Solutions to the Test CasesChapter 6Fig. 6.76 a This is a type B aortic dissectionthe dissection islimited to the descending aorta. The false lumen can be distinguishedfrom the true lumen by residual fiber strands connectingthe intimal flap to the media. The true lumen is the smallerlumenwhich shows more contrast enhancement in this case.

b There is a large tumor in the anterior mediastinum. The tracheais narrowed down to a saber sheath configuration. In anacute setting, such as in this case with upper venous congestion,a lymphoma is the most likely cause. A large retrosternal goitercould produce a similar appearance.

c This CT image shows massivelydilated bronchi over all lung fields. This is severe bronchiectasisin cystic fibrosis. d The redistribution, the Kerley lines, anaccentuated horizontal fissure, unsharp vascular markings,bronchial cuffing, and an enlarged heart prove a cardiogenicpulmonary edema. e The thick-walled cavern in the right lungapex occurred in an HIV-positive patientthis is tuberculosis untilproven otherwise. Tuberculosis it turned out to be. Whatwould you do next if you saw this patient? Of course, for startersyou would make sure the patient had a face mask. f The radiographdepicts a pneumonia of the right upper lobe and some ofthe middle lobe. The bronchi are well seen against the backgroundof the pus-filled alveoli. g The severely increased interstitialmarkings in the periphery (Kerley lines) and centrally(reticular or netlike pattern) suggest an interstitial process.The HRCT (right) confirms the thickened interlobular septa ina patient with carcinomatosis of the pulmonary interstitium.

h The left lung is overly transparent, hypovascular, and volume-reduced in this patient. He suffered from recurring pulmonaryinfections in early childhood until the age of 12.Rightthis is SwyerJames syndrome.

Chapter 7Where and when should the informed consent of the patient beachieved? This should best be done the day before the study,either in the office or on the ward but never where andwhen the study is performed. Which parameters should bewatched? Prothrombin time should be >50%, partial thromboplastintime 50 000/ll.Acetylsalicylic acid (ASA/aspirin) should be discontinued a weekbefore deep-body interventions are performed.Here is the great case: Figure 7.18a shows a close up view of theribs. The infracostal margins are very irregularthey are beingremodeled by the enlarged and varicose intercostal arteries inaortic coarctation. Compare this to the normal ribs of Fig.6.5a. As the aorta is stenosed in this entity (see the sagittalT1-weighted MR; b), the descending aorta is filled via intercostalcollaterals and via arteries in the abdominal wall (see the MRangiography; c). After the insertion of a stent (see the conventionalangiography; d), the stenosis is reduced to a moderatelevel without the risks of open chest surgery (see the sagittallyreconstructed CT; e).

Chapter 8Fig. 8.83 a There is malalignment at the C4/C5 level much likethe degenerative spondylolisthesis seen in the lumbar spine.Ventral osteophytes and disk space narrowing in the lower cervicalspine support the notion of a degenerative cause. b The C2vertebral body in this man has turned sclerotic: this is an osteoblasticmetastasis of a prostate carcinoma. c The hand appearsdemineralized in comparison to the radial metaphysis. The softtissues appear to be swollen. This was Sudeck disease. Remember:The clinical symptoms must fit! d The width of the radiocarpaljoint space is diminished radially. The bordering bone issclerosed. The scaphoid shows a little osteophyte, the lunateseems a little out of line. This is a posttraumatic osteoarthritisand lunate malalignment. e This is a patient with ankylosingspondylitis: both iliosacral joints appear to be fused, more soon the right. f They do not come more pathognomonic thanthis: a gigantic chondrosarcoma engulfs the right half of the pelvis.g This is a typical nonossifying fibromano further measuresare needed. h Right. This is an osteoid osteoma of the talus. i It isa severe inherited osteosclerosis of the CamuratiEngelmanntype. j The patient suffers from multiple myeloma. k The os lunatumshows a dense inhomogeneous structure. You are lookingat an osteonecrosis of the lunatum, also termed Kienboeckdisease. It is a little sister of the femoral head necrosis. If youdiagnosed this by yourself, either you are a genius or youhave leafed through one of those fat books on skeletal radiology.In either casecongratulations! l This patient suffers from lowback pain. Pagets disease of the sacral bone is the diagnosis.

Chapter 9Fig. 9.70 a This is a carcinoma of the hypopharynx that originatesfrom the piriform recess. b Sentinel loops in the small intestinewith airfluid levels at different heights point to a mechanical(obstructive) ileus. c This is a diverticulosis of the descendingcolon. d A scrotal hernia is present bilaterally. e Did youdiagnose the splenic cyst alright? f This is the radiograph of aneonate without any air in the stomach and small intestine.This is a definite sign of esophageal atresia. g This is what a tapewormlooks like in a barium study. h This patient suffers fromchronic pancreatitis. i Have you recognized the liver metastasesand the ascites? j Did you notice that most air is in the smallbowel but none in the distant colon and rectum? Did youalso see the dilated air-filled loops of the proximal colon? Thisa cecal volvulus! Some contrast media rests in the bowel arealso appreciated. k This is a cecal volvulus. l This patient wasreferred from a mental institution because he had ingestedsomething. What material might it be? (It was mercury takenfrom an old thermometer.) m No excuses if you did not getthis one: It is a severe gangrene of small and large bowel dueto mesenteral infarction. n Now this one was for the real eggheads:Contrast is in the vena cava and the liver veins, but not inthe aorta. Two theoretical possibilities that one can think of: (a)This is remote: the contrast is given via a vein of the lower extremitiesthat would never give you that solid filling of the ves-342Eastman, Getting Started in Clinical Radiology 2006 ThiemeAll rights reserved. Usage subject to terms and conditions of license.sels because the venous return of the kidneys would mix in. (b)This is the solution: The patient has severe right heart insufficiencyso the contrast flows through the superior vena cavapast the heart right into the inferior cava and the liver veins.Of course, the contrast is given via the veins of the arm, as almostalways. And, by the way, some people call this the playboybunny sign. o This patient felt uneasy after a long flight as abody packer. The sealed drug packages were swallowed beforethe flight. A leakage of the containers, of course, means serioushealth trouble for the poor fellow.Chapter 10Fig. 10.21 a This is a pelvic kidney with a renal cell carcinoma.b Here you see a posttraumatic priapism. The pubic symphysis istorn, the left iliosacral joint is opened: The configuration is alsocalled an open book injury. The genitals are enlarged owing tohemorrhage, thrombosis, or edema. c This is what a calcifiedtransplant kidney looks like. d There is a tumor thrombusthat has grown through the vena cava into the right atrium.This patient had a renal carcinoma. e Did you diagnose the renalhematoma alright? f Did you detect the concrement in the leftkidney? This is nephrolithiasis. g The lesion in the kidney is amanifestation of lymphoma. If you appreciated the tumor inthe mesentery ventral to the aorta you probably got it right.If you overlooked that tumor, remember the satisfaction ofsearch effect (Chapter 3).Chapter 11Fig. 11.57 a There is a C7 diskal prolapse on the left that significantlycompresses the spinal nerve. b This coronal MR imageof the lumbar spine at the level of the kidneys shows an extraaxial,intrathecal tumora typical meningioma. The tumor hasexpanded the spinal canal c This spinal canal is extremely narrowowing to a congenital stenosis. d A right foraminal prolapse isseen on this CT. e If you have not detected it yet, take a stepback! The left basal ganglia are hypodensean early infarctionmay not become more obvious. CT perfusion would make thediagnosis a lot easier to reach. But there is no hemorrhage:thrombolytic treatment could start. f This dense media signis pretty obvious: this is an early infarction of the right hemisphere.g This CT shows a frontal intracranial hemorrhage incombination with extreme edema.Chapter 12Fig. 12.29 a What you are seeing is a typical plasma cell mastitis.b The breast carcinoma (left image, large arrows) showspronounced acoustic shadowing (right image small arrows).Chapter 13Fig. 13.30 The 48 is an impacted wisdom tooth; the 28 toothhas come through. A granuloma is visible at the root of the 45tooth. The bridge between 25 and 27 is intact; the bridge anchoredon tooth 14 reaches out into nothing. The crown of tooth16 is broken and ground down. There are root fillings in tooth 16and 35. Superimposed over 4244 a sialolith is visualized sittingin the main duct of the submandibular gland.Chapter 14Fig. 14.47 a You are seeing a typical caudal shoulder luxation.You should now worry about impression fractures or avulsions ofthe glenoid. b Now this should have been so easy. If you did notdiagnose this tibial head fracture by its indirect signs, go backand check Fig. 4.4b. This is the Dutch flag signthis time in CT. cExtensive pericardial and pleural hemorrhage in a traumatizedpatient: an immediate chest intervention is necessary. d Thetip of the tracheal tube sits in the right main bronchus. A completeatelectasis of the left lung has resulted. Thank god youwere the one to analyze the imageyou did get this one right,didnt you? e This is a cephalad malposition of the tube. Severeinjury to the glottis will result. f A scalp hematoma and a subduralhematoma with severe edema was diagnosed in this youngchild. In not so clear trauma in children, always exclude batteredchild. g This is a posttraumatic aortic dissection (see the flap?)with left-sided hemothorax. h Two weeks after abdominal traumathis patient presented with paina delayed spleen rupture ispresent. i, j, k, l This was your chance to prove youve understoodit all, you know how to reason, and you are just a littlelucky. The scout view of the abdominal CT (i) displays an air-filleddilated loop of small bowel in the mid-abdomen. Note: A verticalbeam is used in normal scout views, so airfluid levels would notshow. There is a definite problem of bowel peristalsis. The axialCT image (j) confirms the dilated small bowel and finds little airbubbles in the intestinal wallthe string of pearls sign. A necrosisof the bowel wall is most likely present. The sagittal reconstructionof the trauma spiral CT (k) tells you why the patientcame to the hospital in the first place. The L2 vertebral bodyhas been crushed in a deceleration trauma. What else mighthave happened in the process? The last CT reconstruction (l)wraps it all up: The trauma impact caused the L2 fractureand a dissection of the superior mesenteric artery, which ledto the bowel necrosis, which was at the base of the developingileus. Now go through the timewarp back to the first image (i)and search for the string of pearls and the fracture in that imageit was all our forefathers had for diagnosis.343Eastman,