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RadRes MegaPimp 5

QuestionAnswer
What mass of teens and young adults classically fills the maxillary sinus and extends into the nasal cavity enlarging the maxillary ostium and infundibulum? antrochoanal polyp
What classic lateral nasal wall mass of middle-age men often extends into the maxillary sinus and has malignant potential? inverted papilloma. 13% harbor carcinoma.
What are the bimodal age peaks for olfactory neuroblastoma? aka esthesioneuroblastoma, peaks in ages 11-20 (teens) and in the 50s. Malignant: 70% survive to 5 years.
Older patient with mass occupying the maxillary sinus with obvious bony destruction and outward extension. Top Dx? sinonasal SCC. Most common maxillary sinus malignancy. Mets occur late and connote grave prognosis.
What is a ranula? salivary retention cyst in the sublingual space
What is the most common parotid tumor? benign mixed tumor, aka pleomorphic adenoma. Benign.
What is the most common unilateral multifocal tumor in the parotid gland? Hint: 15% of these are bilateral. papillary cystadenoma lymphomatosum, aka Wathrin tumor. Arises from parotid LN. Benign, cystic with solid elements.
Besides SCC, what tumor cell type in the parotid space is known to spread along nerves? adenoid cystic carcinoma, aka cylindroma
What is another name for cylindroma in the parotid space? adenoid cystic carcinoma
What nonneoplastic lesion in the parotid space occurs in HIV/AIDS patients? lymphoepithelial lesions/cysts
What is a node of Rouviere? any of the lateral retropharyngeal space lymph nodes
What structure does a laryngocele hearniate through to become internal-external? thyrohyoid membrane
Congenitally abNL child with aplastic cerebellar vermis, absence of pyramidal decussation, dysplasia of cerebellar nuclei, bat wing 4th ventricle, thickened elongated superior cerebellar peduncles with molar tooth-like appearance. Top Dx? Joubert syndrome, aka vermian aplasia, AR-inh ciliopathy. Prevalence 0.001%. Exquisitely sensitive to respiratory depression.
What is Joubert syndrome? aka vermian aplasia or molar tooth midbrain-hindbrain malformation, AR-inh variable vermis agenesis, absence of fibre decussation in superior cerebellar peduncles, pyramidal tracts. Prevalence 0.001%. Exquisitely sensitive to respiratory depression.
What extracranial abnormalities are associated with Joubert syndrome? coloboma +/- retinal dysplasia (50%), nephronophthisis, multicystic dysplastic kidneys (MCDK, 30%), hepatic fibrosis, polydactyly (15%). Related rare syndromes: Varadi-Papp, Dekaban-Arima, COACH, Senior-Loken, Joubert polymicrogyria.
In what brain malformation are longitudinal callosal fascicles seen? Longitudinal callosal fascicles, aka Probst bundles, are seen in agenesis of the corpus callosum.
What is Henoch-Schönlein purpura? non-thrombocytopenic IgA complex-mediated small vessel acute vasculitis in skin, gastrointestinal tract (50-75%), joints (80%), kidneys, rarely CNS. Peak age 3-10 yrs. Present with palpable purpura, GI bleeding.
6 yo child with GI bleed and purpura has radiographs and CT showing multifocal bowel mucosal thickening, lymphadenopathy, mesenteric edema and vascular engorgement. Biopsy shows IgA complex deposition in small vessell. Top Dx? Henoch-Schönlein purpura (HSP). Often self limiting. Complic’ns: intussusception, obstruction, perforation, bowel infarction (3-5%), renal failure.
What is HELLP syndrome? Hemolysis, Elevated Liver enzymes, Low Platelet count. Life-threatening fulminant hepatitis related to pre-eclampsia in late pregnancy or immediate post-partum period.
CT ordered on primagravida at 36 weeks with malaise , epigastric & RUQ pain, n/v, and hypertension shows wedge shaped hepatic hypoperfusion, intraperitoneal fluid, and a hyperdense blush at the liver margin. Top Dx? HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count complicating pre-eclampsia) with hemorrhagic hepatic infarction and capsular rupture.
What are the most common tumors that occur at the cerebellopontine (CP) angle? AMEN: acoustic neuroma, meningiomas, epidermoid, neuroepithelial cyst (arachnoid)
Solid adrenal mass with heterogeneous enhancement on CT, no rapid washout. MR shows low T1, very high T2 signal. No signal dropout on opposed-phase images. Top Dx? pheochromocytoma. ACC, adenoma, pheo are all heterogeneously enhancing, but pheo is often “light bulb bright” on T2, not seen in ACC or adenoma. Beware “dark pheo”; not always bright.
What chemotherapy agent has been classically associated with pseudo-progression on posttherapy brain MR? temozolomide (Temodar, Temodal, Temcad)
What chemotherapy agent has been classically associated with pseudo-response on posttherapy brain MR? bevacizumab (Avastin)
What adult brain tumor classically has popcorn calcification? oligodendrioglioma
What size pineal cyst can be left alone, assuming no mass effect and no symptoms? less than 12 mm
T/F: Large flow voids argues againsts the diagnosis of choroid plexus papilloma for a frond-like tumor within the ventricles. False. Large flow voids are typical for this highly vascular tumor.
Giant cell astrocytomas in the CNS are associated with what disease? What is another common name for these lesions? aka subependymal giant cell tumor, assoc’d with tuberous sclerosis (TS)
"Martini glass" appearance of the vitreous humor on pediatric brain MR. Dx? persistent hyperplastic primary vitreous (PHPV)
What percent of dysthyroid ophthalmopathy patients are euthyroid? 10% (aka Graves ophthalmopathy). Medial and other IOM swelling from lymphocyte infiltration and mucopolysaccharide deposition, some fat deposition. Mostly bilateral.
Optic nerve gliomas (ONG) occur in NF1 patients, as well as sporadically in non-NF1 patients. How does NF1 status affect outcomes? NF1 patients usually have more anterior ONGs, and tend to do better.
What percentage of optic nerve meningiomas calcify? about 1/3
Patients with what syndrome tend to have a high incidence of carotid cavernous fistula? Ehlers-Danlos syndrome
What medications are classically associated with PRES? Cyclosporine is the most cited, but also FK506, and several others.
What diameter size qualifies a "giant cavernous" aneurysm? at least 25 mm
What is the DDx for persistent consolidation on CXR after 4-6 wks of Abx? eosinophilic PNA, organizing PNA, adenoCA in situ, lymphoma, lipoid PNA, indolent infxn
HIV/AIDS patient with PNA not responding to typical antibiotics. CXR and CT show bilateral symmetric perihilar opacities with distinct peripheral sparing, tiny nodules <5mm. Top Dx? PCP (Pneumocystis jirovecii). Cysts for which this was named are actually uncommon (upper predominance when present). May see PTX.
Bilateral patchy groundglass opacities in a patient found unresponsive in an inner-city drug house. Top Dx? crack lung, from diffuse hemorrhages
ANCA+ small vessel vasculitis with glomerulonephritis; nodules, consolidation, and cavitating masses on CXR; and circumferential tracheal wall thickening that is FDG-avid. Top Dx? granulomatosis with polyangiitis (GPA), aka Wegener granulomatosis. cANCA+.
Name 6 diseases besides pulmonary alveolar proteinosis (PAP) that can present with “crazy paving” pattern on chest CT. exogenous lipoid pneumonia, adenoCA in situ, NSIP, PCP, sarcoidosis, organizing pneumonia
Bilateral lymphangitic carcinomatosis. What are the 3 top cell types? gastric, breast, colorectal. If unilateral, NSCLC is most likely.
What is CREST? Calcinosis, Raynaud's, Esophageal dysmotility, Sclerodactyly, Telangiectasia. aka limited cutaneous scleroderma (lcSSc): skin changes only in distal extremities, face. Anti-nuclear and anti-centromere Ab. Usually spares kidneys. Pulmonary HTN common.
What is the DDx for centrilobular solid nodules? silicosis/anthracosis (CWL), pulmonary LCH, infection (esp. TB, NTM, viral), aspiration, and (rarely) metastases. Tree-in-bud: infection or aspiration.
What is the DDx for centrilobular groundglass nodules? hypersensitivity pneumonitis (HP), bronchiolitis (respiratory, viral), adenoCA, OP/NSIP, and edema/vasculitis
What diagnosis does the “headcheese” sign suggest on chest CT? subacute to chronic hypersensitivity pneumonitis
What is the DDx for randomly distributed lung nodules (homogeneous, not sparing any part) chest CT? Try to name 7 causes. miliary infection (histo, TB), sarcoidosis (usually has some lymphatic predominance), metastases (more lower lobe), silicosis/CWP, pulmonary LCH
Name 8 causes for groundglass opacities on chest CT besides edema and infection. NSIP (subpleural sparing), LIP (diffuse), AIP (patchy, consolidative, traction bronchiectasis), DIP (peripheral, symmetric), drug toxicity (amio), alveolar proteinosis (crazy paving), alveolar hemorrhage syndromes, hypersensitivity pneumonitis
What is BOLT in the context of lung CT? BOLT = bilateral orthotopic lung transplantation
Where is the classic location of airway stenosis in patients with granulomatosis with polyangiitis? subglottic. GPA aka Wegeners.
Calcified nodules and osteochondromas diffusely carpeting the trachea, sparing the posterior membranous portion. Top Dx? tracheopathia osteochondroplastica
What percentage of bronchial carcinoid tumors calcify? a third (37% to be precise)
What causes the luftsichel sign? In some case of LUL collapse, the apical segment is spared and hyperinflated and becomes interposed between collapsed segments and aortic arch, leaving a sickle-shaped lucency between the aortic knuckle and the collapsed LUL.
What causes the reverse S sign of Golden? a mass (usually NSCLC) in the upper right hilum causing collapse of the RUL, which drapes over the mass causing the characteristic curved shadow. This sign usually is not present if there is not a mass.
What is the Kartagener triad? bronchiectasis, chronic sinusitis and nasal polyps, situs inversus
What is Lady Windermere syndrome? MAC: thin, elderly woman with chronic cough, often with pectus deformity. CT: centrilobular nodules, bronchiectasis, affecting middle lobe and lingula.
Name 4 causes of mucoid impaction. ABPA/asthma, bronchial atresia, foreign body, and TUMOR
Woman with vaginal bleeding 1.5 months after UAE for large fibroid. US shows highly echogenic branching, serpiginous, linear structures. Dx? Expected gas-filled potential spaces left by tissue infarction/desiccation after UAE. Barring any evidence for infection or excessive bleeding, this should be left alone.
Middle age woman with watery vaginal discharge, no hemorrhage. US and MR show bubbly cystic cervical mass penetrating deep into the cervical stroma. Top Dx? adenoma malignum
What patterns of calcification indicate which likely diagnoses in the setting of calcified mediastinal mass on CT? teratoma (calcs with gross fat); thymic carcinoma, carcinoid, or mucinous mets (amorphous wispy calcifications); silicosis or sarcoid (eggshell calcs); fungal or mycobacterial (central calcs); chondro/osteosarcoma (chunky dominant calcs)
Besides the 4 Ts, name 6 causes for anterior mediastinal masses. mets, TB/fungal LAD, germinoma, ectopic parathyroid adenoma/carcinoma, hematoma, aneurysm
In general, how long must a solitary pulmonary nodule be followed to establish no growth and benign? 2 years
What is the Fleischner Society management recommendation for a pure groundglass nodule <=5 mm? no CT follow-up required (assuming 1 mm cuts were used to Dx)
What is the Fleischner Society management recommendation for a pure groundglass nodule >5 mm? initial follow-up CT at 3 mo to confirm persistence, then annual CT for at least 3 years
What is the Fleischner Society management recommendation for a mixed groundglass nodule with less than 5 mm solid component? initial follow-up CT at 3 mo to confirm persistence, then annual CT for at least 3 years (same as pure groundglass nodule >5 mm)
What is the Fleischner Society management recommendation for a mixed groundglass nodule with more than 5 mm solid component persisting at 3 mo follow-up? biopsy or resection
What is the Fleischner Society management recommendation for multiple pure groundglass nodules <=5 mm? follow-up CT at 2 and 4 years; if stable, no further surveillance. Consider noncancerous causes.
What is the Fleischner Society management recommendation for multiple pure groundglass nodules >5 mm with no nodule being particularly dominant? What if there is a dominant groundglass nodule? If no dominant nodule, f/u CT at 3 mo to confirm persists, then annual for at least 3 years (same as for single >5mm GG nodule). If dominant nodule, then f/u at 3 months, biopsy/resect if persistent. PET/CT if solid component >5-10 mm.
What are the Wells scores that connote moderate pretest probability for PE? (above and below which probability would be high and low, respectively) 2.0-6.0 =mod prob. Add 3.0 for clinical s/sx of DVT. Add 1.5 for HR>100. Add 1.5 for immobil’n >=3d or surg in prev 4wks. Add 1.5 for prev PE or DVT. Add 1.0 for hemoptysis. Add 1.0 for cancer or tx in past 6 mo. Add 3.0 for PE more likely than other Dx.
Does the Wells score incorporate the D-dimer test? No. Wells score= +3.0 for clinical s/sx of DVT. +1.5 for HR>100. +1.5 for immobil’n >=3d or surg in prev 4wks. +1.5 for prev PE or DVT. +1.0 for hemoptysis. +1.0 for cancer or tx in past 6 mo. +3.0 for PE more likely than other Dx.
What is the range of diameters for Tc-99m MAA used in lung perfusion imaging? 25-50 micron diameter particles
What effect does size of a pleural effusion have on the PIOPED II-based interpretation of a V/Q scan? Low or very low probability for PE. None of these are intermediate. Low prob if <1/3 of pleural cavity. Very low prob if >1/3.
Perfusion scan shows stripe sign around a segmentally shaped perfusion defect in a patient undergoing VQ scan for clinically suspected PE. What is the PIOPED II designation? very low probability
Name 6 causes for false-positive on SPECT myocardial perfusion imaging. coronary spasm, myocardial bridge, LBBB, idiopathic hypertrophic subaortic stenosis (IHSS), diaphram or breast attenuation artifact, physiologic apical thinning
How is transient ischemic dilation quantified on a SPECT MPI? What is the threshold number? divide end-diastolic volume at stress over at rest. More than 1.4 = TID
Compare and contrast the doses of Tc-99m pertechnetate, I-123, and I-131 in evaluation of thyroid uptake with imaging. Tc-99m pertechnetate=5 mCi. I-123=200 microCi. I-131=5-10 microCi
What is the appropriate range of I-131 dose for a thyroid cancer patient with documented regional cervical or mediastinal metastases at thyroidectomy but negative pre-therapy whole-body scan (aside from nonspecific residual thyroid tissue)? 150-200 mCi
What is the appropriate range of I-131 dose for a thyroid cancer patient with documented distant metastases at pre-therapy whole-body scan? at least 200 mCi
In-111 cisternogram shows early activity in the lateral ventricles that persists through 24 hours of scanning. Top Dx? normal pressure hydrocephalus (NPH), in the appropriate clinical setting (dementia, gait disturbance, urinary incontinence)
In-111 cisternogram shows early activity in the lateral ventricles that progressively clears by 24 hours of scanning. Top Dx? transient reflux into the lateral ventricles due to cerebral atrophy, in the appropriate clinical context and with additional imaging evidence of brain atrophy
In-111 cisternogram shows early activity in the interhemispheric space and basal cisterns, but no activity in the lateral ventricles throughout 24 hours of scanning. Top Dx? normal cisternogram
What F-18 labeled tracer is used to study beta amyloid deposits in the brain? F-18 florbetapir (Amyvid). Uptake in gray matter is associated with amyloid deposition. 2 areas of loss of gray-white differentiation, or 1 area of intense uptake gray>white
DaT Scan study on a patient with suspected Parkinson disease shows “comma sign” appearance of basal ganglia uptake. Dx? normal DaT Scan uptake pattern. I-123 ioflupane, a cocaine analog with high affinity for dopamine transporter (DAT) in the basal ganglia.
DaT Scan study on a patient with suspected Parkinson disease shows asymmetric loss of uptake in the posterior basal ganglia. Dx? supportive of diagnosis of Parkinson disease. I-123 ioflupane, a cocaine analog with high affinity for dopamine transporter (DAT) in the basal ganglia.
What is the molecule or protein that is responsible for MIBG uptake? norepinephrine transporter (NET)
What stage of breast cancer requires no further imaging (SLN localization lymphoscintigraphy or FDG PET) after excision? Stage 1 (T1 N0 M0) breast cancer merits no further imaging.
What is the typical activity (dose) of Tc-99m mebrofenin given for hepatobiliary imaging? 3-5 mCi
What is the typical dose of morphine given for hepatobiliary imaging if no GB seen in first hour? 0.04 mg/kg IV, up to a maximum of 4 mg
Name 6 causes of a false-positive HIDA scan. alcoholism, parenteral nutrition, prolonged fasting, critical illness (ICU patient), PO intake within 2 hours, gallbladder cancer
Which has higher protein binding: DTPA or MAG3? MAG3. DTPA has only 2-5% protein binding. Both are Tc-99m labeled.
What is the typical dose for Tc-99m DTPA? 15 mCi
What is the typical dose for Tc-99m MAG3? 10 mCi
What is the typical dose for Tc-99m DMSA? 5 mCi
Name 6 benign bone lesions that are known to have intense uptake on bone scan. fibrous dysplasia (FD), osteoid osteoma, osteoblastoma, aneurysmal bone cyst (ABC), giant cell tumor (GCT), chondroblastoma
Name 4 benign bone lesions that have mild to no uptake on bone scan. enchondroma, bone island, nonossifying fibroma (NOF, aka fibrous cortical defect), osteochondroma
T/F: Both hemangiomas and LCH can have intense uptake on bone scan. True. They can also have very mild to no uptake. Highly variable.
What percentage of solitary sternal lesions in a patient with breast cancer end up being malignant (mets)? 80%. Very strong association with malignancy.
On PET, most benign bone tumors are cold (FDG-nonavid). Name 2 that are not. GCT and LCH
Middle age woman with h/o multiple renal stones. CT shows unilateral renal cortical loss, dilated calices, and marked proliferation of renal sinus fat exerting mass effect on renal vein. No extension into perirenal space lateral or posterior. Top Dx? replacement (fibro)lipomatosis. Response to chronic inflammation, usually unilateral. 70% associated with renal calculi, other sources of chronic infection and inflammation, which cause caliectasis and renal scarring.
What is hydrops tubae profluens? intermittent clear/bloody discharge followed by shrinkage of adnexal mass, pathognomonic for fallopian tubal CA, only seen in 5% pts. Latzko triad: interm't profuse serosanguineous vaginal d/c, colicky pain relieved by discharge, and abdominopelvic mass.
What is the Latzko triad for fallopian tubal carcinoma? intermittent profuse serosanguineous vaginal d/c, colicky pain relieved by discharge, and abdominal or pelvic mass (only reported in minority of patients). See "hydrops tubae profluens."
Mid to older woman with colicky pain, relieved by profuse serosanguineous vaginal discharge, and pelvic mass. Top Dx? fallopian tubal carcinoma. This Latzko triad is diagnostic. The serosanguineous discharge followed by shrinkage of adnexal mass is called hydrops tubae profluens and is pathognomonic for tubal carcinoma.
Chronically short-statured virilized female with bilateral adrenal hyperplasia on CT. Top Dx? congenital adrenal hyperplasia, aka adreno-genital syndrome. AR-inh enzyme deficiency resulting reduced adrenal cortisol output, w/ massive reactive pituitary ACTH secretion resulting in overproduction of other hormones, some w/ testosterone-like effects.
Ultrasound on an adult person shows a small round hyperechoic lesion within the renal cortex. What could this be? What is the next step? angiomyolipoma, renal cell carcinoma, oncocytoma, metastasis. Dedicated renal CT (pre- & 2-phase post-contrast) or MR (with fat-selective sequences) can be performed to identify fat. Caution: RCC can also have fat, but usually not predominant.
Name the two “p to n” nuclear decay scenarios. IOW, which two decay methods result in a decrease in the atomic number? positron (beta plus) release and electron (beta minus, aka negatron) capture
How the probabilities of Compton scatter and photoelectron absorption differ in terms of density of particles in the medium? Probability of Compton scatter is directly proportional to electron density, whereas probability of photoelectron absorption is directly proportional to proton density (Z).
What is the natural log of 0.5? -0.693 (the negative number consistent with DECAY). Compare to ln(2)=0.693 (positive).
Woman with invasive cervical carcinoma found on annual screening pap undergoes staging pelvic MR showing no evidence of the disease. What is the FIGO stage? Stage Ia cervical cancer.
Woman with invasive cervical carcinoma found on annual screening pap undergoes staging pelvic MR showing disease confined to the cervix, with no evidence of vaginal wall invasion or parametrial invasion. What is the FIGO stage? Stage Ib cervical cancer. Hysterectomy is an option at this early stage. If the mass is large (>4 cm), pt may benefit from radiation therapy as well.
Woman with invasive cervical carcinoma found on annual screening pap undergoes staging pelvic MR showing involvement of the upper 2/3 of the vagina but no parametrial invasion. What is the FIGO stage? Stage IIa cervical cancer. Surgery is still an option at this point. Parametrial invasion would confer a stage IIb, which precludes surgery.
Woman with invasive cervical carcinoma found on annual screening pap undergoes staging pelvic MR showing involvement of the lower 1/3 of the vagina and parametrial invasion, no involvement of the bladder, ureters, or rectum. What is the FIGO stage? Stage IIIa cervical cancer.
Woman with invasive cervical carcinoma found on annual screening pap undergoes staging pelvic MR showing involvement of the lower 1/3 of the vagina with parametrial invasion and hydronephrosis. What is the FIGO stage? Stage IIIb cervical cancer. Surgery is no longer an option.
Woman with invasive cervical carcinoma found on annual screening pap undergoes staging pelvic MR showing involvement of the bladder but no distant metastases. What is the FIGO stage? Stage IVa cervical cancer. Also, rectal involvement indicates stage IVa. Any distant metastases indicates stage IVb.
What 2 etiologies belongs in the differential for any lytic bone lesion in a patient under the age of 30? LCH and infection (per C. Helms, Duke Review)
What 3 etiologies belongs in the differential for any lytic bone lesion in a patient over the age of 40? mets, myeloma, and infection (per C. Helms, Duke Review)
In what bones can giant cell tumor produce sclerotic margins (an unusual finding)? flat bones (scapula)
Lytic lesions in the bilateral superior acetabula with faint sclerotic margins in a patient with longstanding renal failure. Top Dx? brown tumors from secondary hyperparathyroidism
What feature do EG, ABC, NOF, chondroblastoma, and solitary bone cyst all have in common? All occur in patients less than age 30 (per C. Helms).
What percent of chondromyxoid fibromas show calcifications on XR? CT? None.
First glance at a bilateral hand radiograph shows symmetric crowded carpus with marked narrowing of the intercarpal joint spaces. What is the first Dx that should come to mind? RA
What is the most common cause of ankylosis in the hands or ankles? psoriatic arthritis
T/F: Reactive arthritis can occur in women. False. Reactive arthritis (aka Reiter’s) does not occur in women. (per C. Helms, Duke Review)
Besides infection, DJD, and the four spondyloarthropathies, what other arthritic disease commonly affects the SI joints? gout (older than 40 yo, mostly men)
Where does chondrocalcinosis classically occur in CPPD? Name 3 sites. aka pseudogout: wrist TFC, knee menisci and articular cartilage, and symphysis pubis
Name 5 causes of vertebra plana. FETISH: Fracture, EG, Tumor, Infection, Steroids, Hemangioma
How do JIA and Klippel-Feil differ in terms of preference of location within the vertebral column? JIA fusions tend to occur in the posterior elements. Klippel-Feil fusions tend to occur mostly in the anterior elements.
Short-stature cleft lip child, poor access to care. XRs: diffuse osteopenia, kyphoscoliosis, tall vert bodies, wormian bones, J-shaped sella, platybasia, basilar invagination, band-like acroosteolysis, mesomelic short arms, radial head hypoplasia. Top Dx? Hajdu–Cheney syndrome. Rare AD-inh, 70 cases. Micrognathia, delayed teeth, coxa valga, genu valgum, gracile serpentine fibula, club foot, hydrocephalus, syrinx, ASD/VSD, PDA, mitral regurg, polycystic kidneys, reflux, cryptorchidism, Müllerian anomalies.
Name 7 causes of osteopenia in a child. Osteogenesis Imperfecta, Ricket's, Scurvy, Leukemia, Chronic Anemia, Renal Osteodystrophy, Liver Dz
What subset of osteoarthritis can feature chondrocalcinosis? OA secondary to CPPD arthropathy. Look for DJD in atypical locations such as shoulder, elbow, radiocarpal joint, MCPs, and isolated patellofemoral joint (sparing the medial and lateral compartments).
Drooping osteophytes at the distal metacarpals is best associated with what arthropathy? CPPD arthropathy
Why is it importantt to diagnose synovial chondromatosis by imaging and not recommend biopsy? Synovial chondromatosis can be confused with chondrosarcoma or synovial sarcoma on pathology and lead to unnecessary amputation.
Flexion or extension injury?: anterior subluxation after spine trauma flexion injury more likely
Flexion or extension injury?: clay shoveler fx flexion injury
Flexion or extension injury?: bilateral zygoapophyseal (interfacetal) dislocation flexion injury
Flexion or extension injury?: simple wedge compression flexion injury
Is a burst fracture considered stable or unstable? assumed unstable. Look for retropulsed fragment.
Is a bilateral interfacetal dislocation considered stable or unstable? assumed unstable with 3-column ligamentous injury. Flexion-distraction injury.
Is a unilateral interfacetal dislocation considered stable or unstable? relatively stable compared to bilateral dislocations. Flexion-rotation injury.
What delayed abnormality can occur in cervical hyperflexion sprain injuries? delayed instability. F/U flex/ext imaging 2 months after injury can reveal distraction of the posterior elements.
Flexion or extension injury?: C1 anterior arch avulsion hyperextension injury
Flexion or extension injury?: teardrop fx with CC dimension > transverse dimension extension teardrop. Usually C4-5. Unstable in extended position. Often seen in younger patients from diving. Flexion or extension injury?: teardrop fx with transverse dimension > CC dimension
Flexion or extension injury?: C1 posterior arch fx hyperextension injury
Flexion or extension injury?: Hangman fx hyperextension injury
Which types of dens fractures are unstable? Types II and III (through basal neck and through portion of C2 body, respectively). Most are type II (66%). 30% type III. Very few are the stable Type I.
What factors differentiate a stable Jefferson fracture from an unstable Jefferson fracture? any overhang of the lateral masses >6 mm, or atlantodental interval (ADI) >4 mm (some say up to 6 mm is ok)
Flexion or extension injury?: Chance fx flexion distraction injury
Trauma. Shoulder radiograph shows inferior dislocation with hyperabduction of the humerus. Name for this? luxatio erecta. Rotator cuff tear (RCT) in 80-100% of cases. Neurologic injury in 60%. Vascular injury in 3%.
What is the particularly high risk associated with sternoclavicular joint dislocation? possible great vessel injury during reduction. Get thoracic surgeon involved.
What fracture is associated with perilunate dislocation? scaphoid waist fx
Who gets Keinbock’s disease? young male manual laborers. 75% association with ulna minus variance.
What is a Malgaigne fracture? vertical shear pelvic fracture (unstable)
For what Gardner classification subcapital fractures can pinning suffice (low risk of AVN)? nondisplaced lateral (Gardner I) or medial (Gardner II) fractures. For displaced Gardner III and IV fractures, hemiarthroplasty is recommended.
What is the next stop for an elderly patient s/p fall onto left hip with hip pain if radiographs are normal? MRI. CT can miss nondisplaced intertrochanteric fractures.
What is the Hawkins sign in ankle radiography? subchondral radiolucent band (arrowheads) in the talar dome, a sign of appropriate disuse osteopenia after talar fracture immobilization (usually after pinning). Lack of a Hawkins sign connotes a high risk of AVN.
What is the Hawkins fracture classification? vertical talar neck fractures (4 classes): Hawkins I (nondisplaced, 0-13% AVN risk); II (subtalar dislocation, 20-50% AVN); III (subtalar and tibiotalar dislocation, 20-100% AVN); Hawkins IV (subtalar, tibiotalar, and talonavicular dislocation, 70-100%)
5 Bees Lick Pollen describes what DDx? DDx for blastic mestatatic bone lesions
What is the DDx for primary malignancies that can cause blastic metastatic bone lesions? ”5 Bees Lick Pollen”: Brain (medulloblastoma), Bronchus, Bowel (esp. carcinoid), Bladder, Breast, Lymphoma, Prostate
Older patient with lytic lesion that has a “mini brain” appearance, located in the iliac bone. Top Dx? plasmacytoma
What is POEMS syndrome? plasma-cell proliferative disorder (typically myeloma) with features including Polyneuropathy, Organomegaly, Endocrinopathy, M proteins, and Skin changes (hyperpigmentation and hypertrichosis). aka Crow–Fukase syndrome, Takatsuki disease.
What is the difference between par-osteal osteosarcoma and peri-osteal osteosarcoma? Par: metaphyseal, cleavage plane/string sign (30%), dense central mineralization. Peri: diaphyseal, soft tissue lytic lesion scalloping underlying cortex. Both are surface lesions and both have better prognosis than conventional/central osteosarcoma.
What is the DDx for an aggressive-appearing lesion on radiographs, with cystic spaces and fluid-fluid levels on MR? Name 5. Hint: All are not malignant. telangiectatic osteosarcoma, ABC, GCT, MFH, angiosarcoma
Name 4 cartilagenous benign bone tumors that can degenerate into chondrosarcoma. enchondroma, Ollier disease, Maffucci syndrome, and hereditary multiple exostosis. (Paget disease, fibrous dysplasia, and radiation therapy changes also can degenerate into malignancy, but are not cartilagenous.
Where do half of all chondrosarcomas occur? in the pelvis and proximal femur. 15% in ribs, 10% in humerus. A small fraction can also occur at skull base (most commonly at the petro-occipital synchondrosis).
What is the best management for a chondroid lesion on radiographs with no aggressive features? F/U, per C. Helms, Duke Review. Establish benignity.
What is the most appropriate term for “tennis elbow?” common extensor tendonopathy, aka lateral epichondylitis (but not really inflammation; more of a healing response or degeneration)
Focal swelling of the Achilles tendon with speckled appearance on T2-weighted MR. Similar finding in the contralateral ankle. Top Dx? xanthoma (usually familial, related to hyperlipidemia). Also seen in hand extensors. Often bilateral.
Palpable nodule at the plantar aponeurosis, painful to walk on. MR shows multiple bilateral nodules associated with the plantar fascia, low T1, intermediate T2 with areas of hyperintensity. Top dx? plantar fibromatosis, a fibrous proliferation and replacement of portions of plantar aponeurosis, may infiltrate surrounding structures.
Smooth remodeling erosion of the femoral neck with smoothly marginated surface lytic lesion at the margin of the femoral head. Bodies on MR with distinctive signal hypintensity. Top DDx? PVNS has this appearance. No visible calcifications.
Chronic renal failure patient with shortened 4th and 5th metacarpals, one of which contains an expansile lytic lesion. Top Dx? HPT (hyperparathyroidism) and brown tumors
What is ITOH in MSK radiology? idiopathic transient osteoporosis of the hip, aka transient regional osteoporosis (TRO), related to regional migratory osteoporosis (RMO). Reactive marrow. Mostly men, pregnant women (left hip). Painful, osteopenic hip, self-limited. Fx risk.
What is regional migratory osteoporosis (RMO)? similar to idiopathic transient osteoporosis of the hip but migratory, recurrent. DDx: septic arthritis. Mostly affects knee, ankle, foot, hip.
What are Looser zones? aka pseudofractures, broad lucent areas in bones perpendicular to cortex, seen in osteomalacia, Rickets, phosphatasia. Seen in axillary margin of scapula, ribs, pubic rami, inner margin of prox femur, posterior margin of prox ulna.
What are 10 causes of dense bones? Hint: There is a mnemonic. Renal osteodystrophy, Sickle cell dz, Myelofibrosis, Osteopetrosis, Paget disease, Metastases, Mastocytosis (NOT myeloma), Pyknodysostosis, Athletes (normal), and Fluorosis. “Regular Sex Makes Occasional Perversions Much More Pleasurable And Fun”
Name two disease that can feature Erlenmeyer flask femoral metaphyses. osteopetrosis and Gaucher disease
What is Albers-Schonberg disease? aka oseteopetrosis. Inherited disease (AD: benign. AR: severe). Cytopenias.
Which one of the following neoplasms is NOT associated with Paget disease?: osteosarcoma, chondrosarcoma, giant cell tumor, myeloma, lymphoma chondosarcoma
In what toxic exposure is calcification or ossification of the sacrotuberous ligament a characteristic finding? fluorosis
What is PASTA in shoulder MR? aka supraspinatus rim rent or insertion tear, PASTA= partial avulsion of supraspinatus tendon attachment. Occurs in younger patients.
In what percentage of patients does the subcoracoid bursa communicate with the joint space? 20-25%
At what location on the glenoid labrum (clockface position) can a normal variant sublabral foramen occur? only 12:00 to 3:00 position
At what location on the glenoid labrum (clockface position) can a normal variant sublabral recess occur? only 11:00 to 2:00 position
What is the name for absence of the anterior-superior glenoid labrum in combination with a thick, cord-like MGHL? Buford complex
Supraspinatus and infraspinatus muscle atrophy associated with a paralabral cyst indicates nerve compression at what location? What nerve? Suprascapular nerve compression at the suprascapular notch.
Infraspinatus muscle atrophy associated with a paralabral cyst with sparing of the supraspinatus muscle indicates nerve compression at what location? What nerve? Suprascapular nerve compression at the spinoglenoid notch.
Isolated fatty involution of the teres minor muscle on shoulder MR suggests what location of nerve impingement? quadrilateral space [syndrome]
What is the normal size for the posterior cruciate ligament on MR? Where is it measured? <6 mm, measured at the posterior vertical portion
What are the 3 grades of MCL injury on MR? Grade 1: signal only adjacent to MCL. Grade 2: signal within ligament with attenuation. Grade 3: MCL disruption (Look for laxity.)
What traumatic abnormalities of cartilage should be found on MR but are notorious for being missed on arthroscopy? delamination injury. Difficult to see on arthroscopy if search is not directed by MR.
What is the SMTCL bursa? (knee) bursa between the semimembranosus [tendon] and the tibial collateral ligament
What is the most common normal variant intrahepatic biliary confluence anatomy? What is the true normal pattern? "cross-over" (16%): posterior right into left duct before the left duct connects with the anterior right duct. Normal 57%: confluence of anterior and posterior right ducts to a common right duct, which then joins the left duct.
What 2 primary malignancies are most associated with gallbladder metastases? RCC and melanoma. Lymphoma can also occur, but not strictly a “metastasis.”
Describe the Todani classification of biliary (choledochal) cystic disease. I: CBD fusiform. II: CBD saccular. III: choledochocele at the duodenum. IVa: extrahepatic + intrahepatic. IVb: extrahepatic and cystic duct. V: intrahepatic only (Caroli, assoc with ARPCKD).
Who gets recurrent pyogenic cholangitis? Asian descent, more commonly
What is the typical enhancement pattern for peripheral cholangiocarcinoma? late enhancement c/t NL liver, best seen by MR using extracellular contrast agent
What is the distance from the ductal confluence that determines changes in management for resectable cholangiocarcinoma? Only disease external to the liver and not involving the ductal confluence can be potentially resected via whipple (without other contraindications). If 0-2 cm from confluence, must perform R-L choledochojenjunostomy. Bismuth-Corlette classification.
What is pancreas divisum? drainage of the main pancreatic duct via the minor papilla [proximal in the duodenum], while the accessory duct and CBD drain via the [more distal and larger] major papilla. Embryologic developmental anomaly.
What 5 critical abnormalities must be ruled out or described on CT or MR in patients with pancreatitis? necrosis, thrombosis, aneurysm, abscess, or hemorrhage
What does an R1 margin mean in pancreatic cancer? R1 margin is a positive margin that is only microscopically visible. R0 is negative margin, and R2 is grossly positive margin.
What is Shwachman–Diamond syndrome? SDS is rare congenital exocrine pancreatic insufficiency, bone marrow dysfunction, skeletal abnormalities, and short stature. 2nd most common cause of exocrine pancreatic insufficiency in children after CF.
Older patient with right adrenal nodule and NECT density of 20 HU. Best next imaging step? MR in/out phase is better for NECT densities of 10-29 HU, as decent chance of finding microscopic fat --> done. If 30 HU, then CT washout, or biopsy if >4cm or aggressive.
What was historically the most common cause of Addison disease (how it was originally described)? TB involving the bilateral adrenal glands. Now bilateral adrenal hematomas or Histo is common infectious cause.
What percentage of adrenal cortical carcinomas are hormonally active? Most common hormones? 50% secrete usually either cortisol (Cushing dz) or androgens (virulization)
What is the recommended follow-up timeframe for a Bosniak IIF? initial in 6 months, then yearly for at least 5 years
What is the stage of renal cancer (RCC)? Is it resectable?: spreads to perinephric fat and adrenal gland, but no venous tumor thrombus or regional or distant lymph nodes stage II, resectable
What is the stage of renal cancer (RCC)? Is it resectable?: venous tumor thrombus but regional nodes or distant mets stage IIIa, resectable
What is the stage of renal cancer (RCC)? Is it resectable?: regional lymph nodes involved, but no venous tumor thrombus or distant mets stage IIIb (not resectable) "2 B, you're out to sea"
What is the stage of renal cancer (RCC)? Is it resectable?: both venous tumor thrombus and regional lymph nodes, but no distant mets stage IIIc (not resectable)
What is the stage of renal cancer (RCC)? Is it resectable?: direct invasion of distant organs, but no venous tumor thrombus, regional nodes, or distant mets stage IVa (not resectable)
What tumor cell type is most commonly responsible for RCC in the setting of acquired renal cystic disease (ARCD)? papillary RCC
What tumor cell type is most commonly responsible for RCC in the setting of a Bosniak 3 cystic renal mass? clear cell RCC
What tumor cell type is most commonly responsible for RCC over 10 cm at presentation? sarcomatoid RCC. Dismal prognosis, not responsive to chemo and not a surgical candidate.
What is an oncocalyx? filling defects within dilated calices seen on excretory urography (IVP), a sign of TCC
Who gets renal medullary carcinoma? mostly sickle cell gene carriers (both trait and disease). Arises from caliceal urothelium, terminal collecting ducts (medullary). Reniform shape usually preserved. Fast, dismal prognosis (5-13 mo survival at Sx onset, 1-7 mo survival at Dx).
What is Bellini duct carcinoma? renal collecting duct CA. Rare variant of RCC, poor prognosis, hematuria, reniform shape preserved, grows into renal sinus, infiltrates, hypOvascular, mets to LNs, blastic bone
T/F: Angiomyolipoma can invade normal tissues. True: AML can invade the renal vein and into IVC. Does not invade perirenal fat or other tissues.
Name 4 primary malignancies that can met to the kidneys. (do not include lymphoma) lung, breast, colon, melanoma
The “Bergman sign” or “goblet sign” on an IVP or CT urogram is best associated with what disease? TCC
What is Rasmussen encephalitis? aka chronic focal encephalitis (CFE), rare unilateral cerebral infiltration of T lymphocytes (probably autoimmune) causing frequent severe seizures, loss of motor skills and speech, hemiparesis, encephalitis, and dementia, generally under age 15.
Recurrent UTIs and pyelonephritis. Urogram shows multiple tiny filling defects throughout the ureter. Top Dx? ureteritis cystica, submucosal cysts caused by chronic irritation
What are 5 causes for medial deviation of the ureters? retroperitoneal fibrosis, retrocaval ureter (unilateral), pelvic adenopathy, pelvic hematoma, adnexal masses
What are 5 causes for lateral deviation of the ureters? aortic aneurysm, retroperitoneal adenopathy (lymphoma), retroperitoneal mass, psoas hypertrophy, central pelvic mass (ovarian, teratoma, etc)
Name 3 causes for “purse string” appearance multiple ureteral strictures. TB, TCC, radiation
What is the most common cause for linear serpentine calcifications in the bladder wall? schistosomiasis
What is the most common cause for penile urethral stricture with dilation of the glands of Littre? gonococcal urethritis
What is focal lobar nephronia? old term for focal acute pyelonephritis, may develop into renal abscess
Pipestem ureteral calcification on KUB. Asymmetric renal swelling on CT with lobar coarse calcifications, rings and swirls. Top Dx? renal TB (putty kidney)
In what percentage of women with a mature cystic teratoma are there bilateral teratomas? 25%
What previous medication use is associated with clear cell adenocarcinoma (CCA) of the vagina or cervix? diethylstilbestrol (DES). Women born to mothers who used DES during pregnancy (“DES daughters”) are at risk. DES use sharply declined in the 1970s after the association was reported in NEJM 1971.
What is myochosis coli? shortening and thickening of the colonic wall as seen in diverticulosis, an uncommonly used term
What is a cecal bar? calcified appendicolith separated from cecal lumen by cecal wall thickening at the orifice, in acute appendicitis
Who gets obturator hernias? mostly older multiparous women
How does the pubic tubercle related to inguinal and femoral hernias? Femoral hernias do not extend medial to the pubic tubercle, while inguinal hernias may or may not.
What surgical material may mimic a post-operative collection or abscess? Surgicel (absorbable hemostatic sponge, appropriately left in the surgical bed)
What is a gossypiboma? retained surgical sponge (Latin: gossypium=cotton)
Postmenopausal woman with glossodynia, postcricoid dysphagia, and iron deficiency anemia. Esophagram shows upper esophageal webs. Dx? Plummer-Vinson Syndrome. Increased risk of esophageal squamous cell carcinoma. Tx: iron supplementation
What is a Killian-Jamieson diverticulum? at muscular gap lateral to longitudinal muscle of esophagus (Killian-Jamieson space). Less common and usually smaller than Zenker diverticulum, rarely symptomatic. Most often unilateral and left-sided, may be bilateral.
What percentage of GISTs calcify? 25%
How does colonic polyp size related to likelihood of malignancy? <5 mm ~0.01% dysplastic/early malignant. >10 mm ~1% malignant. >2 cm ~30-40% malignant.
T/F: Large hepatic adenomas often have a fatty component. True. Look for fat globules, central scar, thin discontinuous capsule, eccentric hematoma, T1 dark T2 bright.
Hepatomegaly with diffuse steatosis and multiple hepatic adenomas. Top Dx? Glycogen storage disease type I (GSD I), aka von Gierke's disease. Most common glycogen storage disease, glucose-6-phosphatase deficiency.
Cirrhosis with large ill-defined hypodense region on NECT, no early arterial enhancement, and delayed persistent enhancement. Top Dx? confluent hepatic fibrosis
If a T1 in-phase sequence is acquired with a TE of 4.2 msec, what is the shortest TE that can be used for an opposed-phase sequence? 2.1 msec. Next shortest TE would be 6.3 msec.
T/F: Ultrasound beam attenuation is logarithmically dependent on frequency. False. The frequency dependence is linear. An attenuation of 2 dB/cm at 1 MHz increases to 12 dB/cm at 6 MHz.
A positive 3 dB change in relative intensity corresponds to what change in pressure amplitude? double (2x) Relative intensity (dB)=10 x log(I1/I2). Log(2)=0.301. 10^.3=1.995
A negative 3 dB change in relative intensity corresponds to what change in pressure amplitude? half (0.5x) Relative intensity (dB)=10 x log(I1/I2). Log(0.5)= -0.301. 10^(-0.3)=0.501
A positive 20 dB change in relative intensity corresponds to what change in pressure amplitude? 100x. Relative intensity (dB)=10 x log(I1/I2). Each 10 dB change corresponds to an order of magnitude (10x) difference.
A negative 20 dB change in relative intensity corresponds to what change in pressure amplitude? 1/100 (0.01x). Relative intensity (dB)=10 x log(I1/I2). Each 10 dB change corresponds to an order of magnitude (10x) difference.
Which of the following factors in [ultra]sound propagation are frequency dependent?: reflection, refraction, scatter, absorption scatter and absorption
Which of the following factors in [ultra]sound propagation are not frequency dependent?: reflection, refraction, scatter, absorption reflection and refraction
In ultrasound, how does maximum depth relate to pulse repetition frequency? Max depth=0.5*PRP*c, where c=speed of sound in tissue.
What are 4 ways to overcome aliasing artifact in ultrasound? increase PRF (widen the scale), use lower frequency transducer, use a higher angle (with proper alignment with the artery), or use power Doppler (no directionality)
Which pulmonary artery (R or L) gets larger in pulmonic stenosis? the LEFT (due to jet directed leftward, orientation of the PV)
What causes the cardiac disease seen in patients with carcinoid syndrome? Generally only seen with hepatic mets, which release toxins into IVC causing changes in tricuspid valve (regurgitation) and pulmonary valve (stenosis), leading to decreased blood flow, right heart enlargement.
With what congenital heart defect is the Eisenmenger phenomenon seen? ASD
What is the 1 cause for dilated left atrial appendage (LAA)? (isolated LA enlargement)
What is the most common cause of annuloaortic ectasia? Marfan disease
Compare “mirror image” vs “aberrant L subclavian” morphologies of right aortic arch in terms of likelihood of congenital heart disease. R arch with mirror image branching (no impressn on post trachea, ant esoph) has a 98% association with CHD (ToF - 90%; also: truncus, DORV, TGA), while R arch with aberrant L subclavian has only a 5% association with CHD.
What side isomerism has the highest association with congenital heart disease, higher complexity, and overall worse prognosis? asplenia (right-sided isomerism). Added problem of poor immune system function.
What percentage of preterm infants have PDA? 20-30%, higher in small infants <1000 g with significant lung disease
Cyanotic infant with increased pulmonary vasculature (high flow), prominent ascending aorta, LAE and biventricular enlargement, and a right-sided aortic arch. Top Dx? truncus arteriosis. Chamber enlargement reflects flow and VSD.
Name 3 other causes besides Ebstein anomaly for wall-to-wall heart on newborn CXR. pulmonary atresia with intact ventricular septum, pericardial effusion, cardiomyopathy (diabetic mother)
What percentage of patients with pulmonary sling also have intracardiac CHD? 50%
What sequence is used in bright-blood delayed enhancement MR imaging of the heart? single inversion recovery (DIR) gradient echo, 5-15 min after IV contrast. Inversion pulse nulls normal myocardium.
What is the DDx for circumferential non-CAD pattern delayed enhancement on post-contrast inversion recover cardiac MR? amyloidosis, and in a transplant patient: rejection
What is the DDx for patchy midmyocarium non-CAD pattern delayed enhancement on post-contrast inversion recover cardiac MR? sarcoid (look for LAD), myocarditis (fever? recent infxn?). Could also see epicardial patchy delayed enhancement in either of these.
What is the DDx for patchy epicardial non-CAD pattern delayed enhancement on post-contrast inversion recover cardiac MR? sarcoid (look for LAD), myocarditis (fever? recent infxn?). Could also see midmyocardial patchy delayed enhancement in either of these.
What are 3 features distinguishing ischemic from nonischemic (dilated) cardomyopathy? delayed enhancement in coronary distribution with focal thinning, RV spared, in ischemic CM, whereas delayed enhancement non-CAD or absent, uniform thinning, and biventricular dilation in dilated CM
Patient with recent infarction has cardiac MR showing subendocardial delayed enhancement with focal wall thinning, no other involvement. Candidate for revascularization (CABG)? yes. Thin subendocardial delayed enhancement (not full thickness) implies lots of viable myocardium, likely good response to revasc.
Besides NET, what is the most likely primary source for hyperenhancing lesion in the pancreas? RCC metastasis. In the tail, consider intrapancreatic splenule (follows spenic enhancement). Melanoma mets are less common.
What 3 hepatic lesions can contain microscopic fat (and therefore drop out on opposed-phase T1 MR)? adenoma, HCC, focal steatosis
Aneurysmal dilation of the bowel or stomach with wall thickening. Top Dx? lymphoma
Dilated fluid filled loops of small bowel with “baloons on a string” appearance. Top Dx? closed loop obstruction
Tiny irregular hypodense nodules in kidneys, liver, and spleen. DDx? Name 3. microabscesses, lymphoma, sarcoidosis
Patient with epigastric and back pain has CT showing hypodense rind around the pancreas. Top Dx? autoimmune pancreatitis (AIP)
Who gets multiple renal oncocytomas? patients with Birt–Hogg–Dubé syndrome
Pseudocystadenomas in the pancreas are most often associated with what phakomatosis? vHL (also see epithelial cysts in the pancreas)
Cyst-within-a-cyst in the liver. DDx? biliary cystadenoma and hydatid cyst
What is the second most common cause of inherited exocrine pancreatic insufficiency after cystic fibrosis? Shwachman-Diamond syndrome (SDS), assoc’d with Shwachman-Bodian-Diamond syndrome (SBDS) gene mutation on chromosome 7. Exocrine pancreatic insufficiency, bone marrow dysfunction, leukemia predisposition, skeletal abnormalities.
What is the second most common cause of fatty replacement of the pancreas after cystic fibrosis? Shwachman-Diamond syndrome (SDS), assoc’d with Shwachman-Bodian-Diamond syndrome (SBDS) gene mutation on chromosome 7. Exocrine pancreatic insufficiency, bone marrow dysfunction, leukemia predisposition, skeletal abnormalities.
What AP foot film findings are seen in hindfoot valgus? Line bisecting talus does not project along 1st metatarsal but rather projects medially, and line bisecting calcaneous does not project through 4th metatarsal but rather projects medially.
Painful pes planus. Top Dx? tarsal coalition (subtalar, calcaneonavicular, calcaneocuboid - only 10%)
What is ectrodactyly? lobster claw, aka split hand or cleft hand. Associated with chromosome 7q defect, many syndromes. Some: Ectrodactyly–ectodermal dysplasia–cleft s., Split-Hand-Foot s., Silver-Russell s., Cornelia de Lange s., Acrorenal s., Focal dermal s.
T/F: The pericardial thickening seen in restrictive pericarditis is diffuse. Focal pericardial thickening does not cause restriction. False. Focal pericardial thickening can cause restriction.
Which findings help to distinguish constrictive pericarditis from restrictive cardiomyopathy?: conically shaped ventricles, biatrial enlargement, ventricular hypertrophy, abnormal delayed enhancement, pericardial thickening, septal bounce Ventricular hypertrophy and abnormal delayed enhancement are seen in restrictive cardiomyopathy, while pericardial thickening and septal bounce are seen in constrictive pericarditis. Conically shaped ventricles and biatrial enlargement are seen in both.
What is the upper limit of normal myocardial thickness on cardiac MR? 10 mm
Classic cause of restrictive cardiomyopathy? Tx? cardiac amyloidosis. See deposits in first in the subendocardium circumferentially, plus atrial walls and valves, then diffuse deposition later involving all chambers. Tx: Transplant, eventually.
Restrictive cardiomyopathy with deposits in subendocardium circumferentially, plus atrial walls and valves. Top Dx? cardiac amyloidosis
Young person with cardiac arrest. MR shows dilated RV with focal thinning, signal abnormality (higher than myocardium), dyskinesis/hypokinesis. Top Dx? arrhythmogenic right ventricular dysplasia (ARVD). Genetic, fibrofatty deposition, sudden death, tx: AICD.
What percentage of atrial myxomas occur in the RV? 20%. The vast majority occur in the LV (80%). Almost all (RA or LA) are septal-based. Myxomas CAN calcify (half).
Most common source for T2 bright, vividly enhancing cardiac mass? (primary or met?) met: melanoma (T1 bright), lung, breast, RCC, HCC, lymphoma. Mets are more common than angiosarcoma.
Cardiac MR shows a T1 bright, T2 bright, vividly enhancing mass. Top Dx? melanoma metastasis
Myocardial bridge has no association with sudden death. So, what health implications are associated and why should it be reported? affects surgical approach for CABG, etc.
What is the classic location for a left ventricular pseudoaneurysm after myocardial infarction? What vessel is most implicated? inferior wall, RCA territory. Worrisome for impending rupture, rapid death.
What is the difference between an active error and a latent error in risk management? Active: human-machine or caregiver-patient error (front line, sharp end). Latent: systemic, organizational, or design error.
What is this called?: structured method to analyze adverse event to identify problems that increase likelihood of error, reconstruction of event, multidisciplinary review, goal to prevent future harm by eliminating latent errors root cause analysis (RCA)
What is EMTALA? Emergency Medical Treatment and Active Labor Act (1986). Prevents hospitals from rejecting patients, refusing to treat, or transferring away because of inability to pay or because Medicare/Medicaid beneficiary
What is this process called?: certification/accreditation for modalities, certification/training of technical staff, certification, training and subspecialization of radiologists, and peer review quality assurance (QA)
What is this process called?: monitoring for minimal standard, compliance with mandated quality standards (MQSA), holding radiologist responsible for exam quality, staff member and physicist responsible for modality-specific quality quality control (QC)
What is this process called?: method to increase quality over time, DMAIC (Define, Measure, Analyze, Improve, Control – from Six Sigma, intended to reduce variation in processes), PDSA (Plan, Do, Study, Act – provides structure to change management) quality improvement (QI)
T/F: Anuric patients with ESRD should NOT receive iodinated contrast material IV due to risk of further injury to the kidneys. False. Per ACR Manual on Contrast Media v. 9 (2013), there is no increased risk of further renal injury.
Per ACR Manual on Contrast Media v. 9 (2013), who should have SerCr checked prior to receiving IV iodinated contrast? age >60, renal disease/transplant/absence, HTN, DM, metformin. NOT general population.
T/F: Gadolinium agents are nephrotoxic at approved dosages for MR imaging, which is why GFR is important. False. Gado is not nephrotoxic, but renal insufficiency raises risk of NSF.
Gadolinium-based contrast agents can interfere with what lab test? serum calcium (Gd causes falsely low results)
If considering epi for laryngeal edema after IV contrast for CT, what is the dose for IV per ACR Manual on Contrast Media v. 9 (2013)? Max dose? 1-3 mL of “cardiac epi” 1:10,000 (=0.1-0.3 mg). For IM, give 0.3 mL of 1:1,000 (same dose, 0.3 mg). Max cumulative dose if repeated: 1 mg.
Per ACR Manual on Contrast Media v. 9 (2013), what is the medication/dose for severe/persistent hypotension with bradycardia after IV contrast for CT? Max dose? Vagal reaction: atropine 0.6-1.0 mg SLOW IV, up to a max of 0.04 mg/kg (2-3 mg)
For patients under age 30, how many renal cysts are required to diagnose ADPCKD? only two total between both kidneys, can be unilateral or bilateral
For patients age 30 to age 59, how many renal cysts are required to diagnose ADPCKD? two cysts in EACH kidney
For patients over age 60, how many renal cysts are required to diagnose ADPCKD? 4 cysts in EACH kidney
What are the top 3 causes of cortical nephrocalcinosis? acute cortical necrosis, chronic glomerulonephritis, and oxalosis
For renal artery Doppler evaluation, what is the upper threshold of normal ratio of main renal artery to aorta peak systolic velocities? 3.5 (unitless)
For transplant renal artery Doppler evaluation, what is the upper threshold of normal ratio of main renal artery to external iliac artery peak systolic velocities? 2.0 (unitless)
What is the DDx for reversed diastolic flow in a transplant renal artery? Name 4. renal vein thrombosis, severe rejection, ATN, subcapsular hematoma
In ultrasound evaluation of a thyroid mass, what are 3 characteristics favoring benign pathology? cystic or predominantly cystic, comet tails, spongiform/honeycomb pattern
Ultrasound of a thyroid mass shows an anechoic nodule with punctate hyperechoic foci having comet tails. Top Dx? colloid cyst
Ultrasound of a thyroid mass shows a heterogeneously hypoechoid nodule with spongiform or honeycomb pattern and flow in the sepae on color Doppler. Top Dx? benign hyperplastic nodule
In ultrasound evaluation of a thyroid mass, what are 6 characteristics favoring malignant pathology? microcalcifications (most commonly papillary), coarse calcification (papillary and medullary), solid hypoechoic, shape taller than wide, poorly defined margin (favors anaplastic), abnormal ipsilateral neck lymph nodes (esp if microcalcs or cystic change)
T/F: Cystic change in a lymph node ipsilateral to an indeterminate thyroid nodule on ultrasound favors benign etiology. False. Cystic change in a lymph node is worrisome finding, whereas cystic change supports benign etiology in the thyroid mass per se.
Thyroid ultrasound shows innumerable micronodules throughout both thyroid lobes with pseudolobulations and fibrotic septae. Top Dx? Hashimoto thyroiditis (correlate with history)
Thyroid ultrasound shows a posterior margin hypoechoic mass with teardrop shape, tapered margins, oriented parallel to the thyroid lobe, with prominent Doppler flow at one pole. Top Dx? parathyroid adenoma (correlate with history)
Testicular microlithiasis on ultrasound: What classifies as classic vs. limited? classic=5 or more per field of view (FOV). Limited = 4 and under.
What cystic lesion is associated with tubular ectasia of the rete testis? spermatocele, usually in the epididymal head (not epididymal cyst, which can occur anywhere in the epididymis)
In what circumstance is a varicocele worrisome when seen on testicular ultrasound for infertility workup? A unilateral RIGHT varicocele suggests IVC thrombus or retroperitoneal mass causing obstruction. Bilateral or unilateral left is common, due to L renal vein drainage.
What is the most common benign solid epididymal tumor? adenomatoid tumor, benign mesothelial neoplasm found in both female and male genital tracts, most commonly male testicular adnexa (60% of benign adnexal tumors, 30% of all). Other cell types: leiomyoma (11%), papillary cystoadenoma (9%). PMID: 802862
What is the DDx for diffuse endometrial thickening? Name 5. endometrial cancer, hyperplasia, endometritis, hematometrocolpos, tamoxifen therapy (irregular with cystic changes)
What is the DDx for focal endometrial thickening? Name 3. polyp, submucosal or pedunculated fibroid, blood clot
How does tamoxifen therapy alter the risk of uterine abnormalities? 2-5x increased risk of polyp formation and risk of endometrial cancer
What is the difference between an ovarian follicle and a benign follicular cyst? Follicular cyst persists beyond 1 cycle
Describe the 3 distinct phases of endometrial complex and their appearances on ultrasound. Early proliferative postmenstrual: thin middle echogenic line surrounded by thin hypOechoic region. Late prolif: thin echogenic line surrounded by thick hypOechoic regions. Secretory: Thick echogenic complex.
Young healthy woman with concern for pelvic mass. Pelvic US shows simple round 2.6 cm cyst attached to but not within the ovary. O/W normal. Top Dx? para-ovarian cyst. Wolffian duct remnant. Mgt: do nothing. No f/u needed if <3 cm.
Young healthy woman with concern for pelvic mass. Pelvic US shows simple round 4.1 cm cyst attached to but not within the ovary. O/W normal. Top Dx? para-ovarian cyst. Wolffian duct remnant. Mgt: f/u to confirm stable since >3 cm.
Young woman w/ concern for pelvic mass, h/o ruptured appendicitis as child. Pelvic US: multiloculated fluid w/ geometric margins, irregular shape conforming to pelvic structures, ovary located on edge of collection. O/W NL. Top Dx? peritoneal inclusion cyst. Ovulated fluid bound by adhesions.
Where does the normal yolk sac reside? Inside or outside the amniotic sac? outside, within the chorionic sac. Fusion by 16 wks. Normal size of yolk sac <6 mm. Above this, possibly nonviable.
What is the rate of malignant transformation of a mature cystic teratoma? What are the risk factors? 0.2-2% rate of malignant degeneration. Risk factors: age >50, size of teratoma >10 cm
What are suspicious features of teratoma malignant degeneration? What is the most common cell type? interval growth, central flow, isoechoic branching structures, solid areas with flow. Usually SCC.
What percentage of endometriomas degenerate into malignancy? Most common cell type? 1% risk of malignant degeneration. Usually endometroid or clear cell carcinoma. Risk factors: age >45, size >9 cm.
What size of simple ovarian cyst merits yearly follow-up in a premenopausal woman? What about a postmenopausal woman? Premenopausal: >5 cm but <=7 cm. Postmenopausal: >1.0 cm to <7 cm. Beyond 7 cm, MRI or surg consult is recommended. No need to mention <3 cm cyst in a pre-. PMID: 20505067
How does MSD and CRL relate in a normal 1st trimester pregnancy? MSL-CRL. MSD minus CRL should be greater than 5 mm. If less than 5 mm (small sac; oligohydramnios), then poor prognosis, probable demise.
During what gestational period (in weeks) is the normal rhombencephalon seen? 8-11 wks
During what gestational period is it normal to see midgut herniation (“gastroschesis”)? 8-12 wks
For partial and complete molar pregnancy, answer the following questions: Is fetal tissue present? Karyotype? serum bHCG level (nl, mod hi, very hi)? Malignant potential? Partial: Fetal tissue present, usually triploid 69XXY, moderate bHCG elevation, low-moderate malignant potential. Complete mole: No fetal tissue, euploid 46 both paternal usually XX, marked bHCG elevation, 15-20% malignant.
What condition that simulates molar pregnancy has low serum bHCG and no malignant potential? hydropic degeneration of placenta (failed pregnancy)
Under what circumstance should suspicion of ectopic pregnancy remain elevated even after finding a normal IUP? In other words, who has high heterotopic risk? ovulation induction (assisted reproduction)
What is the DDx for a pregnancy of unknown location? (+bHCG but no IUP or ectopic on US) very early IUP, failed IUP (aborted), or ectopic pregnancy. F/U serial bHCG, US.
What is the expected doubling time for serum bHCG in normal pregnancy? 2 days
What is the most common cause of fetal hydrops? immune hydrops (Rh incompatibility). Can also see in anti-Kell or anti-Duffy antibody incompatibility. Many causes of nonimmune hydrops: cardiac, chromosomal, etc.
What is the DDx for ventriculomegaly? Name 5. Chiari II, Dandy Walker, aqueductal stenosis, intracranial hemorrhage, encephalocele
What 2 syndromes are most commonly associated with cleft lip/palate? trisomy 21, trisomy 18
What is the DDx for fetal chest mass? Name 5. CPAM, sequestration extralobar, CDH, bronchogenic cyst, teratoma
Fetus with massive multiloculated chest mass, no draining vein or connection to bowel, and ascites and skin edema. Top Dx? cardiac hydrops due to CPAM compressing the heart
CPAM and sequestration: Which most often spontaneously regresses? Most CPAMs spontaneously regress. Half of sequestrations regress without tx.
What is the DDx for large echogenic kidneys? Name 3. ARPKD, Meckel Gruber, trisomy 13
What is the most important thing to look for in a cirrhotic liver other than mass? venous thrombus. Also eval portal HTN, hepatic veins, spleen, varices.
What 2 populations have higher incidence of hepatic adenoma? women taking OCPs, and GSD 1 (von Gierke disease). Resect if >5 cm due to hemorrhage risk (or may stop OCPs and see if regresses).
What is the DDx for target lesions in the liver on ultrasound? Name 5. mets, lymphoma, leukemia, sarcoid, fungal infection (per Duke Review 2013, Haystead)
Top 3 causes of cholecystoduodenal fistula? gallstone, penetrating duodenal ulcer, xanthogranulomatous cholecystitis (lipid-laden foamy macrophages, chronic cholecystitis, GB equivalent of XGP)
What is a multiseptate gallbladder? congenital malformation resulting in persistent fine septations, incomplete vacuolization, “wrinkled” GB wall
What is the best 1st imaging in evaluation of critical leg ischemia (rest pain, ulceration, gangrene)? catheter angiography, so that tx can be performed if/when stenosis is found
What 3 MR contrast agents are cleared by other than renal excretion? Gadobenate dimeglumine (Multihance), gadoxetic acid disodium (Eovist), and gadofosveset (Ablavar) are eliminated through a combination of renal and hepatobiliary pathways.
What is the most appropriate initial imaging study (if any) for an otherwise healthy woman with low-grade fever, pyuria, and increased white cell count? No imaging. Abx should be started empirically for pyelonephritis, with expected response within 72 hrs. CECT if complicated pt (diabetic, imm(-), stones, or not responding to tx).
What imaging modality best depicts perineural tumor spread? C+ fat-sat T1 MR
For a given gradient, what effect does decreasing the receive bandwidth on slice thickeness? decrease slice thickness (thinner slices)
What effect does increasing rBW have on SNR in MRI? Increasing rBW causes a decrease in SNR by the sqrt(rBW). IOW, doubling the rBW causes a 1/(sqrt 2)=1/1.41=0.71 change (or 29% drop) in SNR. SNR proportional to [voxel size * sqrt number of measurements] / [sqrt rBW].
At what age does ACR recommend imaging for a case of hematospermia? >/= 40yo, due to concern for prostate CA. Under age 40, hematospermia is overwhelmingly idiopathic and benign.
In MRI, what changes in TE and TR cause an INcrease in SNR? shortening TE and/or lengthening TR. Proton density sequences (short TE, long TR) have the highest SNR of all spin echo sequences.
What types of sequences (SE, FSE, GRE, or EPI) can show in and out of phase phenomena (chemical shift of the 2nd kind)? only seen on gradient echo sequences. Usually in- and out-of-phase sequences are T1W GRE.
Which T-weighting is affected by changes in TE? T2. Shortening TE results in DEcreased T2 weighting. Shortening TR results in INcreased T1 weighting. So, short TE & TR leads to T1WI, long TE & TR leads to T2WI, and short TE & long TR minimizes T1 & T2 weighting leading to proton spin density weighting.
Which T-weighting is affected by changes in TR? T1. Lengthening TR results in DEcreased T1 weighting. Lengthening TE causes INcreased T2 weighting. So, long TE & TR leads to T2WI, short TE & TR leads to T1WI, and short TE & long TR minimizes T1 & T2 weighting leading to proton spin density weighting.
False profile hip radiographs are used in the evaluation of what suspected anomaly? hip dysplasia
Mid-age woman with 4 cm hypoechoic pelvic mass, multiloculated mix cystic and solid with calcifications and dark T2 in the solid components. Top Dx? Brenner tumor. Most are small, under 5 cm. Derived from ovarian surface epithelium undergoing transitional cell metaplasia. Excise. Vast majority are benign, but atypical and malignant variants occur.
When malignant degeneration occurs in an endometrioma, what is/are the usual cell type(s)? clear cell and endometrioid variants. Look for an enhancing solid component.
AIDS patient with acute renal failure, diffuse bilateral enlargement with hyperechoic renal parenchyma. Top Dx? HIV-associated nephropathy (HIVAN)
What particular infectious agent is associated with chronic PID in the setting of an IUD? actinomyces
Young woman with history of multiple ectopic pregnancies. HSG shows multiple small fallopian tube diverticula extending from lumen into the wall. Top Dx? salpingitis isthmica nodosa. Bilateral in 60-80% of cases. Decreased free spillage suggests worse severity, scarring.
Name and differentiate 4 causes of hematosalpinx. tubal ectopic pregnancy (hx, bHCG), endometriosis (common), tubal carcinoma (look for irregular mass, invasion), and tubal distension with refluxed menstrual blood (cervical stenosis, congenital vaginal septa, imperforate hymen)
What are differentiating features (tendencies) of retroperitoneal nodal metastasis patterns of seminomatous, nonseminomatous, and anaplastic testicular cancer and testicular lymphoma? seminomatous=large, bulky nodal mets; nonseminomatous=numerous small nodal mets; anaplastic and lymphoma=confluent nodal mets. Ref: RadPrimer (entry by M Heller)
What is a hydatid cyst of Morgagni? pedunculated paratubal cyst (related to paraovarian cysts) in close contact with the fimbriated end of the fallopian tube
Young woman with pedunculated paratubal cyst in close contact with the fimbriated end of the fallopian tube. Top Dx? hydatid cyst of Morgagni (subset of paratubal cysts, which are related to paraovarian cysts)
Mid-age woman with multilocular, predominantly cystic mass with an intensely enhancing solid component. Top Dx? struma ovarii due to intense enhancement, but mucinous adenocarcinoma may look similar. Struma ovarii (containing functional thyroid tissue) is a form of germ cell tumor like teratoma, so expect to find complex cystic features.
Woman with endometrial biopsy-proven cancer. Tumor confined to the uterus with <50% invasion of the myometrium. What is the 2009 FIGO stage? stage IA. Dynamic multiphase contrast-enhanced imaging and DWI increase the accuracy of T2-weighted imaging for depicting the depth of myometrial invasion.
Woman with endometrial biopsy-proven cancer. Tumor confined to the uterus with ≥50% invasion of the myometrium. What is the 2009 FIGO stage? stage IB. Dynamic multiphase contrast-enhanced imaging and DWI increase the accuracy of T2-weighted imaging for depicting the depth of myometrial invasion.
Woman with endometrial biopsy-proven cancer. Tumor invades the cervical stroma but does not extend beyond the uterus. What is the 2009 FIGO stage? stage II. Enhancement of cervical mucosa on delayed images (3 min) excludes cervical stromal invasion.
Woman with endometrial biopsy-proven cancer. Tumor invades through the myometrium with serosal or adnexal invasion but no nodal involvement. What is the 2009 FIGO stage? stage IIIA. Dynamic multiphase contrast-enhanced imaging and DWI increase the accuracy of T2-weighted imaging for depicting the depth of myometrial invasion.
Woman with endometrial biopsy-proven cancer. Tumor invades through the myometrium with vaginal or parametrial involvement but no nodal involvement. What is the 2009 FIGO stage? stage IIIB. Parametrial invasion precludes cure by radical hysterectomy. These pts need chemo/RT.
Woman with endometrial biopsy-proven cancer. Tumor invades through the myometrium with metastasis to pelvic but not paraaortic lymph nodes. What is the 2009 FIGO stage? stage IIIC1
Woman with endometrial biopsy-proven cancer. Tumor invades through the myometrium with metastasis to pelvic and paraaortic lymph nodes. What is the 2009 FIGO stage? stage IIIC2
Woman with endometrial biopsy-proven cancer. Tumor invades through the myometrium with extension to the pelvic wall but no lymph node metastasis. What is the 2009 FIGO stage? stage IV
Woman with endometrial biopsy-proven cancer. Tumor invades through the myometrium with involvement of the lower one-third of the vagina but no lymph node metastasis. What is the 2009 FIGO stage? stage IV
Woman with endometrial biopsy-proven cancer. Tumor invades through the myometrium with hydronephrosis but no lymph node metastasis. What is the 2009 FIGO stage? stage IV
Woman with endometrial biopsy-proven cancer. Tumor invades through the myometrium with invasion of bladder or bowel mucosa but no lymph node metastasis. What is the 2009 FIGO stage? stage IVA
Woman with endometrial biopsy-proven cancer. Tumor invades through the myometrium with involvement of abdominal and/or inguinal lymph nodes. What is the 2009 FIGO stage? stage IVB
What type(s) of endometrial carcinoma can involve peritoneal metastasis and serosal deposits similar to the pattern seen in ovarian CA? type 2 (serous papillary & clear cell). These, along with grade 3 (poorly differentiated) type 1 (endometrioid) adenocarcinomas, demonstrate more aggressive biology, have 50% pretest probability of locally advanced or distant disease at manifestation.
Who gets granulosa cell tumors? peri- and postmenopausal women, mostly. Estrogen-secreting tumors, cause endometrial hyperplasia, polyps, carcinoma.
What are the most common virilizing ovarian tumors? Sertoli-Leydig cell tumors. Well-defined enhancing solid mass with small internal cysts. These androgen-secreting tumors usually occur in young adults, teens.
Purely solid enhancing ovarian mass composed of T1 dark T2 iso/hyperintense lobules divided by septa that are best visualized on T2WI is the most characteristic appearance of what tumor cell type? dysgerminoma, aka germinoma, female equivalent of seminoma
Man with biopsy proven prostate cancer. Imaging shows tumor in both sides of the prostate, but no extension outside or distant metastasis. What is the clinical Tumor (T) stage? T2c. (T2a is one side, less than half of the lobe. T2b is still one side, but more than half of the lobe.)
What is the highest clinical Tumor (T) stage of prostate cancer that is undetectable by imaging? T1c. Found on needle biopsy performed in response to elevated PSA. (T1a is incidentally found on TURP for BPH, <5% involvement. T1b is incidentally found on TURP, >5% involved.)
Man with biopsy proven prostate cancer. Imaging shows extension into a seminal vesicle, but not into surrounding tissues, and no distant nodes or other metastasis. What is the clinical Tumor (T) stage? T3b. Extension outside prostate, but not into seminal vesicles or any other surrounding structures would be T3a. T4 tumor involves levator ani, rectum, bladder, and/or pelvic sidewall.
Man with biopsy proven prostate cancer. Imaging shows extension into levator ani, but no distant nodes or other metastasis. What is the clinical Tumor (T) stage? T4. This stage includes an involvement of levator ani, rectum, bladder, and/or pelvic sidewall. If only seminal vesicle is involved, then it is stage T3b.
Man with biopsy proven prostate cancer. Imaging shows extension into rectum, but no distant nodes or other metastasis. What is the clinical Tumor (T) stage? T4. This stage includes an involvement of levator ani, rectum, bladder, and/or pelvic sidewall. If only seminal vesicle is involved, then it is stage T3b.
Man with biopsy proven prostate cancer. Imaging shows extension into bladder, but no distant nodes or other metastasis. What is the clinical Tumor (T) stage? T4. This stage includes an involvement of levator ani, rectum, bladder, and/or pelvic sidewall. If only seminal vesicle is involved, then it is stage T3b.
Man with biopsy proven prostate cancer. Imaging shows extension into pelvic sidewall, but no distant nodes or other metastasis. What is the clinical Tumor (T) stage? T4. This stage includes an involvement of levator ani, rectum, bladder, and/or pelvic sidewall. If only seminal vesicle is involved, then it is stage T3b.
T/F: ADPCKD have cysts in the kidneys, usually liver, and possibly pancreas, and typically eventually experience renal failure. True. Liver cysts in 75%. Pancreas cysts in 10%. 50-75% progress to renal failure needing dialysis by age 70-75.
What is the most sensitive method for detection of malignant degeneration in an endometrioma? subtraction images derived from contrast-enhanced and unenhanced T1WI
Encapsulating peritoneal sclerosis is an complication of what chronic therapy? continuous ambulatory peritoneal dialysis (uncommon complication)
Large well-circumscribed uterine mass with speckled pattern of T2 hyperintensity on MR, with intense enhancement of the T2 foci on postcontrast T1. Top Dx? edematous fibroid/leiomyoma. May be a precursor to degeneration. Necrosis would not enhance.
“Paintbrush” appearance of renal medullary pyramids on reformatted excretory phase postcontrast CT images is classic for what disease? medullary sponge kidney (with tubular ectasia)
T/F: Peritoneal inclusion cysts are loculated tubal fluid collections that become trapped by adhesions, causing displacement of pelvic structures. False. The loculated fluid of a peritoneal inclusion cyst (PIC) typically envelopes the ovary (which secretes the fluid -- not the fallopian tube) and fills the pelvis WITHOUT mass effect on adjacent structures.
In benign prostatic hypertrophy, which portion of the prostate gland is involved? transitional zone between central and peripheral zones, with compression of these zones
In which patients are pancreatic cysts more common: those with VHL? or patients with ADPCKD? VHL. 50-91% of VHL patients have simple pancreatic cysts, compared with only 10% of ADPCKD patients.
What is the range of photon energies at which Compton scatter interactions are the most probable interaction? 26 keV to about 30,000 keV (30 MeV)
What is the most radiosensitive phase in the cell cycle? Least radiosensitive phase? M is the most sensitive. S is least sensitive. G1 is the second least sensitive.
T/F: In helical CT scanning, increasing the beam width while keeping pitch at 1.0 causes overlapping scans. False. If pitch remains at 1.0, there is no overlap. Increasing beam width results in faster table speed, decreased scan time, and less potential for motion artifact.
T/F: In helical CT scanning, increasing the beam width while keeping pitch constant causes an increase in table speed. True.
T/F: In helical CT scanning, decreasing the beam width while keeping table speed constant requires a increase in pitch. True.
T/F: The radiation dose threshold for nonstochastic effects is on the order of 1-2 Sv. False. Wrong units. High acute dose is expressed in Gray, absorbed dose. Sievert (dose equivalent) is a measure of stochastic (probabilistic) effects (cancer, genetic defects), not deterministic effects (erythema, necrosis, or acute radiation sickness).
T/F: Tissue weighting factors (W sub T) are used to communicate tissue sensitivities to stochastic (probabilistic) effects (cancer, genetic defects) as well as deterministic effects (erythema, necrosis, or acute radiation sickness). False. Tissue weighting factors are only used to communicate tissue sensitivities to stochastic (probabilistic) effects (cancer, genetic defects). High acute dose is expressed in Gray, absorbed dose.
What are the typical focal spot sizes for general radiography (CXR, etc)? Vascular interventional radiology? Mammography? 1.2 mm (large) and 0.6 mm (small) for general radiology. 1.0 mm and 0.3 mm for vascular IR. 0.3 mm and 0.1 mm for mammography.
How do typical filament currents compare to typical tube currents? (similar? different? by what factor?) Filament currents are MUCH HIGHER than tube currents, by a factor of at least 10. Filaments currents typically exceed 3000 mA, whereas tube currents range 50-800 mA.
What is “space charge limited” operation? What modality deals with this most? Below 40 kV (mammography), accumulated electron cloud surrounding heated filament does not instantaneously accelerate to the anode in the x-ray tube. Tube current is not linear with filament current, so compensation circuits ned to be implemented.
What is the relationship of focal spot size to edge blur (aka edge gradient) and projection geometry factors SID, SOD, and ODD? edge blur = focal spot size * ODD/SOD. At half SID distance, edge blur will equal the focal spot size. For a 1 mm focal spot on a 100 cm SID system with a phantom 25 cm from the detector, the edge blur will be 1 mm * 25 cm / 75 cm, or 0.33.
What happens in the F center of a phosphor material in a CR plate upon x-ray interaction? F center corresponds to trapped electrons from the europium ion dopant, which gives up an electron to become oxidized from +2 to +3 valent state (trivalent).
What is the most commonly used grid ratio in general purpose radiology (CXR, etc)? mammography? 12:1 for general radiology, and 5:1 for mammography
What is the upper limit of tolerance for the light field to xray field incongruence in all of projection radiolography? 2% of SID. For a typical 100 cm SID system, light field and xray field should be off by no more than 0.02*100 cm, or 2 cm. For a 60 cm SID mammograph, no more than 0.02*60, or 1.2.
In what way is beam geometry different in mammography from general radiography (aside from shorter SID)? The beam is centered at the chest wall side of the image, not in the center of the projected field.
For ACR mammography accreditation using the standard breast phantom, what is the minimum number of visualized objects (fibers, speck groups, masses)? 4 fibers, 3 speck groups, 3 masses
What is the fringe magnetic field strength line for public safety? Sensitive electronic function? 5 Gauss (0.5 mT); 1 Gauss (0.1 mT). 1 Tesla = 10,000 Gauss
At 1 T, what is the Larmor frequency? 42.5 MHz. Changes linearly with field strength, 42.5 MHz/T.
What is the range of typical gradient field strength used in MR? 1-10 mT/m
How does SNR change with change in voxel volume in MR? SNR changes linearly with voxel volume
How does SNR change with total number of excitations? SNR changes by 1/sqrt2 of change in number of excitations (which includes number of averages and number ofo phase encoding steps)
How does SNR change with BW? SNR changes by 1/sqrt2 of change in bandwidth.
Mid-age man with episodes of chest pain, intermediate pretest probability. Cardiac MRI 1st-pass perfusion: Explain a circumferential subendocardial low signal best differentiated at mid- to late-peak intraventricular signal intensity. artifact. Caution: if not completely circumferential or in setting of other evidence of myocardial injury, this could represent an atypical infarct.
What is the typical delay used in delayed myocardial enhancement (DME)? 12 min delay
Cardiac MR on a patient with other clinical evidence shows a small dark focus in the center of a transmural hyperintensity in the anterior myocardium on DME images. What is this? On delayed myocardial enhancement (DME) images, bright is bad, but dark inside bright is even worse. This represents microvascular obstruction from necrotic debris, a predictor of worse outcome.
Delayed enhancement of above what percentage of transmural myocardium is outcome of revascularization predicted to be so poor as to contraindicate this treatment? >75% transmural indicates nonviable. Revascularization is not likely to be of benefit.
22yo man with chronic proximal tibial pain. Radiographs show nearly hemispherical defect in cortex with mild sclerotic borders but without periosteal reaction. No matrix calcification. Top Dx? chondromyxoid fibroma (CMF)
Innumerable dark spots in an enlarged spleen, accentuated on in-phase MR images in comparison to opposed-phase images. Top Dx? Gamna-Gandy bodies (hemosiderin deposits from tiny hemorrhages) related to portal hypertension
Patient of Amish descent with short forearms and lower legs, post-axial polydactyly, widely spaced peg-shaped delayed teeth, cleft palate, epispadias, cryptorchidism, and sparse, fine textured hair. Top Dx? chondroectodermal dysplasia, aka Ellis–van Creveld syndrome
What are the definitions of “pitch,” collimator pitch, slice pitch, and detector pitch? “pitch” = collimator pitch = per-revolution table advance/beam collimation. “detector pitch" = slice pitch (multislice scanners only) = per-revolution table advance/width of a single detector row, which typically results in much higher pitch numbers.
In what CNS entity is the “mother-in-law” sign seen on catheter angiogram? meningioma. Contrast arrives early, stays late.
Young patient with headache. CT shows hyperdense material localized anterior to pons. Angiograms are negative x3. Top Dx? Tx? Prognosis? paramesencephalic subarachnoid hemorrhage, a spontaneous venous hemorrhage with no serious sequellae. Patients are usually young. No tx necessary.
Name 4 findings on head CT consistent with stroke, in order of earliest to latest. hyperdense vessel, insular ribbon sign (loss of GW-WM), loss of deep gray matter differentiation and density, loss of GW-WM in other sites
How is average cerebral blood flow (CBF) calculated in relation to cerebral blood volume (CBV) and mean transit time (MTT)? CBF(avg)=CBV/MTT
T/F: Older patient with parotid mass, confirmed on CT. Next step: biopsy. False. Do not biopsy a pleomorphic adenoma (which is what this is, most likely). High risk of seeding. While these lesions are overwhelmingly benign (aka benign mixed tumor), they can be locally aggressive.
What is the most likely histology of a bright T2 mass in the parapharyngeal space? pleomorphic adenoma. 1-5% “carcinoma ex pleomorphic adenoma.” Pearl: Smaller glands (rests, sublingual) produce more malignant tumors than larger glands like the parotid, where BMTs are overwhelmingly benign.
T/F: chondrosarcoma and chordoma can be differentiated by their relative intensity on on T2WI. False. Both are T2 hyperintense. Size is the best differentiator (chordomas midline, chondrosarcoma off midline centered at the petrooccipital synchondrosis/fissure (POS/POF).
Mid-age patient with MR showing a T2-bright extraaxial mass with incomplete suppression on FLAIR. Restricted diffusion. Top Dx? epidermoid (cystic). If completely suppresses on FLAIR, think arachnoid cysts. Dermoid should suppress on fat-sat.
From whence to NPCs arise? fossa of Rosenmuller. Nasopharyngeal carcinomas respond well to radiation and chemo, and are not typically resected. (Similar to lymphoma in this respect.)
Differentiate the patterns of restricted diffusion in a brain abscess and that in a necrotic tumor. In an abscess, restricted diffusion occurs in the center of the lesion. In a necrotic tumor, the central necrosis does not restrict centrally; rather, the restricted diffusion is around the tumor. DDx for ring enhancing tumor.
Name 3 adenomatous GI polyposis syndromes. Which has the lowest cancer risk? familial polyposis (FAP, AD-inh, 100% cancer risk), Gardner syndrome (AD-inh, 100% cancer risk), Turcot syndrome (AR-inh, high cancer risk but lowest of the three)
Name the 2 most common hamartomatous GI polyposis syndromes (NOT the rare Bannayan–Riley–Ruvalcaba syndrome, BRRS). Which of the 2 has the lowest cancer risk? Peutz‐Jeghers syndrome (AD-inh, low 2‐3% cancer risk) and juvenile polyposis syndrome (JPS, ?AD-inh, low 10% cancer risk, but highest of these two). Contrast to 100% cancer in adenomatous polyposes (FAP, Gardner, Turcot).
Name 2 mixed hamartomatous-adenomatous GI polyposis syndromes. Which has the lowest cancer risk? Cronkite‐Canada syndrome (unknown inh) and Cowden Syndrome (AD-inh). Both have roughly similar, low 10% cancer risk. Contrast to 100% for pure adenomatous polyposes (FAP, Gardner, Turcot).
How are Hounsefield units calculated? What is the equation? HU = 1000 x (µ measured - µ water)/µ water. Therefore, vacuum has HU -1000 (1000 times [[zero minus water] over water]), and water has HU zero (because water minus water equals zero).
Which Nuclear Regulatory Commission regulation deals with notices, instructions and reports to workers: inspection and investigations? 10 CFR Part 19
Which Nuclear Regulatory Commission regulation deals with standards for protection against radiation? 10 CFR Part 20
Which Nuclear Regulatory Commission regulation deals with medical use of byproduct material? 10 CFR Part 35
Young adult with multiple subcutaneous lipomas, macrocephaly, hemangiomas. Family history of rare hamartomatous polyposis. Top Dx? Bannayan–Riley–Ruvalcaba syndrome (BRRS). AD-inh PTEN gene mutation (like Cowden syndrome, Proteus syndrome, and Proteus-like syndrome, which 4 make up PTEN Hamartoma-Tumor syndromes, or PHTS).
What is Bannayan–Riley–Ruvalcaba syndrome (BRRS)? Rare AD-inh hamartomatous polyposis with multiple subcutaneous lipomas, macrocephaly, hemangiomas. PTEN gene mutation (like Cowden syndrome, Proteus syndrome, and Proteus-like syndrome, which 4 make up PTEN Hamartoma-Tumor syndromes, or PHTS)
From what cell type do carcinoid tumors originate? Kulchitzsky cells
In Barrett esophagus, where do the strictures occur? at the upper margin of metaplasia
What is the threshold thickness for suggesting malignant transformation in osteochondroma? greater than 1.5 cm
What is the classic mucosal pattern on esophagram in Barrett esophagus? fine cuboidal pattern. Normal esophagram should not have ANY pattern, just smooth.
How does receiver bandwidth relate to dwell tmie in all MR image aquisition sequences? dell time = inverse or rBW. Doubling the dwell time (same as narrowing the bandwidth to half) doubles the signal strength, thereby increasing signal to noise ratio by sqrt2, or 1.41.
At a fixed gradient, which takes longer: MR slice acquired with narrow bandwidth RF pulse? or one with a higher bandwidth? Narrow bandwidth RF pulses take longer than high bandwidth RF pulses (thicker slices). Ref: RadPrimer.
From what cell type do GISTs arise? cells of Cajal
What GI abnormality is common in any patient on an extended (>1 mo) regimen of daily proton pump inhibitor therapy? gastric polyps
In what part of the bowel tract does GI lymphoma occur most commonly? stomach
Of the following tumors, which can feature gastric polyps?: Peutz‐Jeghers syndrome, juvenile polyposis syndrome (JPS), Bannayan–Riley–Ruvalcaba syndrome (BRRS), Cronkite‐Canada syndrome, Turcot syndrome only Peutz‐Jeghers syndrome, Cronkite‐Canada syndrome, and Turcot syndrome. Patients with Bannayan–Riley–Ruvalcaba syndrome (BRRS) or juvenile polyposis syndrome (JPS) do not develop gastric polyps.
Where in the upper GI tract do fibrobrovascular polyps occur? What are they made of? always originate in upper 1/3 of esophagus. Can be fatty, fibrous, or mixed fatty-fibrous, in addition to vascularity.
Zenker vs Killian Jameson diverticulum: which is more common? Which is a true diverticulum? Zenkers are much more common, overwhelmingly false diverticula (2-3% are true), arise from hypopharynx (not esophagus) herniating through Killian dehiscence above cricopharyngeus (not a Killian Jameson diverticulum, which is a true diverticulum).
Name 4 forms that colonic lymphoma can take. extrinsic mass, apple core lesion, aneurysmal dilation, or submucosal lymphoid hyperplasia
Variceal dilation of what artery or arteries occurs in response to splenic vein thrombosis? Short gastric varices develop most commonly.
What is the eponymous name for the arterial collateral system connecting the gastroepiploic arteries and the transverse colon? arc of Barkow. Anastomosis of right gastroepiploic (branch of GDA) and left gastroepiploic (branch of the splenic), supplying the transverse colon with multiple ascending branches.
In what organs are congenital anomalies (agenesis or dysgenesis) found in association with seminal vesicle cyst? kidneys. Seminal vesicle cysts are also associated with vas deferens agenesis, as well as ectopic insertion of the ureter into the seminal vesicle, vas deferens, ejaculatory duct, or prostatic urethra.
Pelvic US shows innumberable cystic lesions that look like nabothian cysts, but with unusual aggressive appearance. Top Dx? adenoma magnum. Aggressive malignant adenomatous tumor of the cervix.
What is the canal of Nuck? female inguinal canal. Can have with cysts, rare hernias (more often femoral hernias, not inguinal).
What histologic cell layer is involved in adenomyosis? What implication does this have in choice of therapies? decidua basalis (not superficialis), located ectopically the myometrium. Does not respond to hormones like the superficialis.
Dystrophic bladder calcifications in a patient with prior history of non-GU malignancy. Top Dx? chemotherapy-related calcs in bladder wall from old ulcerations
Bladder extrophy has increased assocation with what malignancy? adenocarcinoma (like urachal remnant)
Bladder tumor with calcifications is most likely what cell type? adenocarcinoma. Calcification is extremely rare in TCC. SCC is rare, also rarely calcifies.
What 2 natural anticoagulants exist in the urinary system? urokinase and citrate
What is the likelihood of a 5 mm renal stone passing spontaneously? What about 7 cm? 10 mm? Roughly 50% of 5 mm stones pass. 30% of 7 cm stones pass. Stones 10 mm and above do not pass; need surgery. Rule of thumb: 10 mm minus size of stone x10% = likelihood of passing.
How long after a renal subcapsular hematoma does the complication of chronic hypertension typically develop? Hypertension from Page kidney has onset at months to years after event, so these patients need close follow-up for years.
Name 3 entities that can explain the development of renal subcapsular homogeneous-density mass? subcapsular renal lymphoma (look for nodes), subcap hemorrhage, or in a young child nephroblastomatosis (look for scalloping)
Name 5 causes of gonadal vein thrombosis. PID (pelvic abscess, inflammation), Crohn (granulomatous inflammation), RCC (invasion, compression), pregnancy (compression), any hypercoagulable state (including peripartum)
What are the adrenal contrast washout thresholds for calling a benign adenoma? What is the time delay for the delayed-phase CT? Delay at 15 min: >40 washout for relative, >60 for absolute (although many say 50% is adequate)
Adrenal thickening and loss of adjacent fat planes in an young patient in the ICU for acute illness. Normal adrenals at CT on admission. Top Dx? adrenal hemorrhage. Does not always present as a mass.
What is the acceptable threshold for dropout on opposed-phase MR images in the evaluation of potential microscopic fat? 15-20% drop between in-phase and opposed-phase images (or any visually appreciable dropout)
T/F: Bone scan is highly sensitive for neuroblastoma and is recommended for screening. False. NB can have symmetrical mets to metaphyses, so bone scan in a child is not sensitive enough to exclude metastatic disease. MIBG is used for routine screening.
What unique ultrasonography feature does microcystic adenoma share with hemangioma? Both can have posterior acoustic enhancement as well as being hyperechoic.
What 3 potential morbid complications must be excluded (or discovered) on any CT performed for pancreatitis? ”TAN.” Thrombosis (splenic vein or SMV), Aneurysm, Necrosis +/- abscess.
What is colon cutoff sign? In what entity does this classically occur? pancreatitis with enzyme leakage and inflammation coursing into the omentum and causing a focal transverse colon ileus
In MRI, how is receive bandwidth (rBW) related to the readout gradient strength, noise, and signal-to-noise ratio? What change in rBW increases chemical shift artifact? Weaker readout gradient narrows the rBW, which reduces noise, increasing the SNR, but with the disadvantage of increasing chemical shift artifact.
In MRI, how is receive bandwidth related to the number of frequency encoding steps and sampling time? receive bandwidth (rBW) = Nx / Tline where Nx is the number of frequency encoding steps and Tline is the total sampling time for a whole line of k-space.
In an adult patient with sudden onset of severe, disabling headache, what differentiates a perimesencephalic nonaneurysmal subarachnoid hemorrhage (pnSAH) from a SAH from an occult aneurysm (aSAH)? lack of blood products in the suprasellar cistern and/or lateral sylvian fissures in pnSAH. These do not recur and do not develop vasospasm. Exclude basilar tip aneurysm by CTA.
Name 9 entities featuring diffuse or multifocal bony sclerosis. (mnemonic) 3 M’S PROOF: Mets, Myelofibrosis, Mastocytosis, Sickle dz, Paget/Pyknodysostosis, Renal osteodystrophy, Osteopetrosis, Other (osteopoikilosis, osteopathia striata, multifocal melorheostosis, hyperthyroidism, hypoparathyroidism, athletes), Fluorosis
What is so sexy about diffuse or multifocal bony sclerosis? Can you name 10 causes? The mnemonic: “Regular Sex Makes Occasional Perversions Much More Pleasurable And Fantastic” Renal osteodystrophy, Sickle dz, Myelofibrosis, Osteopetrosis, Pyknodysostosis, Mets, Mastocytosis, Paget disease, Athletes, Fluorosis
Where is pain referred in spine lesions affecting the L3 distribution? L4? L5? S1? L3 distribution involves the anterior thigh region. L4 and L5 involve the foot. L5 and S1 involve the calf region. Notice the overlap. L5 can involve both foot and calf.
What is the expected T2 signal for a biliary hamartoma? hyperintense to liver (as are abscesses and most mets)
What is the only vascular ring in which the anomalous vessel course between the trachea and the esophagus? pulmonary sling
Name the 4 stages of neurocysticercosis. What are the main differentiating features? vesicular (iso to CSF, cyst with scolex), colloidal vesicular (acts like colloid cyst but marked enhancement, hyperdense with high T1, degenerating scolex), granular nodular (retracted walls, more nodular, still enhancing), and nodular calcified
Created by: dudall