radiology spots

1. SPOTTERS
Dr Priyanka Rana
19.6.18

2. 1
Presentation
Pancreatic carcinoma
metastatic to liver
who underwent
placement of a Port-
A-Cath via the right
subclavian vein. On
last chemotherapy
administration
swelling and pain was
noted in the soft
tissue around the
port reservoir and
catheter associated
with chemotherapy
administration. Image
guided evaluation of
the Port-A-Cath has
been requested.

3. 2.

4. 3

5. 4.

6. .
A 25-year-old man with oculocutaneous albinism presented to the
emergency department with multiple exophytic head and neck
masses that had been developing for years.
5

7. 6

9. 15-year-old boy with a
history of chronic swelling
around the left eye
7

10. 8.
A 5-month-old boy brought by his parents to the clinic for
evaluation of bilateral leukokoria. Examination revealed bilateral
retrolental masses. His elder brother was also blind by birth and
developed hearing loss at the age of 12 years. His 2 elder sisters
were completely normal

11. 9.

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26. 24. Sign

27. 25.

28. Key

29. 1
Presentation
Pancreatic carcinoma
metastatic to liver
who underwent
placement of a Port-
A-Cath via the right
subclavian vein. On
last chemotherapy
administration
swelling and pain was
noted in the soft
tissue around the
port reservoir and
catheter associated
with chemotherapy
administration. Image
guided evaluation of
the Port-A-Cath has
been requested.

30. There was difficulty to aspirate the port; contrast injection demonstrates 2 separate
breaks in the catheter: In the catheter approximately 2 cm from the connection to the
port reservoir and a larger break is noted near the right subclavian vein access site. In
addition there is "pinch off" of the catheter at the right subclavian vein insertion site
associated with movement of the medial right clavicle in respect to the right first rib.
Pinch off syndrome

31. Pinch-off syndrome
Pinch-off syndrome is a spontaneous catheter fracture, which
is seen as a complication of subclavian venous catheterisation.
Chest radiograph
• Look for catheter deviation, luminal narrowing and
discontinuity (fracture) of the tube
• Grades of abnormality
• grade 0: no narrowing in the catheter's course
• grade 1: deviation of the catheter with no luminal
narrowing
• grade 2: luminal narrowing as the catheter passes under
the clavicle (pinch-off sign)
• grade 3: transection of the catheter between the clavicle
and the 1st rib with embolization of the distal catheter 1

32. 2.

33. Subpulmonic pleural effusion
The left dome of diaphragm is higher than right with increased distance of diaphramatic
outline to the fundal air bubble of stomach, suggestive of a subpulmonic pleural
effusion.

34. Chest radiograph
•Apparent elevation and flattening of the diaphragm.
What appears to be the diaphragm actually represents
the visceral pleural, and the true diaphragm is obscured
by the presence of intrapulmonary fluid.
•The peak of the pseudo-diaphragm will lie lateral to the
normal position.
•When located on the left, an increased distance may be
seen between the pseudo-diaphragm and the gastric
bubble.
•If required, a decubitus projection can be performed to
clarify the definite presence of a subpulmonic effusion.

35. 3

36. 3 unilateral grade II
germinal matrix
haemorrhage

37. Germinal matrix haemorrhage
• Classification
• grade I
• restricted to subependymal region/germinal matrix which is seen in
the caudothalamic groove
• overall good prognosis 4
• grade II
• extension into normal sized ventricles and typically filling less than
50% of the volume of the ventricle
• overall good prognosis 4
• grade III
• extension into dilated ventricles
• ~20% mortality
• grade IV
• grade III with parenchymal haemorrhage
• 90% mortality 4

38. 4.

39. Mucinous cystadenoma of pancreas
Radiographic features
CT
•The tumour contour tends to be rounded or ovoid.
•Associated calcification tends to be more peripheral
•Contents of the lesion may be heterogenous is
attenuation.
•Internal septations may be present and tend to be linear
or curvilinear.

40. .
A 25-year-old man with oculocutaneous albinism presented to the
emergency department with multiple exophytic head and neck
masses that had been developing for years.
5

41. 20.

42. 20.

43. 6

45. Radiation pneumonitis
Radiation pneumonitis is the acute manifestation of radiation-induced lung disease
(RILD) and is relatively common following radiotherapy for chest wall or intrathoracic
malignancies.
Plain film
Chest x-ray changes are non-specific, but confined to the irradiation port, with
airspace opacities being most common.
CT
Change restricted to the irradiated field, making the diagnosis much easier.
In cases of early or subtle radiation induced pneumonitis, areas of ground-glass
opacity may be evident on CT.
The two most common findings are 1-2:
• ground-glass opacities and / or
• airspace consolidation
Additional features that are sometimes seen include 1:
• focal or nodular opacities
• tree-in-bud appearances
• ipsilateral pleural effusion
• atelectasis

46. 15-year-old boy with a
history of chronic swelling
around the left eye
7

47. • Allergic fungal sinusitis is a disease process with
a similar appearance to invasive fungal sinusitis,
but one that occurs in an immunocompetent
host.
• Imaging findings on CT include hyperdense
opacification of the affected sinuses. Expansion
of the affected sinus is characteristic, and
erosion is not uncommon. Peripheral
enhancement within the affected sinuses
represents enhancement with the mucosa.

48. 8.
A 5-month-old boy brought by his parents to the clinic for
evaluation of bilateral leukokoria. Examination revealed bilateral
retrolental masses. His elder brother was also blind by birth and
developed hearing loss at the age of 12 years. His 2 elder sisters
were completely normal

49. 22.

50. 22.

51. 9.

52. Imaging Findings
•Increased lucency in the pelvis on conventional
radiography due to fat deposition
•Inverted teardrop-shaped bladder (pear-shaped bladder)
•Ureters may be dilated and may be medially or laterally
displaced distally
•Hydronephrosis, usually bilaterally
•The rectum is elongated and symmetrically compressed
•Rectum may be displaced cephalad (tower rectum)
•Increased distance between seminal vesicles and posterior
bladder wall
•CT shows tissue surrounding bladder/rectum to be that of
fat (-40 to -100 Hounsfield units)
Pelvic Lipomatosis

53. 10.

54. Pellegrini-Stieda lesion
Pellegrini-Stieda (PS) lesions are ossified post-traumatic
lesions at (or near) the medial femoral collateral
ligament adjacent to the margin of the medial femoral
condyle. One presumed mechanism of injury is a Stieda
fracture (avulsion injury of the medial collateral ligament
at the medial femoral condyle).
Calcification usually begins to form a few weeks after the
initial injury.
Radiographic features
Plain film
Calcification adjacent to the medial femoral condyle,
often linear in shape.

55. 11.

56. Imaging Findings
Bilateral paraspinal masses with round, lobulated margins
Thoracic masses occur most often in patients with
thalassemia or congenital hemolytic anemia
Medullary expansion of the bony structures with widening
of the ribs being the most pronounced bony finding
Resorption of trabeculae produces coarsened appearance
to bones
Splenomegaly (or absent spleen)
Masses to don’t calcify and do not usually cause bone
erosion
The lesions are usually of low-attenuation on non-contrast
CT and may mildly enhance after contrast
Extramedullary Hematopoiesis

57. 12.

58. Chest
Hypoplasia or absence of clavicles
Clavicle normally forms from three ossification
centers: sternal, middle and distal
One or more segments in any combination may be
absent
Usually of lateral portion
R > L
Clavicles completely absent in 10%
Thorax may be narrowed and/or bell-shaped
Small scapulae
Supernumerary ribs
Incompletely ossified sternum
Cleidocranial Dysostosis

59. 13.

60. Pharyngoesophageal diverticulum
 Occurs in older women
 Posteriorly at site of Killian's dehiscence =
superior boundary is thyropharyngeal muscle and
inferior boundary is cricopharyngeal muscle
 Pulsion diverticulum
 False diverticulum = herniation of mucosa and
submucosa through muscular layer
Zenker’s Diverticulum

61. 14.

62. Imaging Findings
•In newborn, there may be a double bubble sign from dilatation of
the stomach and first portion of the duodenum
•In, adult the diagnosis is usually suggested first by CT and can be
confirmed with MRCP (magnetic resonance cholangio-
pancreaticography) or ERCP (endoscopic retrograde cholangio-
pancreaticography)
•UGI series
•May show extrinsic compression on both lateral and medial
walls of the 2nd portion of duodenum
•CT
•May be mistaken for thickening of the duodenal wall
•On MRCP or ERCP, the duct of the annular pancreas usually
originates anterior to the duodenum
sweeps posteriorly and opens into the main pancreatic duct or
ampulla
Annular pancreas

63. 15

64. Plexiform neurofibroma
Plexiform neurofibroma is a benign tumor of peripheral nerves (WHO grade I)
arising from a proliferation of all neural elements, pathognomonic
of neurofibromatosis type 1(NF1).
MRI
Reported signal characteristics include:
T1: hypointense
T2: hyperintense +/- hypointense central focus (target
sign)
T1 C+: mild enhancemen

65. 16.

66. Liposarcoma
Liposarcoma is the most common (33%) primary retroperitoneal
sarcoma.
Liposarcoma is usually large (average diameter, >20 cm) and is a slow-
growing tumor.
It is a predominantly hypoattenuating lesion on CT because of its fat
content. At MR imaging, it follows fat signal.
The appearance of liposarcoma may be similar to that of a lipoma,
but liposarcoma has thicker, irregular, and nodular septa that show
enhancement after contrast material administration.

67. 17.

68. Pathology
It results from failure of fusion of dorsal and ventral pancreatic
anlages. As a result, the dorsal pancreatic duct drains most of the
pancreatic glandular parenchyma via the minor papilla. Although
controversial, this variant is considered as a cause of pancreatitis.
MRCP/MRI pancreas
This is the standard method of evaluation in modern times.
The key imaging features are:
the dorsal pancreatic duct being in direct continuity with the duct of
Santorini, which drains into the minor ampulla
ventral duct, which does not communicate with the dorsal duct but
joins with the distal bile duct to enter the major ampull
Pancreas divisum

69. 18.

70. Imaging Findings
On conventional radiographs or CT, curvilinear calcifications
in segment of the wall or entire wall
CT is more sensitive than conventional radiographs
Thickness of calcification may vary
On ultrasound, highly echogenic, shadowing, curvilinear
structure in GB fossa
DDx: stone-filled contracted GB
Echogenic GB wall with little acoustic shadowing
Porcelain Gallbladder
•Calcification of all or part of the gallbladder wall
oFlakes of dystrophic calcium within chronically inflamed and fibrotic
muscular wall
oWall is thickened and gallbladder is contracted
•Associated with gallstones in 90%
oCystic duct is always obstructed
o80% of patients with carcinoma of gallbladder have stones

71. 19.

72. Herpes Encephalitis
• Findings
– Bilateral temporal lobe FLAIR
signal (post-seizure edema)
• HSV 2 in neonates
• HSV 1 in adults
– latent infection in the
Gasserian ganglion (CN V)
– predilection for the limbic
syste, cingulate gyrus, and
subfrontal region
– late stage becomes bilateral,
hemorrhage

73. • TEMPORAL LOBE
– Tumor: Ganglioglioma
– Infection: Herpes
– Vascular: Transverse sinus
– thrombosis/infarct

74. 20.

75. Primary Intracerebral Lymphoma
• Findings:
– T2 bright lesion in the left
frontal lobe and basal ganglia
– Crosses both gray and white
matter
– Some mass effect
– No significant enhancement
• An unusual lesion in the non-
HIV/immunosuppred
population
• ddx:
– Low –grade glioma

76. 21.

77. Homolateral Lisfranc
farcture/dislocation
• Findings
– Widening between the base of 1st and 2nd
metatarsals.
– lateral subluxation of the second through
fifth metatarsals
• dislocation is relative to the cuneiforms:
– homolateral
– divergent (1st MT goes medial)
• can be due to trauma or in patients with
diabetic neuropathy

78. 22

79. Prominent solid periosteal reaction affecting phalanges and distal of radius and ulna.
There is also evidence of soft tissue swelling.
Thyroid acropachy is an uncommon manifestation of autoimmune thyroid disease
which presented with digital clubbing, swelling of digits and toes, and periosteal
reaction of extremity bones (The term acropachy is a Greek word for thickening of the
extremities). It is almost always associated with thyroid ophthalmopathy and
dermopathy.
Thyroid acropachy
22

80. 23.

81. Bennett Fracture
• Findings
– Intra-articular fracture-dislocation of proximal first metacarpal
• Mechanism is axial loading of a partially flexed first
metacarpal (fistfight)
– Volar ligamentous fixation of first MC is very strong, so small
volar bone fragment is avulsed and retains a normal position
while the larger fragment subluxes or dislocates dorsally due
to abductor pollicis longus
• Tx: internal fixation

82. 24. Sign

83. CT reveals a confluent mass which is encasing
the abdominal aorta and its branches. These
images two classic signs of lymphoma.
The "sandwich sign" which refers to sandwiching
of vessels by lymphoma and not narrowing
them.
The other sign is "floating aorta" sign - the aorta
is lifted away from the vertebral column by the
lymphoma mass.
sandwich sign

84. 25.

85. Rickets
• Vitamin D deficiency
– Liver or kidney disease (hydroxylation)
– GI malabsorption
– Dietary deficiency
• Findings
– Bowing in weight bearing long bones
– Metaphysis and physis widening, fraying, cupping,
and slipping
– Generalized demineralization
– Coarse trabeculae

86. Thankyou