Escolar Documentos
Profissional Documentos
Cultura Documentos
Compendium
1. CRITICAL DIAGNOSES
! Abdominal
Aortic Aneurysm
! Abdominal trauma, including hepatic, splenic,
and renal injuries
! Aortic Dissection
! Pulmonary Embolism
Findings:
Aneurysmal AAA,
up to 8.0 x 9.0 cm
distally with
extensive mural
thrombus
" What imaging
modality would you
order next?
"
Findings:
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"
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Discussion: AAA
General Features:
"Abdominal aorta is considered aneurysmal when its outer wall to outer wall diameter reaches 3 cm,
outer wall to outer wall diameter. Common iliac artery is considered aneurysmal when it exceeds 2 cm
in diameter.
"AAA can demonstrate fusiform or saccular morphology.
"Most common site for aortic aneurysm is in the infrarenal aorta, although aneurysm can occu anywhere
in the aorta.. Extension into the internal iliac artery is not uncommon, however extension into the
external iliac artery is almost never seen.
"Surgical or endovascular repair is usually recommended for abdominal aortic aneurysm (AAA) > 5.5
cm in diameter and iliac aneurysm > 3 cm.
"Imaging:
" Ultrasound is an excellent non invasive tool for aneurysm screening, follow-up and useful for
assessment of endoleak post endovascular repair. And may demonstrate:
" Bulbous or fusiform dilatation of the aorta/artery, Concentric layers of mural thrombus
may line the interior of large aneurysms, Membrane or intimal flap as present in
dissection, Retroperitoneal hematoma which is highly suggestive of aortic rupture.
" Color Doppler is useful for demonstration of aortic dissection and to confirm patency major
aortic branches, including celiac axis, superior mesenteric artery, renal arteries.
" CT remains the gold standard and preferred imaging modality::
" For evaluationt of possible aortic rupture
" For assessment of suitability for endovascular or surgical repair of the aortic aneurysm
" For post endovascular repair follow-up, particularly for assessment of endoleak
Findings:
"
Definition:
Discussion:
Thoracic Aortic Dissection
"
Aortic dissection: Spontaneous tear between the intima and media layers with
propagation of subintimal hematoma
Staging, Grading, or Classification Criteria:
Stanford classification (preferred classification)
" Type A: Originates in ascending thoracic aorta (60-70%), treated surgically
" Type B: Originates distal to left subclavian artery (30-40%), conservative
treatment with HTN management
DeBakey classification
" Type 1: Ascending and descending thoracic aorta (30-40%)
" Type 2: Ascending only (10-20%)
" Type 3: Descending only (40-50%) A: Extends to diaphragm, B: Descends
below diaphragm
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Findings:
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Findings:
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CT is the imaging modality of choice for diagnosis of intra-abdominal injury after blunt or penetrating
abdominal trauma, and is especially valuable when physical examination is unreliable (i.e. stuporous
patient) or equivocal.
CT is usually obtained for patients with significant abdominal trauma who are hemodynamically stable.
CT is performed WITH intravenous contrast, but WITHOUT oral contrast (at least in our institution).
Rectal contrast (in addition to IV) is reserved for cases with penetrating abdominal trauma (GSW,
stabbing). Delayed images may be obtained for evaluation of injury to the collecting system (higher level
of suspicion in setting of pelvic fractures) or to evaluate vascular injury and possibility of active vascular
extravasation.
Possible CT findings in the setting of acute abdominal trauma may include:
" Solid abdominal organ lacerations Splenic, liver, renal lacerations. These are usually linear areas
of hypodensity, potentially with surrounding fluid or hematoma. It is important to evaluate delayed
images for adjacent hyperdense foci which may represent active extravasation of intravenous
contrast (implies vascular injury), as this needs to be treated surgically. Shattered organs
demonstrated multiple lacerations and may demonstrate hypodense regions from devascularization
injury.
" Hemoperitoneum hyperdense fluid within the abdomen or pelvis, often ~ 30-45 HU. This is not
specific to any one particular injury, but a very hyper dense focal collection of fluid (sentinel clot)
can guide to the injured organ.
" Pneumoperitoneum- nonspecific finding which may be due to bowel laceration in penetrating trauma,
barotrauma, etc.
" Free contrast in peritoneal cavity may be seen with extravasation of rectal contrast through bowel
perforation as seen in above case or from leakage of contrast-opacified urine from the urinary tract.
2. CHEST
! Pneumothorax
! Lung
Collapse / Atelectasis
! Congestive Heart Failure
! Common Tubes and Lines
Pneumothorax
Hyperinflation of lungs pt
has emphysema with bullae
Pneumothorax (air in
pleural space)
chest tube
Next Day
And persisting
pneumothorax
Subcutaneous
emphysema
Residual
pneumothorax
Chest tube
Minor fissure
Inferior/anterior portion
of major fissure
ETT
Endotracheal tube
(ETT) terminates
above carina
R subclavian
central line ends
in SVC
Aortic balloon
pump used in
hemodynamic
instability
29 year-old man
60M
ETT ends above carina
Enteric tube enters nose (NG)
or mouth (OG) and courses
through esophagus into the
stomach (for suction or tube
feeds)
2nd try
Dobhoff tubes are used for tube feeds you want the liquid
to go in the stomach, not the lungs
Endotracheal
tube
Enteric tube
Cancer
! Lung cancer, pulmonary nodules
! Pleural effusion
! Pneumonia
!"#$%&'($
Findings:
There is a cluster of
microcalcifications in the left
mid breast. (hard to see, I
know).
DCIS
Atypical ductal epithelial cells thought to
represent the earliest form of breast cancer.
" Most common presentation is
microcalcifications as seen as previous
mammogram.
" Typically treated with lumpectomy/breast
conserving therapy.
"
Findings:
There is a 2.5 cm pulmonary
nodule in the right upper lobe.
No lymphadenopathy is
identified.
Pulmonary nodule
Lesions upto 3cm are considered pulmonary
nodules, greater than 3cm are considered
masses.
" Generally any nodule greater than 4mm is
followed based on the Fleishner criteria
guidelines.
" Nodules greater than 8mm require more
rigorous followup.
"
Findings:
There is a 2.5 cm nodular
opacity in the right upper lobe
with lobulated borders.
No lymphadenopathy by CT
size criteria.
Path:
Pulmonary adenocarcinoma.
FINDINGS:
There is an opacity in the right lower
lung zone, tracking up the right chest
wall with blunting of the right
costophrenic angle and a meniscus.
Pleural Effusion
"
FINDINGS:
There is a lobar consolidation in
the left lower lobe.
Pneumonia
On CXR, often seen as a focal parenchymal
abnormality in a patient with fever.
" Differential includes atelectasis, edema, and
hemorrhage.
" In patients with lobar pneumonia, followup can
be obtained in 6 weeks to ensure resolution. If
not resolved, a CT can be obtained to rule out
obstructing lesion.
"
4. GASTROINTESTINAL
! Small
Bowel Obstruction
! Colorectal Cancer
! Large Bowel Obstruction
! GI bleed
! Cholecystitis and Biliary Obstruction
! Diverticulitis
Findings
"
"
Adhesions 60%
Hernia 15%
Tumor 15%
Findings
Best clue to diagnosis: a short segment of colon
wall thickening
Early cancer # irregular polyp or sessile
plaque
" Advanced cancer # annular wall thickening
creating an apple core apperance or lumenal
filling defect can cause obstruction
"
Colon adenocarcinoma
Dukes Stage
5 yr Survival by Stage
A # 80 85%
B # 64 78%
C # 27 33%
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"
2.
3.
Liver
Aorta
Common iliac a
Bladder
47 min
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Findings
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"
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Findings
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Sigmoid Volvulus
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Findings:
# Dilated loops,
Stacking. Notice the
stagnant stool in the
small bowel is starting
to fecalize or become
more solid
# Stomach
dilated. Place an NG
Tube to decompress.
Q: What is going
on in the liver?
A: There is abnormal
air in the liver.
Arrow Key:
Medical
record
number
Technical
Parameters
for image
acquisition
Zone of
optimum
Focus
Depth in cm
From skin
Type of US
probe used
Tech s initials
Skin
Anterior
Liver
Head
Feet
Posterior
Gallbladder
Findings
Stones in the gallbladder on ultrasound
" Shadow deep to gallbladder due to lack of
signal from reflected ultrasound waves.
"
Cholelithiasis
"
"
Findings
No oral contrast within colon lumen
" Pockets of air extending from sigmoid colon
" Peri-colonic fat stranding or inflammation
(water density in the fat around the wall)
" Colon wall inflammation # progressed to a
mural abscess
"
Diagnosis?
Diverticulitis
Sigmoid colon involved in 95% of cases
" Fecal impaction at diverticula mouth with
subsequent ischemia. Similar mechanism to
appendicitis!
"
Diagnosis?
Appendicitis Findings
Fluid within the appendix
" Dilated appendix > 7 mm
" Wall thickening or vascular enhancement
" Edema or fat stranding around appendix
" +/- dense appendicolith at mouth of appendix
"
Appendicitis treatment
IV fluids
" Antibiotics
" Pain management
" Bowel rest
" Surgery if no appendix perforation
"
5. GU & GYN
! Nephrolithiasis
! Intrauterine
Diagnosis?...
Previous CT Abd/Pelv
Previous CT Abd/Pelv
Previous CT Abd/Pelv
Nephrolithiasis
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Rate of spontaneous passage indirectly proportional to size (eg, 80% if < 4mm, 50%
if 4-6 mm, 20% > 8mm), often managed accordingly
If obstruction present (hydronephrosis, hydroureter) # affects management
Many types of stones: calcium (oxalate or phosphate, 75-80%), struvite (15-20%),
uric acid, cystine, matrix, xanthine, protease inhibitor-induced
Plain film (XR): misses many
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Radiopaque (visible if large): calcium, struvite or cystine (these two types can be
staghorn calculus that fill the pelvis/calyces to look like staghorns)
Radiolucent: uric acid, xanthine, protease inhibitor
Most stones uniformly dense except matrix and protease inhibitor-induced
If contrast enhanced (I+): could obscure stones. But if urographic phase is done, with
contrast excreted into collecting system, all of the types of stones will be represented by
filling defects in the collecting system
Secondary signs: hydronephrosis, hydroureter; ureteral wall swelling/edema around
stone, perinephric/periureteral stranding of fat (inflammatory changes)
US:
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Stones = echogenic bright focus with posterior shadowing (acoustic waves blocked by
stone, unable to travel through to reflect off structures posterior to stone)
Best seen if in kidneys or ureterovesicular junction (UVJ), difficult to see if in ureter
Can see hydronephrosis/ureter, obstruction from potentially a stone (as in our case)
Diagnosis?...
Ectopic pregnancy
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When no IUP can be confirmed (empty uterus), and serum beta-HCG > 1000-2000
mIU/mL
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Although 5-10% will be totally normal TVUS, just without IUP visualized
suspicion for ectopic MUST be raised
suspicion increases with adnexal/tubal mass
confirmed if see GS in tube
Other signs
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Look in cul-de-sac
Look in abdomen, eg, Morrison s pouch # if there, may suggest bad ruptured ectopic with a lot of
hemorrhage
However, 85% of ectopics are seen on same side as ovarian corpus luteum!
"
Can use TVUS probe to palpate for area of pain # better localize ectopic
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Yolk sac (YS): small ring/sac eccentrically within gestational sac, between
amnion and chorion, confirms IUP, usually at 5.5 wks when GS 5-6 mm,
definitely by GS 8mm (otherwise abnormal)
Fetal pole (embryo)
Fetal heart rate (FHR): should be seen by when fetal pole = 5 mm
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Normal IUP
Normal IUP
42+53'$6'7&6+*3$,*7$
(&-8$-(2$'7820'9&7$.&90,$
Radiographic Anatomy
! Cervical
Spine Fractures
! Lumbar Spine Disc Disease
! Subdural hematoma, epidural hematoma, and
subarachnoid hemorrhage
! Stroke
Normal C spine
C- spine: dens
C spine: Obliques
Alignment
Dens (C2)
Fracture patterns
Type I:
III
II
Type II: Unstable fracture. Most likely to have non-union due to tenuous blood supply.
Type III: Stable # non-union uncommon after bracing.
C2
C2
C4
C4
C6
C6
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Normal L Spine
25F pain
T2
T1
L5
S1
LBP
L5
T1 weighted
S1
T1 weighted
Do you recommend surgery?
T2 weighted
Treatment options
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Part 2: Hemorrhage
EDH
SDH
Subdural Hematoma
(SDH)
Typically venous
bridging vein tear in
extra-axial space #
Elderly
Often spontaneous or low
trauma
Crescentic
Small or isodense may be
difficult to see
Suture line
Blue line=dura
Subdural hematoma
Can cross suture lines
(e.g.
coronal)
Subarachnoid hemorrhage
SAH
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Intraparenchymal Hemorrhage
Subarachnoid Hemorrhage
Epidural Hematoma
EDH
Usually does not cross
falx or tentorium
Suture line
(e.g. coronal)
Epidural Hematoma
Typically arterial
usually middle meningeal
artery AND post traumatic
ie. Younger patient
Most temporal or
temporoparietal lobes
Look for associated
fracture # 85-95%
Lucid interval then rapid
neurologic deterioration
Answer:
Tumors relatively chronic allowing the brain to remodel & adjust
EDH is acute giving the brain no time to adapt to mass effect
SYMPTOMS = LOCATION + SIZE + GROWTH RATE
85 y/o F, p/w
acute weakness and speech difficulty
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=/";>$
Hyperdense
linear thrombus in ipsilateral distal
MCA = hyperdense MCA sign
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Diagnosis?...
Loss of gray-white matter (GM, WM) differentiation: 1st 3 hours post CVA
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GM cortex, normally denser on CT than WM, often affected by stroke first (higher metabolism than
WM) # becomes edematous, more hypodense # blends in with adjacent underlying white matter
Insular ribbon sign, aka loss of normal insular cortex, suggests stroke: GM insular cortex normally
looks like whiter, wavy ribbon line outlining the underlying WM
MRI findings
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Can also see edema changes (swelling & loss of G-WM on T1, high signal on FLAIR &
T2)
Diffusion weighted imaging (DWI) = most sensitive imaging for acute stroke (95%)
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Bright signal on DWI + dark signal on corresponding ADC map = restricted extracellular diffusion of
water protons (eg, from loss of function Na/K ATP pump)
Time-of-flight MRA can be performed based on flow of protons, WITHOUT needing to use
gadolinium contrast!
Figure 1. Drawings (top) illustrate the territories (blue) of the ACA, middle cerebral artery
(MCA) , and posterior cerebral artery.
7. MSK Cases
Osteoarthritis
(Degenerative Joint Disease)
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Caused by trauma
microtrauma)
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Sclerosis
Osteophytosis
Rheumatoid Arthritis
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RA Continued
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Large joints
Marked joint space narrowing
" Osteoporosis
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Hands:
Proximal process
" Bilaterally symmetric
" Ulnar subluxation
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Ulnar Subluxation
ST Swelling and
Ulnar styloid erosion
Osteoporosis
Psoriatic Arthiritis
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No Osteoporosis
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Acroosteolysis
Mouse Ears
Sausage Digit
Pencil-in-Cup
Scaphoid Fracture
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Triquetral Fracture
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Triquetral Avulsion
Fracture
22 YO F fell on outstretched
hand
Colles Fracture
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Transverse Fracture of
the distal radius
Volar angulation of
the distal fragment
33 YO F w/ Arm Pain
Smith Fracture
(Reverse Colles)
Pathologic Fracture
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Radial Head Fx
Supracondylar Fx
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Coracoid
Acromion
Process
Glenoid
Anterior
Posterior
38 YO M w/ Recurrent
Shoulder Dislocation
Hill-Sachs Deformity
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External Rotation
Internal Rotation
34 YO M with Stuck
Shoulder post trauma
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Axillary View
Acromion Process
Reverse Hill-Sachs
Deformity
Glenoid
Coracoid
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Intracapsular vs Extracapsular
Intracapsular: Subcapital, transcervical and basicervical
Extracapsular: Intertrochanteric and subtrochanteric
Intertrochanteric
fracture pre and post
fixation