A 54-year-old man presented with left hip pain and was found to have calcific tendonitis of the gluteus medius tendon near its insertion on the greater trochanter. MRI showed calcification and edema of the tendon. Calcific tendonitis is characterized by calcium hydroxyapatite deposition in tendons and is commonly seen in the rotator cuff or hip tendons. It causes pain exacerbated by activity and is typically self-limiting, treated with rest, ice, anti-inflammatories, or corticosteroid injections. A 55-year-old male presented with headache and was found to have an intradiploic epidermoid cyst in

1. Film Reading Session.
-Bhanupriya Singh.
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2. Case1:MSK: A 54-year-old man presented with pain in the region
of the left hip and greater trochanter for 3 months.
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5. The radiograph shows calcification in the soft tissues adjacent to the greater
trochanter on the plain radiographs. The left hip joint appears normal.
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6. Coronal, proton density, fat-saturated MRI of the left hip shows
calcification with edema (arrow) of the gluteus medius tendon.
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7. Axial, T2W MRI of the left hip shows calcification
(arrow) at the insertion of the gluteus medius tendon.
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8. • Ans: CALCIFIC TENDONITIS.
• Calcific tendonitis is characterized by calcium hydroxyapatite deposition in
various tendons throughout the body.
• It is most commonly seen in the rotator cuff, specifically in the supraspinatus
muscle approximately one to two centimetres from the tendon insertion on the
tuberosity. It can also be seen in various other tendons –
• here, it is seen in the gluteus medius tendon near its insertion on the greater
trochanter of the femur (rotator cuff of the hip).
• It is theorized that tissue hypoxia precipitates deposition of hydroxyapatite
crystals.
• Patients can present with symptoms of pain exacerbated by activities.
• Calcific tendonitis is usually self-limiting. The treatment is initially rest, ice and
anti-inflammatory medications.
• Corticosteroid injections or oral steroids may be used. Needling to palliate the
pain and break up the calcification to hasten healing is also performed.
• Surgery may be performed if there is no relief within 6-12 months.
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9. Case2:Neuro: A 55-year-old male patient presented with a
history of headache
predominantly T2
hyperintense
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10. T1 hypointense lesion is seen
in the right occipital region
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11. Axial diffusion-weighted MRI of the brain shows focal hyperintensity
within the right occipital lesion (arrows), suggestive of restriction
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12. Axial CT scan of the skull shows an intradiploic location (arrows).
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13. • Ans: Epidermoid cysts
• Epidermoid cysts account for 1% of all intracranial tumors. They are usually off-
midline. Forty to 50% arise in the cerebellopontine angle cistern, 10-15% are in
the parasellar and middle fossa space and 10% are in the diploic space.
• Headache and focal seizures due to local pressure are the most common
symptoms.
• They are usually hyperintense on T2W and hypointense on T1W MRI.
Restriction is noted on DWI.
• Intradiploic epidermoid cysts of the calvarial bones are rare lesions.
• Intradiploic epidermoid cysts have been found in all the bones of the
calvarium.
• They are also found in the paranasal sinuses and the maxilla.
• They occur most often in the frontal and parietal areas and at the junctions of
the calvarium and also in the skull base.
• The parietal, occipital, and frontal bones each account for 12 to 15% of the
cases.
• Intradiploic cysts follow MRI features similar to those seen with intracranial
epidermoid cysts.
• CT scan is an excellent imaging modality to confirm the intradiploic location.
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14. Case 3:Abdo: A 47-year-old man presented with a recent episode of
pain in the right upper quadrant and jaundice. He also had a long
standing history of dyspepsia.
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16. Frontal MRCP image shows dilatation of the biliary tree with multiple filling defects in
the intrapancreatic segment and at the ampulla (arrow), compatible with calculi. The
pancreatic duct is seen crossing the CBD (arrowhead)
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17. T1W MRI image shows the pancreatic parenchyma with the pancreatic duct
(dotted arrow) encircling the flattened duodenum (interrupted arrow). The
dilated CBD is seen as a hypointense rounded structure (arrow) more
medially, also encircled by the pancreatic parenchyma.
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18. • Ans: Annular pancreas
• Choledocholithiais or biliary calculi are the commonest causes of biliary
obstruction.
• MRCP has emerged as the non-invasive imaging modality of choice for the
diagnosis of biliary calculi in dilated and non-dilated systems.
• It is important to look at both the projection images and source images to
detect calculi.
• Annular pancreas results due to incomplete rotation of the ventral bud,
resulting in the pancreas encircling the 2 nd part of the duodenum.
• It has a prevalence of one in 2000 persons. It can occur in isolation or
associated with other congenital anomalies (duodenal stenosis or atresia,
Down’s syndrome, tracheo-esophageal fistula and congenital heart defects).
• It can be diagnosed on imaging by either demonstrating the pancreatic
parenchyma or the annular duct encircling the duodenum.
• T1W images with fat saturation are extremely reliable for demonstration of the
normal pancreatic parenchyma.
• Due to suppression of the surrounding peripancreatic fat, the pancreas can be
easily identified as a hyperintense structure.
• Loss of this hyperintensity is used in diagnosing varying pancreatic anomalies
like atrophy, fatty infiltration, neoplasm and pancreatic necrosis.
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19. Case 4:RS: A 22-year-old lady came with cough and fever
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20. Contiguous
axial lung
windows
through the
right lower
lobe.
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21. Contrast enhanced axial CT scan of the chest through the right lower lobe.
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22. • Ans: Right Lower Lobe Bronchus Occlusion
• The radiograph shows consolidation in the right lower
lobe.
• The serial lung window images show a filling defect
within the right lower lobe bronchus after the origin of
the superior segmental bronchus. It is not hyperdense
on the mediastinal windows.
• The differential diagnosis includes foreign body and
tumor, but the lesion was non-enhancing.
• The possibility of foreign body was the most likely and
the patient had a bronchoscopy done. A peanut was
retrieved.
• In any patient with consolidation, it is necessary to trace
the bronchial tree proximally to ensure patency. This is
the best way to make sure that endobronchial disease is
not missed.
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23. Case 5: 48-year-old patient came with cough
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26. • Ans:Foramen of Morgagni hernia
• The radiograph shows an opacity in the anterior cardiophrenic angle.
• Axial plain CT scan of the chest shows herniation of the liver (arrow) through the
foramen of Morgagni
• Coronal and sagittal CT scan images of the chest show herniation of the liver (arrow)
through the foramen of Morgagni
• Differentials include epicardial fat pad, lipoma, pleuropericardial cyst and foramen of
Morgagni hernia.
• The best way to differentiate the etiology is on a CT scan, which will not only tell us
whether the lesion contains fat or fluid, but will also delineate the exact anatomical
status of the lesion
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27. Case 6: 22-year-old lady presented with dyspnea, cough and expectoration.
She had a series of radiographs from Sept 2011 to March 2012.
Chest radiograph of
Sept 25, 2011
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28. Chest radiograph
of Dec 06, 2011
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29. Chest radiograph of
Feb 18, 2012
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30. Chest radiograph
of Mar 26, 2012
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31. Axial high-resolution CT scan of the lungs shows mucoid impaction (red arrow) and
bronchiectasis (blue arrow)
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32. Plain CT scan of the chest shows hyperdense mucoid impaction
(arrow)
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33. • Ans: Allergic Bronchopulmonary Aspergillosis (ABPA)
• The radiographs show waxing and waning opacities, some of them with a
branching appearance. The last radiograph of March 2012 is the most severe.
• The CT scan images show proximal central bronchiectasis and mucoid
impaction
• This combination of findings is highly suggestive (ABPA), in the correct clinical
setting.This patient had asthma and raised IGE levels to Aspergillus
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34. Case7: A 60-year-old man presented with frequency, urgency, dysuria and
generalized fever and malaise for six weeks. His serum PSA was 12 ng/ml.
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35. hypointense T1 signal, which is mildly T2 hyperintense signal.
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36. restricted diffusion within the lesion.
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37. • Ans :Prostate Abscess
• Prostatic abscess is difficult to diagnose because the symptoms at the onset may mimic
several other diseases of the lower urinary tract. A high index of suspicion is required to
diagnose such a rare case of prostatic abscess, as symptoms may mimic lower urinary
tract infection.
• Most of the urinary pathogens are also causative agents of acute and chronic prostatitis
and prostatic abscess. E. coli predominates as a cause of culture positive prostatitis.
• Prostatic abscess is most often seen in diabetics on maintenance dialysis for chronic
renal failure, immunocompromised individuals, those with underlying urethral
instrumentation or those requiring indwelling catheters.
• Transrectal ultrasound [TRUS] is the imaging modality of choice and reveals ill-defined
hypo-echoic areas within an enlarged or distorted gland. TRUS offers high sensitivity for
the diagnosis of large, walled-off abscesses but is often unreliable in the initial stages.
• MRI shows a hypointense signal on T1W images and a hyperintense signal on T2W
images with peripheral contrast enhancement. Diffusion-weighted MRI is important as
diffusion is usually restricted in the setting of a bright signal on T2W images .
• The lesion was mildly hyperintense on T2W images and showed restricted diffusion.
This suggested the diagnosis of abscess rather than tumour.
• The mean ADC values in the abscess were very low (0.61-0.63 x 10 -3 mm 2 /s)
compared not only with normal published values of the peripheral zone (1.57-1.82 x
10 -3 mm 2 /s) but also with cancerous tissue (0.93-1.43 x 10 -3 mm 2 /s).
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38. Case 8: A 60-year-old man presented with a history of
swelling in the right side of the neck.
Axial plain CT scan of the neck
Axial contrast enhanced CT scan
of the neck
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39. USG of the neck Doppler study of the neck
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40. • Ans: Infected second branchial cleft cyst
• Plain CT scan of the neck shows a hypodense fluid-attenuating lesion anteromedial to
the sternocleidomastoid muscle, posterior to the submandibular gland, lateral to and
abutting the carotid vessels on right side.
• CECT of the neck shows peripheral enhancement of the lesion with enhancing septa
within. USG images show a hypoechoic lesion with flow in the septa.
• Second branchial cleft cysts are the most common branchial cleft abnormalities arising
from remnants of the branchial apparatus. Less commonly, a fistula or sinus tract may
develop. Branchial cleft cysts gradually enlarge in size and present as painless fluctuant
neck masses near the angle of the mandible. They are diagnosed based on the
characteristic location as described above.
• The Bailey classification of second branchial cleft cysts includes four types.
• Type 1 is deep to the platysma, anterior to the sternocleidomastoid.
• Type 2 abuts the internal carotid artery and is adherent to internal jugular vein and this
is the most common type.
• Type 3 is an extension between the internal and external carotid arteries.
• Type 4 abuts the pharyngeal wall.
• USG shows an anechoic thin-walled cystic lesion. An infected cyst appears hypoechoic.
A definitive diagnosis on CT scan is based on characteristic morphology, location, and
displacement of surrounding structures.
• MRI shows fluid intensity lesion on all pulse sequences. A secondarily infected cyst may
be iso to mildly hyperintense on T1W images due to infectious debris.
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41. Case 9: A 17-year-old girl presented with pain in the abdomen, vomiting and
fever for a few weeks
Frontal
scannogram
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42. Sagittal and coronal CT scan of the abdomen and pelvis after oral and intravenous
contrast.
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43. • Ans: Peritoneal Tuberculosis (Abdominal Cocoon)
• The patient was clinically diagnosed with intestinal obstruction.
• The topogram from the CT study does not show any small bowel dilatation.
• The coronal reformatted images also show absence of small bowel
dilatation.
• Instead, there are multiple clumped and closely aggregated small bowel
loops that appear encased in peritoneal “cocoons’ with fibrotic
membranes at the periphery of these cocoons. These findings are
compatible with dry tubercular peritonitis.
• "Peritonitis fibrosa incapsulata" was first described in 1907 and is a
condition where the small bowel loops are encased by a thick fibrous
membrane. This condition was renamed as “abdominal cocoon” in 1978.
• Clinically, it presents with features of small bowel obstruction. The plain
films and topogram (as in this case) do not show any bowel dilatation due
to the dense adhesions encasing the bowel loops.
• Patients are usually adolescent girls who present with clinical features of
intestinal obstruction.
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44. • There are three principal types of tuberculous peritoneal involvement
recognized.
• The wet type is the most common and is associated with large amounts
of viscous ascitic fluid that may be either diffusely distributed or
loculated.
• The dry or plastic type is relatively uncommon and is characterized by
caseous nodules, fibrous peritoneal reaction, and dense adhesions.
• The fibrotic fixed type consists of large omental masses, matted loops
of bowel and mesentery, and occasionally loculated ascites
• Tuberculosis may reach the peritoneal cavity as part of a systemic
infection (ie, miliary tuberculosis ), direct extension from the bowel to
the peritoneum, or lymphatic dissemination
• Other findings in the abdomen that suggest a diagnosis of abdominal
tuberculosis are miliary microabscesses in the liver or spleen,
splenomegaly, splenic or lymph node calcification, inflammatory
thickening of the terminal ileum and cecum, and necrotic
lymphadenopathy.
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45. Case:10: A 13-year-old girl presented with a episodic pain in the left lower abdomen for three
months with a palpable lump in the pelvis. Menarche had been achieved six months prior to the
study with scanty irregular menstruation.
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47. Ans: Uterus didelphy with obstructed hemivagina and ipsilateral renal agenesis
The study shows two non-communicating divergent uterine horns with an obstructed left
system (including a dilated fallopian tube) showing hemorrhagic contents. The dilated left
system communicates with a separate cervix and upper vagina. The distended vagina can be
traced till its lower third. The right-sided system is non-dilated with compression of the cervix
and vagina by the obstructed left sided system. The lower third of the vagina shows shows a
normal configuration
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48. There is also non-visualization of the left kidney with a compensatory hypertrophy of the
right kidney
• Mullerian duct anomalies (MDA) result from fusion defects and absence of
development or failure of resorption of the para-mesonephric ducts (Mullerian ducts).
• These are common defects with varying presentation depending on the severity of the
defects and the obstructive or non-obstructive nature of the defects; therefore the
diagnosis may be made at the time of menarche, or during pregnancy, investigation of
infertility or as an incidental finding.
• MRI is the modality of choice for delineation and classification.
• Care must be taken to image with the thinnest possible slice thickness and smallest
possible field of view to enable high-resolution imaging.
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49. • The imaging plane needs to be adjusted depending on the type of anomaly with an
attempt to take at least one plane parallel to the uterine corpus and fundus,
depending on the type of anomaly.
• These anomalies are often associated with renal anomalies due to the close
association of the para-mesonephric and mesonephric ducts,
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50. Thank You !
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