Notes for the European Diploma in Radiology

Table of contents :
Breast Radiology
General
Mammography (MMG)
Fibroadenoma
Fibrocystic change
Phyllodes tumour (cystosarcoma phyllodes)
Cysts
Fat necrosis (oil cyst)
Intraductal Papilloma
Hamartoma (fibroadenolipoma)
Benign breast microcalcification
Malignant microcalcifications
Invasive breast carcinoma
Metastasis
MMG
US
Doppler
European screening
Interventional
Axillary LN staging
Metastatic disease
MRI
Implant rupture
Cardiac and Vascular Imaging
Coronary angiogram
MR coronary angiography
CT coronagraphy
Congential heart disease
Patent ductus arteriosus (PDA)
Valvular pulmonary stenosis
Persistent left-sided superior vena cava (double SVC)
Congenital aortic stenosis
Aortic coarctation
Pseudocoarctation
Tetralogy of Fallot
Ebstein anomaly
Transposition of Great Arteries
Aortic arch anomalies
Pulmonary artery anomalies
Vascular rings and slings
Thoracic situs
Cardiosplenic syndromes
Acquired heart disease
LA enlargement
LV enlargement:
RV enlargement
RA enlargement
Partial anomalous pulmonary venous return (PAPVR)
Scimitar syndrome
Total anomalous pulmonary venous return (TAPVR)
Aneurysm repair
Valvular heart disease
Cardiomyopathies
Lipomatous Hypertrophy of the interatrial septum
Hypertrophic cardiomyopathy
Arrhythmogenic right ventricular dysplasia
Myocardial noncompaction
Takotsubo cardiomyopathy
Variants/Anomalies of coronary vessels
Atherosclerotic coronary artery disease
Kawasaki disease
Pericardial effusion
Constrictive pericarditis
Pulmonary arterial hypertension
Pulmonary edema
Cardiac masses
Myxoma
Lipoma
Rhabdomyoma
Fibroma
Angiosarcoma
Rhabdomyosarcoma
Popliteal artery entrapment syndrome
Pulmonary sequestration (accessory lung)
Pectus excavatum
Peripheral vascular / Doppler
Deep vein thrombosis
Chest Radiology
Important anatomy
Anaphylaxis
HRCT - basic interpretation
GGO vs. consolidation
Tuberculosis
TB vs MAI
Viral pneumonia
Aspergillosis
Pneumocystis jirovecii pneumonia (PCP) infection
Histoplasmosis
Streptococcus pneumoniae pneumonia
Klebsiella pneumoniae pneumonia
Legionnaires’ disease
Neoplasms
Bronchogenic carcinoma
Hamartoma
Carcinoid
Radiation pneumonitis
TNM staging
Fleischner guidelines
Solid nodules
Lymphangitis carcinomatosa
Malignant pleural effusion
Metastases of lung tumours
Metastases to lung
Endobronchial metastases
Miliary metastases
Solitary metastases
Carney triad (Predominantly young women)
Pulmonary blastoma
Chronic lung disease
Sarcoidosis
Lofgren syndrome
Heerfordt syndrome
Lupus pernio
Usual Interstitial Pneumonitis (UIP)
Idiopathic Pulmonary Fibrosis
Non-specific intersitial pneumonia (NSIP)
UIP vs. NSIP
Respiratory bronchiolitis-associated interstitial pneumonia (RB-ILD)
Desquamative interstitial pneumonia (DIP)
Cryptogenic organizing pneumonia (COP or BOOP)
Lymphoid interstitial pneumonia (LIP)
Acute interstitial pneumonia (AIP, Hamman-Rich syndrome)
Plasma cell granuloma
Lymphangioleiomyomatosis (LAM)
Acute Respiratory Distress Syndrome (ARDS)
Collagen vascular diseases
Rheumatoid Arthritis
Ankylosing spondylitis
Systemic lupus erythematosus
Sjogren disease
Wegener granulomatosis
Churg-Strauss syndrome (Eosinophilic granulomatosis with polyangiitis)
Langerhans cell histiocytosis (eosinophilic granuloma)
Scleroderma (Systemic sclerosis)
Silicosis
Coal worker’s pneumoconiosis (CWP)
Asbestosis
Hypersensitivity pneumonitis
Pulmonary infiltrates with eosinophilia
Airway diseases
Malignant tracheal neoplasm
Metastases
Benign neoplasms
Saber-sheath trachea
Tracheobronchomalacia
Tracheobronchomegaly (Mounier-Kuhn disease)
Chronic bronchial disease
Emphysema
Bronchiectasis
Cystic Fibrosis
Neurofibromatosis type 1 (von Recklinghausen)
Tuberous sclerosis
Pulmonary alveolar proteinosis
Bronchiolitis obliterans (Swyer-James syndrome, unilateral emphysema)
Lung and chest injury
Pneumomediastinum
Lobar torsion
Aortic dissection
Lung surgery
Pneumonectomy
Lobectomy
Lung transplantation
Pulmonary embolism
Vasculitis
Pulmonary AVM
Pulmonary varices
Aortic nipple
Pulmonary veno-occlusive disease (PVOD)
Pleura
Pleural fibroma
Malignant mesothelioma
Pleural effusion
Empyema vs. Abscess
Chylothorax
Mediastinum
Anterior tumours
Middle mediastinum
Posterior mediastinum
Superior vena cava obstruction
Castleman disease
Fibrosing mediastinitis
Consolidation
Hepatorenal syndromes
Hidden zones (areas where nodules are missed if

Citation preview

The document you have in front of you is a collection of notes that have been written during the preparation for radiology exams including the EDiR and FRCR by Marcin Czarniecki, a radiologist trained in Poland, United Kingdom, and the United States. The format follows the outline of the European training curriculum, and may be used as a preparatory source for the European Diploma in Radiology (EDiR). This cross-country exam is gaining recognition throughout the world, and is currently missing a comprehensive source for candidate preparation. This document is not that, though. I would like to encourage all readers to participate in improving this document by adding links and content to make this a dynamic, living document, complete with missing material and updated with current tested topics. Links to other free, open-access sources would be highly encouraged, especially Radiopaedia. There is also a great need for a practice question set following the test format. The curriculum sections are divided into three parts: knowledge, skills, and competences & attitudes. These notes deal mostly with the theoretical knowledge needed for the exam. For this reason, it will be most useful in preparation for Part I of the EDiR exam. However, it does not cover the whole curriculum: the sections on Communication & Management as well as Research & Evidence-based medicine are not currently covered in this text. For optimal preparation for the exam, all candidates will benefit from becoming members of both the ESR and RSNA, as membership is free for trainees worldwide. Membership will give free access to an impressive database of online learning and lectures which are made available free of charge. Additionally, you will have free access to all journals which are published by the societies. Please remember that this document is provided for FREE, but donations are strongly encouraged to keep the project going and to help in maintenance costs. You can help by donating for this document at the following link: https://leanpub.com/edirnotes

Good luck!

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Abbreviations used ☞ ∴  > < 1, 2 ~ ABC ACL AD ADPKD AKA AIIS AR ARF ASIS ATN AVN BL BMD Bx CP CPPD CRF CT CTA CTC DD DISH DM DMSA DTPA FD FOOSH Fx Gd GvHD H&N h/o HNPCC SI LCL LES LND LR MAG3 MCL MCP

High Yield Therefore above greater than less than Primary, secondary Approximately Aneurysmal bone cyst Anterior cruciate ligament Autosomal dominant Autosomal dominant polycystic kidney disease Also known as Anterior Inferior Iliac Spine Autosomal recessive Acute renal failure Anterior Superior Iliac Spine Acute tubular necrosis Avascular necrosis Bilateral Bone mass density Biopsy Clinical presentation Calcium phosphate dehydrate Chronic renal failure Computed tomography Computed tomography angiogram Computed tomography colonography Differential Diagnosis Diffuse idiopathic skeletal hyperostosis Diabetes mellitus Dimercaptosuccinic acid Diethylenetriaminepentaacetic Fibrous Dysplasia Fall on outstretched hand Fracture Gadolinium Graft vs. host disease Head & Neck history of Hereditary nonpolyposis colorectal cancer Signal Intensity Lateral collateral ligament Lower esophageal sphincter Lymph nodes Low risk mercaptoacetyltriglycine Medial collateral ligament Metacarpophalangeal

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MFH MM MR MTP MVA NF NM PCL PNET PTH RCC RF SAH SC SCC SD SNS Susp. TB TCC TDLU TMT TS Tx w/o WHO VHL XR

Malignant fibrous histiocytoma Medial meniscus Magnetic Resonance Metatarsophalangeal Motor vehicle accident Neurofibromatosis Nuclear Medicine Posterior cruciate ligament Primitive Neuroectodermal Tumour Parathyroid hormone Renal cell carcinoma Risk factors Subarachnoid hemorrhage subcutaneous squamous cell carcinoma Standard Deviation sympathetic nervous system Suspected Tuberculosis Transition cell carcinoma Terminal ductal lobular unit Tarsal-Metatarsal Tuberous sclerosis Treatment without World Health Organization von Hippel-Lindau syndrome X-ray

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Table of Contents Breast Radiology............................................................................................... 30 General.............................................................................................................................................. 31 Mammography (MMG) .................................................................................................................. 31 Fibroadenoma .................................................................................................................................. 31 Fibrocystic change ........................................................................................................................... 32 Phyllodes tumour (cystosarcoma phyllodes) ................................................................................. 32 Cysts .................................................................................................................................................. 32 Fat necrosis (oil cyst) ....................................................................................................................... 32 Intraductal Papilloma ..................................................................................................................... 32 Hamartoma (fibroadenolipoma) .................................................................................................... 33 Benign breast microcalcification .................................................................................................... 33 Malignant microcalcifications ........................................................................................................ 33 Invasive breast carcinoma .............................................................................................................. 33 Metastasis ......................................................................................................................................... 34 MMG................................................................................................................................................. 34 US ...................................................................................................................................................... 35 Doppler ............................................................................................................................................. 35 European screening ......................................................................................................................... 35 Interventional ................................................................................................................................... 35 Axillary LN staging.......................................................................................................................... 35 Metastatic disease ............................................................................................................................ 36 MRI ................................................................................................................................................... 36 Implant rupture ............................................................................................................................... 36

Cardiac and Vascular Imaging ....................................................................... 37 Coronary angiogram ....................................................................................................................... 38 MR coronary angiography.............................................................................................................. 39 CT coronagraphy ............................................................................................................................. 40

Congential heart disease .................................................................................. 40 Patent ductus arteriosus (PDA) ...................................................................................................... 41 Valvular pulmonary stenosis .......................................................................................................... 41 Persistent left-sided superior vena cava (double SVC) ................................................................ 42 Congenital aortic stenosis................................................................................................................ 42 Aortic coarctation ............................................................................................................................ 42 Pseudocoarctation ............................................................................................................................ 43

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Tetralogy of Fallot ........................................................................................................................... 43 Ebstein anomaly ............................................................................................................................... 43 Transposition of Great Arteries ..................................................................................................... 43 Aortic arch anomalies ...................................................................................................................... 44 Pulmonary artery anomalies .......................................................................................................... 44 Vascular rings and slings ................................................................................................................ 44 Thoracic situs ................................................................................................................................... 44 Cardiosplenic syndromes ................................................................................................................ 45

Acquired heart disease ..................................................................................... 45 LA enlargement ............................................................................................................................... 45 LV enlargement: .............................................................................................................................. 45 RV enlargement ............................................................................................................................... 45 RA enlargement ............................................................................................................................... 45 Partial anomalous pulmonary venous return (PAPVR) .............................................................. 46 Scimitar syndrome ........................................................................................................................... 46 Total anomalous pulmonary venous return (TAPVR)................................................................. 46 Aneurysm repair .............................................................................................................................. 46 Valvular heart disease ..................................................................................................................... 46

Cardiomyopathies ............................................................................................ 46 Lipomatous Hypertrophy of the interatrial septum ..................................................................... 46 Hypertrophic cardiomyopathy ....................................................................................................... 47 Arrhythmogenic right ventricular dysplasia................................................................................. 47 Myocardial noncompaction ............................................................................................................ 47 Takotsubo cardiomyopathy ............................................................................................................ 47 Variants/Anomalies of coronary vessels ........................................................................................ 47 Atherosclerotic coronary artery disease ........................................................................................ 48 Kawasaki disease ............................................................................................................................. 48 Pericardial effusion .......................................................................................................................... 48 Constrictive pericarditis .................................................................................................................. 48 Pulmonary arterial hypertension ................................................................................................... 48 Pulmonary edema ............................................................................................................................ 49

Cardiac masses ................................................................................................. 49 Myxoma ............................................................................................................................................ 49 Lipoma .............................................................................................................................................. 50 Rhabdomyoma ................................................................................................................................. 50 Fibroma ............................................................................................................................................ 50

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Angiosarcoma ................................................................................................................................... 50 Rhabdomyosarcoma ........................................................................................................................ 50 Popliteal artery entrapment syndrome .......................................................................................... 50 Pulmonary sequestration (accessory lung) .................................................................................... 50 Pectus excavatum ............................................................................................................................. 51

Peripheral vascular / Doppler ......................................................................... 51 Deep vein thrombosis ...................................................................................................................... 51

Chest Radiology ................................................................................................ 52 Important anatomy .......................................................................................................................... 53 Anaphylaxis ...................................................................................................................................... 53 HRCT - basic interpretation ........................................................................................................... 53 GGO vs. consolidation ..................................................................................................................... 54 Tuberculosis ..................................................................................................................................... 55 TB vs MAI ........................................................................................................................................ 55 Viral pneumonia .............................................................................................................................. 55 Aspergillosis...................................................................................................................................... 55 Pneumocystis jirovecii pneumonia (PCP) infection ...................................................................... 56 Histoplasmosis .................................................................................................................................. 57 Streptococcus pneumoniae pneumonia ........................................................................................... 57 Klebsiella pneumoniae pneumonia .................................................................................................. 57 Legionnaires’ disease ....................................................................................................................... 57

Neoplasms.......................................................................................................... 57 Bronchogenic carcinoma ................................................................................................................. 58 Hamartoma ...................................................................................................................................... 58 Carcinoid .......................................................................................................................................... 59 Radiation pneumonitis .................................................................................................................... 59 TNM staging ..................................................................................................................................... 59

Fleischner guidelines ........................................................................................ 60 Solid nodules..................................................................................................................................... 60 Lymphangitis carcinomatosa .......................................................................................................... 60 Malignant pleural effusion .............................................................................................................. 60 Metastases of lung tumours ............................................................................................................ 60 Metastases to lung ............................................................................................................................ 61 Endobronchial metastases............................................................................................................... 61 Miliary metastases ........................................................................................................................... 61 Solitary metastases........................................................................................................................... 61

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Carney triad (Predominantly young women) ............................................................................... 61 Pulmonary blastoma ........................................................................................................................ 62

Chronic lung disease ........................................................................................ 62 Sarcoidosis ........................................................................................................................................ 62 Lofgren syndrome ............................................................................................................................ 62 Heerfordt syndrome ........................................................................................................................ 62 Lupus pernio .................................................................................................................................... 62 Usual Interstitial Pneumonitis (UIP) ............................................................................................. 63 Idiopathic Pulmonary Fibrosis ....................................................................................................... 63 Non-specific intersitial pneumonia (NSIP) .................................................................................... 63 UIP vs. NSIP ..................................................................................................................................... 64 Respiratory bronchiolitis-associated interstitial pneumonia (RB-ILD) ..................................... 64 Desquamative interstitial pneumonia (DIP) .................................................................................. 64 Cryptogenic organizing pneumonia (COP or BOOP) .................................................................. 65 Lymphoid interstitial pneumonia (LIP) ........................................................................................ 65 Acute interstitial pneumonia (AIP, Hamman-Rich syndrome) ................................................... 65 Plasma cell granuloma .................................................................................................................... 65 Lymphangioleiomyomatosis (LAM) .............................................................................................. 65 Acute Respiratory Distress Syndrome (ARDS) ............................................................................ 66

Collagen vascular diseases ............................................................................... 66 Rheumatoid Arthritis ...................................................................................................................... 66 Ankylosing spondylitis..................................................................................................................... 66 Systemic lupus erythematosus ........................................................................................................ 67 Sjogren disease ................................................................................................................................. 67 Wegener granulomatosis ................................................................................................................. 67 Churg-Strauss syndrome (Eosinophilic granulomatosis with polyangiitis) ............................... 67 Langerhans cell histiocytosis (eosinophilic granuloma) ............................................................... 67 Scleroderma (Systemic sclerosis).................................................................................................... 68 Silicosis .............................................................................................................................................. 68 Coal worker’s pneumoconiosis (CWP) .......................................................................................... 68 Asbestosis .......................................................................................................................................... 69 Hypersensitivity pneumonitis ......................................................................................................... 69 Pulmonary infiltrates with eosinophilia......................................................................................... 69

Airway diseases ................................................................................................. 69 Malignant tracheal neoplasm ......................................................................................................... 69 Metastases......................................................................................................................................... 70

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Benign neoplasms............................................................................................................................. 70 Saber-sheath trachea ....................................................................................................................... 70 Tracheobronchomalacia.................................................................................................................. 70 Tracheobronchomegaly (Mounier-Kuhn disease) ........................................................................ 70 Chronic bronchial disease ............................................................................................................... 70 Emphysema ...................................................................................................................................... 70 Bronchiectasis .................................................................................................................................. 71 Cystic Fibrosis .................................................................................................................................. 71 Neurofibromatosis type 1 (von Recklinghausen) .......................................................................... 72 Tuberous sclerosis ............................................................................................................................ 72 Pulmonary alveolar proteinosis ......................................................................................................... 72 Bronchiolitis obliterans (Swyer-James syndrome, unilateral emphysema) ............................... 72

Lung and chest injury ...................................................................................... 73 Pneumomediastinum ....................................................................................................................... 74 Lobar torsion .................................................................................................................................... 74 Aortic dissection ............................................................................................................................... 74

Lung surgery ..................................................................................................... 74 Pneumonectomy ............................................................................................................................... 74 Lobectomy ........................................................................................................................................ 75 Lung transplantation ....................................................................................................................... 75 Pulmonary embolism ....................................................................................................................... 76

Vasculitis ........................................................................................................... 76 Pulmonary AVM .............................................................................................................................. 76 Pulmonary varices ........................................................................................................................... 76 Aortic nipple ..................................................................................................................................... 77 Pulmonary veno-occlusive disease (PVOD) ................................................................................... 77

Pleura................................................................................................................. 77 Pleural fibroma ................................................................................................................................ 77 Malignant mesothelioma ................................................................................................................. 77 Pleural effusion ................................................................................................................................ 78 Empyema vs. Abscess ...................................................................................................................... 78 Chylothorax ...................................................................................................................................... 78

Mediastinum ..................................................................................................... 79 Anterior tumours ............................................................................................................................. 79 Middle mediastinum ........................................................................................................................ 80 Posterior mediastinum .................................................................................................................... 81 Did this document help you? Consider a donation Can you make this document better? Email [email protected]

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Superior vena cava obstruction ...................................................................................................... 81 Castleman disease ............................................................................................................................ 81 Fibrosing mediastinitis .................................................................................................................... 82 Consolidation.................................................................................................................................... 83 Hepatorenal syndromes................................................................................................................... 83 Hidden zones (areas where nodules are missed if 10mm on Us, >12mm on CT/MR Levels II-VIII: >8 on US, >10mm on US MR: CE identifies necrotic lymph nodes PET: more sensitive than Ct/MR for lymph nodes

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127

Interventional Radiology

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Interventional Radiology General • •

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Stent size should be 10% larger than vessel diameter Balloon sizes  Common iliac: 8-10mm  EIA: 6-8mm  SFA or renal artery: 4-6mm  Popliteal artery: 3-4mm Absolute contraindications to tPA  Major trauma/surgery within 2 weeks  CVA within 2 months  Bleeding diathesis  Pregnancy  Primary or secondary cerebral malignancy  Irreversible ischemia Treatment of Femoral artery pseudoaneurysms  2cm: US-guided thrombin injection

Fibroid Complications •

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Post-embolization syndrome (>52% of patients)  Flu-like  Lasts up to 10 days Failure of therapy (10%) Persistent non-offensive discharge 7-14% Sepsis 1-2% Premature ovarian failure 1-2%, but increases with age up to 25% in 45+

Popliteal aneurysms • • • •

Most common peripheral aneurysm AAA in 30-50% Contralateral aneurysm in 50-70% Men

TIPSS •

Indications:  Refractory ascites

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Interventional Radiology  Variceal bleeding uncontrolled otherwise

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Interventional Radiology

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 Hepatorenal syndrome  Hepatopulmonary syndrome  Budd-Chiari Contra-indications:  Hepatic encephalopathy Procedure:  Right hepatic vein used as route of access to right portal vein  Flow of contrat toward the porta indicates biliary rupture.  Contrast flowing towards periphery = puncture of portal vein and hepatic artery.  Shunt gradient less than 12mmHg

Endoleak •

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Type I  Leak from stent-graft attachment, divided into a type A and B corresponding to proximal and distal Type II  Retrograde flow through aortic branches, IMA or lumbar arteries  Most common Type III  Structural failure of stent graft Type IV  Due to porosity of graft Type V  Endotension (no obvious cause?)

IVC filter placement •

Check left common iliac vein for presence of double IVC

Paget-Schroetter syndrome • •

Thrombosis of the axillary and subclavian veins usually due to anatomic compression in the costoclavicular space. Usually healthy young adults doing sports with repetitive arm motion (baseball)

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131

Musculoskeletal Radiology

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Musculoskeletal Radiology Trauma General • • • •

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Blunt trauma: spleen most commonly injured Penetrating trauma: liver most commonly injured Heart trauma: aortic and mitral valves most often affected Ligamentous injury  Grade I: increased signal intensity (SI) around an otherwise normal ligament  Grade II: increased SI around ligament AND abnormal thickening of ligament  Grade III: ligamentous disruption Spinal columns  Anterior: anterior longitudinal ligament and anterior ½ of vertebral body  Middle: posterior ½ of vertebral body and posterior longitudinal ligament  Posterior: Posterior ligamentous complex

Salter-Harris Fractures •

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type I  Slipped  Fracture passes through the growth plate only  Good prognosis type II  Above  Most common  Fracture passes through growth plate and metaphysis  Good prognosis type III  Lower  Fracture plane passes through the epiphysis  Poorer prognosis type IV  Transverse  Fracture plane passes through metaphysis and epiphysis  Poor prognosis type V  Rammed  Uncommon  Crush injury of growth plate  Worst prognosis

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133

Musculoskeletal Radiology Head and Neck •

LeFort fractures  Type 1 horizontal maxillary fx  Type 2 fx passes through maxillary alveolar process, maxillary sinuses, infero-medial orbit and nasal bones  Type 3 fx passes through the zygomatic arch, infero-medial orbit and nasofrontal suture

Cervical spine •

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4 continuous curves  Anterior vertebral body line  Posterior vertebral body line  Spinolaminar line  Posterior spinous process line Atlanto-axial distance:  Adults: 3mm  Children: 5mm Prevertebral tissues:  Adults ➢ Nasopharyngeal space < 10mm anterior to C1 ➢ Retropharyngeal space < 5-7mm at C3 and C4 ➢ Retrotracheal space < 22mm at C6  Children ➢ ⅔ width of C2 body at C3 and C4 level ➢ 6mm) on Grashey view (true AP, oblique view)  Electric bulb sign  Trough sign (impaction fracture of medial humeral head)

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Musculoskeletal Radiology •

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Acromioclavicular joint injury  ACJ distance 5mm of posterior articular tibial cartilage uncovered due to anterior displacement of meniscus  Similar-sized posterior and anterior horns of medial meniscus is abnormal (posterior horn should be larger!)  MR: T1 and PD more sensitive, T2 more specific  Grade I: focal or globular high SI, myxoid degeneration.  Grade II: Horizontal clefts of high SI extending to capsule but not the meniscal articular surface (predisposes to tear)  Grade III: High SI within meniscus that comes into contact with either the superior or the inferior articular surface (tear is present)  Vertical tear: usually traumatic  Horizontal tear: commonly degenerative ➢ usually posterior horn of medial meniscus  Longitudinal  Radial tear: radially oriented vertical tear  Meniscal flap tear (parrot beak tear)  Bucket handle tear ➢ vertical peripheral meniscal tear extending circumferentially but remaining attached at to its anterior and posterior attachments to the meniscal tears ➢ medial > lateral meniscus ➢ MR: Coronal images - double delta sign • ACL injury  Due to rotation at the same time with a varus or valgus stress  Tears usually occur at tibial or femoral attachment  MR: Sprain: T2 high SI ➢ Partial: attenuation of some fascicles ➢ Complete: discontinuity within low signal ➢ Chronic: thickened or thinned ligament  Association: Segond Fx • PCL injury  Following posterior displacement of the tibia

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Musculoskeletal Radiology •

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 Usually mid-portion of ligament (unlike ACL!) Patellofemoral dislocation  Most common dislocation in knee  Causes lateral dislocation of the patella relative to trochlear groove of femur  Association: medial patellar retinaculum disruption MCL injuries  Grade I: minimal tear with no instability  Grade II: partial tear with minimal instability  Grade III: complete tear with gross instability  Chronic tear: thickened MCL with normal SI  ☞ O’Donoghue’s triad: ➢ MCL injury ➢ ACL injury ➢ MM damage  Pellegrini-Stieda lesion ➢ post-traumatic ossification of femoral attachment of MCL LCL injuries  May lead to iliotibial band disruption with severe injuries  Sinding-Larsen injury ➢ Avulsion fracture of the lower patellar pole (patellar ligament attachment)  Patellar tendinosis ➢ “Jumper's knee” ➢ Affects superior and inferior tendon insertions  Osgood-Schlatter disease ➢ Traction osteochondrosis of tibial tubercle ➢ Usually young, active patients  ☞ Sinding-Larsen - patellar attachment of patellar tendon  ☞ Osgood-Schlatter - tibial attachment of patellar tendon  Chondromalacia patellae ➢ Grade I: focal hyperintense areas on T1 not extending to cartilage surface ➢ Grade II: focal hypointense areas extending to cartilage surface with preservation of sharp cartilage margins ➢ Grade III: loss of sharp dark margin between articular cartilage and trochlea and focal hypointense areas extending to articular surface but not down to the osseous surface ➢ Grade IV - Extending to subchondral bone

Ankle •

Weber classification  Weber A: lateral malleolar fracture below mortise and oblique fracture of medial malleolus  Weber B: lateral malleolar fracture at the level of mortise with avulsion of deltoid ligament

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Musculoskeletal Radiology • •

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 Weber C: lateral malleolar fracture above mortise with avulsion of deltoid ligament Pilon Fx  Comminuted supramalleolar distal tibial fracture extending into the tibial plafond Trimalleolar Fx  posterior lip of distal tibia fracture  medial and lateral malleolus fracture Maisonneuve Fx  avulsion fracture of medial malleolus with associated proximal fibular fracture ☞ Posterior tibialis tendon injury  2nd most common ankle injury  females without h/o trauma Talus  most of blood supply is through distal talus  ∴ talar neck fracture predisposes osteonecrosis

Foot •

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Normal anatomy  1st metatarsal - medial cuneiform  2nd metatarsal - middle cuneiform  3rd metatarsal - lateral cuneiform  ☞ 4th metatarsal - cuboid  ☞ 5th metatarsal - cuboid Lisfranc fracture  Fracture dislocations at TMT joint  follow severe shear forces due to plantar flexion Jones (dancer’s) fracture  extra-articular fracture of the proximal 5th metatarsal Freiburg infarction  Osteochondritis resulting from repetitive trauma (commonly affects 2nd metatarsal head)

Benign Bone Tumours •

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1st decade  Simple bone cyst  Ewing sarcoma  Chondroblastoma 2nd decade  NOF

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145

Musculoskeletal Radiology

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 Osteochondroma  Osteoblastoma  Osteosarcoma  Osteoid osteoma  ABC  Chondromyxoid fibroma  Chondroma 3rd decade  GCT  Lymphoma  Chondroma 4th decade  GCT and Lymphoma  Fibrosarcoma and malignant fibrous histiocytoma  Osteoma  Parosteal osteosarcoma  Chondroma 5th and 6th decade  Chondroma  Osteoma  Parosteal osteosarcoma  Hemangioma  Chondrosarcoma  Myeloma  Chordoma 7th decade  Osteosarcoma

Enchondroma • • • • • • •

2nd most common benign chondral lesion (osteochondroma is most common) 10-80 years M=F Location proximal phalanges, tibia, humerus. Not in skull XR oval or lobulated eccentric lytic lesions  popcorn type calcifications MR T1 intermediate, T2 high, Gd+ Pearl  periosteal chondroma - long bone metaphyses - no malignant potential  ☞ Ollier’s disease - multiple enchondromas with larger malignant potential ➢ associated risk of glioma, pancreatic and ovarian cancer

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Musculoskeletal Radiology  ☞ Maffucci’s syndrome ➢ associated risk of ovarian ca ➢ multiple enchondromas and soft tissue hemangiomas (phleboliths)

Chondromyxoid fibroma • •   •   • •

Usually 10-30 year olds, immature skeleton CP: pain and swelling but can be asymptomatic 60% in long bones, 40% in flat bones XR: eccentric, lobulated metaphyseal lytic lesion. Thinning and expansion of cortex. bubble appearance sclerotic margin MR: no characteristic features DD: chondrosarcoma, adamantinoma, fibrous dysplasia, ABC

Osteochondroma • • • • • • • •

Most common benign lesion Cartilage shaped exostosis 2-60 year olds (2M:1F) Location most commonly around the knee CT/MRI allows for assessment of cartilage cap - should be 2mm osteoblastoma more likely

Osteoblastoma • •

• • • •

Similar to osteoid osteoma but larger (>1.5cm), and does not respond to salicylates CP: pain more chronic and less severe than osteoid osteoma  80% femur) ☞ Look for falling fragment DD: ABC, fibrous dysplasia

Bone island (enostosis) • • •

Congenital CP: asymptomatic Osteopoikilosis - AD inherited. Multiple bone islands

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148

Musculoskeletal Radiology ☞ Osteopathia striata (Voorhoeve disease) - similar to ^ but linear longitudinal and sunburst striations rather than rounded ones. ☞ Melorheostosis (Leri disease)  regional bone sclerosis with a dripping wax appearance

Osteoma • • •

Slow growing tumour consisting of bone cortex CP: asymptomatic, but can affect sinus drainage ☞ Gardner syndrome - multiple osteomas

Aneurysmal bone Cyst (ABC) • • • • • • •

•

Expansile cavity composed of thin-walled blood-filled cystic cavities Can be induced by trauma or tumour CP: mostly 2nd decade, M=F Locations: spine, metaphysis of long bones XR: Expansile, with thin internal trabeculations (soap bubble appearance) NM: doughnut sign ☞ Secondary ABC seen in:  NOF  chondroblastoma  osteosarcoma DD: telangiectatic osteosarcoma

Osteoclastoma / Giant Cell Tumour (GCT) • •

•

• •

aggressive, benign neoplasm from osteoclasts CP:  pain and swelling  20-45 year olds  2M:3F (unlike ABC!)  skeletally mature patients  usually around knee, in metaphyseal plate XR:  eccentric, lytic lesion  Well-defined non-sclerotic margin MR: very similar to ABC NM: doughnut sign

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149

Musculoskeletal Radiology Non-ossifying fibroma (NOF) / Fibroxanthoma • •

• • • • •

Benign hamartoma located in long bone metaphysis CP: 2nd decade, asymptomatic  NF (5%)  may be multiple and familial XR: intracortical lobulated lesion with a soap bubble appearance MR: T1 intermediate SI, T2 high SI (in 80%), + contrast enhancement ☞ Fibrous Cortical Defect - histologically the same but less than 2cm  common in children ☞ Jaffe-Campanacci syndrome  Multiple NOFs AND cafe au lait spots ☞ Benign Fibrous Histiocytoma  Same histology as NOF but occurs in 3rd-5th decade

Desmoplastic Fibroma (Desmoid) • •

rare, locally aggressive neoplasm CP:  10-30 years, M=F  Long bones, mandible  recurs often

Hemangioma • • • • • • • •

•

Congenital vascular malformation Capillary: arise within the vertebral bodies Cavernous: seen within skull vault CP: usually asymptomatic, may include vertebral collapse Location: Spine (most common), calvarium (2nd most common) ☞ Aggressive Hemangioma  extraosseous extension ☞ Maffucci’s syndrome  soft tissue cavernous haemangiomas and multiple chondromas ☞ Cystic angiomatosis  multifocal condition of either blood or lymphatic vessels  CP: ➢ pain and swelling due to visceromegaly, fractures ➢ 50% before 20 years ☞ Gorham’s disease (vanishing bone disease)

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150

Musculoskeletal Radiology  CP: ➢ weakness and limitation of movement ➢ children and youth  complete excision of bone can halt disease process

Fibrous dysplasia (Lichtenstein-Jaffe Disease) • • •

•

•

•

Developmental disorder of bone, ceases growth with maturity Medullary bone is replaced with well-defined areas of fibrous tissue which can ossify CP:  Painless  Intermediate (mixed) phase ->Late sclerotic (cold) phase CP: elderly, 2M:1F  pain  deafness  high output cardiac failure

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151

Musculoskeletal Radiology •

•

XR:  Skull: basilar invagination (Tom O’Shanter deformity)  Pelvis: thickened iliopectineal line  Vertebrae: picture frame appearance, ivory vertebrae ☞ Complicated by banana fractures, malignant transformation  Osteosarcoma> malignant fibrous histiocytoma> chondrosarcoma

Bone infarction • • •

Sclerotic margins MR: double line sign on T2 serpiginous area with sclerotic margins and not endosteal scalloping

Post-traumatic cortical desmoid (Bufkin tumour) • •

Don’t touch lesion Related to repetitive stress at the attachment of the medial head of gastrocnemius or distal adductor magnus at the posterior medial aspect of the distal femoral metaphysis.

Malignant bone tumours Chondrosarcoma • • •

• • • • •

Cartilage producing better prognosis than osteosarcoma due to late mets CP:  >50% over 40 years  1.5M:1F  rarely pain, palpable mass or path. Fx XR: well-defined, lytic with chondroid matrix mineralization (calcification in 75%) CT/MRI: may demonstrate extraosseous mass which is commonly seen with pelvic lesions  T1 hypointense to muscle, T2 multilobulated ☞ periosteal chondrosarcoma (more in men) ☞ mesenchymal chondrosarcoma  younger age group ☞ clear cell chondrosarcoma  low-grade with better prognosis

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152

Musculoskeletal Radiology Osteosarcoma • • • • •

• •

• •

• •

Malignant osteoid producing tumor Second most common primary bone malignancy after multiple myeloma Central (conventional high or low grade, 75% of cases) Intracortical Surface (4-10%)  Parosteal (30-40 year olds) ➢ slow-growing ➢ good prognosis ➢ posterior distal femur  Periosteal ➢ mean 20 years  High-grade ➢ same as central type histologically May be 2 to Paget’s disease or post-radiotherapy CP:  pain or a palpable mass  80% between 10 - 30 years  2nd peak after 40 w/predilection in flat bone and vertebrae (secondary, due to Paget’s) Location: metaphysis of growing long bone XR:  ☞ Permeative lytic bone  ☞ Codman’s triangle  Periosteal reaction (sunburst appearance) MR: Adds little to diagnosis but invaluable in staging Pearls  ☞ early hematogenous mets, especially lung  ☞ Telangiectatic osteosarcoma ➢ septated blood-filled cavities (can mimic ABC) ➢ 4-11% of osteosarcomas ➢ mean age 24 years ➢ very malignant, poor prognosis  Intracortical osteosarcoma ➢ 30Gy required

Malignant fibrous histiocytoma (MFH) • • •

•

Most common primary malignant tumor of fibrous origin affecting bone 25% arise from Paget’s, post-radiotherapy, infarction  rarely: FD, NOF, chronic osteomyelitis, THR CP:  Peak at 4th decade  Pain and swelling  Central metaphysis of long bones (especially around knee) XR: lytic, resembling mets

Fibrosarcoma • •

Fibrous origin May occur secondary to:  Paget’s  dedifferentiated chondrosarcoma  bone infarction  irradiation  osteomyelitis • CP:  20-50 years M=F  pain and swelling • DD:  MFH

Ewing sarcoma •

•

CP:  5-15 years, 90% under 30  systemic symptoms (pyrexia, high ESR) XR:  diaphysis and metadiaphysis of long bone  lytic, saucerization  Multilaminar, onion peel periosteal reaction  Hair-on-end appearance  ☞ PNET ➢ more differentiated form of Ewing sarcoma

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154

Musculoskeletal Radiology ➢ Askin’s tumour: PNET tumour of the chest wall occurring in children and young adults

Chordoma • • •

•

•

slow growing, aggressive from ectopic remnants of notochord CP:  50-70 years  pain and local pressure effects for about 1 year before presentation  2nd most common primary spinal malignancy  >50% of all sacral tumours Location:  Sacrococcygeal (50%)  Clivus (40%) MR  T1- low to intermediate SI  T2- high  variable enhancement

Adamantinoma • • •

•

locally aggressive, locally recurs epithelial origin CP  ~ 35 years  5M:4F Location: 85% in tibia (midshaft)

Staging MSK tumours •

•

•

•

Stage IA  low grade  Intracompartmental Stage IB  low grade  Extracompartmental Stage IIA  high grade  Intracompartmental Stage IIB  high grade

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155

Musculoskeletal Radiology •

•

 Extracompartmental Stage IIIA  low or high grade  Intracompartmental  ☞ metastases to lung Stage IIIB  low or high grade  Extracompartmental  ☞ metastases to any other site

Metabolic and Endocrine skeletal disease Osteoporosis • •

• • • •

•

most common metabolic disorder (50% of women, 20% of men) WHO definition  BMD > -1 SD of young adult mean normal  BMD between -1 and -2.5SD below mean osteopenia  BMD < -2.5 SD osteoporosis XR changes seen once 50% of density is lost Type I (due to lack of estrogen)  15-20 years after menopause Type II (senile osteoporosis)  due to secondary hyperparathyroidism Reflex sympathetic dystrophy (RSD/ Sudeck’s atrophy)  overactivity of SNS causing pain, swelling and hyperaemia leading to increased bone resorption ☞ Transient osteoporosis of hip  self-limiting affecting young middle aged patients (M>F)  usually happens in 3rd trimester in pregnant women

Osteomalacia • •

Vit D deficiency in mature skeleton Causes  malabsorption (fat soluble)  nutritional deficiency  chronic liver disease  CRF

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156

Musculoskeletal Radiology •

 Meds (anti-convulsants) XR  Looser’s zone (pseudofracture/Milkman’s fracture) ➢ Transient lucent areas within bone ➢ Radiolucent line perpendicular to cortex with slightly sclerotic margin ➢ Seen in: ✓ Paget’s disease ✓ osteogenesis imperfecta ✓ fibrous dysplasia ✓ osteomalacia

Rickets • • •

• •

• •

Vitamin D deficiency in immature skeleton features of secondary hyperparathyroidism XR:  loss of normal zone of provisional calcification adjacent to metaphysis leading to widened growth plate  Harrison’s sulcus: rib in drawing near diaphragm  Craniotabes  Rachitic rosary Vitamin D resistant rickets  due to defective renal tubular reabsorption of phosphate Vitamin D dependent rickets  AR  Type I: defect in renal production of active metabolite  Type II: end-organ resistance to active metabolite Acquired hypophosphatemic rickets (tumor induced oncogenic rickets)  hemangiopericytoma, NOF, GCT, FD, osteoblastoma Metaphyseal chondrodysplasias  mimic rickets ➢ Schmit (mild) ➢ Jansen (severe)

Hyperparathyroidism •

Primary  Due to increased PTH ➢ adenoma (80%) ➢ hyperplasia (15-20%) ➢ carcinoma (0.5%)

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157

Musculoskeletal Radiology •

• • •

Secondary  Due to fall in serum Ca ➢ malabsorption ➢ CRF Tertiary  Due to long-standing secondary hyperparathyroidism when autonomous adenoma develops CP: often asymptomatic. May have stone, nephrocalcinosis, HT, ulcers, pancreatitis, osteoporosis, lethargy XR  95% normal  subperiosteal erosions of bone ➢ radial aspects of middle phalanges of index and middle fingers  acro-osteolysis  pepper pot or salt and pepper skull  chondrocalcinosis ➢ deposition of CPPD in articular cartilage and fibrocartilage ➢ seen only in primary hypoparathyroidism  brown tumours (osteitis fibrosa cystica) ➢ located in usually in mandible, ribs and pelvis  osteosclerosis ➢ rugger jersey spine  osteoporosis

Cushing’s syndrome •

increased free circulating GC  adrenal adenoma, iatrogenic, ectopic ACTH prod (bronchial ca)

Cushing’s disease •

increased free circulating GC from pituitary adenoma

Hypoparathyroidism • •

•

reduced or absent PTH causes  developmental  post-op.  autoimmune  end-organ resistance CP: Tetany and fits due to hypocalcemia

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158

Musculoskeletal Radiology • •

XR generalized or localized osteosclerosis  shortened 4th and 5th metacarpals Pearls  pseudohypoparathyroidism ➢ AD ➢ end organ resistance to PTH  pseudopseudohypoparathyroidism ➢ Features like in PHP but no biochemical abnormality

Thyroid disease •

•

Hyperthyroidism  generalized osteoporosis  thyroid acropachy Hypothyroidism  cretinism results in delayed skeletal maturation  bullet-shaped vertebra  wormian bones

Acromegaly • •

eosinophilic adenoma of pituitary (GH producing) XR  osteoporosis  Skull ➢ enlarged mastoid air cell and sinuses ➢ frontal bossing ➢ prognathism  Spine ➢ large vertebral bodies ➢ posterior scalloping ➢ lordosis  Hands ➢ Arrowhead distal phalanges  Feet ➢ increased heel pad thickness (>25mm)

Osteogenesis imperfect • •

Type I collagen defect Fracture incidence declines following puberty

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159

Musculoskeletal Radiology •

•

•

•

Type I  AD (>70%) 1:30000  mildest and commonest  short stature, joint laxity, vertebral fractures Type II  lethal perinatal  spontaneous dominant mutation  death within 3 mos Type III  15%  severe, progressive Type IV  AD  moderately severe  similar to type I but more severe osteopenia and deformities

Osteopetrosis • •

defective osteoclastic function CP:  AR type - lethal ➢ Erlenmeyer flask deformity ➢ Sandwich appearance ➢ Bone within a bone appearance  AD benign type (Albers-Schonberg disease) - asymptomatic with late manifestations ➢ Type I: fractures unusual ➢ Type II: fractures common  AR intermediate type - rare

Hypophosphatasia • •

AR low levels of serum Alk-Phos or raised urine levels of phosphoethanolamine

Hyperphosphatasia • •

Genetic mutation in osteoprotegerin. Elevated Alk-Phos resembles Paget’s disease, dubbed Juvenile Paget's disease

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160

Musculoskeletal Radiology Renal osteodystrophy • • •

•

bone disease associated with chronic renal impairment Untreated: Vit D deficiency and secondary hyperparathyroidism Treated:  Extensive vascular and soft tissue calcification (phosphate retention) ➢ may lead to ischemic necrosis of skin, SC tissues Renal tubular defects  involves either proximal or distal tubule  Congenital: ➢ Fanconi syndrome ➢ cystinosis ➢ X-linked hypophosphatemia  Acquired: ➢ Wilson’s disease ➢ Toxins ➢ interstitial nephritis ➢ oncogenic rickets

Hypervitaminosis A • •

occurs in patients receiving Vit. A for skin disorders XR: bony outgrowths from the spine (especially cervical spine)

Lead poisoning •

lead is deposited in growing metaphyses

PVC poisoning • •

Raynaud's phenomenon acro-osteolysis

Fluorosis •

Osteosclerosis

Scurvy (vitamin C deficiency) •

Wimberger’s sign  sclerosis of epiphyseal margins

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161

Musculoskeletal Radiology • • •

Frankel’s line  Dense metaphyseal lines Trummerfeld zone  Lucent zone next to Frankel’s line Pelken’s spurs

Joint disease • • •

Osteoarthritis CP: early morning stiffness XR:  joint space narrowing  subchondral cysts and sclerosis  osteophytes  loose bodies  chondrocalcinosis  Hands ➢ 1st MCP ➢ interphalangeal joints  Hips ➢ Egger’s cyst (subchondral cyst)  Foot ➢ Especially seen in 1st MTP joint ➢ Talar beak (talonavicular joint forms bone spur)  ☞ Erosive OA ➢ affects middle aged women ➢ destructive changes outstrip productive changes ➢ XR: gull wing pattern

Hemophilic arthropathy •

• • • •

recurrent bleeding to joins  Hemophilia A - factor VIII deficiency  Hemophilia B (Christmas disease) - factor IX deficiency only expressed in males Stage I  Soft tissue swelling and effusion Stage II  Stage I + periarticular osteoporosis + epiphyseal overgrowth Stage III

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162

Musculoskeletal Radiology • • • •

 Erosions, sclerosis and subchondral cysts Stage IV  Stage III + diffuse joint space narrowing Stage V  Stiff contracted join with sig. degenerative change MR: look for hemosiderin septic arthritis is a rare complication

Neuropathic arthropathy • • • •

Congenital insensitivity to pain (100% prevalence) syringomyelia (20-50%) neurosyphilis DM (1% of cases!)

Juvenile Idiopathic Arthritis • •

•

pain and swelling >/= 1 joints for 6 weeks in 5 joints involved XR:  Knee > wrist  marked radial head enlargement  cervical spine commonly affected

Diffuse Idiopathic Skeletal Hyperostosis (Forestier’s disease) • • •

Flowing ligamentous spinal ossification involving ≥4 contiguous vertebrae T7-T12 common Reaction to stress, not true arthritis

Rheumatoid Arthritis • • •

Inflammatory synovitis with synovial hypertrophy Rheumatoid factor (+) CP: morning stiffness

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163

Musculoskeletal Radiology •

 symmetrical joint swelling  tendon rupture (F>M) XR:  Early ➢ juxtaarticular osteopenia ➢ soft tissue swelling joint space widening  Late ➢ diffuse osteoporosis ➢ joint subluxation and dislocation  End stage ➢ pan-compartmental loss of joint space ➢ carpal bone resorption ➢ arthritis mutilans  Hands: ➢ 2nd and 3rd MCP joints ➢ Styloid processes ➢ Ulnar deviation ➢ Volar subluxation and dislocation of phalanges at MCP joint ➢ Rotary subluxation of scaphoid ➢ Boutonniere deformity ➢ Swan neck deformity ➢ Z deformity of thumb ➢ Telescope fingers  Foot ➢ first hands, then feet ➢ MTP joint (particularly 4th and 5th)  Spine ➢ Atlantoaxial subluxation ➢ Odontoid erosion ➢ Odontoid fracture  ☞ Felty’s syndrome ➢ RA + splenomegaly + neutropenia ➢ weight loss ➢ skin pigmentation  ☞ Caplan’s syndrome ➢ RA + pneumoconiosis

Jaccoud’s arthritis • • •

not related to RA causes severe, non-destructive symmetrical polyarthropathy occurs after rheumatic fever

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164

Musculoskeletal Radiology Ankylosing spondylitis • • •

Involves diarthrodial joints 10M:F XR:  Spine ➢ Shiny or ivory corner ➢ Anterior vertebral body squaring ➢ Romanus lesion ➢ Andersson lesion ➢ Syndesmophytes ➢ Posterior longitudinal ligament calcification

Psoriatic arthropathy • • •

Seronegative spondyloarthropathy Asymmetrical in 70% XR:  bilateral, asymmetrical destructive changes  Pencil-in-cup appearance  Sausage digit  Parasyndesmophytes  Unlike OA - new bone formation  Sacroiliitis common and bilateral

Reiter’s syndrome • • •

• •

Seronegative spondyloarthropathy Male men Reiter’s triad  Conjunctivitis  Urethritis  Arthritis  Also: keratoderma blenorrhagicum STD: Chlamydia, Salmonella, Shigella, Yersinia, Campylobacter Calcaneal and big toe involvement common

Gout • •

Inborn error of purine metabolism -> hyperuricemia -> monosodium urate crystal deposition AD

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165

Musculoskeletal Radiology • •

Lesch-Nyhan syndrome  presents in children with hyperuricemia and mental retardation Saturnine gout  decreased renal urate clearance following a lead nephropathy

Multicentric reticulohistiocytosis (lipoid dermato-arthritis) • •

unknown etiology deposition of giant multinucleated vacuolated histiocytes within soft tissues

Calcium Pyrophosphate Deposition Disease (Pseudogout) (CPPD) • •

• • • • •

Deposition of Calcium pyrophosphate dihydrate crystals in joints, bursae, tendons, intervertebral discs Associated with:  hypothyroidism  haemochromatosis  hyperparathyroidism  joint injury  ochronosis Asymptomatic If symptomatic known as pseudogout Chondrocalcinosis Polarizing microscopy MSU crystals positively birefringent Crowned dens syndrome  tophaceous pseudogout at AAJ

Basic Calcium Phosphate Deposition Disease • • •

Called hydroxyapatite deposition disease (HADD) Due to repetitive trauma with dystrophic calcifications CP:  periarticular deposition common in supraspinatus tendon

Hemochromatosis • • •

Iron overload May be secondary to hepatic xanthine oxidase deficiency XR  symmetrical arthropathy involving 2nd and 3rd MCP joints

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166

Musculoskeletal Radiology Amyloidosis •

Affects large peripheral joints

Ochronosis (Alkaptonuria) • • •

Rare AR disorder of tyrosine metabolism leading to accumulation of homogentisic acid within tissues Black or brown cartilage pigmentation  Brittle, predisposes to early degenerative disease Usually spinal involvement  involves nucleus pulposus

Systemic Lupus Erythematosus (SLE) • •

ANCA (+) symmetrical arthritis of hands, wrists and knees

Scleroderma • • • •

•

Raynaud’s phenomenon Acro-osteolysis ligamentous and intra-articular calcification CREST syndrome  Calcinosis  Raynaud's phenomenon  Esophageal dysmotility  Sclerodactyly  Telangiectasia  Thibierge-Weissenbach syndrome ➢ calcinosis ➢ digital ischemia Mixed connective tissue disorder  Scleroderma  Polymyositis  RA  SLE

Hypertrophic osteoarthropathy (HPOA) •

Triad of:

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167

Musculoskeletal Radiology

•

•

 periosteal new bone formation  painful finger clubbing  synovitis Associated with intrathoracic tumors  Bronchogenic Ca  Mesothelioma  Benign pleural fibroma  Pneumocystis carinii pneumonia in HIV patients ☞ Pachydermoperiostosis  AD, idiopathic form of HPOA  black men  finger clubbing  pachydermia  may resemble acromegaly

Pigmented Villonodular Synovitis • • • • •

Proliferation of entire synovium from joints, bursae, tendons Young adults MRI: black synovium ☞ Giant cell tumour of tendon sheath  PVNS affecting synovium AND tendon sheath ☞ Lipoma arborescens

Synovial osteochondromatosis • • •

metaplastic cartilage formation that can occur throughout synovium  cartilage fragments become detached and float freely within joint or bursa Typically monoarticular calcified loose bodies

Polymyositis •

inflammatory condition of unknown etiology

Dermatomyositis • •

polymyositis accompanied by rash ¾ of criteria  symmetrical proximal muscle weakness

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168

Musculoskeletal Radiology  elevated muscle enzymes  pathology  EMG characteristic

Sarcoidosis • • •

10% with bone involvement distal and middle phalanges XR  cyst-like lucencies  ☞ No joint space narrowing  Lace-like pattern of bone destruction

Acute osteomyelitis • • • • • •

Infants - 12 mo  passes to epiphysis and joint space easily 1-16 years  epiphyseal and joint space infections rare - stays in metaphysis adults  epiphysis Hematogenous  S. aureus, H. influenzae, S. Pneumoniae Foreign body or implant  coagulase negative staphylococci (commensals) Open fracture  Gram-neg rods (pseudomonas)  Anaerobic gram positive rods (clostridium)

Chronic osteomyelitis •

•

XR:  sequestrum ➢ mechanically separate avascular bone fragment (foci of recurrence)  involucrum ➢ shell of living bone surrounding living bone  cloaca ➢ defect in involucrum that can allow pus to escape Pearl  Sclerosing osteomyelitis of Garre ➢ chronic untreated osteomyelitis with a profound sclerotic reaction

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169

Musculoskeletal Radiology  Sickle cell disease: higher incidence of Salmonella osteomyelitis

Syphilis • • • • • •

Wimberger’s sign: granulomas within long bone metaphyses and producing lytic areas Periostitis Metaphysitis Osteomyelitis  Gumma: localized osteomyelitis with sclerosis Syphilitic dactylitis  cortical thinning Charcot joint osteomyelitis  can be differentiated with GD contrast (positive enhancement)

Necrotizing fasciitis •

Group A hemolytic strep and S. Aureus

Tuberculous infection • • •

hematogenous spread From lung with active disease in spinal cord (intramedullary or extramedullary) > medulla (area postrema) Did this document help you? Consider a donation Can you make this document better? Email [email protected]

180

Neuroradiology Brainstem glioma • •

30% of pediatric infratentorial tumours most common pontine lesion, poor prognosis

Medulloblastoma • • • • • • •

30-40% of all posterior fossa tumours Known as PNET of posterior fossa Originates on roof of ventricle, vermian midline! CP: peak incidence at 7 years (seen at midline), 2nd peak in young adults with a less aggressive form (seen in cerebellar hemispheres) Intracranial and intraspinal subarachnoid dissemination seen in ⅓ of patients at presentation (mets!) CT: hyperdense Associations  Li-Fraumeni  Gorlin’s  Basal cell nevus  Turcot syndrome  Cowden syndrome

Atypical teratoid/rhabdoid tumours • • •

Poor prognosis Children younger than with medulloblastoma, usually 80% of cerebellopontine angle lesions  10% meningioma  5% epidermoid ☞ Bilateral Schwannomas = NF2

Epidermoid and Dermoid tumours •

•

•

Epidermoid: tumours with thin capsule of epidermis  Adults  Commonly high on T2WI Dermoid: tumours with a wall containing the full width of the dermis  Children  Similar signal characteristics to fat Conform to shape of arachnoid space

Meningioma • •

Derived from arachnoid cell rests (cap cells) WHO grade I: 90%, benign

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182

Neuroradiology • • • • •

•

WHO grade II: atypical features, increases mitotic activity and necrosis WHO grade III: anaplastic (malignant) CP: 5-6th decade (F>M), NF2 Location: 90% supratentorial CT/MR:  spherical, well-circumscribed or a flat infiltrating ‘en plaque’ lesion  MR: capping cysts ➢ vasogenic edema ➢ cleft sign  MRS: alanine peak ☞ If seen in a child, think NF2

•

☞ Multiple meningiomas and CN tumour - think NF2

•

☞ May occur in lateral ventricles

Chordoma • •

Malignant transformation of notochordal cells Soap-bubble appearance

Glomus Jugulare Tumour (Chemodectoma) • •

Arises from paraganglion cells of chemo- and baroreceptor precursors May cause thrombosis of the internal jugular vein

Cerebral metastasis • • • • • •

Adult  (small cell) lung, breast, colon, malignant melanoma Children  neuroblastoma, Wilms’ tumour, rhabdomyosarcoma, osteosarcoma If calcification present, think: GI tract, breast or osteosarcoma If hemorrhage present, think: melanoma, renal, choriocarcinoma, thyroid, lung, breast 80% supratentorial, 66% multiple CT: Double-dose contrast with delayed imaging best  Small mets homogenous enhancement, larger mets ring enhancement due to necrosis

Meningeal metastasis •

Pachymeninges (dura mater)  Breast ca

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183

Neuroradiology •

➢ ➢ ➢ ➢ ➢

 Curvilinear or diffuse contrast enhancement Leptomeninges (arachnoid and pia mater)  More common! Leukemia Lymphoma Breast Lung cancer Only 25% detected on MR, 50% with single LP, 95% with serial LP

Central neurocytoma • • • •

Benign, slow-growing intraventricular tumour typically arises from septum pellucidum CP: 2-3rd decade, obstructive hydrocephalus common MR: septated cysts, calcifications

Choroid plexus papilloma • • • •

Benign tumour of choroid plexus CP: more common in children, most common brain tumour in L bronchus XR:  Hyperlucent lung  Expiratory film or lateral decubitus

Lower airways Pulmonary sequestration • •

•

☞ Posterobasal most common location Intralobar  Age: adults, older children  Airless or cystic  Venous supply: Pulmonary vein  Arterial supply: Thoracic aorta > abdominal aorta  Associations: 10% of patients (5% skeletal, 5% foregut) Extralobar  Age: neonates  Always airless!  Venous supply: Systemic (IVC or Azygous)  Arterial supply: Thoracic aorta > abdominal aorta  Associations: 65% of patients  25% diaphragmatic defect  25% pulmonary hypoplasia

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Paediatric Radiology Bronchogenic cyst • • •

Results from abnormal budding of the tracheobronchial tree Contain respiratory epithelium Location:  85% in mediastinum  Subcarinal/parahilar

Congenital cystic adenoid malformation (CCAM) • •

Proliferation of glandular lung tissue without normal alveolar differentiation Respiratory distress in first days of life  XR: ➢ Macrocystic ✓ Better prognosis ✓ Mediastinal shift ✓ Stocker 1 (>3cm cysts): most common ✓ Stocker 2 ( internal iliac -> infrarenal aorta Tip above the renal arteries at T8-T12

Umbilical Venous line (UVL or UVC) • •

UV -> left portal vein -> ductus venosus (closes after 96 hours) -> IVC -> Right atrium May be displaced into portal or hepatic branch

Central line •

Central line should be ideally positioned superior to carina

Endotracheal tube (ET tube) •

Tip located between thoracic inlet and carina

Gasless abdomen •

2 hours - stomach

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217

Paediatric Radiology • •

6 hours - small intestine 24 hours – rectum

Gastroschisis • • • • •

Extra-abdominal herniation (evisceration) of fetal or neonatal bowel loops Exit into the amniotic cavity through a periumbilical abdominal wall defect 90% to the right of cord Only 5% associated with congenital anomalies ☞ No surrounding membrane like in omphalocele

Omphalocele • • •

Herniation into base of umbilical cord Liver herniation typical +/- bowel Associations  Beckwith-Wiedemann syndrome  Trisomies

Esophagus • •

• • •

• • •

Esophageal atresia XR:  Performed in prone position with a horizontal beam  Fistula usually above carina N-type 85% (esophageal atresia with a distal tracheal fistula) H-type 5% Associations  Vertebral anomalies  Anorectal anomalies  Cardiovascular anomalies  Tracheal anomalies  Esophageal fistula  Renal anomalies (agenesis)  Limb anomalies  VSD  Ductus arteriosus Reflux LES immaturity in first 3 months of life XR:

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Paediatric Radiology  Scintigraphy most sensitive technique to determine reflux

Stomach Hypertrophic pyloric stenosis •

• •

Associations:  Turner syndrome  Trisomy 18  Rubella XR  Peristaltic waves US  Appears as target lesion  Scan in RPO  Pyloric muscle thickness >3.5mm  Pyloric length >15mm  Transverse diameter >11mm  Shoulder sign  Indented gastric antrum

Volvulus • •

Mesenteroaxial  Pylorus above GEJ Organoaxial  Rare in children  Gastric outlet obstruction  Association: ➢ Large hiatal hernia

Duodenum, pancreas, small bowel Duodenal atresia/stenosis •

Associations  30% Down syndrome  40% polyhydramnios, premature

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Paediatric Radiology •

XR  Double bubble sign

Duodenal web • • • •

Congenital duodenal obstruction with a diaphragm Usually occurs in 2nd part of duodenum Associations  Down syndrome XR  Windsock sign

Malrotation and midgut volvulus • •

•

•

Due to short mesenteric attachment allowing for the bowel to twist. XR/US  SMV anterior or to the left of SMA  Gastric outlet obstruction  Spiraling of duodenum and jejunum around SMA axis Associations  Gastroschisis  Omphalocele  Diaphragmatic hernia  Duodenal/jejunal atresia ☞ Ladd’s bands  Peritoneal bands in patients with malrotation  Located from malplaced cecum in relation to porta hepatis

Non-rotation • • •

Midgut returns to peritoneum without rotation Usually asymptomatic XR:  Small bowel on right side of abdomen  Colon on left side of abdomen  SMV left to SMA

Meconium ileus •

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Paediatric Radiology •

XR:  Neuhauser sign (soap bubble appearance, air mixed with meconium)  Calcification due to meconium peritonitis

Intussusception • • • •

•

95% Ileocolic and ileoileocolic Usually in first 2 years of life Most commonly caused by viral gastroenteritis US  Target/Doughnut sign  Pseudokidney sign Reduction  Contrast or air reduction @ 5 mm in 2nd trimester >10 mm in 3rd trimester

Ureteral duplication • • • •

Orthotopic ureter: drains lower pole and enters bladder near trigone  Associated with VUR Ectopic ureter: drain upper pole and enters bladder inferiorly and medially (Weigert-Meyer rule)  Associated with ureterocele and obstruction Complete ureteral duplication with intersphincteric insertion of the ureter draining the upper moiety may cause incontinence in girls! XR  Increased distance from top of nephrogram to collecting system  Abnormal axis of collecting system  Concave upper border of renal pelvis

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Paediatric Radiology    

Diminshed number of calyces compared to normal side (drooping lily sign) Lateral displacement of kidney and ureter Spiral course of ureter Filling defect in bladder

Congenital ureteropelvic junction • • •

Most common congenital anomaly of the GU tract in neonates 20% bilateral Treated with pyeloplasty

Primary megaureter • •

Congenital dilatation of distal ureter due to functional obstruction (abnormal development of muscle layers, achalasia) 95% isolated finding

Circumcaval ureter • • • • •

•

Abnormality of IVC IVC usually derived of supracardinal vein (posterior to ureter), if derived from right subcardinal vein or postcardinal veins, then the ureter is trapped behind IVC Mostly boys On right, unless situs inversus also present Low loop type (more common)  Fishhook, “J” course  Ureter obstructed High loop type (less common)  Mild obustruction

Cloacal exstrophy • • • • •

Spina bifida aperta Lipomyelomeningocele Diastasis of symphysis Bladder exstrophy Colon exstrophy

Prune-Belly syndrome (Triad syndrome, Eagle-Barrett syndrome) •

Widely separated abdominal rectus, hydroureteronephrosis, cryptorchidism

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Paediatric Radiology Posterior urethral valves • • •

•

Type I (most common)  Derive from plica colliculi Type II  Mucosal folds extend proximally from verumontanum to the bladder neck Type III  Diaphragm with central aperture at the distal prostatic urethra  Verumontanum in this type not enlarged! XR  MCUG is method of choice

Kidneys Autosomal recessive kidney disease • •

The less severe the renal findings, the more severe hepatic periportal fibrosis XR  Enlarged hyperechoic kidneys (hallmark)  Hepatic fibrosis  Portal venous hypertension

Multicystic dysplastic kidneys • • •

Unilateral: normal life expectancy as long as other kidney normal, bilateral = fatal large, noncommunicating cysts XR  Thick fibrous septa  Multiple, large cysts  Absence of renal artery

Multilocular cystic nephroma • •

Congenital renal lesion characterized by large cystic spaces (>10cm) Biphasic distribution

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Paediatric Radiology •

 2mo-4 years (mostly males)  >40 years (mostly females) XR:  Calcifications uncommon  Must be surgically removed because indistinct from cystic Wilms tumor

Vesico-ureteral reflux • • • • •

Grade I: reflux to ureter but not kidney Grade II: reflux into ureter, pelvis, and calyces without dilatations Grade III: reflux to calyces with mild dilatation, blunted fornices Grade IV: to calyces with moderate dilatation, obliteration of fornices Grade V: gross dilatation, tortuous ureters

Lymphangiectasia •

Rare

• •

Abnormal lymphatics cause parapelvic and perinephric cystic spaces XR:  Scalloping of kidney outline  Water signal on CT

Wilms tumour • • •

•

Arises from metanephric blastema 3rd most common malignancy after leukemia and brain tumours Associations:  Nephroblastomatosis  WT gene on chromosome 11 identified in minority of patients ➢ WAGR syndrome (WT-1) ➢ Beckwith-Wiedemann syndrome (WT-2) XR:  Exophytic with pseudocapsule  Cystic areas  renin release via JG baroreceptors. Increased renin (and AT-II) leads to vasoconstriction • Fibromuscular Dysplasia (FMD) 15-20%  ☞ usually mid/distal artery involved  string of beads appearance  Dilation easy w/ angioplasty • Takayasu’s disease: rare disease affecting aorta and its branches • US: limited technique 42% arteries not visualized. ☞ Increased Peak systolic velocity >150 cm/s ☞ Increased Renal artery to aortic velocity ratio >3.5 ☞ Increased Acceleration time >0.07sec • • • •

☞ Increased Resistive index >0.7 ACE renography: 99mTc-DTPA or 99mTc-MAG3  reduction in total and relative function of the affected kidney (>5-10%) CTA: most sensitive MRA: may also provide functional imaging, but inferior to CTA. Good for proximal artery stenosis detection DSA: previously gold standard

Renal artery aneurysm • Causes:  FMD, pregnancy, mesenchymal disease (NF, Ehlers-Danlos), atherosclerosis • ⅓ parenchyma destroyed  70% mortality  streaky, mottled gas radiating peripherally  ?nephrectomy needed • Type 2:  L). May develop calcifications or a pseudocyst

Primary adrenal lymphoma • More commonly in widespread lymphoma (most commonly in NHL) • Primary lymphoma very rare • CT: adrenal enlargement, with retained shape

Primary adrenocortical carcinoma • • • • •

Rare, highly malignant 90% produce steroids, only 50% cause symptoms related to hormone production Result in Cushing’s, with virilization, feminization and hyperaldosteronism CP: 45-55 and M CT: large (85% >6 cm), more commonly on left (10% BL), patchy calcification  internal hemorrhage and necrosis common  heterogenous enhancement  local invasion

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• • • •

MRI: T1 isointense, T2 hyperintense to liver Scintigraphy: NP-59 (131I-6-iodomethyl-19-norcholesterol) reduced uptake Mets: liver, lungs, bones. Common at presentation Associations: Li-Fraumeni syndrome, Beckwith-Wiedemann syndrome

Metanephric adenoma • • • •

Benign More common in middle-aged and elderly females Well-defined, encapsulated, solitary mass NCECT: hyperattenuating

Adrenal myelolipoma • • • • •

Rare, benign neoplasm of fat and bone marrow tissue Asymptomatic and non-functioning Hemorrhage or necrosis may cause pain No malignant potential CT/MRI: fat attenuation with adrenal mass

Endogenous Cushing’s syndrome • Endogenous Cushing’s - excess ACTH production (75%) and excess cortisol from an adrenal neoplasm (25%) • ACTH-dependent Cushing’s disease  BL adrenal hyperplasia  Overt (short-onset): rule out small cell lung ca - producing ACTH  Occult (long duration): rule out bronchial carcinoid tumour (less frequent islet cell, pheo, medullary thyroid ca, thymic carcinoid) • Adrenocortical adenoma (10-20% of Cushing’s)  CT: characteristic low density of adenoma, remainder of the gland atrophic • Adrenal carcinoma (10-15% of Cushing’s)  Carney complex (AD)  Abnormal skin pigmentation  Endocrine abnormalities (commonly primary pigmented nodular adrenocortical disease leading to ACTH-dependent Cushing’s)

Primary Hyperaldosteronism (Conn’s syndrome) • 80% - benign (adrenocortical, Conn’s tumour) adenoma, 20%- BL adrenal hyperplasia, rare adrenocortical ca • Adrenocortical adenoma (Conn’s tumor)

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 within H&N > bladder • 10% rule  10% extra adrenal (paraganglionoma)  10% BL  10% malignant  10% non-functioning  10% inherited  10% calcified  10% invade IVC or Renal v. • Associations:  MEN II (50%)  NF1 (10%)  vHL (10%)  Sturge-Weber syndrome  Carney’s triad  Tuberous sclerosis • CP: tachycardia, headache, hypertension • ☞ hypertensive crisis can be precipitated by CM • NCECT: Round masses, isodense to surrounding soft tissue/ may show fluid filled center (hemorrhage?), speckled calcification, usually ca. 5cm at presentation • CECT: Intense enhancement. Use non-ionic contrast medium to avoid hypertensive crisis • MRI: Method of choice  T1- low SI  T2- very high SI  strong SI post Gd

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• MIBG scintigraphy: increased uptake • Octreotide scintigraphy: increased uptake • Increased vanilmandelic acid levels in 24-hour urine sample test

Adrenogenital syndrome • Androgen-producing adrenal tumours are usually cancerous • CT: usually adrenal enlargement

Adrenal metastasis • • • •

Bronchogenic carcinoma Colorectal ca Breast ca Pancreatic ca

Adrenal injury • Most commonly seen on the right

Pediatric Genitourinary disorders Horseshoe kidney • • • • •

Renal anomaly (1:400 live births), M>F Due to in utero contact of metanephric tissue. Located lower than normal due to inferior mesenteric artery blocking ascent Always associated with malrotation Associations: PUJ obstruction (30%), duplicated ureters (10%). medullary sponge kidney, anorectal and MSK anomalies, Turner syndrome ☞ Increased risk of Wilms’ tumour formation

Cross-fused renal ectopia • One kidney displaced across midline and fused inferiorly to the relatively normally positioned kidney

Septum of Bertin

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• Prominent column of Bertin • Present in ~50% of population

Dromedary hump • Prominent superolateral border of the left kidney

Juvenile nephronophthisis (medullary cystic disease) • Medullary cysts associated with interstitial fibrosis and tubular atrophy • Juvenile nephronophthisis: AD. Juvenile onset, ca. 10 year disease duration • Medullary cystic disease: AD. Adult onset, rapidly progressive - death within 2 years

Medullary (Multicystic) Dysplastic Kidney (MCDK) • Ureteral obstruction or atresia during metanephric stage causing collecting ducts to enlarge into cysts • CP: usually unilateral. asymptomatic, presents with neonatal abdominal mass (2nd most common after hydronephrosis) • US: cluster of grapes appearance • Prognosis depending on contralateral kidney function

Wilms’ tumour (nephroblastoma) • • • • • • •

Arise from metanephric blastema cells Solid with fibrous pseudocapsule May invade renal vein and IVC CP: classically asymptomatic abdominal mass, hematuria. 3rd most child malignancy after leukemia and brain tumours 10% bilateral CT: exophytic mass enhancing less than renal parenchyma  claw sign: normal renal tissue stretched to periphery of the lesion  spreads through direct extension and displacement • Associations:  Beckwith-Wiedemann syndrome: macroglossia, exophthalmos, gigantism  Denys-Drash syndrome: pseudohermaphroditism  Sotos syndrome: cerebral gigantism  Bloom’s syndrome: immunodeficiency and facial telangiectasia  WAGR syndrome: Wilms’, Aniridia, GU abnormalities, mental retardation

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Rhabdoid tumour of kidney • Most aggressive malignant renal tumour in childhood (originates from renal sinus) • CP: 1st year of life  paraneoplastic hypercalcemia • CT: indistinguishable from a Wilms’ tumour

Mesoblastic nephroma • Tumor derived from early renal mesenchyme. Does not invade or metastasize. • Most common solid neonatal renal neoplasm presenting as a renal mass

Multilocular cystic nephroma • Uncommon cystic renal mass derived from metanephric blastema • Nephrectomy curative • Bimodal distribution  males >M, middle age Diabetics and immunocompromised patients High association with E.coli infection May be extremely aggressive invading the perivesical space or even bone destruction

Bladder tumours • Growth pattern in-situ > papillary > infiltrating > ulcerating • TCC: 90%

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• • • •

• • • • • • •

•

•

•

SCC: 1.5-10% Adeno Ca: 1% (bladder exstrophy and urachal remnants) Stomach and Breast ca may metastasize to bladder CP:  hematuria  dysuria  pelvic pain  hydronephrosis Associations: carcinogens present in cigarette smoke, aromatic amines, cyclophosphamides 6th-7th decade M>F ⅓ multifocal at presentation usually around the trigone or around lateral walls IVU/cystogram/US: mass projecting into the bladder lumen CT: useful for showing distant mets/perivesical invasion (T3b)  cannot distinguish between lesions limited to lamina propria (T1) and invading superficial (T2a) and deep muscle (T2b) MR: better than CT for bladder base and dome tumours and differentiation between T3a and T4 disease. May distinguish between T2a and T2b by the integrity of the bladder wall ‘black line’  T2: slightly hyperintense to bladder muscle Treatment  confined to wall or limited spread - resection  superficial - BCG  extensive - systemic chemo, palliative radiotherapy Staging: read about staging here

Bladder injury • Intraperitoneal: 10-20% (follows blunt trauma, usually at dome. Requires surgery) • Extraperitoneal: 80-90% - usually anterolateral walls of base - associated with disruption of urogenital diaphragm. Flame-shaped appearance. Urine seen in:  paracolic gutters  perivesical fat  anterior abdominal wall  upper thigh • subserosal: rare - characterized by elliptical invasion adjacent to bladder • CT cystography: Imaging of choice

Scrotal injury • US: imaging of choice • Scrotal hematoma: echogenic collection btwn tunica dartos and tunica vaginalis or within septum

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• Hematocele: complex collection between leaves of tunica vaginalis • Hydrocele: liquefied hematoma or serous collection between the layers of tunica vaginalis (echolucency around testes) • Testicular rupture • Testicular dislocation

Prostate • Acute and chronic prostatitis  usually staphylococci or E.coli • Granulomatous prostatitis  non-specific: more common, results from escape of prostatic contents, bacterial products of urine into prostatic tissue  specific: produced by known etiological agent (Mycobacterium, schistosomiasis, fungal) • Prostatic TB  almost always secondary to TB elsewhere • Prostatic abscess • Benign prostatic hypertrophy  50-75% of men over 60 years, more common in patients with DM, HT, Afro-Caribbean’s  Bladder volume >30mL  J-shaped or fishhook ureters  Trabeculation of bladder and diverticulum formation

Prostate sarcoma • Rhabdomyosarcoma in children more common • Leiomyosarcoma in adults more common

Prostate cancer • TNM staging: read about staging here

Urethra • Mullerian duct cyst: Mullerian duct is obliterated and usually forms verumontanum. Incomplete obliteration leads to cyst formation between bladder and rectum • Prostatic utricle: cavity communicating with posterior urethra, derived from caudal Mullerian duct • Posterior urethral valve: thickened mucosal folds within posterior urethra. Located near distal verumontanum and result from abnormal migration of mucosal folds (Wolffian duct remnants)  Type 1: two mucosal folds at the level of the verumontanum with an anterior opening. Did this document help you? Consider a donation Can you make this document better? Email [email protected]

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 Type 3: has a pin-point eccentric opening resulting in forward ballooning of the valve giving a wind-in-sail appearance

Urethral diverticulum • F>M • Higher incidence of carcinoma

Urethritis • Gonococcal > Chlamydia t. > Ureaplasma u. > TB > Schistosomiasis • Urethrography: luminal irregularity with filling defects representing sloughed mucosa • Strictures  Treatment: balloon dilatation  Inflammatory (usually proximal urethra)  Traumatic (usually bulbomembranous)  Iatrogenic  Neoplastic (rare) • Benign tumors (rare): papillary adenoma, squamous cell papilloma, Trans cell papilloma, nephrogenic adenoma, inflammatory and fibrous polyps (1-2 cm long processes around verumontanum presenting with intermittent obstruction) • Carcinomas (2F:1M) LND spread before hematogenic!  SCC 60%, TCC 20%, adeno ca 10%, undiff and sarcoma 8%, melanoma 2%  Anterior urethral tumours: distal ⅓ with early presentation and better prognosis • ☞ Tumours involving external meatus spread to superficial and deep inguinal lymph nodes  Posterior urethral tumours: arise from proximal ⅔, present later with poor diff and more advanced grade ➢ Spread to hypogastric, external iliac and sacral nodes  In males (risk factors - previous strictures) ➢ TCC of prostatic urethra most common, with strong association with bladder TCC ➢ Carcinoma in the remainder of the urethra strongly associated with inflammation, 75% SCC. ➢ Penile urethra: drainage along ventral surface to the superficial and deep inguinal lymph nodes ➢ Bulbar/membranous urethra: drainage along dorsal vein of penis to external iliac nodes -> obturator -> hypogastric  MRI: method of choice  Staging: read about staging here

Urethral injury • usually around membranous urethra (posterior)

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• • • • • •

20% of pelvic fractures in men. Impotence may develop in up to 40% of patients. Uncommon in females Type 1: stretched and narrowed urethra secondary to hematoma elevating bladder (no tear) Type 2: tear above urogenital diaphragm Type 3: tear below urogenital diaphragm (almost always complete) complete tears - require surgical repair  no contrast in bladder during retrograde urography • Incomplete: catheterized and usually not operated  some contrast in bladder during retrograde urography • Retrograde urography: imaging of choice  contrast in retropubic space (type 2)  contrast in perineum (type 3)

Testicles • 3.5-4 cm • covered by fibrous capsule, tunica albuginea

Orchitis • most common complication of mumps infection in postpubertal males • more commonly unilateral • US: swelling, homogeneously hypoechoic  increased vascularity

Cryptorchidism • 80% found in inguinal region, usually palpable (BL in 10-25% of cases) • Risk factor for subfertility (even in unilateral) and testicular tumour • Prevalence parallels gestational age  100% of neonates 2.5kg  10days Intravaginal: older age group and most common  associated with bell clapper deformity

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• Extravaginal: affects infants and is rare (the testis and tunica vaginalis twist at the external ring)

Torsion of the testicular appendix (hydatid of Morgagni) • most common cause of acute scrotal pain in children

Primary testicular malignancies • 1% of male malignancies • most common malignancy in 15-30 year old males • Germ cell origin (95%)  Seminoma (40%) 40-50yr olds ➢ Increased chance in patients with undescended testes.  Non-seminomatous germ cell tumour (NSGCT) (60%) 30-40yr olds ➢ Adults: embryonal > yolk sac > teratoma ➢ Children: rare in children, but if occur usually yolk sac tumour • Non-germ cell origin (Gonadal stromal tumour) (1%) ➢ Leydig (secreting androgens, but may also be feminizing), Sertoli (secreting estrogens), theca cell origin ➢ Usually benign but endocrinologically active • Lymphoma (4%): usually older men • CP:  alpha-fetoprotein increased in 60% of patients  bHCG increased in 50% (not pure seminomas!) • US: nonspecific, hypoechoic. Seminomas usually better defined hypoechogenic than NSGCTs. • CT: used for staging. Lymph nodes abnormal if >1 cm. LND metastasis to paraaortics first • Tx  Seminoma: orchidectomy + para-aortic radiotherapy or orchidectomy + chemo for more advanced disease  NSGCT: orchidectomy + paraaortic lymphadenectomy or orchidectomy + chemo for more advanced disease • Testicular mets: prostate > kidney > bronchus > pancreas > bladder > thyroid • Leukemia: testicular involvement seen in 50% of acute leukemia

Testicular cysts • Tunica albuginea cyst: upper anterior or lateral aspect of testis. Firm on palpation • epidermoid cyst: cystic, solid, avascular. ☞ whorled ‘onion-ring’ appearance. • Abscess: acute associated with epididymitis. chronic associated with TB • Tubular ectasia: dilatation of rete testes in older men  DD: teratoma

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• Hydrocele: small amount of fluid surrounding testes normal. If acquired - think trauma, tumour, infection • Spermatocele: retention cyst at the head of epididymis • Epididymal cyst: retention cyst within anywhere in epididymis, no sperm inside.

Microlithiasis • annual follow-up advisable • larger calcifications seen in multiple tumour types

Undescended testes • root of testes 50%, within inguinal canal 20%, abdominal 10%, bilateral 10%

Epididymis • posterolateral to testes

Acute epididymitis • • • •

Most common acute scrotal pathology in postpubertal age group E.coli, Pseudomonas, Aerobacter, N.gonorrhoeae, Chlamydia TB epididymitis - secondary to prostatic TB US: swollen epididymis (>5mm)  usually hypoechoic  hyperaemia

Chronic epididymitis • US: swollen epididymis, hyperechoic

Varicocele • • • •

Tangle of veins measuring >2mm in diameter ☞ Commonest treatable cause of male infertility 95% on left side May be treated with embolisation  coils used  internal spermatic vein occluded

Erectile failure • Dynamic infusion cavernosometry

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281

 needle insertion into corpus cavernosum, the amount of saline flow required to maintain an erection can be measured (should be 120mL/min). Papaverine of PGE2 can be used  afterwards iodinated contrast cavernosogram performed ➢ Normal: no venous drainage ➢ Abnormal: leakage to veins • Doppler US: peak systolic velocity