 Meningioma
Differential Diagnoses
Neuroradiology
Ring-enhancing intracranial leions
 MAGICAL DR mnemonic:
 Metastasis
 Abscess: AIDS, IVDA,
immunocompromised state
 Glioblastoma multiforme, high grade
glioma
 Infarct
 Contusion/hematoma
 AIDS (toxoplasmosis)
 Lymphoma
 Demyelinating disease
 Radiation necrosis
Lesions crossing the corpus callosum
 Glioblastoma multiforme
 Lymphoma
 Progressive multifocal
leukoencephalopathy
 Multiple sclerosis
 Mimic: parafalcine meningioma
Posterior fossa mass, child
 Medulloblastoma
 Cerebellar pilocytic astrocytoma
 Ependymoma
 Pontine glioma
Posterior fossa mass, adult
 Metastasis (most common)
 Cerebellar pilocytic astrocytoma
 Hemangioblastoma (von Hippel-Lindau
disease
 Medulloblastoma (cerebellar hemisphere)
 Hemorrhage (hypertensive)
Extra-axial mass
 Meningioma
 Arachnoid cyst
 Epidermoid cyst
 Dural metastasis
 Bone lesion with intracranial extension
 Empyema, subdural or epidural
 Sarcoidosis
Cerebellopontine angle mass
 Vestibular schwannoma (bilateral,
neurofibromatosis-2)
 Meningioma
 Arachnoid cyst
 Epidermoid cyst (most common)
 Other: ependymoma, schwannoma,
glomus jugulare
Sellar or suprasellar mass
 GATCH MODE mnemonic:
 Germ cell tumor, Granuloma
 Adenoma, Aneurysm, Arachnoid cyst
 Tuber cinerum hamartoma
 Craniopharyngioma, Rathke’s cleft cyst
 Hypothalamic glioma
 Meningioma, Metastasis
 Optic chiasm glioma
 Dermoid
 Epidermoid
 Lymphoma
Suprasellar mass, adult (common)
 Pituitary adenoma (prolactinoma > GH)
 Craniopharyngioma (30-40 y/o)
Cranial nerves 3, 4, 51, 52, 6 traverse the cavernous
 Chiasmatic/hypothalamic glioma sinus, so a cavernous sinus mass may present with
 Aneurysm CN neuropathy. Standing Room Only: V1-Spinosum,
V2-Rotundum, V3-Ovale
Suprasellar mass, child (common)
 Craniopharyngioma (4-5 y/o) Pineal region mass
 Chiasmatic/hypothalamic glioma (NF-1)  Pineal cyst (NL <15 mm)
 Germinoma  Germ cell tumor (germinoma)
 Pineoblastoma (rare, child), pineocytoma
Suprasellar mass, homogeneously enhancing (rare, adult)
 Macroadenoma  Metastasis
 Meningioma (planum sphenoidale, clivus)  Tectal glioma
 Aneurysm  Meningioma
 Germinoma, teratoma  Vein of Galen malformation
Suprasellar mass, partially calcified Temporal lobe lesion, adult
 Meningioma  GBM, metastasis
 Craniopharyngioma  Ganglioglioma (young adult, also parietal
 Aneurysm lobe/cerebellum), DNET
 Granuloma  HSV
 Dermoid  Trauma
 Mesial temporal sclerosis
Suprasellar mass, high attenuation
 Meningioma Absent posterior pituitary bright spot
 Craniopharyngioma  EG
 Adenoma (hemorrhagic)  Diabetes insipidus
 Aneurysm
 Glioma Intraventricular mass
 Germinoma  Meningioma (left atrium)
 Metastases, lymphoma
Pituitary hemorrhage can occur with adenoma,  Ependymoma (4th ventricle)
bromocriptine therapy, pregnancy, XRT,  Subependymoma (rare, 4th ventricle or
anticoagulation, LP frontal horn)
 Choroid plexus papilloma (child, left
Suprasellar mass, Hyperintense T1/T2 atrium; rare adult, 4th ventricle)
 Adenoma (hemorrhagic)  Colloid cyst
 Craniopharyngioma (cystic, proteinaceous  Astrocytoma (giant cell astrocytoma in
material) Tuberous Sclerosis)
 Rathke's cleft cyst  Central neurocytoma (rare, adult)
 Medulloblastoma (child, 4th ventricle;
Infundibular mass, child adult, cerebellar hemisphere)
 Germinoma  Racemose cysticercosis (mimics
 Eosinophilic granuloma epidermoid cyst, arachnoid cyst)
 Meningitis
 Lymphoma CSF seeding of tumor
 Glioma  Germinoma
 Racemose cysticercosis  PNET: medulloblastoma, pineoblastoma,
retinoblastoma
 Ependymoma
Infundibular mass, adult
 Metastasis  Choroid plexus carcinoma
 Sarcoid  GBM
 Germinoma  Metastases
 Lymphoma
 Glioma
 Choristoma (granular cell tumor)
Cavernous sinus mass
 Meningioma
 Schwannoma, neurofibroma
 Aneurysm of ICA
Hyperacute blood (oxyhemoglobin) is diamagnetic
 Cavernous sinus thrombosis
(no unpaired electrons) on MRI, appearing T1
 Carotid-cavernous fistula isointense/T2 hyperintense
 Metastasis
 Lymphoma, sarcoid White matter disease (multiple)
 Macroadenoma  Ischemia
 Extension from bone tumors: metastasis,  Multiple sclerosis
chordoma, chondrosarcoma  Acute disseminated encephalomyelitis:
measles, mumps, mononucleosis,
Cavernous sinus mass, bilateral
varicella; post-vaccination (basal
 Macroadenoma ganglia/thalamus abnormalities
 Meningioma differentiate from MS)
 Lymphoma  PML (classically occipitoparietal regions)
 Metastases  Central pontine myelinolysis
 SLE and other collagen vascular diseases
  Sarcoid
 Lyme disease
 Vitamin B12 deficiency
 Radiation injury
 Dysmyelinating disease: Canavan’s
disease (diffuse, macrocephaly), Krabbe’s
disease (diffuse), Alexander’s disease
(anterior), adrenal leukodystrophy
(posterior), metachromatic
leukodystrophy (diffuse), Pelizaeus-
Merzbacher disease (deficient myelin-
specific lipids)
Infarct, young adult
 Dissection: post-traumatic, Marfan’s
syndrome, FMD, extension of Type A
thoracic aortic dissection into common
carotid artery
 Drug abuse: cocaine, amphetamine
 Vasculitis: giant cell arteritis, PAN,
temporal arteritis; sarcoidosis; SLE,
Wegener’s disease, Behcet’s disease;
methamphetamine, ergotism
 Basilar meningitis: bacterial, TB, fungal,
syphilis
 Fibromuscular dysplasia
 Migraine
 Moyamoya disease (child): idiopathic;
mimics include Sickle cell anemia, NF-1,
connective tissue disorders (Marfan’s
syndrome, Ehlers-Danlos,
homocysteinuria), radiation injury,
Menke’s kinky hair syndrome,
atherosclerosis (uncommon)
Traumatic dissection of the ICA usually occurs
immediately above the carotid bifurcation, near the
skull base, or at the level of the supraclinoid ICA.
Dissection of the vertebral artery occurs at C6, where
it enters the foramina transversarium
Gyriform cortical enhancement
 Stroke
 Cerebritis
 Postictal state
 Hypertensive encephalopathy, eclampsia
 Drugs: cyclosporine, MTX, FK506
(Tacrolimus)
Hypertensive encephalopathy can occur in
pregnancy, renal failure, TTP, hemolytic-uremic
syndrome. It’s similar in appearance to cyclosporine,
FK-506 therapy
Dural venous sinus thrombosis
 Infection: otomastoiditis
 Pregnancy
 Dehydration
 Sepsis
 Neoplasm: falx meningioma
 Hypercoagulable states
Conditions associated with cerebral aneurysms
 AVM
 ADPCKD
 Fibromuscular dysplasia
 NF-1
 Collagen vascular disease
 Marfan’s syndrome
 Coarctation of the Aorta
Aneurysm in unusual location
 Mycotic: bacterial endocarditis
 Vasculitis: PAN, SLE, Wegener’s
granulomatosis, Takayasu’s disease
 AVM
 Post-traumatic
Which aneurysm is bleeding?
 Proximity to site of hemorrhage on CT
 Large size
 Adjacent spasm
 Beaking of aneurysm contour
 Frank extravasation of contrast (rare)
Hemorrhage, intraxial
 Trauma
 Hypertension (putamen, thalamus, pons,
cerebellum)
 Aneurysm (multiple in 15%)
 AVM, cryptic vascular malformation
(cavernous hemangioma, capillary
telangiectasia)
 Thromboembolic, venous infarct
(temporal lobe from transverse sinus
thrombosis, parasagittal subcortical white
matter from superior sagittal sinus
thrombosis, thalami from straight sinus or
vein of Galen thrombosis)
 Hemorrhagic metastasis: melanoma,
thyroid carcinoma, choriocarcinoma,
adenocarcinoma (breast, lung, renal,
colon); GBM, oligodendroglioma
 Amyloid angiopathy
 Drugs abuse: cocaine, amphetamine
 Other: coagulopathy, vasculitis,
encephalitis
Hemorrhage spontaneous intra-axial, elderly
 HTN
 Amyloid angiopathy
 Metastasis
Hemorrhage spontaneous intra-axial, young
 AVM
 Aneurysm
 Drug abuse: cocaine, amphetamine
 Neoplasm
Hemorrhage multifocal intra-axial
 Trauma
 Metastases
 Amyloid angiopathy
 Vasculitis
 Venous infarction
 Coagulopathy
Hemorrhage, subarachnoid
 Aneurysm
 Trauma
 AVM
Hemorrhage, epidural/subdural
 Trauma
 Coagulopathy
Leptomeningeal enhancement
 Metastases: lung, breast, melanoma,
lymphoma/leukemia, PNETs (child)
 Meningitis: TB, fungal; otomastoiditis
 Post-surgical
 SAH
 Meningeal (pial) angiomatosis in Sturge-
Weber
Meningitis bugs
 Group B streptococcus (newborn)
 H. infuenzae (child)
 N. meningititis (adolescent)
 S. pneumonia (adult)
Dural enhancement/mass
 Post-craniotomy or LP, CSF diversion
 Neoplasm: meningioma, metastases
(breast, prostate, lymphoma), direct
extension of primary intracranial tumor,
neuroblastoma (child)
 Meningitis
 Post-hemorrhagic: remote SDH, EDH
 Spontaneous intracranial hypotension
(CSF leak from lumbosacral root sleeve
cyst)
 Sarcoidosis
Ependymal enhancement
 Neoplasm: lymphoma, glioma, CSF
spread of primary intracranial tumor or
metastasis
 Ventriculitis: meningitis, post-shunting;
CMV (AIDS)
Hydrocephalus
 Congenital: idiopathic, Chiari II
malformation, Dandy-Walker
malformation, aqueductal stenosis,
perinatal hemorrhage or
meningoencephalitis (STARCH)
 Communicating: meningitis, SAH,
meningeal carcinomatosis
Parenchymal calcifications, neonate
 CMV
 Toxoplasmosis
 Rubella infection
 Herpes Simplex infection
 HIV (basal ganglia)
 STARCH mnemonic: Syphilis,
Toxoplasmosis, AIDS, Rubella, CMV,
Herpes simplex virus-2
T1 hyperintensity
 Intracellular/extracellular methemoglobin
 Fat
 Proteinaceous fluid
 Melanin
 Slow blood flow on certain sequences
 Calcification (hydrated)
T2 hypointensity
 Vascular flow voids
 Deoxyhemoglobin (acute bleed),
intracellular methemoglobin, ferritin,
hemosiderin
 Calcification or ossification
 Proteinaceous fluid
 Densely cellular mass: meningioma,
lymphoma, PNET (pineoblastoma,
medulloblastoma, neuroblastoma)
 Iron deposition, physiologic (basal
ganglia, substantia nigra, red nucleus,
dentate nucleus), iron deposition,
pathologic
Calvarial button sequestrum
 O ME mnemonic:
 Osteomyelitis
 Metastases
 EG
Solitary lytic defect in skull
 MT HOLE (“empty hole”) mnemonic:
 Metastasis, multiple myeloma
 TB, trauma
 Histiocytosis, hemangioma
 Osteomyelitis
  Leptomeningeal cyst  Metastases (drop): germ cell tumors,  Aggressive sinusitis: aspergillus,
 Epidermoid ependymoma, PNET; adenocarcinoma, mucormycosis
melanoma, lymphoma/leukemia
Loss of lamina dura  Dermoid, epidermoid J-shaped sella
 CHOMP mnemonic:  Lipoma  Cretinism
 Cushing’s disease  MANDELIN mnemonic: meningioma,  Idiopathic
 Hyperparathyroidism metastasis (drop), arachnoiditis,  Hydrocephalus
 Osteomalacia, osteoporosis arachnoid cyst, AVM, neurofibroma,  Gargoylism
 Multiple myeloma dermoid, epidermoid, ependymoma,  Achondroplasia
 Paget’s disease lipoma, infection (TB, cysticercosis) NL  Optic glioma
but tortuous nerve roots  NF-1
Calcifications in brain
 PINEAL mnemonic: Extradural lesion Jugular foramen mass
 Physiologic: pineal gland, choroid plexus,  Degenerative disease: disc protrusion,  Glomus jugulare
basal ganglia osteophyte, synovial cyst  Schwannoma
 Infections: Cysticercosis, toxoplasmosis,  Metastases to vertebrae: lung, breast,  Metastasis
TB, CMV prostate, lymphoma  Meningioma
 Neoplasm: craniopharyngioma,  Other tumors: myeloma, chordoma,  Asymmetrical or thrombosed jugular
oligodendroglioma, meningioma, aneurysmal bone cyst, giant cell tumor, vein, ectatic carotid artery, carotid
chordoma lymphoma/leukemia, osteoblastoma, pseudoanuerysm
 Endocrine: hypervitaminosis D, eosinophilic granuloma, schwannoma,
hypoparathyroidism, neurofibroma, ganglioneuroma, Far lateral disc herniation mimics
ganglioneuroblastoma, neuroblastoma
hyperparathyroidism, Fahr’s disease  Conjoined nerve root
  Epidural abscess: discitis, osteomyelitis
Arterial: atherosclerosis, aneurysm  Perineural cyst
  Hematoma
Lipoma, dermoid  Neurofibroma

Calcified intracranial mass Epidural lesion, child

Tarlov cyst mimics
  Extension of paraspinal or vertebral
Ca++ COME mnemonic:  Intrasacral meningocele
tumor: neuroblastoma,
 Craniopharyngioma  Dural ectasia
ganglioneuroblastoma, ganglioneuroma;
 Astrocytoma, aneurysm
neurofibroma, schwannoma
 Choroid plexus papilloma Arachnoiditis
 Abscess
 Oligodendroglioma  Trauma, surgery
 Ewing’s sarcoma
 Meningioma  Intrathecal steroids, anesthesia
 Lymphoma/leukemia
 Ependymoma (25%)  Myelogram
 Eosinophilic granuloma
 Infection
 Other vertebral body tumors (above)
Basal ganglia calcification
 Idiopathic Globe lesions
Epidural extension over many levels
 Hypoparathyroidism,  Uveal melanoma (lobular), uveal
 Abscess
hyperparathyroidism metastases (plaque-like)
 Hematoma
 Fahr’s disease (familial idiopathic  Choroidal or retinal detachment
 Metastases
cerebral ferrocalcinosis)  Vitreous hemorrhage
 Lymphoma
 Post-inflammatory, post-anoxia  Pseudotumor
 AIDS  Retinoblastoma (child)
Destructive midline, skull-base lesion
 Cockayne’s syndrome  Optic disc Drusen, choroidal osteoma
 Metastases
(lateral to optic disc)
 Myeloma
Intramedullary lesion
 Nasopharyngeal carcinoma
 Neoplasm: ependymoma (adult, conus Optic nerve or nerve sheath enlargement
medullaris/filum, can be cystic or  Chordoma (midline)  Optic glioma (child, NF-1), optic nerve
calcified or bloody), astrocytoma (child),  Chondrosarcoma (off midline) sheath meningioma (adult),
hemangioblastoma, metastasis (rare)  Meningioma lymphoma/leukemia, metastasis
 Infarct, ischemia  Macroadenoma  Pseudotumor
 Hematoma  Lymphoma  Optic neuritis
 Demyelinating disease: MS  Esthesioneuroblastoma (cribiform plate)  Sarcoidosis
 Transverse myelitis: post-viral,  Aggressive sinusitis: aspergillus,
inflammatory, ischemia, MS, ADEM, mucormycosis Rectus muscle enlargement
SLE, XRT  Mucocele, polyposis  Thyroid opthalmopathy
 Cryptic vascular malformation: cavernous (inferior>medial>superior>lateral)
hemangioma, capillary telangiectasia Destructive skull-base lesion, frontal  Pseudotumor
 Syrinx  Esthesioneuroblastoma  Myositis: extension from paranasal sinus
 Contusion  Metastasis infection, pseudotumor
 Abscess  meningioma  Metastasis, lymphoma, others
 Sinonasal carcinoma  Vascular congestion from mass at orbital
Syringomyelia  Lymphoma apex, carotid-cavernous fistula, cavernous
 Trauma (myelomalacia)  Rhabdomyosarcoma sinus thrombosis, dural AVM
 Neoplasm  Aggressive sinusitis
 Chiari 1 or 2 malformation  Mucocele, sinonasal polyposis Lacrimal fossa mass
 Infarct (myelomalacia)  Viral infection
 Arachnoiditis: meningitis, back surgery Destructive skull-base lesion, basisphenoid  Benign neoplasm: dermoid, pleomorphic
 Nasopharyngeal carcinoma adenoma
Intradural, extramedullary lesion  Chordoma  Malignant neoplasm: adenoid cystic
 Meningioma (posterolateral)  Chondrosarcoma carcinoma, lymphoma, metastases
 Nerve sheath tumor (anterolateral):  Metastases, myeloma  Pseudotumor
schwannoma, neurofibroma  Macroadenoma  Sarcoidosis
 Meningioma  Sjogren’s syndrome
 Wegener’s granulomatosis

Lacrimal fossa mass, bilateral
 Lymphoma
 Sarcoid
Intraconal mass
 Cavernous hemangioma (adult), capillary
hemangioma (child), lymphangioma
(child)
 Orbital cellulitis, pseudotumor
 Varix, carotid-cavernous fistula
 Lymphoma, rhabdomyosarcoma (child),
metastasis (child: neuroblastoma to bone;
adult: breast, lung, prostate, melanoma to
uvea, rectus muscles, bone)
Extraconal mass
 Metastasis to bony orbit
 Invasion by adjacent primary tumor:
paranasal sinus or nasal SCC, sphenoid
wing meningioma
 Lacrimal fossa mass
 Subperiosteal abscess or hematoma
Orbital mass, child
 LO VISHON mnemonic:
 Leukemia, lymphoma
 Optic nerve glioma
 Vascular malformation (capillary
hemangioma, lymphangioma)
 Inflammation (pre-, post-septal)
 Sarcoma (rhabdomyosarcoma)
 Histiocytosis
 Orbital pseudotumor, osteoma
 Neuroblastoma
Middle ear mass
 Cholesteatoma, cholesterol granuloma,
inflammatory debris/granulation tissue
 Vascular: aberrant carotid artery,
dehiscent jugular bulb
 Neoplasm: glomus tympanicum (cochlear
promontory, ascending pharyngeal artery
embolization), glomus jugulare invading
middle ear (glomus jugulotympanicum),
hemangioma, others
Lesion causing pulsatile tinnitus
 Aberrant carotid artery, high jugular bulb
or dehiscent jugular bulb
 Transverse sinus/internal jugular vein
thrombosis, high grade carotid stenosis,
dural AVF
 Glomus tympanicum, glomus jugulare
invading middle ear
Vascular retrotympanic mass
 Congenital: aberrant carotid artery, high
jugular bulb or dehiscent jugular bulb
 Neoplasm: glomus tympanicum, glomus
jugulare invading middle ear
 Cholesterol granuloma, inflammatory
debris/granulation tissue
Paranasal sinus mass
 Mucocele
 Squamous cell carcinoma,
adenocarcinoma, lymphoma, inverted
papilloma, esthesioneuroblastoma,
ameloblastoma, rhabdomyosarcoma,
juvenile angiofibroma
 Infectious sinusitis, granulomatous
sinusitis
 Osteoma
 Odontogenic cyst
Parapharyngeal space
 Fat, branches of V3, salivary gland rests
 SCC invading from pharyngeal mucosal ,
parotid, masticator spaces
 Abscess from pharynx (tonsillar abscess),
masticator space (odontogenic abscess)
Pharyngeal mucosal space
 Mucosa, Waldeyer’s ring, eustachian tube
opening, minor salivary glands, muscles
 SCC
 Non-Hodgkin’s lymphoma, tonsillar
abscess
Masticator space
 Muscles of mastication (pterygoids,
masseter, temporalis), mandibular ramus,
branches of V3
 Abscess (odontogenic)
 Mandibular osteosarcoma
 Rhabdomyosarcoma
 SCC invasion from pharyngeal and
parotid spaces
 Non-Hodgkin’s lymphoma
 Neurogenic tumor
Retropharyngeal space
 Fat, nodes
 Abscess
 Reactive adenopathy: NL in child, URI,
tonsillitis
 SCC invasion from pharyngeal and
mucosal spaces
 Nodal metastases from pharyngeal SCC,
Non-Hodgkin’s lymphoma
 Hemangioma
 Neuroblastoma, rhabdomyosarcoma
(child)
Prevertebral space
 Muscles (prevertebral, paraspinal,
scalenes)
 Brachial plexus roots, phrenic nerve,
vertebrae, vertebral arteries
 Discitis, osteomyelitis
 Metastases
 Primary vertebral body tumor
Carotid space
 ICA, internal jugular vein, cranial nerves
9, 10, 11, 12, nodes
 Schwannoma, neurofibroma
 Glomus jugulare, carotid body tumor
 Meningioma of jugular foramen
 Nodal metastases
 Asymmetrical or thrombosed jugular vein,
ectatic carotid artery, carotid
pseudoaneurysm
Remember: carotid body tumor usually splays the
carotid bifurcation, while glomus vagale/jugulare
displaces carotid anteriorly
Parotid space
 Parotid glands (with Stenson’s duct),
intraparotid lymph nodes, branches of CN
7, external carotid artery
 Pleomorphic adenoma (adult, T2 bright),
Warthin’s tumor (adult)
 Mucoepidermoid carcinoma, adenoid
cystic carcinoma, NHL
 Nodal metastases from SCC, NHL,
melanoma
 Abscess
 Lymphoepithelial cysts (AIDS)
 Hemangioma or lymphangioma (child)
 Lymphoma
 1st branchial cleft cyst
Parotid lesions, multiple or bilateral
 Warthin’s tumor
 Nodal metastases from SCC, NHL,
melanoma
 Lymphoepithelial cysts (AIDS)
Submandibular and sublingual spaces
 Salivary glands, mylohyoid muscle,
anterior tongue, nodes, branches of V3,
CN 7, 9, 12
Submandibular space (with Wharton’s duct)
 Nodal metastases
 Direct invasion from SCC, NHL, salivary
gland neoplasm
 Dermoid or epidermoid, cystic hygroma,
hemangioma, salivary gland neoplasm,
lipoma
 Abscess, lymphadenitis
 Second branchial cleft cyst (anterior to
sternocleidomastoid muscle)
 Diving ranula
Submandibular space, cystic mass
 Second branchial cleft cyst
 Cystic hygroma
 Dermoid or epidermoid
 Thyroglossal duct cyst
 Diving ranula
 Abscess or necrotic neoplasm
Sublingual space
 Invasive SCC of the tongue, salivary
gland neoplasm
 Dilated Wharton’s duct, abscess
(odontogenic or sialoadenitis)
 Dermoid or epidermoid
 Ranula (dives below mylohyoid to
submandibular space)
 Cystic hygroma
 Hemangioma, lingual thyroid posteriorly
(child)
Sublingual space, cystic mass
 Dermoid or epidermoid
 Ranula
 Cystic hygroma
 Abscess or necrotic neoplasm
Oropharynx lesions include SCC, lymphoma,
adenoid cystic carcinoma, mucoepidermoid
carcinoma, adenocarcinoma; hemangioma,
lymphangioma, abscess (child)
Larynx extends from the valleculae to the space
between cricoid cartilage/1st tracheal ring.
Supraglottis is epiglottic tip to laryngeal ventricle (if
lesion here only, voice sparing procedure). Lesions in
these areas: SCC, laryngocele, thyroglossal duct cyst,
stenosis, trauma
Infrahyoid neck
 Same as suprahyoid neck
Visceral space lesions
 Thyroid and parathyroid glands,
esophagus, larynx and trachea, recurrent
laryngeal nerve, nodes
 SCC of the larynx, thyroid neoplasm,
esophageal carcinoma, nodal metastases
 or lymphoma, salivary gland neoplasm,
dermoid or epidermoid
 Reactive adenopathy, abscess
 Laryngocele
Bells palsy
 Ramsay-Hunt syndrome (herpes zoster
infection)
 Facial nerve schwannoma
 Perineural tumor spread
 Sarcoidosis
 Lymphoma
 Lyme disease
Odontogenic cyst
 Radicular cyst
 Dentigerous cyst (tooth)
 Keratocyst
 Lateral periodontal cyst
Enlarged vestibular aqueduct (>1.5 mm)
 Sporadic
 Mondini’s disease [cochlear hypoplasia or
incomplete partition of cochlear turns
(only 1-1.5x) with vestibular aqueduct
enlargement]
Cerebellar atrophy
 ETOH
 Anti-seizure medications
Miscellaneous Facts:
1. In acute infarct, DWI is bright (restricted) and
ADC map is dark. T2 shine through from
chronic infarct or other process is bright on
ADC map. ADC is calculated with at least 2
measurements of diffusion capacity with
different b values. We use b=0, b=500 or 1000
2. For epidermoid vs. arachnoid cyst, try FLAIR
(arachnoid cyst is dark) or DWI (restricted
diffusion;bright with epidermoid cyst)
3. Methanol poisoning results in decreased
density of lateral Putamina
4. CO poisoning causes hemorrhagic necrosis of
Globus Pallidus
5. TPN and liver failure: increased T1 signal in
basal ganglia (hydrated Ca++)
6. Wilson’s disease has increased T2 signal in
basal ganglia (putamina)
7. Huntington’s disease: caudate atrophy
8. Amyotrophic lateral sclerosis: atrophy of
frontal lobe, increased T2 signal posterior limb
internal capsule
9. Parkinson’s disease: increased iron in BG,
midbrain
10. Alzheimer’s disease: Diffuse atrophy,
hippocampal atrophy, increased T2 signal in
WM, temporal lobes
11. Pleomorphic Xanthoastrocytoma (young
adult): supratentorial cystic mass with a mural
nodule
12. Hakeem Adams syndrome: NPH (gait ataxia,
dementia, urinary incontinence) and may
respond to VP shunt
13. NAA should be highest peak; a 2:1
choline:creatine ratio suggests tumor
14. CC/VV planes are carotid-cochlea
(anterior)/vestibular-vein (posterior)
15. Diffusion MR will be bright with metastatic
collapse of vertebral body, but not with
osteoporotic collapse
16. Perimedullary and intramedullary AVMs are
very difficult to treat with catheter. However,
dural AVM is amenable to catheter treatment
17. Cisternal portion of 7th cranial nerve normally
enhances minimally
18. Hangman fracture is hyperextension,
distraction/compression forces at C2
19. Cerebral abscess may have thicker enhancing
wall toward the cortical side, and a T2
hypointense rim (free radicals?)
20. Expansile diploic space can occur in chronic
anemias, dilantin therapy
21. Odontoid type 1 fracture (dens tip) is rare, but
mechanically STABLE. Type 2 (base of dens)
is the most common, may result in non-union,
and is mechanically unstable. Type 3 can be
mechanically stable or unstable
22. AVM bleed risk (2-3% per year) increases
with intranidal aneurysm, deep periventricular
location, deep venous drainage
23. Cavernous angioma and developmental
venous anomaly (most common malformation)
often occur together. Cavernous angioma has
no NL intervening brain, while capillary
telangiectasia does
24. A dural AVF may be due to occlusion of a
dural venous sinus
25. A C-C fistula can be high flow (young males,
trauma, direct communication between carotid
and cavernous sinus) or low flow (middle-aged
female, spontaneous, communication between
dural branches of ICA or ECA and cavernous
sinus). Try balloon occlusion
26. Hypertensive bleed occurs in basal ganglia,
thalamus, pons, cerebellum
27. Brain hypoxia/near drowning causes BG,
posterior limb internal capsule, temperoparietal
lobes hypodensity and corresponding T2
hyperintensity
28. An acute hemorrhage may be due to an
underlying mass or vascular malformation if
there is enhancement and/or
disorganized/different clot stages
29. Hemorrhagic transformation (15-50%)
occurs on days 2-14 after ictus, while
hemorrhagic infarction (5%) occurs within 24
hours of ictus
30. Germinal matrix hemorrhage occurs in 67%
of 28-32 week premies. Grades 1 & 2 have
good prognoses, while 3 & 4 have poor
prognoses. Grade 4 is probably due to
hemorrhagic infarction from compression of the
deep medullary veins (90% mortality)
31. Ossification of the posterior longitudinal
ligament (OPLL) is associated with DISH,
usually at C4-C6
32. Unilateral interfacetal dislocation is
mechanically STABLE, whereas bilateral is
mechanically and neurologically UNSTABLE
33. Wallerian degeneration is T2 hypointense the
first month, then T2 hyperintense after 2-3
months
Normal Basion-Dens distance: <12 mm. Power’s
ratio: if the ratio of Basion to posterior arch
C1/Opsthion to anterior arch C1 is >1.0, there is
anterior displacement of the C-spine
Acceptable spine terminology
 Disc bulge
 Protrusion
 Extrusion
Branches of ECA
 SALFOPSI mnemonic:
 Superior thyroid
 Ascending pharyngeal
 Lingual
 Facial
 Occipital
 Posterior auricular
 Superficial temporal
 Internal maxillary (middle meningeal)
Cerebral angiography: Omnipaque 300 (full
strength for cut-film, 50% dilution for DSA), 5F-7F
Simmons (elderly), Berenstein catheter (young adult)
or Head Hunter (general use), AP/lateral/oblique
views as necessary
 CCA run: 10cc/sec for 12cc
 ICA run: 8cc/sec for 10cc
 ECA run: 4cc/sec for 6cc
 VA run: 6cc/sec for 8cc with straight AP
or Waters (basilar tip)/Towne view (PCA)
 2-4 frames/sec
Differential Diagnoses
Chest Radiology
Anterior mediastinal masses
 Retrosternal goiter
 Elongated/aneurysmal dilatation of the
innominate artery
 Thymic masses: thymoma (>40 y/o),
nodular hyperplasia, lymphoma/leukemia,
carcinoma, carcinoid, thymolipoma,
thymic cyst (congenital, s/p XRT in
Hodgkin’s disease)
 Germ cell neoplasms: teratocarcinoma,
dermoid, seminoma, choriocarcinoma,
embryonal cell carcinoma, endodermal
sinus tumor
 Lymphoma
 Ascending aortic aneurysm
 Rare: lymphangioma, mesenchymal
tumors, parathyroid tumors, Morgagni’s
hernia, Castleman’s disease
Middle mediastinal masses
 Lymph node enlargement: metastatic,
lymphoma, granulomatous, sarcoid
 Bronchogenic cyst
 Bronchogenic carcinoma
 Aortic aneurysm
 Esophageal carcinoma, duplication cyst
 Chronic mediastinitis (TB,
histoplasmosis)
 Tracheal neoplasms: adenoid cystic
carcinoma, mixed salivary gland tumor,
carcinoid, SCC, adenocarcinoma
 Castleman’s disease (usually hyaline
vascular type), liposarcoma
Posterior mediastinal masses
 Neurogenic neoplasm: neurofibroma,
schwannoma, neuroblastoma,
ganglioneuroblastoma, ganglioneuroma
  Vertebral neoplasm: osteochondroma,
ABC, chondrosarcoma, osteosarcoma,
Ewing’s sarcoma, myeloma, metastases
 Abscess
 Descending aortic aneurysm
 Extramedullary hematopoiesis
 Lateral thoracic meningocele: NF-1
Fatty mediastinal masses
 Mediastinal lipomatosis
 Lipoma/liposarcoma
 Thymolipoma
 Morgagni’s hernia with omentum
 Epicardial fat pad
 Paraesophageal hernia with fat
 Extramedullary hematopoiesis (rarely
fatty)
 Chylolymphatic cyst
 Teratoma
Cystic Mediastinal masses
 Thymic cyst
 Cystic degeneration of thymic Hodgkin’s
lymphoma
 Germ cell tumors
 Foregut cyst
 Neurenteric cyst
 Meningocele
 Pancreatic pseudocyst
 Lymphangioma
 Abscess
 Hematoma
 Goiter, cystic elements
Diffuse mediastinal widening
 Lipomatosis
 Lymphoma
 Small cell bronchogenic carcinoma
 Mediastinitis
 Anaplastic/poorly differentiated SCC
 Hematoma
Pneumomediastinum
 Spontaneous: asthma, coughing,
decompression during diving
 Barotrauma
 
Tracheobronchial injury
 Vomiting (Boerhaave’s syndrome)
 Extension from retroperitoneum or neck
 Post-operative (<1 week NL)
 Positive-pressure ventilation
 A SHIT mnemonic: asthma,
spontaneous, hyaline membrane disease,
iatrogenic (surgery, chest tube), trauma
(esophageal rupture)
Mediastinitis, infectious
 Esophageal perforation: endoscopy,
tumor, Boerhaave’s syndrome
 Post-operative infection
 Cervical infection spreading caudally
Mediastinitis, fibrosing
 Histoplasmosis, TB
 Autoimmune disease (may be associated
with retroperitoneal fibrosis, sclerosing
cholangitis, Reidel’s thyroiditis, orbital
pseudotumor)
 Methysergide
Bilateral hilar/mediastinal lymphadenopathy
 Sarcoidosis
 Bronchogenic carcinoma (usually
unilateral)
 Lymphoma
 TB (usually unilateral)
 Histoplasmosis
 Coccidiodomycosis (usually unilateral)
 Mycoplasma pneumonia
 Viral disease
 Bacterial infection (usually unilateral)
 Leukemia
 Metastases from extrathoracic primaries
 Silicosis
 Cystic fibrosis
 Langerhan’s cell histiocytosis
Hilar/mediastinal lymphadenopathy in AIDS
 Kaposi’s sarcoma
 TB, MAI
 Lymphoma
 Cryptococcus
Unilateral hilar enlargement
 TB, coccidiodomycosis, histoplasmosis
 Bronchogenic carcinoma
 Lymphoma
 Surgical shunt
 Post-stenotic from pulmonary valvular
stenosis, pulmonary artery coarctation
 Pulmonary embolism
 Partial absence of left pericardium
 Pulmonary AVF
Mediastinal calcification
 Lymph node, treated lymphoma
 Granulomatous disease: histoplasmosis,
TB, coccidiomycosis
 Silicosis
 Contrast material (pseudo calcification)
 Sarcoidosis
 Teratoma
Egg shell calcification
 Silicosis
 Sarcoidosis
 Pneumoconiosis of coal workers (rare)
 Lymphoma after radiation (rare)
Cardiac calcification
 Aortic/mitral valves
 Coronary arteries
 Annulus of aortic/mitral valves (C- or J-
shaped)
 Pericardium (constrictive pericarditis)
 Myocardium
 Endocardium (thrombus)
 Tumors (myxoma, rare)
Focal tracheal mass
 Inflammatory polyp/papilloma: after
instrumentation or tracheotomy
 Mixed salivary gland tumor: adenoid
cystic carcinoma, mucoepidermoid
carcinoma
 Tracheal SCC, adenocarcinoma, small cell Solitary pulmonary nodule, <3 cm
carcinoma
 Invasion from cancer of lung, larynx,
thyroid, esophagus
 Metastases: RCC, breast, colon,
melanoma
 Lymphoma
 Other tumors: neurogenic, smooth muscle,
fibromas, hemangiomas, chondromas
 Hematoma
 Papillomatosis
 Rare causes: Rheumatoid, sarcoidosis,
coccidioidomycosis, scleroderma,
Wegener’s granulomatosis, foreign body,
amyloidosis
Diffuse tracheal narrowing
 Saber-sheath trachea (COPD)
 Relapsing polychondritis
 Tracheopathia osteochondroplastica (50
y/o male)
 Amyloidosis
 Others: RA, scleroderma, Wegener’s
granulomatosis
Focal tracheal narrowing
 Traumatic stricture: post-intubation or
tracheotomy
 Neoplasms
 Infectious/inflammatory masses: TB,
histoplasmosis, Wegener’s granulomatosis
 Extrinsic compression: vascular ring,
neoplasm, goiter
 Vascular ring, pulmonary sling
 Congenital complete tracheal ring (rare)
Tracheomalacia
 Overinflated ETT cuff
 Trauma
 XRT
 TE fistula
 Complication of surgical repair
 Relapsing polychondritis
 Extrinsic mass effect
Bronchial obstruction
 MEAT FACE mnemonic:
 Mucous plug
 Endobronchial granulomatous disease:
broncholith in TB, histoplasmosis
 Adenoma
 TB
 Foreign body
 Amyloidosis, atresia (bronchial)
 Carcinoma (primary)
 Endobronchial metastases: renal, thyroid,
melanoma, breast, colon
Lobar/segmental atelectasis
Intraluminal: foreign body, mucous plug
(CF, asthma with ABPA, post-operative),
bronchial metastasis (RCC, breast, colon,
melanoma)
 Mural: non-small cell carcinoma,
bronchial adenoma, carcinoid tumor,
hamartoma, non-infectious granulomatous
disease (sarcoidosis, Wegener’s
granulomatosis), infectious granulomatous
disease (TB, fungal infections), collagen
vascular disease (rheumatoid
bronchostenosis), congenital bronchial
atresia, bronchiectasis, trauma (fractured
bronchus), middle lobe syndrome (TB,
MAI), lymphadenopathy
 Malignant neoplasm: bronchogenic
carcinoma, lymphoma, sarcoma, carcinoid
(peripheral in 20%), pleural fibroma,
solitary metastasis from colon, kidney,
ovary, testes, melanoma
 Inflammation/infection: granuloma from
post-primary TB, histoplasmosis,
coccidiodomycosis, cryptococcus, hydatid
cyst, round atelectasis, plasma cell
granuloma (child), rheumatoid nodule
  Benign neoplasm: hamartoma, lipoma,
fibroma, neurogenic tumor,
intraparenchymal lymph node
 Splenosis or endometrial tissue
 AVM, hemangioma, pulmonary vein
varix
 Infarct
 Bronchogenic cyst (peripheral in 15%) or
pulmonary sequestration
 Caplan’s syndrome (RA & coal worker’s
pneumoconiosis)
 Progressive massive fibrosis
 Pseudo mass: rib fracture with callus,
pulmonary vein end-on
Solitary mass, >3cm
 Brochogenic carcinoma
 Tuberculoma, histoplasmoma
 Hydatid cyst (uncommon)
 Hamartoma
 Abscess
 Bronchoalveolar cell carcinoma
 Solitary metastasis
 Rheumatoid nodule
 Bronchogenic cyst
 PMF
Notable lung cancer stages
 T1: <3 cm nodule
 T2: >3 cm mass, >2 cm from carina
 T3: <2cm from carina; lung collapse,
pleural/chest wall/pericardial/diaphragm
invasion
 T4: invasion of mediastinum, heart, great
vessels, trachea, carina, esophagus, spine;
malignant pleural effusion, satellite
nodules in same lobe
 N2: ipsilateral mediastinal LNs,
subcarinal LNs; N3: contralateral
mediastinum/hilum, ipsilateral or
contralateral scalene/supraclavicular LNs
 Remember: IIIA=T3N2M0 (surgery),
IIIB=T4N3M0 (inoperable), IV=distant
metastases
Synchronous lung cancers occur in 1-2% cases.
Cancer is most common in the RUL, which happens
to be the most overlooked area on the CXR!
Bronchopleural fistulae usually occur post-op >1
week due to ischemia (long bronchial stump,
proximal ligation of bronchial artery, vascular
disruption from extensive lymph node dissection).
Place chest tube, then Claget window (open drainage
irrigation)
Rasmussen’s aneurysm is secondary to mycetoma
erosion of bronchial artery in a lung cavity (bullae,
TB, tumor, ankylosing spondylitis)
Remember: localized fibrous tumor of the pleura has
NO association with asbestos exposure! It affects the
visceral pleura, and may present with hypoglycemia,
hypertrophic pulmonary osteoarthropathy. With
asbestos exposure and tobacco use, bronchogenic
carcinoma risk increases 50-100x
Multiple nodules/masses, any size
 Metastases: melanoma, sarcomas, breast,
RCC, colon, stomach, testes, ovary
 Lymphoma
 TB, coccidiodomycosis, histoplasmosis
 Broncoalveolar cell carcinoma
 Hamartomas (rare)
 AVMs
 Laryngeal papillomatosis
 Wegener’s granulomatosis, rheumatoid
nodules, Caplan’s syndrome
 Sarcoid, bronchocentric granulomatosis,
foreign body granulomas, Langerhan’s
cell histiocystosis
 Mucoid impaction
 Trauma (hematomas)
 CMV, RSV, measles
 Nodular P. carinii pneumonia,
amyloidosis
Milliary nodules, <10mm
 TB, histoplasmosis, coccidiodomycosis,
blastomycosis, South American paracocci
 Hematogenous metastases: thyroid,
melanoma, choriocarcinoma,
osteosarcoma
 Inhalational lung disease: silicosis,
pneumoconiosis of coal workers,
berylliosis
 Viral pneumonias: varicella
 Multifocal BAC
 Sarcoidosis
 Langerhan’s cell histiocytosis
 Rare: microlithiasis, hemosiderosis,
amyloidosis
 TEMPS BV mnemonic: TB/fungal, EG,
metastases (thyroid, melanoma,
choriocarcinoma, GI adenocarcinoma),
pneumoconioses, silicosis, sarcoidosis,
BAC, viral pneumonia
Calcified pulmonary nodules
 HAM TV’s mnemonic:
 Histoplasmosis, hamartoma
 Amyloidosis, alveolar cell carcinoma
 Mitral stenosis (pulmonary ossification),
metastases (thyroid, osteosarcoma,
mucinous adenocarcinoma)
 TB
 Varicella
 Silicosis
Cavities, thick-walled
 Bronchogenic carcinoma: SCC,
BAC/adenocarcinoma (rare), others never
 Primary lymphoma (rare)
 Metastases: SCC of head and neck,
cervix, esophagus; choriocarcinoma,
adenocarcinoma
 Abscess: Staphylcoccus, Klebsiella,
Pseudomonas; TB, semi-invasive
aspergillosis
 Amebic abscess
 Hydatid cyst
 Paragonimiasis
 Cavitating PMF: TB with silicosis
 Wegener’s granulomatosis
 Cavitating rheumatoid nodules
 Septic emboli
Cavities, thin-walled
 Blebs, bullae
 Traumatic lung cyst
 Pneumatocele (pulmonary laceration)
 Excavating bronchogenic cyst
 Congenital lung cyst
 Cavitating metastases
 Parenchymal laryngopapillomatosis
 Cystic bronchiectasis
 Giant bullous emphysema (young male
smokers)
Cavities with air-fluid level
 Cavitating bronchogenic carcinoma
 TB
 Mycetoma
 Pulmonary bullae, infected or non-
infected
 Infected lung cyst
 Lung laceration with liquefied hematoma
 Infected sequestration
 Necrobiotic rheumatoid nodule
 Cavitary pulmonary infarct
 Infection of pre-existing cavity
 Wegener’s granulomatosis
Consolidation, lobar/segmental
 Pneumonia
 Infarction
 Lung contusion
 Focal edema: positional, RUL with
rupture of anterior mitral valve leaflet
(MR)
 Radiation
 BAC
 Lymphoma
 Alveolar proteinosis
 Hemorrhage
Pulmonary Edema (PCWP in mmHg)
 Vascular redistribution (12-17)
 Interstitial edema (18-25)
 Alveolar edema (>25)
 Often occurs in CHF, volume overload,
renal failure
Atypical pneumonia: Mycoplasma, Chlamydia
psittaci, Coxiella burnetti
Viral pneumonia: adenovirus, varicella, influenza,
RSV, measles, parainfluenza
Sarcoidosis with erythema nodosum and arthralgias
is Lofgren’s syndrome, and carries a good prognosis
AIDS, CD4 count and thoracic disease
 >200: TB, bacterial pneumonias
(staphylococcus, H. influenza,
mycoplasma, legionella)
 200-50: PCP, Kaposi’s sarcoma
 <50: CMV, MAI, AIDS-related
lymphoma
AIDS with pleural effusion, LAD, airspace
consolidation: Kaposi’s sarcoma (201Tl positive)
XRT pneumonitis occurs at 1-3 months, while XRT
fibrosis occurs at 9-12 months
Tubular densities
 Mucoid impaction (bronchocele): ABPA,
CF, congenital (bronchial atresia), tumor
(carcinoid, bronchogenic carcinoma)
 AVM (50% occur in OWR, 1/3rd OWR
multiple; can be simple with a single
feeding artery and single draining vein, or
complex with multiple arteries and veins)
 Pulmonary vein varix (left atrium)
 Bronchiectasis: cylindrical, saccular,
varicose
Bronchiectasis
 Congenital: bronchial atresia,
Kartagener’s syndrome, CF, a-1-
antitrypsin disease, Williams-Campbell
syndrome, Mournier-Kuhn syndrome,
 hypogammaglobulinemia, impaired
mucocilliary clearance
 Post-infectious: measles, Whooping
cough, TB, Swyer-James syndrome,
ABPA
 Necrotizing infection: aspiration
Bronchiolitis obliterans
 Idiopathic
 Infection
 Toxic fumes inhalation
 Drug toxicity
 Dust exposure
 GVHD
 Autoimmune disease
 S/p lung transplant
 Connective tissue disorder
Fleeting infiltrates
 Allergic reactions
 Drugs
 Parasites
 Inhaled antigens
 Loeffler’s syndrome
 Allergic aspergillosis
 Recurrent edema
 Chronic eosinophilic pneumonia with
treatment
 Pneumocystis pneumonia bleeding into
the lung
Peripheral infiltrates
 Loeffler’s disease (acute eosinophilic
pneumonia)
 Chronic eosinophilic pneumonia
 Organizing pneumonia (BOOP)
 Hypersensitivity pneumonitis
 Vasculitis
 Fungal infections
 Hemorrhagic metastases
 Septic emboli
 Resolving pulmonary edema
Ground glass opacities
 Hypersensitivity pneumonitis
 Acute alveolitis: DIP, IPF, viral
pneumonia
 Organizing pneumonia (BOOP)
 PCP
 Alveolar proteinosis
 Eosinophilic pneumonia
 Drugs
 Pulmonary edema
Bronchovascular distribution
 Kaposi’s sarcoma
 Sarcoidosis
 Lymphangitic carcinomatosis
 Lymphoma
Increased lung volumes (chronic disease)
 CF
 COPD
 EG
 LAM/TS
Diffuse air space consolidation
 Edema: cardiogenic, non-cardiogenic
 Pneumonia: PCP, fungus, bacteria,
aspiration
 Hemorrhage: idiopathic pulmonary
hemosiderosis (child), Goodpasture’s
syndrome, bleeding diathesis,
anticoagulation therapy, renal failure,
collagen vascular disease (SLE,
scleroderma, HSP), trauma,
bronchiectasis, tumor, bronchitis
 Proteinaceous material: alveolar
proteinosis
 Adult respiratory distress syndrome
Chronic air space consolidation
 Alveolar proteinosis
 Lymphoma
 Pseudolymphoma (small lymphocytic
infiltrate similar to lymphoma but stains
different immunohistochemically)
 BAC
 Sarcoidosis
 Desquamative interstitial pneumonitis
 TB, fungus (rare)
 Lipoid pneumonia (rare)
 SAD FALL mnemonic: sarcoidosis,
alveolar proteinosis, DIP, fungus/TB,
alveolar cell carcinoma,
lymphoma/pseudolymphoma, lipoid
pneumonia
Usual interstitial pneumonitis (UIP) has low lung
volumes, and is the endstage histologic change of
many things, including IPF, asbestosis (crocidolite
fibers), scleroderma, collagen vascular disease. DIP
may be an early stage of UIP, but this is controversial
Hodgkin’s disease is 3x more likely to have solitary
parenchymal disease than NHL. Stage 3 Hodgkin’s
disease is below the diaphragm, whereas stage 4 is
solid organ involvement (lung, bone, liver)
Multifocal or diffuse transient air space
consolidation
 Recurrent edema
 Recurrent inhalation of toxins
 Recurrent exposure to extrinsic allergens
(hypersensitivity pneumonitis)
 Recurrent hemorrhage
 Intermittent treatment of sarcoidosis
Diffuse interstitial disease
 SCHLITZ mnemonic:
 Sarcoidosis
 Collagen vascular disease, CF
 Histiocytosis
 Lymphangitic carcinomatosis
 Idiopathic pulmonary fibrosis
 Tuberous sclerosis
 Pneumoconioses
Basal interstitial disease
 BALD ASS VR mnemonic:
 Bronchiectasis
 Aspiration (including mineral oil)
 Lymphangitic carcinomatosis
 Desquamative interstitial pneumonitis,
drugs
 Asbestosis, a-1-antitrypsin disease
 Sarcoidosis
 Scleroderma, RA
 Viral pneumonitis
 Rheumatoid lung,
dermatomyositis/polymyositis
Stages of sarcoidosis
 0: NL CXR
 1: mediastinal/hilar lymphadenopathy
 2: mediastinal/hilar lymphadenopathy and
parenchymal disease
 3: parenchymal consolidation only
 4: honeycomb lung
Dermatomyositis can be sporadic or occur with
malignancy, such as ovarian, lung, breast, GI
Interstitial lung disease, chronic septal thickening
 Chronic pulmonary edema
 Lymphangitic carcinomatosis
 Veno-occlusive disease (rare)
 Congenital lymphangiectasia (rare)
Lymphangitic carcinomatosis
 2 neck, 2 chest, 2 abdomen, 2 pelvis
mnemonic:
 Thyroid, laryngeal carcinoma
 Breast, lung
 Stomach, pancreas, colon
 Prostate, bladder carcinoma
Drug toxicity (chronic pneumonitis/fibrosis)
 Bleomycin
 Busulphan
 BCNU
 Nitrofurantoin
 Amiodarone
 Cyclophosphamide
 MTX
Noncardiogenic pulmonary edema
 Laryngospasm
 Aspiration
 Neurologic (bleed, tumor, trauma), raised
intracranial pressure
 Rapid re-expansion of lung
 Drug or transfusion reaction
 Inhalation of noxious agent: smoke,
chemicals
 Heroin
 Early ARDS due to shock, sepsis, trauma
Honeycomb lung
 Idiopathic pulmonary fibrosis (fibrosing
alveolitis)
 Pneumoconiosis: asbestosis, silicosis,
silicoproteinosis, coal workers
pneumoconiosis
 Langerhan’s cell histiocytosis
 Sarcoidosis
 Rheumatoid lung disease
 Scleroderma, Sjogren’s disease, SLE,
mixed connective tissue disease
 Rare: amyloid, Gaucher’s disease,
radiation, gold therapy
 PISSER mnemonic: pneumoconiosis,
IPF, sarcoidosis, scleroderma, EG,
rheumatoid lung
Upper lung fibrosis/hilar elevation
 Post-primary TB
 Radiation for breast or head and neck
tumors
 Sarcoidosis in chronic destructive phase
 PMF
 Histoplasmosis
 Langerhan’s cell histiocytosis
(uncommon)
 Ankylosing spondylitis (rare)
Upper lung interstitial disease
 CASSET P mnemonic:
 CF
 Ankylosing spondylitis
 Silicosis, berylliosis (indistinguishable
from sarcoidosis)
 Sarcoidosis
 EG
  TB
 PCP
Multiple ill-defined nodules, 5–20mm
 Non-infectious granulomatous disease:
Langerhan’s cell histiocytosis,
sarcoidosis, rheumatoid lung, Wegener’s
disease
 Infectious granulomatous disease: TB,
histoplasmosis, coccidiodomycosis, viral
pneumonia
 Metastases, BAC
 Extrinsic allergic alveolitis
 Pneumoconiosis
 Drug reaction
Interstitial lung disease with pneumothorax
 Langerhan’s cell histiocytosis
 Sarcoidosis
 Any interstitial lung disease
 CF
 Lymphangioleiomyomatosis
 PCP
Unilateral hyperlucent lung
 Mastectomy, congenital absence of
pectoral muscle (Poland syndrome)
 Proximal interruption/hypoplasia of the
pulmonary artery, massive emboli
 Central airway obstruction with air
trapping, brochiolitis obliterans (Swyer-
James/Macleod syndrome), congenital
lobar emphysema, atelectasis with
compensatory hyperinflation
 Pneumothorax (supine)
 Giant bullous emphysema (young male)
 Post-transplant native lung emphysema
(pleural effusion opposite side)
Bilateral hyperlucent lungs
 Emphysema
 a-1-antitrypsin disease, methylphenidate
abuse
Common pneumoconioses
 With fibrosis: silcosis, pneumoconiosis of
coal workers, asbestosis
 Without fibrosis: stannosis (tin), siderosis
(iron), barytosis (barium)
 Allergenic: berylliosis, cadminosis
 Organic dusts: farmer’s lung (fungi),
bagassosis (sugar cane), byssinosis
(cotton), bird fancier’s lung (bird
proteins), sequoiosis (tree protein)
Pneumothorax with otherwise NL CXR
 Blebs, bullae
 TB
 Trauma
 Metastases: osteosarcoma
 Asthma
 Decompression (diving)
 Langerhan’s cell histiocytosis
 Spontaneous (tall, thin young male)
Spontaneous pneumothorax
 Blebs
 TB
 Metastasis
 Asthma
 Langerhan’s cell histiocytosis
 Sarcoid
 Any interstitial disease
 CF
 PCP
 SLE
Unilateral pleural effusion with NL lungs  S/p thoracic surgery
 Pleural metastases: adenocarcinoma of
breast, lung Complete opacification of hemithorax
 TB  FAT CHANCE mnemonic:
 Collagen vascular disease: rheumatoid  Fibrothorax (TB)
lung, SLE  Adenomatoid malformation
 PE  Trauma (hemothorax)
 Trauma  Collapse
 Chylothorax  Hernia
 Pancreatitis  Agenesis of lung
 Meig’s syndrome  Neoplasm: mesothelioma
 Post-pericardiotomy syndromes  Consolidation
 Subphrenic abscess  Effusion
 Asbestos-related pleuritis
 Peritoneal dialysis Unilateral elevated hemidiaphragm
 Viral pleuritis (rare)  Subpulmonic effusion (pseudo elevation)
 Mesothelioma  Lobar atelectasis
 S/p resection
Left-sided pleural effusion  Congenital small lung
 PE  Phrenic nerve paralysis: iatrogenic,
 Constrictive pericarditis bronchogenic carcinoma, surgery, trauma
 Aortic dissection with rupture  Hypoplastic lung (usually right side)
 Trauma  Subdiaphragmatic abscess, mass
 Boerhaave’s syndrome  Traumatic rupture of diaphragm
 Pancreatitis  Diaphragmatic tumor: lipoma, lymphoma,
 Trauma to upper thoracic duct mesothelioma, hernia (Bochdalek,
 Apical left heart failure Morgagni), eventration
Right-sided pleural effusion Bilateral elevated hemidiaphragm
 Left heart failure  Shallow inspiration

 Cirrhosis Restrictive lung disease
 S/p liver transplant  Obesity, pregnancy, ascites, abdominal
 Subphrenic abscess mass
 Ascites  Muscle weakness from SLE, myasthenia
gravis, amyotrophic lateral sclerosis
Pleural effusion with lung consolidation/mass
Chest wall mass
 Bronchogenic carcinoma
 Lymphoma  Mesodermal tumor: lipoma, desmoid,
fibroma, muscle
 Metastases
 Empyema  Neurogenic tumor: schwannoma,
neurofibroma, neuroblastoma
 Pancreatitis
 Pneumonia: anaerobes, staphylococci,  Bone tumor
Klebsiella, fungi, mycoplasma, virus,  Vascular tumor: metastases,
amebic abscess chondrosarcoma, multiple myeloma;
hemangioma or hemangiopericytoma,
 PE with infarct
 Trauma with hydrothorax Ewing’s sarcoma, osteosarcoma,
fibrosarcoma
 Hematoma
Pleural mass
 Mesothelioma  Infection: actinomycosis, nocardiasis,
blastomycosis, TB
 Metastases from extrathoracic tumor
 Metastatic lung adenocarcinoma
Rib lesion with surrounding soft tissue mass
 Resolving empyema, hematoma
 Metastases
 Rib lesion
 Multiple myeloma
 Loculated effusion
 Lymphoma
 Extrapleural lipoma
 Fibrosarcoma
 Post-inflammatory fibrin ball
 Neurofibroma
 Transpleural extension of invasive
 Osteitis: TB, mycosis, nocardiasis,
thymoma
blastomycosis
 Splenosis
 Fracture with hematoma/callus: trauma,
 Localized fibrous tumor of the pleura
renal osteodystrophy, Cushing’s
syndrome
Pleural calcification
 Radiation
 Unilateral: asbestos pleural plaques,
healed bacterial or tuberculous empyema,
organized hemothorax
 Bilateral: asbestosis Malignant chest wall tumor, child
 Ewing’s sarcoma
Pleural thickening
 Neuroblastoma
 Healed empyema
 Askin’s tumor (neuroectodermal small
 Resolved hemothorax
cell tumor)
 Resolved asbestos pleuritis
 Rhabdomyosarcoma
 Confluent pleural plaques
 Extrapleural fat
Transthoracic biopsy: FNA or Core with cutting
needle. End-expiration is more reproducible. Co-axial
technique with 19g guide needle and 20-22g Chiba.
PTX in 30-50%. In 5%, a chest tube is necessary
(>25% or symptomatic patient). Increased risk PTX
with large needle, increased depth of respiration,
increased number of visceral pleural punctures, long
biopsy time, patient emphysema/bullae
Miscellaneous facts:
1. Mycetoma forms within pre-existing cavities
such as bullae, pneumatocele, fibrocavitary
disease (TB, fungal, pneumoconioses),
fibrobullous disease (AS), and cavitary
neoplasms
2. Lung abscesses and septic emboli can look
similar. Lung abscess may be due to s. aureus,
s. pneumoniae, anaerobes, and others
3. Pleural thickening may be due to extrapleural
fat, loculated fluid, fibrosis, tumor, hematoma
4. Luftsichel is the LUL collapse sign with
hyperinflation of the LLL into the left lung apex
5. On upright CXR, if 1/3rd of lung opacified by
pleural effusion: 1L; if 2/3rds of lung: 2L; whole
lung: ~3L. Decubitus film with 1 cm deep
pleural effusion at mid thoracic level: ~400cc;
2cm deep: ~800cc; 3cm deep: ~600cc, etc.
6. Electron Beam CT/Multi-detector CT scores
based on size & density of calcifications, and
compared to sex & age-matched controls. 0-10,
10-100, 100-400, 400-1000, etc.
7. The thymus begins to atrophy at puberty, and
little remains (by CT) at age 30
8. Thymoma (>40 y/o): 1/3rd invasive, 1/3rd
associated with myasthenia gravis. Only 10% of
myasthenia patients have thymoma
9. Teratoma occurs in <30 y/o, as does
Castleman’s disease. There are 3 types of
Castleman’s disease, with hyaline vascular
being the most common
10. Saber sheath trachea in COPD has a coronal
diameter that’s 2/3rds the sagittal diameter.
Mimics include mediastinal lymphoma,
lipomatosis
11. A tracheal bronchus (anatomic variant to
RUL) may result in recurrent infection, post-
obstructive pneumonia, bronchiectasis, CCAM,
difficult ETT intubation with intraoperative
hypoxemia/atelectasis RUL. Cancer can cause
obstruction of the RUL also
12. A prominent azygous vein may be due to
increased CVP (CHF, constrictive pericarditis,
tricuspid insufficiency, tamponade), SVC/IVC
obstruction, anomalous pulmonary venous
drainage, azygous continuation of the IVC
13. Pulmonary arterial hypertension can be due
to increased flow or increased pulmonary
resistance. It results in mosaic perfusion on CT
scan. It occurs at three levels: pre-capillary
(primary/idiopathic, chronic pulmonary emboli,
vasculitis), parenchymal (COPD, any chronic
interstitial lung disease), and post-capillary (LV
failure, mitral stenosis, pulmonary vein
stenosis, pulmonary venoocclusive disease).
Can also be seen in obstructive sleep apnea,
obesity
14. High output heart failure may be due to
anemia, thyrotoxicosis, pregnancy
15. Asbestos exposure may result in pleural
effusions, pleural plaques, diffuse pleural
thickening, round atelectasis, malignant
mesothelioma
16. A “water bottle” configuration of the heart is
classic for a pericardial effusion
17. A false myocardial aneurysm is contained by
pericardium only, has a narrow neck, and is
usually located along the posterior
diaphragmatic surface, while a true aneurysm
has all three cardiac layers, a wide mouth, and
is usually seen at the ventricular apex
18. Partial absence of the left pericardium can
result in cardiac torsion, syncope
Differential Diagnoses
Heart & Great Vessels Imaging
ACYANOTIC with INCREASED pulmonary
blood flow, with or without increased heart size
(left-to-right shunt)
 ASD
 VSD
 PDA
 Endocardial cushion defect
 Partial anomalous pulmonary venous
return
 AP window (like PDA but ascending
aorta to main pulmonary artery)
 Coronary artery-to-pulmonary artery
shunt
 Systemic AVF
 SV aneurysm
CYANOTIC with DECREASED pulmonary
blood flow, NL heart size (right-to-left shunt)
 TOF
 Pulmonary atresia
 DORV with pulmonary stenosis
 TGV
 cTGV with pulmonary stenosis
CYANOTIC with INCREASED pulmonary blood
flow, increased heart size (admixture shunt)
 TGV
 Truncus arteriosis
 TAPVR
 Tricuspid atresia
 Single ventricle, single atrium
 Hypoplastic left heart
 DORV
 AV canal
 Large, multiple pulmonary AVMs
CYANOTIC with DECREASED pulmonary
blood flow, increased heart size
 Ebstein anomaly
 Tricuspid atresia (some types)
 Pulmonary atresia (type 2)
 Severe pulmonary stenosis with ASD
CYANOTIC heart disease
 5 Ts mnemonic:
 TOF
 TAPVR
 Truncus arteriosis
 Tricuspid atresia
 TOGV
 Tingles: single ventricle, single atrium
Isolated pulmonary valvular stenosis has
prominent main PA, RV. Congenital aortic stenosis
has LV enlargement, prominent ascending aorta. Fix
by balloon valvulotomy. If supravalvular stenosis,
suspect William’s syndrome.
Aortic coarctation is symptomatic with >50% lumen
stenosis. Preductal (infantile) type has R-L shunt via
PDA, with cyanosis of lower ½ of the body.
Postductal type may be associated with bicuspid
aortic valve. Pseudocoarctation has no pressure
gradient
ASD: ostium primum (Down syndrome), ostium
secundum, sinus venosus, posterior/inferior types.
Note: AV canal may be an ostium primum with high
VSD. ASD has increased incidence of MVP
VSD: inlet, muscular, perimembranous (most
common), outlet (supracristal, infracristal)
Pulmonary hypertension
 Increased flow: reversal of flow in
ASD/VSD with Eisenmenger’s
physiology (which presents clinically as
new-onset cyanosis, and CXR with
rapidly tapering pulmonary arteries)
 Increased pressure: pulmonary emboli
(clots, shistosomiasis, talc), vasculitis,
obstructive/restrictive lung disease
(COPD, sarcoidosis, interstitial fibrosis),
hypoxia/sleep apnea syndrome, idiopathic
Noncardiogenic pulmonary edema
 Via blood: sepsis, drugs (cocaine, heroin,
aspirin overdose, valium, methadone),
anaphylactic reaction (blood, contrast,
antibiotics), poisons, re-expansion (lung
must be atelectatic at least 72 hours)
 Via airway: near drowning, asphyxia,
inhalation of noxious gases (N2O, SO2,
smoke)
 Via nerves: high altitude
 Elevated intracranial pressure
Aortic stenosis
 Congenital
 Degeneration of bicuspid aortic valve
 Rheumatic heart disease
 HTN in elderly
Constrictive pericarditis
 Iatrogenic
 Mediastinal radiation
 Viral infection (repeated episodes)
 Uremia
 TB
Restrictive cardiomyopathy
 Idiopathic
 Sarcoidosis
 Hemochromatosis
 Amyloidosis
Aortic regurgitation
 Bacterial endocarditis
 Rheumatic heart disease
 Myxomatous degeneration of valve
 Aortic root dilatation: Marfan’s syndrome,
syphilitic aortitis, aortic dissection
Dilated cardiomyopathy
 Ischemic heart disease
 Diagnosis of exclusion
TAPVR drainage patterns
 1: left vertical vein to brachiocephalic
vein to SVC to RA (snowman
configuration)
 2: coronary sinus, RA (prominent right
heart due to enlarged coronary sinus)
 3: portal vein, IVC (usually obstructed at
esophageal hiatus, NL heart size with
pulmonary edema)
 4: mixed pattern
Mitral regurgitation
 Rheumatic heart disease
 MVP
  Post-infarction papillary muscle
dysfunction
 Infectious endocarditis
 Degenerative rupture of chordae tendineae
 Marfan’s syndrome
 Associated with annular calcification
 LV dilatation in CHF, cardiomyopathy
Pericardial effusion
 Infection: viral, bacterial
 Malignancy: metastases (lymphoma,
breast, melanoma, carcinoid), direct
invasion (lung, cardiac, thymoma)
 Autoimmune disease: Dressler syndrome
 Collagen vascular disease: SLE
 CHF
 Trauma: hemopericardium
 Uremia
 Postsurgical: CABG, valve replacement
 Idiopathic, XRT, MI
Tricuspid regurgitation
 Bacterial endocarditis (IVDA)
 Rheumatic heart disease
 RV dysplasia
Cardiomegaly
 AR
 MR
 TR
 High-output states: pregnancy,
thyrotoxicosis, anemia, shunt physiology
 Congestive (dilated) cardiomyopathy
 Ischemic cardiomyopathy
 Pericardial effusion
Massive cardiomegaly, child
 Pericardial effusion
 Left ventricular outflow lesion:
hypoplastic left heart, critical aortic
stenosis
 Vein of Galen malformation,
hemangioendothelioma
 Large VSD, ASD
 Cardiomyopathy
 Ebstein’s anomaly
Hypocardia
 AS
 Arterial hypertension
 MS
 Acute MI
 Hypertrophic cardiomyopathy
 Restrictive cardiomyopathy
 Constrictive pericarditis
CHD cardiomyopathy
 Myocarditis: Coxsackie virus, STARCH
 Maternal diabetes
 Ischemia
 Absent coronary artery
 Storage diseases
 Hypoplastic left heart
Coronary angiography
 Judkins or Amplatz catheters: 4-8 cc by
hand, cine 30-60 frames/sec
 Various obliques of LAO, RAO, cranial
and caudal angulation
 RCA branches: conus, SA node, acute
marginals, AV node, posterior descending
 LCA branches: LAD to septal, diagonal
branches, circumflex (obtuse marginal
branches, ramus intermedius)
 50% diameter decrease = 75% cross-
sectional area decrease; 75% diameter
decrease = 95% cross-sectional area
decrease
Dominance means which coronary artery supplies
the diaphragmatic surface of the LV and
interventricular septum. RCA is dominant in 85%,
LCA 8%, co-dominance 7%
Rib notching, bilateral
 Coarctation of the aorta (ribs 4-8)
 Aortic thrombosis (lower ribs)
 Pulmonary atresia
 SVC obstruction
 NF-1
 Pulmonary AVM, chest wall AVM
Rib notching, unilateral right
 Coarctation of aorta proximal to left
subclavian artery origin
 Blalock procedure (subclavian artery-to-
PA) for TOF on right side (upper 3-4 ribs
operation side)
Rib notching, unilateral left
 Coarctation of aorta with aberrant right
subclavian artery origin distal to
coarctation
AFIP congenital heart disease
 Increased vascularity without cyanosis:
ASD, VSD, PDA, AV canal (endocardial
cushion defect)
 Increased vascularity with cyanosis: TGV,
TA, DORV, TAPVR
 Decreased/NL vascularity without
cyanosis: pulmonary stenosis
 Decreased/NL vascularity with cyanosis:
pulmonary stenosis, TOF, Ebstein’s
anomaly
 Decreased vascularity with cyanosis:
pulmonary stenosis, TOF, pulmonary
atresia, TA, Ebstein’s anomaly
ASD,VSD, PDA cause pulmonary overcirculation
(pulmonary HTN) with prominent PA, RV
enlargement. A small aortic arch may be present.
Shunt >2:1 is significant. If new onset cyanosis and
pruning of pulmonary arteries on CXR, there may be
shunt reversal (Eisenmenger’s syndrome)
R-L shunt is seen in TOF, TGA, TA, PDA, Ebstein’s
anomaly. TOF has high VSD, overriding aorta,
infundibular pulmonic stenosis, RVH, resulting in
pulmonary undercirculation. TOF has the “wooden
shoe” appearance of CM due to RVH. TGV
(uncorrected) has ASD, VSD, or PDA that connects
the two circuits. There is CM with “egg-on-a-string”
appearance of the mediastinum, and pulmonary
undercirculation. Remember: RV connected to aorta,
while LV is connected to pulmonary artery. Ebstein’s
anomaly has “atrialized RV” and ASD/PFO, resulting
in globular-shaped CM, RA enlargement, a small PA
with pulmonary undercirculation
Miscellaneous facts:
1. Shunt vascularity is pulmonary
overcirculation. Greater than a 2:1 shunt is
necessary to see changes on CXR
2. CHF shows CM, pulmonary edema, pleural
effusion
3. Ischemic heart disease shows NL CXR or LV
enlargement
4. Acute MI shows NL CXR or CHF with NL
heart size (early), LV aneurysm
5. Cardiomyopathy may be dilated (congestive,
most common), hypertrophic/obstructive with
poor diastolic filling (MR, LA enlargement),
restrictive (rare) with endocardial fibrosis,
CHF. May see CM with/without pleural
effusion, LVH, RA enlargement, pulmonary
oligemia
6. Valvular heart disease: MS, MR, AS, AR,
mixed. MS occurs when valve area is <4-6 cm2.
Grade 1: 2.5 cm2, grade 2: 1 cm2, grade 3: <1
cm2. MS has LA enlargement (double density
frontal view), pulmonary congestion
(longstanding pulmonary HTN causes
pulmonary hemosiderosis), RV enlargement
with eventual right CHF /TR. MR can be due to
ruptured chordae tendinae/papillary muscle
after MI, endocarditis, stretching of valvular
ring. See LA, LV enlargement, small aorta
(decreased LV output), pulmonary congestion
(occurs VERY LATE). Rule of thumb: MS
causes severe pulmonary HTN/mild LA
enlargement, while MR causes mild pulmonary
HTN/severe LA enlargement. If prominent
aorta, suspect coexisting aortic valvular disease.
7. AS can be due to RF, congenital bicuspid aortic
valve, atherosclerosis, and may present with
angina, syncope, CHF. There is LV
enlargement, prominent ascending aorta,
eventual pulmonary venous HTN.
8. AR may be due to RF, endocarditis, aortitis
(syphilis), aortic dissection. There is LV
enlargement (rounded cardiac apex) more
marked than in AS, and later LA enlargement,
pulmonary venous HTN/edema, prominent
ascending & descending aorta
9. Multivalvular disease usually involves MV,
AV. See a combination of both on CXR, often
with LA enlargement
10. In systemic HTN, CXR may be NL, then later
LV enlargement, prominent tortuous aorta
11. Normal pericardial thickness is <4 mm
12. Pericardial/myocardial tumors are usually
secondary to mediastinal invasion. Primary
tumors (myxoma, most common) are rare.
Rhabdomyoma occurs in TS, and is the most
common cardiac tumor to occur in
neonates/child. Most regress by 4 years of age.
In children, fibroma and teratoma (epicardial)
are the next most frequent tumors. Cardiac
sarcomas are extremely rare. Surgery is
warranted for lesions that cause obstruction or
valvular dysfunction
13. Dilated cardiomyopathy (systolic/diastolic
dysfunction with pulmonary venous HTN) can
be due to multiple causes, including infection,
ischemia, metabolic, collagen vascular, toxin
(ETOH, adriamycin), beri beri, and idiopathic
14. Pulmonary sling (aberrant left pulmonary
artery) is the ONLY vascular anomaly that
courses between the trachea and esophagus
15. A pleural effusion is either a transudate (CHF,
hypoproteinemia, cirrhosis, nephrotic
syndrome) or exudate (parapneumonic,
pancreatitis, collagen vascular disease,
pulmonary embolism, bronchogenic carcinoma,
mets, etc)
16. Idiopathic hypertrophic subaortic stenosis
(IHSS) causes outflow obstruction, arrhythmia
(may be fatal)
17. ASD is most common entity to present in young
adults, then VSD>PDA>pulmonary stenosis
18. ASD and cardiac level TAPVR look alike
with prominent right heart and increased
pulmonary vascularity, but cyanosis
differentiates
19. A NL size heart with florid pulmonary
edema can be due to infracardiac TAPVR or
cor triatriatum (rare)
Differential Diagnoses
Mammography
Calcifications, malignant appearance
 Invasive ductal carcinoma
 Ductal carcinoma in situ
 Fat necrosis
 Early vascular disease
 Early fibroadenoma degeneration
 Fibrous capsule adjacent to implant
 Fibrocystic change
 Artifacts: scratches, dust, fingerprints,
static, antiperspirant, talc, ECG paste,
tatoos, gold treatment for RA,
crystallization of processing chemicals
Calcifications, benign appearance
 Skin (dermal)
 Vascular (small “quirky”)
 Degenerating fibroadenoma
 Secretory calcification (duct ectasia,
plasma cell mastitis)
 Oil cyst (rim Ca++, egg shell calcification)
 Milk of calcium
 Adenosis
 Foreign body
 Dermatomyositis (rare)
Mass, circumscribed margins
 Cyst
 Fibroadenoma
 Phyllodes tumor
 Intramammary lymph node: infection,
inflammation, primary breast carcinoma,
lymphoma, metastasis
 Papilloma
 Medullary carcinoma (young), mucinous
carcinoma (old), papillary carcinoma,
invasive ductal carcinoma NOS
 Metastasis: lymphoma, melanoma, lung,
contralateral breast primary, ovarian,
gastric, RCC
Mass, indistinct margins
 Carcinoma: invasive ductal NOS,
medullary, mucinous, papillary, invasive
lobular
 Biopsy scar
 Fat necrosis (mass-like, cyst-like with fat
density, architectural distortion,
calcifications)
 Abscess
 Hematoma: post-surgical, blunt trauma,
bleeding diathesis
 Sclerosing adenosis, fibrous mastopathy
(thyroiditis, diabetes mellitus,
autoimmune disorders)
Mass, spiculated margins
 Invasive carcinoma: lobular, ductal,
tubular, maybe DCIS
 Radial scar (sclerosing duct hyperplasia,
elastosis, indurative mastopathy)
 Biopsy scar
 Fat necrosis
 Breast abscess
 Sclerosing adenosis
 Granular cell tumor (anterior), desmoid
tumor (pectoralis fascia, rare but may be
seen after trauma/surgery or in Gardner’s  Endogenous hormone production from
syndrome) adrenal or ovarian tumors
Mass, obscured margins Axillary lymph nodes
 Any of the previous entities 
Breast carcinoma metastatic to lymph
node (contralateral or ipsilateral)
Subareolar mass  Lymphoma (mass, diffuse increase in
 Papillary carcinoma, complex cyst breast density)
 Post-trauma (resolving seroma,  Other malignancies
hematoma)  Reactive hyperplasia: infection or
 Papilloma inflammation
 Drugs or systemic diseases: gold therapy
Masses, multiple for RA, psoriatic arthritis, SLE,
 Cysts (35-50 y/o) sarcoidosis
 Fibroadenomas (<35 y/o)
 Intramammary lymph nodes Single dilated duct/bloody nipple discharge
 Papillomas  Duct ectasia
 Metastases, lymphoma  Papilloma
 Multifocal or multicentric breast cancer  Malignancy
 Skin lesions: moles, neurofibromatosis,
keratosis, sebaceous/epidermal cysts Subtypes of ductal carcinoma
 Invasive ductal NOS
Masses, fat-containing  Tubular
 Oil cyst  Medullary
 Fat necrosis  Mucinous
 Lipoma (liposarcoma rare)  Papillary
 Galactocele
 Hamartoma (fibroadenolipoma) Subtypes of DCIS
 Intramammary lymph node  Comedo
 Steatocystoma multiplex (AD, multiple  Cribiform
subcutaneous oil cysts, more common in  Micropapillary
males)  Solid
Architectural distortion Increased risk marker lesions
 Carcinoma (especially tubular subtype) 1.5-2x: sclerosing adenosis, peripheral papillomas,
 Radial scar proliferation without atypia, moderate florid ductal
 Post-traumatic fat necrosis (oil cyst, mass, hyperplasia
AD, calcification) 4-5x: atypical ductal hyperplasia, atypical lobular
 Prior surgery (AD, trabecular thickening, hyperplasia, proliferative changes with atypia
skin thickening) 8-10x: lobular neoplasia (LCIS), well-differentiated
 Prior radiation (AD, trabecular thickening, DCIS, atypical ductal hyperplasia with positive
family history (1st degree relative)
skin thickening)
 Fibrocystic change
Gynecomastia causes
 Drugs: marijuana, cimetidine, reserpine,
Asymmetry
 Asymmetric breast tissue: NL variant, cardiac glycosides, exogenous estrogens
for prostate CA
congenital mammary aplasia, Poland’s
syndrome, surgical excision of breast bud  Tumor: testicular seminoma, embryonal
(child), radiation (child), post-reduction cell carcinoma, choriocarcinoma
mammoplasty. Assumes a different  Cirrhosis
appearance in two views. If it’s not
palpable, it’s B9 MRI uses
 Carcinoma (especially invasive lobular)  Check extent of disease (multifocal)
 Help staging
Diffusely increased breast density, trabecular  Evaluate implants (rupture, gel bleed,
thickening, skin thickening migration of implant, capsular
 Diffuse invasive carcinoma, inflammatory contraction), assess recurrence vs. scar
after lumpectomy/radiation
carcinoma
 Evaluate dense breast tissue
 Lumpectomy/surgical biopsies or axillary
dissection (edema)
Spot compression to verify a density is a true mass
 Radiation therapy (skin thickening,
and better define margins
engorged lymphatics)
 Mastitis or inflammation: acute related to
lactation, chronic plasma cell mastitis Spot magnification to evaluate margins of a mass
and check for microcalcifications
related to extravasated secretions, TB
US echogenicity is relative to subcutaneous fat
(rare)
 Dermatologic disorders: psoriasis
US findings of benignity
 Generalized edema: CHF, cirrhosis,
nephrotic syndrome, anasarca  Hyperechoic
 Macrolobulations
 Oval (shorter than wide)
Diffusely increased breast density, trabecular
 Thin, echogenic pseudocapsule
thickening
 Interval weight loss
US intermediate findings
 Hormone replacement therapy
 Isoechoic
 Generalized edema
  Mildly hypoechoic
 NL sound transmission
 Enhanced through transmission
 Heterogeneous echotexture
 Homogeneous echotexture
US findings suggesting malignancy
 Spiculated margins
 Taller than wide
 Angular margins
 Shadowing
 Branching pattern
 Markedly hypoechoic
 Duct extension
 Microlobulation
 Microcalcifications
Screening mammogram for asymptomatic patients,
and should be either NL or possibly ABNL with
additional studies needed
Diagnostic mammogram in symptomatic patients
(nipple discharge, lump, pain, skin changes, redness,
retraction), work-up of abnormal screening exam,
patients with implants or prior lumpectomy
ROLI (shape):
Round, Oval, Lobular, Irregular
C MOI S (margins):
Circumscribed, Microlobulated, Obscured,
Indistinct, Spiculated
High density
Equal density (isodense)
Low density
Fat-containing (radiolucent)
Calcification distributions
Clustered, linear, segmental, regional, diffuse
BI-RADS categories
0 Incomplete (needs additional imaging)
1 Negative
2 Benign Finding (round or oval calcifications, fat-
containing masses, intramammary lymph nodes, AD
at known biopsy site, non-palpable FAD, solitary
dilated duct without nipple discharge, circumscribed
round or oval mass, multiple similar lesions in both
breasts)
3 Probably Benign (short-term follow-up)
4 Suspicious Abnormality (core biopsy)
5 Highly Suggestive (core or excisional biopsy)
Probably Benign (~1.4% malignancy): check prior
studies for stability; if stable, it can be followed by 6-
month mammographic surveillance for 2-3 years. If
worrisome changes, patient anxiety a factor, patient
unlikely to return, or patient pregnant/planning
pregnancy, then biopsy
To avoid sampling error, suspected radial
scar/complex sclerosing lesions should have
excisional biopsy, as they are difficult to differentiate
from tubular carcinoma and may have adjacent
atypical ductal hyperplasia, DCIS, lobular neoplasia,
invasive ductal carcinoma.
Core biopsy is contraindicated if lesion is too close
to chest wall/skin, in a very small breast, or if throw
of needle is greater than compression of tissue
Always correlate final pathologic diagnosis with
imaging appearance (check concordance):
 Low/intermediate suspicion before biopsy
with B9 pathology: 6-month follow up
only to establish a new baseline
 If B9 diagnosis, but does not correlate
with imaging: excisional bx
 If pathology shows high risk lesion
(atypical ductal hyperplasia, atypical
lobular hyperplasia, lobular neoplasia):
excisional bx
 High suspicion before biopsy with DCIS
pathology: excisional bx
 Any discordant finding should lead to
excisional bx
Evaluate focal asymmetric density by additional
views (rolled, lateral), spot compression, and
correlate with physical exam. This has a similar
appearance in two views, but not the defined margins
of a true mass
 If palpable, US to check for NL tissue and
bx, if deemed necessary
 If not palpable and no US findings, BI-
RADS 3 with short-interval follow-up
 If palpable but no US abnormality, bx is
recommended
 If on HRT, consider discontinuing
treatment and follow-up in 2-3 months
Developing density should be compared to oldest
good quality film, and likely requires bx
Magnification view (1.8x): micro-focal spot 0.1mm,
no grid, air gap (breast is moved away from film)
Staging of breast cancer (TNM)
 T1: <2cm, T2: 2-5cm, T3: >5cm, T4: any
size with chest wall extension, skin
edema/ulceration, inflammatory
carcinoma
 N1: mobile ipsilateral LN, N2: fixed
axillary LNs, N3: ipsilateral internal
mammary LNs
 M1: distant metastases
Notable breast cancer stages (0-4)
 Stage 0: DCIS
 Stage 1: mass <2cm only
 Stage 2A: <2cm with or w/out mobile
axillary LNs
 Stage 2B: <5cm w/out mobile axillary
LNs
 Stage 3B: inflammatory carcinoma, skin
ulceration
 Stage 4: distant metastases
Male breast cancer is probably not related to
gynecomastia, and is more common in patients with
Kleinfelter’s syndrome, mumps orchitis after age 20,
and Jewish background
Skin lesions
 Epidermal/sebaceous cyst
 NF-1
 Mondor’s disease (thrombophlebitis of
thoracoepigastric or lateral thoracic vein)
 Steatocystoma multiplex
 Inflammatory carcinoma
Nipple-areolar complex
 Nipple adenoma
 Hidradenitis suppurativa
 Leiomyoma
 Paget’s disease
Major ducts
 Duct ectasia
 Solitary papilloma
 Papillary carcinoma
Terminal duct
 Hyperplasia
 Multiple peripheral papillomas
 Radial scar/complex sclerosis lesion (>1
cm)
 Ductal adenoma
 DCIS
 Invasive ductal carcinoma
 Tubular, medullary, mucinous, invasive
cribiform, adenoid cystic, SCC,
metaplastic, secretory carcinoma
Lobules
 Cysts
 Galactocele
 Juvenile papillomatosis
 Fibroadenoma
 Complex fibroadenoma (cysts, sclerosing
adenosis)
 Juvenile fibroadenoma
 Phyllodes tumor
 Tubular adenoma
 Lactating adenoma
 Sclerosing adenosis
 Lobular neoplasia
 Invasive lobular carcinoma
Stroma
 Fat necrosis
 Lipoma
 Hamartoma
 Fibrosis
 Mastitis/abscess
 Pseudoangiomatous stromal hyperplasia
 Sutural calcification
 Hemangioma
 Diabetic fibrous breast disease
 Extra-abdominal desmoid
 Lymphoma
 Angiosarcoma
 Metastases: contralateral breast,
melanoma, lung, ovary, stomach, cervical
cancer
Preoperative needle localization in nonpalpable
lesion or to ensure 1-to-1 correlation with
mammographic and clinical lesion. Use
mammography, US, stereotactic system. Needle-wire
combination (lengths 3, 5, 7, 9, 11, 15 cm) with hook
wire, j-wire or Hawkins retractable barb. Decide what
type of needle-wire, needle length, approach AP or
parallel to chest wall). Use compression paddle with
fenestration and alphanumeric grid. Steps: Sorry
folks I forgot to put them in here
Miscellaneous facts:
1. If patient has undergone a mastectomy, a
clinical breast exam is all that is necessary for
follow-up
2. A follow-up mammogram is recommended 6
months post-biopsy to establish a new baseline.
Re-biopsy if there is increased density or
distortion at the site
3. A biopsy site should remain stable or decrease
in size/density over time
4. Pleomorphic microcalcifications with linear
and amorphous types predominating
5. Use Conray 60 and 30g blunt-tipped
sialography needle for ductagram
6. A “complex fibroadenoma” has cysts,
sclerosing adenosis
7. On the CC view, one sees the pectoralis
muscle in 20-40 cases. If not seen, look for
cleavage, retroglandular fat laterally
8. On MLO view, the breast is pulled up and out
to open the inframammary fold. May include a
small amount of abdomen, but should have a
convex pectoral muscle. Always check the
posterior nipple line
9. Always check the medial aspect of the CC
view, the subareolar region, the glandular-fat
interface, the retroglandular area. Use anterior
or spot compression for subareolar
abnormalities
10. The average glandular dose (with 4.2 cm
compression) is 0.3 rads/view using film-screen
technique
11. Tubular carcinoma is multicentric in ~28%
cases
12. Fibrosis can be idiopathic or related to
diabetes, thyroiditis, arthropathy
13. If a pneumocystogram is desired after an
atypical cyst aspiration, simply use 1/2 the
amount of aspirated fluid
14. If there are islands of breast tissue in a non-
anatomic distribution, consider reduction
mammoplasty
15. The differential diagnosis for inflammatory
carcinoma is XRT, mastitis, edema, lymphatic
obstruction, trauma, post-lumpectomy, invasive
lobular carcinoma
16. Mimics of DCIS calcifications include
sclerosing adenosis, atypical ductal hyperplasia,
fibroadenoma, papilloma
17. Weight loss, HRT, and lactation increase
breast density, while weight loss and tamoxifen
(used in Europe to treat severe fibrocystic
change) decrease breast density
18. Mammography uses ~25 kV
19. For tangential view, place BB over suspected
location of calcification, spot compress, and use
tangential beam
20. Mondor’s disease (superficial
thrombophlebitis) usually involves the
thoracoepigastric or lateral thoracic vein
21. A radial scar is difficult to see on the
orthogonal view
22. Breast implants can be subglandular or
subpectoral
23. If a core biopsy shows radial scar, an
excisional biopsy should be performed
24. DCIS presents as a mass in <5% of cases
Differential Diagnoses
Interventional Radiology
Always check patient chart, prior imaging studies,
PT/PTT, bleeding time (<8 minutes NL), platelets
(>50K NL). Do pulse exam. For conscious sedation
(midazolam, fentanyl), monitor BP, oxygen
saturation, ECG, HR
Aortic aneurysms
 Atherosclerotic (usually descending
thoracic aorta)
 Infectious: staphylococcus, E.coli,
salmonella, candida, aspergillus, syphilitic
 Traumatic (pseudoaneurysm)
 Congenital (aortic sinuses)
 Cystic medial necrosis: Marfan’s, Ehlers-
Danlos, homocysteinuria
 Aortitis: Takayasu’s disease, giant cell
arteritis, collagen vascular disease (RA,
ankylosing spondylitis)
Note: some authors consider Giant cell arteritis a
general term comprising both Takayasu’s disease and
Temporal arteritis
In acute traumatic aortic injury (ATAI), a
pseudoaneurysm has acute margins, delayed washout
of contrast, and an irregular contour. A ductus
diverticulum has obtuse margins, NO delayed
washout of contrast, and a smooth contour
Aortic dissection
 Hypertension
 Cystic medial necrosis: Marfan’s, Ehlers-
Danlos, homocysteinuria
 Pregnancy (high output)
 Valvular aortic stenosis
 CT, MRI, Angiography, IVUS can be
used to evaluate
Carotid artery dissection
 Trauma
 Marfan’s syndrome
 FMD
 Extension of Type A thoracic aortic
dissection
Surgery in Type B dissection only when:
 Ischemic extremity
 Mesenteric ischemia, renal artery
compromise
 Rupture
 Aneurysmal dilatation (false lumen)
Pulmonary AVM (coil embolization)
 Osler-Weber-Rendu
 Sporadic Middle aortic syndrome
 Trauma
 Infection
 Hepatogenic angiodysplasia
 Pulmonary pseudoaneurysm (secondary to
Swan-Ganz catheterization)
Hypothenar-hammer syndrome mimics
 Raynaud’s disease
 Collagen vascular disease
 Embolic disease Takayasu’s disease
 Beurger’s disease
Budd-Chiari syndrome
 Idiopathic
 Hypercoagulable states: polycythemia
vera, pregnancy, sickle cell anemia, oral
contraceptives
 IVC membranes, webs
 Tumor growth into the IVC or hepatic
veins: HCC, RCC, adrenal carcinoma
 Chemotherapy, immunosuppressive drugs
 Constrictive pericarditis, right heart
failure
For acute Budd-Chiari syndrome in a young
female, try selective thrombolysis and/or balloon
thrombectomy
Gastrointestinal bleeding
 Upper GI tract: Mallory-Weiss tear,
gastritis, peptic ulcer, tumor, pancreatitis
or other process causing pseudoaneurysm,
varices, iatrogenic from endoscopy
 Lower GI tract: diverticulosis,
angiodysplasia, colon tumor, AVM,
varices, pseudoaneurysm, iatrogenic
injury
Mesenteric ishemia (occlusive/non-occlusive)
 Embolic occlusion: cardiac source
 Atherosclerotic plaques with ulceration
 Low flow states: hypotension,
dehydration, poor cardiac output,
vasculitis from radiation therapy or
polyarteritis nodosa, FMD, Takayasu’s
disease, vasovagal
 Venous thrombosis seen in volvulus or
intussusception, incarcerated hernia
 Median arcuate ligament compression
(celiac axis>SMA, accentuated by
expiration)
 Dissection of abdominal aorta
Non-occlusive mesenteric ishemia mimics
 Ongoing hypotension or hypovolemia
 Concurrent use of vasoconstrictive
medications
 Use of ergot alkaloids
 Vasculitis
Check spasm versus atherosclerosis
 Test dose of Priscoline (25mg over 30-60
seconds)
Papaverine therapy protocol for non-occlusive
ischemia
 Test dose of 30-60mg IA over 60-90 min
 Then, 1mg/min for 12-24 hours
Medications, reversal
 Protamine sulfate for heparin
 FFP for coumadin
 Platelets for ASA
 Atherosclerosis
 Radiation vasculitis
 Rubella-associated vasculitis
 Takayasu’s disease
 NF-1
 FMD
 William’s syndrome (infantile idiopathic
hypercalcemia, supravalvular/abdominal
aortic stenosis)
 Type 1: aortic arch and brachiocephalic
vessels
 Type 2: descending thoracic aorta,
abdominal aorta and its major branch
vessels
 Type 3: types 1 & 2
 Type 4: pulmonary artery
Fibromuscular dysplasia
 Intimal, perimedial, adventitial fibroplasia
 Medial hyperplasia
  Medial dissection
 Remember: FMD occurs in long straight
vessels such as the renal, iliac, visceral,
ICA, and rarely vertebral arteries
Popliteal artery disease
 Popliteal entrapment
 Atherosclerotic disease
 Embolic occlusion: cardiac, aortic, iliac
source
 Aneurysm
 Adventitial cystic disease
 Thromboangiitis obliterans (Beurger’s
disease) with Martorell’s sign of
corkscrew collaterals following course of
occluded vessels
 Jogger’s aneurysm (post-chronic trauma)
 Extrinsic compression by popliteal fossa
mass
Portal vein thrombosis
 Idiopathic
 Bland thrombus: portal hypertension,
pancreatitis, septicemia, trauma,
hypercoagulable states, Budd-Chiari
syndrome
 Tumor thrombus: HCC, pancreas
carcinoma, RCC, cholangiocarcinoma,
gallbladder cancer
 Umbilical vein catheter (neonate)
Portal hypertension
 Pre-sinusoidal extrahepatic: portal vein
thrombosis, lymphadenopathy,
pancreatitis, pyelophlebitis, pancreas
carcinoma, splenic/mesenteric venous
occlusion
 Pre-sinusoidal intrahepatic: PBC,
congenital hepatic fibrosis, sarcoid,
Wilson’s disease, shistosomiasis
 Sinusoidal: cirrhosis (alcoholic, hepatitis),
sclerosing cholangitis
 Post-sinusoidal: Budd-Chiari syndrome
Corrected sinusoidal pressure (CSP)
 Wedge hepatic venous pressure – Free
hepatic venous pressure (CSP= WHP-
FHP) to approximate portal venous
pressure
 <5 NL
 5-10 mild
 10-15 moderate
 >15 severe
 Remember: pre- & post-sinusoidal
disease can result in falsely NL CSP. Use
CO2 if possible, as contrast can
extravasate
Renal artery disease
 Atherosclerosis
 Fibromuscular dysplasia
 Arteritides: Takayasu’s disease, PAN,
NF-1
For renal PTA, use heparin, NTG to avoid spasm,
cross lesion, use 6mm balloon in main RA, 4mm
balloon in segmental artery. An early RA bifurcation
may be problematic. Balloon length should be <1cm
on either side of lesion. Balloon should be 10-20%
larger than NL vessel (except aorta where one should
underdilate). A category 1 lesion is a nonostial lesion
with a short (3 cm) focal stenosis
Main renal artery aneurysms
 Atherosclerosis
 FMD
 NF-1
 AML
 Infectious cause
 Post-trauma
Renal vein thrombosis
 RCC with tumor invasion
 Trauma
 Amyloid, glomerulonephritis, nephrotic
syndrome
 Sepsis, dehydration, maternal diabetes
(child)
Renal AVF
 Penetrating trauma
 Iatrogenic (biopsy)
 Neoplasm: RCC, AML
For treatment of a renal transplant AVF or
pseudoaneurysm or post-traumatic hemorrhage, use a
3F tracker (coaxial microcatheter system) and
microcoils (1-20 mm diameter) for superselective
embolization. The patient may present with renal
failure, bleeding, HTN
Visceral/renal peripheral microaneurysms
 PAN
 IV drug abuse-associated vasculitis
 SLE-associated vasculitis
 Radiation vasculitis
 Septic emboli
Femoral graft occlusion
 Anastomotic stricture
 Intraoperative clamp injury
 Poor outflow/run-off
 Non-compliance with anti-coagulation
 Hypotensive condition (dehydration)
 Hypercoagulable states: pregnancy, oral
contraceptive use, PCV, protein c & s
deficiency, anti-thrombin III deficiency,
lupus coagulopathy
Vascular graft complications
 Perigraft infection, perigraft leak
 Anastomotic pseudoaneurysm
 Aortoenteric fistula
 Hematoma, lymphocele
Dialysis fistulagram with UE venogram
A failing hemodialysis graft may cause increased
venous pressures or abnormal urea circulation. The
thrill may be diminished or newly pulsatile. A
prosthetic forearm loop interposition graft (PTFE)
connects the brachial artery to cephalic vein. Place a
5F catheter towards the venous end and compress the
venous end during injection to opacify the graft and
arterial anastomosis. Venous outflow stenosis and
central graft stenosis are common. A semi-permanent
tunneled TESIO dialysis catheter can be placed, if
necessary. A central venous occlusion can cause
dialysis graft malfunction. Try PTA (10-12 mm
balloon), and possibly 12 x 60 Wallstent, if residual
stenosis
Arch aortogram
 5F pigtail catheter: 20-25cc/sec for 40-
50cc
 6F pigtail catheter: 30cc/sec for 60cc
 2-3 frames/sec
 IVC: 15cc/sec for 45cc
Midstream aortogram for renal arteries (RPO)
 5F Pigtail catheter: 20cc/sec for 40cc
Pelvic and lower extremity run off arteriogram
 One-leg run-off: 4cc/sec for 48cc
 Two-leg run-off: 6cc/sec for 72cc
 Internal iliac: 5cc/sec for 25cc
Selective renal, celiac, SMA injection rates
 Renal: 5cc/sec for 15cc
 Celiac: 6cc/sec for 60cc (or 6/36)
 SMA: 6cc/sec for 60cc
 IMA: 2cc/sec for 20cc
 Use 5F Cobra, Niemann, Simmons
catheter for selective work with a 3F
tracker catheter for superselective work
 Splenic/hepatic: 5cc/sec for 50cc
Causes of decreased pulse at access site
 Hypotension
 Vasovagal reaction
 Dissection
 Hematoma formation
 Catheter induced spasm
 Embolus
Acute arterial occlusion
 Pulselessness
 Pallor
 Pain
 Paresthesia

Paralysis
Unsuccessful PTA:
 Residual stenosis >30%
 Residual gradient >10 mmHg or 10%
systolic pressure
 Large post-PTA dissection flap (flow
limiting)
 Hard Ca++ plaque
Consider stent if:
 Post-PTA flow limiting dissection
 Long segment stenosis
 Occlusion
 Recurrent stenosis after PTA
 Unsuccessful PTA
 Ulcerated (complicated) stenosis
Angiography tumor features
 BEDPAN mnemonic:
 Blush
 Encasement
 Displacement
 Puddling
 AV shunting
 Neovascularity
Thoracic outlet syndrome (effort thrombosis)
 Impingement at interscalene triangle,
costoclavicular space, pectoralis minor
tunnel
 Compression by NL variants: cervical
ribs, scalene minimus muscle, anomalous
first rib, anomalous anterior scalene
insertion
 Acquired lesions: muscular hypertrophy,
fracture of clavicle or first rib, soft tissue
tumors or adenopathy
Pleurodesis agents
 Antibiotics: doxycycline, minocycline,
tetracycline
 Chemotherapeutic agents: bleomycin,
cisplatin, doxirubicin, mitomycin C
 Bio agent: IL2, corynebacterium
 Note: these agents cause adhesions
between pleural layers
For simple pleural effusion, an 8F chest tube should
suffice. Use a 12-14F chest tube for pleurodesis.
When <100 cc/day drainage, start pleurodesis
(bleomycin is commonly used). For a small
pneumothorax, use an 8F chest tube, place on Pleuro-
vac suction, then water seal; if no air leak for 24
hours, remove the chest tube
Popliteal artery entrapment
 Type 1: Popliteal artery medial to NL
insertion of medial head gastrocnemious
 Type 2: Popliteal artery medial to laterally
positioned medial head gastrocnemious
 Type 3: Compression by accessory slips
of medial head gastrocnemious or
plantaris muscle
 Type 4: Compression by popliteus muscle
Collateral pathways
 Celiac axis to SMA: arc of Buehler
 SMA to IMA: arc of Riolan, marginal
artery of Drummond
 Internal mammary-superior/inferior
epigastric-external iliac artery
 IMA hemorrhoidal branches-internal iliac
artery
 Intercostal-lumbar-deep circumflex-
external iliac artery
Contraindications to thrombolytic therapy
 Active GI bleed, hematuria
 Recent stroke
 Metastatic disease (intracranial)
 Pregnancy
 Use within 6 weeks of major surgery
 Relative: recent chest/abdomen surgery,
uncontrolled HTN, remote stroke or GI
bleed
Attempt thrombolysis via a multiple side
hole/endhole Simmons, SOS or coaxial infusion
catheter. Distal stenosis is usually the cause for graft
occlusion. After infusion, do angiography through
infusion catheter. If distal embolization occurs,
continue infusion
Typical infusion dose of tPA is 1 mg/hour
Complications of thrombolysis
 Distal embolization
 Bleeding around the catheter
 Pericatheter thrombus
 Bleeding from a distant site
GI Bleeding detection rates and Rx
 Tagged red blood cell scan: 0.1cc/min
 Angiography: 0.5cc/min
 Do IMA, SMA, then celiac because
contrast-filled bladder may obscure distal
bleeding
 Celiac axis: large particle or coil
embolization
 Distal esophagus/gastric fundus: left
gastric artery embolization
 Distal stomach or duodenum:
gastroduodenal artery embolization
Vasopressin (ADH) therapy
 0.2 units/min, study in 20 minutes
 If vasospasm, decrease to 0.1units/min,
study again in 20 minutes; continue for
12-24 hours, then decrease 0.2 units/min
over 8-12 hours
 If still bleeding, increase to 0.4 units/min
at increments of 0.1-0.2units
 Complications: coronary artery spasm
(MI), exacerbation of HTN, bowel
infarction, hyponatremia (seizure),
diarrhea
GI bleeding
 In lower GI bleeds, consider vasopressin
initially, or superselective microcoil
embolization via a coaxial microcatheter
system. Further evaluation is needed once
the patient is stable to determine the
cause. Common causes include
diverticulosis, angiodysplasia, CA, IBD,
polyp, hemorrhoid/ulcer
 For a malignant gastric ulcer, try
selective microcoil embolization via a
coaxial microcatheter system. Usually left
gastric artery in UGI bleeds
 Specifically: embolize tumors with
microcoils or PVA, PUD with gelfoam,
duodenal bleed with microcoil or PVA.
Try vasopressin with gastritis, Mallory-
Weiss tear. If no results in 30 minutes,
embolize with gelfoam
 For a duodenal ulcer or GDA
pseudoaneurysm, try selective microcoil
embolization via a coaxial microcatheter
system. Then, check celiac/SMA for post-
coil collaterals. The SMA may give off
inferior pancreaticoduodenal collaterals.
Common UGI causes of bleeding include
leiomyoma, AVM, ulcer, varices, IBD,
Meckel diverticulum, metastases
(melanoma, Kaposi’s sarcoma). Might
consider vasopressin first in these cases
For IVC filter, do IVCgram to check IVC caliber,
renal vein level, and for presence of IVC thrombus,
venous anomalies (double IVC, circumaortic left
renal vein, left-sided IVC, etc.)
IVC filter indications
 PE despite adequate anticoagulation
 PE/DVT in patient with contraindication
to anticoagulation (recent surgery, GI
bleed, stroke)
 DVT in patient to undergo orthopedic
procedure
 Free-floating caval thrombus
 History of PE/DVT with complication
while on anticoagulation
Use a Bird’s nest filter if IVC >28 mm, a Simmon-
nitonol filter (9F delivery system) if brachial vein,
external jugular or antecubital approach is necessary.
Simmon-nitonol has increased risk of migration,
caval penetration, poor (shape) memory. Recurrent
PE occurs in 2-4%, IVC thrombosis 10%. If double
IVC, place filters in both cavae. Venatech (14.6
delivery system) is MRI safe alloy
Subclavian stenosis or occlusion leading to “steal”
phenomenon
 Atherosclerosis
 Post-traumatic injury
 S/p surgery for coarctation of the aorta
 Aberrant left subclavian artery origin
distal to aortic coarctation
 Apical lung neoplasm
 Takayasu’s disease
Select catheter types
 Quinton temporary dialysis catheter
 Hickman tunneled catheter for
chemotherapy
 TESIO semi-permanent dialysis catheter
(increased infection rate, poor flow rate
compared to surgical AVF)
Select stent types
 Palmaz (balloon-expandable): mount on
PTA balloon, place through sheath,
localize lesion, deploy
 Wallstent (self-expanding)
 Gianturco
Mycotic aneurysms
 IVDA
 Immunocompromised state
 Endocarditis
 Post-surgical
Typical PTA balloon sizes based on location
 Renal artery: 6 mm
 Common iliac artery: 8 mm
 Popliteal artery: 4-5 mm
Miscellaneous facts:
1. Popliteal artery aneurysms are bilateral in
60% cases, associated with AAA in 33% cases
2. Gel foam powder is NOT the same as gel foam
pledgets. Powder causes necrosis
3. A AAA can be fixed by either bifurcating
endoluminal tube graft or onlay graft
4. Use Brodel’s avascular line for renal biopsy
(lateral in coronal plane of kidney)
5. Before stenting for post-angioplasty
dissection, make sure you’re in the true lumen
by running the wire/catheter down into NL
vessel
6. For noninvasive vascular assessment, thigh
pressures are higher than brachial pressures but
 other measurements in lower extremity are
lower than brachial pressure
7. ABI normally is >1.0. For claudication, ABI
0.5-0.8, whereas rest pain is <0.4
8. For symptomatic May-Thurner, use a large
(16x60 mm) Wallstent
9. You may get a transient AVF after arterial
angioplasty. Do not stent these, as they are
transient and due to intimal dissection with vaso
vasorum communications to vein
10. Radiofrequency ablation only works in a
maximum diameter of 5-6 cm
11. Post-thrombolysis distal embolization can be
fixed by thrombolysis, angioplasty, suction
12. A significant gradient across a stenosis is >10
mm Hg or >10% systolic pressure
13. SVC stenosis/occlusion may be due to
indwelling catheter, fibrosing mediastinitis,
XRT, or tumor. If benign, may
PTA/thrombolyse or PTA alone. If malignant,
primarily stent with Gianturco or
thrombolyse/stent
14. For thoracic outlet syndrome, do NOT stent.
May thrombolyse acute disease, but for chronic
changes IR does nothing
15. For pulmonary AVM, Use a large coil or
detachable balloon. May cause infarction or
systemic embolization. Bronchial arteries
usually come off at T4-T6, and may receive
collaterals from internal mammary arteries,
intercostal arteries, thyrocervical trunk. Watch
out for non-target embolization of spinal artery
16. If popliteal artery >7 mm, it is aneurysmal
17. If no pulses in a posterior knee dislocation,
patient goes directly to surgery
18. A splenic artery aneurysm (> 2 cm) occurs in
portal HTN, FMD, pregnancy, pancreatitis. Use
8 mm embolization coils distal & proximal, the
“double ligation”
19. For multiple renal AMLs, use microcatheter
to embolize with PVA (500-700 microns)
20. Use a 5F Cobra catheter in the SMA with a 3F
tracker to supraselectively microcoil a jejunal
bleed. Then, check IMA for other bleeding sites
21. For TIPS shunt, the goal is a portosystemic
gradient of <12 mmHg. Do NOT perform in
right CHF, markedly elevated CVP, polycystic
liver disease, severe hepatic failure, or possible
active intrahepatic infection, severe
encephalopathy, hypervascular liver tumors,
portal venous thrombosis. Don’t forget a
transjugular splenic venogram at the end to
document hepatopedal flow and absent
collateral filling
22. For TIPS shunt malfunction, velocity
measures <50cc/sec, which is equal to >50%
stenosis from myointimal hyperplasia. Hepatic
venous end is most common. PTA alone and/or
place a new 8-12 mm stent. Routine shunt
surveillance should be at 3, 6, 12 months post-
procedure
23. For venous access, there should be no sepsis or
uncorrected coagulopathy. Immediate
complications include hematoma, contrast
reaction, PTX, air embolization. Delayed
complications include infection, wound
dehiscence, catheter dysfunction (fibrin sheath,
thrombosis, malposition), venous
stenosis/thrombosis. For thrombosis, pull it,
give heparin and abx (if sepsis)
24. Knee collaterals via geniculate & sural arteries
25. If diffuse femoral disease, do NOT stent iliac
artery
26. For bronchial artery embolization, in cases of
bronchiectasis, CF, TB, aspergillus, tumor,
AVM, use platinum microcoils for AVM.
Consider PVA (250-750 microns) for other
etiologies. There is usually 1 right bronchial
artery, 2 left bronchial arteries. Watch out for
the non-target embolization to the spinal cord
27. For foreign body retrieval, use a snare and try
to pull to the IVC
28. For hepatic artery bleeding due to trauma, use
microcoils alone or with gel foam
29. For uterine artery embolization, in cases of
post-partum hemorrhage (bilateral internal iliac
artery), symptomatic fibroids or menorrhagia
(uterine artery), use gelfoam pledgets for post-
partum cases, and PVA in bilateral uterine
arteries in other etiologies. Infection may
necessitate hysterectomy
30. LE run-off stations are thigh, leg, foot
31. In an acute DVT, there is a smooth filling
defect in the tibial/popliteal vein (for example),
while in subacute/chronic DVT, there is clot
retraction with an irregular surface.
Recanalization and collateral vessels may occur
in chronic DVT
32. An AVF occurs in 15-20% renal transplants,
and may present with bleeding, HTN, renal
failure
33. If there are no femoral pulses, consider a
transaxillary abdominal aortogram
34. Distal profunda femoris branches to
geniculate arteries to popliteal artery is a
common pathway in SFA occlusion
35. An aortic spindle is fusiform dilatation of the
distal arch/proximal descending thoracic aorta
that can simulate ATAI
36. When performing a PAgram, start on the side
of clinical/CXR abnormality and use nonionic
contrast
37. An iliofemoral graft occlusion reconstitutes
via iliolumbar collaterals and the anterior
division of the internal iliac artery to the CFA.
Usually occlusion is due to distal graft stenosis,
for which balloon angioplasty can be
performed. Use a Simmons/SOS catheter with
coaxial infusion catheter
38. A persistent left SVC sweeps behind the left
atrium to the coronary sinus or right atrium
directly. A left vertical vein in supracardiac
TAPVR is fused pulmonary veins that drain
into the left brachiocephalic
39. A transthoracic biopsy for suspected
lymphoma should be done with a Shure cut
biopsy needle to yield an adequate sample for
subtyping
40. Noninvasive vascular evaluation includes
segmental limb pressures, ABI, Doppler
waveform analysis (velocities, shift), treadmill
stress testing, etc.
41. Blue toe syndrome
42. Oncocytoma is bilateral in 6% cases, and has
the central stellate scar on imaging and a
hypervascular spokewheel appearance on
angiography
43. Intimal cracking is expected with PTA
44. If there is distal profunda femoris and
multifocal distal tibial/pedal arterial disease,
suspect diabetes
45. Try to position the free end of an intravascular
foreign body in the SVC or IVC, then snare it
through a sheath. If F.B. is in the pulmonary
artery, try a pigtail or SOS catheter to pull it
into the SVC or IVC, then snare it
46. For a percutaneous liver biopsy (22g CHIBA
needle), go through NL liver to avoid causing a
large hematoma. Watch out for interposed
bowel, lung, or the gall bladder. If there is
significant ascites, a small liver, or
coagulopathy, consider a transjugular approach
47. PTC drain can be internal, internal-external,
eternal Left side is often better due to a longer
left intrahepatic duct
48. Internal-external ureteral stent may be
helpful as a trial period to see if patient will
tolerate the catheter (especially if patient has
XRT/chemotherapy cystitis)
49. Most hemangioendotheliomas in children
proliferate then involute by 18 months of age
50. Post-XRT stenosis can be delayed several (5-
10) years
51. Transgluteal abscess drainage should be
performed as close to the sacrum as possible,
and as caudal as possible
52. Might consider a Wallstent (16 x 60) in the
trachea with symphony stents in the bronchi for
relapsing polychondritis
53. Might consider antegrade renal stone
removal if single stone >2-2.5 cm, refractory to
ESWL, aggregate stones >2.5-3 cm
54. A persistent sciatic artery is a branch of the
internal iliac artery that is prone to trauma
(pseudoaneurysm). The SFA and PFA are
usually hypoplastic. The sciatic artery continues
in the lower extremity to the popliteal, so if you
inject the external iliac you won’t see the lower
extremity
55. “Restoration of NL lumen caliber without
residual stenosis”
Differential Diagnoses
GI Radiology
Cervical esophagus, extrinsic impression
 Cricopharyngeus
 Postcricoid impression
 Thyroid/parathyroid enlargement
 Lymphoid hyperplasia: allergy, infection,
post-tonsillectomy
 Abscess, hematoma
 Anterior marginal osteophyte, anterior
herniation of intervertebral disc,
neoplasm, inflammation
Thoracic esophagus, extrinsic impression
 Normal structures: aortic arch, left
mainstem bronchus, left inferior
pulmonary vein
 Aortic structures: right aortic arch,
cervical aortic arch, double aortic arch,
coarctation of aorta, aortic
aneurysm/tortuosity
 Nonaortic vascular structures: aberrant
right subclavian artery, aberrant left
pulmonary artery (pulmonary sling),
TAPVR
 Cardiac/pericardial structures: left atrium
and ventricle; effusion, tumor, cyst
 Mediastinal mass: tumor, lymph node
enlargement, duplication cyst, neurenteric
cyst with hemivertebrae, spina bifida,
scoliosis
 Pulmonary mass
Esophagus, discrete filling defect
 Benign tumor: leiomyoma, fibrovascular
polyp, papilloma, inflammatory
esophagogastric polyp, adenoma
 Malignant tumor: SCC, adenocarcinoma,
lymphoma, spindle cell sarcoma, gastric
carcinoma with upward extension, breast
or lung metastases, laryngeal or thyroid
carcinoma by direct extension
 Varices
 Foreign bodies

Esophagus, fistula
 Congenital, s/p TEF repair (neonates)
 Malignancy: esophageal carcinoma after
radiation therapy, bronchogenic
carcinoma
 Perforation: iatrogenic, spontaneous,
foreign body
 Corrosive esophagitis
 Inflammatory disease: TB, histoplasmosis,
actinomycosis, Crohn’s disease
Abnormal esophageal motility
 Esophagitis
 Neuropathy: CVA, postvagotomy
syndrome, IDDM, amyloid,
pseudoobstruction, alcoholism
 Achalasia
 Chagas disease
 Scleroderma
 Connective tissue disease: SLE, RA,
polymyositis, dermatomyositis
 Malignancy
 Striated muscle disorders: myasthenia
gravis
 Presbyesophagus
Esophagus, tertiary contractions
 Presbyesophagus
 Diffuse esophageal spasm
 Esophagitis
 Early achalasia
 Neuromuscular disorders
 NL variant in elderly
Esophagus, narrowing
 Esophageal web (Plummer-Vinson
syndrome), lower esophageal
ring/Schatzki ring
 Infection: candidiasis
 Inflammation: reflux esophagitis,
corrosive esophagitis, Barret’s esophagus
(reticular mucosa), Crohn’s disease,
eosinophilic esophagitis
 Drugs: tetracycline, potassium chloride,
ascorbic acid, quinidine
 Neoplasm: SCC, adenocarcinoma, gastric
carcinoma, breast and lung metastases,
lymphoma
 Iatrogenic: post-surgical stricture, post-
nasogastric tube intubation, radiation
injury
 Epidermolysis bullosa, bullous
pemphigoid
 Intramural esophageal
pseudodiverticulosis
Esophagus, nodules
 Candidiasis
 Reflux esophagitis
 Glycogenic acanthosis
 Superficial spreading esophageal
carcinoma
 Esophageal papillomatosis
 Acanthosis nigricans (rare)
 Cowden’s disease
 Leukoplakia
Esophagus, ulceration
 Inflammation: reflux esophagitis, Barret’s
esophagus, corrosive esophagitis, drug-
induced esophagitis, radiation esophagitis
 Infectious: candidiasis, herpes, CMV,
HIV, TB, Crohn’s disease
 Neoplasm: carcinoma, lymphoma
 Mimics: intramural pseudodiverticulosis,
Mallory-Weiss tear
Esophagus, diverticula
 Pharyngeal: Zenker’s (pulsion)
 Midesophageal: traction
 Distal: epiphrenic (pulsion)
Esophageal cancer risk factors
 ETOH, tobacco
 Achalasia (squamous carcinoma),
scleroderma (adenocarcinoma)
 Head & neck cancer
 Tylosis
 Plummer-Vinson syndrome
 Lye ingestion
Esophagus, surgical procedures
 Reconstruction: gastric pull-through,
colonic interposition, direct anastamosis
(EA)
 Antireflux: Nissan fundoplication, Belsey
Mark 4 fundoplication, Angelchik
prosthesis (sialastic)
 Antivarices: esophageal resection and
reanastomosis with splenectomy,
vagotomy, pyloroplasty
 Procedures for motility: cricopharyngeal
myotomy, Heller myotomy (with Belsey
2700 fundoplication)
Pharyngeal mass
 Malignancy
 Mucous retention cyst
 Laryngocele
 S/p total laryngectomy
 Post-radiation therapy
Stomach, (varioliform) erosions
 ETOH
 NSAIDS, steroids, ASA
 Crohn’s
 Viral/fungal infection: candida, CMV
 Mimics: barium precipitates
Complications of Bilroth procedure
 Marginal ulcers
 Carcinoma at gastric stump (bile reflux)
 Retained gastric antrum
 Jejunogastric intussusception (Bilroth 2)
 Bezoars
 Afferent loop syndrome
Stomach, filling defects
 Bezoar, foreign body
 Benign tumor: leiomyoma, lipoma,
neurofibroma
 Polyps: hyperplastic (Cronkite-Canada),
adenomatous, hamartoma (Peutz-Jegher’s,
Cowden’s disease)
 Malignant tumor: adenocarcinoma,
carcinoid, lymphoma, leiomyosarcoma,
metastatic disease (breast, melanoma,
Kaposi’s sarcoma, lymphoma)
 Ectopic pancreas
 Thickened folds simulating nodules:
Menetrier’s disease, varices, inflammatory
or infectious gastritis
 Peptic ulcer disease (edematous mass)
 Eosinophilic granuloma (inflammatory
fibroid polyp)
 Extrinsic cystic or inflammatory mass
 Duplication cyst
Stomach, fold thickening
 NL variant
 Acute gastritis: ingested agents (ETOH,
aspirin, other medications), corrosive
agents (acid or alkali), chemotherapy
(infusion into hepatic artery), infection (a-
hemolytic Streptococcus, staphylococcus,
E.coli, Clostridium perfringens,
pneumococci, Proteus, candida, Anisakis
worm)
 Chronic erosive gastritis
 Granulomatous gastritis: Crohn’s disease,
chronic granulomatous disease of
childhood, TB
 Menetrier’s disease
 Infiltrative processes: amyloidosis,
eosinophilic gastroenteritis
 PUD, Zollinger-Ellison syndrome
 Neoplasm: lymphoma, carcinoma
 Varices
 Extension of pancreas disease
 Pseudolymphoma
Gas in wall of stomach
 Severe gastritis: infectious (hemolytic
streptococci, clostridium), corrosive
 Ischemia
 PUD with intramural perforation (focal)
 Gastric outlet obstruction
 Iatrogenic: endoscopy, surgery
 Gastric pneumatosis
 Bulla ruptured into esophageal wall
Linitis plastica (leather bottle)
 Malignant: scirrhous carcinoma,
Hodgkin’s lymphoma > NHL, breast
metastases
 PUD
 Acute gastritis (iron intoxication),
granulomatous gastritis (TB, sarcoidosis,
Crohn’s disease)
 Infiltrative processes: amyloidosis,
eosinophilic gastritis
 Polyarteritis nodosa
 Gastroplasty (weight reduction)
Stomach, obstruction
 PUD
 Malignant tumor: antral/pyloric channel
carcinoma, lymphoma, pancreas
carcinoma
 Benign tumor: prolapsed antral polyp
 Inflammatory disorders: Crohn’s disease,
pancreatitis, cholecystitis, corrosive
stricture
 Antral mucosal diaphragm, gastric
duplication
 Gastric volvulus, hypertrophic pyloric
stenosis, gastric bezoar
 Mimics: gastroparesis
Gastric antral narrowing
 SPICER mnemonic:
 Sarcoidosis, syphilis
 PUD
 Infection: TB
 Carcinoma
 Eosinophilic gastroenteritis
 Radiation
Stomach, outpouching/ulceration
 Benign: PUD, gastritis, granulomatous
disease, leiomyoma, radiation-induced
ulcer, pseudolymphoma, diverticula
  Malignant: carcinoma, lymphoma, replacement of pancreas,
leiomyosarcoma, metastases (“bull’s eye” cystadenoma/cystadenocarcinoma NORMAL caliber small bowel with THICK
lesion with melanoma, breast, lung,  Lymph node enlargement: metastases, FOLDS
Kaposi’s sarcoma) lymphoma, reactive  Vascular: ischemia, hemorrhage, radiation
 Cystic lymphangioma of the mesentery therapy
Gastric cancer risk factors  Mesenteric arterial collaterals  Inflammatory: Crohn’s disease, ZE
 Chronic atrophic gastritis  Aortic aneurysm syndrome
 Pernicious anemia  Choledochal cyst  Infiltrative: Eosinophilic enteritis,
 Bilroth II amyloid, Whipple’s disease, mastocytosis,
 Adenomatous polyp (FAP, Cronkite- Duodenum, abnormal folds abetalipoproteinemia
Canada)/villous adenoma  Inflammatory disorders: PUD, ZE  Infectious: TB, Yersinia, typhoid fever,
syndrome, Brunner’s gland hyperplasia, giardiasis, strongyloidiasis,
Duodenum, filling defects pancreatitis, cholecystitis, uremia (chronic cryptosporidiosis, histoplasmosis,
 Pseudo tumors: flexural pseudolesion, dialysis), Crohn’s disease, TB, parasitic MAI/CMV
acute ulcer mound, foreign body infection (giardiasis, strongyloidiasis),  Neoplasm: lymphoma, metastases
 Ectopic pancreas (“bull’s eye” lesion) nontropical sprue (melanoma, ovary, breast, GI tumors),
 Prolapsed antral mucosa  Neoplasm: lymphoma, metastases to carcinoid (ileum)
 Brunner’s gland hyperplasia peripancreatic lymph nodes  Edema: hypoproteinemia (nephrotic
 Benign lymphoid hyperplasia  Diffuse infiltrative diseases: Whipple’s syndrome, cirrhosis, protein-losing
 Hypertrophic gastric mucosa disease, amyloidosis, mastocytosis, enteropathy), venous or lymphatic
 Enlarged papilla eosinophilic enteritis, intestinal obstruction, angioneurotic edema,
lymphangiectasis lymphangiectasia
 Choledochocele
 Vascular disorders: duodenal varices,  Cystic fibrosis
 Duplication cyst
mesenteric arterial collaterals  Graft-versus-host disease
 Varices, mesenteric arterial collaterals
pancreaticodudenal arcade), intramural
 Intramural hematoma: child abuse, MVC
hemorrhage, chronic duodenal congestion NODULES on folds
 Benign tumors: adenomatous polyp,
(portal HTN, CHF), ishemia (radiation,  WHILMA mnemonic:
leiomyoma, lipoma,
collagen vascular disease, Henoch-  Whipple’s disease
prolapsed/intussuscepted antral polyp
Schonlein purpura)  Lymphoma, Lymphangiectasia,
 Variable malignant potential: villous
 Cystic fibrosis Lymphoid hyperplasia
adenoma, carcinoid tumor
 Edema (hypoproteinemia, venous or  Macroglobulinemia, Mastocytosis, Mets
 Malignant tumors: adenocarcinoma,
lymphatic obstruction, angioneurotic  Amyloid, Abetalipoproteinemia
ampullary carcinoma, leiomyosarcoma,
edema  Other: Giardiasis, Cryptosporidiosis,
lymphoma, Kaposi's sarcoma, metastases
MAI, CMV, Eosinophilic gastroenteritis
Paralytic ileus
Duodenum, obstruction
 Ps mnemonic: Wet bowel (malabsorption)
 Congenital: duodenal atresia, annular
 Peritonitis  Sprue
pancreas, diaphragm, intraluminal
diverticulum (wind sock deformity),  Pneumonia  ZE syndrome
midgut volvulus, Ladd’s bands,  PUD  Menetrier’s disease
duplication cyst, preduodenal portal vein  Perforation  Giardiasis
 Inflammatory disorders: postbulbar ulcer,  Pancreatitis  Whipple’s disease
Crohn’s disease, TB, strongyloidiasis,  Pyelonephritis
nontropical sprue, acute pancreatitis,  Pregnancy Gastric and small bowel thickening
chronic pancreatitis, pseudocyst  Pendix  MALEZ mnemonic:
 Malignant tumor: pancreas or duodenal  Porphyria  Menetrier’s disease
carcinoma, metastases  Potassium deficiency  Amyloid
 Intramural hematoma  Post-operative  Lymphoma
 Superior mesenteric artery syndrome  Eosinophilic enteritis
(rapid weight loss) Ischemic enterocolitis  ZE syndrome
 VINTS mnemonic:
Postbulbar ulceration  Vasculitis Simplified small bowel folds, regular (fluid)
 PUD  Incarceration: hernia, volvulus  Blood: coagulation defects
 Zollinger-Ellison syndrome  Non-occlusive mesenteric ischemia: (anticoagulation, liver disease,
 Benign tumors shock, CHF hemophilia), trauma, ischemia, infarction
 Malignant tumors: primary duodenal  Thrombosis: atherosclerosis, emboli,  Edema: hypoproteinemia (cirrhosis,
carcinoma, direct extension from PCV, hypercoagulable states Menetrier’s disease), ascites, mesenteric
pancreas, right colon, right kidney,  Spontaneous lymphatic or venous obstruction, ZE
gallbladder; lymph node and syndrome, giardiasis
hematogenous metastases DILATED small bowel with NL FOLDS
 Crohn’s disease  Obstruction Simplified small bowel folds, irregular (cells)
 TB  Post-vagotomy  Lymphoma
 Aortoduodenal fistula  Ileus  Metastases
 Mimics: ectopic pancreas, bulbar  Scleroderma  Crohn’s disease
diverticulum  Sprue (celiac, tropical)  Whipple’s disease
 GUTED mnemonic: Granulomatous  CF
disease (TB, Crohn’s disease), Ulcer DILATED small bowel with THICK FOLDS  Cryptosporidium, MAC
disease (PUD, ZE syndrome), Tumor  Ischemia  Mastocytosis
(benign, malignant, metastatic), Ectopic  Hemorrhage  Amyloidosis
pancreas, Diverticulum  Radiation therapy  Giardiasis
 Crohn’s disease  Typhoid
Duodenum, widened sweep  ZE syndrome
 NL variant  Lymphoma Predominantly duodenal and/or jejunal
 Pancreatitis, pancreas pseudocyst,  Whipple’s disease  Sprue
pancreas carcinoma, metastatic  Cystic fibrosis
 Amyloid
 Abetalipoproteinemia  Whipple’s disease
  Giardiasis
 Cryptosporidiosis
 ZE syndrome
 Strongyloidiasis
Predominantly jejunal and/or ileal
 Amyloid
 Lymphoma
 Graft-versus-host disease
Predominantly ileal
 Crohn’s disease
 TB, Yersinia, typhoid fever
Other patterns
 Sprue: duodenal, ileal
 Eosinophilic enteritis: stomach, all small
bowel
Terminal ileum narrow with abnormal cecum
 TB
 Crohn’s disease
 Lymphoma
 Carcinoid
 Post-radiation
 Ischemia
Small bowel filling defect
 Benign tumor: adenoma, leiomyoma,
lipoma, hemangioma (TS, Turner’s
syndrome, OWR, blue rubber bleb nevus
syndrome), hamartomatous polyp
 Malignant tumor: carcinoid, lymphoma,
leiomyosarcoma, adenocarcinoma (rarely
seen in sprue, Crohn’s disease, Peutz-
Jegher’s syndrome)
 Metastases: hematogenously by breast,
lung, RCC, melanoma, Kaposi’s sarcoma;
direct extension by RCC, pancreatic,
adrenal; intraperitoneal seeding by
ovarian, appendix, colon carcinoma)
 Intussusception: melanoma metastases
Coned cecum
 Crohn’s disease
 Infection: TB, amebiasis, actinomycosis
(history penetrating trauma, surgery),
Yersinia
 Inflammation: appendicitis, diverticulitis,
typhlitis
 Neoplasm: adenocarcinoma, lymphoma
 Ulcerative colitis
Colon polyps, multiple
 Polyposis syndromes: Familial
adenomatous polyposis (Gardner’s
syndrome, Familial polyposis coli), Peutz-
Jegher’s syndrome, Turcot’s syndrome,
Cronkite-Canada syndrome, Juvenile
polyposis, Cowden’s disease (breast,
thyroid disease)
 Colitidies with inflammatory polyps:
ulcerative colitis, Crohn’s disease,
pseudomembranous colitis
 Neoplasm: lymphoma, Kaposi’s sarcoma
 Other: lymphoid follicles, Colitis cystica
profunda, pneumatosis cystoides
intestinalis
Colon, ulcers
 Crohn’s disease
 Ulcerative colitis
 Amebiasis, TB, Shigellosis, Yersinia,
CMV
 Behcet’s syndrome
 Lymphogranuloma venerum (Chlamydia)
Colon, thumbprinting
 Vascular: ischemia, intramural
hemorrhage, traumatic hematoma,
hemolytic-uremic syndrome
 Advanced colitis: ulcerative colitis,
Crohn’s colitis, amebiasis, CMV,
pseudomembraneous colitis
 Neoplasm: lymphoma, metastases
 Other: pneumatosis cystoides coli
 Amyloidosis
Colon, solitary filling defect
 Benign tumor: adenoma, hyperplastic
polyp, lipoma, hemangioma
 Malignant tumor: adenocarcinoma,
carcinoid, lymphoma, SCC, cloacogenic
carcinoma
 Infection: ameboma, diverticular abscess
 Other: intussusception, appendix (inverted
stump, mucocele)
Colon, segmental narrowing
 Malignant tumor: adenocarcinoma,
metastases (direct extension by cervical,
prostate, ovarian, gallbladder, uterine,
kidney cancer; noncontiguous spread by
mesocolon in pancreas carcinoma and
gastrocolic ligament in stomach cancer;
hematogenous by melanoma, breast,
lung), lymphoma, carcinoid
 Inflammatory/infectious: Crohn’s disease,
ulcerative colitis, diverticulitis, ameboma,
lymphogranuloma venerum
 Vascular: ischemia, radiation colitis
 Other: endometriosis, hemangioma
Colon, dilated
 Obstruction: carcinoma, diverticulitis,
volvulus, intussusception, adhesions,
hernia
 Toxic megacolon: ulcerative colitis
 Ischemia (low flow states)
 Ileus: metabolic, drugs
Colon, smooth (ahaustral)
 Cathartic abuse
 Ulcerative colitis
 Radiation colitis (late)
 Ischemic colitis (late)
Miscellaneous facts:
1. Gastric hyperplastic polyps are usually
multiple, small (<1 cm), on a background of
chronic atrophic gastritis
2. All residents HATE doing GI exams
3. All residents HATE doing GI exams
4. All residents HATE doing GI exams
5. All residents HATE doing GI exams
6. All residents HATE doing GI exams
7. All residents HATE doing GI exams
8. All residents HATE doing GI exams
9. All residents HATE doing GI exams
Differential Diagnoses
Abdominal Viscera Imaging
Biliary tract/GB dilatation
 Obstruction: stones, carcinoma (bile duct,
pancreas, ampulla), stricture (iatrogenic,
postinflammatory), pancreatitis, periportal
adenopathy
 Caroli’s disease: ARPCKD, medullary
sponge kidney (80% associated with
Caroli’s disease)
 Choledochal cyst (child)
 Bacterial cholangitis
 AIDS cholangitis: CMV,
cryptosporidiosis
 Sclerosing cholangitis (diverticula)
 Clonorchiasis (spares extrahepatic ducts)
 Recurrent pyogenic cholangitis
Narrowed or thick-walled ducts
 Sclerosing cholangitis (diverticula with
beaded ducts is classic)
 AIDS cholangitis: CMV,
cryptosporidiosis
 Cholangiocarcinoma: bacterial
cholangitis, clonorchiasis, recurrent
pyogenic cholangitis
 Cirrhosis: hepatic, primary biliary
cirrhosis
Biliary stricture
 Iatrogenic: surgery, hepatic artery
chemotherapy
 Postinflammatory: sclerosing cholangitis,
infectious cholangitis (pyogenic
cholangitis, AIDS cholangitis, recurrent
pyogenic cholangitis, clonorchiasis),
pancreatitis
 Malignant neoplasm: cholangiocarcinoma,
HCC
 Extrinsic compression: periportal
adenopathy, Mirizzi’s syndrome
Intraluminal filling defect in CBD
 Choledocholithiasis
 Pseudocalculus: sphincter of Oddi spasm
 Air bubble
 Cholangiocarcinoma
 Hemobilia: recent trauma or intervention
(TIPS, PTC)
 Parasitic infection
 Sludge ball
Pneumobilia
 Iatrogenic: surgical fistulization, s/p
papillotomy during ERCP
 Cholecystoenteric fistula from gallstone
erosion (gallstone ileus)
 Duodenal ulcer perforation into
gallbladder
 Gallbladder carcinoma perforation into GI
tract
 Septic cholangitis (uncommon)
Choledochal cyst classification
Type 1: fusiform dilatation of extrahepatic duct
Type 2: mid-distal ductal diverticulum
Type 3: choledococele
Type 4: intra- and extrahepatic duct involvement
Type 5: Caroli’s disease (intrahepatic ducts)

Gallbladder intraluminal filling defect/mass
 Gallstones
 Sludge
 Hemobilia: trauma, bleeding diathesis
 Parasitic infection: ascariasis
 Cholesterol polyp
 Polypoid tumor: gallbladder carcinoma,
metastatic melanoma, adenoma
 Sloughed mucosa: acute cholecystitis
Gallbladder wall abnormality
 Cholecystitis: acute, emphysematous,
acalculous, chronic
 Hyperplastic cholecystoses:
adenomyomatosis, cholesterolosis
 Gallbladder carcinoma
 Porcelain gallbladder (20% risk cancer)
 Gallbladder varices
 Metastatic melanoma
 Non-specific wall thickening: cirrhosis,
hepatitis, renal failure, CHF, AIDS, etc.
Liver calcifications
 Infectious: Echinococcus, granulomatous
disease (TB, histoplasmosis), PCP, MAI,
CMV
 Tumors: cysts, fibrolamellar HCC (in
central scar), hepatoblastoma, intrahepatic
cholangiocarcinoma, metastases
(mucinous adenocarcinoma of lung,
colon, ovary, stomach; melanoma,
insulinoma, neuroblastoma)
 Other: intrahepatic choledocholithiasis
(recurrent pyogenic cholangitis), hepatic
artery aneurysm, phleboliths/calcified
thrombus (hemangioma), capsular
calcification (hematoma, infection,
meconium peritonitis)
Liver mass with central scar
 Fibrolamellar HCC (calcified scar)
 FNH
 Hemangioma (giant >5cm)
Liver with diffuse increased attenuation
 Thorotrast
 Hemochromatosis
 Amiodarone therapy
 Gold therapy
 Wilson’s disease
 Glycogen storage disease
Liver cysts
 Cystic neoplasm: metastases
(choriocarcinoma, mucinous pancreatic
carcinoma, leiomyosarcoma, small cell
carcinoma), adenoma/HCC with
hemorrhage, biliary appendicitis, pancreatitis), clotting
cystadenoma/cystadenocarcinoma (rare), disorder
mesenchymal hamartoma,
undifferentiated embryonal carcinoma Liver with echogenic parenchymal foci
 Infection: pyogenic abscess, amebic  Prior infection: TB, histoplasmosis, PCP,
abscess, echinococcal cyst MAI, CMV
 Posttraumatic hematoma/biloma  Intrahepatic ductal stones: recurrent
 Developmental: congenital cyst pyogenic cholangitis
(ADPCKD), Caroli’s disease, choledochal  Pneumobilia: incompetent sphincter of
cyst (child) Oddi, surgery, erosion into CBD by
 Vascular: pseudoaneurysm (bx, injury), gallstone or duodenal ulcer
AVM, peliosis hepatis (bacillary  Portal venous gas: pneumatosis
angiomatosis): TB, cancer, hematologic intestinalis (high amplitude spikes on
disorders Doppler study)
 Hepatitis (portal triads stand out in relief)
Livers masses (not cystic-appearing)
 Non-neoplastic: pyogenic abscess, HCC risk factors
parasitic abscess, hematoma, regenerating  HEPATO mnemonic:
nodule, focal fatty infiltration, focal fatty  Hemochromatosis, chronic hepatitis
sparing, hepatic infarct  ETOH abuse (cirrhosis)
 Benign neoplasm: cavernous  Parasitic infection (shistosomiasis)
hemangioma, adenoma (OCP use), FNH  Aflatoxin, a-1-antitrypsin deficiency
 Malignant neoplasm: HCC, lymphoma,  Thorotrast, tyrosinemia
metastases, cholangiocarcinoma (lobar  Other: Wilson’s disease, glycogen storage
atrophy), angiosarcoma (thorotrast) disease
Hypervascular metastases in the liver Regenerating hepatic nodules are classically T1/T2
 Choriocarcinoma hypointense, while dysplastic nodules are T1, T2
 RCC
 Carcinoid
 Islet cell tumor
 Thyroid carcinoma
Portal hypertension
 Extrahepatic presinusoidal: portal
vein/splenic vein occlusion (pancreatitis,
HCC, trauma, infection), arterioportal
fistula (trauma, HCC)
 Intrahepatic presinusoidal: congenital
hepatic fibrosis, primary biliary cirrhosis,
shistosomiasis
 Intrahepatic sinusoidal: cirrhosis (ETOH, Pancreas cystic lesions
hepatitis, biliary cirrhosis,  Pseudocyst
hemochromatosis/Wilson’s disease),  Simple cyst: ADPCKD, CF, VHL
sclerosing cholangitis (IBD)
 Abscess
 Posthepatic postsinusoidal: Budd-Chiari
 Neoplasm: necrotic adenocarcinoma,
syndrome, polycythemia vera, IVC
cystic neoplasm (microcystic adenoma,
obstruction
macrocystic adenoma, solid and cystic
papillary epithelial tumor, cystic
Liver with diffuse increase in echogenicity
metastases (lung, ovary, melanoma),
 Fatty infiltration lymphangioma
 Cirrhosis  Mimics: splenic artery aneurysm
 Hepatic fibrosis
 Gaucher’s disease
 Hemochromatosis
Liver with diffuse abnormal enhancement
 Budd-Chiari
 Hepatic venoocclusive disease: s/p BMT,
hepatic radiation therapy
 Cirrhosis
 Right-sided venous congestion: CHF,
constrictive pericarditis
Liver geographic lesion
 Infarct: s/p transplant
 Focal fatty infiltration
 Focal fatty sparing
Pancreas mass/focal abnormality
 Radiation change  Neoplasm: epithelial (ductal
adenocarcinoma, microcystic adenoma,
Portal vein thrombosis macrocystic adenoma/adenocarcinoma,
 Idiopathic
solid and cystic papillary epithelial
 Secondary: tumor (HCC), trauma, tumor); acinar cell carcinoma,
intraabdominal sepsis (bacteroides in
pancreaticoblastoma; islet cell tumor
(insulinoma, gastrinoma,
 somatostatinoma, glucagonoma, VIPoma;
metastases (breast, lung, RCC, GI tract,
prostate)
 Inflammatory: acute pancreatitis,
pseudocyst, abscess
Pancreas calcifications
 Chronic pancreatitis: hereditary form,
pseudocyst
 Neoplasm: microcystic adenoma,
macrocystic adenoma/adenocarcinoma,
islet cell tumor
 Vascular: splenic artery, splenic artery
aneurysm
Splenic calcifications
 Infection: TB, histoplasmosis, PCP
 Vascular: infarct (SCD, bacterial
endocarditis), splenic artery (with or
without aneurysm), hemangioma
 Calcified cyst: old hematoma,
echinococcal disease
 Metastases: colon, ovarian cancer
Metastases that calcify
 CHOMP mnemonic:
 Chondrosarcoma
 Osteosarcoma
 Mucinous adenocarcinoma (ovary, GI)
 Papillary thyroid carcinoma
Splenic cystic mass
 Epidermoid cyst (congenital)
 Posttraumatic: hematoma, cyst,
degenerated infarct
 Infection: abscess, echinococcal cyst
 Inflammation: pancreatic pseudocyst
 Cystic neoplasm (primary, metastases like
melanoma)
Splenic solid mass
 Sarcoma (angiosarcoma)
 Lymphoma
 Metastases: breast, lung, ovary, melanoma
 Hemangioma: sporadic, Klippel-
Trenaunay-Weber syndrome
 Hamartoma
Retroperitoneal fibrosis
 A DIRT mnemonic:
 Aneurysm
 Drugs: methysergide, ergots, sansert, LSD
 Idiopathic
 Radiation
 Tumors: lymphoma
Low density retroperitoneal lymphadenopathy
 Treated lymphoma
 TB/MAI infection
 Whipple’s disease
 Testicular non-seminoma
 Squamous cancer of the GI tract
Miscellaneous facts:
1. Chemical shift MRI (In/Opposed phase
imaging) is in phase at 2.1-2.3 sec and its
multiples (4.2, 6.3, etc) using a 1.5T magnet
Differential Diagnoses
Pediatric Radiology
Unilateral opacified hemithorax, neonate
 Chylothorax, pleural effusion
 Congenital cystic adenomatoid
malformation
 Congenital lobar emphysema
 Pulmonary agenesis/aplasia
 Congenital diaphragmatic hernia
 Neoplasm: neuroblastoma, teratoma
Cystic lung lesion
 Congenital lobar emphysema
 CCAM
 Bronchopulmonary dysplasia, Wilson-
Mikity syndrome
 Congenital diaphragmatic hernia
 Papillomatosis
 Langerhan’s cell histiocytosis
 Cystic fibrosis
 Pneumatocele: postinfectious
(coccidiodomycosis, staphylococcus, E.
coli, Klebsiella), post hydrocarbon
ingestion, trauma
Milliary interstitial disease
 TB, fungal infections
 Sarcoidosis
 Lymphocytic interstitial pneumonitis
(AIDS)
 Varicella pneumonia
 Langerhan’s cell histiocytosis
Viral pneumonia in a child (RSV, Chlamydia,
pertussus) mimics include CF, BPD, aspiration
pneumonia
Anterior mediastinal mass
 Germ cell neoplasms: teratoma;
seminoma, choriocarcinoma, embryonal
cell carcinoma, endodermal sinus tumor
(all less common)
 Lymphoma (Hodgkin’s disease, NHL)
 Thymoma (rare in child, >40 y/o usually)
 Thyroid lesions
 Cystic hygroma
 Large NL thymus in young child
Posterior mediastinal mass
 Neurogenic tumors: neuroblastoma,
ganglioneuroblastoma, ganglioneuroma;
nerve sheath tumors
 Dural ectasia, lateral meningocele
 Diaphragmatic hernia
 Extramedullary hematopoiesis:
thalassemia, hereditary spherocytosis
 Neurenteric cysts (spinal dysraphism)
Retropharyngeal mass
 Retropharyngeal cellulitis/abscess
 Cervical neuroblastoma
 Rhabdomyosarcoma
 Cystic hygroma
 Lymphadenopathy: reactive, lymphoma
 Hemorrhage
 Hemangioma
Enlarged epiglottis
 Epiglottitis (H. influenza)
 Angioneurotic edema (AD)
 Omega epiglottis (NL variant)
 Trauma/hemorrhage: foreign body,
caustic ingestion, hemophilia
 Epiglottic cyst, papilloma
Gasless abdomen
 Isolated esophageal atresia: sporadic,
Down’s syndrome
 Severe peritonitis
 Congenital diaphragmatic hernia
(scaphoid abdomen)
 CNS abnormality: intracranial
hemorrhage
 Vomiting
 Paralysis (on ventilator)
Double bubble
 Duodenal atresia/stenosis
 Malrotation with midgut volvulus or
Ladd’s bands
 Duodenal web
 Preduodenal portal vein
 Annular pancreas
 Duodenal duplication
Dilated bowel, newborn
 Intestinal atresia
 Hirschsprung’s disease (partial or total)
 Meconium ileus
 Meconium plug
 Malrotation
 Incarcerated inguinal hernia (thickened
inguinoscrotal fold)
 Intussusception
 Imperforate anus (VACTERL)
 AIM mnemonic: Atresia, Aganglionosis
(Hirschsprung’s disease), Intussusception,
Imperforate anus, Incarcerated inguinal
hernia, Meconium, Malrotation
Bowel obstruction lead point may be due to a
duplication cyst, Meckel’s diverticulum, meconium
ileus, other
Therapeutic enema: meconium ileus, meconium
plug syndrome, intussusception (perform hydrostatic
or air enema if no free air or peritoneal signs)
Bubbly right lower quadrant
 Meconium ileus
 Ileal atresia
 NEC
 Hirschsprung’s disease
Meckel’s diverticulum
 Rule of 2’s:
 2% population
 2x male > female
 2 feet from ileocecal valve
 2 types mucosa (gastric, pancreas)
 2 cm diameter
 You have to look at a SBFT 2x as hard
because it’s 2 fucking small 2 see
Extrinsic rectal mass
 Duplication cyst
 Sacrococcygeal teratoma
 Anterior meningocele
Esophageal stricture
 Caustic ingestion: lye, acid
 Gastroesophageal reflux (barium, 24 hour
pH probe, Tc-labelled sulfur colloid)
 Epidermolysis bullosa (rare)
 Chronic granulomatous disease of
childhood
 S/p esophageal atresia surgery
 NG tube
 Chemotherapy/XRT
Right upper quadrant cystic mass
 Choledochal cyst
 Hydropic gallbladder: Kawasaki’s
disease, prolonged hyperalimentation,
leptospirosis, sepsis
 Duodenal duplication
 Pancreatic pseudocyst: trauma, CF,
steroids, sepsis, hyperlipidemia
 Mesenteric/omental cyst: congenital,
traumatic, infectious, neoplastic
 Ovarian cyst (neonate)
 Hepatic or renal cyst
Focal hepatic lesion
 Hemangioendothelioma (<6 months old;
if thrombocytopenia, DIC: Kassabach-
Merrit syndrome; can cause CHF)
 Hepatoblastoma (< 3 years)
 Hepatocellular carcinoma: chronic
hepatitis, cirrhosis, glycogen storage
disease, Wilson’s disease, tyrosinemia (>
5 years)
 Mesenchymal hamartoma (cystic),
undifferentiated embryonal sarcoma
(cystic, older child/adolescent)
Adrenal masses
 Hemorrhage: birth trauma, maternal
diabetes, hypoxemia, hypovolemia
 
Pheochromocytoma: MEN syndrome, von
Hippel-Lindau disease, NF-1
 Adrenal carcinoma
 Adenoma
 Neuroblastoma (if VIP, Verner-Morrison
syndrome)
 Teratoma (retroperitoneal)
 Abscess
Adrenal calcification
 WHAT mnemonic:
 Waterhouse-Friedrickson disease,
Wolman’s syndrome (AR, lipoidosis,
fatal)
 Hemorrhage
 Addison’s disease: TB adrenalitis
 Tumors: neuroblastoma,
pheochromocytoma, adrenal cortical
carcinoma
Medullary nephrocalcinosis, child
 Lasix
 Barter’s syndrome
 RTA, distal type
 Hyperparathyroidism
 William’s syndrome
 Steroids
 Immobilization
 Hypophosphatasia
Echogenic renal pyramids
 Renal failure with precipitation of Tamm-
Horsfall proteins
 Papillary necrosis
 CMV, candida infection
 Early RVT
Hydronephrosis
 Primary megaureter
 Prune-Belly syndrome (deficient anterior
abdominal wall muscles, urinary tract
dilatation, cryptorchidism)
 Duplicated system with obstructed upper
pole
 Ureteropelvic junction obstruction:
abnormal muscle or fibrosis, crossing Tibial bowing
vessels or bands  NF-1 (anterior bowing)
 Vesicoureteral reflux  Fibrous dysplasia
 Posterior urethral valves  Congenital bowing (posteromedial
bowing)
Start with US, then VCUG to exclude VUR and  Osteofibrous dysplasia
posterior urethral valves in males. Start with NUCS  Generalized dysplasias
study in females, siblings of child with VUR, or as  Osteogenesis imperfecta
follow-up in either sex (1/100th radiation of VCUG)  Hypophosphatasia
 Osteomalacia/rickets
Bilateral enlarged kidneys
 Nephroblastomatosis Slipped capital femoral epiphysis
 Lymphoma (NHL>Hodgkin’s disease)  SHIT mnemonic:
 Autosomal recessive polycystic kidney  Steroids
disease  Hypothyroidism, hyperparathyroidism
 Bilateral Wilm’s tumors (5-10% cases)  Idiopathic
 Leukemia  Trauma
Cystitis, child Wormian bones
 Hemorrhagic (E. coli)  I CHOP PORK mnemonic:
 Cytoxan  Idiopathic (NL until 1y/o)
 Bacterial  Cleidocranial dysplasia
 Eosinophilic cystitis (due to allergy,  Hypothyroidism
parasite, idiopathic; mimics  Osteogenesis imperfecta
rhabdomyosarcoma)
 Pyknodysostosis, progeria
 Pachydermoperiostosis
Bladder mass, child
 Otopalatodigital syndrome
 Rhabdomyosarcoma
Rickets (healing)
 Hemangioma
 Kinky hair syndrome (Menke’s)
 Neurofibroma
 Down syndrome
 Pheochromocytoma
 Eosinophilic cystitis (due to allergy,
Elbow ossification centers (age)
parasite, idiopathic; mimics
 CRITOE mnemonic:
rhabdomyosarcoma)
 Capitellum (1)
Periosteal reaction  Radial head (5)
Physiologic  Internal (medial) epicondyle (7)

PGE2  Trochlea (7)

Metastatic disease: neuroblastoma,  Olecranon (11)

retinoblastoma  External (lateral) epicondyle (12)
 Caffey’s disease
Syphilis (Wimberger’s sign, medial Polydactyly

proximal tibia)  LETS mnemonic:
Prostaglandin therapy  Laurence-Moon-Biedl syndrome

Scurvy (white line of Frankel,  Ellis van Creveld syndrome

Trummerfeld lucent band, Pelekan beak,  Trisomies 13, 18
Wimberger ring)  Simple polydactyly
 Hypervitaminosis A
Trauma: child abuse Miscellaneous facts:

Leukemia 2. Meconium ileus and ileal atresia look alike

radiographically, but air-fluid levels are often
 Osteomyelitis
present in the latter
 SCALP mnemonic: Scurvy, syphilis,
3. Meconium plug syndrome can be seen in CF,
Caffey’s disease, child abuse,
Hirschsprung’s disease, maternal MgSO4 and
hypervitaminosis A, leukemia,
diabetes
physiologic
4. If the descending right pulmonary artery is
wider than the trachea, suspect shunt
Vertebra plana
vascularity
 Langerhan’s cell histiocytosis 5. Membraneous croup (bacterial tracheitis) is
 Leukemia (ALL)/lymphoma usually caused by staphylococcus
 Idiopathic juvenile osteoporosis 6. Legg-Calve-Perthes disease is idiopathic AVN
 Infection: TB of the femoral heads. It is bilateral in 10%
 Steroids: exogenous, Cushing’s syndrome cases. Differential includes hypothyroidism,
 Trauma osteomyelitis. Treatment is aimed at
 Metastases: neuroblastoma containment of the femoral heads in the
acetabulum, either by casting or an abduction
Radial ray anomalies (absent radius) brace. Alternatively, a varus osteotomy and/or
 Thrombocytopenia with absent radius shelf acetabuloplasty can be performed
syndrome (TAR syndrome, check for 7. SCFE is bilateral in 20% cases, especially those
intracranial bleed) of endocrine etiology (hypothyroidism, growth
 Fanconi’s anemia (+/- thumb) hormone deficiency). Can also be due to
 Holt-Oram syndrome trauma, overweight, idiopathic. AVN and
 Cornelia De Lange chondrolysis are known complications of SCFE
 Myositis Ossificans progressiva 8. A toddler fracture can occur in the distal tibia,
 Dystrophic dwarfism calcaneus, cuboid
9. Tarsal coalition of the talocalcaneal type
usually occurs at or just posterior to the
sustentaculum tali (at the middle facet)
10. Duodenal atresia is most likely due to failure
of recanalization at 12 weeks in utero
11. A button battery in the stomach may leak
alkali or cause electrolysis. If it has been
present >48 hours, it should be removed
12. Treatment with pancreatic enzymes in CF
may cause strictures in the terminal ileum or
cecum
13. An antrochoanal polyp starts in the maxillary
sinus and extends into the nasopharynx,
resulting in mastoid opacification and a wide
ostium
14. A juvenile nasal angiofibroma usually
involves the pterygopalatine fossa, and it can be
preoperatively embolized with PVA
15. Do not perform a contrast enema in a patient
with intussusception if there is free air,
peritonitis, shock. The pressure method has a
better successful reduction rate, but increased
perforation rate. Most cases that recur do so in
the first week. Only 7% fail to reduce
16. Polysplenia may be associated with ASD,
VSD, pAPVR, whereas asplenia tends to have
severe CHD (common atrium, single ventricle,
TGV)
17. With retinoblastoma, there is an increased risk
of osteosarcoma at a later age. A retinal
astrocytoma occurs in TS
18. Retinopathy of prematurity and persistent
primary hyperplastic vitreous both have
micropthalmia
19. Croup typically occurs in children ages 6
months-3 years, while epiglottitis occurs in
children ages 3-6years. For suspected
epiglottitis, a portable lateral ST view of the
neck should be performed with an ER physician
present
20. An extraosseous Ewing’s sarcoma usually
occurs in older children, often in the extremity,
abdomen, chest
21. Most infantile neck hemangiomas regress
spontaneously
22. In patient with TE fistula, it is important to
know side of the aortic arch for surgical
planning (thoracotomy will be on opposite side
of arch)
23. If NEC in first 24 hours of life, consider
hypoplastic left heart
24. Fibromatosis colli (torticolis) develops in
neonate at 2-8 weeks, and may spontaneously
disappear at 4-8 months
25. Hamartoma of the tuber cinerum may
present with precocious puberty, and is
isointense to gray matter on all sequences
26. NF-1 may have an acute angle kyphosis, and
white matter changes which may represent
hamartomas or gliomas. There is an increased
incidence of astrocytomas of the optic nerve,
hypothalamus, cerebellum, brainstem
27. Lissencephaly may be due to STARCH (no
severe genetic defects) or a syndrome. Extreme
prematurity can mimic lissencephaly
28. Luckenschadel (lacunar skull) is due to a
mesodermal bone dysplasia (NOT
hydrocephalus) and may disappear by 3-6
months
29. Holoprosencephaly is associated with trisomy
13
30. A solitary sclerotic lesion in the skull may be
an epidermoid inclusion cyst, whereas multiple
punched-out lesions more likely represent EG
31. Chondroblastoma may be curettaged and
filled with bone graft
32. Coronal craniosynostosis (brachycephaly) is
most commonly due to Crouzon’s disease,
Apert’s syndrome. If it occurs only on one side,
it is called plagiocephaly and may be
nonhereditary. The differential is postural
flattening, cerebral hemiatrophy
33. A transtabular prone view shows if an
anorectal malformation is above or below the
pubococcygeal line. If it’s high-intermediate,
then a diverting colostomy and later pull-
through may be performed. If it’s within 1 cm
of the perineum, an anoplasty may be
performed
34. Congenital lobar emphysema is usually
LUL>RML>RUL, and may be associated with
PDA, VSD in 15-30% cases
35. Pulmonary agenesis has no bronchus, while
pulmonary aplasia has a short stump bronchus
36. Intralobar sequestration is probably acquired,
whereas extralobar is more common at birth,
more common in males (4:1), and often (98%)
associated with other abnormalities, such as
CDH, CHD, BP foregut malformation, CCAM
37. A bowel loop is dilated if it is greater than one
vertebral body wide
38. Gray matter heterotopia can be focal
subcortical, subependymal, band-like
39. Vein of Galen malformation can be treated by
both arterial/venous embolization
40. The Currarino triad is an anorectal
malformation, presacral mass, sacral deformity
41. The clinical triad of tuberous sclerosis is
adenoma sebaceum, mental retardation, seizure
disorder
42. Leigh’s disease (subacute Necrotizing
encephalomyelopathy) is the end-stage of many
disease processes, and results in increased T2
signal in the BG, thalamus, dorsal midbrain,
cerebral peduncles
43. Septic joint occurs at 6 mos–2 years, whereas
Legg-Calve-Perthes disease occurs at 4-8 years.
Transient (toxic) synovitis is a diagnosis of
exclusion
44. Hypophosphatasia consists of osteopenia,
wide physis with “scooped out” metaphysis,
and pathologic fractures
45. Congenital tibia vara (Blount’s disease)
occurs in obese black children. The
tibiofemoral angle is >150
46. Fong’s disease is iliac horns,
hypoplastic/absent patellae, nephropathy, elbow
deformity, nail dysplasia
47. Madelung’s deformity (AD) is progressive
ulnar/volar tilt at the distal radial epiphysis
articular surface with dorsal subluxation of the
distal ulna. This is seen in Hurler’s disease,
infection, trauma, osteochondromatoses
48. For meconium aspiration, check humeral
ossification centers suggesting post-maturity.
These babies will have asymmetric
consolidation, air trapping,
PTX/pneumomediastinum
49. Exogenous surfactant may look like
pneumonia because of asymmetric clearing of
HMD. The differential is HMD, neonatal
pneumonia (GBBS, CMV, listeria), pulmonary
edema, sepsis, hemorrhage
50. The four-vessel sign indicates a double aortic
arch, with carotid arteries being more anterior
than the subclavian arteries
51. Retained fetal lung fluid occurs in premies, c-
section (no squeeze), and precipitous delivery,
and should clear by 1-3 days. May cause
hyperinflation. Differential includes neonatal
pneumonia, meconium aspiration, heart failure,
pulmonary lymphangiectasia, pulmonary edema
52. Hyaline membrane disease (HMD) causes
granular appearance of the lungs with
symmetric underinflation. If asymmetric, then
consider superimposed pneumonia
53. Steroids mature type 2 pneumocytes and
decrease thymus size, so premies without a
thymus should NOT have HMD. Consider
GBBS (look for a pleural effusion, which
should NOT occur in uncomplicated HMD)
54. Foreign body aspiration usually occurs
between 6 months-3 years of age, and should be
considered in any child with wheezing,
pneumonia, hemoptysis unresponsive to
treatment
55. Meconium aspiration, neonatal pneumonia,
retained fetal lung fluid look alike on initial
CXR
56. If a typical Wilm’s tumor is present, but there
are bone metastases, consider Clear cell tumor
of the kidney. If there are CNS metastases,
consider Rhabdoid tumor of the kidney
57. In congenital clubfoot, the talus and calcaneus
assume a more parallel configuration with a
decreased talocalcaneal angle. Normally the
calcaneus lines up with the base of the fourth
metatarsal, while the talus lines up with the
base of the first metatarsal. In the less common
congenital vertical talus, the talocalcaneal angle
is increased
58. A Whitiker test allows you to simultaneously
check pressure of the upper collecting system
and bladder during a controlled percutaneous
antegrade infusion of the upper collecting
system
59. UPJ obstruction may be due to crossing
vessels, bands, ureteral kinking, functional
muscle abnormality, stenosis, polyp
60. Bladder diverticula in children may be due to
neurogenic bladder, Prune Belly syndrome,
posterior urethral valves. Differential includes
ovarian cyst, seminal vesicle cyst, ascites,
pseudocyst secondary to VP shunt
61. ADPCKD may be unilateral, and the
differential includes tuberous sclerosis,
Turner’s syndrome
62. ARPCKD can look like nephrocalcinosis.
Check the liver for dilated ducts (ARPCKD) to
help differentiate
63. Megacystis-microcolon-intestinal-
hypoperistalsis syndrome is likely related to
degenerative smooth muscle disorder
64. Cellules are created by mucosal protrusions
into hypertrophied bladder wall muscle
65. Infection or obstruction is necessary for a
renal scar to form. Acute pyelonephritis poses a
greater risk than VUR for scar formation
66. If there is urinary ascites, check for posterior
urethral valves. Valve ablation can be
performed. If the patient is too young and the
scope won’t pass, do temporary urinary
diversion
67. Primary megaureter is more common in
males and on the left side. It’s bilateral in 20%,
or may be associated with contralateral renal
agenesis in 9% cases
68. Consider Noonan’s syndrome (male Turner’s
syndrome) when lymphatic disorder is
identified in a newborn. May occur with
pulmonary stenosis instead of coarctation of the
aorta
Differential Diagnoses
Ultrasound
First trimester bleeding
 NL IUP: subchorionic hematoma
  Abortion
 Early pregnancy failure (anembryonic
pregnancy)
 Ectopic pregnancy
 Gestational trophoblastic disease
 For first trimester, always localize the
GS, take standard measurements of
embryo/fetus, check for fetal cardiac
motion, document the number of fetuses,
evaluate the uterine anatomy and adnexae
In early pregnancy, MSD + 30 = gestational age
(days). For EV/TA ultrasound, yolk sac seen at
8mm/20 mm MSD, and embryo at 16 mm/25 mm
MSD. If CRL 5mm, cardiac activity should be
present. CRL not used after 13 weeks gestation.
Embryo growth is 1mm/day
A NL gestation will double b-HCG levels every 48
hours, whereas ectopic pregnancies will NOT. Molar
pregnancies have very high b-HCG levels
A double decidual sac is present in an early NL
pregnancy, whereas a pseudogestational sac is
present in an ECTOPIC pregnancy. The ectopic
usually involves fallopian tube, uterus cornua, ovary,
cervix, abdomen (rare)
Monochorionic twins have 1 GS and 2 separate yolk
sacs. Dichorionic twins have 2 GS. Monoamniotic is
both twins in 1 amnion, whereas diamniotic is each
twin having a separate amniotic sac
Determine chorionicity by first checking sex of
twins. If opposite, they are necessarily dizygotic
(dichorionic, diamniotic). If same sex, determine
number of placentas. If two placentas: dichorionic,
diamniotic. If apparent single placenta, check for
“chorionic peak” at intertwin membrane:
dichorionicity. If no intertwin membrane seen:
IUGR
monochorionic, monoamniotic or dichorionic with
oligohydramnios of second twin (stuck) or diamniotic
with nonvisualization of intertwin membrane due to
thinness/position. Twin-twin transfusion occurs in
monochorionic/diamniotic. Cord entanglement
occurs in monochorionic/monoamniotic
Third trimester bleeding
 Placenta abruption: retroplacental
hematoma, subchorionic hematoma
 Placenta previa (mimics: uterine
contraction, overdistended bladder)
 Premature rupture of membranes
In 2nd/3rd trimesters, check for fetal life, number,
and presentation; amniotic fluid volume; placental
location and appearance; assess gestational age;
check uterus and adnexae; evaluate fetal anatomy
Most accurate US parameters by dates
 1st trimester: CRL (<13 weeks)
 2nd trimester: BPD
 3rd trimester: FL, others
Elevated maternal serum a-fetoprotein [>2.5
multiples of the mean (MOM)]
 Incorrect dates: actual age of fetus is older
 Twin gestation
 Fetal demise
 Fetal abnormality: neural tube defect,
abdominal wall defect, teratoma, cystic
hygroma, hydrocephalus, Dandy-Walker
malformation, esophageal atresia,
duodenal obstruction, renal abnormality
 NL variant
 GE MINER CO mnemonic:
Gastroschisis, Esophageal atresia,
Multiple gestations, Incorrect dates (most
common), Neural tube defects, Error by
lab, Renal disease (polycystic kidney
disease, obstruction, dysplasia, congenital
nephrosis), Chorioangioma, Omphalocele
Decreased AFP
 Trisomies
 Molar pregnancy (no fetal tissue)
 Fetal demise
 Misdated pregnancy
 NL variant
HC:AC should be 1.2 in 2nd trimester, 1.0 in 3rd
trimester. This is abnormal in maternal diabetes
(macrosomia), asymmetric IUGR, abdominal mass,
CHD, hydrocephalus, microcephaly or anencephaly
Oligohydramnios
 Fetal demise
 GU abnormality: posterior urethral valves, Abnormal placental echotexture
bilateral renal agenesis, ARPCKD,
bilateral MCDK, unilateral MCDK with
contralateral agenesis or UPJ obstruction
 IUGR
 Post-dates pregnancy
 Premature rupture of membranes
 Syndromes
 DRIPPS mnemonic: Demise, Renal
abnormality, IUGR, Post-dates,
Premature rupture of membranes,
Syndromes
Suspect IUGR if interval growth less than expected
compared to prior study, size less than dates and fetal
weight <10%ile, significantly smaller fetal abdomen
compared to other measurements
 Symmetric (early insult): STARCH,
congenital heart disease, chromosomal
abnormality
 Asymmetric (late insult): uteroplacental
insufficiency, maternal smoking, HTN,
collagen vascular disease, poor nutrition,
ETOH
Polyhydramnios
 Idiopathic (60%)
 Maternal diabetes, Rh incompatibility
 Fetus unable to swallow: CNS
abnormality, cleft lip/palate, facial tumor
 Swallowed fluid meets obstruction:
esophageal atresia (VACTERL), duodenal
atresia (Down syndrome), small bowel
obstruction; intrathoracic mass (CCAM,
congenital diaphragmatic hernia), short-
limed skeletal dysplasia, non-immune
hydrops (arrhythmia, STARCH,
chromosomal abnormality)
 Twin gestation
 TARDI mnemonic: Twins, twin-twin
transfusion syndrome, Anomalies (CNS,
GI), Rh incompatibility (hydrops),
Diabetes, Idiopathic
AFI index: sum of largest AP fluid pockets in each
of the four quadrants. Range of NL is 5-24 cm.
Abnormal is >8cm or <2 cm in any quadrant
Discriminatory b-HCG levels to identify IUP
Endovaginal US: 1000
Transabdominal US: 1800
Umbilical artery S/D ratio should decrease over the
course of the pregnancy, being <3.0 at 30 weeks. If
greater, it raises the possibility of IUGR. Reversal of
diastolic flow is an ominous sign. The placental end
is low resistance and is the desired location to
sample, or use the free cord. The fetal end is high
resistance. Fetal arrhythmia and breathing attempts
can change the doppler signal
Umbilical cord should have three vessels (2 arteries,
1 vein) and Wharton’s jelly. If two vessels, increased
risk of chromosomal abnormality. A cord cyst can
occur normally in 1st trimester, but if it is seen later,
look for other anomalies. Hemangiomas occur at
placental end, teratomas are rare, and hematomas can
be seen after cord manipulation
Early ultrasound milestones
 Week 5: gestational sac
 Week 5.5: yolk sac
 Week 6: fetal pole, cardiac activity
 Clinically insignificant sonolucency:
venous lake, subchorionic fibrin
deposition, cystic degeneration,
intervillous thrombosis
 Infarct (usually not seen)
 Hematoma: retroplacental, subchorionic,
preplacental (Breus mole)
 Chorioangioma (at cord insertion)
 Infection
 Molar pregnancy
 Hydrops
 Placental maturation (accelerated
calcification of cotyledons): maternal
smoking, hypertension
 Mimics: uterine contraction, prominent
basal myometrial vascularity
Central placental thickness (mm): should be
<gestational age (weeks) + 10
Placental grading
 0: homogeneous, no Ca++ (1st trimester)
 1: scattered small Ca++ (2nd trimester)
 2: basilar plate Ca++ at junction of
placenta/uterus (>30 weeks)
 3: Cotyledons or calcified compartments
(rare before 36 weeks. If present <36
weeks, suspect IUGR, maternal HTN,
oligohydramnios)
Echogenic mass next to fetus
 Molar pregnancy & NL twin
 Partial molar pregnancy
 Chorioangioma
 Leiomyoma
 Abruptio placenta
Persistent transverse lie
 Fetal mass: sacrococcygeal teratoma
 Leiomyoma
 Placenta previa
 Nuchal cord tethering fetus
 Roomy multiparous uterus
Lower uterine segment abnormality
 Placental previa: complete (symmetric,
asymmetric), partial, marginal
 Myometrial contraction
 Placenta accreta
 Leiomyoma
 Cervical change: shortening <2.8 cm
(premature labor, cervical incompetence)
 Vasa previa
Obstructed uterus
 Stricture: cervical stenosis
 Cervical/endometrial cancer
 Submucosal leiomyoma
Cervical cancer risk factors include HPV/HSV
infection, increased number of partners (sexual not
dance), immunosupression
Fetal ventriculomegaly
 Communicating hydrocephalus: infection,
hemorrhage (immune thrombocytopenia,
severe maternal stress)
 Non-communicating hydrocephalus:
Chiari 2, Dandy-Walker malformation,
aqueductal stenosis, mass (vein of Galen
malformation, teratoma, arachnoid cyst)
 Destruction: porencephaly (parenchymal
hemorrhage, infarction), hydranencephaly
 Malformation: holoprosencephaly,
megalencephaly, white matter dysgenesis,
agenesis of corpus callosum, neuronal
migration abnormality
 NL variant (isolated mild
ventriculomegaly)
Fluid-filled fetal skull
 Massive hydrocephalus (dangling choroid
plexus)
 Hydranencephaly
 Holoprosencephaly
Fetal supratentorial lesion
 Tumor (rare): teratoma, PNET, glioma)
 Hemorrhage: fetal stress (maternal
surgery, burns, acute illness), immune
thrombocytopenia
 Arachnoid cyst
 Vein of Galen malformation
 High riding third ventricle (agenesis of
corpus callosum)
 Choroid plexus cyst: trisomy 18,
transiently NL variant
Fetal posterior fossa abnormality
 Effaced cisterna magna: Chiari
malformation
 Large cisterna magna: Dandy-Walker
malformation, arachnoid cyst, cerebellar
hypoplasia [<24 weeks transverse
measurement of cerebellum (mm) equals
gestation age (weeks)], mega cisterna  Apparent urethral obstruction: posterior
magna urethral valves, caudal regression anomaly
 NL cerebellar vermis is echogenic! (VUR), urethral atresia (male or female),
megacystis-microcolon-intestinal-
Choroid plexus cysts may be seen in NL fetuses, but hypoperistalsis syndrome, persistent
also in up to 25% Trisomy 18 cases. If >1.0 cm, cloaca (female, VUR)
bilateral, and other abnormalities present, recommend
an amniocentesis Grades of Vesicoureteral Reflux
Nuchal thickening/abnormailty (>6mm, measured
at cavum septum pallucidi and cisterna magna)
 NL variant
 Chromosomal abnormality: trisomy 21,
Turner’s syndrome
 Cystic hygroma: Turner’s syndrome
 Encephalocele: occiput, frontal bone,
parietal bone; off-midline with amniotic
band syndrome
 Soft tissue mass: hemangioma, teratoma,
thyroid goiter
Standard fetal measurement levels
 BPD: third ventricle, thalamus
 HC: occipital horns, thalamus
 AC: left portal vein, stomach
 FL: should exclude distal femoral point
(cartilaginous epiphysis)
Fetal chest mass Measurement of NL renal pelvis: <4 mm before 33
 CCAM weeks gestation, <7 mm after 33 weeks gestation; If
 Congenital diaphragmatic hernia abnormal, follow up at 3-4 weeks; if abnormal in
 Bronchopulmonary sequestration third trimester, follow up postnatally. The renal
(extralobar only) pelvis should be <50% transverse diameter of the
 Bronchial atresia (left upper lobe) kidney
 Teratoma (pericardial sac)
 Neuroblastoma (rare) Uterus surrounded by ill-defined material in cul-
de-sac or adnexae (“Frozen Uterus”)
Fetal abdominal wall abnormality  Pelvic abscess, hemorrhage
 Omphalocele  Endometriosis
 Gastroschisis  Ectopic pregnancy
 Amniotic band syndrome  Ovarian cancer, other carcinomatosis
 Limb-body wall complex (lateral  Exophytic leiomyomata
chest/abdomen defects, short umbilical
cord) Large premenopausal uterus (>10 x 5 x 5 cm)
 Pentralogy of Cantrell  Congenital malformation: bicornuate,
didelphys, septate
Echogenic fetal bowel  Leiomyomata
 Down syndrome  Adenomyosis
 IUGR  NL variant
 Fetal demise
 Intraluminal hemorrhage
Cysts in fetal abdomen
 Posterior midabdomen (touches spine):
hydronephrosis, urinoma (kidney
displaced anteromedially), MCDK
 Anterior abdomen: choledochal cyst
(touches porta hepatis), duplication cyst,
meconium pseudocyst, dilated bowel,
urachal cyst (bladder dome), fluid in
mesenteric/omental leaves
 Pelvis/lower abdomen: ovarian cyst,
hydrometrocolpos (tubular),
sacococcygeal teratoma
 NL third trimester colon
Fetal ascites
 Urinary source
 Bowel rupture Thickened endometrium
 Hydrops  Secretory phase of menstrual cycle (NL
<15 mm)
Fetal hydronephrosis  Pregnancy related: IUP (double decidual
 UPJ obstruction sac), ectopic pregnancy
 Apparent UVJ obstruction: ectopic (pseudogestational sac), GTD
ureterocele, megaureter, VUR (hydatidiform mole, invasive mole,
 choriocarcinoma), retained products of  To-and-fro flow at aneurysm neck
conception Abnormality in testis, not definitely a mass
 Hyperplasia  Tumor Rotator cuff US findings (axial & sagittal images)
 Polyp  Infarct  Preserved anterior echogenic arc
 Carcinoma  Abscess  A partial thickness tear shows an
 Endometritis  Tubular ectasia of rete testis intratendinous hypoechoic area or
 HRT, tamoxifen  Sarcoidosis dominant echogenic focus, whereas a full
thickness tear shows discontinuity and
Cystic adnexal mass Diffuse abnormal testicular parenchyma loss of the echogenic arc. A massive tear
 Physiological ovarian cyst: follicular,  Atrophy: prior torsion, inflammation shows non- visualization of the tendon
corpus luteum, theca lutein  Torsion with subdeltoid fascia approximating the
 Benign neoplasm: dermoid (bilateral 15-  Orchitis humeral head
20%)  Infiltrating tumor: lymphoma/leukemia  Remember: be perfectly perpendicular to
 Malignant neoplasm  Testicular microlithiasis the tendon or the “anisotropy artifact”
 Endometrioma (30-45 y/o) may occur, creating a hypoechoic focus
 Hydrosalpinx, pyosalpinx Hepatic visceral echogenic foci that mimics a tear
 Paraovarian cyst, lymphocele  Prior infection: TB, histoplasmosis,
CAROTID DOPPLER PARAMETERS
 Peritoneal inclusion cyst disseminated PCP, MAI, CMV
Peak Systolic Velocity values (cm/sec)
 Ectopic pregnancy  Intrahepatic ductal stones: recurrent
NL Mild Mod Severe Critical
 Abscess (TOA or regional process such as pyogenic cholangitis, Caroli’s disease
0% 1-39% 40-59% 60-79% 80-99%
appendicitis, Crohn’s disease,  Pneumobilia: incompetent sphincter of <110 <110 <110 >130 >250
diverticulitis) Oddi, surgery, erosion into common bile Peak Systolic Velocity ratios (VICA/VCCA)
duct by stone/ulcer <1.8 <1.8 <1.8 >1.8 >3.7
Solid-appearing adnexal mass  Portal venous gas: pneumatosis
 Exophytic leiomyoma intestinalis (high amplitude spikes on At the carotid bifurcation, the ECA is located
 Ovarian torsion doppler exam) anteromedially, and is a high resistance vessel with
 Hemorrhagic cyst  Hepatitis (portal triads stand out in relief) multiple branches. The ICA is located
 Endometrioma (30-45 y/o) posterolaterally, and is a low resistance vessel
 Abscess Hyperechoic hepatic metastases (mucinous, without branches. Try a temporal tap to show
 Ectopic pregnancy calcified) changes in ECA waveform if confused
 Dermoid  Colon
 Solid ovarian tumor: primary (fibroma,  Ovary The NASCET trial (North American Symptomatic
adenofibroma, thecoma, Brenner tumor,  Breast Carotid Endarterectomy Trial) said if 70-99%
dysgerminoma); metastatic Krukenberg  Stomach stenosis, patient will benefit from CEA. The CAS
tumor (gastric, colon, pancreas (Asymptomatic Carotid Atherosclerosis Study) said if
adenocarcinoma) Thyroid nodule >60% stenosis, patient will benefit from CEA
 Adenoma
Management guidelines for ovarian mass  Carcinoma: papillary, follicular, Parvus-tardus effect is dampening of a distal
Cyst <2.5 cm No F/U medullary, anaplastic, mixed, Hurthle cell (arcuate) arterial waveform due to upstream stenosis.
Cyst 2.5-5 cm F/U 4-6 weeks (follicular subtype) A delayed systolic upstroke [acceleration time (T)
Atyp. cyst <5 cm F/U 4-6 weeks  Colloid cyst, abscess, hematoma >0.08], and slowed time to peak systole suggests
Cyst >5 cm Lap./Surgery  Parathyroid gland: cyst, adenoma RAS. Systolic acceleration <300 cm/sec2 is abnormal.
Any solid mass Lap./Surgery  Metastasis, lymphoma For the main renal artery, peak velocity >180 cm/sec,
and peak renal arterial velocity/aortic velocity ratio
Enlarged ovaries US features of thyroid nodule (benign) >3.5 is also suggestive of RAS
 Stein-Leventhal syndrome  Clearly defined margins
 PID Doppler parameters optimization
 Thin, complete halo
 Metastases Doppler equation: 2fcosVblood/Vsoft tissue
 Solid, hyperechoic
 Lymphoma Goal is to increase frequency shift, achieved by:
 Cystic
 Endometriosis  Using highest frequency transducer
 Peripheral eggshell calcification
 Optimizing angle of interrogation (<600)
Acute pelvic pain, reproductive age female US features of thyroid nodule (malignant)  Decreasing PRF (scale), but not too low to
 Ectopic pregnancy cause aliasing. PRF must be at least twice
 Poorly defined margins
 Hemorrhagic cyst/endometrioma the frequency you are sampling (Nyquist
 Hypoechoic
theorem – thanks Helena!)
 Ovarian torsion  Microcalcifications
 Decreasing wall filter
 PID/TOA, appendicitis  Cervical adenopathy
 Increasing gain until low level noise
 Red degeneration of a fibroid (often a
occurs, then decrease slightly
pregnant patient) US features of deep venous thrombosis (DVT)
 Enlarged vein, non-compressible, Miscellaneous facts:
Ovarian mass in an older patient is more suspicious echogenic thrombus, no flow 1. If the junctional zone is >12 mm, consider
of cancer when doppler shows RI <0.4, PI <1.0. The  Doppler waveform phasicity changes with adenomyosis
Pulsatility index: peak systolic velocity-end diastolic respiration, valsalva, and augmentation 2. Fibroids are classically iso/decreased T1 and
velocity/mean, while the Resistive index: peak (squeezing calf) decreased T2 signal. There may be increased T2
systolic velocity-end diastolic velocity/peak systolic
signal if degenerating
velocity US features of AVF 3. Theca lutein cysts can occur in GTD, NL
 NL gray-scale imaging singleton pregnancy, multiple gestation,
Testicular mass  Localized perivascular tissue vibration Pergonal therapy, and resolve weeks-months
 Tumor: benign (epidermoid cyst);  Localized low-resistance arterial flow post-partum
malignant (seminoma, non-seminoma,  Localized turbulent/arterialized venous 4. With abruptio placenta, once the fetal lungs
lymphoma, metastases such as prostate, flow are mature: deliver
RCC, colon)
5. Ovarian torsion may present as increased
 Cyst (mediastinum, tunica) US features of pseudoaneurysm number of cortical follicles in an enlarged ovary
 Abscess  Swirling luminal flow 6. Stein-Leventhal syndrome may present as
 Hematoma  Variable amounts mural thrombus increased size of ovaries (1/3rd are NL size),
 Adrenal rest  May be multiple loculations
 increased number of cortical follicles, increased
LH:FSH ratio >2:1
7. Sudden increase in size of non-gravid uterus
may be due to sarcomatous degeneration of
leiomyoma (0.5% cases)
8. Peritoneal carcinomatosis mimics include
pseudomyxoma peritonei, lymphoma, TB,
malignant mesothelioma
9. A malignant teratoma usually has more soft
tissue and scattered Ca++
10. Leiomyomata respond to GNRH by decreasing
size or bleeding (treat anemia)
11. If surgery needs to be performed on mother, it
should be done during the relatively quiescent
second trimester. Tocolytics are used to prevent
premature labor
12. The differential diagnosis for a cervical
ectopic is abortion in progress, nabothian cyst.
Treat ectopic with MTX
13. A two-vessel cord can be seen in trisomies
13/18, twin gestations, NL pregnancies. Also, it
may be associated with renal and cardiac
anomalies
14. Abnormal lower uterine segment may be due
to myometrial contraction, abruptio placenta,
fibroid
15. Risk of cancer is 25% with serous
cystadenoma and 5% with mucinous
cystadenoma. Mucinous tumors can cause
pseudomyxoma peritonei
16. Disparity in twin sizes can occur in twin-twin
transfusion and NL twins
17. Mature cystic teratoma is bilateral in 15%
cases, and can undergo malignant degeneration
in 1-2% cases
18. Salpingitis isthmica nodosum (SIN) has
diverticula and obstruction of fallopian tubes,
often with a history of PID, infertility. It may
cause ectopic pregnancy. TB rarely causes a
similar appearance
19. Overlapping cranial bones suggests fetal
demise
20. A solid ovarian tumor in a young female
suggests dysgerminoma
21. A fetal chylous effusion is more common on
the right
22. A twin pregnancy can be NL twin with mole,
partial molar pregnancy, or NL fetus with
hydrops of the placenta
23. Ovarian granulosa cell tumor (usually B9)
can liberate enough estrogen to cause
endometrial hyperplasia or cancer
24. A fetus begins to make urine at 14-20 weeks
(mean 16 weeks), and thus is the major
contributor to amniotic fluid thereafter
25. Testicular seminomas do NOT have serum
markers, but non-seminomas do
(choriocarcinoma: b-HCG, endodermal sinus
tumor, teratoma, embryonal carcinoma: a-
fetoprotein). A complex mass in the testis is
more likely a non-seminoma
26. Testicular calcifications can be due to burned
out neoplasm, post-infection or inflammation.
Microlithiasis (1-2 mm Ca++) may be associated
with cancer
27. Echogenic debris within the uterus may
represent a missed AB, anembryonic
pregnancy, pseudogestational sac
28. In a postmenopausal female on HRT, the
endometrial stripe should be <12 mm
29. GTD and retained products of conception are
indistinguishable on US
30. On MRI, the cervix should have a dark
complete stromal ring; if it’s incomplete suspect
cancer
31. On US, if the hypoechoic inner myometrium
is incomplete, suspect endometrial cancer
32. Aldosteronism is caused by adenoma (70%
cases, surgery) and hyperplasia (30% cases,
medical therapy)
33. Adrenal hemorrhage can be due to trauma
(R>L), anticoagulation, adrenal venography,
spontaneous (sepsis, surgery, burns, neoplasm)
34. The portal vein normally measures <13 mm,
and has a NL velocity of >15 cm/sec. In TIPS,
the peak systolic velocity should be 90-200
cm/sec in the shunt. If <90 or >200, or there is a
change of 50 cm/sec from baseline, then
consider shunt malfunction. In TIPS, the native
PV peak systolic velocity should be >30
cm/sec. Stenosis occurs more commonly at the
hepatic vein end
35. The hepatic vein has a triphasic waveform
with 2 periods forward and 1 reverse (due to
atrial contraction)
36. US-guided biopsies of the prostate gland are
sextant, done randomly in the peripheral zone,
apex, base
37. One may see hepatofugal vessels in portal
vein tumor thrombus
38. Hepatic veno-occlusive disease may be due to
chemotherapy in BMT patients or paroxysmal
nocturnal hemoglobinuria
39. Hypoechoic renal lesions in children may
represent nephroblastomatosis, Wilm’s tumor,
lymphoma
40. There may be increased flow in a recent
detorsion of the testis
41. A seminal vesicle cyst may be associated with
unilateral renal agenesis
42. Post-transplant hepatic arterial thrombosis
and stenosis both cause biliary dilatation
43. Hepatic venous waveforms are triphasic with
NL reversal of flow (below baseline). A blunted
hepatic venous waveform is non-specific and
can occur in cirrhosis, Budd-Chiari syndrome,
or any parenchymal disease
44. The fetal kidneys grow 1 mm for each week
gestation, typically measuring 3.5-5 cm at birth.
The renal pyramids should be relatively
hypoechoic at birth
Differential Diagnoses
GU Radiology
Small kidney, unilateral*
 Chronic RAS, RVT
 Chronic obstruction, VUR
 Chronic radiation nephritis
 Chronic amyloidosis (rare)
 Congenital: hypoplasia, MCDK (adult)
 Page kidney
*Notice the word Chronic in the above section
Small kidneys, bilateral
 Chronic medical renal disease: HTN
nephrosclerosis, chronic
glomerulonephritis, bilateral RAS,
analgesic nephropathy
Large kidney, unilateral*
 Acute RVT
 Acute pyelonephritis
 Acute hydronephrosis: VUR, obstruction,
megaureter, residual hydronephrosis after
correction of VUR/obstruction
 Acute trauma: hemorrhage (subcapsular,
intraparenchymal)
 Ureteral duplication
 Compensatory hypertrophy
 Xanthogranulomatous pyelonephritis
 Neoplasm: RCC, lymphoma/leukemia,
myeloma, metastases
 Acute renal infarction, ischemia
 Acute amyloidosis (rare)
 ATN: several chemical and ischemic
causes
*Notice the word Acute in the above section
Large kidneys, bilateral
 Diabetes mellitus (most common)
 Acute glomerulonephritis
 AIDS nephropathy (prognosis <6 months)
 Leukemia/lymphoma
 ARPCKD
 Vasculitis
 Collagen vascular disease
Absent, delayed, or persistent nephrogram
 Vascular: infarction, ischemia, renal vein
thrombosis
 Hypotension: severe cardiac disease,
trauma, contrast reaction
 ATN, glomerulonephritis (post-
streptococcal, IgA nephropathy,
Goodpasture’s syndrome), pyelonephritis
 Obstruction
 Agenesis
Delayed nephrogram by location
 Pre-renal: RAS, renal artery dissection,
hypotension
 Renal: ATN, glomerulonephritis
 Post-renal: RVT, obstruction
Striated nephrogram
 Acute pyelonephritis
 Acute RVT
 Acute obstruction
 Contusion
 XRT nephritis
 ARPCKD
A shock nephrogram is a persistent dense
nephrogram at 10 minutes with loss of pyelogram (it
drains into bladder but no more contrast is filtered
through the kidney)
If patient having anaphylactic reaction, call a code
and administer epinephrine (1:10,000) 3 cc IV. The
other dilution (1:1000) is given 0.3 cc IM. If
vasovagal reaction, raise feet, start IV fluids, consider
administering atropine 1 mg IV
Solitary cystic renal mass
 Simple cyst (cortical, sinus)
 Calyceal diverticulum
 Papillary necrosis cavity (focal or
multifocal)
Multiple bilateral renal cysts
 ADPKD (cysts in liver, pancreas, thyroid,
testes, seminal vesicles, ovaries)
 Von Hippel-Lindau disease (RCC,
pheochromocytoma, cerebellar/spinal
hemangioblastoma, retinal angioma,
pancreas cysts, islet cell tumor,
epididymal cystadenoma
 Tuberous sclerosis (AML, cysts)
 Acquired renal cystic disease of uremia
(RCC, cysts)
Bosniak CT renal cyst classification scheme

1 (Simple benign cyst, 0-1% risk): <20
HU, no enhancement (<10 HU), sharp
margination, no wall thickness or Ca++

2 (Minimally complicated cyst, 5-10%
risk): septae <2 mm, fine Ca++, no
enhancement, some hyperdense cysts (<3
cm, 25% extending outside of kidney,
homogeneous)

2F (Cyst that requires follow-up): Some
hyperdense lesions, more Ca++ in wall,
slightly more complicated. Do 3-, then 6-,
then 12-month follow-up.

3 (Moderately complicated cyst, 50%
risk): thick/nodular septae, multiloculated,
irregular Ca++, non-Bosniak 2 hyperdense
cyst, minimal enhancement (MLCN)

4 (Cystic carcinoma, >95% risk): irregular
margins, solid vascular element,
enhancement
Complex renal mass
 Complicated cyst: hemorrhage, infection,
both
 Abscess
 Hematoma: neoplasm (RCC, AML),
trauma, anticoagulation, bleeding
diathesis
 Cystic RCC
 Multilocular cystic nephroma (male child,
female adolescent/adult)
Solid renal mass
 Benign neoplasm: AML, oncocytoma
 Malignant neoplasm: RCC, invasive
urothelial tumor (TCC, SCC,
adenocarcinoma), lymphoma (multiple,
solitary mass), metastases
 Inflammation/infection: focal
pyelonephritis, xanthogranulomatous
pyelonephritis (focal, diffuse)
 Hematoma: neoplasm (RCC, AML),
trauma, anticoagulation, bleeding
diathesis
Stages of Renal Cell Carcinoma
 1: confined to renal capsule
 2: confined to Gerota’s fascia
 3: extension into renal vein/IVC (3A),
regional LNs (3B), or both (3C)
 4: extension into adjacent organs (4A),
distant metastases (4B)
Synchronous TCC: 30% collecting system/renal
pelvis TCC multiple at diagnosis. Only 2-3% of
bladder TCC multiple at diagnosis
Metachronous TCC: 40-80% upper tract TCC will
at some time develop tumor elsewhere
Renal cortical calcification (nephrocalcinosis)
 Acute cortical necrosis: pregnancy,
ischemia, burns, sepsis, toxins, transfusion
reaction, dehydration, peritonitis
 Hereditary chronic nephritis (Alport’s
syndrome)
 Chronic glomerulonephritis: post-
streptococcal, IgA nephropathy,
Goodpasture’s syndrome
 Oxalosis: IBD, short-gut syndrome
 Chronic transplant rejection
Renal medullary calcification
 Hypercalcemic states:
hyperparathyroidism, paraneoplastic
syndromes, sarcoidosis, milk-alkali
syndrome, hypervitaminosis D
 Distal renal tubular acidosis type 1
 Medullary sponge kidney
 Oxalosis: IBD, short-gut syndrome
 Papillary necrosis
Collecting system/ureteral filling defects
 Urothelial carcinoma (TCC, SCC,
adenocarcinoma)
 Metastases
 Leukoplakia (bladder > collecting
system/pelvis > ureter): infection, stone
 Malacoplakia (bladder > ureter >
collecting system/pelvis): diabetes
 Ureteritis cystica: infection, stone, stent
 Fungus ball: diabetes, indwelling catheter,
immunocompromised state
 Collateral vessels: RAS or occlusion,
RVT or compression, RCC with
recruitment of vessels
 Urolithiasis
 Blood clot: tumor, trauma, stone
 Papillary necrosis (sloughed papilla)
Papillary necrosis
 POSTCARD mnemonic:
 Pyelonephritis (child)
 Obstruction
 Sickle cell anemia
 TB
 Cirrhosis
 Analgesics: phenacetin
 RVT
 Diabetes mellitus
Echogenic kidneys, bilateral
 AIDS
 Glomerulonephritis
 Goodpasture’s syndrome
 SLE
 Diabetes mellitus
Collecting system/ureteral dilatation
 Obstruction: stone, urothelial tumor,
papillary necrosis, fungus ball, blood clot,
UPJ/UVJ, extrinsic mass, stricture,
ureterocele, upper pole moiety of
duplicated system, Fraley syndrome,
endometriosis, retroperitoneal fibrosis
 VUR
 Megaureter
 Pregnancy: hormonal, obstructive
 Residua from prior obstruction or reflux
Collecting system/ureteral narrowing
 Extrinsic: endometriosis (bladder >
ureter), renal sinus lipomatosis (elderly,
obesity), renal sinus cyst (parapelvic,
peripelvic), retroperitoneal fibrosis,
neoplasm/adenopathy
 Stricture: radiation,
infection/inflammation, stone, trauma,
surgery/instrumentation
 Infection: TB, shistosomiasis (bladder >
ureter)
Medial ureteral deviation
 Iliac adenopathy
 Iliac artery aneurysm
 Retrocaval ureter
 Pelvic lipomatosis
 Pelvic surgery (absent uterus,
rectosigmoid colon)
 Psoas hypertrophy (distal ureters)
 Retroperitoneal fibrosis
Lateral ureteral deviation (>1 cm lateral to
transverse process)
 Aortic aneurysm
 Aortocaval adenopathy
 Pelvic mass
 Psoas hypertrophy (proximal ureters)
Bladder filling defects
 Urothelial carcinoma (TCC, SCC,
adenocarcinoma)
 Leukoplakia (bladder > collecting
system/pelvis > ureter): infection, stone
 Malacoplakia (bladder > ureter >
collecting system/pelvis): diabetes
 Cysitis cystica: infection, stone, stent
 Fungus ball: diabetes, indwelling catheter,
immunocompromised state
 Urolithiasis: stasis (outlet obstruction,
diverticula, neurogenic bladder),
infection, foreign body, migrant renal
stone
 Polyp
 Blood clot: tumor, trauma, stone
 Papillary necrosis (sloughed papilla)
 Benign prostate hypertrophy
 Ureterocele (simple/orthotopic, ectopic)
 Pseudoureterocele (secondary to stone,
tumor)
Small capacity bladder with or without
calcification
 Chronic calcification infection:
shistosomiasis, TB
 Noninfectious cystitis: radiation Bladder,
cervical carcinoma), chemical
(cyclophosphamide), interstitial cystitis
Bladder wall calcification
 SCRITT mnemonic:
 Shistosomiasis
 Cytoxan
 Radiation
 Interstitial cystitis
 TB
 TCC
Male urethra
 Trauma
 Stricture: infection, trauma,
instrumentation (penoscrotal junction),
indwelling catheter (diffuse, focal);
congenital (web-like)
 Carcinoma: SCC (bulbous urethra) > TCC
(posterior urethra) > adenocarcinoma
Urethral trauma
 Type 1: stretch injury only
 Type 2: rupture above UG diaphragm at
prostatomembranous junction
 Type 3: rupture below UG diaphragm at
membranobulbous urethra
Adrenal gland
 Hyperplasia: idiopathic, inborn error of
metabolism, pituitary adenoma (Cushing
disease), ectopic hormone production,
exogenous hormone
 Benign neoplasm: adenoma
(nonfunctioning > functioning),
myelolipoma, pheochromocytoma
 Malignant neoplasm: cortical carcinoma,
metastases, lymphoma
 Hemorrhage (newborn, adults)
  Infection: TB, histoplasmosis,
blastomycosis
Adrenal calcification
 Hemorrhage
 Granulomatous disease: TB,
histoplasmosis, blastomycosis
 Neoplasm: adenoma, carcinoma,
pheochromocytoma, neuroblastoma
(child)
Uterine enlargement or mass
 Leiomyoma: intramural, subserosal,
submucosal (least common)
 Adenomyosis
 Pregnancy
 GTD (hydatidiform mole, invasive mole,
choriocarcinoma)
 Endometrial carcinoma
 Obstruction: cervical tumor/stenosis,
imperforate hymen, vaginal web/atresia
Intrauterine filling defect(s)
 Asherman’s syndrome (synechiae):
surgery, instrumentation, infection,
pregnancy
 Endometrial polyp (single, multiple)
 Endometrial carcinoma
 Submucosal uterine leiomyoma
 Pregnancy
 GTD ((hydatidiform mole, invasive mole,
choriocarcinoma)
Cystic adnexal mass
 Physiological ovarian cyst: follicular,
corpus luteum, theca lutein
 Benign neoplasm: dermoid
 Malignant neoplasm
 Endometrioma
 Hydrosalpinx, pyosalpinx
 Paraovarian cyst
 Peritoneal inclusion cyst
 Ectopic pregnancy
 Tuboovarian abscess
If R/O ectopic exam is indeterminate, follow patient
with serial US and b-HCG levels
Solid-appearing adnexal mass
 Exophytic leiomyoma
 Ovarian torsion
 Hemorrhagic cyst
 Endometrioma
 Abscess
 Ectopic pregnancy
 Dermoid
 Solid ovarian tumor: primary (fibroma,
adenofibroma, thecoma, Brenner tumor);
metastatic Krukenberg tumor (gastric
adenocarcinoma)
Intratesticular mass
 Germ cell tumor
 Stromal tumor: Leydig cell tumor, Sertoli
cell tumor, gonadoblastoma
 Orchitis
 Trauma
 “Burned out” tumor (echogenic focus)
Extratesticular mass
 Epididymitis
 Spermatocele (epididymal head)
 Epididymal cyst (head, body, tail)
 Hydrocele: idiopathic, inflammation,
tumor, trauma, torsion
 Trauma (hematocele)  EG
 Varicocele: idiopathic (left), intra-  Enchondromas
abdominal mass causing venous  Metastases, multiple myeloma
obstruction/compression  Hyperparathyroidism (brown tumors)
 Hernia  Infection
Miscellaneous facts: Lesions without associated pain
1. Risk factors for urothelial tumors include  Fibrous dysplasia
tobacco, benzene compounds  Enchondroma
2. TB causes amputated calyx, infundibular  NOF
stricture, corkscrew ureter, putty kidney  UBC
3. The volume of an ovoid organ can be
determined by using the formula for a prolate Similar appearing lesions
ellipse: l x w x h (0.52). NL prostate volume
 ABC + osteoblastoma
<25 cc
 Chondroblastoma (child, adolescent) +
4. The female urethra more commonly develops
clear cell chondrosarcoma (adult)
diverticula (though rare), which may be
associated with squamous carcinoma  Chondromyxoid fibroma (calcified matrix
is NOT seen) + NOF
5. A small uterus can be seen in DES exposure,
nulliparity, senechiae
Bubbly lesion of bone
6. The peripheral zone of the prostate gland is
 FEGNOMASHIC mnemonic:
where 85% of cancers occur, while only 10%
occur in the transitional zone. The  Fibrous dysplasia
 EG, enchondroma
neurovascular bundles enter/exit
 Giant cell tumor
posterolaterally and are a site of capsular
 NOF
penetration. If the capsule is intact, the
periprostatic fat in symmetric.  Osteoblastoma
7. Prostate cancer in classically hypoechoic on  Metastases, multiple myeloma
US and hypointense on MRI (plasmacytoma)
8. Within the prostate gland, a utricle cyst is  ABC
midline, while an ejaculatory duct cyst is  Simple bone cyst
paramedian. Outside the prostate gland, a  Hyperparathyroidism (Brown tumor),
mullerian duct cyst is midline hemangioma
(posterior/superior)  Infection (Brodie’s abscess,
coccidiodomycosis, cryptococcus)
Differential Diagnoses  Chondromyxoid fibroma,
chondroblastoma
Musculoskeletal Radiology
Ill-defined lytic lesion
ABCD’s of MSK radiology  Metastasis
 Alignment  Multiple myeloma
 Bone mineralization  Ewing’s sarcoma
 Cartilage  Acute osteomyelitis
 Distribution  Eosinophilic granuloma
 Soft tissues  Lymphoma/leukemia
 Telangiectatic osteosarcoma (child,
Well-defined lytic lesion metaphysis)
 Metastasis: thyroid carcinoma, RCC  Malignant fibrous histiocytoma
 Multiple myeloma (plasmacytoma)  Fibrosarcoma (metaphysis)
 Giant cell tumor  Hemangioma
 Enchondroma (digits)
 Clear cell chondrosarcoma Expansive lytic lesion
 Desmoplastic fibroma (desmoid)  Metastasis: thyroid carcinoma, RCC
 Fibrous dysplasia  Multiple myeloma (ribs)
 Brown tumor  ABC
 Hemophiliac pseudotumor  GCT (no sclerosis)
 Subacute osteomyelitis (Brodie’s abscess)  Hemophiliac pseudotumor
 Osteoblastoma  Brown tumor
 Enchondroma: Ollier’s disease, Maffuci’s
disease
Only in patients <30 years of age  NOF
 Aneurysmal bone cyst  Fibrous dysplasia
 Solitary bone cyst
 Nonossifying fibroma Multiple lytic lesions
 Chondroblastoma  Metastases: breast, lung, RCC
 Chondromyxoid fibroma  Multiple myeloma (ribs especially)
 Eosinophilic granuloma  Osteomyelitis (hematogenous)
 Fibrous dysplasia (unilateral polyostotic)
Automatics by age  Brown tumor
 <30 y/o: EG, infection  Eosinophilic granuloma
 >40 y/o: metastases, multiple myeloma,  Lymphoma/leukemia
infection  Enchondroma: Ollier’s disease, Maffuci’s
syndrome
Multiple lesions
 Fibrous dysplasia
Epiphyseal lytic lesion (apophysis)  Stress fracture  Post-traumatic osteolysis
 Geode: OA, CPPD, RA, AVN  Parosteal osteosarcoma  Cleidocranial dysplasia (dysostosis)
 Intraosseous ganglion (classically the  Cortical desmoid (posteromedial  Metastasis, multiple myeloma
medial malleolus) suprachondylar linea aspera of distal  Infection: IVDA
 GCT femur at adductor magnus insertion)  Scleroderma
 Chondroblastoma  Parosteal lipoma (rare)
 Clear cell chondrosarcoma (similar to  Melorheostosis (cortical/endosteal High-riding shoulder (<1 cm from acromion)
chondroblastoma) hyperostosis in a spinal nerve dermatomal  Rheumatoid arthritis
 EG distribution)  Rotator cuff tear
 Infection (Brodie’s abscess)  CPPD
 Brown tumor Diffuse periostitis, adult
 Hypertrophic osteoarthropathy (spares Diaphyseal bone lesions
Red marrow lesions epiphyses): bronchogenic carcinoma,  FEMALE mnemonic:
 Metastases other pulmonary conditions, localized  Fibrous dysplasia
 Multiple myeloma fibrous tumor of the pleura, cardiac  EG
 Ewing’s sarcoma disease, GI conditions  Metastasis
 Lymphoma  Pachydermoperiostosis  Adamantinoma, osteofibrous dysplasia
 Thyroid achropachy (feathery, usually  Lymphoma, leukemia
Well-defined sclerotic lesion after treatment)
 Ewing’s sarcoma
 Metastasis: prostate, breast, bladder,  Venous stasis
colon, carcinoid, Hodgkin’s lymphoma,  Fluorosis Lucent metaphyseal bands
medulloblastoma  Severe illness (defective osteogenesis)
 Bone island Diffuse periostitis, child
 Leukemia
 Osteoid osteoma Physiologic

 Neuroblastoma metastasis
 Osteoblastoma Caffey’s disease

 NL variant
 Mature bone infarct: SCD, SLE Child abuse

 Scurvy (white line of Frankel,
 Enchondroma  Malignancy: leukemia, neuroblastoma Trummerfeld lucent zone, Pelekan beak,
 Low grade chondrosarcoma metastases, multicentric osteosarcoma Wimberger ring)
 Fibrous dysplasia  Congenital syphilis  Congenital infection (STARCH)
 Healing stress fracture (metatarsal shafts,  Hypervitaminosis A (>6 months)  Juvenile chronic arthritis
calcaneous, tibia, femur, pubis, sacrum)  Scurvy (>6 months)  Rickets (physeal widening, metaphyseal
 Involuting lytic lesion: NOF, others  PGE2 cupping/fraying )

Ill-defined sclerotic lesion
 Metastasis: prostate, breast, bladder,
colon, carcinoid, Hodgkin’s lymphoma,
medulloblastoma
 Immature bone infarct/osteonecrosis
 Osteosarcoma (amorphous, cloud-like)
 Chondrosarcoma (rings, arcs)
 Hodgkin’s lymphoma
 Chronic osteomyelitis
 Stress fracture (metatarsal shafts,
calcaneous, tibia, femur, pubis, sacrum
 Paget’s disease (pelvis, femur, spine,
skull, tibia)
Stress fractures: Fatigue or Insufficiency fractures
Lesion with sequestrum
 Osteomyelitis (child)
 EG
 Fibrosarcoma: de novo; Paget’s disease,
chronic osteomyelitis, AVN, radiation
osteitis
 MFH
 Desmoplastic fibroma (mandible, ilium,
long bones)
 Lymphoma
 Metastasis (rare)
 Osteoid osteoma (pseudosequestrum)
Lesions with fluid-fluid levels
 ABC
 GCT
 Chondroblastoma
 Osteoblastoma
 Telangiectatic osteosarcoma
Focal periostitis/cortical hyperostosis
 Osteoma: sporadic, Gardner’s syndrome
 Osteoid osteoma
 Osteoblastoma
 Brodie’s abscess
Excessive callus formation
 Steroids: exogenous, Cushing’s disease
 Inadequate fracture immobilization
 Paralysis: heterotopic ossification in SCI,
neuromuscular disorders
 Osteogenesis imperfecta
 NO SIR mnemonic: Neuromuscular
disorders, Osteogenesis imperfecta,
Steroids, Infection, Reduction (poor)
Erlenmeyer flask deformity (undertubulation)
 Gaucher’s disease (rare)
 Thalassemia, other severe anemias
 Niemann-Pick disease (rare)
 Osteopetrosis (rare)
 Metaphyseal dysplasia: Pyle’s disease
(rare)
Enlarged bone
 Paget’s disease
 NF-1
 Acromegaly
 Hemangioma
 Macrodystrophia lipomatosa (rare)
Short metacarpal/metatarsal
 Idiopathic
 Juvenile chronic arthritis
 Turner’s syndrome
 Pseudohypoparathyroidism,
pseudopseuodhypoparathyroidism
 Trauma
 Sickle cell anemia
Dactylitis
 TB
 Sickle cell anemia
 Psoriasis (sausage digit)
Erosion of distal clavicle
 Hyperparathyroidism
 RA
Juvenile chronic arthritis comprises Still’s disease
(seronegative juvenile-onset RA), juvenile onset
seropositive adult-type RA, seronegative
spondyloarthropathy
Dense metaphyseal bands
 Growth arrest/stress lines
 Heavy metal poisoning: lead, arsenic,
bismuth, mercury
 Osteopetrosis
 Hypothyroidism, hypoparathyroidism
 Hypervitaminosis D
 Leukemia
 Rickets (healed)
 Scurvy (white line of Frankel,
Trummerfeld lucent zone, Pelekan beak,
Wimberger ring)
 Congenital infection (STARCH)
 Osteopathia striata (Vooerhoeve’s
disease): coexists with osteopoikilosis,
melorheostosis, osteopetrosis
Epiphyseal irregularity
 AVN
 Congenital infection (STARCH)
 Hypothyroidism
 Dysplasia epiphysealis multiplex:
chondrodysplasia punctata, Meyer’s
dysplasia
 Spondyloepiphyseal dysplasia
 Trisomy 18, 21 (accessory epiphyses)
 NL variant
Avascular necrosis
 ASEPTIC mnemonic:
 Alcohol
 Sickle cell anemia, SLE, scleroderma
 Exogenous or endogenous steroids
 Pancreatitis
 Trauma
  Idiopathic: Legg-Calve-Perthes disease,  Neuropathic arthropathy: diabetes,  Disuse osteoporosis
Blount’s disease, Keinbock’s disease, syringomyelia, congenital indifference to  Hyperparathyroidism
Panner’s disease (capitellum); Iatrogenic: pain  Paget’s disease (lytic phase)
radiation, steroids  Distal embolism
 Caisson’s disease (the “bends”),  Epidermolysis bullosa (rare) Pseudopermeative pattern with cortical holes
Gaucher’s disease  Congenital erythropoietic porphyria  Hemangioma (ST phleboliths)
 PVC exposure (thumb)  XRT
AVN stages  Pyknodysostosis  Aggressive disuse osteoporosis
 Stage 0: NL imaging  Idiopathic acroosteolysis of Hajdu and
 Stage 1: NL x-ray/abn bone scan & MRI Cheney Permeative lesion
 Stage 2: mixed lysis & sclerosis  Leisch-Nyan syndrome  LEMON mnemonic:
 Stage 3: subchondral lucency  Lymphoma
 Stage 4: fragmentation, collapse Acetabular protrusion  Ewing’s sarcoma, EG
 Stage 5: secondary OA  Osteomalacia, rickets  Multiple myeloma
 RA (severe)  Osteomyelitis
Epiphyseal overgrowth  Ankylosing spondylitis  Neuroblastoma
 Hemophilia  Infection
 Juvenile chronic arthritis  OA (atypical medial migration) Bone bowing
 Paralysis  Paget’s disease  Paget’s disease
 Trauma  Osteogenesis imperfecta
Subchondral cyst  Prosthesis, radiation  Osteomalacia/rickets
 DRIP mnemonic:  Familial acetabular protrusion (Otto’s  Fibrous dysplasia
 DJD disease)  Growth plate injury: trauma (Salter-Harris
 RA 5 fracture), iatrogenic injury (ACL repair)
 Ischemic/avascular necrosis  NF-1 (anterior)
 Pseudogout (CPPD) Diffuse osteosclerosis  Physiologic bowing of tibia
 Metastasis: breast, prostate (posteromedial)
SAPHO: Synovitis, Acne, Pustulosis, Hyperostosis,  Renal osteodystrophy
Osteitis, a chronic disease of relapses/remissions,  Sickle cell anemia Premature closure of physis
occurs in the clavicles of children, and is treated with  Osteopetrosis (sandwich vertebrae, rare)  Trauma: Salter-Harris 5 fracture
NSAIDS. Sacroiliitis occurs in 1/3rd of patients.  Pyknodysostosis  Juvenile chronic arthritis
Simulates Ewing’s sarcoma, EG, osteomyelitis 
 Paget’s disease Hemophilia
 Mastocytosis (rare)  Accelerated skeletal maturation: McCune-
Acroosteolysis
 Myelofibrosis Albright syndrome, hyperthyroidism
 Scleroderma
 Fluorosis
 Injury: frostbite, burns, electrical injury Well-formed bone spurs
 MARBLE mnemonic: Myelofibrosis,
 Hyperparathyroidism  Degenerative enthesopathy
Mastocytosis, Metabolic
 Psoriasis  DISH
(hypervitaminosis D, fluorosis,
 Raynaud’s phenomenon/disease (white, hypothyroidism), Anemia (Sickle cell),  Fluorosis
blue, red): primary, secondary to Renal osteodystrophy, Blastic metastases  Acromegaly
scleroderma, RA, SLE, throacic outlet (breast, prostate), Lymphoma, Enigmas:  Ankylosing spondylitis, other
syndrome, methysergide intoxication, pyknodysostosis, osteopetrosis, seronegative spondyloarthropathies
myxedema, trauma melorheostosis, Paget’s disease, Tuberous
sclerosis Poorly-defined bone spurs
 Psoriatic spondyloarthropathy
Expansive lytic posterior element lesion  Reiter’s syndrome
 Osteoblastoma  Ankylosing spondylitis
 ABC  Avulsion injury
 TB
 EG Monoarticular arthritis
 Trauma
Coarse trabeculation  Infection: pyogenic arthritis (gonococcus,
 Paget’s disease staphylococcus), TB
 Osteopenia  Neoplasm: PVNS (rare), synovial
 Hemangioma osteochondromatosis
 Thalassemia  Inflammatory arthritis: RA, seronegative
 Gaucher’s disease (rare) arthritis, juvenile chronic arthritis
Regional osteopenia  Crystal-induced arthritis: gout, CPPD,
 Disuse osteoporosis calcium hydroxyapatite deposition disease
 Reflex sympathetic dystrophy: trauma,
infection, MI, stroke, calcific tendinitis Purely erosive arthritis
 Arthritis (periarticular osteopenia): RA,  RA
septic arthritis, severe gout, SLE  Pyogenic arthritis (acute)
 Transient regional osteoporosis: transient  TB (indolent)
osteoporosis of the hip, regional migratory
osteoporosis Erosive and proliferative arthritis
 AVN  Psoriatic spondyloarthropathy
 Ill-defined lytic lesion: osteomyelitis,  Reiter’s syndrome
neoplasm (telangiectatic osteosarcoma),  Ankylosing spondylitis (can mimic RA)
lytic phase of Paget’s disease  Juvenile chronic arthritis
 Pyogenic arthritis
Cortical striation/tunneling (rapid bone turnover)
 Thyrotoxicosis Arthritis with preserved joint space
 RSD  Gout (until late)
  TB (indolent course) The anterior talofibular ligament is the most
 Juvenile chronic arthritis frequently injured ankle ligament CREST syndrome
 Hemophilia  Calcinosis
 Amyloidosis  Raynaud’s phenomenon
 Synovial osteochondromatosis  Esophageal dysmotility
 Robust (cystic) RA (young male)  Sclerodactyly
 Reactive synovitis: infections, neoplasms,  Telangiectasia
IBD
Chondrocalcinosis
Accelerated osteoarthritis  CPPD
 Articular trauma  Hemochromatosis
 CPPD, hemochromatosis  Hyperparathyroidism (primary >
 Ochronosis secondary)
 Acromegaly  Gout
 Articular dysplasia: spondyloepiphyseal
dysplasia, multiple epiphyseal dysplasia, Spine spondylolistheses
DDH  Spondylolysis
 Facet degeneration
Destructive arthritis with sclerosis and debris  Degenerative disc disease (retrolisthesis)
 Neuropathic arthropathy: diabetes  Trauma
mellitus, syphilis, syringomyelia, MS,  Ligamentous laxity: Marfan’s syndrome,
leprosy, congenital indifference to pain Ehlers-Danlos syndrome
 CPPD
 Chronic pyogenic arthritis Atlantoaxial subluxation
 Ochronosis Olecranon soft tissue swelling (extensor surface)  Trauma
 Gout  Arthritis: RA, seronegative
Neuropathic joint (5 D’s)  RA spondyloarthropathy, multicentric
 Destruction  Bursitis reticulohistiocytosis
 Debris  Trauma  Adjacent infection: pharyngitis, tonsillitis
 Dense  Congenital: Down syndrome, Morquio’s
 Dislocation Ulnar deviation of metacarpophalangeal joints syndrome, congenital hypoplasia of
 Distension (effusion)  RA dens/os odontoideum (Down syndrome,
 SLE Moroquio’s syndrome)
Calcified intraarticular loose body  Jaccoud’s arthropathy: ligamentous laxity  Occipitalization of C1
 Synovial osteochondromatosis due to rheumatic fever  Ligamentous laxity: Marfan’s syndrome,
 Detached osteophyte (OA) Ehlers-Danlos syndrome
 Acute osteochondral fracture Radial deviation of metacarpophalangeal joints
 Osteochondritis dissecans (unstable  Juvenile chronic arthritis Ribbon ribs
fragment)  HORNS mnemonic:
 Ochronosis Sacroiliitis  Hyperparathyroidism
 Ankylosing spondylitis  Osteogenesis imperfecta
Joint effusion  Psoriatic spondyloarthropathy  RA
 Surgical arthrodesis  Reiter’s syndrome  NF-1
 Previous trauma  Enteropathic arthropathy: IBD, Whipple’s  Scleroderma
 Pyogenic arthritis disease
 Coalition  Infection: pyogenic, fungal Rib lesions
 Psoriatic spondyloarthropathy  Hyperparathyroidism (erosions)  Fibrous dysplasia
 Reiter’s syndrome  Gout (less common)  ABC
 Ankylosing spondylitis  Metastases, multiple myeloma
Arthropathy with soft tissue masses  EG
 Erosive OA
 Gout (Ca++ tophi only with concomitant  Enchondroma
 RA (carpal, tarsal)
renal disease)  Chondrosarcoma
 Amyloidosis
 Nodular RA (pressure points of extensor Paravertebral ossification
surfaces)  Asymmetric: psoriatic
 Muticentric reticulohistiocytosis spondyloarthropathy, Reiter’s syndrome
 Symmetric: Ankylosing spondylitis,
Amyloidosis + PVNS similar on T2, but plain film enteropathic arthropathy
shows osteopenia in amyloidosis  Anterior: DISH (4 or more levels)
 Focal mass: TB
PVNS + giant cell tumor of tendon sheath are
similar on MRI, but GCTTS is located in the soft Disc calcification
tissues near the joint  Degenerative disc disease (dystrophic)
 Ochronosis (young adult)
Periarticular soft tissue calcifications
 CPPD (chondrocalcinosis)
 Hydroxyapatite deposition disease
 Surgical fusion
 Gout
 Ankylosing spondylitis
 Scleroderma (CREST syndrome), SLE,
 Hemochromatosis
mixed connective disease
 Tumoral calcinosis: hypercalcemia (renal
failure, milk-alkali syndrome, Ivory vertebrae
hyperparathyroidism, hypervitaminosis D,  Metastasis: breast, prostate
sarcoidosis)  Paget’s disease
 Hodgkin’s disease > NHL
 Chronic osteomyelitis
  Discogenic vertebral sclerosis Floating teeth
 Osteosarcoma  EG
 Leukemia, lymphoma
Enlarged vertebrae  Periapical abscess
 Paget’s disease  Neuroblastoma
 ABC  10 mandibular tumor
 Acromegaly
Calcaneus lesions (epiphysis equivalent)
Bullet-shaped vertebrae  GCT
 HAM D mnemonic:  Lipoma
 Hypothyroidism  UBC
 Achondroplasia  Infection
 Mucopolysaccharidoses  Chondroblastoma
(middle/Moroqio’s, inferior/Hurler’s)
 Down syndrome Fatal Dwarf syndromes - Use Taybi’s book of
metabolic disorders & syndromes to look up cases
Posterior scalloping of vertebrae  Jeune’s asphyxiating thoracic dystrophy:
 Increased spinal pressure: neoplasm narrow chest, short horizontal ribs, handle
(lipoma, neurofibroma, ependymoma), bar clavicles, triradiate acetabulum
syringomyelia, hydrocephalus (long-  Homozygous achondroplasia (more severe
standing)
than heterozygous): small foramen
 Dural ectasia: NF-1, Marfan’s syndrome, magnum, narrow interpediculate distance,
Ehlers-Danlos syndrome posterior vertebral scalloping, square iliac
 Achondroplasia bones (elephant ears), flat acetabulae,
champagne pelvis with small sciatic
 Acromegaly
notch, flared metaphyses
 AMEN mnemonic: Achondroplasia,
Acromegaly, Marfan’s syndrome, Ehlers-  Thanatophoric dwarfism: narrow chest,
telephone receiver femurs with prominent
Danlos syndrome, NF-1
spur of the inner proximal femur,
platyspondyly, metaphyseal
Anterior scalloping of vertebrae
flaring/widening, small foramen magnum,
 Aortic aneurysm
 Lymphadenopathy short wide fingers. Look like homozygous
achondroplasia, so check if both parents
 TB
have achondroplasia
 Osteogenesis imperfecta (congenita):
Absent pedicle
 Metastasis osteopenia, multiple fractures, wormian
 ABC bones, exuberant callus, accordion shape
femurs, platyspondyly. The differential
 Congenital absence (contralateral
includes child abuse, steroid osteoporosis,
hypertrophy)
juvenile osteoporosis
Dense pedicle  Hypophosphatasia: osteopenia, lucent
skull, scooped out metaphyses
 Congenital absence of contralateral
pedicle  Hurler’s disease: J-shaped sella, beaked
vertebrae (inferior), posterior vertebral
 Osteoblastic metastasis
scalloping, thick phalanges, tapered
 Osteoblastoma
proximal metacarpals, Madelung
deformity, flared iliac wings, wide
Dense vertebral endplate
acetabular roof
 Degenerative disc disease
 Moroqio’s disease: vertebra plana, beaked
 Renal osteodystrophy (Rugger jersey) vertebrae (middle), hypoplastic dens,
 Excess steroids (marginal condensation):
short wide phalanges, tapered proximal
organ transplantation, RA, SLE, asthma; metacarpals, flat femoral epiphyses, flared
Cushing’s disease
iliac wings, wide acetabular roof
 Discogenic sclerosis
 Osteopetrosis
Dwarf syndromes based on site of extremity
 Rhizomelia: achondroplasia (AD,
Increased interpediculate distance sporadic), thanatophoric dwarfism
 Trauma  Mesomelia: mesomelic dwarfism,
 Syringomyelia Cornelia de Lange syndrome
 Intraspinal tumor  Acromelia: asphyxiating thoracic
 Dysraphism dystrophy, chondroectodermal dysplasia
 AVM (Ellis van Creveld syndrome),
acrodysostosis
Expansive lesion of sternum
 MAC mnemonic: Neurogenic tumors
 Metastases, multiple myeloma  Peripheral nerve: schwannoma,
 ABC neurofibroma, sarcoma
 Chondrosarcoma  Sympathetic ganglia: ganglioneuroma,
ganglioneuroblastoma, neuroblastoma
Blow-out lesion of the posterior elements  Paraganglia: pheochromocytoma, glomus
 ATOM mnemonic: tumor
 ABC
 TB A target appearance is seen with neurofibroma
 Osteoblastoma secondary to myxoid degeneration (increased T1,
 Metastasis decreased T2). A ganglion occurs in the
superior/posterior aspect of the shoulder in the
spinoglenoid notch
Grades of ligamentous SPRAINS
 1: perifascial edema/hemorrhage
 2: partial tear (increased T2 signal)
 3: complete tear (increased T2 signal with
disruption)
GRE sequences have low TR (20), low TE (15)
MRI protocols to memorize!
 Shoulder
Sag Obl STIR & PD
Cor Obl STIR & PD
Ax GRE & PD
 Knee
Sag T1 & fat sat PD
Cor STIR & PD
Ax T2 & PD
 Elbow
Sag STIR
Cor T1 & STIR & 3D T1 GRE
Ax PD & STIR
 Wrist
Sag T1
Cor T1 & STIR & 3D T1 GRE
Ax T2 & PD
 Brain (screening)
Sag T1
Cor T2 GRE
Ax T2 & FLAIR
Miscellaneous facts:
1. Chondrocalcinosis in CPPD typically occurs
in the pubic symphysis, knee, triangular
fibrocartilage complex of the wrist
2. CPPD likes the elbow, shoulder, radiocarpal
joint, patellofemoral joint
3. CPPD may be associated with
hemochromatosis, hyperparathyroidism, gout
4. In RA, tophi calcify only with associated renal
disease
5. Discogenic vertebral sclerosis has a density
abutting the end plate with narrow disc space
and osteophytes
6. Paravertebral ossification can be vertical
(syndesmophytes) or horizontal (osteophytes)
7. Sarcoidosis involving the digits has a lace-like
osseous destruction with ST swelling
8. SLE of the digits has hypothenar ST wasting,
ligamentous laxity (ulnar deviation)
9. Scleroderma has acroosteolysis, osteopenia,
ST Ca++
10. Distal soft tissue nodules of the digits with
associated erosions may represent multicentric
reticulohistiocytosis
11. AVM of the femoral head is usually
anterior/superior in location with a serpiginous
border
12. A talar slant is seen in JRA, hemophilia,
neuromuscular disease (paraplegia). These also
cause diaphyseal overgrowth, gracile diaphyses
13. Destruction of a total hip arthroplasty can be
secondary to particle disease (polyethylene),
metastases, infection, fracture
14. Scheurmann’s disease is multiple AVM of the
vertebral apophyseal rings +/- kyphosis
15. Osteochondritis dissecans likes the knee,
talus, capitellum
16. UBC is usually curettaged and packed, except
when located in the calcaneus
17. Myositis ossificans progressiva is heterotopic
ossification around multiple joints with a
monophalangic great toe (synostosis between 1st
metatarsal and proximal phalynx). Differential
includes traumatic myositis, exostoses, TB
spondylitis (calcified paraspinal mass),
torticollis, osteomyelitis
18. Os odontoideum should have well-corticated
margins, +/- cortical hypertrophy of the anterior
arch of C1
19. In the 30-40 y/o group, consider GCT,
parosteal osteosarcoma, MFH/fibrosarcoma
20. Erosions in DJD can occur in the pubic
symphysis, AC joint, SI joint, TMJ
21. With rotatory fixation, C1-C2 move en masse
with one side staying wide during rotation of
the head to either side. Normally, if you turn
your head to the right, the right widens; and
with turning to the left, the left widens
22. Mallet finger results from avulsion at the
extensor digitorum tendon
23. Spondylolisthesis grade 1 is <25%, grade 2
<50%, grade 3 <75%
24. Chondrodysplasia punctata (stippled
epiphyses) has short humeri, coronal cleft of the
vertebrae, calcified larynx/sternum
25. Cleidocranial dysostosis has delayed closure
of the fontanelles, wormian bones, delayed
ossification of the pubic symphysis, clavicle
dysplasia (usually the middle 1/3rd), tapered
terminal phalanges, coxa vera
26. A giant cell tumor of the tendon sheath has a
propensity for the foot, and is confined to the
tendon (looks like PVNS). A desmoid tumor
can occur in the foot
27. Up to 80% of tarsal coalitions are bilateral.
Calcaneonavicular and talocalcaneal (middle
facet) coalitions can be osseous, fibrous,
cartilaginous
28. Osteopetrosis has dense bones, fractures,
osteomyelitis, anemia, HSM, loss of
corticomedullary junction, bone-within-a-bone
appearance. Consider BMT
29. Progressive diaphyseal dysplasia and
Ribbing’s disease (multiple hereditary
diaphyseal sclerosis with thick diaphyseal
cortices) are similar, but PDD occurs in
younger patients who have gait disturbance,
muscular abnormalities. Ribbing’s disease is
milder and occurs in middle age
30. Chondroectodermal dysplasia (Ellis Van-
Creveld disease) is ?mesomelic shortening with
a trident acetabular roof and polydactyly, short
tubular hand bones, short ribs, carpal fusion
31. Tibial lesions include fibrous dysplasia,
adamantinoma, osteofibrous dysplasia
(ossifying fibroma), all of which look similar on
plain film
32. The superior glenohumeral ligament parallels
the base of the coracoid process
33. For the short 4th metacarpal differential
diagnosis, hypoparathyroidism is a problem
with the parathyroid glands,
pseudohypoparathyroidism is an end organ
problem, and pseudopseudohypoparathyroidism
is neither a problem with the parathyroid glands
nor the end organs
34. A Segond fracture is an avulsion of the lateral
joint capsule at the tibial plateau. Often occurs
with ACL tear
35. Multiple hereditary exostoses has up to 20%
risk of malignant transformation
36. On T1, any increased meniscal signal is ABNL,
except in children where it represents
hypervascularity. On T2, some increased
meniscal signal is OK
37. Discoid meniscus occurs laterally in children,
and is evident by >2 consecutive bow ties on
sagittal images. On coronal images, it extends
to the interchondylar notch
38. A bucket handle tear of the meniscus is
suggested when only 1 bow tie is seen on
sagittal view. Normally a meniscus is seen on 2
images
39. ACL, MCL and posterior horn of the lateral
meniscus are commonly injured together. Bone
bruises (kissing contusions) occur posteriorly
on the lateral tibial plateau and anteriorly on the
lateral femoral condyle
40. The transverse ligament extends between the
anterior horns of the menisci and can simulate a
tear. At the meniscofemoral ligament insertion
posteriorly, the ligament of Humphrey insertion
may simulate a tear
41. A torn PCL has uniform intermediate signal,
and often is not repaired by orthopods
42. The lateral ligamentous complex consists of a
conjoined tendon posteriorly (biceps femoris
tendon, fibular collateral ligament), and the
iliotibial band anteriorly, which blends into the
patellar retinaculum
43. With patellar dislocation (usually lateral) the
medial patellar retinaculum is disrupted with
increased signal
44. If the medial patellar plica thickens, it may
mimic an MCL tear, the so-called “plica
syndrome”
45. Fluid in the subdeltoid/subacromial bursa may
be bursitis or related to a tear. If large amount,
suspect a full thickness tear
46. The AC joint can be used as an anterior
landmark to localize the critical zone, which is
2-3 cm long just proximal to the supraspinatus
tendon insertion
47. Only increased T2 signal in the critical zone is
ABNL, and may be due to RCT from
impingement (anterior acromion on greater
tuberosity), tendinopathy or partial tear.
Increased T1 signal may be due to volume
averaging with peritendinous fat or magic angle
(supraspinatus tendon 55 degrees to bore of
magnet) or degenerative tendinopathy
48. In the shoulder, the anterior labrum in larger
than the posterior labrum. Labral tears occur
anteriorly>posteriorly, and least often
superiorly
49. A SLAP lesion is due to pull of the long head
of the biceps during throwing motion, or in
older folks may occur with a rotator cuff tear
50. Gadolinium arthrogram/MRI is done using
200:1 saline-to-GAD dilution
51. Two mimics of a superior labral tear are the
sublabral foramen (at the level of the middle
glenohumeral ligament) and the Buford
complex (absent anterior superior labrum with
thick middle glenohumeral ligament)
52. Biceps tendonitis appears as increased tendon
size with increased signal. There may be fluid
in the tendon sheath with or without tendonitis
because it communicates with the joint
53. The Achilles tendon has no sheath so no
tenosynovitis. Partial or complete tear of the
Achilles tendon most often occurs in 40 y/o
athletic males, or patients with collagen
vascular disease, RA, crystal deposition disease,
hyperparathyroidism
Differential Diagnoses
Nuclear Medicine
Modified Biello Criteria
NL
Low probability (3-5%)
 Rat bites only
 V/Q matches with NL CXR
 Non-segmental Q abnormality
(cardiomegaly, aorta, hila)
 Stripe sign
Intermediate probability (20-50%)
 Q = CXR abnormality (triple match)
 COPD > 50% with abnormal CXR
 Single moderate/large V/Q mismatch
High probability (~90%)
 At least 2 moderate/large V/Q mismatches
with NL CXR
 Significantly unmatched Q >> CXR
Total lung perfusion abnormality
 Tumor, lymphadenopathy
 Mediastinal fibrosis
 Large central PE
 Pulmonary agenesis, aplasia
 Swyer-James syndrome
 PTX
 Large pleural effusion
Photopenic lesion on bone scan
 Infarct/AVN (early)
 Certain metastases: RCC, thyroid
carcinoma, neuroblastoma, anaplastic
malignancies
 Neoplasms: multiple myeloma, EG,
lymphoma, neuroblastoma
 Osteomyelitis (early)
 Radiation, orthopedic hardware,
pacemaker, barium
 Artifact: PMT/preamplifier
Diffuse increased uptake on bone scan
(“Superscan”)
 Renal failure/secondary
hyperparathyroidism
 Hyperparathyroidism
 Osteomalacia
 Metastases: prostate, breast, lymphoma,
lung, bladder carcinoma
 Hematologic disorders: myelofibrosis,
mastocytosis, leukemia
MDP imaging
 Increased MDP uptake by kidneys is most
commonly due to dehydration, but can occur
with chemotherapy, hyperparathyroidism,
nephrocalcinosis
 Hyperparathyroidism may cause increased
MDP uptake in the lungs and stomach due to
metastatic calcification
 Multiple myeloma, NO osteoblastic response,
ST attenuation may cause false negative MDP.
If PSA >8 ng, then MDP may be helpful
 Flare phenomenon occurs <6 months after
therapy, usually 2-3 months. Commonly occurs
with breast, prostate, lung, lymphoma
 A donut appearance may occur with MDP in
GCT, Paget’s disease with sarcomatous
degeneration, metastases, osteomyelitis
 Increased liver activity on MDP may be
secondary to faulty preparation of
radiopharmaceutical with colloid formation,
hypercalcemia, necrosis, amyloidosis,
metastases
 Semarium-153 & Strontium-89 can be used for
bone pain due to metastases if hot on MDP
 Myocardial MDP uptake can occur in MI,
angina, atherosclerotic heart disease, congestive
cardiomyopathy, amyloid, doxorubicin toxicity
 For myositis ossificans surgery should be
performed when the bone is mature, shown by
NL MDP study or when >2 successive 6 month
MDP studies show improvement. This may take
up to 2 years in some cases
 Increased pulmonary MDP uptake may occur in
metastatic Ca++ of renal disease, neuroblastoma
or osteosarcoma metastases, XRT, malignant
pleural effusion, bronchogenic carcinoma
 A sternal lesion in a breast cancer patient is
metastatic disease in 76% cases
 Brown tumors are usually photopenic unless
there is a pathologic fracture
 Shoulder or hip amyloidosis may show
increased MDP uptake
 For a MDP superscan, if it follows only red
marrow, then metastases are more likely. If the
while skeleton is involved, consider metabolic
causes
 Poor MDP uptake occurs in incorrect
radiotracer/preparation, Etidronate
(bisphosphonates) use, iron overload, poor
hydration, ESRD
 Increased MDP soft tissue uptake occurs in
metastases, abscess, trauma, contamination,
primary ST tumor, cellulitis, electrical burn
 Cortical focus of MDP uptake may be Brodie’s
abscess, osteoid osteoma, stress fracture,
metastasis
 A superscan can be due to diffuse metastases
(prostate, breast, lung, colon,
lymphoma/leukemia), hyperparathyroidism,
hypervitaminosis D, osteomalacia, dialysis
 Increased MDP uptake in muscle may be due to
rhabdomyolysis, hematoma, myositis
ossificans, sarcoma, polymyositis
 Increased MDP uptake in kidneys may be due
to chemotherapy, hyperparathyroidism,
dehydration, pyelonephritis
 Cold defect on MDP may be due to metastases
(renal, thyroid), hepatoma, Wilm’s tumor,
uterine cancer, SCCa of head & neck, AVN,
artifact, hemangioma, XRT, osteomyelitis
(increased pressure), primary tumor, multiple
myeloma
 Increased diffuse liver MDP uptake may be due
to excess ALUMINUM
 Fractures (90%) are NL by 24 months on MDP.
Acute fractures can be seen <24 hours (young)
or > 48-72 hours (elderly)
 Knee replacement may take >2 years to
normalize, while hip replacements take 6-12
months. Femoral component shows activity for
12 months (cemented) or up to 24 months
(uncemented)
 If suspecting infection in prosthesis, use 111In
& 99mTc sulfur colloid, checking for congruent
uptake in marrow. Loosening occurs at tip and
trochanter, while infection occurs along whole
prosthesis
 If MDP & 111In are incongruent, suspect
infection
 If there is diffuse increased MDP uptake by the
liver, ask if the patient had a recent 99mTc liver
study. Also, excess aluminum (antacids, from
Tc generator), iron overload, liver amyloid
(dialysis) can cause diffuse increased MDP
uptake. More focal liver uptake can occur with
metastases, HCC, hepatoblastoma,
cholangiocarcinoma
 Renal osteodystrophy (osteomalacia,
hyperparathyroidism) may cause increased
MDP uptake in the lungs, stomach, kidneys
 Aluminum breakthrough from Tc generator
should be <10 micrograms/ml. Mo
breakthrough should be <0.15 microCi/1 mCi
99m
Tc
Renal scintigraphy
 A diuretic renogram checks for the presence of
obstruction in a dilated collecting system. Need
good hydration and an empty bladder to
promote diuresis. MAG3 and DTPA are used,
while MAG3 is preferred in a child and renal
insufficiency. Give lasix at 20-30 minutes or
when pelves are full. Check time-activity curve
pre- and post-lasix. Normal time to peak (TTP) 
is <4-5 minutes. Washout T1/2 (half time)
should be <7-10 minutes (no obstruction),
whereas 10-20 minutes is indeterminate and
>21 minutes is obstruction. The 20 minute-to-
peak ratio should be <0.3, unless there’s
cortical retention. A poor response to lasix can
occur due to full bladder, not enough lasix dose, 
dehydration, immature renal function in a
newborn, renal insufficiency. May wish to give
lasix 15 minutes prior to injection of agent to
maximize flow to kidneys
 An ACEi renogram requires the patient to be
off ACEi for 48 hour for best results, although
chronic use without an additional dose at time
of study is allowed at some institutions
(decreased sensitivity). Start with captopril
exam by hydrating patient, then give captopril
and check BP every 15 minutes for 1 hour. At 1
hour void patient and image. Use MAG3 (ERPF
agent, 10 mCi) and lasix (40 mg). Check flow
and functional images for 30 minutes, and time- 
activity curve. If abnormal [delayed time-to-
peak (>5 minutes) with cortical retention of
radiotracer] do a baseline study. With DTPA
(GFR agent), a positive study will show
asymmetry of split renal function. ACEi block
conversion of angiotensin 1 to angiotensin 2.
Hypotension during the exam can cause a false
negative study
 Indications for ACEi study include new HTN
>60 y/o or <20 y/o, severe HTN refractory to
medical therapy, previously well-controlled
HTN now difficult to manage, evidence of
vascular disease elsewhere, abdominal bruit
with HTN
 DMSA study with SPECT or glucoheptonate
can be used to look for smooth renal contours
and homogeneous cortical activity. There is less
activity in medulla and no activity in collecting
system (unless with Glucoheptonate you
imaged early or there’s an obstruction).
Mesoblastic nephroma can concentrate
glucoheptonate
 Interstitial nephritis can show gallium uptake,
but NOT ATN
 ATN occurs during first week after transplant,
and is more common in cadavaric transplants.
This shows good perfusion, but poor function.
Cyclosporine toxicity mimics the appearance
but occurs later
 Acute rejection occurs during first few months
and shows decreased perfusion but good
function. Acute rejection may take up sulfur
colloid, but ATN will NOT
 No flow may be due to renal artery occlusion or
kinking, renal vein thrombosis or hyperacute
rejection
 Lymphocele occurs 1 week to 4 months post-
op, while a ureteral leak occurs days 1-3 post-
op
 Radionuclide cystogram for VUR is graded as
minimal (ureter only), moderate (pelvicalyceal),
severe (pelvicalyceal with dilatation of the
intrarenal collecting system and tortuous ureter
Pulmonary imaging
 Decrease dose/number of particles (1-2
mCi/100 K ) in pregnancy
 The single breath image represents TOTAL
LUNG CAPACITY, while equilibrium (3-5
minutes) shows VOLUME of AERATED
LUNG. The washout images are the most
sensitive for air trapping (NL <2-3 minutes)
 Perfusion defects can occur in cancer, PE, XRT,
TB, pneumonia, collagen vascular disease,
IVDA, tumor emboli
The fissure sign can occur in COPD, pleural
effusion, pleural thickening, very rarely
microemboli
 The majority of PEs resolve in 2-3 months,
depending on age, size, coexisting
cardiopulmonary disease. In young patients,
PEs may resolve in 3-7 days
Ventilation defects with good perfusion can
occur in atelectasis, pneumonia, COPD,
bronchial obstruction (cancer, mucous plug),
lung transplant, pleural effusion (passive
atelectasis)
 A false positive study with perfusion
mismatches can occur in cancer compressing
the pulmonary artery, CHD, fibrosing
mediastinitis, Swyer-James syndrome,
pulmonary artery hypoplasia, post-XRT, aortic
dissection with hematoma compressing right
pulmonary artery (also as complication to aortic
valve replacement), pulmonary artery sarcoma,
Takayasu’s arteritis, PTX, pneumonectomy
If DTPA diffuses into lungs, suspect ARDS,
toxic inhalation, smoking, aspiration
pneumonia, IPF
 If high probability scan with high clinical
likelihood, anticoagulate. NL study NO
anticoagulation. If low probability scan with
low clinical likelihood and NO DVT, NO
anticoagulation or pulmonary angiogram. Low
probability scan with intermediate-high clinical
likelihood, but NO DVT, NO anticoagulation or
pulmonary angiogram. Stable patient with high
probability scan and high clinical likelihood,
anticoagulate. Stable patient with high
probability scan and low-intermediate clinical
likelihood, check doppler exam, if negative do
pulmonary angiogram
 Posterior view shows decreased activity with
NL anterior view, suspect pleural effusion
 A-1-antitrypsin disease causes retention at lung
bases and poor perfusion at bases (loss of
gradient from apex to base)
 Bullae can simulate lobar matched defect, but
so can COPD, cancer, mucous plug, edema,
contusion, XRT, bronchiectasis
 Contour mapping, a mottled appearance of
perfusion, is caused by tumor, fat, and amniotic
fluid microthrombi, collagen vascular disease,
lymphangitic carcinoma, IVDA, primary
pulmonary HTN, vasculitis
 Can perform a preoperative ventilation study
for fractional assessment of lungs for bullae
resection, cancer resection. Check FEV1 in ml x
% of lung to be operated on. Example 31% R,
69% L, then take .69 x FEV1 volume of lung to
show amount remaining. Should be >800 cc for
survival
 False positive FDG PET scans in
granulomatous disease (TB, sarcoid,
Wegener’s), SLE, XRT, surgery,
chemotherapy, upper respiratory infection.
False negative study has been reported in BAC,
bronchial carcinoid
 If CT shows scarring, do FDG PET to show
viable tumor. If physiologic myocardial uptake
a concern, do 8-12 hour fast (glucose use is
minimized, FFA used). Tumors >1 cm
(primary, met, lymphoma)
GI imaging
 In the esophagus, 80% clearance of 99mTc sulfur
colloid occurs within 15 seconds
 In GERD, spontaneous GER > 4% is abnormal,
whereas > 7 % with provocative maneuver is
abnormal. In an infant, >2% is abnormal
 Use a salivagram/GER study to check for
aspiration
 Pentagastrin increases pertechnetate uptake, and
cimetidine blocks secretion during Meckel scan.
Watch out for misleading appearance of ureteral
activity. Plus, duplication, obstruction,
inflammation, ulcer, intussusception,
hemangioma, tumor, AVM can cause false
positive
 A hemangioma shows decreased perfusion,
increased blood pool activity
 In vitro method of RBC tagging has a >95%
labeling efficiency
 A Meckel diverticulum should have the same
intensity of uptake as the stomach
 Colloid shift on liver-spleen study indicates
diffuse liver disease, usually ETOH > other
causes. Check for increased space between
flank and liver edge that suggests ascites
 HCC (>2-5 cm) shows increased activity on
67
Ga, but lymphoma, abscess, metastases (lung,
melanoma) can mimic the appearance
 Non-visualization of liver on sulfur colloid
study may indicate end-stage liver disease.
HIDA may show uptake, however, in cirrhosis,
adenoma, HCC, XRT, FNH, intrahepatic GB,
dilated bile duct
 Dual isotope capsules for Schilling’s test
consists of 58Co-B12 (510, 810 keV) capsule
and 57Co-B12-IF (122 keV) capsule. Collect
urine for 24 hours (minimum 1L), and check %
excreted (NL is 10-40% PO dose). If 58Co-B12
is low and 57Co-B12-IF is NL, then pernicious
anemia (not making IF in stomach), but if 58Co-
B12 is low and 57Co-B12-IF is low, then
malabsorption
 Fatty infiltration should show NL sulfur colloid
uptake, but may show colloid shift when diffuse
fatty infiltration is present
 Hepatic blood pool scintigraphy (tagged RBC
study) for hemangioma uses flow, early (5-20
minutes), delayed (1-2 hours) imaging. Lesions
should be >3 cm for planar imaging, >1.5 cm
for SPECT. False positive in metastases, HCC,
angiosarcoma
 May see renal uptake during sulfur colloid
study due to CHF, or in a renal transplant due to
chronic rejection (microthrombi). Does NOT
occur in ATN
 To visualize small accessory spleens or residual
splenic tissue after splenectomy on sulfur
colloid study, you may need to increase
intensity setting
 FNH (40-70%) on sulfur colloid study show NL
or increased uptake due to Kupfer cells. Masses
should be photopenic. False positive in
hamartoma, hemangioma, HCC
 May see focal intrahepatic hot spot in Budd-
Chiari syndrome (increased caudate lobe
relative to surrounding tissue) and SVC/IVC
obstruction. LE injection with IVC obstruction
via the left umbilical vein to left portal vein. UE
injection with SVC obstruction via the internal
mammary vein to left umbilical vein to left
portal vein
 111
In octreotide scan is used in neuroendocrine
tumors, including carcinoid, islet cell,
medullary carcinoma of the thyroid,
pheo/neuroblastoma, paraganglioma, pituitary
adenoma (GH), Merkel cell, SCCa lung,
meningioma, lymphoma, breast, NSCCA lung.
If good uptake, can do somatostatin therapy.
Check for normalization of urinary 5-HIAA
 HIDA bile pooling may indicate partial
obstruction (stricture, stone, tumor, extrinsic
compression), or can be due to medications
(MSO4)
 Increased uptake on liver-spleen study may
occur in FNH, Budd-Chiari syndrome, SVC
obstruction, cirrhosis with regenerating nodules
 HCC may be mildly photopenic on HIDA.
FNH, adenoma, regenerating nodules can take
up HIDA. If HIDA goes cold to hot on delayed
images, think HCC
 On HIDA, enterogastric reflux may be NL
(post-prandial, s/p cholecystectomy) or
pathologic in obstruction, pyloroplasty, Bilroth
I/II, partial gastrectomy
 Doudenal cut of sign in HIDA imaging suggests
acute pancreatitis (and GB won’t be seen at 60
minutes)
 Small bile leaks may require delayed images
 After Whipple procedure may use HIDA to
check patency of bile ducts
 On HIDA, delayed excretion may be due to
hepatic dysfunction or high-grade bile duct
obstruction. With hepatic dysfunction, there is
poor uptake and delayed visualization of biliary
tree/bowel. With obstruction, there is better/NL
uptake by liver (especially Mebrofennin <20mg
%), and no bowel activity at 24 hours. Branch
photopenia may indicate chronic obstruction
 May have “preferential GB filling” without
obstruction due to chronic cholecystitis
(scarring of sphincter of Oddi?), narcotics, post-
vagotomy, prolonged fasting. Try CCK to
overcome functional obstruction at sphincter
 The GB will NOT be seen in acute cholecystitis
or complete obstruction
 Biliary dyskinesis may show no response to
CCK or an ejection fraction <35%
 Focal 111In colon uptake may occur in
diverticulitis, bowel fistula, GI bleed, Crohn's
disease, abscess. Bowel uptake can occur from
swallowed secretion of URI/pneumonia, or GI
bleed. If suspect IBD, do early (4 hour) and 24
hour imaging to check persistence over time
 For Laveen shunt (from peritoneum to jugular
vein/SVC with catheter extending to near RA,
used for intractable ascites) patency, inject
MAA into peritoneum and check for lung
uptake
 A 99mTc pertechnetate salivary scan (with lemon
juice) shows hot area for Warthin’s tumor
 For tagged RBC bleeding scan, ask is activity
outside of NL blood pool, and if so, does it
show antegrade/retrograde movement within
bowel. Use cine scintigraphy. May see NL renal
activity and free pertechnetate in stomach,
especially with in vivo method of labeling.
Don’t call it erosive gastritis! Check thyroid for
uptake. Angiography 1cc/sec, NUCS 0.4cc/sec.
If colon activity increases at 3 & 24 hours,
likely there is intermittent bleeding from UGI
tract; these patients are more likely to need
angiography, surgery, 2x transfusion
requirement
 Decreased liver blood pool activity on tagged
RBC study suggests liver disease
 False positive bleeding scans can occur in
AAA, varices (caput madusa), left ovarian vein,
pelvic venous collaterals, GDA aneurysm
 HIDA rim sign is seen in acute cholelithiasis,
gangrenous GB, due to edematous/hyperemic
liver tissue with prolonged transit of HIDA.
Similar appearance can occur following recent
cholecystectomy
 Non-visualization of the GB occurs in
acute/chronic cholecystitis, hyperalimentation,
prolonged fasting, pancreatitis, chronic ETOH,
s/p cholecystectomy, physical distention of GB
 At 60 minutes if no GB is seen, give MSO4. If
see GB, suggests chronic cholecystitis. If don’t
see GB over 30 minutes after MSO4, suggests
acute cholecystitis in appropriate clinical
setting. May give booster HIDA at 60 minutes.
Dilated cystic duct sign can occur after MSO4
due to increased pressure, but it is too medial
and transient
Thyroid imaging
 No IV contrast for 1-3 week, PTU (antithyroid
medication) for 1 week, Synthroid for 4-6
weeks, Cytomel (T3) for 2 weeks
 A solitary cold nodule is malignant in 15-25%
cases
 A cold nodule is malignant in multinodular
goiter in 1-6% cases
 Malignancy occurs in toxic nodule or goiter in
<1% cases
 Transient hyperthyroidism after IV contrast
administration is called Jod-Basedow. Consider
a b-blocker before future studies using IV
contrast
 In children, dysembryogenesis (ectopia,
agenesis) and dyshormogenesis (organification
defect) occur
 Hypertrophic and autonomous hot nodules are
different. Hypertrophic nodule is due to
inflammatory insult or degenerative and is
TSH-dependent. Do a Cytomel suppression test
for 7 days, then scan. If hot nodule, then it’s
autonomous
 A discordant nodule may be multinodular goiter
or cancer
 In Grave’s disease, a TSH-dependent cold
nodule is call Marine-Lenhart disease
 A cold area within a hot nodule is suspicious
for cancer
 For medullary carcinoma of the thyroid, use
MIBG or Octreoscan
 Pheochromocytoma occurs in VHL, MEN II
syndrome, NF-1, Carney syndrome, Tuberous
sclerosis
 For pheochromocytoma/neuroblastoma, use
MIBG because renal uptake in kidneys during
Octreoscan may be misleading
 Can use an intraoperative gamma probe for
parathyroid localization
 131
I NP-59 is used for adrenal cortical imaging,
such as Conn’s syndrome (metabolic acidosis,
hypernatremia, hypokalemia) due to
functioning aldosteronomas. Unilateral uptake
 <5 days, consider adenoma, carcinoma.
Bilateral uptake <5 days, consider hyperplasia.
Bilateral uptake >5 days, consider
dexamethasone-suppressible hyperplasia.
 If salivary glands are NOT seen well on 99mTc
thyroid study, may be due to increased uptake
(Grave’s disease)
 A cold nodule in a euthyroid patient has 10%
risk of cancer, while in Grave’s disease it’s
higher
Tumor imaging
 Use a Dual Head Gamma Camera in
Coincidence Mode for PET. Hypermetabolic
focus >1.5 cm
 Gallium uptake occurs in tumors and
inflammation
 Gallium salivary gland uptake occurs in
sarcoidosis, post-XRT, Sjogren’s syndrome, TB
 Lymphoma id gallium (+) and thallium (+),
whereas Kaposi’s sarcoma is thallium (+) only
 FDG PET should be done after 8-12 hour fast.
For a myocardial study, give glucose load (with
or without insulin) to promote glucose use.
Uptake will be seen in all exercised muscles, so
NO talking during exam. Anxiety increases
activity in paraspinal and trapezius muscles.
May see NL uptake in cecum lymphoid tissue
or in the thymus after chemotherapy. False
positives include TB, fungal disease,
sarcoidosis, XRT, pyogenic abscess, suture
granuloma. Use semiquantitative standard
uptake ratio (SUR), which indicates activity in
lesion (microCuries/cc) corrected for patient
weight and FDG dose. In >1 cm nodule, SUR >
2.5 suggests tumor
 MIBI in breast cancer study may show false
positive with fibroadenoma, inflammation,
proliferative disease
 Somatostatin imaging is most useful with
APUD tumor with type 2 SSR. Insulinomas
have few SSR2 receptors, thus poor Octreoscan
uptake
 Use MIBG for pheochromocytoma because
physiologic renal activity with Octreoscan may
be misleading. Use Octreoscan for ALL others!
 Gallium imaging is best for intermediate to
high-grade lymphoma. Relative photopenia can
be seen I necrosis. Try FDG PET for lymphoma
 After chemotherapy, follow-up gallium study
should wait at least 4-6 weeks to avoid false
negative study
 MDP and FDG are better in skeletal lymphoma
than gallium
 FDG uptake in neck may be due to tumor, LAD
(metastatic), Hashimoto’s thyroiditis,
thyroiditis, thyroid lymphoma
 HCC (50%) accumulate FDG. Sulfur colloid
shows photopenic HCC. FNH (70%) on sulfur
colloid show NL/increased uptake
 If PET patient is breast feeding, wait 1 day
before resuming (T1/2 110 minutes)
 Octreoscan for carcinoid may change from
positive to negative when tumor
dedifferentiates. FDG remains positive! May
use intraoperative gamma probe with
Octreoscan
 A hepatic arterial perfusion scan can be
performed to show distribution of
chemotherapy
 Chemoembolization of HCC (doxorubicin,
ethiodol, gelfoam) can be performed. HCC
(63%) hot on gallium, but so are metastases,
abscesses, lymphoma
 FDG can be used to differentiate malignant vs.
osteopenic vertebral compression fracture
 FDG positive in Paget’s disease
 Hyperglycemia causes false negative FDG, so
beware in diabetic patients
 Always compare gallium uptake to liver
(internal control). If >liver, then it’s pathologic
 Gallium uptake in the pelvis of a child, consider
rhabdomyosarcoma, neuroblastoma, lymphoma
 Increased gallium uptake in the kidneys at 24
hours occurs in obstruction,
lymphoma/leukemia, multiple transfusions (iron
deposition), renal carcinoma, pyelonephritis,
vasculitis, ATN. Faint uptake may be NL
 Increased gallium activity may occur in the
thymus and salivary glands after
XRT/chemotherapy
 Always hydrate with PET FDG to avoid
confusing GU uptake
 FDG PET imaging for pulmonary nodule can
be false negative in BAC and carcinoid, and
false positive in granulomatous disease (TB,
histoplasmosis, sarcoid). SUR <2.5 suggests
benignity
 Chest tube needed after transthoracic biopsy in
5% cases
 FDG uptake in cecum, Waldeyer’s ring is NL.
May see uptake in a renal transplant, so don’t
be fooled. Check for absent NL native kidney
uptake
 Sentinel LN injections use sulfur colloid, and an
intraoperative gamma probe can be used. If
sentinel LN is positive, a complete LN
dissection will be performed
 FDG PET in occult breast cancer shows axillary
LAD and breast lesion, but mammogram/US is
negative
 An occult primary adenocarcinoma is usually
from lung, pancreas, GI tract. FDG can show
response to chemotherapy by decrease in uptake
 SCCa lung may have NL MDP, while
Octreoscan (50-75%) shows diffuse disease
 Medullary carcinoma of the thyroid has
elevated calcitonin/CEA, and will be positive
on Octreoscan and FDG
 SPECT Octreoscan lesion should be >9 mm,
and an intraoperative gamma probe can be used
 Use Octreoscan for bronchial carcinoid
 131
I MIBG is used for neuroblastoma, which
may also show increased uptake on MDP due to
microcalcifications. If neuroblastoma shows
avid MIBG uptake, can use it as treatment.
MIBG can be used in paraganglioma, carcinoid,
medullary thyroid carcinoma
 Mucinous GI tumors show increased MDP
uptake
 For paraganglioma, use whole body Octreoscan
to check for multiple tumors
 Gallium uptake in the abdomen can be due to
liver, spleen, EARLY (<24 hours, usually 4
hours) renal activity. Check delayed images,
consider cathartics
 Sarcomas can show increased uptake on FDG,
gallium, thallium (for viability after
chemotherapy or surgery), MIBI
Infection/Inflammation imaging
 Increased diffuse gallium activity in the lungs
may occur with IPF, any pneumonitis, sarcoid,
lymphangitic carcinomatosis, PCP, TB, XRT,
drugs (bleomycin)
 For sickle cell disease with suspected
osteomyelitis, consider gallium scan first
 111
In may be falsely negative if antibiotics have
been given, the patient is leukopenic, or in spine
abnormality
 For infection or loosening of a prosthesis, try
111
In and SC bone marrow study to check for
congruent uptake
 False positive 111In study occurs in RA,
thrombus in pseudoaneurysm, healing fracture,
prosthesis, hematoma, metastases, GI bleed,
swallowed from sinonasal infection, infarction
 For 111In look for congruent activity in bone
marrow with sulfur colloid study. If it extends
beyond margin of sulfur colloid activity,
suspect infection. If same area as sulfur colloid,
then it may be Charcot joint
 111
In likes neutrophils (ACUTE, <2 weeks), so
if FUO is presentation, may try gallium study
first. Plus, gallium will show other cause of
FUO such as tumor
 Use 111In in suspected bowel infection, as
gallium and HMPAO are excreted into bowel
and kidneys, which may be misleading
 111
In photpenia can be due to tumor, vertebral
osteomyelitis (20%), XRT, amyloid, leukemia,
myelofibrosis
 Increased activity on MDP may be due to
primary or metastatic tumor of bone, Paget’s
disease, RSD, acute inflammatory arthritis,
acute fracture, diabetic arthropathy,
osteomyelitis
 For spine infection in adults (not good in child),
try MDP/gallium combination and look for
incongruent uptake
 Gallium imaging is bad in neuropathic joint
with suspected infection. Try Indium
 Acute testicle pain can be due to manual or
spontaneous torsion, torsion of the appendix
testis, referred pain. Torsion should be
diagnosed <4 hours for best chance at salvage
of testis. Early torsion shows photopenia of the
affected testis with asymmetry of the scrotum.
Late torsion shows a halo or bullseye
appearance, but so can an abscess
 Testicular abscess has increased flow, rim
around cold defect on static images. Delayed
torsion has decreased flow, rim around cold
defect on static images. Epididymitis has
increased flow, increased activity in epididymis
on static images
 The torsion study uses immediate flow and
delayed static imaging, with a lead strip over
the median raphae on one image
Brain imaging
 Diamox challenge is used to check vascular
reserve. Give Diamox 30’ before injection of
perfusion agent. Flow should increase 30% in
NL patient. Abnormal vessels do NOT dilate
with Diamox, so less perfusion occurs in the
corresponding territory (steal phenomenon)
 In AIDS, lymphoma shows increased FDG
PET, but low uptake with toxoplasmosis.
Always compare PET uptake to white matter. If
it’s the same, then low grade tumor. If it’s
higher (2x), then high grade tumor
 Hypothermia, drug-induced coma, reversible
metabolic coma, mimic signs of brain death
with isoelectric EEG
 For ictal injection, use HMPAO because uptake
is rapid (maximum at 1 min.), while FDG takes
30-50 minutes to peak
 In Alzheimer’s disease, there is decreased
perfusion in bilateral posterior temperoparietal
area. Similar appearance in Parkinson’s,
bilateral hematomas, bilateral parietal strokes,
XRT, NPH. Unilateral decrease perfusion can
occur (usually on left) in Alzheimer’s disease
and primary progressive aphasia
 Pick’s disease or frontal lobe dementia
 In a diabetic patient, there may be global
decrease in FDG uptake due to hyperglycemia
 Decreased FDG uptake in the basal ganglia
occurs in Huntington’s (caudate), Wilson’s,
progressive supranuclear palsy, multisystem
atrophy
 Increased FDG uptake can occur in
granulomatous disease (TB, fungal disease,
sarcoid) causing a false positive scan
 Acute herpes infection causes increased
perfusion & FDG uptake, while chronic may
cause decreased perfusion
 Thallium SPECT can be used for determining
recurrent tumor vs. XRT necrosis, using
contralateral area of brain as reference. If
>3.5:1 ratio, high-grade glioma, while >1.99:1
suggests low-grade glioma. If <3.5:1, do
HMPAO. Low perfusion suggests XRT
necrosis
 VP shunt malfunction occurs proximally &
distally. If proximal, no ventricles are seen,
whereas distal obstruction shows ventricles but
no peritoneal cavity. Causes include adhesions,
kinking, shunt tip migration, perforated viscous,
peritonitis preventing CSF resorption
 Thallium, MIBI can be used to differentiate
XRT vs. tumor, or high grade vs. low-grade
glioma
Cardiac imaging
 Ejection fraction should increase by 5% during
exercise. If it falls, then suspect exercise-
induced ischemia. Check for regional wall
motion abnormality. In elderly woman, a
patient with a high resting EF, cardiomyopathy,
or valvular disease, it may not change by 5%.
Target heart rate is >85% of the maximal
predicted heart rate (220-age). The double
product (HRxBP) should be >25,000 for an
adequate stress
 We do thallium rest study because ST
attenuation is worse and we don’t want the
stress study to be subject to as much attenuation
artifact
 An exercise LVEF <30% has 62% 6-year
survival
 If previous MI or the patient cannot do
strenuous activity, do a modified Bruce
protocol where speed or grade are incrementally
increased every 3 minutes (Bruce protocol
increases both)
 If patient unable to exercise, then do
pharmacologic stress test
 If LBBB (reversible septal defect), do
Persantine or adenosine study
 Perfusion-metabolism mismatch: viable
myocardium. Perfusion-metabolism match:
myocardial scar
 No dipyridamole or adenosine in bronchospam
disorder, hypotension, recent stroke/TIA, 2nd or
3rd degree heart block, or concomitant use
Aminophylline or caffeine. Give Dobutamine
instead (but if patient on B-blocker, it won’t
work)
 At peak exercise, start imaging. For thallium,
reinject at 2-4 hours (reinjection or rest-
redistribution image). Rest image at 15-30
minutes. Hibernating myocardium may fill in at
24 hours on thallium study. Fixed defect (30-
50%) will fill in on delayed images
 Diaphragm can cause basal inferior wall defect.
Breast attenuation can affect the anterior/septal
wall. Obesity can cause global abnormalities.
LBBB can cause a reversible anteroseptal
defect, seen with significant tachycardia
(exercise, Dobutamine)
 Stress myocardial perfusion imaging
 Can use MIBI in ER patient during chest pain,
then later do without pain study. A pain defect
can be due to MI (acute or remote) or ischemia,
so do delayed imaging to sort it out
 Hibernating myocardium is chronically
ischemic myocardium, where flow is adequate
to preserve cell viability but NOT function.
Revascularization is beneficial
 On thallium, a fixed defect at 3 hours may fill
in at 24 hours, indicating viable myocardium.
Or try FDG. Some institutions are doing
sequential imaging or dual isotope simultaneous
acquisition SPECT with FDG and MIBI. If
FDG positive, MIBI negative, then hibernating
myocardium. If FDG negative, MIBI negative,
then infarct, and unlikely to benefit from
revascularization
 Short axis is filmed apex-base, vertical long
axis septum-lateral wall, horizontal long axis
inferior-anterior wall
 Can use cardiac imaging to assess
preoperatively the risk for perioperative event.
If NO reversible defects, then there is NO
significant difference in risk compared to NL
population. If reversible defect, then risk of
perioperative event increases 4-8x (10-30%) in
low-intermediate risk patients (based on clinical
data/ECG changes)
 Only thallium can show a reverse redistribution
defect, which may be due to prior
revascularization, MI, thrombolytic therapy
 MIBI 1-day protocol use low dose (8mCi) at
rest, and high dose (20-30 mCi) stress injection.
MIBI underestimates viable myocardium to
greater degree than thallium
 Use FDG (preferable) or 24-hour thallium to
check for hibernating myocardium (82% for
FDG vs. 68% with thallium improve with
revascularization)
 If diaphragmatic attenuation is a possibility,
prone imaging may be helpful (artifact should
disappear)
 ECG-gated myocardial perfusion imaging
shows LV regional wall motion abnormality.
Check systolic wall thickening, global systolic
function. Assess endocardial excursion and
segmental wall thicken to help determine if
something is artifact or ischemia/infarct
 Remember there is more ST attenuation with Tc
 A double product >24,000 indicates adequate
140 keV compared to FDG 511 keV, so be
cautious when calling defects, especially in
 Increased RV uptake suggests RV overload or
inferior wall, during a dual isoptope FDG/MIBI
study
 To increase FDG uptake, may give insulin. If
poor uptake in IDDM patient, consider doing
thallium 24 hour imaging
 LBBB shows a reversible anteroseptal wall
defect because exercise increases delay between
R & L ventricular activation relative to the
duration of systole. Occurs less with adenosine
& Persantine compared to Dobutamine, and
most with exercise
 A reversible defect can be due to ischemia,
arterial spasm, myocardial bridge, abnormal
original LCA, hypertrophic cardiomyopathy,
aortic stenosis, syndrome X (angina without
stenosis and NL coronary arteries)
 RVEF best determined by 1st pass method using
Tc pertechnetate or MIBI. An equilibrium
radionuclide ventriculogram can determine
LVEF
 Increased splanchnic activity can cause
increased inferior wall artifacts. Do delayed
images with MIBI or prone positioning to
confirm that was the cause. Thallium cannot
have delayed images because of redistribution,
so instead have patient drink water. An exercise
study should show little splanchnic activity
because it’s shunted away to muscle
 Increased thallium/MIBI uptake can be due to
lactating breasts, neoplasm, thyroid/parathyroid
lesion, hiatal hernia, inflammation, recent XRT
 For breast feeding after thallium, wait 2 weeks.
For MIBI, have patient wait 2-3 days. For FDG
PET wait 1 day
 EF is end diastolic counts – end systolic
counts/end diastolic counts – background
counts. Normal LVEF : 50-80% (55-65% at our
institution)
 If radionuclide ventriculogram looks bad, it’s
either PVCs or poor labeling
 Tc-pyrophosphate requires 24-48 hours
(sometimes <12 hours) to be positive for
myocardial infarction. Mimics include
myocarditis, pericarditis, blood pool activity,
Doxorubin toxicity, XRT, LV aneurysm,
amyloid. Activity decreases over 5-7 days
unless MI is very large
 Radionuclide ventriculogram can be used pre-
post-doxorubicin therapy. If baseline LVEF
<30%, then patient NOT treated with it. Of
LVEF drops during treatment by >10% or to a
EF <50% , stop use of doxorubicin
 Diffuse pulmonary uptake on thallium
(lung:ratio >0.52) on PLANAR imaging
indicates severe LV dysfunction, a low LVEF
and multi-vessel disease
 The resting LVEF and pulmonary uptake on
stress perfusion imaging are 2 parameters
important for prognosis
 Thallium has certain advantages compared to
MIBI, including less frequent/severe artifacts
due to hot liver, and can check stress induced
pulmonary uptake and LV dilatation. A fixed
defect is less likely viable with thallium
compared to MIBI, especially with stress
reinjection. Also you can do a 24 hour image
because of longer T 1/2 to check for
hibernating myocardium (FDG is only agent
that’s better)
 Thallium, however, has increased ST
attenuation due to lower photon energy
 Planar cardiac imaging is only used today in
morbidly obese, claustrophobic, or poorly
cooperative patients
stress for detection of ischemia
hypertrophy
 Radionuclide Ventriculogram (gated blood pool increased free pertechnetate, which is excreted SVC but was more midline, maybe intra-
imaging) shows segmental wall motion by the choroid plexus. Check the purity of the arterial, extravascular, CT shows line
abnormality and RV/LV chamber size radiopharmaceutical by chromotography (>80% clearly in the aortic arch, some
 With decreased LV compliance, there is slow is NL). Contaminants include free management questions, I said that I would
diastolic filling (slow upstroke) on time-activity pertechnetate, hydrolyzed (reduced) Tc just tell the Drs of the location, he seemed
curve, indicating diastolic dysfunction, which unhappy with that approach.
may be due to aortic stenosis, cardiomyopathy, Please refer to the protocols of your own institution,
CAD, HTN. Do an ECHO as well as a review book or CD! 1. invasive pulmonary aspergillosis (air
 Post-PTCA residual defects occur in 20-30%. A crescent)
newly reversible defect in Post-PTCA patient Remember… if you absolutely have NO idea what 2. TB
suggests restenosis you’re looking at go through the various disease 3. fungus ball
 Multi-vessel disease is suggested by stress categories: TIC MTV A 4. RLL sequestration
induced LV dilatation and thallium pulmonary 5. eosinophilic pneumonia
uptake T: tumor (benign, malignant) 6. fibrosing mediastinitis with SVC
I: infection, inflammation, iatrogenic obstruction
Artifacts C: congenital 7. mucoid impaction and metastatic renal
 Check daily the isotope peak calibration and M: metabolic, medication cell
intrinsic (without collimator)/extrinsic flood T: trauma 8. Mournier Kuhn
source V: vascular 9. thymolipoma
 Heterogeneous activity on all images is a A: artifact, allergic, autoimmune, acquired 10. Castleman’s disease
problem with UNIFORMITY 11. alveolar cell ca
12. splenosis

RECALLS
 SPECT imaging requires CENTER of
13. bilat diaphragmatic ruptures
ROTATION checked monthly. If this is off
14. EG
(blurring, halo artifact), recalibrate
15. LAM
 If background noise increases suddenly, it’s
16. IPF (remember association with adenoCa)
equipment malfunction or another patient/dose
17. lymphangitic carcinomatosis
nearby
18. mosaic perfusion
 A photopenic area on all images in same place 19. NF
is PHOTOMULTIPLIER TUBE or preamplifier 20. ATAI
abnormality. Check with flood source 21. LUL collapse
 Faint uptake throughout all images may be The following section was compiled by residents 22. echinococcal cyst (pt presents with
OFF-PEAK window, or possibly too great from another Midwest program. Proceed at your hemoptysis)
distance from camera own risk 23. mediastinal goiter (behind trachea with
 Geometric cold areas may be extrinsic to the calcifications)
patient such as belt buckle, jewelry, button, CHEST 24. bronchogenic cyst
zipper, prosthetic eye! 25. achalasia
 In111 needs a medium energy collimator (172, 1. Cavitary lesion with A/F level. CT 26. asbestosis (plaques not seen on lat)
247 keV) showed empyema. Discussed drainage 27. pleural lipoma
 A star artifact is due to septal penetration by technique
high energy photons. Use a high energy 2. Pericardial cyst PAST RECALLS:
collimator with thick septae 3. Acute LA enlargement.
 When injecting lasix during a renogram, make 4. Pleural plaques with mass in AE recess? 1. Collapse of LUL ?Mass
sure no residual radiopharmaceutical is in the mesothelioma 2. Mitral Stenosis wit LA enlargement on
syringe by using saline. Higher activity will 5. Effusion with probable pseudotumor CXR
show up on the time-activity curve 6. Enlarged central pulm arteries. Discussed 3. Aortic Laceration
 Watch out for urine contamination (blood, pressure measurements and different 4. Persistent L SVC into Coronary Sinus
saliva) causes of pulmonary HTN 5. Eisenmenger Physiology
 Use the correct pharmaceutical 7. Post trauma PTX. Persistent air leak after 6. Apical massPancoast
 Check MAA particle size, or is there a R-L tube placement. 7. Intraparenchymal hematoma
shunt? Image brain 8. CXR with bilateral hilar adenopathy with 8. PE wit Hampton’s Hump
 Clumping of MAA occurs when blood is drawn several vague lung lesions, mets,
back into the syringe, causing multiple hot spots lymphoma, sarcoid. 1998 Recalls:
(labeled microemboli) in the lungs 9. CXR with left hilar mass, worrisome for
 Prior XRT may cause a cold defect CA. 1. CHF.
 Collimator damage looks like a fine line across 10. Mass left heart border on CXR, 2. Diffuse bilateral nodules---Histo, CA etc.
the image. Check with extrinsic flood (without worrisome for CA, CT with lingular 3. Dilated ascending aorta---give DDx.
collimator) to confirm lesion most likely CA, I included 4. Right ventricular aneurysm with
 Mirror image artifact can occur with electronic pericardial cyst in that location. calcification.
malfunction 11. Retrocardiac density CXR left side, ddx, 5. Aortic transection on CXR and CT.
then lateral view esophagram shows 6. Swyer-James.
 Overlap of organs may be due to the
similar kind of middle mediastinal mass, 7. Sequestration.
multiformat imager failing to advance (double
ddx, what if patient just had MI?, included 8. Chest wall mass- cystic with enhancing rim
exposure)
pericardial effusion, LV aneurysm.
 Increased lung and stomach activity can be seen
12. Large heart w/o NL chest, flailed for a 1. Causes of cardiogenic failure?
in hyperparathyroidism (metastatic
while, then showed head CT with ring 2. Talked about guided biopsy and aspiration
calcification)
enhancing lesion worrisome for abscess, 3. Bronchogenic cyst
 Free pertechnetate can occur in any 99mTc study. most c/w right to left shunt, he pushed a 4. I had a case of a child with NF and
The 99MO generator creates 99mTc and free little further and I clammed up. neurofibromas- I’m not sure if that was in Peds
pertechnetate 13. CXR with diffuse tubular lucencies, I or Chest… Chest, I think
 In111 oxine-WBC can clump in the lungs, thought most c/w bronchiectasis. 5. Plain film superior mediastinal mass… MR
creating hot spots. Increased activity at the lung 14. Multiple cases of middle aged people with showed it to be a massive aneurysm of one of
bases may be atelectasis SOB and screwed up looking hearts, NL the great vessels
 Infiltrated MDP can show axillary LN uptake, vessels, I flailed tremendously on these 6. Asbestos plaques
usually with hot spot in antecubital and surely failed them all. 7. Discussion of asbestos exposure, and the
fossa/forearm 15. Portable chest with very hard to see right various diseases and risks
 Prominent uptake in the ventricles on a subclavian CVL, the tip was not over the 8. Malignant mesthelioma.
HMPAO perfusion study may be due to

2000 Recalls:
Dr. Vydareny; she was nice and gave relatively
unhelpful history. For the most part, I have no idea
what I was shown
1. RLL opacification on CXR, fat density on CT:
gave DDx
2. Mitral stenosis
3. Bronchial lesion with post obstructive
pneumonia
4. CXR status post pacemaker replacement with
metal looking like pacer lead in LLL
5. Anterior mediastinal mass
6. Posterior mediastinal mass
7. Foreign body aspiration in kid
8. Pleural rind soft tissue on CXR; gave DDx
9. Cystic fibrosis with focal infiltrate
10. Pericardial effusion on lateral CXR
GI
1. She puts up a film that looks like your
worst nightmare from Riley. There is a
demineralized patient curled over upon
himself into a ball. Severe scoli, bony
dysplasia, anatomy all distorted. I look at
it for a minute and then she says “Now
remember this is a GI case”. I saw one
dilated loop in the RUQ and gave a
differential. She asked what I would do
next, I said I wasn’t sure whether the
abnormality was proximal or distal so I
would do CT. She seemed angry and
asked how else I might work it up. I said
Upper GI. She asked if I would use
Barium. I said I would do a decub to
exclude perforation first. Then she said
“but Barium is inert, why are you
worried?” I was trying real hard not to kill
her and told her about barium peritonitis.
Finally, after all this she gives me the
freaking CT I wanted in the first place. It
looked like a cecal volvulus.Case 128
2. Next case was an IVP with dilated bowel
loops. Again, “remember, this is GI”. I
wanted to reply “then show me some
freaking GI films, bitch” but I didn’t.
Looked like SBO. CT showed Spigalian
hernia.
3. Classic chronic UC. She asked about why
the terminal ileum was abnormal and I
described backwash ileitis. Then she
asked what Crohn’s would look like. I
told her about asymmetry, skip lesions,
mucosal thickening and cobblestoning,
fistulae, everything I could think of about
Crohn’s. Then she says “so how do you
tell the difference between UC and
Crohn’s. I just repeated everything again
and she seemed angry again.Case616-617
4. Multiple duodenal polyps. I said Peutz-
Jeghers. She asked for a dif and I talked
about other polyposis syndromes. Then
she went into a long line of Questioning
about polyposis. She didn’t ask the things
we usually review like inheritance or
associated tumors. Instead she wanted to
know about therapy for Cronkite-Canada
and how long people with that syndrome
live. I wanted to remind her this was a
radiology exam. Bitch. Case 513, 607,
608,632
5. Hepatic Adenoma. The one 3. Pancreatic CA.
straightforward case. Case 319 4. Intussusception.
6. Three phase CT. She showed me the 5. Retained sponge.
images and proceeded to mis-identify 6. Mucocele of appendix.
them. She called a non-contrast image the
1. Ram’s horn stomach
arterial phase and called the arterial phase
2. Long discussion
the venous. Then when she got to the
3. Infiltrative gastric cancer. Led to CT and
venous she got confused and had to start
discussion of what information a surgeon
over and proceeded to mis-identify them
might want to know, which then led to a
in a whole new way. I chose to ignore her
discussion of omental spread in particular,
description and describe the hypervascular
as well as other routes.
liver mass based on what I saw.
4. Focal area of jejunal edema with a tight
7. esophagram with mass at GE junction,
segment of narrowing distally. F/U a
additional images given confirming mass,
week later was NL.
ddx, likely cancer. Case 320-325
5. Discussion of causes of edematous pattern
8. Mesenteric mass with spiculations and
6. Klatskin tumor. That started out with
calcification centrally and associated
U/S. Unfortunately, I asked for CT next,
small bowel wall thickening, likely
which was no help. It was obvious on the
carcinoid, then CT liver with enhancing
ERCP…
mass, likey met. Case 510
7. Some weird bilateral lower abd foreign
9. Long segment narrowing right colon and
bodies in a post-op patient, sort of looked
prox transverse colon with ulcerations
like wadded up Penrose drains. He tried
and? extension into TI, Crohn's vs. UC,
to help by telling me the patient had
other infectious colitis discussed. Case
surgery a year ago. SB study showed a
626
single loop that was about 15 cm in
10. Irregular smooth structure filling with
diameter, with a heterogeneous, bezoar-
contrast on sm. Bwl. Follow through in
like filling defect. It was pretty clear I
the pelvis, ? abnormal loop of bowel vs.
didn’t know what this was…
contained perf vs. other pelvic structure
filling, discussed Crohn's and fistula, other
2000 Recalls:
iatrogenic causes of perf.
11. Large cystic mass left lobe liver with
Dr. Messinger. He seemed tired of the whole process
septation and ? nodule of wall, infectious
and we flew through cases without much discussion.
etiology, met, primary tumor,
He occasionally asked what management I would
hemangioma.
recommend.
12. BE with 2 cm irregular filling defect
1. UGI: filling defect medial part of descending
sigmoid colon, discussed types of colon
duodenum
polyps particularly the malignant ones, bx.
2. SBFT: paraduodenal hernia
Case 605
3. SBFT/CT: Crohn’s
13. Large tubular low density structure RLQ
4. CT: Multiple pancreatic cystic stx: gave DDx
on CT, mucocele appendix, abnormal
5. CT: Portal vein thrombosis
small bowel loop, Meckel’s. Case 636
6. CT: Splenic laceration
7. CT: Hypervascular liver lesion
1. linitis plastica Case 424
8. UGI: Gastric volvulus
2. gastric ulcer with clot Case 412
9. Plain film/CT: Pneumoretroperitoneum
3. vasculitis of SB in pt with SLE Case 525
10. CT: Pelvic lipomatosis
4. NHL of SB Case 520
11. CT: Mesenteric adenopathy
5. villous adenoma in duodenum Case 426
6. sprue
GU
7. scleroderma Case 525
8. Ca of gastric cardia spreading to distal
1. Pyelonephritis.
esophagus Case 323
2. Renal fracture with urinoma
9. Crohn’s Case 514
3. Splenic fracture. Adrenal mass vs.
10. Boerhaave’s Case 331
associated hemorrhage
11. benign pneumatosis coli Case 628
4. Polycystic kidneys with solid tumors. I
12. intraluminal duodenal diverticulum Case
said could be VHL
409
5. Papillary necrosis
13. double channel pylorus
6. Bosniak 2 cyst- thin septa and calcs.
14. SB lymphoma Case 520
7. Contrast reaction-treatment of
15. giant fibrovascular polyp
hypotension/tachycardia
8. mixed fatty mass upper pole right kidney
PAST RECALLS:
vs. adrenal, AML vs. myelolipoma, asked
for density measurements, she asked what
1. FNH
else we could do, MRI.
2. Recurrent Sigmoid CA
9. Hysterosalpingogram with contrast in
3. Ulcerated Esophageal CA
uterus and fallopian tubes, a small filling
4. Antral and Duodenal Narrowing due to
defect present in uterine cavity, air bubble
scirrhous breast CA
vs. polyp vs. small EM cancer, vs. foreign
5. Esoph Stricture distal
object, what else?, after some prompting I
6. Gallstone ileus
came up with a gestational sac—oh oh—
7. Thumbprinting in Colon. DDx ischemic,
what do you do now?, STOP, how much
infection, UC
dose can a embryo take?, I didn’t know
8. Caroli’s Disease wit ADPCK
and said I would call the radiation safety
officer and patient’s Dr.
1998 Recalls:
10. Papillary necrosis on IVP, ddx.
1. Duodenal CA.
2. Carcinoid.
 11. IVP with filling defects in bladder and 6. CT, no contrast: Elliptical fluid collection in 13. Spondylolysis with reactive sclerosis
prox right collecting system, most c/w base of penis…….what the hey? 14. Osteoid osteoma
TCC 7. Plain film: medullary nephrocalcinosis 15. Stress FX
12. Bladder wall calcification then IVP with 8. CT: extraperitoneal bladder rupture 16. Fongs disease
filling defect bladder, TCC vs shisto vs. 9. CT: renal cystic stx with faint wall 17. Achondroplasia
XRT, she said patient just arrived from enhancement. Asked for ultrasound solid 18. HPTH
Cairo or somewhere. mass 19. Enchondroma
13. CT and IVP with medullary 10. Plain film/CT: MCDK 20. Neuropathic Joint
nephrocalcinosis, ddx. 11. CT: renal cell cancer 21. AVN
14. Nasty right kidney mass with non-vis of 12. CT: renal vein thrombosis 22. Myelomas
IVC (probably tumor thrombus) and a 23. Osteochondroma
liver lesion, most likely RCCA with tumor MUSCULOSKELETAL 24. Butterfly Vert Body
thrombus and mets. 25. Sickle cell vert body
15. U/S with mixed echo mass left kidney, CT 1. Pelvic fractures 26. Calcaneal Lipoma
with low density mass left kidney 2. Ankylosing spondylitis 27. Scleroderma
extending into the renal pelvis, (patient 17 3. OCD knee 28. Hook of Hamate Fx
y/o), multilocular cystic nephroma but 4. Calcaneus osteomyelitis 29. OCD
can’t tell that from RCCA, bx or surgical 5. MR Achilles tear 30. SONK
excision. 6. Child with lytic metadiaphyseal lesion 31. Pagets in ileum
16. In the middle of one of the cases she with surrounding periosteal rxn. Gave 32. Tarsal Coalition
stopped me and said a patient in the next typical dif then he asked “what if you saw 33. Frieberg's infraction
room was getting a contrasted head CT the same thing in an adult” 34. Fx of 5th MT
and is now seizing! What are you going to 7. Pregnant woman with transient 35. Myositis Ossificans
do? osteoporosis of hip 36. B Facet lock
8. focal cortical thickening prox humerus 37. NOF
PAST RECALLS: with central lucency, maybe osteoid 38. Post Humeral disloc
osteoma, how would you work that up 39. Oss of Post Lig
1. Emphysematous pyelo further?, CT, CT shows similar findings 40. Ochronosis
2. Adrenal Calcification. DDX but there is a linear lucency going the 41. suprachondylar Process
3. Pevlic Fracture with extraperitoneal cortex, maybe infection with sinus tract. 42. Madelung's deform
Rupture 9. Classic SCFE. 43. Acromegaly
4. Retrograde Urethrogram with anterior 10. Younger patient with widening of right 44. Gout
defectsChondyloma hip joint space, effusion vs infection vs 45. Cupids Bow…NL Variant
5. Traumatic UPJ transection hemarthrosis, but must r/o infection, what 46. Rugger Jersey SpineROD
6. RVT else may appear like this, came up with a 47. Osteopetrosis in Vert
7. Periaortic LAD. Testicular mets vs. synovial proliferative process. 48. Lead Poisoning
Lymphoma 11. Pelvis with healing left superior and 49. Stylohyoid Ca++
8. Renal Lymphoma inferior pubic ramus fractures and bones 50. Osteochondral Fx
9. Enlarged Uterus. Fibroid vs. osteopenic, what type of fracture might 51. Game Keeper thumb
adenomyosis this be?, insufficiency fracture, where do 52. Ca of Flexor Carpi Ulnaris
these fractures occur in the pelvis?, sacral 53. Sarcoid
1998 Recalls: arches, pubic rami. 54. Pelvic Finger
12. Loosers zone scapula, I said 55. Brodies Abscess
1. Papillary necrosis on IVP.
hyperparathyroidism, pelvis with ? SI jt 56. Lupus
2. Transitional cell CA ureter with Bergman's sign on
widening and Lspine with ? osteopenia, I 57. Hemophilia in Knee
retrograde.
still thought hyperparathyroidism, 58. Osteosarc
3. Bilateral angiomyolipomas with acute bleed on
anything else?, I blanked. 59. SAPHO
one side.
13. AP view shoulder with prob posterior 60. Avulsion Fax of PCL
4. Myelolipoma.
shoulder disloc, lengthy discussion on 61. Avulsion Fx of inferior pubic Ramus
5. Adenosis of uterus on MRI.
shoulder dislocations, then showed 62. Thyroid Acropachy
6. Urethral stricture on retrograde with reflux of
scapular Y-view confirming disloc. 63. Silastic Synovitis
contrast into Cowper's glands.
14. Slightly expansile lytic lesion cortex distal 64. Hyperostosis Frontalis
7. Retroperitoneal fibrosis.
tibia in younger patient, ddx, most likely 65. Insufficiency Fx
1. Bosniak grade 3 and grade 4 cysts NOF. 66. Macrodystrophia Lipomatosa
2. Discussion of how to treat these 15. Shoulder MRI with classic rotator cuff 67. Condesans of Clavicle
3. Adult polycystic kidneys tear distal supraspinatus tendon. 68. Ca++ in Gluteus
4. Renal TB ? Strictures, pap necrosis, poor 16. Cspine with anterior ankylosis, pelvis 69. Ollier’s
function with right SI joint sclerosis and several 70. Mehlorheostsis
5. Possibly a cloacal cyst that was adherent enthesophytes, most c/w psoriatic or 71. Lead Poisoning in spine
to bladder wall. Reiters. 72. Posterior Limbus
6. Ureteritis cystica 17. Distal femur with classic parosteal 73. Meniscal Cyst and Tear on MR
7. Leaking AAA with extrav of contrast on osteosarcoma, what other study do you 74. Patellar Tendon Tear on MR
CT. I can’t remember if the beans were want?, MRI, MR shows similar findings 75. ACL Tear on MR
involved. but more extensive appearance. 76. Medial Meniscal Tear on MR
77. PVNS on MR
2000 Recalls: 1. Pagets in spine 78. Synovial Cyst on MR
2. Mets 79. Osteochondral Fx on MR
Dr. Gatenby. Cases were pretty easy and he didn’t 3. Osteopoikolosis 80. Segond Fx on MR
ask for much in the way of differentials or 4. Bone Infarct 81. Bone Bruise on MR
management. 5. Exostosis 82. Bone infarct on MR
1. Xanthogranulomatous pyelonephritis with 6. SCFE 83. AVN of Hip on MR
fistula to colon 7. Sub Ungual Exostosis 84. Transient osteoporosis on MR
2. Renal laceration 8. Inclusion Cyst 85. Tear of Supraspinatus Tendon on MR
3. AML with hemorrhage 9. Perilunate disloc 86. Perilateral Ganglion Cyst on MR
4. MRI: pheochromocytoma 10. Lunate Disloc 87. OCD on MR
5. MRI: uterine fibroid 11. CPPD 88. Achilles Tendon tear on MR.
12. Lipohemarthrosis

PAST RECALLS:
1. Anterior fat pad sign in Elbow.
DDXFracture, effusion(hemophilia),
Gout
2. Lymphangectatic Osteosarc on MR
3. DISH, DDX Reiter, AS, Psoriasis
4. Gout
5. Enchondroma
6. OI
7. Vertebra Plana
8. Pagets
9. Stress Fx of Calcaneus
10. Ewing’s
11. Neuroblastoma mets vs. osteo, eg,
lymphoma, leukemia
12. Physis osteomyelitis
1998 Recalls:
1. Osteomyelitis.
2. Gout.
3. Neuropathic joint.
4. Anterior shoulder dislocation.
5. ST calcification due to HPT.
6. Medial collateral injury on MR.
7. ABC vs. telangiectatic osteosarcoma vs EG on MR
and plain film.
1. First case was an erosive arthritis. It
wasn’t typical of anything, so I discussed
the findings and talked through my
thinking- what it could be and why it
wasn’t typical. “What’s your diagnosis?”
I went with psoriasis. He made a face.
Next case. Strong start…
2. Meniscal cyst
3. Gout
4. Something that started out looking like
OCD of the femur, but there was a lytic
lesion in the prox tibia. Lat view showed a
large effusion or ST mass. He showed
two MR images that demonstrated a huge
mass, then switched cases before I even
had time to discuss it.
5. Trauma case: two views wrist/hand. The
scaphoid, carpal alignment, MCs and
phalanges looked NL. Maybe a tiny
avulsion of base of distal phalanx of
thumb. He bagged it and moved on.
Braunstein won’t tell me what it was, but
he told me lots of people couldn’t see the
finding…
6. Distal metadiaphyseal bubbly lesion in
forearm of 1-2 yo. Path fx + periosteal
rxn. I ran through the usual ddx list, but
he didn’t seem happy.
7. Fibrous dysplasia
8. Multifocal bone infarcts, or so he led me
to believe. Diffuse, thin, sclerotic
longitudinal strips involving ALL portions
of both tib, fib, and what I could see of
distal fems of a child. I offered up fibrous
dysplasia and he asked what if the kid was
from D.C. I said, “this seems far too
diffuse and symmetric for infarcts…” and
got “DON’T YOU THINK IT WOULD
BE MORE SYMMETRICAL THAN
FIBROUS DYSPLASIA?!” as a reply. At
that point he launched into a discussion of
aliens. No kidding. He asked me, “If
aliens came down and sat it these
sessions, and listened to the discussions,
do you know what they would think is the
most common disease? EG. I had
mentioned EG during another case (which
I can’t remember. I’m pretty sure it
wasn’t EG, though.) The bell rang the
second time, and I made a hasty exit.
2000 Recalls:
Dr. Gilula ( ya know, the carpal arcs of Gilula). I
thought this section was the hardest overall, not so
much that the findings were hard but some of the
stuff looked familiar but not classic. He gave me no
histories even when I asked.
1.some strange expansile lytic lesion of prox humerus
with periosteal reaction
2. Segond fracture on MRI
3. Bennet fracture
4. Psoriatic arthritis
5. Hypertrophic osteoarthropathy
6. Osteosarcoma
7. osteomyelitis
8. Pagets
9. osteoporotic female with bilateral sacral
insufficiency fractures.
NEURO
1. Dense MCA/ infarct
2. Intraventricular mass with hydro—I
thought CP papilloma but gave a long dif.
3. MCA bifurcation aneurysm—CT then
MRA. He asked some basic questions
about MRA
4. Sagittal sinus thrombosis- He gave a
history of “post-partum headache”. At
first I thought the pituitary looked
abnormal and was thinking Sheehan’s.
He said, “I agree it looks funny but there
is something else”. That’s when I moved
to the sag sinus.
5. Spinal epidural abscess
6. Temporal bone with mass posteriorly and
inferiorly near jugular foramen. I said it
could be a glomus tumor. I obviously
missed this case because the next case
was…
7. Classic glomus jugulare
8. Degenerated facet with associated
synovial cyst compressing nerve root.
9. Pregnant or recently post-partum woman
with HA, MRI with increased signal in
region of straight sinus, ? sinus
thrombosis, additional images including
MRV confirm.
10. Young female with sag spine MRI
increased T2 throughout distal cord with
enhancement similarly, then showed
myelogram which looked NL, He had to
point out the most subtle tiny tubular
filling defect at the very edge of the film 7.
to which I promptly agreed was real (yeah 8.
right), talked about possibility of spinal 9.
AVM, what would you do next,
arteriogram, agram with tortuous vessels
at cord c/w AVM.
11. Slightly expansile low density lesion
petrous apex on CT, get MR, MR with
hyperintense mass on T1 and T2 most c/w
cholesterol granuloma.
12. Enhancing mass fourth ventricle, ddx,
asked about most common masses here in
kids and adults.
13. Multiple WM lesions C/W MS, asked
what enhancement meant.
14. Low density mass right sub mandibular
gland, ddx.
15. Sag MRI spine with collapsed single
vertebrae with mass effect on cord and
abnormal signal in cord at that level, met
vs trauma vs EG vs plasmacytoma, he
kept asking for more.
16. Irregular lesion right CP angle isointense
to CSF on all imaging sequences, c/w
epidermoid.
PAST RECALLS:
1. Ossification of Posterior Longitudinal Lig.
2. Meningioma in Pineal Region
3. Grey matter heterotopia
4. TS
5. Epidural Hematoma
6. Macroadenoma of Pituitary
7. Bilateral PCA infarcts and edema in BG
8. Superior sagittal sinus thrombosis
9. Leptomeningeal carcinomatosis
10. Herpes encephalitis
11. Arachnoid cyst
1998 Recalls:
1. Arachnoid cyst.
2. MCA stroke.
3. L subdural.
4. Parenchymal AVM.
5. Dural AVM.
6. Disc free fragment.
7. Aortic aneurysm causing recurrent laryngeal nerve
paralysis.
8. Brain mass---discuss DDx.
9. Abnormal WM signal----discuss DDx.
1. Optic neuritis, led to looking at rest of the
head. Sure enough, MS
2. PICA infarct, related to a dissection? The
guy was hit in the head
3. Cavernous sinus mass. Was CN V
schwannoma
4. Another cavernous sinus mass.
Aneurysm.
2000 Recalls:
Dr. Mark. My first case was dural sinus thrombosis
on unenhanced CT (I thought first cases were
supposed to be easy). I nailed that case and the
basilar tip aneurysm (2nd case) and he seemed very
happy and gave me no grief the rest of the way.
1. Dural sinus thrombosis: first non contrast CT
then angio
2. Hyperdense left MCA: CT
3. Sequestered disk in L-spine; MRI
4. Spinal cord ischemia due to aortic dissection on
MRI
5. MRI brain: cryptococcus: young male with
dilated perivascular spaces
6. CT then MRA: basilar tip aneurysm
Petrous apex cholesterol granuloma; MRI
Orbital meningioma; MRI
Colloid cyst: CT
10. CPA mass: gave DDx
INTERVENTIONAL
1. Fractured catheter. Asked what approach
I would use to retrieve.
2. Trauma Arch—Arch looked NL but great
vessels were trash. Bovine arch with
pseudoaneurysm at common origin. I sent
the guy to surgery.
3. SMA embolus—discussed treatment
options. She asked what I would want to
know about the patient. I said physical
exam + labs. She said the guy has
peritoneal signs and lactic acidosis. I said
the guy’s gut is already dead so
 thrombolysis won’t help. Another trip to
surgery.
4. IMA bleed—She literally told me “this
guy is bleeding out the ass” Discussed
causes of bleeding and ways to embolize.
5. Anastomotic stricture post
choledochojejunostomy. I said plasty and
leave internal/external drainage catheter.
6. Diverticular abscess. She asked about
catheter management. Showed me a
injection with persistent fistula. I said
leave the catheter in longer than you
otherwise would.
7. Thoracic outlet syndrome.
8. Renal artery stenosis (ostial)- I said we
primarily stent these. She showed me a
post angioplasty image with
dissection/disruption. I said “that’s why
we go straight to stent.”
9. Post procedure pseudoaneurysm. Asked
about treatment options.
10. Pelvic low density post-op female most
c/w abscess, options?, aspirate/drain, what
size?, what approach?, Risks?, I said
transgluteal drain, any other options?,
transabdominal or transvaginal, she
showed a transvaginal drain and
sinogram, when would you pull drain?—
essentially lots of questions on how to do
procedure and manage patient.
11. Multiple pulmonary AVMs on CXR and
pulmonary angio., c/w Osler-Weber-
Rendu, how would patient present?, how
manage?, coils.
12. SVCgram with stenosis in patient who
had had multiple CVLs, likely stenosis
from these multiple CVLs, could plasty,
should evaluate for other causes of SVC
stenosis using CT, discussed management
of “benign” vs “malignant” SVC stenosis.
13. Patient with prior abdominal surgery for
GSW now with fatigue, abdominal
aortogram shows immediate filling of
celiac, renals, and IVC, c/w AV fistula.
14. Arteriogram of transplant kidney showing
a tight stenosis and a ?pseudoaneurysm,
she focused on stenosis, what to do?,
angioplasty, what result are you satisfied
with?, gradient less then 10 mmHg, how
do you follow this patient?, MRA or U/S,
how do you clinically follow patient?,
creatinine.
15. LE arteriogram showing tight stenosis of
pop. a, she asked about all the disease
processes that can affect the pop. a,
discussed aneurysms, atherosclerotic
disease, cystic medial necrosis, then asked
a bunch of management questions
regarding angioplasty, stenting,
inflow/outflow.
16. Mesenteric angio with tangle of vessels in
RLQ at cecum in patient with heme pos
stool, most c/w angiodysplasia, asked
about anatomy and all I knew regarding
GI bleeding and angio, discussed many
things including CA, diverticulosis,
angiodysplasia, discussed treatment
options including surgery vs embolization
vs vasopressin.
17. SMA injection with filling defect at a
branch point most c/w embolus, asked
about causes and management of emboli,
discussed surgical embolectomy,
thrombolysis, when would you stop
thrombolysis? And what is the time frame
to save the gut?, I wasn’t sure and said
between 6-24 hours.
18. CT with multiple wedge shaped defects were multiple varices. 2) after I asked, he
spleen, kidneys and an aorta that had told me the gradient was 24. 3) after I
mural thrombus, probably embolic looked more carefully, there was still a
disease. tight area where the tract met the PV. 4)
they put another wall in, and the gradient
1. thoracic Ao dissection with aberrant R fell to 10. 5) varices were better, so we
subclav a. and divertic of Kommerall coiled the last of them
2. pelvic hematoma displacing bladder 4. Staghorn calculus with a smaller lower
treated with common iliac a. PTA pole calyceal stone. Talked about
3. air embolism to Ao and brain due to bx of treatment options, and, ultimately, my
lung nodules approach for the perc
4. CABG aneurysm on CT (as ant 5. Portogram with recanalized umbilical
mediastinal mass) vein. Talked about that and other routes
5. pyogenic hepatic abscesses in pt with of shunting
diverticulitis 6. Guy with a urethral stricture undergoing a
6. R psoas abscess dilatation. Now has profuse bleeding.
7. cavernous transformation of PV with Angio showed the vessel which was the
pseudoaneurysm of GDA and multiple obvious source of the bleeding. I said the
hepatic abscesses options would be surgery or possible
8. effort thrombosis (Paget-Schroeder) embolization, but I didn’t know anything
9. pulm AVM about penile embolization, or specific
10. UGI bleeding s/p B2 (Rx: with concerns regarding its blood supply. I’d
vasopressin instead of embo due to post- want to look that up or discuss it with
op altered collateral supply) someone before doing anything to this
11. HCC with cavernous transformation and guy’s schlong… (I think I worded it
PV thrombosis (DO NOT DO TIPS) differently the first time.)
12. TIPS – puncture to IVC via R renal vein
2000 Recalls:
due to initial (mis)selection of inf.
accessory R hepatic vein Dr. Ferris; he seemed grouchy and really tired of the
13. pelvic lymphocele drain placement s/p whole process. As my session progressed, he became
radical prostatectomy a bit more congenial and finally was philosophical at
14. R colonic GI bleed via SMA angio the end….go figure.
15. bleed from jejunal diverticulum 1. IVP with hydronephrosis and septic: discussed
16. inf. phrenic injection of intralobar percutaneous neph tubes
sequestration 2. Port a cath central line headed up internal
17. ATAI: avulsed R subclavian a. jugular: discussed grasping from below to
18. Rasmussen's aneurysm reposition
19. ruptured Ao-bifem graft with contained 3. PA gram: film had obvious PE but he never
leak asked me to discuss the film. Instead we talked
about technique, indications, and
PAST RECALLS: contraindications to pulmonary angiography.
4. Angio of portosystemic shunt: shunt was
1. Median Arcuate compression Syndrome obviously malfunctioning and we discussed
2. Pelvic Kidney and Replaced R. Hepatic treatment
A. 5. External iliac/common femoral artery
3. Aortic Laceration dissection; discussed treatment
4. Pseudo CoarctationAre there 6. Pelvic AVM on MRI. Then showed me an
collaterals? angio and we discussed treatment.
5. Dialysis Graft Stenosis in Venous Limb 7. Subclavian vein stenosis on angio; discussed
6. Pancreatic Abscess drainage causes and treatment.
7. SMA occlusion What are the collateral 8. Percutaneous cholangiogram with CBD
Pathways? stricture: this one due to surgery, we discussed
8. Biliary Stent occlusion with intrahepatic treatment.
BDD. 9. GI bleed on angio; discussed treatment options
10. Venogram with retroaortic left renal vein
1998 Recalls: 11. Ulnar artery transection from trauma; treatment
is surgical
1. Hypothenar hammer syndrome.
2. Thoracic outlet syndrome.
BREAST
3. Pelvic bleed s/p trauma.
4. Bronchial artery bleed.
1. Spiculated mass
5. Pancreatic abscess.
2. Architectural distortion. Discussed
6. Portal HTN.
possibility of radial scar and biopsy
7. Abd. aortic occlusion.
options
1. Stab wound to shoulder. Pseudoaneurysm 3. DCIS
of one of the vessels arising from 4. Mass with benign looking Calcs but
subclavian. Wished I knew all those poorly defined borders. I said the borders
vessels better. What do I do now? What still made it worrisome.
do I tell the patient are the risks for 5. Asymmetric density that went away on
embolization? spot-mag
2. Heroin addict. CXR shows septic emboli, 6. Hamartoma
with the F/U showing marked increase in 7. Intramammary lymph node
left/superior mediastinum. Angio showed 8. Intermediate calcifications
mycotic aneurysm. We talked about that. 9. Post surgery patient Discussion of
3. Showed a TIPS in progress. Two wall indications/contraindications for breast
stents already in place. “Tell me if we’re conserving therapy
done.” The bottom line was: 1) there
 10. Breast asymmetry—right breast smaller 6. Spiculated mass 10. Chiari II with MM
but denser—discussed dif. 7. Nodule seen only on MLO. Asked for XCC or 11. subclavian steal
11. I know she showed me more but she went straight ML and got an ML; lesion moved up so 12. ectasia of rete testes
so fast it was a blur. it’s located medial. Then I asked for a cleavage 13. omphalocele
12. Focal pleomorphic calcifications, bx, view which showed the lesion. 14. appendicitis
DCIS vs Inv. Ductal CA. 8. 3 nodules in one breast; had to work each one 15. carotid dissection
13. Simple cyst mammo and U/S, do nothing up 16. fetal demise
unless symptomatic then drain. 9. Architectural distortion work up and DDx 17. testicular cancer with microlithiasis
14. Very subtle spiculated CA behind a bunch 10. Cluster of suspicious microcalcifications 18. lupus nephritis
of dense FG tissue, WOW, almost missed 11. Solid mass with indistinct borders 19. biliary dilatation with stones
this one, pulled it together at last second. 12. Asymmetric density; disappeared with 20. anencephaly
15. Unilateral trabecular thickening in patient compression views, need to make sure 21. ovarian dermoid
with mastitis symptoms, c/w mastitis, additional views are positioned properly 22. liver mets
what do you do now?, talk to her Dr. to 23. Gastroschisis
start antibiotics and f/u to make sure she ULTRASOUND 24. tricuspid insufficiency with ascites
gets better, OK she doesn’t get better and 25. anembryonic pregnancy
mammo looks same what do you do?, 1. Cholecystitis/Cholelithiasis 26. R epididymo-orchitis
that’s concerning for other causes of 2. DVT 27. posterior urethral valves
trabecular thickening such as 3. Tumor thrombus in portal view. 28. incompetent cervix
inflammatory CA, what do you do now, Discussed various doppler waveforms. 29. renal transplant rejection, lymphoma
skin bx, Is that how you dx inflamm CA?, 4. Anencephaly . Discussed MSAFP 30. tuberous sclerosis (bilat renal
yes. 5. Increased nunchal translucency angiomyolipomas)
16. Subtle area of arch dist, spots show better, 6. Germinal matrix 31. semilobar holoprosencephaly
worrisome, bx. hemorrhage/hydrocephalus 32. vasa previa
17. Focal spiculated mass with ?microcalcs, 7. Complicated ovarian cystic mass. Ask 33. Beckwith-Weideman
spot with a encapsulated larger mass with how workup would differ pre and post
fatty tissue c/w hamartoma, but I wasn’t menopause. PAST RECALLS
sure the original area was there, I’m still 8. Echogenic right kidney. Then showed me
concerned about first area. a midline image and asked what I thought 1. Physiologic Gut herniation
18. This first study was called NL, here’s the of the other kidney. At first I thought he 2. Nuchal Cord
next study, there was slight increase in a was a moron then I realized there was no 3. Echogenic Bowel
nodular density, I’m concerned. L renal artery or vein and I said the patient 4. Single Umbilical Artery
19. Breasts with multiple characteristically probably doesn’t have one. 5. VSD
benign calcifications (vascular, inv 9. Double duct sign 6. Partial Mole
fibroadenoma, calcified oil cysts) and a 10. Diaphragmatic hernia. Asked for 7. IUFD
small irreg nodule, spot, real, bx. differential. Asked “if this was CCAM 8. Ectopic
what type would it be” 9. Renal A. Stenosis
PAST RECALLS 11. Midline abdominal mass in fetus; I gave a 10. Carotid Stenosis
long dif but couldn’t really decide. 11. Dermoid
1. Well circumscribed mass in L. Spiculated 12. Slightly enlarged uterus with internal 12. Endometrioma
mass in R echoes, some very bright, history given as 13. TOA
2. Milk of CA recently post-partum, most likely retained 14. Hydrosalpinx
3. Asymmetric breast tissue products of conception. 15. Endouterine Polyp
4. Two regions of suspicious Ca. 13. Two images groin trans, one shows art 16. Epididymitis
5. Axillary well circumscribed lesion and vein, the other shows short videoclip 17. Germinal Matrix hemorrhage
6. Spiculated mass of compression demonstrating complete 18. NL Uterine serosal vasculature
compression of the venous structures, no 19. Choroid Plexus cyst
1998 Recalls: DVT. 20. Congenital diaphragmatic hernia
14. Fetus with lemon head and dilated lat 21. Omphalocele
1. Dystrophic calcification s/p XRT/lumpectomy.
vent, concerned for MMC, L/S spine then 22. IVC Thrombus
2. Spiculated masses X4 cases.
shown showing dysraphic changes c/w 23. Periaortic LAD
3. DCIS.
MMC.
4. Simple cysts. 5. Fibroadenoma.
15. Point out the anatomy case trans and long 1998 Recalls:
6. Inflammatory CA.
liver/porta hepatis.
1. CDH.
1. He asked several non-film related 16. Carotid color images with narrowing,
2. Intrauterine pregnancy.
questions: How much radiation from a pulse wave with PSV=300 cm/sec and
3. Clubfoot.
mammo?, what kvp do we use? Etc. EDV=100 cm/sec, c/w high grade stenosis
4. Dandy Walker.
2. Clustered pleomorphic calcifications (70-99%).
5. Cholecystitis.
3. Discussed various forms of biopsy 17. Ovary in younger female with focal
6. Medullary nephrocalcinosis.
4. Benign calcifications hyperechoic lesion, hemorrhagic cyst vs
7. Renal cell CA.
5. Spiculated mass ectopic vs tumor vs met vs endometrioma,
8. Testicular CA.
6. Adenosis he kept asking for more and seemed
9. NL anatomy at the porta hepatis.
7. Plain film ruptured implant, probably unsatisfied.
ruptured on other side as well 18. Large filling defect in GB, GB CA vs 1. Gallstones with distal CBD stone and
8. Discussed implants, routine mammo, and invading HCC vs tumefactive sludge. obstruction
other imaging options for implants 19. Gallstones with intra and extrahepatic bil 2. Pt with bleeding. There was a live
9. Fibroadenomas dil, likely CBD obstruction. intrauterine pregnancy with a crescentic
hypoechoic area peripherally. Couldn’t
2000 Recalls: 1. testicular torsion figure out what it was
2. carotid stenosis 3. Fetal u/s with oligo, keyhole bladder, and
Dr. Bassett; was nice and we flew thru the cases. 3. MCDK cystic collections near upper pole of one
Asked no difficult questions. 4. ectopic pregnancy kid, and near bladder. Obstructed
1. Spiculated mass 5. acute cholecystitis with gallstone duplicated system on top of bladder outlet
2. Secretory calcifications 6. duodenal atresia obstruction?
3. Fat necrosis 7. pseudoaneurysm in neck 4. Testicular microlithiasis. This may have
4. Hamartoma 8. gestational trophoblastic disease been a GU case…
5. Amorphous calcifications 9. pyloric stenosis
 5. High-grade carotid stenosis. We talked
about this for a while… various velocities,
ratios and findings in stenoses
6. Renal transplant u/s with reversal of
diastolic flow. Talked about
complications in renal transplants
7. Parathyroid hyperplasia. Discussed
differences between adenomas and
hyperplasia
2000 Recalls:
Dr. Woodward, yes THE Dr. Woodward. She was
nice and seemed to understand I was nervous. We
started with some easier cases and eventually got to
cases where I had no idea what I was looking at. She
was very good at giving histories that directed your
differentials.
1. bilateral choroid plexus cysts
2. echogenic mass in fetal thorax
3. enlarged echogenic kidneys in 6 year old
female
4. segmental biliary dilatation
5. ectopic pregnancy
6. column of Bertin vs. renal pelvic mass
7. hypoechoic adrenal lesion in 6 week old
8. complex cystic pelvic mass
9. thickened endometrium in postmenopausal
female
10. enlarged and irregular yolk sac on ob
ultrasound
11. medullary nephrocalcinosis
12. deep venous thrombosis
PEDS
1. Patient who received pelvis radiation.
First developed AVN then later film
showed post irradiation osteochondroma.
2. Cyanotic patient with increased
vascularity. Discussed various admixture
lesions and how they differ.
3. Thoracic paraspinal mass
4. CXR with asymmetric vascularity and
compression upon the trachea. I thought
this was PA sling. He said “sorry, we had
a sling this morning?” Then he showed
me an esophagram which I couldn’t figure
out. Then he said “you know, I can’t make
anything out of this picture either.”
5. PIE
6. Nodules in the trachea ? papillomatosis
7. Absent radius, thumb present- I gave a dif
with TAR #1.
8. US of cystic mass extending from pelvis
to umbilicus. I ask for the sex of the
patient. He wanted a dif for each
possibility.
9. At this point he started asking me what I
was going to do with my life, where I was
from, etc. I don’t think he was supposed
to do that but I figure it means I had
passed.
10. Started off with a head MRI!, I literally
thought I was in the wrong room, it took
me a couple of minutes to remember that
she did in fact say this is the peds section
when I came in, the case was still up
there, there were multiple T1 increased
areas deep WM and GM areas, she asked
about the eyes, there was focal thickening
of right optic nerve, probably NF-1, what
a start!
11. Then a bone case, I thought I’ll fail for
sure, multiple areas of expansile lytic
destructive bone lesions in prox humeri,
hands bilaterally, I blanked, maybe some
kind of metaphyseal dysplasia I said, like 4. Cleidocranial dysostosis
what?, this had to have been the most 5. Multiple enhancing lesions in brain???
painful silence ever. 6. Lytic Tibial lesion
12. KUB unremarkable, RUQ U/S with 7. Coarc of the Aorta
tubular hypoechoic structure, ? bowel,
then showed IDA scan with large 1998 Recalls:
collection RUQ and bowel activity,
probably choledochal cyst. 1. Neonatal Group B Strep pneumonia.
13. Ankle film with markedly irregular tibial 2. Lytic skull lesions---give DDx.
physis showing widening and sclerosis, I 3. Jejunal atresia.
think there was also a linear lucency in 4. Lung abscess. 5. Testicular CA with lung mets.
metaphysis, ?Salter 2 fracture, then 6. Shocked bowel on CT.
showed pelvis film with dysraphic
changes in L/S spine, can you connect the 1. Meconium aspiration
findings?, I wasn’t sure but vaguely 2. VATER, duodenal atresia
remembered an increase risk of leg 3. U/S then CT of CMV calcifications
fractures in MMC patients. 4. Multifocal septic joints
14. Renal U/S with hydro and dilated ureter to 5. Newborn with cyanotic cardiac dz, big
bladder bilaterally, discussed bilat UVJ vessels
obstruction possibly from ureteroceles,
discussed simple and ectopic ureteroceles 2000 Recalls:
and duplication anomalies.
15. Abdomen CT with ascites, bowel edema, Dr. Fellows: This guy eviscerated me, I felt totally
no perfusion of spleen, fractured pancreas, gutted by the time I was done. He kept asking for
asked if patient had had any trauma—no, differentials when I couldn’t think of one thing most
this could be non-accidental trauma, then of the time. This was the only section where I stayed
showed head CT with multiple skull the entire 25 minutes.
fractures, SDH, c/w non-accidental 1. Caffey’s dz.
trauma. 2. leukemia with osteoporosis, vertebral body
16. Renal U/S with echogenic kidneys 9 mos compression fx, and lucent metaphyseal lines
old, I said it was abnormal, then showed 3. pulmonary sling; given AP and lateral chest
CXR which showed bilateral dense then axial MRI
kidneys—no IV contrast was given, 4. malrotaion with midgut volvulus
discussed bilateral calcified kidneys, 5. shunt vascularity-give DDx for both cyanotic
maybe bilat MCDK, infarction. and acyanotic
17.CXR with hyperexpanded lungs, ?para 6. child abuse
hilar infiltrates, most c/w viral pneumonia, 7. osteomyelitis
ddx reactive airway disease, foreign body 8. Wilms tumor
trachea. 9. multiple pulmonary AVMs (I think); gave AP-
multiple nodules, then angio
1. talocalcaneal coalition 10. weird area of sheet-like high density in soft
2. Morquio's (ant beaking of spine) tissue near ankle; gave DDx
3. meconium ileus 11. Lytic skull lesion on plain film then CT showed
4. Jeune's beveled edgesEG
5. septic L hip arthritis/osteomyelitis NUCLEAR
6. thyroglossal duct cyst or Ranula
7. Beckwidth-Weidman 1. Bone scan AVN of femoral head in pt
8. Canavan's / Alexander's with renal transplant. Case 115
9. horseshoe kidney 2. CSF leak. Asked how we de the exam.
10. multiloc cystic nephroma Case 603,604
11. TS 3. V/Q post trauma—fat emboli. Asked what
12. cystic hygroma agent we use for vent study. Ask what else
13. Madelung deformity might look like this if there was no history
14. meconium aspiration of trauma. Case 409
15. cerebral hemihypertrophy 4. Cardiac SPECT and corresponding CINE
16. croup stress induced ischemia with secondary
17. hepatoblastoma/hemangioendothelioma vent dilatation.
18. cong. lobar emphysema 5. Gallium Scan with cardiac activity ?
19. tension PTX amyloid
20. pulm a stenosis 6. Renovascular HTN imaging. Asked a lot
21. Blount's about our protocol Case 203
22. CF 7. Splenosis on sulfur colloid. Asked how
23. double Ao arch (vasc ring) else you might look for splenic tissue.
24. branchial cleft cyst Case 310
25. hydrocarbon pneumonia (***on ddx for 8. WBBS in patient with prostate CA, search
bibasilar infiltrates in kid) for mets was unsuccessful except for a
26. Caffey's tiny area in the lateral skull, what are the
27. ABC chances that that is a met?, low, keep
looking he said, sit back in your chair he
PAST RECALLS: said, finally after like an hour I saw
uptake in the heart, discussed possibility
1. Right Chest mass. DDXTeratoma, of calcific pericarditis, infarction. Case
lyphangioma, Brochogenic cyst, CLE, 111
CCAM 9. Stress/rest cardiac perfusion study typical
2. Liver mass. Hemangioendothelioma vs short and long axis views, asked what can
hepatoblastoma you use to stress a patient?, treadmill,
3. Caustic ingestion in Esopha dobutamine, adenosine, dipyridimole,
 when should you not use some of these?, 7. Pheochromocytoma Difference btwn
shouldn’t use adenosine or dipyridimole HMPAO and DTPA
in patients with reactive airway disease or 8. Brain Death Study
COPD, then the study looked absolutely 9. Myocardial Fixed Defect
NL with no perfusion defects, he pushed 10. Lymphoma on Gallium
me to show him where the ischemia was 11. Vesicoureteral Reflux
multiple times, then he showed a cine in 12. V/Q scan with no perfusion to R Lung.
same patient showing apical akinesis, Mass in Hilum.
back to the SPECT images, OK now
where’s the area of ischemia?, this was 1998 Recalls:
really frustrating because the perfusion
1. Hot solitary thyroid nodule.
was perfect everywhere, OK point to the
2. Meckel's.
ischemia in the inferior wall, I’m gonna
3. PCP on Gallium.
kill this guy!, then discussed what blood
4. Breast CA mets to bone.
vessel supplies the inferior wall. (this guy
5. Osteomyelitis on Bone-indium.
must be getting billions in kickbacks
6. MUGA with dyskinetic apex.
from the cardiologists if he’s calling
7. Thallium study with ischemia.
ischemia like this-WOW!).
8. Triple match on V/Q.
10. GI bleeding study with a left colon bleed.
Case 303 I thought I was doing really well in nukes, but didn’t
11. High prob V/Q scan with NL CXR. Case get let out early. Oh well.
415 Off the bat, she told me she wasn’t interested in
12. Brain SPECT with right MCA distribution hearing energies and half lives. Woo Hoo!
defects c/w infarcts, then showed Diamox 1. Renal scan with lasix showing
study same patient showing similar obstruction. What sorts of agents do we
findings, he said images are sort of bad use? Any sort of pretreatment? I think she
aren’t they, I didn’t say anything. Case was looking for hydration. This guy was
619 dehydrated last week. Would my
13. Thyroid scan with uptake only in right interpretation change? She kept pushing
lobe, hemiagenesis vs partial resection vs me on that…
hyperfunctioning nodule on right, could 2. Inferior wall infarct. We discussed
do thyroid supression test, how would you cardiac imaging
treat a hyperfunctioning nodule?, I-131 20 3. Low back pain, leading to bone scan.
mCi (I wasn’t completely sure). Case 705 Little bit of funny uptake near one of the
SI joints. Stress fx? Got SPECT, and it
1. off peak scan (blurry) became clear the bladder was masking a
2. multinodular goiter Case 706 huge abnormality involving most of the
3. subacute thyroiditis (ddx for low uptake) sacrum. Turns out the guy had a history
Case 709 of colon cancer…
4. osteosarcoma with met to chest 4. We discussed QA on SPECT cameras.
5. pheochromocytoma on MIBG scan Page Oh well.
28 5. Graves dz. However, she showed Tc flow
6. Meckel's Case 317 images, and a single static image instead
7. lower GI bleed on RBC scan case 303 of Iodine.
8. biliary atresia Pg 802 6. Gallium- Sarcoid. What else is it good
9. testicular torsion (pertech) Case 821 for? That was a long discussion.
10. sarcoid- diffuse lung uptake on Gallium
scan case 428,430 2000 Recalls:
11. inf. wall infarct Dr. Brown; all cases were straight forward and
12. cardiomyopathy discussion was minimal. He let me out at least 10
13. defect on brain SPECT – tumor minutes early. This was my last session and I didn’t
14. bile leak Case 307 let the door hit my rear on the way out.
15. scar on DMSA 1. Bone scan with solitary lesion in distal femur:
16. scatter @ neck on bone scan from pt gave DDx
treated with I-131 2 Lung nodule on CXR then CT. He asked what
17. lymphoma on Gallium scan Case 302 “metabolic” imaging we could do, I said PET
18. superscan due to osteomalacia Case 114 and got one with a hot focus in chest.
19. stress fracture Case 101, 107, 108 3 Hepatobiliary scan with delayed activity in both
20. alpha-1 antitrypsin on V/Q Pg 117 gall bladder and bowel
21. captopril on MAG-3 showing bilat renal a. 4 Gallium scan with bilateral hot lungs: gave
stenosis pg 390 DDx
22. parathyroid adenoma (sestamibi) Case 5 Neonatal hypothyroidism: discussed imaging
713 techniques and etiologies
23. CSF cisternogram (use In-111 DTPA) 6 RL shunt on lung perfusion scan
Case 602 7 IHSS and stress induced myocardial ischemia.
24. osteomyelitis on 3phase bone scan History was given as a young man status post
(Brodie's abscess) Case 108 cardiac arrest
8 Cine of child MAG-3 scan: duplex collecting
PAST RECALLS: system with lower pole reflux
9 SPECT of head with temporal lobe seizure
1. Cold Thyroid Nodule focus
2. Bile Leak 10 GI bleed
3. Ureteral Leak
4. Colonic Bleed
5. Testicular Torsion
6. Discitis and Femur Fracture