HEAD TRAUMA CT EVALUATION

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Causes of Bilateral diminished concentration of contrast material in the pelvocalyceal system

1- Overhydration/ inadequate dehydration :
Causes dilution of the contrast material (Note that the kidneys may be entirely normal).

2- Polyuria :
Excretion of large volumes of hypotonic urine due to diuretic therapy, diabetes insipidus (lack of antidiuretic hormone ADH secreted by the posterior lobe of the pituitary gland), diabetes mellitus, and intrinsic renal diseases.

3- Renal failure (uremia) :
Severely decreased renal function due to a variety of underlying causes.

4- Nephrosclerosis :
Long-standing hypertension causes narrowing of extraand intrarenal arteries with prolonged intrarenal circulation time and decreased excretion of contrast material.
Malignant nephrosclerosis. Nephrotomogram obtained 5 minutes after the injection of contrast material shows minimum opacification of small, smooth kidneys.

5- Technical :
Injection of an inadequate dose of contrast material.


Causes of Bilateral diminished concentration of contrast material in the pelvocalyceal system

X-ray of Gallstone ileus

Imaging Findings :

Classic triad of
  1. jejunal or ileal filling defect
  2. gas or barium in the biliary tree
  3. small bowel obstruction.

Gallstone ileus is caused by a large gallstone entering the small bowel via a fistula from the gallbladder or the common bile duct to the duodenum. Usually occurs in elderly women.

Gallstone ileus. Upper gastrointestinal series demonstrates the obstructing stone (white arrows) and barium in the biliary tree (black arrow).

 Localized osteoporosis due to Burn, Frostbite and Electric shock

The bone demineralization is most marked where softtissue damage was greatest, is an early radiographic finding that may persist for a prolonged period.

Electrical injury. This X-ray shows comminuted fracture of the head and shaft of the humerus associated with mottled decalcification of the humeral head.
The cortex of the humerus is thin, and the medullary cavity is widened. Discrete areas of rarefaction can be seen in the shaft and distal metaphyseal region.

Disuse osteoporosis follows prolonged immobilization

To maintain osteoblastic activity at normal levels, bones must be subjected to a normal amount of stress and muscular activity. Within a few weeks after the fracture of a bone, localized osteoporosis becomes detectable, especially distal to the site of injury.

The cortical margin of an involved bone never completely disappears (unlike bone destruction due to disease). Similar disuse atrophy due to immobilization follows neural or muscular paralysis.


Disuse osteoporosis. (A) Severe periarticular demineralization follows prolonged immobilization of the extremity.


(B) In a patient with a fractured patella, there is pronounced subcortical demineralization in the distal femur. The cortical margin (arrows) remains intact.

A brief introduction to Extradural haematoma in CT

Extradural haematoma arises between the inner table of the skull and the dura of the brain. They usually develop from injury to the middle meningeal artery or one of its branches,So it is usually temporoparietal in location.
A temporal bone fracture is often the cause, but is not essential. The expanding haematoma separates the dura from the skull; this attachment is quite strong such that the haematoma is confined, giving rise to its characteristic biconvex shape, with a well defined margin.

It may present as primary depressed consciousness or following a lucid interval. The bleeding is usually acute and so of high attenuation. There is often significant mass effect with compression of the ipslateral lateral ventricle and dilatation of the opposite lateral ventricle due to obstruction of the foramen of Munro. The basal cisterns may be effaced.

This is the typical appearance and location of an acute extradural haematoma. Note the high density of the haematoma and slight midline shift .

A Pancreatic mass or just papillary process of the caudate lobe of liver

This patient presented with abdominal discomfort and underwent sonography of the abdomen. Ultrasound images show a rounded mass in the region of the pancreatic head and isthmus. It shows the same echogenicity as the liver (photos 1 and 2). This suggested the possibility of a pancreatic mass, possibly malignant.
1-
2-
However, images 3 and 4, reveal a different diagnosis- the possible "mass" appears to be an extension of the caudate lobe of the liver. These ultrasound images are diagnostic of "papillary process of the caudate lobe of liver."This normal variant may thus mimic pancreatic or preaortic lymph node masses.
3-
4-
Images courtesy of Dr. Ravi Kadasne, UAE.

Ischaemic colitis Clinical and Radiological findings

Clinical characteristics
• Ischaemic colitis is caused by interruption to the colonic blood supply that include thrombosis , bowel obstruction and trauma.
• Some Predisposing factors included as age,oral contraceptives,sickle cell disease and surgical ligation of the inferior mesenteric artery.
• Presents with acute lower abdominal pain and tenderness,usually out of proportion to the clinical signs.There may be rectal bleeding or diarrhoea.
• Most commonly affects the left side of the colon, especially at the splenic flexure where there is a watershed between the territories of the superior and inferior mesenteric arteries.The rectum is usually spared.
• May be a transient condition with spontaneous resolution over a few months. May lead to incomplete healing with smooth stricture formation. Severe disease can lead to colonic infarction,with a high associated mortality.

Radiological features
• AXR : plain film is often normal;however,gas within the colon may out line the characteristic thumb printing of thickened, oedematous folds seen in this condition.
• Barium enema : single-contrast instant enema may demonstrate thumb printing and ulceration associated with this condition.Adoublecontrast enema shows these findings more reliably but should be used with caution in anacutely ill patient.A smooth stricture maybe demonstrated on a delayed study.
Late-stage ischaemic colitis. Single-contrast barium enema demonstrates a clear zone of transition between normal and abnormal colon at the junction of the middle and distal thirds of the transverse colon.The proximal colon has normal mucosa and haustral pattern while the distal
segment is featureless and abnormally narrowed.
• CT :contrast-enhanced spiral CT is the usual first-line investigation for suspected ischaemic colitis.Adual phase scan,performed in the arterial and portal phases,may demonstrate thrombus in both the mesenteric arterial or venous systems.The affected colon may appear abnormally circumferentially thickened and demonstrate poor contrast enhancement.There may be a sharp cut off between normal and abnormal colon at the boundary of vascular territories.Mural gas may be seen in more advanced disease and,in severe cases,portal gas may be identified. The latter is a poor prognostic factor.
Superior mesenteric artery (SMA) thrombosis. Normal enhancement of the aorta (arrowhead). No enhancement seen in the SMA (arrow).
• Angiography :a more limited role in the era of multislice spiral CT but may demonstrate attenuated arterial flow or the presence of a thrombus.


Ischaemic colitis Clinical and Radiological findings

CT Images of Heart in abdominal

Regardless of bad pt. positioning or quality, notice the heart ♥️ in the abdomen! That's a presentation of a rare congenital malformation in which the heart is abnormally located either partially or totally outside of the thorax.

CXR: absence of heart
CT: heart in abdomen

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Topic :
Scanning, and topic as below..

Right kidney
Left kidney
Renal cortex
Renal columns
Pyramids
Renal pelvis
Ureter

Adrenal gland
Stomach
Fundus of stomach
Body of stomach
Antrum of stomach
Cardia
Duodenal bulb
Duodenum
Small bowel
Right colic flexure
Left colic flexure
Bladder
Opening of ureter
Urethra
Prostate
Seminal vesicle
Uterus
Vagina
Right ovary
Left ovary
Rectum
Spinal column
Symphysis pubis
Acoustic shadow
Gas
Artifact
Psoas muscle
Diaphragm
Pelvic bone
Heart
Thyroid gland
Sternohyoid muscle
Sternothyroid muscle
Sternocleidomastoid muscle
Omohyoid muscle
Internal jugular vein
Common carotid artery
Tracheal cartilage

Radiological features of Bezoar

Bezoar is an intestinal mass caused by the accumulation of ingested
material which Can lead to obstruction or ulceration.
Bezoar Types :
A phytobezoar is formed from poorly digested plant fibre.
A trichobezoar is formed from ingested hair, almost always in females.

Trichobezoar. Large ‘hair ball’ mass completely filling the stomach (arrow).

Radiological features :
 AXR:
• A mass may be seen within the stomach.
• May demonstrate bowel obstruction.
 Barium studies:
• May demonstrate an intraluminal filling defect that does not have a fixed site of attachment to the bowel wall.
• Barium may flow into crevices within thebezoar.
 CT:
• This may demonstrate a low-density mass containing pockets of air.
• As on barium studies, oral contrast may intersperse with the mass
though gaps between the ingested materials.

Trichobezoar (same patient) in coronal CT reformat.Oral contrast is seen outlining the huge trichobezoar.

Syphilitic Aortitis in Chest X-ray

Syphilitic Aortitis in Chest X-ray appears as a dilatation of the ascending aorta, frequently with mural calcification

It may cause inflammation of the aortic valvular ring that results in aortic insufficiency. Approximately one-third of patients develop narrowing of the coronary ostia that may lead to symptoms of ischemic heart disease.

Syphilitic aortitis. Aneurysmal dilatation of the ascending aorta with extensive linear calcification of the wall (arrows). Some calcification is also seen in the distal aortic arch.

What is Ultrasound Gain–correct, over, under (with photos)

Gain refers to the control sonologists use to adjust the brightness with which returning sound waves are displayed by the ultrasound machine. When an echo returns from body tissue, it does so within an amplitude range.
The ultrasound device translates that amplitude range to a brightness, which it displays on the monitor. The overall gain allows the sonologist to adjust the brightness of all returning echoes. Decreasing the gain makes the overall image less bright, while increasing the gain makes the image more bright .

These figure shows the types of gain:

(A) (Correct) This image is correctly gained

(B) (Over) The image has too much gain applied to the image. Compared with image A, echoes are found where there should be none.

(C) (Under) The image is undergained. The image is too dark, potentially making it difficult for accurate diagnosis.

Sonography of fibroid with calcification


This middle aged female patient complained of pain in the suprapubic region. Ultrasound imaging revealed a small uterus with a calcific well-defined, intramural mass in the lower part of the body of uterus.
There is clear acoustic shadowing posterior to the calcific lesion. These findings suggest a calcific fibroid of the uterus. Fibroids are often known to undergo calcificaiton in elderly females.

Crescent sign of femoral AVN

Definition :
The crescent sign that is associated with avascular necrosis (AVN) is seen on conventional radiographic films and is recognized as a curvilinear subchondral radiolucent line . It is typically seen along the anterolateral aspect of the proximal femoral head, which is optimally depicted on the frog-leg radiographic view "obtained with the patient’s thigh abducted and flexed ".

A Conventional radiograph of the right femur in the frog-leg position shows subchondral area of hyperlucency (arrows) in the anterolateral aspect of the proximal femoral head. (Courtesy of Clyde A. Helms, MD, Department of Radiology, Duke University Medical Center, Durham, NC.)


EXPLANATION
The crescent sign is explaned by Inadequate perfusion in the articular ends of bones that leads to the processes of osteonecrosis and repair . Repair begins at the interface between necrotic and viable bone.
Reactive new bone is laid down over dead trabeculae, which produces a sclerotic margin. An advancing front of fibrosis, hyperemia, inflammation, and bone resorption extends into the necrotic segment of bone as repair is attempted. Mechanical failure of trabecular bone at this interface results in progressive microfracture (as seen below ) and collapse of the adjacent dead subchondral cancellous trabeculae, which leads to the development of a subchondral radiolucent area along the fracture line, or the crescent sign
Specimen radiograph of a coronally sectioned femoral head segment reveals a subchondral fracture (arrows), which manifests as the crescent sign. Note the fragmentation and compaction of the subchondral cancellous trabeculae, which weakens the articulating surface.

Role of Abdominal X-ray in Appendicitis

The aetiology of Appendicitis is usually related to luminal obstruction,often by lymphoid hyperplasia or a faecolith.

Radiological features in abdominal X-ray:
• Abdominal X-ray Is neither sensitive nor specific for Appendicitis but can provide clues.
• The presence of a calcified appendicolith in the RLQ ,combined with
abdominal pain,has ahigh positive predictive value for acute appendicitis.
• Other signs are less specific and include caecal wall thickening,small-bowel ileus and decreased small-bowel gas in the RIF.
• Free peritoneal fluid can lead to loss of the psoas out line,loss of the fat planes around the bladder and loss of definition of the inferior liver outline.

Rickets X-ray Before and After vitamin D therapy

Systemic disease of infancy and childhood in which calcification of growing skeletal elements is defective because of a deficiency of vitamin D in the diet or a lack of exposure to ultraviolet radiation (sunshine).
Most common in premature infants and usually develops between 6 and 12 months of age.

Classic radiographic signs :
It include cupping and fraying of metaphyseal ends of bone with disappearance of normally sharp metaphyseal lines; delayed appearance of epiphyseal ossification centers, which have blurred margins (unlike the sharp outlines in scurvy); and excessive osteoid tissue in the sternal ends of ribs producing characteristic beading (rachitic rosary).

(A) Initial film shows severe metaphyseal changes involving the distal femurs and proximal tibias and fibulas. Note the pronounced demineralization of the epiphyseal ossification centers.


(B) After vitamin D therapy, there is remineralization of the metaphyses and an almost normal appearance of the epiphyseal ossification centers.

Associations of Absent thumb cases

An absent thumb can have many associations. They include :

* Fanconi anemia (pancytopenia-dysmelia syndrome)
* Franceschetti syndrome
* Holt-Oram syndrome
* phocomelia (e.g. thalidomide embryopathy)
* Poland syndrome (pectoral muscle aplasia - syndactyly)
* Rothmund-Thomson syndrome
* Seckel syndrome (bird-headed dwarfism)
* trisomy 18
* Yunis-Varón syndrome

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