Radiological Signs (Shënja Radiologjike) - 5

1
Sllavko K. Kallfa

Prmbledhje Artikujsh nga
Radiopaedia.org
2

domesticated and wild animals
X-ray signs

o anteater nose sign.............................f.3
o bat's wing opacities........................f.9
o bear's paw sign...................................f.17
o bull's eye....................................................f.25
o claw sign....................................................f.32
o eye of tiger sign..................................f.38
o feline oesophagus.............................f.44
o hidebound sign...................................f.48
o panda sign............................................... f.52
o panda sign of sarcoidosis......... f.55
o pleural mouse...................................... f.56
o scotty dog sign.................................... f.57
o staghorn calculus............................ f.63
o rat tail sign........................................... . f.76
o winking owl sign............................. f.79
tigroid pattern or leopard skin sign ..f.91
moose head appearance ............f.94
snake eyes - ......................................... .f.100
dural tail : of meningioma.... f.104
3

Anteater nose sign
Dr Jeremy Jones and Dr Andrew Dixon et al.
The anteater nose sign refers to an anterior tubular prolongation of the superior calcaneus which
approaches or overlaps the navicular on a lateral radiograph of the foot. This fancifully
resembles the nose of an anteater and is an indication of calcaneonavicular coalition
1-2
.
Etymology
The sign was first described by Oestreich et. al. in 1987
1
.
References
1. Oestreich AE, Mize WA, Crawford AH et-al. The "anteater nose": a direct sign of
calcaneonavicular coalition on the lateral radiograph. J Pediatr Orthop. 7 (6): 709-11. - Pubmed
citation
2. Crim JR, Kjeldsberg KM. Radiographic diagnosis of tarsal coalition. AJR Am J Roentgenol.
2004;182 (2): 323-8. AJR Am J Roentgenol (citation) - Pubmed citation
Synonyms & Alternative Spellings
Synonyms or Alternative Spelling Include in Listings?
Anteater sign
Anteater's nose sign
Ant-eater nose sign

4

Anteater Please see case description page for licence and original file information. From the case:
Anteater
Modality: Photo
5

From the case: Calcaneonavicular coalition
Modality: X-ray
6

Calcaneonavicular coalition
7

From the case: Calcaneonavicular coalition
Modality: X-ray
8

From the case: Calcaneonavicular coalition "anteater nose sign"
Modality: X-ray
9

Bat wing pulmonary opacities
Dr Yuranga Weerakkody and Dr Behrang Amini et al.
Bat's wing or butterfly pulmonary opacities refer to a pattern of bilateral perihilar shadowing.
It is classically described on a frontal chest radiograph but can also refer to appearances on chest
CT
3-4
.
Bat's wing pulmonary opacities can be caused by
pulmonary oedema (especially cardiogenic)
pneumonia
o aspiration pneumonia
o pneumocystis pneumonia (PCP)
o viral pneumonia
o lipoid pneumonia
inhalation injury
o noxious gas
o liquid
pulmonary alveolar proteinosis
3

pulmonary haemorrhage (e.g. Goodpasture syndrome)
lymphoma / leukaemia
bronchoalveolar carcinoma
References
1. Shah PL, Hansell D, Lawson PR et-al. Pulmonary alveolar proteinosis: clinical aspects and
current concepts on pathogenesis. Thorax. 2000;55 (1): 67-77. doi:10.1136/thorax.55.1.67 - Free
text at pubmed - Pubmed citation
2. Webb WR and Higgins CB. Chapter 2. Consolidation and atelectasis. in Thoracic Imaging:
Pulmonary and Cardiovascular Radiology. 2004; Lippincott Williams & Wilkins.
10

3. Swensen SJ, Aughenbaugh GL, Douglas WW et-al. High-resolution CT of the lungs: findings in
various pulmonary diseases. AJR Am J Roentgenol. 1992;158 (5): 971-9. AJR Am J Roentgenol
(abstract) - Pubmed citation
4. Gluecker T, Capasso P, Schnyder P et-al. Clinical and radiologic features of pulmonary edema.
Radiographics. 19 (6): 1507-31. Radiographics (full text) - Pubmed citation
Bat wing opacity
Bat wing pulmonary opacities
Bat's wing opacity
Bat's wing pulmonary opacity
Batwing pulmonary opacities

11

From the case: Pulmonary oedema
Modality: X-ray

12

From the case: Fruit bat
Modality: Photo
13

From the case: Pulmonary haemorrhage
Modality: X-ray
14

15

From the case: Pulmonary haemorrhage
Modality: X-ray
16

From the case: Bat's wings of pulmonary oedema
Modality: X-ray
17

Bear's paw sign
Dr Jeremy Jones and Dr Frank Gaillard et al.
The bear's paw sign is seen in xanthogranulomatous pyelonephritis and refers to the cross-
sectional appearance of the kidney which is said to resemble the paw of a bear. The renal pelvis
is contracted whereas the calyces are dilated, mimicking the toe-pads of the paw.
References
1. Dyer RB, Chen MY, Zagoria RJ. Classic signs in uroradiology. Radiographics. 2004;24 Suppl 1
(suppl 1): S247-80. doi:10.1148/rg.24si045509 - Pubmed citation
Bear's paw sign of XPN
Bear's paw sign in XPN
Bear's paw sign of xanthogranulomatous pyelonephritis
Bear's paw sign in xanthogranulomatous pyelonephritis

18

Polar bear Image courtesy of wikimedia user Cburnett. Please see case description page for licence and
original file information. From the case: Polar bear
Modality: Photo
19

Bear's paw sign annotated Single image from the CT with the right kidney outlined. Note how the dilated
low density calyces form an appearance which has been likened to that of the pads of a bear paw. From
the case: Xanthogranulomatous pyelonephritis
Modality: Diagram
20

From the case: Xanthogranulomatous pylonephritis
Modality: CT
21

22

23

24

From the case: Xanthogranulomatous pylonephritis
Modality: CT

25

Bull's eye sign - general
Dr Henry Knipe and Dr M Udayakumar et al.
There are many bull's eye signs, also referred to as target signs:
red bone marrow located in shaft of long bone with central yellow marrow on MRI
peripheral plexiform neurofibromas on MRI
intussusception: see target sign of intussusception
choledocholithiasis: see target sign of choledocholithiasis
cerebral metastases
cerebral abscess
barium studies
2

o aphthoid ulcers - earliest lesion seen in Crohn's disease on barium enema
o gastic lymphoma with central ulceration
4

o GIST with central ulceration
o hematogenous gastric metastases
o gastric adenocarcinoma with central ulceration
lung granuloma
lyme disease
target sign of haematoma on MRI (also called concentric ring sign on MRI)
also described in tears of deep tendon of rectus femoris in athletes

References
1. Dunnick NR, Harell GS, Parker BR. Multiple "bull's-eye" lesions in gastric lymphoma. AJR Am J
Roentgenol. 1976;126 (5): 965-9. AJR Am J Roentgenol (citation) - Pubmed citation
2. Rubesin SE, Levine MS, Laufer I. Double-contrast upper gastrointestinal radiography: a pattern
approach for diseases of the stomach. Radiology. 2008;246 (1): 33-48.
doi:10.1148/radiol.2461061245 - Pubmed citation
Synonyms or Alternative
Spelling
Include in Listings?
Bulls eye sign - general
26

Synonyms or Alternative
Spelling
Include in Listings?
Target sign - general

Archery target Archery target for use in target sign articles. target sign of
intussesceptionPermission is granted to copy, distribute and/or modify this document under the
terms of the GNU Free Documentation License, Version 1.2 or any later version published by the
Free Software Foundation; with no Invariant Sections, no Front-Cover Texts, and no Back-Cover
Texts. A copy of the license is included in the section entitled "GNU Free Documentation
License".Original file: http://commons.wikimedia.org/wiki/File:Archery_target.jpgAuthor: Casito

27

T1
T1WI with Gad
From the case: Bull's eye sign (from cerebral metastasis) Case 1 : with a cerebral metastasis
Modality: MRI
28

From the case: Intussusception
29

Modality: Ultrasound
From the case: Bull's eye sign
Modality: MRI Case 3 : with a tear of rectus femoris
30

A
small 'pit' of barium contained within an ulcer cavity in the body of the stomachFrom the case: Gastric
ulcer - a bull's eye
Modality: Fluoroscopy Case 4 : with a gasric ulcer

31

From the case: Cerebral absceses
Modality: MRI

32

Claw sign
The claw sign is useful in determining whether a mass arises from a solid structure or is located
adjacent to it and distorts the outline.
It refers to the sharp angles on either side of the mass which the surrounding normal parenchyma
forms when the mass has arisen from the parenchyma. As such, normal parenchyma extends
some way around the mass.
Examples where a claw sign is useful include:
meningioma vs intraparenchymal brain tumour
Wilms tumour vs neuroblastoma
renal angiomyolipoma vs retroperitoneal liposarcoma
References
1. Routhier JR, Woodfield CA, Mayo-smith WW. AJR teaching file: fat-containing retroperitoneal
mass presenting with acute flank pain. AJR Am J Roentgenol. 2009;192 (6): S122-4.
doi:10.2214/AJR.07.7007 - Pubmed citation
Claw-sign

33

From the case: Wilms tumour
34

Modality: CT
35

Modality: CT
36

From the case: Suspicion of solid pseudopapillary neoplasm of the pancreas (Hamoudi tumour)
Modality: MRI
37

C+ portal venous phase
No calcification in the right sided abdominal mass. An important consideration with paediatric
abdominal mass in distinguishing a Wilm's tumour from neuroblastoma. From the case: Wilm's tumour -
claw sign
Modality: CT
38

Eye of tiger sign
Dr Frank Gaillard et al.
The eye of the tiger sign refers to abnormal low T2 signal (due to abnormal accumulation of
iron) on MRI in the globus pallidus with a longitudinal stripe of high signal (due to gliosis and
spongiosis) that can be seen in:
Hallervorden-Spatz syndrome : classical but not 100% pathognomonic.
progressive supranuclear palsy
early-onset levodopa-responsive parkinsonism
corticalbasal ganglionic degeneration
References
1. Guillerman RP. The eye-of-the-tiger sign. Radiology. 2000;217 (3): 895-6. Radiology (full text) -
Pubmed citation
2. Angelini L, Nardocci N, Rumi V et-al. Hallervorden-Spatz disease: clinical and MRI study of 11
cases diagnosed in life. J. Neurol. 1992;239 (8): 417-25. - Pubmed citation
3. Savoiardo M, Halliday WC, Nardocci N et-al. Hallervorden-Spatz disease: MR and pathologic
findings. AJNR Am J Neuroradiol. 1993; 14 (1): 155-62. AJNR Am J Neuroradiol (citation) -
Pubmed citation
4. Yang S-K, Hu C-J, Yuan R-Y, Wang H-J, Sheu J-J. Presence of the Eye-of-the-tiger Sign on
Magnetic Resonance Imaging in a Subject with Atypical Hallervorden-Spatz Syndrome Lacking
Pantothenate Kinase 2 Mutation. J. Exp. Clin. Med. [Internet]. Elsevier; 2012 Feb 1 [cited 2013
Nov 12];4(1):734. Journal of Experimental and Clinical Medicine citation
Globus pallidus T2 hypointensity

39

From the case: Hallervorden-Spatz
syndrome
Modality: MRI
40

41

42

43

44

Feline oesophagus
Dr Laughlin Dawes et al.
Feline oesophagus also known as oesophageal shiver, refers to the transient transverse bands
seen in the lower oesophagus on a double contrast barium swallow.
The appearance is almost always associated with active gastro-oesophageal reflux
2,3
and
is thought to be due to contraction of the muscularis mucosae with resultant shortening of the
oesophagus and 'bunching up' of the overlying mucosa
2
.
Radiographic features
The folds are 1-2 mm thick and run horizontally around the entire circumference of the
oseophageal lumen. The findings are transient, seen following reflux and not during swallowing.
The appearance is confined to the distal two-thirds of the thoracic oesophagus.
Etymology
Transverse oesophageal folds were originally described in 1970 by Bremner et al
5
as a normal
anatomic feature of the cat oesophagus. The term feline oesophagus has hence been applied to
the similar transient appearance in the human oesophagus.
Differential diagnoses
scarring from reflux
1-2

o permanent
o thicker
o cross less than half of the lumen
oesophageal spasm
1

o much thicker bands
eosinophilic oesophagitis
4

o 'ringed oesophagus' seen in ~50%
o similar sized bands
o permanent
o stricturing
45

References
1. Gohel VK, Edell SL, Laufer I et-al. Transverse folds in the human esophagus. Radiology.
1978;128 (2): 303-8. doi:10.1148/128.2.303 - Pubmed citation
2. Furth EE, Rubesin SE, Rose D. Feline esophagus. AJR Am J Roentgenol. 1995;164 (4): 900. AJR
Am J Roentgenol (citation) - Pubmed citation
3. Samadi F, Levine MS, Rubesin SE et-al. Feline esophagus and gastroesophageal reflux. AJR Am
J Roentgenol. 2010;194 (4): 972-6. doi:10.2214/AJR.09.3352 - Pubmed citation
4. Zimmerman SL, Levine MS, Rubesin SE et-al. Idiopathic eosinophilic esophagitis in adults: the
ringed esophagus. Radiology. 2005;236 (1): 159-65. doi:10.1148/radiol.2361041100 - Pubmed
citation
5. Bremner CG, Shorter RG, Ellis FH. Anatomy of feline esophagus with special reference to its
muscular wall and phrenoesophageal membrane. J. Surg. Res. 1970;10 (7): 327-31. J. Surg. Res.
(link) - Pubmed citation
esophageal shiver

Black cat named Lilith
Author: DrLOriginal file: http://commons.wikimedia.org/wiki/File:Blackcat-Lilith.jpgModifications:
croppedLicense: This file is licensed under the Creative Commons Attribution ShareAlike 2.5 License. In
46

short: you are free to share and make derivative works of the file under the conditions that you
appropriately attribute it, and that you distribute it only under a license identical to this one. Official
licens
From the case: Feline oesophagus - endoscopic view
47

Modality: Photo
rom the case: Feline oesophagus
Modality: Barium Barium swallow Image credit Dr Evan Stein

48

Hidebound bowel sign
Dr Jeremy Jones and Dr Andrew Dixon et al.
The hidebound bowel sign refers to an appearance on a barium study of the small bowel in
patients with scleroderma. The sign describes the narrow separation between the valvulae
conniventes which are of normal thickness despite dilatation of the bowel lumen.
Although the term hidebound is used specifically to describe scleroderma, the same appearance
can be present in sprue. Stack of coins is an alternate descriptive term that can be used for both
conditions.
The cause of hidebound appearance in scleroderma is thought to be asymmetric smooth muscle
atrophy of the inner circular muscularis layer relative to the outer longitudinal layer. Contraction
of the longitudinal layer results in foreshortening of the bowel and close packing of the valvulae
conniventes.
References
1. Pickhardt PJ. The "hide-bound" bowel sign. Radiology. 1999;213 (3): 837-8. Radiology (full
text) [pubmed citation]
2. Marc S. Levine et.al, Pattern Approach for Diseases of Mesenteric Small Bowel on Barium
Studies, November 2008 Radiology, 249, 445-460.
Stack of coins bowel sign
Stack of coins
Hide-bound

49

From the case: Scleroderma small bowel involvement
Modality: Barium
50

From the case: Scleroderma small bowel involvement
Modality: Barium
51

52

Panda sign of the midbrain
The panda sign in neuroimaging refers to the appearance of the midbrain, when the red nucleus
and substantia nigra are surrounded by high T2 signal.
It is classically seen in Wilson disease, although whenever the white matter is diffusely abnormal
in the region a similar appearance will be perceived.
See also
panda sign of sarcoidosis

References
1. Schott JM. A neurological MRI menagerie. Pract Neurol. 2007;7 (3): 186-90.
doi:10.1136/jnnp.2007.120261 - Pubmed citation
2. Hitoshi, S., M. Iwata, et al. (1991). "Mid-brain pathology of Wilson's disease: MRI analysis of
three cases." J Neurol Neurosurg Psychiatry 54(7): 624-626.
3. Stefano Zagami, A. and P. M. Boers (2001). "Disappearing "face of the giant panda"."
Neurology 56(5): 665.
4. Thapa, R. and A. Ghosh (2008). "'Face of the giant panda' sign in Wilson disease." Pediatr
Radiol 38(12): 1355.
Panda sign - midbrain Photograph - panda

53

.
54

From the case: Toxic leukoencephalopathy
Modality: MRI
55

Panda sign of sarcoidosis
Dr Jeremy Jones and Dr M Udayakumar et al.
The panda sign of sarcoidosis is a gallium-67 citrate scan finding. It is due to bilaeral
involvement of parotid and lacrimal glands in sarcoidosis, superimposed on the normal uptake in
the nasopharyngeal mucosa.
The presence of perihilar adenopathy adds the lambda distribution of increased uptake in the
chest, which at times has been included in the description of the panda distribution.
The panda sign is not specific for sarcoidosis, although it is one of few disorders that affect the
salivary and lacrimal glands symmetrically.
Since Ga-67 citrate accumulates in areas of inflammation and malignancy, the differential
diagnosis for the symmetric bilateral accumulation in the lacrimal and salivary glands includes
lymphoma (after irradiation), Sjgren syndrome, and acquired immunodeficiency syndrome.
When the normal accumulation of the radionuclide in the nasopharynx is combined with
increased symmetric accumulation in the parotid and lacrimal glands, the image shows a striking
similarity to the mottled coloring of the giant panda.
References
1. Kurdziel KA. The panda sign. Radiology. 2000;215 (3): 884-5. Radiology (full text) - Pubmed
citation
Panda sign in sarcoidosis

56

Pleural mouse
Dr Frank Gaillard et al.
A pleural mouse (also known as a fibrin body), is a 1-2 cm mobile rounded clump of fibrin left
over after resolution of a pleural effusion.
Pleural mice
Pleural fibrin body

57

Scotty dog sign
Dr Ayush Goel and Dr Frank Gaillard et al.
The scotty dog sign refers to the normal appearance of the lumbar spine when seen
obliquely. On oblique views, the posterior elements form the figure of a Scotty dog with
the transverse process being the nose
the pedicle forming the eye
the inferior articular facet being the front leg
the superior articular facet representing the ear
the pars interarticularis (the portion of the lamina that lies between the facets) equivalent to
the neck of the dog.
If a spondylolysis is present, the pars interarticularis, or the neck of the dog, will have a defect or
break. It often looks as if the dog has a collar around the neck (or decapitation for those with a
bloodier imagination).
References
1. Mellado JM, Larrosa R, Martn J et-al. MDCT of variations and anomalies of the neural arch
and its processes: part 1--pedicles, pars interarticularis, laminae, and spinous process. AJR Am J
Roentgenol. 2011;197 (1): W104-13. doi:10.2214/AJR.10.5803 - Pubmed citation
2. Yochum TR, Rowe LJ. Essentials of Skeletal Radiology. Lippincott Williams & Wilkins. (2004)
ISBN:0781739462. Read it at Google Books - Find it at Amazon
Scotty dog appearance
Scottie dog sign
Scotty dog's sign

58

From the case: Scotty dog Scotty dog Oblique view of the lumbar spine with scotty dog appearance.
Modality: X-ray
59

.
From the case: L5 pars defect
Modality: X-ray
60

From the case: L5 pars defect
Modality: X-ray
61

From the case: Pars interarticularis defect
Modality: X-ray
62

From the case: Scotty dog appearance - oblique view
Modality: X-ray
63

Staghorn calculus
Dr Yuranga Weerakkody and Dr Frank Gaillard et al.
Staghorn calculi (also sometimes called coral calculi) obtain their characteristic shape by
forming a cast of the renal pelvis and calices, thus resembling the horns of a stag.
For a general discussion of renal calculi please refer to nephrolithiasis.
Epidemiology
Staghorn calculi are the result of recurrent infection and are thus more commonly encountered in
4
women, those with renal tract anomalies, reflex, spinal cord injuries, neurogenic bladder or ileal
ureteral diversion.
Clinical presentation
The majority of staghorn calculi are symptomatic, presenting with fever, haematuria, flank pain
and potentially septicaemia and abscess formation.
Pathology
Staghorn calculi are composed of struvite (magnesium ammonium phosphate) and are usually
seen in the setting of infection with urease producing bacteria (e.g. Proteus, Klebsiella,
Pseudomonas and Enterobacter). Urease hydrolyses urea to ammonium and increase in the
urinary pH
1-3
.
64

The struvite accounts for approximately 70% of these calculi, and is usually mixed with calcium
phosphate thus rendering them opaque on both plain films and CT. Uric acid and cystine are the
underlying component of a minority of these calculi
3
.
Plain film
The vast majority of staghorn calculi are radiopaque and appear as branching calcific densities
overlying the renal outline and may mimic an excretory phase IVP. Lamination within the stone
is common.
Ulrasound
The collecting system is filled with a densely calcific mass producing intense posterior acoustic
shadowing.
CT
Staghorn calculi are radiopaque and conform to the renal pelvis and calyces, which are often to
some degree dilated. When viewed on bone windows they have a laminated appearance, due to
alternating bands of magnesium ammonium phosphate and calcium phosphate
3
.
Treatment and prognosis
Staghorn calculi need to be treated surgically (PCNL) +/- ESWL and the entire stone removed,
including small fragments, as otherwise these residual fragments act as a reservoir for infection
and recurrent stone formation.
If left untreated, staghorn calculi result in chronic infection and eventually may progress to
xanthogranulomatous pyelonephritis
3
.
Differential diagnosis
There is usually little differential, provided intravenous contrast has not been administered. In
the latter situation the opaque collecting system may be attributed to contrast rather than the
calculus, especially when staghorn calculi are bilateral.

References
1. Fishman MC, Hoffman AR. Medicine. Lippincott Williams & Wilkins. (2004) ISBN:0781725437.
Read it at Google Books - Find it at Amazon
65

2. Nissenson AR, Berns JS, Lerma E. CURRENT Diagnosis & Treatment Nephrology &
Hypertension. McGraw-Hill Professional. (2008) ISBN:0071447873. Read it at Google Books -
Find it at Amazon
3. Silverman SG, Cohan RH. CT urography, an atlas. Lippincott Williams & Wilkins. (2006)
4. Reilly RF, Reilly R, Perazella MA. Nephrology in 30 Days. McGraw-Hill Professional. (2005)
Staghorn calculi
coral calculus
coral calculi
Struvite calculi
Staghorn renal calculi
Struvite renal calculi
Staghorn type calculi

66

From the case: Red deer stag Red deer stag Image courtesy of Mehmet Karatay. Please see case
description page for licence and original file information.
Modality: Photo
67

From the case: Staghorn calculus
Modality: X-ray
68

From the case: Staghorn calculus
Modality: X-ray
69

From the case: Staghorn calculus Staghorn calculus Image courtesy of H. Zell. Please see case
description page for licence and original file information.
Modality: Photo
70

From the case: Bilateral stag-
horn calculi
Modality: CT
71

From the case: Staghorn calculi
Modality: X-ray
72

From the case: Staghorn
calculus
Modality: CT
73

74

Zoom
Staghorn calculi (coral calculi) in left kidney. (with zoom)
75

3D
Staghorn calculus
76

Rat-tail sign
The rat-tail sign is used to refer to the tapering of the inferior oesophagus in achalasia. The same
appearance (although it is difficult to see the similarity) is also referred to as the bird-beak sign.

rat-tail sign
Rat's tail sign
77

78

From the case:
Achalasia
Modality: Barium
79

The winking owl sign
Dr Henry Knipe and Dr Roberto Schubert et al.
The (absent) pedicle sign, also called the winking owl sign, occurs on plain film when a pedicle
is absent.
The term, winking owl sign, where the missing pedicle corresponds to the closed eye, the
contralateral pedicle to the other open eye, and the spinous process to the beak of the animal AP
views of the thoracic or lumbar spine
1, 2
.
Pathology
Aetiology
There is a wide aetiology
3, 4
:
destroyed pedicle
o spinal metastases
o intraspinal malignancies
o tuberculosis and other infections
o uncommon: primary bone lesion; lymphoma
congenital absence/hypoplasia of a pedicle
neurofibromatosis
poorly visualised
radiation therapy
References
1. Jacobs WB, Perrin RG. Evaluation and treatment of spinal metastases: an overview. Neurosurg
Focus. 2001;11(6). Free pdf
2. Boos N, Aebi M (eds). Spinal disorders: Fundamentals of diagnosis and treatment. Springer
Berlin (2008) ISBN-10: 3540405119. Read it at Google Books
4. Ortiz D. Reeder and Felson's gamuts in radiology. Praeger. ISBN:0313312168. Read it at
Google Books - Find it at Amazon
80

Absent pedicle sign
Winking owl sign
Winking owl's sign
Winking eye sign
Pedicle sign
81

i
Figure 1: winking owl

82

From the case: Absent pedicle in spinal metastases
Modality: X-ray
Case 1: absent right L4 pedicle

83

From the case: Absent pedicle - from spinal metastasis
Modality: X-ray
Case 2: absent left T11 pedicle

84

From the case: Absent pedicle - from spinal metastasis
Modality: X-ray
85

From the case: Absent pedicle sign (breast cancer
metastases)
Modality: X-ray
Case 3: absent left L2 pedicle

86

From the case: Absent pedicle sign (breast cancer
metastases)
Modality: X-ray

87

From the case: Winking owl sign
Modality: X-ray Case 4
From the case: Absent pedicle in spinal metastases

88

89

From the case: Winking owl sign
Modality: X-ray

There is a wide aetiology
3, 4
:
destroyed pedicle
o spinal metastases
o intraspinal malignancies
o tuberculosis and other infections
o uncommon: primary bone lesion; lymphoma
90

congenital absence/hypoplasia of a pedicle
neurofibromatosis
poorly visualised
radiation therapy
References
1. Jacobs WB, Perrin RG. Evaluation and treatment of spinal metastases: an overview. Neurosurg
Focus. 2001;11(6). Free pdf
2. Boos N, Aebi M (eds). Spinal disorders: Fundamentals of diagnosis and treatment. Springer
Berlin (2008) ISBN-10: 3540405119. Read it at Google Books
4. Ortiz D. Reeder and Felson's gamuts in radiology. Praeger. ISBN:0313312168. Read it at
Google Books - Find it at Amazon
Absent pedicle sign
Winking owl sign
Winking owl's sign
Winking eye sign
Pedicle sign
91

Leopard skin sign
Dr Maxime St-Amant and Dr Praveen Jha et al.
The Leopard skin sign (also known as tigroid pattern or stripe sign) results from dark-spots or
stripes (spared perivascular white matter) within bright demyelinated periventricular white
matter on T2W images. It is characteristically seen in :
metachromatic leukodystrophy
Pelizaeus-Merzbacher disease
autosomal recessive spastic ataxia of Charlevoix
References
1. Chavhan GB, Shroff MM. Twenty classic signs in neuroradiology: A pictorial essay. Indian J
Radiol Imaging. 19 (2): 135-45. doi:10.4103/0971-3026.50835 - Free text at pubmed - Pubmed
citation
Tigroid pattern
Tigroid appearance
Stripe sign
Leopard's skin sign
92

Tigroid sign

From the case: Metachromatic leukodystrophy
Modality: MR
93

From the case: Metachromatic leukodystrophy (infantile type)
Modality: MRI
94

Moose head appearance
Dr Matt Skalski and Dr Frank Gaillard et al.
The moose head appearance referes to the lateral ventricles in coronal projection in patients
with dysgenesis of the corpus callosum. The cigulate gyrus is everted into narrowed and
elongated frontal horns.
An alternative name is the viking helmet sign.
References
1. Shenoy C. Shapiro syndrome. QJM. 2008;101 (1): 61-2. doi:10.1093/qjmed/hcm106 - Pubmed
citation
Moose head appearance of corpus callosal dysgenesis
95

96

From the case: Corpus callosum agenesis illustrations
Modality: Diagram
97

From the case: Corpus callosal lipoma - tubulonodular variety
Modality: Annotated image
98

From the
case: Corpus callosum dysgenesis
Modality: MRI
99

From the case: Agenesis of the corpus callosum
Modality: MRI
100

Snake eyes - facial nerve
Dr Henry Knipe et al.
On coronal cross-sectional imaging the facial nerve within its canal in the petrous temporal bone
classically takes on a "snake eyes" appearance as the tympanic segment doubles back next to the
labyrinthine segment adjacent to the cochlea. Anteriorly, these two segments converge at the
geniculate ganglion .
"Snake eyes" refers to the appearance of dice when two "ones" or "pips" are rolled (see picture).
References
1. May M. The facial nerve. Thieme. ISBN:0865778213. Read it at Google Books - Find it at
Amazon
2. Swartz JD & Loevner LA. Imaging of the temporal bone. Thieme Medical Publishers.
101

From the case: Snake eyes - facial nerve
Modality: CT
102

From the case: Snake eyes - facial nerve
Modality: Annotated image
103

From the case: Snake eyes - dice (creative commons photo)
Modality: Photo
104

Dural tail sign
Dr Henry Knipe and Dr Frank Gaillard et al.
The dural tail sign occurs as a result of thickening of the dura and, in the majority of cases, is
associated with meningioma formation. It was initially thought to result from direct invasion of
the dura, however subsequent studies demonstrated it to be more a reactive process. As
experience grew, it became increasingly noted to be present in other conditions, although without
the same regularity.
meningioma: ~65% (range 60-72%) have a tail
pleomorphic xanthoastrocytoma (PXA)
It has also been reported with
chloroma
dural plasmacytoma
primary CNS lymphoma
sarcoidosis
vestibular schwannoma
metastatic tumours
syphilitic gumma
medulloblastoma
desmoplastic infantile ganglioglioma
105

Etymology
It was first described in 1989 by Wilms et al as thickening of the dura surrounding meningiomas.
References
1. Wallace EW. The dural tail sign. Radiology. 2004;233 (1): 56-7. doi:10.1148/radiol.2331021332
- Pubmed citation
2. Bourekas EC, Wildenhain P, Lewin JS et-al. The dural tail sign revisited. AJNR Am J
Neuroradiol. 1995;16 (7): 1514-6. AJNR Am J Neuroradiol (citation) - Pubmed citation
3. Detwiler PW, Henn JS, Porter RW et-al. Medulloblastoma presenting with tentorial "dural-tail"
sign: is the "dural-tail" sign specific for meningioma? Skull Base Surg. 1998;8 (4): 233-6. Free text
at pubmed - Pubmed citation
Dural tail
Dural-tail
Dural-tail sign
Dural tails

106

From the case: Illustration of a "dural tail" sign
Modality: Diagram
107

dural tail
meningioma
From the case: Meningioma
Modality: MRI
108

From the case:
Meningioma of the planum sphenoidale
Modality: MR
109

dural tail
meningioma
110

From the case: Meningioma with dural tail
Modality: MRI
111

rom the case: Meningioma - craniovertebral junction
Modality: MRI
112

From the
case: Meningioma
Modality: MRI

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