Radiology WB 2025 PDF

Radiology WHERE THE ART OF MEDICINE IS LOVED, THERE IS ALSO LOVE FOR HUMANITY. HIPPOCRATES DR. KHALEEL AHMED  KNOW YOUR MENTOR! For Medical students aspiring to excel in radiolo...

Radiology WHERE THE ART OF MEDICINE IS LOVED, THERE IS ALSO LOVE FOR HUMANITY. HIPPOCRATES DR. KHALEEL AHMED  KNOW YOUR MENTOR! For Medical students aspiring to excel in radiology one name stands out as a beacon of knowledge and expertise: Dr. Khaleel Ahmed. A Nationally renowned Radiology Faculty and director of the Prestigious Arise Medical Academy. Dr. Khaleel Ahmed MD Radiodiagnosis D ir ec t or A ris e M e d ic al A c a d e my His Passion for teaching and Commitment to empowering medical graduates for past 15 years have solidified his position as a revered educator. He has been an elite National faculty for the training of medical students for different exams like NEETPG, INICET, NEXT, FMGE. Connect with Dr. Khaleel As a director of the Arise Medical Academy, Dr. Khaleel Ahmed's contributions have and will continue to shape the future of Foreign Medical Graduates, ensuring they are equipped with the knowledge and confidence to make a difference in the world of medicine.  Ionizing Radiation Nonionizing Radiation Electromagnetic Radiation Electromagnetic radiation X rays → Extranuclear UV rays  rays → Intranuclear Visible light Cosmic rays Infrared rays Radio waves Particulate Radiation  rays Sound waves  rays proton Neutron Period of organogenesis → 3weeks – 8weeks Max risk of teratogenicity → Period of CNS development → 9weeks - 15weeks Max risk of mental retardation TIFFA scan → 18weeks -20weeks Targeted imaging for fetal anomalies 28 day rule :- All diagnostic modalities using ionising radiation in a female of reproductive age group should be done After asking menstural history In first 10 days of menstural cycle   28 day rule 10 day rule 1  INTRODUCTION DIAGNOSTIC MODALITIES lonizing Radiations Non-Ionizing Radiations X-Rays used in -Rays (nuclear scans) used MRI in CT-scan Radionucleide Scan / MRCP Scintigraphy Radiography Bone-scan Thermography HIDA scan DEXA SPECT – Single photon USG Emission tomography IVP/IVU/MCU/RGU PET –positron Emission Doppler tomography HSG Bronchography t1/2 Tc 99m = 6 hrs t1/218 FDG – 110 min ERCP Fluoroscopy Angiography Mammography Barium studies C- Arm Mammography is contraindicated in mastitis / breast abscess 3D mammography (Digital tomosynthesis) >2D Mediolateral Oblique Cranio Caudal view (MLO view) (CC view) Maximum Breast Tissue and Medial Aspect of Axillary tail breast Target of Anode in Mammography – Radiation exposure in Mammography – Window used in Mammography – Radiation exposure in Mammography - 2  Bone scan “- Tc99 m – MDP (Methylene diphosphonate) / Medronate Hot uptake (increased uptake) on bone scan – Osteoblastic activity Prostrate mets Osteoarthritis Pagets Fibrous dysplasia Osteomyelitis Early phase Blood pool phase Delayed phase Cellulites O.M Mickey mouse appearance on bone scan – HONDA sign on bone scan - Double density sign on bone scan – Pet Scan CT Scan Pet - CT 3 Radiation Units : Dose Conventional SI Unit 1. Exposure Dose Roentgen Coulombs/kg 2. Absorbed Dose Rad Gray (1Gy=100 Rad) 3. Equivalent Dose Rem Sievert (1SV = 100Rem) (Radiation quality factor) 4. Effective Dose Rem Sievert (Tissue weighting factor) 5. Radioactivity Curie Bac-querel (1 disintegration /Sec) Thermoluminescent dosimeter (TLD badge) Measures radiation exposure in occupational workers read every 3 months Made of LiF / Caso4 dysprosium Worn under lead apron Maximum radiation exposure in occupational worker should not exceed Thickness of lead apron - Abd Fetus Pregnant occupational worker 2 Msv 1 Msv Pregnant female 1 Msv 0.5 Msv ALARA As Low as reasonably Achievable DICOM Digital Imaging and Communication in Medicine PACS Picture Archiving and Communication System POCUS Point of care ultrasound RUSH Rapid ultrasound for shock and hypotension ACUTE RADIATION SYNDROMES >1-2 Gy –Acute hematopoietic Syndrome >6-10 Gy- Acute GI syndrome >20GY-Acute CNS syndrome Progresses through four stages Prodromal stage –latent stage – manifest stage – recovery / death 4 Radiation Effects : Stochastic Deterministic (Non – stochastic) Dose independent Dose dependent Can occur at low dose Occur at high dose above threshold dose No threshold dose Has a threshold dose Ex : mutations , cancers Ex: skin erythema , cataracts , acute radiation syndromes teratogenicity Severity is not related to dose , but probability Severity is directly proportional to dose increases with dose White Black X-rays Radio opaque Radiolucent CT Hyperdense hypodense MRI Hyperintense hypointense USG Hyperechoic hypoechoic Radiolucent (black on x rays) Fat Hypodense (black on CT) Hyperechoic (white on USG) Hyperintense (white on MRI) (both on T1 and T2) 5 DEXA SCAN – Dual energy X ray absorptiometry Used for bone mineral density for osteoporosis DEXA – Female > 65 yrs, Male > 70 yrs Best site for Dexa Scan – spine > Hip > wrist T-Score -BMD of Pt is compared With young Z-Score- BMD of ptis compared with age, sex matched individual WHO recommends T.Score Quantitative CT : is more sensitive than DEXA for osteoporosis 6  ULTRASOUND ULTRASOUND: → REAL TIME IMAGING → OPERATOR DEPENDANT Principle of ultrasound →pulse-echo principle Uses piezo electric effect Transducer / probe made of Lead zirconate titanate Ultrasound uses sound frequency – 2 – 20Mhz PROBES /TRANSDUCERS →LINEAR PROBE CURVILINEAR ENDOCAVITARY 10-12 MHz 3-5 MHz 7-10 MHz Less Penetration More Penetration Endocavitary Location More Resolution Less Resolution For superficial For TRUS Imaging Deeper structure TVUS Thyroid, carotid, →OBG USG Dvt, scotralusg, →USG Abdomen Breast usg Phase Array Probe Intra vascular ultrasound Ultrasound Biomicroscopy 7  Subxiphoid view RUQ/RT lumbar LUQ/left lumbar Pelvic view FAST + FAST→Focused Assessment with Sonography for Trauma 1st view→Subxiphoid view→pericardial collection most sensitive for hemoperitonium→RUQ/RT lumbar FAST detects pericardial collection and hemoperitoneum E-FAST→Extended FAST →4 FAST views + right and left anterior thorasic views Seashore sign Barcode / stratosphere sign Normal Lung Pneumothorax On B – mode Absent Lung Sliding Lung Sliding Absent B lines B Lines On M mode Barcode / Stratosphere sign Seashore sign Lung Point Limitations of FAST →Retroperitoneal hematoma →Subcutaneous Emphysema →Fluid < 100ml →bowel/mesentry/diaphragm injuries 8  Blunt Trauma Abdomen Q.A 25-Yrs old RTA patient, with bruises over chest & abdomen BP-90/40, PR-30/mins, what is next Step in management? a) USG b) NCCT c) CECT d) Emergency laparotomy Q. A 30-Yrs old RTA patient, sustained blunt trauma abdomen FAST, BP-130/80, PR-72/min, next step → BP-90/40, PR-25/min, next step → USG is I0C for – pericardial effusion (2d echo) - minimal pleural effusion - ascites/hemoperitoneum - hydronephrosis / hydrocele - Breast abscess - Different solid vs cystic areas USG is I0C for most gall bladder Pathologies → Acute cholecystitis → Chronic cholecystitis → GB polyp →Cholelithiasis Except GB cancer & Emphysematous cholecystitis IOC for acute cholecystitis→ Most sensitive / Most accurate for acute cholecystitis→ Duplex USG → Varicose Veins →Varicocele → DVT → Portal hypertension → Vasa previa →Ovarian torsion / Testicular Torsion 9 Color Doppler → based on frequency shift Color coding → based on direction of flow Flow towards the probe →Red Flow away from probe →Blue Intensity of color→ based on Velocity of flow loss of cortico medullary differentiation – Renal calculi/ stones posterior acoustic Shadowing Calculi on color Doppler - Thyroid Ultrasound B scan Orbital USG Thyroid cancer→ hypoechoic V shape / Funel Shaped retinal detachment → Taller than wide → Calcifications A - Mode B - Mode M - Mode Amplitude mode Brightness Mode Motion Mode Axial length of eye ball Routine Ultrasound Echo Cardiography Lung Ultrasound 10  →Endoscopic Ultrasound (EUS) Uses frequency of 20MHZ Very good resolution Divides gut wall into 5 layers 1. Mucosa 2. Muscularis Mucosa 3. Submucosa 4. Muscular is propria 5. Serosa EUS- detects local invasion of GI cancers for small periampullary carcinoma Pancreatic cyst Pancreatic Insulinoma Cholelithiasis / Multiple Gall Stones Comet tail artifacts of GB → Acute cholecystitis Chronic cholecystitis → GB distension Shrunken GB → GB wall thickening >3mm Wall-Echo Shadow sign →Sonographic murphys 11  Cystic lesion  Posterior acoustic Enhancement Longitudnal view. Short transverse view IOC for acute appendicitis child adult → Blind ending, tubular target sign →Aperistaltic →non-compressible. corpus luteal cyst(mc) Ring of Fire appearance on Ectopic pregnancy Color Doppler Tubal Ring / Bagel Sign Snowstorm appearance on antenatal scan → Molar pregnancy 12 Mickey mouse appearance on Usg thigh → SFJ Mickey mouse appearance (Sapheno femoral junction) Usg liver Portal triad MRI brain Progressive supranuclear palsy (PSP) Antenatal scan Anencephaly Bone scan Pagets disease NT-NB Scan nuchal translucency scan Nuchal Nuchal → 11weeks – 13weeks 6 days translucency Skinfold → CRL – 45 – 84 mm scan Thickness Absent nasal bone and  NT aneuploidy →11w – 13w 6days →18w – 24w 13 PARAMETER SIGNIFICANCE → CROWN RUMP LENGTH (CRL) Most accurate for GA in first trimester Most accurate for EDD → BIPARIETAL DIAMETER (BPD) GA in second trimester → HEAD CIRCUMFERENCE (HC) GA in abnormal shape of skull → FEMUR LENGTH (FL) GA in late third trimester Telephone Handle femur →Thanatophoric skeletal dysplasia Short femur → aneuploidy → ABDOMINAL CIRCUMFERENCE (AC) For fetal growth IUGR/ macrosomia →Trans cerebellar Diameter → Least affected by IUGR/ → GA in IUGR  Sign / Twin Peak sign – T sign - Spalding sign →Overlapping of sutural bones Robert sign →aiR in great vessels heart Anencephaly - failure of Closure of anterior Neuropore earliest congenital anamoly to be diagnosed Acrania Frog eye / Anencephaly  Mickey mouse appearance absent cranial and vault Earliest Best time 14  Omphalocele Gastroschisis Umblical cord are inserted Umblical cord is to the left on the defect of the defect Congenital Congenital anamolies are more anamolies are rare common Tiffa→ Targeted Imaging For Fetal Anomalies→18w -22 Weeks PCOS OHSS (Ovarian hyperstimulation syndrome) →Thick central stroma B/l, large cysts Ovarian volume > 10 ml Central spoke wheel stroma Ovarian follicles < 10 mm Third space collections - pleural effusions or > 20 in number ascites Can be u/l Hemoconcentration – thrombosis Ovarian cysts + Ascites + effusions → Ovarian mass + Ascites + pleural effusions → Bilateral enlarged ovaries with large cysts and increased  HCG - 15  Endometrial thickening Focal thickening →Endometrial polyp Diffuse thickening → Endometrial carcinoma → Feeding artery/ Pedicle artery On Doppler True gestational sac false gestational sac → Intra decidual sac sign Central Single layer →Double decidual sac sign → Double bleb sign Mean sac diameter >25 mm and no yolk sac – CRL > 7 mm, no cardiac activity - 16 – Anechoic cyst with posterior Reticular/lacy/fish net Ground glass appearance on acoustic enhancement appearance on Usg Usg T1 T2 FLUID DARK WHITE FAT WHITE WHITE → T1 hyperintense cyst → Dot & dash pattern on usg Pelvic Adenomyosis – IOC – Keyhole appearance on antenatal scan 17 USG Elastography → Evaluates stiffness of tissue → Guide FNAC & biopsy → Progression of chronic liver disease Cirrhosis Spectral Doppler Peripheral artery → Triphasic pattern (ECA, Brachial artery, Radial artery, popliteal artery) Visceral artery → Monophasic pattern with pulsatality (ICA, CCA) Veins → Monophasic without pulsatality, only phasicity Umbilical artery Doppler S ratio of Umbilical artery > 3.5 Reversal of diastolic flow in umbilical artery D  Terminate the pregnancy < 34 weeks > 34 weeks   Rx steroids Terminate pregnancy 18 Uterine artery Doppler < 22 weeks > 22 weeks absent diastolic > 22 weeks Diastolic notch notch persistence of diastolic notching Fetal MCA Doppler → peak systolic velocity in fetal MCA or High pulsatality in fetal MCA Therapeutic uses of USG → ESWL → extra corporeal shock wave Lithotripsy → Phacoemulsification → Cataract surgeries → HIFU → High Intensity Focussed USG → Rx of fibroids pain management 19  URORADIOLOGY IOC FOR RENAL TB — Ct urography Renal Tb Kidney Ureter Bladder Moth eaten - Beaded/tortous Thimble Bladder calyces (Earliest) Corkscrew ureter → Low volume, Non Phantom Calyx calcific Bladder - Putty kidney - Kerr kink - cement kidney - Golf hole ureteric →Loin pain orifice on cystoscopy →Sterile Pyuria Cement kidney Shaking hand sign Flowervase sign on ivp Young female with HTN Cobra Head appearance/adder head appearance Corkscrew appearance of renal artery 20 Cork screw / Beaded / tortous Appearance → pancreatic duct → chronic pancreatitis → fallopian tube → TB salpingitis → Ureter → Renal TB → Renal artery → fibromuscular dysplasia → Superior ophthalmic vein → Carotico -cavernous fistula → Esophagus → DES (Diffuse Esophageal Spasm) → Duodenum → Non rotation / midgut volvulus ADPKD(adult) ARPKD (childhood) B/l enlarged kidneys B/l enlarged kidneys Hepatic cysts hepatic cysts, Hepatic Berry aneurysms fibrosis Swiss cheese Striated nephrogram Nephrogram Spider Leg Appearance on pyelogram 21  Striated nephrogram- Bear Paw Sign - ARPKD - Pyelonephritis Medullary Sponge kidney Cortical Nephrocalcinosis - → Cystic Dilation Of Collecting Duct Paint brush/bouquet of flower Appearance on IVP Medullary Nephrocalcinosis Medullary Nephrocalcinosis - _______________________________________________________________________ Soap bubble appearance On antenatal scan →Multi cystic dysplastic kidney M.C cystic kidney disease →Always Unilateral →No nephrogram _______________________________________________________________________ Renal cyst → classified by Bosniak Classification I, II → conservative, II F - → follow up III & IV → Surgery (CECT) 22 Renal Cyst Hydronephrosis Elderly Diabetic patient, high fever, chills,  BP Rim Sign/crescent sign — chronic gross hydronephrosis CECT CORONAL AXIAL RTA patient, Non Enhancement of left kidney 23 Calcific density on lateral radiograph Overlaps Calcific density on lateral radiograph vertebral Shadow Anterior to vertebral Shadow →Dual source/dual energy ct→ Used to characterise type of kidney stone Lucent stones - Drugs X ray CT INDINAVIR Uric acid Stone Radiolucent Seen LYSINE, lipid URIC ACID Indinavir Stone Radiolucent Not seen XANTHINE 24 Pelvic kidney → MC site of Kidney ectopic kidney Horse shoe kidney Pancake/Doughnut kid crossed fused ectopic →Heterogenous Central stellate scar in Kidney fat containing Lesion of Enhancement of renal Mass, kidney Elderly Smoker with Hematuria→ RCC Bilateral RCC – 25 Neuroblastoma Wilms Tumor < 2 years 3-4 years Painful abdominal mass Painless abdominal mass calcifications -more common 80-90% Less common ,10% (10% rule) Solid mass Often cystic necrotic components claw sign indicating origin from the kidney Encases vessels but does not invade Invades vasculature with invasion Elevates aorta into renal vein and ivc in about 10% Metastasis Commonly to bone Metastasis Commonly to lung Crosses midline behind the aorta Does not cross midline Multiple punched out lytic lesions in the bones→ Child 60 yrs Neuroblastoma Wilms Tumor Q) Identify the condition based on the given IVP image? A) Pelvic kidney B) horse shoe kidney C) Duplex kidney D) crossed Ectopic kidney 26  Q) Identify the condition based on given IVP image? A) Crossed Fused Ectopic B) Crossed Unfused Ectopic C) Duplication of ureter D) Horse Shoe Kidney Weigert Meyer Rule →duplication / duplex kidney →superior ureter inserts inferomedially (ectopically) and is prone to obstruction(ureteocele) →Inferior ureter Inserts superolaterally (orthotopic/ Normal) and is prone to reflux (VUR) Q) Identify the condition based on given IVP image? A) Pelvic Kidney B) Crossed Unfused Ectopic C) Duplex kidney →Drooping lily D) Horse Shoe Kidney 27 Maiden waist deformity on IVP Reverse J/fish hook appearance Of Rt midureter → Fish hooking of distal ureter→BPH Lamellated appearance—Vesicle calculus Spiculated appearance→ Jackstone calculus Post menopausal female; chronic pelvic pain Popcorn Ca+2 on pelvic radiograph Popcorn Ca+2 on iliac bone→ 28  Bladder Shape Condition Fetal skull Like calcification of Bladder Wall Schistosomiasis Christmas tree or Pine tree appearance of Neurogenic bladder Bladder Tear Drop or Pear Shape Bladder Extrinsic compression-pelvic LN/pelvic hematoma Key hole appearance of bladder Posterior urethral valve (PUV) Thimble Bladder Tb A child with weak abdominal musculature; B/l cryptorchidism; b/l VUR— 29 On cystography Contrast extravasation between bowel Contrast extravasation in the perineum giving loops and peritoneal folds → molar tooth sign → Young male with STDs or Male with post void dribbling RTA blood @ external history of faulty of urine Urethral meatus catheterisation and narrow stream of urine 30  Micturating or voiding Retrograde Urethrogram Cystourethrography RGU → Anterior Urethra MCU → Posterior Urethra IOC for Urethral IOC for Urethral IOC for VUR IOC for PUV stricture trauma Q. A 54 year old man presents with complaint of painless hematuria and CECT done revealed a mass lesion in the right kidney. Most likely diagnosis is? a. Angiomyolipoma b. RCC c. Simple cyst d. Oncocytoma 31  Q. Patient with abdominal pain and Sterile pyuria A) Putty kidney B) Nephrocalcinosis C) Calcified psoas abscess D) Staghorn calculi 32  X-RAY Mammography - cluster of Breast within breast Popcorn calcification on microcalcifications appearance mammography POPCORN CALCIFICATION → ON MAMMOGRAPHY →Fibroadenoma → ON CHEST RADIOGRAM → Pulmonary hamartoma → ON MRI BRAIN → Cavernous angioma → ON ILIAC BONE → chondrosarcoma → ON PELVIC RADIOGRAPH →Post menopausal female-calcified fibroid Coin in esophagus. Coin in trachea Double Ring Step off 33 Cardiac pacemaker – 2 thin electrodes Implantable cardioverter Defibrillator → single lead and thick coils IOC to know integrity of cardiac pacemaker /ICD → Prosthetic mitral valve Left sided mastectomy/ Poland syndrome gingko leaf sign → subcutaneous emphysema 34 Multiple ribs fracture with paradoxical movement of chest wall -inward during inspiration; outward during expiration Best x ray view to look at sella → lateral skull Best x ray view to look at orbital floor → waters view All sinuses are seen in lateral view Occipito frontal view → Occipito mental view with closed mouth → Occipito mental view with open mouth → Petrous ridge below maxillary sinus- Petrous ridge below orbit – Caldwell view Waters view 35 Normal endo tracheal tube tip > 5cm from Post intubation Chest X-ray → carina. Coiling of nasogastric tube and air in Abdomen Best X ray view Pneumoperitoneum or hollow viscus perforation CxR erect Pneumothorax → Expiratory film Pleural effusion → Ipsilateral lateral decubitus view Patella # → Skyline view Acetabular # → Judet view CTEV → KITE View CxR erect ( pA view) → Mc radiograph full inspiration; arms abducted; erect 36 CxR (AP VIEW) Trauma LL # Icu → Expiratory film → Pneumothorax and foreign body Supine Abdominal Radiograph → Intestinal Obstruction KVP → Kilo voltage peak MAS – milliampere second Kvp  Energy (Quality of x rays) Mas  number (quantity of xrays)  penetration power  blackening of film 1  ________  contrast Contrast - To improve contrast of x ray film →KvP (chief),  mas - To improve contrast of a x ray film in a morbidly obese pt→ 37  → X-ray film → Silver Bromide (Ag Br) → Safe light used in dark room procedure → Red light Computerised Radiography Direct Digital Radiography Phosphor plate Fixed Electronic Panel (CSI/amorphous  selenium Laser Beam   Electronic Image Electronic Image → X ray are generated when fast moving electrons from cathode strike target of anode → Deceleration of fast moving electrons (K.E of e → X ray photon) → chief source of x ray generation → Bremstrahlung radiation / Braking radiation → Filter is used in X ray tube to filter out low energy X rays. Filter is made of Aluminium. → CONES & Collimators → made of lead, Convert a divergent beam to directional beam → Grid → placed behind the patient and in front of film, grid prevents scatter radiation from forming image. Grid is made of parallel lead lines Compton effect → The chief source of scatter radiation in diagnostic radiology 38 Characteristic Radiation → chief source of x ray generation in mammography 39  CT SCAN CT MRI Cortical Bones White Black Fat Black White on T1 , T2 CT Scan is Based on linear attenuation of x ray It is Measured in Hounsfield units It is Based on Electron density of tissue HOUNSFIELD UNITS -1000 → Air -50-100 → Fat Hypodense Reference Value 0 → CSF/Water (Black) +60-+70 → Acute Bleed +130 → Contrast Hyperdense +200-+250 → Calcification (White) +400-+1000 → Cortical Bone Coronal Axial CT – cisternography 40 Ct Urography MR urography → Huntingtons chorea → atrophy of caudate → Sensory relay centre → Thalamus → Cortico Spinal tracts pass through posterior limb → Melatonin production → pineal gland → M.C site of HTN bleed → Putamen → CSF production → choroid plexus → Swallow tail sign → Normal appearance of substaintia nigra → Absent swallow tail sign → Parkinsons disease → Suprasellar calcifications → Craniopharyngioma 41 Double density sign on ct pns Holman miller sign /Antral sign- Anterior bowing of posterior wall of maxillary sinus (adolescent male with epistaxis) → Ncct→ Delta sign Cect→ Empty Delta Sign 42  Most anterior chamber – RV Most posterior chamber - LA Ct angiography MDCT with high dose contrast Ct angiography IOC for → acute PTE → acute aortic dissection Rt pneumothorax Indications for NCCT Indications of CECT → Head trauma →Abdominal trauma ( to know organ of → Acute SAH injury) → Renal calculi /ureteric colic → Tumours - RCC , lung cancer → Stroke-hg stroke v/s ischemic →Infections—Renal tb, appendicitis → Coronary calcifications → Inflammations —pancreatitis IOC to know vascular invasion in RCC → MRI 43  RTA patient, with contrast, extravasation from liver →Rta CECT → coronary ca+2 scoring →Agatston Scoring → plain MDCT → Cardiac ct coronary done in mid diastole → Ctcolonoscopy-3DCTwithvolumereconstruction, endoluminal view 44  Virtual bronchoscopy→ 3DCT →Noninvasive → Can evaluate post stenotic area → Biopsy cannot be taken 3DCT→ For complex facial # → Pelvic # HRCT—High Resolution CT Indications for HRCT Uses thin slices (1-3 mm) ILD Uses Bone algorithm → sharpness bRonchiectasis CT cisternography / COVID - 19 Temporal bone (ear ossicle disruption)/ conductive deafness after head trauma Ice cream cone appearance On HRCT On MRI BRAIN IOC for → paranasal air sinus → mastoid air cells → pneumocephalus, → pneumothorax → pneumomediastinum → pneumoperitoneum → Emphysematous infections → Intestinal obstruction 45 Q. A 25 year old female with severe headache is advised a CT scan of the Head. Which of the following history will you definitely ask before doing the CT study ? a. History of fall b. Cochlear implant surgery c. Last menstrual period d. History of hypertension Q. A whole body CT scan done for trauma includes all except ? a. Cervical spine b. Limbs c. Head d. Abdomen 46 Dual Energy / Dual source CT → To characterise the type of kidney stone → To differentiate Stent vs calcifications → To obtain virtual Non contrast CT Spiral / Helical CT → slip ring Technology MDCT → multi detector CT → → cone beam of x rays → large area covered with less movement artifacts for cardiovascular imaging 47 MRI → Multiplanar Imaging → long acquisition time T1 → short TE, short TR T2 → long TE, long TR → Most pathologies are hypointense on T1 and hyperintense on T2 → Dark on both T1 and T2 → Signal void Air Bone Ca+2 Dense fibrous tissue → tendons, ligaments, meniscis Flowing blood MR – Angiography Gadolinium contrast without contrast “Time of flight” 48 Hyperintense on T1 (white on T1) Fat → Lipoma, Dermoid cyst Methhemoglobin → subacute Hemorrhage Melanin Minerals like Cu+2 Protein content → Posterior pituitary (vasopressin) Craniopharyngioma Paramagnetic substances like Gadolinium 49  MRI →based on Gyromagnetic property of H+ Ions →uses NMR (Nuclear magnetic resonance) Super conducting magnet (1.5T, 3T) Gradient Coil Radiofrequency Coil Spin – Echo Sequence T1 T2 Gain in longitudinal magnetisation Loss of transverse magnetisation Spin – lattice interaction Spin – spin interaction Z axis X, Y axis For anatomy For pathology Short time to Echo (TE) Long TE Short time to Repeat (TR) Long TR T1 → Bone – Black T2 → Bone – Black Fat → more white → Fat – White Grey matter → Grey Grey matter – white White matter → white White matter → Black CSF/fluid → dark CSF / fluid → white (WW-II) Indications of MRI Neuroimaging Cardiac Imaging Women Imaging Ortho Imaging Brain Spine Cardiomyopathies High risk screening AVN Brain tumors Spinal mets Myocarditis Screening in young AVN in young (Perthes) Encephalitis Spinal trauma Myocardial scar Breast implants Acute Osteomyelitis Diffuse Axonal SCIWORA Ventricular Placenta increta Ankylosing Injury (Spinal cord function (Most placenta percreta spondylitis Injury without accurate ) Radiographic abnormalities) Multiple Potts spine Pelvic adenomyosis Stress Sclerosis #/March # Ankylosing Scar vs residual / Cartilage spondylitis recurrence in breast cancer (CE-MRI) PIVD Paraplegia 50 P’s of MRI → Posterior fossa IOC – for Pancoast tumor Posterior mediastinum Potts spine Paraplegia PIVD Perthes Pelvic adenomyosis Placenta percreta / increta Contraindication of MRI Not a Contraindication of MRI → Intraocular metallic foreign body (hammer → Cu T – IUD, pregnancy and chisel) → Coronary stent → Cardiac Pacemaker → Orthopaedic Implants (Titanium) → ICD, Aneurysmal clips, insulin pumps →foleys / Ryles tube → Cochlear Implants → claustrophobia (relative) → Swan – Ganz catheter T1 W T2 W T1 T2 Contrast studies of MRI are done in T1 Linguine sign and Keyhole sign on MRI → Intracapsular Breast implant rupture 51  Rt sided hemiplegia CT – normal DWI → Lt MCA infarct DWI → Most sensitive for acute infarct → Pineal Gland tumour (Germinoma) compressing superior colliculi and causing upward gaze palsy is called Parinaud syndrome → Posterior pituitary → bright spot on T1 (vasopression) →absence of bright spot of posterior pituitary → central DI → Pituitary macroadenoma it can compress optic chiasma, producing Bitemporal heterononymous hemianopia Diffusion weighted MRI (DWI) →based on Brownian movements → Diffusion restriction → bright signal on DWI, low Apparent Diffusion coefficient (ADC) → DWI → detects cytotoxic Edema before vasogenic Edema Lesion showing Diffusion Restriction Infarct Abscess Medulloblastoma Epidermoid cyst 52 FLAIR → Fluid Attenuation Inversion Recovery → Fluid Suppressing sequence → same as T2 with fluid suppression → Best sequence for plaques of multiple sclerosis FLAIR – MRI multiple sclerosis STIR – MRI→ Short Tau Inversion Recovery → Fat suppressing sequence → Evaluates bone marrow Edeme → Orthopaedic Imaging IOC for Ankylosing Spondylitis - STIR – MRI Susceptibility Weighted MRI (SWI) → Micro haemorrhages → Diffuse axonal injury, cerebral amyloid angiopathy → Hemosiderin → Calcification Susceptibility weighted MRI Blooming artifacts 53 Diffusion Tensor Imaging (DTI) →Tractography → evaluates white matter tracts → uses anisotropic movements Superior → inferior fibres → Blue Left → Right fibres → Red Anterior → Posterior fibres → Green DTI FMRI → functional MRI → Evaluates functional areas of Brain → Evaluates speech centres, fine motor areas, visual centres → for Brain mapping → Based on BOLD technique “Blood O2 level dependent” Ligaments, tendons, menisci → dark on both T1& T2 Saggital MRI knee Bowtie appearance ? (Question mark like appearance). Double PCL Sign - 54 MR – Spectroscopy →Evaluate chemical metabolitis of the lesion Normal Hunters angle → 450 Choline peak @ 3.2 ppm Tumors Lipid – lactate peak @ 1 ppm Tuberculoma N-Acetyl asparatate (NAA) peak @ 2 ppm CANAVANS disease Choline and Alanine peak Choline and Taurine peak 55 Black turbinate sign – on contrast enhanced Hippocampal volumetry is done on oblique MRI - coronal MRI Hippocampal atrophy In case of dementia In case of Epilepsy 56 57  NEURORADIOLOGY Normal sites of calcification in brain →Pineal gland (Posterior to third ventricle) →Choroid plexus (In occipital horns) →Folds of dura →Lens Diffuse Nodular calcifications – Subependymal calcifications – Starry Sky calcifications – Periventricular Bilateral basal ganglia calcifications – Calcifications- EDH (Epidural hematoma) →Extradural hematoma → Due to rupture of middle meningeal → Biconvex / lentiform / lemon shaped artery appearance seen → Fracture of pterion (H shaped suture) → Limited by suture lines, does not cross → Causes brain stem hemorrhages called sutures Duret hemorrhages → Causes uncal herniation → Causes third nerve palsy → Has lucid interval 58 SDH (Subdural hematoma) → Seen with → Concavo-convex or Crescentic or banana Chronic old trauma shaped Cortical atrophy → Crosses suture lines Alzheimer's → Happens due to rupture of Bridging veins disease Punch drunk syndrome Battered baby syndrome MCC of acute SAH – trauma MCC for spontaneous SAH – berry aneurysm rupture IOC of acute SAH – NCCT Rupture of charcot bouchard anemysm 59 Mount Fuji Sign - Lipohyalinosis of lenticulo striate branches Sign of acute infarct on CT Scan Sylvian dot sign Hyperdense MCA sign loss of insular ribbon obliteration of lentiformnucleus Hyperdense MCA Sign – Dawsons Fingers – Periventricular white matter hyperintensities perpendicular to ventricles 60  Vesicular stage of NCC Calcific nodular stageof NCC parasite alive stary sky appearance cyst with central scolex parasite dead minimal perilesional edema no edema Rice grain calcifications - Starry sky appearance →On NCCT Brain →On histopathology →On USG liver → On Immunofluorescence Conglomerate ring enhancing lesions showing lipid lactate peak on MRS - Ring enhancing lesions showing diffusion restriction - → Ring enhancing lesions at grey white matter junction – → Ring enhancing lesions in HIV / AIDS – 61 → Soap bubble appearance on MRI brain - White matter leukodystrophies (dysmyelination disorders) – → Involving bilateral frontal lobes – → Involving bilateral Occipital lobes - → Involving bilateral Thalami - → Involving deep white matter with tigroid / lamellated / leopard skin appearance – → Involving diffuse white matter with NAA peak - alcoholic patient with ataxia, confusion, and opthalmoplegia  ENCEPHALITIS → Encephalitis involving b/L temporal (most common) and basifrontal areas – → Encephalitis involving bilateral Thalami – → Encephalitis involving Cerebellum - fever patient with bilateral thalamic involvement child with delayed mile stones with bilateral thalamic involvement 62 White cerebellum sign – Swallow Tail Sign – normal appearance of substantia Irreversible brain hypoxia nigra (Nigrosome – 1) - Absent Swallow Tail sign – Parkinsonism Humming bird sign Mickey Mouse sign Panda sign – Wilsons disease Molar Tooth Sign – joubert syndrome Vermis hypoplasia Vermis herniation Vermis agenesis 63 Gyral and basal gangliahyperintensity Hockey stick sign - Cortical ribboning - Hyperintensities in Corticospinal Tracts - wine glass appearance on MRI Puff of smoke appearance on angiograhy – Moya – moya Moya – Moya disease – chronic disease vasospasm of supra clinoid part of ICA Triad of Hydrocephalus + midline vascular HOT CROSS BUN SIGN - swelling + CHF →Vein of Galen Malformation Multisystem Atrophy Type – C Prominent median prosencephalic vein AV fistula 64 Suprasellar calcification – Figure of 8/snow man appearance Craniopharyngioma Pituitary macro-adenoma Solid – cystic lesion at sella - Glioblastoma multiformis / butterfly glioma Enhancing lesion with necrosis crossing mid line, invading corpus callosum Broad base towards dura – dural tail sign Spoke wheel vasculature Mother-in-law sign – early enhancement and delayed washout Hyperdense on CT Calcifications skeletal hyperostosis Pneumosinusdilatans Meningioma CSF cleft 65 Subependymal calcification – Candle Drippling SEGA – subependymalgaint cell astrocytoma Tuberous Sclerosis) (@ foramen of monro) Cystic lesion with enhancing mural nodule in cerebellar Frontal lobe tumor withchicken hemisphere wire calcifications Acoustic Neuroma / Vestibular Bilateral Vestibular Schwanomma Schwanomma Agenesis of corpus callosum – Racing car sign / Moose head / Viking Helmet Sign 66 Agenesis of corpus callosum – lipoma of corpus callosum - Necrosis of corpus callosum - Sturge – weber syndrome–Trigemino- Encephalic Vascular Tram Track appearance on Malformation CT Brain Portwine stain, Lepto Meningeal vascular malformation, Hemiatrophy of Brain Cystic lesion not communicating with lateral ventricle - arachnoid cyst Cystic lesion communicating with lateral ventricle – Schizencephaly Arachnoid cyst Epidermoid cyst →Common at the region of Sylvian fissure →Common at the CP angle →CSF containing cyst →Keratin containing cyst →Suppressed by FLAIR →Not completely on suppressed by FLAIR →No diffusion restriction →Diffusion restriction →HIGH ADC value →Low ADC value →Dark on DWI →Bright on DWI 67  Silver beaten / copper beaten skull appearance - feature of increased ICT Earliest Radiological Sign of increased ICT in children – sutural diastasis in Adults – erosion of dorsum sella HalloverdenSpatz disease (“Pantothenate kinase associated neuro degeneration”/ PKAND) Eye of tiger appearance on MRI Lemon sign andBanana sign Chiari Malformation and Spina Bifida Wrapping of Cerebellum around brain stem – Anterior Bulging of frontal bone – Dandy Walker Malformation Lissencephaly– agyria mega cisterna magna Large posterior fossa Agenesis of celebellar vermis and Large Posterior Fossa 68  Blow out # or tear drop fracture – orbital floor # Water’s view - best view to look for Orbital floor Syringomyelia Diastematomyelia Normal Spinal Cord Cauda Equina Empty Thecal Sac Sign – Empty Thecal Sac Sign – Empty Delta Sign - Empty Sella - 69 RTA patient - lyre sign - hypothalamic hamartoma – grows at tuber cinereum 70 Stroke/CVA/Hemiplegia 71 72  ANGIOGRAPHY contrast is black contrast is white Digital substraction angiography or Bone-white Bone-black catheter Angiography   CT-Angio MR-Angio MR angiography showing circle of willis MR-venography showing Dural venous sinuses Posterior communicating artery is a branch MR Angiography of Internal carotid Pcom joins ICA with PCA With contrast Without contrast Gadolinium Time of Flight young pt with HTN and asymmetrical Kidneys -Renal artery stenosis Initial Ix - USG With Doppler IOC - CT- Angio IOC if RFT is abnormal - MR-Angio(Time of Flight) 73 young patient with HTN – corkscrew appearance of Renal artery / Beaded/tortous / Pile of plates appearance of Renal Artery - Fibromuscular dysplasia Elderly, Hep B, P-anca - Renal artery microaneurysms→Polyarteritisnodosa → M.C artery involved in PAN - Renal artery coronary artery microaneurysms→Kawasaki Disease Caput Medusa No Nidus   Venous Malformation Nidus and feeding artery →True AVM AV Fistula (Arteriovenous Malformation) Lobar haemorrhage in young non hypertensive patient → AVM Lobar haemorrhage in elderly non hypertensive patient→ cerebral amyloid angiopathy Sagittal CT Sagittal MRI Child with CHF + Hydrocephalus + midline Vascular swelling in brain / (intracranial bruiting ) AV Fistula prominent median prosencephalic vein →Vein of GalenMalformation 74 75 76 77  WOMEN IMAGING Breast USG BIRADS : breast imaging reporting and data system Mammography Used to grade the breast lesion Breast MRI BIRADS Grade Interpretation Management 0 Incomplete evaluation Complete it 1 Normal Routine mammography 2 Benign (Popcorn ca+2 / Involuted fibro adenoma) Routine mammography 3 Probably benign (95% chances of malignancy) Biopsy 6 Biopsy proven Definitive treatment IOC for mullerian anomaly/uterine anamolies→3D USG MRI is more sensitive/problem solving investigation Gold/standard confirmatory →laparoscopy + hysteroscopy Unicornuate uterus Uterine didelphys Bicornuate uterus → Wide intercornual Angle Septate uterus → narrow intercornual Angle Arcuate T-shaped Endometrial cavity →DES exposure DES exposure In mother - Uterine hypoplasia in off spring septate uterus Clear cell ca of vagina 78 Beaded/tortous/cork screw app/tobacco pouch Appearance of fallopian tube →TB salpingitis →Best time for HSG → 6th – 10th day of menstrual cycle Grossly distended fallopian tube with no Spill of contact →Hydrosalpinx (b/l) Irregular filing defects in the endometrium H/O recent abortion H/O molar pregnancy (dilation & curettage) done asherman syndrome IOC for routine screening of Breast cancer Mammography >30Yrs - Mammo + MRI High risk screening (family history,BRCA+,P53+) 25-30Yrs→ MRI Lump in a young female –(Fibroadenoma) USG Painful lump in lactating mother –(breast abscess) USG Ioc for patients with Breast implant MRI IOC In pts of Ca cervix to look for parametrial involvement MRI In Pelvic adenomyosis MRI Placenta increta/percreta MRI Vasa Previa Doppler USG Ovarian Torsion Doppler USG Screening of breast cancer in young females MRI Lump in young females USG Scar vs residual/recurrence of breast cancer CE MRI Best time for Breast MRI - 2nd week of menstural cycle 79 80  RADIOTHERAPY →Teletheraphy →Brachytheraphy →Systemic RT Palliative radiotherapy Curative radiotherapy Prophylactic radiotherapy Emergency radiotherapy Mechanism of action of radiotherapy – ionisation of molecules - free radicle injury - double stranded DNA damage EBRT  - Rays x-rays electron beam Proton beam Co-60 LINAC (linear For superficial Has Bragg peak accelerator) tumors t1/2= 5.2yrs Mycosis fungoides For deep seated Mc rays used in RT Intraoperative tumors radiotheraphy -brain stem glioma Megavoltage xrays - skull base chordoma are preferred due to skin sparing effect Inverse Square Law – Most common side effect of radiotherapy – skin erythema Most common cancer after radiotherapy - leukemia most common thyroid cancer after Papillary thyroid cancer radiotherapy - most common bone tumor after radiotherapy Osteosarcoma Intensity Modulated Radiotherapy (IMRT) 81 Stereotactic Radiotherapy → In SRT-large dose of radiation is deposited on the tumor in single fraction with high precision Gamma Knife Cyber Knife →  rays → co-60 → xrays → LINAC → leksell frame → no leksell frame (special helmet) → robotic arms Head / brain tumors → used elsewhere in body → Uses of stereotactic RT Solitary brain metastasis Meningiomas Trigeminal neuralgias Schwannomas AV malformation Pituitary adenoma Craniospinal irradiation Medulloblastoma Non-Hodgkins Small cell lung ca ALL M.C hormone deficiency after craniospinal irradiation – Growth hormone Radiosensitizers Radioprotectors Metronidazole, misonidazole Amifostine Hyperbaric oxygen IL-1 Cisplatin GM-CSF 5 FU, Gemcitabine Pentoxyphyline hydroxyurea But not CYCLOPHOSPHAMIDE 82 Radiation Recall Syndrome– Anthracyclines (DoxoRubucin) - Paclitaxel Radio Sensitive Radio Resistant Stage of cell cycle G2M check point > M Phase Late S Phase Organ Ovaries, testis Vagina Tissue Bone marrow Nervous tissue (law of Bergonie and Undifferentiated cells Quiescent cells Tribondeau) Blood cell Lymphocyte Platelet Eye lens Sclera Radiosensitive tumors Radioresistanttumors Wilms (Nephroblastoma) HCC Ewings Osteosarcoma Lymphoma Melanoma Multiple Myeloma Pancreatic ca Seminoma 5 R’s of radiobiology Repair of sublethal damage Reoxygenation Reassortment Repopulation Radiosensitivity Mantle field RT →Hodgkins lymphoma above diaphragm Inverted Y RT →Hodgkins lymphoma below diaphragm, bilateral seminoma Dog leg field RT →Seminoma 83 Fractionated RT / Regular / Conventional RT – 5 fractions / week , once daily (OD) Mon – Fri Hyperfractionated RT→> 5 fractions / week (BD /TID) Aggressive cerebral gliomes Small cell lung ca Hypofractionated RT→< 5 fractions / week Palliative Ex:- Bone mets – single fraction of 8Gy CHART regimen - continuous hyperfractionated Accelerated RT →Non small cell lung cancer Systemic RT→Oral / IV I-131 → Well differentiated papillary / follicular thyroid ca Sr – 89 (Strontium) →Bone mets Sanarium – 153 p-32 → PCV Brachytheraphy LDR – BT (low dose rate) HDR – BT (High dose Rate ) I – 125 seeds Ir – 192, Co-60 Remote after loading → Used for Brachytheraphy– 84 85 86  CVS Axial Coronal cect 3DCT abdominal aortic aneurysm - infra renal aorta (M.C) Rupture of aortic aneurysm YIN-YANG sign On color Doppler Pseudoaneurysms And large true aneurysms Double Lumen with intimal flap →Aortic Arch Descending aorta Dissection True lumen False lumen Smaller in size Larger in size More contrast Less contrast COBWEB sign Beak sign IOC for Acute Aortic dissection Stable patient Unstable patient 87 Neonate with cyanosis and plethora on CxR Transposition of great arteries (TGA) Narrow superior mediastinum Egg on string/egg on side Appearance Plethora on CxR Egg in cup app on CXR → Constrictive Pericarditis (Pericardial Ca+2) Child with cyanosis, CxRoligemia→TOF Severity—infundibular pulmonary stenosis Overriding of aorta Large membranous VSD Last to develop RVH Cardiac silouhette is normal Concave pulmonary area Upward cardiac apex Heel of boot—RVH COR EN SABOT(boot shaped heart) → TOF 88  Ebsteinanamoly → Low lying tricuspid valve → Large RA → small RV,oligemia on CXR →Atrialisation of RV (Li+ Toxicity / Bipolar Mother / Mania) Box shaped heart →ebstein's anomaly Snowman/fig of 8 / cottage loaf heart →Supracardiac TAPVC Scimitar sign Partial anamolous pulmonary venous communication (PAPVC) RIPV opens into IVC PAPVC associated with Rt lung hypoplasia scimitar syndrome / venolobar syndrome 89  coarctation of aorta Reverse 3/E sign on Barium 3 sign on CXR High bp in UL AND low Bp in LL Radiofemoral delay In COA →Roeslers sign Inferior rib notching-3-10th rib Child >10 years Money bag Leather bottle apperance Pericardial effusion → on lateral →oreo cookie sign CXR Pulmonary arterial HTN→ Jug handle appearance on CXR Prominent dRPA (Descending right pulmonary artery) Prune tree app on CXR Prune tree app on ERCP/MRCP — 90  On echo Apical ballooning of heart Octopus pot heart Takotsubo cardiomyopathy Broken heart syndrome catecholamine surge on echo —RV hypokinesia→mcconnell sign →PTE On echo Assymetrical thickening of IVS SYSTOLIC ANTERIOR motion of mitral valve leaflet (SAM) (SAM) IOC for HOCM - Cardiac MRI IOC for cardiomyopathies - Cardiac MRI (DCM, HOCM,takotsubo) IOC for myocarditis - Cardiac MRI (gold standard for myocarditis - Endomyocardial biopsy) IOC to evaluate myocardial scar after MI – CEMRI IOC for Arrhytmogenic RV cardiomyopathy (ARVC) - Cardiac MRI Most accurate for ventricular function →Cardiac MRI Nuclear scans in cardiac diseases Myocardial perfusion imaging- Thallium 201, sestamibi, tetrofosmin - N-13 Ammonia PET → most sensitive for Myocardial perfusion Reversible ischemia → Stress thallium study Myocardial infarction Imaging→TC 99m –pyrrophosphate Area of Infract On thallium on pyrrophosphate Scan scan   Cold Hot Myocardial perfusion → N-13 Ammonia PET Myocardial viability → 18 FDG PET 91 N-13 Ammonia PET –ve,18 FDG PET –ve- Scar tissue N-13 Ammonia PET –ve,18 FDG PET+++- Ischemic but Viable Myocardium Hibernating myocardium N-13 Ammonia PET +,18 FDG PET +,Ventricular dysfunction - Stunned myocardium Cyanotic heart disease Plethora on CXR Oligemia on CXR   TGA TAPVC Persistent TOF lowlying Tricuspid Egg on  Truncus  tricuspid atresia string Snowman/ Arteriosis Boot valve Fig of 8  Sabot  Sitting duck Ebsteins Appearance Anamoly  Box shaped Non Cyanotic heart disease Plethora on Normal lung CXR field (L-R Shunt)     COA ASD VSD PDA    Wide Pansystolic continous Fixed murmur machine like Splitting murmur Of S2 92 LAE/MITRAL STENOSIS → Straightening of left heart border → splaying of carina → double right heart border → enlargement of left atrial appendage (earliest) → elevation of left man branchus → walking man sign on cxr → anterior indentation of esophagus on barium swallow 93 94  RESPIRATORY Normal CXR lt hilum is @ higher level than Rt hilum Hilum on CXRis mainly formed by PA and UL PV LL PV do not form hilar shadow Rthemidiaphragm is at higher level than Lt hemidiaphragm due – heart on left side Posterior ribs – horizontal Anterior ribs – oblique Dextrocardia Dextrocardia with situs Inversus→ Kartagener syndrome Most anterior chamber of heart- RV Most posterior chamber of heart – LA Right heart border is NOT formed by- RV LT heart border is NOT formed by - LA 95 Volume gain Volume loss No net change in volume Pneumothorax Atelectasis,  Massive pleural effusion Collapse, Consolidation /  Pneumonectomy Pneumonia Trachea shifts to opposite   side Trachea shifts to same side No tracheal shift Retrocardiac air fluid level  Hiatal hernia → IOC → CT with oral contrast Rt middle lobe is in close contact with Rt heart border and overlaps cardiac shadow CXR findings of Pneumonia / consolidation →No tracheal shift →Ill defined →Fluffy borders → air bronchogram CXR findings of pleural effusion →Meniscus sign →Ellis curve →Concave upward curve →Obliteration of costophrenic angle IOC to evaluate pleural effusion → CT Scan IOC To look for mininal pleural effusion → USG Best X ray view → lateral decubitus view with horizontal beam of X rays 96  CXR findings of lung collapse →Trachea and mediastinum shifts to →Same side →Bronchial cut off →Crowding of ribs Lobar Collapse → Sharp margins Causes of Air bronchogram →Consolidation/pneumonia →Pulomonaryedema →ARDS/HMD →broncho alveolar Ca Golden S sign.→ Bronchogenic Ca with Rt upper lobe collapse →Silouhette sign Rt heart border is obscured by RML Pathology Lt heart border is obscured by lingularvpathology Hemidiaphragmsare obscured by LL pathologies Aortic knuckle is obscured by ltapico posterior pathology Silouhetting of Rt heart border – RML pathology 97 Silouhetting of lt heart border – Lingular Luftsichelsign-lt upper lobe collapse Pathology Sickle is formed by compensatory hyperinflation of superior segment of lt lower lobe CXR findings of pneumothorax  Absent bronchovascular markings Visceral pleural line Deep sulcus sign(supine CXR) Pneumothorax CXR findings of pneumomediastinum -> Spinnaker Sign (Angel wing sign) continous diaphragm Sign. Pneumomediastrum air around aorta, PA, bronchus, trachea Boerrharve Syndrome - Esophagealpreforation causing Pneumomediastinum Naclerios V sign →Thymic Sail sign –normal 98 Pneumomediastinum Pneumopericardium Air under Rt hemidiaphragm → hollow viscus perforation / pneumoperitoneum Rx → I.V fluids + Emergency laprotomy Assymptomatic, routine check up → chiladiti sign (pseudopneumoperitoneum) Fever, RUQ pain, H/O diarrhea past few weeks → ruptured liver abscess Rt pleural effusion D – shape collection- Loculated pleural effusion broad base forwards pleura doesnot change position Lentiform collection along the Split pleura sign →Empyema Fissural lines →Interlobar effusion or Phantom tumor 99 Horizontal air fluid level →Hydropneumothorax Hospitalised child with fever and cough  Pneumatoceles→ M.C → Staph Aureus Alcoholic pt, productive cough, fever  Bulging fissure Sign  Klebsiella pneumonia → red currant jelly sputum Fever, tachypnea, dry cough Reticular opacites on CXR  Interstitial pneumonia → Mycoplasma → Legionella → Viral pneumonia Antero posterior gradient on CT chest →ARDS 100  CXR findings of Emphysema | COPD hyper inflated lung fields widening of ICS →Flattening of domes of diaphragm →Longitudinal heart Retrosternal Space Increased Obliterated   Emphysema RVH Sarcoidosis →b/L hilar LN + Rtparatracheal LN 1,2,3sign →Garland sign Egg shell calcification Silicosis Sarcoidosis On CT - Galaxy sign On Gallium-67 scan →Lambda sign in Sarcoidosis thorax →Panda sign in face 101  Milliary mottling → Mitral Stenosis → Pulmonary hemosiderosis → Histoplasmosis → Sarcoidosis Millet seed opacities →Miliary TB Allergic Bronchopulmonary aspergillosis(ABPA) → UL opacities → Finger in glove opacities →Mucocele / bronchoceles → Central bronchiectasis MONOD Sign - Aspergilloma / fungus ball MONOD Sign changes position in prone and supine HALO Sign→Angioinvasiveaspergillosis Air crescent Sign →Angioinvasiveaspergillosis Immunocompromised Doesn’t change position - good prognosis 102 Bronchiectasis → signet ring appearance tram track appearance bunch of grapes appearance Tram track appearance → On Histopathology of kidney - MPGN → on CT – Brain →sturge weber syndrome → on spine Radiograph →Ankylosing spondylitis canon ball opacities  Pulmonary mets → RCC (m.c) →Chorioca Bat wing opacities on CXR ->perihilar confluent opacities →pulmonary Edema DOC → Furosemide - water lily - camalotte sign -floating membrane sign → Honey comb app on USG liver Hydatid Cyst – Echinococcus Hydatid Lung Liver   Doesnot Cyst Calcify Wall Ca+2 103  Cavitating mass in lung → Squamous cell carcinoma Cavitating lesions Cancers →Squamous cell carcinoma Abscess Vascular Emboli → Septic Thick walled cyst with horizontal air -fluid level’→lung abscess Emboli Infections → TB Trauma Young crazy pavement app of CT chest →Pulmonary Alveolar proteinosis/ Covid - 19 Farmer with exposure to organic dust, mosaic attenuation on CT chest → Hypersensitivity pneumonitis / Extrinsic Allergic alveolitis Hiv +, CD4subpleural honey combing NSIP-> GGO, Subpleural Sparing 2-3yr old, sudden onset of respiratory distress CXR - lucent hemithorax /opaque hemithorax→ suspect foreign body(air trapping in expiratory film) 106 Thumb sign - Acute Epiglottitis Steeple sign - Acute Laryngotracheobronchitis(ALTB) parainfluenza Cervical rib Newborn with respiratory distress CXR-> white out lung Lung volume decreased ARDS | Hyaline membrane disease CT- Diffuse Ground glass premature delivery 107 - New born with respiratory distress, term.on CXR -perihilar opacity’s, sunray appearance delivery - clears within 48-72 hrs precipitous delivery – lung volumes – normal H/o Caesarean section. Transient Tachypnea of newborn Newborn with respiratory distress, → post term delivery → on CXR B/l patchy opacities Lung volumes increased  Meconium Aspiration syndrome Dysphagia lusoria-Aberrant Rt Subclavian artery popcorn app on CxR - Pulmonary hamartoma Spiculated - lesion lung cancer Pancoast tumor -apical lung cancer IOC for pancoasttumor -> MRI → Invasion of Brachial plexus and subclavian vessels Solitary pulmonary nodule → well defined < 3 cm → Evaluated on low dose non contrast CT → SPN > 8 mm → PET scan 108 Post primary TB Tree in bud opacities →B/l Upper lobes heterogenous Bronchiolitis and endobronical spread of TB opacity cavitation (active TB) → Tree in bud opacities Miliary TB Tb lymph nodes multiple matted, Peripheral enhancement And central necrosis Pleural effusion COVID Imaging First line Imaging modality in COVID → CXR CXR → CT Scan → RTPCR +, confirmed COVID +, mild symptoms → Typical Findings of Covid -CORADS 5 →B/l multifocal peripheral GGO →Crazy pavement app →multifocal consolidation →Reverse Halo sign 109  Earliest and mc covid finding - Ground glass opacites CXR → advised as baseline in confirmed RT PCR + with high risk CT scan in COVID → to look for complications like ARDS, PTE, Pneumothorax GGO - vascular markings seen Consolidation → No vascular markings Air bronchogram Crazy pavement appearance Multi focal consolidations Reverse Halo sign →PAP (Pulmonary Alveolar Organising pneumonia Proteinosis) Covid - 19 →COVID – 19 CORADS → COVID – 19 Reporting and Data system Atypical of COVID →doesnot indicate severity Cavitation →indicates level of suspicion Lymphadenopathy Typical findings → CORADS – V Pleural effusion Lobar consolidation For severity of COVID → CT – severity score Total CT – severity Score → 25 (Max) →< 7/25 → Mild > 7 → risk of respiratory working 110 Asbestosis – Holly Leaf Sign Comet Tail Sign 111 112  MUSCULOSKELETAL Young male with back ache, uveitis, heel pain and restricted lumbar flexion (schober test) Bamboo Spine Bilateral Sacroileitis Dagger Sign Trolley Track Sign Romanas Lesions Interosseous membrane ca+2- Meniscal ca+2- Intervertebral disc ca+2- Ossified Posterior Longitudnal Ligament – japans Ossification of Anterior Longitudnal Ligament disease Diffuse idiopathic skeleton hyperstosis (DISH) Fused Cervical Vertebra 113 Q) A 9yr old girl has brown skin rashes on chest, multiple bone lesions and fractures which show increased uptake on bone scan and endocrine thyroid abnormalities, what is likely diagnosis A) Papillary ca with bone mets B) Mccune Albright syndrome C) NF1 with bone lesions D) Langerhan cell Histiocytosis Groundglass, appearance of bones Increased hot up take on bone scan 114 Elderly patient with fatigue, serum calcium-14,bone pains, and Increased serum creatinine levels Cotton Wool Skull -