RADIOLOGY QUICK REVISION NOTES

GENERAL RADIOLOGY Effects of radiation

STOCHASTIC “chance” DETERMINISTIC
Mechanism of action of ionizing
No threshold Threshold exists
radiation
Probability increases with Severity increases with
1. DNA damage -- ds DNA damage (M/C)Q dose dose
2. Free radicals damage Delayed Immediate
Cancer, Genetic mutations Skin erythema (M/C),
“All or none” Cataracts, epilation.

Ionising radiation
RAYS PARTICULATE MATTER
Cosmic rays γ-rays X-rays Radiotherapy
•• a particles
•• Background •• Nuclear medicine scan •• Radiographs •• β particles
radiationQ - Scintigraphy •• Fluoroscopy •• Neutrons
- SPECT •• DSA •• Protons
•• PET •• CT

Modalities Using Ionising Radiation

NON-IONISINGQ IONISING : X-RAYS IONISING : GAMMA RAYS
- USG - Radiography - Scintigraphy
- MRI - CT scan - SPECT
- Thermography - Fluoroscopy / Contrast study - PET scan
eg; HSG/ ERCP/ IVP
- DEXA scan

Radiation Unit
Entity SI Unit Conventional unit
Radioactivity Becquerel / Disintegration per Curie
second (dps) 1 Ci = 3.7 x 1010 Bq
Exposure Coulomb/Kg Roentgen
(basically means ionization)
Absorbed dose GrayQ Rad
Air kerma 1 Gy = 100 Rad
(ABG RAD)
Equivalent Sievert (Sv) Rem
1 Sv = 100 Rem
Effective dose Sv Rem
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Radiology

Maximum permissible dose according to AERB

(Atomic Energy Regulatory Board)
Occupational Exposure Public Exposure
Overall 20 mSv/year averaged over 5 consecutive years Q 1 mSv / year
- 30 mSv in any single year
Lens 150 mSv in a year 15 mSv / year
Skin, Extremities 500 mSv in a year 50 mSv / year
Pregnant female 2 mSv / yearQ 1 mSv / year
Fetus 1 mSv / year 0.5 mSv / year

Thermoluminiscent Dosimeter / TLD BADGE

•• Made up of:- CaSO4: Dysprosium (LiF can also be used)
•• 3 monthly
•• Worn below the lead apron at the level of the chest.Q

LEAD Apron
•• Minimum thickness: 0.25 mmQ
•• M/C thickness used: 0.5 mm

Basics of imaging modalities -

Modality X-ray CT MRI USG

Ionising Radiation √ √ x X
Overall Status Initial IOC: IOC: Initial / Best
investigation; - Acute - Brain/ Spine / - GB
- Air haemorrhage Nerve - Fluid/cyst
- Ortho - Foreign body
- Ca2+
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Thumb rules: X-ray

EMERGENCIES – AIR MSK FOREIGN BODY LINES & TUBES
- Pneumothorax - Fracture Initial - X-ray - Best – X-rayQ
- Pneumoperitoneum - Bone Tumor IOC-NCCTQ Exception:-
- Intestinal obstruction - Arthritis CI-MRIQ ET Tube → ET Co2

Thumb rules: CT
IOC → NCCT
CALCIUM BONE FOREIGN BODY ACUTE HEMORRHAGE AIR

- Intracranial Ca2+ - Fracture - IOC: Head traumaQ Lung pathology

- Renal / Ureteric except- C/I → MRI - Initial: StrokeQ
stones HRCT – IOC: ILD,
stress fracture Q

- Salivary stonesQ Bronchiectasis,

except- COVID-19Q
- Osteoid osteoma
Gall stone (USG)

Periventricular calcification: Left ureteric calculus Left intraocular Right acute EDH
Congenital CMV metalic foreign body left acute SDH
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Radiology

NCCT: CECT: CT ANGIOGRAPHY:

-IOC for head, spine trauma (Q) Lung Tumors Aortic dissectionQ
-IOC for acute SAH (Q) Renal Tumors Aortic aneurysmQ
-IOC for intracranial calcification (Q) Pancreatic Carcinoma Pulmonary embolism
-IOC for renal calculi Liver Tumors Mesenteric ischemia
-IOC FOR IOFB Mediastinal Masses Sequestration
-IOC for bone cortex Acute Pancreatitis
-Initial Investigation in stroke (Q)

MRI
Sequences of MRI
•• Since bones are black, it is MRI
•• Once recognized that it is MRI, look at the CSF.
•• CSF is white, it is T2 (Water, Fluid is white on T2: WW2)

T1 T2 FLAIR
- Grey matter: Grey - Grey matter: White - CSF in the ventricles is suppressed
- White matter: White - White matter: Grey - Periventricular white matter is hyperintense
- T1 follows the anatomy - FLAIR helps to pick oedema in the
periventricular area
- Helps in demyelinating lesions as in Multiple
sclerosis (Dawson fingers)

STIR (Short Tau Inversion Sequence MRI)

•• T2 WI MRI in which fat signal is suppressed
•• IOC → Bone marrow oedema -- Osteomyelitis, Sacroiliitis, Stress fracture
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SWI (Susceptibility Weighted Imaging)Q

•• Susceptibility artefact: Substances that alter the magnetic field locally.
•• Picks up: Bleeding and Calcification
•• Trauma & low GCS: Sequence of choice for DAI
•• SWI shows Multiple foci of blooming

DWI (Diffusion Weighted Imaging MRI)

•• DWI is used in cases of
–– Stroke – ischemia (most sensitive sequence: DWI)
–– Epidermoid cyst (Keratinaceous)
–– Abscess
–– Hypercellular tumors

DTI (Diffusion Tensor Imaging)

•• To study white matter tract
•• Used in; Preoperative planning, Trauma.
Tractography: 3D representation of DTI

Thumb Rules: MRI

CNS SPINE NERVES BM EDEMA LIGAMENTS
CARTILAGE
SOFT TISSUE
- Tumor - Tumor - Tumor - Stress fracture
- Pancoast tumorQ
- Acute OM IOC - MRI
- Posterior mediastinal mass - Sacroiliitis Q

(neurogenic)Q - Bone tumor

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Radiology

USG PROBES

CURVILINEAR LINEAR PROBE ENDOCAVITARY PHASED ARRAY PROBE /

PROBE USG ECHO PROBE
Frequency 2-5 MHz 6-15MHz 5-11MHz 1-5 MHz

Resolution ↓ ↑ ↑ ↓

Depth ↑ ↓ ↓ ↑

Use Abdomen / Pelvis Thyroid / Breast / TVS – Uterus/ TRANS-THORACIC ECHO

Scrotal USG Ovaries
TRUS- Prostate

DOPPLER

B-MODE USG COLOR DOPPLER / DUPLEX USG SPECTRAL DOPPLER /TRIPLEX USGQ
- Direction of blood flow Velocity of blood flow determined.
- Flow towards the probe is red
colour and away from probe is blue
colour.
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DOPPLER WAVEFORMS

Triphasic flow Biphasic flow Monophasic flowQ

Extremity arteries Visceral arteries Veins

Deep Vein Thrombosis

IOC → Doppler

Normal vein DVT

COMPRESSIBILITY ++ --
FLOW Monophasic Absent flow
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Radiology

Thumb Rules: USG

GALL BLADDER FLUID/ CYST PREGNANCY DVT / VARICOSE ARTERIAL DISEASES
VEINS

- Gall stonesQ - Ascites 1st line IOC: USG+DOPPLER Peripheral arterial disease,
- Cholecystitis - Pleural effusion Renal artery stenosis,
- Pericardial Pulsatile neck mass:Q
effusion - Initial: Doppler
- IOC: CT Angio

Contrast Media
Contrast media Modality Route Pre-requisite Complication

Iodinated contrast X-ray / CT IV RFT CIN- Contrast induced NephropathyQ

eGFR<60ml
Creatinine >1.5 mg/dL

Gadolinium MRI IV RFT NSF- Nephrogenic systemic Fibrosis

(woody limbs)

Sonovue USG IV Sulfa Allergy Safe in Renal failure

Barium sulfate X-ray Oral / CXR-PA Erect / C/I:Q
Enema AXR Perforation /Intestinal obstruction
TEF / Post op
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Q Q

I : P ratio : 3:2 6:2 3:1 6:1

Osmolarity: 1200 (HOCM) 600(LOCM) 600(LOCM) 300(Iso osmolar)

No. of Iodine No. of Iodine

Monomer: 3 Ionic: 2
Dimer: 6 Non-Ionic: 1

GI RADIOLOGY

Ba swallow Ba meal Ba meal follow throughQ Ba EnteroclysisQ Barium enema

Oesophagus Stomach D1 SI SI LI

IOC SI → CT Enterography
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Radiology

Bird Beak → Achalasia cardiaQ Rat Tail → Carcinoma oesophagusQ

•• Young patient c/o dysphagia which worsens with •• Elderly patient c/o dysphagia which worsens with solids
liquids > solids > liquids
•• Bird beak sign •• Rat tail sign
•• IOC: Manometry Q
•• IOC: Upper GI endoscopy + Biopsy

Pseudo-trachea / Feline oesophagusQ Shaggy oesophagus Diffuse Oesophageal spasm

↓ (DES)Q
Eosinophilic esophagitis H/O HIV/AIDS ↓
↓ Corkscrew oesophagus
Candida esophagitis IOC → Manometry
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Important Barium Signs

String signQ Lead pipe colon Apple core signQ Saw tooth signQ
↓ ↓ ↓ ↓ ↓
TB CROHN’S ULCERATIVE COLITIS Carcinoma Colon Sigmoid diverticulosis
↓ ↓
String sign of Kantor Earliest sign on barium: (Diverticulitis IOC → CECT)
Mucosal granularity
MC site of GI TB -Ileocecal
junction
MC site of Crohn’s disease-
Terminal ileum

Congenital diaphragmatic hernia

TYPES:
Morgagni hernia Bochdalek hernia (BPL)Q

- Anterior defect - Posterior defect

- More common on the Right side - More common on the Left side
- Liver herniate - Bowel loops herniate

C/F: Respiratory distress at birth / Scaphoid abdomen

Most Important Prognostic Factor: Pulmonary hypoplasia
Initial Mx: ET Tube, NG Tube
C/I: Bag & Mask Ventilation

Intussusception
AGE: 6 – 8 months of age (Rotavirus vaccine)
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Radiology

C/F: Pain + Red currant jelly stool

M/C Type: Ileocolic intussusception
Initial: USG
IOC/Gold standard: Barium enema
(Air / Saline enema)

Target sign / Donut sign / Sandwich sign / Pseudo kidney Claw sign / Coiled spring signQ
sign

PneumoperitoneumQ
C/F: Patient; with severe pain abdomen +
Acute abdominal rigidity / Guarding (signs of peritonitis)
Most Sensitive X-Ray: CXR-PA erect (Air under Rt diaphragm)
Most Sensitive investigation: CT
Next Step: Exploratory Laparotomy
(If IV fluids mentioned in the question then next step is IV fluids
and the exploratory laparotomy)Q
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APPROACH TO INTESTINAL OBSTRUCTION

Pain abdomen + Obstipation + Abdominal distension + Vomiting

↓
IV fluids + NPO + NG tubeQ

↓
Initial – AXR
CXR-PA
IOC → CECT

Small bowel obstructionQ Large bowel obstruction

SBO LBO

M/C cause Adhesions Malignancy

Distribution Central Peripheral

Diameter > 3cm > 6 cm

Valvulae conniventes +++ --

String of pearls sign ++ --

Haustra -- +++

Mx Conservative: If not responding: Sx Sx

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Radiology

Sigmoid Volvulus Vs Cecal Volvulus

Sigmoid Volvulus Cecal Volvulus
Direction Anti-clockwise Clockwise
Predisposing factors Elderly, Constipation Pregnancy, Pelvic Sx
Starting from base Left lower quadrant Right lower quadrant
Apex RUQ LUQ
No of loops 2 1
Associated bowel loop dilation Large bowel Small bowel
Haustrations -- ++
Mx Endoscopic detorsion Sx

Coffee bean signQ C-sign

Two dilated loops without haustrations Single bowel loop with haustrations

Abdominal Trauma
eFAST
Full form: Extended Focussed Assessment with sonography in traumaQ
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Sensitivity: to detect fluid upto 100 mlQ

Limitations: Retroperitoneal HematomaQ
Pneumoperitoneum – Bowel injury

BLUNT TRAUMA ABDOMEN

Unstable Stable
↓ ↓
eFASTQ eFASTQ
+ - + -
↓ ↓ ↓ ↓
OT OT CECTQ Observe
(IOC → Localise the injury)
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Radiology

Hepatobiliary Radiology
Hydatid Cyst
•• Causes by: Echinococcus granulosus
•• Humans: Accidental host
•• IOC → USG
•• Dissemination - CECT

HONEYCOMB signQ WATER LILY sign CALCIFIED HYDATID CYST

(inactive)Q

Gall Bladder Pathologies

IOC → USG

Cholelithiasis Acute Cholecystitis GB Polyp Adenomyomatosis

(Gall bladder calculi)
- 3mm wall thickening. -Nondependent hyperechoic Comet tail sign
Hyperechoic calculus -Calculus (obstructive) structure + no posterior acoustic
with Posterior acoustic causing the Posterior shadowing
ShadowingQ acoustic shadowing
Any polyp >1 cm is an indication
Most accurate Ix – HIDA of elective cholecystectomy (↑
scan risk of malignancy)
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Bile Duct Pathologies

Approach To Obstructive Jaundice
C/F – Bilirubin direct↑, ALP↑, GGT ↑
Initial -USGQ

IHBRD CBD dilation >6mm IOC-MRCPQ Gold standard-ERCP

Approach To Suspected Bile Leak

C/F – Post-op Jaundice / Leak++
Initial – USG → Biloma++ → Pigtail catheterQ
BEST – ERCPQ
MOST SENSITIVE – HIDA scan.Q
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Radiology

Primary Sclerosing Cholangitis

•• Beaded appearance on MRCP (Hallmark of PSC)Q
•• Associated with Inflammatory bowel disease
•• Pre-malignant - ↑ risk of cholangiocarcinoma

Pancreatic Pathologies

ACUTE PANCREATITIS
CHRONIC CALCIFIC PANCREATITIS X-RAY
Initial – USG
IOC – CECT >48 Hrs

CHRONIC PANCREATITIS AUTOIMMUNE PANCREATITIS AIP

IOC- ERCP - IgG4 related disease
- Chain of Lakes appearance
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Genitourinary Radiology
Intravenous Pyelogram (IVP) Signs

URETEROCELEQ HORSE SHOE KIDNEYQ

Adder head / Cobra head appearance Shaking hands calyces /
Cystic dilatation of distal ends of unilateral / bilateral Flower vase appearance
ureters M/C congenital fusion anomaly of kidney

FISH HOOK URETER Fish hook ureter BPH

- Retrocaval ureter (J-shaped)
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Radiology

RETROPERITONEAL FIBROSIS MEDULLARY SPONGE KIDNEY

- Maiden waist sign - Bouquet of flowers appearance / Paint brush appearance
Various causes of RPF:

1° 2°
- Idiopathic: Ormond’s - IgG4 related disease
disease - Radiotherapy
- Drugs: Methysergide,
β blockers, Hydralazine

POLYCYSTIC KIDNEY DISEASE DUPLEX COLLECTING SYSTEM

AD-PCKD -Drooping Lily sign
- Spider leg sign-pyelography -Weigert-Meyer Law:Q
- Swiss cheese sign- nephrogram (Trick: vowels stick together)
- Upper moiety is a/w → Ureterocele, Obstruction, Ectopic
insertion
- Lower moiety is a/w → vesico-ureteric reflux
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PUTTY KIDNEYQ STAGHORN CALCULUSQ

(lobar calcification of kidney)
- Auto nephrectomy
- Sterile pyuria
- GU TB – end stage

IVP

MEDULLARY NEPHROCALCINOSIS PUJOQ

HyperPTH / Hyperoxaluria / Medullary sponge kidney PELVIURETERIC JUNCTION OBSTRUCTION
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Radiology

Renal Masses
IOC → CECT

DIAGNOSIS RCC- Clear cellQ AML-AngiomyolipomaQ Oncocytoma / Chromophobe RCC

TYPICAL Heterogeneous, ↑ vascular -ve HU ( -10 to -100) → Fat Central stellate scar

SYNDROME VHL -3p Tuberous sclerosis Birt-Hogg-Dube syndrome

Pheochromocytoma Seizures Lung cyst/ pneumothorax /
FEATURES Hemangioblastoma Adenoma sebaceum Follicular lesions
Subependymal nodules

Bosniak ClassificationQ
Simple cyst – no risk of malignancy
Type I, Type II – Reassurance
Type II F - + nodular Ca2+ → Follow up after 6 months
Renal cyst
Type III, Type IV → Resection (high risk of malignancy)

MCU / MICTURATING / VOIDING VESICO-URETERIC REFLUX (VUR)Q

CYSTOURETHROGRAPHY - MCC of recurrent UTI in children
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POSTERIOR URETHRAL VALVE (PUV) ANTENATAL USG – Keyhole sign

- M/C/C of obstructive uropathy in children
Q

Urethral Trauma
Triad → Inability to void, Blood at meatus, High riding prostate on DRE

C/I → Foley’s / MCU

IOC → RGU
↓
SPC – Supra pubic cystotomy
↓ 4-6 weeks
Urethroplasty
(Delayed)

Normal Bulbar urethral rupture

RGU – Retrograde urethrography

IOC For Bladder Trauma: CT CystographyQ

Type : Extraperitoneal Bladder Rupture (MC) Type: Intraperitoneal Rupture

(Flame/ Molar tooth sign) Mx: Surgical management
Mx: Conservative
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Radiology

NEUROGENIC BLADDER TEAR DROP/ PEAR SHAPED BLADER FETAL SKULL APPEARANCE
- Vertically oriented bladder - Pelvic hematoma - Schistosomiasis
- Pine tree / Christmas tree bladder - Pelvic lipomatosis - ↑ risk of squamous cell Ca
- Any extrinsic mass / Tumor

Women’s Imaging
Early Pregnancy Scan

GESTATIONAL SAC YOLK-SAC EMBRYO / FETAL POLE DOUBLE BLEB SIGNQ

TVS: 4 – 5 weeks TVS: 5.5 – 6 weeks TVS: 6.5 – 7 weeks TVS: 7.5 – 8 weeks
•• 1st Sign: Intradecidual Sign of confirmation of FHR++ Amnion + Yolk sac
sign intrauterine pregnancy Sign of fetal viability
•• Double decidual sign
•• Decidua capsularis
•• Decidua Parietalis

TWIN USG

Sign: Twin Peak Sign / Lambda SignQ Sign: T-Sign

Intertwin Membrane: >2mm Intertwin Membrane: < 2mm
Type: Dichorionic-Diamniotic Twin Type: Monochorionic Diamniotic Twin
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Anomalies
Anencephaly
SIGN: Frog eye/ Mickey mouse signQ
Earliest Anomaly To Be Detected: 10 – 11 weeks
Prevention:

- Folic acid intake -0.5 mg 3 months prior to

conception and throughout pregnancy
- H/O NTD - 5 mg

B/L Enlarged Ovaries-Approach

PCODQ H/O – IVF H/O – Molar pregnancy

Multiple small follicles: ↓ ↓
String of Pearls Appearance OHSS Q
THECA LUTEIN CYST
Raised stromal volume & echogenicity:
Most specific findings in PCOS

Molar Pregnancy
Diagnosis: Hydatid Mole
Sign: Snowstorm / Cluster of Grapes AppearanceQ
Mx: Suction & EvacuationQ

Respiratory Radiology

DIAGNOSIS: PLEURAL EFFUSION

Sign: Meniscus Sign / Ellis S Curve
Earliest Finding: Blunting Of CP Angle
Mediastinal Shift: C/L
Most Sensitive Ix: USGQ
Most Sensitive Xray: I/L Lateral Decubitus
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Radiology

Diagnosis: PneumothoraxQ
Mediastinal Shift: C/L
Most Sensitive Ix: CT
Most Sensitive Xray: Expiratory CXR
(Only 2 Indications: Pneumothorax, Suspected Foreign Body)
Mx: Unstable Stable
↓ ↓
Tension PneumothoraxQ ICD
↓
Needle thoracostomy
↓
ICD

M-MODE USG

SEASHORE SIGNQ Barcode/stratosphere sign

Normal Lung PNEUMOTHORAX

HRCT Pathologies-Approach

Consolidation with air bronchogram signQ Tree in bud sign

- TB (Active – Endobronchial)
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Halo-signQ Signet ring signQ

- Invasive Aspergillosis - Bronchiectasis

Multifocal / Bilateral GGOs Milliary TBQ ILD

- COVID 19 TB – Hematogenous spread UIP/IPF
CORADS- Diagnostic D/D for miliary nodules- Hallmark: HoneycombingQ
Histoplasmosis
Silicosis
Hemosiderosis
Loeffler’s syndrome/TPEQ

PNEUMATOCELE SILHOUETTE SIGNQ Middle Lobe consolidation overlying heart;

- Staph aureus pneumoniaQ
RML consolidation obscuring right Lower lobe consolidation overlying spine
heart border
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Radiology

Q. 28-year-old male with HIV and CD4 count of 120 cells/mm3 and non-productive cough. Diagnosis?
a) TB
b) Pneumococcus
c) Invasive aspergillosis
d) Pneumocystis carinii

POPCORN SIGN

FIBROADENOMAQ HAMARTOMAQ CAVERNOMA

Pediatric Infections

THUMB SIGNQ STEEPLE SIGNQ BRONCHIOLITIS;Q

ACUTE EPIGLOTTITIS CROUP MCC:RSV
MCC: Strep > Hib Laryngotracheobronchitis H/O ↑ wheeze
MCC: Parainfluenza ↑ Linear perihilar markings
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CVS Radiology
Cardiogenic Pulmonary Edema
PCWP FINDINGS
13 – 18 mm Cephalisation / Redistribution - UL↑

18 – 25 mm Kerley / interlobular septal thickening

> 25 mm Batwing sign

Stag antler / Reverse Kerley lines (B >A)Q Batwing sign

moustache sign

Congenital Heart Diseases

TETRALOGY OF FALLOTQ EBSTEIN’S ANOMALY

- Boot shaped heart / Coer-en-sabot - Box shaped heart
- Right ventricular hypertrophy - Atrialization of RV
- VSD - Maternal intake of Lithium
- Infundibular pulmonary stenosis (Oligemia) - Oligemia
- Overriding of aorta
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Radiology

TRANSPOSITION OF GREAT ARTERIES TAPVCQ

- Egg on side / string Total Anomalous Pulmonary Venous Circulation
- Plethora - Figure of 8 / Snowman shaped heart
-Septum dependent Type I – Supraardiac variant
-Plethora

Important Heart Appearances

LA enlargement / Mitral Stenosis Pericardial effusionQ Calcific constructive pericarditis

- Double RHB Leather bottle / water bottle sign - Egg in cup sign
- Straightening of LHB -Causes :TB / RT /CKD
- Carinal angle splaying
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Aortic Dissection
MC R/F: Hypertension
C/F: Acute chest pain radiating to back
IOC Stable: CT Angiography
IOC Unstable: TEE – Transoesophageal Echo
Management: Stanford Classification
↓ ↓
A B
↓ ↓
Sx Medical Mx
IV ESMOLOL

Pulmonary Embolism
•• H/O DVT
•• U/L Limp pain / swelling ++
•• Acute dyspnoea
•• IOC → CTPAQ

Neuroradiology
Head Trauma
Initial Investigation: NCCT (Non contrast CT scan)Q
IOC: NCCT Scan except DAI (MRI-SWI Best Sequence)
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Radiology

EDH vs SDH

Right EDH, Left SDH

Subarachnoid Haemorrhage
•• M/C/C: Trauma > Berry Aneurysm Rupture
•• C/F: Acute headache (Thunderclap Headache)
→ Worst Headache of life
•• M/C Site Of Berry Aneurysm: Junction Of
Anterior Cerebral Artery And Anterior
Communicating Artery
•• Initial Investigation: NCCT
•• IOC: CT Angiography
•• Gold Standard: DSA (Digital Subtraction
Angiography)Q
•• Treatment of Choice → Endovascular Coiling
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Diffuse Axonal Injury

•• C/F: High Energy Trauma: Low GCS/ Comatosed Patient
•• NCCT: Normal / Small Petechial Hemorrhage
•• IOC: MRI -SWI: Blooming

Stroke
•• Irreversible Focal Neurological Deficit
•• Initial IOC: NCCT- Rule Out Haemorrhage
•• Most sensitive Ix: MRI → DWI
•• If not a candidate for IV thrombolysis → CT Angiography next to rule out large vessel stroke where
intra-arterial procedures can be attemptedQ
Intracranial Hemorrhage
Diagnosis: Basal Ganglia Bleed
M/C Site: PutamenQ
M/C Risk Factor: Hypertension
Vessel: Artery of Charcot → Lenticulostriate Branch of
Middle Cerebral Artery

Important "Empty" signs

EMPTY SELLA SIGNQ EMPTY THECAL SAC SIGNQ EMPTY DELTA SIGNQ

Sheehans Syndrome Arachnoiditis SSS thrombosis-CECT

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Radiology

Brain Tumours – Adults

GLIOBLASTOMA
1. MC Malignant
2. Can Cross Midline
MENINGIOMA –“Butterfly glioma” VESTIBULAR SCHWANNOMAQ
1. MC Benign tumour in adults 3. WHO Grade IV Tumour Ice cream cone appearance
2. Dural Tail Sign 4. Poor Prognosis MC cerebellopontine angle tumor

Brain Tumours In Children

MC BENIGN → PILOCYTIC MC MALIGNANT → CRANIOPHARYNGIOMAQ

ASTROCYTOMA MEDULLOBLASTOMAQ
Optic Chiasma Compression-
Cyst With Enhancing Nodule Bitemporal Hemianopia
CT : Calcified Lesion In Suprasellar
Aspect
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CNS Infections
IOC-CE-MRI

NEUROCYSTICERCOSISQ TUBERCULOMAQ

1. Starry Sky Appearance 1. Around Brain Stem

2. Multiple Fluid Filled Lesions 2. Multiple Ring Enhancing

CEREBRAL ABSCESSQ
with central scolex Lesions
Ring Enhancing Lesion
3. Caused By Taenia Solium 3. Conglomerating Lesions
4. Lipid- Lactate peak is seen on
MRS

HSV ENCEPHALITIS
1. Behavioural Changes
2. Medial temporal and frontal lobes shows
hyperintensity
3. Micro-haemorrhage +
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Radiology

CNS Infection – HIV / AIDS

White matter involvement

T2W – soap bubble Ring enhancing target lesionsQ – progressive multifocal
appearance – cryptococoma – Toxoplasmosis (m/c) leukoencephalopathy – JC virus

SKULL X RAYS → LYTIC LESIONS

LANGERHAN’S CELL
HISTIOCYTOSISQ
SALT AND PEPPER APPEARANCE → 1. Geographical Lytic Lesion
PUNCHED OUT SKULL/ RAIN
HYPER PTH
DROP SKULLQ 2. Bevelled Margin
1. Primary : PTH Adenoma
1. MULTIPLE MYELOMA 3. If Solitary : Eosinophilic
2. IOC : Sestamibi Scan Granuloma
2. LYTIC METASTASIS
4. On Electronic Microscope :
Birkbeck’s Granules
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HAIR ON END APPEARANCE

TRAM TRACK APPEARANCE
/ CREW CUT APPEARANCEQ
PAGET’S DISEASE Q
Sturge Weber Syndrome
Thalassemia / Sickle Cell
Cotton Wool Appearance Anaemia + Port Wine Stain

PNS X RAY

WATER’S VIEWQ
•• Best For Maxillary Sinus
•• Open Mouth/ Modified Water’s : Pierre’s View
•• Occipitomental Position
•• Post. Ethmoidal Sinus not visualised
•• Sinusitis : Horizontal Air Fluid Level

CALDWELL’S VEWQ
•• Maxillary Sinus Not Seen Here
•• Best For Frontal Sinus
•• Occipitofrontal View
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Radiology

PNS Anatomy And It’s Variants

IOC: HRCTQ
Gold Standard: FESS (Functional Endoscopic Sinus Surgery)
Largest: Bulla Ethmoidalis
Anterior-Most: Agger Nassi Cells
Posterior-Most: Onodi Cells → ON compression
Infraorbital: Haller Cell
Pneumatized Middle Turbinate: Concha BullosaQ

OSTEOMEATAL AGGER NASI: HALLER CELLS : ONODI CELL:

UNIT : INFRA ORBITAL
ANTERIOR MOST POSTERIOR
Bulla Ethmoidalis + MOST
Hiatus Semilunaris
+ Infundibulum +
Uncinate Process
+Concha Bullosa

MUSCULOSKELETAL RADIOLOGY
Bone Tumors
Chondroblastoma
Epiphyseal tumor
•• < 20 years
•• Chicken wire calcification
•• Also known as Codman’s tumor
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Giant Cell Tumor = OsteoclastomaQ

Epiphyseal tumor

30 -50 years
Distal end of radius – specific
Soap bubble appearance
HPE – giant cells with mononuclear cells (malignant)

Osteoid Osteoma
•• HALLMARK: Nidus-Secreted PGE2
•• C/F – nocturnal pain relieved on NSAIDS
•• IOC – CT
•• Treatment – CT guided Radiofrequency ablationQ

Ewings SarcomaQ
•• 0-20yrs
•• C/F mimics inflammation – redness, fever, swelling
•• Onion-skin periosteal reaction
HPE – Small round cell tumor, Homer-wright Pseudorossettes
Most radiosensitive and chemosensitive tumor

EnchondromaQ
Benign tumor of short tubular bones of the hand
Multiple enchondromas – olllier syndrome
Enchondromas + hemangioma – mafucci syndrome
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Radiology

Fibrous Dysplasia
•• MC seen in femoral metaphyses
•• Ground glass matrix
•• Shepherd crook deformity: Deformity due to Pathological #Q
•• Polyostotic fibrous dysplasia:
1) Mc Cune Albright syndrome – precocious puberty +fibrous dysplasia
2) Mazzabraud syndrome – myxomas

Ankylosing SpondylitisQ

AGE: Young male

HLA B27 +
C/F: Back pain – Inflammatory ↑ with rest / ↓ activity
B/L heel pain-enthesitisQ
SACROLITIS-Most sensitive – MRI (STIR)
BAMBOO SPINE
TRAM TRACK SIGN (Complete fusion)
DAGGER SIGN

Osteoporosis
DIAGNOSIS: OSTEOPOROSISQ
SIGN: Codfish Mouth Sign
BIOCHEMICAL: Normal Ca, PO4, PTH, ALP
IOC: DEXA
WHO – T score < - 2.5 SD - Osteoporosis

Recent Advances: Quantitative CT / USG

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Spine Xrays-Approach

Chronic Osteomyelitis
SEQUESTRUMQ
Central sclerotic area: Dead bone
INVOLUCRUM
Lucent granulation tissue surrounding sequestrum
CLOACA
Area of defect in the bone leading to discharging sinus

Scoliosis
Lateral curvature of spine on AP view
Cobb’s angleQ
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Radiology

RICKETS VS SCURVY

RICKETSQ SCURVYQ
Widening of growth plate Frenkel’s line
Zone of provisional calcification deficient Trummerfield zone
Metaphyseal cupping / Splaying / Fraying Pelkan spurs
White metaphyseal line : Healing rickets Wimberger ring sign
Subperiosteal sign
Pseudo-paralysis

Nuclear Medicine
SCAN USE
Tc99m – DMSA Morphological / static scan-IOC for renal scarringQ
Tc99m – DTPA Dynamic / Functional scan (Better for GFR)
Tc99m - MAG3 Dynamic / Functional scan (Better for overall function)
Diuretic renography Partial vs complete obstruction
Captopril renography Renal artery stenosis

Tc99m – DMSA Tc99m – DTPA

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Radioisotope Test
Tc99m-MDP (Methylene diphosphonate) Bone scan (Multiple myeloma-Cold spot)
Tc99m-HIDA Bile duct; Bile leaks: most sensitiveQ
EHBA
Tc99m Sestamibi IOC – PTH AdenomaQ
Tc99m Sulphur colloid scan Reticuloendothelial system RES / Occult abscess / Splenenculi
(accessory spleens)
Tc99m pertechnate Meckels diverticulum, Warthin Tumor, Thyroid scan
Tc99m Labelled RBC GI Bleed (Most sensitive)
Tc99m tetrofosmin, Sestamibi, Th-201 Myocardial perfusion study
Tc99m pyrophosphate Infarct + + (Hot spot)Q

Bone Scan Tc99m-MDP Tc99m-HIDA - Tc99m

most accurate Sestamibi -IOC
Hot spot
for acute for PTH adenoma
•• Metastasis cholecystitis
•• Fracture
•• Tumor
•• Acute osteomyelitis
Cold spot: Multiple myelomaQ
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Radiology

Sulphur colloid scan - Hot spot Tc99m pertechnate – Tc99m tetrofosmin, Sestamibi, Th-201 – MPI:
Meckels diverticulumQ Cold spot-ischemia
Kupfer cell + FNH – Fibrous
nodular hyperplasia

PET-CTQ
18 FDG – 18 fluoride deoxy glucose
(Positron emitter)
Warburg effect
e+ + e- → γ rays
511 Kev x 2

Na F – Bone metastasis (best)

DONATOC -PET -NET PancreasQ

RADIOTHERAPY

Types of Radiotherapy

Agents for Radiotherapy

Gamma rays X-ray Electrons / β particles Protons
Co- 60 (MC) Source: LINAC Source: Cyclotron
Cs – 137 Source: LINAC
Source: Nuclear reactor
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LINAC - LINEAR ACCELERATORQ REMOTE AFTERLOADING:Q

BRACHYTHERAPY

GAMMA KNIFE
Leksell frameQ
Source γ rays – Co 60
Targeted radiation
Indications: Pituitary adenoma, Vestibular Schwannoma,
Glomus tumor, solitary metastasis

FRACTIONATED RT – 5RS
Repopulation
Reoxygenation
Repair
Redistribution
Radiosensitivity

ELEMENTS HALFLIFE
18-FGD 110 minQ
Tc 99 6 hrsQ
I 123 13 hrs
I – 124 4 days
I – 125 60 days
I – 131 8 daysQ
P -32 14 days
Ir – 192 74 days
Co – 60 5.2 yearsQ
Cs – 137 30 years
Au – 198, Yt -90 2 days
Radium – 226 1622 years a+β+γ
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Radiology

ONE-LINERS
Most Common Side Effect Of RT- ERYTHEMA
MC RT-Induced Malignancy- LEUKEMIA
MC Brain Tumor After Cranio-Spinal RT- MENINGIOMA
Prophylactic cranio-spinal irradiation: ALL/ Small Cell / Ca Lung, MedulloblastomaQ
MC RT-Induced Thyroid Carcinoma- PAPILLARY CAQ
MC Bone Cancer After RT- OSTEOSARCOMAQ

Type Most sensitive Least sensitive

Cell Type Constantly dividing, undifferentiated Well differentiated / Quisent
Organ Gonads (ovary > testis)Q Vaginal epithelium
Blood cell Lymphocytes PlateletsQ
Tissue Haematopoietic CNS
Cell cycle phase G2 -M SQ
Structure of eye Lens Sclera
Tumors (WELMS) (HOMP)
Wilms tumor HCC /RCC
Ewing’s sarcomaQ Osteosarcoma
Lymphoma / Leukaemia Melanoma
Multiple myeloma Pancreatic Ca
Seminoma
Acute radiation Haematopoietic -----> GI ----> CNS – CVS
syndromeQ 1 – 8 Gy 8 – 12 Gy 12 – 100 Gy

Radiological AnatomyQ
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