1. SPOTS
Dr. Nehal Shah

2. 1 3D

3. DIAGNOSIS "Bronchus Suis" or Pig bronchus with dissection of aorta
D/D :-
Diverticula of the right upper lobe bronchus (Diverticula lacks cartilaginous rings seen in tracheal bronchi.)

4. FINDINGS
Right upper lobe bronchus arises directly from the lateral wall of the trachea prior to the bifurcation. 

5. Of all bronchial anatomy variants, tracheal bronchus is one of the more common.
It is almost always found on the right, supplying the apical segment of the right upper lobe. 
This anatomy is normal in other mammals such as pigs and therefore it is referred to as a "pig bronchus" or "bronchus suis". 
Although usually asymptomatic it may cause impaired drainage, respiratory infections, persistent coughing, stridor, bleeding, and bronchomalacia. 
It may be associated with tracheal hypoplasia or stenosis, lobar emphysema, pulmonary cysts, tracheo-esophageal-fistula, and has been seen in patients with Down’s syndrome. 
It can lead to right upper lobe atelectasis, especially in intubated patients.

6. Three variations of a tracheal bronchus have been described:
The right tracheal bronchus may be a displaced bronchus with all three segments to the right upper lobe arising from it.  In this variety there is no right upper lobe connection to the right main bronchus.
The tracheal bronchus may consist of only a right upper lobe apical bronchus while anterior and posterior upper lobe bronchi arise from the right main bronchus.
There is a supernumerary bronchus, the tracheal bronchus, leading to the right upper lobe in addition to normally structured (trifurcated) right main stem bronchus.

7. Pt with knee pain

9. CPPD crystal diposition disease.
Chondrocalsinosis

10. 2
Elderly women with wrist and neck pain

12. Rhematoid arthritis

13. 3

15. Calcified Aneurysm of Abdominal Aorta

16. 4

17. 11.
K/C/O CA-ESOPHAGUS.

18. Findings
The SVC is not present in its usual location to the right of the ascending aorta. There is an enhancing structure to the left of the aortic arch which is clearly a vessel. There is not normally any soft tissue structure (other than fat) in this location.
This structure runs inferiorly to enter the coronary sinus, which on the third image is seen to course behind the left ventricle and drain into the right atrium.

19. It typically drains via the coronary sinus.
Persistent left sided SVC, with absence of the right SVC.
Discussion
This variant occurs as a result of persistence of the left anterior cardinal vein.
The right SVC often persists, but may be absent, as in this case. The incidence is approximately 0.5%.
It typically drains via the coronary sinus.

20. 5

22. FLAIR & T2WI

23. CAVERNOUS ANGIOMA

24. Commonest of all vascular malformations of brain.
CT scan: may be normal.
may show popcorn calcification.
absent / minimal enhancement
MRI: complete Hemosiderin rim
Multiple lesion are very common. Therefore, when one cavernous angioma is found, do GRE to detect other lesions. (GRE is more sensitive in lesion-detection, because of the blooming of the Hemosiderin rim, caused by magnetic susceptibility.)

25. 5

27. Mediastinal lipomatosis
It is a benign condition in which increased amounts of unencapsulated, histologically normal fat are seen in a variety of areas in the mediastinum.
It has been associated with exogenous obesity, corticosteroid administration, and Cushing syndrome.
On CT, the fat, which is homogeneous and similar in attenuation to subcutaneous fat (approximately -80 to -120 HU), most commonly is seen in the upper anterior mediastinum but also can be seen in the cardiophrenic angles and paraspinal region. Occasionally collections of fat can be seen in atrioventricular or interventricular grooves.
If the fat is inhomogeneous, mediastinitis, neoplastic infiltration, or prior irradiation/surgery should be considered.
However, small residual foci of thymic tissue should not be interpreted as being secondary to infiltration of the mediastinal fat

28. 6. 30 year old female presented with chronic left knee pain.
She had suffered minor trauma to the knee nine months previously.

30. MRI images (T1 sagittal, T2 sagittal, T1 coronal) show a well defined ossicle containing high signal marrow fat, lying in the posterior horn of the medial meniscus.

31. Diagnosis
Meniscal ossicle
Meniscal ossicles are a rare incidental finding. Usually found in the posterior horn of the medial meniscus, their etiology is uncertain.
A congenital origin with the ossicle being formed from rests of primitive mesenchyme cells is preferred, but recent evidence supports a traumatic etiology.

32. 7

33. 31.

35. The radiographs show a curvilinear fat containing lucency with an exostosis-like structure arising from the radius. The CT scan shows a lipoma with the exostosis in the centre of the lipoma.
This appearance is characteristic of a parosteal lipoma.

36. Parosteal Lipoma
It is a rare tumor, most common in the age group of and forms 0.3% of all lipomas.
It is most common in the thigh, but also seen in the upper extremity and other parts of the body. The exact site of origin of this lesion is uncertain.
The appearance of a lipoma with a bony excrescence is classic for this tumor.

37. 8.

38. Biliary Ascariasis

39. 9

40. Axial reformatted CT image

41. Ménétrier disease.
Axial reformatted image shows large, lobulated folds and preserved gastric mucosa in the fundus.

42. Ménétrier disease is a rare chronic gastric disorder of unknown origin that predisposes for gastric cancer. It occurs most commonly in middle life, more often in men than in women.
Grossly thickened lobulated folds of the gastric fundus and body are characteristic signs of Ménétrier disease, with relative antral sparing.
The greatest degree of fold thickening occurs on or near the greater curvature.
Focally enlarged folds can be mistaken for polypoid carcinomas.

43. 10
Patient with a history of IV drug use and endocarditis.

45. Septic Pulmonary Emboli
Multiple pulmonary masses, some of which are cavitating, are seen in both lungs and are compatible with septic puomonary emboli in this patient with a history of IV drug use and endocarditis.

46. 11
This 58-year-old patient presented to the ER with breathlessness, productive cough, and fever.

48. Findings:
A density is identified throughout much of the left lung. The left heart border is obscured. A crescent of air is seen around the aortic arch and lucency is seen at the left lung apex. Volume loss in the left hemithorax is appreciated. The right lung is clear, no infiltrate nor abnormal lucency is seen.
The lateral view of the chest demonstrates increased density projecting anteriorly and superiorly in the chest projecting just superior to the heart and lying against the anterior chest wall.

49. Diagnosis: Left upper lobe collapse – Luftsichel sign

50. 12
h/o blunt trauma with insertion of ICD since 1 week.

52. Frontal chest x-ray demonstrates the ‘fallen lung sign’.
The pneumothorax fails to respond to a chest tube & the lung sags to the bottom of the pleural space due to complete right main stem bronchus rupture.

53. Tracheobronchial rupture is relatively uncommon but in 90% of cases the tear is located within a main stem bronchus & in 10% it is located in the trachea within 2 cm of carina.
Radiographic findings include pneumomediastinum & pneumothorax which is typically failing to respond to a chest drain.
With complete rupture of right mainstem bronchus, the lung may sag to the floor of the pleural cavity-the ‘fallen lung sign’- as the intact vessels are unable to support the lung.

54. 13

56. Pie-in-the-sky bladder
A pie-in-the-sky bladder may be seen with pelvic trauma.
The sign refers to a high position of the opacified bladder within the pelvis at imaging and implies the presence of a large pelvic hematoma.
Observation of this sign should raise concern for an associated urethral injury

57. 14

59. Smith's Fracture
A dorsally angulated distal radial fracture with vollar displacement of distal fragment.

60. 15

62. CP angle lipoma

63. 16

65. Aberrant right subclavian artery
Contrast material-enhanced CT scan shows an aberrant right subclavian artery that arises as the last branch of a left-sided aortic arch posterior to the esophagus.

66. 17

67. Diagnosis: Pelvic lipomatosis
Findings: IVU demonstrating elevation and lateral compression of bladder. CT of pelvis with contrast demonstrating increased fat surrounding the bladder causing lateral compression with elevation of the bladder floor.
Diagnosis: Pelvic lipomatosis

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70. REVERSAL SIGN
Transverse unenhanced CT scans demonstrate reversal sign with decreased attenuation overall and loss of gray-white differentiation. Note relatively increased attenuation of (a) basal ganglia (arrows), (b) thalami (thin arrows), and cerebellum (wide arrows).

71. Pathogenesis of the reversal sign is complex and not yet fully understood.
One theory is that preservation of central structures is due to transtentorial herniation secondary to acute edema, with pressure partially relieved as the brain herniates through the incisura. The pressure relief is thought to improve tissue perfusion to central structures, thus delaying or preventing necrosis.

72. The relative preservation of attenuation in the posterior fossa likely reflects preferential maintenance of blood flow in the posterior circulation relative to that in the anterior circulation.
Other researchers have suggested that postischemic hypervascularity may cause the relatively increased attenuation seen in the thalami and basal ganglia. However, administration of intravenous contrast material does not aid in the detection of the reversal sign

73. The reversal sign indicates diffuse cerebral injury in a patient who has suffered an anoxic insult.
Causes of the reversal sign include head trauma, hypoxia, birth asphyxia, drowning, status epilepticus, hypothermia, bacterial meningitis, strangulation, nonaccidental trauma, and other causes of global cerebral ischemia.
When other causes have been excluded, demonstration of intracranial blood in the presence of the reversal sign should be considered an indicator of nontraumatic injury.

74. The reversal sign is associated with a poor prognosis and indicates irreversible brain damage.
Mortality rates are high in children whose CT images show the reversal sign (35%), and those who survive have profound neurologic deficits with severe developmental delay.

75. 19

77. Double aortic arch

78. Commonest cause of symptomatic vascular ring in children
Commonest cause of symptomatic vascular ring in children. ( tracheal & esophageal compression by the ring.)
The descending aorta is commonly on the left side.
On PA chest, look for the right Para tracheal opacity.
On lateral view, look for retro tracheal opacity, with anterior tracheal bowing.

79. 20.

80. Pectus excavatum

81. THANK YOU