@

Copyright2911 by Mohammed El-Matary

All rights reserved. No part of this book may be used or reproduced in any manner whatsoever without written permission, except in the case of brief
quotations embodied in critical articles or reviews.
publishers hqve made every effort to trace the copyright holders for borrowed material. If they have inadvertently overlooked ony, theywill be pleased to make the nec es s ary arrangements at the firs t opportunity.
The

First Edition 2006 Second Edition 2008 Third Edition (New Edition) 2011

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Dedication
qflfithe oltruercfil,
G[o acceytflrts

Ttug Qlue

ffon

@or tlu

soultrymother

6he wasyour

glfrJ**

The author wishes to acknowledge with gratitude all those who had helped in preparation and production of this book & who have contributed with their suggestions and ideas for the new edition:

Ahmed Abdel-Majeed, M.B.B.Ch Ain Shams University

Kareem Mohamed Ali, M.B.B.Gh

Ain Shams University

Cover design

Kareem Darweesh, M.B.B.Ch

Ain Shams Universie

This book provides an update for medical students who need to keep abreast of recent developments. I hope also it will be useful for those preparing for postgraduate examination

This book is designed to provide a concise summary of knowledge about surgical radiology, which medica! students and others can use as study guide by itself or with readings in current textbooks, monographs, and reviews. This book is written primarily for those who have some

knowledge

of

anatomy, physiology, biochemistry and

pharmacology.

The author is extremely grateful to all the contributors for the high standard of the new chapters, and hopes that you, the reader, will enjoy going through these pages as much as
he had.

M. El-Matary

Chest radiology 2- Esophagus radiology 3- Stomach & duodenum radiology 4- Hepatobiliary radiology 5- lntestine radiology 6- Vascular radiology 7- Urosurgery radiology 8- Orthopedic radiology 9- Breast radiology 1 0- Neurosurgery radiology I 1 - Miscellaneous radiology

1-

14 22

46 88
108

150 198

262 272 284

284
289 296

I I

Jaw Salivary glands Thyroid gland

Not+s I Normal cardio-thoracic ratio. I Clear lung fields. I Glear costo-phrenic angles. I No hilar or mediastinal abnormalities.

Note:

I I

The lung is collapsed. The right pleural cavity is filled with air, which looks jet black due to absence of broncho-vascular markings of the lung

Note:

There is marked shift of the mediastinum to the opposite side with flattening of the diaphragm and wide intercostal spaces.

1. There is evidence of lung collapse. T 2. There is evidence of surgical emphysema. T 3. This x-ray should have not been done as this case should be diagnosed

clinically and treated

immediately.

4. Clinically, there is dullness in the atfected 5. The first line of treatment is insertion of wide bore needle in the intercostal space in the mid-clavicular

side. line.

T
F
2nd

Xote: il obliteration of the costo-phrenic angle with opacity rising to the

axilla.

Notc: I Shift of mediastinum to the opposite side.

1, ln massive effusion, the trachea is shifted to the same side. 2. lf the mediastinum is not shifted with massive effusion, suspect

malignant effusion.

Note:

There is air fluid level seen in the pleural space.

1, There is evidence of multiple rib fracture in this x-ray. 2. Hemothorax can be treated conservatively.

T
F

Note:

Differential diagnosis includes bronchogenic carcinoma, solitary metastasis, adenoma, Iung cyst & lung abscess.
T T
F

1. This lesion may cause Dyspnea, hemoptesis & wheezes. 2. Trachea is central. 3. This lesion is definitely bronchogenic carcinoma.

4. Biopsy is indicated.

1. Appearance of air fluid level suggestive of lung abscess. 2. This lesion can be bronchogenic carcinoma.

T T

1. Fluffy cotton appearance is a characteristic radiological sign. 2. The underlying cause may be cancer breast. 3. Palliative treatment is the treatment of choice.

T T T

1. This lesion may be due to cancer colon. 2. This lesion may be due to hypernephroma or seminoma.

T T

Barium swallow

Note:

Double contrast.

Noter

Well defined pouch filled with barium with rounded borders at the root of neck.

1. This diverticulum is known as Zencker's divertlculum. 2. The underlying cause is neuro-rnuscular incoordination. 3. Male to female ratio is 5:1 .

4. Patient usually presents by dysphagia. 5. Carcinoma may develop within the pouch. 6. Cricomyotomy is the line of treatment in early cases.

T T T T T T

Note: I Arrest of lipidol dye in the chest ) blind upper esophageal pouch. I Presence of gastric air bubble is suggestive of lower esophageal fistula with the trachea.

1. This study is made using gastrograffine. 2. This abnormality is commonly associated with other congenital

anomalies. T presentation patient 3. The main of this is excessive salivation. T 4. This patient may suffer from chest infection. T 5. This abnormality is treated by ligation & restoration of esophagus. T

rotea

Multiple smooth filling defects in the lower irregular contour of the esophagus.

Ts

of the esophagus &

1. This patient presents mainly by hematemesis. 2. This condition is not commonly associated with secondary piles. 3. This patient may present with left upper abdominal mass. 4. Abdominal US is an essential investigation for this patient. 5. The principle line of treatment is injection sclerotherapy.

T
F

T T T

Note:

lrregular filling defect with shouldering & rat tail appearance usually in the middle third of esophagus (esophagus is interrupted above the diaphragm).

1. Dysphagia is an early symptom in this disease. 2. This patient has dysphagia to fluids more than solids. 3. Barrett's esophagus is a predisposing factor. 4. Endoscopy & biopsy is the investigation of choice. 5. Esophageal intubation is the best palliative treatment.

F F

T T
F

Note;

Narrowing in the middle third with smooth outline & mild proximal dilatation.

1. The underlying cause is ingestion of a caustic material. 2. Chest infection can be a possible complication.

T T
F

3. Chemical antidote is indicated. 4. The main line of treatment is dilatation. 5. Gastric pull up is the best line of treatment.

T
F

Note:

Smooth narrowing of the lower end of esophagus at or below diaphragm (Parrot beak), marked dilatation of esophagus & absence of gastric air bubble.
T
F F

1. This patient has dysphagia to fluids more than solids. 2. This patient may present with abdominal distention. 3. Barrett's esophagus is a complication of this disease.

4, Manometric study is a useful investigation for this disease. 5. This condition is treated by cardiomyotomy.

T T

Barium swallow

Noteg I Esophago-gastric junction & fundus of stomach situated above the diaphragm.

1. This study is done while the patient is in Trendlenburg position.

2. This patient may present by chest pain. 3. The cardia is seen above the diaphragm. 4. pH study is not of value in this patient. 5. Fundoplication is a line of treatment.

T T T
F

Note:

I I

Part of the fundus of stomach situated in chest beside the normal esophagus. The angle between esophagus & stomach is preserved.

{. This study is done while the patient is in Trendlenburg

2. This patient may present by dyspnea following meals. 3. The cardia is seen above the diaphragm.

position.

T T
F

4. lt is herniation of the greater curvature of stomach.

5. Antacids are a line of treatment.

T
F

Notes I Distended stomach with narrowing of pyloric canal in a child.

1. This study is gastrographin meal with lateral view image. 2. The infant is presented by vomiting dating since birth.
Iike pyloric mass in the epigastrium. U/S is the investigation of choice. Pyloromyotomy is the main line of treatment.

T
F

3. Physical examination of this patient reveals visible gastric waves & olive 4. 5.
T T T

l* Notc:

I I

UIcer niche projecting usually on the lesser curvature & a notch in the opposite side on the greater curvature. After emptying, a barium flake is seen in the ulcer niche & mucosal folds are seen radiating from it.

T 1. Helicobacter infection is the main cause of this condition. 2. Periodic exacerbation of symptoms is a common feature of this disease.
F

3. Multiple biopsies are mandatory on endoscopy to exclude malignancy. 4. Hematemesis is a possible complication of this

condition. 5. Vagotomy & drainage is the main line of treatment.

T T
F

Barium meal

lote:

I I

Stomach is dilated reaching down to the pelvis with soup dish appearance. Minimal contrast material pass through pylorus to intestine.

1.

2, 3. 4. 5.

The underlying cause is fibrosed duodenal ulcer. This patient may present by carpo-pedal spasm. This patient may present by pulsatile epigastric swelling. This condition may lead to metabolic alkalosis. Vagotomy & gastro-jejunostomy is the main line of treatment.

T T
F

T T

lt may present as:

Mass causing irregular filling defect in the antrum & body

ln the pylorus which may cause irregular contours on both lesser & greater curvatures.

Ulcer causing malignant ulcer niche anywhere in stomach particularly in the antrum or greater curvature, on top of a mass (not projecting beyond stomach margin), without mucosal folds radiating from the ulcer & without notch.

Marked narrowing of the lumen of stomach without interruption of the flow of barium.

1. The patient in early stages complains of non-specific symptoms. T 2, The patient may present with symptoms of pyloric obstruction. T 3. Endoscopy & biopsy is the investigation of choice. T 4. Subtotal radical gastrectomy is the main line of treatment in early cases.

5. Gastro-jejunostomy is a line of treatment in complicated

cases.

T T

X-ray, barium meal.

Seen as displacement & compression of the stomach &

CT scan

Seen as a cyst in the tail of pancreas.

1. This is a cyst related to pancreas.

2. lnfection & abscess formation is a possible complication.

3. Abdominal aortic aneurysm is differential diagnosis.

4. Conservative treatment is a line of treatment in early cases. 5. Cysto-gastrostomy is the treatment of choice.

T T T T T

Note:

I I

Dilated stomach (S). The part of duodenum (D) above the obstruction contain gas bubbles (double bubble sign).

1. This study is x-ray imaging in erect position. 2. The neonate presents by picture of intestinal obstruction. 3. Annular pancreas may be a possible cause.

T T T

lt may be seen as

1. The underlying cause may be Zollinger Ellison syndrome.

T T

2. Periodic exacerbation of symptoms is a common feature of this

3. Endoscopy & biopsy are mandatory to exclude malignancy. F 4. Endoscopy is more accurate in diagnosis of this condition. T 5. Medical treatment is the treatment of choice in uncomplicated cases.
T

condition

90% on the Ieft side

Nots:

Air under diaphragm

Barium meal

Triple gas bubbles.

totee

Air under diaphragm in erect x-ray abdomen.

f . Perforation of duodenal ulcer causes this radiologic finding in 60% of T 2. Perforated duodenal ulcer is the commonest cause of this radiologic T T 3. This radiologic finding may be seen after T 4. This patient is presented clinically with

cases.

finding.

laparoscopy. peritonitis.

Seen as laceration in the liver with free intraperitoneal fluid adjacent to liver (peri-hepatic hematoma).

F 1. Liver is the commonest organ to be injured in blunt trauma. generalized peritonitis 2. Evidence of ongoing blood loss & necessitate

surgical

exploration.

Seen as well defined multi-loculated cyst due to multiple daughter

cysts.

1. This condition occurs due to echinococcus granulosus infection of the liver. T 2. Most common liver cyst is hydatid cyst. T 3. Similar cysts may be seen in the spleen. T 4. Rupture of this cyst may lead to anaphylaxis. T 5. Medical treatment is the first line of treatment. T

seen as irregular mass with heterogenous density & areas of central breakdown.

Note: I A characteristic of hepato-cellular carcinoma is enhancement after lV contrast injection.

1. Hepato-cellular carcinoma is the commonest primary liver tumour. T 2. Liver cirrhosis is the commonest etiological factor for this condition. T T 3. Food contamination with aflatoxin can lead to this condition.

4. Serum alpha-fetoprotien can help in diagnosis. 5. Surgical treatment is the only line for treatment of this condition.

T
F

Seen as multiple masses with low density and different sizes.

Primary is mostly from GIT or pancreas. 2. Metastasis is the most common malignant liver tumor. 3. The main line of treatment is chemotherapy.

{,

T T T

Seen as lesion with low density surrounded by region of increased density, but the higher density region may not be seen.

}' {'**,
-d7t

- *i4

tr Seen

as multi-loculated cystic mass & air-fluid level may be present.

1. CT findings are enough to diagnose liver abscess without need to

clinical picture and laboratory results. F 2. Amoebic liver abscess causes hectic fever. F pyogenic 3. Diagnosis of liver abscess should be confirmed by guided aspiration. T

Solitary stone gall hladder US (with posterior acoustic shadow)

Multiple stones gall bladder US (with posterior acoustic shadow)

Seen as echogenic foci.

Notc:

Normal gall bladder is not seen in plain x-ray.

Seen as multiple small, faceted & calcified stones (only 10-15% of gall bladder stones are calcified enough to be seen in x-ray).

I
J

i******-

Seen as catcified gall bladder wall.

Seen as multiple radiolucent filling defects.

qd-

with

Seen as concentration of the dye in gall bladder.

Acute chplecystitie

Seen as failure of visualization of gall bladder as its neck is obstructed by stone

1. US is

2. 3. 4.
5. 6. 7.

T the investigation of choice of this condition. This condition is commonly seen among middle aged females. T This condition may be complicated by acute pancreatitis. T Lateral view film is important to differentiate a gall stone seen in AP xT ray from renal stone. Telepaque tablets are taken 12 hours before oral cholecystography. T T Porcelain gall bladder is a precancerous condition. F Treatment of this condition is mainly medical.

@ndoseopic Betrograde Chotanglo.Pancreatography)

Common bile duct

Gall bladder

Common hepatic duct

ffiq"

& L*" faep,m*{c dwc*s

Normal ERCP

Notor

The endoscope used to visualize & cannulate ampulla of Vater to inject dye.

Seen as radiolucent filling defect in the common bile duct with

proximal dilatation.

Seen as stricture with irregular margins in the lower biliary duct with proximal dilatation.

Seen as short segment stricture with irregular margins in the

upper biliary ducts with proximal dilatation.

Stent in common bile duct inserted for palliative treatment of malignant obstructive jaund ice.

(Percutaneous Trans.trepatic Chotangiography)

Notc:

The Chiba needle used to inject dye in biliary ducts.

Seen as radiolucent filling defect.

Seen as stricture with irregular margins in the lower biliary duct with proximal dilatation.

Seen as short segment stricture with irregular margins in the

upper biliary ducts with proximal dilatation.

Benign stricture

Seen as short segment stricture in the middle of common bile duct in a patient with previous cholecystectomy (benign strictures are

mostly iatrogenic).

Seen as meniscoid filling defect obstructing flow of the dye.

Done through cannulation of common bile duct intra-operative to assess common bile duct stones to determine the need of common bile duct exploration.

(lttagneltlc Besonanee Gholang[o'Pancreatography)

1. Stones in common bile duct are found in 30% of patients undergoing

2. Bleeding tendency is a contraindication to ERCP. 3. Bleeding tendency can be corrected by lV vitamin K. 4. Pancreatitis is a possible complication of ERCP. 5. Abdominal US is essential investigation before ERCP. 6. The dye used for T-tube cholangiography is urographin. 7. T-tube cholangiography is done 2 days after cholecystectomy.

cholecystectomy.

T
F

T T T T
F

I
L

The pancreas is thickened and edematous.

This condition causes severe symptoms with minimal T in lesser 2. This condition could be complicated by cyst formation the sac.

signs.

3. Serum amylase is helpful investigation for diagnosis of this condition. T

Liver Gall bladder

(markedly dilated)
Cancer head
k&dmev

lvc
Aorta

Seen as mass in the head of pancreas may be associated with gall bladder mass.

r r
*

Seen as a mass in the tail of pancreas.

1. Cancer pancreas usually arises in the tail. 2. Main presentation of cancer head of pancreas is painless obstructive

jaundice.

T
F

3. Most patients of this condition are curable by surgery at presentation.

Seen as laceration in the spleen with free intraperitoneal fluid adjacent to spleen (peri-splenic hematoma).

1. Spleen is the most common visceral organ to rupture following blunt

T T Cullen may be 2. sign 3. Splenectomy is the main line of treatment of this condition in adults. T

trauma.

present.

Afewa

.,

in small bowel

X-ray erect

Showing normal gas pattern.

$mall intestinal obs,truetion x-ray suplne

I I

Showing dilated loops in central abdomen having moucosal folds crossing all the lumen from one side to the other (valvulae conniventes or plica circularis) seen in jejunal loops. While ileal loops appear as dilated loops with no mucosal pattern.

Large intestinal obstruction x-ray supine

Showing dilated loops in periphery of abdomen having haustrations not crossing all the lumen.

Intestinal obstruction x-ray erect

Showing multiple fluid levels at different levels.

1. The etiology of intestinal obstruction may be mechanical or functional.T 2. Patients with intestinal obstruction present with painless abdominal

distention.

3. Patients with paralytic ileus have frequent intestinal 4. Tenderness & rigidity necessitate urgent 5. lnitial management is naso-gastric suction & lV

sounds. laparotomy. fluids.

F F

T T

Showing that both mucosal & serosal surfaces of the bowel are outlined by gas indicating presence of free gas within peritoneal cavity.

1, This condition is caused by rupture viscous organ. 2. ln erect x-ray fim for this patient, free air under diaphragm is seen.

T T

Showing dilated sigmoid colon extending from the pelvis to upper abdomen seen as dilated inverted U shaped loop.

1. This x-ray shows coffee bean sign. 2. This condition is common in young aged persons. 3. Early cases can be treated by colonoscopic decompression.

T
F

I I

Barium enema The colon is filled with barium until it stops in the area of intusssuception seen as mass arresting progress of barium with trace of barium seen on both sides of the mass (claw sign).

T 1. This condition is commonly seen in 2. Patients are usually infants presented with screaming & withdrawing

children.

legs & red current jelly 3. Palpable abdominal mass can be found on clinical 4. This investigation is both diagnostic & 5. This condition may be

stools.

recurrent.

therapeutic.

examination.

T T T T

Seen as irregular narrowing & filling defect of the colon showing characteristic shouldering & apple core appearance.

1. 2. 3. 4. 5.

Patient may be presented by recent change of bowel habits. Acute intestinal obstruction may be the first presentation. Colonoscopy & biopsy is the investigation of choice. Massive bleeding per rectum is a common complication. Radical surgical treatment is possible even with hepatic metastasis.

T T T
F

I I

Seen as projections outside the wall of the colon full of barium

(most common in sigmoid colon). Saw tooth appearance may be seen.

1. The main etiology of this condition is chronic constipation. T 2, Barium enema is contraindicated in acute diverticulitis. T 3. Profuse bleeding caused by diverticulosis usually stops spontaneously.

4. This condition is 5. Surgical treatment is indicated in complicated cases

premalignant.

only.

Seen as multiple rounded filling defects affecting the whole colon.

1, This condition is inherited as autosomal dominant trait.

2. 3. 4. 5.

Family screening starting from the age of 10 years is indicated. This condition is 100% premalignant. Colonoscopy & biopsy is the investigation of choice. Surgical treatment is the only line of treatment.

T T T T T

Seen as narrow spastic aganglionic segment with dilated proximal normal segment & funneling of the transition zone inbetween the

two segments.

1. Barium enema should be done for this condition

2. 3.

4. 5.

with little amount of barium. There is organic stricture of the anal canal. Abdominal distention & constipation in infancy are common presentations. Rectal mucosal biopsy is the investigation of choice. Surgical treatment is the only curative line of treatment.

without preparation &

T
F

T T T

Note:

The gas shadow in the rectum is below the pubo-coccygeal line.

Noto:

The gas shadow in the rectum is above the pubo-coccygeal line.

1. This investigation is called invertogram. T 2. This investigation should be done after more than 24 hours after birth with the baby inverted upside down & flexed thighs with lateral imaging.

3. Abdominal distention is present in such condition. 4. lt may be associated with other congenital anomalies. 5. Colostomy is the only line of treatment.

T T T
F

Note:

I I I

Showing loss of haustrations, short & narrow colon causing pipe steam appearance. Filling defects caused by wide spread ulcers & filling excesses caused by mucosal regeneration give ground glass appearance. Affection of the rectum with or without variable segments of colon with no skip lesions is characteristic for ulcerative colitis.

1. Diarrhea, blood & mucous per rectum are common clinical

2.
3. 4. 5.

presentations for this condition. Tender palpable colon & weight loss are common features for this condition. Stool analysis can confirm the diagnosis. Colonoscopy can confirm the diagnosis. Medical treatment is the main line of treatment.

T
F

T T

Barium follow through

Notes I Showing narrowing of the terminal ileum with nodular mucosal pattern. I Extensive narrowing with associated deep ulceration is seen in the caecum & ascending colon.
1. This condition may be due to autoimmune 2. Malabsorption & weight loss are the main presentations for this

disorder.

T condition. F 3. Massive bleeding per rectum is a possible complication. 4. lntestinal obstruction & fistula formation are common complications for T this 5. Medical treatment is the first step in management of this condition. T

condition.

Lower abdominal aorta 2. Common iliac A. 3. lnternal iliac A. 4. Externa! iliac A. 5. Deep femoral a.
1.

External iliac A. 2.Common femoral A. 3. Superficial femoral A. 4. Deep femoral A.

1.

Popliteal A,-' 2. Anterior tibial A.

1.

3. Peronea! A. 4.

Posterior tibial A.

Seen as calcification in the wall of aorta in front of the

vertebrae.

I Seen as dilatation in the aorta which can be measured in

comparison to scale in the CT with or without mural thrombosis (the part of the lumen not stained with dye) and wall calcification.

IShowingdilatationoftheinfra.renalportionofaorta.

CT angiography

Showing dilatation of the infra-renal portion of aorta and both iliac arteries.

GT scan of leaking

aortic aneurysm

I Seen as leak of dye outside the aorta in the retroperitoneal space.

CT scan of asrtic dissection

Seen as splittig of the lumen of aorta (double Iumen) with or without mural thrombosis.
The most common cause of AAA is atherosclerosis. AAA may be presented with backpain & pulsating abdominal mass. U/S is the investigation of choice for screening for AAA. Angiography is the best investigation to determine the true diameter

1. 2, 3. 4.

T T T

AAA.

of
F F

5. AAA more than 4 cm should be treated conservatively. 6. AAA can be treated by synthetic exclusion graft.

2. Popliteal artery aneurysm rupture is a common complication. T 3. Surgical treatment of popliteal artery aneurysm is indicated to avoid
distal

1. Screening investigation for popliteal artery aneurysm is angiography.

embolization.

Saccular aneurysm

1. This condition may be a complication of trauma. 2. Conservative treatment is a line of treatment.

T
F

3. Follow up of this aneurysm will show gradual increase in size then

rupture.

Ireriche syndrome

(infia-renal aorto-iliac
disease)

ffi Seen as

stenosis or occlusion of infra-renal portion of aorta together with iliac arteries on both sides with collaterals appearing around the occluded arteries indicating chronic ischemia.

T pain T in buttocks & 2. Patients present with claudication 3. Examination of this patient will reveal absent femoral pulses on both T

1. This imaging technique is digital subtraction

angiography. thighs.

sides.

I seen as stenosis or occrusion of the iliac artery with

collaterals a-ppearing around the occluded artery indicating chronic ischemia.

rro-T
fl

F*

rstt#{ r
t

Before dilatation

After dilatation

Balloon dilatation

Balloon dilatation with stent

f"v
$

,$
*L {di

&

*fu*
'.,1

C tu&

Extra-anatomical bypass (femoro-femoral bypass) i for treatment of left iliac occlusion

femoro-DoDliteal llisease

Seen as stenosis or occlusion of the femoral or popliteal arteries

with collaterals appearing around the occluded artery indicating chronic ischemia.

Short segment stenosis

Treatment by vascular graft

Atherosclerosis is the most common cause of femoral artery stenosis. T 2, CT angiography is more accurate than conventional angiography.
F

{.

3. CT angiography can be used in patients with borderline renal functions.

F

4. Checking the run-off is essential before deciding the treatment modality.

T 5. Balloon angioplasty is the treatment of choice in short segment stenosis of a big artery. T 6. Extra-anatomical bypass is used in high risk patients unable to tolerate

7.

T Saphenous vein is preferred over synthetic grafts for treatment of long segment stenosis of the femoral T

surgery.

artery.

Infra-Dopliteal disease

Burger's disease seen as diseased arteries below the knee with corkscrew collaterals down to the foot with no refilling (no run-off).

1. This disease is inflammatory disease involving neuro-vascular bundle. T 2, Smoking is a predisposing factor for this T 3. Arterial bypass is a line of treatment for this F

disease. disease.

!
:

^*

lnfra-popliteal atherosclerosis seen as stenosis or occlusion of one or more of tibial arteries with collaterals appearing around the occluded artery indicating chronic ischemia with or without refilling (run-off) in distal arteries.
T
F

1. This condition is common in diabetic patients. 2. Patients usually present with calf claudication pain. 3. Arterial bypass is a line of treatment if there is distal run-off.

To identify presence of acute ischemia, there must be associating history suggestive of acute ischemia.

flcute embolism

I Seen as healthy arterial tree with clot silhouette I Which looks like filling defect in the artery

Or with reversed meniscus sign.

f,sute thrombosis

r seen as obstruction

of an artery with well deveroped collaterals around the artery.

Post-traumatic Ischemia

Seen as cause of obstruction in the x-ray e.g. fracture or dislocation with obstruction of the circulation in the

angiography.

T 1. Cardiac causes are the most common causes of 2. Effect of embolism is more dangerous than ligation of the same artery. T 3. Presence of known source of embolism is essential to prove the cause F of acute ischemia is 4. Patients with acute thrombosis usually give history of claudication pain. T 5. Treatment of post-traumatic ischemia begins with treatment of the T cause (reduction of the fracture or

embolism.

embolism.

dislocation).

I Seen as extra-rib attached to C7 vertebra.

I Seen as compression of the subclavian artery with

elevation of the arm.

Seen as defective circulation of the hand with healthy

proximal circulation to the level of radial & ulnar arteries

1, Cervical rib is the most common cause of thoracic outlet syndrome. 2. Vascular compression is the most common manifestation of thoracic

outlet syndrome. 3. Renaud's disease is common in middle aged females.

I Seen as stenosis of the internal carotid artery (the artery

which gives no branches in the neck).
1. Atherosclerosis is the most important cause of internal carotid artery stenosis. T

2. Prophylactic surgical treatment is indicated in more thanT0o/o stenosis

of internal carotid T 3. Balloon dilatation is the treatment of choice for carotid artery stenosis.

artery.

I Seen as highly vascular mass in the branching point of

common carotid artery (between internal & external carotid arteries).
1. This imaging technique is digital subtraction angiography. 2. This tumour originates from carotid sinus.
T T T

3. Gel foam embolization is a line of treatment.

I Seen as stenosis in the proximal part of the renal artery

after it originates from abdominal aorta.
1. Renal artery stenosis is usually presented with severe hypertension
young 2. Atherosclerosis is a cause of renal artery 3. Balloon dilatation & stenting is a line of treatment of renal artery

age.

in

stenosis.

T T T

stenosis.

Shows normal

S,i- 1. i

With impaired pulmonary perfusion.

Ventilation

(V/Q scan)

- perfusion scan

Pulmonary angiography

Shows filling defects in the pulmonary vessels.

Shows filling defect in the pulmonary vessels.

1. The best investigation to diagnose pulmonary embolism is spiral CT. T 2. Pulmonary embolism is always preceded by history suggestive of DW. F 3. Pulmonary embolism is a differential diagnosis for tension

pneumothorax & myocardial

infarction.

Seen as obstruction of the flow of the vein in ascending

venography.

*;***,

Normal Plain Urinary Tract PUT.

Normal lntra-Venous Urography lVU.

Normal cystography.

bladder

Normal micturating cysto-urethrography.

Normal GT abdomen showing kidneys.

Seen as double pelvis of the right kidney & double pelvis & double ureter of the left kidney.

1. This condition is usually asymptomatic & accidentally discovered. 2. The lesion may be complete or incomplete. 3. Surgical treatment is indicated only if the patient is complaining.

T T T

I Seen as a kidney located outside its normal place I e.g. pelvic kidney with short ureter or kidney located on
the opposite side below the other kidney.

MU showing malrotation of both kidneys seen as calyces directed to medial side together with calyces directed to lateral side.

f CT showing fusion of both kidneys in their lower

poles.
1. These kidneys are located at lower level than normal. 2. This condition is usually asymptomatic.
T T
F

3. Surgical treatment is required.

I Seen as homogenous well defined cyst.

f CT scan with lV contrast showing enlarged both

kidneys with multiple cysts.

W
.r*s

rd

$i

IVU showing stretched & widely separated pelvi-calyceal

system caused by cysts (spider leg appearance).

1. This disease is inherited as autosomal dominant trait. 2. Patients usually complain of flank pain & hematuria in young age. 3. Chronic renal failure is a common complication of this disease.

T
F

T
F

4. Nephrostomy is a line of treatment for this condition. 5. Family screening has special importance for this disease.

pelvis

ISeen as markedly dilated pelvis & calyces with normal

ureter.

I Seen as ballooning of intramural part of the ureter with

mild back pressure on the ureter (cobra head
appearance).

Micturating cysto-urethrography seen as dilated ureters filled with contrast material while the patient micturates.

Bladder ileclr

Micturati ng cysto-urethrography

ISeen as obstruction of the urethra with proximal

dilatation.

I X-ray I Seen as wide separation of pubic rami.

1. Absence of anterior abdominal wall & bladder wall is associated to this

condition.
2. 3. 4. 5.

The patient is incontinent to urine. Waddling gait is a common presentation. Malignancy & renal failure are common complications. Surgical treatment is the only line of treatment.

T T T T T

ICT scan

I Showing sub-capsular hematoma either alone or

together with peri-nephric hematoma.

I I

IVU

Showing escape of contrast material from the kidney indicating laceration of the kidney with involvement of the pelvi-calyceal system.

1. Patients may present with hematuria & pain in the flank. T 2. Patients may present with abdominal distention & vomiting. T possible 3. Shock is a complication. T 4. Conservative treatment is a line of treatment in non-complicated cases.
T

IShowing escape of contrast material from the injured

ureter.

1. The main cause of ureteric injury is iatrogenic during ureteric

catheterization.

Showing escape of contrast material from the bladder either to the pelvis with associated fracture seen in the pelvis or upwards in intra-peritoneal rupture.

1- This investigation is ascending cystography. 2- Patients may present with urine retention. 3- Urgent catheterization is required. 4- Surgical treatment is the only line of treatment.

T
F F

I Ascending cysto-urethrography showing escape ot

contrast material from the urethra.

1. Bladder visualization indicates that urethral injury does not include the
whole urethral 2. Rupture posterior urethra usually results from fracture 3. This patient may present with 4. Urethral stricture is the most common complication. 5. Urgent catheterization is indicated,

circumference. hematuria.

pelvis.

T T T T
F

PUT showing radio opaque stone in left kidney.

Ultrasound showing stone in the kidney seen as echogenic focus with acoustic shadow.

PUT showing stag horn stone in the right kidney.

IVU showing delayed secretion of contrast material in the

right kidney in the same patient.

IVU showing smooth

filling defect in the right renal pelvis

possibly radiolucent stone.

I CT scan showing stone in the right kidney.

T 2. CT scan is important to differentiate radiolucent stone from transitional T cell T 3. Hyperthyroidism is important cause of multiple urinary pain presentation T for this 4. Loin is a common clinical 5. ESWL can be a line of treatment.

1. About 5o/o of renal stones are

radiolucent.

carcinoma.

stones. condition.

Seen opposite either transverse lumbar vertebrae, sacroiliac joint or ischeal spine.

PUT showing stone in the lower left ureter.

!!l!lof

the same patient showing hydronephrosis of the

left kidneY.

PUT showing stone in the left ureter.

r lvu late film of the same patient showing delay in passage

of contrast material from the left kidney, dilatation of the collecting system & retention of the contrast materia! in the renal parenchyma indicating obstruction of the ureter.

I I

Ultrasonography Showing stone in the ureter seen as echogenic focus with acoustic shadow & dilatation of the proximal part of the ureter.

1. Colicky loin pain is a common presentation for this condition. T 2. Acute appendicitis is a differential diagnosis for right side stone ureter.

3. Conservative treatment

is tried with stones less than 0.5

cm.

T T

PUT showing stone in the urinary bladder.

1. This patient can present with terminal hematuria'

T T T

2. Frequency & dysuria are common clinical presentations for this

condition. 3. Cystolithotomy is a line of treatment for this condition.

ffi X-ray

showing stone in the urethra.

I I I

MU showing left hydroureter & hydronephrosis. Hydronephrosis seen as dilated pelvi-calyceal system: Ioss of waist, flattening, clubbing then ballooning of minor calyces. Hydroureter seen as continuity contrast material inside the ureter then dilatation of the ureter.

ffi Urinary bladder calcification plain x-ray.

'",{

*a

-.:*t*

Stricture of the lower end of the ureter.

T 2. Burning micturation is a common clinical presentation for this condition. T T 3. This condition is 4. Curettage & litholapaxy is the treatment of choice for urinary bladder T

1. This condition is caused by schistosoma

hematobium.

premalignant. calcification.

Seen as smooth basal filling defect of the urinary bladder in the IVU.
T

1. Acute urinary retention is a possible clinical presentation,

2. Cystography may show chronic urinary retention & diverticulum

T formation in the bladder secondary to SEP. T 3. Neglected cases may be complicated by renal failure. 4. Conservative medical treatment is contraindicated once acute retention F occurred. T 5. TURP is the best line of surgical treatment.

r IVU seen as irregular filling defect in the urinary bladder

with or without back pressure changes in the kidneys & ureters .

CT scan showing irregular

filling defect arising from the

bladder wall.

with hematuria. 2. Bilharziasis is a major predisposing factor for this condition. 3. This condition is common with young age. 4. Cystoscopy & biopsy is indicated for this condition.

1. This condition may be presented clinically

T T
F

CT scan showing replacement of the kidney by a huge solid mass in a child.

I I

IVP seen as irregular filling defect in the rena! pelvis d ifferential diag nosis.

for

lt may be multicentric with other foci in the renal pelvis, ureter & urinary bladder.

l ft

$i

..*t
I
IVU showing a space occupying lesion causing distortion of pelvi-calyceal system in the form of stretching &

amputation of calyces.

r cr showing soft tissue mass in the kidney & infiltrating

surrounding structures.

lnvasion of the renal vein may be seen giving finger in glove appearance.

1. U/S is useful to differentiate solid & cystic space occupying lesions

2. Painless hematuria
3.

T is the most common presentation of this condition. T This condition may be complicated by secondary varicocele.
is the best line of treatment of this

IVU.

in

4. Nephrectomy

condition.

T T

1. This fracture occurs most commonly due to fall on outstretched hand. T

2. Malunion
3.

is the common complication for this Open reduction & internal fixation is the main line of

fracture. T treatment. F

[. f,nterior $houlder
Ilislocation

1. This is the most common joint to be distocated in the 2. Patients usually present with locking of shoulder

shouldercontour.

T movements & loss of --T

body. --

3. Closed reduction & fixation in adduction is the main line of treatment.T

[. fracture ileck 0f
Humenrs

1. Axillary nerye injury is a common complication.

T
F

2. Closed reduction & external fixation

is the treatment of choice.

B. fracture $ha,ft 0f
Humenrs

fracture. 2. closed reduction & external fixation is the treatment of choice.

1. Radial nerve injury is commonly injured in spiral groove with this

T T

1. This type of fractures is common in children. 2. Vascular injury is a common complication with this fracture. 3. closed reduction & internal fixation is the treatment of choice.

T T T

[. Posterior Elbow
Dislocation

T 1. This condition occurs due to fall on outstretched hand. 2. Disruption of the joint line between olecranon & condyles is present. T F 3. Open reduction & internal fixation is the best line of treatment.

B. fracture ltledial
Epicond

G. fracture 0lecranon

Cross union is a possible complication. Open reduction & internal fixation is the main Iine of treatment.

T T

1. This fracture is common in osteoporotic patients. 2. Distal segment is displaced backwards, laterally & upwards. 3. Sudeck's atrophy may complicate this condition.

T T T

$mith fracture

fracture Sft lfietacaryal

Bone

* Noto: I Fracture of both upper & lower pubic rami.

Noteg

Separation of symphysis pubis.

1. Rupture bladder & rupture urethra must be excluded with this fracture.

2. Severe blood loss is a common 3. Open reduction & internal fixation is the main line of

complication.

treatment.

T T T

[. Posterior hip
dislocation

1. This is the most common type of hip T 2. Patients usually present with flexed, adducted & internally rotated hip.

dislocation.

T
3. Sciatic nerve injury is a common complication.

G. Gentral Hip

Ilislocation

Il. Gongenital Hip

Ilislocation (Riuht $ide

1. This fracture is common in young F 2. Avascular necrosis of the head of femur is a common complication of
this 3. Early surgical treatment is recommended for this 4. This fracture carries a mortality of about

age.

fracture.

fracture. 20%.

T T T

1. Avascular necrosis of head of femur is a complication of this fracture. F 2. This is a common site for pathological T 3. ORIF is the best line of treatment of this T

fractures. fracture.

,l. This fracture is commonly a compound fracture. 2. Cross union is a possible complication. 3. Open fracture should be treated with internal fixation.

T T
F

Irt

fracture

Fracture of one malleolus either medial or lateral malleolus.

2od

Fracture of both medial & lateral malleoli.

Fracture of medial, lateral malleoli & posterior tibial margin.

1. Sudeck's atrophy can complicate this condition.

2. 3'd degree fracture should be treated by ORIF. 3. 1't degree fracture can be treated by below knee plaster cast.

T T T

,*"ry

Below knee amputation showing cutting of tibia at a leve! lower than cutting of fibula.

Operative repair is indicated if there is neurological deficit related to pressure area of the underlying T T 2. Open skull fractures should be treated

{.

brain. surgically.

1. This condition may be complicated by extra-dural hemorrhage.

T
F

2.

All cases of skull fissure fracture should be treated surgically.

1. This fracture results usually from axial loading. 2. This fracture may result in spinal cord injury.

T T

Hyperextension fracture of
G2

1. This fracture is common in elderly with osteoporosis. 2. This fracture is potentially unstable.

T T

Gompression (ffedge) L2

fracture of

1. This fracture is stable fracture.

2. Urgent surgical treatment is required.

T F

fracture dislocation of thoracic

spine

1, This fracture is unstable resulting in injury of the spinal 2. The cause of this fracture is flexion rotation injury. 3. Urgent surgical intervention is indicated.

T T T

Ghronic osteomyelitis of tibia.

1. This disease is common in children. 2. This condition may be complicated with pathological fracture. 3. Surgical treatment is the best Iine of treatment.

T T T

I
-

Chronic osteomyelitis of big toe.

This condition is common with diabetic foot infection.

I X-ray I Showing osteolytic lesion causing destruction of both

vertebrae & inter-vertebral discs.
1, This condition is caused by malignancy. 2. Paraplegia can occur with this condition either early or late. 3. lnitial treatment depends on anti-tuberculus drugs. F

T T

Seen as obliteration of joint space.

seen as a shadow of calcification outside the bone.

Seen as acro-osteolysis together with multiple bone cysts.

Seen as a unilocular cyst without septa.

I Seen as multilocular cyst.

Seen as radiolucent well defined mass usually arising from short long bones commonly metacarpal bones.

1. Enchondroma expand bone from inside. 2. Chondroma may be complicated with pathologica! fracture. 3. Curettage & bone graft is the treatment of choice.

T T T

Seen as cartilage covered bony projection arising metaphysis of a long bone.

1. Clinical examination reveals a mass bigger than seen in x-ray. 2. This lesion can lead to limitation of movement of adjacent joint.

T T

Seen as soft tissue mass arising from metaphysis of long bone with bone destruction & new bone formation in the form of sunray layering & Codman's triangle.

1. This tumor usually occurs in young T 2. It is a locally malignant F 3. Codman's triangle is composed of lifted periosteum due to new bone

tumor.

age.

formation. 4. Surgical treatment is the best line of treatment.

T T

I Seen as well localized soft tissue mass arising from

epiphysis of long bone causing bone destruction with no new bone formation.

1. This is a locally malignant tumor. 2. Recurrence is a common complication after treatment. 3. Differential diagnosis of this condition includes acute osteomyelitis.

T T
F

r seen as a tumor with areas of calcification

affecting flat bones.

usually

1. Differential diagnosis of this condition includes multiple myeloma &

bone metastasis. 2. They should be differentiated from each other by bone scan. 3. Bone metastasis is the commonest bone malignancy. T T T

*
*.

.'.-:..,:

,.

Seen as !?'!ultiple &tot {dark} spots.

I Normal appearance of breast varies with age. I With progress of oge, female breast loses some of its

glandular tissue & becomes less dense on mammogram.

I I

Either cyst or fibroadenoma appear in mammography As well defined radio-opaque mass without microcalcifications.

Gyst appears in ultrasound as well defined anechoic (black) mass with posterior echoic accentuation (white),

Fibroadenoma appears in ultrasound as well defined hypo-echoic homogenous mass.

Lipoma appears in mammography as well defined radiolucent mass with thin capsule with or without coarse calcifications.

1, Mammography is better than US in diagnosis of breast lesions in young F T 2. Mammography is used in screening programs for breast 3. Mammography & US are enough for diagnosis of breast lesions without

females.
biopsy.

lesions.

) Findings suggestive of malignancy in mammography:

lrregular mass with speculated outline.

I Microcalcifications

Mass with nipple retractlon.

Mass with skin retraction.

1. Most common clinical presentation for this condition is painless breast

lump.

aspiration T 3. Skin ulceration, bleeding per nipple & distant metastasis are possible T 4. Radical surgery is the treatment of choice in early T

2. The next step after mammography & us should be fine needle

biopsy. complications.

cases.

* mtel I Hyperdense biconvex lesion on the inner side of the skull. I Shift of midline structures to the opposite side with or without
compression of ventricular system.

T 2. The most common cause of this condition is middle meningeal artery T injury. pass 3. Patients usually from concussion stage to compression stage F without lucid interval. T 4. Urgent surgical treatment is required for this condition.
1. This condition is traumatic.

skull with shift of midline structures to the opposite side with or without compression of the ventricutar sysiem.

Appearsi as concavo-convex lesion on the inner side of the

Appears as hyperdense lesion.

Loses its density gradually & may appear as hypodense lesion.

F 1. This condition occurs spontaneously. 2. This condition occurs mostly due to injury of bridging cerebral veins. T F 3. Medical treatment is the main line of treatment.

ls seen as a mass in the brain causing shift of midline structures with marked enhancement after !V contrast material admi nistration.

ls seen as multiple brain masses surrounded by edema zone which appears grey.

1. Brain metastases are the most common brain T 2. Brain tumors show central enhancement while brain abscess shows

malignancies.

ring enhancement in CT with T 3. Patients of brain tumors present with manifestations of increased intracranial T 4. Biopsy can confirm the diagnosis of brain T 5. Surgical treatment is the main line of treatment of meningioma. T

contrast.

tension.

abscess.

showing dilatation of ventricular system of the brain.

Seen as absent spinous process of the vertebra (L5 in the

photo).

1. The cause of this condition is congenital absence of posterior neural

arch of the 2. Most common site of this condition is lumbo-sacral 3. Subtypes of this condition are occulta &

vertebrae.

manifesta.

vertebrae.

T T T

Shows multiple levels of narrowing of myodil column in the sub-arachnoid space indicating multiple level disc prolapse.

Shows prolapse of inter-vertebral disc between L5 & S1.

1. Myodil myelography is an old invasive technique, 2. MRI is essential investigation to evaluate this condition. 3. Surgery is reserved for complicated cases only.

T T T

Plain x-ray showing fracture mandible.

Panoramic view showing fracture mandible fixed with plates & screws.

T 1. This is the most common site for fracture mandible. 2. This fracture is associated clinically with irregular occlusion of teeth. T 3. Panoramic view study is the best investigation for fracture mandible. T 4, Surgical treatment is the main line of treatment of fracture mandible. T

I ls seen as multilocular cyst at the angle of mandible.

r ls seen as unilocular cyst related to carious tooth.

I ls seen as unilocular cyst containing unerupted tooth.

I Showing branches of the parotid duct which

diminishes in size with branching.

Showing branches of the parotid duct which get bigger with branching.

4.

lipidol. 3. Radiological sign seen is snow storm appearance.

1. The contrast material used in this condition is T 2. This condition is presented clinically with recurrent sialadenitis. T
T The main line of treatment for this condition is conservative treatment. T

ffi Plain

x-ray lateral view skull.

I Plain x-ray occlusal view.

.* Sialography with digital subtraction showing submandibular duct stone.

1. Occlusal view is the best view to detect submandibular T 2. Submandibular stones represent about 80% of salivary T pain 3. Complete obstruction of submandibular duct causes & swelling of

stone. stones.

submandibular gland before or during T Treatment of choice for submandibular gland stone is surgical removal of the gland.

meals.

Pleomorphic adenoma GT scan seen as well defined mass mostly in the parotid gland.

1. The mass seen is mostly F 2. Surgical enucleation is enough for removal of this F 3. Superficial conservative parotidectomy is the treatment of choice for this

malignant.

condition.

condition.

I MRI showing malignancy of parotid gland seen as ill

defined mass extending into both superficial & deep lobes.

For differential diaqnosis: a. Malignant tumor. b. Benign tumor. c. Colloid nodule. d. Colloid cyst.

1. The main cause of

2. 3. 4. 5.

this condition is simple nodular goiter. Fine needle aspiration cytology is indicated for this condition. Ultrasound can differentiate solid lesions from cystic lesions. Radioactive iodine is the main line of treatment for this condition. Surgery is the principle line of treatment for this condition.

T T T
F

si * if".
'i&

fi,o"
h_"

*
*-',I,ff

&*,{*

ft,*'':

IShowing diffuse low uptake of radioactive iodine.

Showing diffuse intense increased uptake of radioactive iodine.

1. This disease is due to autoimmune condition. 2. This condition may be associated with true exophthalmos.

3. Medical treatment should be tried first.

T T T

Showing areas of increased uptake & areas of decreased uptake (hot & cold areas) with uneven uptake.

1. This patient is presented clinically with manifestations of thyrotoxicosis.

2.
3.

T Palpation of the gland may reveal dominant nodule or multiple nodules. T Surgical treatment is the treatment of choice for this condition, T

*t

Showing increased uptake in a single nodule with suppression of the rest of the gland.

1, This condition is mostly malignant. 2. Estimation of serum T3,T4 & TSH can help the diagnosis.

T
F

3. Radiotherapy is reserved for complicated cases only.