Image Cases Flashcards by Stephen Babcock

What is going on in this radiograph?

This patient had a left pneumonectomy!

The left lung is gone, and the trachea and heart have moved over to fill the void.

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What is going on in this spine MRI?

The L4-L5 disc has herniated!

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What is going on in this spot fluoroscopic film?

This is organoaxial volvulus of the stomach. It is most likely due to a large hiatal hernia into the chest (type IV hiatal hernia).

It produces an ‘upside-down’ apperance of the normal anatomy. These patients will typically present with epigatric/chest pain and vomiting.

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What is going on in this lateral radiograph?

This is the “donut sign”, demonstrating a hilar region that is full of ‘stuff’

Typically this indicates hilar lymphadenopathy. This particular patient has sarcoidosis, but this sign may be present in any form of hilar lymphadenopathy.

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What is going on in this radiograph?

Left atrial enlargement

The potential space over where the left ventricle sits is where the atrium will expand into. You can also tell by the upward deviation of the carina, and the obtuse carinal angle

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What is going on in this radiograph?

Post-stenotic dilation of the ascending aorta, indicative of aortic stenosis

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What is going on in this radiograph?

This one is tricky

It could be CHF, or it could be an atypical pneumonia like Mycoplasma.

Mycoplasma can do most if not all of the things CHF can, including Kerley A and B lines.

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What is going on in this radiograph?

PCP pneumonia

This sort of very diffuse reticular pattern is highly suggestive in the right clinical context, and you might consider ordering an HIV test.

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What is going on in this radiograph?

This radiograph shows a right pleural “pseudotumor”, aka fluid in the major fissure

A pleural “pseudotumor” is a loculated or localized collection of fluid in a major (oblique) fissure or right minor (horizontal) fissure and it can be mistaken for mass in the lung

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What is going on in this radiograph?

This patient has bilateral large superior pulmonary bullae related to emphysema (ribs count 11 above the diaphragm)

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What is going on in this CT?

Ascending and descending aortic dissection

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What is going on in this radiograph of a post-operative patient?

A couple things

Firstly, the aortic notch and mediastinum appear shifted to the left, but that is because this patient had a left sided wedge lung resection, so it is not indicative of aortic dissection.

There is an opacity behind the heart and we can no longer see the left hemidiaphragm. This is a common post-operative finding due to atelectasis of the lower lobe, but may also occur in the setting of a lower lobe pnemonia or left sided pleural effusion.

“Left lower lobe atelectasis/consolidation and/or effusion” is often the diagnosis

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What’s going in in this CXR?

This is a postpneumonectomy patient, with the surgical clips in place.

This was taken POD1 following pneumonectomy. Over the next months, this space will slowly fill with fluid, and then over the following 3 months it will gradually fibrose. The heart and mediastinum will then shift towards this side due to myofibroblast contraction.

The patient will also be missing the 5th or 6th rib, taken as part of the procedure, and surgical clips will be present.

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What is going on in this CXR?

These radiographs show atelectasis of the right middle lobe

You can tell that this is atelectasis rather than a consolidation by the downward displacement of the minor fissure

Fissures move towards a collapsed lobe, as do the trachea and heart, and the ipsilateral diaphragm.

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What is going on in this CXR?

Subsegmental atelectasis

Subsegmental atelectasis produces linear densities of varying thickness usually parallel to the diaphragm, most commonly at the lung bases. It is most likely related to deactivation of surfactant

It occurs mostly in patients who are “splinting” (i.e., not taking a deep breath), such as postoperative patients or patients with pleuritic chest pain

It can look almost identical to linear lung scarring, however subsegmental atelectasis will change/disappear over days.

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What is going on in this radiograph?

Obstructive atelectasis of the right upper lobe

Note the triangular distribution with the apex at the hilum

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What is going on in this radiograph?

Left upper lobe obstructive atelectasis, aka Aunt Minnie sign again

Note the broad based triangle with an apex at the hilum and the movement of the major fissure towards the space of the collapse upper lobe.

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What is going on in this radiograph?

Left lower lobe atelectasis

Note the triangle with the apex at the hilum

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What is going on in this radiograph?

Right lower lobe atelectasis

Note the triangle with the apex at the hilum

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What is going on in this CXR?

This patient has a large right sided pleural effusion

Note how the frontal view almost looks like a hemidiaphragm (an “apparent hemidiaphragm”) due to the curved interface of the effusion fluid with the lung tissue on the lateral view.

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What is going on in this CXR?

Here the left costophrenic angle appears blunted, but the whole left lower lobe-diaphragmatic interface is also slanted.

Don’t be fooled into thinking that this is a pleural effusion. The angle is blunted here because of pleural thickening and fibrosis. The ski slope sign can help you differentiate them: the surface is slanted rather than concave like a meniscus.

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What is going on in this radiograph?

There are multiple loculated pleural effusions

Loculated effusions can be suspected when an effusion has an unusual shape or location in the thorax (e.g., the effusion defies gravity by remaining at the nondependent part of the thorax when the patient is upright on a conventional radiograph or in the supine position on a CT scan of the chest)

What is going on in this radiograph?

This is a pseudotumor

They are lenticular in shape, most often occur in the minor fissure (75%) and frequently have pointed ends on each side where they insinuate into the fissure, much like the shape of a lemon. They do not tend to flow freely with a change in patient positioning.

They disappear when the underlying condition (usually CHF) is treated, but they tend to recur in the same location each time the patient’s heart failure recurs

What is going on in this radiograph?

This is a laminar effusion

A laminar effusion is a form of pleural effusion in which the fluid assumes a thin, band-like density along the lateral chest wall, especially near the costophrenic angle. The lateral costophrenic angle tends to maintain its acute angle with a laminar effusion, unlike the blunting that occurs with a usual pleural effusion.

They are almost always the result of elevated left atrial pressure, as in CHF or secondary to lymphangitic spread of malignancy. They are usually not free-flowing.

What is going on in this radiograph?

This is a pneumonia of the lingular portion of the left upper lobe Note the loss of the cardiac margin

What is going on in this radiograph?

Right upper lobe pneumonia Most likely Streptococcus pneumoniae

What is going on in this radiograph?

This is an excellent example of a segmental pneumonia, aka bronchopneumonia This can be caused by many organisms, but **Staphylococcus aureus is prototypical**. **Pseudomonas aeruginosa** or other **gram negative rods** are also classical. These pneumonias spread **through the bronchial tree to many foci in the lung**. As such, they **do not respect lobar boundaries**, and often have a **hazy/fuzzy margin.** Unlike lobar pneumonia, segmental bronchopneumonias produce exudate that fills the bronchi. Therefore, **air bronchograms are usually not present** and frequently some volume loss (**atelectasis**) is associated with bronchopneumonia.

What is going on in this radiograph?

This radiograph shows an **interstitial pneumonia** with a clear reticular pattern, involving the walls of the alveolar septae. In contrast with most fibrotic processes (which start peripherally and spread centrally), the interstitial pattern in interstitial PNAs starts centrally and spreads peripherally. Likely causative organisms are **viral pneumonia, mycoplasma pneumonia, or PCP pneumonia** (if in an AIDS patient). As it happens, this particular radiograph is from a patient with PCP pneumonia. Usually no pleural effusions and no hilar adenopathy are seen.

What is going on in this radiograph?

This one is tricky. It is a **round pneumonia**, but the same apparent soft tissue mass in another context may suggest cancer. However, the differential is helped by the fact that round pneumonias mostly occur in **children,** and are almost always in the **posterior, lower lobes.** Causative agents include **Haemophilus influenzae, Streptococcus, and Pneumococcus.** Generally speaking, if you see this in a patient **\< 12 years of age,** it's probably **pneumonia.** If you see it in a patient **\> 12 years of age**, it's probably **cancer.**

What is going in in this chest xray?

This is **postprimary TB**. Whether it is "active" or "latent" is really a clinical diagnosis taking into account symptoms and labs. The cavities associated with postprimary TB are **thin walled, smooth on the inner margin**, and contain **no air-fluid level**

What's going on in this contrast CT scan?

This patient has **bilateral main pulmonary artery emboli.** Yikes.

What is going on in this radiograph?

There is a slightly lobular mediastinal mass which does not appear to affect the course of the trachea or aortic knob. This is Hodgkin's lymphoma in the anterior mediastinum

What is going on in this CT scan?

This is an anterior medistinal teratoma The very heterogeneous, but discrete different tissue architectures are a great hint You can see that it has a little bone growing inside

What is going on in this lung CT? (Note, the opacity marked D is the diaphragm)

This is a good old hamartoma Note the "popcorn" appearance.

What is going on in this radiograph?

A mass is present in the peripheral right upper lung field. There is ipsilateral hilar lymphadenopathy and contralateral mediastinal lymphadenopathy with subtle tracheal deviation. This was a case of adenocarcinoma.

What is going on in this lung CT?

These are acquired pulmonary cysts, also called pneumoatoceles. They may occur during and after infection with Staphlococci or Pneumocystis 10% of patients with pneumocystis pneumonia will develop pneumoatoceles.

What is going on in this CXR?

This is bronchiectasis The black arrows point to the "tram track" sign, which is a dilated bronchiole. This correlates with the "signet ring" sign on CT. The white arrows point to prominent hila.

What is going on in this CT?

This is bronchiectasis The "signet ring" sign is highlighted in figure A. Figure B demonstrates tram tracking with dilated bronchi that extend all the way to the parietal pleura. **T****he absence of tapering bronchi is the most sensitive sign of bronchiectasis on CT.**

What's going on in this CT?

This is a pericardial effusion

What is going on in this CT?

This patient has mitral stenosis with a heavily dilated left atrium

What is going on in this CT?

**Constrictive pericarditis** Note the calcifications of the pericardium If you see this, the patient needs **pericardiectomy.**

What is going on in this KUB?

Focal ileus due to pancreatitis Note the involvement of the LUQ

What is going on in this KUB?

This patient has pneumoperitoneum You can tell by the presence of the **falciform ligament sign**

What is going on in this KUB?

These calcifications outline a **large abdominal aortic aneurysm** This is waaay more than 5 cm. This patient needs surgery, *soon*.

What is going on in this KUB?

There is calcification in both the urinary bladder wall *and* the ureters bilaterally This is highly suggsetive of schistosomiais, in the right clinical context.

What is going on in this KUB?

This is the calcified wall of a large uterine fibroid

What is going on in this KUB?

This image demonstrates bilateral **medullary nephrocalcinosis** This typically represents a metabolic derangement involving calcium and phosphate metabolism, primarily **hyperparathyroidism**

What is going on in this KUB?

This radiograph demonstrates edema within the wall of the transverse colon, suggesting colitis (may be inflammatory, infectious, or ischemic). There is also thumbprinting of the colon, providing additional evidence for thickening of the bowel wall. There are also small calcifications that may be seen overlying the liver, which may represent gallstones.

What is going on in this barium enema KUB?

There is an "apple core" sign, indicative of colon cancer This particular patient has a history of Crohn's

What is going on in this lumbar spine radiograph?

There is a **severe compression fracture of L1** with mild narrowing of the spinal canal. The remaining vertebral bodies have normal height and disc interspaces. Alignment is normal. Diffuse osteopenia. Degenerative changes lower posterior facet joints. There is substantial abdominal aortic calcificiation, indicating severe atherosclerotic disease. Treatment for compression fractures with preserved alignment is usually **conservative,** however it is also often worth getting an **MRI** to ensure that the spinal cord is not involved. Otherwise, **vertebroplasty** (surgical injection of bone cement into vertebral body) is indicated.

What is going on in this CT?

There is deep vein thrombosis of the right iliac vein

What is going on in this postmenopausal patient's right ovarian ultrasound?

Enlargement with heterogeneous hypoechogenicity and no evidence of internal vasculature This is a hemorrhagic ovarian cyst. A follow-up ultrasound is recommended in 3 months in a postmenopausal patient.

What is going on in this postmenopausal patient's uterine ultrasound?

Endometrial hyperplasia Endometrial hyperplasia tends to have a cystic appearance. They should still be biopsied to rule out endometrial cancer arising in the background of hyperplasia.