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Once again, our evaluation of the pulmonary vasculature should be systematic, starting with assessment of the size of the right descending pulmonary artery and proceeding to an evaluation of the distribution of flow in the lungs, but this time only from the hilum to the periphery.

If the answer to question B is no, then move to question C. Table 3 summarizes the causes and findings associated with a prominent main pulmonary artery. To answer question B, Is the main pulmonary artery big? In this case, it does solid white arrow. The right descending pulmonary artery is normal in size open white arrow. The pulmonary vasculature is normal. This patient had valvular pulmonic stenosis since birth. The barium in the esophagus in this case, and others in this chapter, was part of an older method to assess cardiac chamber enlargement by having the patient swallow barium to mark the position of the esophagus.

D is for dilated or delta. A, Normal. The ascending aorta is a low-density, almost straight edge solid white arrow and does not project beyond the right heart border dotted white arrow. The aortic knob is not enlarged double arrow , and the descending aorta solid black arrow almost disappears with the shadow of the thoracic spine.

B, Aortic stenosis. The ascending aorta is abnormal as it projects convex outward solid white arrow almost as far as the right heart border dotted white arrow. This is due to poststenotic dilatation. The aortic knob double arrow and descending aorta solid black arrow remain normal. C, Hypertension. Both the ascending solid white arrow and descending aorta solid black arrow project too far to the right and left, respectively. The aortic knob is enlarged double black arrows.

Question D: Is the heart dilated or delta shaped? This cardiac silhouette is markedly enlarged. This is a dilated or a delta-shaped heart. The main differential diagnosis for such a heart is pericardial effusion versus cardiomyopathy, and they are frequently difficult or impossible to differentiate on conventional radiographs.

In this case, though, the globular shape of the heart and the absence of any recognizable contours points toward pericardial effusion. The patient had uremic pericarditis. Notice that the soft tissue density of the heart and the pericardial fluid appear as the same radiographic density using conventional radiography.

Pericardial effusion is best diagnosed using ultrasound. B Is the main pulmonary artery big or bulbous? C Is the main pulmonary artery segment concave? D Is the heart dilated or delta shaped? These are evidence-based guidelines designed to assist health-care providers in making the most appropriate imaging or treatment decision for a patient with a specific clinical condition. Edeiken J: Radiologic approach to arthritis, Semin Roentgenol —15, Johnson JL: Pleural effusions in cardiovascular disease: pearls for correlating the evidence with the cause, Postgrad Med —, Kundel HL, Wright DJ: The influence of prior knowledge on visual search strategies during the viewing of chest radiographs, Radiology —, Lingawi SS: The naked facet sign, Radiology —, Resnick D: Diagnosis of bone and joint disorders, ed 2, Philadelphia, , Saunders.

Resnick D: Diagnosis of bone and joint disorders, ed 4, Philadelphia, , Saunders. Amjadi K, Alvarez GG, Vanderhelst E, et al: The prevalence of blebs or bullae among young healthy adults: a thoracoscopic investigation, Chest — , Finished the text already? That was speedy reading on your part. Here are the answers to the quiz that appears in Chapter 1. There are multiple air-filled and dilated loops of small bowel white arrows with virtually no gas in the large bowel.

The stomach S is also dilated. The disproportionate dilatation of small bowel is indicative of a mechanical small bowel obstruction caused, in this case, by adhesions from previous surgery.

A curvilinear band of increased attenuation in the right parietal region black arrows is causing a subfalcine shift of the midline structures to the left white arrow. The crescentric increased density, paralleling the inner table, is classic for a subdural collection.

The patient fell from a height and struck his head. A large, right-sided pneumothorax completely collapsed the right lung toward the hilum white arrows. A slight shift of the trachea to the left black arrow raises suspicion that the pneumothorax is under slight tension. The patient had a spontaneous pneumothorax. This is a cystogram in which contrast is instilled into the urinary bladder B through a Foley catheter. Such images are obtained to determine if the contrast remains in the bladder as it should.

In this case, contrast flows freely out of the bladder into the peritoneal cavity black arrows from a hole in the dome of the bladder. The patient had been in an automobile collision. There is a round sonolucent mass C in the mid-right section of the kidney K with a strong back wall of echoes white arrows , indicating that the mass is a fluidfilled renal cyst.

This was found incidentally on a scan of the kidneys performed for flank pain. L, Liver. Child abuse may sometimes be suspected only on the basis of injuries seen on imaging studies that would be unusual for accidental trauma. This 4-month-old was brought to the Emergency Department for irritability, but a chest x-ray revealed bilateral healing rib fractures white arrows , an injury that is very unlikely to be accidental at this age.

A thorough history confirmed the suspicion of child abuse. Unlike the other set of Multiple Choice Quizzes that focus several questions on a single topic e. If you have not taken the Multiple Choice Quizzes yet, you may want to go back and test your knowledge on those quizzes before proceeding to this Appendix.

The studies in this Appendix can be viewed in two ways: 1. As a set of 25 unknown cases in the Unknown Cases Assessment. In the assessment, you will be shown an image or two, given the history, and presented with a series of answers set as multiple choices, before the correct answer and an explanation are given.

As a set of 25 cases with the diagnosis revealed in this Appendix, which you may scroll through to learn more about those particular topics. Axial CT scans demonstrate a large right parietal subdural hematoma hyperdense to the brain white arrows in A and B. There is associated mass effect with effacement of the sulci on the right compare circles on both sides in B. Note how the subdural hematoma is concave inward to the brain; epidural hematomas are frequently convex inward toward the brain.

A, There is an anterior, subcoracoid dislocation of the humeral head H relative to the glenoid black arrow. A large fracture has occurred where the posterior, lateral aspect of the head strikes the glenoid on dislocating Hill-Sachs fracture white arrow. The head of the humerus H is no longer in the glenoid but in an anterior, subcoracoid white arrow position.

The linear densities paralleling the mediastinum represent pneumomediastinum solid white arrows. In addition, there is a left plural effusion black arrow. There is also subcutaneous emphysema dotted arrows. The combination of a left pleural effusion and pneumomediastinum, especially in someone with a history of retching or vomiting, should raise suspicion for a ruptured esophagus.

B There are healing fractures of the right 5th and 6th ribs and the left 6th rib arrows. Rib fractures would be a very unusual fracture for a nonambulatory 1-year-old to sustain accidentally. There is marked widening of the mediastinum double black arrow. While an AP supine radiograph can produce spurious enlargement of the mediastinum, the size of this vascular pedicle is far too large.

In a patient with chest pain, such a finding should raise suspicion for an aortic aneurysm and a CT scan of the chest would be indicated.

Normally, the epiglottis is about the size of the tip of the little finger. When it assumes the size of a thumb, it is usually enlarged.

Also, the aryepiglottic folds are markedly enlarged white arrow , an associated sign of epiglottitis. There are multiple fractures of multiple ribs black and white arrows. Generally speaking, a flail chest is defined as two or more fractures in two or three contiguous ribs. There is underlying airspace disease representing a pulmonary contusion.

A large amount of subcutaneous emphysema is present. This is a an upright view of the chest. Just beneath each hemidiaphragm, there is a crescentric rim of air density representing free intraperitoneal air that has risen to the highest part of the abdomen; in this case, under the diaphragm.

In judicial hanging, the mechanism is hyperextension and distraction, not axial compression. There would be distraction of the bodies of C2 and C3 from disruption of the C2-C3 disc and ligaments.

There is a fracture of the posterior elements of C2 solid black arrow. This allows the anterior aspect of the C2 vertebral body to slip forward on C3 dotted black arrow.

There is posterior displacement of the spinolaminar white line of C2 solid white arrow relative to the spinolaminar white line of C3 dotted white arrow. Because the spinal canal frequently widens as a result of this injury, there is frequently no neurologic impairment. An abdominal radiograph demonstrates a soft tissue mass in the right side of the abdomen black arrows with several air-containing and minimally dilated loops of small bowel white arrow.

In a patient with crampy abdominal pain, this is highly suggestive of an intussusception. There is a large homogeneous area of hypoattenuation in the distribution of the middle cerebral artery solid white arrows with effacement of the lateral ventricle on the left dotted arrow.

A, There is bilateral lateral offset of the lateral masses of C1 dotted white arrows compared with the outer edges of the lateral masses of C2 solid white arrows on a frontal open-mouth view of the cervical spine that represents a burst fracture of C1. B, An axial CT image of the C1 vertebral body demonstrates multiple fractures in the ring of C1 white arrows. There is complete opacification of the right hemithorax. There are four entities to consider: a large pleural effusion, complete atelectasis of the right lung, pneumonia, or postpneumonectomy.

There is a shift of the heart white arrow and trachea black arrow away from the side of the opacification, suggesting the opacity is taking up additional space. This is characteristic for a large effusion. The patient had a bronchogenic carcinoma on the right, visible only on CT of the chest.

The tip of the feeding tube is seen at the top of the image entering the right lower lobe of the lung white arrow. After the insertion of a nasogastric or Dobbhoff tube, it is always appropriate to obtain an abdominal radiograph to check for the proper positioning of the tube before beginning tube feedings.

The tip of the endotracheal tube solid white arrow is below the carina in the right bronchus intermedius. Thus the only lobes being aerated are the right middle and lower lobes. The right upper lobe dotted arrow points to elevation of the minor fissure and the entire left lung black arrow are atelectatic. There are multiple dilated loops of small bowel white arrows in A with multiple air-fluid levels white arrows in B. Classically, small bowel loops demonstrate the valvulae conniventes extending from one wall to the other.

When the loop exceeds about 2. In this case, the small bowel is disproportionately dilated compared with the large bowel, which is a sign of small bowel obstruction. There is left upper lobe white arrows and right lower lobe black arrows airspace disease. Air bronchograms, a good sign of airspace disease, can be seen in the upper lobe pneumonia on the frontal view.

Aspiration would be more likely in the lower lobes, septic emboli tend to be more nodular, pulmonary infarcts are less common in the upper lobe, and pulmonary edema is usually more widespread. A, On the frontal view, a white line parallels the left heart border white arrow representing the pleural surface lifted up off of the heart by air in the mediastinum.

B, On the lateral view, air is seen anterior to the heart extending into the upper mediastinum black arrows. A supine view of the abdomen reveals several dilated loops of small bowel in which both the inside and outside of the bowel wall are visualized white arrows. While normal bowel gas will outline the inner margin of the bowel, the wall itself will be visible only when outlined by air on both sides.

This patient was only 1 day postoperative see skin clips in lower abdomen , and the air can be normal at this time. Most air introduced by surgery gradually disappears by 5 to 7 days after surgery. A, There is a linear radiolucency in the capitellum C of the humerus white arrow that represents a fracture in the epiphysis itself. B, The linear radiolucency posterior to the distal humerus is fat that is being displaced from its normal invisible position outward by fluid in the elbow joint, in this case most likely blood.

This is a positive posterior fat pad sign. There is a massively dilated loop of bowel occupying most of the abdomen. Only the large bowel can achieve this dimension. Upon close examination, the loop white line has a coffee-bean or kidney-bean shape and seems to arise from the pelvis extending into the right upper quadrant.

A line, representing the walls between the two apposed loops of dilated sigmoid is seen white arrow. This is the characteristic appearance of a volvulus of the sigmoid colon. The sigmoid has twisted around the point of the dotted arrow.

A, Noncontrast enhanced CT scan of the brain demonstrates high attenuation blood filling the basal cisterns white arrow. B, There is blood in the Sylvian fissures black arrows and the interhemispheric fissure dotted white arrow. There is a large left-sided pneumothorax as shown by the visceral pleural white line white arrows and the absence of lung markings distal to that white line.

There is also a shift of the heart and mediastinal structures i. A chest tube was immediately inserted and the pneumothorax relieved. Rickets 4. Holt-Oram syndrome 2. Child abuse 5. Scurvy 3. Sickle cell anemia QUESTION 2 History: A year-old in a fight with a friend was stabbed in the chest and became short of breath Based on the history of the patient and imaging findings, which of the following is the diagnosis? Eosinophilic granuloma 4.

Boerhaave syndrome 2. Laceration of lung 5. Emphysema 3. Calcific tendinopathy 2. Acromioclavicular separation 3. Anterior dislocation of the shoulder 4. Posterior dislocation of the shoulder 5. Heterotopic ossification Based on the history of the patient and imaging findings, which of the following is the diagnosis?

Croup 2. Ingested foreign body 3. Fracture of hyoid bone 4. Epiglottitis 5. Large bowel obstruction 2. Adynamic ileus 3. Free air 4. Enlarged kidneys 5. Pneumomediastinum 2.

Free air 3. Sarcoidosis 4. Subsegmental atelectasis 5. Pancoast tumor Based on the history of the patient and imaging findings, which of the following is the diagnosis? Dobbhoff tube was never inserted 2. Dobbhoff tube in lung 3. Perforation of stomach 4. Small bowel obstruction 5.

Misplaced AICD automated implantable cardioverter defibrillator lead 2. Aortic stenosis 3. Right lower lobe pneumonia 4. Thymoma 5. Dissecting aortic aneurysm Based on the history of the patient and imaging findings, which of the following is the diagnosis?

Epidural hematoma 2. Acute subdural hematoma 3. Hemorrhagic stroke 4. Ischemic stroke 5. Craniopharyngioma Based on the history of the patient and imaging findings, which of the following is the diagnosis? Sarcoidosis 2. Atelectasis 3. Large pleural effusions 4. Pulmonary edema 5. Fracture of the radial head 2. Dislocated radius 3. Fracture of capitellum 4. Fracture of medial epicondyle 5. B, 4 hours later. C, CT done 30 minutes after image B. Based on the history of the patient and imaging findings, which of the following is the diagnosis?

Tuberculosis 2. Congestive heart failure 3. Aspiration pneumonia 4. Mucus plug 5. Alzheimer disease 2. Subarachnoid hemorrhage 4. Acute epidural hematoma 5. Meningioma Based on the history of the patient and imaging findings, which of the following is the diagnosis? Small bowel obstruction 2. Abscess 3. Recognizing the correct placement of lines and tubes and their potential complications: Critical care radiology -- Recognizing diseases of the chest -- Recognizing adult heart disease -- Recognizing the normal abdomen: Conventional radiology -- Recognizing the normal abdomen and pelvis on computed tomography -- Recognizing bowel obstruction and ileus -- Recognizing extraluminal gas in the abdomen -- Recognizing abnormal calcifications and their causes -- Recognizing the imaging findings of trauma -- Recognizing gastrointestinal, hepatic, and urinary tract abnormalities -- Ultrasonography: Understanding the principles and recognizing normal and abnormal findings -- Magnetic resonance imaging: Understanding the principles and recognizing the basics -- Recognizing abnormalities of bone density -- Recognizing fractures and dislocations -- Recognizing joint disease: An approach to arthritis -- Recognizing some common causes of intracranial pathology -- Recognizing pediatric diseases -- Nuclear medicine: Understanding the principles and recognizing the basics -- The ABCs of heart disease: Recognizing adult heart disease from the frontal chest radiograph -- What to order when -- Chapter 1 quiz answers -- Unknown cases: Additional information -- Unknown cases quiz.

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