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Seeing the signs of Radiology

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…” Or something like that. Classic signs. Apple core sign. Must r/o adenocarcinoma of colon DDx:

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Seeing the signs of Radiology

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  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. Apple core sign • Must r/o adenocarcinoma of colon • DDx: • Malignant neoplasms (adenocarcinoma, lymphoma) • Benign neoplasms (villous adenoma) • IBD (chronic Crohn’s 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 >1cm and 39% of all polyps. May miss 15-22% of colorectal cancers • Use decreasing due to more accurate colonoscopy or CT colonography

  5. 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

  6. 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

  7. 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 (>60yrs) and diabetics.

  8. Champagne sign • Emphysematous cholecystitis • Imaging • Plain films may show air in wall/lumen • CT scan: • GB wall thickening >3mm • Cholelithiasis • Increased bile density (>20H) • Loss of clear GB wall definition • Pericholecystic fluid (halo) • Treatment • Percutaneous preoperative drainage + antibiotics • Open cholecystectomy – laparoscopic less successful

  9. Bat’s wings or butterfly appearance • Congestive heart failure (HF) • Chest x-ray is often first diagnostic test • Differentiates between HF and 1̊ pulmonary disease (dyspnea) • Bat’s wings are bilateral perihilar edema • Findings suggestive of HF • Cardiomegaly – cardiac:thoracic width >50% • 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 >90% specificity for HF • Cardiomegaly had only 50% sensitivity

  10. Codman’s triangle • Osteosarcoma • 1̊ 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 - <20yrs and >65yrs • Most common sites • Children: metaphyses of long bones (distal femur 75%, proximal tibia, proximal humerus) • Adults: axial skeleton

  11. Codman’s triangle • Osteosarcoma • Risks • Prior irradiation/chemotherapy • Paget’s disease – usually osteosarcoma in pts >40yrs • Chronic osteomyelitis • Multiple hereditary exostoses • Fibrous dysplasia • Metallic implants • Hereditary retinoblastoma • Li-Fraumeni syndrome (p53 mutation)

  12. Codman’s triangle • Dx: • First diagnostic test usually plain radiograph • Codman’s 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 (Ewing’s, lymphoma, mets) • Benign bone tumors (osteoid osteoma, chrondroblastoma, osteochrondroma) • Non-neoplastic (osteomyelitis, eosinophilic granuloma, bone cysts)

  13. Hampton’s hump & Westermark’s sign • Pulmonary embolus • Hampton’s hump • Pleural based, wedge shaped consolidation  represents area of infarction and atelectasis • Westermark’s sign • Area of decreased density lateral to PE  represents oligemia distal to PE as well as distended/engorged pulmonary vessels.

  14. Hampton’s hump & Westermark’s sign • Pulmonary embolus • Radiographic abnormalities common in PE but not helpful diagnostically

  15. Strange signs

  16. 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

  17. 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

  18. 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 >3mm & flexed scaphoid. • Lateral view  increased scapholunate angle • MRI helpful • In children: difficult to interpret due to incomplete ossification • Incomplete tear of ligament

  19. 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.

  20. 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.

  21. 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

  22. References • Winawer, SJ, Stewart, ET, Zauber, AG, et al. A comparison of colonoscopy and double-contract barium enema for surveillance after polypectomy. National Polyp Study Work Group. N Engl J Med 2000; 342:1766. • Toma, J, Paszat, LF, Gunraj, N, Rabeneck, L. Rates of new or missed colorectal cancer after barium enema and their risk factors: a population-based study. Am J Gastroenterol 2008; 103:3142. • Klauser, A, Bollow, M, Calin, A, et al. Workshop report: clinical diagnosis and imaging of sacroiliitis, Innsbruck, Austria, october 9, 2003. J Rheumatol 2004; 31:2041. • 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; 116:363. • Le Vu, B, de Vathaire, F, Shamsaldin, A, et al. Radiation dose, chemotherapy and risk of osteosarcoma after solid tumors during childhood. Int J Cancer 1998; 77:370. • Grimer, RJ, Cannon, SR, Taminiau, AM, et al. Osteosarcoma over the age of forty. Eur J Cancer 2003; 39:157. • Papagelopoulos, PJ, Galanis, EC, Vlastou, C, et al. Current concepts in the evaluation and treatment of osteosarcoma. Orthopedics 2000; 23:858. • Blakemore LC, Cooperman DR, Thompson GH. The rigid flatfoot. Tarsal coalitions.  The rigid flatfoot. Tarsal coalitions. Clin Podiatr Med Surg. Jul 2000;17(3):531-55. [Medline]. • Crim JR, Kjeldsberg KM. Radiographic diagnosis of tarsal coalition.  AJR Am J Roentgenol. Feb 2004;182(2):323-8. [Medline]. • Waters, PM. The upper limb. In: Lovell and Winter's Pediatric Orthopaedics, 6th ed, Morrissy, RT, Weinstein, SL (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p. 921. • Steven J. Michel, The Mount Fuji Sign. Radiology August 2004 232:44945010.1148/radiol.2322021556 • Ishiwata Y, Fujitsu K, Sekino T, et al. Subdural tension pneumocephalus following surgery for chronic subdural hematoma. J neurosurgery 1988; 68:58-61 • Tommaso Lupattelli, The Yin-Yang Sign. Radiology March 2006 238:1070107110.1148/radiol.2383031884

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