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1

2 types of lipomatous lesion involving a joint

  • intra-articular lipoma (very rare)
  • lipoma arborescens (more common)

2

Types of ovarian tumor

  • surface epithelial-stromal tumor / epithelial carcinoma
    • serous
    • endometroid
    • mucinous
    • Brenner tumor - transitional-type epithelial cells with longitudinal nuclear grooves (coffee bean nuclei) lying in abundant fibrous stroma
    • transitional cell carcinoma
  • sex cord-stromal tumor
    • granulosa
    • sertoli-leydig cell
  • germ cell tumor
    • teratoma
    • dysgerminoma - LDH
    • endodermal sinus tumor - AFP
    • choriocarcinoma - beta-hCG
  • mixed tumors

3

Neurogenic tumors

Arising from: 

  • peripheral nerves or nerve sheath
    • neurofibroma
    • neurilemmoma
  • sympathetic ganglia
    • ganglioneuroma
    • neuroblastoma
  • paraganglial cells
    • pheochromocytoma
    • chemodectoma

4

Most common cause of a posterior mediastinal mass in patients with neurofibromatosis?

Anterior and lateral thoracic meningocele

5

How do you tell bronchiectatic airways from cystic lung disease on CXR?

  • bronchiectatic airways - can contain air fluid levels
  • cystic lung disease - should not contain air fluid levels unless there is secondary infection

6


Saying:

"hazinessness along the walls of vessels and ill-definition of the bronchi".

"hazinessness along the walls of vessels and ill-definition of the bronchi".

7


Difference in location of NSIP and UIP

  • UIP is strictly peripheral/subpleural
  • NSIP can be central

8


When the aorta is tortuous...

It can pull the left lung and pleura to the right along with it

9


PJP

 


Usually just GGO

NO discrete nodules

10

What should you see at the level of superior hila

i.e., at the level of carnia?

Right: apical segment bronchus

Left: apicoposterior segment bronchus

11

Superior segment bronchus in lower lobes take off at which level?

Bronchi of the superior segments of the lower lobes

take off at the same level as the 

RML and lingular bronchus take off/bifurcation

12

Phlegmasia cerulea dolens

= painful blue edema

Uncommon severe form of DVT

Phlegmasia alba dolens

= painful white edema

 

13

Phthisis bulbi

14

Bronchial abnormality detected on CT

15

Bronchogenic tumors

16

Difference b/t hilar lymphadenopathy caused by

lymphoma/TB vs sarcoidosis?

  • lymphoma/TB - often asymmetric LAD
  • sarcoidosis - often symmetric LAD

17

Types of mediastinitis

  • Acute mediastinitis
    • related to esophageal perforation or spread of infection
    • patient +++ sick
  • Granulomatous mediastinitis
    • TB, fungal (histo/cocci), sarcoid
    • often asymmetric LAD (except sarcoid - symmetric LAD)
    • calcification and fibrosis common
  • Sclerosing/fibrosing mediastinitis
    • similar process as retroperitoneal LAD
    • calcification does NOT occur*

18

Thyroid tumor

  • Although the primary site of carcinoma within the thyroid may be iodine avid, pulmonary metastases may not be secondary to tumor dedifferentiation.
  • US characteristics include hypoechogenicity (solid), internal vascularity, presence of microcalcifications, and a nodule that is taller than it is wide. 
  • Microcalcifications, also known as psammoma bodies, are round, laminar, crystalline calcific deposits of 10–100 um. They are one of the most specific features of thyroid malignancy, with a specificity of 85–95%, and are most common in the papillary variant.

19

Sayings:

"Extensive mediastinal adenopathy as described.  In addition there are multiple tiny indeterminate pulmonary nodules. 

This in combination with the abdominal findings would render a neoplastic process the diagnosis of exclusion-metastatic disease from an occult primary, or lymphoma. 

Given the enhancement of the lymph nodes, plasma cell subtype type of Castleman's disease would be a lesser consideration. "

"Extensive mediastinal adenopathy as described.  In addition there are multiple tiny indeterminate pulmonary nodules.

This in combination with the abdominal findings would render a neoplastic process the diagnosis of exclusion-metastatic disease from an occult primary, or lymphoma.

Given the enhancement of the lymph nodes, plasma cell subtype type of Castleman's disease would be a lesser consideration. "

20

Sayings:

"DDx would include..., and less likely, ..."

"Consider..., if clinically relevant."

"DDx would include..., and less likely, ..."

"Consider..., if clinically relevant."

21

Most common location of tracheal bronchus

i.e., "pig bronchus"

RUL

usually the apical segment of the RUL

associated with recurrent infections

22

Bronchial atresia

  • LUL most common location*
  • local narrowing or obliteration of a lobar/segmental/subsegmental bronchus
  • mucus plugging in bronchi distal to the obstruction - tubular, branching, or ovoid mucus plug - "finger in glove"
  • air trapping in the lobe b/c collateral air flow - hyperlucent or hypovascular

23

DDx for "finger in glove" appearance

  • ABPA
  • congenital bronchial atresia

24

Most common location for pulmonary sequestration?

Posteromedially on the left

25

Pulmonary AVM is associated with which syndrome?

Osler-Weber-Rendu syndome

aka

Hereditary hemorrhagic telangiectasia

26

"2 faces" of AVM

  • a single dilated vascular sac - smooth, sharply defined, round or oval nodule (most common)
  • a tangle of dilated tortuous vessels - lobulated or serpiginous mass
  • most common location of pulmonary AVM - immediately subpleural
  • with contrast - rapid and dense opacification --> rapid washout

27

Intralobular vs Extralobular 

pulmonary sequestration

  • Intralobar - infection - adults
  • Extralobar - infants and children

28

4 features of hypogenetic lung syndrome

scimitar syndrome

  1. hypoplasia of the right lung/lobe/segment
  2. hypoplasia of the right pulmonary artery
  3. PAPVR draining the RUL or entire right lung to the IVC or RA
  4. *systemic arterial supply to a portion of the hypoplastic right lung (often the lower lobe)*

29

4 features of rounded atelectasis

  1. ipsilateral pleural disease - thickening or effusion
  2. volume loss - atelectasis
  3. comet tail sign - swirling of bronchovascular structures
  4. *extensive contact with the pleural surface*

30

31

"air crescent sign"/"monod sign"

in angioinvasive aspergillosis vs

aspergilloma/mycetoma

angioinvasive aspergilloma

  • infarcted and necrotic lung pulling away from the remainder of the lung within the cavity
  • air crescent sign

 

aspergilloma/mycetoma

  • fungus ball occupying a pre-existing cavity
  • also called "monod sign"

32

What does "satellite nodules" indicate?

A granulomatous process

  • TB
  • fungal 
  • sarcoidosis (“Sarcoid Galaxy” Sign)
  • etc

33

Approach to ground glass opacity

  • differentiate which is abnormal - GGO or lucent lung?
    • usually GGO is abnormal
    • lucent lung is abnormal if the vessels are diminished
  • acute vs chronic
    • acute
      • infection (atypical - PCP)
      • edema
      • hemorrhage
      • subacute HSP
    • chronic
      • PAP
      • BAC
      • fibrosis - UIP/NSIP
      • DIP
      • lipoid pneumonia
      • bronchiolitis obliterans

34

3 lung diseases with cysts as the primary manifestation

3L's

  • LAM
  • Langerhans histiocytosis/EG
  • LIP (Sjogren's syndrome)

35

Causes for pulmonary alveolar proteinosis

PAP

  • idiopathic - most often
  • exposure to dusts (silica)
  • hematologic/lymphatic malignancy
  • chemotherapy
  • PAP is associated with what infection?
    • nocardia
    • mycobacteria

36

DDx for bronchiolitis obliterans organizing pneumonia

organizing pneumonia

(peripheral distribution, atoll sign)

IIADE

  • idiopathic - cryptogenic organizing pneumonia
  • infection
  • autoimmune
  • drug toxicity/toxins
  • eosinophilic pneumonia

37

Lymphangiomyomatosis

LAM

is associated with...

Tuberous sclerosis (TS)

  • LAM
  • exclusively child-bearing age women
  • associated with
    • lymphadenopathy
    • chylothorax
    • pneumothorax

38

The presence of air within the empyema is due to:

  • recent thoracentesis (most common)
  • bronchopleural fistula
  • gas-forming organism

39

Empyema necessitatis

  • extension of an empyema to involve the chest wall
  • TB - 2/3 of the cases
  • actinomyces
  • nocardia 

40

Saying:

"asbestos related pleural disease"

"asbestos related pleural disease"

41

Which layer of pleura is involved in

asbestos related pleural disease?

Parietal pleura

diaphragmatic pleural often involved

42

Features of malignant involvement of the pleura

  • nodular thickening
  • >1cm in thickness
  • involving mediastinal pleura
  • concentric pleural thickening that encases the lung 

43

Localized fibrous tumor of the pleura

  • arises from visceral pleura
  • associated with
    • chest pain
    • hypoglycemia
    • hypertrophic pumonary osteoarthropathy - HPOA
  • 70% benign, 30% malignant 

44

thymoma drop mets

usually NOT associated with pleural effusion

45

DDx for pleural calcifications

  • prior asbestos exposure
  • prior empyema - TB most comon
  • resolved hemothorax
  • talc pleurodesis

46

Borders of the axillary space

  • anterior - pectoralis major and minor
  • posterior - latissimus dorsi, teres major, subscapularis
  • medial - chest wall, serratus anterior
  • lateral - coracobrachialis, biceps 

47

Diaphragmatic hiatus

  • aortic hiatus
    • aorta
    • azygos
    • hemiazygos
    • thoracic duct
    • intercostal arteries
    • splanchnic nerves
  • esophageal hiatus
    • esophagus
    • vagus nerves
    • small blood vessels
  • IVC hiatus
    • IVC

48

Abnormality?

Left atrial appendage thrombus in A-Fib

  • Most common arrhythmia - atrial fibrillation
  • Most common site of thrombus formation in patients with atrial fibrillation - left atrial appendage
  • Test of choice to detect LA appendage thrombus - TEE
  • Pulmonary vein ostia - overwhelmingly are the origin of ectopic activity initiating atrial fibrillation
  • Identification of atrial thrombus is important as it is an absolute contraindication to radiofrequency ablation therapy.
      
  • Cardiac CT is most frequently used for anatomical mapping prior to ablation of arrhythmogenic foci and also has a very high sensitivity for the detection of thrombi.

49


Left paraspinal line often follows the course of the tortuous aorta

Left paraspinal line often follows the course of the tortuous aorta

50


DDx for acute interlobular septal thickening

  • edema
  • acute eosinophilic pneumonia
  • pulmonary veno-occlusive disease

51

ARDS

vs

cardiogenic pulmonary edema

  • cardiogenic edema often has pleural effusions
  • ARDS/non-cardiogenic edema has less pleural effusion

52


Reverse westmark sign


infarcted lung (secondary to PE) within atectatic lung - due to relative hypoperfusion

53


What lung tumor often gives you dense bone mets?


Carcinoid

54

Cephalohematoma

  • Cephalohematoma is a traumatic SUBPERIOSTEAL hemorrhage due to rupture of blood vessels between the skull and the periosteum, and it is confined by cranial sutures.
  • They are thought to result from birth trauma, with risk factors including prolonged and difficult deliveries. They usually increase in size after birth.
  • On CT or MR imaging, these typically appear as crescent-shaped lesions adjacent to the outer table of the calvarium, confined by cranial sutures and possibly calcified. MR signal intensity is dependent on age of the blood products.
  • Patients with cephalohematoma are typically managed conservatively. They can occasionally become infected, possibly requiring antibiotics and/or I&D. These typically resolve over months with skull growth and bony remodeling; prolonged resorption can lead to calcification.

55

Most common pattern of ILD?

UIP - 40%

NSIP - 20%

smoking related (RB/DIP) - 20%

organizing pneumonia - 20%

56

Diagnostic criteria for UIP

  • subpleural, basal predominance
  • reticular abnormality
  • honeycoming with or without traction bronchiectasis
  • absence of features inconsistent with UIP

 

“Possible" UIP

  • absence of honeycombing (only present in 70-80% of patients with UIP)

57

Diagnostic criteria for NSIP

  • better survival than UIP
  • usually associated with an underlying condition
    • collagen vascular disease
    • drug toxcities (e.g. nitrofurantoin)
    • hypersensitivity pneumonitis   (environmenta exposure)
  • 2 types
    • fibrotic - most common
    • cellular

  • basal predominance
  • ***more perivascular; but subpleural sparing***
  • confluent pattern
  • volume loss
  • groundglass
  • reticular
  • traction bronchiectasis
  • consolidation +/- honeycombing rare

58

Best predictor of NSIP

as opposed to UIP etc?

Subpleural sparing

59

Best predictor of chronic hypersensitive pneumonitis?

  • lack of upper lung predominance
  • upper and mid lung predominance

60

RB

RB-ILD

difference: with vs without clinical symptoms

  • "dirty lung" appearance
  • centrilobular nodules
  • groundglass
  • +/- emphysema

61

DIP

  • basal, peripheral predominance
  • groundglass
  • reticular
  • cysts

62

Organizing pneumonia

causes

IIADE

  • idiopathic
  • infectious
  • autoimmune/collagen vascular disease; aspiration
  • drugs
  • eosinophilic

  • subpleural/peribronchial
  • consolidation
  • groundglass
  • perilobular thickening/irregular thickening of the interlobular septa
  • reverse halo/atoll sign - peripheral conslidation and central ggo

63

Overall most common pattern of ILD in patients with collagen vascular disease

NSIP

64

Most common pattern of ILD in rheumatoid arthritis

UIP

65

Most common pattern of ILD in patients with scleroderma

fibrotic NSIP

pulmonary HTN WITH OR WITHOUT lung disease

66

SLE and ILD

  • fibrotic ILD uncommon in patients with SLE
  • if ILD does occur - NSIP, UIP

67

LIP is most common associated with which collagen vascular disease?

Sjogrens

68

Causes of ALI and ARDS

  • Pulmonary
    • infection - bacterial, viral, fungal (PCP)
    • near-drowning
    • toxic fume inhalation
    • lung contusion
  • Extra-pulmonary
    • systemic sepsis
    • non-thoracic trauma
    • hypertransfusion (TRALI)
    • cardiopulmonary bypass

69

Typical appearance of ALI and ARDS

A gradient

dependent lungs are more dense (areas of more edematous, atelectatic lungs)

but dependent lungs being atelectatic, are protected from barotrauma from high pressure ventilation

70

Breast angiosarcoma

  • 2 types of angiosarcoma:
    • primary - typically affects women at a younger age, usually in the third or fourth decade of life. There are no known risk factors for primary angiosarcoma
    • secondary - older women; related to prior radiation and lymphedema
  • The most common presentation of angiosarcoma of the breast is a palpable, rapidly enlarging, unilateral, painless mass with possible associated bluish discoloration of the overlying skin.
  • The prognosis for angiosarcoma depends upon the tumor grade.

71

Types of centrilobular "stuff"

  • discrete centrilobular nodules
    • silicosis/CWP; siderosis (welder - iron deposition)
    • infection
    • aspiration
  • centrilobular nodules with a tree-in-bud appearance (nodules + linear stuff)
    • infection
    • aspiration
    • centrilobular spread of tumor
  • centrilobular groundglass
    • subacute hypersensitivity pneumonitis
    • respiratory bronchiolitis - RB/RB-ILD
    • infection (viral)
    • follicular bronchiolitis

72

Pulmonary hypertension

vs

Pulmonary arterial hypertension

  • pulmonary hypertension
    • resting meanPAP > 25mmHg
    • of any cause
  • pulmonary arterial hypertension
    • subgroup of pulmonary hypertension with a normal pulmonary venous pressure (wedge pressure < 15mmHg)

73

Pulmonary arterial dilatation and calcification

common in patients with longstanding left to right shunt

74

Pulmonary veno-occlusive disease

PVOD

  • idiopathic
  • associated with
    • collagen vascular dz (scleroderma)
    • bone marrow transplant
    • HIV
    • sarcoid
    • langerhans cell histocytosis
    • smoking
    • cytotoxic drugs and radiation
  • age mean = 40y/o
  • m=f
  • imaging
    • smooth interlobular septal thickening
    • GGO centrilobular nodules
    • mediastinal LAD
    • enlarged right heart chambers

75

Pulmonary capillary hemangiomatosis

PCH

  • idiopathic
  • predisposing factors similar to PVOD
  • HRCT imaging features similar to PVOD
    • except that groundglass centrilobular nodules more common*
  • as PVOD, Px worse than PAH

76

Coronary artery dominance

  • right dominant - 85%
  • left dominant - 7.5%
  • co-dominant - 7.5%
    • RCA --> PDA; LCX --> PLA
    • RCA and LAD both --> PDA's

77

Abnormal proximal course of coronary artery

  • inter-arterial - malignant - sudden death
    • direction compression by aorta and main PA
    • acute angle of the ostium arising from the aorta
    • slit-like ostium (rather than round)
    • intra-mural course - vessel traveling within the adventitia of the aorta - Rx - unroofing
  • other
    • septal
    • pre-pulmonic
    • retro-aortic

78

Abnormal coronary termination

  • coronary-cameral fistula - coronary terminates within a cardiac chamber, often RV
  • coronary-coronary sinus fistula
  • coronary-PA fistula
  • coronary-SVA
  • dilated tortuous coronary arteries

complications

  • right to left shunt
  • steal phenomenon - normal myocardium cannot get enough blood due to shunt

79

Indications for CABG

  • left main disease
  • triple vessel disease
  • medically refractory disease

80

Best to evaluate the mitral and tricuspid valves

  • 4 chamber view
  • spical displacement of the septal leaflet of the tricuspid valve --> Ebstein anomaly

81

Grades of aortic stenosis

  • mild > 1.5cm2
  • moderate 1-1.5cm2
  • severe < 1cm2

82

Mitral valve prolapse

MVP

  • MV bowing into the LA by 2mm in systole
  • common cause of MR

83

Counterpulsation IABP

intra-aortic balloon pump

  • systole - balloon deflates, allowing systemic perfusion
  • diastole - balloon inflates --> increases afterload (EDP) ==> allowing blood to prefuse the coronary arteries
  • position
    • proximal end should be immediately distal to the left subclavian artery

84

Acute papillary muscle rupture

  • acute MI can cause acute rupture of the papillary muscle and/or cordae tendineae
  • acute mitral regurgitation
  • pulmonary edema in the RUL (regurg directed at the right superior pulmonary vein)

85

True vs false LV aneurysm

  • True aneurysm
    • apical/apicoanterior
    • rarely ruptures
    • wide mouth/orifice = neck/body dimension = 1
    • pericardial LGE
  • False aneurysm
    • posterior/posterolateral
    • risk of rupture
    • narrow mouth/orifice = neck/body dimension ratio<1
    • mural LGE

86

Cardiomyopathy on CMR

  • ischemic dilated cardiomyopathy
    • subendocardial or transmural LGE
  • idiopathic dilated cardiomyopathy
    • poor systolic function
    • dilated ventricles and atria
    • no LGE or linear midwall LGE
  • other non-ischemic non-idiopathic CMP
    • alcohol
    • toxins
    • autoimmune
    • endstage viral myocarditis
  •  

87

DDx of arrhythmias and focal systolic dysfunction in a young patient?

  • ARVC/ARVD
  • non-compaction
    • failure of compaction of the endocardium during 5-8 wk of embryogenesis
    • over-trabeculated endocardium --> lacy appearance
    • 2:1 ratio - trabeculated/compacted myocardium
    • apex, inferior and lateral walls
    • NO LGE
    • can co-exist with complex CHD
  • cardiac sarcoidosis

88

Viral myocarditis on CMR

  • T2 edema
  • pericardial effusion
  • usually focal hypokinesis
  • LGE - subepicardial most typical***; can be nodular or transmural
    • DDx for subepicardial LGE
      • viral myocarditis
      • polymyositis
      • sarcoidosis
      • muscular dystrophy

89

Tako Tsubo cardiomyopathy

  • broken heart syndrome
  • reversible
  • severe stress --> catecholamine release --> 
  • middle aged women
  • ECG similar to stress induced ischemia
  • akinesia of the mid to apical LV, preserved contractility at the basal LV --> LV ballooning during systoli (octopus pot)
  • NO LGE

90

What do you think about in a patient with both

systolic and diastolic dysfunction?

  • restrictive/infiltrative cardiomyopathy
  • LV and RV walls can be thick but normal size***
  • marked dilatation of the LA and RA***
  • pleural effusions, pulmonary edema, dilated IVC, hepatic veins and coronary sinus; nutmeg liver
  • need to differentiate from constrictive pericarditis*
    • pericardial thickening and calcification
    • enhanced interventricular dependence with inspiration

91

Cardiac amyloidosis

  • thickened LV and RV
  • diffuse hypokinesis
  • LGE - subepicardial*, transmural, mesocardial
    • can be circumferential
    • RV LGE maybe seen
    • poor opacification of lumen
    • difficulty determining inversion time

92

DDx for circumferential subendocardial LGE

  • 3 vessel CAD with infarcts
  • amyloidosis
  • eosinophilic cardiomyopathy
  • fabry disease
  • post-cardiac transplant cardiomyopathy

93

Cardiac sarcoidosis

  • subepicardial, mesocardial, or transmural
  • nodular, linear, or confluent
  • can be reversible with steroids
  • most common location - LV base, lateral wall, septum
  • pulmonary sarcoidosis almost always present

94

Distinctive pattern of LGE in patients with cardiomyopathy secondary to pulmonary hypertension of any cause

LGE at the RV attachment to the septum both anteriorly and inferiorly - due to chronic mechanical shear injury at the attachment sites from pulmonary hypertension

95

Hypertrophic cardiomyopathy

  • autosomal dominant, variable penetrance
  • Dx - anteroseptal wall at end distole > 12mm
  • obliteration of LV lumen
  • mesocardial LGE
  • thick and abnormally arranged myocardium
    • myocaridal infarct
    • ventricular arrhythmias (Vfib and sudden death)
  • 4 types
    • diffuse
    • septal
    • apical
    • mid-ventricular
  • systolic anterior motion of the septal leaflet of the mitral valve (SAM)
    • seen with septal* hypertrophic cardiomyopathy/obstructive hypertrophic cardiomyopathy (HOCM)
    • LVOT narrowing --> neg pressure --> Venturi effect - anterior motion of the septal leaflet of the mitral valve --> further narrowing the LVOT -- subaortic dephasing jet, eccentric mitral regurg jet

96

Patterns of LGE and Dx

  • subendocardial
    • infarct
    • amyloidosis
    • eosinophilic cardiomyopathy
    • cardiac transplant CMP
    • polymyositis
  • mesocardial
    • hypertrophic cardiomyopathy
    • dilated cardiomyopathy
    • pulmonary hypertension
  • subepicardial
    • viral myocarditis
    • sarcoidosis
  • transmural
    • infarction
    • myocarditis (severe)
    • sarcoid (chronic)
  • patchy
    • sarcoid
    • amyloid
    • myocarditis

97

Types of endoleak

  • type I - at the stent graft ends - proximal or distal
  • type II - retrograde filling from branch artery
  • type III - damaged integrity of the stent graft

NOTE: endovascular stent graft can only be used for type B dissection; if there is type A dissection, elephant trunk procedure needs to be performed - i.e., open repair of type A and hybrid open and endovascular repair of the discending aorta

98

Cervicothoracic sign

and

Thoracoabdominal sign

Cervicothoracic sign

  • if a mediastinal mass is well defined superior to the clavicles, it must be POSTERIOR
  • an anterior mediastinal mass is silhouetted by soft tissues of the neck

Thoracoabdominal sign

  • if a mediastinal mass is well defined / extends below the dome of diaphgram, it must POSTERIOR
  • an anterior mediastinal mass is silhouetted by the diaphgram

99

Hilar overlay sign

and 

Hilar convergence sign

Hilar overlay sign

  • if hilar vessels project through the the mass, the mass must be either anterior or posterior to the hilum

Hilar convergence sign

  • if vessels converge on the hilar opacity, the opacity is likely a pulmonary artery
  • if vessels course through the hilar opacity, the opacity is likely a mediastinal nodule/mass

100

Distribution of endemic fungal infections

  • Histoplasmosis - Mississippi, Ohio, St. Lawrence River Valley --> nodules
  • Blastomycosis - Wisconsin & Minnesota (but entire central and eastern North America) --> consolidation and mass that can cavitate; also bone infection!***
  • Coccidioidomycosis - California, Arizona, San Joaquin Valley --> consolidation coalesce to become nodule
  • Cryptococcosis
    • C. neoformans --> mainly immunosuppressed (opportunistic fungus), HIV 
    • C. gattii --> healthy hosts