Radiological Signs (Shënja Radiologjike) - 7

1
Sllavko K. Kallfa

Prmbledhje Artikujsh nga
Radiopaedia.org
2

vegetable and plant inspired
X-ray signs

aubergine sign..........................................................................f.3
celery stalk metaphysis................................................f.10
celery stalk anterior cruciate ligament.. f.14
chocolate cyst........................................................................... .f.21
coffee bean sign.......................................................................f.31
cottage loaf sign......................................................................f.35
cotton wool appearance of bone.......................f.40
doughnut sign............................................................................f.134
linguine sign.................................................................................f.43
miliary opacities.....................................................................f.47
onion skin periosteal reaction.............................f.62
pancake brain............................................................................f.70
pancake vertebra..................................................................f.73
popcorn calcification.......................................................f.90
salt and pepper skull.......................................................f.108
rice grain calcification..................................................f.110
tree in bud..................................................................................... f.115
waterlily sign..............................................................................f.127

3

Aubergine sign
Dr Henry Knipe and Dr Andrew Dixon et al.
The aubergine sign (also known as egg-plant sign or deformity) is a clinical sign of a fractured
penis. Haemorrhage beyond the tunica albuginea produces swelling and bruising of the penis
simulating the appearance of an aubergine.
References
1. Jack GS, Garraway I, Reznichek R et-al. Current treatment options for penile fractures.
Rev Urol. 2011;6 (3): 114-20. Free text at pubmed - Pubmed citation
Synonyms & Alternative Spellings
Synonyms or Alternative Spelling Include in Listings?
Egg-plant sign
Eggplant sign
Egg-plant deformity
Eggplant deformity

From the case: Aubergine photo (creative commons)
4

Modality: Photo
Pre-operative
Swollen echymosed penis
From the case: Penile fracture
Modality: Photo
5

Coronal T1
Modality: MRI
6

Modality: MRI
7

Coronal T2
Sagittal T2 fat sat
8

Sagittal T2
9

Sagittal T1

10

Celery stalk metaphysis
Dr Jeremy Jones and Radswiki et al.
Celery stalk metaphysis refers to a plain film appearance of the metaphyses in a number of
conditions characterised by longitudinally aligned linear bands of sclerosis. They are seen in:
congenital infections
o congenital rubella
o congenital syphilis
o congenital CMV
osteopathia striata
References
1. Grunebaum M. Pediatric Radiological Signs:. iUniverse, Inc. (2005)
ISBN:0595339603. Read it at Google Books - Find it at Amazon
2. Roche CJ, O'Keeffe DP, Lee WK et-al. Selections from the buffet of food signs in
radiology. Radiographics. 2002;22 (6): 1369-84. Radiographics (full text) -
doi:10.1148/rg.226025521 - Pubmed citation
11

From the
case: Osteopathia striata
12

13

From the
case: Osteopathia striata

14

Celery stalk sign (ACL)
Dr Ian Bickle and Dr Frank Gaillard et al.
The celery stalk sign is a term given to the appearance of the anterior cruciate ligament which
has undergone mucoid degeneration has been likened to that of a celery stalk. Its low signal
longitudinal fibers are separated from eachother by higher signal mucinous material, best seen on
T2 weighted images.
References
1.Papadopoulou P. The celery stalk sign. Radiology. 2007;245 (3): 916-7. Radiology (full
text) - doi:10.1148/radiol.2453050159 - Pubmed citation
Celery stalk Original photo:
Eric Hunt. See case page for further details. Original photo: Eric Hunt - cropped by uploaderPermission is
granted to copy, distribute and/or modify this document under the terms of the GNU Free
Documentation license, Version 1.2 or any later version published by the Free Software Foundation;
with no Invariant Sections, no Front-Cover Texts, and no Back-Cover Texts. A copy of the license is
included in the section entitled "GNU Free Documentation license".
15

PD
Fat Sat PD From the case: Celery stalk sign in ACL mucoid degeneration
Modality: MRI

16

PD
Fat Sat PD
17

18

From the case: Celery stalk sign in ACL mucoid degeneration
Modality: MRI
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Case 2 : Celery stalk sign in ACL mucoid degeneration
20

From the case: Celery stalk sign in ACL mucoid degeneration
Modality: Diagram

21

Endometrioma
Dr Yuranga Weerakkody and Dr Jeremy Jones et al.
An endometrioma (also known as a chocolate cyst or endeometriotic cyst) is a localised form
of endometriosis (usually within the ovary).
Epidemiology
It affects women of reproductive age.
Pathology
It contains dark degenerated blood products following repeated cyclical haemorrhage. The cysts
may be up to 20 cm in size although they are usually smaller (2-5cm)
Location
Typical locations include
ovaries : ~ 75%
anterior / posterior cul-de-sac : ~ 70 %
posterior broad ligament : ~ 50%
uterosacral ligaments : ~ 35%
uterus : ~ 10 %
colon : ~ 5%
Radiographic features
Plain film
Not usually helpful in diagnosis. ~ 10% of endometriomas can calcify.
Ultrasound
In the typical situation there is acoustic enhancement with diffuse homogenous low-level internal
echoes as a result of the haemorrhagic debris. This appearance occurs in 95% of cases and is
considered the classic finding on ultrasound examination. Features of multi-locularity and hyper-
echoic wall foci may be present. Anechoic cysts may occur, but they are rare.
MRI
Signal characteristics vary according to the age of any complicating haemorrhage
6
.
T1 - typically, lesions appear hyper-intense while acute haemorrhage occasionally
appears hypo-intense
22

T2 -
o typically hypo-intense owing to the presence of deoxyhaemoglobin and
methaemoglobin
o old haemorrhage occasionally appears hyper-intense.
A shading sign
3
may be seen and is very suggestive of an endometrioma.
Treatment and prognosis
Although endometrioma is a usually a benign entity, there is an approximately 1% rate of
malignant transformation
4
. It is seen mostly in women > 40 years after several years of latency,
with endometriomas larger than 9cm
4-5
. Malignant transformation is uncommon in masses <
6cm.
If not surgically excised, follow-up should be at least yearly
4
. GnRH agonists may be used for
medical management.
Differential diagnosis
General imaging differential considerations include
haemorrhagic ovarian cyst
ovarian dermoid cyst - will show fat suppression on fat suppressed sequences on MRI
cystic neoplasm
tubo-ovarian abscess
References
1. Lee SI. Radiological reasoning: imaging characterization of bilateral adnexal masses.
AJR Am J Roentgenol. 2006;187 (3): S460-6. doi:10.2214/AJR.05.2226 - Pubmed
citation
2. Lee, Susanna I. Imaging Evaluation of Adnexal Masses: Self-Assessment Module
American Journal of Roentgenology. 187 (3_Supplement): S457.
doi:10.2214/AJR.06.0785 -
3. Glastonbury CM. The shading sign. Radiology. 2002;224 (1): 199-201. Radiology (full
text) - doi:10.1148/radiol.2241010361 - Pubmed citation
4. Levine D, Brown DL, Andreotti RF et-al. Management of asymptomatic ovarian and
other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus
Conference Statement. Radiology. 2010;256 (3): 943-54. doi:10.1148/radiol.10100213 -
Pubmed citation
5. Kobayashi H. Ovarian cancer in endometriosis: epidemiology, natural history, and
clinical diagnosis. Int. J. Clin. Oncol. 2009;14 (5): 378-82. doi:10.1007/s10147-009-
0931-2 - Pubmed citation
6. Umaria N, Olliff JF. Imaging features of pelvic endometriosis. Br J Radiol. 2001;74
(882): 556-62. Br J Radiol (full text) - Pubmed citation
23

Chocolate cyst
Chocolate cysts
Endometriomas
Endometriotic cyst
Endometriotic cysts
Endometriomata

24

T2
From the case: Endometrioma, fibroid and cyst
Modality: MRI
25

From the
case: Endometriosis
26

From the case: Endometriosis
27

From the case: Endometrioma
Modality: Ultrasound Case 7: chocolate cyst in right adnexa
28

Modality: MRI
29

Axial
T1
From the case: Ovarian endometrioma
Modality: MRI
30

T1 C+ fat sat
Modality: MR

31

Coffee-bean sign
Dr Frank Gaillard et al.
The coffee-bean sign (also known as bent inner tube sign
4
) is a sign on an abdominal plain
film of a sigmoid volvulus although some authors have also used the term to refer to closed loop
small bowel obstructions. This contrasts to a kidney bean sign which is seen with a caecal
volvulus.
This thick 'inner wall' represents the double wall thickness of opposed loops of bowel, with
thinner outer walls due single thickness.
References
1. Roche Clare J., David P. OKeeffe, W. Kit Lee et al. Selections from the Buffet of
Food Signs in Radiology1. Radiographics 22, no. 6 (November 2002): 1369-1384.
doi:10.1148/rg.226025521.
2. Burgener Francis A. and Martti Kormano. Differential Diagnosis in Conventional
Gastrointestinal Radiology. Thieme, 1997. ISBN: 0865776768, 9780865776760.
3. Monson John R. T., Graeme Duthie and Kevin O'Malley. Surgical emergencies.
Wiley-Blackwell, 1999. ISBN: 0632050470, 9780632050475.
4. Feldman Deborah. The Coffee Bean Sign1. Radiology 216, no. 1 (July 2000): 178-
179.
Coffee bean sign
Bent inner tube sign

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Coffee Bean Roasted Coffee
beanPhoto by: http://et.wikipedia.org/wiki/Kasutaja:BoyOriginal file:
http://commons.wikimedia.org/wiki/File:Kohvioad_suurelt.jpgPermission is granted to copy, distribute
and/or modify this document under the terms of the GNU Free Documentation License, Version 1.2 or
any later version published by the Free Software Foundation; with no Invariant Sections, no Front-Cover
Texts, and no Back-Cover Texts. A copy of the license is included in the section entitled "GNU Free
Documentation License".
33

Coffee bean sign. From
the case: Sigmoid volvulus
Modality: X-ray
34

Sigmoid Volvulus

35

Cottage loaf sign
Dr Jeremy Jones and Dr Katarzyna Skorupka et al.
A cottage loaf sign occurs as a result of a right-sided diaphragmatic rupture occurs with partial
herniation of the liver through the diaphragmatic defect.The herniated component is separated by
a waist at the diaphragm from the larger intra-abdominal component. This shape is reminiscent
of a cottage loaf, a particular shape of bread in which larger and smaller roughly spherical balls
are squashed together, forming a cottage shape
2
.
References
1. Roche Clare J., David P. OKeeffe, W. Kit Lee et al. Selections from the Buffet of
Food Signs in Radiology1. Radiographics 22, no. 6 (November 2002): 1369-1384.
doi:10.1148/rg.226025521.
Cottage loaf sign in diaphragmatic rupture

36

Cottage loaf Photo courtesy
of: mer de glace original file. CC BY 2.0
37

From
the case: Cottage loaf sign - diaphragmatic rupture Sagittal view

Modality: CT
38

Axial view
39

Coronal view
From the case: Cottage loaf sign - diaphragmatic rupture
Modality: CT
40

Cotton wool appearance of bone
Dr Frank Gaillard et al.
The cotton wool appearance is a plain film sign of Paget's disease and results from thickened,
disorganized trabeculae which lead to areas of sclerosis in a previously lucent area of bone -
typically the skull. These sclerotic patches are poorly defined and fluffy.

References
1. Smith SE, Murphey MD, Motamedi K et-al. From the archives of the AFIP. Radiologic spectrum
of Paget disease of bone and its complications with pathologic correlation. Radiographics.
2002;22 (5): 1191-216. Radiographics (full text) - Pubmed citation
2. Richards PS, Bargiota A, Corrall RJ. Paget's disease causing an Arnold-Chiari Type 1
malformation: radiographic findings. AJR Am J Roentgenol. 2001;176 (3): 816-7.
doi:10.2214/ajr.176.3.1760816 - Pubmed citation
Cotton wool bone
The Cotton wool appearance of bone

41

Cotton on a cotton plant.
Cotton wool appearance of bone is one of the many signs of Paget's disease Original file here.
42

From the case: Paget's disease - skull
Modality: X-ray

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Linguine sign
Dr Laughlin Dawes et al.
The Linguine sign is one of the imaging signs of intracapsular rupture of a breast implant.
After implantation of a silicone or saline breast implant, a fibrous capsule (scar) forms around
the implant shell. In an intracapsular rupture, the contents of the implant are contained by the
fibrous scar, while the shell appears as a group of wavy lines. This has been termed the "linguine
sign" and has been most commonly described with MR imaging. Here, the same findings are
seen on CT imaging in a patient with bilateral ruptured saline implants.
References
1. Safvi A. Linguine sign. Radiology. 2000;216 (3): 838-9. Radiology (full text) -
Pubmed citation
Linguini sign

44

Fettuccine with pesto Not
quite linguine but close Photo: Cliff HutsonThis file (original wikimedia commons) is licensed under
Creative Commons Attribution 2.5 LicenseIn short: you are free to distribute and modify the file as long
as you attribute its author(s) or licensor(s). Photograph : fettuccine with pesto
fter implantation of a
silicone or saline breast implant, a fibrous capsule (scar) forms around the implant shell. In an
45

intracapsular rupture the contents of the implant are contained by the fibrous scar while the shell
appears as a group of wavy lines. This has been termed the Linguine sign and has been most
commonly described with MR imaging. Here, the same findings are seen on CT imaging in a
patient with bilateral ruptured saline implants. Reference Safvi A. Linguine Sign. Radiology
2000; 216: 838-839. Credit Dr Evan Stein Case 1 : CT of intracapsular breast implant rupture

From the case: Intracapsular breast implant rupture - linguine sign
Modality: MR
46

From the case: Intracapsular breast implant rupture - linguine sign
Modality: MR
47

Miliary opacities
Dr Henry Knipe and Dr Frank Gaillard et al.
The term miliary opacities refers to innumerable, small 1-4 mm pulmonary nodules scattered
throughout the lungs. It is useful to divide these patients into those who are febrile and those who
are not.
Additionally, some miliary opacities are very dense, narrowing the differential - see multiple
small hyperdense pulmonary nodules.
Pathology
Aetiology
The causes can be broadly sub grouped dependent on whether or not the patient is febrile.
Afebrile
infection
o tuberculosis (often febrile but may be afebrile) - miliary tuberculosis
o fungal (often febrile)
immunocompromised or elderly patients may be afebrile
o healed varicella pneumonia
metastases - miliary metastases
o thyroid carcinoma
o renal cell carcinoma
o breast carcinoma
o malignant melanoma
o pancreatic neoplasms
48

o osteosarcoma
o trophoblastic disease
sarcoidosis
pneumoconioses
o silicosis
o coal workers pneumoconiosis
pulmonary haemosiderosis
hypersensitivity pneumonitis
Langerhans cell histiocytosis (LCH)
multifocal micronodular pneumocyte hyperplasia (MMPH)
pulmonary alveolar proteinosis
o small acinar opacities can mimic a miliary pattern
6

Febrile
infection
o tuberculosis
o fungal
o viral pneumonitis
o nocardosis
o salmonella
hypersensitivity pneumonitis (mild fever if any)
Etymology
The term miliary stems from millet seed, a term used to describe a group of small-
seeded species of cereal crops or grains, widely grown around the world for food and fodder
5
.
References
1. Umeoka S, Koyama T, Miki Y et-al. Pictorial review of tuberous sclerosis in various organs.
Radiographics. 28 (7): e32. doi:10.1148/rg.e32 - Pubmed citation
2. Mccook TA, Kirks DR, Merten DF et-al. Pulmonary alveolar proteinosis in children. AJR Am J
Roentgenol. 1981;137 (5): 1023-7. AJR Am J Roentgenol (abstract) - Pubmed citation
3. Collins J, Stern EJ. Chest radiology, the essentials. Lippincott Williams & Wilkins. (2007)
4. Roche CJ, O'keeffe DP, Lee WK et-al. Selections from the buffet of food signs in radiology.
Radiographics. 22 (6): 1369-84. doi:10.1148/rg.226025521 - Pubmed citation
5. Andreu J, Maulen S, Pallisa E et-al. Miliary lung disease revisited. Curr Probl Diagn Radiol.
2003;31 (5): 189-97. Pubmed citation
6. Voloudaki AE, Tritou IN, Magkanas EG et-al. HRCT in miliary lung disease. Acta Radiol. 1999;40
(4): 451-6. Pubmed citation
7. McGuinness G, Naidich DP, Jagirdar J et-al. High resolution CT findings in miliary lung disease.
J Comput Assist Tomogr. 1992;16 (3): 384-90. Pubmed citation
49

Differential of miliary pulmonary opacities
Miliary nodules
Miliary nodule
Miliary opacity

Pearl millet Pearl millet that was harvested by combine, before cleaning for food use. Image courtesy of
50

J. Wilson, USDA-ARS. Please see case description page for licence and original file information. From
the case: Pearl millet
Modality: Phot
From the case: Miliary tuberculosis
Modality: X-ray
51

From the case:
Miliary tuberculosis
Modality: X-ray
52

Miliary tuberculosis of the lung Image courtesy of Yale Rosen, M.D.. Please see case description page for
licence and original file information. From the case: Miliary tuberculosis - pathology
Modality: Photo

53

Miliary tuberculosis of the spleen Image courtesy of Yale Rosen, M.D.. Please see case description page
for licence and original file information. From the case: Miliary tuberculosis - pathology
Modality: Photo
54

Miliary pattern
55

This patient had had a
thyroid malignancy treated with surgical excision and radioactive iodine. This scan was obtained as
followup. Note the innumerable miliary metastases. Miliary metastases Thyroid neoplasms Case 3:
thyroid cancer metastases
56

From the case: Miliary
tuberculosis - CT
Modality: CT
57

From the case: Papillary
thyroid carcinoma with miliary metastases
Modality: CT
58

From the case: Papillary thyroid carcinoma with miliary metastases
59

Modality: CT From the
case: Non-small cell lung cancer with miliary metastases
Modality: CT

60

From the case: Miliary metastases from papillary thyroid cancer
Modality: CT
61

From the
case: Miliary tuberculosis
Modality: X-ray
62

Multilayered periosteal reaction
Dr Behrang Amini et al.
A multilayered periosteal reaction, also known as a lamellated or onion skin periosteal
reaction, demonstrates multiple concentric parallel layers of new bone adjacent to the cortex,
reminiscent of the layers on an onion. The layers are thought to be the result of periods of
variable growth
2
.
It can be seen with
osteosarcoma
acute osteomyelitis
Ewing sarcoma
Langerhans cell histiocytosis (LCH)
References
1- Wenaden AE, Szyszko TA, Saifuddin A. Imaging of periosteal reactions associated with focal
lesions of bone. Clin Radiol. 2005;60 (4): 439-56. doi:10.1016/j.crad.2004.08.017 - Pubmed
citation
2- Roche CJ, O'Keeffe DP, Lee WK et-al. Selections from the buffet of food signs in radiology.
Radiographics. 22 (6): 1369-84. doi:10.1148/rg.226025521 - Pubmed citation
Onion skin periosteal reaction
Lamellated periosteal reaction

63

Spanish onion Spanish onion
demonstrating alternating layers reminiscent of onion-skin periosteal reaction. Photo credit: Frank
Gaillard Photograph - onion
64

From the case: Ewing sarcoma - distal femur
Modality: X-ray
65

66

Ewing sarcoma - Onion skin From the case: Ewing sarcoma - distal femur
Modality: X-ray
67

LCH periosteal
reaction From the case: Langerhans cell histiocytosis
Modality: X-ray

68

LCH From the
case: Langerhans cell histiocytosis
Modality: X-ray
69

From the case: Langerhans cell histiocytosis
Modality: MRI

70

Pancake brain
Dr Yuranga Weerakkody and Dr Praveen Jha et al.
Pancake brain, is the classical sign of alobar holoprosencephaly. It is due to fusion of cerebral
hemisphere leaving a single ventricle in its center. It is the most severe form of
holoprosencephaly. It is associated with multiple facial abnormality
References
1. Chavhan GB, Shroff MM. Twenty classic signs in neuroradiology: A pictorial essay.
Indian J Radiol Imaging. 19 (2): 135-45. doi:10.4103/0971-3026.50835 - Free text at
pubmed - Pubmed citation
2. Osborn AG, Salzman KL, Barkovich AJ. Diagnostic imaging, Brain. Lippincott
Williams & Wilkins. (2009) ISBN:1931884722. Read it at Google Books - Find it at
Amazon
71

From the case: Alobar holoprosencephaly
Modality: CT
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From the case: Alobar holoprosencephaly
Modality: CT

73

Vertebra plana
Dr Jeremy Jones and Dr Katarzyna Skorupka et al.
A vertebra plana or pancake vertebra is the term given when a vertebral body has lost almost
its entire height anteriorly and posteriorly, representing a very advanced crush fracture. It can
occur with a variety of settings, including:
trauma
osteoporosis
eosinophilic granuloma (LCH)
osteogenesis imperfecta
leukaemia
vertebral metastases
multiple myeloma
lymphoma
osteomyelitis
spinal tuberculosis
2

vertebral haemangioma
References
1. Roche CJ, O'keeffe DP, Lee WK et-al. Selections from the buffet of food signs in
radiology. Radiographics. 22 (6): 1369-84. doi:10.1148/rg.226025521 - Pubmed citation
2. Moorthy S, Prabhu NK. Spectrum of MR imaging findings in spinal tuberculosis. AJR
Am J Roentgenol. 2002;179 (4): 979-83. AJR Am J Roentgenol (full text) - Pubmed
citation
Silver dollar sign
Pancake vertebra
Coin-on-edge sign

74

T2
T2 Sag From the case: Spinal lymphoma
Modality: MRI Case 1 - in lymphoma

75

T1
T1 Cor
From the case: Spinal lymphoma Case 1 - in lymphoma
Modality: MRI
76

From the case: Lymphoma (NHL)
Modality: X-ray Case 2 - with lymphoma : NHL
77

From the case: Lymphoma (NHL)
Modality: X-ray
Case 2 - with lymphoma : NHL
78

From the case: Vertebra plana
79

80

81

82

From the case: Vertebra plana
83

From the case:
Vertebra plana
Modality: X-ray
84

From the case:
Vertebra plana
Modality: X-ray
85

From the case: Langerhans cell histiocytosis with vertebra plana
86

87

88

From the case: Langerhans cell histiocytosis with vertebra plana
89

From the case: Langerhans cell
histiocytosis
Modality: X-ray

90

Popcorn calcification
Dr Yuranga Weerakkody and Dr Frank Gaillard et al.
Popcorn calcification refers to amorphous calcifications often with rings and arcs that resemble
popped corn kernels. This type of calcification may be seen in many radiological settings
including
1
:
chondroid lesions (e.g enchondroma, chondrosarcoma)
fibrous dysplasia
pulmonary hamartomas
degenerating fibroadenomas of the breast - see popcorn calcification in the breast
calcified uterine fibroid
3

They are also seen in metaphyses and epiphyses of long bones of children with osteogenesis
imperfecta. In this case they represent scalloped lucencies with sclerotic margins
2
.
References
1. Roche CJ, O'keeffe DP, Lee WK et-al. Selections from the buffet of food signs in
radiology. Radiographics. 22 (6): 1369-84. doi:10.1148/rg.226025521 - Pubmed citation
2. Goldman AB, Davidson D, Pavlov H et-al. "Popcorn" calcifications: a prognostic sign
in osteogenesis imperfecta. Radiology. 1980;136 (2): 351-8. Radiology (abstract) -
Pubmed citation
3. . Radiology Fundamentals. Springer. (2012) ISBN:1461409446. Read it at Google
Books - Find it at Amazon
Popcorn calcifications
Pop-corn calcifications
Pop-corn calcification

91

Popcorn Image of popcorn to
illustrate popcorn calcification article. Author: http://en.wikipedia.org/wiki/User:Fir0002Original file:
http://commons.wikimedia.org/wiki/File:Popcorn02.jpgLicensePermission is granted to copy, distribute
and/or modify this document under the terms of the GNU Free Documentation License, Version 1.2 only
as published by the Free Software Foundation; with no Invariant Sections, no Front-Cover Texts, and no
Back-Cover Texts. A copy of the license is included in the section entitled "Text of the GNU Free
Documentation License." Photograph popcorns
92

From the case: Enchondroma-
CT findings
Modality: CT

93

94

From the case: Enchondroma- CT findings
Modality: CT

95

From the case: Chondrosarcoma - proximal femur
Modality: Diagram
96

From the case: Chondrosarcoma - proximal femur
Modality: Diagram
97

From the case: Osteogenesis imperfecta
Modality: X-ray
98

From the case: Osteogenesis imperfecta
Modality: X-ray
99

From the case: Involuted fibroadenoma of breast
Modality: Mammography
100

101

102

From the case: Involuted fibroadenoma of breast
Modality: Mammography
103

From the case: Uterine fibroids - calcified
Modality: CT
104

105

106

107

From the case: Uterine fibroids - calcified
Modality: CT

108

Salt and pepper sign - skull
Dr MT Niknejad et al.
Salt and pepper sign of the calvaria refers to multiple tiny hyperlucent areas in the skull vault
caused by resorption of trabecular bone in hyperparathyroidism.
There is loss of definition between the inner and outer tables of the skull and a ground-glass
appearance as well as spotty deossification.
References
2. Brant WE, Helms CA. Fundamentals of diagnostic radiology. Lippincott Williams &
Wilkins. (2007) ISBN:0781765188. Read it at Google Books - Find it at Amazon
3. Dhnert WF. Radiology Review Manual. Lippincott Williams & Wilkins. (2011)
Salt and pepper skull
Salt and pepper appearance
Salt and pepper calvaria
Salt and pepper sign of the skull
Salt and pepper sign of the calvaria
Pepper pot skull

109

From the case: Salt and pepper sign - skull
Modality: X-ray

110

Rice grain calcification
Dr Ayush Goel and Dr MT Niknejad et al.
The rice grain calcification is characteristic of infection with Taenia solium (cysticercosis);
when the inflammatory response of the host kills the larval cysts (cysticerci), they undergo
granulomatous change and become calcified.
Ovoid flecks of calcification resembling grains of rice in the soft tissues. The calcifications
parallel the long axis of the muscle.
References
2. Brant WE, Helms CA. Fundamentals of diagnostic radiology. Lippincott Williams &
Wilkins. (2007) ISBN:0781765188. Read it at Google Books - Find it at Amazon
3. edited by Gagandeep Singh and Sudesh Prabhakar. Taenia solium cysticercosis
[electronic resource]. CABI. (2002) ISBN:0851998399. Read it at Google Books - Find it
at Amazon
111

From the case:
Cysticercosis - soft tissue
Modality: X-ray
112

Soft tissue
cysticercosis (lateral knee)
113

From
the case: Rice grain calcification- cysticercosis
Modality: X-ray
114

From
the case: Rice grain calcification- cysticercosis
Modality: X-ray

115

Tree-in-bud sign
Dr Henry Knipe and Dr Achint Singh et al.
The tree-in-bud sign describes the CT appearance of multiple areas of centrilobular nodules
with a linear branching pattern. Although initially described in patients with endobronchial
tuberculosis, it is now recognised in a large number of conditions.
Pathology
Pathogenesis
The tree-in-bud sign occurs as a result of a number of processes, although often they co-exist in
the same condition:
bronchioles filled with pus or inflammatory exudate
o e.g. pulmonary tuberculosis, aspiration bronchopneumonia
bronchiolitis - thickening of bronchiolar walls and bronchovascular bundle
o e.g. cytomegalovirus pneumonitis, obliterative bronchiolitis
bronchiectasis with mucus plugging
o e.g. cystic fibrosis
tumour emboli to centrilobular arteries (or carcinomatous endarteritis)
3

o e.g. breast cancer, stomach cancer
bronchovascular interstitial infiltration
o e.g. lymphoma, leukaemia
4-5

Aetiology
The tree-in-bud appearance represents endobronchial spread of infection. Causes include
infective bronchiolitis
o pulmonary tuberculosis, e.g. Mycobacterium tuberculosis infection
o atypical mycobacterial infections, e.g Mycobacterium avium (MAIC)
o viral pneunomia
o fungal pneumonia, e.g. aspergillus
o allergic bronchopulmonary aspergillosis (ABPA)
o pneumocystis pneumonia
congenital
o cystic fibrosis
o immotile cilia syndrome, e.g. Kartagener syndrome
o yellow nail syndrome
connective tissue disorders
o rheumatoid arthritis (RA)
o Sjogren syndrome
bronchial
o obliterative (constrictive) bronchiolitis
116

o diffuse panbronchiolitis
o follicular bronchiolitis
neoplastic
o bronchioloalveolar cell carcinoma
o primary pulmonary lymphoma
5

o chronic lymphocytic leukaemia
4

Tree-in-bud sign is not visible on plain film
2
and is best seen on HRCT. Typically they are
composed of centrilobular nodules (which are usually 2-4mm in diameter and peripheral, within
5 mm of pleural surface) connected by opacified or thickened branching structures extending
proximally (representing the dilated and opacified bronchioles)
1-3
.
References
1. Gosset N, Bankier AA, Eisenberg RL. Tree-in-bud pattern. AJR Am J Roentgenol.
2009;193 (6): W472-7. doi:10.2214/AJR.09.3401 - Pubmed citation
2. Eisenhuber E. The tree-in-bud sign. Radiology. 2002;222 (3): 771-2.
doi:10.1148/radiol.2223991980 - Pubmed citation
3. Rossi SE, Franquet T, Volpacchio M et-al. Tree-in-bud pattern at thin-section CT of
the lungs: radiologic-pathologic overview. Radiographics. 25 (3): 789-801.
4. Fretz, Gregory; Krause, Martin; Thurnheer, Robert. Chronic lymphocytic leukaemia,
dyspnoea and tree-in-bud sign on chest CT scan BMJ Case Reports. 2009
doi:10.1136/bcr.03.2009.1672
5. Hwang JH, Kim TS, Han J et-al. Primary lymphoma of the lung simulating
bronchiolitis: radiologic findings. AJR Am J Roentgenol. 1998;170 (1): 220-1. AJR Am J
Roentgenol (citation) - Pubmed citation
Tree-in-Bud Sign
Differential diagnosis for Tree-in-Bud opacities
Tree-in-Bud opacities
Tree-in-Bud opacities
Tree in bud appearance
Tree in bud changes
Tree in bud appearances
Tree-in-Bud opacity
Tree-in-bud pattern

117

"Tree in bud" sign
118

From the case: Tree in bud sign
Modality: CT
119

From the case: Tree-in-bud sign and bronchiectasis
Modality: CT
120

Modality: CT
121

From the case: Infectious bronchiolitis with extensive tree-in-bud pattern
Modality: CT
122

Modality: CT
123

From the case: Tree-in-
bud appearance - endobronchial spreading of pulmonary tuberculosis
Modality: CT
124

Modality: CT
125

126

Modality: CT

127

Water-lily sign
Dr Henry Knipe and Dr Frank Gaillard et al.
The water-lily sign is seen in hydatid infections when there is detachment of the endocyst
membrane which results in floating membranes within the pericyst that mimic the appearance of
a water lily.
It may be seen on ultrasound and CT-scan. It is classically described on plain films (mainly chest
X-ray) when the collapsed membranes are calcified.
References
1. Kerimoglu U, Kapicioglu S, Emlik D et-al. Case 161: hydatid disease with water lily
sign manifesting as a soft-tissue mass in the calf of a child. Radiology. 2010;256 (3):
1007-10. doi:10.1148/radiol.10081066 - Pubmed citation
2. Gwee A, Chinnappan M, Connell TG et-al. The Water Lily Sign. J. Pediatr. 2013;: .
doi:10.1016/j.jpeds.2012.12.068 - Pubmed citation
3. Gezgin S, Sanal HT. "Water-lily sign" as a rare finding of spinal hydatidosis. Spine J.
2012;12 (6): e5-7. doi:10.1016/j.spinee.2012.05.013 - Pubmed citation
4. Kerimoglu U, Kapicioglu S, Emlik D et-al. Case 161: hydatid disease with water lily
sign manifesting as a soft-tissue mass in the calf of a child. Radiology. 2010;256 (3):
1007-10. Radiology (full text) - doi:10.1148/radiol.10081066 - Pubmed citation
Water lilly sign
Waterlily sign
Water-lilly sign
Water lily

128

From the case: Pulmonary hydatid cyst
Modality: X-ray
129

From the case: Pulmonary hydatid cyst
Modality: X-ray
130

From the case: Pulmonary hydatid cyst Modality: CT

131

132

From the case: Hepatic hydatid cyst
Modality: Ultrasound
133

img2
Detachment of Endocyst (Laminated membrane) (red color) from Pericyst (green color) . Note the
multiple echogenic foci (yellow arrows) due to hydatid sand. From the case: Hepatic hydatid cyst

134

Doughnut sign on bone scan
Dr Yuranga Weerakkody and Dr Mohammad Taghi Niknejad et al.
The doughnut sign refers to bone scan pattern which demonstrate increased uptake peripherally
with a photopenic center. This appearance maybe seen in a number of cystic lesions include :
aneurysmal bone cyst
giant cell tumour
simple bone cyst
The doughnut sign isn't specific sign and also can be present in chondrosarcoma, telangiectatic
osteosarcoma and any other lesions which shows aneurysmal bone cyst changes within.
References
1 - Imaging of Bone Tumors and Tumor Like Lesions. Springer. (2009)
2 - Murphey MD, Nomikos GC, Flemming DJ et-al. From the archives of AFIP. Imaging
of giant cell tumor and giant cell reparative granuloma of bone: radiologic-pathologic
correlation. Radiographics. 2001;21 (5): 1283-309. Radiographics (full text) - Pubmed
citation
3 - Seven B, Varoglu E, Alper F et-al. Aneurysmal bone cyst of the second metatarsal:
three-phase bone scan findings and radiological assessment. Hell J Nucl Med. 2009;11
(3): 189-90. Pubmed citation
Doughnut sign of bone
Donut sign on bone scan

135

innish doughnuts being fried
Munkkeja (Finnish for doughnuts) being deep fried. To be used to illustrate various doughnut
signs:doughnut sign of intussusceptionPhoto taken by Muu-karhuPermission is granted to copy,
distribute and/or modify this document under the terms of the GNU Free Documentation License,
Version 1.2 or any later version published by the Free Software Foundation; with no Invariant Sections,
no Front-Cover Texts, and no Back-Cover Texts. A copy of the license is included in the section entitled
"GNU Free Documentation License".If this file is eligible for relicensing, it may also be used under the
Creative Commons Attribution-ShareAlike 3.0 license.Original
file: http://commons.wikimedia.org/wiki/File:Munkinpaisto.jpg
136

rom the case: Aneurysmal bone cyst (ABC)
Modality: Nuclear medicine

Target sign of intussusception
Dr Ian Bickle and Dr Frank Gaillard et al.
There are many target signs, one of which the the appearance of intestinal intussusception, also
known as the doughnut sign.
The appearance is generated by concentric alternating echogenic and hypoechogenic bands. The
echogenic bands are formed by mucosa and muscularis whereas the submucosa is responsible fo
the hypoechoic bands.
137

See also
pseudokidney of intussusception
doughnut sign on bone scan
References
1. Del-Pozo G, Albillos JC, Tejedor D. Intussusception: US findings with pathologic correlation-the
crescent-in-doughnut sign. Radiology. 1996;199 (3): 688-92. Radiology (abstract) - Pubmed
citation
2. Roche CJ, O'Keeffe DP, Lee WK et-al. Selections from the buffet of food signs in radiology.
Radiographics. 2002;22 (6): 1369-84. Radiographics (full text) - doi:10.1148/rg.226025521 -
Pubmed citation
Target sign of intussuception
Doughnut sign of intussusception
Donut sign of intussusception
Bulls eye sign
138

139

140

From the case: Intussusception

141

Intussusception
invagination of a bowel segment into distal segment in right iliac region in a paediatric patient
with acute abdomen

142

From the case: Intussusception due a small bowel lymphoma
Modality: Annotated image
143

From the case: Intussusception due a small bowel lymphoma
Modality: Annotated image
144

From the case: Intussusception

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What conditions can cause celery stalk appearance of the metaphyses?

What is the doughnut sign and what conditions can it refer to?

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