Radiology Review Booklet by Dr. Aryan (Medical Booklet Series by Dr. Aryan Part 16)

Radiology Review
A Free Booklet Series by Dr. Aryan

Preface:
• This is the study material designed by Dr. Aryan with creation and compilation of the best
of the best and the most finest slides on the subject. I would like to offer a billion heartily
thanks for everyone who contributed directly or indirectly to the creation of the material
through creation and dissemination of the scientific information.
• Covering everything in one study material is next to impossible. Hence, refer to gold
standard textbooks for building solid concepts or in case of any doubt. Textbooks are
acknowledged at the end of the presentation. If any source has been missed to
acknowledge, it doesn’t lessen their impact and contribution in any way.
• Don’t keep searching for pattern between the consecutive slides. You won’t find many.
Rather to boost your recall and review, I have constructed many slides and are deliberately
placed with no much relation between the preceding and the succeeding ones.
• The main rule of a review material is that it must make you recall or learn maximum
amount of information in minimum amount of time and space.
• Motivational quotes and articles are included within the slides. Always remember that
every good idea, nice piece of information and everything else is literally and absolutely
worthless unless you execute.
• If you know everything in the slides in much detail, you probably wouldn’t need this
material.
Best of luck WORK & SUCCESS! Dr. Aryan
(Anish Dhakal)

Order of Ossification:
Dr. Aryan (Anish Dhakal)

Basal ganglia and thalamus

Internal capsule

Normal calcification
►Pineal gland
►Choroid plexus
►Basal ganglia, dentate nucleus pituitary lens
►Habenula (above thalamus: part of epithalamus along with pineal
gland)
►Dura
►Ligament (Petroclinoid ligament)
►Pacchionian bodies (arachnoid granulations: projections of arachnoid
membrane in the dural sinuses)

Arbitary Linear Scale: Hounsefield Units

Preparation for IVU:
•Fasting overnight or at-least 8 hours
•Bowel preparation:- Laxatives
•H/O of allergy to contrast media
•H/O systemic disease like DM, Renal disease
•Investigations: serum urea (5-20mg/dl) and creatinine (0.6-1.4mg/dl)
•Written consent
•Basic life support tools should be at hand

Plain X-Ray (Control film)
To check for:-
• adequate bowel preparation
• B/L psoas shadow
• adequate X-ray exposure dose
• visible osseous structures
• any radio-opacity
• Abnormal radio opaque objects

Procedure IVU…
• Series of plain films
1. Control
2. Nephrogram (Immediate) – shape, size, outline, position, lie, axis,
prompt contrast excretion
3. Pyelogram (5 min) – shape, size, outline, cupping pattern, filling
defect, abnormal dilatation
4. Ureterogram (10 min) – course, caliber, outline, strictures, filling
defect, abnormal dilatation
5. Cystogram (Full bladder) –outline, filling defect, out pouching,
distensibility, wall defect
6. Post-micturition – bladder outlet obstruction, urethral meatus
stenosis

Non-ionic contrast for IVU Ionic contrast for IVU
Iohexol Metrozoic acid
Ioversol Diatrizoic acid
Iopamidol Iothalamate

Side Effects of Contrast
Mild Moderate Severe Delayed
Itching
Metallic taste
Nausea
Mild rash
Vomiting
Urticaria
Fever
Abdominal pain
Anaphylaxis:
•Bronchospasm
•Profound hypotension
•Severe urticaria
Occurs in 30 -60 mins
after contrast injection
•Flu-like symptoms:
•Fever
•Chills
•Nausea/vomiting
•Abdominal pain
•Fatigue
•Congestion

Consolidation in right middle & upper zone
with Air Bronchogram

Cyst Vs. Cavity
• Cyst - lucency with a thin wall (less than 3 mm)
• Cavity - lucency with a thick wall (more than 3 mm)
• Emphysema - lucency without a visible wall

Spinous process clay-shoveller's' fracture

Basic thoracolumbar spine injury causes
(number of Denis column involved)
• 1 column - Anterior compression (or isolated spinous process injuries)
• 2 column - Burst injuries
• 3 column - Flexion-distraction 'Chance-type' injuries

Pneumothorax:
• In supine radiograph, pneumothorax air displaces costophrenic
sulcus inferiorly and increases lucency of that costophrenic sulcus
(Deep sulcus sign)
• Double diaphragm sign: air may outline the anterior portion
of hemi diaphragm causing visualization of anterior costophrenic
sulcus

Frontal radiograph needs at least 200 mL of fluid to be visible. USG is more sensitive: can
detect as little as 15 mL of fluid (usually up to 50 mL is needed).

Hydropneumothorax: horizontal fluid level

Silhouette sign:
• The silhouette sign is the
absence of depiction of an
anatomic soft-tissue border
resulting from the
juxtaposition of structures
of similar radiographic
attenuation.
• The sign actually refers to
the absence of a silhouette.

AP, Lat and
skyline

Ankle injuries
• Fractures of the medial or lateral malleoli.
• The posterior edge of the distal tibia is sometimes referred to as the
'posterior malleolus'.
• Trimalleolar fracture

Maisonneuve fractures
• Fracture of the proximal fibula associated with injury to the medial
side of the ankle and disruption of the distal tibiofibular syndesmosis.
• visible medial malleolus fracture
• invisible injury of the medial ligaments.

Base of 5th metatarsal fracture – Jones fracture

Abnormal shape
►Dolicocephaly – abnormal long in relation to transverse diameter
►Brachycephaly – broad in relation to length
►Bathrocephaly – step like deformity back of skull occipital bone
►Craniosynostosis – abnormal premature fusion of skull suture

Tripod fracture:
►Zygoma separated from frontal bone at zygomaticofrontal suture
►Comminuted # zygomatic arch
►Orbital floor #
►Breach of lateral wall of maxillary antrum
Orbital Blow out fracture:
►Tear drop sign
►Trauma to orbit – increased pressure in orbit – thin bone of orbital floor
burst – herniation of orbital contents in maxillary sinus

►Spondylosis – degenerative changes
►Spondylolysis - # of pars interarticularis
►Spondylolisthesis – forward slippage of vertebral body
►Spondylitis – inflammation of vertebral body

Normal AXR
11th rib
Hepatic flexure
Gas in
stomach
T12
Gas in
caecum
Iliac crest
Femoral head
SI joint
Gas in sigmoid
Transverse colon
Splenic flexure
Psoas margin
Sacrum
Left kidney
Liver
Bladder

Large Vs. Small bowel in Radiology
• Large bowel
• Peripheral (except RUQ occupied by liver)
• Haustral markings don’t extend from wall to wall
• Haustra placed far apart
• 6 cm diameter (except caecum which is 9 cm)
• Small bowel
• Central
• Valvulae conniventes extend across lumen
• Valvulae conniventes spaced closer together even when bowel dilated
• 3 cm diameter

VIEW LOOK FOR
SUPINE ABDOMEN Bowel gas pattern
Calcifications
Masses
PRONE ABDOMEN Gas in rectosigmoid
Gas in ascending and
descending colon
UPRIGHT ABDOMEN Free air, air-fluid levels
UPRIGHT CHEST Free air, lung pathology
secondary to intraabdominal
process
Acute abdominal series
What to look for
Substitutes: Prone Lateral rectum
Upright Left lateral decubitus
Upright chest Supine chest

Normally the tracheobronchial tree not visible beyond 4th order as the bronchus contains
air and the surrounding alveoli contains air (no contrast). Air bronchogram usually seen
in pneumonia, pulmonary edema, hyaline membrane disease, lymphoma, etc.

Colon cut off sign
Explanation:
Inflammatory exudate in acute
pancreatitis extends into the
phrenicocolic ligament via lateral
attachment of the transverse
mesocolon
Infiltration of the phrenicocolic
ligament results in functional
spasm and/or mechanical
narrowing of the splenic flexure at
the level where the colon returns
to the retroperitoneum.
Abrupt cutoff of colonic gas column at the splenic flexure (arrow). The colon is
usually decompressed beyond this point.

Apple core sign
• Radiologic manifestation of a
focal stricture of the bowel
usually at contrast material
enema examination. The
stricture demonstrates
shouldered margins and
resembles the core of an apple
that has been partially eaten.
The most common cause is an
annular carcinoma of the
colon.

Sialography

• Rt paratracheal stripe
• 60%
• Less than 5mm width
• Pathological widening
1.Mediastinal
lymphadenopathy
2.Tracheal malignancy
3.Mediastinal tumors
4.Mediastintis
5.Pleural effusion
• Lt paratracheal stripe-not
visualized

HILA
• 97%-left higher 3%-same level
• Hila should be of equal density, similar size & clearly defined
concave lateral borders
• Structures in the hilum
1.Pulmonary arteries & upper lobe/superior pulmonary veins-
significant contribution to hilar shadow
2.Normal LN - not seen in plain radiography
3.Bronchi- walls seen end on

Heart Failure Radiology:

Cervico-thoracic sign
• If the thoracic lesion is in anatomic contact with soft tissues of
neck its contiguous border will be lost.
• Lesion clearly visible above the clavicles lies posteriorly within the thorax
• If cephalic border of the lesion disappears as it approach the clavicles 
cervico-thoracic lesion
(partly in anterior mediastinum and partly in neck)

Grade 3 carries the highest risk of subsequent vasospasm.

Direct & Indirect signs of collapse
• Direct signs
1. Loss of aeration
2. Displacement of fissures
3. Displacement of hilum
4. Crowded pulmonary vessels and bronchi (in early stage)
• Indirect signs
1. Compensatory hyperinflation of uninvolved lobes or lung
2. Trachea & Mediastinal shift
3. Elevation of diaphragm (@shift of diaphragm)
4. Crowding of ribs

Few signs of Ankylosing spondylitis:

Multiple Myeloma X-Ray Features:
• numerous, well-circumscribed, lytic bone lesions (more common)
• punched out lucencies
• raindrop skull
• endosteal scalloping
• generalised osteopenia (less common)
• often associated with vertebral compression fractures/vertebra plane

Osteomyelitis Features X-Ray:
Regional osteopenia
Periosteal reaction/thickening (periostitis): also includes formation of
Codman triangle
Focal bony lysis or cortical loss
Endosteal scalloping
Loss of bony trabecular architecture
New bone apposition
Eventual peripheral sclerosis
Codman triangle is the triangular area of new subperiosteal bone that is created when a lesion, often a tumor raises
the periosteum away from the bone

Primary TB Post-primary TB
Lobar pneumonia (with associated
adenopathy)
Cavitary lesion
Pleural effusions Fibrotic changes
Hilar or Mediastinal adenopathy without
parenchymal disease (in children)
Nodular opacities
Cavitation is rare Tubercle formation, Caseous necrosis

Occipito Mental view

Acknowledgements:
Best of the best slides, pictures and information on the web. Special
thanks to all those brilliant minds for their act of creation and
compilation of scientific material without which this work would not
be possible
• Textbook of Radiology and Imaging, David Sutton
• Manual of Diagnostic Ultrasound, WHO
• Critical Observations in Radiology for Medical Students
• Atlas of Emergency Radiology, Rita Agarwala

Do successful and rich people work harder than
rest of the population or just got plain lucky?
https://medium.com/@anishdhakal718/do-rich-people-work-harder-than-rest-of-
the-popu-5920a3b3731a

Radiology Review Booklet by Dr. Aryan (Medical Booklet Series by Dr. Aryan Part 16)

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