and the mortality rate is high (15%). The disease is characterized by a relapsing and remitting course and by varying neurologic symptoms, depending on the location of the lesion within the CNS. Old granulomatous disease C. Fatty liver D. Osler-Weber-Rendu disease 11-2. Axial (A) and coronal (B) CT images show intimal flap of type A dissection (arrows). 10-7. Multislice helical scanners with subsecond rotation times have been developed that collect data for reconstruction of several slices in each rotation; thus, a 30-cm length of patient anatomy can be imaged in 15 seconds or less. A 22-year-old HIV-positive female with debilitating and chronic illness with vague right upper quadrant pain, but no tenderness on palpation over the gallbladder. These subtypes are based on the location of the humeral head relative to the glenoid fossa and coracoid process. If the lesion is single, a cavitating pneumonia should be the first B Figure 4-42. When the patient is severely incapacitated by pain and not moving the joint, “disuse” osteopenia can be seen at radiography. This appearance is often referred to as a globular shape or a water-bottle heart. Focal, well-defined, spherical lucencies within subchondral bone, known as subchondral cysts or geodes (eg, osteoarthritis, rheumatoid arthritis). On all modalities with intravenous contrast, hemangiomas usually enhance early and retain contrast. 7-7. What is the most likely cause of the saccular structure (x) seen in the distal small bowel in Case 10-10 (Figure 10-31)? Identification of the spinolaminar line also helps in the evaluation of alignment (Figure 13-1 B). In supine patients, the dependent regions are the posterior segments of the upper lobes, and the superior and posterior basilar segments of the lower lobes. MIBG is most often used in detecting metastatic or recurrent disease, or locating extraadrenal lesions. Displacement is always described in terms of the position of the distal fragment relative to that of the proximal fragment. The biliary system is normally demonstrated as an area of low signal intensity on T1-weighted images and high signal intensity on T2weighted images. 10-6. 278 PART 4 ABDOMEN Figure 10-39. There are five manifestations of asbestos-related pleural disease: asbestos-related pleural effusion, diffuse pleural thickening, pleural plaques, rounded atelectasis, and malignant mesothelioma. 8-17. Note anterior cerebral (A), ophthalmic (O), posterior communicating (PC), and middle cerebral (M) branches. After a few millimeters, the duct narrows again and then branches as it enters the lobe containing the glands drained by this ductal system. In addition to these metabolites, others have been assessed, including alanine, glutamine, myoinositol, and succinate, using various MR strategies. Therefore, a chest x-ray will not be a good choice. See also Dislocation Subsegmental atelectasis, 87 Superior vena cava (SVC), 27 Supraspinatus tendon, 195 Swan-Ganz (SG) catheter, 40–41 placement complications, 41 Synovial osteochondromatosis, 209 395 Systemic disease, 173–180 Systemic lupus erythematosus (SLE), 205 T Technetium bone scan, 161 Technetium-labeled mercaptoacetyltriglycine (Tc-MAG3), 241 “Temple of truth”, 233 Thoracic aortography, 4 Thorotrast, 299 Three-dimensional ultrasound (3D-US), 9 Thumbprinting, 284, 285 Tramline shadow, 128 Transcranial Doppler, 334 Transesophageal echocardiography (TEE), 9, 29 Transitional cell carcinoma (TCC). The soreness indicates a benign process. The TV image can be recorded using a videotape recorder or a videodisc recorder, the latter having the advantage of being able to view one frame at a time as well as providing random access rather than the sequential viewing required by videotape. Processes that alter pleural capillary or lymphatic permeability include infection, inflammation, pulmonary embolism, and neoplasms. 255 10 Technique Selection Patient Preparation Clinical Indications Exercises 10-1 Dysphagia 10-2 Upper Gastrointestinal Bleeding 10-3 Small-Bowel Bleeding 10-4 Small-Bowel Obstruction 10-5 Colonic Bleeding 10-6 Colonic Obstruction EXAMINATION TECHNIQUES Luminal Contrast Studies Luminal contrast examinations of the gastrointestinal tract can be performed with a variety of contrast materials. squamous-cell carcinoma (A is the correct answer to Question 10-3). INTRACRANIAL VASCULAR ABNORMALITIES 12-14. (C) Axial contrasted CT image demonstrates the loculated pleural fluid seen on chest radiograph. Figure 1316 shows the typical radiographic appearance of expansile, lytic destruction. CT shows similar morphologic findings, as well as enhancement of the wall after intravenous contrast material infusion. Table 5-1 includes guidelines for frequency. (B) Sagittal T2-weighted MR image shows the tumor and resulting enlargement of the thoracic spinal cord, with areas of central hyperintense signal (arrows) probably representing necrosis. Finally, all chapters end with questions and imaging exercises to enhance and reinforce the principles of each chapter. (A,B) Normal radiographic anatomy. Advances in scanning technology now permit simultaneous acquisition of multiple images during a single rotation of the x-ray tube (eg, currently up to 256 slices) during a breath-hold. 3-47. Medially, the pes anserinus tendons, which comprise the sartorius, gracilis, and semitendinosus muscles-(the way to remember this is the phrase, “say grace before tea”). (C) Axial CT image demonstrates a comminuted fracture of the inferior aspect of the calcaneocuboid joint. DOWNLOAD Basic Radiology, Second Edition (LANGE Clinical Medicine) PDF Online. MR imaging may be the most sensitive modality for detecting and characterizing diffuse diseases of the liver, including cirrhosis and hemochromatosis, especially when combined with contrast agents. Basic interpretation There is a medial malleolar fracture. On US, gallstones usually appear as mobile, intraluminal, echogenic foci that cast a well-defined acoustic shadow (Figure 11-49). (B) Barium enema in the patient did not show colonic involvement, but reflux into a normal-caliber terminal ileum (l) demonstrated angulated obstruction (arrows) of the small bowel due to the pelvic malignancy with more proximal dilated (D) bowel loops (C, cecum). Lateral foot radiographic in a patient with long-standing Reiter’s disease shows marked narrowing of the hindfoot and midfoot, proliferative changes, and sclerosis. It should be noted, however, that the added risk from diagnostic x-ray procedures is generally negligible compared to the normal risks of pregnancy, because fetal doses are typically below 5 rad in these procedures. Although metastatic disease can have variable appearances and cannot be radiographically excluded, the lesion is also typical for a pheochromocytoma and, given the clinical history, this is the most likely diagnosis (A is the correct answer to Question 9-3). C. pneumonia. Left-sided abscess is difficult to discern because gas in the splenic flexure, stomach, or jejunum may mimic gas within the abscess. “Gas, mass, bones, stones” can be used as a reminder of main areas to examine on the abdominal 234 PART 4 ABDOMEN radiograph. 5. St. Louis: Mosby; 1993. A. Regarding Case 13-12, what is the main abnormality visualized in Figure 13-28? Gallbladder stones are usually present, and there is a higher incidence (approximately 10% to 20%) of gallbladder carcinoma. 4 STAR DOODY’S REVIEW! Case 8-3. H, humeral head; G, glenoid; C, distal clavicle; F, contrast. B Figure 4-8. B 3-34. However, if there is a recurrence of dislocation or if the patient remains chronically symptomatic, MR imaging or CT arthrography of the shoulder should be obtained to search for the cause of the dislocations and any associated shoulder abnormalities resulting from the dislocation. A Inflammatory lesions are the most common cause of lung cavities (Table 4-9). Pleural effusions are usually approached clinically according to whether the effusion develops because of alterations of the Starling equation, which controls fluid flow and maintenance in body compartments, or whether the pleura is affected primarily by a disease process. On CT, the pancreas may be ill defined, enlarged, or even disrupted, that is, fractured. Although there can be associated volume loss as the surfactant within the alveoli is lost, the signs of volume loss are RADIOLOGY OF THE CHEST A CHAPTER 4 89 B Figure 4-21. A fine needle (20- to 25-gauge) usually suffices to extract the fluid. 5. In the frontal position, the paired valleculae (v) and piriform sinuses (p) have a symmetric appearance and are seen separately. Less frequently, ultrasound is utilized to guide percutaneous biopsy of mediastinal or peripleural lung lesions. This was biopsy-proven carcinoid, which may not be hypermetabolic on PET imaging. Postcontrast axial T1-weighted (E) MR image reveals intravascular enhancement over the right cerebral cortex (arrows), reflecting slow flow of intravascular contrast. These catheters have minimal risk, can remain in place for longer periods of time without being exchanged, and are primarily used for the delivery of fluids and long-term antibiotics. In adults, the most common causes of pneumoperitoneum are postoperative status, ruptured abdominal viscus, and peritoneal dialysis. CHAPTER 7 IMAGING OF JOINTS 183 Magnetic Resonance Imaging Figure 7-3. Soft tissue has echoes of mild to moderate intensity. 84 PART 2 CHEST A B Figure 4-15. Aneurysms Although cerebral arteriography has traditionally been considered the “gold standard” for cerebral aneurysm evaluation, CTA has supplanted catheter arteriography as the first-line imaging modality for aneurysm detection. A particular patient may require an individualized program for specific reasons: for example, a 30-year-old asymptomatic woman whose mother died of breast cancer at age 35 may justifiably begin yearly screening mammography. Air and bone do not interfere with CT examinations. B. metastasis. This diagnosis should have been made at birth or shortly thereafter so that corrective therapy could have been instituted. She has substantial limitation of motion in the right hip on physical examination. (B) Axial CT of the chest in this patient reveals a heterogeneous superior mediastinal mass originating from the thyroid gland. The obstruction to flow due to the coarctation results in elevated upper-extremity blood pressure and decreased lower-extremity blood pressure. Philadelphia: Walters Kluwer, Lippincott Williams & Wilkins; 2008. In this situation, the diagnosis may be suggested by the secondary signs of volume loss. In children, necrotizing enterocolitis produces intramural gas within mesenteric veins to the liver; the mortality rate in patients with the sign of hepatic portal venous gas is higher than in those without portal venous gas. When it does occur, its favorite location is the skull. In this case, an extradural defect is seen at and below the L4-5 disk space, and the right L5 nerve root does not fill. 3rd ed. Contrast arthrogram with plain radiograph: AP wrist arthrogram view obtained after injection of contrast material into the radiocarpal joint shows contrast material passing through the scaphoid (S) and lunate (L) space from the radiocarpal joint into the mid-carpal joint (arrowheads). MR enterography is used in the evaluation of small-bowel disease (Figure 1-10). Figure 11-23. A. Crescent of air around the transverse section of the aortic arch resulting from hyperexpansion of the superior segment of the left lower lobe B. Posterior displacement of the left major fissure on the lateral view C. Obscuration of the right heart border D. Tracheal deviation to the right E. Inferior displacement of the left hilum 82 PART 2 CHEST Figure 4-9. Note how much easier it is to see the lesion and the spiculation (around it) with spot compression. See also Musculoskeletal imaging anatomy of normal joint, 185 arthritides, 200–207 arthrography, 182 clinical exercises and case examples. The major indications for the technique are listed in Table 3-2. Breast Imaging. Lymphomas may involve any level of the small intestine but are most common in the ileum; the gross pathologic patterns include nodular or polypoid masses, constricting lesions that resemble carcinoma, or a more diffusely nodular or infiltrative process. CHAPTER 12 335 metabolic activity and lowest to areas with low metabolic demand. What is the most likely diagnosis in Case 8-23 (Figure 8-48)? Figure 3-36. Normal structures include the corpus callosum (CC), lateral ventricle (LV), cavum septum pellucidum (CS), sylvian fissure (SF), third ventricle (3V), fourth ventricle (4V), temporal lobe (TL), frontal lobe (FR), occipital lobe (OCC), cerebellum (CER), and thalamus (TH). Philadelphia: Lippincott, Williams & Wilkins; 2008. Both ultrasound and hepatobiliary NM studies are the modalities of choice to evaluate possible cholecystitis. A discussion of normal anatomy and some important fundamental concepts of interpretation are included. During fluoroscopic examinations, the x-ray tube is typically operated below 100 kV and below 3 mA tube current. The wide range of joint abnormalities is summarized below, and many of these processes are discussed in the exercises. Sagittal T1-weighted (A), axial T1-weighted (B), and axial T2-weighted (C) images. MEDIASTINAL MASSES AND COMPARTMENTS 4-17. The different disease processes may have overlapping appearances on breast images, and refining the differential diagnosis therefore depends on accurate breast physical examination and the patient’s history. A Figure Figure 11-73. A. Adrenal calcification B. Calcified hepatic metastases C. Pancreatic calcification D. Primary calcified mucoproducing adenocarcinoma in the colon Figure 8-3. Others would prefer a biopsy before proceeding to further treatment. A 65-year-old female with long history of a pancreatic mass. X-ray grids are used to reduce scatter radiation and improve image quality. It also is a fairly common injury pattern. Pyogenic liver abscess in a 55-year-old man with 3 days of fever, chill, and productive cough after right lobectomy. SYSTEMIC DISEASE 6-10. These expansile lesions are slow-growing, and the ensuing mass effect on the adjacent brain parenchyma is gradual. A Figure The configuration of the heart in Case 3-10 (Figure 3-36) has been called the A. boot-shaped heart. The CT results (Figure 9-22 B) show that this lesion (arrow) does indeed contain fat. Intracranial Hemorrhage The best examination to perform in most cases of suspected acute intracranial hemorrhage is a head CT scan. MR imaging of the thorax is most commonly used for cardiovascular imaging, but there are indications for MR imaging in mediastinal and pulmonary parenchymal imaging as well (Table 4-5). Retrograde Pyelography/ Cystography/Urethrography Direct injection of water-soluble iodinated contrast material is a useful method of examining various regions of the urinary tract. Needle biopsies of palpable lesions do not necessarily need radiologic intervention. This time radiographs were coned more closely to the finger and care was taken on the lateral view to image the ring finger separately from the others. Longitudinal US image of the normal biliary duct, showing the narrow caliber and the thin, uniform ductal walls (cursors denote the internal walls of the duct). New York: Thieme Medical Publishers; 1993. When a chest radiograph is taken in the expiratory phase of respiration, the patient may appear to have cardiomegaly, vascular congestion, and even pulmonary edema. Low osmolar contrast media include ionic (meglumine ioxaglate) and nonionic (iohexol, iopamidol, ioversol, iopromide) monomers, as well as nonionic dimers (iodixanol). A 151 D. They are most likely due to necrosis in duct walls. What is the most likely diagnosis in Case 8-4 (Figure 8-6)? The hands of the 45-year-old woman in Case 7-13 (Figure 7-35) show soft-tissue calcifications that are most consistent with a diagnosis of A. osteoarthritis. Therefore, A and D are not correct answers to Question 5-9. In recent years, many new techniques, such as CT angiography, CT colonography, MR angiography, MR cholangiopancreatography, and positron emission tomography (PET)/CT have emerged with new generations of CT and MR equipment. PA (A) and lateral (B) views of patient with night sweats show an anterior mediastinal mass, which fills in the retrosternal space on the lateral view (arrowheads). In Case 9-9, a renal ultrasound (Figure 9-26) demonstrates rounded highly echogenic areas throughout the central parenchyma of the kidney. The ability to image in any plain is advantageous for MR imaging. The incidence of CIN is variable. (B is the correct answer to Question 4-10). New York: Springer-Verlag; 2000. (B) Foci of increased T2 signal abnormality are demonstrated within the globus palladi (arrows). The angiogram plays little role in diagnostic evaluation of the renal parenchyma, having been supplanted by cross-sectional imaging techniques. Also, because the bladder acts as a temporary storage site prior to excretion, carcinogens remain in contact with the epithelium of the bladder for a longer period of time than they do with that of the remainder of the urinary tract. in a cavity or air-filled lucency within the lung. Apical blebs are pres- ent in a high percentage of patients with primary spontaneous pneumothorax, and their rupture is thought to be the most frequent cause of spontaneous pneumothorax. LIVER, BILIARY TRACT, AND PANCREAS A CHAPTER 11 315 B Figure 11-56. Similarly, most pyogenic abscesses are the result of hematogenous dissemination from a non-CNS source. All are findings of 11-61. This is a malignant tumor of the pleura that usually presents as pleural nodules or pleural effusion (Figure 4-50 A,B). Endoluminal ultrasound using blind probes or those attached to an endoscope has been used in the upper gastrointestinal tract and the colorectum to detect and stage malignancy; other indications include fine-needle aspiration (FNA) of pancreatic masses through the gastroduodenal wall. In recent years digital image receptors have come into use. Radiographic Findings In Case 9-10, the first image from the excretory phase of a CT urogram (Figure 9-29 A) shows thickening of the mucosal surface (arrow) of the right renal pelvis, compared to the contralateral kidney where the wall is imperceptibly thin. With Doppler technology, cardiac chamber function, valvular function, and intracardiac shunts frequently seen in congenital heart disease can be assessed. Figure 5-13. Streak artifacts (arrows) commonly obscure portions of the brainstem, posterior fossa, and temporal lobes on routine head CT scans. Intracardiac shunts that result in increased pulmonary arterial flow can also enlarge the pulmonary vascular system. NM has only infrequent applications. During voiding, the urethra is fairly uniformly distended and tubular in appearance. In general, ultrasonography is the primary modality now used to evaluate the gallbladder (Figure 8-9). As previously mentioned, MR imaging is excellent in detecting disk herniations (Figures 13-13 B, C) and eliminates the need for painful, invasive procedures such as myelography. Figure 11-7. However, the peroral smallbowel study is probably the least effective method of examining this organ; techniques that better distend the small bowel with higher volume are now preferred depending on the indications. Screening mammography B. Excisional biopsy C. Ultrasonography Radiologic Findings 5-1. The major fissure is displaced posteriorly, as well as rotated into a more sagittal orientation than the normal coronal orientation (D is the correct answer to Question 4-5). The two most common spinal cord tumors are astrocytomas and ependymomas. Bronchogenic carcinoma, particularly adenocarcinoma, frequently presents as a solitary pulmonary nodule in the periphery of the lung. This patient has a small (about 1 cm) spiculated mass in the central part of the breast (Statement A is true). Although plain film of the abdomen is not sensitive in assessing small amounts of intraperitoneal fluid, the plain film can demonstrate moderate and large amounts of fluid collection. Other benign causes of these physical findings include hematoma, abscess, and lipoma (Statement E is true). In general, fluid is anechoic (has no 290 PART 4 ABDOMEN Figure 11-1. The two can overlap, especially because one may lead to another: for example, cirrhosis can cause hepatocellular carcinoma. C. Surgical repair will likely be successful. D. pericardial effusion. INTRODUCTION 1. Pharyngeal function is complex and is best evaluated with motion-recording techniques that allow slow-motion review. RadioGraphics. About 10% of invasive ductal carcinomas represent the better-differentiated subtypes, including medullary carcinoma, mucinous (colloid) carcinoma, and papillary carcinoma, all of which are frequently seen as circumscribed masses. Associated CNS anomalies may be present, such as agenesis of the corpus callosum, holoprosencephaly, or herniation of brain tissue (encephaloceles). Rubesin SE, Levine MS, Laufer I. Double-contrast upper gastrointestinal radiograph: a pattern approach for diseases of the stomach. (A) Normal mammograms of fatty breasts. The morphologic appearance of adenocarcinomas of the small intestine consists of polypoid, ulcerative, stenosing, and infiltrative forms, which are similar to their counterparts in the stomach and colon. CT scan with contrast of the abdomen in a 39-year-old male patient who presented with refractory hypertension and episodes of headaches and palpitations. LIVER, BILIARY TRACT, AND PANCREAS Figure 11-21. AIDS-associated cholangiopathy is marked by the frequent isolation of opportunistic organisms, including Cryptosporidium and cytomegalovirus from the bile, and by considerable inflammation of the bile duct wall. Understanding the proper use of these data and ordering radiographic studies in the optimal sequence are helpful for making the diagnosis most efficiently. Islet-cell tumors and their metastases have extremely high signal intensity on T2-weighted MR imaging, which can be used to characterize the origin of the lesion. Obtaining additional imaging studies to evaluate this lesion further is not a bad idea.

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