteoarthritis e oo eb I m oo eb m m c o ee ks ks fre fre fre ks oo eb m I e e co co m m • Most important diagnostic feature (indicates irreversible joint damage) which contain inflamed synovium-enhance on postcontrast imaging • Ball-catcher’s view to see erosions • USG more sensitive than radiographs for erosions • Earliest sites –– Bare areas between edge of articular cartilage and site of attachment of joint capsule –– Wrist, MCP and PIP MC at radialvolar aspect of head of 2nd and 3rd metacarpals are commonly involved co m Erosions co m co m Musculoskeletal Radiology 179 e co e ks fre e m m e co re sf om m e oo k eb m m e c fre co m m e oo ks eb m m e e fre fre ks ks om c ee m eb m om c ee e oo oo eb m m c o • ee m eb • oo eb m m co e co e fre ks oo fre ks oo • • m m e co fre fre ks oo eb m eb m e co • • m • co m eb • oo ks eb m om e c oo ks f • • e co m • re • • • • co m m eb oo • fre • Sign of papillary necrosis on IVU Colonic polyp Malignant gastric ulcer Sign of Caroli’s disease Specific but not commonly seen ultrasound finding for emphysematous cholecystitis Tip of the iceberg sign Ultrasound sign that may be seen with mature cystic teratomas Apple core lesion (ba enema) Circumferential narrowing of the lumen secondary to colon cancer Comet sign Sign to differential a phlebolith from a ureteral stone Calcified phlebolith represents the comet nucleus and the adjacent, tapering, noncalcified portion of the vein is the comet tail (also see softtissue rim sign) Medusa-lock sign Round worm infestation Corkscrew esophagus Diffuse esophageal spasm and presbyesophagus Lobster claw sign (IUV) Sign of papillary necrosis Paintbrush appearance Linear striations of contrast material opacifying collecting tubules that may be seen with medullary sponge kidney Double track sign Appearance of hypertrophic pyloric stenosis that may be seen on upper GI series Football sign (CXR) Pneumoperitoneum (seen on supine radiographs) Frostburg’s reverse ‘3’ sign Carcinoma head of pancreas (hypotonic duodenography) Lead pipe colon (ba enema) Narrowing of colon with loss of haustra that may be seen in patients with ulcerative colitis Picket fence Appearance of bowel that may be seen on small bowel series with whipple disease or gastrointestinal amyloidosis Coffee bean sign Sigmoid Volvulus Molar tooth sign (CT cystogram) Perivesicular extravasation of contrast on CT cystogram in a patient with extraperitoneal bladder rupture Corkscrew sign (upper GI series) Midgut volvulus Moulage sign (enteroclysis) Effaced loop of bowel that may be seen on a small bowel series in sprue Nubbin sign Reflux nephropathy involving the lower pole of a duplicated collecting system Nutmeg liver Pattern of liver enhancement seen with passive congestion ks m co m • m m m m e co fre Ball-on-tee sign Bowler’s hat sign (ba enema) Carman’s meniscus sign (ba meal) Central dot sign (Doppler) Champagne sign eb oo • • • • • ks Gastrointestinal Radiology co m co m e e e m co m 258 Review of Radiology e m e m om e c fre co m m e oo ks eb m co e e fre fre ks ks ee c om om c ee e m m eb oo oo eb m m c o m e co re e Psoriasis Ankylosing spondylitis Ankylosing spondylitis Paget’s disease (seen in leg bones) MRI sign that may be seen in patients with intracapsular breast implant rupture Abc Elbow effusion Sclerotic end plates that may be seen with osteopetrosis Acl tear Hemolytic anemia Osteopetrosis Volar perilunar dislocation Eosinophilic granuloma Appearance of ribs that may be seen with mucopolysaccharidoses m m co e oo ks fre Bone bruise sign Hair on end skull Bone in Bone’/Endobone sign Crowded carpal sign Button Sequestrum Canoe paddle ribs ee e co e ks fre sf oo k eb m m co • Blood fluid levels (MRI) • Sail sign • Sandwich vertebra eb fre ks eb m eb Sausage digit Dagger sign Bamboo spine Blade of grass sign Linguine sign (MRI breast) oo oo ks f Musculoskeletal Radiology m oo fre ks oo eb m e co m re • Snowstorm pattern (ob/gyn) m eb m m co e e c fre ks oo eb m m • Tit sign co m m e co fre om co m • Pearl necklace sign • Rosary sign • Sandwich sign • Target sign • Umbrella sign (on BMFT) • Soft-Tissue Rim Sign • • • • • • US appearance that may be seen with posterior urethral valves Pattern of uptake that may be seen on bone scan in patients with hypertrophic osteoarthropathy US appearance that may be seen with hepatitis Appearance of hypertrophic pyloric stenosis that may be seen on upper GI series MRI sign that may be seen with adenomyomatosis CT sign that may be seen with adenomyomatosis Bulky lymphoma encasing mesenteric vessels CHPS Intussuception Hepatic candidiasis and liver metastases Sign of IC TB Appearance of a ureteral edema surrounding a calculus Helps differentiates a calculus from a phlebolith (also see comet sign) Small bowel obstruction US sign of midgut volvulus in a neonate Ileocaecal TB, hypertrophic pyloric stenosis, Crohn’s disease (seen on upper GI series) Appearance of hypertrophic pyloric stenosis that may be seen on upper GI series US pattern for a molar pregnancy oo ks eb m • Starry sky sign • Shoulder sign (ba meal) • • • • • m m m m e co fre ks m eb oo • Parallel track sign co m co m e e e m co m • Keyhole sign (USG) • String of beads sign • Whirlpool sign • String sign Few Thumb Rules in Radiology 259 m co e e m e co m m co e sf re fre e e c co om m eb m m e oo k ks oo eb m fre fre eb m co co m m e oo ks ks oo eb m m co m e co m om c ee ee c om m e m m m eb eb oo oo ks ks fre fre e e e .c o • ee m eb oo • • • • • • • fre • ks m eb • • • ks fre oo eb m m om e c fre re oo ks f co m m eb oo • • • • • • • • • • • • • • ks • m m e co fre oo ks eb eb oo m co m • • e e m m m e co fre Appearance of tibia that may be seen with syphilis Paget disease Irregular appearance of metaphyses in patients with rubella Also used to describe metaphyses in patients with osteopathia striata Champagne-glass pelvis Achondroplasia Scottie dog sign On oblique radiographs, the posterior elements form the appearance of a scottie dog Spondylolysis can have the appearance of a collar around the neck Bullet carpal bones Appearance of carpal bones that may be seen with mucopolysaccharidoses Brim sign Paget’s disease Rugger Jersey Sign Chronic renal failure C Sign Subtalar coalition Deep lateral femoral notch sign Acl tear Fallen fragment sign Unicameral bone cyst FBI Sign Lipohemarthrosis fish vertebra Osteopenia Flaring of anterior ends of ribs Rickets Fragment-In-Notch Sign Bucket-handle tear of the menisci Groundglass appearance Fibrous dysplasia of bone H-Shaped Vertebra Sickle cell anemia Tumbling Bullet Sign Post-traumatic bone cyst Trolley-Track Sign (X-ray) Ankylosing spondylitis Lemon sign (antenatal US) Refers to shape of calvarium associated with spina bifida Half Moon Sign Absent in posterior dislocation of the shoulder Lace like pattern (X-ray) Pattern that may be seen with sarcoid arthropathy Corduroy vertebral body Appearance of thickening trabeculations seen in vertebral hemangiomas (polka-dot sign on CT) Lacunar skull Appearance of skull that may be seen in infants with Chiari ii malformation Breast in a breast sign Term used to describe fibroadenolipomas Lateral capsular sign Acl tear - segund fracture Metacarpal sign Short 4th metacarpal Pedestal sign Loosening prosthesis Bow Tie sign (MRI knee) Discoid meniscus Crescent sign (X-ray) Avascular necrosis Pencil in cup deformity Erosion pattern of digits that may be seen in patients with psoriatic arthritis Drooping shoulder sign Inferior subluxation of the shoulder ks • Saber shin • Picture frame vertebral body • Celery stalking co m co m e e m co m 260 Review of Radiology e co e e e e co m co e e fre fre ks ks oo oo om c ee ee c om m m e eb eb m m c o ee m eb m m m co e fre ks oo eb m m fre oo ks ks oo m eb eb • John Caffey • Laterbeur and Mansfield • Wilhelm Roentgen m e c co Radioactivity Image guided medical procedures; Father of Interventional Radiology Positron Emission Tomography (PET) Alpha/beta particles, neutrons; Father of Nuclear Physics Computed Tomography (CT) scan Ultrasonography (USG); Father of Obstetric Ultrasound Father of Pediatric Radiology MRI (Nobel Prize in Medicine) X-rays (Nobel Prize in Physics); Father of Diagnostic Radiology fre re oo ks f • David E Kuhl • Ernest Rutherford • Godfrey Hounsfield • Ian Donald m om m e co m • Antoine Henri Bacquerel • Charles Dotter m e co re sf oo k m eb oo eb m • Swan neck deformity • Telephone receiver shaped femora Few Important Discoveries in Radiology m e ks fre oo eb m ks ks oo eb m Appearance of hands that may be seen with achondroplasia A circular, opaque radiologic shadow surroundsing epiphyseal centers of ossification in patients with scurvy Rheumatoid arthritis Appearance of femora that can be seen with thanatophoric dysplasia fre fre e e c co m om co m • Wimberger’s ring sign co m m e co fre oo ks eb m • • m m m m e co fre m eb oo ks Paget’s disease Appearance of proximal femur that may be seen with fibrous dyplasia Snowstorm pattern (breast) US pattern for breast implant rupture Trough Line In posterior shoulder dislocation, frontal radiographs reveal two nearly parallel lines in the superomedial aspect of the humeral head Spade shaped tufts Shape of tufts that may be seen with acromegaly Vacuum Phenomenon (CT/MRI) Degenerative disk disease Step-Off Vertebral Body Sign Sickle cell, Gaucher’s disease • • • • • Trident hand co m co m e e e m co m • Cotton wool skull • Shepard’s Crook Deformity Few Thumb Rules in Radiology 261 om c ee om m c o c ee ee co m e m co m m co e m co e e fre ks oo eb m fre ks oo eb m fre ks oo eb m co m e m om e c fre m co e fre ks oo ks eb m oo eb m e co m re oo ks f eb m m co e m re m e co m om co e c e fre fre sf oo k eb m ks oo eb m ks oo eb m co m e m m co m e co m e co e ks fre oo eb m fre fre oo ks eb m ks eb oo m co m e m e m e m e m om c ee om m c o c ee ee co m e m co m m co e m co e e fre ks oo eb m fre ks oo eb m fre ks oo eb m co m e m om e c fre e m fre fre re sf oo k eb m ks oo eb m ks oo eb m Image Based Questions m co e fre ks oo ks eb m oo eb m e co m re oo ks f eb m m co e co m m co e om co m e c Section E e m m co m e co m e co e ks fre oo eb m fre fre oo ks eb m ks eb oo m co m e m e m e m e m om c ee om m c o c ee ee co m e m co m m co e m co e e fre ks oo eb m fre ks oo eb m fre ks oo eb m co m e m om e c fre m co e fre ks oo ks eb m oo eb m e co m re oo ks f eb m m co e m re m e co m om co e c e fre fre sf oo k eb m ks oo eb m ks oo eb m co m e m m co m e co m e co e ks fre oo eb m fre fre oo ks eb m ks eb oo m co m e m e m e m e m e co e ks fre oo e eb re sf oo k e eb m m om m e c co e fre fre co m m co fre e e fre ks ee c om om c ee e m m eb oo ks oo eb m A child had an episode of seizure and fell unconscious The child was referred to a neurologist who prescribed for a NCCT head What is the diagnosis: m c o m eb m a Spondylolisthesis, Scottish dog with collar b Spondylolysis, beheaded Scottish dog c Spondylolisthesis, beheaded Scottish dog d Spondylosis, Scottish dog with collar e oo ks ks oo eb m m co e fre ks ee m e co e fre ks oo eb oo ks f oo eb m m m co m a Aneurysmal bone cyst b Giant cell tumor c Simple bone cyst d Osteomyelitis An adult patient was presented with severe low back pain at the level of L5 vertebra with no motor weakness A CT LS spine was advised What is the diagnosis and corresponding Xray sign? m e co m re a Hydropneumothorax b Pleural effusion c Pneumothorax d Consolidation of right lower lobe A 28 years old female presented with knee pain in the orthopedics OPD She did not have fever or constitutional symptoms X-ray knee was advised What is the diagnosis: eb m m m e co fre oo ks eb m om e c fre ks oo eb m m co m m m m e co fre ks eb oo m co m Chest X-ray of an adult male presented with respiratory distress What is the diagnosis co m co m e e e m co m Image Based Questions e m m co fre co m m e oo ks eb m m co e e fre fre ks ks oo oo om c ee ee c om m m e eb eb m m c o e e m om e c co e fre ks oo eb m m co e fre ee m m oo k eb m m a Breast abscess b Carcinoma breast c Fibroadenoma d Simple cyst A patient was presented with knee pain and found to have a lytic lesion the X-ray A NCCT was done for the better evaluation of the lesion and found to be a nonaggressive lesion All the features are seen on this NCCT except: a Isoechoic collection in scrotal sac b Hypoechoic collection in scrotal sac c Anechoic collection in scrotal sac d Hyperechoic collection in scrotal sac ks oo eb e sf re fre ks oo eb m e co m re oo ks f eb m m e co co e e c fre ks oo eb m m An adult was presented with left scrotal swelling with no constitutional features, having a dull character An USG was done by a radiologist who diagnosed it a left sided hydrocele What is the characteristic USG finding in hydrocele co ks fre oo eb m om m m m eb eb oo oo ks ks fre fre e co e co m m m m e e e m co m co m a Tuberculoma b Metastasis c Abscess d Neurocysticercosis co m co m A 36 years old female presented with lump in right breast with no features of nipple discharge, skin puckering or weight loss USG reveals an oval iso to hypoechoic soft-tissue nodule which shows lateral distal shadow with no surface irregularity What is the diagnosis e m m e co e co ks fre fre a Acoustic enhancement b Acoustic shadowing c Comet-tail artefact d Twinkling artefact 10 Where we see this sign ? a Gallbladder calculi b Kidney calculus c Gallbladder cyst d Both A and B 11 In a patient with back pain, NCCT spine reveals the following appearance of the vertebra What is the diagnosis and the sign known on X-ray? e m om e c fre e m co co m m m eb oo ks a Hemangioma, corduroy appearance b Hemangioma, polka dot appearance c Osteoporosis, H-shape vertebrae d Osteoporosis, polka dot appearance 12 A patient presented in the chest clinic for follow-up of pulmonary Kochs post ATT having dyspnea CT scan was advised which revealed: e e fre fre ks ks oo oo om c ee ee c om m m e eb eb m m c o ee m e co re sf oo k eb m m co e fre ks oo eb m m co e fre ks oo m m m co e fre ks oo eb m e co m re oo ks f eb eb m e eb oo oo ks eb m om e c fre ks oo eb m m m m m m e co fre ks eb oo m co m m co a Monochorionic diamniotic, twin peak sign b Monochorionic diamniotic, T sign c Dichorionic diamniotic, twin peak sign d Dichorionic diamniotic, T sign What is this USG sign (arrow) known as in the sonography of gallbladder? co m co m e e e m co m a Well-defined lytic lesion b Narrow zone of transition c No surrounding sclerotic rim d Associated exophytic soft-tissue component A female patient presented in the ANC OPD for routine checkup She was found to have twin pregnancy USG was done to assess the chorionicity of the placenta What is the diagnosis and USG sign on given image e m m e co e co ks fre fre a Presbyoesophagus, barium swallow b Diffuse esophageal spasm, barium swallow c Diffuse esophageal spasm, manometry d Multiple strictures, barium study 15 A follow-up patient of healed pulmonary tuberculosis who had fibro-atelectatic collapse of left lung presented with acute onset respiratory distress, cough and fever Urgent CECT was advised as the CXR was inconclusive The CT revealed (arrow) in the right lung What is the diagnosis? e m om e c fre m co m co e e fre fre ks ks om c ee m eb m om c ee e oo oo eb m a Hydropneumoperitoneum, football sign m c o ee e oo ks m m m m eb eb a Collapse b Consolidation c Malignancy d Abscess 16 A patient presented with acute abdomen and came to emergency department After initial pain management X-ray abdomen was done to rule out acute obstruction What is the diagnosis and sign known as? co e fre ks oo m e co re sf oo k eb m m co e fre oo ks oo ks f eb eb m m m co e fre ks oo eb m e co m re a Pyelonephritis b Renal calculus c Abscess formation d Cyst with internal hemorrhage 14 A patient presented with dysphagia with pain A barium swallow was advised Which revealed multiple alternating constrictions and dilatations giving shish-kebab appearance What is the diagnosis and gold standard investigation? m e eb oo oo ks eb m om e c fre ks oo eb m m m m m m e co fre ks eb oo m co m m co co m co m e e e m co m a Consolidation with airbronchogram with ipsilateral mediastinal shift b Collapse with bronchiectatic changes and ipsilateral mediastinal shift c Collapse with airbronchogram and ipsilateral mediastinal shift d Consolidation with bronchiectatic changes with ipsilateral mediastinal shift 13 A patient presented with acute left lumbar pain of colicky nature USG KUB was advised which revealed the following finding in left upper ureter (arrow) What is the diagnosis? e co e ks fre m e co re sf oo k e eb m m om m co e c e oo ks fre fre ks oo co co m m m m e eb eb m m e e fre fre ks ks oo oo e eb eb ee c om om c ee m m m a T-Tube cholangiogram, invasive b MRCP- noninvasive m c o ee m m m co e fre ks oo eb a Arteriovenous malformation b Cavernous hemangioma c Fusiform aneurysm d Berry aneurysm 20 Identify the investigation done to rule out CBD calculus: co e fre ks oo eb m e eb oo a Medulloblastoma b Abscess c Meningioma d Ganglioglioma 19 An old aged patient presented with worst headache of his life NCCT head revealed acute SAH MR angiography was performed What is the diagnosis (arrow)? m e co m re oo ks f eb m m m e co fre oo ks eb m om e c fre ks oo eb m co m m m m e co fre ks eb oo m co m m a Hirschsprung’s disease, transition zone b Diverticulosis, cork screw appearance c Diverticulosis, saw tooth appearance d Ulcerative colitis, pseudopolyps 18 An adult female presented with headache which was not responding to conservative treatment Contrast enhanced MRI was done which shows the following space occupying lesion in the brain What is the most probable diagnosis co m co m e e e m co m b Pneumoperitoneum, string of beads sign c Acute small bowel obstruction, string of beads sign d Pneumoperitoneum, Rigler’s sign 17 An old age patient presented with left lower abdominal pain with bleeding per rectum occasionally Barium enema was done What is the diagnosis and sign in the radiograph? e m m e co e co ks fre fre a Osteosarcoma, sunburst periosteal reaction b Ewing’s sarcoma, sunburst periosteal reaction c Osteosarcoma, onion ring periosteal reaction d Ewing’s sarcoma, onion ring periosteal reaction 23 A child presented with pain in right shoulder X-ray reveals an expansile lytic lesion with the radiographic appearance as shown below What is the diagnosis? e m om e c fre e m co co m m m eb oo ks ks oo eb m m e e fre fre ks ks oo oo om c ee ee c om m m e eb eb m m c o ee m e co re sf oo k eb m m co e fre a Simple bone cyst b Aneurysmal bone cyst c Giant cell tumor d Osteosarcoma 24 A follow-up case of healed pulmonary tuberculosis presented with hemoptysis Chest X-ray was undertaken which revealed old fibrotic opacities in bilateral lungs and a focal lesion in the right upper zone (arrow) What is the probable diagnosis co e fre ks oo eb m m m co e fre ks oo eb m e co m re oo ks f eb m m e eb oo oo ks eb m om e c fre ks oo eb m co m m m m e co fre ks eb oo m co m m a Ascites b Pneumoperitoneum c Hydropneumoperitoneum d Liver abscess 22 A child presented with severe leg pain with fever On examination, a large soft tissue was noted in the leg A radiograph was obtained which reveals a soft tissue and periosteal reaction What is the probable diagnosis and the type of periosteal reaction co m co m e e e m co m c T-Tube cholangiogram, noninvasive d ERCP, invasive 21 A diagnosed patient of severe peptic ulcer disease presented in the emergency with severe abdominal pain and abdominal rigidity An emergency CECT was performed to see the cause of the pain Which reveals: e e m om e c fre oo ks e eb m m co m m co e e a Pleural effusion and pericardial effusion b Pleural effusion and pericarditis with effusion c Empyema and pericarditis with effusion d Empyema with pericardial effusion ks fre fre ks om c ee m eb m om c ee e oo oo eb m m c o m m e co re sf oo k eb m m co e fre ks oo m m co e fre ks oo a Consolidation b Collapse with no mediastinal shift ee e co m co e fre ks oo a Hydropneumothorax b Pneumothorax c Tension pneumothorax d Collapse of lung with hyperinflated contralateral lung 28 A patient of tuberculosis underwent CECT which reveals following findings eb eb m eb e ks fre oo eb m m eb m e co m re oo ks f 26 What is the diagnosis? m m m e co fre oo ks eb c Collapse with mediastinal shift d Collapse with mediastinal shift with bronchiectasis 27 A child presented with acute respiratory distress X-ray reveals a life threatening condition Diagnosis is: om e c fre ks oo eb m m a Lung abscess b Lung cyst (simple) c Hydatid cyst d Hydropneumothorax co m m m m e co fre ks eb oo m co m 25 A patient from north east presented with respiratory distress An NCCT was prescribed which reveals a large cystic lesion with following features What is the diagnosis? co m co m e e e m co m a Abscess with cavity formation b Fungal ball with air crescent sign c Hydatid cyst d Consolidation e co e m m m m e co co e sf re fre oo k ks oo e eb m m oo e c oo ks ks fre fre e co om m Acute EDH Hyperacute EDH Chronic EDH Subacute EDH m m co m m co fre d 14 c 21 c 28 b om c ee c om m m e oo ks c 13 b 20 a 27 c eb eb m ee c o c 12 b 19 d 26 d e e fre ks d 11 a 18 c 25 c oo c 10 d 17 c 24 b m b b 16 d 23 a 30 a ee e eb eb m m co e fre ks oo eb e ks fre oo eb eb m eb m a b c d e co m re oo ks f eb m m m m e co fre oo ks 30 A patient presented in the emergency department after head trauma NCCT was advised What is the diagnosis? om e c fre ks oo eb m m co ANSWERS a c 15 b 22 d 29 d m m m m e co fre ks eb oo m co m a Acute pulmonary edema with cephalisation of pulmonary vessels b Pulmonary edema with acute interstitial edema and septal thickening c Aspiration pneumonia with pleural effusion d Frank pulmonary edema with bat wing appearance co m co m e e e m co m 29 An ICU patient presented with acute respiratory distress and frothy pink sputum CXR reveals: ... Distribution of affected joints Presence of soft tissue swelling Bone density Cartilage space narrowing Reactive bone formation Site and character of erosions Subarticular cystic lesions Presence of soft... Earliest sites –– Bare areas between edge of articular cartilage and site of attachment of joint capsule –– Wrist, MCP and PIP MC at radialvolar aspect of head of 2nd and 3rd metacarpals are commonly... 184 Review of Radiology e m m co e re I oo oo k ks sf e c fre e m –– Reappearance of dense zone of provisional calcification –– Increase in cupping of healing metaphysis –– Recalcification of