Transcript Dx Imaging 3 Final - Logan Class of December 2011

DX IMAGING 3 FINAL
COMPILED BY CASEY FOSTER
Neuroradiology
 Diff Dx
 Extradural
 Intradural Extramedullary
 Intradural Intramedullary
Extradural
 Mass outside the dura compressing from out
to in
 Diff Dx
 DJD changes (osteophytes, herniations)
 Trauma (bone fragment, hematoma)
 Iatrogenic (post surgical complication)
 Infection (abscess)
 Tumor (mets, myeloma)
DJD changes
 Osteophytes
 Herniations
Trauma
 Bone fragment
Iatrogenic
 Iatrogenic
hematoma
Infection
 Abscess
Stenosis
Normal
Tumor
 Diff Dx
 Mets, Primary bone tumor, Neurofibromatosis
Intradural Extramedullary
 Between the Dura and the cord/brain
 Diff Dx
 Meningitis
 Meningioma, Schwannoma
 Mets
Meningitis
 Arachnoiditis most common
 Findings: thickened and clumped nerve roots
Meningioma/Schwannoma
Meningioma (CNS) Schwannoma (PNS/CN 8)
Meningioma/Schwannoma
 Which is this?
 We don’t know could be either
Metastasis
 Could be from anywhere
 Can’t find specific pictures
Intradural Intramedullary
 Inside the dura and the cord/brain itself
 Diff Dx
 Blood (subdural hematoma)
 Inflammation (transverse myelitis)
 Cells (ependymoma, astrocytoma, mets)
 MS (demyelination of nervous tissue)
 Syringomyelia (CSF pocket within cord)
Blood
 Intraspinal
hematoma
Inflammation
 Transverse Myelitis
 Characterized with local
enlargement of the spinal
cord and increased signal
intensity on T2 images.
 Typically the high signal
intensity extends over
several spinal segments
Tumors
 Ependymoma
(#1 inAdults)
Astrocytoma
(#1 in Kids)
Multiple Sclerosis
 Focal but progressive demyelination disorder
Syringomyelia
 Collection of CSF fluid within the cord
parenchyma
Skull series
 Lateral
 PA (Caldwell)
AP (Towne)
Skull series
 Physiologic calcifications
 Pineal gland
 Choroid plexus
Hyperostosis Frontalis
(normal variant)
 Flax cerebri
 Tentorium cerebelli
 Pathological calcifications
 Tumors
 Mets
Skull series (misc)
 Normally brain has ~ 3 mm cortex
 Thinning of cortex=loss of Fx
 Parietal bone is most commonly fracture
 Enlarging ventricles=making up for brain loss
Sinus Series
 PA
Waters (PA tilt)
 Lateral of paranasal sinuses
F=frontal
E=Ethomoid
Sp=Sphenoid
M=Maxillary
Osseous lesions-Lytic
 Multiple Myeloma-#1 primary malignancy of
skeleton
 Paget’s (expands bone and
sclerosing/softening)
 Lytic->mixed->blastic->malignant (rarely reached)
 Osteomyelitis
Osseous lesions-Blastic
 Osteoma (asymptomatic, benign)
 Osteoblastic mets
Multiple Sclerosis
 20-40 females > males
 Demyelination of idiopathic origin
 Visual disturbance, sensory and muscle probs
 Intermittent and relapsing
Dementia
 Dementia=slow and progressive decline in
mental Fx (progressive cognitive decline)
 Alzheimer's and small infarcts are top 2
causes
 Imaging findings
 Generalized atrophy of cerebral cortex
Stroke
 Death of brain tissue due to vascular
compromise (hypoperfusion)
 Risks=atherosclerosis & hypertension
 MCA=most common site
 Types
 Ischemic
 Reduced flow from plaque (atherosclerosis) or other
obstruction (embolus-FIND SOURCE!)
 Hemorrhagic
 Vessel burst/damage
 Blood leak into vault
 More deaths
Stroke continued
 Dx
 History and physical
 Confirm with CT/MRI
 Symptoms depend on part of brain hit
AP Chest radiology
 Search pattern basics
 Soft tissues
 Bone
 Central shadow
 Hilum
 Lung
AP Search pattern: Soft tissues
 Paraspinal
 Neck
 Axilla
 Breast
 Diaphragm
shape/height
 Subdiaphragm
 Liver
 Spleen
AP Search pattern: Bone
 Vertebral column
 Body
 Pedicles
 Shoulder
 Humerus
 Scapula
 AC/SC joints
 Ribs
 Back
 Front
 Clavicle
AP Search pattern: Central shadow
 Central
 Trachea
 Descending aorta
 Right border
 Right Ventricle
 Left border
 Aortic knob
 Left pulmonary artery
 Left ventricle
AP Search pattern: Hilum
 Right and left hilum
 A calcified mass here is
bronchogenic carcinoma
until proven otherwise
 Anything suspect in this
region gets a CT scan
 Can also be pulmonary
hypertension (COPD,
Scoliosis)
AP Search pattern: lung
 Only thing
that should be
in lung on
normal film is
blood vessels
Search pattern: lung
 Opaque




Nodule-soft tissue density < 3 cm
Mass-soft tissue density > 3 cm
Consolidation-pneumonia/tumor
Atelectasis-air is reabsorbed
 Lucent
 Hyperinflation-COPD
 Pneumothorax-spontaneous
 Cavitary lesions-hollow center
 Others
 Nodular
 Reticular patterns
Masses
Vascular alterations
Lateral Search pattern
 Posterior skin and bones
 Vertebra get lucent lower
 Lucent stuff (normal)




Trachea
Bronchi
Retrosternal space
Retrocardiac space
 Opaque stuff (normal)
 Heart
 Aorta
 Pulmonary arteries
 Anterior skin and bones
 Diaphragm arc
Chest Overview: heart
 Cardiothoracic ratio should be approx 1:2
(heart should take up <55% of thorax)
 Cardiomegaly if above 60%
 Right border should be visible on right side of
vertebral column
 Deviation of heart to left may be due to
 Atelectasis
 Pectus excavatum
Chest Overview: mediastinum
 Contents
 Heart
 Aorta
 Pulmonary arteries
 Esophagus
 Lymph
 Divisions
 Anterior
 Middle
 posterior
Anterior mediastinum
 From sternal to front of
pericardium
 Diff Dx (5’ts)
 Thymoma
 Thyroid
 Teratoma
 Terrible lymphoma
 Terrible aneurysm
Middle mediastinum
 From the pericardium
to the anterior 1/3 of
vertebral body
 Diff Dx
 Bronchogenic
carcinoma
 Lymphoma
Posterior mediastinum
 From posterior 2/3 of
vertebral body to back
of ribs
 Diff Dx
 Neuronal tumors
 Aneurysm
 Paraspinal masses
Chest overview: hilum
 Pulmonary arteries seen as radiopaque
(white) lines on lateral chest
 Left pulmonary artery higher than right
 If any other masses are seen high likelihood
of lung cancer presence
 Pulmonary arteries enlarge in hypertension
(COPD)
AP Lordotic view
 Allows for better
imaging of lung
apicies
 Brachiocephalic
artery better
visualized as well
 1st rib easily viewed
Chest CT
 Chest CT is done with different levels
 Two contrast levels shows different things
 Lung window
Mediastinum window
Chest CT: heart
 Cross section showing parts of the heart
 a=L ventricle
 b=R ventricle
 c=R atrium
 d=L atrium
 e=thoracic
aorta
e
Chest CT: levels
 Aortic arch
 Trachea
 Right Ventricle
 Pulmonary arteries
 Right ventricle
 Left ventricle
Anatomy of the Chest
 2 lungs
 Right has 3 lobes
 Left has 2
 Heart shifted to left
 4 ventricles
 4 valves
 Aorta
 Ascending and
descending
 Trachea
 Divides at carina
into right and left
primary bronchus
 Aortic arch
 Brachiocephalic
trunk
 Left common
carotid
 Left subclavian
Lung diseases
 Solitary pulmonary nodule Diff Dx
 Aka: coin lesion
 Typically in people under 70
 Granulomatous disease (99% of time) if calcified
 Tumor (bronchogenic or mets)
 TB
 Fibrotic repair
 Sarcoidosis
 1,2,3 sign=paratracheal mass and mass in each hilum
Lung diseases
 Granulomatous disease
 99% from Histoplasmosis (central US)
 Almost all calcify
 Findings
 Hilar adenopathy
Lung diseases
 Tuberculosis
 Organism gets walled off (granuloma formation)




and may calcify
Typically in poor areas/countries that are densely
populated (India)
Typically infects the hilum first then may go to
lung apicies (Horner’s syndrome)
May infect the spine producing Pott’s vertebra
May be dormant for years on end
Lung diseases
 Bronchogenic carcinoma
 Typically people over 70
 Solitary pulmonary nodule larger than 3 cm (not
likely to be found if less than 6 cm though)
 Higher incidence in smokers or those with
occupational hazards
 If metastatic it likely came from another lung
cancer
Lung diseases
 Coccidioidomycosis
 San Jauquin Valley fever (SW US) fungal infection
 Findings
 Multiple pulmonary nodules
 Mostly in lung bases
 Mostly with cavitation
Lung diseases
 Pneumonia
 Effects immunocompromised
 Bacterial
 Lobal (focal airspace loss)
 TB-thick walled (miliary, re-infected)
 Fungal-thick walled
 Histoplasmosis, Coccidiomycosis, Cryptococcus,
Aspergillus, Pneumocystis
 Viral
 Influenza, CMV, Varciella
Lung disorders
 Pleural effusion
 Thickening of liquid between pleural space
 Gravity dependent
 Produces pleural friction rub
 Types:
 Transudate-CHF or neoplasm (from plasma)
 Exudate (from plasma)
 Empyema-infection (from organisms)
 Hemothorax-bleed (pure blood)
 Chylothorax-trauma or neoplasm (lymph duct rupture)
Lung disorders
 Atelectasis
 Defined as incomplete inflation of the lung
 Multiple etiologies
 Cicatrization (lung pulled by scar tissue)
 Obstruction (bronchogenic carcinoma)
 Resorption of air from alveoli
 Indirect signs
 Displaced mediastinum, tracheal deviation, hilum
deviation, diaphragmatic elevation, intercostal
narrowing
 Direct sign=fissure displacement
Lung disorders
 COPD (Chronic Obstructive Lung Disease)
 #1 cause is Emphysema  Findings
 Cystic fibrosis
 Barrel chest
 Chronic asthma
 Low diaphragm
 Chronic bronchitis
 Vertical, small heart
 Bronchiectasis
 Hyper lucent lungs
 Patterns
 Pink puffer
 Blue bloater
 Large retrosternal
space
 Dilated central
pulmonary artery
Lung disorders
 Cystic fibrosis
 #1 autosomal carried disorder
 Fibrotic repair of the lungs due to chronic
pneumonia
 Chronic pneumonia due to plugged air passages
due to thickened mucous secretions
 Bronchiectasis
 Abnormal widening of bronchial tubes
 Due to recurrent infections
Heart disorders
 Cor Pulmonale
 Right ventricular hypertrophy due to pulmonary
hypertension
 Typically caused by COPD
 Congestive heart failure
 Left ventricle hypertrophy
 Caused by systemic hypertension
Diaphragm disorders
 Elevation of the diaphragm (should be at 10th
rib)
 Atelectasis
 Paresis of diaphragm (phrenic nerve compressed
in mediastinum)
 Push from abdominal contents
 Eventration=congenital anomaly
 Referral to neck and shoulders
 Air underneath=peritonitis
Rib disorders
 Lytic destruction
 Mets
 Commonly from the lung
 Myeloma
 Raindrop pattern
 Positive lab tests
 Blastic building
 Primary tumor
 Prostate mets
 Get bone scan if hot in many areas then mets
Mediastinal disorders
 Aortic
 Tortuosity=twisting of aorta due to hypertension
 Aneurysm
 Dissection (tearing)
 Lymph
 Lymphadenopathy (widening of mediastinum)
 Mets to lymph nodes (widening of mediastinum)
Aortic aneurysm
 Bulging or swelling of circumference of a
blood vessel (aorta)
 Causes
 Atherosclerosis
 Aortitis (due to syphilis)
 Vasculitis
 Cystic necrosis
 Trauma
 Marfan’s syndrome
True aneurysm
Involves all layers
Saccular or fusiform
False aneurysm
Involves media and
adventitia
Has false lumen
Abdominal disorders
 Peritonitis will cause air under the right
hemidiaphragm due to rupture of a hollow
organ
 Multiple air fluid levels
 Indicates small bowel obstruction
Head and neck disorders
 Horner’s syndrome
 Meiosis, ptosis, anhydrosis
 Caused by compression of cervical chain
sympathetics by apical lung tumor
 Pancoast syndrome
 Horner’s plus arm pain and tingling
 Caused by compression of brachial plexus by
malignant tumor
Vertebral disorders
 Scoliosis
 After 55° curvature noted the risk of pulmonary
hypertension increases->Cor Pulmonale
Congenital anomalies
 Tetrology of Fallot
 Pulmonary stenosis
 Inter-ventricular defect
 Dextroposed (right sided) aorta getting blood
from both ventricles
 Right ventricle hypertrophy
 Findings
 Pulmonary oligemia (less vessels in lungs)
 Boot shaped heart
Congenital anomalies
 Tricuspid atresia
 Anomalous tricuspid valve
 Atrial septal defect
 Left ventricle hypertrophies due to increased load
(does work of right and left ventricles)