1. EMW Workshop SSEM 2019
Clinical Imaging

2. Common Imaging Studies in EMW
Plain X rays
Chest
Abdomen
MSK
POCUS
CTB

3. CASE 1
55M
PH – HT lipids
Chest pain for 2/7
ECG no ST changes
1st TnI <0.01
Pending 2nd TnI

4. Ca lung
Metastatic – breast, HN, melanoma, colon, kidneys, sarcoma
Lymphoma
Benign – TB & infectious granuloma,
Infections – abscess, aspergillus
Benign tumors- hamartoma, lipoma
Inflammatory – rheumatoid nodule, sarcoidosis
Others – LN, located fluid (pseudotumor), mucoid impaction
Nipple shadow –
bilateral and symmetric
Oval and round, 5-15 mm
"fuzzy" margins or radiolucent "halo"
sharp lateral border and poorly defined medial border (may be present only on PA projections 3)
nodules are in a characteristic position:
male: between the 5th and 6th ribs anteriorly
female: at the inferior aspect of the breast shadow
were not present on a very recent film
prominent nipples may be visible on a lateral projection

5. Solitary Pulmonary Nodule
≤30mm
Malignancy risk
Clinical
Radiological
Advanced imaging CT
PET
Size >30mm is mass - high probably, < 8mm low risk
8-30 – need consideration
Malignancy risk – clinically & predictive models
Clinically – age, risk factors, family hx
X rays – size, location upper lobe, part solid, spiculation, lower nodule count, emphysema, growth/stable
Imaging:
Size, malignancy risk, growing or not
PET:
-FDG- Avid or not – benign or malignant
But inflammatory or infection – also avid
Search for metastasis

6. CASE 2
35M
IVDU
Back pain for few days
Low grade fever
BP normal
ECG TnI normal

7. TAA ddx –
Degenerative (sporadic) – most common becos of atherosclerosis, screen for AAA too
Dissecting – not true TAA
Trauma – most common pseudoanurysm
Aortitis – infection : septic embolism, contiguous infection, direct bacterial innoulcation
Inflammatory – giant cell arteritis, Takayasu, RA, AS
Connective tissue diseases – marfan, turner Sx, familial
mycotic

8. Mycotic Thoracic Aneurysm
2.7% of TAA
Pathogenesis
Hematogenous – pneumonia, sepsis
Lymphatic – TB
Direct – peri/endocarditis, OM
SA, salmonella sp.
Diagnosis
CT, aortography, TOE
Persistent fever/sepsis
WCC, ESR, Blood c/st -ve in 25%
Treatments
Antibiotics
Surgery

9. CASE 3
55M
PH - Asthma, HT
SOB and chest pain
No fever no injuries
ECG TnI normal

10. Scapular lesions
Benign bone or soft tissue tumor
Bone sarcoma – ewing’s chondrosarcoma
Hematological malignancy - non-Hodgkin’s lymphomas
Metatstasis - Lungs, kidneys and adenocarcinoma of unknown origin
Soft tissue sarcoma
Depends on age, x rays findings , risk factors

11. Easily Missed CXR Findings
Occult pnTx – apices & bases
Pleural neoplasms
Subtle pneumoperitoneum
Pneumomediastinum
Abd organomegaly
Bone & soft tissue

12. CASE 4
80F
PH – DM CHF AF
Admitted for GE
Abd pain with vomiting
Increasing in pain

13. PPU
Bowel obstruction
Ruptured diverticulum
Penetrating trauma
Ruptured inflammatory bowel disease (e.g., megacolon)
Necrotising enterocolitis/pneumatosis coli
Bowel cancer
Ischemic bowel
Steroids
Iatrogenic - After laparotomy, laparoscopy, Breakdown of a surgical anastomosis, Bowel injury after endoscopy
Peritoneal dialysis (PD)
Colonic or peritoneal infection
From chest (e.g., bronchopleural fistula)
Non-invasive PAP (positive airway pressure) can force air down duodenum as well as down trachea

14. Dependent air under central tendon of diaphragm
Cupola Sign
“Little Cup”
Dependent air under central tendon of diaphragm
Ant sub-hepatic space or morrison’s pouch free gas
Air ant to ventral surface liver
Rigler’s sign – bowel wall outlined by intra/extramural air
Decubitus abd sign –
Falciform lig sign – outline by air
Football sign – airfilled peritoneum
Continuous diaphragm sign
Double bubble sign – subdiagramatic free gas + normal stomach bubble
Less sac sign
Triangle sign p- small triangle of free gas btw large bowel and flank
Abscess gas – bubble of gas not within normal hollow viscus
Pneumoretroperitoneum – air surrounding lat border of kid

15. CASE 5
49F
Good PH
Admitted for AP fever
Treated with Augmentin
USG to identify HN

17. Complications of AP
Perinephric or intrarenal abscess
Pyonephrosis
Emphysematous AP
MDRO
Sepsis

18. CASE 6
F46
Ca ovary
Back sprain with persistent pain
X rays NAD
RUQ tenderness

20. Liver metastases in USG
Hypoechoic
Lung, breast, pancreatic, lymphoma
Hyperechoic
Colon, RCC
Bull’s eye lesion
Lung, GI, breast and others
Cystic
SCC, ovarian, pancreatic, colon
Bull’s eye appearance:
Peripheral halo, hypoechoic halo
metastases the halo is most probably related to a combination of compressed normal hepatic parenchyma around the mass and a zone of cancer cell proliferation
Aggressive behaviour
Also in HCC and benign tumor and abscess

21. CASE 7
78M
PH – DM HT IHD
Left leg cellulitis
With increasing in swelling
POCUS done

22. downward pressure to the ultrasound transducer will make the pus move around.  This is often called a “swirl sign” 

23. POCUS in MSK Infection Cellulitis Abscess Edema, fluid surrounding fat
Cobblestoned street
Abscess
Anaechoic fluid collection
Internal echoes
Swirl sign
Debris or pus
Isolated abscess – avoid unnecessary antibiotics

24. CASE 8
60M
LBP 3/52 worsening
Low grade fever
Not response to Tx

26. Spondylodisciitis Workup Routes Pathogens WCC, inflammatory markers
CT/MRI
Routes
Hematogenous, direct, contiguous
Pathogens
SA, streptococci, Gm-ve bacilli
TB, MRSA, fungal
Hematogenous – most common route, genitourinary tract, skin, resp tract, intravascular devices, IE etc.
Contiguous – tissues adjacent to spine, e.g. soft tissue, aorta, esophagus, bowel, iliopsoas muscles
Less likely direct inoculation in this case (no history of trauma or invasive spinal procedures)

27. CASE 9
67M
PH: Ca lung, DM
LBP on and off 1 year
No injury
Persistent pain

29. Osteoblastic Osteolytic Mixed Spinal Metastases Prostate RCC Carcinoid
Melanoma
SC lung MM HL
Non-SC Lung
Mixed
Thyroid
NHL
Breast, GI

30. CASE 10
52M
PH – DM HT COAD AF
UTI and fever
Increased back pain
Not responsive to Tx

32. Iliopsoas Abscess Extraperitoneal TB spondylitis Pyogenic
Spinal, aortic graft, perinephric, bowel (Crohn’s, diverticulitis, appendicitis, perforated Ca)
Primary - rare

33. CASE 11
46F
PH – HT depression
Headache for 2/52
No injury
No fever
P/E – no focal signs

35. CVSTs Prothrombotic RF Headache, ICHT, seizure CT CTV, MRI, MRV
OCP, genetic, preg, IBD, malignancy, infection
Headache, ICHT, seizure CT
25% normal, cord sign, dense/empty triangle
CTV, MRI, MRV
Treatments
Heparin, LMWH, thrombolysis

36. CASE 12
70M
Hx of AF CHF
Drunk + ?HI
Disorientated in ward

37. SAH
Zig zag
bilatereal
Oct 2010

38. Interhemispheric SDH Parasagittal Crescentic Hounsfield Unit
Unilateral
Flat medial & convex lateral border
Posterior superior fissure
Hounsfield Unit
Falx 46 Blood >65
Individual variation
Behind above splenium of corpus collosum
On warfarin – need balance
If small SDH no increase ICH – may need continue warfarin and monitor
Stop warfarin – need 5 d
Vit k – 10mg IV slow
FFP – transient (if PCC not a/v)
PCC (4 factors) – transient, with vit k (2,7,9,10)

39. CASE 13
48M
PH good
Fall during football game
With HI
Brief period of LOC
No headache or vomiting

41. Tear of bridging veins adj to tentorium Rarely need surgery
Tentorial SDH
Pure tentorial rare
Tear of bridging veins adj to tentorium
Rarely need surgery
Good neurological outcome
Limited no. of veins
Lesser tension at tentorium

42. CASE 14
35M
Good PH
Headache for 3/52
Increasing in pain
No HI, no fever

44. Intracystic hemorrhage & rupture (SDH)
Arachnoid Cysts
Form embryologically
48% in MCF
Intracystic hemorrhage & rupture (SDH)
Spontaneously or minor trauma
Tear of bridging veins
Non-hemorrhagic rupture
Subdural hygroma

45. CASE 15
52F
Good PH
Vertigo for 1/52
Mild headache
No focal neurology
No cerebellar signs

47. CPA Syndrome CN V VII VIII Causes Acoustic neuroma (80%) Meningioma
Cerebellar astrocytoma
Epidermoid
Metastases

48. Take home messages
Imaging in EMW
Comprehensive interpretation
Review it yourself
Be open-minded