Subject: Radiology

Topic: Um..?
Lecturer: The usual
Shifting /Date: 2nd shifting, August 9 2008
Trans group: Chicken Naguits :D

Trauma classification • Up to 95% of patients with bladder rupture

• Grade 1 present with gross hematuria
o subscapular hematoma non-expanding • The susceptibility of bladder to injury is
o contusions and small infarcts dependent on degree of distention, a distended
o no parenchymal laceration urinary bladder is much more prone to injury
• Grade II than a nearly empty one
o less than 1 cm laceration • Urine extravasation, whether intraperitoneal or
o non-expanding perirenal hematoma extraperitoneal, is dependent on the location of
• Grade III the bladder. Intraperitoneal rupture often
o greater than 1 cm laceration results from a direct blow to a distended
o not extending to collecting system bladder
• Grade IV • Delayed scans may help display extravasated
o laceration with urinary extravasation urine
o main renal artery or vein injury with
Adrenal Adenoma
contained bleed
• Grade V • Incidence in the population is 2-8%
o main renal artery thrombosis • Diagnosis is often made as an incidental finding
o shattered kidney on CT examination
o renal hilar injury with devascularization of • In patient with no known primary, an adrenal
kidney mass is almost always a benign adenoma
o avulsion at UPJ • In a patient with a known neoplasm, especially
lung cancer, an adrenal mass is problematic
CT is highly useful for: and diagnosing a metastasis versus and
1. Diagnosing and staging renal injuries adenoma is critical for prognosis
2. Determining the depth of cortical • CT findings
lacerations o Size greater than 4 cm tend to be
3. The quantity of devascularized renal tissue metastases or adrenal carcinoma
4. The status of the renal collecting system - heterogeneous appearance and irregular
5. The extent of peri-renal hemorrhage shape are malignant characteristics
o Homogeneous and smooth are benign
Clas Criteria characteristics
s - intracellular lipid in adenoma results in low
Contusions, small attenuation on CT
corticomedullary o Little intracytoplasmic fat in metastases
I Lacerations that do not results in high attenuation on non-enhanced
communicate with the collecting CT
system o Non-enhanced CT (NECT)
II Laceration that communicates - threshold 10 HU
with the collection system - sensitivity 79%, specificity 96%
III Shattered kidney, injury to the o Contrast-enhanced CT (CECT)
vascular pedicle -because majority of CT examinations in
IV UPJ avulsion, laceration of the oncology use IV contrast, the % washout is
renal pelvis useful after 10 minutes.
- adenomas have greater than 50%
Bladder washout after 10 minutes
-washout can also be used on adrenal
• Occurs in association with blunt pelvic trauma,
masses that measure >10 HU on NECT
pelvic fractures or penetrating injuries
- alternative is to do MR or PET
• Gross hematuria almost always accompanies
bladder rupture

MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY KC JAM CECILLE DENESSE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC
PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU
RACHE ESTHER JOEL GLENN TONI

MR findings:
• Chemical Shift
- most sensitive method for differentiating
adenomas from metastases
- sensitivity 81-100%, specificity 94-100%
- the difference in resonance rate of protons in
fat and water is exploited in chemical shift
-- intracellular lipid and water in same voxel
result in
summation of signal on “in-phase” and
canceling out of
signal on “out of phase”
• Spleen or muscle is used as an internal
standard to visually quantify signal drop-off
- liver is not a reliable standard because of
steatosis
Adrenocortical carcinoma
• Rare malignancy with a poor prognosis
• Reported incidence: 2 cases per million persons
• Tumors frequently are large, measuring 4-10
cm in cross-sectional diameter
• Arise from the adrenal cortex
• Bilateral in up to 10% of patients
• Approximately 50-80% are functional tumors,
with most causing Cushing syndrome
• Sign and symptoms
o A large palpable mass, abdominal pain, or
Cushing syndrome
o Cushing syndrome is the most common
clinical presentation in adults with adrenal
cortical carcinoma, although
o Patients can present with virilization,
feminization, precocious puberty, or Conn
syndrome
o In children, the most common clinical
presentation is virilization , followed by
Cushing syndrome
• Endocrine syndromes associated with
adrenocortical carcinoma
o Cushing syndrome
o Virilization and precocious puberty
o Feminization
o Primary hyperaldosteronism
MRI findings:
• A large mass
- lower signal intensity than the liver on T1-
weighted images and
- higher signal intensity than the liver on T2-
weighted images
- often, the tumor demonstrates
heterogeneously hyperintensity on T1- and T2-
weighted images, due to the central necrosis
and hemorrhage
Subject: Radiology
Topic:
Page 2 of 8
• Coronal and sagittal images may be helpful in
determining adrenal origin of the mass, thus
differentiating it from renal cell carcinoma or
hepatocellular carcinoma, especially if CT is
equivocal
CT findings
• Large mass (>4 cm)
• Central necrosis or hemorrhage
• Heterogeneous enhancement
• Invasion into adjacent structures
• Venous extravasation into the renal vein or
inferior vena cave
Adrenal metastases
• Unilateral adrenal mass or enlargement
• Small masses (<1 cm)
o Adenoma
o Ganglioneuroma
o Hyperplasia
o Metastasis
o Pheochromocytoma
• Large masses (>4 cm)
o Carcinoma of adrenal cortex
o Cyst or pseudocyst
o Hematoma
o Infection
o Inflammation (eg, tuberculosis,
histoplasmosis)
o Metastasis (eg, lung or breast related)
o Myelolipoma
o Neuroblastoma
o Ganglioneuroblastoma or ganglioneuroma
o Pheochromocytoma (eg, multiple endocrine
neoplasia)
Bilateral adrenal enlargement
Common causes: hemorrhage (eg in infants,
trauma, bleeding disorder), histoplasmosis,
hyperplasia, metastasis (eg, lung or breast
related), neuroblastoma, and tuberculosis
Uncommon causes: Addison disease, adenomas,
amyloidosis, carcinomas (eg, multiple, primary),
infection (ie, others), lymphoma,
pheochromocytoma (multiple endocrine neoplasia),
and Wolman disease (eg, familial xanthomatosis)
CT Findings
• Appear as focal masses or distortion of the
contour of the adrenal gland
• Smaller than 3 cm may be homogenous
• Large lesions may have central necrosis or
hemorrhage. These lesions are heterogenous

and may have thick enhancing rims. They may
also invade contiguous organs such as the
kidneys.
• Attenuation values of less than 10 HU on
unenhanced
MRI Findings
• Are usually hypointense on T1-weighted images
and
• Relatively hyperintense on T2-weighted images
• The exception is metastatic melanoma, which
may be bright on T1-weighted images
• Occasionally, lesions may remain hyperintense
on long-echo time T2-weighted images,
mimicking pheochromocytomas
CASE: 43 year-old women with hypertension
• A middle aged woman presented to her primary
care physician with hypertension and episode
sweating. She was referred to a urologist who
obtained a 24 hour urinary vanillymandelic acid
(VMA) which was elevated
CASE: 35 year-old women with HPN
• A large, right-sided, inhomogenous, adrenal
mass with a central area of low attenuation
that represents hemorrhage or necrosis
Subject: Radiology
Topic:
Page 3 of 8
Left: T1-weighted, a mixed isointense-to-
hypointense right adrenal mass
Right: T2-weighted, the right adrenal tumor has
high signal intensity
Pheochromocytomas
CT Findings
• Large tumors (often > 3 cm)
• They are usually round or oval masses with an
attenuation similar to that of the liver
• Larger lesions frequently demonstrate necrosis,
hemorrhage, and fluid-fluid levels
• As a result, they often appear inhomogenous
• Calcification is rare, but it is reported
MRIs
• Usually hypointense or isointense relative to
the liver on T1-weighted spin-echo (SE) images,
and
• They are highly intense on T2-weighted SE
images
• The reason for this difference is unknown, but
likely results from the high water content in
cellular homogenous tumors or the high water
content in necrotic regions
• Tumors that have bled show the features
typical of hemorrhage, depending on the age of
the hemorrhage
Normal Uterine Size:
By ultrasound, the normal postmenarchal
nulliparous uterus is 5-8 cm in length, 1.5-3 cm
thick, 2.5-5 cm wide.
Myometrium:
The normal myometrium is hypoechoic,
homogenous, and reasonably well demarcated
from the endometrial echos
Endometrial Structure:
The endometrium consists of a constant basal
layer (basalis), and a cycling functional layer
(functionalis). The functional layer includes a thin
compactum layer and a thick spongiosum layer.
 Subject: Radiology
Topic:
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sac is often considered abnormal, but
occasional normal pregnancies do not show
yolk sac up to 20mm.
Name Of Phase Days
Menstrual Phase 1-4 • By lower resolution abdominal scanning, a sac
Follicular phase 4-14 > 20mm MSD with no yolk sac is abnormal.
(aka proliferative
phase) Vaginal scanning to improve certainty should
Ovulation (not a 14 be done.
phase, but an
event dividing
phases
Luteal phase (aka 15-26
secretory phase)
Ischemic phase 27-28
(some sources
group this with
secretory phase)

Phase Days Thickness

Menstrual 1-4 Thin
phase
Proliferativ 4-14 Trilaminar
e Phase
Secretory 15-28 Thick
phase

Early pregnancy
• Gestational Sac first appears in the substance
of the deciduas (intradecidual) at 4.5 weeks,
and should be seen virtually in all normal 5
week intrauterine pregnancies. Abnormal gestational sac size (3cm) neither
a yolk sac not an embryo is identified.
• The yolk sac is a definite evidence of a true
gestational sac, first seen at 5 weeks. It is a
landmark to the early embryo, which develops
along its outer margin. Yolk sac should be seen
when the sac is 8-10mm. MSD by vaginal
probe, or 20mm. MSD by abdominal probe.

• By vaginal probe high resolution scanning, the

embryo is first seen between 5.7 – 6.1 weeks
with heartbeat appearing at 6.2 weeks. Small
normal embryos may not have a heartbeat.
Embryo should be seen by high resolution scan
at 18mm MSD, or 25mm MSD by abdominal
scan.

Anembryonic Gestation (Blighted Ovum)

• By high resolution vaginal scanning, a sac >

13mm MSD (mean sac diameter) with no yolk

Associated findings in threatened abortion
• Subchorionic bleeding
o Often visible as endometrial fluid surrounding
the external (deciduas capsularis) aspect of
the gestational sac. As long as the placental
(decidua vera) interface of the gestational
sac and deciduas remain intact, the
pregnancy often continues.
o From the standpoint of hemorrhage volume
estimated using--
 length (cm) x height (cm) x depth (cm) x
0.52 = volume ml
less than 75-200mL is often associated
with continued development.
• Slow heartbeat
o Embryonic heart rate <85 bpm is a negative
prognostic sign, but is less reliable in small
embryos
• Small Sac
o When the mean sac diameter (MSD) exceeds
crown rump length (CRL) by less than 5mm,
loss rate is 80%. However this “small sac”
sign occurs in only 2% of the time.
Incomplete Spontaneous Abortion (embryo
dead)
• In many cases, embryo has already died.
Persistent chorionic function maintains a
positive HCG assay
• Expulsion of the sac is often delayed several
days, though it may be seen to slowly migrate
from the initial fundal location toward the
uterine cervix.
Subject: Radiology
Topic:
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Obstetrical Ultrasound Measurements
• Gestational Sac
o The first element to be measured is the
gestational sac of pregnancy. It is measured
in three dimensions, and the average—the
MSD is used for estimating the gestational
age.
o It is useful between 5-8 menstrual weeks
with accuracy of +/- 0.5 week (95% CI).
o As a rough rule of thumb, the MSD + 30 =
Menstrual Age in days.
• Embryonic Crown Length
o The length of the embryo in the longest axis
(excluding the yolk sac) constitutes the
crown rump length.
o This is among the best documented
parameters to date the embryo, with
accuracy of +/- 3-5days.
o As a rule of thumb, the CRL +6.5 =
Menstrual age in weeks
• Biparietal diameter (BPD)
o The transverse width of the head at it’s
widest, usually recognized by a symmetric
measure from the leading edge to leading
edge of the bones, because this leading
interface is most distinct.
o The BPD best used after 12 weeks. Accuracy
is +/- 1.1 week 14-20 weeks, +/- 1.6 weeks
20-26 weeks, +/- 2.4 week 26-30 weeks, and
+/- 3.4 weeks after 30 weeks.
• Head Circumference
o A measurement which considers both
transverse (BPD) and front to back (APD) will
be more accurate. This combined
measurement is called the head
circumference. A true circumference is not
actually measured through. The BPD and

APD (anterior/posterior diameter) are
measured and the circumference of the
result in oval calculated
o If the machine does not calculate Head
Circumference, you can do it easily with the
formula:
(APD + BPD)/2 X 3.14 = Head
Circumference
• Femur Length
o The femur length is a repeatable
measurement with accuracy similar to the
BPD. It is affected by skeleton dysplasia, but
since these are rare, it is reliable
measurement which confirms measurements
of the head. It is best measured after 14
weeks.
• Abdominal Circumference
o The abdominal circumference is another
circumference estimate made by averaging
the anterior-posture and transverse
diameters times 3.14. it is made at the
widest point in the abdomen, through the
liver at the level of the left portal vein or
stomach.
o Fetal Breathing Movements: Complex Reflex,
Sensitive but not Specific, False + in sleep.
o Fetal Trunk and Extremities Movements:
Moderate Complexity less Sensitive, more
specific All pregnancies 26 weeks or more
must show motion during routine ultrasound,
if not, further evaluation id done, First
Acoustic Stimulation, an if negative, Formal
Biophysical Profile.
o Fetal tone: Simple maintenance of flexion
“Fetal Position” posture. Relatively
insensitive, but ominously specific often for
more advanced distress.
o Amniotic fluid volume: not neural reflex, but
a physiologic reflection of uteri ne production
and uterine retention.
Subject: Radiology
Topic:
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Ang mga sumusunod ay mga hango lamang sa
mga sinabi ni doc na naitala po namin 
Delayed Film – used to determine if there is a
nephrogram
Case of Hydronephrosis:
You have a bladder which has a smooth margin
outline, then the left kidney is now visualized, this
is the post void the distal third of the ureter this is
one hour delay. So what is the purpose of having a
delayed film? We could appreciate if there is a
nephrogram in the left kidney. So until the three
hour delay there is no evidence of nephrogram.
The patient was ultrasound, the left kidney is very
small it was 8.7 with cortical thickness of 0.8, so
this is a medical renal disease. So this is the rt
kidney showing you the hydronephrosis. In that
case the left kidney is not malfunctioning.
Case of Enlarged Kidney:
Another patient showing you calcification in the left
pelvic region there are no calcifications in the
region of the renal shadow as well as in the areas
of the ureters. So this is a one minute film showing
you a right kidney with a normal pelvocalyceal
system, the left kidney show you a urethrogram
and the left kidney is enlarged.
There’s hydronephrosis in the dilated ureter to the
area of the uretero pelvic junction so there is a
stone.
Normal Ultasound Findings:
Normal Size: 9-12
Presence of corticomedullary differentiation - the
medulla is usu. whiter or hyperechogenicicity
compared to the cortex.
Normal thickness of the urinary bladder: 0.3cm or
3mm for a well distended bladder; for a post ovoid
bladder it’s 0.5cm of 5mm
So how will you know if it’s a fully
distended/underfield bladder? The bladder should
have 200cc, if it’s less than 250cc it’s underfield in
adults.
Case of Nephrolithiasis
In the kidney there is shadowing echogenicity,
there is nephrolithiasis.
Case of Acute Renal Failure
Multiple shadowy echogenicity in the kidney - This
is a staghorn calculi; acute renal failure because
the kidney is around 7.7. So once the kidney is

small and there is no cortical differentiation mean
chronic medical renal disease. Then you have to
correlate it with the serum creatinine. Serum
creatinine is elevated, so most likely the px is
either acute renal failure or in a chronic stage.
Case of Acute Renal Failure
This is the left kidney, it’s small because it’s shows
8.9 but still there is cortical differentiation.
Case of Mild Pelvocalceal/Hydronephrosis
Ureter
Fluid filled on urine field. So the patient has
lithotripsy there is no evidence of stones in the
kidney but the kidney shows hydronehprosis so
possibly the remaining stones were put in the
distal or proximal ureter producing hydronephrosis
 obstruction. So this is an example of a
hydronephrosis ureter. Somehow you have a
thinned out cortex and you have dilated proximal
ureter.
Limitation of Ultrasound: If you have a very gassy
abdomen you could not visualize the distal ureters.
Case of Perirenal Hematoma
One of the complication of a lithotripsy is a
hematoma. The patient has a perirenal hematoma.
Usually the px will have utz everyday to monitor if
it’s increasing or decreasing. Increasing  surgeon
will evacuate hematoma.
Case of Angiomyolipoma
Angiomyolipoma so this is fat. In this case the px
has a double collecting system, forming the entire
echogenicity meaning the single collecting system
in this case we now have as 2, which is a normal
variant.
Case of Cystitis
You have a very thick walled, patient has cystitis.
Case of Kidney Abscess
Abnormal kidney has an abscess in the fascia. If px
has prev. hx of trauma, could be hematoma. If px
has prev. hx of lithotripsy also could be hematoma.
Grading of Trauma
Grade 1
• Hematuria with normal imaging studies
• Contusions
• Nonexpanding subcapsular hematomas
Grade 2
• Nonexpanding perinephric hematomas
confined to the retroperitoneum
Subject: Radiology
Topic:
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• Superficial cortical lacerations less than 1
cm in depth without collecting system injury
Grade 3
• Renal lacerations greater than 1 cm in
depth that do not involve the collecting
system
Grade 4
• Renal lacerations extending through the
kidney into the collecting system
• Injuries involving the main renal artery or
vein with contained hemorrhage
• Segmental infarctions without associated
lacerations
• Expanding subcapsular hematomas
compressing the kidney
Grade 5
• Shattered or devascularized kidney
• Ureteropelvic avulsions
• Complete laceration or thrombus of the
main renal artery or vein
CT Scan useful for genitourinary dx or staging
injuries, depth of the cortical laceration, extent of
perirenal hemorrhage, devascularize tissue,
collecting system.
CT Sonoram is a plain CT Scan which is able to
visualize if there are pancake calcifications in the
GUT. So in px with a very high serum creatinine
and they want to know if there is stone because of
microscopic hematuria, CT sonogram can be done.
Case of Phechromocytoma
On UTZ adrenals are not visualized unless they are
enlarged. If it’s >1cm, it’s enlarged. The normal
structure is either a “Y’ or a “V”. if patient has lung
CA, CT scan usually includes adrenals to check for
metastasis. Also used for unexplained elevated
BP, so px has pheochromocytoma.
Most common lesion in the adrenals is the
adenoma.
Subject: Radiology
Topic:
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