Radiology Review Manual PDF 8th Edition

FHB (FOUAD GARATY ) Radiology Review Manual 8th edition Wolfgang Dähnert, MD Department of Radiology Aurora Bay Care Medical Center Green Bay, Wisconsin 2 Acquisitions Editor: Ryan Shaw Editorial Coordinator: Lauren Pecarich Senior Production Project Manager: Alic...

FHB (FOUAD GARATY ) Radiology Review Manual 8th edition Wolfgang Dähnert, MD Department of Radiology Aurora Bay Care Medical Center Green Bay, Wisconsin 2 Acquisitions Editor: Ryan Shaw Editorial Coordinator: Lauren Pecarich Senior Production Project Manager: Alicia Jackson Design Coordinator: Stephen Druding Manufacturing Coordinator: Beth Welsh Marketing Manager: Dan Dressler Prepress Vendor: Aptara, Inc Eighth edition Copyright © 2017 Wolters Kluwer Seventh Edition © 2011 by Lippincott Williams & Wilkins, a Wolters Kluwer business Sixth Edition © 2007 by Lippincott Williams & Wilkins Fifth Edition © 2003 by Lippincott Williams & Wilkins Fourth Edition © 1999 by Williams & Wilkins Third Edition © 1996 by Williams & Wilkins Second Edition © 1993 by Williams & Wilkins First Edition © 1991 by Williams & Wilkins All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com (products and services). 987654321 Printed in China Library of Congress Cataloging-in-Publication Data Names: Dähnert, Wolfgang, author. Title: Radiology review manual / Wolfgang Dähnert. Description: Eighth edition. | Philadelphia : Wolters Kluwer, | Includes bibliographical references and index. Identifiers: LCCN 2016044206 | ISBN 9781496360724 Subjects: | MESH: Radiography | Diagnosis, Differential | Diagnostic Imaging | Outlines Classification: LCC RC78.17 | NLM WN 18.2 | DDC 616.07/572–dc23 LC record available at https://lccn.loc.gov/2016044206 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work. 3 This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work. LWW.com 4  “If a little knowledge is dangerous, where is the man who has so much to be out of danger!” T.H. Huxley, 1825–1895 from Elementary Instruction in Physiology published in 1877 “It is the tragedy of the world that no one knows what he doesn’t know — and the less a man knows, the more sure he is that he knows everything” Joyce Cary, British author 1888–1957 “Nothing in the world can take the place of persistence. Talent will not; nothing is more common than unsuccessful men with talent. Genius will not; unrewarded genius is almost a proverb. 5 Education will not; the world is full of educated derelicts. Persistence and determination alone are omnipotent.” Calvin Coolidge 1872–1933 Vice President 1921–1923 President 1923–1929 6  About the Author Wolfgang Dähnert, M.D. Wolfgang Dähnert was born in Hamburg, Germany. After graduating from the Wilhelm-Gymnasium High School in Braunschweig, Lower Saxony, in 1966 he enlisted into the German Air Force for four years. After his discharge from the armed services he studied medicine at the Heinrich-Heine Universität in Düsseldorf, North Rhine-Westphalia, for his preclinical years and at the Johannes- Gutenberg Universität in Mainz, Rhineland-Palatinate, for his clinical years. He graduated from medical school in 1975 and received his doctor of medicine degree shortly thereafter based on his dissertation “Pulse Flow Photocytometry of Prostate Punch Biopsies”. A one-year rotating internship in urology, internal medicine and sports medicine at the Johannes-Gutenberg Universität and at the municipal Dr. Horst Schmidt Klinik in Wiesbaden was followed by a one-year residency in general surgery at the Deutsches Rotes Kreuz Krankenhaus in Mainz, Germany. In 1978 he switched to begin a residency in radiology at the municipal and teaching hospital in Darmstadt, Hesse, under the directorship of Prof. H.K. Deininger. He continued his education in diagnostic 7 and therapeutic radiology at the Johannes-Gutenberg Universität in Mainz under the directorship of Prof. Manfred Thelen and Prof. Rolf W. Günther receiving his German certification for radiology in 1982. Dr. Dähnert started a 2-year fellowship in ultrasound and computed tomography at the Johns Hopkins Hospital in Baltimore in 1984 under the leadership of Roger Sanders / Ulrike Hamper and Stanley Siegelman / Elliot Fishman and was appointed Clinical Instructor in 1986. In 1985 he sat for the federal licensing exam, and in 1987 took his oral exam in diagnostic radiology in Louisville, Kentucky. The American Board of Radiology had approved a 2-year fellowship program for him in lieu of a residency in radiology. The foundation of Radiology Review Manual was laid during the three years at Hopkins while preparing for the ABR exam. Between 1987 and 1989 he worked as Assistant Professor of Radiology in ultrasound at Thomas Jefferson Hospital in Philadelphia under Barry Goldberg. During this period in Philadelphia Radiology Review Manual was taken to fruition culminating in the publication of its first edition in 1991. Dr. Dähnert joined Clinical Diagnostic Radiology & Nuclear Medicine in Phoenix, AZ, in 1989 as director of ultrasound. This group practice of approximately 25 mostly fellowship-trained radiologists served three center city hospitals and their affiliated residency program in radiology, the latter at St. Joseph’s Hospital and Medical Center, before it ceased operations in 2006 brought about by a fiscally unsustainable management style and culture. In September of 2004 Dr. Dähnert relocated to Green Bay, Wisconsin, joining a group of eight radiologists as part of a multispecialty group practice at Aurora BayCare Medical Center, the northern hub of Aurora Health Care, one of Wisconsin’s largest private-sector employers. 8  PREFACE Since the first publication of Radiology Review Manual in 1990 momentous changes have occurred in radiology. We have progressed from films developed in the dark-room to images on a computer screen. We have gone from an initially voluntary lifetime certificate of qualification to a never-ending process of proving to the public that our knowledge, skills, and clinical ability in the area of radiology has kept apace with the times. The first ABR Core Examination took place in October 2013. It tests knowledge and comprehension of anatomy, pathophysiology, physics and all aspects of diagnostic radiology including breast, cardiac, gastrointestinal, interventional, musculoskeletal, neuroradiology, nuclear, pediatric, reproductive/endocrinology, thoracic, urinary, vascular, computed tomography, magnetic resonance, radiography/fluoroscopy, ultrasound, physics, safety and radioisotope safety. The first Certifying Examination was in fall 2015. Given the predominant practice pattern in the United States I estimate that General Radiology makes up at least 10% to 20% of the work a radiologist with subspecialty training is asked to perform. This is true for the vast majority of radiology practices, with the possible exception of those practices that employ more than 20 radiologists. Our clinical colleagues expect from us a depth of medical knowledge and familiarity with all imaging modalities suitable to address their clinical questions, regardless of our favored subspecialty. To remain relevant to them we need to stay current at their level. Commensurate with an explosion of knowledge in medicine the number of pages for this volume have more than doubled, while radiologists have been squeezed between knowing more and reading faster. Radiology Review Manual has developed over the years from a simple preparatory text for the “oral boards” to something that has kept pace with my own growth in radiology. Since 1987 and between editions I have never stopped working on this book: new (eg, genetic) insights were added, variations in categorizations amended, words tweaked, numbers changed, and statements clarified. It is my humble attempt to put into a single reference much of the information that is or could be relevant to my practice and, hopefully, also yours. The decision for inclusions or omissions herein have always been governed by my own practical needs. We have conducted a survey among radiology residents to help us with the decision what topics to delete in an effort to diminish the number of pages. The results showed such a wide variation in opinions that I didn’t have the guts to wield the eraser at all. A single author book does not require collaboration, and thankfully I didn’t have to defend this decision. The popularity of the “green giant” or the “green bible”, as it has been dubbed by residents, and the continued impressive number of sales and several translations into other languages confirms the usefulness of this type of publication. The outline style chosen for the sake of conserving space provides only an extract of information and may, at times, jeopardize the intended meaning of statements without any prior background knowledge of the subject. Accordingly, be careful, this book is not intended for the uninitiated. How to use this book: I have selected one of many possible ways to organize a book of this size and scope with the intent 9 to cover all modalities and provide room for growth and change over time. The material is presented anatomically from head to heel (when possible) to avoid duplications and save space. Systemic diseases have been forced into this topographical scheme rather than occupying a separate section. Departing from prior editions, NUC imaging findings are now relegated to the respective entity. A general section has been introduced that also includes some aspects about techniques in nuclear medicine in addition to contrast media, statistics, sedation, analgesia, and local anesthesia. As in the 6th edition I hope we can again use the inside of the cover pages to provide immediate access for accepted therapies of contrast reactions. The organization within the individual chapters follows the practical approach of reading images. Often the initial step of image interpretation is to scrutinize for a radiologic pattern that may help suggest the disease process at hand. Therefore, differential diagnoses of radiologic patterns are presented in the first section of a chapter. Occasionally, important clinical signs and their differential diagnoses, relevant to the practice of radiology, are included in the first portion of a chapter as well. Lists of differential diagnoses can be presented in many fashions. There is no right or wrong way, but there certainly is a chaotic versus an organized approach. Accordingly, an attempt is made to categorize differential diagnostic considerations or etiologies of certain diseases in a manner digestible for recapitulation. It is a common experience that this is not always possible, logically satisfactory, or complete. The majority of this book deals with disease entities presented in the last section of a chapter. The disease entities are presented in alphabetical order and headed by their most commonly used name with other designations listed below. Not infrequently and without explanations name switches occur from one publication to another. As a radiologic diagnosis should be entertained in context with its probability to be correct, percentages in regard to frequency of signs and symptoms are included liberally, often giving the lowest and the highest number found in the literature. The truth may be somewhere in between for nonselected patient populations, and occasionally a third number is provided between the high and low number as the most frequently cited. I had to arbitrate choices when different or contradictory results are found in the literature – unfortunately, an occurrence not at all infrequent. This latest edition includes text on a gray background to guide the reader toward an emphatic statement made by a speaker or author on a particular topic. These two sections in each chapter are separated by a few pages of functional, anatomic, or embryologic aspects. Mnemonics (which I personally abhor) have been liberally added. The index, which selectively refers to those pages with significant information, concludes the manual and is usually the starting point for many. The index also includes so-called “buzz words” that are miraculously attached to diseases. Acknowledgement: Various sources are responsible for the content: individuals (named in prior editions), ACR syllabi, handouts from various CME courses, major textbooks, hand-written notes taken during lectures, feed-back from board examinees and most importantly the journals dedicated to imaging with brilliant review articles, in particular the practice-oriented publication of Radiographics. Accordingly, the material in this book is a compilation and extraction of other’s work presented from my perspective of relevance and perhaps with omissions of my ignorance. Our radiologic ancestors, mentors, teachers and scientists alike, throughout the world deserve our admiration and gratitude for the collective knowledge passed on to us for the benefit of our profession and our 10 http://pdfradiology.com patients. I realize, in retrospect, that the omission of references may present a problem when certain statements appear unlikely and their verification has to be left to the user. For my defense, I can say that I have tried to extract all data as diligently as possible. I sincerely hope that Radiology Review Manual will serve you in your preparation for the board exam, in teaching situations, and particularly in your daily work assignments — the way it continues to help me. Green Bay, August 2016 11 http://pdfradiology.com  CONTENTS Treatment of Adverse Contrast Reactions1 Treatment of Adverse Contrast Reactions2 Preface Abbreviations MUSCULOSKELETAL SYSTEM Differential Diagnosis of Musculoskeletal Disorders Anatomy and Metabolism of Bone Bone and Soft-Tissue Disorders CENTRAL NERVOUS SYSTEM Differential Diagnosis of Skull and Spine Disorders Anatomy of Skull and Spine Skull and Spine Disorders Differential Diagnosis of Nervous System Disorders Anatomy of the Nervous System Nervous System Disorders ORBIT Differential Diagnosis of Orbital and Ocular Disorders Anatomy of Orbit Orbital and Ocular Disorders EAR, NOSE AND THROAT7 Differential Diagnosis of Ear, Nose, and Throat Disorders Anatomy and Function of Neck Organs Ear, Nose, and Throat Disorders CHEST Differential Diagnosis of Chest Disorders Anatomy and Function of Lung Chest Disorders BREAST 12 http://pdfradiology.com  Differential Diagnosis of Breast Disorders Breast Anatomy and Mammographic Technique Breast Disorders HEART AND GREAT VESSELS Differential Diagnosis of Cardiovascular Disorders Cardiovascular Anatomy Cardiovascular Disorders LIVER, BILE DUCTS, PANCREAS AND SPLEEN Differential Diagnosis of Hepatic, Biliary, Pancreatic and Splenic Disorders Anatomy of Liver, Bile ducts, Pancreas and Spleen Disorders of Liver, Biliary Tract, Pancreas and Spleen ABDOMEN AND GASTROINTESTINAL TRACT Differential Diagnosis of Gastrointestinal and abdominal Disorders Anatomy and Function of Abdomen and Gastrointestinal Tract Gastrointestinal and Abdominal Disorders UROGENITAL TRACT Differential Diagnosis of Urogenital Disorders Anatomy and Function of Urogenital Tract Renal, Adrenal, Ureteral, Vesical, and Scrotal Disorders OBSTETRICS AND GYNECOLOGY Differential Diagnosis of Obstetric and Gynecologic Disorders Anatomy and Physiology of the Female Reproductive System Radiology Considerations for Mother & Fetus & Neonate Obstetric and Gynecologic Disorders GENERAL RADIOLOGY Nuclear Medicine Statistics Contrast Media, Nephrotoxicity, Premedication, Control of Heart Rate Sedation, Analgesia, Local Anesthesia INDEX 13 http://pdfradiology.com  ABBREVIATIONS √ radiologic sign clinical sign, symptom = equals, is ≠ is not @ at anatomic location of / or, per + and, plus, with ± with or without < less than > more than, over › separation of points » method ◊ important comment → leads to, is followed by ← due to, 2° to, caused by ↑ increased ⇑ much increased ↓ decreased ⇓ much decreased ↔ unchanged ~ about, approximately ÷ ratio 1° primary 2° secondary 2-D two-dimensional 3-D three-dimensional 5-HIAA 5-hydroxyindole acetic acid aa. arteries AAA abdominal aortic aneurysm AAAs abdominal aortic aneurysms ABC aneurysmal bone cyst ABER abduction + external rotation ABO blood group ABR American Board of Radiology 14 http://pdfradiology.com AC abdominal circumference ACA anterior cerebral artery ACE angiotensin I–converting enzyme ACEI angiotensin-converting enzyme inhibitor ACL anterior cruciate ligament aCom anterior communicating artery ACR American College of Radiology ACTH adrenocorticotropic hormone ADC apparent diffusion coefficient ADH antidiuretic hormone; atypical ductal hyperplasia ADPKD adult polycystic kidney disease AF-AFP amniotic fluid alpha-fetoprotein AFI amniotic fluid index AFP alpha-fetoprotein AICA anterior inferior cerebellar artery AIDS acquired immune deficiency syndrome AIP acute interstitial pneumonia AJCC American Joint Committee on Cancer ALARA as low as reasonably achievable AlkaPhos alkaline phosphatase ALL acute lymphoblastic leukemia ALPSA anterior labroligamentous periosteal sleeve avulsion ALSA aberrant left subclavian artery ALT alanine aminotransferase AMA antimitochondrial antibody AML acute myeloblastic leukemia; angiomyolipoma aML anterior mitral valve leaflet AMLs angiomyolipomas ANA antinuclear antibodies ANCA antineutrophil cytoplasmic autoantibodies Angio angiography ANT anterior Ao aorta AP anteroposterior; arterial phase; alkaline phosphatase APA aldosterone producing adenoma aPL-ab antiphospholipid antibody approx. approximately APUD amine precursor uptake and decarboxylation APUDomas endocrine cells tumors APVR anomalous pulmonary venous return 15 http://pdfradiology.com APW absolute percentage washout ARA-C arabinoside C ARDS acute respiratory distress syndrome ARF acute renal failure AS aortic stenosis ASA acetylsalicylic acid ASD atrial septal defect ASH asymmetric septal hypertrophy AST aspartate aminotransferase ATN acute tubular necrosis ATP adenosine triphosphate AV arteriovenous; atrioventricular AVF arteriovenous fistula AVM arteriovenous malformation AVMs arteriovenous malformations AVN avascular necrosis AVNA atrioventricular node artery Ba barium BAH bilateral adrenal hyperplasia BAL bronchoalveolar lavage BALT bronchus-associated lymphoid tissue BCG bacille Calmette-Guérin BCNU bis-chloronitrosourea BDI basion-dens interval BE barium enema BF blood flow b.i.d. bis in die, Latin = twice per day BIDA butyl iminodiacetic acid BI-RADS Breast Imaging Reporting and Data System BIH benign intracranial hypertension BKG background BKGcounts background counts BLC biceps-labral complex BLL benign lymphoepithelial lesions BMD bone marrow density BOOP bronchiolitis obliterans organizing pneumonia BP blood pressure BPD biparietal diameter BPH benign prostatic hyperplasia 16 http://pdfradiology.com bpm beats per minute BPP biophysical profile Bq Becquerel (1 Bq = one nucleus decays per sec) BRCA breast cancer suppressor gene BSA body surface area BSO bilateral salpingo-oophorectomy Bx biopsy Ca calcium Ca2+ calcium ion c-ANCA cytoplasmic pattern of antineutrophil cytoplasmic autoantibodies CA-125 cancer antigen 125 CABG coronary artery bypass grafting CAD coronary artery disease CADASIL cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy CAM cystic adenomatoid malformation CBD common bile duct CBF cerebral blood flow cBPD corrected biparietal diameter CBV cerebral blood volume CC craniocaudad CCA common carotid artery CCK cholecystokinin CCMC common carpometacarpal joint CCNU 1-(2-Chloroethyl)-3-cyclohexyl-1-nitrosourea CD4 specialized lymphocyte responsible for cell-mediated immunity CDC Center for Disease Control CDH Congenital Diaphragmatic Hernia CEA carcinoembryonic antigen CECT contrast-enhanced computed tomography CEMR contrast-enhanced MR CF cystic fibrosis CFI color flow imaging CFTR cystic fibrosis transmembrane regulator gene cGy centigray = rad CHAOS Congenital high airway obstruction syndrome CHD common hepatic duct; congenital heart defect CHF congestive heart failure CLL chronic lymphatic leukemia 17 http://pdfradiology.com cm centimeter cm2 square centimeter cm3 cubic centimeters CMC carpometacarpal CME continuing medical education CML chronic myelogenous leukemia CMV Cytomegalovirus CN cranial nerve CNS central nervous system CO carbon monoxide CoA coarctation of aorta COPD chronic obstructive pulmonary disease COW circle of Willis CP cerebellopontine CPA cerebellopontine angle CPAP continuous positive airway pressure CPD cardiopulmonary disease CPDN cystic partially differentiated nephroblastoma cpm counts per min CPPD calcium pyrophosphate dihydrate CPR cardiopulmonary resuscitation cps counts per sec cRCC conventional renal cell cancer; cystic renal cell cancer CRF chronic renal failure CRL crown rump length CRT cathode ray tube CSF cerebrospinal fluid CSI chemical shift imaging CST contraction stress test C/T cardiothoracic ratio CT computed tomography CTA computed tomography angiogram CVA cerebrovascular accident CVC central venous catheter CVJ craniovertebral junction CVS chorionic villus sampling CWP coal worker’s pneumoconiosis Cx complication CXR chest x-ray CXRs chest x-rays 18 http://pdfradiology.com d day(s) D5W solution of 5% dextrose in water DCBE double-contrast barium enema DCIS ductal carcinoma in situ DDH developmental dysplasia of hip DDx differential diagnosis DES diethylstilbestrol DEXA dual energy X-ray absorptiometry DFSP dermatofibrosarcoma protuberans DIC disseminated intravascular coagulation DIDA diethyl iminodiacetic acid DIP desquamative interstitial pneumonia; distal interphalangeal DISH diffuse idiopathic skeletal hyperostosis DISIDA diisopropyl iminodiacetic acid dist distal DIT diiodotyrosine DLCL diffuse large cell lymphoma DLCO diffusion capacity of lung for carbon monoxide DMSA dimercaptosuccinic acid DORV double outlet right ventricle DPLD diffuse parenchymal lung disease DSA digital subtraction angiography DTPA diethylenetriamine pentaacetic acid DVT deep vein thrombosis DWI diffusion weighted images Dx diagnosis dz disease EAC external auditory canal EBV Epstein-Barr virus EC-cells enterochromaffin cells ECA external carotid artery ECD endocardial cushion defect; ethyl cysteinate dimer ECF extracellular fluid ECG electrocardiogram ECHO echocardiogram; enteric cytopathic human orphan (virus) ECMO extracorporeal membrane oxygenation EDD enddiastolic diameter EDTA ethylenediaminetetraacetic acid 19 http://pdfradiology.com EDV enddiastolic volume EEG electroencephalogram EF ejection fraction EFW estimated fetal weight EG eosinophilic granuloma eg exempli gratia EGA estimated gestational age EHDP ethylene hydroxydiphosphonate EKG electrocardiogram ELISA enzyme-linked immunosorbent assay EMA epithelial membrane antigen ENT ear, nose and throat ErbB epidermal growth factor receptor gene ERC endoscopic retrograde cholangiography ERCP endoscopic retrograde cholangiopancreatography ERPF effective renal plasma flow ERV expiratory reserve volume ESD endsystolic diameter esp. especially ESR erythrocyte sedimentation rate EtOH ethanol ESV end-systolic volume F female; fluorine Fab fragment antigen binding FAI femoroacetabular impingement FAP familial adenomatous polyposis FDA Federal Drug Administration FDG fluorodeoxyglucose Fe2+ ferrous ion Fe3+ ferric state FEV forced expiratory volume FEV1 FEV at 1 sec FEV3 FEV at 3 sec FHM fetal heart motion FIGO Fédération Internationale de Gynécologie et d’Obstétrique FISH fluorescence in situ hybridization FK-506 code number for tacrolimus FL femur length FLAIR fluid-attenuated inversion recovery sequence 20 http://pdfradiology.com FLASH fast low-angle shot FN false negative FNAB fine needle aspiration biopsy FNH follicular nodular hyperplasia FOOSH fall on outstretched hand FP false positive Fr French = unit of linear measure of circumference (1 F = 1/3 mm ≈ 1 mm in diameter) FRC functional residual capacity FS fractional shortening FSE fast spin echo FSH follicle stimulating hormone FVC forced vital capacity FWHM full-width at half-maximum Fx fracture GA gestational age GB gallbladder GBM glioblastoma multiforme GCT giant cell tumor; granulosa cell tumor GCTs giant cell tumors Gd gadolinium GDA gastroduodenal artery GE gastroesophageal GER gastroesophageal reflux GERD gastroesophageal reflux disease GFR glomerular filtration rate GH growth hormone GHA glucoheptonate GI gastrointestinal GIST gastrointestinal stromal tumor GMP guanosine monophosphate GMRH germinal matrix–related hemorrhage GN glomerulonephritis GNRH gonadotropin releasing hormone GRASS gradient recalled acquisition in steady state GRE gradient refocused echo GS gestational sac GSV great saphenous vein GnRH gonadotropin releasing hormone 21 http://pdfradiology.com GU genitourinary Gy 1 gray = absorption of 1 joule of ionizing radiation by 1 kilogram of matter = 1 J kg-1 = 1 m2 sec-2 γGT gamma-glutamyltransferase HAART highly active antiretroviral therapy HAGL humeral avulsion of the glenohumeral ligament Hb hemoglobin HBME-1 mouse monoclonal antibody to mesothelioma HBP high blood pressure HBV hepatitis B virus HC head circumference HCC hepatocellular carcinoma HCCs hepatocellular carcinomas hCG human chorionic gonadotropin HCl hydrochloric acid Hct hematocrit HD Hodgkin disease HELLP hemolysis, elevated liver enzymes, low platelets Hg mercury HHV8 human herpes virus type 8 HIAA hydroxyindole acetic acid HIDA hepatic 2,6-dimethyl iminodiacetic acid HIE hypoxic ischemic encephalopathy Histo histology HIV human immunodeficiency virus HL Hodgkin lymphoma HLA human leukocyte antigen HMB-45 monoclonal antibody against human melanoma black HMPAO hexamethylpropyleneamine oxime = exametazime HNP herniated nucleus pulposus HOCM hypertrophic obstructive cardiomyopathy; high-osmolar contrast media HPF high power field (400 x magnification) HPO hypertrophic pulmonary osteoarthropathy HPS hypertrophic pyloric stenosis HPT hyperparathyroidism HPV human papilloma virus hr hour(s) HRCT high-resolution CT HRT hormone replacement therapy 22 http://pdfradiology.com HSA human serum albumin HSG hysterosalpingography HSV herpes simplex virus HTN hypertension HU Hounsfield unit HV hepatic vein HypoPT hypoparathyroidism Hx history IAA interruption of aortic arch IAC internal auditory canal ICA internal carotid artery ICBT intercostal bronchial trunk a. ICP intracranial pressure IDA iminodiacetic acid IDC invasive ductal carcinoma IDDM insulin-dependent diabetes mellitus IDM infant of diabetic mother ie id est IgA Immunoglobulin A IgE Immunoglobulin E IgG Immunoglobulin G IGL inferior glenohumeral ligament IGHLC inferior glenohumeral labroligamentous complex IGL inferior glenohumeral ligament IgM immunoglobulin M IHSS idiopathic hypertrophic subaortic stenosis IIP idiopathic interstitial pneumonia ILC invasive lobular carcinoma IM intramuscular IMA inferior mesenteric artery IMH intramural hematoma IMV inferior mesenteric vein In indium inf inferior intermed intermediate IPF idiopathic pulmonary fibrosis IPH idiopathic pulmonary hemosiderosis; intraparenchymal hemorrhage IPMT intraductal papillary mucinous tumor IQ intelligence quotient 23 http://pdfradiology.com IR inversion recovery IRP international reference preparation IRU inferior radioulnar joint IRV inspiratory reserve volume IS iliosacral; international standard IU international unit = amount of a substance, based on measured biological activity or effect IUD intrauterine device IUGR intrauterine growth retardation IUP intrauterine pregnancy IV intravenous IVC inferior vena cava IVDA intravenous drug abuse IVH intraventricular hemorrhage IVP intravenous pyelogram IVS intraventricular septum IVU intravenous urogram JAA juxtaposition of atrial appendages KCC Kulchitsky cell carcinoma kDa atomic weight in terms of kilodaltons keV 1 kiloelectron volt = 1.60217646 × 10-16 joules kV kilovolt kVp kilovolt peak KUB kidney + ureter + bladder on one film L left L-DOPA 3-(3,4-dihydroxyphenyl)-levo-alanin LA left atrium LAD left anterior descending LAO left anterior oblique LAT lateral LATS long-acting thyroid stimulating lbs pounds (Libra pondo, Latin) LCA left coronary artery LCH Langerhans cell histiocytosis LCIS lobular carcinoma in situ LCL lateral collateral ligament LCx left circumflex coronary artery 24 http://pdfradiology.com LDH lactate dehydrogenase LE lupus erythematosus LES lower esophageal sphincter LFTs liver function tests LGA large for gestational age LGE late gadolinium-induced enhancement LH luteinizing hormone LHBB long head of biceps brachii LHRH luteinizing hormone releasing hormone lig. ligament ligg. ligaments LIP lymphocytic interstitial pneumonitis LL lower lobes LLL left lower lobe LLQ left lower quadrant LM left main coronary artery; lateromedial LMP last menstrual period Lnn lymph nodes LOCM low-osmolar contrast media LPA left pulmonary artery LPD lymphoproliferative disease LPO left posterior oblique LPV left portal vein L/S Lecithin-Sphingomyelin (ratio) LSA left subclavian artery LSD lysergic acid diethylamide LUL left upper lobe LUQ left upper quadrant LV left ventricle LVEF left ventricular ejection fraction LVET left ventricular ejection time LVFT1 left ventricular fast filling time LVOT left ventricular outflow tract LVPW left ventricular posterior wall M male m meter m. muscle MA menstrual age MAA macroaggregated albumin 25 http://pdfradiology.com MAG mercaptoacetyltriglycine MAI Mycobacterium avium intracellulare MALT mucosa-associated lymphoid tissue Mammo mammography max. maximum MBC maximum breathing capacity MBq mega Becquerel = 106 Bq MCA middle cerebral artery MCDK multicystic dysplastic kidney mCi millicurie (1 mCi = 3.7×107 disintegrations per sec) MCP metacarpophalangeal MCL medial collateral ligament MDMA 3,4-methylenedioxymethamphetamine MDP methylene diphosphonate MEA multiple endocrine adenomas MED medial MELAS Mitochondrial myopathy, Encephalopathy, Lactic acidosis, And Strokelike episodes MEN multiple endocrine neoplasms mEq milliequivalent mets metastases MFH malignant fibrous histiocytoma MGL middle glenohumeral ligament mGy absorbed energy of ionizing radiation (1 Gy = 1 J kg-1 = 1 m2 sec-2) MHA microhemagglutination assay MIBG metaiodobenzylguanidine MIBI methoxyisobutylisonitril min. minimum min minute(s) MIP maximum intensity projection MIT monoiodotyrosine mIU 1 10-6 IU ML middle lobe MLCN multilocular cystic nephroma MLO mediolateral oblique mm. muscles MMAA mini-microaggregated albumin colloid MMFR maximal midexpiratory flow rate mo month(s) MoM multiple of mean 26 http://pdfradiology.com MPA main pulmonary artery MPS mucopolysaccharidosis MPV main portal vein MR magnetic resonance MRA magnetic resonance angiography MRCP magnetic resonance cholangiopancreatography MRV magnetic resonance venography MS-AFP maternal serum - fetoprotein mSv millisievert (1 Sv = 1 J/kg) MT metatarsal MTP metatarsophalangeal MTT mean transit time MUGA multiple gated acquisition MV mitral valve MVA motor vehicle accident MVC motor vehicle collision Myelo myelography NASCET North American symptomatic endarterectomy trial N.B. nota bene NCCT noncontrast CT NECT nonenhanced computed tomography NF1 neurofibromatosis type 1 NG nasogastric NHL non-Hodgkin lymphoma NIDDM non-insulin dependent diabetes mellitus nn. nerves NMLE non-masslike enhancement NOS not otherwise specified npl neoplasm NPO nulla per os NPV negative predictive value NRC Nuclear Regulatory Commission NSAID nonsteroidal antiinflammatory drug NSAIDs nonsteroidal antiinflammatory drugs NSIP nonspecific interstitial pneumonia NST nonstress test NTD neural tube defect NTDs neural tube defects NUC nuclear medicine 27 http://pdfradiology.com OB obstetrical OB-US obstetrical ultrasound OBL oblique OEIS omphalocele, (bladder) exstrophy, imperforate anus, spinal defects OFD occipitofrontal diameter OHSS ovarian hyperstimulation syndrome OI osteogenesis imperfecta OIH orthoiodohippurate OKC odontogenic keratocyst P phosphorus p-ANCA perinuclear antineutrophil cytoplasmic autoantibodies PA posteroanterior; pulmonary artery PACs premature atrial contractions PAH para-aminohippurate; precapillary pulmonary arterial hypertension PALM premature with accelerated lung maturity PAP primary atypical pneumonia; pulmonary alveolar proteinosis PAPVR partial anomalous pulmonary venous return PAS periodic acid Schiff PASH pseudoangiomatous stromal hyperplasia Path pathology PAVM pulmonary arteriovenous malformation PAWP pulmonary artery wedge pressure PBF pulmonary blood flow PCA posterior cerebral artery PCKD polycystic kidney disease PCL posterior cruciate ligament pCom posterior communicating artery PCP Pneumocystis carinii pneumonia PCWP pulmonary capillary wedge pressure PD posterior descending artery PDA patent ductus arteriosus PE pulmonary embolism PEEP positive end expiratory pressure PEP preejection period PET positron emission tomography, pancreatic endocrine tumor PFT pulmonary function tests pHPT primary hyperparathyroidism PHPV persistent hyperplastic primary vitreous 28 http://pdfradiology.com PHypoPT pseudohypoparathyroidism PICA posterior inferior cerebellar artery PID pelvic inflammatory disease PIE pulmonary infiltrate with eosinophilia; pulmonary interstitial emphysema PIOPED prospective investigation of pulmonary embolus detection PIP proximal interphalangeal PIPIDA paraisopropyl iminodiacetic acid PLCH pulmonary Langerhans cell histiocytosis PLSA posterolateral segment artery pML posterior mitral valve leaflet PMMA polymethylmethacrylate PMN polymorphonuclear PMNs polymorphonuclears PMT photomultiplier tube PNET primitive neuroectodermal tumor PNST peripheral nerve sheath tumor PO per os, Latin = by mouth pO2 oxygen pressure POST posterior PPD purified protein derivative PPG photoplethysmography PPHypoPT pseudopseudohypoparathyroidism ppm parts per million PPROM preterm premature rupture of membranes PPV positive predictive value; positive-pressure ventilation pRCC papillary renal cell cancer preval prevalence p.r.n. pro re nata, Latin = as the circumstance arises PS pulmonary stenosis PSA prostate-specific antigen PSS progressive systemic sclerosis PSV peak systolic velocity PTA percutaneous transluminal angioplasty PTC percutaneous transhepatic cholangiography PTH parathyroid hormone pTL posterior tricuspid valve leaflet PTU propylthiouracil PV portal vein; pulmonary valve PVC polyvinyl chloride PVCs premature ventricular contractions 29 http://pdfradiology.com PVH pulmonary venous hypertension PVL periventricular leukomalacia PVNS pigmented villonodular synovitis PVP portal venous phase PVR pulse volume recording; postvoid residual PYP pyrophosphate QPS quantitative perfusion SPECT R right RA rheumatoid arthritis; right atrium RAA right aortic arch; right atrial appendage rad radiation absorbed dose, in 1975 replaced by gray (Gy) RAIU radioactive iodine uptake RAO right anterior oblique Rb Rubidium RB-ILD respiratory bronchiolitis-associated interstitial lung disease RBC red blood cell RBCs red blood cells RCA right coronary artery RCC renal cell carcinoma RCCs renal cell carcinomas RDS respiratory distress syndrome rel. relative RES reticuloendothelial system RHV right hepatic vein RI resistive index RIBA recombinant immunoblot assay RIND reversible ischemic neurologic deficit RISA radioiodine serum albumin RLAT right lateral RLL right lower lobe RLQ right lower quadrant RML right middle lobe RMS root mean square ROC receiver operating characteristic ROI region of interest ROIs regions of interest RPF renal plasma flow RPO right posterior oblique 30 http://pdfradiology.com RPV right portal vein RPW relative percentage washout RSV respiratory syncytial virus RTA renal tubular acidosis RUL right upper lobe RUQ right upper quadrant RV residual volume; right ventricle RVOT right ventricular outflow tract RVT renal vein thrombosis Rx therapy S1Q3T3 prominent S wave in lead I + Q wave and inverted T wave in lead III S/P status post SAE subcortical arteriosclerotic encephalopathy SAG sagittal SAH subarachnoid hemorrhage SBE subacute bacterial endocarditis SBFT small bowel follow-through SBO small bowel obstruction SCC squamous cell carcinoma SCBE single-contrast barium enema SCLC small cell lung cancer SCMM sternocleidomastoid muscle S/D systolic / diastolic (ratio) SD standard deviation SDS summed difference score SE spin echo Sens sensitivity SGA small for gestational age SGL superior glenohumeral ligament sHPT secondary hyperparathyroidism SI signal intensity SIJ sacroiliac joint SIS Second International Standard SLAP superior labral tear from anterior to posterior SLE systemic lupus erythematosus SMA superior mesenteric artery SMV superior mesenteric vein Sn stannum SNHL sensorineural hearing loss 31 http://pdfradiology.com SOB shortness of breath S/P status post Specif specificity SPECT single photon emission SPIO superparamagnetic iron oxide SQ subcutaneous SRS summed rest score SSS summed stress score STH somatotrophic hormone STIR short tau inversion recovery supp suppositorium, suppository Surg surgery SUV standardized uptake values SVC superior vena cava SVCs superior venae cavae T1WI T1-weighted image T2WI T2-weighted image TAH total abdominal hysterectomy TAPVR total anomalous pulmonary venous return TB tuberculosis TBG thyroxin-binding globulin Tc Technetium TCC transitional cell carcinoma TDLU terminal ductal lobular unit TDLUs terminal ductal lobular units TE echo time TEF tracheoesophageal fistula TGA transposition of great arteries TGV transposition of great vessels tHPT tertiary hyperparathyroidism TIA transitory ischemic attack TIAs transitory ischemic attacks TLC total lung capacity Tm transport maximum across tubular cells Tmax time to maximum peak TMB-IDA 2,4,6-trimethylbromo-acetanilide iminodiacetic acid TN true negative TNF tumor necrosis factor TNM tumor nodes metastasis 32 http://pdfradiology.com TOA tuboovarian abscess TOF tetralogy of Fallot; time of flight TORCH toxoplasmosis, rubella, cytomegalovirus, herpes virus TP true positive TPN total parenteral nutrition TPROM term premature rupture of membranes TR repetition time TRH thyrotropin-releasing hormone TRV transverse TSC tuberous sclerosis TSH thyroid-stimulating hormone TURP transurethral resection of prostate TV tidal volume UA umbilical artery UCL ulnar collateral ligament uE3 unconjugated estriol UGI upper gastrointestinal series UICC Union Internationale Contre le Cancer UIP usual interstitial pneumonia UL upper lobe UPJ ureteropelvic junction URI upper respiratory infection US ultrasound USA United States of America USP United States Pharmacopoeia USP XX United States Pharmacopoeia, 20th edition UTI urinary tract infection UTIs urinary tract infections UVJ ureterovesical junction Uvol urine volume VACTERL vertebral, anorectal, cardiovascular, tracheo-e sophageal fistula, renal, limb anomalies VC vital capacity VCUG voiding cystourethrogram VDRL venereal disease research laboratory vHL Von Hippel-Lindau disease VIP vasoactive intestinal peptides VMA vanillylmandelic acid 33 http://pdfradiology.com VP ventriculoperitoneal V/Q ventilation perfusion VR Virchow-Robin space vs. versus VSD ventricular septal defect VSDs ventricular septal defects VUR vesicoureteral reflux vv. venae, veins WAGR Wilms tumor, aniridia, genital abnormalities, mental retardation WBC white blood cell WBCs white blood cells WDHA watery diarrhea, hypokalemia, achlorhydria WDHH watery diarrhea, hypokalemia, hypochlorhydria WM white matter wk week(s) w/o without WPW Wolff-Parkinson-White wt/vol weight/volume percent = amount of solute in g per amount of solution in mL XGP xanthogranulomatous pyelonephritis YS yolk sac yr year(s) 34 http://pdfradiology.com  TREATMENT OF ADVERSE CONTRAST REACTIONS1 PRINCIPLES OF TREATMENT 1. Give high doses of oxygen 2. Infuse physiologic fluids 3. Establish adequate airway 4. Monitor heart rate & blood pressure ◊ No therapeutic role in acute adverse reaction: antihistamines, H2 antagonists, corticosteroids VASOVAGAL REACTION hypotension (systolic blood pressure < 80 mmHg) with sinus bradycardia (pulse < 60 bpm) dizziness, diaphoresis loss of consciousness ⇒ Monitor vital signs ⇒ Leg elevation > 60° + Trendelenburg position ⇒ Secure airway + O2 6–10 L/min ⇒ Secure IV access + rapid IV infusion of isotonic Ringer’s lactate / normal saline if symptoms persist, add: ⇒ atropine slowly IV 0.6–1.0 mg ⇒ Repeat atropine every 3–5 min slowly IV up to a total dose of 0.04 mg/kg (3 mg) in adults [pediatric: 0.02 mg/kg IV; starting dose: min. 0.1 mg, max. 0.6 mg; may repeat to total dose of 2 mg] DERMAL CONTRAST REACTION hives = urticaria itching = pruritus flushing facial angioedema (= nonpruritic SQ edema of eyelid / peroral) Mild Urticaria ⇒ Discontinue injection if not completed ⇒ No treatment needed in most cases ⇒ H1-antihistamine, ie diphenhydramine (Benadryl®) PO/IM/IV 25–50 mg or hydroxyzine (Vistaril®) PO/IM/IV 25–50 mg Severe Urticaria add H2-antihistamine: ⇒ cimetidine (Tagamet®) 300 mg PO / slowly IV (diluted in 20 mL D5W solution) 35 http://pdfradiology.com  [pediatric: 5–10 mg/kg diluted in 20 mL D5W solution] or ranitidine (Zantac®) 50 mg PO / slowly IV (diluted in 20 mL D5W solution) if widely disseminated: ⇒ IV line started + kept open (with normal saline / Ringer’s lactate) ⇒ epinephrine IV (1÷10,000) IV slowly over 2–5 min 1.0 mL (= 0.1 mg) if no cardiac contraindication NAUSEA / VOMITING may be the 1st signs of a more severe reaction ⇒ watch patient closely RESPIRATORY DISTRESS wheezing (inconsequential) bronchoconstriction (life-threatening) laryngeal edema (life-threatening) Facial / Laryngeal Edema ⇒ epinephrine SQ (1÷1,000) 0.1–0.2 mL (= 0.1–0.2 mg) or – if patient hypotensive – epinephrine (1÷10,000) slowly IV 1.0 mL (= 0.1 mg) Repeat after 15 min up to a maximum of 1.0 mg ⇒ O2 6–10 L/min (via mask) monitor: ECG; O2 saturation (pulse oximeter); BP If not responsive to therapy: ⇒ Seek assistance (CODE team) ⇒ Consider intubation Bronchospasm (isolated) ⇒ O2 6–10 L/min (by mask, not nasal prongs) monitor: ECG; O2 saturation (pulse oximeter); BP ⇒ β2-agonist metered dose inhaler in 2–3 deep inhalations: metaproterenol (Alupent®) / terbutaline (Brethaire®) / albuterol (Proventil®) NOT: diphenhydramine as it thickens secretions If unrelieved with normal blood pressure + stable bronchospasm ⇒ epinephrine SQ (1÷1,000) 0.1–0.2 mL (= 0.1–0.2 mg); may give 0.3 mg [pediatric: 0.01 mg/kg up to 0.3 mg max.] with decreased blood pressure + progressive bronchospasm ⇒ epinephrine IV (1÷10,000) slowly over 2–5 min IV 1.0 mL (= 0.1 mg) [pediatric: 0.01 mg/kg IV] Repeat after 15 min up to a maximum of 1.0 mg 36 http://pdfradiology.com Alternatively ⇒ aminophylline 6 mg/kg IV in D5W over 15–20 min (loading dose); then 0.4–1.0 mg/kg/hr Cx: hypotension, cardiac arrhythmia or terbutaline 0.25–0.50 mg IM/SQ ⇒ 200–400 mg hydrocortisone IV if unsuccessful, may require intubation if anxiety exacerbates bronchospasm, sedation with 5–10 mg Demerol IV ⇒ Call for assistance (CODE team) for severe bronchospasm / if O2 saturation persists < 88% 37 http://pdfradiology.com  TREATMENT OF ADVERSE CONTRAST REACTIONS2 ANAPHYLACTOID REACTION = acute rapidly progressing generalized systemic reaction characterized by multisystem involvement tachycardia (pulse > 100 bpm) hypotension (systolic blood pressure < 80 mmHg) dizziness, diaphoresis loss of consciousness Hypotension with Tachycardia ⇒ leg elevation > 60° + Trendelenburg position ⇒ monitor: ECG; pulse oximeter; BP ⇒ O2 6–10 L/min (via mask, not nasal prongs) ⇒ rapid IV infusion of isotonic Ringer’s lactate / normal saline ⇒ suction as needed if poorly responsive to fluid therapy add vasopressors ⇒ call CODE ⇒ epinephrine IV (1÷10,000) slowly over 2–5 min IV 1.0 mL (= 0.1 mg); [pediatric: 0.02 mg/kg IV; starting dose of min. 0.1 mg to max. 0.6 mg; may repeat to 2 mg total dose] repeat after 15 min up to a maximum of 1.0 mg (titrated to effect) ⇒ dopamine if still poorly responsive: ⇒ transfer to ICU in adults without IV access: ⇒ epinephrine SQ (1÷1,000) 0.3 mL (= 0.3 mg) in infants / children: ⇒ epinephrine SQ (1÷1,000) with body weight determining the correct dose Seizure / Convulsion ⇒ protect patient from injury ⇒ monitor airway from obstruction by tongue ⇒ suction as needed ⇒ O2 6–10 L/minute (by mask) if uncontrolled: ⇒ diazepam (Valium®) 5.0 mg / midazolam (Versed®) 2.5 mg IV ⇒ monitor: ECG, O2 saturation (pulse oximeter), BP if longer effect needed: ⇒ obtain consultation 38 http://pdfradiology.com  ⇒ phenytoin (Dilantin®) infusion 15–18 mg/kg at 50 mg/minute ⇒ consider CODE for intubation Pulmonary Edema ⇒ Elevate torso ⇒ Apply rotating tourniquets for venous compression ⇒ O2 6–10 L/minute (via mask) ⇒ furosemide (Lasix®) 40 mg IV, slow push ⇒ Consider morphine ⇒ Transfer to ICU ⇒ Corticosteroids optional SEVERE HYPERTENSION ⇒ monitor: ECG, pulse oximeter, BP ⇒ IV fluids very slowly to maintain venous access ⇒ nitroglycerin 0.4 mg tablet sublingual; may repeat x 3; topical 1–2” strip of 2% ointment ⇒ sodium nitroprusside arterial line (infusion pump necessary to titrate) ⇒ transfer to ICU for pheochromocytoma: ⇒ phentolamine (Regitin®) Adult dose: 5.0 mg IV; Pediatric dose: 1.0 mg IV ANGINA ⇒ O2 6–10 L/min (via mask, not nasal prongs) ⇒ IV fluids, very slowly ⇒ nitroglycerin 0.4 mg, sublingually; may repeat q 15 minutes ⇒ morphine 2 mg IV AIR EMBOLISM air hunger, dyspnea, expiratory wheezing, cough chest pain, pulmonary edema, tachycardia, hypotension stroke ← decreased cardiac output / paradoxical air embolism / pulmonary AVM / R-to-L intracardiac shunt Rx: ⇒ 100% O2 administration ⇒ left lateral decubitus position CONTRAST EXTRAVASATION = escape of contrast material from vascular lumen + infiltration of interstitial tissue during injection Incidence: 0.1–0.4%; no direct correlation with injection flow rate (although frequent with power injectors) Risk: fragile veins, IV catheter indwelling for many days, multiple puncture attempts during IV placement Effect: (a) acute inflammatory response (peaking in 24–48 hrs) related to hyperosmolality of 39 http://pdfradiology.com  contrast material (b) compartment syndrome (c) ulceration + tissue necrosis (as early as 6 hours) (d) fibrosis (e) muscle atrophy may be asymptomatic; edema, erythema swelling, tightness, tenderness, stinging, burning pain Evaluate for: (1) Skin injury (blanching, discoloration) (2) Nerve compromise (3) Vascular compromise Dx: (1) Palpate catheter venipuncture site during initial seconds of injection (2) Ask patient to report any sensation of pain / swelling at injection site Severe Cx (uncommon): compartment syndrome, skin ulceration, tissue necrosis Rx: (1) Elevation of affected extremity above heart → decrease capillary hydrostatic pressure (2) Cold compress → decreases cellular uptake (3) Warm compress → vasodilatation promotes absorption (4) Discharge with instructions to watch for symptoms that indicate a need for surgical evaluation (5) Surgical consultation if › extravasation > 50 mL › ↑ in swelling / pain after 2–4 hours › ↓ in capillary refill time › change in sensation (paresthesia) in affected limb › skin ulceration / blistering (5) Documentation in medical record (6) Notification of referring physician (7) 24-hour follow up (phone call, examination) 40 http://pdfradiology.com  MUSCULOSKELETAL SYSTEM DIFFERENTIAL DIAGNOSIS OF MUSCULOSKELETAL DISORDERS UNIVERSAL DIFFERENTIAL DIAGNOSIS mnemonic: VINDICATE Vascular and cardiac Infectious, Inflammatory Neoplasm Drugs Iatrogenic, Idiopathic, Intoxication Congenital Autoimmune, Allergic Trauma Endocrine and metabolic DIAGNOSTIC GAMUT OF BONE DISORDERS Conditions to be considered = “dissect bone disease with a DIATTOM” Dysplasia + Dystrophy Infection Anomalies of development Tumor + tumorlike conditions Trauma Osteochondritis + ischemic necrosis Metabolic disease Dysplasia = disturbance of bone growth Dystrophy = disturbance of nutrition LIMPING CHILD Limping Child at 1–4 Years A. CONGENITAL 1. Developmental dysplasia of hip B. TRAUMATIC 1. Toddler’s fracture 2. Nonaccidental trauma 3. Other fractures 4. Foreign body C. INFLAMMATORY 1. Diskitis 41 http://pdfradiology.com  2. Septic arthritis 3. Osteomyelitis 4. Transient synovitis of hip Limping Child at 4–10 Years A. TRAUMATIC B. INFLAMMATORY 1. Septic arthritis 2. Osteomyelitis 3. Transient synovitis of hip 4. Diskitis 5. Juvenile rheumatoid arthritis C. VASCULAR 1. Legg-Perthes disease Limping Child at 10–15 Years A. TRAUMATIC 1. Stress fracture 2. Osteochondritis dissecans 3. Osgood-Schlatter disease B. INFLAMMATORY 1. Juvenile rheumatoid arthritis 2. Ankylosing spondylitis 3. Septic arthritis 4. Osteomyelitis C. HORMONAL 1. Epiphyseolysis of femoral head DELAYED BONE AGE A. CONSTITUTIONAL 1. Familial 2. IUGR B. METABOLIC 1. Hypopituitarism 2. Hypothyroidism 3. Hypogonadism (Turner syndrome) 4. Cushing disease, steroid therapy 5. Diabetes mellitus 6. Rickets 7. Malnutrition 8. Irradiation of brain (for cerebral tumor / ALL) C. SYSTEMIC DISEASE 1. Congenital heart disease 2. Renal disease 3. GI disease: celiac disease, Crohn disease, ulcerative colitis 42 http://pdfradiology.com  4. Anemia 5. Bone marrow transplantation (< 5 years of age) D. SYNDROMES 1. Trisomies 2. Noonan disease 3. Cornelia-de-Lange syndrome 4. Cleidocranial dysplasia 5. Lesch-Nyhan disease 6. Metatropic dwarfism UPTAKE PATTERN IN BONE LESIONS Superscan Cause: A. METABOLIC 1. Renal osteodystrophy 2. Osteomalacia √ randomly distributed focal sites of intense activity = Looser zones = pseudofractures = Milkman fractures (most characteristic) 3. Hyperparathyroidism √ focal intense uptake ← site of brown tumors 4. Hyperthyroidism → rate of bone resorption > rate of bone formation (= decrease in bone mass) hypercalcemia (occasionally) elevated alkaline phosphatase √ radiographically NOT visible √ susceptible to fracture B. Widespread bone lesions 1. Diffuse skeletal metastases: prostate, breast, multiple myeloma, lymphoma, lung, bladder, colon, stomach (most frequent) 2. Myelofibrosis / myelosclerosis 3. Aplastic anemia, leukemia 4. Waldenström macroglobulinemia 5. Systemic mastocytosis 6. Widespread Paget disease √ diffusely increased activity in bones: particularly prominent in axial skeleton, calvarium, mandible, costochondral junctions (= “rosary beading”), sternum (= “tie sternum”), long bones √ increased metaphyseal + periarticular activity √ increased bone-to-soft-tissue ratio √ “absent kidney” sign = little / no activity in kidneys but good visualization of urinary bladder √ femoral cortices become visible 43 http://pdfradiology.com  CAVE: scan may be interpreted as normal, particularly in patients with poor renal function! Hot Bone Lesions mnemonic: NATI MAN Neoplasm Arthropathy Trauma Infection Metastasis Aseptic Necrosis Long Segmental Diaphyseal Uptake A. BILATERALLY SYMMETRIC 1. Hypertrophic pulmonary osteoarthropathy 2. Thigh / shin splints = mechanical enthesopathy 3. Ribbing disease 4. Engelmann disease = progressive diaphyseal dysplasia B. UNILATERAL 1. Inadvertent arterial injection 2. Melorheostosis 3. Chronic venous stasis 4. Osteogenesis imperfecta 5. Vitamin A toxicity 6. Osteomyelitis 7. Paget disease 8. Fibrous dysplasia Doughnut Sign of Bone Lesion = radiotracer accumulation at periphery of bone lesion with little activity at its center 1. Aneurysmal bone cyst 2. Giant cell tumor 3. Chondrosarcoma 4. Telangiectatic osteosarcoma Photon-deficient Bone Lesion = decreased radiotracer uptake A. Interruption of blood flow in local bone = vessel trauma or vascular obstruction by thrombus / tumor 1. Early osteomyelitis 2. Radiation therapy 3. Posttraumatic aseptic necrosis 4. Sickle cell crisis B. Replacement of bone by destructive process 1. Metastases (most common cause): central axis skeleton > extremity, most commonly in carcinoma of kidney + lung + breast + multiple myeloma 44 http://pdfradiology.com  2. Primary bone tumor (exceptional) mnemonic: HM RANT Histiocytosis X Multiple myeloma Renal cell carcinoma Anaplastic tumors (reticulum cell sarcoma) Neuroblastoma Thyroid carcinoma Radionuclide Uptake in Benign Bone Lesions A. NO TRACER UPTAKE 1. Bone island 2. Osteopoikilosis 3. Osteopathia striata 4. Fibrous cortical defect 5. Nonossifying fibroma B. INCREASED TRACER UPTAKE 1. Fibrous dysplasia 2. Paget disease 3. Eosinophilic granuloma 4. Melorheostosis 5. Osteoid osteoma 6. Enchondroma 7. Exostosis BONE SCLEROSIS Diffuse Osteosclerosis mnemonic: 5 M’S To PROoF Metastases Myelofibrosis Mastocytosis Melorheostosis Metabolic: hypervitaminosis D, fluorosis, hypothyroidism, phosphorus poisoning Sickle cell disease Tuberous sclerosis Pyknodysostosis, Paget disease Renal osteodystrophy Osteopetrosis Fluorosis Acquired Syndromes with Increased Bone Density 1. Renal osteodystrophy 2. Osteoblastic metastases 3. Paget disease of bone 45 http://pdfradiology.com  4. Erdheim-Chester disease 5. Myelofibrosis 6. Sickle cell disease Constitutional Sclerosing Bone Disease 1. Progressive diaphyseal dysplasia 2. Infantile cortical hyperostosis 3. Melorheostosis 4. Osteopathia striata 5. Osteopetrosis 6. Osteopoikilosis 7. Pachydermoperiostosis 8. Pyknodysostosis 9. Van Buchem disease 10. Williams syndrome Sclerosing Bone Dysplasia Endochondral bone formation: primary spongiosa forms at 7th week of embryogenesis → resorption around 9th week with conversion into secondary spongiosa → osteoclastic remodeling into trabeculae + medullary cavity Target sites for endochondral bone formation: tubular + flat bones, vertebrae, skull base, ethmoids, ends of clavicle Intramembranous ossification: = transformation of mesenchymal cells into cortical bone without intervening cartilaginous matrix beginning at 9th week of fetal life to beyond closure of growth plates Target sites for intramembranous bone formation: cortex of tubular + flat bones, calvaria, upper facial bones, tympanic temporal bone, vomer, medial pterygoid process A. DYSPLASIA OF ENDOCHONDRAL OSSIFICATION (PRIMARY SPONGIOSA) = failure in resorption + remodeling of primary immature spongiosa by osteoclasts √ accumulation of calcified cartilage matrix packing the medullary cavity 1. Osteopetrosis 2. Pyknodysostosis B. DYSPLASIA OF ENDOCHONDRAL OSSIFICATION (SECONDARY SPONGIOSA) = errors in resorption + remodeling of secondary spongiosa √ focal densities / striations along trabecular bone 1. Osteopoikilosis 2. Osteopathia striata C. DYSPLASIA OF INTRAMEMBRANOUS OSSIFICATION = disequilibrium between periosteal bone formation + endosteal bone resorption 1. Progressive diaphyseal dysplasia 2. Hereditary multiple diaphyseal sclerosis 3. Hyperostosis corticalis generalisata 4. Diaphyseal dysplasia with anemia 46 http://pdfradiology.com  5. Oculodento-osseous dysplasia 6. Trichodento-osseous dysplasia 7. Kenny-Caffey syndrome D. MIXED SCLEROSING DYSPLASIAS = OVERLAP SYNDROME (a) predominantly endochondral disturbance 1. Dysosteosclerosis 2. Metaphyseal dysplasia (Pyle disease) 3. Craniometaphyseal dysplasia 4. Frontometaphyseal dysplasia (b) predominantly intramembranous defects 1. Melorheostosis 2. Craniodiaphyseal dysplasia 3. Lenz-Majewski hyperostotic dwarfism 4. Progressive diaphyseal dysplasia Nonhereditary Sclerosing Dysplasia 1. Intramedullary osteosclerosis 2. Melorheostosis 3. Overlap syndromes = disorder of endochondral + intramembranous ossification Combination: melorheostosis + osteopoikilosis + osteopathia striata Solitary Osteosclerotic Lesion A. DEVELOPMENTAL 1. Bone island B. VASCULAR 1. Old bone infarct 2. Aseptic / ischemic / avascular necrosis C. HEALING BONE LESION (a) trauma: callus formation in stress fracture (b) benign tumor: fibrous cortical defect / nonossifying fibroma; brown tumor; bone cyst (c) malignant tumor: lytic metastasis after radiation, chemotherapy, hormone therapy D. INFECTION / INFLAMMATION (low-grade chronic infection / healing infection) 1. Osteoid osteoma 2. Chronic / healed osteomyelitis: bacterial, tuberculous, fungal 3. Sclerosing osteomyelitis of Garré 4. Granuloma 5. Brodie abscess E. BENIGN TUMOR 1. Osteoma 2. Osteoblastoma 3. Ossifying fibroma 4. Healed fibrous cortical defect 5. Enchondroma / osteochondroma 47 http://pdfradiology.com  F. MALIGNANT TUMOR 1. Osteoblastic metastasis: prostate, breast 2. Lymphoma 3. Sarcoma: osteo-, chondro-, Ewing sarcoma G. OTHERS 1. Sclerotic phase of Paget disease 2. Fibrous dysplasia Cortical Sclerotic Lesion in Child 1. Osteoid osteoma 2. Stress fracture 3. Chronic osteomyelitis 4. Healed fibrous cortical defect Multiple Osteosclerotic Lesions A. FAMILIAL 1. Osteopoikilosis 2. Enchondromatosis = Ollier disease 3. Melorheostosis 4. Multiple osteomas: associated with Gardner syndrome 5. Osteopetrosis 6. Pyknodysostosis 7. Osteopathia striata 8. Chondrodystrophia calcificans congenita 9. Multiple epiphyseal dysplasia = Fairbank disease B. SYSTEMIC DISEASE 1. Mastocytosis = urticaria pigmentosa 2. Tuberous sclerosis Bone-within-bone Appearance = endosteal new bone formation 1. Normal (a) thoracic + lumbar vertebrae (in infants) (b) growth recovery lines (after infancy) 2. Infantile cortical hyperostosis (Caffey) 3. Sickle cell disease / thalassemia 4. Congenital syphilis 5. Osteopetrosis / oxalosis 6. Radiation 7. Acromegaly 8. Paget disease 9. Gaucher disease mnemonic: BLT PLT RSD RSD Bismuth ingestion Lead ingestion 48 http://pdfradiology.com  Thorium ingestion Petrosis (osteopetrosis) Leukemia Tuberculosis Rickets Scurvy D toxicity (vitamin D) RSD (reflex sympathetic dystrophy) Dense Metaphyseal Bands mnemonic: DENSE LINES D-vitamin intoxication Elemental arsenic + heavy metals: lead, bismuth, phosphorus Normal variant Systemic illness Estrogen to mother during pregnancy Leukemia Infection (TORCH), Idiopathic hypercalcemia Never forget healed rickets Early hypothyroidism (cretinism) Scurvy, congenital Syphilis, Sickle cell disease also: methotrexate therapy OSTEOPENIA = decrease in bone quantity maintaining normal quality √ increased radiolucency of bone: √ vertical striations in vertebral bodies √ accentuation of tensile + compressive trabeculae of proximal femur √ reinforcement lines (= bone bars) crossing marrow cavity about knee √ cortical resorption of 2nd metacarpal: √ measuring outer cortical diameter (W) and width of medullary cavity (m) at mid portion of bone and reporting combined cortical thickness (CCT = W + m) √ subperiosteal tunneling Categories: A. DIFFUSE OSTEOPENIA 1. Osteoporosis = decreased osteoid production 2. Osteomalacia = undermineralization of osteoid 3. Hyperparathyroidism 4. Multiple myeloma / diffuse metastases 5. Drugs 6. Mastocytosis 7. Osteogenesis imperfecta B. REGIONAL OSTEOPENIA Osteoporosis 49 http://pdfradiology.com = reduced bone mass of normal composition secondary to (a) osteoclastic resorption (85%): trabecular, endosteal, intracortical, subperiosteal (b) osteocytic resorption (15%) Prevalence: 7% of all women aged 35–40 years; 12% for males + females aged 50–79 years; ◊ Most common of all metabolic bone disorders; 14 million worldwide by 2020 Classification: (a) Primary / involutional osteoporosis ← cumulative bone loss as people age and undergo sex hormone changes 1. Type I (postmenopausal) osteoporosis = accelerated trabecular bone resorption ← estrogen deficiency Fracture pattern: spine and wrist 2. Type II (senile) osteoporosis = proportionate loss of cortical and trabecular bone Fracture pattern: hip, proximal humerus, tibia, pelvis (b) Secondary osteoporosis (in 20–30%) = consequence of various medical conditions / use of certain medications Etiology: A. CONGENITAL DISORDERS 1. Osteogenesis imperfecta ◊ The only osteoporosis with bending of bones! 2. Homocystinuria B. IDIOPATHIC (bone loss begins earlier + proceeds more rapidly in women) 1. Juvenile osteoporosis: < 20 years 2. Adult osteoporosis: 20–40 years 3. Postmenopausal osteoporosis: > 50 years (40–50% lower trabecular bone mineral density in elderly than in young women) 4. Senile osteoporosis: > 60 years progressively decreasing bone density at a rate of 8% (3%) in females (males) per year C. NUTRITIONAL DISTURBANCES scurvy; calcium deficiency; protein deficiency (nephrosis, chronic liver disease, alcoholism, anorexia nervosa, kwashiorkor, starvation, malnutrition, malabsorption) D. ENDOCRINOPATHY Cushing disease, hypogonadism (Turner syndrome, eunuchoidism), hyperthyroidism, hyperparathyroidism, acromegaly, Addison disease, diabetes mellitus, pregnancy, paraneoplastic phenomenon in liver tumors E. RENAL OSTEODYSTROPHY decrease / same / increase in spinal trabecular bone; rapid loss in appendicular skeleton F. IMMOBILIZATION = disuse osteoporosis G. COLLAGEN DISEASE, RHEUMATOID ARTHRITIS 50 http://pdfradiology.com  H. BONE MARROW REPLACEMENT infiltration by lymphoma / leukemia (ALL), multiple myeloma, diffuse metastases, marrow hyperplasia ← hemolytic anemia I. DRUG THERAPY corticosteroids, heparin (15,000–30,000 U for > 6 months), methotrexate, excessive alcohol consumption, smoking, Dilantin, aromatase inhibitors, gonadotropin-releasing hormone antagonist J. RADIATION THERAPY K. LOCALIZED OSTEOPOROSIS immobilization / disuse, Sudeck dystrophy, transient osteoporosis of large joints, regional migratory osteoporosis of lower extremities serum calcium, phosphorus, alkaline phosphatase frequently normal hydroxyproline may be elevated during acute stage Significant predictors of osteoporotic fractures: 1. Age 2. History of fracture 3. Failed chair test (= inability to rise from a chair in 3 successions without using arms) 4. Fall within past 12 months Clinical manifestation: (1) Vertebral compression fracture (HALLMARK) (2) Femoral fracture: neck + intertrochanteric region (3) Fracture of distal radius (Colles) and tibia Technique of Bone Densitometry: (1) Single-Photon Absorptiometry measures primarily cortical bone of appendicular bones, single-energy 125I radioisotope source Site: distal radius (= wrist bone density), os calcis Dose: 2–3 mrem Precision: 1–3% (2) Dual-Photon Absorptiometry radioactive energy source with 2 photon peaks; should be reserved for patients < 65 years of age because of interference from osteophytosis + vascular calcifications Site: vertebrae, femoral neck Dose: 5–10 mrem Precision: 2–4% (3) Single X-ray Absorptiometry = area projectional technique for quantitative bone density measurement Site: distal radius, calcaneus Dose: low Precision: 0.5–2% (4) Dual Energy X-ray Absorptiometry (DXA / DEXA) = quantitative digital radiography ◊ Most widely used & most precise technique! ◊ Standard of reference for diagnosis of osteoporosis in conjunction with Fracture Risk Assessment Tool at http://www.shef.ac.uk/FRAX/ for results of a 10-year probability of a major osteoporotic fracture in hip, spine, proximal humerus, distal 51 http://pdfradiology.com  forearm Technique: » mobile x-ray source composed of 2 different photon energy levels (constant + pulsed) moves together with detection system » rectilinear / fan-beam scanners » attenuation values of soft tissues are subtracted, leaving only the attenuation values of bone » lateral scanning of spine increases accuracy without superimposition of posterior elements + marginal osteophytes + vascular calcifications Advantage: (1) low radiation dose with higher radiation flux than radioisotope source of dual- photon absorptiometry (2) uses sites where osteoporotic fractures occur (3) low cost; ease of use; rapidity of measurement Limitation of 2-dimensional (areal) technique: (1) no distinction between cortical + trabecular bone (2) no discrimination between changes secondary to bone geometry + increased bone density (3) regulatory oversight for ionizing radiation Site: (a) lumbar spine (L1–L4) (b) proximal femur (total hip, femoral neck, trochanter, Ward area) (c) calcaneus (95% trabecular bone) (d) forearm (suboptimal ← mostly cortical bone) Dose: < 3 mrem Precision: 1–2% Data collected: BMD (bone marrow density) value (g/cm2) T-score = how far is the score from the mean of 50 with a SD of 10 compared with young adults 20–30 years of age (= peak of bone mass) Z-score = location of a score compared to age-matched + gender-matched controls in a distribution with a mean of 0 and a SD of 1.0; particularly important in patients aged > 75 years Interpretation: normal (≥ –1.0); osteopenia (< –1.0 but > –2.5); osteoporosis (≤ –2.5); severe osteoporosis (≤ –2.5 with a fragility fracture) Pitfalls: 52 http://pdfradiology.com  › weekly phantom calibration to detect scanner drift › improper patient positioning (decentering of lumbar spine, abduction / external rotation of hip) › improper numbering of vertebrae, placement of intervertebral markers, detection of bone edges › blurring / irregular contour of bone margins ← patient motion › anatomic artifacts from (a) superimposed disease: degenerative disk disease, compression fracture, postsurgical defect, overlying atherosclerotic calcifications (b) implanted devices: stent + vena cava filter, GI barium, hardware, vertebroplasty cement (c) external objects: piercing, bra clips, metallic buttons ◊ Results from different scanners not interchangeable ← differences in scanners and software programs (5) Quantitative Computed Tomography = determines true volumetric density (mg/cm3) by providing separate estimates of trabecular + cortical bone BMD over 2–4 vertebrae (T12–L4) high-turnover cancellous bone is important for vertebral strength and has high responsiveness trabecular bone + low-turnover compact bone can be measured separately Advantage: › allows separate analysis of trabeculae + cortices › selective assessment of metabolically active trabecular bone in center of vertebral body › better sensitivity than projectional methods (DXA) › exclusion of structures not contributing to spine mechanical resistance 53 http://pdfradiology.com  Disadvantage: › high radiation dose › poor precision limited to longitudinal assessment › high costs › high degree of operator dependence › need for considerable amount of space › limited scanner access Pitfalls affecting measurements: myelofibrosis + hematopoietic disorders + fat Technique: » use of low-dose commercial CT scanner » compared to external bone mineral reference phantom that is scanned simultaneously with patient to calibrate CT attenuation measurements » 10-mm–thick section with gantry angle correction through center of vertebral body » results expressed as absolute values / Z and T scores Site: vertebrae L1–L3, other sites Use: assessment of vertebral fracture risk; measurement of age-related bone loss; follow-up of osteoporosis + metabolic bone disease (a) single energy: 300–500 mrem; 6–25% precision (b) dual energy: 750–800 mrem; 5–10% precision ◊ Most sensitive technique! (6) Peripheral Quantitative CT = exact 3-dimensional localization of target volumes with multisection data acquisition capability covering a large volume of bone Site: distal radius (7) Quantitative Heel Ultrasound = determines US stiffness index(SI) using formula SI = 0.67 BUA [dB/MHz] + 0.28 SOS [m/s] – 420 SOS = speed of sound BUA = broadband ultrasound attenuation for 200–600 kHz as a risk assessment independent from DEXA ◊ Fracture risk increases with decrease in SI Precision: 2.2% Disadvantage: lack of sensitivity, equipment drift Location: axial skeleton (lower dorsal + lumbar spine), proximal humerus, neck of femur, wrist, ribs Radiographs: ◊ Radiographs: insensitive prior to bone loss of 25–30% ◊ Bone scans do NOT show a diffuse increase in activity √ increased radiolucency = decreased number + thickness of trabeculae = osteopenia (“poverty of bone”): √ relatively prominent primary trabeculae ← initially selective loss of secondary trabeculae √ juxtaarticular osteopenia with trabecular bone predominance (eg, distal radius + proximal femur): √ accentuation of compressive + tensile trabeculae 54 http://pdfradiology.com  √ sparsely trabeculated region in inferomedial femoral neck between converging primary and secondary compressive groups = Ward triangle ◊ Trabecular bone responds to metabolic changes faster than cortical bone √ cortical thinning (endosteal + intracortical + periosteal resorption): √ scalloping of inner cortical margin √ widening of marrow canal √ prominent longitudinal cortical striations = tunneling √ irregular definition of outer bone surface ◊ Most specific finding of high bone turnover √ delayed fracture healing with poor callus formation (DDx: abundant callus formation in osteogenesis imperfecta + Cushing syndrome) Cx: fracture for 1÷2 women + 1÷4 men > age 50 years (1) Fractures at sites rich in labile trabecular bone (eg, vertebrae, wrist) in postmenopausal osteoporosis (2) Fractures at sites containing cortical + trabecular bone (eg, hip) in senile osteoporosis Rx: calcitonin, sodium fluoride, diphosphonates, parathyroid hormone supplements, estrogen replacement Osteoporosis of Spine Clinical manifestation: vertebral compression fracture occurring (a) spontaneously (b) during lifting / bending / coughing (c) load simply caused by muscle contraction progressive loss of stature → shortening of paraspinal musculature requiring prolonged active contraction for maintenance of posture → pain from muscle fatigue Location: thoracolumbar junction (T12, L1), midthoracic area (T7, T8) √ diminished radiographic density √ vertical striations = rarefaction of trabeculae ← marked thinning of secondary horizontal (transverse) trabeculae + relative accentuation of primary vertical trabeculae along lines of stress √ accentuation of endplates √ “picture framing” (= accentuation of cortical outline with preservation of external dimensions ← endosteal + intracortical resorption √ anterior wedge fracture resulting in spinal deformity: √ kyphosis ← multiple fractures in 20–30% ◊ The greater the degree of osteoporosis the greater the number of fractures! √ “dowager’s hump” √ reduction in thoracic and abdominal space → impaired pulmonary function protuberant abdomen alteration in body shape √ endplate fracture = compression deformity with reduction in mid height + protrusion of intervertebral disks: 55 http://pdfradiology.com  √ biconcavity of vertebra √ Schmorl nodes √ crush fracture = reduction of overall height of a vertebra relative to adjacent vertebrae: √ height loss > 4 mm (posterior height is normally 1–3 mm more than anterior height for thoracic vertebra) √ decreased height of vertebrae → loss of body height √ absence of osteophytes MR: √ heterogeneously hyperintense SI on T1WI: √ focal fatty marrow usually has a round morphology √ round lesions coalesce to involve entire vertebral body √ variable T2 signal intensity Osteoporosis of Appendicular Skeleton @ Hand (on industrial hard-copy film) √ corticomedullary index = evaluation of cortical thickness of 2nd metacarpal bone Digital X-ray Radiogrammetry (DXR) = digitized PA radiograph with automatic segmentation of cortex + medulla of midshafts of 2nd + 3rd + 4th metacarpal bones → average cortical thickness + average bone width in region of interest Advantage: high reproducibility; capacity to predict future fracture; widely available; inexpensive; low radiation dose @ Femur √ Singh classification system = trabeculae in proximal femur disappear in predictable sequence @ Calcaneus √ Jhamaria index = lateral radiograph of calcaneus Osteomalacia = accumulation of excessive amounts of uncalcified osteoid with bone softening + insufficient mineralization of osteoid due to (a) high remodeling rate: excessive osteoid formation + normal / little mineralization (b) low remodeling rate: normal osteoid production + diminished mineralization Etiology: (1) dietary deficiency of vitamin D3 + lack of solar irradiation (2) deficient metabolism of vitamin D: › chronic renal tubular disease › chronic administration of phenobarbital (alternate liver pathway) › diphenylhydantoin (interferes with vitamin D action on bowel) (3) decreased absorption of vitamin D: › malabsorption syndromes (most common) › partial gastrectomy (self-restriction of fatty foods) (4) diminished deposition of calcium in bone › diphosphonates (for treatment of Paget disease) Histo: excess of osteoid seams + decreased appositional rate 56 http://pdfradiology.com  bone pain / tenderness; muscular weakness serum calcium slightly low / normal decreased serum phosphorus elevated serum alkaline phosphatase √ uniform osteopenia √ fuzzy indistinct trabecular detail of endosteal surface √ coarsened frayed trabeculae decreased in number + size √ thin cortices of long bone √ bone deformity from softening: √ hourglass thorax √ bowing of long bones √ acetabular protrusion √ buckled / compressed pelvis √ biconcave vertebral bodies √ increased incidence of insufficiency fractures √ pseudofractures = Looser zones √ mottled skull Localized / Regional Osteopenia 1. Disuse osteoporosis / atrophy Etiology: local immobilization secondary to (a) fracture (more pronounced distal to fracture site) (b) neural paralysis (c) muscular paralysis 2. Reflex sympathetic dystrophy = Sudeck dystrophy 3. Regional migratory osteoporosis, transient regional osteoporosis of hip 4. Rheumatologic disorders 5. Infection: osteomyelitis, tuberculosis 6. Osteolytic tumor 7. Lytic phase of Paget disease 8. Early phase of bone infarct and hemorrhage 9. Burns + frostbite Bone Marrow Edema = hypointense on T1WI + hyperintense on T2WI relative to fatty marrow 1. Trauma (a) “bone bruise” (b) radiographically occult acute fracture (c) recent surgery 2. Infection = osteomyelitis 3. Aseptic arthritis 4. Osteonecrosis = early stage of AVN 5. Neuropathic osteoarthropathy 6. Reflex sympathetic dystrophy (some cases) 7. Transient osteoporosis of hip 57 http://pdfradiology.com  8. Infiltrative neoplasm Transverse Lucent Metaphyseal Lines mnemonic: LINING Leukemia Illness, systemic (rickets, scurvy) Normal variant Infection, transplacental (congenital syphilis) Neuroblastoma metastases Growth lines Frayed Metaphyses mnemonic: CHARMS Congenital infections (rubella, syphilis) Hypophosphatasia Achondroplasia Rickets Metaphyseal dysostosis Scurvy MYELOPROLIFERATIVE DISORDERS = autonomous clonal disorder initiated by an acquired pluripotential hematopoietic stem cell Types: 1. Polycythemia vera 2. Chronic granulomatous / myelogenous leukemia 3. Essential idiopathic thrombocytopenia 4. Agnogenic myeloid metaplasia (= primary myelofibrosis + extramedullary hematopoiesis in liver + spleen) Pathophysiology: › self-perpetuating intra- and extramedullary hematopoietic cell proliferation without stimulus › trilinear panmyelosis (RBCs, WBCs, platelets) › myelofibrosis with progression to myelosclerosis › myeloid metaplasia = extramedullary hematopoiesis (normocytic anemia, leukoerythroblastic anemia, low platelet count, reticulocytosis, normal / reduced WBC count) BONE TUMOR Role of Radiologist 1. Is there a lesion? 2. Is it a bone tumor? 3. Is the tumor benign or malignant? 4. Is a biopsy necessary? 5. Is histologic diagnosis consistent with radiographic image? 58 http://pdfradiology.com Assessment of Bone Tumor A systematic approach is imperative for assessment of a bone tumor with attention to size, number, and location of lesions; margins and zone of transition; periosteal reaction; matrix mineralization; soft-tissue component. 1. Age (and gender) of patient 2. Precise tumor location (a) transverse: medullary, cortical, juxtacortical (b) longitudinal: epi-, meta-, diaphyseal 3. Pattern of bone destruction / aggressiveness (a) nonaggressive √ well-defined sharp margins √ smooth solid-appearing periosteal reaction (b) aggressive infiltrative osseous process √ broad zone of transition √ poorly defined borders √ disrupted / “sunburst” appearance DDx: destructive metabolic / infectious process 4. Lesion matrix √ “rings-and-arcs” appearance = chondral origin √ opaque cloud-like matrix = osseous mineralization √ osteolytic lesion → FEGNOMASHIC √ CT for cortical continuity / disruption Action Following Bone Tumor Assessment A. BENIGN 1. Diagnosis certain: no further work-up necessary 2. Asymptomatic lesion with highly probable benign diagnosis may be followed clinically 3. Symptomatic lesion with highly probable benign diagnosis may be treated without further work-up B. CONFUSING LESION not clearly categorized as benign or malignant; needs staging work-up C. MALIGNANT: needs staging work-up Staging work-up: Bone scan: identifies polyostotic lesions (eg, multiple myeloma, metastatic disease, primary osteosarcoma with bone-forming metastases, histiocytosis, Paget disease) Chest CT: identifies metastatic deposits + changes further work-up and therapy Local staging with MR imaging: (1) Margins: encapsulated / infiltrating (2) Compartment: intra- / extracompartmental (3) Intraosseous extent + skip lesions (4) Soft-tissue extent (DDx: hematoma, edema) (5) Joint involvement 59 http://pdfradiology.com  (6) Neurovascular involvement Local assessment with CT imaging: √ matrix / rim calcifications V ESSEL AND NERVE INVOLVEMENT √ tumor encasement of neurovascular bundle by – 180–360° = indicates infiltration by tumor – 90–180° = indeterminate for infiltration by tumor – 0–90° = infiltration by tumor unlikely Tumorlike Conditions 1. Solitary bone cyst 2. Juxtaarticular (“synovial”) cyst 3. Aneurysmal bone cyst 4. Nonossifying fibroma; cortical defect; cortical desmoid 5. Eosinophilic granuloma 6. Reparative giant cell granuloma 7. Fibrous dysplasia (monostotic; polyostotic) 8. Myositis ossificans 9. “Brown tumor” of hyperparathyroidism 10. Massive osteolysis Pseudomalignant Appearance 1. Osteomyelitis 2. Aggressive osteoporosis Pattern of Bone Tumor Destruction / Aggressiveness A. GEOGRAPHIC BONE DESTRUCTION Cause: (a) slow-growing usually benign tumor (b) rarely malignant: plasma cell myeloma, metastasis (c) infection: granulomatous osteomyelitis √ well-defined smooth / irregular margin √ narrow zone of transition B. MOTH-EATEN BONE DESTRUCTION Cause: (a) rapidly growing malignant bone tumor (b) osteomyelitis √ less well-defined / demarcated lesional margin √ broad zone of transition mnemonic: H LEMMON Histiocytosis X Lymphoma Ewing sarcoma Metastasis Multiple myeloma Osteomyelitis Neuroblastoma 60 http://pdfradiology.com  C. PERMEATIVE BONE DESTRUCTION Cause: aggressive bone tumor with rapid growth potential (eg, Ewing sarcoma) √ poorly demarcated lesion imperceptibly merging with uninvolved bone √ broad zone of transition Size, Shape, and Margin of Bone Tumors ◊ Primary malignant tumors are larger than benign tumors √ elongated lesion (= greatest diameter of > 1.5 times the least diameter): Ewing sarcoma, histiocytic lymphoma, chondrosarcoma, angiosarcoma √ sclerotic margin (= reaction of host tissue to tumor) Tumor Position in Transverse Plane A. CENTRAL MEDULLARY LESION 1. Enchondroma 2. Solitary bone cyst B. ECCENTRIC MEDULLARY LESION 1. Giant cell tumor 2. Osteogenic sarcoma, chondrosarcoma, fibrosarcoma 3. Chondromyxoid fibroma C. CORTICAL LESION 1. Nonossifying fibroma 2. Osteoid osteoma D. PERIOSTEAL / JUXTACORTICAL LESION 1. Juxtacortical chondroma / osteosarcoma 2. Osteochondroma 3. Parosteal osteogenic sarcoma Tumor Position in Longitudinal Plane 61 http://pdfradiology.com A. EPIPHYSEAL LESION 1. Chondroblastoma (prior to closure of growth plate) 2. Intraosseous ganglion, subchondral cyst 3. Giant cell tumor (originating in metaphysis) 4. Clear cell chondrosarcoma 5. Fibrous dysplasia 6. Abscess mnemonic: CAGGIE Chondroblastoma Aneurysmal bone cyst Giant cell tumor Geode Infection Eosinophilic granuloma [after 40 years of age throw out “CEA” and insert metastases / myeloma] B. METAPHYSEAL LESION 1. Nonossifying fibroma (close to growth plate) 2. Chondromyxoid fibroma (abutting growth plate) 3. Solitary bone cyst 4. Osteochondroma 5. Brodie abscess 6. Osteogenic sarcoma, chondrosarcoma C. DIAPHYSEAL LESION 1. Round cell tumor (eg, Ewing sarcoma) 2. Nonossifying fibroma 3. Solitary bone cyst 4. Aneurysmal bone cyst 5. Enchondroma 6. Osteoblastoma 7. Fibrous dysplasia mnemonic: FEMALE Fibrous dysplasia Eosinophilic granuloma Metastasis Adamantinoma 62 http://pdfradiology.com  Leukemia, Lymphoma Ewing sarcoma Tumors Localizing to Hematopoietic Marrow 1. Metastases 2. Plasma cell myeloma 3. Ewing sarcoma 4. Histiocytic lymphoma Diffuse Bone Marrow Abnormalities in Childhood A. REPLACED BY TUMOR CELLS (a) metastatic disease 1. Neuroblastoma (in young child) 2. Lymphoma (in older child) 3. Rhabdomyosarcoma (in older child) (b) primary neoplasm 1. Leukemia B. REPLACED BY RED CELLS = red cell hyperplasia = reconversion (a) severe anemia: sickle cell disease, thalassemia, hereditary spherocytosis (b) chronic severe blood loss (c) marrow replacement by neoplasia (d) treatment with granulocyte-macrophage colony stimulating factor C. REPLACED BY FAT 1. Myeloid depletion = aplastic anemia D. REPLACED BY FIBROUS TISSUE 63 http://pdfradiology.com  1. Myelofibrosis Incidence of Bone Tumors ◊ 80% of bone tumors are correctly determined on the basis of age alone! Most Frequent Benign Bone Tumor 1. Osteochondroma 20–30% 2. Enchondroma 10–20% 3. Simple bone cyst 10–20% 4. Osteoid osteoma 5. Nonossifying fibroma 6. Aneurysmal bone cyst 5% 7. Fibrous dysplasia 8. Giant cell tumor Most Frequent Malignant Bone Tumor A. Bone malignancy 1. Metastasis B. Primary bone malignancy 1. Multiple myeloma 2. Osteosarcoma 3. Chondrosarcoma 4. Ewing sarcoma C. Primary bone malignancy in children & adolescents 1. Osteosarcoma 2. Ewing sarcoma Sarcomas by Age mnemonic: Every Other Runner Feels Crampy Pain On Moving Ewing sarcoma 0–10 years Osteogenic sarcoma 10–30 years Reticulum cell sarcoma 20–40 years Fibrosarcoma 20–40 years Chondrosarcoma 40–50 years Parosteal sarcoma 40–50 years Osteosarcoma 60–70 years Metastases 60–70 years EWING SARCOMA FAMILY 1. Ewing sarcoma of bone 2. Extraskeletal Ewing sarcoma 3. Primitive neuroectodermal tumor 4. Askin tumor Malignancy with Soft-tissue Involvement 64 http://pdfradiology.com  mnemonic: My Mother Eats Chocolate Fudge Often Metastasis Myeloma Ewing sarcoma Chondrosarcoma Fibrosarcoma Osteosarcoma Tumor Matrix of Bone Tumors Cartilage-forming Bone Tumors √ centrally located ringlike / flocculent / flecklike radiodensity A. BENIGN 1. Enchondroma 2. Parosteal chondroma 3. Chondroblastoma 4. C