Radiological Signs (Shënja Radiologjike) - 8

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Sllavko K. Kallfa

Prmbledhje Artikujsh nga
Radiopaedia.org
2

fruit inspired
X-ray signs

apple core sign - colon....................... f.3
apple core sign - femur.................... f.11
apple-peel intestinal atresia.......f.53
banana sign......................................................f.14
banana fracture........................................ f.17
berry aneurysm......................................... f.20
bunch of grapes sign.......................... .f.39
lemon sign........................................................ .f.43
pear-shaped bladder........................... f.45
strawberry gallbladder....................f.49
strawberry skull........................................ f.52

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Apple core sign - colon
Dr Henry Knipe and Dr MT Niknejad et al.
The apple core sign, also known as a napkin ring sign (bowel), is most frequently associated
with constriction of the lumen of the colon by a stenosing annular colorectal carcinoma.
Differential diagnosis
The appearance of the apple-core lesion of the colon also can be caused by other diseases
3
:
lymphoma with colonic involvement - appears more diffuse
Crohns disease
chronic ulcerative colitis
ischaemic colitis
Chlamydia infection
colonic tuberculosis
Helminthoma
colonic amoebiasis
colonic cytomegalovirus
villous adenoma
radiosurgery such as high doses of Cyberknife used for treating unresectable abdominal
malignancies
References
1. Mulligan ME. Classic radiologic signs, an atlas and history. Informa HealthCare.
(1997) ISBN:1850706646. Read it at Google Books - Find it at Amazon
2. Freyschmidt J. The apple core sign. Eur Radiol. 2002;12 (1): 245-7. Eur Radiol
(abstract) - doi:10.1007/s00330-001-1193-1 - Pubmed citation
3. Alzaraa A, Krzysztof K, Uwechue R et-al. Apple-core lesion of the colon: a case
report. Cases J. 2009;2 (1): 7275. doi:10.4076/1757-1626-2-7275 - Free text at pubmed -
Pubmed citation
Synonyms & Alternative Spellings
Synonyms or Alternative Spelling Include in Listings?
Napkin ring sign - colon
Apple core sign of the colon
Apple core appearance of the colon

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Apple core sculpture Photo for
use in apple core sign of colorectal carcinoma. 'Apple Core', from Claes Oldenburg and Coosje
van Bruggen, Israel Museum Art Garden, Jerusalem, Israel Original file:
http://commons.wikimedia.org/wiki/File:Caro%C3%A7o_de_ma%C3%A7%C3%A3,_Museu_d
e_Israel.jpgAuthor: Boaz Gabriel CanhotoPermission is granted to copy, distribute and/or
modify this document under the terms of the GNU Free Documentation License, Version 1.2 or
any later version published by the Free Software Foundation; with no Invariant Sections, no
Front-Cover Texts, and no Back-Cover Texts. A copy of the license is included in the section
entitled "GNU Free Documentation License". Figure 1: apple core

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DWI
Stenosing Adenocarcinoma of the Colon Stenosing colorectal adenocarcinoma with apple core sign. ID#:
64 Description: Gross pathology of adenocarcinoma, colon "Napkin-ring" configuration of colonic
adenocarcinoma. Surgical specimen.Content Providers(s): CDC/ Dr. Edwin P. Ewing, Jr.Creation Date:
1974Copyright Restrictions: None - This image is in the public domain and thus free of any copyright
restrictions. As a matter of courtesy we request that the content provider be credited and notified in
any public or private usage of this image.Original file:
http://commons.wikimedia.org/wiki/File:Adenocarcinoma,_colon,_gross_pathology_64_lores.jpgThis
image is a work of the Centers for Disease Control and Prevention, part of the United States Department
of Health and Human Services, taken or made during the course of an employee's official duties. As a
work of the U.S. federal government, the image is in the public domain. Figure 4: gross pathology -
colorectal cancer

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Typical apple-core sign of the colon
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Acute marginal angles or shouldering sign may disappear proximally because of its dilatation.
8

Grey-scaleFrom the case: Apple core sign
Modality: Barium

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Apple core sign - Barium enema "Apple core sign" in the distal portion of the descendant colon.
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Virtual colonoscopy
From the case: Apple core sign - cancer colon
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Apple core sign - femur
Dr MT Niknejad et al.
Apple core sign has been used to describe the circumferential erosion of the femoral neck seen
in synovial chondromatosis. Although this is the most common process that may lead to an apple
core erosion of the femoral neck, this has also been observed with:
pigmented villonodular synovitis
amyloidosis
rheumatoid arthritis
References
1. Mulligan ME. Classic radiologic signs, an atlas and history. Informa HealthCare. (1997)
ISBN:1850706646. Read it at Google Books - Find it at Amazon
2. Goldberg RP, Weissman BN, Naimark A et-al. Femoral neck erosions: sign of hip joint synovial
disease. AJR Am J Roentgenol. 1983;141 (1): 107-11. AJR Am J Roentgenol (abstract) - Pubmed
citation
Apple core sign of the femur
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From the case:
Synovial chondromatosis
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From the case: Synovial chondromatosis
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Banana sign
Dr Frank Gaillard et al.
The banana sign, is one of the many a notable fruit inspired signs. It is seen on axial imaging
through the posterior fossa of fetus as a sign of a Chiari II malformation. It describes the way the
cerebellum is wrapped tightly around the brain stem as a result of spinal cord tethering and
downward migration of posterior fossa content. The cisterns magna gets obliterated. The shape
of the cerebellum has appearance of a banana
It is also seen in the majority of fetuses with spina bifida, but disappears after 24 weeks. It is
only rarely seen in a normal fetus. There is very frequent concurrent hydrocephalus.
Associated signs
The same condition also gives rise to the lemon sign.

References
1. Reuter KL, Babagbemi TK. Obstetric and gynecologic ultrasound. Mosby Inc. (2006)
2. Weissleder R, Wittenberg J, Harisinghani MM et-al. Primer of Diagnostic Imaging, Expert
Consult- Online and Print. Mosby Inc. (2011) ISBN:0323065384. Read it at Google Books - Find it
at Amazon
15

Banana cerebellum

Banana Photo of a banana,
used in Banana sign. Author: DarkoneOriginal file:
http://commons.wikimedia.org/wiki/File:Bananen_Frucht.jpgModifications: added white background
and changed image sizeLicense: This file is licensed under the Creative Commons
Attribution ShareAlike 2.5 License. In short: you are free to share and make derivative works of the file
under the conditions that you appropriately attribute it, and that you distribute it only under a license
identical to this one. Official license
16

From the case:
Myelomeningocoele
Modality: Ultrasound
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Banana fracture
Dr Yuranga Weerakkody and Dr Katarzyna Skorupka et al.
A Banana fracture refers a complete, horizontally oriented pathological fracture that is typically
seen in softened bones affected by Paget disease. This should not be confused with incremental
fractures that may also be seen in Paget disease, which represent incomplete insufficiency
fractures.
References
1. Tehranzadeh Jamshid. Musculoskeletal Imaging Cases. McGraw Hill Professional, 2008. ISBN:
0071465421, 9780071465427.
Synonyms & Alternative Spellings Banana fractures

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From the case: Incremental fractures in Paget's disease
Modality: X-ra
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From the case: Incremental fractures in Paget's disease
Modality: X-ra
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Saccular cerebral aneurysm
Dr Donna D'Souza et al.
Saccular cerebral aneurysms (also known as berry aneurysms) are
intracranial aneurysms typically with a characteristic rounded shape and account for the vast
majority of intracranial aneurysms. They are also the most common cause of non-traumatic
subarachnoid haemorrhages.
Epidemiology
Prevalence of saccular cerebral aneurysms in the asymptomatic general population has been
reported over a wide range (0.2-8.9%) when examined angiographically, and in 15-30% of these
patients, multiple aneurysms are found
4
.
A familial tendency to aneurysms is also well recognised, with patients who have more than one
affect first degree relative affected having a 17-44% chance of themselves having an aneurysm
4
.
Pathology
Grossly aneurysms are rounded lobulated focal outpouchings which usually arise at the arterial
bifurcations, it may arise from the lateral wall.
Most of the intracranial aneurysms are true aneurysm. The aneurysmal pouch is composed of
thickened hyalinised intima with the muscular wall and internal elastic lamina being absent as
the normal muscularis and elastic lamina terminate at the neck of the aneurysm. As the aneurysm
grows it may become irregular in outline, and may have mural thrombus. Typically rupture
occurs from the dome
4
.
Associations
Numerous associations have been identified, most relating to abnormal connective tissue.
Associations include:
Ehlers-Danlos syndrome (type IV)
Marfan syndrome (controversial
3
)
autosomal dominant polycystic kidney disease (ADPKD)
1

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coarctation of aorta
2

bicuspid aortic valve
neurofibromatosis type 1 (NF1)
3

hereditary haemorrhagic telangiectasia
alpha 1 antitrypsin deficiency
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cerebral arteriovenous malformation : flow related aneurysm
fibromuscular dysplasia
Location
Cerebral aneurysms typically occur at branch points, usually of sizable vessels, but sometimes at
the origin of small perforators which may not be seen on imaging. Approximately 90% of such
aneurysms arise from the anterior circulation
4
.
anterior circulation: ~ 90%
o ACA / ACoA complex: ~30-40%
o supraclinioid ICA and ICA / PCoA junction: ~30%
o MCA (M1/M2 junction) bi/trifurcation: ~ 20-30%
posterior ciculation: ~ 10%
o basilar tip
o SCA
o PICA
Radiographic features
Berry aneurysms can be imaged in a variety of methods:
1. CT angiography (CTA)
2. MR angiography (MRA)
3. digital subtraction (catheter) angiography (DSA)
Each of these confers certain advantages and disadvantages, although in general digital
subtraction catheter angiography, especially with 3D acquisitions, is considered the gold
standard in most institutions.
Required description on a radiology report
Regardless of the modality used, a number of features need to be assessed to allow a decision in
relation to treatment to be made.
size - ideally 3 axis maximum size meansurements
neck - maximal width of the neck of the aneurysm
shape and lobulations
orientation - the direction in which the aneurysm points is often important in both endovascular
and surgical planning
any smaller branches in the vicinity of the aneurysm
any branch taking off from the aneurysm
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Treatment and prognosis
Treatment of large or symptomatic aneurysms is with either endovascular coiling or surgical
clipping.
Management of small aneurysms is controversial. At less that 7mm in maximal diameter
aneurysms are statistically unlikely to rupture, however due to their prevalence anyone working
in the area has seen numerous patients with small aneurysms which have ruptured resulting in
subarachnoid haemorrhage, often with devastating consequences.
5 year cumulative risk of rupture of anterior circulation aneurysms
5
:
< 7 mm : 0%
7-12 mm : 2.6%
13-24 mm : 14.5%
> 25 mm : 40%
5 year cumulative risk of rupture of posterior circulation aneurysms
5
:
< 7 mm: 2.5%
7-12 mm: 14.5%
13-24 mm: 18.4%
> 25 mm: 50%
As such management will vary according to local experience, the location and appearance of the
aneurysm, patient demographics etc...
Differential diagnosis
When the abnormality has been confirmed to be vascular, the differential includes:
fusiform aneurysm
infundibulum - usually triangular dilatation with the vessel arising from the apex
dissecting aneurysm
mycotic aneurysm
)
References
1. Nahm AM, Henriquez DE, Ritz E. Renal cystic disease (ADPKD and ARPKD). Nephrol. Dial.
Transplant. 2002;17 (2): 311-4. doi:10.1093/ndt/17.2.311 - Pubmed citation
2. Konen E, Merchant N, Provost Y et-al. Coarctation of the aorta before and after correction:
the role of cardiovascular MRI. AJR Am J Roentgenol. 2004;182 (5): 1333-9. AJR Am J Roentgenol
(full text) - Pubmed citation
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3. Wardlaw JM, White PM. The detection and management of unruptured intracranial
aneurysms. Brain. 2000;123 ( Pt 2) : 205-21. Brain (link) - Pubmed citation
4. Takahashi S. Neurovascular Imaging, MRI & Microangiography. Springer Verlag. (2010)
5. Wiebers DO, Whisnant JP, Huston J et-al. Unruptured intracranial aneurysms: natural history,
clinical outcome, and risks of surgical and endovascular treatment. Lancet. 2003;362 (9378):
103-10. Lancet (link) - Pubmed citation
Intracranial aneurysms
Intracranial aneurysm
Berry aneurysm
Cerebral aneursyms
Cerebral aneursym
Berry aneurysms
Saccular cerebral aneurysms

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Norwegian blueberry Photo
of a Norwegian blueberry. Author: Thomas MuesOriginal file:
http://commons.wikimedia.org/wiki/File:Norwegian_blueberry.jpgModifications: croppedLicense: This
file is licensed under Creative Commons Attribution ShareAlike 2.0 LicenseFigure 1: photograph -
Norwegian blueberry
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This small berry aneurysm projecting
inferiorly from the ACOM had pushed into the optic chiasm causing a bitemporal hemianopia, similar to
that seen in pituitary lesions.
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SAH angiogramCase 2: at basilar tip
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T1 C+
Partially thrombosed MCA aneurysm : T1 gad
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From the case: Giant middle cerebral artery aneurysm
Modality: MRI
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From the case: A-comm aneurysm
Modality: CT
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From the case: A-comm aneurysm
Modality: CT
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From the case: Thrombosed PICA aneurysm
Modality: MRI
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From the case: Thrombosed PICA aneurysm
Modality: MRI
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From the case: MCA berry aneurysm
34

Modality: MRI
From the case: MCA aneurysm
Modality: MRI
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From the case: Carotid cave aneurysm (coiled) and MCA fenestration
Modality: DSA (angiography)

36

From the case: MCA and
basilar tip aneurysms
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From the case:
Anterior communicating artery aneurysm
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From the case: Middle cerebral artery aneurysm
39

Bunch of grapes sign
Dr Jeremy Jones and Dr Andrew Dixon et al.
The bunch of grapes sign refers to the ultrasound appearance of multiple cystic spaces within
the uterus as the result of hydropic swelling of trophoblastic villi within a hydatidiform mole.
This sign is also described in bronchiectasis where on plain radiograph, the dilated bronchi in
approximation appear as a brunch of grapes.
The same term is used to described the appearances of an intraductal papillary mucinous
neoplasm of the pancreas (IPMN).
Cluster of grapes sign

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From the case: Complete hydatidiform mole
Modality: Annotated image
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From the case: Pancreatic intraductal papillary mucinous neoplasm
Modality: MRI
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From the case: Pancreatic intraductal papillary mucinous neoplasm
Modality: MRI Case 2: bunch of grapes from IPMN of the pancreas
43

Lemon sign
The lemon sign, noted on antenatal imaging, is one of the many notable fruit inspired signs. It is
a feature when there appears to be an indentation of the frontal bone (depicting that of a lemon).
It is classically seen as a sign of a Chiari II malformation and also seen in the majority (90 -
98%) of fetuses with spina bifida.
Radiographic assessment
It is seen on axial imaging (usually antenatal ultrasound, although antenatal MRI will also
demonstrate this sign) through the head and relates to concavity (not just flattening) of the frontal
bones.
Several diagnostic points should be remembered about this sign:
when obtaining images of the calvarium, the transducer should not be angled downward
anteriorly, as the fetal orbits may simulate the lemon sign
this sign is seen more often in fetuses less than 24 weeks and may not be present in older
fetuses (usually disappears after 24 weeks
4
).
this may be due to the decreased pliability of the fetal calvarium with advancing gestational age
or the increased intracranial pressure with associated hydrocephalus
this sign may be rarely seen in normal patients ( ~ 1 % of cases) and in those with other non-
neural axis abnormalities.
Conditions associated with lemon sign
Chiari II malformation
spina bifida
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encephalocele
Dandy Walker malformation
thanatophoric dysplasia
cystic hygroma
diaphragmatic hernia
corpus callosal agenesis
6

hydronephrosis
umbilical vein varix
Associated signs
it is also associated with the banana sign.
References
1. Johnson PT, Kurtz AB. Obstetric and gynecologic ultrasound, case review. Mosby Inc. (2001)
2. Weissleder R, Wittenberg J, Harisinghani MG. Primer of diagnostic imaging. Mosby Inc. (2007)
3. Roche CJ, O'keeffe DP, Lee WK et-al. Selections from the buffet of food signs in radiology.
Radiographics. 22 (6): 1369-84. doi:10.1148/rg.226025521 - Pubmed citation
4. Thomas M. The lemon sign. Radiology. 2003;228 (1): 206-7. doi:10.1148/radiol.2281020448 -
Pubmed citation
5. Entezami M, Albig M, Knoll U et-al. Ultrasound Diagnosis of Fetal Anomalies. Thieme. (2003)
6. Ball RH, Filly RA, Goldstein RB et-al. The lemon sign: not a specific indicator of
meningomyelocele. J Ultrasound Med. 1993;12 (3): 131-4. J Ultrasound Med (abstract) -
Pubmed citation
Lemon head
Lemon head sign

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Pear-shaped bladder
A pear-shaped (or tear-drop-shaped) bladder is one whose normal round or ovoid shape has
been extrinsically compressed to resemble a pear. The pear may be inverted or upright,
depending on how the excess pelvic tissue compresses the bladder. Causes of a pear-shaped
bladder include:
pelvic fluid
o pelvic haematoma - the original description of the inverted pear-shaped bladder was in
patients with pelvic trauma and hematoma; it can also be seen in patients receiving
anticoagulation therapy.
o bilateral lymphocoeles - may develop following radical pelvic lymph node dissection.
o extravasated urine/bilateral urinomas
o abscess
pelvic lipomatosis - non-malignant overgrowth of fat around the bladder that causes an
inverted pear-shaped bladder. Most common in middle-aged black men.
vascular dilatation
o bilateral iliac artery aneurysms; upright pear-shape.
o inferior vena cava (IVC) occlusion; causes formation of collateral vessels that compress
the bladder and form an inverted pear-shaped bladder. In the olden days of intravenous
urograms, the combination of a renal mass and a pear-shaped bladder was a red flag for
renal cell carcinoma involving the renal vein and IVC
2

symmetric lymph node enlargement
psoas muscle hypertrophy
o upright pear-shape - especially in people with narrow pelvises.
o a ratio of the (sum of the widths of the two psoas muscles):(the pelvic width)>0.98
makes predisposes to bladder compression
2-3,6
.
References
1. Ambos MA, Bosniak MA, Lefleur RS, Madayag MA. The pear-shaped bladder. Radiology. 1977;
122(1):85-8. PubMed
2. Amendola MA. Imaging of Benign Conditions of the Bladder. in Lower Genitourinary
Radiology: Imaging and Intervention, Jafri SZH, Amendola MA, and Diokno AC (Editors). Springer.
1997. p 65. ISBN:978-0387947068
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3. Chang SF. Pear-shaped bladder caused by large iliopsoas muscles. Radiology. 1978
Aug;128(2):349-50.PubMed
4. Dyer RB, Chen MY, Zagoria RJ. Classic signs in uroradiology. Radiographics. 2004; 24 Suppl
1:S247-80. PubMed
5. Roche CJ, O'Keeffe DP, Lee WK, Duddalwar VA, Torreggiani WC, Curtis JM. Selections from the
buffet of food signs in radiology. Radiographics. 2002 Nov-Dec;22(6):1369-84. PubMed
6. Wechsler RJ, Brennan RE. Teardrop bladder: additional considerations. Radiology. 1982;
144(2):281-4.PubMed
Pear shaped bladder
Tear drop shaped bladder

Pear USDA photo by Keith Weller. Image
Number K5299-1. See case description for more details. Original file hereThis image is a work of a United
States Department of Agriculture employee, taken or made during the course of the person's official
duties. As a work of the U.S. federal government, the image is in the public domain.USDA photo by Keith
47

Weller. Image Number K5299-1. Inverted
pear USDA photo by Keith Weller. Image Number K5299-1. See case description for more details.
Original file hereThis image is a work of a United States Department of Agriculture employee, taken or
made during the course of the person's official duties. As a work of the U.S. federal government, the
image is in the public domain.USDA photo by Keith Weller. Image Number K5299-1.
48

AP view from a
cystogram showing a pear shaped bladder. Right superior pubic ramus fractureFrom the case: Pear
shaped bladder
Modality: Fluoroscopy
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Strawberry gallbladder
A strawberry gallbladder refers not to the shape, but to the surface appearance of the mucosa
of the gallbladder, when multiple small collections of triglycerides and cholesterol esters within
the lamina propria of the gallbladder wall.
Strawberry gallbladder is diffuse cholesterolosis and is a common idiopathic non-neoplastic
condition. It is not currently visible on imaging.
When cholesterosis is focal, it forms cholesterol polyps.
References
1. A. R. Boscak "Adenomyomatosis of the Gallbladder" RadioGraphics 2006;26:941-946
2. Rumack CM, et al. Diagnostic Ultrasound Elsevier Mosby, 3rd edition, 2005.
50

mage courtesy of Jian-Hua Qiao. Please see case description page for licence and original file
information. From the case: Strawberry gallbladder and cholesterol stones
Modality: Photo
51

Image courtesy of Mobius. Please see case description page for licence and original file information.
From the case: Strawberries
Modality: Photo
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Strawberry skull
A strawberry shaped skull is a feature that can be seen in trisomy 18 (Edward syndrome) and
refers to the shape of the head. It is thought to relate to hypoplasia of the frontal lobes.
References
1. Reuter KL, Babagbemi TK. Obstetric and gynecologic ultrasound. Mosby Inc. (2006)
2. Weissleder R, Harisinghani MG, Wittenberg J. Primer of diagnostic imaging. Mosby Inc. (2007)
Strawberry shaped skull
Strawberry skull shape

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Apple-peel intestinal atresia
Apple-peel intestinal atresia, also known as type IIIb or Christmas tree intestinal atresia, is a
rare form of small bowel atresia in which the duodenum or proximal jejunum ends in a blind
pouch and the distal small bowel wraps around its vascular supply in a spiral resembling an apple
peel. Often a vast segment of small bowel is absent
While apple-peel intestinal atresia is usually reported as an isolated malformation, it has been
associated with malrotation. Additionally, syndromic association has been reported with
microcephaly and ocular anomalies.

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