Lecture 6- (xray-head/peds), exam3 Flashcards
1
Q
What are the standard skull radiographic views?
A
- AP or PA
- Lateral (or cross-table lateral)
- Oblique
2
Q
Trauma views of skull must include what?
A
Trauma views must include 2 views 90* (both sides) from each other
3
Q
What are these skull views?
A
- Right: lateral
- Left: AP
4
Q
Skull trauma
- There is little correlation between what?
- What is the mainstay of emergent diagnostic neuro radiology?
A
- There is little correlation between skull bony injury and underlying brain damage
- CT is the mainstay of emergent diagnostic neuro radiology
5
Q
What do these images show? What is the importance of these two different types of images?
A
Shows a skull fracture
* You were able to see the fx on the x-ray on the left but that is not always the case so CT like the one of the right is best
6
Q
What views are these?
A
Face x-ray: to see sinus or zygomatic process
* Right: lateral face
* Left: AP face
7
Q
Waters view of the skull
* What does it evaluate?
* Patient must be in what position?
* What is fuchs view?
A
- Evaluation of air-fluid levels of the maxillary sinuses
- Patient MUST be upright to evaluate air-fluid levels on this view
- Fuchs view is the same thing to evaluate for dens when patient cannot open mouth due to c-collar
8
Q
What is the view of this image?
A
Waters View of the Skull
* you can see the frontal and maxillary sinuses
9
Q
What do these images show?
A
- Air fluid level (on left)
- complete opacification (on right)
10
Q
Sinus series:
* What position must the patient be in? What does it assess?
* What image is limited and what image is preferred?
* What does not require imaging?
A
- Patient MUST be upright; assess the sinusesfor air-fluid levels or opacification in complicated cases only
- XR use is limited, CT is preferred
- Uncomplicated sinusitis does not require imaging
11
Q
What view is this?
A
AP face
12
Q
Sinus Submentovortex
* What does it look at?
A
Looks at Ethmoid and Sphenoid sinuses from under patients’ chin
13
Q
What image is this?
A
Sinus Submentovortex
14
Q
What does the nasal bone series consist of?
A
Waters and lateral
* Only for nasal fx; no entrapment or soft tissue issue
15
Q
Mandible series:
* What is it for? What does it look for?
* Hard to x-ray due to what?
A
- For mandible trauma, always look for afracture in two places, because ring-shaped structures, when they break, break in TWO places.
- Hard to X ray due to its contours and round shape.
16
Q
What image view is this?
A
PA Mandible
17
Q
What are these image views?
A
18
Q
When your patient has this fx, what else do you need to look for?
A
We need then to look for the second fracture since mandible is ring-shaped. Do an oblique view since we don’t see it here
19
Q
What view is this?
A
Oblique mandible
20
Q
What view is this?
A
PANOREX Mandible
* Step-off is evident indicating fracture
21
Q
What are plain films of the face reserved for (3)?
A
- Patients with a low likelihood of fracture
- Patients with suspected limited fractures such an isolated zygomatic arch fracture or mandible fracture
- Trauma patients who are too unstable for CT
Otherwise, CT Facial Bones without contrast is the modality of choice
22
Q
What is the modality of choice of facial bones?
A
CT Facial Bones without contrast
23
Q
What are the two zygoma components?
A
- Zygomatic arch
- Zygomatic body
24
Q
- What is the most common cause of zygoma fx?
- What are the two types of fx can occur?
A
Blunt trauma most common cause.
Two types of fractures can occur:
* Arch fracture (most common)
* Tripod fracture (most serious)
25
What view is this and what does it show?
bucket handle view (Submental view) of the zygomatic arch demonstrating a depressed fracture
26
Tripod fractures consist of fractures through: (3)
1. Zygomatic arch
2. Zygomaticofrontal suture
3. Inferior orbital rim and floor
27
What do these facial bone ct show?
* Collapse of left zygoma and maxillary antrum with soft tissue edema and emphysema.
* Fractures extend into left orbital floor.
* Old deviation of the nasal septum suggest previous encounters.
28
What are the sxs of orbital blowout fx?
1. Periorbital tenderness, swelling, ecchymosis.
2. Enopthalmus or sunken eyes.
3. Impaired ocular motility. Usually caused by entrapment of the inferior rectus muscle.
4. Infraorbital anesthesia. Infraorbital nerve injury causes anesthesia of the maxillary teeth and upper lip is more reliable than numbness over the cheek.
5. Step off deformity can be appreciated over the infraorbital rim.
29
# From notes
How do orbital blowout fractures happen? (2)
They occur when the globe sustains direct blunt force.
* The first is a true blowout fx, where all the energy is transmitted to the globe. Since the spherical globe is stronger than the thin orbital floor, the force is then transmitted to the thin orbital floor or medially through the ethmoid bones with the resultant fx. The object causing the injury must be smaller then 5-6cm, otherwise the globe is protected by the surrounding orbit. Fists or small balls are the typical causative agents.
* The second mechanism occurs when the energy from the blow is transmitted to the to the infraorbital rim causing a buckling of the floor. Entrapment and globe injury is less likely with this injury.
30
What nerve can be affected in orbial blowout fx?
CN5= maxillary brach
31
CT of orbits:
* Details what?
* Excludes what?
* What image view will be enough?
CT head:
* What does it rule out?
CT of orbits
* Details the orbital fracture
* Excludes retrobulbar hemorrhage
* Frequently CT Facial Bones will be enough
CT Head
* R/o intracranial injuries
32
What do you need to look for in an orbital blowout fx?
Look for external SQ emphysema
* Subcutaneous emphysema is pathognomonic for a fracture into a sinus or nasal antrum.
33
What are the different Le Fort fx? (3)
Le Fort I, II, III – each higher number is worse
* I: Maxilla fracture (floating palate)
* II: Maxilla, orbital rim and nasal bones (floating maxilla)
* III: II+ zygomatic arch fracture (floating face)
34
Le Fort Fractures:
* What will you note on PE?
* What will happen with le fort 3?
* What do you need to check?
* What is a common group of peoples does these fx happen in?
* You will note facial bone movement with exam
* Le Fort III is a craniofacial dys-junction and the patient has a dish-face appearance (flat face)
* Check mobility of hard palate
* Elderly who falls face first and MVA
35
What do these images show?
Lefort fxs
36
You are seeing a 75yo male in a c-collar following MVC where patient struck a steering wheel with his face. Airbags did not deploy. Exam shows entrapment of superior oblique muscle. You also note smell of ETOH from patient's breath. Exam of torso/abdomen and all extremities show no abnormalities. What combination of imaging studies should you order to rule out pathology?
1. CT Facial bones without contrast
2. CT Facial bones with contrast, CT Brain with contrast and CT C-Spine with contrast
3. CT Orbit without contrast
4. CT Facial bones without contrast, CT Brain without contrast and CT C-Spine without contrast
CT Facial bones without contrast, CT Brain without contrast and CT C-Spine without contrast
37
Thyroid imaging:
* What is the initial study of choice? (lab and imaging)
* What tumors are more likely?
* What will identify the blood flow?
The initial study of choice is Ultrasound combined with laboratory evaluation of TSH
* Benign tumors are more likely (Thyroid Adenomas or cysts)
* US will identify the blood flow
38
# thyriod
What are type of nodules that appear unstable? What will they require?
Nodules that appear unstable will require FNA
* Solid masses
* Irregular borders
* Microcalcifications
* Intranodal Vascularity
39
What does primary, secondary hypothyroidism cascade look like (TRH, TSH, TH hormone levels)? What about primary, secondary hyperthyroidism?
40
What are the ti-rads?
Thyroid Imaging Reporting & Data System - Provides recommendation for FNA or f/u US or leaving nodules alone
41
What is TR1, TR2?
* TR1: 0 points
– Benign, no FNA required
* TR2: 2 points
– not suspicious, no FNA required
42
What does TR3 and TR4 entail?
TR3: 3 points
* mildly suspicious, ≥1.5 cm follow up, ≥2.5 cm FNA
* follow up: 1, 3 and 5 years
TR4: 4-6 points
* moderately suspicious, ≥1.0 cm follow up, ≥1.5 cm FNA
* follow up: 1, 2, 3 and 5 years
43
What does TR5 entail?
TR5: ≥7 points
* highly suspicious, ≥0.5 cm follow up, ≥1.0 cm FNA
* annual follow up for up to 5 years
44
What is the percentage risk of malignancy for TR1-5?
* TR1: 0.3%
* TR2: 1.5%
* TR3: 4.8%
* TR4: 9.1%
* TR5: 35%
45
Parathyroid Imaging
* What is the initial evaluation?
* What is the study of choice if US is negative?
* What should you conside?
* Initial evaluation with ultrasound
* Nuclear PTH Tc-99m Sestamibi is the study of choice if thyroid abnormality is not identified on US
* Consider clinical presentation and laboratory evaluation of Ca++ (issue with Ca -> low or high)
46
CNS Imaging:
* What does the imaging start with?
* What is the sensitivity of CT and MRI?
* What is rarely requested and why?
* What is the modalities of choice in a trauma pt?
* Imaging of CNS conditions effecting other parts of the body, usually begins with higher-tech studies such as CT and MRI
* A CT is 58% sensitive for infarction within the first 24 hours. MRI is 82% sensitive. If the patient is imaged greater than 24 hours after the event, both CT and MR are greater than 90% sensitive.
* In head trauma - Skull films are rarely requested because they only show the bony skull and do not reveal abnormalities of the brain
* CT Brain usually combined with CT C-Spine, both without contrast, and are imaging modalities of choice in a trauma patient.
47
Computed Tomography:
* Recent technical advances in CT scanning dramatically increased what?
* Conventional CT scans take pictures like what?
* How big are the slices?
* How does the newer spiral CT work?
48
What do you need to make sure of for CT interpretation?
49
Brain CT Key Concepts
* White matter will appear as what on CT? Why?
* What will appear black on CT?
* What will appear gray?
* Acute hemorrhage will appear as what?
* After the administration of IV contrast, vascular structures will appear what?
50
51
What slice is this?
The X: base of skill or bottom of brain
* You can see the frontal sinuses
52
What Ct slice is this?
The star-> higher up than x
53
What CT slice is this?
Happy face
54
What CT slice is this?
The sad face
* You can falx cerebri
55
What CT slice is this?
The worms
56
What CT slice is this?
The coffee bean
* top of the head
57
* Headache:
* No imaging in primary headaches is indicated when?
* Primary or secondary headache work-up rarely requires what?
* MRI with perfusion maybe useful when?
58
* What is a primary headache? What is a secondary HA?
* Light sensititivity can be seen in what?
* A primary headache has no known underlying cause. Secondary headache is the result of another condition causing traction on or inflammation of pain-sensitive structures. Headache due to psychiatric disease is also considered secondary.
* Light sensititivity can be seen in many conditions other than meningitis such as ocular migraine, corneal abrasion or glaucoma and is not a severe feature requiring imaging.
59
With HA, blunt trauma imaging indicated when?
60
What does this show?
* What does this pathology result from?
* Patient will have what in their CSF?
* What are common causes?
Subarachnoid Hemorrhage
* Subarachnoid hemorrhage results from disruption of the subarachnoid vessels.
* The patient will have blood in the CSF.
* Aneurysm/A-V malformation or Direct Trauma
61
What does this show?
* Typically seen in who?
* Frequently also have what?
* An isolated version may be due to what?
Intraventricular hemorrhage
* Typically seen in trauma or hypertensive issues
* Frequently have subarachnoid bleeds as well (arrowheads)
* An isolated intraventricular hemorrhage may be due to rupture of subependymal veins.
62
What does this show?
Epidural hematoma
63
Epidural hematoma:
* What are the characteristics?
* Usually results from what?
* What is the classic presentaiton?
* What occurs quickly?
* Results from blood in the epidural space resulting in a **biconvex lesion on CT Scan (football sign).**
* Usually results from trauma to the temporal bone with disruption of the **middle meningeal artery(origin)**
* Classic presentation: LOC (>5min), lucid, Herniation
* Herniation occurs quickly
64
What is this?
Subdural hematoma
65
Subdural Hematoma
* Bleeding occurs where?
* Usually results from what?
* What are the different types?
* These are commonly seen in who?
* Bleeding occurs between the dura and the arachnoid space resulting in a crescent-shaped lesion on CT Scan.
* Usually results from venous origin
* These can be acute, subacute or chronic
* These are seen commonly in elderly and in alcoholics and children under 2 y.o.
* Smaller brains or atrophy
66
What does this show?
Hemorrhagic stroke
67
Hemorrhagic stroke:
* Accounts for _ of all strokes
* Blood appears _ of CT
* Can stem from what?
* Account for 16% of all strokes
* Blood appears white on CT
* Can stem from berry aneurisms, drug abuse, HTN or coagulopathy.
68
What does this show?
Ischemic stroke
* Right side will be have broca aphasia since in frontal/temporal lobe
69
Ischemic stroke
* Look for what?
* Ischemic area is what?
* What is the mainstay for imaging of acute stroke?
* Look for absence of hemorrhage or actual vessel occlusion
* Ischemic area is hypoattenuated
* Non-contrast CT of the brain remains the mainstay of imaging in the setting of an acute stroke.
70
What does this show?
brain tumor
71
brain tumor:
* Generally presents with what?
* Can be confused with what?
* Correlate _
* What can be used to cause necrosis of tumor?
* Generally present with a focal neurological deficit, seizure, or headache.
* Can be confused with ischemic or hemorrhagic strokes
* Correlate clinically
* Targeted radiofrequency ablation can be used to cause necrosis of tumor.
72
What is this?
* What are the mc causes (3)?
* Ct findings include what?
Extra-axial empyema
* 50% are from frontal sinusitis
* 30% are post-craniotomy
* Rest are infectious – meningitis
* CT findings include a focal fluid collection usually with an enhancing margin in a subdural or epidural location
| Rim enhancing epidural fluid collection (arrowheads)
73
What does this show?
* who is this seen in?
* Some may show what?
Cerebral abscess
* More likely to be seen in HIV patients (CD4<200), those with lymphoma or toxoplasmosis
* Some may show air fluid levels
74
What does this show?
Meningitis
75
Meningitis:
* Clinically will present with what?
* What is an intermediate quality test?
* What is the study of choice?
* Clinically patients will have fever, headache and neck pain
* CT is intermediate quality test and therefore should be avoided as it is unlikely to influence treatment
* MRI brain with and without contrast is the study of choice to evaluate for diffuse or focal enhancements
76
What does these images show?
* MR has been chosen for the above images because of its ability to show greater detail in Alzheimer's disease.
* The image on the left is a thin-section coronal T1-weighted MRI of an individual with Alzheimer's.
* The arrows indicate focal, assymetric atrophy of the right medial temporal lobe.
* Also visible on the left are the dilated lateral and third ventricles most likely due to diffuse atrophy.
* The image on the right is an age-matched control for comparison.
77
Alzheimer's Disease
* Affects >65% of patients with what?
* Caused by waht?
* What is shown on CT?
* What imaging is more sensitive?
* Affects >65% of patients with known dementia
* Caused by neuronal degeneration from amyloid precursor protein production causing inflammation
* See marked diffuse atrophy of brain mass, enlarged lateral ventricles and widened Sulci on CT
* MRI is more sensitive
78
What does this show?
Parkinson's Disease
79
Parkinson's Disease
* Occurs due to what?
* Triad of what?
* CT appears similar to what?
* What is image is more sensitive?
* Occurs due to selective loss of neuromelanin containing dopaminergic neurons
* Triad of bradykinesia and hypokinesia, resting tremor, and increased tonicity of voluntary musculature and loss of postural reflexes.
* CT appears similar to Alzheimer's with enlarged lateral ventricles and widened Sulci on CT
* MRI is more sensitive to show diffuse cortical hypometabolism
80
What does this show?
Huntington's Disease
* The image on the left exhibits bilateral caudate head atrophy (red arrowheads), as seen by a decrease in the medial convexities, & lateral ventricle dilatation.
* Generalized atrophy evident as diffusely widened sulci is also apparent in the image on the left.
* The image on the right is an age-matched control.
81
Huntington's Disease
* What is the cause?
* What is the triad?
* What will you see on imaging?
* What imaging is more sensitive?
82
What does this image show?
Pick's Disease
* The images above are axial Head CT scans.
* In the image on the left, focal bifrontotemporal atrophy can be seen, as exhibited by marked widening of the frontal and temporal sulci, dilation of the lateral ventricles, and the "knife-like" projections of the gyri.
* The image on the right is an age-matched control for comparison.
83
What does this image show?
* who do you see this in?
* What imaging is the best? What do you see?
Multiple sclerosis
* Middle-aged women with monocular vision loss
* MRI brain w/w/o contrast is best to see multiple hyperintense periventricular and subcortical white matter lesions "Dawson Fingers"
84
No
85
Carotid Screening:
* In absence of acute findings on brain CT or even MRI/MRA of brain in the setting of acute neurologic deficit, what is ordered?
carotid US is usually ordered to screen for stenosis, especially in stroke-like presentations or other carotid presentations
86
* Carotid US can differentiate what (3)?
* Carotid artery disease screening is appropiate for who?
Carotid US can differentiate
* Calcified plaque (more stable)
* Hypoechoic Soft plaque (less stable)
* Doppler flow and evaluate for dissections
Carotid artery disease screening is appropriate for all adults age 55+. It is also appropriate for adults age 40+ who have risk factors for cardiovascular disease.
87
MR Angiography
* MRA often does not require what?
* Consequently, MR is a good way to image what?
* MRIA is also useful in evaluating what?
* MRA often does not require any exogenous contrast material and in such cases the procedure can be repeated without any risks to the patient.
* Consequently, MR is a good way to **image blood vessels of patients in renal failure**, who cannot be given iodinated contrast material used for conventional angiography.
* MRA is also useful in evaluating aortic abnormalities such as dissections and aneurysms, and atherosclerotic peripheral arterial disease in the lower extremities.
88
MRA
* What is the IV injection?
* What can 3D software programs do?
* MRA has proven most valuable for what?
* Routinely today, MRA is used to diagnose what?
* IV injection of gadolinium contrast agents can enhance visualization of cardiovascular structures.
* In addition, three- dimensional software programs can convert a stack of contiguous MR slices of white blood vessels into a 3D angiographic model.
* MRA has proven most valuable for neurovascular imaging of blood vessels of the neck and brain.
* Routinely today, MRA is used to diagnose carotid artery stenoses, cerebral aneurysms, and cerebral AVMs.
89
What do these images show/
Gadolinium-enhanced MR angiography of the chest.
A: Coronal MR scan through the left ventricular chamber (LV), aortic valve, and ascending aorta (AA). The main pulmonary artery (PA) can also be seen.
B: Coronal scan through the superior vena cava (SVC) where it enters the right atrium (RA). The ascending aorta and pulmonary artery are again seen.
90
What do these images show?
MRA Brain: cervical and circle of willis MRA
91
What does this image show?
3d MRA
* 3D MR angiogram showing the pulmonary arteries arising from the main pulmonary artery (PA) and the pulmonary veins entering the left atrium (LA).
* The ascending aorta (AA) is again seen. Note the excellent visualization of the brachiocephalic arteries and veins.
92
Interventional Radiology
* What does IR do?
* What needs to be otained?
* What do you need to ensure with patient?
* What may require the patient to be NPO for 8hr?
* What should you do in procedure?
* Most procedures require what?
93
Interventional Neuroradiology:
* Interventional neuroradiology procedures have proven valuable in the treatment of what?
* Certain cerebral aneurysms are located at sites that are extremely difficult for neurosurgeons to access safely. These aneurysms can be successfully treated with what?
* two conditions affecting the CNS: cerebral aneurysms, and cerebral arteriovenous malformations.
* transcatheter embolization
94
What does this image show?
Neuroangiography
95
What does this image show
* Transcatheter embolization of a left middle cerebral artery aneurysm in a 58-year-old woman who presented with dizziness.
* Her initial CT scan shows a contrast filled aneurysm (black arrow) to the left of the circle of Willis (white arrows).
96
What do these images show
Transcatheter embolization
* Left: Anterior view of a left internal carotid (LIC) arteriogram shows a small aneurysm (arrow) arising from the left middle cerebral artery (LMC). Also shown are the left anterior cerebral (LAC) artery branches.
* Right: Postembolization arteriogram shows the aneurysm occluded with multiple small metal coils.
97
Right internal carotid angiogram demonstrates an occlusion of the right middle cerebral artery.
Flow in the right middle cerebral artery is re-established at 28 minutes during a selective infusion of urokinase into the right middle cerebral artery. The patient recovered her former neurologic function while she was on the angiography table
98
Middle aged Asian female presents for evaluation of cold and pulseless upper extremities
* What is suspected?
* What may the US revel?
* Large vessel arteritis (aortic arch syndrome/Takayasu Arteritis) is suspected
* US may reveal "Macaroni sign" which is concentric thickening of aortic wall
99
What is the study of choice for Takayasu Arteritis
CT angiogram
100
shows extraperitoneal hemorrhage with active extravasation
101
Identify bleeding site
* Intraperitoneal will require what?
* What can you do for Extraperitoneal areas?
* May result in what?
* Intraperitoneal will require laparotomy
* Extraperitoneal areas you can inject gel foam slurry or metallic coils into affected vessels
* May result in wrong area occlusion leading to necrosis and continued hemorrhage
102
What does this show? What are the management options?
Postrenal right ureteral obstruction from mass is diagnosed.
Management options
* Surgical resection
* Retrograde ureteral stent placement
* Percutaneous nephrostomy tube placement
103
* If condition is not caused by stone, what is appropriate?
* Done with the assist of what?
* If condition is not caused by stone, temporary percutaneous nephrostomy tube is most appropriate
* Done with assist of direct ultrasound or fluoroscopy
104
* The term virtual endoscopy refers to what?
* The data are obtained from CT scans and the models are produced on what?
* Two of the most popular techniques in use today are what?
105
Virtual Colonoscopy and Virtual Bronchoscopy
* Virtual endoscopy holds promise for replacing what?
* What can be avoided in virtual alternatives?
* Virtual procedures are what?
106
Virtual Colonoscopy
* What is the mc indication for virtual colonoscopy?
* What is the 3rd leading cause of cancer deaths?
107
What do these images show?
* Left: Coronal CT reformation shows a filling defect (arrow) in the right colon – a polyp.
* Right: Virtual colonoscopy image shows that the defect represents a polyp (arrow).
108
What do these images show?
* Left: 3D reformation of the tracheal air column.
* Right: View of the carina as seen from above.
109
Virtal bronchoscopy:
* Can be used to diangose and display what?
* Ideal method for what?
* Can diagnose and display tracheobronchial stenoses, tumors, and foreign bodies.
* Ideal method for following the progression of tracheobronchial stenoses, because a repeat virtual bronchoscopy is much easier for a patient to accept and tolerate than repeat conventional bronchoscopy.
110
Three-Dimensional Ultrasound
* most commonly used where?
* In gynecological imaging, 3D ultrasound can enhance the visualization of what?
* 3D ultrasound is a new technique and has only recently become clinically available.
* Most commonly used today in obstetrical imaging.
* In gynecological imaging, 3D ultrasound can enhance the visualization of uterine polyps, uterine fibroids, and congenital uterine abnormalities.
111
What do these images show?
* Left:3D ultrasound of an 11-week-old fetus. Note also the umbilical cord (arrow).
* Right: 3D ultrasound of the face of a 33-week-old fetus.
112
PET (Positron Emission Tomography)
* Cancer cells require a great deal of what?
* PET utilizes what?
* The molecule is tagged to what? What does this form?
* FDG accumulates within what? why?
* What is this useful for?
Fluorine breaks down and gives off positrons – positron emission tomography (PET)
113
What is this?
PET Scans
* PET scans of a patient with metastatic lung cancer.
* Activity within the primary tumor is seen on left (arrow).
* Note the liver metastasis in both images and the mediastinal node metastases on right.
* In both scans you can see increased activity within the bladder as the isotope is excreted through the urinary tract.
114
Fusion Imaging with PET-CT
* What is fusion imaging?
* PET scans visual what?
* Fusion imaging is the merging of diagnostic images of the same anatomic area produced by different imaging modalities into a single image that combines the information yielded by all of the modalities.
* PET scans visualize physiological and biochemical processes, whereas CT scans visualize anatomical structures.
115
Fusion Imaging with PET-CT
* Pet can identify cancer cells even when?
* The PET scan alone, however, often cannot pinpoint what?
* Pet can identify cancer cells even at an early stage when other modalities such as CT cannot detect them because they are too small.
* The PET scan alone, however, often cannot pinpoint the precise location of the cancer for diagnosis and treatment. But if the PET scan abnormality is superimposed over a CT scan, the exact location of the cancer can be identified.
116
What does this show?
Combines PET and CT to improve localization by superimposion
* A- CT; B – Hybrid, C – PET.
117
What does this show?
PET-CT examination of a patient with metastatic colon cancer. You see axial and coronal images from a PET scan. Increased uptake of radioactive glucose occurs at sites of metastatic disease, where the cancer cells cause an increase in cellular metabolic activity. To anatomically localize these sites the PET scan images are superimposed onto the patient’s CT scan in the same axial and coronal planes. The liver metastases are easy to localize. The arrows point to metastases in abdominal lymph nodes.
118
What is PET or PET-CT used for? (there is a lot so I am sorry, I don't want more cards lol)
119
PET/PET-CT
* PET-CT can show tumor cells how?
* PET-CT can show not only the early spread of cancer cells, but also what?
* PET-CT can show tumor cells in normal sized lymph nodes, consequently altering the staging and treatment plan for newly detected cancers.
* PET-CT can show not only the early spread of cancer cells, but also the absence of spread, a finding that should preclude injury to healthy tissues through radiation or surgery
120
What does this image show?
PET/PET-CT
* Lesion in the breast showing high uptake of the glucose.
121
Pediatric Imaging:
* What is the goal?
* Patients from 1 day old to 1 year dont what?
* Patients over 4 years old are what?
* Patients from 1year to 3 years old usually need to be what?
* Patients from 1 to 3 years old may not cooperate for what?
122
What is this?
Pigg-o-stat
123
What are the most common seen pediatric pathology? (6)
* Croup and epiglottitis
* Viral pneumonia
* Bronchitis
* Cystic fibrosis
* Foreign bodies
* Retropharyngeal abscess
124
What image is this? What does this show?
Nose to Anus study in 1 view is indicated for foreign body
125
Croup
* What does it cause?
* Peak incidence at what age?
* What is the critical site? What does this cause in appearance?
* Causes acute airway obstruction; caused by influenza and parainfluenza viruses
* Peak incidence: between 6 months and 3 years
* The critical site is immediately below the larynx, where edema narrows the subglottic trachea. This area has an inverted “V” appearance that is characteristic of croup.
126
What do these images show?
croup
127
Epiglottitis
* What bacteria causes this?
* How is the film taken?
* A lateral soft tissue neck film will show what?
* Caused by Hemophilus influenza and Streptococcus pneumoniae; and is a much more dangerous (life threatening) condition than croup
* The film must be taken upright
* A lateral soft tissue neck film will show marked enlargement of the epiglottis, and thickening of the surrounding tissues
128
What do these images show?
129
Airway Abscess
* Can be what?
* Clinically present with what?
* What is the study of choice?
* Can be peritonsillar or retropharyngeal
* Clinically present with fever, difficulty swallowing and lymphadenitis
* CT neck (NOT cervical) with contrast is a study of choice
130
What does this show?
airway abscess
131
Pneumonia
* What do chest films show?
* Bronchiolitis occurs in who? Bronchitis?
* Chest films show thickening of the bronchial wall, hyperaeration, and increased lung markings
* Bronchiolitis occurs in infants (less than 1 year old), bronchitis in toddlers and children
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Bronchiolitis and Pleural Effusions
* RSV showing the typical bilateral perihilar fullness of bronchiolitis.
133
What do these images show?
Round Pneumonia
* Left and Middle: In a child with signs and symptoms of pneumonia, a spherical mass-like opacity on a chest radiograph is usually a "round pneumonia".
* This phenomenon is usually seen in children under 8 years of age.
* Right: F/u at 1 week following ABX treatment. Does not require biopsy.
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Cystic Fibrosis
* How is the diangosis made?
* What are the clinical manifestations?
* In older children, the films may show what?
* Other pulmonary complications such what may occur?
* What is the mc organism?
* In infants and young children, the chest film may be entirely normal, the diagnosis of cystic fibrosis having been made clinically
* Clinical manifestations include chronic cough, recurrent pulmonary infections, and obstructive pulmonary disease
* In older children, the films may show hyperaeration, peribronchial cuffing, increased lung markings, and dilated bronchi (bronchiectasis)
* Other pulmonary complications such as pneumonia, lung abscess, pneumothorax, and atelectasis may occur
* Most common organism is Pseudomonas aerugenosa
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Abdominal Masses in Infants and Children:
* Almost half of the abdominal masses in children are _ in origin
* What is the singal most common cause of neonatal abdominal mass?
* Almost half of the abdominal masses in children are renal in origin; most of these are benign and have an excellent prognosis
* Hydronephrosis is the single most common cause of neonatal abdominal mass
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Abdominal Masses
* In older infants and children, the majority of abdominal masses are also renal in origin, what what is 22% of tumors?
* What is the recommmended inital imaging?
137
What does this show?
Renal mass
138
Parainfluenze
139
Plain Film Radiography Importance
* Plain x-ray evaulation is the GOLD STANDARD for what?
* What is the inflam, reparative and remodeling phase?
140
explain the process
141
What do these images show?
* Left – Fracture
* Middle – Callus
* Right – Remodeling
142
Child Abuse
* Radiologic manifestations of child abuse includes what?
healing fractures of various stages, fractures at the edges of the metaphysis, epiphyseal and metaphyseal fractures, posterior rib fractures, and compression fractures of the vertebral bodies
143
Pediatric fractures differ from adult fractures since young bones are more what?
more pliable than older ones related to calcium content
144
What type of fx is this/
Torus fracture (aka “buckle” fracture)
* Involves buckling of one cortex side
145
What is this?
Greenstick Fracture
146
What fx is this?
Bowing Fracture
* Right tibial fracture with associated bowing fracture of fibula in a 5-year-old male.
147
What does this show?
Greenstick and buckle fracture.
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If child abuse is suspected, you should request a Skeletal Survey which consists of what ?
* AP and Lat skull
* AP views of the chest, abdomen, and pelvis
* AP views of all the long bones of the extremities, including the hands and feet
* You may need a CT head depending on other injuries
## Footnote
Imaging studies are important because they may supply evidence of multiple episodes of abuse
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What do these images show?
* Multiple fractures of long bones in different stages of healing (a–c on the same patient: radioulnar and tibioperoneal fractures; (d) another patient with humeral and radial fracture in different stages of healing.
* CT with intracerebral radiopacities
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Child Abuse
* The vast majority of fractures occur in patients under what?
* The extremities are convenient what?
* The vast majority of fractures occur in patients under 3 years of age, and half of them are in infants.
* The extremities are convenient “handles” by which the child can be grabbed, swung, shaken, or pulled. Hence extremity fractures are most common.
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Child Abuse
* The metaphyseal lesion of child abuse is what?
* This fracture extends where?
* This type of fracture may also appear as what?
* The metaphyseal lesion of child abuse is virtually pathognomonic
* This fracture extends transversely across the extreme end of the metaphysis
* This type of fracture may also appear as a metaphyseal chip fracture.
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What is this ?
Metaphyseal chip fracture
* Likely secondary to forceful pulling of an extremity
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* What type of fx are highly suggestive of abuse, especially in the non-ambulatory child?
* What does this image show?
* Diaphyseal spiral fractures are highly suggestive of abuse, especially in the non-ambulatory child
* Acute femur fracture – no callus formation with sharp edges.
154
* What fx has a high specificity for child abuse?
* What is rarely seen in child abuse cases?
* Multiple fractures seen at different stages of healing have what?
* Callus in diaphyseal fractures generally forms no earlier than what?
155
* Rib fractures are highly suggestive of child abuse, what is it seen in?
* Rib fractures are practically never seen after what?
* What is ideal for detecting rib fractures?
156
What does this image show?
* Multiple ribs (acute) and clavicle (old) fractures.
* Different stages of healing in multiple fractures – abuse.
157
What is this?
Calluses on ribs indicate healing fractures. Can be seen in Shaken Baby Syndrome
158
What does this show?
Nuclear medicine bone scans indicate increased osteoblastic activity related to fracture healing process.
159
What does this show?
Patient hit in the back of the head, producing a fracture of the odontoid process and subluxation of C1.
* A high specificity for child abuse is found in fractures of the sternum and spinous processes of the spine
160
* The most common cause of death from child abuse is what?
* A linear skull fracture is not highly suggestive of child abuse, but the level of suspicion should increase with what?
* The most common cause of death from child abuse is from trauma to the head
* A linear skull fracture is not highly suggestive of child abuse, but the level of suspicion should increase with complex skull fractures
161
What does this show?
Fx-> serious event or child abuse
162
What do these images show in child abuse?
* Acute – subdural hematoma with mass effect.
* Chronic – subdural hematoma that’s old – isodense (same radiopacity as the brain). Highly suggestive of child abuse.
163
What does this image show?
Note subdural hemorrhages in the frontal and occipital lobes and along the falx.
* shaken baby
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Child Abuse:
* What is a fairly frequent site of abusive trauma, particularly after the child becomes ambulatory?
* Blunt force in the form of a fist or knee can cause severe damage to what?
* What is the most common abdominal injury seen in child abuse?
* What is also common?
* The abdomen is a fairly frequent site of abusive trauma, particularly after the child becomes ambulatory
* Blunt force in the form of a fist or knee can cause severe damage to the intraabdominal viscera and is associated with a high mortality rate
* Intramural hematoma of the duodenum is the most common abdominal injury seen in child abuse
* Laceration of the liver and pancreas are also common
165
What does this image show?
Duodenal Hematoma and Pseudocyst in the tail of the pancreas due to abdominal trauma.
166
Call the Department of Children and Family Services
