A brief introduction to Extradural haematoma in CT

Extradural haematoma arises between the inner table of the skull and the dura of the brain. They usually develop from injury to the middle meningeal artery or one of its branches,So it is usually temporoparietal in location.
A temporal bone fracture is often the cause, but is not essential. The expanding haematoma separates the dura from the skull; this attachment is quite strong such that the haematoma is confined, giving rise to its characteristic biconvex shape, with a well defined margin.

It may present as primary depressed consciousness or following a lucid interval. The bleeding is usually acute and so of high attenuation. There is often significant mass effect with compression of the ipslateral lateral ventricle and dilatation of the opposite lateral ventricle due to obstruction of the foramen of Munro. The basal cisterns may be effaced.

This is the typical appearance and location of an acute extradural haematoma. Note the high density of the haematoma and slight midline shift .

A Pancreatic mass or just papillary process of the caudate lobe of liver

This patient presented with abdominal discomfort and underwent sonography of the abdomen. Ultrasound images show a rounded mass in the region of the pancreatic head and isthmus. It shows the same echogenicity as the liver (photos 1 and 2). This suggested the possibility of a pancreatic mass, possibly malignant.
However, images 3 and 4, reveal a different diagnosis- the possible "mass" appears to be an extension of the caudate lobe of the liver. These ultrasound images are diagnostic of "papillary process of the caudate lobe of liver."This normal variant may thus mimic pancreatic or preaortic lymph node masses.
Images courtesy of Dr. Ravi Kadasne, UAE.

Ischaemic colitis Clinical and Radiological findings

Clinical characteristics
• Ischaemic colitis is caused by interruption to the colonic blood supply that include thrombosis , bowel obstruction and trauma.
• Some Predisposing factors included as age,oral contraceptives,sickle cell disease and surgical ligation of the inferior mesenteric artery.
• Presents with acute lower abdominal pain and tenderness,usually out of proportion to the clinical signs.There may be rectal bleeding or diarrhoea.
• Most commonly affects the left side of the colon, especially at the splenic flexure where there is a watershed between the territories of the superior and inferior mesenteric arteries.The rectum is usually spared.
• May be a transient condition with spontaneous resolution over a few months. May lead to incomplete healing with smooth stricture formation. Severe disease can lead to colonic infarction,with a high associated mortality.

Radiological features
• AXR : plain film is often normal;however,gas within the colon may out line the characteristic thumb printing of thickened, oedematous folds seen in this condition.
• Barium enema : single-contrast instant enema may demonstrate thumb printing and ulceration associated with this condition.Adoublecontrast enema shows these findings more reliably but should be used with caution in anacutely ill patient.A smooth stricture maybe demonstrated on a delayed study.
Late-stage ischaemic colitis. Single-contrast barium enema demonstrates a clear zone of transition between normal and abnormal colon at the junction of the middle and distal thirds of the transverse colon.The proximal colon has normal mucosa and haustral pattern while the distal
segment is featureless and abnormally narrowed.
• CT :contrast-enhanced spiral CT is the usual first-line investigation for suspected ischaemic colitis.Adual phase scan,performed in the arterial and portal phases,may demonstrate thrombus in both the mesenteric arterial or venous systems.The affected colon may appear abnormally circumferentially thickened and demonstrate poor contrast enhancement.There may be a sharp cut off between normal and abnormal colon at the boundary of vascular territories.Mural gas may be seen in more advanced disease and,in severe cases,portal gas may be identified. The latter is a poor prognostic factor.
Superior mesenteric artery (SMA) thrombosis. Normal enhancement of the aorta (arrowhead). No enhancement seen in the SMA (arrow).
• Angiography :a more limited role in the era of multislice spiral CT but may demonstrate attenuated arterial flow or the presence of a thrombus.

Ischaemic colitis Clinical and Radiological findings

CT Images of Heart in abdominal

Regardless of bad pt. positioning or quality, notice the heart ♥️ in the abdomen! That's a presentation of a rare congenital malformation in which the heart is abnormally located either partially or totally outside of the thorax.

CXR: absence of heart
CT: heart in abdomen


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Right kidney
Left kidney
Renal cortex
Renal columns
Renal pelvis

Adrenal gland
Fundus of stomach
Body of stomach
Antrum of stomach
Duodenal bulb
Small bowel
Right colic flexure
Left colic flexure
Opening of ureter
Seminal vesicle
Right ovary
Left ovary
Spinal column
Symphysis pubis
Acoustic shadow
Psoas muscle
Pelvic bone
Thyroid gland
Sternohyoid muscle
Sternothyroid muscle
Sternocleidomastoid muscle
Omohyoid muscle
Internal jugular vein
Common carotid artery
Tracheal cartilage

Radiological features of Bezoar

Bezoar is an intestinal mass caused by the accumulation of ingested
material which Can lead to obstruction or ulceration.
Bezoar Types :
A phytobezoar is formed from poorly digested plant fibre.
A trichobezoar is formed from ingested hair, almost always in females.

Trichobezoar. Large ‘hair ball’ mass completely filling the stomach (arrow).

Radiological features :
• A mass may be seen within the stomach.
• May demonstrate bowel obstruction.
 Barium studies:
• May demonstrate an intraluminal filling defect that does not have a fixed site of attachment to the bowel wall.
• Barium may flow into crevices within thebezoar.
• This may demonstrate a low-density mass containing pockets of air.
• As on barium studies, oral contrast may intersperse with the mass
though gaps between the ingested materials.

Trichobezoar (same patient) in coronal CT reformat.Oral contrast is seen outlining the huge trichobezoar.

Syphilitic Aortitis in Chest X-ray

Syphilitic Aortitis in Chest X-ray appears as a dilatation of the ascending aorta, frequently with mural calcification

It may cause inflammation of the aortic valvular ring that results in aortic insufficiency. Approximately one-third of patients develop narrowing of the coronary ostia that may lead to symptoms of ischemic heart disease.

Syphilitic aortitis. Aneurysmal dilatation of the ascending aorta with extensive linear calcification of the wall (arrows). Some calcification is also seen in the distal aortic arch.

What is Ultrasound Gain–correct, over, under (with photos)

Gain refers to the control sonologists use to adjust the brightness with which returning sound waves are displayed by the ultrasound machine. When an echo returns from body tissue, it does so within an amplitude range.
The ultrasound device translates that amplitude range to a brightness, which it displays on the monitor. The overall gain allows the sonologist to adjust the brightness of all returning echoes. Decreasing the gain makes the overall image less bright, while increasing the gain makes the image more bright .

These figure shows the types of gain:

(A) (Correct) This image is correctly gained

(B) (Over) The image has too much gain applied to the image. Compared with image A, echoes are found where there should be none.

(C) (Under) The image is undergained. The image is too dark, potentially making it difficult for accurate diagnosis.

Sonography of fibroid with calcification

This middle aged female patient complained of pain in the suprapubic region. Ultrasound imaging revealed a small uterus with a calcific well-defined, intramural mass in the lower part of the body of uterus.
There is clear acoustic shadowing posterior to the calcific lesion. These findings suggest a calcific fibroid of the uterus. Fibroids are often known to undergo calcificaiton in elderly females.

Crescent sign of femoral AVN

Definition :
The crescent sign that is associated with avascular necrosis (AVN) is seen on conventional radiographic films and is recognized as a curvilinear subchondral radiolucent line . It is typically seen along the anterolateral aspect of the proximal femoral head, which is optimally depicted on the frog-leg radiographic view "obtained with the patient’s thigh abducted and flexed ".

A Conventional radiograph of the right femur in the frog-leg position shows subchondral area of hyperlucency (arrows) in the anterolateral aspect of the proximal femoral head. (Courtesy of Clyde A. Helms, MD, Department of Radiology, Duke University Medical Center, Durham, NC.)

The crescent sign is explaned by Inadequate perfusion in the articular ends of bones that leads to the processes of osteonecrosis and repair . Repair begins at the interface between necrotic and viable bone.
Reactive new bone is laid down over dead trabeculae, which produces a sclerotic margin. An advancing front of fibrosis, hyperemia, inflammation, and bone resorption extends into the necrotic segment of bone as repair is attempted. Mechanical failure of trabecular bone at this interface results in progressive microfracture (as seen below ) and collapse of the adjacent dead subchondral cancellous trabeculae, which leads to the development of a subchondral radiolucent area along the fracture line, or the crescent sign
Specimen radiograph of a coronally sectioned femoral head segment reveals a subchondral fracture (arrows), which manifests as the crescent sign. Note the fragmentation and compaction of the subchondral cancellous trabeculae, which weakens the articulating surface.

Role of Abdominal X-ray in Appendicitis

The aetiology of Appendicitis is usually related to luminal obstruction,often by lymphoid hyperplasia or a faecolith.

Radiological features in abdominal X-ray:
• Abdominal X-ray Is neither sensitive nor specific for Appendicitis but can provide clues.
• The presence of a calcified appendicolith in the RLQ ,combined with
abdominal pain,has ahigh positive predictive value for acute appendicitis.
• Other signs are less specific and include caecal wall thickening,small-bowel ileus and decreased small-bowel gas in the RIF.
• Free peritoneal fluid can lead to loss of the psoas out line,loss of the fat planes around the bladder and loss of definition of the inferior liver outline.

Rickets X-ray Before and After vitamin D therapy

Systemic disease of infancy and childhood in which calcification of growing skeletal elements is defective because of a deficiency of vitamin D in the diet or a lack of exposure to ultraviolet radiation (sunshine).
Most common in premature infants and usually develops between 6 and 12 months of age.

Classic radiographic signs :
It include cupping and fraying of metaphyseal ends of bone with disappearance of normally sharp metaphyseal lines; delayed appearance of epiphyseal ossification centers, which have blurred margins (unlike the sharp outlines in scurvy); and excessive osteoid tissue in the sternal ends of ribs producing characteristic beading (rachitic rosary).

(A) Initial film shows severe metaphyseal changes involving the distal femurs and proximal tibias and fibulas. Note the pronounced demineralization of the epiphyseal ossification centers.

(B) After vitamin D therapy, there is remineralization of the metaphyses and an almost normal appearance of the epiphyseal ossification centers.

Associations of Absent thumb cases

An absent thumb can have many associations. They include :

* Fanconi anemia (pancytopenia-dysmelia syndrome)
* Franceschetti syndrome
* Holt-Oram syndrome
* phocomelia (e.g. thalidomide embryopathy)
* Poland syndrome (pectoral muscle aplasia - syndactyly)
* Rothmund-Thomson syndrome
* Seckel syndrome (bird-headed dwarfism)
* trisomy 18
* Yunis-Varón syndrome

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Lymphoma in the Brain of transplant recipient paient

Single or multiple ring-enhancing lesions that primarily affect transplant recipients (high incidence of central nervous system lymphoma in these patients).

Lymphoma developing after renal transplantation. Heart-shaped, peripherally enhancing, central lucent lesion (arrow) situated in the frontoparietal region. There is moderate surrounding edema.

Simple bone cyst in x-ray

Simple bone cyst appears in x-ray as Expansile lucent lesion that is sharply demarcated from adjacent normal bone. May contain thin septa (scalloping of underlying cortex) that produce a multiloculated appearance. Tends to have an oval configuration with its long axis parallel to that of the host bone.

Simple bone cyst in the proximal humerus. The cyst has an oval configuration, with its long axis parallel to that of the host bone. Note the thin septa that produce a multiloculated appearance.

Notes :
Simple bone cyst is a True fluid-filled cyst with a wall of fibrous tissue. Begins adjacent to the epiphyseal plate and appears to migrate down the shaft (in reality, the epiphysis has migrated away from the cyst). Bone cysts arise in children and adolescents and most commonly involve the proximal humerus and femur. Often presents as a pathologic fracture that may show the fallen fragment sign (fragments of cortical bone are free to fall to the dependent portion of the fluid-filled cyst, unlike a bone tumor that has a firm tissue consistency).

Voluminous inflammatory exudate due to Klebsiella pneumonia

Pneumonia due to Klebsiella infection Tends to form a voluminous inflammatory exudate that produces a homogeneous parenchymal consolidation (containing an air bronchogram) and bulging of an interlobar fissure. High frequency of abscess and cavity formation (rare in pneumococcal pneumonia).

Klebsiella pneumonia. Downward bulging of the minor fissure (arrow) due to massive enlargement of the right upper lobe with inflammatory exudate.

Typical flow of cerebrospinal fluid  (CSF) in MRI image

Sagittal T1-weighted image of the normal brain showingtypical flow of cerebrospinal fluid (CSF).
In T1-weighted magnetic resonance imaging sequences, CSF is black. From the paired lateral ventricles (LV), CSF passes through the paired interventricular foramina of Monro (yellow arrow) into the single midline third ventricle (TV). CSF then flows down the single midline aqueduct of Sylvius (a channel shaped like a toothpick and slender in all diameters; green arrow) into the single midline fourth ventricle (FV). CSF leaves the ventricular system through the two lateral foramina of Luschka and the midline foramen of Magendie. Here, CSF is shown exiting through the foramen of Magendie (blue arrow) and entering the cisterna magna (CM). Within the subarachnoid space (SAS), CSF flows over the convexities of the brain and the folia of the cerebellum, and around the brainstem (curved arrows). From the CM, CSF also courses inferiorly to surround the spinal cord (orange arrow).

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