1

Sllavko K. Kallfa





Prmbledhje Artikujsh nga
Radiopaedia.org
2

weapon and munition inspired signs







cannonball metastases..........................f.3
dagger sign...........................................................f.7
panzerherz (armour heart)..f.19
saber-sheath trachea............................ .f.20
Scimitar syndrome.................................. f.23
target sign............................................................ f.35





3

Cannonball metastases
Dr Henry Knipe and Dr Ian Bickle et al.
Cannonball metastases refer to large, well circumscribed, round metastases to the lung that
appear like cannonballs.
Metastases with such an appearance are classically from renal cell carcinoma or
choriocarcinoma, and less commonly from an alternative primary tumour, such as prostate
cancer, synovial sarcoma or endometrial carcinoma.
The French term "envole de ballons" which translates to "balloons release" is also used to
describe this same appearance.

References
1. Arkless R. RENAL CARCINOMA: HOW IT METASTASIZES. Radiology. 1996;84:
496-501. Pubmed citation
Synonyms & Alternative Spellings
Synonyms or Alternative Spelling Include in Listings?
Cannonball pulmonary metastases
Cannonball metastasis
Cannonball lung metastases
Cannon-ball metastases
Balloons release appearance

4

From the case: Renal cell carcinoma with pulmonary metastases
Modality: X-ray
5

From the case: Cannon ball metastases - from synovial sarcoma
Modality: CT
6

Frontal
Cannon-ball metastasis From the case: Lung metastases
Modality: X-ray






7

Dagger sign
Dr Henry Knipe and Dr Frank Gaillard et al.
The dagger sign is a radiographic feature seen in ankylosing spondylitis as single central
radiodense line on frontal radiographs related to ossification of supraspinous and interspinous
ligaments.

o
References
1. Bone and joint imaging. Donald Resnick, Mark J. Kransdorf. Philadelphia, Pa. :
Elsevier Saunders, c2005. ISBN:0721602703 (find it at amazon.com)
Synonyms & Alternative Spellings
Synonyms or Alternative Spelling Include in Listings?
The dagger sign

8

Dagger Photo by Jrgen Adam Holen. This file is licensed under Creative Commons Attribution 1.0
license
9

Dagger sign of ankylosing spondylitis
10

From the case: Ankylosing spondylitis of the
lumbar spine
Modality: X-ray
11

From the case:
Dagger sign in ankylosing spondylitis
Modality: X-ray
12

From the case:
Ankylosing spondylitis with bamboo spine and dagger sign
Modality: X-r
13

From the case:
Ankylosing spondylitis - with dagger sign
Modality: CT
14

From the case:
Ankylosing spondylitis
Modality: X-ray
15

From the case:
Ankylosing spondylitis
Modality: X-ray
16

From the case: Ankylosing spondilitis
Modality: Annotated image
17

18

From the case: Ankylosing spondilitis
Modality: Annotated image



19

Panzerherz
Dr Yuranga Weerakkody and Dr Ian Bickle et al.
Panzerherz (or armoured heart) is a term used to describe the appearance of the heart in
calcified constrictive pericarditis.
The pericardium becomes circumferentially thickened with calcification, limiting the ability of
the heart to contract. The rim of dense calcification describes how the heart is "armoured", in the
manner a military vehicle is.
The calcification is a generic response to a number of potential insults causing constrictive
pericarditis including:
tuberculosis
viral infections
trauma
radiation treatment


References
1. Dewey M, Eddicks S, Hamm B. Images in cardiology: Armoured heart. Heart. 2005;91
(10): 1256. doi:10.1136/hrt.2005.060616 - Free text at pubmed - Pubmed citation
2. Eastman G, Wald C. Getting Started in Clinical Radiology: From Image to Diagnosis.
TIS. ISBN:B005NA3D1U. Read it at Google Books - Find it at Amazon
Synonyms & Alternative Spellings
Synonyms or Alternative Spelling Include in Listings?
Porcelin heart
Armoured heart
Armored heart
Armour-plated heart
Armor-plated heart


20

Saber sheath trachea
Dr Henry Knipe and Dr Frank Gaillard et al.
Saber-sheath trachea refers to diffuse coronal narrowing of the intra-thoracic portion of the
trachea with concomitant widening of the sagittal diameter. It is not uncommon and is
pathognomonic for chronic obstructive pulmonary disease (COPD)
1
.
The sagittal:coronal diameter is over 2:1
2
and the extra-thoracic portion of the trachea is not
narrowed.
Radiographic features
Marked decrease in the coronal diameter of the intra-thoracic trachea associated with an increase
in its sagittal diameter.
CT
Additional features may include:
inward bowing or displacement of the lateral tracheal walls as a result of cartilage
weakness
mild intra-thoracic tracheal wall thickening
ossification of tracheal rings
during forceful expiration, there may be further inward bowing

References
1. Marom EM, Goodman PC, Mcadams HP. Diffuse abnormalities of the trachea and
main bronchi. AJR Am J Roentgenol. 2001;176 (3): 713-7. AJR Am J Roentgenol (full
text) - Pubmed citation
2. Webb EM, Elicker BM, Webb WR. Using CT to diagnose nonneoplastic tracheal
abnormalities: appearance of the tracheal wall. AJR Am J Roentgenol. 2000;174 (5):
1315-21. AJR Am J Roentgenol (full text) - Pubmed citation
3. Ciccarese F, Poerio A, Stagni S et-al. Saber-sheath trachea as a marker of severe
airflow obstruction in chronic obstructive pulmonary disease. Radiol Med. 2014;119 (2):
90-6. doi:10.1007/s11547-013-0318-3 - Pubmed citation
Synonyms & Alternative Spellings
Synonyms or Alternative Spelling Include in Listings?
Saber sheath trachea

21

From
the case: Saber sheath trachea
Modality: X-ray
22

From the case: Saber sheath trachea
Modality: CT



23

Scimitar syndrome
Dr Yuranga Weerakkody and Dr Frank Gaillard et al.
Scimitar syndrome (also known as pulmonary venolobar syndrome or hypogenetic lung
syndrome)
4
is characterised by a hypoplastic lung that is drained by an anomalous vein into the
systemic venous system. It is a type of partial anomalous pulmonary venous return.
Pathology
It is essentially a combination of pulmonary hypoplasia and partial anomalous pulmonary venous
return (PAPVR). It almost exclusively occurs on the right side.
Haemodynamically, there is an acyanotic left to right shunt. The anomalous vein usually drains
into
inferior vena cava - most common
right atrium
portal vein
The lung is frequently perfused by the aorta, but the bronchial tree is still connected and thus the
lung is not sequestered.
Associations
congenital heart disease (e.g. ASD, VSD, tetralogy of Fallot, PDA)
ipsilateral diaphragmatic anomalies (e.g. accessory diaphragm, diaphragmatic hernia)
localised bronchiectasis
horseshoe lung
vertebral anomalies (e.g. hemivertebrae
4
)
genitourinary tract abnormalities
4

Radiographic features
The diagnosis is made by transthoracic or transesophageal echocardiography, angiography, or by
CT or MR angiography.
Plain film
Chest radiographic findings are that of a small lung with ipsilateral mediastinal shift, and in one
third of cases the anomalous draining vein may be seen as a tubular structure paralleling the right
heart border in the shape of a Turkish sword (scimitar). The right heart border maybe blurred.
Complications
24

A potential complication that could develop is development or pulmonary hypertension an
Eisenmenger physiology.
Treatment
Surgical correction should be considered in the presence of significant left to right shunting and
pulmonary hypertension. This involves creation of an inter-atrial baffle to redirect the pulmonary
venous return into the left atrium. Alternatively, the anomalous vein can be re-implanted directly
into the left atrium.
Etymology
The term was first given by C A Neill et al in 1960
5
.
Differential diagnosis
General imaging differential considerations include
pulmonary sequestration
right middle lobe atelectasis (on AP plain film)
unilateral absence of pulmonary artery (UAPA)

References
1. Dahnert WF. Radiology Review Manual. (2011) ISBN:1609139437. Read it at Google
Books - Find it at Amazon
2. Melduni RM, Mookadam F, Mulligan ME. Scimitar syndrome: another one for the
radiologists. Radiology. 2006;241 (2): 629. doi:10.1148/radiol.2412051952 - Pubmed
citation
2. Olson MA, Becker GJ. The Scimitar syndrome: CT findings in partial anomalous
pulmonary venous return. Radiology. 1986;159 (1): 25-6. Radiology (citation) - Pubmed
citation
4. Berrocal T, Madrid C, Novo S et-al. Congenital anomalies of the tracheobronchial tree,
lung, and mediastinum: embryology, radiology, and pathology. Radiographics. 24 (1):
e17. doi:10.1148/rg.e17 - Pubmed citation
5. Schramel FM, Westermann CJ, Knaepen PJ et-al. The scimitar syndrome: clinical
spectrum and surgical treatment. Eur. Respir. J. 1995;8 (2): 196-201. Eur. Respir. J. (link)
- Pubmed citation
6. Baskar karthekeyan R, Saldanha R, Sahadevan MR et-al. Scimitar syndrome:
experience with 6 patients. Asian Cardiovasc Thorac Ann. 2009;17 (3): 266-71.
doi:10.1177/0218492309104750 - Pubmed citation
7. Woodring JH, Howard TA, Kanga JF. Congenital pulmonary venolobar syndrome
revisited. Radiographics. 1994;14 (2): 349-69. doi:10.1148/radiographics.14.2.8190958 -
Pubmed citation
25

8. Konen E, Raviv-Zilka L, Cohen RA et-al. Congenital pulmonary venolobar syndrome:
spectrum of helical CT findings with emphasis on computerized reformatting.
Radiographics. 2003;23 (5): 1175-84. doi:10.1148/rg.235035004 - Pubmed citation
Synonyms & Alternative Spellings
Synonyms or Alternative Spelling Include in Listings?
Pulmonary venolobar syndrome
Congenital pulmonary venolobar syndrome (CVLS)
Scimitar's syndrome
Hypogenetic lung syndrome



26

Scimitar Syndrome A tubular
lesion in in the right lower zone with increasing diameter inferiorly.This is classic apperance of the
scimitar syndrome. It can be associated with hypoplasia of the right middle/ lower lobe.
27

From the case: Scimitar syndrome
Modality: MRI
28

From the case:
Scimitar syndrome
29

30

From the case: Scimitar syndrome
31

From the case: Scimitar syndrome
Modality: X-ray
32

Abnormal
curvilnear shadow overlying the heart in the right hemithorax - characteristic Scimitar finding. From
the case: Scimitar syndrome
Modality: X-ray From the case: Scimitar syndrome
Modality: X-ray

33

Abnormal curvilnear shadow
overlying the heart in the right hemithorax - characteristic Scimitar finding. From the case: Scimitar
syndrome
Modality: X-ray
34

From the case: Scimitar syndrome
Modality: CT



35

Bull's eye sign - general
Dr Henry Knipe and Dr M Udayakumar et al.
There are many bull's eye signs, also referred to as target signs:
red bone marrow located in shaft of long bone with central yellow marrow on MRI
peripheral plexiform neurofibromas on MRI
intussusception: see target sign of intussusception
choledocholithiasis: see target sign of choledocholithiasis
cerebral metastases
cerebral abscess
barium studies
2

o aphthoid ulcers - earliest lesion seen in Crohn's disease on barium enema
o gastic lymphoma with central ulceration
4

o GIST with central ulceration
o hematogenous gastric metastases
o gastric adenocarcinoma with central ulceration
lung granuloma
lyme disease
target sign of haematoma on MRI (also called concentric ring sign on MRI)
also described in tears of deep tendon of rectus femoris in athletes

References
1. Dunnick NR, Harell GS, Parker BR. Multiple "bull's-eye" lesions in gastric lymphoma.
AJR Am J Roentgenol. 1976;126 (5): 965-9. AJR Am J Roentgenol (citation) - Pubmed
citation
2. Rubesin SE, Levine MS, Laufer I. Double-contrast upper gastrointestinal radiography:
a pattern approach for diseases of the stomach. Radiology. 2008;246 (1): 33-48.
doi:10.1148/radiol.2461061245 - Pubmed citation
Synonyms & Alternative Spellings
Synonyms or Alternative Spelling Include in Listings?
Bulls eye sign - general
Target sign - general

36

Archery target Archery target
for use in target sign articles. target sign of intussesceptionPermission 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".Original file:
http://commons.wikimedia.org/wiki/File:Archery_target.jpgAuthor: Casito
37

From the case:
Bull's eye sign (from cerebral metastasis)
Modality: MRI
38

From the case: Intussusception
Modality: Ultrasound
39

From the case: Bull's eye sign
Modality: MR
40

A
small 'pit' of barium contained within an ulcer cavity in the body of the stomachFrom the case:
Gastric ulcer - a bull's eye
Modality: Fluoroscopy
41

From the case: Cerebral absceses
Modality: MRI