Radiology Notes for Students
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Transcript of Radiology Notes for Students
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RAJAT JAIN
MD(MAMC), DNB,FRCR(UK)
NEW DELHI
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Energy associated with any radiation can be transferred to matter. This transfer of energy can remove electrons from the orbit of atoms
leading to the formation of ions
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Type Mass& Charge Comment
Electromagnetic
1). X-ray
2). Gamma ray
Particulate
1). Electron (e)
2). Proton (p)
3). Neutron (n)
4). Alpha particle
0
0
variable mass
&
Charge
X-rays and gamma rays do not
differ except in the source. Gamma
rays are produced intranuclearly,
and x-rays are produced
extranuclearly (i.e., mechanically).
—
Exhibits a Bragg peak
Cannot be accelerated by an
electrical field
Helium nucleus
IONIZING RADIATION
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Major Sources of ionizing radiation include Most nuclear processes (e.g., nuclear
fission, nuclear fusion, radioactive decay),
X-ray equipment, high-energy physics experiments, and Background radiation.
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All human beings are constantly exposed to ionizing radiation.
Environmental sources include the cosmic radiation from space and radiation from the ground and from inhaled and ingested materials.
Airline travel and mining both increase exposure to the background radiation.
Radiation originating in the body comes mainly from radioactive potassium, which emits beta and gamma rays.
Cosmic exposure contributes 28 mrem per year. The ground and internal sources contribute 26 and 27 mrem
per year, respectively.
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X-ray tube
Patient
Cassette
collimator
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X-RAY TUBE
PARTS OF X RAY TUBE
1) Glass Envelope 2) Cathode Filament Supporting wires Focusing cup 3) Anode Stationary Rotating
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Tube Housing - Made of cast steel - Contained in a glass envelope (Pyrex) - Concept of target window
Cathode - Made up of the filament (s) (Tungsten) and a focusing cup. - Addition of Thorium to the filament Anode - Target (Tungsten – rhenium alloy) - Tungsten has: High atomic number (74), thermal conductivity level & melting point
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When kVp increases - X-ray penetration increases, exposure increases (darker film) and contrast goes down.
Maximum energy as well as number of x-rays increased.
Film contrast - primarily dependent on kV. Increasing mAs - increased film exposure
(more x-rays produced), which darkens the film.
Maximum energy of x-rays - NOT changed. Rajat Jain
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S. No. Type of Radiation Quality
factor
1.
2.
3.
4.
X, gamma or beta radiation
Alpha particles and multiple charged particles
Neutrons
High energy protons
1
20
10
10
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TISSUE WEIGHTING FACTOR
Gonads 0.2
Active bone marrow, Colon, Lungs, Stomach. 0.12
Bladder, Breast, Esophagus, Liver, Thyroid 0.05
Bone surfaces, Skin 0.01
At diagnostic energy levels, the rad, rem and roentgen
may all be considered equal , because the energy
deposited in soft tissues by 1 R of exposure is only 5%
more than a rad. i.e. 1 R= 1 rad= 1 rem. Rajat Jain
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Unit Quantity Measured
Roentgen (R) Exposure
Rad Dose
Gray (Gy)
(KERMA)
Dose
Sievert (Sv) Dose Equivalence
Rem Dose Equivalence
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Chest (single PA film) Skull Thoracic spine Lumbar spine Hip Pelvis Abdomen IVU Barium follow thrugh CT head CT chest CT abdomen or pelvis
0.02 0.07 0.7 1.3 0.3 0.7 1.0 2.5 3 2.3 8 10
Diagnostic procedure dose(msv)
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Occupational workers public
Limit Annual
equivalents
Limit
Annual
equivalents
ICRP 20mSv/yr over 5 years 20 mSv 1mSv/yr over 5
years 1 mSv
NCRP Cumulative dose= Age in yrs x
10mSv 50 mSv
5mSv for 5 yr
period 1 mSv
AERB 100mSv for 5 year period 30mSv 1mSv/yr for 5
years 1mSv
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Dose limit of 2mSv applied to the surface of her
lower abdomen equal to 1msev dose to fetus
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Conventional x-ray
Phosphor plate (PSP)
Latent image
Laser beam
Emission of light
Ultra-sensitive PMT
Electronic signal (digital)
CRT or Hard copy
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X-ray
Patient
Flat panel detector
Electrical energy
Digital image
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•Advantages – Better contrast resolution Less ‘repeat’ rates Compatible with PACS Teleradiology
•Limitations –
Cost
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Low energy X-ray spectrum (20-35 KV) Small focal spot size(0.2-0.5 mm) Beryllium Window Target-Filter combination Molybdenum(preferred);Rhodium;Tungsten
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Grade Interpretation Managemant
0 Incomplete evaluation Complete it
1 Normal None
2 Benign None
3 Probably benign (<2%) Short follow-up
4 Suspicious/ indeterminate Biopsy
5 Highly suspicious (>95%) Biopsy
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If a non-palpable mammographic lesion is noted and there is low index of suspicion (<2%), CORRECT further advise should be?
Mammographic follow-up annually
Mammographic follow-up in 3–6 months
Stereotactic core biopsy
Surgical biopsy
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If a non-palpable mammographic lesion is noted and there is low index of suspicion (>2%), CORRECT further advise should be?
Mammographic follow-up annually
Mammographic follow-up in 3–6 months
Stereotactic core biopsy
Surgical biopsy
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Acoustic shadow is produced by - Calculus - Air - Fluid - Fat
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Acoustic enhancement is produced by - Calculus - Air - Fluid - Bone
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Note : illuminated warning sign
sliding shielded doors
radiation warning sign
CT Room Entrance
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Thin beam from various directions
Detectors measure attenuation
Local attenuation at each point Translated to CT no Shades of gray
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Chest (single PA film) Skull Thoracic spine Lumbar spine Hip Pelvis Abdomen IVU Barium follow thrugh CT head Bone scan CT chest CT abdomen or pelvis
0.02 0.07 0.7 1.3 0.3 0.7 1.0 2.5 3 2.3 <5.0 8 10
Diagnostic procedure dose(msv)
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Substance HU value
Air -1000
Fat -50 to -100
Water 0
Muscle 10-40
Blood ~60
Contrast 130
Bone >400
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Quantitative scale for describing density Radio-density of distilled water at STP is
defined as 0 HU while the radio-density of air at STP is defined as -1000 HU.
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Thin slices (1-1.5 mm) are used with 10-mm spacing
Covers only 10% of the chest but provides improved detail while minimizing radiation dose
high spatial frequency algorithm -sharpens images, increases noise, not problematic in lungs
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True 3D image acquisition within a single breath hold.
Continuous acquisition of projection data
Continuous rotation of the x-ray tube and detectors and simultaneous translation of the patient through the gantry opening
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Multislice CT era started in 1992 with the introduction of Elscint CT Twin- dual slice
1998- Four-slice CT scanners
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Faster acquisition Coverage of larger area Less movement artifacts Isotropic multi-planar reformats Improved vascular and cardiac imaging Potential for faster throughput of patients
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T1 - measure of relaxation time in the Longitudinal plane
T2 - measure of relaxation time in the Transverse plane.
Fluid –hyperintense (white) to virtually everything else on T2W images. Low-to- intermediate signal on T1W.
Where to look - Urinary bladder & CSF.
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Things bright on T1W -
Fat Hemorrhage Proteinaceous
substances Melanin Paramagnetic agents
(gadolinium).
Dark on both T1W & T2W -
Air Flowing blood (on
SE/FSE images) cortical bone, and Ligaments, tendons,
and other dense fibrous tissues
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Contra-indications for RCM - Multiple myeloma - Renal failure - History of allergy/ asthma - Diabetic nephropathy - Severe dehydration - Previous reactions to contrast media
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Copyright © 2006 by the American Roentgen Ray Society
Gleeson, T. G. et al. Am. J. Roentgenol. 2004;183:1673-1689
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CT
Anatomical images
PET
Functional images Fusion
(software)
PET/CT
Fused anatomical + functional images
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Short-lived positron emitters - 11C, 13N, 15O, 18F, 82Rb, 68Ga
Principle – Annihilation coincident detection (511kev)
18F – metabolism, 13N – perfusion
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Type Mass& Charge Comment
Electromagnetic
1). X-ray
2). Gamma ray
Particulate
1). Electron (e)
2). Proton (p)
3). Neutron (n)
4). Alpha particle
0
0
variable mass
&
Charge
X-rays and gamma rays do not
differ except in the source.
Gamma rays are produced
intranuclearly, and x-rays are
produced extranuclearly (i.e.,
mechanically).
—
Exhibits a Bragg peak
Cannot be accelerated by an
electrical field
Helium nucleus
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Penetrating power
Ionization power
Damaging power
Maximum Gamma Alpha Alpha
Minimum Alpha Gamma Gamma
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Used in both tele and brachy Cs>Co> Ir
Radiotherapy
Teletherapy Brachytherpy Interstitial Intracavitatory Mould Temporary Permanant
•Co60 •Cs137 •Linear accelerator
•Ir 192 •Cs137 •Sr 90 •Co60 •Ra 226 •Radium 222 •Yetrium 169
•Au 198 •Pd103 •Cs 131 •I125
Systemic Radionuclide •I131 •P32
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Emission of Beta Rays by Both Beta+ gamma rays
Ytterium Gold
Phosphorus I- 131
Strontium Radium
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Most Least
Stage of cell cycle G2M S
Organ Ovary,testis Vagina>bone>cns
Tissue Gonads, bone marrow
Nervous tissue
Cellt ype undifferentiated, well nourished, divide quickly and are highly metabolically active
quiscent
Blood cell Lymphocyte platlet
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isotope Half life
Tc99 6 hours
I123 13 hours
I125 60 days
I131 8 days
I132 2.3 hours
P32 14 days
Co60 5.2 years
Ra 226 1622 years
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Highly sensitive Least Radiosensitive
Wilms Hepatoma
Ewings Osteosarcoma
Lymphoma Melanoma
myeloma Pancreatic Carcinoma
seminoma
WELMS HOMP
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Nuclear Scans
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Radiopharmaceutical compound is used Most common radioactive compound is
Tc99m Pharmaceutical compound depends on the
imaging organ DTPA for GFR DMSA for cortical scarring
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•TC pyrophosphate - Acute Myocardial infarction •TC thallium subtraction scan - Parathryoid gland •TC 99 Macroaggregated albumin – Pulmonary perfusion •TC 99 Human serum albumin - Cardiac chamber •TC labeled RBC – Splenic diseases •Thallium scan - Myocardial Perfusion •Gallium scan - tumors/Abscess •Xenon gas - lung ventilation •Chromium -RBC labeling •DTPA –GFR •DMSA -Cortical Structure of kidney •Selenium 75 Methionine - Pancreas •Selenium and I131 -Thyroid •I 131 & I132 -Placental Function •I 131 Orthohippurate -Kidney
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imaging
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Swirl sign
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hematoma- imaging
Crescent shaped collection
Not limited by sutures – can spread along entire hemisphere.
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hematoma
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EDH SDH Assc with skull
fractures
Biconvex collection
Limited by sutures
Not limited by dural reflection – can cross the midline
Shear type injury
Crescent shaped collection
Not limited by sutures
Limited by dural reflection – does not cross the midline
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Diffuse Axonal Injury
White matter injury – unequal rotation or deceleration of adjacent tissues
Predilection for – lobar white matter, corpus callosum and dorsolateral brainstem.
80% of lesions are non hemorrhagic.
Staging system – Adams’
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CT findings in DAI
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Cerebral contusion Most frequently encountered intra axial injury
Areas of hemorrhage ,necrosis and edema.
Coup/contracoup injuries
Gyral crests are frequently involved
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TUMORS
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Herpes Simplex type 1
Temporal and frontal lobes, parahippocampal, uncus, cingulate gyri
Involvement of the insula and white matter lateral to the lentiform nucleus is characteristic
Sparing of basal ganglia
Patchy hemorrhage + contrast enhancement
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Herpes Encephalitis
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Japanese Encephalitis (JE)
Location - Thalamus, basal ganglia, brainstem,
cerebral hemispheres, cerebellum
MR – T2 hyperintensity, No gad enhancement
Hemorrhagic transformation described in
thalamus and cortex
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Japanese Encephalitis (JE)
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Japanese Encephalitis
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BARE ORBIT
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DIASTEMATOMYELIA
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OPTIC NERVE SHEATH MENINGIOMA
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SPINAL CORD EDEMA
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MENINGIOMA
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TB MENINGITIS
Rajat Jain
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NEUROFIBROMA
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LACUNAR INFARCT
Rajat Jain
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Unilateral lung hyperlucency Patient positioning
Rotation Scoliosis
Chest wall defect Mastectomy Poland syndrome (absent pectoralis muscle)
Pneumothorax
Airway obstruction Bronchial compression (hilar mass, cardiomegaly) Endobronchial obstruction with air trapping (foreign body, tumor) Obliterative bronchiolitis Swyer-James syndrome
Pulmonary vascular cause Pulmonary embolism Pulmonary artery hypoplasia
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Silhouette/Structure Contact with Lung
Upper right heart border/ascending aorta
Anterior segment of RUL
Right heart border RML (medial)
Upper left heart border Anterior segment of LUL
Left heart border Lingula (anterior)
Aortic knob Apical portion of LUL (posterior)
Anterior hemidiaphragms Lower lobes (anterior)
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Westermark Sign
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Hampton Hump
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Fleischner Sign
.
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Reverse S Sign
With mass adjacent to a fissure, the fissure takes the shape of an "S". The proximal convexity is due to a mass, and the distal concavity is due to atelectasis.
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Football Sign
Large oval radiolucency that represents a large amount of pneumoperitoneum in the shape of an American football. The ovoid appearance is the acknowledged hallmark of the football sign. Infants with GIT perforation
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Miliary Nodules What is a Miliary
Pattern?
Diffuse
Well defined
Randomly distributed
Round or oval lesions
1-5 mm diameter
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Differential Miliary Nodules Common Causes:
Tuberculosis / Fungi
Metastases Thyroid (Papillary)
Renal
Melanoma
Pneumoconiosis Silicosis
Talcosis
Sarcoidosis
Less Common Causes:
Amyloidosis
Alveolar microlithiasis
Hemosiderosis Mitral stenosis
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HYDATID CYST Meniscus/double arch/moon/crescent sign due to
thin radiolucent crescent in uppermost part of cyst.
Combo sign due to air fluid level inside endocyst and air between pericyst and endocyst.
Collapsed membranes inside the cyst outlined by air causing ‘serpent’ sign.
Completely collapsed crumpled cyst membrane floating on the cyst fluid produces “water Lilly” sign of Camalotte.
Cyst in cyst sign
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Bronchiectasis Irreversible bronchial dilatation Cylindrical, Varicose, Cystic Identification of an enlarged internal bronchial
diameter
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Bronchiectasis
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25 M
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Neuroenteric cysts Abnormal connection between the primitive
endoderm and ectoderm during the 3rd week of life.
Vertebral segmental abnormalities
Persistent connection between spinal canal and foregut
Harmatomas (displaced nests of endodermally derived tissue)
Other names - enterogenous cyst, enteric cyst, gastrocytoma, dorsal enteric fistula
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Neuroenteric cysts
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Quantifying Pleural Pathologies Pneumothorax –
Erect X-ray – 50 cc
Supine – 500 cc
Expiratory - <50 cc
Pleural effusion –
Lateral decubitus – 5 cc
Lateral – >75
Frontal – >200
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QUESTION A 16 yo with CoA has anomalous post-coarctation
origin of the right subclavian artery. The ribs most likely to demonstrate inferior rib notching would be: -
- Left third to ninth ribs
- Bilateral third to ninth ribs
- Right third to ninth ribs
- Bilateral first and second ribs
- Left first and second ribs
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Rib Notching – Superior 1) CTDs
RA SLE SS SjS
2) Metabolic HPT
3) Others
NF
RLD
Polio
Marfan’s
OI
Progeria
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Rib Notching - Inferior 1) Arterial
CoA Aortic
Thrombosis Subclavian
obstruction
2) Venous SVC obstruction
3) AV
Pulmonary AVM
Chest wall AVM
4) Neurogenic
NF
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QUESTION True among the following?
“Figure of 8” heart: Infracardiac TAPVC
“Sitting-duck” heart: Tricuspid atresia
“Box-shaped” heart: Infracardiac TAPVC
“Globular” heart with plethoric lung fields: TGV
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TGV
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TGV Normally, aorta is anterior to & at the right of PA In TGA, PA is to the right of its normal location
and obscured by aorta on chest X-ray This malposition+stress-induced thymic atrophy
+hyperinflated lungs = apparent narrowing of the superior mediastinum (most consistent sign of TGA)
CV silhouette enlarged and globular – “egg on a string”
Pulmonary flow - increases with closure of the ductus arteriosus.
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TAPVR
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Ebstein’s Anomaly
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PAPVC
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ToF
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Endocardial Cushion Defects
Sitting goose with an elongated neck on the AP projection in left ventricular angiography
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Explanation LA:
- Enlargement of the LA appendage
- “Splaying" of the carina
- Elevation of the LMB
- “Double density" projecting over the central portions of the heart
- Displacement of descending aorta to the left (Bedford sign)
- Always check left heart border for straightening.
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M mode cardiac US
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M mode cardiac US M-mode (Motion-mode) US shows the motion
of cardiac structures.
High sampling frequency (up to 1000 pulses per second)
Yields a one-D image, sometimes called an 'ice pick' view of the heart.
Detect valvulopathies (calcifications, etc.) & cardiomyopathies (dyskinesis, aneurysm, etc.).
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CORONARY ARTERIES
LCx
LM
Ao
LAD
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CT Coronary Angiography
Clinical Applications : Diagnosis of CAD
Evaluation of CABG graft patency
Evaluation of CA stent patency
Identification & characterization of plaques
Surgical planning prior to CABG
Anatomic abnormalities of coronaries
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MUGA Multiple gated acquisition scan is a method of
assessing EF. Also assesses LV wall motion & cardiac muscle
damage. Injecting RBCs, radiolabeled with Tc99, into the
patient's bloodstream & recording the emissions with a gamma camera.
Asses and follow cardiac function in patients on adriamycin.
Detects early changes in cardiac function that might easily be missed by other techniques, such as the echocardiogram.
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Explanation Thallium Stress Testing
What is this?
When is thallium stress testing the answer?
When is it the wrong answer?
What is the alternative choice?
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Thallium/Persantine Thallium Test Most accurate method of assessing myocardial
perfusion without an angiography.
Thallium-labeled RBCs are injected into the patient's blood-stream.
Provides a view of the blood flow into heart muscle.
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Thallium Test Indications
- when resting EKG changes make exercise EKG difficult to interpret
- to localize the region of ischemia
- to assess revascularization following bypass or angioplasty.
- History of chest pain - not certain if it is ischemic in nature (equivocal cases).
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CORONARY CALCIUM SCORING Agatston score
standardized EBCT protocol score < 11, minimum risk shows variable reproducibility*
SCORE > < 1 130 199
2 200 299
3 300 399
4 400
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Normal Peristaltic Activity Primary peristalsis
Major stripping wave
Initiated by deglutition
Starts from pharyngo-esophageal jn.
Secondary peristalsis
Arises due to local distention
Clears residual bolus
Appearance same as primary wave
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Tertiary contractions
Uncoordinated, non-peristaltic, non-propulsive segmental contractions
Function unknown
Asymptomatic persons
Increased incidence with age (presbyesophagus)
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Mass impression on the gastric antrum
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Intussusception
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Barium enema
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Serous Cystadenoma Older age - 60 yrs
> 6 cysts, each cyst < 2 cm in diameter
Calcification - central stellate scar within fibrous stroma, may have a sunburst appearance
Multilocular cyst with a thin (< 2 mm) wall and lacks mural nodules or calcifications
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Mucinous Cystadenoma Body and tail
Female
Fewer cysts > 2 cm in diameter
Enhancement of tumor nodule
Peripheral calcification
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APPROACH TO A PATIENT WITH
ABDOMINAL TRAUMA
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CAB EVALUATION & INITIAL RESUSCITATION
HEMODYNAMIC STABILITY
UNSTABLE STABLE
SIGNS OF I/P
INJURY
FAST (+)
LAPAROTOMY
RELIABLE CLINCAL EXAM
NOT
POSSIBLE
CT/ OTHER
INVESTIGATIONS
POSSIBLE
EVIDENCE OF I/P INJ
YES NO
OBSERVE
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Obstructive jaundice
USG
Calculi
MRCP CT
Mass
DPCT
No obv mass
IHBRD No IHBRD
Liver biopsy +/- MRCP
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Achondroplasia Limbs Rhizomelic micromelia
Symmetric
Splayed and cupped metaphyses with bowing
Trident hand
‘V’ shaped notches in the
growth plates (chevron sign)
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Achondroplasia
Pelvis
- Ilium short and flat (tomb stone like)
- Acetabulum is horizontal with thick triradiate cartilage (champagne glass appearance)
- Small sciatic notch
Thorax
- Squared inferior angle of scapula
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DISH Wave like hyperostosis
Flowing ossification
>4 contiguous vertebras
Thoracic spine
Ossified ALL
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Ankylosing Spondylitis
B/L symmetric Lower two third Rosary bead appearance Reactive sclerosis Bony ankylosis osteoporosis
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Ankylosing Spondylitis Romanus lesion(erosion)
Squaring
Shiny corner sign
Marginal Syndesmophytes
Bamboo spine
Trolley-track sign
Dagger sign
SPINE
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Osteomalacia Osteopenia
Looser’s zones or pseudofractures –
Linear areas Under mineralised psteoid
Bilateral and symmetric
Right angle to the cortex.
Axillary margins of scapula, sup and inf pubic rami, inner margin of prox femur, post margin of prox ulna , ribs
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Deformities
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Tri-radiate Pelvis
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Subperiosteal resorption Pathognomic
Sites
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Lamina
dura
resorption
Dental
sepsis
FD
Paget’s
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Trabecular resorption
Throughout the skeleton
‘Salt and pepper’ skull
(classic)
Focal areas of skull thickening
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Brown tumor
Sites - Mandible, clavicle, ribs, pelvis, tubular bones
Heals after parathyroidectomy
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Renal lesions
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Primary HPT Secondary HPT
FEATURES HPT only HPT + ROD
Skeletal changes Less florid More florid
Sclerosis Rare Common
Brown tumor More common Less common
Chondrocalcinosis More common Less common
Soft tissue & vas
calcification
Less common More common
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Introsseous
membrane ossification
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CALCIFICATION AT THE MUSCULAR AND LIGAMENTOUS ATTACHMENTS
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Rose thorn appearance in ribs
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Rickets - Imaging findings
Widening of growth plate- earliest
Irregular metaphyseal margins
Splaying and cupping of metaphyses- paintbrush appearance
Osteopenia
Epiphyses – irregular borders
Skeletal deformities
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Rickets
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Scurvy - Imaging features
Osteoporosis
White line of Frenkel
Trummerfeld zone
Wimberger’s ring
Pelkan’s spur
Corner sign
Subperiosteal haemorrhage
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PROTRUSIO ACETABULI
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HEMANGIOMA
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Tuberculosis
Earliest –frequency, Later -Dysuria and hematuria
IVP- modality of choice
Early stages - only finding may be irregularity or destruction of one or more papillae
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Advance Changes
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RAS/RVH
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