Showing posts with label RADIOLOGY. Show all posts
Showing posts with label RADIOLOGY. Show all posts

Radiology Signs -Juxta Phrenic Peak Sign

By Deepu
The juxtaphrenic peak sign refers to the peaked or tented appearance of a hemidiaphragm which can occur in the setting of lobar collapse.

 It is caused by retraction of the lower end of diaphragm at an inferior accessory fissure, major fissure or inferior pulmonary ligament. It is commonly seen in upper lobe collapse but may also be seen in middle lobe collapse.

The negative pressure of upper lobe atelectasis causes upward retraction of the visceral pleura, and protrusion of  extrapleural fat into the recess of the fissure is responsible

Occurs in upper lobe atelectasis, describes the triangular opacity projecting superiorly at the medial half of the diaphragm

Image Archives SVC obstruction- CT findings

By Dr Deepu

Sarcoidosis- CT findings

By Dr Deepu

conglomerated micronodules and centrilobular
 nodules in both lungs
Enlarged mediastinal  lymph nodes

 Bilateral hilar lymph nodes

Chest CT scans show conglomerated micronodules and centrilobular nodules in both lungs. We can see the enlarged mediastinal and bilateral hilar lymph nodes.
Sarcoidosis is a multi-system disease of unknown etiology, usually affecting the respiratory tract and other organs, and is characterized by the formation of nonnecrotizing epithelioid granulomas. The diagnosis depends on a combination of a typical clinicoradiological presentation, the finding of nonnecrotizing epithelioid granulomas in a tissue biopsy, and exclusion of other possible diseases, especially those of infectious etiology.

 Sarcoidosis results from an uncontrolled cell-mediated immune reaction. Interactions between chemokines and receptors that activate mitogen-activated protein kinase pathways play a major role in inflammation and T-cell responses. Tumor necrosis factor (TNF)-[alpha] is an important player in granuloma formation, and recent clinical trials have investigated the efficacy of TNF-[alpha] inhibitors in sarcoidosis.

HRCT findings of Atypical Adenomatous Hyperplasia.

By Dr Deepu

Focal area of ground glass attenuation on Left Upper Lobe. Rest of the appearances are unremarkable.
 Atypical Adenomatous Hyperplasia (AAH) of the human lung has been recently implicated as a possible precursor lesion of bronchioloalveolar carcinoma (BAC). The atypical adenomatous hyperplasia-adenocarcinoma sequence has been likened to the adenoma-carcinoma sequence in the large intestine. Atypical Adenomatous Hyperplasia is the earliest lesion in stepwise development of bronchioloalveolar carcinoma.By multivariate analysis, sphericity was statistically significantly associated with atypical adenomatous hyperplasia, and internal air bronchogram with bronchioloalveolar carcinoma

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Signs in chest radiology- The hilum overlay sign

By Dr Deepu

The hilar overlay sign is another sign described by Felson.The hilum overlay sign refers to an appearance on frontal chest X ray of patients with a mass at the level of the hilum which is in fact either anterior or posterior to the hilum.

When a mass arises from the hilum, the pulmonary vessels will be in contact with the mass and hence their silhouette is obliterated. The ability to see and trace the edges of the vessels through the mass implies that the mass is not contacting the hilum, and is therefore either anterior or posterior to it. 

Most of these masses usually are found to be in the anterior mediastinum.

want to read more in chest radiology??? Have a look at the following pages

Signs in chest radiology- The silhouette Sign

By Dr Deepu
Silhouette sign/loss of silhouette sign/ loss of outline sign.
I was always confused with the silhouette sign for its hidden meaning and failure to decode it by many medical students. So, I thought it would be apt to unravel it so that it could be handy for many medical students.
One of the most useful signs in chest radiology is the silhouette sign. This sign was described by Dr. Ben Felson. The silhouette sign is in nothing but  elimination of the silhouette or loss of lung/soft tissue interface caused by a mass or fluid in the normally air filled lung. For instance, if an intrathoracic opacity is in anatomic contact with, for example, the heart border, then the opacity will obscure that border. The sign is commonly applied to the heart, aorta, chest wall, and diaphragm. The location of this abnormality can help to determine the location anatomically. 

Just go through the X Ray to know the  various structures seen in the chest x ray.

Let me explain this with this image.
What do we see???
There is plastic bottle which is surrounded by air, the margins of the shadow is very  well demarcated from the surrounding air.

First scenario: There are two bottles, made of same material, placed apart from each other. The shadows appears separate from each other. Let us consider the right bottle to be the heart and the air surrounding the bottle as lung. The left bottle as a mass, since they are far from each other, the border of both  is visible clearly.

Second scenario: Here we see the bottles are touching each other at two points and there is no gap in between and if we look at the shadow, we cannot differentiate between the two shadows, they appear like a single opacity at the upper and lower ends.

For the heart, the silhouette sign can be caused by an opacity in the RML, lingula, anterior segment of the upper lobe, lower aspect of the oblique fissure, anterior mediastinum, and anterior portion of the pleural cavity.
This contrasts with an opacity in the posterior pleural cavity, posterior mediastinum, of lower lobes which cause an overlap and not an obliteration of the heart border. Therefore both the presence and absence of this sign is useful in the localization of pathology.

want to read more in chest radiology??? Have a look at the following pages
Chest Radiology
Signs in Chest Radiology

signs in chest radiology Bulging Fissure Sign

By Dr Deepu
Bulging Fissure Sign

The bulging fissure sign, it represents expansive lobar consolidation causing fissural bulging or displacement by copious amounts of inflammatory exudate within the affected parenchyma, seen in a chest x ray. It is classically associated with right upper lobe consolidation due to Klebsiella pneumoniae , any form of pneumonia can manifest the bulging fissure sign.  The prevalence of this sign is decreasing,because of prompt administration of antibiotic therapy to patients with suspected pneumonia . The bulging fissure sign is also less commonly detected in patients with hospital-acquired Klebsiella pneumonia than in those with community-acquired Klebsiella infection .
   Other diseases that manifest a bulging fissure
 any space-occupying process in the lung, such as
pulmonary hemorrhage,
 lung abscess, and
want to read more in chest radiology??? Have a look at the following pages

Plombage - An Obsolete Technique of Historical Importance in treating TB

By Dr Deepu
Chest X Ray of Plombage using Lucite Balls

CT Thorax of the same Patient

Plombage was a surgical method used prior to the introduction of anti-tuberculosis drug therapy to treat cavitary tuberculosis of the upper lobe of the lung. The term derives from the Latin word "plumbum" (lead) and refers to the insertion of an inert substance in the pleural space. The technical medical term for plombage is extraperiosteal or extrapleural pneumonolysis.
The underlying theory of plombage treatment was the belief that if the diseased lobe of the lung was physically forced to collapse, it would heal quickly. There were positive results in tuberculosis therapy following plombage in the decades of the 1930s, 40s and early-50s. However, with the introduction of drugs which were effective in destroying the tuberculosis bacterium (Mycobacterium tuberculosis), plombage treatment fell into disfavor. In addition, complications of plombage began to appear in patients who had been so treated. These complications included hemorrhage, infection and fistulization  of the bronchus, aorta, esophagus and skin.
The technique involved surgically creating a cavity underneath the ribs in the upper part of the chest wall and filling this space with some inert material. A variety of substances were typically used and included air, olive or mineral oil, gauze, paraffin wax, rubber sheeting or bags and Lucite balls. The inserted material would force the upper lobe of the lung to collapse.


CT Scans May Cause Cellular Damage.

By Dr Deepu
Fox News (7/23, Kwan) reports that research published in the Journal of the American College of Cardiology: Cardiovascular Imaging suggests that “computerized tomography (CT) scans may cause cellular damage.” Investigators “examined the blood of 67 patients undergoing cardiac CT angiograms (CTA), and measured biomarkers of DNA damage before and after undergoing the procedure.” The investigators “found an increase in DNA damage and cell death after a single CT scan, but most of the cells were repaired or eliminated.” Medscape (7/23) reports that “in addition to DNA damage, the group also observed a significant increase in cellular apoptosis in 15 of 25 patients with measured levels oif apoptotic cell death before and after cardiac CT angiography.” HealthDay (7/23, Preidt) points out that “in 2007, the U.S. National Cancer Institute predicted that 29,000 future cancer cases could be linked to the 72 million CT scans performed in the country that year alone.”


By Dr Deepu

 The melting ice(cube) sign describes the resolution of. pulmonary haemorrhage following pulmonary embolism. 
When there is pulmonary haemorrhage without infarction following PE, the typical wedge-shaped, pleural-based opacification (Hamptons Hump) resolves within a week while preserving its typical shape. It is named due to its resemblance with a melting ice cube.

1. Webb WR, Higgins CB. Thoracic Imaging: Pulmonary and Cardiovascular Radiology, North American Edition. Lippincott Williams & Wilkins. (2010) ISBN:1605479764. 

Suggested Reading
1. Chest X Ray Part 1- Normal Anatomy And ItsVariants

HRCT view of cannonball secondaries

Ever wondered how cannon ball secondaries are seen on HRCT thorax??? Go through the video to find the cannon ball secondaries on HRCT thorax..
Unable to view the video watch it in youtube 
Want to Know more about cannon ball secondaries? Read this article

Grand Rounds - Opaque hemithorax.

Pulmonary Medicine Blog By Dr Deepu

Grand Rounds:

This patient an elderly lady presented to us with breathlessness and cough eith sputum with increased sputum in right lateral position. Spo2 was 89% 
Examination revealed trachea deviated to left. Apicak impulse felt in left axilla 5th Ics. Breath sounds diminished on left with added crepitations on left side.
This X ray was taken in emergency room.

 CT confirmed fibrosis of left lung.
Complete white out(opacification) of the hemithorax on CXR has a limited number of causes.
 The differential diagnosis can be zeroed on with one simple observation - the position of the trachea. 
Is it central, pulled or pushed from the side of opacification?
  • pulled trachea : pneumonectomy, total lung collapse, pulmonary fibrosis,pulmonary agenesis
  • central: consolidation, mesothelioma, collapse with effusion. Lung mass 
  • pushed: pleural effusion, diaphragmatic hernia.

Clinical Case - Give Your Diagnosis!!!

Pulmonary Medicine Blog By Dr Deepu
An elderly female came to the outpatient department with a history of cough since 2 weeks minimally productive sputum, she also give history of increased breathlessness since 3 weeks, the symptom of breathlessness being present since three years, she also complains of decreased sleep due to productive cough, and a known hypertensive since 5 years.
  Clinical examination reveals pitting pedal edema and bilateral basal crepitations and no other significant clinical findings were present.
Investigations revealed a total count of 13000 and this chest x ray. EKG was normal. What could be the differential diagnosis????

Spotter : Identify the radiological sign in chest X ray.

Spotter for you: What is your Diagnosis?? What are the differentials and source of such condition.

Chest X Ray- The Diaphragm is unique and provides clue to your diagnosis!!!

Pulmonary Medicine Blog By Dr Deepu

There are a few things which beginners often miss in a chest x ray, one among those is failure to comment on the diaphragms.
Today I am going to discuss importance of tracing diaphragm in a chest X ray with an example.
          Normal diaphragm in a chest X ray has the following characteristics
1.     Trace the diaphragm on right and left
2.     The right diaphragm is usually placed between the fifth and the sixth Rib in the mid clavicular line, It can be seen upto middle of sixth and seventh rib.
3.     The Diaphragms are usually not at the same level on the frontal , erect , inspiratory chest X rays, but they are usually within one rib intercostals space height ( roughly 2 cm) of each other.
4.     The left diaphragm is usually lower than right.
5.     The costophrenic angles should be sharp, making an acute angle.
6.      If the left hemidiaphragm is equal to Right or higher than Right or Right diaphragm is higher than left by more than 3 cms, Causes of diaphragmatic elevation should be considered.
The causes of elevated hemidiaphragm are
1.            Causes above the diaphragm- decreased lung volume due to Lung Collapse, lobectomy, pneumonectomy , fibrosis and pulmonary Hypoplasia
2.            Causes in the diaphragm- Phrenic nerve palsy , diaphragmatic evantration
3.            Causes below the diaphragm- abdominal malignancy, subphrenic abscess, distended   hollow viscus.
After knowing the cause I want to discuss with you a chest x ray where the subtle change in the diaphragm was missed.
Before we proceed Read the chest X ray

 The Chest X ray showed a subtle change in Diaphragm
1. Both the diaphragms are at the same levels.
2. The air shadow underneath the left diaphragm is more prominent.
3. The patient was not evaluated further because chest X Ray appeared normal and sent home with conservative treatment for COPD. 
He came back to our center with hemoptysis one month later referred from the center which treated him initially, a second Radiograph was performed. study the Chest X Ray before proceeding further.  

The chest X ray  now shows features of full blown disease, the hilum is prominent with CORONA RADIATA SIGN suggestive of bronchogenic carcinoma, The left Diaphragm is now placed higher compared to right. Further HR and CECT revealed a tumor in the Left Main bronchus with lymph node metastasis. With Bronchoscopy the diagnosis of squamous cell carcinoma was made.

With this I will end this post, requesting everyone to look at any subtle changes in diaphragm which if ignored may cause some grave diagnosis at a later date.

The Rings !!!The Trams!!!, Chest X Ray Findings in Bronchiectasis

Pulmonary Medicine Blog By Dr Deepu
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Bronchiectasis is  an abnormal and permanent distortion of one or more of the conducting bronchi or airways.
In 1950, Reid characterized bronchiectasis as cylindrical, cystic, or varicose types.

Types of bronchiectasis

Cylindrical Bronchiectasis
Mild Form shows Tram Track Appearance

Varicose Bronchiectasis
Moderate Form appears as string of pearls

Cystic/ Saccular Bronchiectasis
Severe Form appears like Bunch of Grapes

       Chest radiography Chest radiography (CXR) is usually the initial study performed in both suspected bronchiectasis and the evaluation of nonspecific respiratory symptoms, such as dyspnoea and haemoptysis, when bronchiectasis may be identified incidentally.

Signs on CXR are the identification of
Read This X Ray Before Proceeding Further

1.     Parallel linear densities, tram-track opacities.

what was seen on the chest X ray, it is nothing but the tram line appearance, unable to spot it, here comes the Modified image
Now Compare the previous X Ray with the one above , Here are few examples of tram line shadows
The black arrows points towards tram line and the white to shadows which will be discussed below
Read this X ray before proceeding
What Can we see here
if you have got it proceed further
What we see here is the ring shadows, there are many other ring shadows in the x ray , only a few are  marked
One More X ray below showing the ring shadows in Cystic Fibrosis Patient 

2.     Ring shadows reflecting thickened and abnormally dilated bronchial walls. These bronchial abnormalities  may vary from subtle or barely perceptible 5-mm ring shadows to obvious cysts.
3.      Fluid or mucous filling of bronchi is seen and leads to Tubular branching opacities conforming to the expected bronchial branching pattern.

4.     The Definition of vessel walls is lost due to  peribronchial fibrosis.
5.     Signs of complications/exacerbations, such as patchy densities due to mucoid impaction and consolidation
6.      Volume loss secondary to bronchial mucoid obstruction or chronic cicatrisation, are also seen.
7.     In the more diffuse forms , such as cystic fibrosis (CF), generalised hyperinflation and oligaemia are often present, consistent with severe small airways obstruction.
The radiograph may raise the initial suspicion of bronchiectasis, triggering more definitive imaging. 
CXR also plays a role in the follow-up of bronchiectasis and management of exacerbations.Although CXR has limitations in specificity in diagnosing bronchiectasis and in detecting early or subtle changes, it is useful for assessing more florid cases of bronchiectasis, in CF and in follow-up of bronchiectatic patients. Computed tomography.

suggested Reading
1. Chest X Ray Part 1- Normal Anatomy And ItsVariants