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Seeing the signs of Radiology

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Seeing the signs of Radiology Trevor Downing, MSIV To quote Dr. Neuffer These are the things Radiologists come up with when they sit in the dark too long – PowerPoint PPT presentation

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Title: Seeing the signs of Radiology


1
Seeing the signs of Radiology
  • Trevor Downing, MSIV

2
To quote Dr. Neuffer
  • These are the things Radiologists come up with
    when they sit in the dark too long
  • Or something like that

3
Classic signs
4
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5
Apple core sign
  • Must r/o adenocarcinoma of colon
  • DDx
  • Malignant neoplasms (adenocarcinoma, lymphoma)
  • Benign neoplasms (villous adenoma)
  • IBD (chronic Crohns or UC)
  • Vascular disorders (ischemic colitis)
  • Infections (tuberculosis, helminthoma, ameboma)
  • Studies of double-contrast barium enema as
    screening for colorectal cancer
  • Detects only 1/2 of adenomas gt1cm and 39 of all
    polyps. May miss 15-22 of colorectal cancers
  • Use decreasing due to more accurate colonoscopy
    or CT colonography

6
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7
Bamboo spine
  • Ankylosing spondylitis
  • Chronic inflammatory disease of the axial
    skeleton causing back pain and progressive
    stiffness of spine
  • Peak age of onset 20-30yrs
  • Ankylosis refers to fibrous or bony bridging of
    joints
  • Part of the spondyloarthritis disorders
    inflammation of the entheses (insertion sites of
    ligaments on bones).
  • Dx
  • Clinical findings (inflammatory back pain, ?ROM
    of back)
  • Lab testing HLA-B27
  • Imaging

8
Bamboo spine
  • Imaging
  • Abnormal SI joint on plain AP pelvic radiographs
    seen in longstanding disease.
  • Findings joint widening, erosions, sclerosis or
    ankylosis
  • If no findings but suspicion is high then follow
    with MRI of pelvis.
  • If MRI contraindicated then CT scan can detect
    erosions, bony sclerosis but not acute
    inflammatory changes

9
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10
Champagne sign
  • Emphysematous cholecystitis
  • US image reveals multiple tiny echogenic
    reflectors within the gallbladder lumen (arrows)
    corresponding to gas bubbles leaving from
    dependent wall.
  • Often a complication of acute cholecystitis,
    caused by gas forming bacteria (mostly C.
    perfringens, Ecoli, gut bacteria)
  • More common in men, elderly (gt60yrs) and
    diabetics.

11
Champagne sign
  • Emphysematous cholecystitis
  • Imaging
  • Plain films may show air in wall/lumen
  • CT scan
  • GB wall thickening gt3mm
  • Cholelithiasis
  • Increased bile density (gt20H)
  • Loss of clear GB wall definition
  • Pericholecystic fluid (halo)
  • Treatment
  • Percutaneous preoperative drainage antibiotics
  • Open cholecystectomy laparoscopic less
    successful

12
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13
Bats wings or butterfly appearance
  • Congestive heart failure (HF)
  • Chest x-ray is often first diagnostic test
  • Differentiates between HF and 1 pulmonary
    disease (dyspnea)
  • Bats wings are bilateral perihilar edema
  • Findings suggestive of HF
  • Cardiomegaly cardiacthoracic width gt50
  • Cephalization of pulmonary vessels
  • Kerley B-lines pulmonary edema in interlobular
    septa
  • Pleural effusions
  • Study of 880 patients showed
  • Cephalization, alveolar edema or interstitial
    edema all had gt90 specificity for HF
  • Cardiomegaly had only 50 sensitivity

14
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15
Codmans triangle
  • Osteosarcoma
  • 1 malignant tumor of bone malignant cells make
    osteoid or immature bone
  • Uncommon tumor but 1 primary malignancy of bone
    in children and adolescents
  • Bimodal distribution - lt20yrs and gt65yrs
  • Most common sites
  • Children metaphyses of long bones (distal femur
    75, proximal tibia, proximal humerus)
  • Adults axial skeleton

16
Codmans triangle
  • Osteosarcoma
  • Risks
  • Prior irradiation/chemotherapy
  • Pagets disease usually osteosarcoma in pts
    gt40yrs
  • Chronic osteomyelitis
  • Multiple hereditary exostoses
  • Fibrous dysplasia
  • Metallic implants
  • Hereditary retinoblastoma
  • Li-Fraumeni syndrome (p53 mutation)

17
Codmans triangle
  • Dx
  • First diagnostic test usually plain radiograph
  • Codmans triangle ? new periosteal bone formation
    lifting the cortex.
  • The associated sunburst appearance ? soft tissue
    ossification.
  • No bone findings are pathognomonic biopsy
    needed
  • DDx
  • Malignant bone tumors (Ewings, lymphoma, mets)
  • Benign bone tumors (osteoid osteoma,
    chrondroblastoma, osteochrondroma)
  • Non-neoplastic (osteomyelitis, eosinophilic
    granuloma, bone cysts)

18
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20
Hamptons hump Westermarks sign
  • Pulmonary embolus
  • Hamptons hump
  • Pleural based, wedge shaped consolidation ?
    represents area of infarction and atelectasis
  • Westermarks sign
  • Area of decreased density lateral to PE ?
    represents oligemia distal to PE as well as
    distended/engorged pulmonary vessels.

21
Hamptons hump Westermarks sign
  • Pulmonary embolus
  • Radiographic abnormalities common in PE but not
    helpful diagnostically

22
Strange signs
23
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24
Anteater nose sign
  • Calcaneonavicular tarsal coalition
  • Tarsal coalition ? abnormal union or 2 or more
    tarsal bones
  • 2 most common types
  • Calcaneonavicular
  • Talocalcaneal
  • Causes are congenital or acquired
  • Acquired trauma, infection, surgery, articular
    disorders

25
Anteater nose sign
  • Initial evaluation of tarsal coalition
    conventional radiography
  • Oblique, AP and lateral weight bearing views of
    feet
  • CT/MRI for complicated cases or preoperative
    planning
  • MRI is useful for nonosseous fibrous or
    cartilaginous coalitions

26
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27
David Letterman sign(Aka Terry Thomas)
  • Scapholunate dissociation (dislocation)
  • Most common and significant wrist ligament injury
  • Mechanism of injury
  • Similar to scaphoid fx falling on outstretched
    hand (carpal loading)
  • Common in contact sports due to jamming extended
    hand into other athletes
  • Imaging
  • AP radiograph ? scapholunate distance gt3mm
    flexed scaphoid.
  • Lateral view ? increased scapholunate angle
  • MRI helpful
  • In children difficult to interpret due to
    incomplete ossification
  • Incomplete tear of ligament

28
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29
Mount Fuji sign
  • Tension pneumocephalus
  • Causes
  • Iatrogenic most commonly after neurosurgical
    evacuation of subdural hematoma (2.5-16
    incidence).
  • Other skull base surgery, paranasal sinus
    surgery
  • Non-iatrogenic head trauma, nitrous oxide
    anesthetic, scuba diving?
  • Mount Fuji sign useful test to distinguish
    tension from non-tension pneumocephalus
  • Emergency surgery vs non-operative
  • Ishiwata study showed Mount Fuji sign positive in
    4/5 patients with surgically confirmed tension
    pneumocephalus, not seen in any non-tension cases.

30
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31
Yin-yang sign
  • True and false aneurysm
  • Yin-yang sign due to partial thrombosis of
    aneurysm. Contrast enhanced CT delineates lumen
    with active blood flow from the thrombosed
    portion
  • Utility
  • Two studies showed 82 89 of aneurysms
    demonstrated presence of mural thrombus.
  • This finding particularly helpful in 2 regions of
    body where hard to differentiate from ddx
  • Brain suprasellar meningiomas,
    craniopharyngiomas, hemorrhagic metastases
  • Abdomen cystic pancreatic tumors, islet cell
    tumors, solid/epithelial neoplasms, pseudocysts,
    gastric leiomyomas and leiomyosarcomas
  • However, not a specific sign for aneurysms
  • Rare solid or papillary neoplasms may show sign.

32
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33
Throckmorton sign(John Thomas sign)
  • Penis points towards the side of pathology
  • The sign tends to be commented on by middle-aged
    male radiologists and orthopedists suffering from
    Peter pan syndrome.
  • 2 studies
  • Medical Journal of Australia 1998 ? sensitivity
    70, specificity 67
  • UK study ? sensitivity 30, specificity 86
  • Mark Morton sign is a smaller Throckmorton

34
References
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    barium enema and their risk factors a
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  • Klauser, A, Bollow, M, Calin, A, et al. Workshop
    report clinical diagnosis and imaging of
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  • Knudsen, CW, Omland, T, Clopton, P, et al.
    Diagnostic value of B-Type natriuretic peptide
    and chest radiographic findings in patients with
    acute dyspnea. Am J Med 2004 116363.
  • Le Vu, B, de Vathaire, F, Shamsaldin, A, et al.
    Radiation dose, chemotherapy and risk of
    osteosarcoma after solid tumors during childhood.
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  • Grimer, RJ, Cannon, SR, Taminiau, AM, et al.
    Osteosarcoma over the age of forty. Eur J Cancer
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  • Papagelopoulos, PJ, Galanis, EC, Vlastou, C, et
    al. Current concepts in the evaluation and
    treatment of osteosarcoma. Orthopedics 2000
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  • Blakemore LC, Cooperman DR, Thompson GH. The
    rigid flatfoot. Tarsal coalitions.  The rigid
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