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RadRes MegaPimp 4

How does SAR change in relation to echo train length? Radiofrequency SAR increases linearly with ETL (number of echoes per TR), which is why SAR can be an issue with echo planar imaging (EPI) techniques such as DWI and DTI.
If SAR = RF power deposition power per unit mass, why then is SAR not lower in larger patients? Radiofrequency SAR is increased linearly with patient size to maintain signal density.
What are these classic signs indicative of?: "painful bones, renal stones, abdominal groans, and psychic moans" hyperparathyroidism
Name 3 other names for benign gallbladder polyp. gallbladder cholesterol polyp, focal gallbladder cholesterosis, polypoid cholesterosis. Don't let the "cholesterol" component throw you. It's the same thing as a "benign polyp." They can have vascularity. Carcinoma and metastasis remain in the DDx.
What types of metastatic disease can result in an echogenic liver mass, to be considered in the DDx of hemangioma on US? neuroendocrine tumor, carcinoid, or renal cell carcinoma
1 yr old baby with lethargy and colicky abdominal pain. Radiograph shows paucity of bowel gas centered in the upper abdomen. What is the most likely and concerning cause? intussusception. Proximal bowel (intussusceptum) invaginates into distal bowel (intussuscepiens).
What is the life threatening risk of air or fluid reduction of intussusception? tension pneumoperitoneum after perforation.
What is the typipcal age rage for intussusception? 3 months to 3 years. After this age, look for a lead point.
Small bubbles of air overlying the soft tissues in the groin in a child with abdominal pain and bloating. Top Dx? incarcerated inguinal hernia
Based on KDOQI, what is the preferred location for placement of a dialysis AV fistula? radiocephalic, then braciocephalic, then brachiobasilic (this last one has to be created then superficialized). Remember: Long term patencies of fistulas are much better than grafts.
What is the “rule of 6s” regarding evaluation of dialysis fistula function? 3 items: Lower limit of adequate flow = 600 mL/min. Depth below skin = 6 mm. Minimal outflow diameter = 6 mm.
Name 3 indications for conversion of G tube to GJ tube. aspiration, gastric outlet obstruction (GOO), and -- this last one really isn’t a good indication: gastroparesis (trouble with vomiting, malpositioning, should have a surgical GJ tube placed)
What are the 2 accepted indications for emergent percutaneous nephrostomy tube placement? Sepsis/pyonephritis, and rising Cr in setting of hydronephrosis.
What is the treatment for a type V endoleak? surgical. This is a “tension” endoleak, usually diagnosed by catheter angiogram after ruling out other endoleak types, and needs urgent management.
What is postthrombotic syndrome? all the clinical complications related to chronic venous stasis due to valve malfunction due to chronic clot
VQ scan: Linear “contour mapping” pattern on perfusion images, but no segmental perfusion defects. Top Dx? lymphangitic spread of tumor (metastatic if bilateral diffuse, primary lung CA if localized)
“Ribbon bowel” is a buzzword for what disease process? What does it look like? graft vs. host disease (GVHD). Effacement and thickening of folds resulting in featureless (atrophic) bowel loops on small bowel follow through.
What are the Milan criteria used for? Criteria for treating HCC with liver transplantation. For transplantation, a patient must have no more than 3 lesions, all less than 3 cm. If there is only one lesion, it can be up to 5 cm and still be resected. “1 less than 5, up to 3 less than 3”
Patient with cirrhosis and three HCC lesions measuring 2 cm, 2.4 cm, and 3.5 cm. Is he a candidate for transplantation as tx for HCC? No. Milan criteria: “1 less than 5, up to 3 less than 3”
Patient with cirrhosis and four small HCC lesions measuring 1.8 cm, 2.2 cm, 2.4 cm, and 1.2 cm. Is he a candidate for transplantation as tx for HCC? No. Milan criteria: “1 less than 5, up to 3 less than 3”
Patient with cirrhosis and a single HCC lesion measuring 5.4 cm. Is he a candidate for transplantation as tx for HCC? No. Milan criteria: “1 less than 5, up to 3 less than 3”
Patient with cirrhosis and three HCC lesions involving both lobes, measuring 2 cm, 2.4 cm, and 1.8 cm. Is he a candidate for transplantation as tx for HCC? Yes. Milan criteria: “1 less than 5, up to 3 less than 3”
Patient with cirrhosis and a single 4.8 cm HCC lesion involving the left lobe. Is he a candidate for transplantation as tx for HCC? Yes. Milan criteria: “1 less than 5, up to 3 less than 3”
Which types of CPAM have increased risk of malignancy? What are the most common cell types (name two)? All 3 CPAM types have risk of malignancy and should be resected. Most commonly pleuropulmonary blastoma, but also adenocarcinoma.
Which types of sequestrations have increased risk of infection? Both intralobar and extralobar sequestrations have increased risk of recurrent infections, and should be resected. Sequestrations look solid until they get infected, at which point they become connected to the airways.
What are the top 4 causes of free intraperitoneal air in first month of life? all are etiologies of perforation: NEC, spontaneous, iatrogenic, distal obstruction
T/F: Free intraperitoneal air in a newborn 1 week after surgery is routine and expected. False. Post-op free air in a newborn should resolve by 4-5 days. In adults, it takes longer: 2 weeks.
T/F: Free intraperitoneal air in an adult 1 week after surgery is routine and expected. True. Post-op free air in an adult should resolve by 2 weeks. In a newborn, it should be resolved by 4-5 days.
What are the four normal echogenic structures on neonatal brain ultrasound? choroid, pia mater of the sulci, vermis, ventral brainstem
What is the earliest appropriate age for hip ultrasound in the evaluation of possible developmental dysplasia of the hip (DDH)? Why? 4 weeks. Transplacental maternal estrogen in fetal circulation can cause loosening, takes 4 weeks to clear and effect to dissipate.
Radiographs in a newborn with complicated delivery show “crumpled paper” appearance. What is this classic for? osteogenesis imperecta (OI). DDx includes phosphatasia and other metabolic abnormalities.
What shunt ratio must be present in the newborn circulation for a right to left shunt to be visualized on chest radiograph? QP/QS must be greater than 2.
Name 4 lethal skeletal dysplasias. OI type II, thanatophoric dysplasia, asphyxiating thoracic dystrophy (ATD), homozygous achondroplasia
Late newborn with nonbilious vomiting has ultrasound not quite meeting criteria for HPS. What is this called? What is the management? Pylorospasm should be followed up at 1 week intervals to look for development of HPS.
What is the normal limit for cord descent in a newborn or child (or anyone)? Normal cord ends above the inferior endplate of L2.
Heterogenously hypoechoic and isoechoic adrenal mass in an infant subjected to birth stress is likely what Dx? What is the management? adrenal hemorrhage. F/U in 4 weeks. If persists, neuroblastoma is a significant possibility.
What are the risk factors for hypertrophic pyloric stenosis? First born male sex, age 2-7 weeks, maternal smoking, preterm, low weight, C-section, breech, congenital malformations
Infant with paraspinal mass. What URINE labs might be positive if this is neuroblastoma? VMA, HVA, metanephrines. homovanillic acid (HVA) from dopamine breakdown, normetanephrine from norepinephrine breakdown, metanephrine from epinephrine breakdown, and vanillylmandelic acid (VMA) from epi and norepi breakdown
What is Parsonage-Turner Syndrome (PTS)? aka idiopathic brachial plexopathy or neuralgic amyotrophy. Rare, abrupt onset, unilateral, pain, weakness, dysesthesias, numbness. Postop, postinfxn, posttrauma, postvax, unclear. Can last for months or years, usually self limited within 2 years.
What is Birt–Hogg–Dubé syndrome (BHD)? AD-inh, fibrofolliculomas on face and upper trunk, renal and pulmonary cysts, spontaneous pneumothorax - 24%, renal tumors - 14-34%.
What is the maximum force allowable for a power-driven mammography compression device? 25-45 lbs, or 111-200 newtons
What is the strawberry sign on fetal ultrasound and with what is it associated? strawberry-shaped skull (flattening of the occiput with pointing of the frontal bones) is associated with trisomy 18 (Edwards syndrome), about 80% of cases. Ref: PMID 1503648
Child with abdominal fullness, vomiting, and lethargy has US showing “bowel within bowel” measuring up to 1.5 cm in diameter in the left lower quadrant. The right lower quadrant shows no abnormality. What is the appropriate next step in management? Do nothing. This is too small and on the wrong side to be ileocolic intussusception. Rather, this represents ileoilial intussusceptions, which is transient.
Name two absolute contraindications to performing pneumatic (water or air) reduction of intussusception in a child with US-proven intussusception. pneumoperitoneum (perforation), or clinical signs of peritonitis (even without apparent perforation)
Elevated alpha-fetoprotein is associated with what pediatric tumor? hepatoblastoma. 90-95% have abnormal alpha-fetoprotein, and it is usually “sky high.”
What are the most common sites for metastasis in neurofibromatosis? Name two sites. liver and bone
What stage of neuroblastoma has the best prognosis? Choices are I, II, III, IV, and IV-S. Stage IV-S neuroblastoma has 100% survival, presents with marrow, skin, liver involvement at <1yo, often at birth, may spontaneously regress. The other stages have survivals of 90% (stage I, localized) to 10% (metastatic to bone in >1yo, very bad).
Hyperenhancing adrenal glands in a child s/p trauma suggests what phenomenon? SHOCK. Look for other signs such as shock bowel and make sure aggressive urgent fluid resuscitation is underway.
If you have the Modulation Transfer Function (MTF) curves for all of the components (subsystems) of an imaging system, how would you derive the MTF for the entire system? Multiple all of the subsystem MTFs. The system MTF is the product of its subsystem MTFs.
What is the k-edge of silver? 25.5 keV (or just 26)
Newborn with traumatic birth has renal US showing a “mass” of homogenous echotexture and moderate echogenicity superior to the kidney. What is the most appropriate management? F/U ultrasound in 4 weeks. Likely an adrenal hematoma, should resolve on its own, but neuroblastoma should be excluded. Because NB at this age is often self-limited with excellent prognosis, following up in 1 month has virtually no risk.
Post trauma patient undergoes MR for suspected carotid dissection. Which sequence is most helpful to establish the diagnosis? noncon fat-suppressed T1
Woman with HA that improves with lying down, worsens upon standing, o/w (-) PMH. T1+ images show pachymengeal enhancement, normal sized symmetric ventricles, patent dural venous sinuses, and a Chiari I malformation. Top Dx? intracranial hypotension due to (presumably acquired) Chiari I malformation
What is the upper acceptable limit for average glandular dose delivered to a standard test phantom in breast mammography? What view is used for this test? 3 mGy (0.3 rad). Performed in CC view.
Of the following MR acquisition techniques, which is least sensitive to susceptibility artifact?: GRE, spin echo, fast spin echo, echo planar? Put them in order from least to most sensitive. Fast spin echo is LEAST sensitive. Echo planar is MOST sensitive. FSE, SE, GRE, EPI
What effect does decreasing the flip angle have on T1 weighting in gradient echo MR pulse sequences? lowers T1 weighting. Also, increasing the time to repetition decreases T1 weighting.
What effect does increasing field strength have on relaxitivity of gadolinium contrast agents? decreases relaxivity (and therefore ??DECREASES?? tissue contrast.
What is the most sensitive modality/study for evaluation of non-accidental trauma? skeletal survey, more sensitive than bone scan (or even NaF PET), particularly in evaluation of metaphyseal corner fractures
What is the best modality for initial evaluation of suspected duplicated collecting systems on VCUG (drooping lilly sign)? Contrast enhanced CT? Ultrasound? MR? MAG3? renal ultrasound. Can evaluate upper system and detect ureteroceles.
Diffuse bilateral symmetric white matter disease in a child with developmental delay. Subtle transverse “tigroid” bands in the centrum semiovale. Top Dx? metachromatic leukodystrophy
Where are the neurologic effects of vitamin B12 deficiency most evident on imaging? spine: dorsal columns of the cord
Symmetric bilateral white matter disease with posterior predominance and enhancing leading edge in a child with developmental delay. Top dx? adrenoleukodystrophy
What is dolichocephaly? “long head” = scaphocephaly (“boat-shaped” head)
At what size is resection indicated for focal nodular hyperplasia because of increased risk of hemorrhage? There is no increased risk of hemorrhage in FNH. Resection should only be performed if the lesion causes unacceptable mass effect (obstruction, etc).
What part of the CT equipment corrects for beam hardening artifact? bow tie filter
What is the DDx for rapidly appearing airspace disease on CXR? 4 items edema, aspiration, hemorrhage, or infection in the immunocompromised patient
CC: small kneecaps. Knee radiographs show hypoplastic patellae. AP radiograph of the right iliac crest shows focal exostosis at the posterior flat portion of the iliac (horn). Top Dx? nail patella syndrome (NPS), aka hereditary onycho-osteodysplasia (HOOD syndrome). Posterior iliac horns is pathognomonic. Also: hypoplastic fingernails, elbow arthrodysplasia. May have scoliosis, scapular hypoplasia, cervical ribs, kidney disease. AD-inh
What is the risk of missing a malignancy when calling “multiple bilateral circumscribed masses” negative on mammography? Extremely low risk. Only 0.14% developed cancer in subsequent one-year interval. This is actually LESS than the general population (0.24%).
Spiculated mass on mammography. DDx? Name 5 possibilities. Cancer (mostly tubular ca), radial scar, post-op scar, granular cell tumor (needs complete wide local excision or will recur), and desmoids/fibromatosis (also recurs).
T/F: A breast mass that is hyperdense is less concerning than a mass that is isodense to glandular parenchyma. False. Hyperdense masses are highly suspicious: 70% are malignant, compared with 22% of isodense masses.
What is steatocystoma multiplex? Multiple sebaceous skin cysts on the anterior trunk, breasts, proximal extremities. Benign inheritied condition, most often seen in adolescents and young adults. Cosmetic only.
What is the appropriate management for architectural distortion on mammography that biopsy proves to be “radial scar?” Send for surgical consultation. Decision to excise is controversial. Studies vary: 0-15% have cancer upon excision.
Of the following patterns of calcification, which is/are not overwhelmingly benign?: skin calcs, vascular, rim calcs, coarse/popcorn calcs, large rod-like, round, lucent-centered, suture, dystrophic, or milk of calcium Round calcifications are suspicious when they are segmental, or unilateral diffuse. Can be BI-RADS 3 (6 mo f/u) if grouped round calcs on baseline mammography.
What is the appropriate management for coarse heterogeneous calcs on mammo? Biopsy, unless bilateral diffuse. Likely fibroadenoma, maybe evolving dystrophic calcs in fibrosis, but unacceptable risk of cancer.
Fine linear branching calcs are usually what pathology? DCIS (almost always)
What is the appropriate management for reddening and itching of the nipple without a clear history explaining the etiology? mammography to look for a mass to biopsy. If negative, do a nipple wedge resection (not as skin punch biopsy).
“Grouped” microcalcs on mammogram means [how many] calcs in [what volume] of tissue? at least 5 calcs in 1 mL
Palpable string-like cord under the skin of the breast, with mammogram showing asymmetric tubular density. Dx? Mondor disease (thrombosed superficial vein). No tx needed.
Baseline screening mammography shows asymmetric increased density with scalloped borders, no clear mass, occupying more than a quadrant. No palpable abnormality. What is this? Management? Global asymmetry. BI-RADS 3, 6 mo f/u. If stable after 2 years, then benign. If palpable or changes, biopsy is recommended.
Chronic bilateral nipple inversion. Is this a concern? No. Benign variant. Worry if unilateral, or new.
BI-RADS 5 lesion is biopsied. Path says benign. Management? Send for excision (lumpectomy). The reason core biopsy is indicated first is to prepare for sentinel node biopsy at time of lumpectomy, which is generally not done without a pathologic diagnosis of cancer.
Baseline screening mammography shows a lesion which workup reveals all the features of a fibroadenoma (well circumscribed hypoechoic parallel with rare lobulations, popcorn calcs) on both diagnostic mammography and ultrasound. Management? BI-RADS 3 -- 6 month followup, then at 12 months and 24 months, before back to screening.
What is a “radial fold,” “keyhole sign,” and “teardrop sign,” in terms of MR for breast implant evaluation? Silicon implants can have a fold (“radial fold”) that does NOT indicate rupture. Keyhold or teardrop signs indicate rupture, and can be seen along with linguine sign and subcapsular lines.
Woman sent for screening breast MR. The MR tech states that the patient’s screening reveals diabetes with chronic GFR 29. Management? Do not scan. Gadolinium is contraindicated. Breast MR without gadolinium is useless. Refer patient back to breast health clinic.
What is the conventional maximum size of a “focus” of enhancement on breast MR? less than 5 mm. Otherwise, call either a mass, or non-mass enhancement (NME).
Screening breast MR shows a single 3 mm focus with persistent enhancement pattern in the right breast. Management? Biopsy (BI-RADS 4). Can be called benign if multiple, bilateral.
What is Grid Ratio? grid height over HOLE diameter
What is the definition of “limiting resolution?” Best definition of limiting resolution is spatial frequency at 10% MTF.
What is the term for measurement of variance of noise in an image over its range of spatial frequencies? Noise Power Spectrum (NPS)
What is the best measurement of x-ray absorption efficiency and delivery of signal to noise of a particular detector? Detective Quantum Efficiency (DQE), which is equal to the square of actual SNR over the square of ideal SNR
Newborn with markedly dilated bilateral collecting systems on prenatal ultrasounds, distended abdomen lacking muscular tone, and cryptorchidism. Dx? prune belly syndrome(PBS), aka Eagle-Barrett syndrome. Oligohydramnios, pulmonary hypoplasia, 10% have cardiac anomalies. Almost all are male.
Fetal ultrasound shows enlarged bladder +/- hydronephrosis, dilated small bowel, abdominal wall laxity. What rare condition should be in the differential? Megacystis-microcolon. Extremely rare condition, far more common in females.
Patient with cysts and solid tumors in the kidneys, cysts in the lower lobes with history of spontaneous PTX, and chronic fibrous follicular nodules on face and upper trunk. Top Dx? Birt–Hogg–Dubé syndrome. AD-inherited.
What are the two types of parent/daughter decay equilibrium? Which is involved in nuclear medicine generators? transient equilibrium (parent decays, but at longer half-life than daughter, as used in Mo-99/Tc-99m generators), and secular equilibrium (parent has much longer half life, essentially no relative decay away)
Isolated septal perfusion defect on exercise-stress myocardial perfusion imaging without evidence of anterior, inferior, or lateral wall involvement suggests what diagnosis? Management? Patients with LBBB who undergo MPI using exercise- or dobutamine-induced stress (increasing the patient’s heart rate) may appear to have an isolated reversible or fixed septal perfusion defect. Get EKG to confirm.
What quality control test is used to assess for possible colloid formation in a Tc-99m labeled preparation (such as MDP)? How does colloid formation in the tracer preparation appear on a bone scan? colorimetric strip test. Marked uptake in the liver and spleen.
In shin splints, what pattern is expected on a 3-phase bone scan? Normal flow and blood pool, but increased delayed-phase uptake longitudinally (not focally) along the medial and lateral periostia of the tibiae.
No Doppler flow is demonstrated within a mass of dilated tubular structures in the right scrotum. Does this indicate thrombosis? No. Have the patient valsalva to elicit retrograde flow into this suspected varicocele. At rest, flow may be too slow to detect.
What virus is associated with PTLD in a transplant patient? EBV.
What virus is associated with Kaposi sarcoma in an AIDS patient? HHV-8
What is the most common CARDIAC abnormality associated with aortic coarctation? bicuspid aortic valve (seen in 50-80% of coarctation cases). PDA is also common (66%)
What sequence is used in the bright-blood cinegraphic MR evaluation of the heart? steady state free precession (SSFP - aka FIESTA, True Fisp) without contrast. ECG gated, holding breath. "T1/T2" weighting.
What sequence is used in dark-blood delayed enhancement MR imaging of the heart? double inversion recovery (DIR) gradient echo, 5-15 min after IV contrast. One inversion pulse nulls normal myocardium, while a separate inversion pulse nulls the blood pool.
Delayed enhancement MR images of the heart show an area of high subendocardial signal intensity in a coronary artery distribution. Dx? This pattern and transmural signal are both classic for scar or fibrosis from an old infarct (subendocardial or transmural). Ref: Vogel-Claussen. RadioGraphics 2006; 26:795–810
What extent (thickness) of myocardial scar or fibrosis on cardiac MR imaging indicates low likelihood for recovery of contractile function following coronary revascularization? Myocardial scar or fibrosis involving >50% of myocardial wall thickness on delayed enhancement MR should lead to a decision NOT to revascularize. If <50%, revascularization MAY be of benefit. Ref: Vogel-Claussen. RadioGraphics 2006; 26:795–810
T/F: A transmural area of high signal intensity in a coronary artery distribution on delayed enhancement MR is best attributed to old infarction. False. Unlike in ischemic heart dz, DE in nonischemic dz such as myositis generally does not correspond to a particular coronary distribution & is often midwall rather than subendocardial or transmural. Ref: Vogel-Claussen. RadioGraphics 2006; 26:795–810
Cardiac MR in a young patient with ventricular arrhythmias shows multiple T2-bright foci scattered throughout the left myocardium predominating in the septum, and demonstrating both early and delayed enhancement. Top Dx? Management? cardiac sarcoidosis. Subendocardial biopsy to confirm. Ref: Vogel-Claussen. RadioGraphics 2006; 26:795–810
What is the most common form of PAPVR? supracardiac (not scimitar, which is infracardiac)
T/F: Scimitar syndrome with pulmonary hypoplasia is associated with left to right shunt. True. There is pulmonary recirculation of oxygenated blood.
T/F: Scimitar syndrome is associated with VSD. False. No reported association.
32 M w/ sudden-onset severe R shoulder pain awakening him from sleep, some improvement in pain over 1wk but beginning progressive weakness in ext rotation. MR: diffusely increased fluid signal in supraspinatus, infraspinatus, and teres minor. Top Dx? Parsonage-Turner Syndrome (PTS), aka idiopathic brachial plexopathy. Postop, postinfxn, posttrauma, postvax, unclear. Can last for months or years, usually self limited within 2 years.
What lung tumor is classically associated with hypoglycemia? fibrous tumor of the pleura. Look also for signs of hypertrophic osteoarthropathy.
T/F: The best next step for management of a coughing patient with bilateral upper lung cavitary consolidations and masses on CXR is to further evaluate with CT. False. This patient likely has TB and should be isolated, with initial tests to include PPD and sputum cultures. CT is not needed for this diagnosis given the information provided.
What CT feature of the mesentery distinguishes diverticulitis from colon cancer in a patient with abdominal pain and focal thickening of the sigmoid colonic wall on CT? Edema in the root of the mesentery is fairly specific for an inflammatory/infectious condition rather than cancer. Treat with abx and follow up in 4-6 weeks to verify complete resolution. Colonoscopy if thickening persists.
Goblet sign on IVP is associated with what condition? TCC. Not stone. Stones would be picked up on plain KUB, before this kind of work up.
What diagnosis does “spongiform” appearance on thyroid ultrasound connote? benign hyperplastic nodule
What is the appropriate management for acute appendicitis with evidence of contained rupture and abscess on CT? percutaneous drain placement, not surgery
What is the appropriate next step for a patient in the ED for abdominal pain who has CT evidence of SBO and a cecal mass worrisome for carcinoma? colonoscopy, not surgery. Additional colon tumors must be excluded.
A 2 week old baby presents with dyspnea, heart failure, failure to thrive, and no cyanosis. CXR shows normal sized heart with interstitial edema. What uncommon abnormality of the atria should be included in the DDx, in addition to mitral stenosis? cor atriatum (sinistrum). Abnormal incorporation of pulm v structures into L atrium with fibromuscular membrane dividing left atrial chamber. Often have pulmonary hypertension. Usually fatal by age 2. Right atrial (dexter) variant exists.
Who gets femoral hernias? elderly women, classically
What landmark differentiates femoral hernias from inguinal hernias? pubic tubercle. If all of the hernia is lateral to the pubic tubercle, then femoral hernia is best Dx. Look for compression of CFV. If most or all of the hernia is medial to the pubic tubercle, then most likely inguinal hernia.
T/F: Takotsubo cardiomyopathy can present with elevated cardiac enzymes and ECG changes of STEMI and show balanced 3-vessel coronary narrowing. False. This stress-induced cardiomyopathy, aka transient apical ballooning or broken heart syndrome, can present with a true infarction, but is non-coronary. The vessels are normal on catheter angiography.
T/F: Systolic septal bounce distinguishes constrictive pericarditis from restrictive cardiomyopathy. False. Septal bounce is seen in constrictive pericarditis and not restrictive cardiomyopathy, but it occurs during diastole.
What is ventricular interdependence and in what condition is it present? In constrictive pericarditis, right ventricular filling INCreases during INSpiration, but the constrictive pericardium limits left ventricular filling (interdependence). During expiration, RV fills less so LV fills more, improving contraction.
What are the growth rate and the diameter limits for recommending follow-up vs surgical repair for ascending aortic aneurysm in a patient with Marfan syndrome? What is the recommended f/u interval? growth rate >= 5 mm/yr, or diameter >= 5.5 cm. CTA every 12 months for follow-up.
T/F: Treatment with anticoagulation is not recommended in a patient s/p RLL-ectomy with subsequent development of in situ thrombus in the pulmonary arterial stump. False. Most advocate treatment. Incidence of in situ thrombus in a stump is related to arterial stump length.
What are the three top cancers of the aortic arch, in order of incidence? Undifferentiated pleomorphic sarcoma is the most common histopathology. Then MFH (?same thing?). Then angiosarcoma.
What is the most commonly injured ligament in lateral ankle sprains? anterior talofibular ligament (ATFL)
Nonfatty soft tissue proliferation in the rotator interval and associated thickening of the IGHL with scant joint space fluid indicates what pathology? Who gets this? adhesive capsulitis. More common in WOMEN than in men, and more common in diabetics than in the general population.
What benign bone lesions have a characteristic exuberant surrounding edema on MR? chondroblastoma, osteoid osteoma, osteoblastoma
Pivot shift contusion (contusions in the lateral femoral condyle and posterior lateral tibial plateau) is reliably associated with what ligamentous injury? In what population is this finding NOT as well correlated? Almost all adults with pivot shift injury have an ACL tear. This is not reliable in children, however.
Young adult after knee injury. MR shows increased T2 signal in the lateral femoral condyle and posterior lateral tibial plateau. What is this injury called? What is associated with it? pivot shift contusion. Almost all adults with pivot shift injury have an ACL tear. This is not reliable in children, however.
T/F: PVNS never calcifies. True. (Essentially.) If there is calcium on XR or CT, then the diagnosis is more likely something else (like synovial osteochondromatosis).
Reticular thickening predominantly centered about the bronchovascular structures, interlobular septae, and pleura is associated with what structural component of the lung, and is most likely what disease? This is a perilymphatic pattern. Slight nodularity most strongly suggests sarcoidosis. No nodularity whatsoever would favor pulmonary edema. Strong (predominant) nodularity favors lymphangitic spread of tumor
What is the favored approached to biopsy in the tissue sampling of nonacute perilymphatic thickening on imaging? Transthoracic or transbronchial? bransbronchial biopsy. The disease will be present in the peribronchial tissues.
What syndrome is best associated with epididymal cyst? von Hippel Lindau
T/F: An anomalous left main coronary artery arising from the right coronary sinus and following a transeptal course to feed the LAD and LCx is a life-threatening condition and should be treated surgically. False. No risks above general population (also for prepulmonic and retroaortic course). However, the most common variant is interarterial, which more prone to cardiac death (“malignant”); CT surgery consultation. Ref: RadioGraphics 2012; 32:453–468
What is the definition of “high coronary artery origin?” Is this a concern? Origin of coronary artery >1 cm above sinotubular junction has no inherent hemodynamic consequence but may complicate catheterization or valve/aorta surgery. RCA variant is associated with bicuspid aortic valve. RCA variant >>LMCA.
How can a transeptal origin be distinguished from an interarterial course in the setting of anomalous orgin of coronary artery? Transeptal course has lower position, caudad to crista supraventricularis; surrounded by septal myocardium at some point; no oblong or slitlike orifice; downward dip (hammock sign at conventional angiography). Transeptal artery is usually the LAD or LMCA.
What is the 2010 SIR recommended pre-procedural prophylaxis for angiography, angioplasty, thrombolysis, closure device placement, and/or stent placement? Antibiotics are NOT routinely recommended. In cases of high risk of stent infection or other risk of infection, cefaxolin 1 gram IV can be used.
What is the 2010 SIR recommended pre-procedural prophylaxis for endograft placement? Antibiotic prophylaxis are ROUTINELY RECOMMENDED for endograft placement. First line: cephazolin 1 gram IV.
What is the 2010 SIR recommended prophylaxis for IVC filter placement? No antibiotics are routinely recommended. Very low risk of infection.
Per 2010 SIR guidelines, what groups of people undergoing placement of indwelling deep venous catheters should receive antibiotic prophylaxis? immunocompromised patients undergoing catheter placement before chemotherapy, or those with a history of catheter infection. First line: cefazolin 1 gram IV.
What is the 2010 SIR recommended pre-procedural prophylaxis for embolization or chemoembolization procedures? Abx ARE RECOMMENDED. No concensus on 1st-line recommendation. Cover skin and gut flora. Choices: Amp/sulbactam (Unasyn), cefazolin, amp/gent, and ceftriaxone (Rocephin). UC Davis: ceftriaxone 1g IV. Consider bowel prep if spincter of Oddi not intact.
What is the 2010 SIR recommended pre-procedural prophylaxis for UAE? Abx ARE RECOMMENDED. No concensus on 1st-line recommendation. Choices: cefazolin, clinda + gent, ampicillin, ampicillin/sulbactam. UC Davis: cefazolin 1 gram IV.
What is the 2010 SIR recommended pre-procedural prophylaxis for tumor ablation (RFA, etc)? No consensus. Lack of evidence. UC Davis: cefazalin 1gm IV AND metronidazole 500mg IV.
What is the 2010 SIR recommended pre-procedural prophylaxis for purcutaneous abscess drainage? Many will already be on broad-spectrum abx. If not, prophylaxis IS RECOMMENDED. Many possibilities. UC Davis: no specific recommendation. Probably depends on site of infection, attending preference.
What is the 2010 SIR recommended pre-procedural prophylaxis for percutaneous biopsy? None recommended, unless transrectal route (no consensus on 1st line recommendation).
What is the 2010 SIR recommended pre-procedural prophylaxis for percutaneous vertebroplasty? RECOMMENDED. 1st line: cefazolin 1 gram IV.
What is the 2010 SIR recommended pre-procedural prophylaxis for perc neph tube, NUS, or stent placement or exchange? Antibiotics are ROUTINELY RECOMMENDED except in cases of routine tube exchange in uninfected patients. UC Davis: ceftriaxone 1gm IV, including exchanges.
What is the 2010 SIR recommended pre-procedural antibiotic prophylaxis for G-tube or GJ-tube placement? NO CONSENSUS for push technique (UC Davis: NONE). However, for pull-through G-tube placement, antibiotics ARE RECOMMENDED. 1st line: cefazolin 1 gram IV.
What is the 2010 SIR recommended pre-procedural prophylaxis for biliary drain placement? Prophylactic antibiotics ARE RECOMMENDED. No consensus on 1st line. UC Davis: Ceftriaxone 1gm IV AND Flagyl 500mg IV.
What is the 2010 SIR recommended pre-procedural prophylaxis for TIPS placement? Prophylactic antibiotics ARE RECOMMENDED. No consensus on 1st line. UC Davis: Ceftriaxone 1gm IV.
What is the k-edge of calcium? 4.0 keV (or just 4)
What are the top 3 causes of medullary nephrocalcinosis? Name 5 additional causes. hyperparathyroidism, renal tubular acidosis type I (distal, hyperkalemic), and medullary sponge kidney. Additionally: milk-alkali syndrome, hypervitaminosis D, hyperoxaluria, sarcoidosis, and diuretics (such as Lasix).
What is Pena-Shokeir syndrome? aka pseudo-trisomy 18, fetal akinesia/hypokinesia sequence. Lethal, AR-inh, euploid. Arthrogryposis (rockerbottom feet, clenched hands), facial anomalies (d/t fetal akinesia), micrognathia, camptodactyly, polyhydramnios, pulmonary hypoplasia, IUGR.
Third trimester fetus with nuchal edema, excessive skin, extreme flipper-like panmelic limb shortening (micromelia), extremely short ribs, and poorly ossified spine and cranium. Top Dx? achondrogenesis. All subtypes are lethal: 1a and 1b are autosomal recessive (1a, unknown locus; 1b, SLC26A2). Type 2 (Langer-Saldino subtype) is an autosomal dominant defect in COL2A1.
What are features that distinguish a spermatocele from an epididymal cyst? Spermatocele has irregular margins, internal septa, internal echoes, association with tubular ectasia of the rete testis, and can be quite large. In contrast, epididymal cysts are smoothly marginated, anechoic, and typically much smaller, often tiny.
Mixed cystic/solid mass with calcifications arising in oral/nasal cavity or pharynx in a fetus about to undergo a special C-section procedure. Top Dx for the mass (specific word)? What is the procedure? epignathus, aka nasopharyngeal, oropharyngeal, or facial teratoma. Lethal if unable to establish airway. Substantial improvement in survival achieved with ex utero intrapartum treatment (EXIT) procedure.
What is the appropriate term to describe distention of renal collecting system with pus or infected urine, with or without perinephric fluid or pus? Pyonephrosis. Not pyelonephritis, which is infection within the parenchyma of the kidney. (Overlap may occur.) Note: This is a urologic emergency and may proceed rapidly to sepsis and shock without immediate percutaneous nephrostomy.
Child in 1st decade of life with large pancreatic tumor with calcifications, vessel encasement, and liver metastases. Top Dx? pancreaticoblastoma, exocrine neoplasm usually in the head or tail, ages 1-8. Beckwith-Wiedemann syndrome: increased risk. aFP elevated in 55%. Mets in 15%. Less likely: Burkitt lymphoma, rhabdomyosarcoma.
What is the lobar predilection order in congenital lobar overinflation (CLO, aka CLE, CLH)? left upper > right middle > right upper. Look for associated congenital anomalies (14-50% of patients), such as cardiac.
1yo of African descent with periosteal reaction about several metacarpals. Top Dx? sickle cell dactylitis. Look for other radiographic manifestations of sickle disease, which may not be present at this age.
What is "gymnast wrist?" On wrist radiographs in a young gymnast, abnormal widening of the distal radial growth plate consistent with chronic physeal stress injury.
Young child with diffuse osteopenia and subtle lucent transverse metaphyseal bands on radiographs of the knees, hips, and shoulders. Top Dx? leukemia. These are the typical appearance of "leukemic lines."
4 yo with knee and hip pain present with radiographs showing a well-circumscribed deep concave lucent lesion with sclerotic rim located in the distal femoral metaphysis medially. Top Dx? distal femoral metaphyseal irregularity (DFMI), aka cortical desmoid, aka avulsive irregularity. Benign stress rxn, thought to be secondary to traction from the attachment of gastrocnemius medial head or adductor magnus. Frequently bilateral (up to 100%).
1 yo boy with mild microphthalmos, leukocoria, hyperdense material under a retinal detachment, tethered at the optic disk, without calcification, high T1 signal on MR, NO restricted diffusion. Top Dx? Coats disease, aka exudative retinitis, retinal telangiectasis, with retinal detachment. Rare congenital disease.
1 yo boy with leukocoria, CT showing congenital chorioretinal anomaly adjacent to the optic disc, with a focal outpouching. Dx? coloboma
In which of the biliary cystic dilations outlined by the Todani scheme is the risk of cholangiocarcinoma the highest? Caroli disease (type IV choledochal cysts, all intrahepatic)
What is the most common congenital anomaly of the aortic arch? right arch with aberrant left subclavian artery. A vascular "ring" is created by the ligamentum arteriosum. If there is a diverticulum of Kommerell, this ring can be tight and symptomatic. If not, then it is typically loose, asymptomatic.
What is the significance of the presence or absence of a diverticulum of Kommerell in the setting of right arch with aberrant left subclavian artery? The vascular ring created by the ligamentum arteriosum is typically tight & symptomatic if there is a Kommerell diverticulum. Without such focal widening at the base of the aberrant left subclavian artery, the vascular ring is usually loose, asymptomatic.
Newborn with cardiomegaly, increased pulmonary vascularity, no cyanosis. What is the DDx? VSD, ASD, atrioventricular septal defect (AVSD, aka endocardial cushion defect [ECC] or common AV canal [CAVC]), and PDA can all have this appearance. VSD is most common. All h L->R shunt. May have pulmonary edema with complete white-out. No cyanosis.
MR for abnormality on screening echo shows round, well-demarcated mass slightly hyperintense to myocardium, endophytic from the free wall of the LV. What is it? What syndrome is associated? What is the likelihood the syndrome is present in this case? rhabdomyoma. If single, 50% have tuberous sclerosis. If multiple, TS in 100%. Grow during pregnancy but spontaneously regress after birth. Surgical excision should be considered only for those with refractory arrhythmias or hemodynamic compromise.
What is the most common cardiac tumor in childhood? Is there an associated disease? rhabdomyoma. If single, half are sporadic, half have tuberous sclerosis. If multiple, all have TS. Spontaneously regress after birth.
2d-old with nonbilious vomiting and abdominal distension. X-rays: multiple dilated loops of bowel, no air in rectum. BE shows small caliber left colon to splenic flexure with abrupt transition. Rectal caliber is normal. Most LIKELY Dx? Biopsy? Most common cause for these findings is meconium plug syndrome, aka small left colon syndrome, functional immaturity of the colon. Increased in maternal diabetes, magnesium, prematurity. Bx if not resolved within few days to exclude Hirschsprung disease.
Name the 3 most common etiologies for soft tissue tumor involving the lower pelvis in a young child. Which is the MOST common? Rhabdomyosarcoma is the MOST common tumor in the low pelvis in children, with peak incidence at about 2-6 years. Others include sacrococcigeal teratoma (calcs, fat) and neuroblastoma (usually higher in the abdomen). Ref: RadPrimer
T/F: The CT appearance of hepatic encephalopathy can mimic that of diffuse cerebral edema from anoxic-ischemic injury. True. Ref: RadPrimer
Child with congenitally short limb. Radiographs show a short femur with dysplasia predominantly affecting the proximal femur with dysplastic right acetabulum. Dx? proximal femoral focal deficiency (PFFD). Bilateral <15%.
What is the DDx for a newborn exhibiting cyanosis + increased pulmonary blood flow? T lesions of admixture: transposition (TGV), truncus arteriosis, TAPVR, tricuspid atresia (sort of "intracardiac TAPVR"), single ventricle, single atrium, hypoplastic left heart, DORV (double outlet right ventricle).
What Dx is suggested by this typical triad?: right-sided aortic arch, increased pulmonary vasculature, and cyanosis truncus arteriosis
Young child with seizures, MR showing T2 hypointense lobar atrophy and overlying increased leptomeningeal enhancement. Top Dx? Sturge-Weber syndrome (vs Rasmussen encephalitis, which would have NO leptomeningeal enhancement, and the atrophy would be T2 bright)
Young child (<1yo) with seizures, MR showing T2 hyperintense lobar atrophy and no overlying leptomeningeal enhancement. Top Dx? Rasmussen encephalitis (vs Sturge-Weber syndrome, which would have positive leptomeningeal enhancement, and the atrophy would be T2 hypointense)
What defines the Group I pediatric cardiac abnormalities? Acyanotic with INCReased pulmonary bloodflow (L to R shunt)
What are the Group I pediatric cardiac abnormalities? ASD, AVSD, VSD, and PDA (all have L to R shunts)
What defines the Group II pediatric cardiac abnormalities? CYAnotic with NORMal or DECReased pulmonary blood flow, and little or NO cardiomegaly
What are the Group II pediatric cardiac abnormalities? Tetralogy of Fallot, and other lesions with restricted pulm outflow and unrestrictive intracardiac defect, such as pulmonary atresia with VSD, some forms of tricuspid atresia with large ASD or VSD, equalized R-L pressures.
What defines the Group III pediatric cardiac abnormalities? CYAnotic with NORMal or DECreased pulmonary blood flow, and cardioMEGaly
What are the Group III pediatric cardiac abnormalities? Ebstein anomaly (and some other lesions such as critical pulm stenosis, some forms of pulm atresia and tricuspid atresia)
What defines the Group IV pediatric cardiac abnormalities? CYAnotic with INCreased pulmonary blood flow (Heart size does not factor in Group IV.)
What are the Group IV pediatric cardiac abnormalities? hypoplastic left heart (HLHS), the "T" lesions: TGA, TAPVR, Truncus arteriosus, Tricuspid atresia, and "T"ingle (single) ventricle or atrium, and double outlet RV or LV.
What are the two "signposts" in the diagnostic pathway in evaluating a Group I pattern on pediatric CXR? 1: ?LA enlargement? (NO: ASD or AVSD. Yes: VSD or PDA), and 2: ?AORTIC ARCH SIZE? (Large: PDA. Normal: VSD)
What is the most common Group IV pediatric cardiac abnormality? transposition of the great arteries (TGA)
Cyanotic infant with CXR showing right-sided aortic arch and increased pulmonary blood flow. Top Dx? truncus arteriosis (usually type I)
Cyanotic infant with CXR showing widened mediastinum and increased pulmonary blood flow. Top Dx? supracardiac TAPVR (This is the "snowman" shape.)
CXR shows large main pulmonary artery segment, and enlarged left pulmonary artery. Top Dx? pulmonic stenosis (with poststenotic dilatation)
What is the most common form of partial anomalous pulmonary venous connection? RUL pulmonary vein to SVC
CXR shows enlarged left atrium with dilated left atrial appendage. Top Dx? rheumatic heart disease (mitral valve)
What is the typical age range at presentation and M:F ratio for Legg-Calve-Perthes disease? 4 to 8-year-old females or 5 to 9-year-old males. Males are much more frequently affected than females (4-5:1).
2d-old with no passage of meconium, a proximal colonic obstruction on radiographs (no gas in rectum), narrow colon throughout on BE, with a question-mark shape. Top Dx? total colonic aganglionosis, aka Zuezler-Wilson syndrome, comprises 2-13% of cases of Hirschsprung disease
What is Ménétrier disease? (aka hypoproteinemic hypertrophic gastropathy) rare acquired premalignant gastric disease with massive folds, excessive mucous and resultant protein loss, and little or no acid production. Associated with excessive TGF-α secretion, activation of EGFR. Often follows CMV or URI. Self-limited in kids.
What are the two types of congenital hemangiomas? noninvoluting congenital hemangiomas (NICH), which do not change significantly with time, and rapidly involuting congenital hemangiomas (RICH) which undergo rapid fatty involution
What are the components of the VACTERL association? Vertebral anomalies, Anal atresia, Cardiac anomalies, Tracheoesophageal fistula, Esophageal atresia, Renal anomalies, and Limb malformations
What is the Currarino triad? sacral dysgenesis, anal atresia, and presacral teratoma or meningocele. AD-inherited disease caused by mutation of HLXB9 homeobox gene.
What percentage of primary pelvic Ewing sarcoma patients have metastases at the time of presentation? Where do they metastasize most frequently? 30%. Lungs. Survival has improved by treating all patients as having presumed metastatic disease at presentation.
What abnormality of the colon is a fetus at risk for when born of a woman treated with commonly used regimens for preeclampsia? Functional immaturity of the colon (meconium plug syndrome) is associated with maternal treatment with magnesium sulfate for preeclampsia, and also associated with maternal diabetes.
What bone lesions are known to form, on occasion, secondary aneurysmal bone cysts? Name 4. chondroblastoma, giant cell tumor, fibrous dysplasia, and osteosarcoma
What percentage of patients with initial presentation of dermatomyositis do NOT have soft tissue calcifications? Most. Only 25-50% of cases of dermatomyositis have associated soft tissue calcifications, and they usually develop at least 6 months after onset of disease, usually periarticular, and may not develop for years, or ever.
What is the muscle predilection for involvement of dermatomyositis? Proximal thighs (particularly the anterior compartment) and pelvic musculature greater than the upper extremities.
Above what age range does osteomyelitis typically NOT involve the epiphysis? Transphyseal vessels regress usually by 18 months, beyond which osteomyelitis typically involves the metaphysis only. Exception may occur in cases of direct inoculation, or in direct extension from septic arthritis.
Newborn w/ preseptal medial orbital mass. CT: smooth medial orbit preseptal mass widens nasolacrimal duct into nasal cavity, obstructs, + bony remodeling. A smaller but similar mass is present contralaterally but without bony expansion. Top Dx? bilateral asymmetric nasolacrimal duct mucoceles (aka dacryocystoceles). Can cause respiratory distress in a newborn if nasal passages are obstructed (obligate nose breathers).
T/F: All patients with gastroschisis will have malrotation once the bowel is returned to the abdomen (and thus be predisposed to developing a midgut volvulus). True. Also, while there are associated atresias, there are no associated congenital syndromes or other defects.
What abnormalities are associated with congenital talipes equinovarus (CTEV), aka club foot (CF)? Developmental defects with LE neurologic impairment (e.g., myelomeningocele), in-utero packing disorders (i.e., oligohydramnios of various causes), connective tissue disorders (Marfan, E-D), chromosomal anomalies (T-18), other syndromes (Meckel Gruber).
What imaging abnormalities might be seen in a patient with Williams syndrome (elvin facies, low IQ, unusually cheerful and social)? supravalvular aortic stenosis, supravalvular pulmonic stenosis, hernias, colonic and bladder diverticula (elastin defects), dental abnormalities, abnormalities related to hypercalcemia, hypothydroidism, or diabetes
When do patients with Kawasaki disease develop coronary aneurysms? Are they silent? Sporadic and random? Predictable? Coronary aneurysms silently develop 2-8 wks after episodes of acute myocarditis and fever (they ARE somewhat predictable), then present with chest pain or infarction. F/U 3 months after diagnosis to screen for coronary artery aneurysm formation.
Young adult with cough, CT: diffuse pulmonary thick-walled cavitary cystic lesions with irregular shapes, and diffuse tracheal wall thickening involving posterior membranous portion. h/o chronic renal dysfunction and sinus disease. Top Dx? Wegener granulomatosis. Subglottic stenosis is common later in the disease. Consider also Recurrent respiratory papillomatosis (RRP) without the renal and sinus disease, and with thinner walled cysts
What is cardiac dextroversion? This is not true dextrocardia, but rather R-shift of normal anatomic heart due to L-sided masses (e.g., congenital diaphragmatic hernia or CPAM) or causes of decreased R lung volume (e.g., atelectasis or scimitar syndrome with R lung hypoplasia).
Infant <1yo with painless rapidly enlarging heterogeneously enhancing hypervascular extremity mass with red ulcerated overlying skin. Top Dx? infantile fibrosarcoma, aka desmoplastic fibrosarcoma of infancy, congenital or congenital-infantile fibrosarcoma, juvenile fibrosarcoma, medullary fibromatosis of infancy, aggressive infantile fibromatosis. Malignant.
Child with cough, fever, and imaging showing a hilar tubular branching mass with "finger-in-glove" appearance and surrounded by hyperinflated lung. Top Dx? bronchial atresia (an Aunt Minnie). The branching mass is a segmental, noncommunicating bronchus filled with mucus. Recurrent respiratory tract infections is a common presentation.
A 1d-old infant undergoes CT to evaluate difficulty breathing when feeding and reveals choanal atresia and coloboma. What other organs should be evaluated for commonly associated abnormalities? Heart anomalies, Retarded growth and development, Genital hypoplasia, and Ear anomalies, which make up the rest of the CHARGE association/syndrome (along with Coloboma and Atresia of choanae).
What are the 4 possible mechanisms of mucosal or systemic injury from an ingested button battery that gets lodged in the esophagus? (why they need to be removed emergently) pressure erosion (like any object of same size, such as a coin), electrical burn ("live" battery), caustic alkali burn (if materials leak out), & toxic heavy metals (again, if materials leak out or comes in contact with gastric acids and dissolves).
Under what Salter-Harris classification do pediatric lateral condylar fractures fall? Lateral condylar fractures always extend through the cartilage to the articular surface and therefore are considered a Salter-Harris IV injury, and thus, an orthopedic urgency. Ref: RadPrimer
At what age does Osgood-Schlatter disease typically present? during the time of tibial tubercle ossification, before fusion (boys 10-15 yrs, girls 8-13 yrs).
What is associated with duodenal atresia? 50% have additional abnormalities. Down syndrome is seen in 30% of cases.
What other cardiovascular abnormalities are associated with aortic coarctation? PDA is the most common abnormality (66%), followed by bicuspid aortic valve (50%), VSD (33%), and transposition of the great vessels.
What other craniofacial abnormalities are associated with pyriform aperture stenosis? single midline incisor, holoprosencephaly spectrum, Tri-13
2yr-old child with chronic lung disease. CXR shows asymmetric areas of hyperinflation and atelectasis as well as increased, rope-like perihilar densities. Born term with complicated birth, neonatal pneumothorax. What was the likely cause of the lung dz? meconium aspiration syndrome
Congenital talonavicular dislocation is usually a part of what general foot deformity? congenital vertical talus (rocker bottom foot)
What is the "gallbladder ghost" triad and with what disease is it associated? Small gallbladder (length <19 mm), irregular margins, and discontinuous echogenic wall. Biliary atresia. Look for lack of echogenic "triangular cord" anterior to the portal vein bifurcation, due to fibrosis at expected site of absent CBD.
Suprarenal hypoenhancing mass with numerous T2-hyperintense hypoenhancing liver lesions in a young child. Top Dx? This pattern is virtually always a metastatic neuroblastoma originating in the adrenal gland.
T/F: 8-month old with neuroblastoma with skin, skeletal involvement with intense uptake on MIBG and bone scans, and liver metastases is stage IV-S, which has very favorable survival. False. Strictly, the skeletal involvement can only include marrow (uptake on MIBG scan but not on bone scan). Otherwise this would be stage IV-S with virtually 100% survival and frequent spontaneous regression. Cortical involvement worsens prognosis.
T/F: 8-month old with localized neuroblastoma with skin, skeletal involvement with intense uptake on MIBG but not bone scan, and liver metastases is stage IV-S, which has very favorable survival. True. This is Stage IV-S with virtually 100% survival and frequent spontaneous regression, although primary resection is often performed.
Describe the germinal matrix hemorrhage grading system. I: caudothalamic groove. II: Extends into vent but does not expand. III: Fills/distends vent. IV: Parenchymal hemorrhage/edema/ischemia beyond germinal matrix. Remember: Secondary hydrocephalus occurring several days after grade II is not grade III.
What are the 8 viruses in the Herpesviridae family? HHV-1 & -2 (HSV-1 and -2), -3 (VZV), -4 (EBV), -5 (CMV), -6 (roseolovirus, 6th), -7 (pityriasis rosea), -9 (Kaposi sarcoma-associated herpesvirus, KSHV)
What is the typical brain MRI pattern for herpes encephalitis? nonenhancing asymmetric or unilateral poorly defined T2 hyperintensity with gyral enlargement in the limbic system (medial temporal lobe) and inferior frontal lobes. Look for early hemorrhagic conversion.
What is the typical brain MRI pattern for CMV encephalitis? poorly defined T2 hyperintensity in the periventricular white matter
What is the typical brain MRI pattern for EBV encephalitis? poorly defined symmetric T2 hyperintensity in the basal ganglia, thalami, brainstem, also cortex
What is the typical location for CNS involvement in VZV encephalitis? Depends on syndrome: Varicella can affect multifocal areas of cortex. Zoster tends to involve brainstem and cortical gray matter, cranial nerves.
What is the typical brain MRI pattern for Eastern equine encephalitis (EEE)? poorly defined T2 hyperintensity in the basal ganglia and thalami
What is the typical brain MRI pattern for West Nile virus (WNV) encephalitis? poorly defined T2 hyperintensity in the basal ganglia and/or thalami, possibly brainstem, cerebral white matter, substantia nigra, cerebellum, spinal cord
What is the typical pattern on MRI for Rocky Mountain spotted fever encephalitis? multiple punctate foci of diffusion restriction in cerebral white matter with surrounding T2 signal, no significant enhancement
With what syndrome is annular pancreas most associated? trisomy 21 (often with additional gut anomalies such as malrotation, duodenal atresia, esophageal atresia)
In cases of unilateral renal agenesis, what about the orthotopic kidney should be closely evaluated? the lower pole. Don’t miss a cross fused ectopia.
Early adolescent with single limb pain. Radiographs show a subtle with permeation and remodeling in a long bone with MR showing a large soft tissue mass out of proportion to the radiographically visible bony findings. Top Dx for this pattern? Ewing sarcoma
What is the lobar predilection for congenital lobar emphysema? left upper > right middle > right upper
What is the triad of findings for scimitar syndrome? partial anomalous pulmonary venous return (PAPVR), hypoplastic right lung, and systemic arterial supply to the right lower lobe (the last finding being what often causes heart failure)
What are the top 3 causes of acute scrotal distress in a young boy (including prebubescents)? torsion of testicular or epididymal appendage (most common cause), testicular torsion (needing emergent detorsion and/or surgery), and epididymoorchitis. Dx of epididymoorchitis may merit follow-up imaging evaluation for vesicoureteral reflux (with VCUG)
What is the ultimate goal of the 3-stage Norwood procedure? total cavopulmonary bypass. Systemic venous return feeds directly into pulmonary arterial tree. The only “systemic” venous return to heart is coronary sinus (draining myocard capillary bed). All pulm venous return goes to single fxn'g vent (R, in HLHS).
What is the Fontan procedure? 3rd in 3-stage Norwood @ 18-36 mo. Completion cavopulmonary bypass, either via extracardiac conduit (preferred) or R intraatrial tunnel connecting IVC to PA. Small fenestra b/t Fontan & R atrium prevent pulm volume overload & mods retrn pressures.
What is the goal of the Glenn procedure? superior cavopulmonary bypass (most commonly bidirectional -- SVC to central pulmonary artery, vs unidirectional to just one pulm art)
Among congenital heart disease, what are the “effective single ventricle” pathologies? Remember to include tricuspid atresia. Also, single R or L ventricle, double-inlet R or L ventricle, hypoplastic left heart syndrome (HLHS), and some heterotaxies
What is the fistulous connection in a vein of Galen malformation? VGM is a midline intracranial varix that develops from a fistula between deep choroidal arteries and median prosencephalic vein of Markowski.
What are the possible locations to see abnromal enhancement from alternate venous drainage pathways in Sturge-Weber syndrome? any ipsilateral leptomeninges (anterior or posterior), ipsilateral choroid plexus, ipsilateral posterior globe (choroid angioma), or even ipsilateral bone. Look also for calcification.
What is the age range for infantile hepatic hemangioma? very young: 85% are less than 6 months old. aka hemangioendothelioma.
What is the age range for hepatoblastoma? What percentage calcify? almost all are <5 yrs old. 2 of 3 are less than 2 yrs old. Half of all hepatoblastomas calcify. If a pediatric hepatic mass is calcified, it is likely a hepatoblastoma. The other common primary tumors of the liver in children typically do not calcify.
What is the most common primary for hepatic metastases in young children? neuroblastoma, almost always
Young child with calcified hepatic mass, enhancing less than background liver. Top Dx? hepatoblastoma. Most common pediatric primary hepatic malignancy. 50% calcify. The other common primary tumors of the liver in children do not typically calcify. Almost all are <5 yrs old. 2 of 3 are less than 2 yrs old.
Pedunculated hepatic mass with innumerable well-defined variably sized cysts (less than 1cm up to 6 cm), heterogeneously enhancing intervening stroma with areas of necrosis, no calcifications. Top Dx? mesenchymal hamartoma.Pedunculated in up to 20%
What is an omega epiglottis? ”Omega epiglottis” describes 2 entities: 1. pseudo-abnormality on XR, thick-appearing epiglottis d/t oblique patient positioning (mimicking epiglottitis); and 2. omega-shaped appearance of the epiglottis en face in patients with laryngomalacia.
Describe the International Reflux Study Committee grading system for vesicoureteral reflux. Grade I: Reflux into ureter not reaching renal pelvis. Grade II: Reflux into pelvis without calyceal blunting. Grade III: Mild calyceal blunting. Grade IV: Ureterocaliceal dilation. Grade V: Very dilated, tortuous collecting system, intrarenal reflux.
What distinguishes a complex ureteropelvic duplication from a simple? Complex: duplicated to bladder with ectopic ureter (following W-G rule) and ureterocele. Simple: both drain to single ureter, so no ectopic ureter, no ureterocele, no obstruction; reflux may occur (as in single ureters) but unrelated to the duplication.
Newborn with sz. MR: “hourglass" "figure 8" shape cerebral hemispheres, absent or diminished number of sulci in cerebral hemispheres, thin/smooth outer cellular layer and deeper thick layer of arrested neurons mimicking band heterotopia. Top Dx? classical lissencephaly (type 1, LIS1 gene mutation, X-linked)
Name 5 possible complications of mature cystic teratoma (aka dermoid cyst). torsion, rupture, malignant transformation, infection, and autoimmune hemolytic anemia
Newborn with radiographs showing dilated proximal and mid bowel loops, and either (1) localized or diffuse flocculent linear/nodular calcifications on peritoneal surfaces, or (2) a rim-calcified mass, are two possible presentations of what disease? meconium peritonitis from an in-utero bowel perforation (with meconium pseudocyst formation in the case of rim-calcified mass), primary etiologies of which include bowel atresias, meconium ileus (from cystic fibrosis), volvulus, and internal hernia
Name 3 other primary etiologies of meconium peritonitis (from an in-utero bowel perforation) besides meconium ileus and cystic fibrosis. bowel atresias (look for T21), volvulus, and internal hernia. Essentially, any in-utero high-grade obstruction and perforation.
Of the 6 DDx for neonatal medical lung disease outlined by “CHIMP+TTN” mnemonic, which does NOT typically feature pleural effusion? No pleural effusions in SDD. Remember: CHIMP+TTN: Cardiac, Hyaline membrane dz (RDS, aka SDD), Immature lung, Meconium aspiration, PNA, and TTN (aka retained fetal fluid)
Child 6-10 yrs of age with cough, fever, x-rays showing subglottic narrowing and a linear, soft tissue filling defect within airway. Top Dx? exudative tracheitis. Best clue: older age, linear ST filling defect (membrane) within airway. Can lead to airway obstruction, resp failure, death, so tx aggressively. aka "membranous croup" (avoid as easily confused with benign "croup," age 6mo-3yrs)
Newborn with tachypnea, cyanosis, and CXR showing right-sided aortic arch and “sabot”-appearing upturned cardiac apex with cardiomegaly and increased pulmonary vascularity. Top Dx? truncus arteriosus, differentiated from tetralogy of Fallot (ToF) by the cardiomegaly and increased pulmonary vascularity (not present in ToF).
What percentage of patients with truncus arteriosus have a right aortic arch? 35%, higher than the 25% association in tetralogy of Fallot (ToF). But ToF is much more common than truncus, so favor ToF if a right arch is seen on CXR of a newborn with cyanosis.
What variant of infantile hepatic hemangioma is most associated with Kasabach-Merritt syndrome? Kaposiform hemangioendothelioma, a rare and distinct entity
What is the significance of defining discoid meniscus as complete, incomplete, and the Wrisberg variant? Complete (generally stable): extends to intercondylar notch; Incomplete (also generally stable): covers less than 80% of plateau; Wrisberg variant: unstable, lacks a posterior meniscotibial attachment. Tears in up to 70%.
4-word mnemonic reminder for KUB evaluation gases, masses, stones, and bones
Young adult after MVC. CT shows crescentic, posterior, lower lobe opacification with subpleural sparing. Top Dx? lung contusion, favored over aspiration (which usually does NOT have subpleural sparing)
Young child with bone pain, XR showing lesion in tibia that looks a lot like NOF with narrow zone of transition but is large and has cortical breakthrough and periosteal reaction (not typical of NOF aka fibroxanthoma). Top alternative Dx? chondromyxoid fibroma
What amount of intraarticular stepoff in a triplane fracture at the ankle requires surgical fixation to prevent premature joint degeneration? greater than 2 mm intraarticular stepoff
What is a neuroblastic tumor? neuroblastic tumor (NT) is a general term that includes the spectrum of ganglioneuroma (GN), ganglioneuroblastoma (GNB), and neuroblastoma (NB)
Name 4 tumors in the DDx for a childhood paraspinal mass with extension through the neural foramen. in no particular order: lymphoma, rhabdomyosarcoma, peripheral nerve sheath tumors (schwannoma and neurofibroma), and the neuroblastic tumors (including ganglioneuroma-GN, ganglioneuroblastoma-GNB, and neuroblastoma-NB)
Among childhood rhabdomyosarcomas, which has a propensity to occur in genitourinary or head and neck regions, and which more often occurs in the extremities or trunk? embryonal type in genitourinary or head and neck regions, and alveolar in the extremities or trunk
What are the top three malignancies in childhood? leukemia, central nervous system tumors, and neuroblastoma
Newborn with jaundice, raised yellowish skin lesions, broad, prominent forehead, deep-set eyes, and a small pointed chin. Imaging shows sabot shaped heart, butterfly vertebrae. Top Dx? Alagille syndrome, an AD-inherited disorder. The facial features are characteristic. There is paucity or absence of intralobular bile ducts on path but no specific imaging features of the liver. Tetralogy of Fallot is common in these children.
Newborn with jaundice. US shows small gallbladder measuring 14 mm with irregular margins, discontinuous echogenic wall. Portal vein & hepatic artery are visualized, but there is an echogenic triangle in the expected location of the CBD. Top Dx? Biliary atresia. The small size, irregular margins, and discontinuous echogenic wall of the GB constitute the "gallbladder ghost triad."
Of the 6 DDx for neonatal medical lung disease outlined by “CHIMP+TTN” mnemonic, which have low lung volumes? hyperexpanded lungs? Hyaline membrane dz (aka SDD, RDS) has low volumes. Meconium aspiration has hyperexpansion. PNA can have NL or low volumes. RFF, edema have NL vol. Remember: CHIMP+TTN: Cardiac, Hyaline membrane dz (RDS), Immature lung, Mec asp, PNA, and TTN (aka RFF)
Young child with knee pain, effusion and synovitis on contrast enhanced MR, and numerous tiny rice bodies. No calcifiations. Top Dx? JIA. Also seen in granulomatous diseases, such as tuberculosis.
Very young (but not newborn) child with large hydropneumothorax, heterogeneously enhancing lung mass (not mediastinal or chest wall). Top Dx? pleuropulmonary blastoma (PPB). Rare malign embryonal mesench neoplasm. 3 types: 1. Air-filled, multiloc. 2. Cystic w variable ST. 3. ST mass; opacif'd hemithorax with contralat shift. Spont PTX. Most common pulm malign of early childhood. 94% <6 yrs old.
Central beaking vs. inferior beaking of the vertebral bodies. What collection of diseases does this pertain to? Which is which? Dysostosis multiplex (the mucopolysaccharidoses). Middle = Morquio. Central beaking is seen in Morquio. Inferior beaking in Hurler or Hunter syndrome.
Young child with chronic limb swelling, pain. XR: loss of definition of soft tissue planes, many phleboliths. MR: T2-hyperintense infiltrative multilobulated mass, marked enhancement, fluid-fluid levels, several ovoid low signal intensity foci. Top Dx? venous malformation. Congential slow flow vascular anomaly that grows commensurate with patient. May have old hemorrhage, fluid-fluid levels.
Very young child (age 6mo-3yrs) with typical crampy abdominal pain and an abnormal abdominal x-ray. Next step? Standard of care in most institutions is to proceed straight to a therapeutic air enema, rather than waste time confirming the diagnosis with ultrasound. This child has intussusception.
What are the 3 most classic RADIOGRAPHIC findings of LCH in a child? 1. "punched out" lytic skull lesion w beveled edges (+/- "button" sequestrum). 2. vertebra plana with severe vertebral body flattening. 2. "floating tooth" (lucent lesion replaces bony lamina dura surrounding a tooth, most commonly mandibular molar).
What is the diameter threshold for megaureter? 7 mm
Cutaneous hemangiomas at the neck and mandible have up to a 60% association with what potentially life-threatening complication? Beard hemangiomas have a high association with potentially life-threatening airway/subglottic hemangiomas.
What disease of the testicles has been markedly reduced by a vaccine? mumps orchitis, rarely seen now due to mumps, measles, and rubella (MMR) vaccine
What is the difference between a “small” omphalocele and a “giant” omphalocele? Small <5cm, giant >5cm. Small assoc’d with Tri13 and Tri18. Giant more likely contains liver, other abdominal viscera, less assoc’d with other abnormalities.
CT on a very young child with flank swelling reveals large mass arising from the kidney. What is the next appropriate question to ask and step to perform? Look for (Wilms) tumor invasion into the renal vein, IVC, and R atrium.
From which coronary artery does the left posterolateral branch (PLB) arise? LCx, posteriorly in the atrioventricular groove
From which coronary artery do the obtuse marginal branches arise? LCx, coursing anteriorly
From which coronary artery do the acute marginal branches arise? RCA, coursing anteriorly
From which coronary artery does the right posterolateral branch (PLB) arise? RCA, posteriorly in the atrioventricular groove after the PDA origin
What constitutes clinically significant diameter narrowing on coronary CTA? >50% diameter narrowing corresponds to a 70% area narrowing and a 90% reduction in flow
Name 3 classic MR imaging features of chondroblastoma. low-intermediate T2 signal intensity (which differs from other T2-hyperintense cartilaginous tumors), exuberant surrounding T2-hyperintense inflammatory reaction, joint effusions or enhancing synovitis. Aneurysmal bone cysts (ABCs) in up to 1/3.
What is the radiologic difference between the 2 types of multilocular cystic renal tumors? No distinguishing imaging features between multilocular cystic nephroma (MLCN) and cystic partially differentiated nephroblastoma (CPDN), but they are histologically distinct. Both have the same excellent prognosis with excision.
What are the most common 3 primary malignancies to metastasize to the stomach? melanoma, breast, lung
Premature infant with complicated delivery, bilateral cystic periventricular WM change, decreasing over time with development of white matter gliosis and box-like configuration of the bilateral frontal horns. Top Dx? periventricular leukomalacia (PVL). Damage to periventricular white matter from mild-mod hypoxic event in premature infant. Motor and visual injuries most frequent, classic pattern of lower extremity more than upper (spastic diplegia).
Markedly dilated bowel loop in the RUQ with diffusely dilated small bowel loops and no evidence of dilated transverse or descending colon. Top Dx? cecal volvulus
T/F: UC can have fistulas. True, but unusual.
T/F: PMC can have fistulas. True, but unusual.
What is Rigler’s triad? pneumobilia, small bowel obstruction, gallstone in GI tract, usually in the right iliac fossa. Indicates gallstone ileus. Mostly older females. Mortality 10-25%.
Name 3 syndromes that have an elevated risk for hepatoblastoma. Beckwith-Wiedemann syndrome, hemihypertrophy, Gardner syndrome
Asymptomatic young adult. CT: poorly-defined multisegmental lucency in lower lobe without significant mass effect. Corresponding pulmonary vessels taper from normal size in normal lung to small in affected lung, but the bronchi are normal size. Top Dx? Swyer-James (bronchiolitis obliterans, BO). Relative oligemia throughout the region of airtrapping.
Ice cream scoop shaped short femurs are seen in what skeletal dysplasia? achondroplasia. Also look for increased lumbar lordosis with platyspondyly, bullet-shaped vertebral bodies, narrowing of the interpedicular distance of the lower lumbar spine, squaring of the iliac wings. Autosomal dominant rhizomelic dwarfism.
What do toddler fractures look like in the hindfoot? Linear intramedullary sclerosis (us. vertical or transverse) in calcaneus, cuboid, talus, from repetitive compression, visible 10d after sx onset. Periosteal rxn not expected (these bones develop by endochondral ossification, lack periosteum).
With what overlapping abnormalities of the liver are ARPKD associated? Caroli disease (combination aka Caroli syndrome) and congenital hepatic fibrosis
T/F: Craniopharyngioma is a malignant tumor and has low survival rate even with treatment. False. Benign tumor, but morbidity is high due to location and difficulty with resection.
Infant with aniridia, renal mass, falling milestones. Top Dx? WAGR syndrome. Rare syndrome from deletion on chromosome 11. Almost all have aniridia. Predisposed to develop Wilms tumor (50%), Gonadoblastoma, and mental Retardation. aka WAGR complex, Wilms tumour-aniridia syndrome, aniridia-Wilms tumour syndrome.
What are tbe 2 most common tumors associated with Beckwith-Wiedemann syndrome? Wilms tumor
Fetus with hydrocephalus, microcephaly, disordered cortical organization, cerebellar hypoplasia, and hyperechoic foci in the basal ganglia and periventricular white matter. Top Dx? TORCH infection, most likely CMV. MR to further evaluate. CT after birth to confirm calcs if needed.
What is extravaginal testicular torsion? Extravaginal testicular torsion occurs outside the tunica vaginalis and is exclusive to newborns. The testis is typically infarcted at birth. The torsion seen in children and young adults is intravaginal and occurs within the tunica vaginalis.
3 month old infant with bilious vomiting and abrupt termination of contrast at the 3rd portion of the duodenum, no contrast seen distally. Top Dx? midgut volvulus. DDx: duodenal web, unusual annular pancreas (has been reported around D3)
Why should a newborn with schizencephaly undergo thorough ophthalmologic exam? Up to 70% of cases are associated with septo-optic dysplasia. Neuroimaging is relatively insensitive to detection of optic nerve hypoplasia.
CT with hyperenhancing small nodule in the liver, hetergeneously enhancing mass in the pancreas, and marked thickening of the gastric wall. Top Dx? metastatic pancreatic gastrinoma with Zollinger-Ellison syndrome
Calcified enhancing lesion in the pancreas. Top 2 diagnoses? SPEN and neuroendocrine tumor (NET). Remember that NETs can calcify.
What are the 3 most common primary hepatic tumors in early childhood? Name them in order of most to least common. hepatoblastoma (most common, malignant), infantile hepatic hemangioma (IHH, aka hemangioendothelioma, benign), and mesenchymal hamartoma (MH, benign)
Anechoic space inferior to the splenium of the corpus callosum in the pineal region on newborn head ultrasound. DDx? (2 entities) How to differentiate? cavum vellum interpositum (CVI) or vein of Galen malformation (VGM, aka VGF, fistula). Doppler differentiates the two.
Linear branching hyperechoic structures in the basal gangila on newborn ultrasound. What is this called and what are 5 causes? lenticulostriate vasculopathy, aka mineralizing or necrotizing vasculopathy. Seen in TORCH infection (namely CMV), Tri13, chromosomal mosaicism, maternal drug/EtOH abuse, congenital heart disease.
Infant spinal ultrasound shows a 3 mm dilation of the central canal near the tip of the cord. Serial exams show no change. Dx? DDx? ventriculus terminalus, a normal variant ependyma-lined dilation in the distal cord. If changes, may be either syrinx (worsens) or transient dilation of the central canal (resolves in first week of life, also a normal variant).
A newborn with a sacral dimple undergoes spine ultrasound which reveals a filar cyst but no other abnormalities. What is the management? Nothing. This is a normal variant.
What is the upper limit of normal diameter for a prominent filum terminale? <2 mm
Solid renal mass in a young child with associated bone metastases. Top Dx? clear cell sarcoma more likely than Wilms tumor, which does not go to bone
Solid renal mass in a young child with associated synchronous CNS tumor. Top Dx? rhabdoid tumor more likely than Wilms tumor if CNS met is present
Solid renal mass in a young child with sickle cell trait. Top Dx? renal medullary carcinoma more likely than Wilms tumor in this case
What is the DDx for an adrenal mass in a pediatric patient? Name 4. neuroblastoma, adrenal hemorrhage, ACC, pheo
With what tumor is opsoclonus myoclonus syndrome (OMS) associated as a paraneoplastic syndrome? neuroblastoma. OMS affects 2-3% of cases. OMS is aka opsoclonus-myoclonus-ataxia (OMA).
What degree (%) of reduction in the cross-sectional area of the trachea is associated with elevated risk of respiratory failure and death during induction of anesthesia? 50% diameter airway narrowing puts the patient at increased risk during anesthesia.
The clinical triad of mental retardation, seizures, and facial angiofibromas is classic for what disease? tuberous sclerosis. Classic triad only seen in 30% of cases.
Intraarticular involvement by venous malformations might have what features on imaging? hemosiderin from recurrent hemarthrosis, enhancement from synovitis, and cartilage destruction, joint space narrowing. Expect the primary mass to have serpiginous or diffuse enhancement.
T/F: The septa of lymphatic malformations should NOT enhance, and raise concern for infection or malignant degeneration. False. Septal enhancement to varying degrees is expected in benign run-of-the-mill lymphatic malformations.
What is the most common cause of rapid growth of a lymphatic malformation? intralesional hemorrhage or infection, not malignancy
What maternal condition has a particularly high association with caudal regression syndrome? maternal diabetes
Name 6 abnormalities associated with caudal regression syndrome. diabetic mother, VACTERL association, omphalocele, bladder exstrophy, imperforate anus, other spinal anomalies
What is the most common extratesticular intrascrotal neoplasm seen in young males? rhabdomyosarcoma. Overwhelmingly the most common extratesticular intrascrotal neoplasm in young males, rhabdomyosarcoma has a better prognosis than rhabdomyosarcoma in other regions.
Name 2 common superimposed abnormalities seen in patients with bone pain and diffuse marrow infiltration with metaphyseal lucencies on plain radiography. The pattern described suggests leukemia. Superimposed infarction and/or osteomyelitis is commonly seen.
Well-circumscribed mass with smooth margins abutting an extremity long bone, respecting cortex, with lack of surrounding edema. High T2 and low T1 signal. Diffuse enhancement without flow voids. Is this benign or malignant? Is a biopsy necessary? Could be benign, but extremity rhabdomyosarcoma can look exactly like this, necessitating biopsy.
3 mo infant with flank mass. Claw sign from kidney. No cystic components. No other mass seen. Top Dx? mesoblastic nephroma (too young for Wilms tumor)
What is the most common form of urinary tract obstruction in pediatrics? ureteropelvic junction obstruction (UPJ)
What is Holt-Oram syndrome? Congenital heart defects (mostly ASD, but also VSD) and upper limb abnormalities (radius or thumb aplasia, hypoplasia). Similar to thalidomide teratogenic effects (phenocopy). AD-inh mutation in TBX5 gene. 50-80% may be de novo mutations.
Fetal ultrasound shows an ASD and absent radius. Top Dx? Holt-Oram syndrome. AD-inh mutation in TBX5 gene. 50-80% may be de novo mutations. Similar to thalidomide teratogenic effects (phenocopy). Variations: VSD, thumb aplasia.
Name 7 abnormalities associated with congenital hematometrocolpos. hydronephrosis, Müllerian duct fusion anomalies, (particularly didelphys), aganglionosis (Hirschsprung), imperforate anus, urogenital sinus, cloacal anomalies, cardiac anomalies
What is platybasia? horizontal orientation of the clivus
What is the classical term for horizontal orientation of the clivus? platybasia
What abnormalities of the skull can be seen in patients with OI? Name at least 3. macrocranium, frontal bossing, wide fontanelles and sutures, multiple wormian bones (10 or more), basilar impression or invagination. Also increased risk of intracranial hemorrhage with minimal or no preceding trauma.
At what distance across pyriform aperture can a confident diagnosis be made of pyriform aperture stenosis? less than 11 mm
2-week-old infant with difficulty breathing when feeding. Imaging reveals central single megaincisor, lobar holoprosencephaly, and vertebral body abnormalities. What is the abnormality pertinent to the airway called? pyriform aperture stenosis. Normal distance across the pyriform aperture is at least 11 mm.
What is Fahr disease? aka familial cerebral ferrocalcinosis. Symmetric calc in globus pallidus, then caudate, lentiform n., thalamus, dentate n., atrophy. AD-inh, 4th-5th dec (poss earlier), progr neuropsych. Exclude: Ca++/phosph, vasculitis, mitochondrial d/o, infxn, toxin.
What is the managment for a lateral condylar fracture? urgent surgical management. Lateral condylar fractures always extend to articular surface, a Salter-Harris IV injury. Cannot be appreciated on radiographs because growth cartilage of condyle not yet ossified.
Name 3 syndromes with an association with genitourinary rhabdomyosarcoma. Li-Fraumeni syndrome, neurofibromatosis type I, Beckwith-Wiedemann syndrome
Infant with hyperexpanded chest, cardiomegaly, and prominent pulmonary vasculature. Top Dx? Next step? This pattern suggests a shunt lesion (ASD, AVSD, VSD, or PDA; all can look similar). Confirm acyanotic. Echocardiogram is next step.
Young man with testicular mass. US shows well-marginated spherical hypoechoic mass with laminated appearance of concentric alternating hyperechoic and hypoechoic rings. Top Dx? testicular epidermoid cyst. The onion skin pattern is typical. Rings represent layers of keratin.
Dark T1 signal in epiphyseal region on a nonsuppressed T1. DDx? Consider leukemia, severe chronic anemia, storage disorder. Lack of bright T1 signal (fat) in epiphyses beyond early childhood is abnormal. Reactive red marrow stimulation (reconversion) occurs in reverse order of developmental conversion to yellow.
What is the peak age range for ependymoma? ages 1-5 years
What is the DDx for focal activity within liver on HIDA scan with normal GB appearance? FNH and intrahepatic biloma. Nothing else causes this appearance.
Name 4 causes of emphasematous gastritis. infection, ulceration without infection, ischemia, and less likely radiation gastritis. NOT Crohn disease.
What is the DDx for a NONobstructive gastric or small bowel tumor? lymphoma, GIST, peritoneal metastasis
For what 2 malignancies are patients with UC at increased risk? adenoCA (colon) and cholangiocarcinoma (biliary/liver) associated with sclerosing cholangitis
What tumor is associated with Crohn disease? lymphoma
What hormone can induce a Crohn disease flare? progesterone (pregnancy)
T/F: FNH can have a substantial fatty component. TRUE
Which metastatic diseases in the liver can cause focal biliary obstruction? colon, breast, lung. Liver metastases from these primary tumors can cause focal biliary obstruction.
What is Léri-Weill dyschondrosteosis? mesomelic dwarfism (short forearms and legs), bowing of the radius and tibia with relative sparing of the ulna and fibula, Madelung deformity (bayonet-like deformity of the forearms). Rare pseudoAD-inh SHOX gene deletion.
In correcting for background count rate in quantitative nuclear medicine studies, how does standard deviation get treated? IOW, what is the standard deviation of the difference? Add the two standard deviations of gross (g) and background (bg) count rates to get the standard deviation of the net count rate (n). SD(n)=SD(g)+SD(n)
How often must survey tests be performed for uncontrolled areas in a nuclear medicine department? How about controlled areas? How about wipe tests (controlled vs uncontrolled)? Controlled areas: daily survey and weekly wipe. Uncontrolled areas: weekly survey and monthly wipe.
What is the TI on a nuclear medicine package label? Transportation Index (TI) is the exposure rate at 1 m distance from the package, expressed in mR/hr. A TI of 3 means an exposure rate of 0.003 R/hr at 1 m.
Per NCRP, the maximum permissible lifetime effective dose for radiation occupational workers should not exceed what value? worker’s age in years multiplied by 10 mSv
What is the whole body effective dose of radiation required to double the spontaneous mutation rate in humans? 1 Sv per Raphex exam, but 1.5 Gy per Duke review
T/F: Mental retardation is the primary abnormality seen from irradiation of a fetus in the 15 to 24 weeks of gestation. False. Mental retardation is the primary abnormality when a fetus is irradiated between weeks 8 and 15 (inclusive).
Define contrast-to-noise ratio (CNR) as it pertains to CT. difference between HU in signal/bright regio vs background regionn (contrast), divided by the standard deviation/sigma (noise).
What is CTDIvol in terms of CTDIw and pitch? CTDIvol = CTDIw / pitch
Define “effective mAs” in terms of reported mA, rotation time, and pitch. Effective mAs = mA * rotation time / pitch
Define magnification factor in terms of source to image distance, source to object distance, and object to detector distance. mag factor = SID / SOD (“Syd over sod.”) A 5 mm BB in an obese patient, located in the anterior SQ fat and 70 cm from the x-ray source with 100 cm SID, will be magnified by a factor of 1.43 on the image (100/70).
T/F: Genetic effects of radiation have not been detected in any human population or subpopulation. True. No human genetic effects have been seen.
What is the typical peak skin dose in CT? (Choices: 3 x different orders of magnitude x units) 30 mGy
What would be the typical peak skin dose to a staff member if he/stood 1 m from a patient undergoing CT scan? 1/1000th of the dose to the patient. In this case, CT peak skin dose is roughly 30 mGy to the patient, so the staff member would receive 30 microGy.
What is the critical organ for head CT? thyroid gland, not lens of the eye
What is “f factor” in radiation physics and dose determinations? The “f factor” is a constant by which exposure (X) is multiplied to determine absorbed dose (D). D=fX
What is the typical range of effective dose to the fetus in a CT abdomen/pelvis performed on a pregnant woman? 10-50 mGy
What peak skin dose is the Joint Commission threshold for calling a “sentinel event” in fluroscopy? 15 Gy peak skin dose. Note that this is also the dose level at which moist desquamation/late erythema is said to occur. Transient erythema at 2 Gy (threshold for deterministic effects). Dermal necrosis at roughly 18 Gy. FDA '94
T/F: The mass of a nucleus is ALWAYS less than the sum of the masses of its constituent protons and neutrons. True. The mass defect is equal to the binding energy.
How does HVL relate to attenuation coefficient (mu)? HVL=ln(2)/mu=0.693/mu
Medical outcomes audits in mammography must involve a comparison of surgical results with which BI-RADS categories? 3, 4, 5
In calculating ejection fraction from a MUGA scan, why does background NOT have to be subtracted from the two values in the numerator, but only the value in the denominator? One could subtract background from both end-diastolic and end-systolic ROI counts, but they would cancel to zero anyway. The denominator (end-diastolic ROI counts) must be corrected for background by subtraction.
In ultrasound equipment, what is “Q factor?” Q factor = operating frequency / bandwidth. A transducer with a high Q factor has a narrow bandwidth, a long spatial pulse length (SPL), low spatial resolution, and is better for Doppler.
What is the incidence of cancer in the 1 year interval after diagnosis of “multiple bilateral circumscribed masses” BI-RADS 2 on screening mammography? 0.14%, compared to general population incidence of 0.14% per year. IOW, extremely low risk (but probably not actually protective as the numbers might suggest). Leung, Sickles AJR 2000, PMID: 10882241.
T/F: A spiculated mass on mammography which has demonstrated stability over 3 years is overwhelmingly benign and can be called BI-RADS 2. False. Biopsy all spiculated masses. Tubular carcinoma can be particularly slow growing, but still malignant.
Calcifications with “crumpled paper” appearance on mammogram are most classically what type of calcifications? dystrophic. Usually radiation or trauma hx. Irregular chape, >0.5 mm, often lucent centers
Is a “rosette” on mammography a worrisome pattern? No. This is a cluster of round and punctate calcs with equidistant spacing, forming in the acini of lobules. Typically benign.
What patterns of “coarse heterogeneous calcifications” on mammography are benign? What would a malignant pattern be? Bilateral diffuse coarse heterogeneous calcifications are benign. Otherwise, elevate suspicion. If single breast, must biopsy.
What is the DDx for a lucent hemithorax in a newborn Day 0? Name 3. PTX (pleural edge often not seen), CLE, CPAM type 1
What is the most common location in the chest for a CPAM? LLL
At what age range should we start shifting our suspicions from that of retropharyngeal abscess to one toward peritonsillar abscess? around age 4, due to developmental changes in lymphatic drainage
What is bacterial tracheitis? = exudative tracheitis. Older child with cough, fever, subglottic narrowing, linear ST filling defect within airway, can lead to obstruction, resp failure, death, tx aggressively. aka "membranous croup" (too confused with benign "croup" age 6mo-3yrs)
Name the 4 childhood diseases most frequently associated with pulmonary hemorrhage. in no particular order: idiopathic pulmonary hemosiderosis (IPH), Goodpasture disease, Wegener granulomatosis, blood dyscrasias such as leukemia
At what whole-body absorbed dose of photon radiation are rings, deletions, and other chromosomal abnormalities detectable in circulating lymphocytes? 0.1 Gy. Dose of 0.3 Gy causes lymphocyte drop in 1-2 days. Dose of 1 Gy causes drop in granulocyte (CG) count. Dose of 4-6 Gy (4 Gy is LD50) causes early increase in GC count, then profound decrease after 1 wk, nadir @ about 3 wks.
What is the threshold radiation dose to a fetus to cause teratogenicity? At what gestational age? What system is most severely affected? 0.12-0.2 Gy to fetus, at 8-15 weeks, most severely affects the neurologic system (microcephaly, mental retardation, etc).
At what gestational age does a fetus’s thyroid develop the ability to organify iodine (and therefore be damaged by I-131)? 10-12 weeks gestational age
What is the threshold activity for determining whether an I-131 spill is minor or major? What about Tc-99m? 1 milliCurie for I-131, but 100 mCi for Tc-99m
What is the first step to managing ANY radiation spill? Notify personnel in the area. THEN: if minor, cover and clean up. If major, cover but DO NOT TRY TO CLEAN UP. Secure area and notify RSO immediately. Then decontaminate yourself.
How many half-lives must medical radioactive waste be stored before checking other parameters and (if passes) disposing in normal waste stream? 10 half-lives
What is the longest half-life of radiotracer that can be stored for >10 half-lives and discarded in normal waste stream after a negative survey? nothing with a half-life longer than 120 days
What are the quality control actions and intervals for a SPECT camera? Name 3. Field uniformity daily using a flood source. Field linearity weekly using a bar phantom. Center of rotation monthly using software adjustment.
What is the 10 CFR 35 limit for molybdenum break-through? How long must records be maintained? must be less than 0.15 microCi Mo-99 per 1 mCi Tc-99m. Same as 150 ppm. Maintain measurement records for 3 years.
T/F: Any unsealed radiation administered to a Wrong Patient, Wrong Radiopharmaceutical, Wrong Route of Administration, or >20% deviation from prescribed dose, is a MEDICAL EVENT and MUST be reported to NRC or Agreement State authority. False. The estimated dose equivalent to the patient or fetus must also be over 50 mSv (or organ dose > 500 mS) to require reporting as a “medical event.”
What percentage of duodenal atresias occur proximal to the biliary papillae and therefore present with nonbilious emesis? 0.2
Newborn with skeletal dysplasia characterized by small thorax, normal spine, and handlebar clavicles. Top Dx? asphyxiating thoracic dystrophy (ATD), aka Jeune syndrome. Viability determined by thoracic size.
Newborn with skeletal dysplasia characterized by widened pubic symphysis, Wormian bones, and absent or deficient clavicles. Top Dx? cleidocranial dysplasia (aka dysostosis). Delayed ossification of midline structures.
Newborn with skeletal dysplasia characterized by thick skull, J-shaped sella turcica, canoe paddle thick ribs, and proximal tapering of the metacarpals, among other abnormalities not listed. Based on these so far, what is the top Dx? Dysostosis multiplex (mucopolysaccharidoses). Other abnormalities: oval vertebral bodies with anterior beaking (central in Morquio, inferior in Hurler or Hunter), gibbus deformity, and inferior narrowing of the iliac bones (look like ping pong paddles).
What is the disease most classically associated with “bone within bone” appearance of the vertebral bodies? osteopetrosis. Also see rugger jersey spine. Diffusely dense bones that fracture (brittle).
What is a differentiating feature between dense metaphyseal bands that occur in lead poisoning (“lead lines”) and those that occur in normal variants? Both occur in the distal femur and proximal tibia, but only lead lines occur in the proximal fibula. The normal variant spares the proximal fibula.
Name the 6 most likely etiologies for an aggressive appearing bone lesion in a child. Age ranges? Primary bone tumors Ewing (5-20 yrs) and osteosarcoma (10-20 yrs), metastatic neuroblastoma (<5 yrs), leukemia (<10 yrs), osteomyelitis (mostly <5 yrs), and aggressive histiocytosis (<5 yrs)
Lucent metaphyseal bands in a child <2 yrs old are fairly specific for what disease? leukemia (“leukemic lines”)
T/F: Linear skull fractures are moderately specific for nonaccidental trauma. False. Linear skull fractures are low specificity, but complex skull fractures have moderately high specificity. The highly specific fractures are corner/bucket handle metaphyseal, posterior ribs, “S” bones: scapula, spinous processes, sternum
What defines Milch I vs II in pediatric condylar fractures? lateral vs medial condylar fracture and relation of fracture line to the articular surface of the lateral trochlear ridge (LTR). Milch II (unstable): Lateral condylar fx extending medial to LTR, or medial condylar fx extending lateral to LTR.
What eponymous lines are used to evaluate pediatric hip pathology? Hilgenreiner’s line extends “H”orizontally across the triradiate cartilages. Perkin’s line descends vertically from superolateral lip of the acetabulum. Shenton’s arc courses under lesser trochanter and superior pubic ramus. Acetabular angle NL>35 degr.
What is the normal alpha angle on infant US hip evaluation? What is the appropriate age range for this evaluation? >60 degrees. 2-3 weeks to 4-6 months, after which x-ray is more appropriate (ossified). Maternal hormones affect laxity in the first 2-3 weeks of life.
Define Legg-Calve-Perthes disease vs. hip AVN. Legg-Calve-Perthes disease is idiopathic hip AVN. If other causes, then not Legg-Calve-Perthes disease, but secondary AVN. Top causes in a child: steroids, sickle cell disease. In an adult, alcoholism is a top cause. Others: ASEPTIC.
What is the normal tibio-calcaneal angle? What pathology is this most often used to evaluate? A tibio-calcaneal angle above 90 degrees constitutes equinus calcaneus, seen along with other malalignments in congenital talipes equinovarus, aka clubfoot.
What is the normal talocalcaneal angle on AP view? What pathology in infants is this most often used to evaluate? A talocalcaneal angle under 20 degrees on AP view constitutes hindfoot varus, seen along with other malalignments in congenital talipes equinovarus, aka clubfoot.
Radiographs for a child with lower extremity abnormality show symmetric medial metaphyseal beaking with depressed, irregular, and fragmented appearance. Top Dx? Blount disease, aka idiopathic tibia vara
Name 4 indications for MR in pediatric scoliosis. onset under age 10, left-ward thoracic curve, acute-angle or short-segment curve, rapid progression
By what gestational age is the germinal matrix normally nearly completely involuted? 36 weeks. It is largest at 23-24 weeks gestation.
Diffusely increased echogenicity of white matter with increased gray-white differentiation on US of an infant indicates what process? diffuse edema
Symmetric cystic spaces slightly below the superolateral margins of the body and frontal horns of the lateral ventricles anterior to the foramina of Monro in a newborn evaluated for intracranial hemorrhage. Top Dx? coarctation of the lateral ventricles, aka connatal cysts or frontal horn cysts. Believed to be a normal variant.
What are the “10% rules” for pheochromocytoma? Name 6. 10% in children, 10% bilateral, 10% malignant, 10% extra-adrenal, 10% not associated with HTN, 10% familial (MEN IIA and IIB)
What are the differences among MEN I, MEN IIa, and IIb? MEN I (3 Ps): Pituitary adenoma, Parathyroid hyperplasia, Pancreatic NET. MEN IIa (1M,2Ps): Medullary Thyroid Ca, Pheochromocytoma, Parathyroid. MEN IIb (2Ms,1P): Medullary Thyroid Ca, Marfanoid habitus/mucosal neuroma, Pheochromocytoma
Prenatal & 1st-year imaging shows hypertelorism, ventricular enlargement, periventricular pseudocysts, medial peri-rolandic pachygyria, lateral polymicrogyria, stippled scimitar-shaped patellar calcs, hyperechoic kidneys, hepatomegaly. Top Dx? Zellweger syndrome, aka cerebro-hepato-renal synd, rare leukodystrophy, AR-inh defect in PEX gene (multi types) affecting cellular peroxisomes, accumulate fatty acids, r/t neonatal adrenoleukodystrophy and infantile Refsum, usually die in first year.
What are imaging features of Zellweger syndrome? aka cerebro-hepato-renal syndrome: ventriculomegaly, subependymal cysts, medial peri-rolandic pachygyria, lateral polymicrogyria, hypertelorism, abnormal prenatal swallow, hyperechoic kidneys, hepatomegaly, stippled or scimitar-shaped patellar calcs
T/F: Schizencephaly and porencephaly can be differentiated by the presence or absence of communication between the ventricles and the subarachnoid space. False. Both can communicate, and either can have an intact membrane (which can rupture). Differentiation is best based on what lines the cavity: white matter (porencephaly) or dysplastic gray matter (schizencephaly).
What is the difference between schizencephaly and porencephaly in terms of etiology? Schizencephaly = developmental neuronal migration anomaly (poss r/t very early ischemic insult p/t neuronal migration, so dysplastic gray matter lines cavity) while porencephaly = early gestational ischemic insult after neuronal migration.
What is Leriche syndrome? aka aortoiliac occlusive disease, occlusive atherosclerosis involving the abdominal aorta and/or the iliac arteries
What is the eponymous name for aortoiliac occlusive disease caused by atherosclerosis? Leriche syndrome
What is the eponymous name for left iliac vein compression by the overlying crossing right common iliac artery? May-Thurner syndrome
What is May-Thurner syndrome? left iliac vein compression by the overlying crossing right common iliac artery
What is the threshold BP that is an absolute contraindication to IV thrombolysis? 180/110 mm Hg
How soon after intracranial surgery or CVA can IV thrombolysis be performed? no less than 6 months
How soon after GI bleed or major surgical procedure or trauma can IV thrombolysis be performed? no less than 10 days
What are the 3 top organs that develop polyarteritis nodosum (PAN)? (in order) kidney (of course), then liver, then mesentery
Median arcuate ligament syndrome imaging features of celiac trunk compression and hook-like shape are exaggerated on inspiration, or on expiration. Which is true? exaggerated on EXpiration. If visible on INSpiration, then significant and likely explains symptoms.
Describe the International Reflux Study Committee grading system for vesicoureteral reflux, per Duke review. Grade I: Reflux into ureter not reaching renal pelvis. Grade II: Reflux into pelvis without dilation. Grade III: Mild ureterocaliceal dilation. Grade IV: Mildly tortuous ureter. Grade V: Tortuous, loss of papillary impressions.
What is a prolapsing ureterocele? Ureterocele that has entered the os of the urethra. Must be large.
T/F: A small percentage of multicystic dysplastic kidneys (MCDK) will maintain some function. False. They have no function whatsoever. Any function suggests another etiology.
Newborn with bulging flanks and respiratory distress. Renal ultrasound shows bilaterally enlarged kidneys with reversal of normal corticomedullary differentiation. Top Dx? Reason for respiratory distress? Associated diseases? Autosomal recessive polycystic kidney disease (ARPCKD). Hypoplastic lungs from in utero renal insufficiency, oligohydramnios. ARPCKD is associated with congenital hepatic fibrosis and Caroli dz.
Name 7 diseases or syndromes associated with renal cysts. tuberous sclerosis (TS) complex, von Hippel Lindau (vHL) syndrome, Zellweger syndrome, Beckwith-Wiedemann syndrome, Tri-13, Tri-18, and Tri-21
10% of patients with ADPCKD have what CNS abnormality? Berry aneurysms
What is the classic triad of prune-belly syndrome? cryptorchidism, urinary tract anomalies, absent abdominal wall musculature. aka Eagle-Barrett syndrome.
What are the diameter size limits for calling aortic aneurysm? (Include ascending, descending thoracic, and abdominal aorta measurements.) ascending > 4.0 cm, descending thoracic > 3.5 cm, abdominal > 3.0 cm
Attenuated common and proper digital arteries with corkscrew collateral arteries in the wrist and hand. Top Dx? Buerger disease. Smokers.
Moving from medial to lateral, what neurovascular structures are you likely to encounter during a transrectal biopsy if you do not stay medial? inferior gluteal (IG) a/v, inferior pudental (IP) a/v, and sciatic n.
What is the part of the kidney called where there are minimal blood vessels in the parencha, located at the junction between the medial 1/3 and the lateral 2/3? Brodel’s line, or Brodel’s bloodless line. Ideal side for percutaneous nephrostomy.
Which IVC filter can be removed from an inferior (groin) approach? Optease
What causes S-distortion in fluoroscopy? What types of systems might have this type of distortion? External magnetic field causes S-shaped spatial warping, only seen in Image Intensifier type systems (not flat panel).
At low dose rates, which systems perform better: II or FPD? Image intensifier based detectors perform better at low dose rates due to brightness gain (product of minification gain and electronic flux gain)
List T1, T2, and T2* times in their order of magnitude in general. T1 >> T2 > T2*
How is T1 weighting controlled in gradient echo sequences? Two variables cause INcrease in T1 weighting: higher flip angle and shorter TR
What general MR sequence category utilizes a 180-degree refocusing pulse? spin echo
In MR, how does “receiver on time” related to bandwidth? Decreased receive bandwidth will lead to increased “receiver on time” and therefore increased signal, all other variables kept constant.
What are the different grades of miniscal signal on MR? Grade 1: globular (degeneration). Grade 2: linear, not extending to surface. Grade 3: extends to surface (tear).
How do the following changes affect SNR in MR imaging?: decr receiver BW, incr NEX, incr number of lines measured vs calculated, incr voxel size, incr field strength, incr number of coil elements, decr matrix size, decr flip angle (GRE) high to medium All of these INCREASE signal-to-noise ratio.
What are 2 names for the technique of fat suppression used for "standard fat sat" MR? frequency selective, aka chemically selective
What magnetism do oxyhemoglobin and deoxyhemoglobin have? Oxyhemoglobin is diamagnetic experimentally (no unpair electrons) and maintains T2 signal (bright), whereas deoxyhemoglobin is paramagnetic and dissipates local T2 signal (dark).
On what sequences is magic angle effect seen? long TE sequences
What is the FDA limit for MR whole-body average SAR? no more than 4.0 W/kg
What part of the brain ventricular system is the first to enlarge upon obstruction at the aqueduct of Sylvius? temporal horns of the lateral ventricles
Nonenhancing cystic “gelatinous pseudocysts” within the perivascular spaces is classic for what CNS disease? cryptococcosis
Strictly posterior symmetrical centrum semiovale white matter disease that crosses the corpus callosum, without mass effect, with marked enhancement at the subcortical U-fibers. Top Dx? How is it treated? adrenoleukodystrophy. X-linked (boys) is most common, 4-8 yrs old. Tx: Stem cell transplantation. Other form is Neonatal, AR-inh, affects all of white matter.
On cross section of the spinal cord, where do the classic MS lesions occur? posterior columns, asymmetric, peripheral. If symmetric, think about B12 deficiency.
Infant with macrocephaly and frontal-predominant symmetric white matter disease. Top Dx? Alexander disease (leukodystrophy, dysmyelinating)
Infant with macrocephaly and diffuse symmetric white matter disease, with a dramatically elevated NAA peak. Top Dx? Canavan disease (leukodystrophy, dysmyelinating). No other disease has this dramatic NAA peak.
Infant with diffuse symmetric white matter disease with tigroid appearance. Top Dx? metachromatic leukodystrophy
Markedly elevated T2 signal in the pons with anterior “trident” appearance is classic for what CNS disorder? central pontine myelinolysis (CPM). Can occur outside the pons as well.
Cyclosporine and FK506 have been implicated in what reversible white matter disease? PRES
Lytic lesion involving a vertebral body, with a “mini brain” appearance on transaxial slides. Top Dx? multiple myeloma. Looks like a slice of brain sometimes.
Where do most chordomas occur? sacrum (50%), then clivus (35%), then remainder (15%)
Differentiate ADEM and NMO in terms of ages affected most. ADEM affects mostly peds, while NMO affects mostly adults.
Differentiate NMO and MS in terms of length of spinal cord affected. MS affects short segment (<2 levels), while NMO affects long segment (>4 levels). Also, NMO (aka Devic dz) rarely has brain involvement (but optic neuritis is common), and can be tested for anti-aquaporin-4 antibody.
Patient with subacute/chronic headache and sensorimotor deficits has basal leptomeningeal enhancement on brain MR and a spinal cord lesion. What extracranial finding might provide evidence that the diagnosis is sarcoidosis? lymphadenopathy
What is the classic appearance of the spinal cord in vitamin B12 deficiency? bilateral symmetric dorsal column T2 hyperintensity in an "inverted V" or "inverted rabbit ears" distribution. Lateral columns may be involved in severe cases.
What is MISME syndrome? Multiple Inherited Schwannoma Meningioma and Ependymoma, aka NF2. Also prone to syringohydromyelia and cataracts.
Which phakomatosis is prone to development of brainstem gliomas? NF1
What is the most common spinal cord tumor in childhood? astrocytoma. Long infiltrating poorly delineated lesions, often with internal cysts, usually some enhancement. More frequent in NF1 (brainstem gliomas).
What mnemonic reminds of the relationship of the middle ear ossicles and where they connect with the inner ear? ”MISO soup.” Malleus (TM) to Incus to Stapes to Oval window.
Why do cholesterol granulomas at the petrous apex have T1 signal, but cholesteatomas do not? Cholesterol granulomas have recurrent small hemorrhages, so the blood products are T1 bright.
What disease is strongly associated with rupture of the subclavian artery on presentation? Ehlers-Danlos syndrome
What is the Monro-Kellie hypothesis? Any increase in volume of one of the cranial constituents must be compensated by a decrease in volume of another, because the intracranial volume is fixed.
Which nuclear medicine is most sensitive for evaluating glomus tympanicum? Octreoscan is slightly more sensitive than MIBG for evaluating glomus tympanicum.
The mnemonic “stones, bones, psychic moans, abdominal groans, and hypertones” describes clinical features of what disease? severe hypercalcemia
What pattern of insufficiency fractures have been attributed to bisphosphonates? LATERAL horizontal insufficiency fx in femurs just distal to lesser trochanter level (LATERAL, not medial)
What % of glomus tympanicum tumors are hereditary? bilateral? malignant? 1/4 are hereditary. 10% are bilateral. Only 3% are malignant.
Name 3 associated syndromes and chromosomal anomalies associated with omphalocele. 1. Beckwith-Wiedemann, 2. OEIS (omphalocele, bladder extrophy, imperforate anus, and spinal anomalies), and 3. pentalogy of Cantrell
What are the small biliary ducts that drain directly into the gallbladder and are implicated in many post-cholecystectomy biliary leaks? ducts of Luschka
Patient with headache, otorrhea, and lateral rectus palsy. This clinical triad is classic for lesions in what location? What is the most likely Dx if the patient has fever? petrous apex. Fever, bone destruction, and enhancement would all support the diagnosis of petrous apicitis (for which this clinical triad is classic).
What is the most common congenital anomaly of the inner ear? large endolymphatic sac anomaly, from arrested development, associated with cochlear dysplasia
What is labyrinthitis obliterans? membranous labyrinth ossification in response to infection, inflammation, trauma, surgery. 2 types: fibrosing vs ossifying.
What is the DDx for high density material in the maxillary sinus? Name 5 possibilities. fungal sinusitis (dark on T2), hemorrhage, thick secretions (as seen in CF), calcified polyps, sinonasal lymphoma
What extremely vascular mass in young male adolescents is characteristically centered at the sphenopalatine foramen (SPF) and expands the pterygopalatine fossa (PPF)? juvenile nasal angiofibroma. Often presents with epistaxis.
Created by: dudall