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com

Cata[yst for a{{ <Pq :Jvledica[ <E~aminations

·t_ Volume 2
,..-.J lat est Topics~
(()Vere!ftom
/1LL India 2011
Medical Sciences
Al l:l1.fl 2011
.___,, PGI 201 J ___.
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Medicine, Dermatology,
~
~

•
PsychiatrY., Pediatrics, Radiology

3rd
Edition
JAYPEE
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 PLATINUM NOTES 2012-13

Important Points in Radiology

O Radiation and its Types: High Yield for AIPGMEE, AIIMS, PGI 2012/2013
X Rays: 5
William Roentgen discovered X rays.*" MP 2004

Attenuation of X rays depends on “Absorption Coefficient”*-

X rays are modified Electrons. TN 1990

Differ from light in Energy status Al 2010

§
Tungsten is the Target metal used in x rays'.*- PGI 1983 5
O
Filters used in radiology results in “beam of greater intensity”*- JIPMER 1984 O
o
Use of cone results in “film of higher contrast”*"

X ray beam restrictor is a device regulating the shape and size of x ray beam.*-

Grid is a device used to “reduce scattered radiation. ”*" AIIMS 1985

Penetrating power of x ray can be increased by increasing “frequency”.*-

Contrast in x ray depends on “Kv.”** ASSAM 1995

Photosensitive material used in x rays is Silver bromide.*-

Radiation exposure is measured by “Dosi meter.”*"

Units of Radiation asked in Examinations i

Activity is measured by: Becquerel*-*- MP 2004
'

Exposure is measured by: Coulomb/cm2

*

Absorbed dose is measured by: Gray*-*- MP 2006, MAH 2012

Dose equivalent: Sievert

Radioactivity: Curie Delhi 1993

:
Discovered by: Curie Kerala 1988

Year (1896) MP 2004 m

Xeroradiography: Here instead of x ray film, a thin layer of “semi conductor” is used to produce image
which is transferred to paper.
It is used in Breast cancer detection.*

Pantomography: Is a special radiographic technique used for “curved surface”. ¥

475
 fi || .. _--4t
PLATINUM NOTES 2012-13

O Electromagnetic Radiation: High Yield for AIPGMEE, AIIMS, PGI 2012/2013

It is classified according to frequency of waves into:
S Radiowaves
5 Microwaves
S Infrared radiation PGI 2011
S Visible light

* UV radiation
X rays
>-
CD Gamma rays
O Factors that affect the quality and quantity of the X ray beam.
2
Q

2 1 . kVp: The kVp affects both the quantity and the quality of the radiation beam.
The kVp across the X- ray tube influences the force of attraction experienced by an electron released by the
filament as it moves towards the anode. Thus if the kVp is increased, then the kinetic energy (E) of the electron
increases. If the kVp is doubled, then the intensity increases by a factor of four. The quality or the penetrating
power of the beam increases as the kVp increases. Quality of radiation depends almost entirely on the kVp.

2. mA/mAs: affect the quantity of radiation. It has no effect on quality of beam. It has no effect on quality of
4
beam.
If the mA is doubled, then the quantity is doubled, and the dose is increased by a factor of two. When the
current through the X-ray tube (mA) is doubled the number of electrons flowing across the tube in unit time is
doubled. If all other factors remain unchanged, each electron will have the same chance of creating X-ray
photons and so the number of photons wifi be doubled. The same applies to mAs.The quantity of the X-ray beam
is directly proportional to the mA through the tube.

3. Filtration: filtration affects both the quality and quantity of the beam. A filter is always inserted in the
X-ray beam to remove low energy photons. This removal reduces the quantity, and as a result, the mean
energy to the beam increases. The beam becomes more penetrating or harder. Thicker filters reduce the
quantity of the beam, but increases beam quality. A filter is intended to protect the patient by removing
these low-energy photons.

4. Target material: Target material with higher atomic numbers increase both the quantity of photons slightly
. and quality (energy) of the beam. Tungsten produces a significantly more efficient spectrum than
molybdenum.

5. Source to image receptor distance (SID): The SID affects the quantity of photons but has no effect on the
quality. The quantity is affected by the inverse square law, which states that the intensity (quantity) is

.
inversely proportional to the square of the distance.
i Compton scattering occurs for intermediate energy. It is the principal mechanism of absorption for gamma
rays in the intermediate zone of 100 kev to 10 Mev.

476
 :- •
- .

PLATINUM NOTES 2012-13

SSllilllli
<=> Differentiate
Atomic number is number of Protons.** PGI 2001
Atomic weight is number of protons + neutrons*"
Isotopes are substances with same atomic number but different atomic weight.*" MH 2006
5
Isobars are atoms having same atomic weight but different atomic numbers**
Isomers are atoms having same atomic number and atomic weight but different energy states in nucleus.

O Gamma Rays
m Gamma rays are electromagnetic energy. (Photons)
m They are emitted from nucleus of unstable (radioactive) atoms. 9
m
o
Henry Becquerel discovered gamma rays.#
o
•Gamma rays are high energy ionizing radiations.# o
-<
m Gamma rays have “no mass” and “no electric charge”.#
Gamma rays travel at speed of light*
m Cesium -137, Cobalt and Radium emit predominantly emits gamma rays. PGI 1988
» “Phosphorus 40” is a natural source of gamma rays.#
m Gamma rays have Maximum penetration power. MH 2007
» Uses:
v' Cancer treatment***"
:
S Diagnostic/imaging
S Measure soil density at construction sites
S Ensure proper fill levels in packing of food and drugs.
Inspection of weld parts and metals for defects.
“Radiation sickness” is mostly due to gamma rays.*"*"
m
Ionizing Radiations are:**

Alpha radiation (MOST IONIZING) Al 2010

Beta radiation
Gamma radiation
X rays
:
Neutron

Infrared rays are used in:*#

Placental Localization
Thermography
Orbital Pneumography
Intracerebral infarct diagnosis
!
477
 PLATINUM NOTES 2012-13
1 mmsm H p Imtn
; : :
3 Ultrasound
Ultra sound is sound with frequency greater than 20, 000 cycles/ second.*ÿ*ÿ

5 In medical use we use frequency between 1 MHz and 20 MHz.*-** PGI 2001

“Pizo electric crystal activation” principle is used in USG.*-*-

Ultrasound probe is made of “Lead Zirconate titanate” now a days and also Quartz previously. MH 2000

USG is non mutagenic. •*

Contrast used is sonavist PGI 2007

S
3
O
USG is non ionizing.*- (MRI and thermography also are non ionizing) Al 2006

Q Small organisms are destroyed by USG because of “Cavitation ”.*ÿ

S Types of Ultrasonography

— M-Mode

A Scope
For moving parts eg, valves of heart etc.

For cerebral lesions. Shift of mid- line structures

B Scope For 2 dimensional view e.g. Obstetrics and abdominal masses

Grey scales For Contrast studies

I O Echocardiography: High Yield for AIPGMEE, AIIMS, PGI 2012/2013

ft This noninvasive technique uses high-frequency sound waves that reflect from cardiac structures, permitting
the imaging of cardiac anatomy and motion. Two-dimensional echocardiography has largely replaced the
Mrmode display, although the latter provides superior quantitative details regarding wall thickness and chamber
dimensions. This examination is now standard in the assessment of ventricular function (including regional wall
fvj motion) and valvular abnormalities.

The Doppler method is the standard technique for assessing intracardiac blood flow, shunts, and valvular stenosis

r and regurgitation. Echocardiography is diagnostic in cases of

» Left atrial myxoma,

» Mitral valve prolapse, and
» Hypertrophic cardiomyopathy
•Visualization of vegetations on heart valves in patients with infective endocarditis. Pericardial fluid and
tamponade.
Transesophageal echocardiography gives high-resolution images of the heart and proximal great vessels and
is particularly useful for evaluating suspected aortic dissection.
High-resolution B-mode ultrasonography with color Doppler imaging is of substantial value in the noninvasive
diagnosis of both peripheral arterial (including carotid) and venous disease.

478
 ‘
PLATINUM NOTES 2012-13
£ il£

3 CT Scan/MRI
CT scan was invented by Hounsfield.•-

Hounsfield number in CT Scanning depends on “Mass density” *ÿ AIIMS 2009

CT scan rooms are shielded by lead Al 2010

5
In CT Value of water is zero TN 2008

Bone has highest density on CT. BHR 2006

MRI
MRI works on the principle of “Gyro magnetic property of proton “or Hydrogen Nucleus. *ÿ•* §
There is no radiation exposure in MRI. *" 9
o
r
It is Non ionizing*- Al 2006 O
O
Most common contrast agent used in MRI is Gadolinium DTPA.*- PGI 2000 -<
MRI is best for posterior cranial fossa lesions*-
Cardiac pacemakers, aneurysmal clips, AIIMS 2008
S Cochlear prosthesis, Ferromagnetic IVC Filters,
S Ocular metallic foreign bodies, Cochlear prosthesis are contraindications to use of MRI *** ffjjggn
S MRI is used to detect Non ferrous objects like wood. (Concentrate) AMU 2005

MRI rooms are shielded by continuous sheets of copper or aluminum for interference from external
electromagnetic radiations called Faraday cage.*-*- AIIMS 2003

T1 and T2 Relaxation Times: Therate of return to equilibrium of perturbed protons is called the
relaxation rate. The relaxation rate is different for different normal and pathologic tissues. The relaxation
rate of a hydrogen proton in a tissue i* influenced by surrounding molecular environment and atomic
neighbors. Two relaxation rates, the T1 and T2 relaxation times, are measurable. •"

T1 relaxation rate is the time for 63% of the protons to return to their normal equilibrium state,

T2 relaxation rate is the time for 63% of the protons to become dephased owing to interactions among :
adjacent protons.*

AIPGME 2012/DNB 2011

;
ci> Housenfield Units:
The Hounsfield unit (HU) scale is a linear transformation of the original linear attenuation coefficient
measurement in one in which the radiodensity of distilled water at standard pressure and temperature (STP)
is defined as zero Hounsfield units (HU), while the radiodensity of air at STP is defined as -1000 HU. £
For a material X with linear attenuation coefficient pX, the corresponding HU value is therefore given by where is .ÿ
t ,

the linear attenuation coefficient of water.

Thus, a change of one Hounsfield unit (HU) represents a change of 0.1% of the attenuation coefficient of water
since the attenuation coefficient of air is nearly zero.
It is the definition for CT scanners that are calibrated with reference to water. \ •

479
I m
;n*fi
pm

PLATINUM NOTES 2012-13

Bills
i
Tissue CT number (HU)
' Bone 1000

5 Liver
White matter
40-60
~20-30 HU
Grey matter ~37-45 HU
Blood 40
Muscle 10-40
Kidney 30
0 Cerebrospinal fluid 15
O Water 0
2
Q Fat -
-50 -100
2 Air -1000
3 Computed Tomography Rooms
» Computed tomography rooms typically have high workloads and high kilovoltage technique settings.
» They are shielded by Lead. (Pbl

•As a result, at least “1/16-Inch lead shielding” or equivalent is required for the walls, doors, floors,
/ ceilings, and operator’s barrier. AIIMS 2009
m » CT rooms with high workloads and with fully occupied uncontrolled space directly adjacent to the scanner
al
;.;V
may need shielding that is thicker than 1 /16-inch lead or 4 to 6 inches of concrete to meet the
recommended NCRP.
E
3 Advantages of MRI over CT scan
Selection of any plane possible (Coronal/saggital/Oblique)*-ÿ

i No ionizing radiation*-
More sensitive to tissue damage (Demyelination)*-
. No bony artifacts*-

3 Disadvantages
Limited slice thickness*-
Bony imaging displays marrow only*"

Contraindicated in:
v Patients with pace makers*"*•
S Cochlear implants*-*-
S Prosthetic heart valves*-*"
s Intraoccular metallic objects*-*-
V Aneurysmal clips*-

480
 H : '
.;
• PLATINUM NOTES 2012-13
-.a."-

Claustrophobia*-
MRI examination is now regarded as the procedure of choice for imaging soft tissue masses. MRI enhances the
contrast between tumor and adjacent structures and provides excellent three-dimensional definition of
fascial planes. However, CT is still better than MRI in the evaluation of patients with acute intracerebral
hemorrhage, acute head trauma, subarachnoid hemorrhage, or disease processes requiring analysis with fine
5
bone detail, such as facial or spinal fractures. Calcification is also poorly identified on all sequences of MRI.
AIPGME 2012

•=> Positron Emission Tomography (PET Scan)

PET relies on the detection of positrons emitted during the decay of a radionuclide that has been injected
into a patient.
* s3
The most frequently used moiety is 2-fluoro-2-deoxy-D-glucose (FDG), which is an analogue of glucose and o
IT
is taken up by cells competitively with 2-deoxyglucose.* o
0
Multiple images of glucose uptake activity are formed after 45 to 60 min.# -<
Images reveal differences in regional glucose activity among normal and pathologic brain structures. #
FDG PET scanning has been used to assist in :
S Differentiating radiation necrosis from active neoplasm following therapy,*ÿ•ÿ AIIMS 2005
S In localizing temporal lobe epileptic foci, *ÿ

S In detecting metastatic disease *-

•S Determining cardiac viability.*ÿ
v' A lower activity of FDG in the parietal lobes has been associated with Alzheimer's disease*-
i ,

3 Myelography: High Yield for AIPGMEE, AIIMS, PGI 2012/2013

Technique: Myelography involves the intrathecal instillation of water-soluble iodinated contrast medium (into
the lumbar or cervical subarachnoid space via a percutaneously placed spinal needle (22 gauge or smaller). •***
Metrizimide is the dye used. TN 2003
Indications: For diagnosis of diseases of the spinal canal and cord, myelography has been largely replaced l
by CT, CT myelography, and MRI. #
i
Contraindications •"
Any patient with suspected herniation,
Elevated intracranial pressure, or a history of allergic reaction to intrathecal contrast media.
Lumbar puncture is to be avoided in patients with bleeding disorders, including patients receiving
anticoagulant therapy l

Complications i

Vasovagal syncope may occur during lumbar puncture

Headache is most frequent complications of dural puncture and myelography. Al 1999 ;
These symptoms are thought to result from neurotoxic effects of the contrast agent, persistent leakage of
CSF at the puncture site, or psychological reactions to the procedure. The incidence of headache has been
reduced with the use of smaller-gauge spinal needles and nonionic, water-soluble contrast agents.*-*-
'.VKA

L-
481
 fi

PLATINUM NOTES 2012-13 :

A >Ji «af rii rfi iii.' * - /-••Mv Mtw

Postural headache (post-lumbar puncture headache) is generally due to prolonged leakage of CSF from the
puncture site, resulting in CSF hypotension. *-
Hearing loss is a rare complication. It may result from a direct toxic effect of the contrast medium or from
5 an alteration of the pressure equilibrium between CSF and perilymph in the inner ear.*-
Puncture of the spinal cord is a rare but serious complication of cervical (C1-2) and high lumbar puncture. *ÿ
Aseptic meningitis and Encephalopathy *-
Other reported symptoms include, hyperthermia, hallucinations, depression, and anxiety states.
These neurotoxic side effects have been reduced by the development of nonionic, water-soluble contrast
>ÿ agents, as well as by head elevation and generous hydration following myelography.*ÿ•"
0
O Arachnoiditis, or inflammation of the Leptomeninges *ÿ

9
Q
NIRS: Near Infrared Spectroscopy:
§ Near Infrared Spectroscopy (NIRS)
m Is a spectroscopic method which uses the Near Infrared Region of the electromagnetic spectrum
m NIRS depends on: Biological tissue absorbs light in the near infrared spectrum (700-1000 nm) far less
than visible light; photons at near infrared wavelengths are thus able to penetrate greater distances.
Pulse oximeters, which use visible light, function over 1 to 2 cm. Greater photon penetrance allows NIRS to
be performed over 6 or 8 cm; enough to transilluminate an infants head
» Brain contains only three mobile chromophores (compounds which absorb light); oxyhaemoglohin,
deoxyhaemoglobin and cytochrome oxidase (the terminal component of the mitochondrial electron
I transport chain). Attenuation of transmitted light in the brain due to othercauses can be assumed to be
I
!
- constant. Consequently any change in observed absorption is due to a change in the concentration of a
mobile chromophore. Using suitable algorithms, changes in absorption can be converted into changes in
concentration of the three mobile chromophores.
» Thus near infrared spectroscopy derives information on cerebral haemodynamics and oxygenation from

i; T.' -
3 changes in the absorption of light.
•NIRS can be used to estimate cerebral blood flow, cerebral blood volume and other indices of cerebral
haemodynamics.

O Radionuclide Studies: High Yield for AIPGMEE, AIIMS, PGI 2012/2013

These tests involve injection of radioisotopes into the circulation with detection by special instrumentation.
One of the most useful of these techniques is radionuclide ventriculography, also referred to as gated blood
pool scanning.
Technetium 99m (99mTc) bound to red blood cells stays in the blood pool and permits imaging of the size
j
and contractile function of cardiac chambers.
& Scanning with radioactive thallium (201TI) or 99mTc sestamibi permits assessment of myocardial perfusion.
m The radioisotope is injected at maximum exercise or pharmacologically induced stress and localizes in
1 cardiac muscle as a function of coronary flow; areas of diminished myocardial perfusion are visualized as
"cold” spots on the myocardial image. Viable but ischemic myocardium subsequently fills in with more
-
homogeneous radionuclide distribution, whereas previous infarction produces a persistent cold spot.

482
 .
.

PLATINUM NOTES 2012-13

• .. Em m
Scanning with 99mTc pyrophosphate or radiolabeled antimvosin antibody can be used to visualize areas of
myocardial necrosis and is occasionally useful in evaluating patients with suspected myocardial infarction,
transplant rejection, or myocarditis when other studies are equivocal.

In Nutshell 5
Optical technique for measuring blood oxygenation in brain.

Spectroscopic method utilizing near infra red region of electromagnetic spectrum.

Depends on attenuation of light which itself depends on blood oxygenation.

Cerebral blood flow even in an asphyxiated child is best measured by this technique Al IMS 2009
?O
Effective Radiation Doses in Procedures: AIIMS 2010 O
O
» -
MCU 1.2 mSv

-
O
-<
IVP - 2.5 mSv
» Chest X-ray PA - 0.02 mSv
m Chest X-ray lateral - 0.04 mSv
» Chest X-ray lateral - 0.7 mSv
» CT head - 2 mSv PF
» CT chest - 8 mSv

-
CT abdomen 10 mSv

•CT low dose protocol -1.5 mSV

Scans Used
Hot spot in Ml is shown by: technetium scan AIIMS 1996

Pancreatic scanning uses Selenium 75 AIIMS 1994

Sestamibi scan is used for parathyroid’s PGI 2003

.
Renal GFR is measured by Tc 99DTPA scan. Al 2008

Cortical function: DMSA scan

VUR is seen by MAG3 -Tc 99 scan. PGI 2005
C:
Isotope used for thyroid scan is 1 131* PGI 2000

Tc labelled RBC are used for spleenic diseases

PACS: “Picture Archiving and Communication System”: AIIMS 2008

Is a new system aiming to replace conventional analogue film and paper clinical request forms and reports with
a completely computerized network whereby digital images are viewed on monitors in conjunction with the
clinical details of the patient and associated radiological report displayed in electronic format.*-*'*'

483
 ... . .
.

PLATINUM NOTES 2012-13

!
Z

i o Chest X ray: (CXR)

| * Important Points
CXR
5 Rt Border is formed by JK 2009
Superior vena cava/ Rt. Braciocephalic vessels*-*-
Rt Atrium*-*-
I nferior vena cava*-*-
Lt Border is formed by
>-
O
O Aortic arch*-

2
D
Left ventricle*-

§ Pulmonary artery*-
Lt atrial appendage*-

Chest radiograph is best performed at: 90-120 kVp**

Optimum distance used in Radiography Examination is: 90-100 cms*

Apex of lung is best seen in Apical view*(A-A)

m ' Enlargement of Lt atrium is best viewed as

Causes of Gross Cardimegaly

Increase in tracheal bifurcation.*

lam Multiple valve disease

Pericardial effusion
Dilated cardiomyopathy
a® Ebsteins anomaly
V v!
mi
tea j
Cor pulmonale

<=> Causes of Small Heart

Constrictive pericarditis
Addisons disease
m Pulmonary emphysema

<=> Air Bronchogram and Consolidation DNB 2011

* ;ÿ An air bronchogram is an air-filled bronchus against surrounding opacified alveoli. It is indicative of an airspace
process, and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due
to obstruction (as air is resorbed). Air bronchograms can be seen with :

m
me
S
S
v'
Pulmonary consolidation
Pulmonary oedema
Non-obstructive atelectasis
fit
484
 :
PLATINUM NOTES 2012-13

s Severe interstitial disease

Neoplasm: bronchioloalveolar carcinoma; pulmonary lymphoma
Pulmonary infarct
S Normal expiration
5
Causes of “Miliary Mottling” on Chest Radiography
Tuberculosis, Rheumatoid Arthritis PGI 2003
s Histoplasmosis, Blastomycosis, Coccidoidomycosis PGI 2000
S Sarcoidosis, PCP infection PGI 2006
S Metastasis
22
Pneumoconniosis, Varicella pneumonia PGI 1999
O
S Eosinophilic granuloma O
O
Amyloidosis, Pulmonary edema PGI 2006 -<
PGI seems to be very interested in this topic but a headache for Aspirants of PG.

Causes of “Ground Glass Pattern” on Chest Radiography

PCP Al 2001
HMD Al 2001
/ Obstructive TAPVC
v' Interstitial pneumonia
S Pulmonary haemorrhage
S Alveolar proteiniosis
S Pneumonia Al 2001
y Collagen vascular diseases
Silicosis
;
O Eggshell Calcification
Old concept but High Yield for AIPGMEE, AIIMS, PGI 2012/2013
Refers to fine calcification seen at the periphery of a mass, and usually relates to lymph node calcification.

Remember:
In Jacobsen and Felson published criteria to help "avoid over-reading of the incidental circumferential concentrations
of calcium and to eliminate confusion with the ring shadows of bronchi on end." These criteria were:
m Shell-like calcifications up to 2 mm thick must be present in the peripheral zone of at least two lymph nodes
•The calcifications may be solid or broken
» In at least one of the lymph nodes the ringlike shadow must be complete
» The central part of the lymph node may show additional calcifications
» One of the affected lymph nodes must be at least 1 cm in its greatest diameter

485
r
r PLATINUM NOTES 2012-13
£t

L-
..
'

____
___
_
mmM ; .

Peripheral calcification of lymph nodes, "Eggshell calcification," commonly occurs in patients with

•Silicosis
m Coal-worker’s pneumoconiosis.
5 m Sarcoidosis,
» Postirradiation Hodgkin disease,
•Blastomycosis, and
» Scleroderma
•Amyloidosis (rarely), Histoplasmosis, (rarely)
>-
O
O O Miscellaneous “Signs” and “Points”
2 Rounded atelectasis: Comet tail sign*’
O
2 Right Hilar mass: Golden S sign*-

Pneumoniae: Air Bronchogram*-

Continuous diaphragm: Pneumomediastinum*-

Wave sign of Mulvay/Thymic sail sign: Mediastinal Air outlines Thymus*-

Pneumatocele: Staphyloccocus aureus*-
Bulging fissure sign: Klibessela pneumonia*-
; Meniscus sign

Moon sign
Cresecent sign
Double arch ABPA*-
Peri Hilar bronchiectasis

Serpent sign ABPA*-

“Air” crescent sign: Aspergilloma*-

Minimal amount of fluid seen in pleural space in CXR: 50 ml*-

Radiographic Clinical Scenarios Asked

Try to read in between lines. I exemplify by:
n A child with acute respiratory distress with hyperinflation of lung most p- Foreign body aspiration.
- invariably has

Clue: child, acute distress.

A newborne with acute respiratory distress , cystic air filled cavities in p Congenital diaphragmatic
IRK' chest and scaphoid abdomen has hernia
Clue: Newborne

486
—
 mm 1
J
An AIDS patient has history of non productive cough with bilateral hilar
PLATINUM NOTES 2012-13

pep infection
opacities without effusion is most likely having

Clue: AIDS, non productive cough, opacities without effusion

An Occupational worker has extensive pleural thickening, pleural Asbestosis

5
calcification of diaphragm is most likely having
Clue: Occupational worker, pleural thickening

On comparing the CXR of a child and an elderly, a mass like projection Thymic swelling
is seen in neck area of the child, absent in case of an elderly.
The radiologist reports it a normal feature, Most likely it is
2
5
Clue: child, normal swelling
o
O Different Appearances Frequently asked: o
O
-<
High Yield for DNB, AIPGMEE, AIIMS, PGI 2012/2013
Boot shaped heart: Fallots Tetralogy*" TN 2008
Egg on side heart: TGA*" Al 2010

Snow man heart: TAPVC*" TN 2004

Great Hilar dance on Flouroscopy: ASD*"

Hands up sign: CCF*"
!
Square root sign:
Docks sign:
Constrictive Pericarditis*"

Coarctation of Aorta*"
rm
i
Globular heart with plethoric lung: TGA*-

Globular heart with oligemic lung: Tricuspid atresia*"

Water bottle heart: Pericardial effusion*"

Double shadow Mitral stenosis TN 2005

.
Water lilly sign Hydatid cyst DNB 2007

Important “X-ray Changes” in Congenital Heart Diseases: (Details)

! *
: -
r* Cardiomegaly (Rt atrium and Rt ventricular Enlargement),
Atrial Septal Defect
<*ÿ Plethoric lung fields.

Ventricular Septal * Cardiomegaly (Lt ventricular),

r* pulmonary plethora .£
Defect
n Normal sized heart in patients with small shunt (due to Small VSD or
... . v'
associated PAH or pulmonic stenosis).

Patent Ductus
<ÿ* Cardiomegaly (It ventricular),
f* Pulmonary plethora.
Ateriosus

487
 £ '

PLATINUM NOTES 2012-13 .

Terology of Fallot <ÿ* Cor-en-Sabot,

f Normal sized heart with upturned apex
<ÿ* (Rt. Ventricular hypertrophy), pulmonary oligemia
|
5 Tricuspi d Atresia r+

f
Cardiomegaly (Lt. ventricular) broad apex,
Prominent SVC,
r+ Pulmonary oligemia.
TAPVC (non- * Cardiomegaly.
Obstructive)
TAPVC (obstructive) r* Normal sized heart.
>-
O Ebstein’s anomaly Cardiomegaly,
O * Pulmonary oligemia. AIPGME 2010
9
Q
SVC: Superior vena cava
§ VSD: Ventricular septal defect
PAH: Pulmonary arterial hypertension

Kerly Lines:
Kerly A Line: Upper Zone (perihilar fluffy opacities) JIPMER 1992
Kerly B Line: Basal Zone (early change of pulmonary edema) KAR 1995
Kerley C Line: Central Zone
Kerley D Line: Criss crossing of Kerley A And B Lines
i
Kerley lines are a sign seen on chest radiographs with interstitial pulmonary edema. They are thin linear

! pulmonary opacities caused by fluid or cellular infiltration into the interstitium of the lungs.

m
vy

k
Kerley A lines: are longer (at least 2cm) unbranching lines coursing diagnonally from the periphery toward
the hila in the inner half of the lungs. They are caused by distension of anastomotic channels between
peripheral and central lymphatics of the lungs. Kerley A lines are less commonly seen than Kerley B lines.
Kerley A lines are never seen without Kerley B or C lines.
Kerley B Lines: are short parallel lines at the lung periphery. These lines represent interlobular septa, which
are usually less than 1 cm in length and parallel to one another at right angles to the pleura.
Kerley C lines: are the least commonly seen of the Kerley lines. They are short, fine lines throughout the
\
lungs, with a reticular appearance. They may represent thickening of anastomotic lymphatics or
superimposition of many Kerley B lines.

Kerley-B lines are: Due to visible interlober lymphatics and their surrounding connective tissue, 1-3 cm long'
less than 1 mm thick, extending from and perpendicular to the pleural surface. Best seen in the
costophrenic angle. It is seen in:
B&v
Due to pulmonary venous hypertension:
.
S Left ventricular failure.
S Mitral stenosis.

Li 488
Jv
Hi
;

Due to lymphatic obstruction

Pneumoconioses
Lymphangitis carcinomatosa.
_
_ '-1'1 PLATINUM NOTES 2012-13

Sarcoidosis (less common)

Chronic Kerley B lines may be caused by fibrosis or hemosiderin deposition caused by recurrent pulmonary edema.
5
O T ransposition of Great Vessels
•Is the most common cyanotic congenital heart disease in the newborn infant (Tetralogy of Fallot is more
common overall, but many tetralogy of Fallot cases present after the newborn period).
m Aorta arises from the right ventricle
m Pulmonary artery from the left ventricle, with the aorta positioned anterior and to the right of the
52
pulmonary artery. o
m It is incompatible with life unless a communication exists between systemic and pulmonary circulation O
O
» During the newborn period, the PDA and patent foramen ovale (PFO) maintain this communication. As the <
PDA starts to close and the PFO by itself is inadequate in size, the patient develops intense cyanosis, and the
patient becomes tachypneic.
•On auscultation, the second heart sound is greater in intensity UPSC 2006
» X ray shadow secondary to a small thymus, sometimes giving the appearance of “Egg on side” or “Apple on
a string” appearance. DNB 2006
» Echocardiography confirms the Diagnosis.
The “Arterial Switch Procedure” offers the best prognosis with a mortality of about 5%.

Cardiac Scan: 5
..
Radiotracers that can be used:
:
»Thallium 201
I
-
•Tecnecium 99
SestaMIBI
» Tetrofosmin

» Teboroxime
>

Resting perfusion abnormalities are seen in:

Reversible ischemia AIPGE 2009 v
Ml
S Fibrosis
Area supplied by severe stenosis (greater than 85%)
!
I ; ;
Fat Containing Breast Lesion: AIIMS 2010
» Lipoma i
•Galactocele
»
»
Fat necrosis (
\
Oil cyst
•Hamartoma \

489
 *h
4-.:; ;ÿ ;
.
‘
'
lV
>
PLATINUM NOTES 2012-13

•=> Cause of Gas under Diaphragm

Rupture or perforation of any gas containing organ, causes of which are
DU Perforation.
5
r*

<-* Enteric perforation.

Perforating injury.
<+ Surgical procedures.
<ÿ* Hysterosalpingography.
r* Rupture of pneumatosis cystoides intestinalis.
>ÿ
0 Pulmonary Embolism:
O
1. Westmarks Sign*-*-
2
Q
2. Hamptons Hump*-*- AIIMS 2007
2 3. Palas Sign*-
4. Fleischners Sign*-

Bronchiectasis Shows :

Gloved tree appearance

Bunch of grapes

: ; Ring of shadows
.
.

&
Tram Track appearance
y'; Best method for minimal Bronchiectasis is HRCT. Al 1992

O Pulmonary Hamartoma*#**
,
Properties Benign Malignant

Size <2 cms >2 cms

mt'-
tfti Margin Smooth Rough

Calcification AIIMS 1995, AIIMS 1998 Pop corn / Bulls eye Peripheral, diffuse

: Concentric dense

Bone destruction No Yes

Attenuation Homogeneous Heterogenous

m ci> Pulmonary Nodule Can be: AIIMS 1991

MM
Tuberculoma
S
m ;; S
Adenoma

Hamartoma
•M

490
 mmm jam*.** ';7

vM* ?k PLATINUM NOTES 2012-13

v.,
«
_ j

3 Gastrointestinal Tract:
Typical Radiographic Appearances
Esophagus

•Rat tail appearance: Carcinoma Esophagus*"*"

5
•Cock screw esophagus: Diffuse esophageal spasm*"
m Nut Cracker esophagus:

•Dysphagia lusoria: Compression of esophagus by aberrant blood vessel*"

Stomach 95
m Pyloric teat sign: Pyloric stenosis*" o
» Beak sign: S Pyloric stenosis*" O
O
m Caterpillar sign v' Pyloric stenosis*" -<
» Umbrella sign: S Pyloric stenosis*"
» Single bubble sign * Pyloric stenosis AIIMS 1997

•String sign Pyloric stenosis KOL 2009

j Hamptons line: Gastric Ulcer*"
S Carmans Meniscus Sign: Carcinoma stomach*" (C-C)

3 High Yield for AIPGMEE, AIIMS, PGI 2012/2013 .

* The “Solitary/ Single bubble” sign on X-ray abdomen is pathognomonic sign of pyloric atresia.
.

* The “double bubble” sign is typical for duodenal obstruction in the newborn.

* The "Triple bubble” sign in neonate is a sign of jejunal atresia. MAH 2012

3 Gall Bladder
Adenomyomatosis of Gall Bladder: AIIMS 2008 - .

Diffuse thickening of gall bladder wall on USG *

Hyperechoic nodules at neck and *"

.

Commet tail artifacts *"

Investigation of choice for acute cholecystitis: HIDA Scan. PGI 2002

Features of Cholecystitis on USG: PGI 2001
Thick gall bladder wall.
S Perigall bladder halo
v' Stone impaction at neck.

491
 •i
PLATINUM NOTES 2012-13

Pancreas:
Annular pancreas: Double Bubble sign*-*-
Chronic pancreatitis: Chain of lake appearance*-*-
.....
EL '
m?
•

PGI 1988
Al 1996
-
5 Acute pancreatitis: Fox sign. APPG 2006

Ca pancreas:
s Frostburgs Reverse three sign *ÿ*ÿ*••ÿ

y Antral Pad sign*-

y Scrambled egg sign*-
y Widening of duodenal C loop: Ca head of pancreas PGI 1985
>-
0 Serous cystadenoma Pancreas: Sunburst Calcification, Eggshell calcification*-*-
O
O o Double Bubble Sign
Q
The finding implies two air-filled structures in the upper abdomen, with little or no air distally. Horizontal-
2 »

beam radiographs will demonstrate air and fluids levels in both bubbles.
» The first bubble (proximal and left sided) is: Stomach.
» The second bubble (to the right of the midline) is: Duodenum
"Intrinsic” causes:
m Duodenal atresia

mm •Duodenal stenosis
m Duodenal webs
m "Extrinsic” causes:
» Annular pancreas,
» Mal-rotation of the gut
» Preduodenal position of the portal vein.

ip- Intestinal Tuberculosis:

“Ulcerative form” most frequent*-*-
“Ileocecal region” most common*-
Stierlin sign: Rapid emptying of narrowed terminal ileum*-
Fleischners sign*-

m V
Barium Study of Ileocecal Tuberculosis
Spasm and edema of IC valve, (ileocecal)
S Thickening of valve lips and narrowing of terminal ileum. (Fleschner sign, umbrella sign)*-*-
y Linear, stellate ulcers with elevated margins.*-
Symmetric annular napkin ring stenosis in late cases.*ÿ*•
y Loss of ileocecal angle, dilatation of terminal ileum. Goose neck deformity*-*-
V
Narrowing of ileum with short rigid cecum. Sterlins sign*-*-

492
 : -•
>
'
: '
:
;

PLATINUM NOTES 2012-13

WkM "i

Features of Barium Study of Ileocecal TB PGI 2009

» String sign
m Goose neck sign
•Right sided obstruction 5
m Pulled up caecum
•Sterilin sign
Causes of Soap Bubble Appearance in abdominal radiographs of infants: AIIMS 2010

Meconium ileus
•+ Meconium plug B2
f Necrotizing enterocolitis o
r* Hirshsprungs disease o
Fecoliths o
** -<
O High Yield for DNB, JK BOPEE, MAH KCET, AIPGMEE AIIMS, PGI 2012/2013
Radiological Signs of GIT Imaging:
Cork screw Oesophagus / Diffuse Esophagal spasm*-**
Rosary Oesophagus Diffuse Esophagal spasm*-*-
“Double Bubble sign in X ray abdomen” Annular Pancreas, AIIMS 2009 r
i
Duodenal atresia
Duodenal stenosis
PGI 2007
\
Duodenal web
“Scalloping of sigmoid colon” s Ulcerative colitis*-*-
“Microcolon on barium enema.” s Ileal Atresia*-
“Bird of prey sign.” S Sigmoid volvolus*" DNB 2008
J Crohns disease*- KCET 2012
“String sign.” (KANTOR) ,
“Pipe stem colon.” s Ulcerative colitis*-
t
Saw tooth appearance of colon. * Diverticular disease*-
Apple Core Lesion/Napkin Ring appearance S Lt Colonic Ca.*- .

v' Volvolus*" $
Coffee bean sign:
S Intussception*-
Claw Sign/Signe de dance m
Thumb printing sign v' Ischemic colitis*- PGI 1996

=> Best Tests

f4
Manometery: Best for esophageal spasm
24 hour p H Study: Best for GERD
CT scan: Best for acute pancreatitis
DISIDA, HIDA,: Best for acute cholecystitis

493
 i
PLATINUM NOTES 2012-13

Radiological Signs of Urinary Tract Imaging

Bilateral spider leg pattern* Polycystic kidneys

m
::-zi

Li
>S :’"

........ . .
.
'

. - Wl»ilW-PWwpÿ* ysy

.
_;. ,
PGI 1999, TN 2003

5 Thimble bladder* Chronic Tuberculosis DNB 2007

Golf hole ureter TB Urinary bladder

Crescent sign* Hydronephrosis

Rim Sign* Hydronephrosis AIIMS 1998

>- Cobra Head/Ader Head appearance MANIPAL 2006

CD * Ureterocele
O Dropping flower sign* Ectopic Ureter
-l
2
Q Fish hook bladder* BPH
2 Flower vase appearance Horse shoe kidney

O Contrast Nephropathy
Seen in:
CRF

m Diabetes mellitus
CCF
.
Dehydration
Multiple Myeloma
Patients on metformin

P Contrast nephropathy classically presents as an acute (onset within 24 to 48 h) but reversible (peak 3 to 5 days,
resolution within 1 week) rise in blood urea nitrogen and creatinine and is most common in individuals with
preexisting chronic renal insufficiency, diabetes mellitus, congestive heart failure, hypovolemia, or multiple
myeloma.

A patient presents with sudden anuria and renal failure. USG and KUB is normal. Investigation giving best
1 information is DTPA
Renal imaging has been accepted as the test of choice for the evaluation of diseases which induce focal or

——
generalised alteration in renal function. Some of the common indications are:
Obstruction of the drainage system,

>ÿ1
i —— Urinary tract infection
Evaluation in renal failure,

—— Renovascular problems,
Assessment of renal transplants
Evaluation of global renal function.

494
 - mm PLATINUM NOTES 2012-13

Particularly important is the fact that the studies are:

mCost-effective
•Relatively non-operator dependent,
mNon-invasive with minimal
•Discomfort 5
•No known risk factor.
Dynamic Renal Scan (DT PA scan)
This investigation gives information about the blood flow to the kidneys and how well each kidney is functioning
for the production of urine.
The test also shows if there are any obstructions in urine output.
2
Static Renal Scan (DMSA Scan) o
This scan gives information about the size, shape and position of the kidneys, and whether there are scars on the o
kidney from a previous infection. AIPGME 2012
o
-<
REASONS: Static imaging using technetium-labeled dimercaptosuccinic acid (DMSA) is useful in identifying
and quantifying parenchymal damage, because DMSA is concentrated only by functioning renal tissue.

Dense Persistent Nephrogram

Bilateral global
xrywT":

1. Systemic hypotension or severe dehydration F

2. Intratubular obstruction from protein: Tamm-Horsfall, Bence-Jones, and myoglobin
[
3. Tubular damage by contrast material
Unilateral global !i
.
1 Renal artery stenosis I
2. Renal vein thrombosis
3. Urinary tract obstruction
Segmental I
1. Obstructed moiety of duplicated collecting system
2. Obstructing renal calculus
3. Obstructing neoplasm
4. Focal stricture
5. Focal parenchymal disease: tubulointerstitial infection

3 Orthopedics: High Yield for AIPGMEE, AIIMS, PGI 2012/2013

Sign Metabolic Disease
Wimberger sign Scurvy*
Wimberbers Mne Syphilis*
Moth eaten appearance of epiphysis Rickets*

* Moth eaten alopecia(syphilis) not a radiographic sign

495
 PLATINUM NOTES 2012-13

Cod fish vertebrae Osteoporosis*

Polka dot in vertebrae Hemangiomas KOL 2008

Soldiers helmet skull Pagets disease*

5 Champagne glass pelvis Achondroplasia* JIPMER 2002
Triradiate pelvis Osteomalacia*
Pencil thin cortex Scurvy TN 2008

*=> Features of Malignant Lesion of Bone on Radiography

>-
O — Cortical erosion**

——
O Cortical Destruction*-
9
Q
Absence of Sclerotic margin*-

2
——
Associated soft tissue mass*-
Irregular boundaries*-

Irregular periosteal reaction*-

=> Plain X-ray Changes of RA

Soft tissue changes
Osteoporosis
*
Joint space narrowing
Periostitis
Bone erosions
Secondary osteoarthritis
"

m. O Different Appearances of Bony Tumors:

Onion Skin appearance: Ewings sarcoma JK BOPEE 2011

*
Honey comb appearance: Adamantinoma

Breech of Cortex: Osteoclastoma, Aneurysmal bone cyst.

Fallen fragment sign: Aneurysmal bone cyst. KOL 2009
Soap bubble appearance: Osteoclastoma

Codmans triangle and Sun ray appearance: Osteosarcoma JK BOPEE 2011

Chicken wire pattern: Chondroblastoma
Linear Striations: Vertebral Hemangioma
.
Physalipharous cells: Chordoma
Cotton wool/Ground Glass Appearance: Fibrous Dysplasia COMED 06

496
 PLATINUM NOTES 2012-13

Radiographic Features of Hyperparathyroidism

Brown tumors

Subperiosteal erosion

Loss of lamina dura of teeth

5
Rotting fence post appearance of femur

Pepper pot

Salt pepper appearance

Radiographic Features of Scurvy

2
Metaphyseal lucency (Trummer field zone)*"*"*-
o
r
O
G)
Metaphyseal fracture (Pelkan spur)*"*" -<
Radiodense metaphyseal end (Frankels white line)*"*"*"

Small epiphysis with sclerotic radiodense rim (Wimberger sign)*-*-

Bowing of long bones*" AIIMS 2009

Periosteal elevation*" m
Radiographic Features of Hyperparathyroidism DNB 2011
S Osteopenia;
S Spine: vertebral compression fractures;
S Skull: so-called salt-and-pepper skull, tiny punched out lesions may be present in the skull, producing so ggs
called salt and pepper appearance
S Phalanges: subperiosteal resorption of digital tufts and phalanges (which is usually more marked on
radial than on the ulnar side of the hand);
Brown Tumors: occurs in severe cases; referred to as "Giant Cell Tumor of Diaphysis". microscopical
exam revealed that it was composed of numerous osteoclasts with stromal hemorrhage
S Soft Tissues Calcification:
Bone: mobilizes bone and phosphate; activating and increasing number of osteoclasts, which destroys
hydroxyapatite, thus releasing calcium and phosphate;

O Radiographic Features of Osteomalacia

Loosers zone or pseudofractures
'm
Cod fish vertebrae
Rugger jersy spine

Protrusion acetabuli
Triradiate pelvis

497
 mgmm
!
PLATINUM NOTES 2012-13 PSHPIKIS; __— .
-
.
• -

3SM

O Radiographic Features of Childhood Leukemia

:
Metaphyseal translucencies

5 Metaphyseal cortical erosions

Osteolytic lesions
Periosteal reactions
Metaphyseal osteosclerosis

=> Radiographic Changes in Osteomyelitis:*-

>-
0 Soft tissue swelling {earliest) KOL 2008
O
-I Haziness
9
Q Loss of density of effected bones
2 Subperiosteal reaction
Bone death and appearance of (sequestrum)
Periosteal new bone formation (involcrum)

Squared patella Hemophilic arthritis

Squared vetebrae Ankylosing spondylitis
Pencil in cup deformity Psoriatic arthritis
Opera glass hand
Ivory phalynx
Punched out skull lesions Eosinophilic granuloma/multiple myeloma

Champagne glass pelvis Achondroplasia

Trident hand
Scottish dog appearance Spondylolesthiesis

O Important Points about Metastasis to Bone:

» Common malignancies with bone are metastasis from Breast, Bronchus, Prostate, Kidney and Thyroid
» Axial skeleton more commonly affected
» Usually Multiple
Lytic lesions :
S Ca bronchus,
Cervix,
v' Endometrium,
Rectum,
v'Adrenal tumors,
S Wilms Tumor

498
 inni SI
PLATINUM NOTES 2012-13
J22 ; •
'

» Lytic and Expansile:

Renal Cell Ca
Thyroid
S Melanoma
5
•Sclerotic: Carcinoid, Prostate, Stomach
•Bone metastasis in children:
S Neuroblastoma,
Retinoblastoma,
S Wilms tumor

•Bone scan increased activity at the site of metastatic deposits 59

m Uptake of radiotracer is quantitatively measured by SUV (standard uptake value) o
r
m Tc99m polyphosphate: radiopharmaceuticals used
O
O
-<
o High Yield for AIPGMEE, AIIMS, PGI 2012/2013
Important Views for

Strykers view: Shoulder*- *-

Sky line view: Patella*-*-

Schullers view : Mastoid*- mm

Waters view/Occipito mental view: JK BOPEE 2011 Maxillary, Sphenoid, Ethmoid sinuses*-
\
Caldwell view/ Occipito frontal view: Frontal, Ethmoid sinus*-

Townes View: Cranial fossa*- [:

Odontoid view C1 C2 vertebrae. AIIMS 2009
r5
:
Calcification of menisci is seen in pseudogout
Calcification of Intervertebral disc is seen in alkaptonuria.
Calcification of interosseous membrane is seen in skeletal flourosis

Remember:
Ankle Brachial Pressure Index suggestive of ischemia: 0.9 -:v;*
Subclavian steal syndrome is reversal of blood flow in ipsilateral vertebral artery
:
Amount of air needed to create pneumomediastinum in laproscopy: 800 ml
m
Radiological Signs of Fetal Death:#*#
m Roberts sign: Appearance of gas shadows in Heart/Great vessels*-*-
» Spadlings Sign: Overlapping of cranial bones due to liquefaction of brain matter*- *-
» Balls sign: Hyperflexion of spine*-
» Halos sign: Elevation of Pericranial fat*-

499
 PLATINUM NOTES 2012-13 '
mm
V
•ÿ

gff; ~

Important Points in Brain Imaging

» Bi convex hyperdense lesion brain is suggestive of EDH.*#
» EDH is due to rupture of Middle Meningeal artery # most often the anterior division.
5 » Pterion # is an important land mark.
m Burr hole surgery * is done in relation to Pterion to evacuate haematoma.
» Lucid interval
* is seen in EDH
» Concavo convex hyperdense lesion# is suggestive of SDH.
>-
O
O
m Rupture of. bridging cortical veins# is the cause.

Q » Lucid interval is not seen*

O
2 •SAH is due to rupture of aneurysm (Berry Aneurysm)* mostly.
Non contrast CT is the investigation of choice * Calcutta 2k
» Blood in ventricles indicates SAH.*

O Location of CNS LESIONS

Cerebello-Pontine Angle (CPA)
.
•Vestibular Schwannoma
» Meningioma

Epidermoid
»ÿ Glomus Tumor

Hemispheric Cerebellar Mass/Cyst with Nodule

m?' » Pilocytic Astrocytoma (5-15 yrs)

m&-
:;n » Hemangioblastoma (35-45 yrs)
» Metastasis, Infarction, Abscess

Sella and Parasellar/Suprasellar

» Pituitary Adenoma (adults)

. » Craniopharyngioma
W'# » Hypothalamic Glioma (children)
» Chordoma, Meningioma, Metastasis

» Langerhans Histiocytosis, Germinioma, Lymphoma, Sarcoid

:
•Aneurysms

500
 .

ifi KN PLATINUM NOTES 2012-13

Pineal Region (Quadrigeminal Cistern)

m Germ Cell Tumor
m Pineal Parenchyma (mature Pineocytoma, immature Pineoblastoma)
m Pineal Cyst 5
m Extension of Glioma (Astrocytoma) from corpus callosum, tectum, or thalamus
m Meningioma
m Lipoma
•Vein of Galen Malformation
Epidural Space 2
g
S Epidural Hematoma o
r
S Epidural Empyema o
S Dura/ Epidural Mets (Prostate, Breast, Lymphoma)
o
-<
S Granulomatous Disease (e.g. Sarcoid, Tuberculosis, Fungal)

Subdural Space
Subdural Hematoma
Subdural Empyema
r
S Dural/Subdural Mets (Prostate, Breast, Lymphoma)
S Granulomatous Disease (e.g. Sarcoid, TB, Fungal)
\
Intracranial Calcification is Seen in Kerala 1990
v' Pineal calcification
S Dural calcification ,

S Cystercosis

“Basal ganglia calcification” is seen in Hypoparathyroidism, FAHRS Syndrome. Al 2007 !

“Suprasellar calcification” is seen in craniopharyngioma, meningioma. TN 1989
“Rail road calcification” is seen in Sturge Weber Syndrome. HPU 2005
“Periventricular calcification” is most likely due to CMV infections. PGI 1997
“Bracket calcification” in skull is seen in Corpus Callosum Lipoma. JIPMER 2002
“Tram track calcification” Sturge Weber Syndrome.

S Neural tube defects/ Arnold chiari Malformation i

Lemon sign Infolding of frontal bones

Banana sign : cerebellar deformity s Neural tube defects/ Arnold chiari Malformation
i
Moth eaten appearance of skull Syphilis i

Rice grain calcification of Brain Not Skull v' Neurocystercosis

Hair on end appearance of skull S Hemolytic anemias/Thalessmias .

k
501

r
 I

PLATINUM NOTES 2012-13

; =>
——
Signs of Increased Intracranial Tension in a Child in a Skull X-ray:
Separation of the sutures DNB 2007

—
Tense anterior fontanelle
5 Silver beaten appearance of the bones

Commonly asked Investigations:

» Cerebral blood flow in an asphyxiated child is best measured by: NIRS AIIMS 2008

•Gold standard investigation for recurrent gastrointestinal stromal tumor is: PET CT AIIMS 2008

6q m A 40-year-old female patient on long term steroid therapy presents with recent onset of severe pain in the
right hip. Imaging modality of choice for the problem is: MRI AIIMS 2005
9
o m Investigation of choice for detection and characterization of interstitial lung disease is: High resolution CT scan

2 “ÿ
Techniques best for differentiating recurrence of brain tumour from radiation therapy induced necrosis PET scan
m The gold standard for the diagnosis of Osteoporosis is Dual energy X-ray absorptiometry
» Imaging modality most sensitive to detect early renal tuberculosis
Intravenous urography AIIMS 2002

•Imaging modality most sensitive for evaluation of extra-adrenal pheochromocytoma MRI AIIMS 2002
m A 40 years old man presents with a recurrent hemoptysis and purulent cough. X-ray was found to be normal.
The next investigation done to aid in diagnosis is: Bronchoscopy

m A patient presents with a solitary pulmonary nodule (SPN) on x-ray. The best investigation to come to a
diagnosis would be: CT Scan

Neuroendocrinal tumors (NET) can be best detected by: Radionuclide scan

» Para meningeal Rhabdomyosarcoma is best diagnosed by: MRI

A boy presented in the OPD with minimal pleural effusion on the right side. The best method to detect this
m. »

would be: Right lateral decubitus chest X-ray AIIMS 2001

:
» Most sensitive investigation for DCIS Ductal carcinoma in situ of breast is MRI. DNB 2007

Investigations of Choice

1 . Investigation of choice to detect bronchiectasis: HRCT*-*- UPSC 2000

2. Investigation of choice to detect minimal intraperitoneal air: CT Scan*-*-
3. Investigation of choice to detect minimal Ascites: USG*-*-
4. Investigation of choice to detect Acute Pancreatitis: CT Scan with contrast*’*'
5. Investigation of choice to detect Acute cholecystitis: HIDA Scan*'*’
6. Investigation of choice to detect splenic rupture: CT Scan*-
7. Investigation of choice to detect bladder rupture: Cystogram

502
 mmm. V* sT** Y r •>' • •;

:•
PLATINUM NOTES 2012-13

Signs Asked in Various PG Exams Lately

—— Pelkan spur is seen in: Scurvy

Bamboo-spine is seen in: Ankylosing-spondylitis
MH 2000
Karnataka 2005 5
—— Frostberg’s reverse 3 sign’ is seen in: Carcinoma head pancreas MH 2000
MH 2002

——
Dural tail sign: features of meningioma
‘Onion peel’ appearance is seen with: Ewing’s sarcoma MH 2007

Adder head’ appearance on voiding cystourethrogrom in bladder is feature of: Ureterocele MH 2007

—— Carman’s meniscus sign is diagnostic of: Carcinoma of stomach

String sign of Kantor is seen in: Crohn’s disease
MH 2007
AP 2008
59
O

—— Claw sign is seen in:lntussusception

Electric bulb sign on X-ray is seen in:Posterior dislocation of shoulder joint
AP 2008
AP 2006
r-
o
O

—— Fox sign is seen: Acute pancreatitis AP 2006

Jharkhand 2006

——-
Cupola sign: Radiological finding in supine posture for pneumoperitoneum

Trifoliate appearance is in: Peptic ulcer Jharkhand 2006

Spalding sign associated with: Dead fetus Jharkhand 2004

—— Popcorn calcification is seen in: Pulmonary hemartoma

Molten wax sign: Melhorrheostosis
DPG 2008
JK BOPEE 2009
;

3 Radiotherapy: High Yield for AIPGMEE, AIIMS, PGI 2012/2013 i

Radioactivity was discovered by Henry Becquerel*-*- \

Gamma camera in Nuclear medicine is used for: Organ imaging*-
Radiotherapy is based on principle of: Ionizing molecules*-
“Karnosfky scale” is used to evaluate patient before radiotherapy.*ÿ
Radioactive gold is used in Malignant ascites*-
!
“Mantle irradiation” is used to treat Hodgkins disease*- PGI 1998
“Hyper fractionation” radiotherapy is used to treat Lung Cancer. *• KERALA 2001
“Intraoperative radiotherapy” is used to treat Pancreatic cancer. *ÿ
KERALA 2001
;
Stereotactic radiosurgery is a form of radiotherapy AIIMS 2003
“Intensity modulated radiotherapy” is used to treat Ca prostate*-
1
Emergency radiotherapy is given in: PGI 2005
v' SVC syndrome
s Pericardial tamponade
T'CP 1
* Spinal cord compression.

503
 PLATINUM NOTES 2012-13
wmmm -

p*.' 1. Brachy therapy is type of radiation therapy which uses sources placed within or near tumor for therapy**
2. Many favor primary radiation treatment of cancer of the cervix, especially those staged beyond IIA.
The purpose of therapy is to deliver to the lesion and to areas of possible pelvic spread sufficient
5 radiation to destroy the cancer and still not cause irreparable damage to surrounding tissues. Most
therapists employ a combination of external supervoltage therapy, such as from cobalt-60, linear
accelerators, and the betatron megavoltage units, as well as brachytherapy and intravaginal,
contravaginal, and intracervical irradiation with radium or cesium. MAH 2012
3. Teletherapy is type of radiation therapy which uses external beam irradiation

>- 4. TAT is Targeted Alpha Therapy used for control of dispersed cancers.
0
O 5. Placental localization is done with 1 131*-«-
O 123
Al 2007
O 6. But RAIL) is done using mostly I

2 7. Gallium is concentrated in abscess cavities.**

“Photodynamic Therapy” with Hematoporphyrins and light is used in treatment of:

* Ovary ca
v' Skin ca
s Colon ca MH 2010
BBpI
A

Half life of important isotopes:

1 131: 8 days**** JIPMER 1985

\
w, 1
: Rn 222: 3-6 days PGI 1988

mi Co 60: 5. 2 years Delhi 1986

P 32: 14 days**
Gallium: 3 days**

Thallium: 3 days*-

O Radiosensitivities and Radioresistancies:

.
: High Yield for AIPGMEE, AIIMS, PGI 2012/2013
Most radiosensitive phase of cell cycle: M phase****

'
Most radiosensitive structure in cell: DNA** PGI 2002
Most radiosensitive cell: Lymphocyte** (100 RADS) AIMS 1993
Radiation causes cataract of type: Posterior subcapsular**

Mx permissible dose of Radiation should not exceed 5 rad/year. •* Al 1992

Lead aprons of size 0.5 mm are used for protection.**

Radioresistant structure is Cartilage AIIMS 1997

504
 ___ _ ..
SSsie Iw.'folk SkliJSgi
- \ PLATINUM NOTES 2012-13

Most radiosensitive lung cancer s Small cell ca AIIMS 1993

Most radiosensitive brain tumor s Medulloblastoma AIIMS 1997

Most radiosensitive ovarian tumor
Most radiosensitive testicular cancer
S

S
Dysgerminoma
Seminoma AIIMS 1993
5
Most radiosensitive bone tumor Ewings tumor

CT Scan Appreances Commonly Asked:

m Central stellate scar on CT scans in kidney indicate: Renal oncocytoma COMED 2008
m Cresentric hyperdense lesion on CT scan of skull indicates: SDH. MH 2006 g
•Lentigenous appearance on CT scan of brain indicates: Medulloblastoma. TN 2006
O
•CT scan of head with tram track appearance indicates: Sturge Weber Syndrome. AIIMS 2001
O
O
Dyes/ Contrast agents used frequently
Bronchography: Dianosil*
OCG: lopanoic acid#
Intra venous cholangiography: Biligrafin*
Lymphangiography: Lipiodal*
IVP: Conray 480#
MRI: Gadolinium* (

Myelography (Dye used) Myodil*

D Myelogram (Contrast used) lohexol*
!
3 Radiation-Important Points: High Yield for AIPGMEE, AIIMS, PGI 2012/2013
Chromosome breaks can occur when cells are irradiated. i
Chromosome abnormalities typically occur in cells irradiated in the G1 phase of the cell cycle, before the
doubling of genetic material. If cells are irradiated in the G2 phase, chromatid aberrations may result.
Because ionizing radiation damages DNA, rapidly dividing cells are more vulnerable to injury than are quiescent
cells. Except at extremely high doses that impair DNA transcription, DNA damage is compatible with survival in !
nondividing cells; however, during mitosis cells that have incurred irreparable DNA damage die, because
chromosome abnormalities prevent normal division.
m Therefore, tissues with a high rate of cell turnover, such as gonads, bone marrow, lymphoid tissue, and
the mucosa of the Gl tract, are extremely vulnerable to radiation, and the injury is manifested early after
}
exposure.
i
» Tissues with nondividing cells, such as brain and myocardium, do not suffer cell death, except at doses
that are so high that transcription of vital molecules is affected.
I
The dose-response curve for all mammalian cells appears to have a linear-quadratic relationship.
Four important processes that occur after radiation exposure can be summarized as the "four R's” of
:
radiobiology.
m
505
 PLATINUM NOTES 2012-13 tu vf* Zr & V-r '-f
LW
— ... - «« i~C. '«ÿ»

Repair is temperature dependent and is thought to represent the enzymatic mechanisms for healing
intracellular injury.
The second R is reoxygenation, a process whereby oxygen (and other nutrients) are actually better
5 distributed to viable cells following radiation injury and cell killing.
The third R is repopulation, the ability of the cell population to continue to divide and to replace dying and
dead cells.
The fourth R is redistribution, which reflects the variability of a cell’s radiosensitivity over the cell cycle.
Radiation therapy is effective in cancer treatment when it exerts greater cytotoxic effects on tumor cells
>-
CD
than on normal tissues.
O
_i Stochastic effect of radiation is the probability that effect will increase as the dose of radiation
2
Q
increases. Al 2010
§ Cells surviving radiant energy damage show a wide range of structural changes in chromosomes, including
deletions, breaks, translocations, and fragmentation.
The mitotic spindle often becomes disorderly, and polyploidy and aneuploidy may be encountered.
Nuclear swelling and condensation and clumping of chromatin may appear;
S Sometimes the nuclear membrane breaks.
S Apoptosis may occur.
m All forms of abnormal nuclear morphology may be produced. Giant cells with pleomorphic nuclei or
: more than one nucleus may appear and persist for years after exposure. At extremely high dose levels
:
of radiant energy, nuclear pyknosis or lysis appears quickly as a marker of cell death.

Most common source of radiation originating in body: radioactive potassium.

Chromosomal abnormalities due to radiation occur in: G1 phase
te - ’ i
:
Chromatid abnormalities due to radiation occur in: G2 phase
m \
Phase of cell cycle most sensitive to radiation: G2 M AIMS 2002
Phase of cell cycle most resistant to radiation: S phase

O Effect of Radiation on Different Organs:

High Yield for AIPGMEE, AIIMS, PGI 2012/2013
! Temporary sterility in Testes at low doses.
• Depression of hematopoiesis in Bone marrow
Reversible skin effects (e.g., erythema) at low doses.

l Permanent sterility Ovaries at moderate doses.

Temporary hair loss: Skin at low doses.
Permanent sterility Testis at high doses.
S Cataract in Lens of eye

506
 PLATINUM NOTES 2012-13

Remember:
Background Radiation
Radiation is present, usually in low levels, almost everywhere in the environment;
This widespread radiation is known as Background radiation and is usually not detrimental to life. 5
Radiation in the environment is, for the most part, completely natural and comes from natural
environmental sources rather than from the actions of humans.
There are radioactive substances in the Earth’s crust, some of which are even mixed in the soil in small
quantities. Radioactive gases also exist in the air in small quantities; these gases tend to come from the
Earth as well.
Trace amounts of radioactive substances can be found in the human body. 52
O “Stochastic Effect” of Radiation o
o
»ÿ
Stochastic effects are those that occur by chance and consist primarily of cancer and genetic effects. o
-<
•Stochastic effects often show up years after exposure. AIIMS 2008/2009
»• Stochastic effect of radiation is: “As the dose increases, the probability that effect will occur also increases.”
» As the dose to an individual increases, the probability that cancer or a genetic effect will occur also
increases.
» However it can never be determined for certain that an occurrence of cancer or genetic damage was due to
B
a specific exposure.

Non Stochastic (Acute) Effects

» Unlike stochastic effects, nonstochastic effects are characterized by a threshold dose below which they do
not occur.
•Nonstochastic effects have a clear relationship between the exposure and the effect. In addition, the
magnitude of the effect is directly proportional to the size of the dose. •:
m Nonstochastic effects typically result when very large dosages of radiation are received in a short amount
of time. I
m Examples include erythema (skin reddening), skin and tissue burns, cataract formation, sterility, radiation
sickness and death
i
“Ionizing radiation” includes that part of the electromagnetic wave spectrum comprising X-rays and gamma rays
and certain types of particulate radiation (alpha and beta particles, neutrons, protons, and deuterons). |
Have in common the ability to produce ionization within tissues exposed to them.
;
The basic unit of ionizing irradiation is the gray (Gy), which has superseded the rad (1Gy = 100 rads).
•By interaction with molecular oxygen, radiation induces the formation of superoxide, hydrogen
peroxide, or hydroxyl radicals that damage or break cellular DNA, the critical target for radiation-
induced cell death. Both single-and double-strand breaks of the DNA helix can be induced, with the
M
latter constituting lethal damage. Single-strand breaks, if not repaired by the cell, can also result in cell
.
death. High linear energy transfer (LET) radiation can induce direct damage to the molecular structure
of DNA. MAH 2010
m -

507
 PLATINUM NOTES 2012-13
1
:
'ÿ

superficial therapy in skin neoplasms such as mycosis fungoides.

’
__
,

AIPGME 2012
Low-energy (kilovoltage) X-rays expend most of their effects on the overlying tissues above a deep-
iizc&smI
Electron beam irradiation deposits most of its energy in the skin and soft tissues and can be useful for

5 seated tumor and therefore cause considerable normal tissue damage. By contrast, higher energy x-rays
(megavoltage) or g-irradiation from a cobalt-60 source spare the skin, deposit their energy at greater
depth, and provide a better approach to treating deep-seated neoplasms.
Most ionizing radiation is Alpha rays
“Natural radiation” is derived from radioactive elements in the environment and cosmic rays. In addition,
radioactive substances have been used in nuclear medicine, nuclear power plants, nuclear weapons, and nuclear
>-
o
propulsion.
o _
E|ectromagnetjc spectrum :a bunch of types of radiation
9
o m Radiation is energy that travels and spreads out as it goes
2 m The difference between X-rays and visible light rays is the energy level of the individual photons.

3 Radiation Syndromes: High Yield for AIPGMEE, AIIMS, PGI 2012/2013

n Early symptoms of acute total-body irradiation, known as the Prodromal radiation syndrome, last for a
limited time. Clinical manifestations depend on the total-body dose.
..... Skin is the most common effected area.
Most common manifestation in skin is erythema Al 1998
m Papillary ca thyroid develops in infancy due to radiation exposure Al 2003
At doses >100 Gy, death usually occurs 24 to 48 h later from neurologic and cardiovascular failure. This is
m known as the Cerebrovascular syndrome. Because cerebrovascular damage causes death very quickly, the
failures of other systems do not have time to develop.
At doses between 5 and 12 Gy, death may occur in a matter of days as a result of the Gastrointestinal
syndrome. The symptoms during this period may include nausea, vomiting, and prolonged diarrhea for

several days leading to dehydration, sepsis, and death.

A total-body dose >10 Gy is uniformly fatal unless supportive therapy (fluid, electrolytes, blood products,
i; and antibiotics) is given. The process of intestinal denudation depends on the dose and may take between
3 and 120 days. Death from intestinal denudation usually occurs before the full effects of radiation on the
i blood-forming elements are seen.
i At total-body doses between 2 and 8 Gy, death may occur 2 to 4 weeks after exposure from bone
marrow failure, The Hematopoietic Syndrome.

m m The full effect of radiation is not apparent until the mature hematopoietic cells are depleted.
» Clinical symptoms during this period may include chills, fatigue, and petechial hemorrhage. Peripheral blood

lymphopenia develops during the first 12 to 48 h after any significant exposure.

;
m Beyond 5 to 6 Gy, the rate and magnitude of the drop are not well correlated to radiation exposure.
m Some stem cells may survive acute exposure to >10 Gy.
Death is from infection or bleeding and usually occurs before anemia can develop (red blood cell half-life is
'

i »

100 to 120 days).

508
 1I$1 ’
rv
PLATINUM NOTES 2012-13
'
'ÿ-ÿa'.
’ .
V

3 Radiation Carcinogenesis: High Yield for AIPGMEE, AIIMS, PGI 2012/2013

Ionizing radiation causes

s Chromosome breakage,
5
Translocations, and,
Less frequently, point mutations,

Leading to genetic damage and carcinogenesis.

S UV rays induce the formation of pyrimidine dimers within DNA, leading to mutations. Therefore UV rays
can give rise to squamous cell carcinomas and melanomas of the skin. 59
3 Inflammatory Oncotaxis: o
r~
O
Is a term describing the attraction of cancer cells to an area of tissue trauma resulting presumably because O
-<
trauma (surgery and radiation) causes inflammation and capillary disruption, thus predisposing cancer cells
to settle in these areas. For example, cutaneous metastases from colon, kidney, and cervix have been known
to localize in abdominal wall surgical incisions.

3 Amifostine
Amifostine is a thiophosphate (Cytoprotective agent).*-*-*- BHR2005 AIPGME 2012 rr--f
It is used for reduction of renal toxicity of Cisplatin.*- i.
i

It also reduces xerostomia in patients undergoing therapy for head and neck cancer.*-
i ..
It is administered iv after reconstitution withcfiormal saline.*- :

Hypersensitivity to mannitol is a contraindication to its use.*- ,

Cisplatin causes mitochondrial injury and apoptosis plus necrosis of renal tubular cells. ••*• ; -
*
Amifostine is given to reduce the renal toxicity.

Radiotherapy is most useful in:*-*-*-*- I

:

Medulloblastoma JK 2008 H '

Small cell carcinoma lung

ALL
r
l
l-
m
Germinoma
!
!;
Leptomeningeal Rhabdomyosarcoma
:
Non Hodgkins Lymphoma

509
 '
;
j

'

PLATINUM NOTES 2012-13 :L..

• . ’
Utiil

O Stereotactic Radio Surgery: High Yield for AIPGMEE, AIIMS, PGI 2012/2013
(AIIMS 2009)
The use of highly advanced computers to locate and create a three-dimensional image of a tumor is called
5 stereotaxy. When used during surgery, this technique is called stereotactic surgery.*ÿ*•

Stereotactic surgery requires only a small incision and a hole less than 1/2 inch in diameter to be made in the
skull. This is usually done under local anesthesia. Because stereotactic brain surgery is "minimally invasive" many
stereotactic surgeries can be performed on an outpatient basis.

Administered to effectively deliver high dose irradiation which is precisely targeted.

>-
o It utilizes three dimensional mapping technique.
o
-I Stereotactic radiosurgery is used as an alternative to surgery and especially used for tumors and blood vessel
9 abnormalities of structures close to brain.
o
2 Stereotactic surgey is done by three means:
•Gamma knife using gamma rays.*- (Cuts tumors in different location) PGI 2006
» Linear accelerator using high energy X-rays.*-
» Proton beam.*"

O Radio Sensitizers: High Yield for AIPGMEE, AIIMS, PGI 2012/2013

- :
» Oxygen *-*-

Cisplatin*-
i
» 5 FU*- AIIMS 1997

' Hydroxy urea AIIMS 1997

*; » Paclitaxel*- <
•:
v
• » Metronidazole*-
s »ÿ Misonidazole*-
: » Gemcitabine*-

•i
•Cytochlor*-
O Radio Protectives
» Amifostine*-*-*- Al 2001
» Etramustine*-
Pentoxyphylline*-

Wm » Zinc oxide*-

•IL1*•
GM CSF*"

510
 *
.
.
WM. v
PLATINUM NOTES 2012-13

O Important Questions Repeatedly and Recently Asked

SI unit of dose of radiation absorption: Gray MHPGMCET 2006, MH 2010
Already given in explanation

Hallmark of breast malignancy on mammography is “Clusters of microcalcification” MH 2010 5

Already given in explanation In Platinum notes Radiology
Bilateral Pleural plaques and Pulmonary fibrosis involving bases is hallmark of: Asbestosis MH 2010
X-ray chest showing globular cardiomegaly with oligemic lung fields in a child is suggestive of Ebstein’s
anomaly MH 2010
Already given in explanation In Platinum notes Radiology

On DSA, typical “String of Beads” Appearance of arteries is seen in: Fibromuscular dysplasia
2
AIIMS May 2004, MH 2010 o
r~
Already given in explanation In Platinum notes Radiology O
Q
“Double bubble" sign with air shadows absent in distal bowel coils on X-ray abdomen is characteristic of: -<
Duodenal atresia MH 2010/JK BOPEE 2011
Already given in explanation In Platinum notes Radiology
“Looser’s zones” can be characteristically seen in: Osteomalacia MH 2010
Already given in explanation In Platinum notes Radiology

——
X-ray features of Hypoparathyroidism are MHPGMCET 2003, MH 2010
Osteosclerosis

—
Calvarial thickening
Subcutaneous calcification
Already given in explanation In Platinum notes
I
\
“Expansile lytic lesion” with fluid-fluid levels within it in the metaphysis of fibula seen on CT scan and MRI
\
in an early adolescent female is typical of Aneurysmal bone cyst MH 2010
given in explanation In Platinum notes
!
“Brachytherapy” means: Intra or juxta lesional implant MHPGMCET 2003, MH 2010
Already given in explanation In Platinum notes Radiology
i
Important Questions Asked and Liable to be Repeated
C1 and C2 vertebrae are best visualized by “odontoid” view. AIIMS 2009
;

Radiological findings of pappilary necrosis on excretory urogram are:

}
Ring shadows,
s Egg in cup appearance, I
S Tracks and horns from calyces. AIIMS 2009 l
I
'
Gold standard used for diagnosis of Recurrent GIST (Gastrointestinal stromal tumors) is PET CT.
I
AIIMS 2009 i
On USG of abdomen, GB wall showing diffuse thickening with hyper echoic nodules at neck and comet tail
artefacts indicates: Adenomyomatosis. AIIMS 2008 :K
511
 mmm
PLATINUM NOTES 2012-13
I Si >;
: JX xi
I

Hampton hump is a feature of Pulmonary Embolism. AIIMS 2007

Floating water lilly sign is a feature of lung hydatid AIIMS 2007

Egg shell calcification is a feature of Silicosis, Sarcoidosis. PGI 2006

5 Bird of Prey Sign in a barium Radiograph is a feature of sigmoid volvolus COMED 2008

Tech 99 scan shows hot spot in type of salivary gland tumor: Adenolymphoma MAHE 2007

Coiunads Segment IV of liver corresponds to Quadrate Lobe AIIMS 2007

Fox sign is seen in Acute Pancreatitis. AIPG 2006

>
O
Central stellate scar on CT scan is seen in which renal condition: Renal oncocytomas COMED 2008
o Persistent fetal lobulation of kidney is a normal variant. AIIMS 2007
2
Q Adder Head or Cobra Head Appearance in IVP is seen in Ureterocele Manipal 2006
2
Radiation hazard is not a feature of MRI and DOPPLER USG. PGMEE K 06
Back ground radiation is present everywhere in nature Al 2010

ONE Gray equals 100 RADS. PGI 2007

Most common neurogenic tumor in NF 1 is Optic Glioma. AIIMS 2007

Spectrum of solar radiation is 200-400 nm. MANIPAL 2006
n Principle of Linear Accelerator is used in X RAYS. PGI 2006

•V
Phosphorus 32 emits Beta particles. PGMEE 07

m
m
•<:

I
•*

u
m . -

512