Written 2008

Front 1

1. Most important quality control issue in SPECT?
-Field uniformity
-Attenuation correction
-Other wrong answers

Back 1

Field uniformity

Front 2

175. Amount of aluminum contaminant allowed from Moly/Tech reaction (Units are micrograms/mL). Page 9 of Nuc Med Requisites.
e. 100
f. 1
g. 10
h. 0.1

Back 2

10

Every eluate should be checked for Al3+ impurities

Al3+ can cause a degradation in image quality due to poor incorporation of 99mTc into the tracer.

Limits:

10 µg Al3+/ml of eluate (for generators produced from fission of 235U)

The test kit that measures Al3+ ion is special colorimetric test paper strip containing a chemical sensitive to the presence of aluminium ion at the microgram level The test is performed by placing a drop of the eluate and a drop of a standard solution on the test strip and comparing the colours of the spots on the paper.

Front 3

3. Acceptable dose to other patients to release patient after I131 therapy

Back 3

NRC regulations permit patients to be released after receiving I-131 if the TEDE to
other people is likely to be no greater than 500 mRTo determine if this condition will
be met Regulatory Guide 8.39 presents an equation to calculate the expected TEDE
to people who may come in contact with the person who has received I-131. The
TEDE equation has three variables: The activity of I-131 that will be administered to
the patient, the result of a thyroid uptake study, and a factor called the “occupancy
factor”, which takes into account the amount of time the treated individual will spend
around other people during the first few days after receiving I-131.
http://www.springerlink.com/content/glr60p147un52k21/fulltext.pdf

Front 4

4. Indications for using prostate specific monoclonal antibody imaging?
-New diagnosis of cancer
-Followup after hormonal therapy
-Evaluate bone mets
-Evaluate distant mets after complete prostatectomy

Back 4

# Indication for capromab imaging: Previous definitive treatment, then rising PSA without obvious source

* Disease localized to prostate bed: Candidate for definitive salvage (radiation, surgery)
* Disease spread outside prostate: Hormonal blockade, chemotherapy

Front 5

REPEAT Indication for PET in breast cancer?
- Response to therapy

Back 5

Response to therapy

Front 6

6. Not a cause of presinusoidal portal hypertension?
-Hepatic vein stenosis
-AV fistula
-Portal vein thrombosis
-Schistosomiasis

Back 6

Hepatic vein stenosis*

Front 7

. Question about volar plate fractures?
-Caused by forced hyperextension
-Volar dislocation usually

Back 7

Caused by forced hyperextension

Front 8

8. What is the common mechanism of PCL tear
-Flexion with posterior tibial translation
-Flexion with anterior tibial translation
-Hyperextension
-Rotation

Back 8

Terminology
• Disruption of the PCL usually after forced posterior displacement of the tibia
Imaging Findings
• Best diagnostic clue: Discontinuous and/or thickened PCL fibers of increased signal intensity on all pulse sequences
• Normal ligament appears as decreased signal intensity on all pulse sequences "hockey stick" in the notch of the knee (sagittal images)
• Protocol advice: FS PD FSE in sagittal and coronal planes
Top Differential Diagnoses
• Mucoid Degeneration
• Osteochondral Injuries
• PCL Graft Surgery
• Posterolateral Corner (PLC) Injury/Surgery (Post Lat Cor Sx)
Pathology
• Most commonly occurs by direct trauma impacting the anterior knee in a posterior direction (dashboard injury with the knee in flexion)
Clinical Issues
• Most common signs/symptoms: Positive posterior drawer sign (excessive mobility of the tibia posteriorly)
Diagnostic Checklist
• In setting of anterior tibial trabecular injury

Front 9

9. Isolated edema to the anterior tibial plateau
-PCL tear
-ACL tear
-MCL tear
-LCL tear

Back 9

Terminology
• Disruption of the PCL usually after forced posterior displacement of the tibia
Imaging Findings
• Best diagnostic clue: Discontinuous and/or thickened PCL fibers of increased signal intensity on all pulse sequences
• Normal ligament appears as decreased signal intensity on all pulse sequences "hockey stick" in the notch of the knee (sagittal images)
• Protocol advice: FS PD FSE in sagittal and coronal planes
Top Differential Diagnoses
• Mucoid Degeneration
• Osteochondral Injuries
• PCL Graft Surgery
• Posterolateral Corner (PLC) Injury/Surgery (Post Lat Cor Sx)
Pathology
• Most commonly occurs by direct trauma impacting the anterior knee in a posterior direction (dashboard injury with the knee in flexion)
Clinical Issues
• Most common signs/symptoms: Positive posterior drawer sign (excessive mobility of the tibia posteriorly)
Diagnostic Checklist
• In setting of anterior tibial trabecular injury

Front 10

10. REPEAT Most predictive of enchondroma versus low grade chondrosarcoma?
-Clinical symptoms
-MRI, CT, plain film, etc

Back 10

Clinical symptoms

Front 11

11. REPEAT Edema of the lateral tibial plateau and femoral condyle?
-MCL injury
-Medial meniscus
-LCL

Back 11

MCL injury

Front 12

12. Not associated with AVN?
-Scaphoid waist
-Talar neck
-Talar dome
-Subcapital femur
-Surgical neck humerus

Back 12

Surgical neck humerus

Front 13

13. Associated with posterior shoulder dislocation?
-Greater tuberosity fracture
-Ant/Inf glenoid fracture
-Hill Sachs
-Internal rotation of shoulder joint

Back 13

-Internal rotation of shoulder joint

Front 14

. REPEAT More common with laparoscopic gastric bypass?
-Internal hernia
-Infection
-Bleeding
-Splenectomy

Back 14

-Internal hernia

Front 15

13. High grade carotid stenosis? Which is not seen
-Increased PSV
-Increased PDV
-Reversed flow in vertebral*
-Increased IC/CC ratio

Back 15

Reversed flow in vertebral

Front 16

14. Most common posterior fossa lesion in a 30 year old?
-Met*
-Hemangioblastoma
-Astrocytoma
-Medulloblastoma

Back 16

Met*

Front 17

5. REPEAT Chronic liver disease, MRI finding?
-Increased T1 signal in basal ganglia

Back 17

-Increased T1 signal in basal ganglia

Front 18

16. HIV patient with multiple non enhancing cystic lesions in basal ganglia?
-Toxo
-Lymphoma-
-PML
-Cryptococcus
-CMV

Back 18

16. HIV patient with multiple non enhancing cystic lesions in basal ganglia?
-Toxo
-Lymphoma-
-PML
-Cryptococcus*
-CMV

Front 19

17. Which neonatal infection does not cause calcification?
Toxo
CMV
HIV
HSV 2
Rubella

Back 19

17. Which neonatal infection does not cause calcification?
Toxo
CMV
HIV*
HSV 2
Rubella

Front 20

18. REPEAT Most common cause of spinal drop mets?
- Medulloblastoma*

Back 20

18. REPEAT Most common cause of spinal drop mets?
- Medulloblastoma*

Front 21

19. Guy has had prior back surgery. There is homogenous epidural enhancement about the right L5 nerve root. Cause?
-Epidural fibrosis
-Abscess
-Recurrent disc
-Lipomatosis

Back 21

19. Guy has had prior back surgery. There is homogenous epidural enhancement about the right L5 nerve root. Cause?
-Epidural fibrosis*
-Abscess
-Recurrent disc
-Lipomatosis

Front 22

20. REPEAT Gastric emptying studies. Which is true
-Solids are more sensitive than liquids in evaluating early delayed gastric emptying*

Back 22

20. REPEAT Gastric emptying studies. Which is true
-Solids are more sensitive than liquids in evaluating early delayed gastric emptying*

Front 23

21. What do you use to pretreat a kid before a biliary atresia study?
-Phenobarbital
-CCK
-Morphine

Back 23

21. What do you use to pretreat a kid before a biliary atresia study?
-Phenobarbital*
-CCK
-Morphine

Front 24

21. REPEAT Guy has heart rate of 90 and comes for cardiac coronary CT. Which do you give?
-Metoprolol*

Back 24

21. REPEAT Guy has heart rate of 90 and comes for cardiac coronary CT. Which do you give?
-Metoprolol*

Front 25

22. Which drug is commonly used for gated cardiac CT? Beta blocker not a choice
-Adenosine
-Dipyramidole
-Aminophylline
-Nitrates
-Dobutamine

Back 25

22. Which drug is commonly used for gated cardiac CT? Beta blocker not a choice
-Adenosine
-Dipyramidole
-Aminophylline
-Nitrates* (or nitroglycerine)
-Dobutamine

Front 26

23. Which would adversely affect images most in coronary CT?
-A Fib
-prior aortic valve repair
-prior CABG
-systemic blood pressure >200

Back 26

A Fib??? is a contraindication to CTA according to google Huard would go with AFIB

Front 27

24. On coronary CTA, you see a focal high grade stenosis of RCA. What next?
-Medical management
-Coronary angiography
-Stent and angioplasty
-Nothing

Back 27

Well to get a stent you have to do angio. In single vessel disease I would assume stent/angioplasty would be the best answer.

Presentation

* Most common signs/symptoms
o More difficult to diagnose because of inferior, posterior location of ischemia
o Angina may be typical but GI symptoms more common
o Rarely, abdominal discomfort above umbilicus
o Frequently associated with nausea or vomiting
o Can present with diaphragmatic irritation when ischemia is severe
* Other signs/symptoms: Hiccups
* ECG findings
o ST segment depression in inferior ECG leads
o RCA stenosis is an independent predictor of atrial fibrillation in pre-surgical and post CABG patients
* Sinus and AV node ischemic symptoms more common; bradycardia
* Bradyarrhythmias, sinus bradycardia, atrioventricular (AV) block

Treatment

* Treatment is complex and driven by pretest probability of disease and the likely need for definitive structural treatment
* Divide into symptom relief, coronary revascularization, secondary prevention
o Symptom relief
+ Rapid-acting nitrate
+ Beta-blockers/calcium channel blockers
+ Long-acting nitrate
o Coronary revascularization
+ Angioplasty has excellent 5-year survival for single ~ 93% and multivessel disease ~ 87%
+ Technically difficult in "shepard's crook" RCA (approximately 5% general population)
+ Coronary artery bypass graft (CABG)
+ Graft options include right internal mammary, radial, gastroepiploic artery or saphenous vein graft
o Secondary prevention
+ Cardiac rehabilitation: Explanation, understanding, specific interventions (smoking cessation, diet, exercise), long-term adaptation
+ Antiplatelet therapy (aspirin or clopidogrel), lipid-lowering therapy (stains or fibrates), Beta-blockers, ACE inhibitors

Front 28

26. Why do you get quantitative VQ scanning?
-Assess expected post pneumonectomy lung capacity
-Assess bronchogenic carcinoma respectability

Back 28

-Assess expected post pneumonectomy lung capacity*

Front 29

27. REPEAT Right lower lobe mass with subcarinal adenopathy. What stage

Back 29

N2

Front 30

28. REPEAT Multiple pulmonary opacities with negative gallium scan.

Back 30

Kaposi sarcoma*

Front 31

29. Which is most likely to be confused with sarcoid on lung biopsy?
-EG
-NSIP
-DIP
-LIP
-Berylliosis

Back 31

-Berylliosis

Terminology

* Strong lightweight element with a high melting point, used in alloys in wide variety of industries, inhalation causes 2 pulmonary syndromes: Acute chemical pneumonitis and chronic granulomatous lung disease

Imaging Findings

* Best diagnostic clue: Sarcoid pattern in patient with exposure to beryllium
* Symmetric bilateral hilar adenopathy associated with lung disease, adenopathy not an isolated finding (33%)
* Nodules (65%) > ground-glass opacities (55%) > septal lines (50%)
* Resolution ground-glass opacities replaced by microcysts or septal lines

Top Differential Diagnoses

* Sarcoidosis
* Tuberculosis
* Langerhans Cell Granulomatosis
* Silicosis
* Hypersensitivity Pneumonitis
* Idiopathic Pulmonary Fibrosis

Clinical Issues

* History of beryllium exposure, latent period 1 month to 40 years (average 10-15 years)
* Positive blood or bronchoalveolar lavage beryllium lymphocyte proliferation test
* Noncaseating granulomas on lung biopsy
* 10% of patients with acute disease go on to develop chronic disease

Front 32

30. REPEAT Most common appearance of lymphangitic carcinomatosis?

Back 32

-Beaded interlobular septal thicking with polygonal arcades*

Imaging Findings
• Best diagnostic clue: Nodular or beaded septal thickening which may spare whole lobes or lung
• Location: Usually diffuse but confined to 1 lung or lobe in 30%
• Chest radiograph may be normal (30-50%)
• Hilar and mediastinal lymphadenopathy may be present (30%)
• Pleural effusion common (50%)
• Frequency of involvement: Axial (75%) > axial + peripheral (20%) > peripheral (5%)

Front 33

31. Which pediatric tumor does NOT met to lung?
-Neuroblastoma
-Osteosarcoma
-Rhabdomyosarcoma
-Wilms

Back 33

-Neuroblastoma*

Front 34

32. Which pediatric tumor mets to bones?
-Wilms
-Clear cell sarcoma
-Rhabdoid
-Multilocular cystic nephroma

Back 34

-Clear cell sarcoma

Front 35

33. Which finding of renal mass is most worrisome for malignancy?
-Enhancement
-Cystic regions
-Calcifications

Back 35

Enhancement*

Front 36

34. Findings in renal TB?
-Usually associated lung dz
-Ureteral strictures and calcification are seen early
-Large vacuolated medullary spaces which look similar to papillary necrosis

Back 36

-Large vacuolated medullary spaces which look similar to papillary necrosis* (mimics papillary necrosis)

• Early: Normal kidney or small focal cortical lesions with poorly defined border ± calcification
• Progressive
• Papillary destruction with echogenic masses near calyces
• Distorted renal parenchyma
• Irregular hypoechoic masses connecting to collecting system; no renal pelvic dilatation
• Mucosal thickening ± ureteric and bladder involvement
• Small, fibrotic thick-walled bladder
• Echogenic foci or calcification (granulomas) in bladder wall near ureteric orifice
• Localized or generalized pyonephrosis
• Late
• Small, shrunken kidney, "paper-thin" cortex & dense dystrophic calcification in collecting system
• May resemble chronic renal disease
• Less sensitive than CT in detection of
• Calyceal, pelvic or ureteral abnormalities
• Isoechoic parenchymal masses
• Small calcifications
• Small cavities that communicate with collecting system
• US unable to evaluate renal function

Front 37

35. REPEAT Risk factor for ureteral cancer?
-Uretertis cystica
-Malakoplakia
-Bladder cancer
-TB

Back 37

35. REPEAT Risk factor for ureteral cancer?
-Uretertis cystica
-Malakoplakia
-Bladder cancer*
-TB

Front 38

36. Gastric emphysema usually caused by?
-NG tube placement
-Left gastric artery occlusion
-Gastric volvulus

Back 38

As answered - ng tube placement.

But read the following:

Emphysematous gastritis

• Rare and severe gastritis secondary to mucosal disruption and gas-forming bacterial invasion
• Characterized by air in the wall of the stomach
• Causes:
o Ingestion of toxic material such as corrosives
o Alcohol ingestion
o Trauma
o Gastric infarction
o Ulcer disease
• Submucosa is invaded by gas-forming organisms which include:
o Hemolytic strep
o Clostridia Welchi
o E. Coli
o Staph aureus
• Clinical:
o Sudden and violent onset of bloody emesis
o Fever
o Nausea
o Chills
o Leukocytosis
• X-ray:
o Linear small gas bubbles in gastric wall
 Gastric emphysema is more linear, streak-like
o Gas in portal vein
• Prognosis:
o 60-80% fatal
• Best way to differentiate emphysematous gastritis from gastric emphysema:
o Look at patient
 Patients with gastric emphysema are a asymptomatic from the bowel gas air
 Patients with emphysematous gastritis are usually deathly ill


Treatment
• Stop offending agents: Alcohol, tobacco, NSAIDs, steroids and coffee
• H. pylori treatment: Metronidazole, bismuth and clarithromycin, amoxicillin or tetracycline
• Hypertrophic gastritis: Antisecretory agents (H2-receptor antagonists or proton-pump inhibitors)
• Atrophic gastritis: Replace vitamin B12
• Eosinophilic gastritis: Steroids
• Emphysematous gastritis: IV fluids, antibiotics, but no nasogastric tube
• Caustic ingestion gastritis: Steroids, antibiotics, parenteral feedings and ± surgery

Front 39

37. REPEAT Most likely place to find post transplant lymphoproliferative disorder?

Back 39

-Small bowel*

Front 40

38. Young person tapered narrowing of upper esophagus with multiple concentric rings?
-Feline esophagus
-Caustic ingestion
-Reflux

Back 40

Likely Caustic ingestion

Terminology
• Corrosive esophagitis
• Esophageal inflammation/injury due to alkali or acid
Imaging Findings
• Best diagnostic clue: Nondistensible, rigid segment (stricture) of esophagus with ulcerated mucosa
• Diffusely narrowed esophagus with irregular contour
• Double-barreled appearance: Linear or streaky collections of barium in esophageal wall
• Long or short segmental strictures: Smooth, concentric & symmetric or irregular, eccentric & asymmetric
• Diffuse long stricture: Thread-like or filiform appearance of entire thoracic esophagus (due to extensive scarring & fibrosis)
Top Differential Diagnoses
• Reflux esophagitis
• Infectious esophagitis
• Esophageal carcinoma
• Radiation esophagitis
• Nasogastric intubation
Diagnostic Checklist
• Rule out other inflammatory & noninflammatory pathology which can cause long segmental strictures
• Usually history of strong alkali or acid ingestion & endoscopy with biopsy yields definitive diagnosis
• Diffuse long segmental narrowing of thoracic esophagus with irregular contour & extensive ulceration giving rise to thread-like or filiform appearance highly suggestive of caustic ingestion

Front 41

39. Optical imaging is most similar to which because it can detect molar concentrations?
-MRI
-PET
-CT
-US

Back 41

???

Front 42

40. Paget’s disease is distinguishable because of what finding?
-diaphyseal location
-ground glass density
-polyostotic

Back 42

-polyostotic

Front 43

41. Which should not have marrow edema?
-osteoid osteoma
-osteoblastoma
-chondroblastoma
-osteosarcoma
-NOF

Back 43

-NOF

Front 44

42. What is the typical appearance of a Brodie’s abscess?
-Central mineralization on CT
-Central enhancement on MR
-Fading sclerosis on radiograph

Back 44

? Not sure.

Front 45

42. What is the typical appearance of a Brodie’s abscess?
-Central mineralization on CT
-Central enhancement on MR
-Fading sclerosis on radiograph

Back 45

none of these:

Brodie's abscess or subacute osteomyelitis:

- children
- radiographic - well circumscribed lytic lesion with slcerotic borders in the the metaphysis of a long bone. Periosteal reaction and a sequestrum may somethimes be present.
- most frequent in the tibia and fibula.
- MR well cicumscribed serpiginous or oval lesion of low to intermediate signal on t2
- may resemble a chondroblastoma. Use of IV contrast shows peripheral enhancement in a abscess as compared to neoplasm.

Front 46

43. REPEAT Most similar distribution to RA in hands and wrist?
-Reactive arthritis
-Gout
-CPPD
-OA

Back 46

-Gout*

Front 47

44. Soft tissue swelling in RA looks like what?
-Fusiform swelling
- Heberden and Bouchard nodes
-Sausage like digits
-Calcinosis cutis

Back 47

-Fusiform swelling*

Front 48

46. REPEAT Branch of the right coronary?

Back 48

- Acute marginal*

Front 49

47. Question about nasopharyngeal carcinoma?
-most likely presentation is lymphadenopathy
-most common type is adenoid cystic
-Epstein barr virus located in some poorly differentiated tumors
-most common in Waldeyers rings

Back 49

Presentation
• Most common signs/symptoms
o Asymptomatic neck mass due to metastatic adenopathy
o Unilateral conductive hearing loss secondary to otitis media
o Triad of neck mass, serous otitis media & bloody nasal discharge common
• T4 NPCa typically have multiple cranial neuropathy (CN9-12)
Etiology
• Strong relationship between Epstein-Barr virus (EBV) & NPCa well-documented
o EBV DNA found in tumor cells
• Etiology based also on interaction between environmental factors (carcinogens) & genetics
Microscopic:

NPCa defined as squamous differentiation with intracellular bridges or keratinization (± keratin pearls)
• 3 histologic subtypes
o Keratinizing SCCa, non-keratinizing carcinoma & undifferentiated carcinoma
• Further classified as well, moderate & poorly differentiated by amount of differentiation identified
Terminology
• Abbreviation: Nasopharyngeal carcinoma (NPCa)
Imaging Findings
• Best diagnostic clue: Mass centered in lateral pharyngeal recess of NP with deep extension & cervical adenopathy
• Metastatic nodal spread
• Nodal metastases present in 90% of cases at presentation
• Multi-planar images best show invasion of clivus, sphenoid bone & sinus, C1 & C2 vertebral bodies
• Obliteration of normal fat at skull base foramina, especially foramen ovale, suggests perineural spread of tumor
• Moderate hyperintensity of NPCa compared to muscle
• Enhanced MR imaging best tool for evaluating intracranial extent via direct, perivascular ± perineural routes
• Bone CT in axial & coronal planes with 1-2 mm slice thickness helps assess bone invasion

Front 50

REPEAT Most medially located in cavernous sinus?

Back 50

Cranial nerve 6*

Front 51

49. REPEAT With what does the vagus nerve traverse the diaphragm?

Back 51

Esophagus*

Front 52

50. REPEAT How often is a non-palpable, well-circumscribed mass on mammo malignant?

Back 52

-<2%*

Front 53

51. REPEAT How many cancers are found after screening 1000 women?

Back 53

-2-10*

Front 54

53. Biopsy for suspicious calcifications comes back ADH? What is the classification for medical audit?
-True positive
-True negative
-False positive
-False negative

Back 54

-False positive

Front 55

54. REPEAT Biopsy show ADH. What do you do?

Back 55

-Excisional biopsy

Front 56

55. Biopsy for pleomorphic calcification in a spiculated mass come back as adenosis? What do you do?

Back 56

Excisional biopsy (these are discordant findings)

Front 57

56. Why do you perform breast MRI?
-Screen low risk patients
-Further evaluate a biopsy proven invasive ductal cancer
-Evaluate need for axillary node dissection
-Evaluate tissue asymmetry seen on only one mammography view

Back 57

-Further evaluate a biopsy proven invasive ductal cancer*

Front 58

57. REPEAT What is the sentinel node?

Back 58

First node seen*

Front 59

58. Give the course of umbilical catheter through umbilical vein to heart.

Back 59

-UV to left portal to ductus venosis to left hepatic vein to IVC*

Front 60

59. REPEAT Lady with multiple pleural nodules and upper extremity weakness. Most likely cause?
-thymoma
-mesothelioma
-lung cancer
-fibrous tumor of pleura

Back 60

thymoma*

Front 61

60. Most common cause of chronic hydro in renal transplant?
-Bladder insertion stricture
-Clot
-Stones
-Outside mass effect

Back 61

-Bladder insertion stricture

Front 62

61. Difficulty urinating after urethral straddle injury most likely related to ?
-bulbar urethral stricture
-bladder neck injury
-UG diaphragm injury
-anterior urethral injury

Back 62

bulbar urethral stricture*

Front 63

87. Pt s/p liver transplant with decreased resistive index?

Back 63

a. Hepatic artery stenosis (old recalls)

Front 64

63. Which study limits bias?
-Randomized control trial
-Cohort
-Case control

Back 64

63. Which study limits bias?
-Randomized control trial
-Cohort
-Case control

Front 65

63. Which study limits bias?
-Randomized control trial
-Cohort
-Case control

Back 65

63. Which study limits bias?
-Randomized control trial*
-Cohort
-Case control

Front 66

64. REPEAT To evaluate patient survival after interventional technique, which type of study should you use?
-Kaplan Meier survival study
-logistic regression aanalysis
-Chi square
-Some other survival analysis

Back 66

64. REPEAT To evaluate patient survival after interventional technique, which type of study should you use?
-Kaplan Meier survival study*
-logistic regression aanalysis
-Chi square
-Some other survival analysis

Front 67

65. REPEAT Which is dependent on prevalence?
- PPV and NPV
-Other wrong choices which include sensitivity and specificity

Back 67

- PPV and NPV

Front 68

66. REPEAT What is sensitivity?

Back 68

- TP/ TP + FN

Front 69

67. What is true about septate uterus?
-Usually have other urinary malformations
-Has less incidence of spontaneous abortion as compared to bicorn ate
-More obtuse angles between cornua when compared to bicorn ate
- Septal resection usually through lapartomy
- Need to visualize the external contours for complete differentiation of septate and bicornuate

Back 69

67. What is true about septate uterus?
-Usually have other urinary malformations
-Has less incidence of spontaneous abortion as compared to bicorn ate
-More obtuse angles between cornua when compared to bicorn ate
- Septal resection usually through lapartomy
- Need to visualize the external contours for complete differentiation of septate and bicornuate*

Front 70

70. Which is not required to be documented on 2nd trimester ultrasound?
-Facial structures
-Cerebellum
-Lateral ventricles
-Kidneys
-Umbilical cord insertion

Back 70

All of the above.

Complete list
Patient demographic
information
• Patient name, second patient identifier (birth date, hospital identifier, health insurance number)
• Indication for consultation
• Requesting physician/caregiver (preferably with contact information)
• Starting date of last normal menstrual period (LNMP)
• Examination date
• Date of written report
• Name of interpreting physician
Number of fetuses and
indications of life
Presence of cardiac activity for each fetus
If multiple gestation: chorionicity and amnionicity should be reported
Biometry Should be reported all in millimetres or in centimetres along with equivalent estimated gestational age for:
• Biparietal diameter
• Head circumference
• Abdominal circumference
• Femur length
Should be reported in millimetres if abnormal
• Nuchal fold
• Cisterna magna
• Cerebellar diameter
• Lateral ventricle width
Fetal anatomy Should be reported as: normal OR abnormal (with details) OR not seen, with explanation
Should be reported for:
• Cranium
• Cerebral ventricles, cavum septi pellucidi, the midline falx, the choroid plexus
• Posterior fossa: cisterna magna, cerebellum
• Face: orbits, lips
• Spine
• Chest
• Cardiac four-chamber view
• Cardiac outflow tracts
• Heart axis
• Cardiac situs
• Stomach
• Bowel
• Kidneys
• Bladder
• Abdominal cord insertion
• Number of cord vessels
• Upper extremities and presence of hands
• Lower extremities and presence of feet
Amniotic fluid amount Should be reported as: normal OR increased OR decreased OR absent
Placenta • Position should be reported as well as relationship to the cervical os
Maternal anatomy uterus,
ovaries, cervix, bladder
Should be reported as:
• normal OR abnormal with details OR not seen

Front 71

71. The nephrographic phase of renal CT is due to what?
-Tubular secretion
-Glomerular filtration
-Combination of both above
-Tubular reabsorption of water

Back 71

probably glomerular filtration of contrast and tubular secretion of water.

Front 72

72. REPEAT Renal mass with HU of -70. What is true?
-No followup needed
-Likely renal cell carcinoma
-Need in and out of phase MRI

Back 72

no follow up needed since likely blood clot

Front 73

73. MAG 3 renal scan. Which is true?
-estimates ERPF
-glomerular filtration
-metabolized before reaching kidney

Back 73

-estimates ERPF*
- filtration DTPA is best

Front 74

74. REPEAT Post renal transplant. Normal flow to the kidney with increased cortical retention and decreased secretion. Which is most likely?
-ATN
-Acute rejection
-Hyperacute rejection
-Chronic rejection

Back 74

-ATN*

Front 75

75. REPEAT 6 hours post renal transplant with reversed diastolic flow in renal arteries. Likely cause?
-RV thrombosis
-Rejection
-Other wrong answers

Back 75

-RV thrombosis

Terminology
• Transplant renal artery stenosis (TRAS)
• Transplant renal artery thrombosis (TRAT)
• Transplant renal vein thrombosis (TRVT)
Imaging Findings
• TRAS: Focal elevation of TRA blood flow velocity with post-stenotic turbulence
• TRAT: Absence of blood flow in TRA; absent arterial flow in kidney
• TRVT: Absence of blood flow in TRV and persistent diastolic flow reversal in the TRA
• TRAS: Focal color shift or aliasing indicating elevated flow velocity
• TRAS: Post-stenotic turbulence
• TRAT: TRA visualized but without blood flow
• TRAT: Absent arterial flow in kidney hilum and parenchyma
• TRVT: TRV visualized, distended, and without blood flow
• TRVT: Absent venous flow in kidney hilum and parenchyma
• TRAS: PSV > 200 or 300 cm/sec (> 50-60%d) to > 400 cm/sec (> 70%d) (d = diameter reduction)
• TRAT: Absent or severely damped (collateralized) spectral Doppler signals in kidney
• TRVT: Sustained flow reversal in TRA, with shelf-like or inverted "M" shape
Top Differential Diagnoses
• Abrupt TRA Curves & Kinks: Mimic TRAS
• Acute, Severe Rejection or Tubular Necrosis: Mimic TRAT & TRVT

Front 76

76. Patient with CT shows bladder cancer and 2 cm adrenal mass. What to do next?
-FU in 6 months
-Pre, post and delayed images
-Nothing
-Nuclear adrenal cortex scan

Back 76

-Pre, post and delayed images*

Front 77

77. REPEAT Fracture of the distal phalanx of the great toe most associated with?

Back 77

-Osteomyelitis

Front 78

78. Man with PSA of 8ng/ml. What do you do next?
-Bone scan
-Prostate biopsy and ultrasound
-CT A/P
-Nothing

Back 78

In this situation, the PSA is greater than 4. Need to know age of patient and size of prostate. If both are advanced, then bone scan is the next study


Imaging Findings
• Best diagnostic clue: ↓ Signal in a normally high signal peripheral zone on T2WI
• Peripheral zone (70%): Posterior region (> common)
• Imaging accuracy for local staging suboptimal
• Signs of extracapsular extension (ECE)
• Obliteration of periprostatic fat plane
• Obliteration of rectoprostatic angle & neurovascular bundle
• Osteoblastic bone metastases
• Hypoechoic (60-70%) lesion in peripheral zone, abutting the adjacent normal tissue
Top Differential Diagnoses
• Benign prostatic hypertrophy (BPH)
• Rectal carcinoma
Pathology
• Advancing age, hormonal influence, environmental & genetic factors play a role in development
• 1 in 11 males will develop prostate cancer
• More common in Western world & rare in Asians
• Approximately 300,000 new cases detected annually
• 95% of tumors are adenocarcinoma
Diagnostic Checklist
• Prostate cancer until proven otherwise in an elderly man with osteoblastic metastases on a plain x-ray
• Probable cancer in a man with abnormally ↑ PSA levels + enlarged prostate on digital rectal exam
• Annual screening: PSA levels + digital rectal exam
• Area of abnormal low signal in a normal high signal peripheral zone on T2WI ± ECE & bony metastases


Consider
• Prostate cancer until proven otherwise in an elderly man with osteoblastic metastases on a plain x-ray
• Probable cancer in a man with abnormally ↑ PSA levels + enlarged prostate on digital rectal exam
• Annual screening: PSA levels + digital rectal exam
Image Interpretation Pearls
• Area of abnormal low signal in a normal high signal peripheral zone on T2WI ± ECE & bony metastases

Front 79

HCC on CT. Typical appearance?

Back 79

Enhances on early arterial images with central washout on delays (rapid washout)

Front 80

Man with prostate cancer. Elevated PSA. Single foci of increased signal on bone scan in posterior rib. Likely?
-Fracture
-Met

Back 80

-Fracture*

Front 81

81. All of the following make pancreatic cancer unresectable except?
-Liver mets
-Lung mets
-Colon invasion (I think this is correct)
-Short segment SMA invasion
-Short segment portal vein invasion

Back 81

81. All of the following make pancreatic cancer unresectable except?
-Liver mets
-Lung mets
-Colon invasion (I think this is correct) prob not colon but duodenal invasion as this is taken out during surgery.
-Short segment SMA invasion
-Short segment portal vein invasion


Signs of unresectability include: (1) extension of the tumor beyond the margins of the pancreas, (2) tumor involvement of adjacent organs, (3) enlarged regional lymph nodes (>15 mm), (4) encasement or obstruction of peripancreatic arteries or veins (5) metastases in the liver, and (6) peritoneal carcinomatosis. Only 10% to 15% of patients have tumors that are potentially resectable using these criteria

Front 82

82. Most common calcified met in the liver?
-Colon
-Lung
-Renal
-Melanoma

Back 82

-Colon*

Front 83

83. Regarding cirrhosis and HCC
- Most common cause of cirrhosis worldwide is alcoholic liver disease
-Regenerative nodules are precursors to HCC
-Fibrolamellar type of HCC has elevated AFP
-Two other wrong answers

Back 83

Regenerative nodules are precursors to HCC*
- Most common cause of cirrhosis worldwide is Hep A – according to BH
- Fibrolamellar carcinoma is a hepatocellular malignancy with clinical and pathologic features that are distinct from HCC (17). Tumors typically present as a large liver mass in a young adult (mean age, 23 years) with none of the risk factors for HCC and without elevation of α-fetoprotein levels.

Front 84

84. REPEAT Hypoperfusion complex has dense enhancement of all of the following except
-Liver
-Kidney
-Bowel
-Adrenal

Back 84

Fractured recall:
Basically, hypoperfusion complex is an emergency in pediatric patients who have the ability to compensate for shock with rapid downhill transition. Multiple causes. Most sig findings are intense adrenal enhancement, shock looking bowel, small caliber aorta and IVC and intense enhancement of all solid organs.


Imaging Findings
• Best imaging clue: Diffuse bowel wall enhancement and thickening associated with abnormal enhancement of solid organs and abnormal enhancement and small caliber of vessels
• Abnormal intense enhancement of:
• Bowel wall
• Mesentery
• Adrenal glands
• Liver
• Kidneys
• Pancreas
• Intense enhancement and decreased caliber:
• Inferior vena cava
• Aorta
• Diffuse bowel wall thickening
• Diffuse bowel dilatation
• Unexplained ascites
• CT findings may be apparent before clinical findings of shock
Clinical Issues
• In one series, progressive hypotension developed within 10 minutes of CT in 19% of children
• In same series, mortality rate associated with presence of hypoperfusion complex was 85%, compared with 2% of all children who suffered blunt trauma
• Immediately transfer child from CT to more supportive area or operating room
• Intense monitoring
• Fluid/blood volume replacement

Front 85

85. Which PET metabolite can you use to localize necrotic portions of a brain tumor? No kidding

Back 85

Whatever - who cares
- No clue here, several FDG molecules, 13C methionone, thymidine I think

Front 86

86. Prominent areas of increased T1 signal in the basal ganglia of a neonate. Cause?
-CMV
-basal ganglia calcifications
-ischemia
-something about the basilar artery, maybe ischemia

Back 86

Not sure

common


Physiologic Calcification, Brain


Neurofibromatosis Type 1


Hepatic Encephalopathy


Hyperalimentation



less common


Hypoxic-Ischemic Encephalopathy, NOS


• HIE, Term


• Hypotensive Cerebral Infarction


CO Poisoning


Kernicterus


Wilson Disease



rare


Endocrine Disorders


• Hypothyroidism

• Hyperparathyroidism

• Hypoparathyroidism

• Pseudohypoparathyroidism

• Pseudopseudohypoparathyroidism


Hypoglycemia


Hallervorden-Spatz Syndrome


Fahr Disease


Encephalitis (Miscellaneous)


• Japanese Encephalitis


• HIV, Congenital

Front 87

87. Most common appearance of Coates disease?
-Bilateral
-Calcification
-Retinal detachment
-Enhancement

Back 87

Retinal detachment

Coats Disease
• Key facts: Primary retinal vascular anomaly with retinal telangiectasis and exudative retinal detachment
o Unilateral in 80-90% of patients
o Most patients male
• Imaging
o Advanced stages may appear to obliterate vitreous
o CT: Mild diffusely and homogeneously hyperdense vitreous without calcification
o MR: Retinal detachment with nonenhancing T1 and T2 hyperintense subretinal exudate

Front 88

88. Lymphocytic interstitial pneumonia most commonly seen with which connective tissue dz?
-Sjogrens
-RA
-Lupus
-Scleroderma

Back 88

-Sjogrens

Terminology
• Diffuse disease commonly referred to as LIP
• Focal disease commonly referred to as pseudolymphoma
Imaging Findings
• Best diagnostic clue: Thin-walled cysts and centrilobular nodules
• Location: Basilar interstitial thickening in adult with Sjögren syndrome
• Morphology: BALT lymphomas have identical radiographic characteristics to non-neoplastic lymphoid lesions
Top Differential Diagnoses
• Nonspecific Interstitial Pneumonia (NSIP)
• Angioimmunoblastic Lymphadenopathy
• Castleman Disease
• Lymphomatoid Granulomatosis
• Hypersensitivity Pneumonitis
Pathology
• Pseudolymphoma and LIP identical histologically
• Small lymphocytes and plasma cells
• When centered on small airways: Follicular bronchiolitis
• When more florid into alveolar septa: LIP
Clinical Issues
• Dysproteinemia
• Gender: Adults: Women primarily
• May evolve into B-cell lymphoma, especially in Sjögren (5%)

Front 89

89. REPEAT Young man with bilateral parotid cysts and bilateral cervical adenopathy. Most likely?
-AIDS*
-Sjogrens
-Abscesses
-Brachial cleft cyts

Back 89

-AIDS

Terminology

* Abbreviation: Benign lymphoepithelial lesions of human immunodeficiency virus (BLL-HIV)
* Synonym: AIDS-related parotid cysts (ARPC)

Imaging Findings

* Best diagnostic clue: Multiple cystic & solid masses enlarging both parotid glands associated with tonsillar hyperplasia & cervical reactive adenopathy
* Thin rim-enhancement of cystic lesions with heterogeneous enhancement of solid lesions

Top Differential Diagnoses

* 1st branchial cleft cyst
* Sjögren syndrome
* Sarcoidosis
* Warthin tumor
* NHL in parotid nodes
* Metastatic disease to parotid glands

Pathology

* General path comments: Cystic spaces lined by squamous epithelium accompanied by abundant lymphoid stroma
* 5% of HIV positive patients develop BLL of parotids
* Associated abnormalities: Cervical lymphadenopathy & nasopharyngeal lymphofollicular hyperplasia

Diagnostic Checklist

* Image from skull base to clavicles to fully evaluate extent of parotid involvement & adenopathy
* Bilateral cystic & solid masses within enlarged parotids in an HIV positive patient should be considered BLL until proven otherwise

Front 90

90. REPEAT Thyroglossal duct cyst. Which is true?
-papillary cancer most common cancer
-sprayed
-superficial to strap muscles
-septated
-enhance

Back 90

-papillary cancer most common cancer*

Terminology

* TGDC: Remnant of thyroglossal duct found between foramen cecum of tongue base & thyroid bed in infrahyoid neck

Imaging Findings

* Best diagnostic clue: Midline cystic neck mass embedded in infrahyoid strap muscles ("claw sign")
* 20-25% in suprahyoid neck
* Almost 50% at hyoid bone
* About 25% in infrahyoid neck
* Wall may enhance if infected

Top Differential Diagnoses

* Lingual or sublingual thyroid
* Dermoid or epidermoid of tongue
* Submandibular or sublingual space abscess
* Malignant Delphian chain necrotic node

Pathology

* Failure of involution of TGD & persistent secretion of epithelial cells lining duct result in TGDC
* TGDC can occur anywhere along route of descent of TGD
* Most common congenital neck lesion

Clinical Issues

* Entire cyst & midline portion of hyoid bone is resected

Diagnostic Checklist

* Any associated nodularity or chunky calcification suggests associated thyroid carcinoma
Microscopic Features
• Cyst lined by respiratory or squamous epithelium
• Small deposits of thyroid tissue with colloid commonly associated
• Papillary carcinoma is most common associated malignancy

Front 91

91. Give patient iron oxide. What appearance will benign lymph nodes have on MRI?
-Homogenous decreased signal*
-Homogenous increased signal
-Heterogenous increased signal

Back 91

-Homogenous decreased signal*

The use of node-specific contrast agents can overcome some of the limitations of cross-sectional imaging. Ultrasmall superparamagnetic iron oxide particles (USPIO) ([ferumoxtran-10] [Sinerem; Laboratoire Guerbet, Aulnay sous Bois; and Combidex; Advanced Magnetics)]) are a relatively new class of MRI contrast agents developed in the 1980s for intravenous MR lymphography (69,70). These nanoparticles have been evaluated for improved detection of lymph node metastases in various clinical trials (27,71–75). Evaluation with nanoparticles requires 2 MR scans performed 24 h apart. The first scan is used to evaluate the existence and location of the lymph nodes. Twenty-four hours after the injection of the contrast agent, the second MR scan is performed to evaluate contrast enhancement of the identified lymph nodes.

After intravenous administration, ferumoxtran-10 extravasates slowly from the vascular space into the interstitial space and is then transported to lymph nodes through lymphatic vessels (Fig. 9). Once within the nodes, these nanoparticles bind to macrophages, producing a decrease in signal intensity on T2- and T2*-weighted images. The degree of signal intensity reduction is dependent on the dose of ferumoxtran-10 and the pulse sequence used for MRI. The recommended optimal dose at this time is 2.6 mg Fe per kilogram (76), and the most appropriate pulse sequence for evaluation of signal loss is the gradient-echo T2*-weighted sequence. This sequence is more sensitive to the magnetic susceptibility effects of ferumoxtran-10. If part of the node or the entire node is infiltrated with tumor, there is lack of ferumoxtran-10 uptake and these areas continue to retain their high signal intensity after administration of the contrast material.

Front 92

92. REPEAT What is the most important aspect of Tc 99 labeled red cell scanning for gastric bleeding?
-24 hour imaging
-Intermittent imaging

Back 92

Imaging Recommendations

* Best imaging tool
o Tc-99m RBC: Procedure of choice when patient is actively bleeding and hemodynamically stable
+ Superior to Tc-99m SC due to longer window for detection following injection if patient is bleeding intermittently
+ Best guide to bleeding site prior to endoscopy or angiography
+ Best indicator of bleeding over 24 hour period; location may not be possible with delayed views
+ Sensitivity depends on bleeding rate at time of study (> 0.5 cc/min Tc-99m RBC)
+ Specificity depends on study quality and completeness
o Angiography: Procedure of choice when patient is hemodynamically unstable
+ Successful if patient is actively bleeding at time of study (brisk bleed > 0.5 mL/min for mesenteric angiography and > 5-7 mL/min for non-selective aortic angiography
+ When positive, localization is more precise than scintigraphy
+ Best used when endoscopy is inconclusive, especially when nuclear study is positive but localization difficult
* Protocol advice
o Tc-99m RBC
+ Flow phase acquisition for 1 min (3 sec/frame x 20): Main utility to delineate vascular structures of abdomen and pelvis; occasional detection of bleeding site
+ Dynamic phase acquisition for 90-120 min: Usually displayed at 2 min/frame (acquired on computer at 30 sec/frame)
+ Display: Frame by frame hard copy or computer monitor; cine loop for continuous viewing
+ Delayed imaging at 4-6 and 24 hr post-injection: Dynamic acquisition for 60 min at 2 min/frame; occasionally helpful for localization; main use to assess bleeding status

Front 93

93. What is associated with an AV fistula of the cecum?
-Osler Weber Rendu
-prior appendectomy
-aortic stenosis
- who knows*

Back 93

-Osler Weber Rendu

Front 94

REPEAT SPECT most common appearance with Alzheimers?

Back 94

-Decreased signal in the parietal lobes*

Terminology
• Progressive neurodegenerative disease of brain of unknown etiology, likely related to amyloid cascade with β-amyloid and tau protein deposition ⇒ neuronal, glial cell death
Imaging Findings
• Parietal, posterior temporal lobes: Relative reduction in metabolism (FDG PET) or perfusion (SPECT)
• Accuracy of diagnosis with FDG PET or SPECT > clinical assessment, especially in early AD
• Severity of findings on FDG PET or SPECT: Parallel or often precede clinical dementia, degree of cognitive impairment
• Probability of AD low if no progression on FDG PET or SPECT within 12-18 months
Top Differential Diagnoses
• Vascular Dementia
• Lewy Body Disease
• Frontotemporal Dementia
• Creutzfeldt-Jakob Disease
• Progressive Supranuclear Palsy
• Corticobasal Degeneration
• Reversible Dementias
Diagnostic Checklist
• Parietal/temporal with occipital involvement on FDG PET or SPECT likely Lewy body disease, not AD
• Hippocampal atrophy on MR with biparietal defects on FDG PET or SPECT predicts AD
• Basal ganglia defects along with classic AD findings on FDG PET or SPECT suggests vascular disease also contributing to dementia

Front 95

101. REPEAT Parvus et tardus waveforms in both carotids is caused by what?

Back 95

-Aortic stenosis*

Front 96

102. Stenosis in Tetralogy of Fallot is where?
-Aorta
-Subpulmonic infundibulum
-Supravalvulur pulmonary artery
-Pulmonary valve
-Distal pulmonary artery

Back 96

-Subpulmonic infundibulum

Terminology
• Underdevelopment of pulmonary infundibulum due to unequal partitioning of conal truncus resulting in subvalvular or valvular right ventricular (RV) outflow tract (RVOT) stenosis, subaortic ventricular septal defect (VSD), overriding aorta and RV hypertrophy
Imaging Findings
• Right-sided aortic arch in 25%
• RV hypertrophy, concave pulmonary artery segment: "Boot-shaped" heart = "coeur en sabot"
• Decreased pulmonary vascularity (pulmonary oligemia)
• Initial diagnosis with echocardiography
• CTA or MR for PA anatomy
Top Differential Diagnoses
• Trilogy of Fallot
• Pulmonary valvular stenosis, RV hypertrophy, and ASD with right to left shunt due to increased right-sided pressures
• Pentalogy of Fallot
• Tetralogy with additional atrial septal defect (ASD)
Pathology
• Right-sided aortic arch with mirror image branching (25%)
• Balance between RVOT obstruction and VSD
• Classic (blue) Tet = decreased pulmonary blood flow results in greater right to left shunting → cyanosis
• "Pink" Tet = normal or increased pulmonary flow → congestive heart failure

Front 97

103. REPEAT What causes elevated ejection fraction?
-Aortic insufficiency
-Other wrong answers, note hypertrophic cardiomyopathy and mitral regurg not answers

Back 97

-Aortic insufficiency

Front 98

104. REPEAT What causes systolic anterior motion of the mitral valve?

Back 98

-Hypertrophic cardiomyopathy*

Terminology
• HCM is a genetic disease of the cardiac sarcomere
• Increased left ventricular (LV) mass with resultant hypertrophy without an obvious etiology
Imaging Findings
• Hallmark is myocardial hypertrophy which cannot be explained by another disease (i.e., hypertension, aortic stenosis)
• Most common diagnostic criterion of HCM is LV wall thickness > 15 mm, although cases may exist with less hypertrophy
• Most common location is basal septum hypertrophy with or without obstruction
• Morphology: Nondilated and hyperdynamic LV
• LV outflow tract (LVOT) obstruction with abnormal flow dynamics in some cases
• Mitral valve regurgitation and systolic anterior motion (SAM) of the mitral valve leaflet
• Echocardiography is diagnostic
Top Differential Diagnoses
• Aortic Stenosis
• Restrictive Cardiomyopathy
• Systemic Arterial Hypertension
• Aortic Coarctation
Pathology
• Autosomal dominant with incomplete penetrance and variable expressivity resulting in clinical heterogeneity among patients and family members
Clinical Issues
• Most common cause of sudden cardiac death (SCD) in both preadolescent and adolescent children

Front 99

105. The Fontan procedure is commonly used for repair of which congenital heart defect?
-Tetralogy of Fallot
-Transposition
-Tricuspid atresia

Back 99

-Tricuspid atresia

Definitions
• Pulmonary artery (PA) banding: Palliative procedure to decrease pulmonary perfusion in left → right shunt lesions, when definitive repair is not yet feasible
• Blalock-Taussig (BT) shunt: For initial palliation of cyanotic lesions with decreased pulmonary flow
o Aortopulmonary shunt (high → low pressure): Size and length determine pressure drop
o Performed via lateral thoracotomy
o Classic BT shunt: Subclavian artery is ligated and connected end-to-side to ipsilateral PA
 On side opposite aortic arch, to avoid kinking
 Collaterals develop to ipsilateral upper extremity → unilateral rib notching
o Modified BT shunt: Gore-Tex tube is interposed between subclavian and ipsilateral PA
 Can be performed on either side
 No compromise of upper extremity perfusion
o Central shunt: Aorta to PA conduit, alternative to BT
• Glenn shunt: In complex cyanotic heart disease, as initial stage of Fontan operation
o Cavopulmonary anastomosis (low pressure), performed via median sternotomy
 Decreases volume load on single ventricle
 Can be unilateral or bilateral [in case of bilateral superior vena cava (SVC)]
 Can be unidirectional or (most often) bidirectional (i.e., perfuses both PAs)
o Hemi-Fontan: Variation of Glenn, with temporary occlusion patch between right atrium and right PA
o Kawashima operation: For azygos continuation Inferior vena cava (IVC)
 (Hemi-)azygos vein is incorporated in cavopulmonary anastomosis
• Fontan: In complex heart disease, not suitable for bi-ventricular repair (single ventricle physiology)
o IVC → right PA shunt
o Classic Fontan: Anastomosis between right atrial appendage and right PA (for tricuspid atresia)
o Intra-atrial lateral tunnel Fontan: Gore-Tex shunt
 With fenestration, which serves as pop-off valve for elevated central venous pressures
 Can be closed later with occluder device
o Extra-cardiac conduit from IVC to right PA
• Mustard/Senning: Venous switch for L-transposition of the great arteries (TGA)
o Mustard: Intra-atrial pericardial baffle redirects blood from right atrium to left ventricle (LV) and from left atrium to right ventricle (RV)
o Senning: Flap fashioned from atrial septum redirects systemic and pulmonary venous blood to LV and RV
• Jatene: Arterial switch for L-TGA
o Coronary arteries are also transposed
o Complication: Stretching of pulmonary artery branches, major airway compression
• LeCompte: For TGA with ventricular septal defect (VSD) and pulmonary stenosis
o Tunnel connecting LV to aorta, closure VSD, connection PA to RV using pericardial patch
o Avoids complications of Rastelli conduit
• Norwood: For hypoplastic left heart syndrome (HLHS)
o Stage 1: Connection of main PA to descending aorta, side-to-side anastomosis of PA to hypoplastic aorta
 BT shunt for PA perfusion
 Sano shunt: RV → PA confluence (less PA overcirculation and better coronary flow than BT)
o Stage 2: Take-down of BT shunt; creation of cavopulmonary (Glenn or hemi-Fontan) shunt
o Stage 3: Completion of Fontan operation
• Damus-Kay-Stansel: Side-to-side anastomosis between ascending aorta and main PA, in selected cases of TGA and single ventricle with LV outflow tract obstruction
• Ross-Konno: In selected cases of aortic stenosis
o Aortic valve replaced by patient's pulmonary valve
o Pulmonary valve is substituted by valved conduit
• Rastelli: RV to PA conduit
o For right ventricular outflow tract obstructive lesions
 Pulmonary atresia, VSD, aortopulmonary collaterals
 Tetralogy of Fallot
 TGA with VSD and pulmonary stenosis
• Cardiac transplantation: For HLHS, end-stage CHD
o More complicated in CHD patients: Abnormal situs, transposition, scarring from prior surgeries
o Need for life-long immunosuppression
o When pulmonary hypertension: Prognosis guarded

Front 100

106. Patient after contrast has rapidly progressive wheezing and stridor, which should you give?
-1-3mL 1:10,000 epi IV
-1-3 mL 1:1000 epi IV
-1-3 mL 1:10,000 epi SC* (or intramuscular?)
-1-3 mL 1:1000 SC

Back 100

Epinephrine (EpiPen, Adrenalin)
DOC for shock, angioedema, airway obstruction, bronchospasm, and urticaria in severe anaphylactic reactions. Administer IM (preferred) or SC, except for patients in extremis for whom it is administered IV. May be administered SL or via ET when no IV access available. Continuous infusion may be administered in cases of refractory shock.
Adult
0.3-0.5 mL 1:1000 soln SC or IM q15min
0.5-1 mL 1:10,000 soln IV; slow administration; repeat prn
0.3-0.5 mL 1:1000 soln SL q15min
1 mL 1:1000 soln ET in approximately 10 mL NS
IV infusion: 0.1-1 mcg/kg/min
Pediatric
0.01 mL/kg (minimum 0.1 mL) 1:1000 soln IM (preferred) or SC q15min
0.1 mL/kg 1:10,000 soln IV prn slow administration; repeat prn
0.01 mL/kg (minimum 0.1 mL) 1:1000 soln SL q15min
0.01 mL/kg (minimum 0.1 mL) 1:1000 soln ET in approximately 1-3 mL NS
IV infusion: 0.1-1 mcg/kg/min

Front 101

107. REPEAT After giving midazolam, patient becomes somnolent with decreased O2 sats. What do you do?
-Alert resuscitation team
-Prepare reversal agents
-Arouse patient and secure airway
-Give oxygen by facemask

Back 101

Arouse patient and secure airway

Flumazenil is the reversal agent:

Adult
• Initial dose: 0.2 mg administered intravenously over 15 seconds*
• Additional doses: If desired consciousness is not reached within 45 seconds, up to 4 additional doses 0.2 mg can be administered at 60 second intervals
• Onset of action: 1-2 minutes
• Peak effect: 3 minutes
• Duration of effect: 10-15 minutes
• Repeat treatment: If resedation occurs, repeated doses can be administered at 20 minute intervals. No more than 1 mg (given as 0.2 mg/min) should be administered at any one time. No more than 3 mg should be given in any one hour.

Front 102

108. REPEAT Brain hematoma which is isodense on T1 and hypointense on T2. What type of blood degradation products?

Back 102

Deoxyhemoglobin*

<br>NEW! I Be IdDy BidDy BaBy DooDoo (also IB, II, ID, BD, BB, DD)
<br>
<br>I - isointense, B - bright, D - dark
<br>
<br>• I Be - Immediate - IB to II (T1/T2)
<br>» Intracellular Oxy-Hgb
<br>
<br>• IdDy - Hyperacute (4-6 hrs) - II to ID (T1/T2)
<br>» Intracellular De-oxy-Hgb
<br>
<br>• BiDdy - Acute (7-72hrs) - BD (T1/T2)
<br>» Intracellular Met-Hgb
<br>
<br>• Bee Bee (BaBy) - Subacute (1-4 wks) - BB (T1/T2)
<br>» Extracellular Met-Hgb
<br>
<br>• Dee Dee (DoDo)- Chronic (> 4 wks) - ID or DD (T1/T2)
<br>» Hemosiderin and ferritin
<br>

Front 103

109. REPEAT Which is the most serious neck injury in a child?
- Anterior flexion teardrop*
- Hangmans
- Jefferson
- Facet lock

Back 103

serious neck injury in a child?
- Anterior flexion teardrop*

Front 104

110. REPEAT What type of injury is a Hangmans fracture?
-Hyperextension
-Hyperflexion
-Axial loading
-Torque

Back 104

Hyperextension*

Front 105

111. REPEAT Which is not an indication for sonohysterography?
-Acute pelvic inflammatory dz
-Several other right answers including endometrial path, congenital defects, bleeding, etc.

Back 105

Acute pelvic inflammatory dz*

Front 106

Male patient with retroperitoneal mass which encases vessels and decreased T1 and T2 signal?

Back 106

retroperitoneal fibrosis*

Front 107

113. REPEAT Which ovarian tumor has estrogenic effects?

Back 107

granulosa cell tumor*

Terminology
• Neoplasm composed of a pure or at least 10% population of granulosa cells often in a fibrothecomatous background
• Major subtypes: Adult and juvenile type
Imaging Findings
• Best diagnostic clue: Large solid and cystic adnexal mass and thickened endometrial stripe
• Almost always unilateral
• Low signal on T2WI or fluid-fluid levels with intracystic hemorrhage
• Color Doppler: Low resistance vessels in thickened septations or solid component
Pathology
• Endometrial lesion: Classically described is anovulatory pattern with cystic hyperplasia
• Atypical hyperplasia or endometrial carcinomas in 5% of tumors
• Tumor cells grow in a variety of patterns, best known is microfollicular with Call-Exner bodies
Clinical Issues
• Metrorrhagia, postmenopausal bleeding
• Isosexual precocious puberty in pediatric population
Diagnostic Checklist
• Tumor secretes estrogen therefore consider when endometrial lesion is seen in association with heterogeneous solid adnexal mass

Front 108

114. REPEAT What is associated with a unilateral seminal vesicle cyst?

Back 108

renal agenesis*

Front 109

115. REPEAT Which renal disease is most commonly unilateral?
-MCDK
-ADPKD
-ARPKD
-Chronic renal failure related cysts
-Medullary cystic disease

Back 109

-MCDK

Front 110

116. In utero radiograph in fetus with peritoneal calcifications. What do they definitely have?
- Prior bowel perforation
- Cystic fibrosis
- Meconium pseudocyst

Back 110

Prior bowel perforation

Terminology
• Chemical peritonitis due to intrauterine bowel perforation
Imaging Findings
• Combination of ascites, calcifications and dilated bowel is pathognomonic
• Calcifications most specific finding
• Intraperitoneal calcifications in 85%
• Implants on peritoneal surfaces
• Liver capsule often most obvious
• Ascites secondary to both spilled contents and inflammatory response
• Meconium pseudocyst
• Dilated bowel
• Infection may lead to vascular compromise and perforation
Top Differential Diagnoses
• Hyperechoic bowel
• Infection
• Gallstones
• Enteroliths
Pathology
• Cystic fibrosis in 8% of fetal cases
Clinical Issues
• Calcification visible 1-2 weeks after perforation
• Prognosis much better for fetus than neonate
• Spontaneous in utero closure of perforation may occur
• Mortality 11-14% for in utero diagnosis
• Genetic counseling for cystic fibrosis

Front 111

117. Most common cause of a hydrocele in a newborn?
-patent processus vaginalis
-torsion
-infection
-epididymitis

Back 111

-patent processus vaginalis*

Front 112

Nuchal lucency measured at what age?

Back 112

-11-14 weeks*

Front 113

Normal level of the conus in a newborn?

Back 113

-L1-L2*

Front 114

120. REPEAT Giant ulcers in the esophagus are least likely caused by?
-HSV
-CMV
-HIV
-melanoma mets
-esophageal cancer

Back 114

-HSV*

Front 115

111. REPEAT Which is not an indication for sonohysterography?
-Acute pelvic inflammatory dz
-Several other right answers including endometrial path, congenital defects, bleeding, etc.

Back 115

Acute pelvic inflammatory dz*

Front 116

Male patient with retroperitoneal mass which encases vessels and decreased T1 and T2 signal?

Back 116

retroperitoneal fibrosis*

Front 117

113. REPEAT Which ovarian tumor has estrogenic effects?

Back 117

granulosa cell tumor*

Terminology
• Neoplasm composed of a pure or at least 10% population of granulosa cells often in a fibrothecomatous background
• Major subtypes: Adult and juvenile type
Imaging Findings
• Best diagnostic clue: Large solid and cystic adnexal mass and thickened endometrial stripe
• Almost always unilateral
• Low signal on T2WI or fluid-fluid levels with intracystic hemorrhage
• Color Doppler: Low resistance vessels in thickened septations or solid component
Pathology
• Endometrial lesion: Classically described is anovulatory pattern with cystic hyperplasia
• Atypical hyperplasia or endometrial carcinomas in 5% of tumors
• Tumor cells grow in a variety of patterns, best known is microfollicular with Call-Exner bodies
Clinical Issues
• Metrorrhagia, postmenopausal bleeding
• Isosexual precocious puberty in pediatric population
Diagnostic Checklist
• Tumor secretes estrogen therefore consider when endometrial lesion is seen in association with heterogeneous solid adnexal mass

Front 118

114. REPEAT What is associated with a unilateral seminal vesicle cyst?

Back 118

renal agenesis*

Front 119

115. REPEAT Which renal disease is most commonly unilateral?
-MCDK
-ADPKD
-ARPKD
-Chronic renal failure related cysts
-Medullary cystic disease

Back 119

-MCDK

Front 120

121. REPEAT Hepatic hydrothorax, which is true?
-Can occur with little ascites
-Most common on left
-Can be seen without cirrhosis
-Pleurodesis best initial treatment

Back 120

-Can occur with little ascites

Front 121

122. Which of the following injuries is caused by NON-tensile forces?
-Transverse patellar fx
-Patellar sleeve fracture
-Stellate patellar fx
-Quadriceps tendon strain
-Tibial tubercle avulsion

Back 121

-Stellate patellar fx

• Direct fx: Forceful blow to patella & flexed knee
• Common cause of stellate and vertical fractures
• More comminuted
• Less displaced
• More articular cartilage damage
• Indirect fx: Forceful jump, twist, fall, or near fall
• Transverse fracture
• Patellar retinaculum tear → fx diastasis

Front 122

123. In a child, linear areas of decreased MRI signal lining the synovium most likely related to?
-Hemophilia
-Osteochondromatosis
-Some other wrong answers

Back 122

-Hemophilia*

Front 123

124. REPEAT Child with intramuscular mass with phleboliths. He is 10 years old. What is it likely?
-Venous malformation
-Capillary hemangioma
-Lymphatic malformation

Back 123

-Venous malformation

Soft tissue hemangioma (cavernous) venous malformation
Imaging Findings
• Soft tissue mass of muscle-fat density on radiographs or CT, phleboliths (diagnostic)
• Areas of high signal on T1 and T2WI MR with flow voids
Top Differential Diagnoses
• Lipoma
• Hematoma
• Hemophilia
Pathology
• 7% of all benign tumors
• Most common tumor of infancy and childhood
Clinical Issues
• Most hemangiomas are asymptomatic
• Superficial lesions: Purple discoloration of overlying skin
• Intramuscular lesions: Pain after exercise
• Synovial lesion: Recurrent episodes of joint pain, swelling, effusion
• Benign lesion, no malignant transformation
• 90% of juvenile capillary hemangiomas involute by age 7
• Cavernous hemangiomas do not involute, can cause local destruction by increased pressure
• Capillary hemangiomas: Followed clinically
• Cavernous hemangiomas: Often require surgical resection with wide margins

Front 124

125. REPEAT Kid with multiple calcified para-articular soft tissue masses. Most likely cause?
-Idiopathic tumoral calcinosis
-Other wrong answers

Back 124

Idiopathic tumoral calcinosis

# The soft tissue calcifications may be single or multiple, lobulated, cystic or solid.
# It usually occurs about the hips, elbows and shoulders.
# The masses may range in size from 1 to 20 cm in diameter.
# There may be a family history in 30 - 40 % of cases.
# Onset is usually during childhood or adolescence.
# There may be an increased prevalence in patients of African descent.
# Laboratory findings may be normal or slightly elevated:


* Normal renal and parathyroid function
* Normal or slightly elevated serum calcium, phosphorus, uric acid, and
alkaline phosphatase

Front 125

126. Tendon would be best imaged with what type of transducer?
-10mHz Linear
-10mHz Curved
-10mHz Phased array
-5mHz Linear
-5 mHz Curved

Back 125

-10mHz Linear

Front 126

. REPEAT Flow is at 300 m/sec. You have your equipment set at 200 m/sec. Which artifact will occur?

Back 126

Aliasing*

Front 127

128. Some question about HELLP syndrome? Which is true
-Does not cause hepatic rupture
-Associated with pre-eclampsia 95% of the time
-Liver bleeding associated with the syndrome not treatable by interventional techniques
-Common in 1st trimester

Back 127

Associated with pre-eclampsia 95% of the time



*Terminology
• Hemolysis, Elevated Liver enzymes, Low Platelets (HELLP)
• HELLP syndrome is a serious variant of preeclampsia seen primarily in young primigravidas
Imaging Findings
• Best diagnostic clue: Intrahepatic or subcapsular fluid collection (hematoma) on US or CT
• Acute: Hyperattenuating (first 24-72 hours)
• Chronic: Decreased attenuation (after 72 hours)
Top Differential Diagnoses
• Bleeding hepatic tumor
• Spontaneous bleed (coagulopathy)
• Hepatic trauma
• Acute fatty liver of pregnancy
Pathology
• 4-12% of patients with preeclampsia have HELLP syndrome
Clinical Issues
• Acute epigastric & RUQ pain present in 90% of cases
• Overall maternal mortality rate is 3.5%
• Maternal and fetal mortality approach 50% in cases of liver rupture
Diagnostic Checklist
• Rule out bleeding liver tumors like adenoma, HCC & other liver pathologies like acute viral hepatitis & acute fatty liver of pregnancy
• Very rarely, can occur without classic preeclampsia triad (hypertension, proteinuria & edema)

Front 128

128. REPEAT Which type of endoleak needs immediate correction?
-Proximal attachment leak
-They gave two different types of retrograde, Type 2 leaks
-Graft porosity

Back 128

-Proximal attachment leak*

Terminology
• Persistent perfusion of aneurysmal sac after endovascular aneurysm repair (EVAR)
Imaging Findings
• Leakage of contrast media outside endograft into aneurysm sac
• CT angiography is shown to be superior to intraarterial DSA for detecting endoleaks
• Delayed CT angiography sequence performed 1-2 min following contrast administration to detect late endoleak
• MR only in Nitinol based stent grafts
• MR greater sensitivity than CT for slow flow type II endoleaks
• Best surveillance method is CTA or MRA with aneurysm volume measurements
Top Differential Diagnoses
• Type I Endoleak (Graft-Related Endoleak)
• Type II Endoleak (Nongraft-Related Endoleak)
• Type III Endoleak (Device Failure)
• Type IV Endoleak (Graft Porosity)
• Type V Endotension
Pathology
• Epidemiology: Eurostar registry: Endoleaks occur in 2.4-45.5% of patients following endovascular repair of thoracic and abdominal aortic aneurysms
Clinical Issues
• Persistence of types I and III endoleak beyond 3-6 months increases the risk of aneurysm rupture
• Role of type II endoleaks relative to aortic rupture is controversial

Front 129

129. REPEAT Older lady with cough, bilateral middle lobe and lingular opacities and bronchiectasis. Causes?

Back 129

- MAI infection* (“Lady Windemere” syndrome)

Front 130

130. Child with cavitating pneumonia and parapneumonic effusion. Most likely cause?
-Strep pneumo
-TB
-Klebsiella
-Mycoplasma
-Staph not a choice

Back 130

Strep pneumo*

Front 131

131. REPEAT Clockwise rotation of the interventricular septum caused by which?

Back 131

-Pulmonary artery hypertension*

Front 132

132. REPEAT What breast MRI contrast enhancement characteristics are most worrisome for cancer?
-Early enhancement and rapid washout
-Early with plateau
-Early with increasing delayed enhancemnet
-Late enhancement with rapid washout

Back 132

Early enhancement and rapid washout*

Front 133

133. Most common cancer to present as a spiculated mass?
-Tubular*
-Papillary
-Lobular
-Mucinous
-Medullary, Ductal not an answer

Back 133

Tubular*

Terminology

* Special type of well differentiated invasive ductal carcinoma (IDC) composed of well differentiated tubular structures with open lumina lined by a single layer of epithelial cells

Imaging Findings

* Small spiculated mass on mammogram, can be stable for years
* One of the smallest infiltrating cancers
* Associated amorphous or pleomorphic microcalcifications (Ca++) in up to 50%
* Can be source of false negative MR
* Typically highly conspicuous on US

Top Differential Diagnoses

* Radial Scar or Radial Sclerosing Lesion (RSL)
* Tubular carcinoma may co-exist with radial scar/RSL
* Invasive Ductal Carcinoma (IDC), NOS
* Infiltrating Lobular Carcinoma (ILC)
* Sclerosing Adenosis

Pathology

* 2% of female breast cancers
* ↑ Incidence of contralateral carcinoma: 10-15%
* Myoepithelial cell layer absent: Lacks actin or p63 staining (sometimes performed to distinguish from sclerosing adenosis)

Clinical Issues

* Most lesions detected on screening mammography
* Mean: 50 years
* Slow growing, favorable prognosis
* 95-98% five-year survival

Front 134

134. REPEAT Blur related to motion most pronounced where/on which mammo view?
-Inferior breast on MLO view*
-Superior breast on MLO
-Medial on CC
-Lateral on CC

Back 134

Inferior breast on MLO view*

Front 135

135. REPEAT Wilms tumor not associated with which of the following?
-Hereditary aniridia
-Beckwith-Wiedemann
-Hemihypertrophy

Back 135

Hereditary aniridia - as apposed to sporadic in the case of wilms

• Associated abnormalities
• Genitourinary anomalies
• Overgrowth syndromes (Beckwith-Wiedemann and isolated hemihypertrophy)
• Sporadic aniridia
• Trisomy 18
• Sotos syndrome
• Bloom syndrome
• Denys-Drash syndrome
• WAGR syndrome: Wilms tumor, aniridia, genitourinary anomalies, and mental retardation
o Contiguous gene deletion syndrome involving the Wilms tumor 1 gene (WT1), the paired box gene 6 (PAX6), and possibly other genes on chromosome 11p13
Major congenital anomalies include genitourinary anomalies (WAGR and Denys-Drash syndromes, 5% of cases), ectopic solitary horseshoe kidney, hypospadias and cryptorchidism, hemihypertrophy and organomegaly (Beckwith-Wiedemann syndrome, 2% of cases); and aniridia (1% of cases). Children with such syndrome anomalies should undergo periodic testing for Wilms tumor. Ultrasonography of the kidneys (once or twice per year) is a good screening tool.

Front 136

136. Which is true regarding choledochal cysts?
-Most common in males
-Not increased risk of cholangiocarcinoma
-Type 2 most common
-Pancreatitis in 30%

Back 136

136. Which is true regarding choledochal cysts?
-Most common in males (no, more prevalent in females)
-Not increased risk of cholangiocarcinoma (no, there is increased risk of cholangio)
-Type 2 most common (no, type 1 is most common)
-Pancreatitis in 30%

Front 137

137. REPEAT Which fracture is most specific for child abuse?
-Scapula
-Vertebrae
-Clavicle
-Skull
-Corner fx and posterior rib not choices

Back 137

-Scapula

Front 138

138. Necrotic erythema migrans associated with which of the following tumors?
-Glucagonoma
-Insulinoma
-Wermers syndrome

Back 138

-Glucagonoma

Glucagonoma syndrome -- necrolytic migratory erythema
• alpha cell tumor of the pancreas; occasionally no neoplasm found
• abdomen, thighs and buttocks
• patchy erythema with flaccid vesicles and bullae
• glossitis, angular cheilitis, normocytic anemia, low amino acid levels in serum

General Features
• General path comments
o Embryology-anatomy
 Originate from embryonic neuroectoderm
• Etiology
o Arise from APUD cells
 APUD: Amine precursor uptake & decarboxylation
o Pathogenesis
 Insulinoma: β-cell tumor → hyperinsulinemia → hypoglycemia
 Gastrinoma: Islet cell tumor → increased gastrin → increased gastric acid → peptic ulcer
 Glucagonoma: α-cell tumor → increased glucagon→ erythema migrans & diabetes mellitus
 Nonfunctioning: Derived from α & β cells
• Epidemiology
o Insulinoma: Most common islet cell tumor
 Solitary benign (90%); malignant (10%)
o Gastrinoma: 2nd common
 Multiple & malignant (60%); MEN I (20-60%)
o Nonfunctioning: 3rd common
 Accounts 20-45% of all islet cell tumors
 Malignant (80-100%)
• Associated abnormalities
o Gastrinoma (Zollinger-Ellison syndrome)
 Associated with MEN type I
Presentation
• Most common signs/symptoms
o Insulinoma: Whipple triad (hypoglycemia + low fasting glucose + relief by IV glucose)
 Palpitations, sweating, tremors, headache, coma
o Gastrinoma (Zollinger-Ellison syndrome)
 Peptic ulcer, increased acidity & diarrhea
o Glucagonoma: Necrolytic erythema migrans, diarrhea, diabetes, weight loss
o Nonfunctional
 Mostly asymptomatic
 Pain, jaundice, variceal bleeding

Front 139

139. REPEAT Most common appearance of ADH on mammo?
-Calcifications
-Ill defined mass
-Well defined mass
-Asymmetry focal

Back 139

-Calcifications

Mammographic Findings
• Amorphous calcifications (Ca++) most common
o Clustered distribution > regional
• Other Ca++ morphologies: Punctate, pleomorphic
o Fine linear Ca++ favor DCIS
• ADH can be incidental finding at histopathology
o Within a fibroadenoma (FA) or papilloma
o Within fibrosis, other fibrocystic changes (FCC)
o Along spicules of radial scar or radial sclerosing lesion (RSL)
 RSL may be manifest as architectural distortion
o Adjacent to or admixed with carcinoma
Consider
• Frequent upgrade to malignancy after CNB diagnosis
Image Interpretation Pearls
• Clustered amorphous Ca++ suspicious, merit biopsy
• Patient is at high risk for developing cancer
o Careful evaluation of both breasts at time of diagnosis of ADH
o High-risk surveillance: Strategies evolving

Front 140

Pulsatile exopthalmos in NF kid caused by?

Back 140

Sphenoid hyperplasia*

The entity of cranio-orbital-temporal neurofibromatosis is an uncommon subtype of NF-1 and is characterized by pulsatile exophthalmos orbital neurofibromas, sphenoid wing dysplasia, expansion of the temporal fossa and herniation of the temporal lobe into the orbit [3]. One such case encountered recently is presented.

Front 141

142. Oligohydramnios caused by all of the following except?
-maternal diabetes
-posterior urethral valves
-PPROM
-growth restriction

Back 141

-maternal diabetes

Front 142

143. REPEAT What liver tumor is more common in people with glycogen storage dz?

Back 142

hepatic adenomas*

Terminology
• Hepatocellular adenoma (HCA) or liver cell adenoma
• Benign tumor that arises from hepatocytes arranged in cords that occasionally form bile
Imaging Findings
• Best diagnostic clue: Heterogeneous, hypervascular mass with hemorrhage in a young woman
• Subcapsular region of right lobe of liver (75%)
• Average size: 8-10 cm
Top Differential Diagnoses
• Hepatocellular carcinoma (HCC)
• Fibrolamellar hepatocellular carcinoma
• Focal nodular hyperplasia (FNH)
• Hypervascular metastases
Pathology
• Hemorrhage, necrosis & fatty change
• No scar within tumor
• ↑ Risk in oral contraceptives & anabolic steroid users
Clinical Issues
• RUQ pain (40%): Due to hemorrhage
• May be mistaken clinically/pathologically for HCC
• Clinical Profile: Woman on oral contraceptives
Diagnostic Checklist
• Rule out other benign & malignant liver tumors which have similar imaging features, particularly HCC or FNH
• Check for history of oral contraceptives & glycogen storage disease (in case of multiple adenomas)

Front 143

144. Young male with cystic lesion anterior and superior to bladder. This is most likely?
-urachal cyst
-seminal vesicle cyst
-dilated utricle
-mullerian remnant

Back 143

-urachal cyst*

Terminology
• Urachal abnormalities: Incomplete obliteration of embryonic connection between bladder dome and allantoic duct
• Patent urachus: Entire urachal channel fails to close
• Urachal cyst: Umbilical and bladder openings close; channel in between remains open and fluid-filled
• Urachal sinus: Dilatation of urachus at umbilical end; no communication with bladder
• Urachal diverticulum: Dilatation of urachus at vesical end; no communication with umbilicus
Imaging Findings
• Urachal carcinoma: Midline supravesical soft tissue mass; calcification in 70%
Clinical Issues
• Urachal carcinoma: 5 year survival ≤ 15%

Front 144

145. Which stone is most radiolucent?
-Struvite
-Matrix
-Uric acid
-Cystine

Back 144

-Uric acid*

• Radiopacity (most to least): Calcium oxalate and/or phosphate > cystine > struvite > uric acid

Front 145

146. REPEAT Older male with scrotal mass involving the testis and epididymis?
-Lymphoma
-Adenomatoid tumor
-Seminoma

Back 145

-Lymphoma*

Front 146

147 Most common cause for microcolon?
-Ileal atresia
-Hirschprungs
-Meconium plug
-Duodenal atresia

Back 146

-Ileal atresia

Front 147

148. REPEAT Cystic hygroma in a fetal ultrasound. They most likely have what syndrome?
-Turners
-Trisomy 21
-Trisomy 18
-Trisomy 13

Back 147

-Turners*

Cystic hygroma

Terminology
• Dorsal and lateral nuchal cyst
Imaging Findings
• Best diagnostic clue: Multiseptated nuchal fluid
• Multiple fine linear septations
• Thick midline septation is nuchal ligament
• Size can be massive
• Small CH can evolve into thick nuchal fold (↑ NF)
• Non-immune hydrops common with large hygromas
• Cardiovascular anomalies often present
• Aneuploidy in 2/3 fetuses with 2nd trimester CH
• Turner syndrome
• Trisomy 21 (T21)
• Largest 1st trimester nuchal translucencies seen in Turner syndrome
Top Differential Diagnoses
• Increased nuchal fold
• Cervical teratoma
• Body/trunk lymphangioma
• Occipital encephalocele
Clinical Issues
• Fetal demise
• Only 9% survive without major morbidity
• Webbed neck from smaller resolved hygromas
Diagnostic Checklist
• Genetic testing when CH seen
• T21 > Turner with 1st trimester CH
• Turner > T21 with 2nd trimester CH
• CH + hydrops with grim prognosis

Front 148

149. REPEAT Which pattern of microcalcifications is most worrisome?
-Segmental
-Regional
-Bilateral diffuse
-Unilateral diffuse

Back 148

-Segmental
Terminology
• Calcification (Ca++) deposits in a duct or multiple ducts and their branches
• Involves one or multiple segments or lobes of the breast
• Enhancement on MR in a single ductal system
Imaging Findings
• Best diagnostic clue: Ca++ or MR enhancement radiates toward the nipple along expected course of ductal system(s)
• Unless secretory Ca++, distribution suggests malignancy
• Punctate and/or amorphous calcifications suspicious
• Pleomorphic or fine linear calcifications highly suggestive of malignancy
• US can help target biopsy if associated mass, likely invasive component
• Protocol advice: Magnification CC and ML views help define extent and morphology of Ca++
Top Differential Diagnoses
• Ductal Carcinoma in Situ (DCIS)
• Extensive Intraductal Component (EIC)
• Invasive Ductal Carcinoma (IDC), NOS
• Secretory calcifications: Usually bilateral, coarse, smooth, rod-like, ≥ 1 mm in diameter
Clinical Issues
• 74% segmental calcifications malignant
• 34-67% segmental MR enhancement malignant; specificity 96%

Front 149

150. There are stable linear, pleomorphic calcifications that have been present and stable for 2 years. What do you do next?
-Annual mammo
-Short interval mammo, 6 months
-Stereotactic biopsy
-Surgical excision

Back 149

Biopsy

Terminology
• Heterogeneous, granular calcifications (Ca++); "shard-like" Ca++
• Typically denser and more conspicuous than amorphous Ca++
Imaging Findings
• Mammography findings are considered suspicious and warrant recommendation for biopsy
• MR may demonstrate mass or non-mass enhancement patterns in the areas of the calcifications
• Vacuum-assisted large core needle with 10-12 samples recommended
Top Differential Diagnoses
• Ductal Carcinoma in Situ (DCIS)
• Atypical Duct Hyperplasia
• Fat Necrosis
Pathology
• Overall have an intermediate, 25-40% risk of malignancy; BI-RADS 4B or 4C
Clinical Issues
• Most common signs/symptoms: Incidental mammographic finding
• If DCIS, progression to invasion in 33-50% cases
Diagnostic Checklist
• Careful assessment of Ca++ morphology revealing pleomorphic findings should not result in a BI-RADS 3 short interval follow-up

Front 150

151. Coronary calcification is thought to signify what?
-Calcified, healed previously ruptured plaques
-Clinically significant stenotic regions
-Some other wrong answers

Back 150

-Clinically significant stenotic regions

Front 151

152. REPEAT Complete right homonymous hemianopsia. Where is the lesion?
-Optic nerve
-Optic chiasm
-Medial geniculate
-Optic tract
-Optic radiations

Back 151

Optic tract and or radiations

Homonymous hemianopia is a visual field defect involving either the two right or the two left halves of the visual fields of both eyes. It is caused by lesions of the retrochiasmal visual pathways, ie, lesions of the optic tract, the lateral geniculate nucleus, the optic radiations, and the cerebral visual (occipital) cortex

Front 152

153. REPEAT Most specific physiologic lung finding in COPD?
-Reduced FEV/FVC ratio
-Reduced FEV
-Reduced FVC
-Reduced TLC

Back 152

-Reduced FEV/FVC ratio*

Front 153

154. Patient with prior renal artery angioplasty. Now with CHF, hypertension and painless hematuria. Cause?
-AV fistula
-Pseudoaneurysm
-Renal vein thrombosis
-Some other wrong choices

Back 153

-AV fistula

Front 154

155. REPEAT Most common location of intraventricular meningioma?
-Atria of the lateral ventricles
-Frontal horns
-Third ventricle
-Fourth ventricle

Back 154

-Atria of the lateral ventricles*

Front 155

Where do you place an IVC filter?

Back 155

Below the renal veins*

Front 156

157. Most common complication of IVC filter placement?
-Migration
-Renal vein thrombosis
-Lower extremity thrombosis
-Infection
-IVC thrombosis

Back 156

-IVC thrombosis

Filters vary the most in incidence of caval thrombosis, with rates in the 3% to 9% range (Fig. 25.20). Additional complications include filter migration, caval perforation, tilting of the filter, and filter fracture.

Front 157

158. REPEAT What procedure do you perform prior to removal of IVC filter?

Back 157

- IVC venogram to evaluate for residual thrombus in filter*

Front 158

159. REPEAT What are most important findings to evaluate in rectal cancer?

Back 158

-Depth of invasion and regional lymph nodes*

Front 159

160. Which will give you a decreased bone mineral density on DEXA?
-Multiple myeloma
-Blastic mets
-Pagets disease
-Degenerative disc disease

Back 159

-Multiple myeloma*

Front 160

161. REPEAT What will help cure chronic bleeding gastric varices related to chronic splenic vein thrombosis?
-Splenectomy
-TIPS
-Beta blocker

Back 160

Splenectomy*

Front 161

162. REPEAT Most likely injured vessel in Mallory Weiss tear?
-Left gastric artery
-Coronary vein
-Other wrong choices

Back 161

-Left gastric artery*

Front 162

163. Cystic artery most commonly originates from which artery?
-Right hepatic
-Left hepatic
-Left gastric
-Gastroduodenal
-SMA

Back 162

-Right hepatic*

Front 163

164. Lesser sac communicates with which peritoneal cavity via the foramen of Winslow?
-Left posterior subhepatic
-Left anterior subhepatic
-Subphrenic recess
-Hepatorenal recess
-Right paracolic gutter

Back 163

164. Lesser sac communicates with which peritoneal cavity via the foramen of Winslow?
-Left posterior subhepatic
-Left anterior subhepatic
-Subphrenic recess
-Hepatorenal recess
-Right paracolic gutter

Best guess is hepatorenal space or morrison's pouch

Front 164

165. Which is true of left gastroduodenal hernias?
-Arise from defect in the mesocolon
-Usually posterior to pancreatic tail
-Usually displace SMV posteriorly
-Extend through foramen of Winslow


170. Which is associated with a left paraduodenal hernia?
a. Arise from defect in the mesocolon
b. Usually posterior to pancreatic tail
c. Usually displace SMV posterior
d. Extend through foramen of Winslow

Back 164

probably left paraduodenal hernia is what they are looking for.

Terminology

* Protrusion of bowel loops through mesenteric defect within abdominal cavity

Imaging Findings

* Best diagnostic clue: CECT: Cluster of dilated bowel loops with distorted mesenteric vessels
* Left (75%): Via paraduodenal (lateral to 4th part) mesenteric fossa of Landzert, near ligament of Treitz
* Right (25%): Via jejunal mesentericoparietal fossa of Waldeyer
* Best imaging tool: CECT, SBFT

Top Differential Diagnoses

* Closed Loop Obstruction (SBO)
* Transmesenteric Internal (TMI) Hernia

Pathology

* Congenital or developmental mesenteric anomalies
* Complication of surgery or trauma

Clinical Issues

* Smaller hernias are clinically silent but easily reducible
* Larger hernias: Vague discomfort, abdominal distension, periumbilical colicky pain, palpable mass, localized tenderness

Diagnostic Checklist

* Consider incarceration if bowel loops are thickened
* Cluster of dilated small bowel loops lateral to ascending or descending duodenum with crowded/twisted mesenteric vessels

Front 165

166. Which is true regarding I131 therapy for Plummers dz versus Graves?
-Plummers requires a higher dose usually
-More incidence of hypothyroidism with increased dose used in Plummers
-Ophthalmopathy is a side effect

Back 165

-Plummers requires a higher dose usually*

Treatment
• Medical therapy: Thyroid-blocking propylthiouracil (PTU) or methimazole
o Often used to achieve protective euthyroid state before radioiodine ablation, thyroidectomy
o Usually only successful in short term (thyrotoxicosis almost always recurs)
• Radioiodine ablation: 25-30 mCi (925-1110 MBq) I-131 usually effective
o More radio-resistant than Graves
 Higher I-131 doses used
 May require multiple treatments
o Risk of thyroid crisis/storm after treatment
 Beta blocker or thyroid-blocking medications protective
o Postablative hypothyroidism
 Occurs less frequently than with Graves treatment
 Suppressed thyroid relatively protected
 < 10% of patients hypothyroid by 5 years
• Surgical treatment: Lobectomy or nodule excision
o Common therapy for large toxic nodules
o More successful treatment of solitary toxic nodules than MNG, Graves
o Recurrent thyrotoxicosis, hypothyroidism after surgery very rare

Front 166

167. REPEAT Which structure is not lateral in the knee?
-Semimembranosus
-Popliteus tendon
-Plantaris tendon
-Fibular collateral ligament

Back 166

-Semimembranosus

Front 167

Popliteal cysts in the knee usually arise between which 2 structures?

Back 167

-Medial head of gastrocnemius and semimembranosus*

Terminology
• Fluid distension of gastrocnemius/semimembranosus bursa which is usually in communication with the knee joint
Imaging Findings
• Best diagnostic clue: Fluid signal intensity mass in typical location (gastrocnemius/semimembranosus bursa)
• Morphology: Flattened sac to oval shaped cystic mass depending on the amount of fluid
• Typical findings of fluid-filled mass on ultrasound
• Best imaging tool: MRI
Top Differential Diagnoses
• Meniscal Cyst
• Cystic Adventitial Degeneration of a Popliteal Artery
• Popliteal Artery Aneurysm
Pathology
• Baker's cyst usually communicates with the joint at posteromedial knee
• Fluid from joint effusion extending into cyst
Clinical Issues
• Popliteal mass, swelling, dull ache, knee effusion
• Cyst may regress or enlarge
Diagnostic Checklist
• Evaluate underlying disorder as a popliteal cyst is common and is frequently associated with intraarticular pathology
• Follow the course of the popliteal cyst proximally for confirmation of orgin and joint communication

Front 168

169. Which structure divides the right and left hepatic lobes?
-Gallbladder fossa
-Right hepatic vein
-Right portal vein
-Ligamentum venosus

Back 168

-Gallbladder fossa

Front 169

170. Radiographs of a breast specimen with calcification should be obtained why?
-Be sure the lesion has been localized and resected
-Evaluate margins
-Predict pathology in specimen
-Other wrong answers

Back 169

-Be sure the lesion has been localized and resected*

Front 170

171. REPEAT Which part of myocardium is most susceptible to ischemia?
-Subendocardium
-Subepicardium
-Myocardium

Back 170

Subendocardium*

Front 171

172. Patient with anterior pericardial calcifications. There is enlargement of both atria and the azygous vein. Most likely cause?

Back 171

Constrictive pericarditis*

Front 172

173. REPEAT Absolute contraindication to breast conservation therapy?
-Prior breast irradiation
-Multifocal masses
-Single large mass

Back 172

-Prior breast irradiation

Front 173

78. Edema in muscles of posterior compartment of forearm...
a. Radial nerve
b. Ulnar nerve
c. Median nerve
d. Posterior interosseous nerve

Back 173

radial

78. Edema in muscles of posterior compartment of forearm...
a. Radial nerve
b. Ulnar nerve
c. Median nerve
d. Posterior interosseous nerve

Ans: given the incomplete recall, prob A:

“The posterior compartment of the arm is an anatomic compartment which contains muscles which are all supplied by the radial nerve.”

Front 174

175. Most common cause of acute mesenteric ischemia?
-Cardiogenic thrombotic source
-Atheroemboli from aortic source
-Occlusion at focal atherosclerotic plaque in the mesenteric artery
-Other wrong answers

Back 174

-Cardiogenic thrombotic source

Ischemic enteritis
General Features
• General path comments
o Accounts for 1% of acute abdomen
o Arterial > venous occlusive ischemia: 9:1
o 60-70% of acute ischemia due to arterial occlusion, 5-10% due to venous occlusion
o 20-30% of acute ischemia is nonocclusive
• Etiology
o Vascular occlusion: Embolic events (atrial fibrillation, endocarditis), thrombotic events (atherosclerosis) or mechanical obstruction (strangulation, tumor)
o Closed loop obstruction especially dangerous
o Hypercoagulable states: Oral contraceptives, protein C deficiency, factor V Leiden deficiency
o Inflammatory: Pancreatitis, peritonitis or vasculitis
 Common cause of ischemia in younger patients
 Systemic lupus erythematosus, polyarteritis nodosa, other collagen vascular diseases
 Vasculitis may affect kidneys and other organs
 Angiography may show microaneurysms and occluded vessels
o Iatrogenic causes: Radiation and chemotherapy, therapeutic drugs (digitalis, dopamine, vasopressin), illicit drugs (heroin, cocaine)
o Hypoperfusion (more common in ischemic colitis): Low flow states, hypotension, sepsis, heart failure
• Epidemiology: Risk factors of chronic ischemia include hypertension, coronary artery disease, cerebrovascular disease

Front 175

176. REPEAT What is the sentinel node?

Back 175

-First node seen*

Front 176

177. REPEAT Most common cause of failure of dialysis graft?

Back 176

Outflow tract stenosis

Front 177

178. Most common finding during failure of dialysis graft?
-Elevated venous pressures
-Palpable thrill
-Systemic HTN
-Increased urea clearance

Back 177

-Elevated venous pressures*


Presentation
• Most common signs/symptoms: Acute AV graft thrombosis with resultant loss of graft patency and inability to dialyze patient
• Other signs/symptoms
o High venous pressures during dialysis predictive of underlying venous stenosis
o "Steal syndrome": Cool, painful and sometimes ischemic extremity distal to fistula
 Results from arterial stenosis distal to arterial anastomosis of graft, with resultant preferential arterial flow into graft

Front 178

179. REPEAT Which is true regarding ultrasound guided breast biopsy?
-Needle tip should be approx 1 cm proximal to lesion before firing
-Needle entry 1 mm from transducer tip
-Take a vertical approach
-Needle tip oriented perpendicular to transducer plane

Back 178

-Needle tip should be approx 1 cm proximal to lesion before firing

Patient Position/Location
• Best procedure approach
o Patient supine or rolled, ipsilateral arm raised
 Usually operator on right side of patient; may need left-sided approach or swap hands
 Needle path ideally near-horizontal, lesion directly in front of operator
 Minimize operator stretching or angulation
Equipment Preparation
• Arrange couch, US machine & monitor according to approach
• Ensure appropriate probe and tissue presets selected
Procedure Steps
• Informed consent signed
• Ensure proper lesion being targeted
• Mark skin at planned puncture site location
o Farther from probe for deeper lesions
o Needle path preferably along probe face
• Inject local anesthetic into skin subcutaneously
o Raise wheal by injecting just deep to skin first then withdrawing slightly
o Inject to edge of lesion, deep to lesion, and beyond lesion along expected path of core needle
o For posterior lesions, can "elevate" lesion off chest wall by injecting anesthetic posterior to mass
• Make small skin nick (2-3 mm) with scalpel blade
• Insert (optional) 12-13 gauge coaxial trocar/cannula to edge of lesion
• Probe-needle-lesion alignment
o Keep needle shaft angle < 30° relative to probe face
o Gentle compression over lesion to stabilize
o Alternately move needle and probe to confirm needle position
o Needle tip has specular reflection, especially with bevel facing downwards
o Direct visual check of needle and probe alignment
o Document needle position before ("pre") and after ("post") firing gun
 Can confirm needle through lesion with short-axis perpendicular view
• Semi-automated biopsy system ("fire-in-place" type)
o Push inner needle through lesion
o Ensure trough is across lesion, then fire
• Automated biopsy gun system ("fire-forward" type)
o Desirable to sample edge of lesion: Avoid necrotic center
o Mobile mass: Can anchor tip of needle in edge of mass prior to firing
o Double check alignment & depth of needle throw (15 mm or 22 mm typical)
o Compress lesion with probe to stabilize, then fire
• Remove needle, open notch and place core into specimen jar
o If touch imprint cytology, first touch core in trough onto clean slide
o Smear, fix and stain slides as for fine needle biopsy
• 3 cores diagnostic in vast majority of masses
o ~ 70% accuracy with 1 core, ~ 95% with 3 cores
o ↑ # Cores for small lesion (< 7-10 mm), target = Ca++, uncertainty in targeting and/or needle gauge (e.g., 12-g)
• Consider insertion of marker, clip or coil
o Through coaxial cannula, or independently if needle-mounted
• Apply dressing: Sterile tape over skin incision
• For multiple lesions, check numbering and consistency
Findings and Reporting
• Confirm lesion numbering, location and sequence, especially if multiple lesions
• Describe approach(es), puncture site(s), biopsy type, # passes
• Report any problems or complications
• Addend report with histopathology results, statement of concordance, final management recommendation, to whom results were communicated
Alternative Procedures/Therapies
• Radiologic
o Stereotactic core or vacuum-assisted biopsy (if mammographically visible)
o US-guided vacuum-assisted biopsy (esp. if lesion is very small or target is Ca++ without a mass)
o US-guided FNAB of axillary lymph nodes
o US-guided FNAB of highly suspicious masses
 10% insufficient samples with nonpalpable lesions
• Surgical
o Freehand core biopsy for palpable lesions
 Higher miss rate (13% vs. < 2% for US CNB in one series)
o Diagnostic surgical biopsy, needle-localized if nonpalpable

Front 179

180. REPEAT Which is true regarding images of the breast?
-A lesion that moves down on a true lateral view when compared to MLO view is in lateral breast*

Back 179

lead sinks muffins rise

Front 180

Real time compounding” refers to using multiple what

Back 180

-Angles*


The principle of
compound scanning is to combine slices that
have been obtained from different spatial orien-
tations to generate an improved sonographic im-
age. In conventional real-time sonography, each
target is insonated at a single, constant angle. On
the other hand, in compound sonography, multi-
ple coplanar images obtained from different
viewing angles are combined into a single image
at real-time frame rates [1–5]. Generating an im-
age from multiple scanning lines that strike the
target from different angles results in better de-
lineated margins, reduced image artifacts and
noise, and enhanced image contrast.

Front 181

182. REPEAT What can be seen in association with pulmonary sling?

Back 181

Tracheal stenosis*

Front 182

183. REPEAT 4 chamber view of heart in fetal ultrasound best at showing what?
-AV canal
-Double outlet right ventricle
-Other wrong choices

Back 182

Atriventricular septal defect



• Best diagnostic clue
o Missing "crux" of heart in four chamber view
 Atrial and ventricular septum meet atrioventricular (AV) valves at "crux" of heart
o Usual offset of AV valves is absent
o Presence of atrial and ventricular septal defects

Front 183

L transposition of great vessels has what?

Back 183

Arterioventricular discordance, atrioventricular discordance*

Definitions

* Ventriculoarterial (VA) discordance in TGA
o Aorta arises from right ventricle
o Pulmonary artery (PA) arises from left ventricle
* Atrioventricular (AV) and VA discordance in CTGA (ventricular inversion)
o Right atrium → left ventricle → pulmonary artery
o Left atrium → right ventricle → aorta

Front 184

185. REPEAT Infarct involving the lateral wall of the left ventricle most likely affects which coronary artery?
-Right
-LAD
-Circumflex

Back 184

-Circumflex*

Front 185

186. REPEAT Which is most accurate regarding intubation?
-With neck flexion, the distal tip moves caudal
-Cuff prevents aspiration
-Left main stem bronchus intubation more common than right
-Granulomas of posterior trachea common

Back 185

-With neck flexion, the distal tip moves caudal

In spite of large differences for magnitude of
tracheal tube displacement between patients, head-neck
extension consistently led to an upward movement of the
tracheal tube tip whereas head-neck flexion moved the
tracheal tube tip towards the carina.

Front 186

187. REPEAT How do you treat a pulmonary AVM?
-Coil
-Alcohol
-Gelfoam
-PVA particles

Back 186

-Coil*

Front 187

188. Regarding pulmonary AVMs, which is true?
-Usually one feeding artery
-30% of people will have HHT
-Most common in upper lobes
-Only diagnosed on angiography

Back 187

No answer as all are incorect:


AVM pulmonary:
Terminology
• Spectrum of abnormal direct communications between pulmonary arteries and pulmonary veins
• Congenital: Most of congenital PAVMs associated with hereditary hemorrhagic telangiectasia
Imaging Findings
• Best diagnostic clue: Nodule(s) with feeding artery(s) and draining vein
• Morphology: Single or multiple well-circumscribed nodules with feeding artery(s) and draining veins
• Round or oval nodule of uniform density
• Lobulated but sharply-defined
• May be multiple (33%), solitary (66%)
• Located in lower lobes (50-70%) in medial third of the lung
Top Differential Diagnoses
• Carcinoid
• Metastases
• Septic Emboli
• Solitary Pulmonary Nodule
Pathology
• Multiple AVMs highly associated with HHT (90%)
Clinical Issues
• Epistaxis presenting feature in HHT due to associated nasal telangiectasia (80%)
• Hemorrhagic complications increased in pregnancy
• CNS complications (40%)
• Recurrence possible but rare
• Treat all AVMs with feeding artery > 3 mm in diameter

Front 188

189. Asian young girl with patchy migratory opacities, eosinophilia and cough. Likely cause?
-ABPA
-Ascariasis
-Pneumonia
-Atypical pneumonia

Back 188

Ascariasis• Ascariasis
• Migratory, fleeting perihilar air space opacities or nodules mimics eosinophilic pneumonia

Front 189

190. A patient has a right coronary artery arising from the left cusp. The artery passes posterior to aorta. What do you do ?
-Nothing
-Angioplasty
-Reimplant artery

Back 189

In an article sited in radiology all three patients with this anomaly had an anterior (intervascular) course that is associated with spontaneous death and usually requires reimplantation. However, if the artery courses posterior, it probably requires nothing.

• Either left coronary originating from the right cusp (sinus) or right coronary arising from the left cusp (sinus), if it courses between the aorta and MPA -- it is called "intervascular course" and is associated with poor outcome.
• If it courses between the aorta and RV outflow tract inferior to the plane of the pulmonic valve, it is "intraseptal course" and considered "comparatively benign"

Front 190

191. REPEAT Which is not seen with Von Hippel Lindau?
-Angiomyolipoma
-Renal cysts
-Renal carcinoma
-Other right answers

Back 190

-Angiomyolipoma*

Vhl:
Terminology
• von Hippel-Lindau (VHL) syndrome
• Rare, autosomal dominant multi-systemic disorder characterized by abnormal growth of tumors
Imaging Findings
• Best diagnostic clue: Retinal or cerebellar tumor (hemangioblastoma) + multiple renal cysts or adrenal tumor (pheochromocytoma)
• CHb occurs in 44-72% of all VHL cases
• Simple cysts: Well-defined, rounded, thin-walled, nonenhancing, near water density lesions
• Multiple, bilateral solid hypovascular or complex cystic masses + mural nodules, septa (RCC)
• Well-defined, round, suprarenal mass (muscle HU)
• Honeycomb or sponge-like pancreatic head mass
Top Differential Diagnoses
• AD polycystic kidney disease (ADPKD)
• Acquired cystic kidney disease of uremia (ACKD)
• Medullary cystic disease
Clinical Issues
• More than one hemangioblastoma in CNS or retina
• One hemangioblastoma + visceral manifestation
• Known family history + one of above manifestation
Diagnostic Checklist
• Annual clinical, biochemical & imaging screening of VHL patients & at risk family members, relatives
• Genetic testing in family members, define their status
• Retinal & CNS Hbs; renal & pancreatic cysts
• Bilateral solid renal masses-CT (RCCs); hyperintense adrenal mass T2WI (pheochromocytoma)


Vhl:
Terminology
• von Hippel-Lindau (VHL) syndrome
• Rare, autosomal dominant multi-systemic disorder characterized by abnormal growth of tumors
Imaging Findings
• Best diagnostic clue: Retinal or cerebellar tumor (hemangioblastoma) + multiple renal cysts or adrenal tumor (pheochromocytoma)
• CHb occurs in 44-72% of all VHL cases
• Simple cysts: Well-defined, rounded, thin-walled, nonenhancing, near water density lesions
• Multiple, bilateral solid hypovascular or complex cystic masses + mural nodules, septa (RCC)
• Well-defined, round, suprarenal mass (muscle HU)
• Honeycomb or sponge-like pancreatic head mass
Top Differential Diagnoses
• AD polycystic kidney disease (ADPKD)
• Acquired cystic kidney disease of uremia (ACKD)
• Medullary cystic disease
Clinical Issues
• More than one hemangioblastoma in CNS or retina
• One hemangioblastoma + visceral manifestation
• Known family history + one of above manifestation
Diagnostic Checklist
• Annual clinical, biochemical & imaging screening of VHL patients & at risk family members, relatives
• Genetic testing in family members, define their status
• Retinal & CNS Hbs; renal & pancreatic cysts
• Bilateral solid renal masses-CT (RCCs); hyperintense adrenal mass T2WI (pheochromocytoma)

Multiple angiomyolipomas is associated with tuberous sclerosis.

Front 191

192. Pseudomembranous colitis. Which is true?
-Usually presents with abdominal pain, diarrhea
-Usually presents with acute abdomen
-Treat with vancomycin
-Toxic megacolon is complication

Back 191

all can be true

Presentation
• Most common signs/symptoms
o Mild: Watery diarrhea
o Severe: Acute abdomen
 Fever, abdominal pain & tenderness, tachycardia
 Dehydration, leukocytosis, sepsis
• Clinical profile: Patient with history of watery diarrhea after antibiotic use or hospitalization
• Diagnosis
o Demonstration of C. difficile toxins in stool
 Typically takes 48 hours to confirm
o Proctosigmoidoscopy or colonoscopy
 Adherent yellow plaques 2-10 mm in diameter
Demographics
• Age: Elderly are at higher risk for developing PMC & recurrent PMC than young
• Gender: M = F
Natural History & Prognosis
• Complications
o Range from watery diarrhea to toxic megacolon, sepsis, perforation & death
• Prognosis
o If treated early, full recovery expected
o Recurrence rate higher in women & elderly
o Severe cases may need colectomy
o Untreated cases can lead to perforation, acute abdomen & death (mortality rate 1.1-3.5%)
Treatment
• Mild cases: Discontinue offending antibiotic therapy
• Severe cases
o Metronidazole (drug of choice) or oral vancomycin
o Fulminant & toxic megacolon: Colectomy

Front 192

193. Which is not a cause of spinal stenosis?
-Degenerative disc disease
-Morquios
-Epidural lipomatosis
-Ankylosing spondylitis

Back 192

Ankylosing spondylitis

Front 193

194. REPEAT Complication associated with glucophage and IV contrast.

Back 193

- Lactic acidosis*

Front 194

195. REPEAT How large is an ovarian follicle before it ruptures?
-10mm
-20mm
-30mm
-40mm

Back 194

-20mm

Front 195

196. They showed a CT picture with upper lobe architectural distortion, bronchiectasis septal thickening and lower lobe centrilobular nodules. They asked what most likely cause. Really the question and picture was that lame!
-Sarcoid
-EG
-Beryliosis
-Other wrong asnwers

Back 195

Could be sarcoid or if the exposure history is mentioned Beryliosis.

Terminology
• Common systemic granulomatous disease of unknown etiology
Imaging Findings
• Best diagnostic clue: Symmetric hilar and mediastinal lymphadenopathy; without or with pulmonary opacities
• Micronodules (1-5 mm)
• Centrilobular, perivascular, perilymphatic, bronchovascular bundles, subpleural, septal
• Often extends in a swath from the hilum to lung periphery
• Predilection for posterior (sub)segment upper lobes and superior segments lower lobes
• Alveolar sarcoid: Airspace nodules and consolidation with air bronchograms
• Progressive massive fibrosis, architectural distortion, honeycombing, cysts, bullae
Top Differential Diagnoses
• Berylliosis
• Silicosis
• Tuberculosis (TB)
• Cryptococcus
Clinical Issues
• Major complications include respiratory failure from fibrosis, mycetomas, hemorrhage, cor pulmonale
• Cardiac disease: Myocardial infarction in 5%, arrhythmias, heart block, sudden death
• Variable, worse in African-Americans (more extrapulmonary involvement); better in children

Front 196

197. REPEAT Chronic prostaglandin therapy in a kid leads to what?

Back 196

Periosteal elevation

Front 197

198. REPEAT Most medial nerve in cavernous sinus?

Back 197

-6* abducens

Front 198

199. REPEAT Vagus nerve runs through diaphragm with what?

Back 198

Esophagus*

Front 199

200. It is acceptable to give thrombolytics to a patient with what symptoms?
-Stroke 2 weeks ago
-Active heparin therapy
-Brain tumor
-Acute GI bleed
-Neurogenic pain related to vascular compromise

Back 199

-Neurogenic pain related to vascular compromise*

Front 200

Hemangioma in the spine. Signal characteristics?

Back 200

- Increased T1 and T2 signal*

MR Findings
• Typical "benign" (fatty stroma) hemangioma
o T1WI: Hyperintense, with avid contrast-enhancement
o T2WI: Hyperintense
o Occasional radiographically benign lesions are isointense or hypointense on T1WI, and difficult to distinguish from metastases
• "Aggressive" ("malignant") hemangioma
o T1WI: Isointense to hypointense, with avid contrast-enhancement
o T2WI: Hyperintense
o Pathologic fracture or epidural extension common
o Clinically aggressive hemangiomas are usually radiographically aggressive as well

Front 201

202. REPEAT Far lateral disc herniation at L4-L5 will lead to what symptoms?
-L4 radiculopathy
-L5 radiculopathy
-L4 and L5 radiculopathy
-No symptoms

Back 201

L4 radiculopathy*

Front 202

203. REPEAT MR spectroscopy, which is true?
- NAA is found in axons and neurons
-Creatine signifies increased cellular turnover
-Choline is normal in pathologic processes
-Choline is dominant peak

Back 202

- NAA is found in axons and neurons

MRS can be used to determine the degree of malignancy. As a general rule, as malignancy increases, NAA and creatine decrease, and choline, lactate, and lipids increase. NAA decreases as tumor growth displaces or destroys neurons.� Very malig-nant tumors have high metabolic activity and deplete the energy stores, resulting in reduced creatine.� Very hypercellular tumors with rapid growth elevate the choline levels. Lipids are found in necrotic portions of tumors, and lactate appears when tumors outgrow their blood supply and start utilizing anaerobic glycolysis. To get an accurate assessment of the tumor chemistry, the spectroscopic voxel should be placed over an enhancing region of the tumor, avoiding areas of necrosis, hemorrhage, calcification, or cysts.

Front 203

204. REPEAT Patient with painful thyroid gland, increased T4 and decreased uptake, cause?
-Subacute thyroiditis*
-Hashimotos
-Graves dz
-Other wrong answers

Back 203

-Subacute thyroiditis

Subacute thyroiditis
Terminology
• Subacute thyroiditis (SAT)
• Inflammatory thyroid disorder with 3-phase clinical course
Imaging Findings
• Best diagnostic clue: Very low thyroid RAI uptake + clinical hyperthyroidism
• In acute phase SAT, thyroid RAI uptake very low (often < 1% at 24 hours)
• Uptake key to differentiating SAT from other causes of hyperthyroidism (e.g., Graves)
• Uptake improves with recovery phase, eventually normalizes
• RAI therapy contraindicated (self-limited disease)
• Thyroid scan shows very low, absent thyroid activity in early SAT
Top Differential Diagnoses
• Graves Disease
• Toxic Multinodular Goiter & Toxic Adenoma
• Hashimoto Disease
• Infiltrative Thyroid Diseases
• Acute Thyroiditis
• Iatrogenic Factors
Diagnostic Checklist
• Major cause of hyperthyroidism with very low uptake
• Important to distinguish from other causes of hyperthyroidism because RAI therapy contraindicated
• Most often, low thyroid uptake enough to diagnose SAT
• Uptake may be normal in recovery phase of SAT
• Thyroid scan necessary only in diagnostic dilemmas

Graves Disease
• Hyperthyroidism + high uptake measurement (> 50-80%)
Toxic Multinodular Goiter & Toxic Adenoma
• Hyperthyroidism + normal to elevated thyroid uptake
Hashimoto Disease
• Hyperthyroidism or Hashitoxicosis may develop < 5% of cases
• Thyroid uptake may be low with hypothyroidism, elevated with hyperthyroidism
Infiltrative Thyroid Diseases
• Lymphoma, leukemia, amyloid, tuberculosis, metastatic adenocarcinoma may present with enlarged thyroid, hyperthyroidism
Acute Thyroiditis
• Suppurative thyroid disease: Patients have fever, ↑ white blood count
• More common in immunocompromised patients
Iatrogenic Factors
• Amiodarone may ⇒ hyperthyroidism, hypothyroidism lasting weeks to months (iodine effect, follicular cell injury)
• Iodinated contrast: Low RAI uptake after IV contrast; may ⇒ hyperthyroidism (Jod-Basedow iodine effect)
• Thyroiditis factitia: Exogenous thyroid hormone ingestion may ⇒ hyperthyroidism, low RAI uptake
• Thyroid trauma (biopsy, surgery, seatbelt injury, vigorous palpation) ⇒ transient thyroid hormone release
• Interferon and radiation therapy can induce thyroiditis

Front 204

205. REPEAT On MUGA, artificial elevation of the ejection fraction related to what?
-Including spleen in background counts
-Including left atrium in systolic counts
-Including aorta and both systolic and diastolic counts
-Including stomach in background

Back 204

-Including spleen in background counts*

Front 205

206. Which is not associated with centrilobular nodules on HRCT?
-Tuberous sclerosis
-Panbronchiolitis
-CF
-Other right answers

Back 205

Tuberous sclerosis*

TS
• Associated abnormalities
• Renal: Angiomyolipoma and cysts 40-80%
• Cardiac: Rhabdomyomas 50-65%; majority involute over time
• Lung: Cystic lymphangiomyomatosis/fibrosis
• Solid organs: Adenomas; leiomyomas
• Skin: Ash-leaf spots (majority) including scalp/hair; facial angiofibromas; shagreen patches 20-35% post pubertal
• Extremities: Subungual fibromas 15-20%; cystic bone lesions; undulating periosteal new bone formation
• Ocular: "Giant drusen" (50%); retinal astrocytomas (which may regress)
• Dental pitting permanent teeth in most adults with TSC

Front 206

REPEAT Proper placement of a nephrostomy tube?

Back 206

Posterior calyx*

Front 207

208. Post transplant lymphoproliferative disorder, which is true?
-Most common in first 2 weeks
-Caused my monoclonal T cell proliferation
-Cause thought to be related to Epstein Barr Virus
-Don’t remember the rest

Back 207

-Cause thought to be related to Epstein Barr Virus

Posttransplant lymphoproliferative disorder of B cells related to Ebstein-Barr virus (EBV) infection

Front 208

209. REPEAT Reflux of contrast in acinus during ERCP related to what?
-post procedure pancreatitis
-pancreatic cancer
-other wrong answers

Back 208

-post procedure pancreatitis*

Front 209

Non-immune hydrops is NOT caused by:

Back 209

Erythroblastosis fetalis*

Erythroblastosis fetalis develops in an unborn infant when the mother and baby have different blood types. The mother produces substances called antibodies that attack the developing baby's red blood cells.

The most common form of erythroblastosis fetalis is ABO incompatibilityABO incompatibility, which can vary in severity.

The less common form is called Rh incompatibilityRh incompatibility, which can cause very severe anemia in the baby.

Front 210

211. REPEAT Inflammatory breast cancer associated with what?

Back 210

-Invasion of dermal lymphatics*

Terminology
• IBC: Locally advanced breast cancer with inflammatory skin changes
• Diffuse breast erythema
• Warmth, enlargement, pain, induration
• Peau d'orange (skin like an orange peel)
Imaging Findings
• 18FDG PET-CT helpful in whole body staging at diagnosis
Top Differential Diagnoses
• Secondary Skin Invasion by Breast Cancer
• Leukemia, uncommonly lung cancer metastases
• Mastitis ± Abscess
• Post Lumpectomy and Radiation Therapy
Pathology
• 1-6% of breast cancers
• Poorly differentiated IDC NOS
• Tumor emboli in dermal lymphatics typical
Clinical Issues
• May be misdiagnosed as benign inflammatory process
• Multimodality treatment: 5 year survival up to 50%
• Lymph node metastases common, adverse prognosis
• Early systemic metastases
• Risk of false negative sentinel node biopsy
Diagnostic Checklist
• Skin punch biopsy preferred to breast core biopsy
• Targeted US-guided core biopsy if punch biopsy nondiagnostic

Front 211

212. REPEAT Most common finding worrisome for malignancy on thyroid ultrasound?
-Punctate calcs
-Egg shell calcs
-Hypervascularity

Back 211

Punctate calcs*

Front 212

213. REPEAT One week following bone marrow transplant, new pulmonary nodules are present some of which have a ground glass halo. Cause?
-Fungal
-Bacterial
-CMV

Back 212

Fungal

Front 213

214. REPEAT Which fracture is more likely a Salter Harris 4 fracture than a Salter Harris 2 Fracture?
-Lateral epicondyle of elbow
-Lateral epicondyle of knee
-Other wrong answers

Back 213

Staging, Grading, or Classification Criteria

* Classification of Milch for unicondylar humeral fractures
o Milch type I fx: Lateral trochlear ridge intact - preserved medio-lateral stability (Salter Harris type II)
o Milch type II fx: Fracture line medial to trochlear groove so lateral trochlear ridge is part of fragment
+ Unstable (Salter Harris type IV), more common
+ Stability may be preserved by articular cartilage hinge even with complete physeal injury

Front 214

215. REPEAT Wegners granulomatosis most associated with what?
-C-ANCA
-P-ANCA

Back 214

C-anca

Terminology
• Classic Wegener granulomatosis (WG) triad: Sinus, lung, & renal disease
• Multisystem disease of unknown etiology characterized by necrotizing granulomatous small-vessel vasculitis
Imaging Findings
• Multiple cavitary lung nodules & large airway narrowing
• Nodules: Most common manifestation (70%)
o Multiple, < 10 in number
• Cavitation (50%)
• Parenchymal: Ground-glass opacities or consolidation(50%)
o Usually represents hemorrhage (seen in 15% of patients with WG)
o Wedge-shaped peripheralconsolidation: Infarcts or airway involvement
o Diffuse ground-glass opacities ("bat wing") with subpleural sparing
Top Differential Diagnoses
• Metastases
• Septic Emboli
• Pneumonia: Bacterial, Fungal
Pathology
• 2.4x risk of pulmonary malignancy
• 50% have pulmonary infection during course of treatment
Clinical Issues
• c-ANCA
o Sensitivity (90%), specificity (70%)
• Median survival without treatment: 5 months

Front 215

REPEAT Second most common origin of the left vertebral artery?

Back 215

Off aortic arch, between the left carotid and left subclavian origins*

Front 216

217. Status post PEG tube placement. Increasing pneumoperitoneum by radiographs. What do you do?
-Check location of side holes
-Feed patient
-Aspirate the bulb
-Replace with larger French size catheter

Back 216

Looked in every major textbook and nothing about managing complications. Do not feed the patient is about all I can come up with.

Front 217

Right upper lobe pulmonary edema related to what valvular process?
-Mitral regurgitation
-Mitral stenosis
-Aortic stenosis
-Aortic regurg

Back 217

-Mitral regurgitation*

Terminology
• Asymmetric edema more severe in the right upper lobe due to left heart decompensation and mitral regurgitation
Imaging Findings
• Best diagnostic clue: Right upper lobe consolidation, mild diffuse edema elsewhere, and cardiomegaly
• Left upper lobe (rare): Usually associated with mitral valve prosthesis
Top Differential Diagnoses
• Pneumonia
• Aspiration
• Left Heart Failure
• Negative Pressure Pulmonary Edema
• Re-Expansion Pulmonary Edema
Pathology
• Mitral valve: Valve plane faces posterior, superior, and to the right
• Regurgitant stream is directed to the right superior pulmonary vein: Especially due to malfunction of posterior mitral valve leaflet
• Asymmetric right upper lobe edema in 10% in those with severe mitral regurgitation (20% in children)
• Gravitational: Patients with CHF prefer right lateral decubitus position
Diagnostic Checklist
• Pulmonary edema usually not thought of as a predominant cause of focal pulmonary consolidation
• Asymmetric edema in left upper lobe in patient with mitral valve prosthesis: Consider perivalvular leak

Front 218

219. REPEAT Patient has been in car wreck with injury to chest wall from steering wheel. New onset CHF and holosystolic murmur. Which is most likely?
-Ventricular septal rupture
-Papillary muscle rupture
-Don’t remember the rest

Back 218

-Ventricular septal rupture (think it’s this one)

Why its not papillary muscle rupture:
Terminology

* Partial or complete rupture of a papillary muscle (PM), most commonly in the setting of acute myocardial infarction (AMI)

Imaging Findings

* Flail of the chordae and/or PM into the left atrium along with severe mitral regurgitation on several imaging modalities
* Posteromedial PM affected more commonly than the anterolateral PM
* Usually inferior ECG lead abnormalities
* Specific CXR finding is right upper lobe edema, caused by mitral leaflet flail and jet of regurgitant blood directed into right superior pulmonary vein
* TEE is superior to TTE in detecting PMR

Clinical Issues

* Acute hemodynamic collapse in setting of acute myocardial infarction (AMI)
* Severe mitral regurgitation: Detectable by several modalities
* Systolic murmur at the left lower sternal border, though may be very faint or absent
* Systolic function is better than anticipated, or hyperdynamic, in setting of hemodynamic compromise
* Once stabilized, early surgery is essential
* Most commonly presents 2-9 days post AMI with acute onset chest pain and shortness of breath

Front 219

220. REPEAT What is a Blalock Taussig shunt a communication of?

Back 219

Subclavian artery to ipsilateral pulmonary artery*

Front 220

221. Keeping records of nuclear medicine dose misadminstrations is a function of what process?
-Quality control,
-Quality assurance
-Quality improvement

Back 220

-Quality control ?

Front 221

222. The ROC curve is determined using what parameters?

Back 221

Sensitivity and specificity*

a receiver operating characteristic (ROC), or simply ROC curve, is a graphical plot of the sensitivity, or true positives, vs. (1 − specificity), or false positives, for a binary classifier system as its discrimination threshold is varied.

Front 222

223. Most common cause of bilateral breast edema?
-CHF
-Bilateral inflammatory breast cancer
-Mastitis
-Other wrong answers

Back 222

CHF

Front 223

224. Which of the following would you follow up with 6 month mammogram?
-Single well circumscribed mass
-Multiple bilateral masses
-Round calcifications
-Asymmetry seen on only one view
-Well circumscribed radiolucent mass

Back 223

not sure

Front 224

225. Vagal paraganglioma found in what neck space?
-Carotid
-Masticator
-Parapharyngeal
-Other wrong answers

Back 224

-Carotid*

Front 225

226. REPEAT Blunt aortic injury, which is true?
-CT angiography has a approx 98% negative predictive value
-TEE is equivalent to CT in evaluation of aortic injury
-Most injuries occur at the aortic root
-Supine radiograph able to exclude aortic trauma

Back 225

CT angiography has a approx 98% negative predictive value*

Front 226

227. Which is true about iliac artery aneurysms?
-Most commonly unilateral
-Usually not symptomatic until rupture*
-Not associated with abdominal aneurysm
-Most common in external iliac artery

Back 226

-Usually not symptomatic until rupture*

Imaging Findings

* Aneurysms involve common and internal iliac arteries > external iliac arteries
o Iliac artery aneurysm defined as vessel diameter > 1.5 times normal iliac artery diameter or ≥ 25 mm in diameter
* CECT with CTA provides excellent information for surveillance and/or treatment planning
o Maximum aneurysm diameter and length
o Aneurysm relationship to aortic and iliac artery bifurcations
* Angiography with calibrated catheter may allow both diagnosis and therapy

Pathology

* Most common cause is atherosclerosis
* Isolated iliac artery aneurysms rare; 0.03% incidence

Clinical Issues

* Most iliac artery aneurysms incidentally found
o More than 65% asymptomatic
* Natural history of progressive expansion, rupture
o Rupture associated with up to 80% mortality risk
* Repair iliac artery aneurysm > 3 cm in diameter
o Conventional treatment is open surgery
o Endovascular aneurysm repair (EVAR) with stent graft increasing as primary therapy
o Aortoiliac EVAR necessary if common iliac artery origin aneurysmal; inadequate proximal "landing zone" for graft seal and endoleak prevention
o Common iliac artery aneurysm involving iliac bifurcation requires graft extension into external iliac artery; embolization of internal iliac artery

Front 227

228. Long term patency after angioplasty is most likely in which artery?
-Iliac
-Superficial Femoral
-Common femoral
-Popliteal
-Anterior tibial or peroneal

Back 227

-Iliac*

Terminology
• Stenosis or occlusion of one or more major pelvic arterial vessels
Imaging Findings
• Arterial stenoses, usually at bifurcations
• Collateral vessels imply chronic rather than acute obstruction
• Post-stenotic dilatation distal to severe chronic stenoses
• Severe stenosis may progress to occlusion
o Thrombus forms at lesion and propagates proximally and distally to first patent outflow vessel
• CTA accurately depicts stenoses, occlusions and collateral vasculature in similar format to conventional angiography
Clinical Issues
• Disease manifests as pain or muscle cramping that worsens with activity and improves with rest
• Endovascular treatment of iliac stenotic disease
o Focal (< 5 cm length): Angioplasty with stent 97% primary patency, 80-90% 5-year patency
o Diffuse (> 5 cm length): May attempt angioplasty and stent placement, poorer long-term patency than bypass
• Surgical treatment of iliac stenotic or occlusive disease
o Endovascular therapy can be attempted as first line therapy; may have inferior long-term patency compared to vascular bypass surgery
o Surgical bypass performed as aortobifemoral graft or extra-anatomic bypass (e.g., axillofemoral graft)

Front 228

229. Chronic reflux of urine is most likely to be seen in which type of bladder reconstruction? Not a clue here
-Bladder augmentation
-Ileal pouch
-Some other random answers

Back 228

I would imagine an ileal pouch since there are no valves.

Front 229

230. REPEAT Which is not a germ cell tumor?
-Leydig
-Seminoma
-Embryonal
-Teratoma

Back 229

-Leydig*

Front 230

231. Which of the following types of cholangitis causes multiple intra and extra hepatic strictures AND papillary stenosis?
-AIDS*
-Recurrent pyogenic
-Ascending
-Another wrong answer, primary scalloping not an option

Back 230

AIDS

Aids cholangiopathy
Terminology
• Spectrum of biliary inflammatory lesions caused by AIDS-related opportunistic infections leading to biliary stricture/obstruction or cholecystitis
Imaging Findings
• Best diagnostic clue: AIDS patient with multiple intrahepatic strictures, ampullary stenosis, or gallbladder (GB) wall thickening from cholecystitis
• Ampullary stenosis with CBD dilation, CBD ulcerations, mult intrahepatic strictures on ERCP
• High signal dilated ducts; intra- and extrabiliary strictures on MRCP
• Diffuse GB thickening; periductal hyper- or hypoechoic areas; dilated intrahepatic ducts; diffuse CBD thickening on US
• US protocol: Parasagittal view of CBD to demonstrate mural thickening
• MRC protocol: Axial and coronal SSFSE; obliques, heavily weighted T2WI
Pathology
• General path comments: Opportunistic infection of GB, bile ducts from cryptosporidium & CMV; periductal inflammation, acalculous cholecystitis
Clinical Issues
• Poor prognosis due to advanced AIDS presentation
Diagnostic Checklist
• AIDS patient with distal ampullary stenosis, intrahepatic strictures or acalculous cholecystitis

Front 231

232. What is improved in SPECT imaging versus planar imaging?
-Contrast resolution
-Spatial resolution
-Two other wrong choices

Back 231

-Contrast resolution*

Front 232

233. Patient has a 7 cm mass in liver abutting the porta hepatis. What can be done?
-RF ablation
-Cryotherapy
-Hepatic vein embolization
-Hepatic resection

Back 232

Perhaps surgery.
No RF or cryo secondary to vascular structures.

Front 233

234. Aortic stenosis caused by which of the following?
-Takayasu arteritis
-Temporal arteritis
-Burgers dz
-Raynauds?

Back 233

Takayasu arteritis*

Takayasu arteritis
Terminology
• Granulomatous inflammatory vasculitis affects walls of medium and large vessels, especially aorta and branches
Imaging Findings
• Best diagnostic clue: Smooth narrowing of aorta and major vessels
• Occasional pulmonary artery involvement
• Distribution usually patchy, symmetric great vessel distribution common
Top Differential Diagnoses
• Aortic Coarctation
• Other Vasculitis
• Aortic Aneurysm
• Fibromuscular Dysplasia
• Middle Aortic Syndrome
Pathology
• Most common in Asian countries
• Patchy thickening of large and medium size vessels
Clinical Issues
• Early phase inflammatory or prepulseless phase
• Late phase occlusive or pulseless
• Age < 30 in 90% of patients
• Gender: M:F = 1:8, but may be less female predominant in non-Asian countries
• Morbidity and mortality due to hypertension and stroke
• Corticosteroids are mainstay of therapy

Front 234

235. Why is a chelate used with gadolinium?
-Decrease toxicity
-Better images
-Other wrong answers

Back 234

-Decrease toxicity*

Front 235

236. Which complication of asbestos exposure has the shortest time of onset after exposure?
-Pleural effusion
-Mesothelioma
-Pleural plaque
-Fibrosis

Back 235

Pleural effusion*