Solutions to the Test Cases

Chapter 6
Fig. 6.76 a This is a type B aortic dissectionthe
dissection is
limited to the descending aorta. The false lumen
can be distinguished
from the true lumen by residual fiber strands
connecting
the intimal flap to the media. The true lumen is the
smaller
lumenwhich shows more contrast enhancement
in this case.
b There is a large tumor in the anterior
mediastinum. The trachea
is narrowed down to a saber sheath
configuration. In an
acute setting, such as in this case with upper
venous congestion,
a lymphoma is the most likely cause. A large
retrosternal goiter
could produce a similar appearance.
c This CT image shows massively
dilated bronchi over all lung fields. This is severe
bronchiectasis
in cystic fibrosis.
d The redistribution, the Kerley lines, an
accentuated horizontal fissure, unsharp vascular
markings,
bronchial cuffing, and an enlarged heart prove a
cardiogenic
pulmonary edema.
e The thick-walled cavern in the right lung
apex occurred in an HIV-positive patientthis is
tuberculosis until

proven otherwise. Tuberculosis it turned out to be.

What
would you do next if you saw this patient? Of
course, for starters
you would make sure the patient had a face mask.
f The radiograph
depicts a pneumonia of the right upper lobe and
some of
the middle lobe. The bronchi are well seen against
the background
of the pus-filled alveoli.
g The severely increased interstitial
markings in the periphery (Kerley lines) and
centrally
(reticular or netlike pattern) suggest an interstitial
process.
The HRCT (right) confirms the thickened
interlobular septa in
a patient with carcinomatosis of the pulmonary
interstitium.
h The left lung is overly transparent, hypovascular,
and volumereduced in this patient. He suffered from recurring
pulmonary
infections in early childhood until the age of 12.
Rightthis is SwyerJames syndrome.

Chapter 7
Where and when should the informed consent of
the patient be
achieved? This should best be done the day before
the study,

either in the office or on the ward but never where

and
when the study is performed. Which parameters
should be
watched? Prothrombin time should be >50%,
partial thromboplastin
time <35 seconds, and thrombocyte count >50
000/ll.
Acetylsalicylic acid (ASA/aspirin) should be
discontinued a week
before deep-body interventions are performed.
Here is the great case: Figure 7.18a shows a close
up view of the
ribs. The infracostal margins are very irregular
they are being
remodeled by the enlarged and varicose intercostal
arteries in
aortic coarctation. Compare this to the normal ribs
of Fig.
6.5a. As the aorta is stenosed in this entity (see the
sagittal
T1-weighted MR; b), the descending aorta is filled
via intercostal
collaterals and via arteries in the abdominal wall
(see the MR
angiography; c). After the insertion of a stent (see
the conventional
angiography; d), the stenosis is reduced to a
moderate
level without the risks of open chest surgery (see
the sagittally
reconstructed CT; e).
Chapter 8
Fig. 8.83 a There is malalignment at the C4/C5
level much like

the degenerative spondylolisthesis seen in the

lumbar spine.
Ventral osteophytes and disk space narrowing in
the lower cervical
spine support the notion of a degenerative cause.
b The C2
vertebral body in this man has turned sclerotic: this
is an osteoblastic
metastasis of a prostate carcinoma.
c The hand appears
demineralized in comparison to the radial
metaphysis. The soft
tissues appear to be swollen. This was Sudeck
disease. Remember:
The clinical symptoms must fit!
d The width of the radiocarpal
joint space is diminished radially. The bordering
bone is
sclerosed. The scaphoid shows a little osteophyte,
the lunate
seems a little out of line. This is a posttraumatic
osteoarthritis
and lunate malalignment.
e This is a patient with ankylosing
spondylitis: both iliosacral joints appear to be
fused, more so
on the right.
f They do not come more pathognomonic than
this: a gigantic chondrosarcoma engulfs the right
half of the pelvis.
g This is a typical nonossifying fibromano further
measures
are needed.
h Right. This is an osteoid osteoma of the talus.
i It is
a severe inherited osteosclerosis of the Camurati
Engelmann

type.
j The patient suffers from multiple myeloma.
k The os lunatum
shows a dense inhomogeneous structure. You are
looking
at an osteonecrosis of the lunatum, also termed
Kienboeck
disease. It is a little sister of the femoral head
necrosis. If you
diagnosed this by yourself, either you are a genius
or you
have leafed through one of those fat books on
skeletal radiology.
In either casecongratulations!
l This patient suffers from low
back pain. Pagets disease of the sacral bone is the
diagnosis.
Chapter 9
Fig. 9.70 a This is a carcinoma of the hypopharynx
that originates
from the piriform recess.
b Sentinel loops in the small intestine
with airfluid levels at different heights point to a
mechanical
(obstructive) ileus.
c This is a diverticulosis of the descending
colon.
d A scrotal hernia is present bilaterally.
e Did you
diagnose the splenic cyst alright?
f This is the radiograph of a
neonate without any air in the stomach and small
intestine.
This is a definite sign of esophageal atresia.
g This is what a tapeworm

looks like in a barium study.

h This patient suffers from
chronic pancreatitis.
i Have you recognized the liver metastases
and the ascites?
j Did you notice that most air is in the small
bowel but none in the distant colon and rectum?
Did you
also see the dilated air-filled loops of the proximal
colon? This
a cecal volvulus! Some contrast media rests in the
bowel are
also appreciated.
k This is a cecal volvulus.
l This patient was
referred from a mental institution because he had
ingested
something. What material might it be? (It was
mercury taken
from an old thermometer.)
m No excuses if you did not get
this one: It is a severe gangrene of small and large
bowel due
to mesenteral infarction.
n Now this one was for the real eggheads:
Contrast is in the vena cava and the liver veins, but
not in
the aorta. Two theoretical possibilities that one can
think of: (a)
This is remote: the contrast is given via a vein of
the lower extremities
that would never give you that solid filling of the
ves-

342

Eastman, Getting Started in

Clinical Radiology 2006
Thieme
All rights reserved. Usage
subject to terms and
conditions of license.
sels because the venous return of the kidneys
would mix in. (b)
This is the solution: The patient has severe right
heart insufficiency
so the contrast flows through the superior vena
cava
past the heart right into the inferior cava and the
liver veins.
Of course, the contrast is given via the veins of the
arm, as almost
always. And, by the way, some people call this the
playboy
bunny sign. o This patient felt uneasy after a long
flight as a
body packer. The sealed drug packages were
swallowed before
the flight. A leakage of the containers, of course,
means serious
health trouble for the poor fellow.
Chapter 10
Fig. 10.21 a This is a pelvic kidney with a renal cell
carcinoma.
b Here you see a posttraumatic priapism. The
pubic symphysis is
torn, the left iliosacral joint is opened: The
configuration is also

called an open book injury. The genitals are

enlarged owing to
hemorrhage, thrombosis, or edema. c This is what
a calcified
transplant kidney looks like. d There is a tumor
thrombus
that has grown through the vena cava into the
right atrium.
This patient had a renal carcinoma. e Did you
diagnose the renal
hematoma alright? f Did you detect the
concrement in the left
kidney? This is nephrolithiasis. g The lesion in the
kidney is a
manifestation of lymphoma. If you appreciated the
tumor in
the mesentery ventral to the aorta you probably
got it right.
If you overlooked that tumor, remember the
satisfaction of
search effect (Chapter 3).
Chapter 11
Fig. 11.57 a There is a C7 diskal prolapse on the
left that significantly
compresses the spinal nerve. b This coronal MR
image
of the lumbar spine at the level of the kidneys
shows an extraaxial,
intrathecal tumora typical meningioma. The
tumor has
expanded the spinal canal c This spinal canal is
extremely narrow
owing to a congenital stenosis. d A right foraminal
prolapse is
seen on this CT. e If you have not detected it yet,
take a step

back! The left basal ganglia are hypodensean

early infarction
may not become more obvious. CT perfusion would
make the
diagnosis a lot easier to reach. But there is no
hemorrhage:
thrombolytic treatment could start. f This dense
media sign
is pretty obvious: this is an early infarction of the
right hemisphere.
g This CT shows a frontal intracranial hemorrhage
in
combination with extreme edema.
Chapter 12
Fig. 12.29 a What you are seeing is a typical
plasma cell mastitis.
b The breast carcinoma (left image, large arrows)
shows
pronounced acoustic shadowing (right image small
arrows).
Chapter 13
Fig. 13.30 The 48 is an impacted wisdom tooth; the
28 tooth
has come through. A granuloma is visible at the
root of the 45
tooth. The bridge between 25 and 27 is intact; the
bridge anchored
on tooth 14 reaches out into nothing. The crown of
tooth
16 is broken and ground down. There are root
fillings in tooth 16
and 35. Superimposed over 4244 a sialolith is
visualized sitting
in the main duct of the submandibular gland.
Chapter 14
Fig. 14.47 a You are seeing a typical caudal
shoulder luxation.

You should now worry about impression fractures

or avulsions of
the glenoid. b Now this should have been so easy.
If you did not
diagnose this tibial head fracture by its indirect
signs, go back
and check Fig. 4.4b. This is the Dutch flag sign
this time in CT. c
Extensive pericardial and pleural hemorrhage in a
traumatized
patient: an immediate chest intervention is
necessary. d The
tip of the tracheal tube sits in the right main
bronchus. A complete
atelectasis of the left lung has resulted. Thank god
you
were the one to analyze the imageyou did get
this one right,
didnt you? e This is a cephalad malposition of the
tube. Severe
injury to the glottis will result. f A scalp hematoma
and a subdural
hematoma with severe edema was diagnosed in
this young
child. In not so clear trauma in children, always
exclude battered
child. g This is a posttraumatic aortic dissection
(see the flap?)
with left-sided hemothorax. h Two weeks after
abdominal trauma
this patient presented with paina delayed spleen
rupture is
present. i, j, k, l This was your chance to prove
youve understood
it all, you know how to reason, and you are just a
little

lucky. The scout view of the abdominal CT (i)

displays an air-filled
dilated loop of small bowel in the mid-abdomen.
Note: A vertical
beam is used in normal scout views, so airfluid
levels would not
show. There is a definite problem of bowel
peristalsis. The axial
CT image (j) confirms the dilated small bowel and
finds little air
bubbles in the intestinal wallthe string of pearls
sign. A necrosis
of the bowel wall is most likely present. The
sagittal reconstruction
of the trauma spiral CT (k) tells you why the
patient
came to the hospital in the first place. The L2
vertebral body
has been crushed in a deceleration trauma. What
else might
have happened in the process? The last CT
reconstruction (l)
wraps it all up: The trauma impact caused the L2
fracture
and a dissection of the superior mesenteric artery,
which led
to the bowel necrosis, which was at the base of the
developing
ileus. Now go through the timewarp back to the
first image (i)
and search for the string of pearls and the
fracture in that image
it was all our forefathers had for diagnosis.

343

,Eastman