FHB

(FOUAD GARATY)
CRACK THE

CORE EXAM
CASE COMPANION

PROMETHEUS LIONHART, M.D.

Crack the Core Exam - Case Companion

First Ed. - Version 1.1

Disclaimer:

Readers are advised - this book is NOT to be used for clinical decision making. Human error
does occur, and it is your responsibility to double check all facts provided. To the fullest extent
of the law, the Author assumes no responsibility for any injury and/or damage to persons or
property arising out or related to any use of the material contained in this book.

Copyright © 2015 by Prometheus Lionhart

All rights reserved - Under International and Pan-American Copyright Conventions. This book,
or parts thereof, may not be reproduced in any form without permission from the Author.

Published by: Prometheus Lionhart

Title ID: 5260855

ISBN-13: 978-1507810859

Cover design, texts, and illustrations: copyright © 2015 by Prometheus Lionhart

Disclaimer:

Readers are advised - this book is NOT to be used for clinical decision making. Human error
does occur, and it is your responsibility to double check all facts provided. To the fullest extent
of the law, the Author assumes no responsibility for any injury and/or damage to persons or
property arising out or related to any use of the material contained in this book.
FATE RARELY CALLS UPON US AT A
MOMENT OF OUR CHOOSING

Optimus Prime
 WHAT LIES WITHIN
PART 1: "AUNT MINNIE'S" -125 CASES

- Neuro (Cases 1-19) Concentrated Reviews of:

- MSK (Cases 20 - 43} - Phakomatoses (pg 19-20)
- Cardiac ( Cases AA - 53) The Sinus (pg 25-26}
- Thoracic (Cases 54- 59) Cord Tumors (pg 41-42)
- GI (Cases 60 - 70) Arthritis (pg 59-60}
- GU (Cases 71 - 75} Knee Meniscus (pg 79-80)
- GYN (Cases 76 - 79) Cardiac MRI (pg 109-110)
- Nukes (Cases 80 - 83) Congenital Heart (pg 119-120)
- Reproductive (Cases 84- 86, 91- 92} Cystic Renal Disease (pg 161-162}
- Peds (Cases 89 - 90, 93 - 100) Dementia Imaging (pg 181-182)
- Mammo (Cases 101 - 103) Uterine Malformations (pg 203-204}
- Vascular/ IR (Cases 104 - 108) Peds Age & Syndrome (pg 221-222}
- Physics ( Cases 109 - 125)

PART 2: "THIS VS THAT" - 50 CASES

- Neuro (Cases 1-12)

- MSK (Cases 13 - 15)
- Thoracic ( Cases 16 - 19)
- GI (Cases 21 - 24, 26)
- GYN / Reproductive (Case 25, 27)
- Peds (Cases 28- 33)
- Nukes (Cases 34 - 42)
- Mammo (Cases 43 - 45)
- Vascular/ IR ( Cases 46- 50)

PART 3: "ANATOMY" - 30 CASES

- Neuro (Cases 1 - 11)
- Vascular/ Angiograms (Cases 12 - 19)
- Cardiac (Cases 20 - 21}
- Abdomen US/ Prostate MR (Cases 22 - 23)
- MSK - ( Cases 24 - 27}
- Nukes Mystery Whole Body Scans (Cases 28 - 30)
Aunt Minnie 's
CASE 1 - 31 YEAR OLD FEMALE

1. What is the Dx?

A. Rasmussen Encephalitis
B. Chronic Ischemic White Matter Disease
C. PRES
D. CADASIL

2. What is the "Classic History"?

A. Gelastic Seizures
B. Precocious Puberty
C. Migraines
D. Ascending Paralysis

3. White matter involvement where is "Classic" ?

A. It classically spares white matter
B. Temporal Lobes
C. Parietal Lobes
D. Occipital Lobes

4. Sparing of the white matter where is "Classic"?

A. Frontal Lobes
B. Temporal Lobes
C. Parietal Lobes
D. Occipital Lobes

Aunt Minnie 1
CASE 1 - CADASIL

CADASIL

Cerebral Autosomal Dominant

Arteriopathy with Subcortical Infarcts
and Leukoencephalopathy).

"" It's an inherited condition. (hence the

name). It typically presents between
age 30-40.

- The history of mi:'1"3mes ( sometimecg

with aura) is classic. Depression and
focal meurologic defects can also
1. What is the Dx? occur. For tke purpose of multipl,e
A. Rasmussen Encephalitis
choice, I'd go with mi;grame.
B. Chronic Ischemic White Matter Disease
C. PRES
D. CADASIL - Lots of things involve the frontal
white matter. However, in:volvement
2. What is the "Classic History"? of tile temporal white .matter -
A. Gelastic Seizures especially when severe in a 30 year
B. Precocious Puberty oldshould make you say CADASIL.
C. Migraines
D. Ascending Paralysis
- The othter cl�ic finding is relative
3. White matter involvement where is "Classic" ? sparimg of the occipital subcortical
A. It classically spares white matter white matter and If-Fibers,
B. Temporal Lobes
C. Parietal Lobes - The MRA is useslly normal, witlt
D. Occipital Lobes minimal if any atherosclerosis.

4. Sparing of the white matter where is "Classic" ?

A. Frontal Lobes
B. Temporal Lobes
C. Parietal Lobes
D. Occipital Lobes

Aunt Minnie 2
CASE 2- DEVELOPMENTAL DELAY

1. What is the diagnosis ?

A. Looks normal to me
B. Polymicrogyria
C. Hydranencephaly
D. Schizencephaly
E. Agenesis of the corpus callosum

2. What part of the corpus callosum forms first?

A. Genu
B. Splenium
C. Body
D. Rostrum

3. What condition( s) are classically associated with agenesis of the Corpus Callo sum ?
A. Intracranial Lipoma
B. Hydrocephalus (Colpocephaly)
C. Chiari II Malformations
D. Dandy Walker Spectrum
E. All of the above

Aunt Minnie 3
CASE 2 - AGENESIS OF THE CORPUS CALLOSUM

The 3 Classic Looks

(Notice the Sagittal is not among them - that makes it too obvious)

Wide Spaced Colpooephaly Steer Horn

Vertical Veatric les Appearance on Coronal

1. What is the diagnosis? Essential Trivia:

A. Looks normal to me
B. Polymicrogyria -There are 3 dassk ways to show this (as above)
C. Hydranencephaly
D. Schizencephaly
- There are tons of associatioas. The ones I would
E. Agenesis of the corpus callosum
know are: Colpocephaly (JO%), Intracranial
2. What part of the corpus callosum Lipoma (10%), Dandy Walker (11%), Chiari II
forms first? (7%), Hcloprosencepbely, sad Fetal EtOH
A. Genu syndrome.
B. Splenium
C. Body -The C. C. forms froDt to back then Rostrum last.
D. Rostrum

3. What condition( s) are classically

associated with agenesis of the
Corpus Callosum ?
A. Intracranial Lipoma
B. Hydrocephalus (Colpocephaly)
C. Chiari II Malformations
D. Dandy Walker Spectrum
E. All of the above

Aunt Minnie 4
CASE 3- ATAXIA AND SLEEP APNEA

1. What is the diagnosis?

A. Normal
B. Chiari II Malformation
C. Dandy Walker Spectrum
D. Joubert Syndrome

2. What is the buzzword?

A. Prominent Vermis
B. Eye of the Tiger Sign
C. Panda Sign
D. Molar Tooth Sign

3. What is the most common association

A. Retinal Dysplasia
B. Aortic Aneurysm
C. Medulloblastoma
D. Syndactyly

Aunt Minnie 5
CASE 3- JOUBERT SYNDROME

Jouoort Syntlrome

Also known as vermian aplasia

or molar tooth midbrain-hindbrain
malformation.

Essential Trivia:

-Tbis is an inherited condition (AR)

- A lack. of normal deoessation of

superior cerebellar peduncnlar fiber
1. What is the diagnosis? tracts leads to enlargement of the
A. Normal peduncles. All this together makes the
B. Chiari II Malformation midbrain look l:ike a molar tooth.
C. Dandy Walker Spectrum
D. Joubert Syndrome
- There are several associations tha:t
2. What is the buzzword? are worth knowing:
A. Prominent Vermis • Retinal Dysplasia (occurs in 50%
B. Eye of the Tiger Sign of cases)
C. Panda Sign • Multicystic dysplastic kidney
D. Molar Tooth Sign (occurs in 30% of cases)
• Polydactyly ( occurs in 15% of
3. What is the most common association
cases)
A. Retinal Dysplasia
B. Aortic Aneurysm
C. Medulloblastoma
D. Syndactyly

Aunt Minnie 6
CASE 4- NOTORIOUS DRUNK, Now WITH QUADRIPLEGIA

1. What is the diagnosis?

A. Pontine Glioma
B. Marchiafava-Bignami
C. Wernicke encephalopathy
D. Central pontine myelinolysis

2. What is the pathophysiology?

A. Rapid correction of Thiamine
B. Rapid correction ofNa+
C. Correction of Na+ was too slow
D. Autoimmune Demyelination

3. What is the earliest sign?

A. Restricted diffusion in the lower pons
B. T2 Hypointensity
C. Homogeneous Contrast Enhancement
D. Blooming on Gradient

Aunt Minnie 7
CASE 4- CENTRAL PONTINE MYELINOLYSIS (CPM)

CPM

T:li:i s is an acute <ien1yetination of the wkiie

matter tracts of the potis. It, s seen in tlle
setting of acute osmotic d1an1es, da:ssicaUy
deseneed with the rapid correction of
llyponatretnia

Essential Tri'via:

- The classic history is a chrome aloonolic

(nursing ltome patient or transplant patient),
who kad a rapidly corrected Na+. He/She
felt much better after the correction, the,m
returns to the ED 3 filays lator with spastic
quadriparesis and pseadobulbar palsy
(hyperactive pg reflex, and dysanhria).

- The ftrst sign is restricted diftbsion in .the

lower Pons.
1. What is the diagnosis?
A. Pontine Glioma
- Low signal on T 1 aad lili;h si1nal oa T2 in
B. Marchiafava-Bignami
the smne region (lower pons) may not show
C. Wemicke encephalopathy
D. Central pontine myelinolysis up for two weeks.

2. What is the pathophysiology? - It can enhance like an acute MS plaque (but

A. Rapid correction of Thiamine doesn't have to).
B. Rapid correction of Na+
C. Correction of Na+ was too slow
- Periipberal fibers are .classicailly spared.
D. Autoimmune Demyelination

3. What is the earliest sign?

A. Restricted diffusion in the lower pons
B. T2 Hypointensity
C. Homogeneous Contrast Enhancement
D. Blooming on Gradient

Aunt Minnie 8
 CASE 5- HISTORY WITHHELD

1. What is the diagnosis?

A. Pituitary Adenoma
B. Teratoma
C. Glioma
D. Tuber Cinereum Hamartoma

2. What is the classic history?

A. Infertility
B. Sudden Death
C. Gelastic seizures
D. Grand mal seizures

3. What the hell is this "tuber cinereum" ?

A. It's part of the pituitary
B. It's part of the optic chiasm
C. It's part of the mamillary bodies
D. It's part of the hypothalamus

Aunt Minnie 9
CASE 5- TUBER CINEREUM HAMARTOMA

Toher Cinereum Hamartoma

A 1llamat1oma located within a specific

locasioa of the 'hypothalamus

- The location is very typical. Tltis is a

tme Awt Minnie.

- In addition to the characteristic

location, this twDg shottld be iso-
intense to cortex· on Tl with. no
enillancement.

- The most testab),e trivia regarding

tbese tlmilgs is the classic clinical
history. There are actwtBy two classic
clinica;l stories:
•[Link]. ( laugbin�) seizures
1. What is the diagnosis? • [Link] Puberty
A. Pituitary Adenoma
B. Teratoma
- The tuber c:ineretJtm is the part of the
C. Glioma
hypothalamus located between fle
D. Tuber Cinereum Hamartoma
optic ehiasm and the mamiflary
2. What is the classic history? bodies.
A. Infertility
B. Sudden Death
C. Gelastic seizures
D. Grand mal seizures

3. What the hell is this "tuber cinereum" ?

A. It's part of the pituitary
B. It's part of the optic chiasm
C. It's part of the mamillary bodies
D. It's part of the hypothalamus

Aunt Minnie 1 O
CASE 6- ALTERED MENTAL STATUS

1. What is the diagnosis?

A. MCA infarct
B. ACA infarct
C. Artery ofHeubner Infarct
D. Artery of Percheron infarct

2. Which of the follow could also be included in the differential for bilateral thalamic
Hypodensities on CT?
A. Wemicke-Korsakoff
B. Internal Cerebral Vein Thrombosis
C. Top of the Basilar Syndrome
D. All of the Above

3. The Artery of Percheron arises from , and supplies ?

A. Bilateral PCAs, Unilateral Thalamus
B. Unilateral PCA, Unilateral Thalamus
C. Bilateral PCAs, Bilateral Thalamus + Midbrain
D. Unilateral PCA, Bilateral Thalamus+ Midbrain

Aunt Minnie 11
CASE 6- ARTERY OF PERCHERON INFARCT

Artery of
Normal Percheron

Artery 0:f Pereheroa Infarct

1. What is the diagnosis?
A. MCA infarct The artery of Percheron is a rare
B. ACA infarct vascular variant, in whid1 a simgle
C. Artery of Heubner Infarct common tntmk arises from one of the
D. Artery of Percheron infarct PCAs to supply ooth thalami and the
mi€llbrain.
2. Which of the follow could also be included in
the differential for bilateral thalamic Essential Trivia:
Hypodensities on CT?
A. Wemicke-Korsakoff
- This is a unique example of a
B. Internal Cerebral Vein Thrombosis
C. Top of the Basilar Syndrome unilateral blood vessel supplying
D. All of the Above structures on both sides of the
midbrain.
3. The Artery of Percheron arises from _
and supplies ? - Occlusion of the Artery of Percheron
A. Bilateral PCAs, Unilateral Thalamus
will cause a bilateral infarction of tne
B. Unilateral PCA, Unilateral Thalamus
C. Bilateral PCAs, Bilateral Thalamus+ thalamus and a "V-Shaped" infarct of
Midbrain the rostral midbrain.
D. Unilateral PCA, Bilateral Thalamus+
Mid brain - On CT, occlusion of the bilateral
cerebral veins, occlusion of the tip of
the basilar artery, or even Wernickes
can give a similar appearance.

Aunt Minnie 12
CASE 7- HISTORY WITHHELD

1. What is the Diagnosis? 3. What is the classic history?

A. Looks normal to me A. AVM or Aneurysm
B. Superficial Siderosis B. Down Syndrome
C. Cavemoma(s) C. NF-2
D. Leptomeningeal Spread of CA ( or infection) D. Pituitary Teratoma

2. What is the classic presentation? 4. What is the "next step"?

A. Seizure A. PETCT
B. Thunderclap Headache B. CT with Perfusion
C. Gelastic Seizures C. Conventional Angiogram
D. Sensorineural Hearing Loss D. No further imaging needed.

Aunt Minnie 13
CASE 7- SUPERFICIAL SIDEROSIS

Superficial Siderosis

Depo ition of hemosiderin along the

Jeptomeninges.

Essential Trivia:

- The etiology is typically recurrent or

extensive . ubarachnoid hemorrhage.
'J his can be from any cause; trauma.
bleeding brain tumor, AV M, or
aneurysm.

- lf you are forced into a "next step"

situation, you would want to look for
the cause of bleeding. Angiogram
(conventional or CTA) would be the
answer I would choose.

- Sensorineural hearing low i found in

95% of patients, and i the most
1. What is the Diagnosis?
A. Looks normal to me common clinical presentation. It is
B. Superficial Siderosis typically bilateral and gradual in
C. Cavemoma(s) onset.
D. Leptomeningeal Spread of CA ( or infection)
- The second mo t common symptom
2. What is the classic presentation?
(found in 88% of cases) is ataxia.
A. Seizure
B. Thunderclap Headache
C. Gelastic Seizures
D. Sensorineural Hearing Loss

3. What is the classic history? 4. What is the "next step"?

A. AVM or Aneurysm A. PETCT
B. Down Syndrome B. CT with Perfusion
C. NF-2 C. Conventional Angiogram
D. Pituitary Teratoma D. No further imaging needed.

Aunt Minnie 14
CASE 8- HISTORY WITHHELD

1. What is the diagnosis? 3. What if this patient had "cafe au lait"

A. Chondrosarcoma spots?
B. Osteosarcoma A. Mazabraud Syndrome
C. Fibrous Dysplasia B. McCune-Albright Syndrome
D. Mets (breast or lung) C. Jaffe-Campanacci Syndrome
D. Rhinophyma

2. Fibrous Dysplasia vs Pagets ? 4. What if this patient had intramuscular

A. Fibrous Dysplasia involves the inner table myxomas?
B. Pagets involves the inner table A. Mazabraud Syndrome
C. Fibrous Dysplasia never crosses sutures B. McCune-Albright Syndrome
D. Fibrous Dysplasia spares the sinuses C. Jaffe-Campanacci Syndrome
D. Rhinophyma

Aunt Minnie 15
CASE 8 - FIBROUS OYSPLASIA

Fibrous Dysplasia

Benign tumor like process, that occurs as a

re ult of screwed up osteoblastic function.
The result is the progres ive replacement of
normal bone with immature woven bone.

Essential Trivia:

- "Leontiasis Ossea" or "Lion Face" is the

historic term used for craniofacial F.D.

- "Ground Glass" is the classic buzzword.

- Pagels is the primary DDx. The

Expanded Ground Glass Matrix difference is that F.D. spares the inner
table and Pagets clas ically involves it.

- McCune Albright Syndrome: precocious

1. What is the diagnosis? puberty 'cafe au lait' spots + polyostotic
A. Chondrosarcoma
fibrou. dysplasia
B. Osteosarcoma
C. Fibrous Dysplasia
D. Mets (breast or lung) - Mazabraud Syndrome: polyostotic fibrous
dysplasia + multiple oft tissue myxomas
2. Fibrous Dysplasia vs Pagets ? (usually in large muscle groups). This has
A. Fibrous Dysplasia involves the inner table an increased ri k of malignant
B. Pagets involves the inner table transformation
C. Fibrous Dysplasia never crosses sutures
D. Fibrous Dysplasia spares the sinuses

3. What if this patient had "cafe au lait" 4. What if this patient had intramuscular
spots? myxomas?
A. Mazabraud Syndrome A. Mazabraud Syndrome
B. McCune-Albright Syndrome B. McCune-Albright Syndrome
C. Jaffe-Campanacci Syndrome C. Jaffe-Campanacci Syndrome
D. Rhinophyma D. Rhinophyma

Aunt Minnie 16
CASE 9- HEADACHE

1. What is the diagnosis?

A. Von Hippel Lindau
B. NF-1
C. NF-2
D. Tuberous Sclerosis

2. Unlike NF-1, NF-2 is NOT associated with?

A. Schwannomas
B. Meningiomas
C. Ependymomas
D. Neurofibromas

3. Which of the following is associated with NF-1?

A. Bilateral Vestibular Schwannomas
B. Giant Cell Tumors of the Humerus
C. Lateral Thoracic Meningocele
D. Cardiac Rhabdomyomas

4. NF-1 Patients get Optic Nerve Gliomas, these are typically __ ?

A. Higher Grade than those that occur sporadically
B. Lower Grade than those that occur sporadically
C. Equal Grade compared to those that occur sporadically
D. NF-1 Patients never get optic nerve gliomas

Aunt Minnie 17
CASE 9- NF-2

NF-2

Rare Autosomal Dominant

Neurocutaneous Disorder.

Essential Trivia:

- "MISME'" - Multiple Inherited

Schwannomas Meningiomas and
Ependymomas

1. What is the diagnosis?

A. Von Hippel Lindau - Neurofibromas are NOT part of
B. NF-1 the NF-2 spectrum, making the
C. NF-2 name a misnomer.
D. Tuberous Sclerosis
- The finding of a meningioma in
2. Unlike NF-1, NF-2 is NOT associated with?
a child should rai e the question
A. Schwannomas
ofNF-2.
B. Meningiomas
C. Ependymomas
D. Neurofibromas - Ependymomas a ociated with
NF-2 are typically spinal (not
3. Which of the following is associated with NF-1? intracranial).
A. Bilateral Vestibular Schwannomas
B. Giant Cell Tumors of the Humerus
- Schwannomas associated with
C. Lateral Thoracic Meningocele
the NF-2 usually invol e the
D. Cardiac Rhabdomyomas
v stibular branch of CN8.
4. NF-1 Patients get Optic Nerve Gliomas, these are
typically __ ?
A. Higher Grade than those that occur sporadically
B. Lower Grade than those that occur sporadically
C. Equal Grade compared to those that occur
sporadically
D. NF-1 Patients never get optic nerve gliomas

Aunt Minnie 18
THE OTHER PHAKOMATOSES - ESSENTIAL TRIVIA

NF-1
There are multiple as ociations that are testable including:
- Sphenoid Wing Dsyplasia
- Plexiforrn Neurofibromas
- Bad Scoliosis
- Renal Vascular Hypertension
- Lateral Thoracic Meningioceles***
- Pseudoarthrosis of the Fibula

The optic nerve gliomas "'een with NF-1 are typically WHO Grade 1 JPAs. The optic
nerve gliomas seen in the wild are typically WHO Grade 4 GBMs (which fucking
destroy you).

TUBEROUS SCLEROSIS
- In the Brain - Think Cortical Tubers Subependymal Tubers and Subependymal Giant
Cell Astrocytomas ( SGCA ).

- Renal AA1Ls - Tend to be large, multiple and bilateral

- Lungs - Lymphangioleiomyomatosis (LAM). Thin walled cysts + Chylous Pleural

Effusions.

- Cardiac Rhabdomyomas - Typically involve the ventricular septum, and nearly all
occur before I year of age.

VON HIPPEL LINDAU

- In the Brain - Think Hemangioblastomas (cyst and nodule). and Endolymphatic sac
tumors (temporal bone thing. more on this later).

- In the Abdomen -
- Think "Lots of Cysts." Cysts in the kidneys, cysts in the liver, simple cysts in
the pancreas, Serous ' Cystadenomas in Pancreas.
- Then some tumors too: Pheochromocytomas, and Bilateral Clear Cell RCCs.

Aunt Minnie 19
COWDEN SYNDROME

- Bowel Hamartoma + BREAST CANCER+ Lhermitte Duclos (Dysplastic Cerebellar

Gangli ocytoma).

- Lhermie Dulcos - Striated non-

enhancing cerebellar tumor, that
does NOT cross the midline.

GORLIN SYNDROME

This one has ton · of features, but the ones I would

remember are:

Multiple Odontog nic Cysts+ Massive Faix Cerebri

Calcification · + Medulloblastorna

The reason there i any clinical utility to knowing thi · at

all is that when they get radiation for their
medulloblastoma they develop LOTS OF BASAL CELLS

Odontogenic Cysts

Aunt Minnie 20
CASE 10 - STUFFY NOSE

1. What is the diagnosis?

A. SNUC
B. Inverting Papiloma
C. Fungal Sinusitis
D. Esthesioneuroblastoma

2. This cancer originates from?

A. The submucosal cells of the sinonasal tract
B. The middle turbinate
C. The olfactory cells
D. The osseous maxilla

3. What is the classic finding (s) for the tumor?

A. Enhancement, and T2 bright
B. Bony destruction, and T2 bright
C. Peritumoral cysts, and "Dumbbell" appearance
D. Large Mass without MIBG uptake

4. The typical age for this tumor is?

A. <20
B. Bimodal: 20s and 50s
C. Always > 60
D. It's random, can occur at any age.

Aunt Minnie 21
CASE 10 - ESTHESIONEUROBLASTOMA

Esthesioneu roblastoma

Essentially a neuroblastoma of
the olfactory cells.

Essential Trivia:

- Has a bimodal distribution-

occurs 20· and 50s

- Starts growing at the cribriform

plate then (usually) grows down
1. What is the diagnosis?
and up, waisting in the middle.
A. SNUC
This creates a dumbbell
B. Inverting Papiloma
C. Fungal Sinusitis appearance.
D. Esthesioneuroblastoma
- The characteristic finding is
2. This cancer originates from ? peritumoral cysts at the top. If
A. The submucosal cells of the sinonasal tract they want a single diagnosis
B. The middle turbinate
they have to show you this
C. The olfactory cells
(otherwise it' a squamous eel.I -
D. The osseous maxilla
which is more common).
3. What is the classic finding ( s) for the tumor?
A. Enhancement, and T2 bright - They enhance a idly (duh, they
B. Bony destruction, and T2 bright are tumor).
C. Peritumoral cysts, and "Dumbbell" appearance
D. Large Mass without MIBG uptake
- They take up MIBG, because
they are basically a
4. The typical age for this tumor is?
A. <20 neuroblastoma,
B. Bimodal: 20s and 50s
C. Always> 60
D. It's random, can occur at any age.

Aunt Minnie 22
CASE 11 - STUFFY NOSE

1. What is the diagnosis?

A. SNUC
B. Inverting Papilloma
C. Fungal Sinusitis
D. Esthesioneuroblastoma

2. What is the classic finding (s) for the tumor?

A. The superior turbinate
B. The middle turbinate
C. The cribriform plate
D. The nasal septum

3. What is classic "buzzword" finding?

A. Peritumoral Cysts
B. Light bulb bright Tl
C. Panda Sign
D. Cerebriform pattern

4. Hidden within 10-15% of inverting papillomas is?

A. A piece of chewing gum
B. That crayon you stuck up there in 1st Grade
C. A squamous cell cancer
D. A fungal ball

Aunt Minnie 23
CASE 11 - INVERTING PAPILLOMA

Inverting [Link]

Thi' is a benign sinonasal tumor, wit:h

distinctive imaging feature (making
it testable).

Essential Trivia:

- The most testable fact (probably) is

the I 0-15% conversion to squamous
cell CA.

"Cerebriform pattern" of alternating

high and low signal - The typical location i . the lateral
wall of the nasal cavity associated
1. What is the diagnosis? with the middle turbinate.
A. SNUC
B. Inverting Papilloma - On MRl - They have the classic
C. Fungal Sinusitis "cerebriform pattern" of
D. Esthesioneuroblastoma
alternating high and low signal
2. What is the classic finding (s) for the tumor? (suppo. edly looks like cortical
A. The superior turbinate gyrations). This is een on both T2
B. The middle turbinate and Tl +C. The sign is pretty good,
C. The cribriform plate found in at least 50% of these and
D. The nasal septum fairly unique to the tumor.

3. What is classic "buzzword" finding?

- On CT - 'These look like lobulated
A. Peritumoral Cysts
B. Light bulb bright Tl masses containing fragmerus of
C. Panda Sign destroyed bone.
D. Cerebriform pattern
- When I say "frequent local
4. Hidden within 10-15% of inverting papillomas recurrence despite adequate
is? resection ' you say Scbneiderian
A. A piece of chewing gum
CA. This is a rare form of
B. That crayon you stuck up there in 1 st Grade
C. A squamous cell cancer malignancy that has histology
D. A fungal ball indistinguis hable from the usual
inverting papilloma.

Aunt Minnie 24
 THE SINUS - ESSENTIAL TRIVIA

Fungal Sinusitis

There are 4 types of fungal sinusitis: Allergic, non-invasive, acute invasive, and chronic
invasive. Allergic and Invasive are the most likely tested.

Allergic - The most common. This occurs as an IgE response to fungal antigens. Tends
to affect aM the sinuses at the same time. Mucin (which contains concentrated protein,
fungal elements, and heavy metals) results in a hyper dense look on CT and a DAR:1{
look on both Tl and T2. This mimics a pneumatized sinus. Trying to get you to ca11 a
fungus Iadcn sinus as pneumatized sinus , n MRI is the oldest trick in the book.

Angio-lnvasive - Think about Mucor eating the diabetic dudes face off.

Essential trivia

- CT best for bony change. MRI b st for intracrainal or orbital spread.

-The "black turbinate sign" - an

i. chemic (non enhancing) middle
turbinate mucosa is an early indicator of
invasi e fungal.

Aunt Minnie 25
 Juvenile Nasopharyngeal Angiofibroma

Benign but locally aggressive vas cular tumor.

ALWAYS seen in MALES around age of 15-20.

Bloody nose is the classic history, but can also come in with chronic ear infections
from eustachian tube blockage.

Testable Point= Arise in the Sphenopalatine Foramen

Testable Point= Classically extend into the Pterygopalatine Fossa

....

Sinus Tumor Essential Trivia Blitz

Inverting Papilloma = l 0-15% Harbor a Squamous Cell CA

nverting Papilloma = Cerebriform Pattern

E ·thesioneuroblastoma = Dumbbell Shaped with Peritumoral Cysts

Esthesioneuroblastoma = MJBG Avid

Squamous Cell CA= Most Common Sinonasal Malignancy

SNUC = Monster Squamous Cell CA

Aunt Minnie 26
CASE 12 - HISTORY WITHHELD

1. What is the diagnosis?

A. Labyrinthine Ossificans
B. Otosclerosis
C. Gusher Syndrome
D. Wide Vestibular Aqueduct

2. What is the classic history?

A. Childhood meningitis
B. History of MS
C. Progressive conductive hearing loss
D. Aneurysm repair 3 months ago

3. This condition has what surgical implication?

A. Requires a transmastoid approach to repair
B. Requires both sides be performed on the same day
C. Increases the risk of ACA territory intact
D. May complicate or preclude cochlear implantation

Aunt Minnie 27
CASE 12 - LABYRINTHINE OSSIFICANS

Labyrinthine Ossificans

Fibroblasts from prior infection (or

inflammation) lead to a pathologic
ossification of the normally fluid
filled spaces of the bony labyrinth.

Essential Trivia:

- Bacterial meningitis is the most

common acquired cause

- Usually associated with evere

sen orineural hearing loss

1. What is the diagnosis? - The other major symptom with this

A. Labyrinthine Ossificans is vertigo (this is one of the 'dead
B. Otosclerosis ear" vertigo causes).
C. Gusher Syndrome
D. Wide Vestibular Aqueduct
- The earliest changes are typically
2. What is the classic history? seen in th basal turn of the cochlea
A. Childhood meningitis and scala tympani
B. History of MS
C. Progressive conductive hearing loss - Osseous de truction at the round
D. Aneurysm repair 3 months ago window niche makes placement of
th cochlear implant difficult. {the
3. This condition has what surgical implication?
A. Requires a transmastoid approach to repair
further into the cochlear turns you
B. Requires both sides be performed on the same can put the electrode the better they
day do).
C. Increases the risk of ACA territory intact
D. May complicate or preclude cochlear
implantation

Aunt Minnie 28
CASE 13 - HEADACHE

1. What is the diagnosis?

A. Dehiscent Jugular Bulb
B. Paraganglioma (jugulare)
C. Wide Vestibular Aquaduct
D. Endolymphatic Sac Tumor

2. This diagnosis is found in what syndrome?

A. Tuberous Sclerosis
B. NF-1
C. NF-2
D. Von Hippel Lindau

3. What is classic for the diagnosis?

A. The location
B. Enhancement patterns
C. Bony Destruction
D. It's totally non-specific

Aunt Minnie 29
CASE 13 - ENDOLYMPHATIC SAC TUMOR

Cochlea

Aperture of Vestibular Aqueduct . - �

Tumor.,.y

1. What is the diagnosis? Endolymphatic Sac Tumor

A. Dehiscent Jugular Bulb
B. Paraganglioma (jugulare) Rare locally invasive tumor of the
C. Wide Vestibular Aqueduct endolymph sac. It doesn't metastasize, but
D. Endolymphatic Sac Tumor does locally invade and cause hearing lo

2. This diagnosis is found in what syndrome?

Essential Trivia:
A. Tuberous Sclerosis
B. NF-1
C. NF-2 - The location is very typical (the region of
D. Von Rippel Lindau the endolymph sac).

3. What is classic for the diagnosis? - The boney erosion pattern is sometimes
A. The location
called 'moth-eaten"
B. Enhancement patterns
C. Bony Destruction
D. It's totally non-specific - Highly associated with VHL (about 15%
of VHLers have them)

Aunt Minnie 30
CASE 14 - HISTORY WITHHELD

1. What is the diagnosis ? 2. What is the classic history ?

A. Dehiscent Jugular Bulb A. Childhood meningitis
B. Paraganglioma (jugulare) B. History of MS
C. Wide Vestibular Aqueduct C. Conductive hearing loss
D. Endolymphatic Sac Tumor D. Sensorineural hearing loss

3. How often is this finding bilateral ? 4. This is associated with absence of the "?"
A. Never 90% of the time
B. Always A. Bony Modiolus
C. Usually B. Scutum
D. Rarely C. Lenticular Process
D. Tympanic Membrane

Aunt Minnie 31
CASE 14 - LARGE VESTIBULAR AQUEDUCT SYNDROME

Large Vestibular
Aqueduct Syndrome (LYAS)

Po. sibly resulting from reflux of fluid

from the endolymph sac into the inner
ear, this is a very common cause of
sensorineural hearing loss.

Essential Trivia:

- You aren't born deaf. Jt s

progressive.

- As a helpful rule, if the Vestibular

I . What is the diagnosis ? Aqueduct is larger than the posterior
A. Dehiscent Jugular Bulb semicircular canal ( or facial nerve
B. Paraganglioma (jugulare) canal) then they have LYAS
C. Wide Vestibular Aqueduct
D. Endolymphatic Sac Tumor
- It is usually bilateral (50-90%)

2. What is the classic history?

A. Childhood meningitis - LYAS is often ru . ociated with other
B. History of MS malformation - the mo t common of
C. Conductive hearing loss which is absence of the bony
D. Sensorineural hearing loss modiolus (seen in 90%).

3. How often is this finding bilateral?

A. Never
Extra redit: Mondini Abnormality
B. Always
C. Usually - Abnormal Cochlea (missing a tum)
D. Rarely - Enlarged Vestibule but normal SCC
- Enlarged Vestibular Aquaduct
4. This is associated with absence of the"?"
90% of the time
A. Bony Modiolus
B. Scutum
C. Lenticular Process
D. Tympanic Membrane

Aunt Minnie 32
CASE 15 - HISTORY WITHHELD

1. What is the diagnosis?

A. Dehiscent Jugular Bulb
B. Paraganglioma (jugulare)
C. Wide Vestibular Aqueduct
D. Superior semicircular canal dehiscence

2. What is the classic symptom for this syndrome?

A. Noise induced vertigo
B. Motion induced nausea
C. Noise induced nausea
D. Motion induced vertigo

3. Is this finding always associated with symptoms?

A. Yes
B. No

Aunt Minnie 33
CASE 15 - SUPERIOR SEMICIRCULAR CANAL
DEHISCENCE SYNDROME

Superior Semicircular Canal

Dehiscence Syndrome

Clinical syndrome associated with

absence of the bony covering of the
superior semicircular canal

Essential Trivia:

- The bony covering of the SSC is

absent in about l 0% of the general
population.

- The classic symptom is a noise

induced vertigo • Tul1io
Phenomenon." This was originally
1. What is the diagnosis?
described in pigeons after a mad
A. Dehiscent Jugular Bulb
B. Paraganglioma (jugulare) scienti: t drilled holes in their beads.
C. Wide Vestibular Aqueduct
D. Superior semicircular canal dehiscence - Tullio also created a "Pigeon-Rat"
by sewing the back of a pigeon to
2. What is the classic symptom for this syndrome? the back of a rat.
A. Noise induced vertigo
B. Motion induced nausea
C. Noise induced nausea
D. Motion induced vertigo

3. Is this finding always associated with symptoms?

A. Yes
B. No

Aunt Minnie 34
CASE 16 - HISTORY WITHHELD

1. What is the diagnosis?

A. Otosclerosis (Otospongiosis)
B. Dehiscent Jugular Bulb
C. Paraganglioma (jugulare)
D. Wide Vestibular Aqueduct

2. What is the typical history?

A. Hearing loss at birth
B. Hearing loss in childhood (5-10)
C. Hearing loss in adulthood (40s)
D. Vertigo

3. The most common location of the lesion is?

A. The margin of the oval window (fissula ante fenestram)
B. The otic capsule ( especially around the cochlea)

Aunt Minnie 35
CASE 16 - OTOSCLEROSIS (OTOSPONGIOSIS)

Otospongiosis (Fenestral)

Idiopathic disorder of the bony labyrinth in

which the dense, ivory like endochondral
bone is replaced with a spongy irregular
haversian bone (deafness follows).

"Grey" Spongy Bone, Replaces Essential Trivia:

Normal Ivory Bone
- It's usually seen in white women in their
40s.

- If you catch it early you can prevent their

1. What is the diagnosis? deafne s. If you miss it, I'm sure the jury
A. Otosclerosis (Otospongiosis) will understand. "Let him off judge ... he's
B. Dehiscent Jugular Bulb doing his best.
C. Paraganglioma (jugulare)
D. Wide Vestibular Aqueduct - It might get wor e with pregnancy

2. What is the typical history?

- There are two types:
A. Hearing loss at birth
B. Hearing loss in childhood (5-10) - Fenestral (most common) - targets the
C. Hearing loss in adulthood (40s) anterior margin of the ovaJ window
D. Vertigo (fissula ante fenestram) more
conductive hearing loss
3. The most common location of the lesion
is?
- Retrofenestral (less common) - targets
A. The margin of the oval window
the otic cap ule around the cochlea
(fissula ante fenestram)
B. The otic capsule (especially around the causes a more sensorineural hearing
cochlea) loss.

Aunt Minnie 36
CASE 17 - VISION PROBLEMS (AGE 3)

1. What is the diagnosis? 3. What is this "trilateral

A. Phthisis Bulbi retinoblastoma" ?
B. Retinoblastoma A. Retinoblastoma in both eyes +
C. Orbital Rhabdomyosarcoma cerebellum
D. PHPV B. Retinoblastoma in both eyes +
CSF mets
2. Children are also at increased risk of? C. Retinoblastoma in both eyes +
A. Osteosarcoma optic chiasm
B. Fibrous Dysplasia D. Retinoblastoma in both eyes+
C. Ewing Sarcoma pinealoblastoma
D. Aneurysmal Bone Cysts

Aunt Minnie 37
CASE 17 - RETINOBLASTOMA

Retinoblastoma

The most common intraocular neopla m

of childhood.

Essential Trivia:

- These usually occur around 18 month

of age, and nearly always occur before
age 5.

-There is an association with a bad RB

suppressor gene, which also affects
osteosarcoma patients.

-On CT think about a calcified

intraoccular mass, in a kid with a
normal sized globe.

I. What is the diagnosis?

- For the purpose of multiple choice
A. Phthisis Bulbi
tests any mass in the globe of a kid is
B. Retinoblastoma
C. Orbital Rhabdomyosarcoma probably RB, especially if shown on
D. PHPV gradient (for the blooming).

2. Children are also at increased risk of? - It's bilateral about 30% of the time
A. Osteosarcoma and can also be "trilateral" with
B. Fibrous Dysplasia
development of a pinealoblastoma
C. Ewing Sarcoma
about 3 year after the ocular I sions
D. Aneurysmal Bone Cysts
form.
3. What is this "trilateral retinoblastoma"?
A. Retinoblastoma in both eyes + cerebellum -DDx:
B. Retinoblastoma in both eyes + CSF mets - Coats -Not u ually calcified.
C. Retinoblastoma in both eyes + optic chiasm - Persistent Hyperplastic Primary
D. Retinoblastoma in both eyes + pinealoblastoma
Vitreous (PHPV) = small globe
- Retinopathy of prematurity =
small globe
Aunt Minnie 38
CASE 18 - BACK PAIN

1. What is the diagnosis?

A. Neurofibroma
B. Schwannoma
C. Myxopapillary Ependymoma
D. Hemangioblastoma

2. Is this location typical for this tumor?

A. Yup
B. Nope

3. Compared to the normal ependymomas, the myxopapilaries do what?

A. Are found in the cervical cord more
B. Are found in the thoracic cord more
C. Tend to bleed more
D. Present under the age of 20

Aunt Minnie 39
CASE 18 - MYXOPAPILLARY EPENDYMOMA

Myxopapillary Ependymoma

The most common primary cord tumor

of the lower spinal cord

Essential Trivia:

- This form is almost exclusively seen

in the corms and film (95%)

- More than 50% of all tumors of the

film terminal and conus medullaries
are myxopapillary ependymomas.

- They have a tendency to bleed. even

mor o than the intramedullary type
1. What is the diagnosis?
A. Neurofibroma
- They tend to occur in the 40s-50s.
B. Schwannoma
C. Myxopapillary Ependymoma
D. Hemangioblastoma - They can usually be exci ed
completely but if they extend into the
2. Is this location typical for this tumor? subarachnoid . pace and/or surround
A. Yup the roots of the cauda equina then they
B. Nope
are a huge pain in the ass to get rid of.

3. Compared to the normal ependymomas, the

myxopapilaries do what?
A. Are found in the cervical cord more
B. Are found in the thoracic cord more
C. Tend to bleed more
D. Present under the age of20

Aunt Minnie 40
 CORD TUMORS - ESSENTIAL TRIVIA

Tumors are grouped based on location.

lntramedullary DDx: Extramedul/ary - Extradural DDx:

- Astrocytoma lntradural DDx: - Disc Disease
- Ependymoma - Schwannoma - Bone Tumors
- Hemangioblastoma - Meningioma - Mets
- Neurofibroma - Lymphoma
- Epidermoid Cysts

Aunt Minnie 41
 Astrocy'toma: Ependymoma Hemangioblastoma

- Most common -More common in adults -30% have Von Hippel

intramedullary tumor in Lindau
child. - More common in the
lower cord -Typical in thoracic cord
-Usually in the upper
thoracic cord. -Tend to arise more central - Widened cord with a lot
(astrocj tomas arise more of edema
-Fusiform and expand the posterior
cord over several segment. -Adjacent serpiginous
-Usually in the upper areas of signal void
-Tend to have associated thoracic cord. (draining veins) are
syrinx formation (with typical
rostral and caudal cysts). -They bleed more.

EXTRAMEDULLARY- INTRA DURAL TRIVIA

Schwannoma Neurofibroma Meningioma

• Don't envelop the dorsal • Do envelop the dorsal • Adhere to (but don't
sensory nerve root. sensory root originate from) the dura.
Instead grow
asymmetrically next to • Posterior lateral in
the nerve. thoracic spine. Anterior
• Generally multiple to cervical spine.
• Gen rally Solitary
• Associated with NF even • Enhance homogeneous
• MOT associated with NF when single (more than
(in the pine). schwannoma), and slight
T2 bright (less than
• High peripheral T2, with schwannoma).
low signal in center
'target" • F>M

Aunt Minnie 42
CASE 19 - BUTT DIMPLE

1. What is the diagnosis?

A. Lipoma
B. Tethered Cord with Lipoma
C. Terminal Ventricle
D. Tabes Dorsalis

2. The cord is considered low lying when the tip of the conus is below?
A. T12
B. Ll
C. L2
D. L3

3. Fat associated with the film terminal is?

A. Always bad and associated with horrible things
B. Never bad and often a sign of good luck (buy a lottery ticket!)
C. Usually an incidental finding (seen about 5% of time), but sometimes associated
with cord tethering.

Aunt Minnie 43
CASE 19 - TETHERED CORD WITH LIPOMA

Tethered Cord with Lipoma

Abnormal spinal cord attachment that

can lead to neurologic symptoms from
stretching of the cord.

Essential Trivia:

- The spinal column grows faster than

the cord, so if the cord is tethered by
an abnormal attachment it can I will
get stretched.
1. What is the diagnosis?
A. Lipoma - A lipoma of the filum terminale is
B. Tethered Cord with Lipoma common (usually incidental) but is
C. Terminal Ventricle
associated with a tethered cord.
D. Tabes Dorsalis

2. The cord is considered low lying when the tip of the - Tethered cord is closely linked to
conus is below (in an adult) ? pina bifida.
A. T12
B. Ll - Normally the conus should NOT be
C. L2 lower than L2-L3 (LI-L2 in adults).
D. L3
Any cord below L3 is uspect.

3. Fat associated with the film terminal is?

A. Always bad and associated with horrible things - With regard to screening, just
B. Never bad and often a sign of good luck (buy a remember that low sacral dimples
lottery ticket!) (< 2.5crn from the anus) don't need to
C. Usually an incidental finding (seen about 5% of be screened. Pretty much everything
time), but sometimes associated with cord else does.
tethering.

Aunt Minnie 44
CASE 20 - NEW MOM WITH WRIST PAIN

1. What is the diagnosis?

A. De Quervain's Tenosynovitis
B. Mycobacterial Infection
C. Intersection Syndrome
D. Drummer's Wrist

2. What tendon(s) are involved?

A. Extensor Carpi Radialis (Brevis & Longus)
B. Extensor Digiti Minimi
C. Extensor Carpi Ulnaris
D. Extensor Pollicis Brevis and Abductor Pollicis Longus

3. What extensor compartment is involved?

A. 1
B. 2
C. 3
D. 7

Aunt Minnie 45
CASE 20 - DE QUERVAIN'S TENOSYNOVITIS

First Extensor Compartment

- Fluid in Tendon Sheath

_,_

De Quervain's Tenosynovitis
1. What is the diagnosis?
A. De Quervain 's Tenosynovitis
An overuse tendinopathy c1assically seen
B. Mycobacterial Infection
in mothers and childcare worker's afflicted
C. Intersection Syndrome
D. Drummer's Wrist with the terrible ta sk of lifting infants

2. What tendon(s) are involved? Essential Trivia:

A. Extensor Carpi Radialis (Brevis &
Longus) - The EPB and APL are invol ed (first
B. Extensor Digiti Minimi
compartment)
C. Extensor Carpi Ulnaris
D. Extensor Pollicis Brevis and Abductor
Pollicis Longus - The ortho test is the 'positive Finkelstein
test" - pain with passive ulnar deviation.
3. What extensor compartment is involved?
A. 1 - Tenosynovitis is pretty non. pecific (fluid
B. 2 in the tendon sheath, and peritendinous
C. 3
edema I enhancement). The location is
D. 7
classic.

- First Compartment = De Qucrvains

- 2nd Compartment = intersection
Syndrome ** overuse tendinopathy seen
in rowers

Aunt Minnie 46
CASE 21 - PAIN

__
,

1. What is the diagnosis?

A. Sever's Disease
B. Kohler Disease
C. Panner's Disease
D. Diaz Disease

2. What is the typical age for this to occur?

A. Adults (30s-40s)
B. Elderly (60s-80s)
C. Teenagers
D. Young School Age (4-8)

3. What is the mechanism here?

A. It's post traumatic (jumping)
B. It's AVN - maybe from a vascular insult
C. It's secondary to infection

Aunt Minnie 47
CASE 21 - KOHLERS

Kohlers

This is an AYN of the navicular bone,

causing a wafer-like appearance. This
belongs to a group of things called
"osteochondroses."

Essential Trivia:
- You see this in kids (4-8 years old).

- Believe it or not with treatment (rest

and I or ca t), this gets better and
goes back to normal.

1. What is the diagnosis? - Osteochondroses -These are a group

A. Sever's Disease of conditions (usually seen in
B. Kohler Disease childhood) that are characterized by
C. Panner's Disease involvement of the [Link]
D. Diaz Disease
apophysis with findings of collapse,
sclerosis and fragmentation -
2. What is the typical age for this to occur?
A. Adults (30s-40s) suggesting osteonecrosis,
B. Elderly (60s-80s)
C. Teenagers - Other Notable Osteochondroses:
D. Young School Age ( 4-8) • Freiberg - Second Metatarsal
Head, seen in Adolescent Girl
3. What is the mechanism here?
• Severs - Calcaneal Apophysi -
A. It's post traumatic (jumping)
maybe a normal "growing pain"
B. It's AVN - maybe from a vascular insult
C. It's secondary to infection • Panners - Capitellum of school age
throwers
• Perthes - Femoral Head - white
kids ·chool age (4-8)
• Kienbock - Carpal Lunate -
associated with ulnar positive
variance

Aunt Minnie 48
CASE 22 - PAIN

1. What is the diagnosis?

A. Klippel-Feil Syndrome
B. Juvenile Rheumatoid Arthritis
C. Panner's Disease
D. Ankylosing Spondylitis

2. What makes this different than the adult variety?

A. It favors the carpals
B. It has symmetric joint space narrowing
C. It causes ankylosis
D. RF factor is usually negative

3. When it occurs in teenagers, it favors?

A. Boys
B. Girls
C. It has no gender bias

Aunt Minnie 49
CASE 22 - .JUVENILE RHEUMATOID ARTHRITIS (.JRA)

JRA

Inflammatory Arthritis(> 6 weeks)

PLUS Growing Skeleton { < 16 years
old)

Essential Trivia:
- It's usually seronegarive -RF lab
test is negative (like 85%)

- Di itributionfavor the carpal , - It usually affects female , except

bones are v IJ osteopeni · when it occurs acutely under the age
of 5 'Stills Disease ' - then it s M=F

- The knee i the most common

involved (ankle i #2, wrist is #3)
1. What is the diagnosis?
A. Klippel-Feil Syndrome
B. Juvenile Rheumatoid Arthritis - Characteristic findings are
C. Panner's Disease • osteopenia,
D. Ankylosing Spondylitis • uni form joint space narrowing
• bony ankylosis
2. What makes this different than the adult variety?
A. It favors the carpals
B. It has symmetric joint space narrowing
C. It causes ankylosis
D. RF factor is usually negative

3. When it occurs in teenagers, it favors?

A. Boys
B. Girls
C. It has no gender bias

Aunt Minnie 50
CASE 23 - PAIN

1. What is the diagnosis?

A. Psoriatic Arthritis
B. Juvenile Rheumatoid Arthritis
C. Osteoarthritis
D. Ankylosing Spondylitis

2. The distribution in the hands typically ?

A. Favors the carpals
B. Favors the MCP Joint
C. Favors the IP Joints
D. Mainly just targets the DRUJ

3. The SI joint involvement is usually?

A. Unilateral
B. Bilateral - Symmetric
C. Bilateral - Asymmetric

Aunt Minnie 51
CASE 23 - PSORIATIC ARTHRITIS

Psoriatic Arthritis

Inflammatory Arthritis associated with

the gross "yucky skin of psoriasis.

Essential Trivia:
- This is one of the "seronegative
spondyloarthritides." The other 3 are
Inflammatory Bowel related
(Enteropathic), Reiters (Reactive), and
Anky losing Spondylitis.

-About 30% of psoriasis patients get it -

with the skin finding bowing up about
10 years earlier.

Fingeri Ankylosis: Mainly - Finger nail involvement is very

Seen With Erosive OA and
common (85%)
Psoriasis

- In general: Erosive change + adjacent

1. What is the diagnosis? bone proliferation with a distal
A. Psoriatic Arthritis involvement (IP joints more than MCP).
B. Juvenile Rheumatoid Arthritis
C. Osteoarthritis
- SI joint involvement i asymmetrical
D. Ankylosing Spondylitis

2. The distribution in the hands typically ? - There are lots of characteristic

A. Favors the carpals buzzwords for this one:
B. Favors the MCP Joint
C. Favors the IP Joints • ' Pencil in Cup" Deformity
D. Mainly just targets the DRUJ • ' Fuzzy Appearance' near affected
joint - from bone proliferation
3. The SI joint involvement is usually?
• Sausage Digit ' - soft tissue
A. Unilateral
B. Bilateral - Symmetric welling
C. Bilateral - Asymmetric • "Ivory Phalanx - Sclerotic looking
big toe

Aunt Minnie 52
CASE 24 - PAIN

1. What is the diagnosis?

A. Psoriatic Arthritis
B. Gout
C. Osteoarthritis
D. Ankylosing Spondylitis

2. This disease "NEVER" ?

A. Involves the knee
B. Causes erosions
C. Causes joint space narrowing
D. Has sclerotic margins

3. This modem technique can be used to accurately diagnose Gout

A. MRI Spectroscopy
B. F-18 PET-CT
C. Dual Energy CT

Aunt Minnie 53
CASE 24 - THE GOUT

The Gout
Lots of soft tissue
calcifications
Crystal arthropathy (mono odium
urate). Causes well defined erosions
with sclerotic margins and the
classic "overhanging edges.

Essential Trivia:

- 1t does not happen (usual1y) in men

younger than 30, and in women
prior to menopause.

- Often targets the big toe first

"Podagra"

- Radiologic Buzzwords I Findings:

• WeU marginated eccentric

erosions with "overhanging
1. What is the diagnosis? edges'
A. Psoriatic Arthritis • Erosions appear "punched out' -
B. Gout with sclerotic margins
C. Osteoarthritis
• 'NEVER' causes joint. pace
D. Ankylosing Spondylitis
narrowing- until it doe - with
2. This disease "NEVER" ? end stage f rms of the disease
A. Involves the knee
B. Causes erosions - Using Dual energy 'T can be done
C. Causes joint space narrowing by using 80 and 140 kV p energie
D. Has sclerotic margins plus a material decomposition
algorithm to identify uric acid.
3. This modem technique can be used to accurately
diagnose Gout
A. MRI Spectroscopy
B. F-18 PET-CT
C. Dual Energy CT

Aunt Minnie 54
CASE 25 - PAIN

1. What is the diagnosis?

A. Psoriatic Arthritis
B. Gout
C. Osteoarthritis
D. Erosive Osteoarthritis

2. The typical demographic for this group is

A. YoungMen
E. Young Women
F. Old Men
G. Old (Postmenopausal) Women

3. The classic finding for this diagnosis is?

A. Marginal Erosions
B. Central Subchondral Erosions
C. Fusiform Soft Tissue Swelling
D. Osteopenia

Aunt Minnie 55
CASE 25 - EROSIVE OSTEOARTHRITIS

Erosive Osteoarthritis

This is a ubtype of osteoarthriti that

includes an erosive I inflammatory
component.

Essential Trivia:

- For the purpose of multiple choice this

only occurs in postmenopausal females
=
- The hand is the most commonly
involved body part (hip and knee are
1. What is the diagnosis?
rarely involved).
A. Psoriatic Arthritis
B. Gout
C. Osteoarthritis - Onset is typically more rapid than the
D. Erosive Osteoarthritis conventional OA

2. The typical demographic for this group is - Radiologic Buzzwords I Findings:'

A. Young Men
E. Young Women
• Central subchondral ero ior -
F. Old Men
G. Old (Postmenopausal) Women ''gull-wing" - this is the "Classic
Feature"
3. The classic finding for this diagnosis is? • Joint Ankylosis
A. Marginal Erosions • Diffuse cartilage space loss
B. Central Subchondral Erosions
C. Fusiform Soft Tissue Swelling
- Why is this not JU?
D. Osteopenia

• The distribution favors the DIP, PIP

and First CMC - unlike RA which is
more carpals and MCP
• Typically RF Negative
• Erosions are more central (RA has
more marginal)

Aunt Minnie 56
CASE 26 - PAIN

1. What is the diagnosis?

A. Psoriatic Arthritis
B. Lupus
C. Osteoarthritis
D. Rheumatoid Arthritis

2. A mimic for this diagnosis is?

A. Reactive (Reiters) Arthritis
E. Jaccoud's Arthritis
F. Erosive O.A.
G. Hemochromatosis

3. The classic finding for this diagnosis is?

A. Deformation with Erosions
B. Deformation without Erosions
C. Fusiform Soft Tissue Swelling
D. First CMC Osteophyte Formation

Aunt Minnie 57
CASE 26 - SLE (LUPUS) ARTHRITIS

SLE Arthritis

Arthriti seen with Lupus is common (up

to 80% of patients).

Essential Trivia:

- The classic feature is a def rming

arthritis without erosions

- The finding of vrever ing subluxations" =

Subluxations - i the c1assic \i ay to show this. Hands

seen only in flat against the film in the PA reduce the
Norgaard View subluxation, which then reoccur in the
ball catcher (Norgaard) iew.

1. What is the diagnosis?

- The main mimic is Jaccoud
A. Psoriatic Arthritis
B. Lupus Arthropathy" causes a similar reversing
C. Osteoarthritis subluxation - usually ulnar sided. The
D. Rheumatoid Arthritis only thing to know is that it occurs post
rheumatic fever.
2. A mimic for this diagnosis is?
A. Reactive (Reiters) Arthritis
- Lupus patients are at an increas d risk
E. Jaccoud's Arthritis
of tendon rupture and AVN with teroid
F. Erosive O.A.
G. Hemochromatosis therapy.

3. The classic finding for this diagnosis is? - Radiologic Buzzwords I Findings:
A. Deformation with Erosions
B. Deformation without Erosions • Symmetric Polyarthritis involving the
C. Fusiform Soft Tissue Swelling
hands and knees
D. First CMC Osteophyte Formation
• It's non erosive
• Nonspecific periarticular o teopenia
• Correctable Subluxations - u ually
ulnar sided.

Aunt Minnie 58
 ARTHRITIS - ESSENTIAL TRIVIA

••••
•••• •••
• ••••
•• •••• • • ••• * •••
• •
•
Erosive OA
--'
.......

RA
OA CPPD
This is the classic "targeted distribution" (most common area involved)

The Gout

This is the classic - "over hanging

edge", and "punched out lesions."

Aunt Minnie 59
 "Axial
Direction"

OA RA

. . .
; Subperiosteal Resorption, Tuft Resorption Rugger Jersey Brown Tumor
I
and brown tumors
' ,
'"�' __· ._.·_·_._.:..·_.·.,_,·_._:"="_" :______!__._,·. \ �\.-.1...... • - • •

SI Joints

Unilateral = Infection Asymmetric = Symmetric=

Psoriasis, Reiters Inflammatory Bowel, AS

Aunt Minnie 60
CASE 27 - PAIN

1. The most common location for this type of lesion is?

A. Femoral Condyle
B. Talus
C. Capitellum of Elbow
D. Rib

2. The most important goal of MRI with a lesion such as this is to?
A. Determine the location of the lesion
B. Determine if the lesion is solitary or multiple
C. Determine the size of the lesion
D. Determine the stability of the lesion

3. Stable vs Unstable is denoted by?

A. Cartilage Injury= Unstable
B. Subchondral Edema= Unstable
C. High Signal around fragment = Unstable
D. T2 Dark Signal within the fragment= Unstable

Aunt Minnie 61
CASE 27- OSTEOCHONDRAL LESION

Osteochondral Lesion

lnj ury to both articular cartilage and

bone, though to be ·econdary to
repetitive trauma, In the elbow, it's
usually from gymnastics or throwing.
The typical age is a young teenager.

Essential Trivia:

- The most common location is the

medial femoral condyle, ( econd most
common is the taller d me, third most
1. The most common location for this type of common is the anterolateral capitellum).
lesion is?
A. Femoral Condyle
- MRJ i · obtained to tell if the lesion is
B. Talus
stable or not.
C. Capitellum of Elbow
D. Rib
- Under cutting of T2 high signal around
2. The most important goal of MRI with a the fragment defines it as unstable (by
lesion such as this is to? MRJ
A. Determine the location of the lesion
B. Determine if the lesion is solitary or
- The "» eudodefect' of the capitellum is
multiple
the most common pitfall. This occurs
C. Determine the size of the lesion
D. Determine the stability of the lesion by the sharp change in angle on coronal
images around the posterior lateraJ edge
3. Stable vs Unstable is denoted by? (remember thi OCL is u rually anterior
A. Cartilage Injury= Unstable not po terior).
B. Subchondral Edema= Unstable
C. High Signal around fragment=
- "Panner �,; Disease" is an
Unstable
o teochondrosis (AYN) of the
D. T2 Dark Signal within the fragment=
Unstable capitellum, It occurs in a younger age
(5-10) is self limiting, and does NOT
have loose bodies.

Aunt Minnie 62
CASE 28 - PAIN

1. What is the diagnosis?

A. Pigmented Nodular Synovitis
B. Synovial Chondromatosis
C. Lipoma Arborescens
D. Hemophilia

2. What factors favor primary type over secondary type?

A. Severe degenerative changes
B. History of trauma
C. Loose bodies are different sizes
D. Loose bodies are similar sizes

3. Is the primary form a malignant cancer?

A. Yup - get the saw ready
B. Nope - won't need to amputate this time

Aunt Minnie 63
CASE 28- SYNOVIAL CHONDROMATOSIS

Synovial Chondrornatosis

Disorder with multiple intra-articular

cartilaginous loose bodies. There are two
distinct subtypes.

Essential Trivia:

- Primary Type - Self limiting neoplastic

proces s in which the synovium of a
single joint goes bananas and starts
proliferating into chondroid nodule .
These flake off into the joint and are
bathed in the synovial fluid - which
1. What is the diagnosis? makes them grow big. The key i · they
A. Pigmented Nodular Synovitis
are usually all the same size.
B. Synovial Chondromatosis
C. Lipoma Arborescens
D. Hemophilia - 'Secondary Type - Thi· is associated
with trauma or bad OA. You get
2. What factors favor primary type over cartilage knocked off which gets bathed
secondary type? by synovial fluid and . tarts to grm .
A. Severe degenerative changes The loose bodies are different sizes in a
B. History of trauma
background of bad degenerative change.
C. Loose bodies are different sizes
D. Loose bodies are similar sizes
-Treatment between primary and
3. Is the primary form a cancer? secondary types i different. Both get
A. Yup - get the saw ready the loose bodies remo ed. but
B. Nope - won't need to amputate this time sometime urgeons will do a
synovectomy in the primary type (local
recurrence rate are quoted between
3-23%).

- Se n more commonly in bigger joints

shoulders and knees), but can occur in
any joint even the TMJ).

Aunt Minnie 64
CASE 29- PAIN

-·-

1. What is the diagnosis? 3. What is the major concern?

A. AVN of the femoral head A. Soft tissue involvement
B. Multiple Myeloma B. Progression to ankylosis
C. Pagets C. Malignant Transformation
D. Giant Cell Tumor D. High Risk of Osteomyelitis

2. What is the most common location 4. In diffuse disease what bone is most
A. Femoral Condyle likely to be spared?
B. Talus A. The fibula
C. Skull B. The tibia
D. Pelvis C. The skull
D. The spine

Aunt Minnie 65
CASE 29 - PAGETS

Page ts

Poorly under tood relatively common (4% at 40,

8% at 80) chronic di ease of bone formation.

Ess ntial Trivia:

- "Wide Bone· with Thick Trabecula" (nothing

else really does that).

- Complications: Deafness (actually pretty

common) spinal stenosis ·tress fracture CHF
(high output) econdary hyperparathyroidism
1. What is the diagnosis? (10%)
A. AVN of the femoral head
B. Multiple Myeloma
- "Mostfeared complication" = secondary
C. Pagets
D. Giant Cell Tumor o steosarcoma - high grade and a mother fucker

2. What is the most common location - Skull - Large area of osteolysis in the Frontal
A. Femoral Condyle and Occipital Bones "Osteoporosis
B. Talus Circumscripta' in the lytic phase. The skull will
C. Skull
look "cotton wool" in the mixed phase. Favors
D. Pelvis
the outer table.
3. What is the major concern?
A. Soft tissue involvement - Spine - Cortical Thickening can cause a picture
B. Progression to ankylosis frame ign' ( ame as osteopetrosis). Also can
C. Malignant Transformation give you an ivory vertebral body.
D. High Risk of Osteomyelitis
- Peli is - Most common bone involved. "Always
4. In diffuse disease what bone is most
involv s the iliopectineal line on the pelvic
likely to be spared?
A. The fibula brim.
B. The tibia
C. The skull - Long Bones - Advancing margin of lucency
D. The spine from one end to the other is the so called "blade
of grass' or 'flame.' Will often spare the fibula.

Aunt Minnie 66
CASE 30 - PAIN

1. What is the diagnosis?

A. Chordoma
B. Pagets
C. Particle Disease
D. Plasmacytoma

2. A key feature to this diagnosis is?

A. Marked sclerotic border
B. No secondary reaction (no periosteal reaction)
C. Loose bodies of different sizes
D. Associated asymmetric SI joint erosions

3. If the patient has no fever I no white count, MRI of the lytic areas will probably be?
A. T2 Bright
B. T2 Isointense to muscle

Aunt Minnie 67
CASE 30 - PARTICLE DISEASE

Particle Disease

Locally aggressive histolytic re ponse to

small poly thylene particles hed from the
lining

Essential Trivia:

- Mechanism: mall particles are shed into

the joint fluid and leak into the adjacent
bones - often through the screw holes. -·-
Gray Arrows = Bad Osteolysis
White Arrows = Tiny flecks of particle These particles illicit a sterile
Black arrows= Probably some wear I shift lateral inflammatory re ponse which lysis the
crap out of the bone. Bones wiggle more,
particles pread more.
1. What is the diagnosis?
A. Chordoma
- Typically occurs between l-5 year. after
B. Pagets
surgery.
C. Particle Disease
D. Plasmacytoma
- Radiologic Buzzwords I Findings: '
2. A key feature to this diagnosis is? • Aggressive osteolysis around the hardware
A. Marked sclerotic border • Often a sociated with polyethylene wear
B. No secondary reaction (no periosteal (but doesn t have to be)
reaction)
• 'I he key feature is that there is no
C. Loose bodies of different sizes
secondary bone response (no sclerotic
D. Associated asymmetric SI joint
erosions reaction)

3. If the patient has no fever I no white - Why is this not infection?

count, MRI of the lytic areas will probably • Clinically won't have fever and/or other
be? igns of infection
A. T2 Bright
• Ou MRJ - lytic lesions of osteomyelitis
B. T2 Isointense to muscle
tend to be T2 bright. Particle disease lytic
lesions are mainly inflammatory and
fibrou tissue which i · i ointense to
muscle on TI and T2

Aunt Minnie 68
CASE 31 - PAIN

1. What is the diagnosis?

A. Creep
B. Wear
C. Loosening
D. Fracture

2. Shifting of the head inside the cup is considered pathologic when ?

A. It's towards the spine
B. It's lateral

3. This finding predisposes to what ?

A. Particle disease
B. Infection
C. Myositis Ossificans
D. Heterotopic Ossification

Aunt Minnie 69
CASE 31 - POLYETHYLENE WEAR

Polyethylene Wear

The prosthetic head should be centered

symmetrically within the cup. Lateral
shifting is considered pathologic.

Essential Trivia:

- Poor Locking of the PE linear in the cup,

micro-motion, or abnormal loading can
predi pose to wear.

- Creep = A normal process of mild

penetration of the femoral head component
1. What is the diagnosis?
into the cup (in the direction of the spine).
A. Creep
B. Wear This occurs in the first 2 years of
c. Loosening placement.
D. Fracture
• Breaking down f the the PE linear can
2. Shifting of the head inside the cup is lead to particle disease (as seen in case 30)
considered pathologic when ?
A. It's towards the spine
B. It's lateral

3. This finding predisposes to what ?

A. Particle disease
B. Infection
C. Myositis Ossificans
D. Heterotopic Ossification

Aunt Minnie 70
CASE 32 - PAIN

1. What is the diagnosis? 3. Which bundle of the UCL is the "most

A. Radial Collateral Ligament Tear important" stabilizer?
B. Annular Ligament Tear A. Anterior
C. Ulnar Collateral Ligament Tear B. Posterior
D. Lateral Ulnar Collateral Ligament Tear C. Transverse
D. All are equally important
2. This injury is most commonly seen in?
A. Linebackers 4. Where does the UCL attach?
B. Kickers A. The Sublime Tubercle
C. Throwers - from valgus stress B. The Olecranon Fossa
D. Throwers - from varus stress C. The Radial Tuberosity
D. Gerdes Tubercle

Aunt Minnie 71
CASE 32 - PARTIAL ULNAR COLLATERAL LIGAMENT
TEAR - "THE 'T' SIGN"

Partial UCL Tear

"T-Sign"

The Ulnar Collateral Ligament normally

attaches firmly to the "sublime tubercle.
When it tears, gadolinium will undercut the
tubercle creating the appearance of a T.

Essential Trivia:

- The ulnar c llateral ligament consists of 3

bundles (anterior, posterior, and
transverse). The anterior one is the most
1. What is the diagnosis? important re traint to the valgus tress seen
A. Radial Collateral Ligament Tear in thrower.
B. Annular Ligament Tear
C. Ulnar Collateral Ligament Tear
- Throwers injure 3 main things from valgus
D. Lateral Ulnar Collateral Ligament Tear
overload - the UCL the common flexor
2. This injury is most commonly seen in? tendons and the ulnar nerve
A. Linebackers
B. Kickers - Because the flexor I pronator mass keeps
C. Throwers - from valgus stress the function of the elbow normal even
D. Throwers - from varus stress after a tear of the UCL, it's usually
managed with conservative therapy - in the
3. Which bundle of the UCL is the "most
non- athlete.
important" stabilizer?
A. Anterior
B. Posterior - For the elite athlete (or f r high chooler
C. Transverse who e father failed to achieve their own
D. All are equally important dreams and are trying to live them out
through their children), the 'Tommy John
4. Where does the UCL attach?
recon truction can be done. Usually the
A. The Sublime Tubercle
palmaris longus i used as the donor
B. The Olecranon Fossa
C. The Radial Tuberosity tendon.
D. Gerdes Tubercle

Aunt Minnie 72
CASE 33 - FELT A BUMP

1. What is the diagnosis?

A. Fibrous Dysplasia
B. Pagets
C. Enchondroma
D. Aneurysmal Bone Cyst

2. Up to 40% of the time a secondary ABC is associated with?

A. Osteosarcoma
B. Chondrosarcoma
C. Giant Cell Tumor
D. Bizarre Parosteal Osteochondromatous Proliferation (BPOP)

3. The typical age for the lesion is?

A. > 30
B. <30
C. No age preference

Aunt Minnie 73
CASE 33 - ANEURYSMAL BONE CYST

Aneurysmal Bone Cyst

(ABC):

Aneurysmal bone cysts are

aneurysmal lesions of bone with
thin-walled, blood-filled spaces
(fluid-fluid level on MRI).

Essential Trivia:

- They are typically thought of as _,_

** Fluid-Fluid Levels, in the
metaphysis of a long bone. either primary or secondary. The
secondary ones arise out of
another tumor (classically Giant
Cell Tumors).
I. What is the diagnosis?
A. Fibrous Dysplasia - They can develop after a trauma
B. Pagets
C. Enchondroma
- Mo t Patients are less than 20
D. Aneurysmal Bone Cyst

2. Up to 40% of the time a secondary ABC is - The metaphysis of tibia is the

associated with? most common location (the
A. Osteosarcoma second most common is the
B. Chondrosarcoma posterior elements).
C. Giant Cell Tumor
D. Bizarre Parosteal Osteochondromatous
-DDxfor a Fluid-Fluid Level on
Proliferation (BPOP)
MRI:
3. The typical age for the lesion is? • ABC
A. >30 • Giant Cell Tumor
B. <30 • Telangiectatic Osteosarcorna
C. No age preference • imple Bone Cyst (after Fx)

Aunt Minnie 7 4
CASE 34 - PAIN -

1. What is the diagnosis?

A. ACL Tear
B. PCL Tear
C. MCL Tear
D. Medial Meniscus Tear

2. The "Double PCL sign" can only occur with a medial meniscal tear when?
A. The ACL is also tom
B. The ACL is intact
C. The PCL is also tom
D. The MCL is also tom

3. Which sequence is the least sensitive for meniscal tears?

A. Tl
B. T2
C. Proton Density (PD)

Aunt Minnie 75
CASE 34 - BUCKET HANDLE MENISCUS TEAR
- "DOUBLE PCL"

Bucket Handle Meniscus Tear

The result of a tom inner meniscal

segment from a longitudinal or oblique
tear "flipping' - mo t commonly into the
intercondy lar notch.

Essential Trivia:

- The double PCL sign" , as seen in this

case, consi ts of meniscus flipped into
the notch, inferior and parallel to th PCL
seen in the same sagittal plane.

1. What is the diagnosis? - It' more common medially

A. ACL Tear
B. PCL Tear
- It · only seen medially - in the setting of
C. MCL Tear
an intact ACL.
D. Medial Meniscus Tear

2. The "Double PCL sign" can only occur - The "Ab ent Bow Tie ign describes the
with a medial meniscal tear when? absent meni cal body on two consecutive
A. The ACL is also tom slices - with false positi es seen in
B. The ACL is intact children. and smaJl adults.
C. The PCL is also tom
D. The MCL is also tom
- A short TE is required to see meni cal
3. Which sequence is the least sensitive for tears effectively. Longer TEs mi the
meniscal tears? difference between an intact meniscu
A. Tl and one that is chewed up. Thi is wh
B. T2 T2 sucks for the meniscus. Remember Tl
C. Proton Density (PD) and PD have short TE. and T2 has a ion 'r
TE.

Aunt Minnie 76
CASE 35 - PAIN -

1. What is the diagnosis?

A. Discoid Meniscus
B. Mensical Seperation
C. Parrot Beak Meniscal Tear
D. Flipped Meniscal Fragment (Bucket Handle Tear)

2. Discoid meniscus is most commonly seen on?

A. The Medial Side
B. The Lateral Side
C. Both Sides Equally

3. Which disco id variant has no posterior coronary or capsular attachment?

A. The "Complete"
B. The "Incomplete"
C. The "Wrisberg"
D. The "Humphrey"

Aunt Minnie 77
CASE 35 - DISCOID MENISCUS

Discoid Meniscus

Congenital variant in which the

meniscus is nearly disk shaped (instead
of' C shaped").

Essential Trivia:

- The diagnosis is . uggested by rneniscal

tissue on 3 contiguous sagittal lices
"too many bow-ties", or a meni seal
body extending into the intercondylar
notch on coronal images (as in this
case).
I. What is the diagnosis?
A. Discoid Meniscus
B. Mensical Seperation - The discoid meniscus has an increased
C. Parrot Beak Meniscal Tear incidence of tearing.
D. Flipped Meniscal Fragment (Bucket
Handle Tear) - The 3 subtype· of discoids are:
complete, incomplete and Wri berg.
2. Discoid meniscus is most commonly seen
The Wri berg has the most symptoms
on?
A. The Medial Side ( napping sensations). and has no
B. The Lateral Side po terior coronary or capsular
C. Both Sides Equally attachment.

3. Which discoid variant has no posterior - Discoid meui cus i more common in
coronary or capsular attachment? Asians (Japanese and Koreans) up to
A. The "Complete"
15% - depending on what you read.
B. The "Incomplete"
C. The "Wrisberg"
D. The "Humphrey"

Aunt Minnie 78
 MENISCUS - ESSENTIAL TRIVIA

Vascularity
Medial Meniscus Lateral Meniscus

Covers 50% of the medial Covers 70% of the lateral The vascularity of the
plateau plateau meniscus is divided in a "Red
Zone" and a "White Zone."
More "Open" C Shape More "Closed" C Shape
Red Zone - The peripheral
Anterior Horn = Posterior 30%. It has good blood flow.
Posterior Horn is Thicker
than Anterior Horn Horn and can potentially heal if
injuried.
Anterior Horn attaches in Anterior horn has fibers
front of the ACL from the ACL extending White Zone - The inner 70%.
into it's root. This causes It has shitty blood flow, and
a ''striated" or "comb-like" =
will not heal.
appearance
The percentage of "Red Zone"
Less Mobile - because of Meniscofemoral is more like 50% in kids. This
peripheral attachments to ligaments (Wrisberg and is why they heal their
the deep MCL fibers Humphrey) attach to the meniscus better than adults.
posterior horn

White Zone

{---. - .. __ . .l.\------ --- ' r=:i1..---;

j •• t
I !i l

Meniscal Tear in the Setting of ACL Tear:

• Acute ACL Tear - The Lateral Meniscus is torn twice as often as the MCI!..

• Most Meniscal Tears (in the setting of acute ACL injury) are peripheral
longitudinal tears of posterior �om of the lateral meniscus

• In the Chronic Setting ("ACL Deficient knee") - increased mobility leads to

shear forces of the less mobile posterior horn of the Medial meniscus

Aunt Minnie 79
Diagnosis and Classification of the Tear:

The normal meniscus is dark on all sequences. Criteria for calling a tear is going to
be either (a) abnormal signal extending to the meniscal articular surface, or (b)
abnormal morphology- i.e. the triangle looks blunted.

Tears can be thought of as either (1) vertical , (2) horizontal, or (3) "complex" (both).
Horizontal is just plain horizontal. However, vertical is sub-divided into longitudinal,
radial, or parrot-beak. The parrot beak is uncommon - forget I mentioned it.

Horizontal

) =

--

-
..
--+!.
:
"
...
.->:

Aunt Minnie 80
CASE 36 - PAIN -

-·-

1. What is the diagnosis?

A. Flexor Digitorum Tear
B. Flexor Hallucis Longus Tear
C. Peroneus Longus Tear
D. Peroneus Brevis Tear

2. This injury is associated with?

A. The presence of a peroneus quartus
B. The absence of a peroneus quartus
C. The presence of an accessory navicular
D. The absence of an accessory navicular

3. Avulsion fractures at the base of the 5th Metatarsal involve what tendon?
A. Flexor Digitorum
B. Flexor Hallucis Longus
C. Peroneus Longus
D. Perone us Brevis

Aunt Minnie 81
CASE 36 - SPLIT PERONEUS BREVIS

Split Peroneus Brevis

Split tearing of the peroneus brevis is

common with inversion injury.

Essential Trivia:

- Things that predispose to tearing of the

peroneus brevis include things that
crowd the tendon (low lying peroneal
muscle body, acces ory muscle - most
famously the peroneus quartus and
thickening of the calcaneofibular
1. What is the diagnosis?
A. Flexor Digitorum Tear ligament). When you dorsiflex and
B. Flexor Hallucis Longus Tear invert your foot ( 'twist your ankle") -
C. Peroneus Longus Tear the tendon gets mashed into the lateral
D. Peroneus Brevis Tear malleolu: . Over time it tears.

2. This injury is associated with?

- Tearing is characteristically in the shape
A. The presence of a peroneus quartus
of a C" or a 'boomerang.'
B. The absence of a peroneus quartus
C. The presence of an accessory navicular
D. The absence of an accessory navicular - There is an 80% association with lateral
ligament tears and split tears of the
3. Avulsion fractures at the base of the 5th peroneus brevis. This is why the injury
Metatarsal involve what tendon? is associated with chronic ankle
A. Flexor Digitorum
instability
B. Flexor Hallucis Longus
C. Peroneus Longus
D. Peroneus Brevis - Another classic piece of trivia is that the
peroneus bre is inserts onto the base of
the Sth Metatarsal. When you get an
avulsion fracture of the 5th MT
"Dancer's Fracture 'this is the tendon
that does the avulsing.

Aunt Minnie 82
CASE 37 - PAIN

_,_

1. What is the diagnosis?

A. Flexor Digitorum Tear
B. Flexor Hallucis Longus Tear
C. Posterior Tibialis Tear
D. Peroneus Longus Tear

2. This injury is associated with?

A. Development of pes planus (flat foot)
B. Development of pes cavus
C. Development ofhindfoot varus
D. The absence of an accessory navicular

3. Rupture of this tendon places abnormal stress on which ligament?

A. The Deltoid Ligament
B. The Anterior Talar Fibular Ligament
C. The Posterior Talar fibular Ligament
D. The Spring Ligament (plantar calcaneonavicular)

Aunt Minnie 83
CASE 37 - TEARING OF POSTERIOR TIBIAL TENDON

Tear of the Posterior Tibial Tendon

This is the most commonly injured medial

ankle tendon.

Essential Trivia:

- The posterior tibial tendon is the largest

and most medial of the 3 medial ankle
tendons (Tom Dick and Harry - or
Posterior Tibiali · Flexor Digitorum, and
Flexor HaUucis Longu )

- Tearing of the tendon is most common at

the level of th medial malJeolus

- The tendon is a major . upporter of the

arch. A tear of the tendon can lead to
1. What is the diagnosis? co11apse of the longitudinal arch.
A. Flexor Digitorum Tear
B. Flexor Hallucis Longus Tear - When you hav a po terior tibial tendon
C. Posterior Tibialis Tear tear, there is a cascade of events that can
D. Peroneus Longus Tear
occur:
• (1) PTT Tears
2. This injury is associated with?
A. Development of pes planus (flat foot) • (2) Spring Ligament Fail
B. Development of pes cavus • (3) SubIalar Ligaments Fail (causing
C. Development of hindfoot varus Sinus Tar i Syndrome).
D. The absence of an accessory navicular • (4) Pt walks on a painful flat foot -
and tries to heel strike to avoid pain.
3. Rupture of this tendon places abnormal
Thi lead to Plantar Fasciitis.
stress on which ligament?
A. The Deltoid Ligament
B. The Anterior Talar Fibular Ligament - Tearing of the tendon is associated with
C. The Posterior Talar fibular Ligament the presence of an accessory navicular
D. The Spring Ligament (plantar bone or large medial tubercle ( comuate
calcaneonavicular) proce ).

Aunt Minnie 84
CASE 38 - PAIN

1. What is the diagnosis?

A. Humeral Avulsion of the Glenohumeral Ligament (HAGL)
B. "Perthes" Lesion
C. Adhesive Capsulitis
D. Long Head of Biceps Tear

2. What is the classic diagnostic finding?

A. Thickening of the inferior glenohumeral ligament
B. Absence of the middle glenohumeral ligament
C. Absence of the anterior superior labrum
D. Medial Subluxation of the Long Head of the Biceps

3. What might you expect on arthrography?

A. Increased Joint Capacity (can hold more than 30 cc comfortably)
B. Decreased Joint Capacity ( can hold less than 10 cc)
C. Gad in the sub deltoid bursa
D. Gad in the subscapularis muscle

Aunt Minnie 85
 Adhesive Capsulitis
CASE 38 - ADHESIVE
CAPSULITIS
'Frozen Shoulder' - Contraction of
the joint capsule - often seen after
** Loss of normal fat in surgery or trauma.
the rotator cuff interval
Essential Trivia:

- The clinical buzz phrase is "Severe

glenohumeral limitation to
movement without other cause. ·

- The diagnosis is traditionally

con idered a clinical one ... until
you are asked to make it on a
multiple choice te st,

- On Arthrography low capacity

(less than lOcc) of the joint is a
clas ic sign (it' too stiff to be
di: tended by contra, t),

1. What is the diagnosis?

A. Humeral Avulsion of the Glenohumeral - Classic MRI Finding include:
Ligament (HAGL) • Thickening of the r nferior
B. "Perthes" Lesion Glenohumeral Ligament,
C. Adhesive Capsulitis Capsular Structures, Axillary
D. Long Head of Biceps Tear Pouch,
• Los· of Fat in the Rotator Cuff
2. What is the classic diagnostic finding?
Interval
A. Thickening of the inferior glenohumeral
ligament
B. Absence of the middle glenohumeral ligament
C. Absence of the anterior superior labrum
D. Medial Subluxation of the Long Head of the Biceps

3. What might you expect on arthrography?

A. Increased Joint Capacity (can hold more than 30 cc comfortably)
B. Decreased Joint Capacity (can hold less than 10 cc)
C. Gad in the sub deltoid bursa
D. Gad in the subscapularis muscle

Aunt Minnie 86
CASE 39 - PAIN

1. What is the diagnosis?

A. Humeral Avulsion of the Glenohumeral Ligament (HAGL)
B. "Perthes" Lesion
C. Anterior Labral Periosteal Sleeve Avulsion (ALPSA)
D. Buford Complex

2. The Buford Complex is?

A. A tearing of the superior labrum seen commonly in throwers
B. A tearing of the posterior labrum seen commonly in swimmers
C. A tearing of the anterior labrum seen in both throwers and swimmers
D. A normal varient

3. What is thickened in the Buford Complex?

A. The anterior band of the inferior glenohumeral ligament
B. The posterior band of the inferior glenohumeral ligament
C. The middle glenohumeral ligament (MGHL)
D. The superior glenohumeral ligament (SGHL)

Aunt Minnie 87
CASE 39 - BUFORD COMPLEX

Buford Complex

Normal variant of the glenoid labrum

seen in about 1 .5% of the general
population.

Essential Trivia:

- The complex has 3 components:

• (1) Ab ent Anterior Superior
Labrum
=
• (2) Thickened Middle
1. What is the diagnosis? Glenohumeral Ligament (MGHL)
A. Humeral Avulsion of the Glenohumeral mid
Ligament (HAGL) • (3) Originati n of the MGHL in a
B. "Perthes" Lesion more superior position - at the base
C. Anterior Labral Periosteal Sleeve Avulsion of the biceps labrum anchor.
(ALP SA)
D. Buford Complex
- It s important to recognize, as it can
2. The Buford Complex is? mimic a Jabrum tear. However. if ortho
A. A tearing of the superior labrum seen "repairs" it - that can lead to altered
commonly in throwers mechanics ... and probably a law suit
B. A tearing of the posterior labrum of which you'll certainly get drawn
seencommonly in swimmers into (fucking scumbag lawyers).
C. A tearing of the anterior labrum seen in
both throwers and swimmers
D. A normal varient

3. What is thickened in the Buford Complex?

A. The anterior band of the inferior
glenohumeral ligament
B. The posterior band of the inferior
glenohumeral ligament
C. The middle glenohumeral ligament
(MGHL)
D. The superior glenohumeral ligament
(SGHL)

Aunt Minnie 88
CASE 40 - PAIN

1. What is the diagnosis?

A. Chondrocalcinosis
B. Rotator Cuff Tear
C. Calcium Hydroxyapatite Deposition
D. Uric Acid Deposition

2. The most common location for this diagnosis?

A. Rotator Cuff (Supraspinatus Tendon)
B. Rotator Cuff (Subscapularis Tendon)
C. Knee (Quadriceps Tendon)
D. Shoulder (Long Head of Biceps Tendon)

3. Mineralization within cartilage is most likely?

A. Uric Acid Deposition
B. Calcium Pyrophosphate Dihydrate (CPPD)
C. Calcium Hydroxyapatite Deposition
D. Could be anything ...

Aunt Minnie 89
CASE 40 - CALCIFIC TENDONITIS

Calcific Tendonitis

Sell' limiting (but painful) deposition of

calcium hydroxyapatite within a tendon.

Essential Trivia:

- The most common location is the

rotator cuff usually the supraspinatous
tendon. The "critical one.. of the
tendon, just before the foot print is the
most usceptible - as it has the least
oxygen tension.

- Even though the rotator cuff is classic,

the deposition can occur in any tendon
in the body.

- Pain occurs when the mineralization

extravasates into adjacent soft ti 'Sues
(for example the subacr mial bursa)

1. What is the diagnosis? - Hydroxyapatite deposition does not

A. Chondrocalcinosis occur in joint cartilage if you see that -
B. Rotator Cuff Tear
c. Calcium Hydroxyapatite Deposition you are mo. t likely dealing with
D. Uric Acid Deposition PPD.
2. The most common location for this diagnosis?
A. Rotator Cuff (Supraspinatus Tendon) - Classic Imaging Feature :
B. Rotator Cuff (Subscapularis Tendon)
• Plain Film: ' Globular' or
C. Knee (Quadriceps Tendon)
D. Shoulder (Long Head of Biceps Tendon) "Arnorphou 'with poor margins.
• Ultra: ound: It will shadow - just
3. Mineralization within cartilage is most likely?
A. Uric Acid Deposition like a tone anywhere else.
B. Calcium Pyrophosphate Dihydrate (CPPD) • ,WR/: Dark on Tl and T2, with
C. Calcium Hydroxyapatite Deposition
D. Could be anything ... blooming on gradient.

Aunt Minnie 90
CASE 41 - PAIN

Same Tendon
Time Point 1

Same Tendon
5 seconds later in exam

1. What is the explanation?

A. The tendon spontaneously tore
B. The tech turned the probe

2. Does this artifact have a name?

A. Magic Angle
B. Anisotropy
C. Chemical Shift
D. Truncation

3. The tendon becomes dark when ?

A. It's seen perpendicular to the sound beam
B. It's NOT perpendicular to the sound beam

Aunt Minnie 91
CASE 41 - ANISOTROPY

Anisotropy
1. What is the explanation?
A. The tendon spontaneously tore A common artifact in MSK Ultrasound
B. The tech turned the probe
that can mimic a tendon tear

2. Does this artifact have a name?

A. Magic Angle Essential Trivia:
B. Anisotropy
C. Chemical Shift - The echogenicity of a tendon depend on
D. Truncation the orientation of the beam relati e to th
tendon structure. If the tendon is
3. The tendon becomes dark when ?
perpendicular it i bright, and you can see
A. It's seen perpendicular to the sound
the fibers. 1 fit s not perpendicular then it
beam
B. It's NOT perpendicular to the sound looks dark.
beam
- Thi can be used to your advantage when
distingui shing a hyper echoic tendon
from a hyper echoic blob of fat.

- The artifact is the bigge t pain in the ass

at the supraspinatous (as it curves along
the contour· of the humeral head) and
the long head of the biceps in the
bicipital groo e

Aunt Minnie 92
CASE 42 - PAIN

1. What is the diagnosis?

A. SNAC
B. SLAC
C. Ulnar Styloid Impaction Syndrome
D. Lunotriquetral Ligament Injury (VISI)

2. This injury is associated with ?

A. VISI
B. DISI

3. With this diagnosis, arthritis classically occurs FIRST in what location?

A. Between scaphoid and radius
B. Between capitate and lunate
C. Between lunate and radius
D. Between the triquetrum and ulna

Aunt Minnie 93
CASE 42 - SLAC WRIST WITH 0151

]) 2) 3) DISI Deformity

SL Ligament Injured Capitate Migrates Proximal Arthritis begins

SL Interval Widens Scaphoid Flexes at the scaphoid -
Lunate Extends radial styloid joint [Link] » 60

SLAC Wrist
'Scapholunate Advanced Collapse. "

Progressive instability in the scapho-lunate

ligaments lead to progressive in tability,
and e entual advanced arthritis.

Essential Trivia:

- The general idea is that the scaphoid

always wants to flex (tilt volar) and the
lunate always wants to extend (tilt
dorsal). Normally these oppo. ite ideas
I. What is the diagnosis? hold each other neutral but if the S-L
A. SNAC
B. SLAC ligament breaks they rotat towards their
C. Ulnar Styloid Impaction Syndrome natural inclination. This rotary
D. Lunotriquetral Ligament Injury (VISI)
subluxation leads to abnormal
2. This injury is associated with ? articulation. which lead to instability
A. VISI
B. DISI and advanced arthritis (first at the radial-
scaphoid joint).
3. With this diagnosis, arthritis classically occurs
FIRST in what location?
A. Between scaphoid and radius - For multiple choice just remember it s
B. Between capitate and lunate always DJSI (never VlSI). and that CPPD
C. Between lunate and radius
D. Between the triquetrum and ulna can be a cause of weakened ligament.

Aunt Minnie 94
CASE 43 - PAIN

1. What is the usual order of elbow ossification?

A. (1) Capitellum, (2) Olecranon, (3) Medial Epicondyle, (4) Trochlea, (5) Radial Head,
(6) Lateral Epicondyle
B. (1) Capitellum, (2) Radial Head, (3) Lateral Epicondyle, (4) Trochlea, (5) Olecranon,
(6) Medial Epicondyle
C. (1) Capitellum, (2) Radial Head, (3) Lateral Epicondyle, (4) Olecranon (5) Trochlea,
(6) Medial Epicondyle
D. (1) Capitellum, (2) Radial Head, (3) Medial Epicondyle, (4) Trochlea, (5) Olecranon,
(6) Lateral Epicondyle

2. What is the pathology in this case? 3. Which fractures are more common?
A. Displaced medial epicondyle A. Medial epicondyle more common than
B. Displaced lateral epicondyle medial condyle
C. Bro, this case is normal B. Lateral epicondyle more common than
lateral condyle
C. Medial condyle more common than
medial epicondyle
D. All statements are false
Aunt Minnie 95
CASE 43 - DISPLACED MEDIAL EPICONDYLAR FX

1. What is the usual order of elbow The Dreaded Peds Elbow

ossification?
A. (1) Capitellum, (2) Olecranon, (3) Medial
Epicondyle, (4) Trochlea, (5) Radial Head, So many little bones ... damn these peds
(6) Lateral Epicondyle
B. (l) Capitellum, (2) Radial Head, (3) elbow
Lateral Epicondyle, (4) Trochlea, (5)
Olecranon, (6) Medial Epicondyle
C. (1) Capitellum, (2) Radial Head, (3) There are two major tricks with this one.
Lateral Epicondyle, (4) Olecranon (5) ( l) Because the medial picondyle is an
Trochlea, (6) Medial Epicondyle extra articular tructure its avulsion will not
D. (1) Capitellum, (2) Radial Head, (3) necessarily result in a joint effusion. (2) It
Medial Epicondyle, (4) Trochlea, (5)
Olecranon, (6) Lateral Epicondyle can get interposed between the articular
surface of the humerus and olecranon.
2. What is the pathology in this case? Avulsed fragments can gel tuck in the joint,
A. Displaced medial epicondyle
even wh en there is no dislocation.
B. Displaced lateral epicondyle
C. Bro, this case is normal Anytime you ee a dislocation - ask yourself
3. Which fractures are more common? - ls the patient 5 years old? And if so where
A. Medial epicondyle more common than is the medial epicondyle.
medial condyle
B. Lateral epicondyle more common than Remember CRITOE, you .hould never ee
lateral condyle the TOE before the I.
C. Medial condyle more common than
medial epicondyle Lateral Condyle and Medial Epicondyle Fxs
D. All statements are false are common, the other ones aren't.

Aunt Minnie 96
CASE 44 - CHEST PAIN

1. What is the diagnosis?

A. Hypertrophic Cardiomyopathy
B. Non-Compaction
C. Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)
D. TB

2. How do you get this?

A. Too much Burger King
B. Not enough Burger King
C. Smoking
D. Bad Luck (It's inherited).

3. What causes death (usually)?

A. Ventricular Arrhythmia with Left Bundle Branch Blocks
B. A-Fib -> Stroke

Aunt Minnie 97
CASE 44 - ARVC

Arrhythmogenic Right Ventricular

Cardiomyopathy (ARVC)
1. What is the diagnosis?
A. Hypertrophic Cardiomyopathy Inherited cardiomyopathy that causes
B. Non-Compaction sudden death in oung men
C. Arrhythmogenic Right Ventricular
Cardiomyopathy (ARVC) Essential Trivia:
D. TB

• Characterized by fibrofarty degeneration

2. How do you get this?
of the RV leading t arrhythmia and
A. Too much Burger King
sudden death.
B. Not enough Burger King
C. Smoking • Features include: dilated RV with
D. Bad Luck (It's inherited). reduced function fibrofatty replacement
of the myocardium and normal LV.
3. What causes death (usually) ?
A. Ventricular Arrhythmia with Left • ardiac MRI can do a lot of sneaky
Bundle Branch Blocks thing .. ln particular (]) High Tl signal
B. A-Fib -> Stroke in the RV wall - from aJJ the fat and
(2) fat sat showing signal drop out in the
RV.

• People u c this major/minor criteria

ystem that includes a bunch of KG
changes that no radiologist could
pos ibly understand (if they are stupid
enough to ask ju t say left bundle branch
block).

Aunt Minnie 98
CASE 45 - HISTORY WITHHELD

1. What is the diagnosis?

A. Hypoplastic Left Heart
B. Truncus Arteriosus
C. Cor Triatriatum Sinistrum
D. Tetrology of Fallot (TOF)

2. This structural abnormality mimics what valular disorder?

A. Aortic Stenosis
B. Mitral Stenosis
C. Tricuspid Regurgitation
D. Tricuspid Stenosis

3. The classic history is?

A. Pulmonary Hypertension in a newborn (unexplained)
B. Fainting spells in a teenager
C. Chest Pain in a 10 year old
D. It's totally asymptomatic - seen on autopsy incidentally

Aunt Minnie 99
CASE 45 - COR TRIATRIATUM SINISTRUM

Cor Triatriatum Sinistrum

Congenital heart defect where the left

atrium is subdivided by a thin membrane -
creating a 3 chamber look.

Essential Trivia:

• This is a very rare situation where you

have an abnormal pulmonary vein
draining into the left atrium (sinistrum
meaning left) with an unnecessary
fibromuscular membrane that causes a
. ub divi ion of the left atrium.

• This creates the appearance of a tri-

1. What is the diagnosis?
[Link] heart.
A. Hypoplastic Left Heart
B. Truncus Arteriosus • It can occur on the right ide - and i
C. Cor Triatriatum Sinistrum called "dextrum" in tead of" inistrurn"
D. Tetrology of Fallot (TOF) but this is extremely rare and is ery
unlikely to be tested (mainly becau e no
2. This structural abnormality mimics what one can find a case of it to show).
valular disorder?
A. Aortic Stenosis • This can be a cause of unexplained
B. Mitral Stenosis pulmonary hypertension in the peels
C. Tricuspid Regurgitation selling.
D. Tricuspid Stenosis
• Basically it acts like mitral ·[Link] , and
3. The classic history is? can cause pulmonai _ edema.
A. Pulmonary Hypertension in a
• The outcomes are often bad (fa b tal
newborn (unexplained)
within two year ) depending on surgical
B. Fainting spells in a teenager
intervention and as ociated badness.
C. Chest Pain in a 10 year old
D. It's totally asymptomatic - seen on
autopsy incidentally

Aunt Minnie 100

CASE 46 - CHEST PAIN

1. What is the diagnosis?

A. Anomalous Left Coronary Artery from the Pulmonary Artery (ALCPA)
B. Aberrant Course of the Left Coronary Artery
C. Coronary Artery Aneurysm
D. Endocarditis

2. In the United States what is the most common cause for this diagnosis?
A. Post Viral
B. Autoimmune
C. Too much Burger King (Atherosclerosis)
D. Not enough Burger King (Bacon Deficiency)

3. In children, this "?" is an important cause

A. Myocardial Bridging
B. Takayasu Arteritis
C. Kawasaki Arteritis
D. Atherosclerosis

Aunt Minnie 101

CASE 46 - CORONARY ARTERY ANEURYSM

Coronary Artery Aneurysm

Dilated coronary 1.5 x the diameter of

normal ve el.

Essential Trivia:

• lf the coronary vessel has a fusiform

dilation morphology think about a high
flow tate - i.e. coronary fistula

• In an adult think about atherosclerosis

• In a child think about Kawasaki

• Kawasaki can progres. · to coronary

1. What is the diagnosis? aneurysm about 25% of the time (if they
A. Anomalous Left Coronary Artery from don't get aspirin and gamma-globulin).
the Pulmonary Artery (ALCPA)
B. Aberrant Course of the Left Coronary • A large percentage (like 50%) of the
Artery kawasaki aneury ms will regress.
C. Coronary Artery Aneurysm
D. Endocarditis • Cardiac cath is an important cause of these
things as well. The testable pearl
2. In the United States what is the most regarding that is that caths cause pseudo
common cause for this diagnosis? aneurysms, not the regular three wall
A. Post Viral dilations.
B. Autoimmune
C. Too much Burger King
(Atherosclerosis)
D. Not enough Burger King (Bacon
Deficiency)

3. In children, this "?" is an important cause

A. Myocardial Bridging
B. Takayasu Arteritis
C. Kawasaki Arteritis
D. Atherosclerosis

Aunt Minnie 102

CASE 47 - CHEST PAIN

1. What is the diagnosis?

A. Hypertrophic Cardiomyopathy
B. Non-Compaction
C. Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)
D. TB

2. What is the "buzzword" for this condition?

A. Hypertrabeculated
B. Hypotrabeculated
C. Cylinder Heart
D. Vase Shaped Heart

3. On MRI the measurement made to make this diagnosis is performed during?

A. End Systole
B. End Diastole

Aunt Minnie 103

CASE 47 - NON-COMPACTION

• Dilated LV with very prominent

trabeculation,
• The trabeculated portion of the wall
measures greater than 2.3 times
the thickness of the compacted
myocardial wal I.

Non-Compaction

1. What is the diagnosis? Uncommon congenital cardiom opaihy that is the

A. Hypertrophic Cardiomyopathy result of loosely packed myocardium.
B. Non-Compaction
C. Arrhythmogenic Right Essential Trivia:
Ventricular Cardiomyopathy
(ARVC)
• The left ventricle has a spongy appearance with
D. TB
increased trabecularions and deep intertrabecular
recesses.
2. What is the "buzzword" for this
condition? • The buzzword u ed is "Hyper-Trabeculaied"
A. Hypertrabeculated
B. Hypotrabeculated • Not only i the trabecula malformed but the
C. Cylinder Heart underlying capillary beds are screwed up too.
D. Vase Shaped Heart This set them up for ischemia, infarct. and
fibrosis.
3. On MRI the measurement made to
make this diagnosis is performed • A you might expect these guys get heart failure
during? at a young age.
A. End Systole
B. End Diastole • With MRJ, the diagnosis is made from a ratio of
non-compacted end-diastolic myocardium lo
compacted end-diastolic myocardium of more
than 2.3: I. With E HO this ratio is mea ured
on end -systole.

Aunt Minnie 104

CASE 48 - CHEST PAIN

1. What is the diagnosis?

A. Hypertrophic Cardiomyopathy
B. Amy loidosis
C. Chronic Infarct
D. Acute Infarct

2. With regard to the finding near the arrow, is this a good thing?
A. Yes - it's associated with rapid recovery
B. Nope - it's associated with a lack of :functional recovery

3. Which of the following is true?

A. Microvascular obstruction can be seen in both acute and chronic infarct
B. Chronic Infarct will have thickened myocardium, from hypertrophic scarring
C. In the setting of ischemia T2 bright tissue may represent salvageable tissue
D. Chronic Infarct will have delayed enhancement, Acute infarct will NOT

4. What vascular distribution is this in?

A. RCA
B. LAD
C. LCx (Circumflex)

Aunt Minnie 105

CASE 48 - ACUTE INFARCT

Acute Infarct
with Microvascular Obstruction

Cardiac MRI can be done in the first 24

hours post Ml to evaJuate the size and
distribution of necrosis. Cardiac MRI for
this purpose is an excellent use of
resources ... since all health care is free
anyway.

I. What is the diagnosis? Essential Trivia:

A. Hypertrophic Cardiomyopathy
B. Amyloidosis
C. Chronic Infarct • Classic Look: zone of enhancement that
D. Acute Infarct extends from the ubendocardium
2. With regard to the finding near the arrow, is toward the epicardiurn in a vascular
this a good thing? distribution
A. Yes - it's associated with rapid recovery
B. Nope - it's associated with a lack of • Microva scular obstruction wi11 present
functional recovery as islands of dark signal in the enhanced
3. Which of the following is true? tissue and thi ' repre ents an acute and
A. Microvascular obstruction can be seen in subacute finding (NOT Chronic).
both acute and chronic infarct
B. Chronic Infarct will have thickened • Microvascular Obstruction is a poor
myocardium, from hypertrophic scarring prognostic :finding, associated with lack
C. In the setting of ischemia T2 bright
tissue may represent salvageable tissue of functional recovery
D. Chronic Infarct will have delayed
enhancement, Acute infarct will NOT • In the acute setting (I week) injured
myocardium will have increased T2
4. What vascular distribution is this in? signal, which can be used to estimate the
A. RCA area at risk.
B. LAD
C. LCx (Circumflex)
• Both Acute and Chronic MI will have
delayed enhancement.

• Acute Ml can have normal thickness,

Chroni · tends to thin up.

Aunt Minnie 106

CASE 49 - CHEST PAIN

1. What is the diagnosis?

A Constrictive Pericarditis
B. Myocarditis
C. Chronic Infarct
D. Acute Infarct

2. What vascular territory does this diagnosis favor?

A LAD
B. RCA
C. LCX
D. Classically has a non-coronary distribution

3. The most common cause of this entity is?

A Viral (Coxsackie virus B)
B. Bacterial (Strep)
C. Fungal (Candida)
D. Inherited (genetic)

Aunt Minnie 107

CASE 49 - MYOCARDITIS

Myocarditis

Inflammation of th' mvocardium

... ' from
any number of random cause ( drugs,
iral, Lupus parasites i.e. Trypanosome
Cruzi I Chagas),

Essential Trivia:

• Inflammation of the heart can come

from lots of causes (often viral i.e,
Mid Wall Pattern of Enhancement _,-

-Dark, White, Dark- Coxsackie virus).

• The late Gd enhancement follow a

1. What is the diagnosis? non-vascular distribution preferring
A. Constrictive Pericarditis the lateral free wal I.
B. Myocarditis
• The pattern will be epicardial or mid
C. Chronic Infarct
wall (NOT subendocardial).
D. Acute Infarct
• The main predictor of death (or
2. What vascular territory does this diagnosis transplant) is bi-ventricular wall motion
favor? abnormality
A. LAD
B. RCA
C. LCX
D. Classically has a non-coronary
distribution

3. The most common cause of this entity is?

A. Viral (Coxsackie virus B)
B. Bacterial (Strep)
C. Fungal (Candida)
D. Inherited (genetic)

Aunt Minnie 108

 CARDIAC MRI - ESSENTIAL TRIVIA

Physics I Basic Technique

There are 3 main sequences you should be able to recognize, and understand.

Dark Blood Bright Blood Inversion Recovery

-This is created with a -This is created with a - The "PSIR'' or Phase
spin echo sequence. gradient sequence. Sensitive Inversion
-More specifically a -The sequences are Recovery
"double inversion" shorter and are --Myocardium is nulled
is used to null signal considered the "work- by selecting the correct
from flowing blood. horse" of the modality. T.I. - usually around 330
"-The sequences take -This is used for msec but this varies.
longer, but are better ventricular function, -The Tl. is chosen
for anatomy, and blood velocity, & flow when the myocardium
more resistant to measurements. is the darkest (lets you
metal artifact. -Just remember "SSFP" see the white delayed
steady state free enhancement the best).
precision

Coronary Distributions

You should be able to recognize and distinguish the 3 territories on all axises. The
"what vessel is involved?" questions, are just too easy to give up.

Aunt Minnie 109

 Late Gad Enhancement Patterns

The last general topic to have cold for cardiac MRI is to have the distributions of
late GD enhancement.

Subendocardial: Infarct Transmural: Infarct Subendocardial Circumferential

Amyloidosis

Mid-Wall "Cloudy" Mid-Wall - Crescent-Septal Mid-Wall Crescent -Lateral

HOCM Myocarditis, Idiopathic Dilated CM Myocarditis, Sarcoidosis

Epicardial:
Myocarditis, Sarcoidosis

Amyloid

Deposits in the myocardium causes

abnormal diastolic function.

Classic Findings:
• Late Gd enhancement over the entire
subendocardial circumference.
• The myocardium is often difficult to
suppress (Tl. like 350 milliseconds). Tl
will be so long that the blood pool may be
darker than the myocardium.
Blood Darker Than Myocardium
on Inversion Recovery Sequence

Aunt Minnie 110

CASE 50 - CHEST PAIN

1. What is the diagnosis?

A. Ascending (tubular) Aortic Aneurysm
B. Coronary Artery Aneurysm
C. Coronary Sinus Aneurysm
D. Sinus of Valsalva Aneurysm

2. What part is most commonly involved?

A. Right
B. Left
C. Non coronary

3. What procedure is done to fix this?

A. Bentall
B. Glenn
C. Fontan
D. Jatene

Aunt Minnie 111

CASE 50- SINUS OFVALSALVAANEURYSM

Sinus of Valsalva Aneurysm

Aneurysm of of the inus ofValsalva (or

the aortic sinus) are rare but do occur.

Essential Trivia:

• Valsalva sinus aneury sm occurs abo e

the aortic valve annulus ("prolapsing
aortic cusp" occurs below the annulus).

• These are seen in Marfans and Ehler =

Danlos patients, but can also be
1. What is the diagnosis? acquired from infection.
A. Ascending (tubular) Aortic Aneurysm
• Most commonly in elves the right
B. Coronary Artery Aneurysm
coronary . inns
C. Coronary Sinus Aneurysm
D. Sinus of Valsalva Aneurysm • VSD is the most common associated
cardiac anomaly.
2. What part is most commonly involved?
A. Right • Rupture can lead to cardiac tarnponad ·.
B. Left
C. Non coronary • Surgical repair with Bentall procedure
(graft replacement of the aortic root
3. What procedure is done to fix this? a cending aorta re-implantation of the
A. Bentall
coronaries and replacement of the
B. Glenn
valve).
C. Fontan
D. Jatene

Aunt Minnie 112

CASE 51 - TACHYARRHYTHMIA

=-

1. What is the diagnosis?

A. VSD
B. PDA
C. Tetralogy of Fallot
D. Ebsteins

2. What valve is abnormal ?

A. Mitral
B. Tricuspid
C. Aortic

3. What teratogenic medication is often the culprit?

A. Coumadin
B. Valproic Acid
C. Lithium
D. ACE Inhibitors

Aunt Minnie 113

CASE 51- EBSTEIN'S ANOMALY

Ebsteins Anomaly

Congenital Heart disease econdary to a

malformed tricuspid valve. It produce· a
classic "box shaped" heart of CXR and
therefore i highl testable.

Essential Trivia:

• Seen in children who. e moms used

Lithium (most ca es are actually
sporadic).

• The tricuspid valve is hypoplastic

and the posterior leaf is displaced
apically (downward).
1. What is the diagnosis?
A. VSD • 'Ole result is enlarged RA , decreased
B. PDA RV ("atrialized") and tricuspid
C. Tetralogy of Fallot regurgitation.
D. Ebsteins
• Often presents with fetal tachy-
arrythmia.
2. What valve is abnormal ?
A. Mitral • Cyanosi depends on the degree of
B. Tricuspid atrial shunting.
C. Aortic
• TheASD is commonly associated.
3. What teratogenic medication is often the
culprit? • Imaging Findings:
A. Coumadin
B. Valproic Acid • CXR: TI1 y have the massive 'box
C. Lithium shaped" heart.
D. ACE Inhibitors
• CT I MRI -ifth · tricuspid septa!
attachment lies more than 2 cm
"beneath" (towards the apex) the
rnitral septa! attachment, this is
Eb. tein anomaly.

Aunt Minnie 114

CASE 51 - CYANOSIS

1. What is the diagnosis?

A. VSD
B. ASD
C. Tetralogy of Fallot
D. Truncus Arteriosus

2. In this disorder, the degree of symptoms is related to ?

A. How big the VSD is
B. How big the ASD is
C. The presence or absence of an aortic coarctation
D. How severe the RVOT obstruction is

3. The "Blalock Taussig Shunt" is a communication between?

A. Pulmonary Artery and Subclavian Vein
B. Pulmonary Artery and Subclavian Artery
C. Pulmonary Artery and SVC
D. Pulmonary Artery and Aorta

Aunt Minnie 115

CASE 51 - TETRALOGY OF FALLOT (TOF)

Tetralogy ofFallot (TOF)

The "most common cyanotic heart disease."

Essential Trivia:

• Describe 4 major finding :

(I) V D,

(2) RVOT Obstruction-· often from

valvular obstruction,

(3) Overriding Aorta

4) RV hypertrophy (develops after birth).

1. What is the diagnosis?
A. VSD **not cyanotic • The'tboot shape' - with the upturned apex
B. ASD ** not cyanotic wi LI not be pre sent at birth because the RV
C. Tetralogy of Fallot hypertrophy hasn't kicked it.
D. Truncus Arteriosus ** would have • The degree of severity in symptom is
increased pulmonary vasculature related to how bad the RVOT obstruction is.

2. In this disorder, the degree of • Pentaology of Fallot if there is an ASD.

symptoms is related to ?
A. How big the VSD is • Surgically it s usually fixed with primary
B. How big the ASD is repair. The various shunt procedures
C. The presence or absence of an aortic (Blalock-Taussig being the most famous) is
coarctation only done if the kid is inoperable or to
D. How severe the RVOT obstruction bridge until primary repair.
is • Blalock -Taus ig is a hunt between the PA
and the Subclavian Artery
3. The "Blalock Taussig Shunt" is a
communication between? CXR Findings:
A. Pulmonary Artery and Subclavian
Vein • Right Arch (I look for this first) TOI· and
B. Pulmonary Artery and Subclavian Truncus are the Cyanotics that classically
Artery have it).
C. Pulmonary Artery and SVC • Decreased/Normal Pulmonary Vasculature
D. Pulmonary Artery and Aorta
• "Boot Shaped Heart" with upturned apex.

Aunt Minnie 116

CASE 52 - CYANOSIS

1. What is the diagnosis?

A. PDA
B. VSD
C. Supra-cardiac Total anomalous pulmonary venous return
D. Infra-cardiac Total anomalous pulmonary venous return

2. Which of the follow is commonly seen with this form of heart disease?
A. Polysplenia
B. Asplenia
C. Malrotation
D. Hirschsprung disease

3. What is required to survive with this form of heart disease

A. Aortic Stenosis
B. Left Ventricular Hypertrophy
C. Large PFO
D. Courage

Aunt Minnie 117

CASE 52 - SUPRA-CARDIAC TAPVR

Tetralogy ofFallot (TOF)

A cyanotic heart disease characterized by

all of the pulmonary venous system

•
draining to the right side of the heart

Essential Trivia:

•• • There are 3 types but only two are likely

to be tested ( cardiac type 11 just doesn t
have good testable features).
1. What is the diagnosis? • Type I - Supra-Cardiac, the most
A. PDA ** this is not cyanotic common type. Veins drain ABOVE
B. VSD ** this is not cyanotic the heart giving you a snowman look
C. Supra-cardiac Total anomalous to the heart
pulmonary venous return
D. Infra-cardiac Total anomalous • Type 111 - Infra-Cardiac. Veins drain
pulmonary venous return ** this tends to BELOW the diaphragm (either into
cause massive pulmonary edema in the IVC or hepatic veins), and
newborn, and not snowman classical1y get obstructed on the way
back through the diaphragm - causing
2. Which of the follow is commonly seen full on pulmonary edema
with this form of heart disease?
• Large PFO (or ASD) needed to survive
A. Polysplenia
B. Asplenia * seen with lots of cyanotic • Asplenia - 50% of asplenia patients
heart disease, but especially this one. have congenital heart issues of tho e
C. Malrotation nearly 100% include TAPVR (85%
D. Hirschsprung disease have additional endocardial cushion
defects).
3. What is required to survive with this form
of heart disease
A. Aortic Stenosis
B. Left Ventricular Hypertrophy
C. LargePFO
D. Courage ** although admirable
sometimes thats just not enough, be your
adversary cyanotic heart disease or a
badly written multiple choice test.

Aunt Minnie 118

 CONGENITAL HEART - ESSENTIAL TRIVIA

Cyanotlc or NOT

I talk about this in greater depth in my book "Crack the CORE Exam," but you
need to have a few lists memorized to help you eliminate distractors on multiple
choice tests. The first one and most important one is "Cyenotic or Not," this
information is often found in the header of the question.

Cyanotic: Things that start with "T"; TOP:, TAPVR, Transposition, Truncus,
Tricuspid Atresia.

NOT Cyanotic: ASD, VSD, PDA, PAPVR, and Aortic Coarctation (post ductal-
adult type).

Congenital Heart Buzzwords

• I say "pulmonary edema is a newborn", you say TAPVR Type Ill (infracardiac)
• I say "small heart", you say Adrenal Insufficiency (Addisons) - "the Grinch who
stole Christmas" would also be correct.
• I say "most common congenital heart disease - in child," you say VSD
• I say "most common congenital heart disease - in adult" you say Bicuspid AV
• I say "most common cyanotic heart disease," you say TOF
• I say "box shaped heart," you say Ebsteins
• I say "boot shaped heart," you say TOF
• I say "snow man shaped heart," you say TAPVR Type I (Supracardiac)
• I say "egg on a string shaped heart," you say Transposition
• I say "Right Arch," you say TOF or Truncus
• I say "Splaying the carina," you say left atrial hypertrophy
• I say "Right Sided PAPVR," you say Sinus Venosus ASD
• I say "Rib Notching," you say Aortic Coarctation
• I say "Aortic Coarctation." you say Bicuspid Valve
• I say 'L-Type Transposition," you say "Lucky Type"
• I say "D-Type Transposition," you say "Doomed Type"
• I say "Asplenia," you say cyanotic heart disease (usually TAPVR)
• I say "Anterior indentation on esophagus," you say Pulmonary Sling
• I say "Supra-valvular aortic stenosis," you say Williams Syndrome
• I say "Right upper lobe pulmonary edema." you say mitral regurgitation

Aunt Minnie 119

 Congenital Heart Surgeries

Glenn:

This is a communication made Glenn=

between the SVC to the Vein to Artery
pulmonary artery (usually the SVC to R-PA
right one).

It's done for tricuspid atresia

and part of the staged hypo
plastic heart repair.

Blalock Taussig Shunt:

Originally developed tor use BT Shunt=

with TOF. Shunt is created Artery to Artery
between the Subclavian Subclavian A to PA
artery and the pulmonary
artery.

Ross Procedure:
ROSS=
Performed for Diseased Aortic Valves in Children. -Aortic Valve Fix
Replaces the aortic valve with the patient's pulmonary Using Pulmonic Valve
valve and replaces the pulmonary valve with a -Pulmonic Valve Gets
cryopreserved pulmonary valve homograft. a Homograft
Aortic Switch Procedures:

Used for transposition of the great vessels.

• Senning - Baffle (shunt thingy) - created from the right atrial wall and atrial
septal tissue WITHOUT use of extrinsic material. RV still systemic pump.

• Mustard - Involves the resection of the atrial septum and creation of a baffle
using pericardium (or synthetic material). RV still systemic pump.

• Rastelli - Baffle placed within the right ventricle diverting flow from the VSD to
the aorta, essentially using the VSD as part of the LVOT. Pro - LV is systemic
pump, Con - kid will need multiple surgeries as he/she grows.

• Jatene - No baffle. Instead a direct resection of aorta and pulmonary artery, and
direct switch. Requires coronary re-implantation. Pro - LV is systemic pump,
Con - very technically difficult surgery.
Aunt Minnie 120
CASE 53 - CHART SAYS "SOB," BUT HE SEEMS LIKE A
NICE GUY TO ME.

,,

1. What is the diagnosis?

A. NSIP
B. DIP
C. UIP
D. COP

2. What is the trademark feature of this process?

A. Ground Glass
B. Nodules (Centrilobular)
C. Nodules (Perilymphatic)
D. Honeycombing

3. Where is the disease classically worse?

A. Apex
B. Base
C. There is typically no gradient

4. Could this be end stage sacroid?

A. Sure
B. Nope

Aunt Minnie 121

CASE 53 - UIP (USUAL INTERSTITIAL PNEUMONIA)

UIP

This is the most common

Interstitial Lung Disease. When the
cause is idiopathic it is called TPF.

Essential Trivia:

• un> describes a set of

morphologic changes. You can
get these changes from idiopathic
disease (IPF) or from known end
1. What is the diagnosis? stage disease (RA, cleroderma,
A. NSIP etc ... ).
B. DIP • The prognosis sucks (similar to
C. UIP lung CA)
D. COP
• CT Findings:
2. What is the trademark feature of this process?
A. Ground Glass • Apical to basal gradient
B. Nodules (Centrilobular) (worse in bases
C. Nodules (Perilymphatic) • Traction bronchiectasis
D. Honeycombing
• Honeycombing is found 70%
3. Where is the disease classically worse? of the time, and people expect
A. Apex you to knee jerk UTP when
B. Base that term is uttered.
C. There is typically no gradient
• CXR Findings:
4. Could this be end stage sacroid? • Low Lung Volumes (Fibrosis)
A. Sure
B. Nope* honeycombing is uncommon in end • Reticular pattern in the
stage sarcoid. Also, that typically has an apical posterior costophrenic angle
predominant pattern. is supposedly the first finding
onCXR.

Aunt Minnie 122

CASE 54 - THE ED IS CONVINCED HE HAS A PE

1. What interstitial lung disease does this dude have?

A. NSIP
B. DIP
C. UIP
D. COP

2. What is the trademark feature of this lung process?

A. Ground Glass
B. Nodules (Centrilobular)
C. Nodules (Perilymphatic)
D. Honeycombing

3 What is the "buzzword" for this disease?

A. Honey combing
B. Reticulation
C. Sub pleural sparing

Aunt Minnie 123

CASE 54 - NSIP (NONSPECIFIC INTERSTITIAL PNEUMONIA)

Ground Glass NSIP

with Sub-pleural
Sparing Less Common than UTP. Even though the
name infers that its non- pecific, it's
actually a specific entity.

Essential Trivia:

• Histologically it is homogeneous
inflammation or fibrosis (UIP was
heterogeneous).

• rt is a common pattern in collagen

vascular disease, and drug reactions.

• It is the most common interstitial lung

1. What interstitial lung disease does this
disease seen with scleroderma
dude have?
A. NSIP • There are two flavors: cellular (the good
B. DIP one - with mostly ground glass), and
C. UIP fibrotic (the bad one with bronchiectasis)
D. COP
• CT Findings:
2. What is the trademark feature of this
• Distribution is lower lobe posterior,
lung process?
and peripheral predominant
A. Ground Glass
B. Nodules (Centrilobular) • Sparing of the immediate sub pleural
C. Nodules (Perilymphatic) lung from the ground glas is seen in
D. Honeycombing 50% of cases, and i "classic"

3. What is the "buzzword" for this disease? • Honeycombing ( when present, and
A. Honey combing lower lobe predominant) is "the most
B. Reticulation useful HR Tfeature" to differentiate
C. Sub pleural sparing histologic Uf P from either fibrotic or
cellular NSI P. In other words, lower
lobe honeycombing= UIP.

Aunt Minnie 124

CASE 55 - CHEST PAIN

1. What is the diagnosis?

A. Lymphoma (not treated)
B. RA
C. Fibrosing Mediastinitis
D. Mediastinal Lipomatosis

2. What is the "classic cause" (not necessarily the most common)?

A. Histoplasmosis
B. EBV
C. AIDS
D. Varicella

3. What is the dreaded complication when present in this location?

A. Metastasis to the myocardium
B. Metastasis to the lung parenchyma
C. Superior Vena Cava Syndrome
D. MI

Aunt Minnie 125

CASE 55 - FIBROSING MEDIASTINITIS

Collaterals From Fibrosing Mediastinitis

Bagged SVC

Non malignant fibrou • tissue proliferativ

condition occurring within the
mcdiastinum.

Essential Trivia:

• It's classically caused by histoplasmosis

(but the most common cause is actually
Soft tissue mass with calcifications that
infiltrates the normal fat planes. idiopathic).

• Other cause· include TB, radiation. and

'arcoid.
1. What is the diagnosis?
A. Lymphoma (not treated) • It's a soft ti sue mass with calcifications
B. RA that infiltrates the normal fat planes.
C. Fibrosing Mediastinitis • It has been known to cause superior v na
D. Mediastinal Lipomatosis cava syndrome.

2. What is the "classic cause" (not necessarily • It's associated with retroperitoneal
the most common) ? fibrosis when idiopathic - in the "lgG4''
A. Histoplasmosis spectrum I associated disorders.
B. EBV
C. AIDS • IgG4s that go together (ifyou see one
D. Varicella think of the others ... the test writers
will):
3. What is the dreaded complication when • Fibrosing Mediastinitis
present in this location?
A. Metastasis to the myocardium • Retroperitoneal Fibrosis
B. Metastasis to the lung parenchyma
C. Superior Vena Cava Syndrome • Autoimmune Pancreatitis
D. MI • Tubulointerstitial nephritis

• Orbital Pseudotumor

• Basically all the weirdfibrosing shit

Aunt Minnie 126

CASE 56 - COUGH

I. What is the diagnosis (did I mention he enjoys unprotected sex with multiple
anonymous partners while at the same time experimenting with mind altering IV
drugs)?
A. PCP
B. CMV
C. Kaposi �arcoma
D. AIDS related pulmonary lymphoma

2. Your attending thinks it's either Kaposi Sarcoma or Lymphoma- how can you tell the
difference ( other than the classic CT findings seen in this case) ?
A. Kaposi is Thallium Positive, Gallium Negative, Lymphoma is Thallium Positive
B. Kaposi is Thallium Positive, Gallium Positve, Lymphoma is Thallium Negative
C. Kaposi is Thallium Negative, Gallium Negative, Lymphoma is Thallium Positive
D. They are both negative on Thallium and Gallium ... clinical correlation

3. For this disease to occur, the CD4 count must be less than?
A. 400
B. 200
C. 50

Aunt Minnie 127

 CASE 56 - KAPOSI SARCOMA:

Kaposi Saarcoma

Tumor cau ed by Herpes Viru 8, and

commonly seen in AID- patient

Essential Trivia:

• This is the most common lung tumor in AIDS

patients (Lymphoma is number two).

• A CD4 count le s than 200 is needed

• The tracheobronchial mucosa and perihilar

lung are favored.
I. What is the diagnosis (did I mention he • The buzzword is "flame shaped."
enjoys unprotected sex with multiple
anonymous partners while at the same • A bloody pleural effusion is common (50%).
time experimenting with mind altering
IV drugs)?
• Hypervascular lymph nodes (also seen in
A. PCP
B. CMV Castlemans)
C. Kaposi Sarcoma
D. AIDS related pulmonary lymphoma • Slow Growth with asymptomatic patient
(despite lungs looking terrible)
2. Your attending thinks it's either Kaposi
Sarcoma or Lymphoma- how can you tell • Nuke correlations:
the difference ( other than the classic CT
= findings seen in this case) ? • Kaposi:
A. Kaposi is Thallium Positive,
Gallium Negative, Lymphoma is • Gallium Negative
Thallium Positive
B. Kaposi is Thallium Positive, Gallium • Thallium Positive
Positve, Lymphoma is Thallium
Negative
• lymphoma
C. Kaposi is Thallium Negative, Gallium
Negative, Lymphoma is Thallium
Positive • Gallium Positive
D. They are both negative on Thallium
and Gallium ... clinical correlation • Thallium Po titive

3. For this disease to occur, the CD4 count The way to remember this is that Thallium
must be less than? works on the Na/K+ pump mimicking K + it
A. 400 needs a li ing cell to work. Gallium just works
B. 200 with inflammation and Kaposi is not that
c. 50
inflammatory ( why the 1 ungs look v orse than
the patient feels).
Aunt Minnie 128
CASE 57 - COUGH:

1. What is the diagnosis ?

A. Castlemans
B. PAP
C. Lipoid Pneumonia
D. Hypersensitivity Pneumonia

2. This is "Strongly Associated with the Disease" ?

A. EtOH Abuse
B. AIDS
C. Smoking
D. Anti-Rejection Drugs

3. This patient has a brain abscess, what do you think the culture is gonna grow?
A. Strep
B. Staph
C. Nocardia
D. Neurocysticercosis

Aunt Minnie 129

CASE 57 - PULMONARY ALVEOLAR PROTEINOSIS (PAP)

PAP

Rare lung disea e secondary to abnormal

surfactant accumulation.

Essential Trivia:

• This can be primary (90%), or secondary

(10%). Secondary causes include cancer
"Crazy Pavingn or inhalation (. ilico-proteinosi ).
-Interlobular septa/
thickening and ground • They are at increased risk ofNocardia
glass- infectious, and can have nocardia brain
abscess.

• Smoking i - strongly associated with the

disease,
1. What is the diagnosis ?
A. Castlernans • When seen in children (presenting before
B. PAP age I) there is a known association with
C. Lipoid Pneumonia alymphoplasia.
D. Hypersensitivity Pneumonia
• Can progre · to pulmonary fibro. is
2. This is "Strongly Associated with the (30%).
Disease"?
A. EtOHAbuse
B. AIDS Crazy Paving - The classic imaging
C. Smoking finding.
D. Anti-Rejection Drugs
• Interlobular sept al thickening and
3. This patient has a brain abscess, what do ground glass.
you think the culture is gonna grow?
• This isn't alway PAP in fact in real life
A. Strep
that it is usually NOT PAP. There is a
B. Staph
differential that includes common things
C. Nocardia
like edema, hemorrhage BA , Acute
D. N eurocysticercosis
Interstitial Pneumonia.

• Just know that for the purpose of

multiple choice te t the answer is almost
always PAP.

Aunt Minnie 130

CASE 58 - WHEEZY

1. What is the diagnosis ?

A. Wegeners
B. Amyloid
C. Tracheobronchopathia Osteochondroplastica (TBO)
D. Saber Sheath Trachea

2. This is finding is critical to narrowing your differential:

A. Involvement of the left main stem
B. Involvement of the right main stem
C. Sparing of the posterior membrane
D. Lung Parenchymal Involvement

3. Relapsing Polychondritis (which has a similar look), differs from this entity by?
A. Sparing of the posterior membrane
B. Involving of the posterior membrane
C. Involvement of the right main stem
D. Smooth Thickening (instead of bumpy nodules)

Aunt Minnie 131

CASE 58 - TRACHEOBRONCHOPATHIA
OSTEOCHONDROPLASTICA
(TBO)
Tracheobronchopathia
Osteochondroplastica (TBO)

Rare airway disease characterized by the

pre ence of nodules on the trachea and
bronchial walls.

Essential Trivia:

• Spares the posterior membrane.

Sparing of
Posterior Membrane • You have de elopment of cartilaginous
and osseous nodules within the
submucosa of the tracheal and bronchial
1. What is the diagnosis ? v alls.
A. Wegeners
• Classically involve the lower 2/3rds of
B. Amyloid
the trachea and proximal portions of the
C. Tracheobronchopathia
bronchi.
Osteochondroplastica (TBO)
D. Saber Sheath Trachea • Most patients are asymptomatic and it".
an incid ntal findings. (Sometime they
2. This is finding is critical to narrowing your ulcerate & bleed -> hcmoptysis in the
differential: setting of infection).
A. Involvement of the left main stem
B. Involvement of the right main stem • DDx:
C. Sparing of the posterior membrane
• Relapsing Polychondritis - Also
D. Lung Parenchymal Involvement
spares the posterior membrane.
But. has mooth narrowing (not
3. Relapsing Polychondritis(which has a
nodules). These guys have
similar look), differs from this entity by?
symptoms, and get systemic cartilage
A. Sparing of the posterior membrane
issues & recurrent pneumonia.
B. Involving of the posterior membrane
C. Involvement of the right main stem • Am Loid - Can involve the trachea,
D. Smooth Thickening (instead of bumpy but typically does involve the
nodules) posterior membrane.

• Wegeners - The trachea i often

invol ed. Does involve the posterior
membrane.

Aunt Minnie 132

CASE 59 - HISTORY WITHHELD

1. Where should you look next?

A. The Brain
B. The Scrotum
C. The Mediastinum
D. The Colon

2. The most common etiology for the underlying cause of this finding is?
A. Malignancy (Lung CA or Lymphoma)
B. Malignancy (Colon CA)
C. Malignancy (HCC)
D. Histoplasmosis

Aunt Minnie 133

CASE 59 - HOT QUADRATE SIGN - SVC OBSTRUCTION

HOT Quadrate I SVC Obstruction

A well described finding of SVC

Obstruction, which can trick the un-
initiated ... but we are initiated.

Essential Trivia:

• The mechanism is complicated. and

involves disruption of collateral
pathways. The gist of it is, extra blood is
forced into the umbilical and
paraumbilical veins which preferentially
drain into the left branch of the portal
vem. 11 this extra flow results in a
. ystemic-portal hunt, cau ing increased
blood flow in the arterial phase of the
liver supplied by the I ft branch of the
portal vein - hence the hot quadrate.
Central Venous Gath
-Likely Culprit • SVC syndrome is one of only two
reasons a radiation oncologis t has to get
out of bed at night (the other i cauda
1. Where should you look next? equina syndrome).
A. The Brain • Obstruction of the SVC - most
B. The Scrotum commonly from a malignancy (lung or
C. The Mediastinum lymphoma) can cau e facial swelling,
D. The Colon arm welling and generalized badness.

2. The most common etiology for the • Other causes include scarring from
underlying cause of this finding is? central venous catheters (as in this case),
A. Malignancy (Lung CA or Lymphoma) pace maker wires, or fibrosing
B. Malignancy (Colon CA) mediastinitis.
C. Malignancy (HCC)
D. Histoplasmosis

Aunt Minnie 134

CASE 60 - BELLY PAIN

1. What is the diagnosis ?

A. HCC
B. Cholangiocarcinoma
C. Budd Chiari
D. Hemochromatosis

2. The most common etiology for the underlying cause of this finding is?
A. Birth Control
B. Protein C and/or S def
C. Idiopathic
D. Pregnancy

3. Which part of the liver classically enlarges with this entity?

A. Quadrate
B. Caudate
C. Segment 3
D. Segment 5

Aunt Minnie 135

CASE 60 - BUDD CHIARI SYNDROME

Enhancement Centrally,
with Delayed Perfusion
Peripherally
.
i.
.
:

Budd Chiari
1. What is the diagnosis ?
A. HCC
Hepatic vein outflow obstruction.
B. Cholangiocarcinoma
C. Budd Chiari
D. Hemochromatosis Essential Trivia:

2. The most common etiology

- Pre entation can be acute or chronic.
for the underlying cause of this
finding is? - Acute from thrombus into the hepatic vein or IYC.
A. Birth Control The e guys will present with rapid onset ascites.
B. Protein C and/or S def
C. Idiopathic - Chronic from fibre is of the intrahepatic veins
D. Pregnancy presumably from inflammation.

lassie Findings
3. Which part of the liver
classically enlarges with this - Massive caudate lobe hypertrophy (spared from
entity? separate drainage into the lVC).
A. Quadrate
B. Caudate - The enhancement pattern will be 'flip-flopped' with
C. Segment 3 enhancement of the central liver early and periph ral
D. Segment 5 portion later.

- The liver has been described as "nutmeg" with an

inhomogeneous mottled appearance and delayed
enhancement of the periphery of the liver.

- Regenerati e (Hyperplastic) Nodules - big and bright -

** vascular nodules that simulate H 'C.

Aunt Minnie 136

CASE 62- BELLY PAIN AFTER BICYCLE WRECK (AGE 5)

1. What is the diagnosis of exclusion for this same finding in a 6 month old?
A. Adenocarcinoma
B. Intussusception
C. Non-Accidental Trauma
D. Neuroblastoma

2. What finding would make a bad situation worse for this kid?
A. Adjacent fluid collection without contrast
B. Duodenal wall thickening
C. Free Air in the Retroperitoneum
D. Aspiration Pneumonia

3. What is the most common cause of pancreatitis in a child?

A. Gallstones
B. EtOH
C. Medication Induced
D. ERCP
E. Trauma

Aunt Minnie 137

CASE 62 - DUODENAL HEMATOMA

Duodena 1 Hematom a

Hepatic vein outflow obstruction.

Essential Trivia:

- If you see these findings (or traumatic

pancreatitis) in any kid to young to ride a
bike you have to think about non-
accidental trauma.

- The case becomes surgical if there is

perforation (which is not uncommon). You
have to look for gas or contrast in the
1. What is the diagnosis of exclusion for retroperi toneum
this finding in a 6 month old?
A. Adenocarcinoma - FJuid collections (without contrast) can be
B. Intussusception seen without perforation - they aren't that
C. Non-Accidental Trauma helpful.
D. Neuroblastoma - If it' .. perforated - they can usually
1101
manage it conservatively.
2. What finding would make a bad situation
worse for this kid? - Back in the tone ages ED Docs I Surgeon·
A. Adjacent fluid collection without did a thing called 'peritoneal lava re"
contrast where they would try and aspirate the
B. Duodenal wall thickening peritoneum looking for blood. This would
C. Free Air in the Retroperitoneum cause a false positivefor rupture on the
D. Aspiration Pneumonia later T (air bubbles in the retro-
peritoneum). Since this practice hasn't
3. What is the most common cause of been performed since the Cretaceous
pancreatitis in a child? period it's unlikely that the "test of the
A. Gallstones future" would ask anything about it.
B. EtOH Unless the person writing the questions
C. Medication Induced trained during that period (which is likel ).
D. ERCP
E. Trauma

Aunt Minnie 138

CASE 63 - BELLY PAIN

I . What is the diagnosis ?

A. Neuroblastoma
B. Sickle Cell
C. Non-Accidental Trauma
D. Cystic Fibrosis

2. What if I told you this kid is short and has bad eczema ( and no friends) ?
A. Dorsal Pancreatic Agenesis
B. Shwachman-Diamond Syndrome
C. Alagille Syndorme
D. Blackfan-Diamond Anemia

3. Where is the pancreas located?

A. Intraperitoneal
B. Retroperitoneal

Aunt Minnie 139

CASE 63 - CYSTIC FIBROSIS

Cystic Fibrosis

'Lipomatous pseudohypertrophy of the

pancreas," as seen commonly in CF.

Essential Trivia:

- The pancreas i affected in 85-90% of CF

patients.

- Inspissated ecretions cause proximal duct

obstruction leading to the two main
changes in CF:

- (I) Fibrosis (decreased Tl and T2

ignal) and the more common one

- (2) Fatty replacement (increased Tl).

1. What is the diagnosis ?
A. Neuroblastoma - Patient's with CF, who are diagnosed as
B. Sickle Cell adults, tend to have more pancreas
C. Non-Accidental Trauma problems than those diagnosed as children.
D. Cystic Fibrosis
- Those with residual pancreatic exocrine
2. What ifl told you this kid is short and function can have bouts of recurrent acute
has bad eczema (and no friends)? pancreatiti s.
A. Dorsal Pancreatic Agenesis
- Small (l-3mm) pancreatic cyst are
B. Shwachman-Diamond Syndrome
common.
C. Alagille Syndorme
D. Blackfan-Diamond Anemia - Fibrosing Colonopathy: Wall thickening
of the proximal colon as a complication of
3. Where is the pancreas located? enzyme replacement therap .
A. Intraperitoneal
B. Retroperitoneal *the tail can be - Shwachman-Diamond Syndrome: It also
intraperiotneal causes lipomatous pseudohypertrophy of
the pancreas, and is the 2nd most common
cau e of pancreatic insufficiency in kids
(CF# I). Basically it's a kid with diarrhea,
hort tature (metaphyseal chondroplasia)
and eczema.

Aunt Minnie 140

CASE 64- BELLY PAIN

1. What is the diagnosis ?

A. Peliosis
B. Multiple Hemangiomas
C. Sarcoidosis
D. Portal Hypertension

2. What sequence on MRI would be the most sensitive for this finding?
A. Turbo Spin Echo
B. Fast Spin Echo
C. STIR
D. Gradient

3. This finding is the result of?

A. Micro-hemorrhage in the setting of metastatic invasion
B. Micro-hemorrhage seen after a trauma
C. Micro-hemorrhage in the setting of portal hypertension
D. A side effect of endoleak treatment

Aunt Minnie 141

CASE 64 - GAMNA GANDY BODIES

Gamna Gandy Bodies

Also called iderotic Nodules they are

ba ically small foci of hemosiderin.

Essential Trivia:

- Mechanism: Micro-hemorrhage resulting

in hernosiderin and calcium deposition
followed by fibroblastic reaction.
Buncha little black dots in the spleen
- Who gets them? Classically Portal
Hypertension, but they can also be seen in
sickle cell (and a whole bunch of other
1. What is the diagnosis ? random things).
A. Peliosis
- They are gonna be dark on TI and T2 but
B. Multiple Hemangiomas
remember that Gradient is going to be
C. Sarcoidosis
most sensitive because of the local field
D. Portal Hypertension
effects (Spin Echo sequences make a more
homogeneous field because of the 180
2. What sequence on MRI would be the
degree refocusing pulse).
most sensitive for this finding?
A. Turbo Spin Echo
B. Fast Spin Echo
C. STIR
D. Gradient

3. This finding is the result of?

A. Micro-hemorrhage in the setting of metastatic invasion
B. Micro-hemorrhage seen after a trauma
C. Micro-hemorrhage in the setting of portal hypertension
D. A side effect of endoleak treatment

Aunt Minnie 142

CASE 65 - RECTAL BLEEDING

1. What stage is it ?
A. Tl
B. T2
C. T3
D. T4

2. What changes surgically between Stage 2 and Stage 3?

A. Stage 2 gets Chemo, Stage 3 is palliative only
B. Stage 2 gets Surgery, Stage 3 is palliative only
C. Stage 2 gets Surgery, Stage 3 gets chemo/radiation first (then surgery)
D. Stage 2 gets Radiation only, Stage 3 gets chemo and radiation

3. What changes surgically between cancer in the lower 3rd vs middle 3rd?
A. Lower 1/3 gets a Lower Anterior Resection and keeps continence - no diaper:)
B. Lower 1/3 gets a Lower Anterior Resection and loses continence - diaper time :(
C. Lower 1/3 gets a Abdominal Perineal Resection and keeps continence - no diaper:)
D. Lower 1/3 gets a Abdominal Perineal Resection and loses continence - diaper time :(

Aunt Minnie 143

CASE 65 - RECTAL CANCER - STAGE 3

t tt
Mesorectal Fascia

1. What stage is it ? Rectal Cancer

A. Tl
B. T2
C. T3 Essential Trivia:
D. T4

2. What changes surgically between Stage 2 - Nearly always (98%) adenocarcinoma

and Stage 3?
A. Stage 2 gets Chemo, Stage 3 is - If the path say Squamous - the cause was I·Il)V
palliative only (use your imagination on how it got there).
B. Stage 2 gets Surgery, Stage 3 is
palliative only - Total mesorectal excision is standard surgical
C. Stage 2 gets Surgery, Stage 3 gets
method
chemo/ radiation first (then surgery)
D. Stage 2 gets Radiation only, Stage 3
gets chemo and radiation
- Lower rectal cancer (0-5 cm from the anorectal
angle) has the highest recurrence rate and gets
3. What changes surgically between cancer the dreaded APR for surgery resulting in the
in the lower 3rd vs middle 3rd? loss of continence. LAR i · used for tumors in
A. Lower 1 /3 gets a Lower Anterior the upper 2/3 and preserves sphincter function.
Resection and keeps continence - no
diaper:)
- MRI is used to stage (contrast is NOT needed).
B. Lower 1/3 gets a Lower Anterior
Resection and loses continence - diaper
time:( - Stage T3 - called when tumor breaks out of the
C. Lower 1/3 gets a Abdominal Perinea) muscularis externa ( outer layer of rectum) and
Resection and keeps continence - no into the peri-rectal fat.
diaper:)
D. Lower 1/3 gets a Abdominal Perineal - Stage T4 - called when the tumor abuts the
Resection and loses continence - mesorectal fascia (this is bad news).
Diaper Time:(

Aunt Minnie 144

CASE 66 - BELLY PAIN

1. What is the diagnosis?

A. Carcinoid
B. Crohns
C. Ulcerative Colitis
D. Appendiceal Mucocele

2. This thing isn't cancer right?

A. Oh no way, that thing is fine. It's just a giant snot booger.
B. That thing is totally cancer - this guy is screwed.
C. It's hard to tell ... could be.

3. What is a feared complication of this entity?

A. Paraneoplastic syndrome (SIADH)
B. Bowel Infarct
C. Stricture from chronic inflammation
D. Pseudomyxoma peritonei

Aunt Minnie 145

CASE 66 - APPENDICEAL MUCOCELE

Appendiceal MucoceJe

Essential Trivia:

- Cystic dilation of the appendix thought to be

, econdary to proximal luminal obstruction
(fecalith adhesions a cancer, etc .. ) leading to
accumulation of mucus and dilation of the
distal appendix.

- The term mucocele is misleading as it is

inclusive of both benign and malignant le ions.

1. What is the diagnosis? - All mucoceles greater than 2 cm hould be

A. Carcinoid excised to remove premalignant lesions
B. Crohns
- it's still usually benign, and found incidentally.
C. Ulcerative Colitis
D. Appendiceal Mucocele ompl ications:

2. This thing isn't cancer right? - Cancer (underlying primary lesion causing
A. Oh no way, that thing is fine. It's the obstruction)
just a giant snot booger.
- Rupture may lead to pseudornyxorna
B. That thing is totally cancer - this
peritonei
guy is screwed.
C. It's hard to tell ... could be. - Can act as a lead point for ileo-colic
intussusception
3. What is a feared complication of this
entity?
A. Paraneoplastic syndrome
(SIADH)
B. Bowel Infarct
C. Stricture from chronic
inflammation
D. Pseudomyxoma peritonei

Aunt Minnie 146

CASE 67 - BELLY PAIN

1. What is the diagnosis?

A. Hemangioma
B. Focal Nodular Hyperplasia
C. Biliary Cystadenoma
D. Von Meyenburg Complex

2. This thing isn't cancer right?

A. Oh no way, that thing is fine.
B. That thing is totally cancer - this guy is screwed.
C. It's hard to tell ... could be.

3. If you resect it and it grows back that means it's cancer right?
A. Yes, get wider margins next time
B. Not necessarily, some times they just grow back

Aunt Minnie 147

CASE 67 - BILIARY CYSTADENOMA

Biliary Cystadenoma

Benign cystic neoplasm ot the liver.

Essential Trivia:

- Intra-hepatic cyst (uni-locular or multi-

locular) made of biliary epithelium.

- There are no specific imaging features to

differentiate the ·e things from their
cancerous cousin the
cystadenocarcinoma,

- Some people consider them on a

continuum and ther fore call them "pre-
1. What is the diagnosis? malignant.'
A. Hemangioma
B. Focal Nodular Hyperplasia - Even though they are benign they can
C. Biliary Cystadenoma still reoccur after re ection.
D. Von Meyenburg Complex
- They can exert local ma effect and
have been known to cause obstructive
2. This thing isn't cancer right?
jaundice.
A. Oh no way, that thing is fine.
B. That thing is totally cancer - this guy is
screwed.
C. It's hard to tell ... could be.

3. If you resect it and it grows back that

means it's cancer right?
A. Yes, get wider margins next time
B. Not necessarily, some times they just
grow back

Aunt Minnie 148

CASE 68 - SEPTIC ICU BOMB

1. What is the diagnosis?

A. Inflammatory Bowel Disease
B. Severe Hypotension
C. Pseudomyxoma Peritonei
D. Portal Hypertension

2. If this was a non-contrasted study, what would you expect the bowel to look like?
A. Denser than the psoas
B. Less Dense than the psoas
C. Equally Dense to the psoas

3. With this diagnosis you expect the Liver to enhance ?

A. More than the spleen
B. Less than the spleen
C. Equal to the spleen

Aunt Minnie 149

CASE 68 - HYPOPERFUSION COMPLEX

Flat IVG

Shock Bowel

Radiologic features of severe hypotension,

1. What is the diagnosis?
A. Inflammatory Bowel Disease Essential Trivia:
B. Severe Hypotension
C. Pseudomyxoma Peritonei - CT Features include:
D. Portal Hypertension
- Thickened Enhancing Bowel Loops
2. If this was a non-contrasted study, what (small bowel affected more than
would you expect the bowel to look like? larger bowel)
A. Denser than the psoas
- On Non-Contrast bowel loops may
B. Less Dense than the psoas
appear denser than the psoas
C. Equally Dense to the psoas
- Collapsed IVC
3. With this diagnosis you expect the Liver to
enhance? - HYPO-enhancement of olid organs
A. More than the spleen (liv rand pleen)
B. Less than the spleen * classic teaching
- H'(PER-enbancement oftb adrenals
is 25 HU less than spleen, although
both liver and spleen hypo-perfuse
relative to a normal scan.
C. Equal to the spleen

Aunt Minnie 150

CASE 69 - BELLY PAIN (THIS GUY HAS A
TRANSPLANTED KIDNEY)

1. What is the diagnosis?

A. Inflammatory Bowel Disease
B. Typhlitis
C. C-Diff
D. Ischemic Colitis

2. What part of the bowel does TB favor?

A. Proximal Small Bowel
B. Terminal Ileum
C. Transverse Colon
D. Rectum

3. Toxic Megacolon classically causes massive dilation of the?

A. Proximal Small Bowel
B. Terminal Ileum
C. Transverse Colon
D. Rectum

Aunt Minnie 151

CASE 69 - TYPHLITIS

Thyphlitis

Al so called "Neutropenic Colitis, 'this is

the pattern of coliti in the severelj
immunosuppre sed population.

Essential Trivia:

- Mechanism: Intramural bacterial

in asion without an inflammatory
reaction.

- Classic Look: Wall thickening

stranding, and maybe pneurnatosis
1. What is the diagnosis? primarily centered around the cecum.
A. Inflammatory Bowel Disease
- Contraindication: They should NEVER
B. Typhlitis
get a barium enema - they will perforate.
C. C-Diff
D. Ischemic Colitis

2. What part of the bowel does TB favor? Other Random Infectious Bowel Trivia:
A. Proximal Small Bowel
• Entamoeba Histolytica - Scars the
B. Terminal Ileum
cecum, but spares the terminal ileum
C. Transverse Colon
(T.l.)
D. Rectum
• TB - Classically involves the 1.J.
3. Toxic Megacolon classically causes
massive dilation of the? • Yersinia - Classically involves the T.I.
A. Proximal Small Bowel
• C -Diff I Toxic Megacolon - Dilates the
B. Terminal Ileum
colon (most notably the transverse
C. Transverse Colon
colon).
D. Rectum
• Giardia & Strongyloides - Classically
like the proximal smal1 bowel.

Aunt Minnie 152

CASE 70 - HEADACHE

I. What is the diagnosis?

A. Adrenal Adenoma (lipid rich)
B. Adrenal Adenoma (lipid poor)
C. Pheochromocytoma
D. Wollman Syndrome

2. Where is the Organ of Zuckerkandl usually located?

A. SMA
B. IMA
C. Right Iliac
D. Carotid Bifurcation

3. This diagnosis is included in what syndrome?

A. Carney's Complex
B. MENI
C. MEN Ila
D. Angelman Syndrome

Aunt Minnie 153

CASE 70 - PHEOCHROMOCYTOMA

Pheochromocytoma

A rare neuro-endocrin tumor of the adrenal or

extra -adrenal tissue.

Essential Trivia:

- Uncommon in real life (common on multiple

choice tests).

T2 Bright Solid Adrenal Mass - They are usually large at presentation (larger
than 3cm).

- Rule of l Os: l 0% are extra adrenal (Organ of

1. What is the diagnosis? Zuckerkandl - usually at the IMA). 10% are
A. Adrenal Adenoma (lipid rich) bilateral 10% are in children 10% are
B. Adrenal Adenoma (lipid poor) hereditary 10% are NOT active (no HTN).
C. Pheochromocytoma
D. Wollman Syndrome - Imaging Features:

T· Heterogeneous mas on CT.

2. Where is the Organ of Zuckerkandl
usually located? - N!Rl: They are T2 bright.
A. SMA
B. IMA* these neuro-crest cells - Nukes: Both MIBG and Octreotide could be
actually extendfrom the SMA used (but MJBG is better since Octreotide
down to the aortic bifurcation, also uptakes in the kidney).
but are MOST concentrated at the yndromic Associations:
IMA
C. Right Iliac - /vfEN Ila: Mcdullary Th. roid Cancer
D. Carotid Bifurcation (100%), Parathyroid hyperplasia.
Pheochromocytoma (33 %)
3. This diagnosis is included in what
syndrome? - [Link]: Medullary Thyroid Cancer (80%),
A. Camey's Complex **Carneys Pheochromocytoma (50%), Mucosa!
Syndrome has pheos, the Neuroma, Marfanoid Body Habitus
"complex" is cardiac stuff - Carney .'s· Syndrome: Extra-Adrenal Pheo,
B. MEN I GIST and Pulmonary Chondroma
C. MEN Ila (harnartoma).
D. Angelman Syndrome
- Von Hippel Lindau: Bilateral Rena] Cell
Carcinoma, Pheos, and Hemangioblastomas
Aunt Minnie 154
CASE 71- BELLY PAIN

1. What is the diagnosis?

A. Renal Cell Carcinoma
B. Multi-locular Cystic Nephroma
C. Pheochromocytoma
D. Xanthogranulomatous Pyelonephritis

2. What is "always" associated?

A. A big stag-horn stone
B. Diabetes
C. History of lithotripsy
D. Bladder cancer

3. What is the treatment?

A. Lots of antibiotics
B. Needs a tube, gotta drain that beast. Then it will get better.
C. Nephrectomy - that thing is toast.

Aunt Minnie 155

CASE 71 - XANTHOGRANULOMATOUS PYELONEPHRITIS (XGP)

Xanthogranulomatous
Pyelonephritis (XGP)

Uncommon form of chronic

pyelonephriti re ulting in a non-
functioning kidney.

Essential Trivia:

- Chronic destructive granulomatou ·

process that i basical1y always seen
with a staghorn stone acting as a
nidus for recurrent infection,

1. What is the diagnosis? - You can have an associated psoas

A. Renal Cell Carcinoma abscess with minimal peri-renal
B. Multi-locular Cystic Nephroma infection.
C. Pheochromocytoma
- It's an Aunt Minnie, with a very
D. Xanthogranulomatous Pyelonephritis
characteristic 'Bear Paw" appearance
on CT.
2. What is "always" associated?
A. A big stag-horn stone - The kidney i not functional and o ften
B. Diabetes nephrectorny is done to treat it.
C. History of lithotripsy
D. Bladder cancer

3. What is the treatment?

A. Lots of antibiotics
B. Needs a tube, gotta drain that beast. Then
it will get better.
C. Nephrectomy - that thing is toast.

Aunt Minnie 156

CASE 72- BELLY PAIN (PATIENT'S AGE IS 40)

1. What is the diagnosis?

A. AD Polycystic Kidney Disease
B. AR Polycystic Kidney Disease
C. Von Hippel Lindau
D. Tuberous Sclerosis

2. This patient is NOT on dialysis. Are they are increased risk for RCC?
A. Yes
B. No

3. With regard to AR Polycystic Kidney Disease, if the disease in the kidneys is bad ... ?
A. The liver fibrosis is bad too
B. The liver fibrosis is better
C. The cysts in the liver are bad too
D. The cysts in the liver are better

Aunt Minnie 157

 CASE 72- AD - POLYCYSTIC KIDNEY DISEASE

Autosomal Dominant
Polycystic Kidney Disease

Hereditary form of adult cystic renal

disease

Essential Trivia:

- "AD" is seen in ADults

- Kidneys get progressively larger and Lo e

function (you get dialysis by 5th decade).

1. What is the diagnosis? - They get cysts in the liver 70% of the
A. AD Polycystic Kidney Disease time.
B. AR Polycystic Kidney Disease
C. Von Hippel Lindau
- They get Berry Aneurysm, (which can
D. Tuberous Sclerosis
rupture and kill).
2. This patient is NOT on dialysis. Are they
are increased risk for RCC? - They don t have an intrinsic risk of
A. Yes cancer but do get cancer once they are
B. No on dialysis.
--,

3. With regard to AR Polycystic Kidney

AR-PKD (The Pediatric Form):
Disease, if the disease in the kidney's is
bad ... ?
A. The liver fibrosis is bad too - The Ii er involvement is different than
B. The liver fibrosis is better the adult form. Instead of cyst they have
C. The cysts in the liver are bad too abnormal bile ducts and fibrosis. This
D. The cysts in the liver are better congenital hepatic fibrosis i ALWAYS
present in ARPKD. The ratio of liver and
kidney di ease is in ers . The worse the
liver is the better the kidneys do. The
better tbe liver is the worse the kidneys
are.

Aunt Minnie 158

CASE 73- BELLY PAIN

1. What is the diagnosis?

A. AD Polycystic Kidney Disease
B. Multi-locular Cystic Nephroma
C. Multicystic Dysplastic Kidney
D. Oncocytoma

2. What is the classic demographic?

A. Young Boys and Girls
B. Middle Aged Men, and Younger Girls
C. Young Boys, Middle Aged Women
D. Middle Aged Men and Women

3. In an adult you can be 100% sure this is benign right?

A. Oh yeah, there is no way that's cancer
B. Um ... can't tell. You can never tell with kidneys.

4. What's the buzzword for these things?

A. "Multiple thin walled cysts"
B. "Protrudes into the renal pelvis"
C. "Bulges the renal contour"

Aunt Minnie 159

 CASE 73- MUL TI-LOCULAR CYSTIC NEPHROMA

Muhi-locular Cystic Nephroma

Rare benign cystic neopla m of the kidney.

Essential Trivia:

- 'Non-communicating fluid-filled
locules, surrounded by thick fibrou
capsule.'
Protruding into the renal pelvis
- By definition these thing are
characterized by the absence of a solid
component or necrosis.
1. What is the diagnosis?
A. AD Polycystic Kidney Disease - Buzzword is "protrude into the renal
B. Multi-locular Cystic Nephroma pelvi -. '
C. Multicystic Dysplastic Kidney
D. Oncocytoma
- The question is likely the bimodal
2. What is the classic demographic? occurrence (4 year old boy , and 40 year
A. Young Boys and Girls old women). I like to think of this as the
B. Middle Aged Men, and Younger Girls Michael Jackson lesion - it loves young
C. Young Boys, Middle Aged Women boys and middle aged women.
=
D. Middle Aged Men and Women
- It s not a cancer, but you can't tell it
3. In an adult you can be 100% sure this is
from a cystic R C in an adult, or a cy tic
benign right?
A. Oh yeah, there is no way that's cancer Wilms in a kid. So they typically end up
B. Um ... can't tell. You can never tell with radical ( or partial nephrectomj ).
with kidneys.

4. What's the buzzword for these things?

A. "Multiple thin walled cysts"
B. "Protrudes into the renal pelvis"
C. "Bulges the renal contour"

Aunt Minnie 160

CYSTIC RENAL DISEASE - ESSENTIAL TRIVIA

AD Polycystic Kidney Disease

- Cysts in Kidneys
- Kidneys are BIG
- Cysts in Liver

Von Hippel Lindau

- Cysts in Kidneys
- RCCs in the Kidneys
- Cysts in Pancreas

Uremic Cystic Disease

- Cysts in Kidneys
- Kidneys are SMALL

About 40% of patients with end stage renal

disea e develop cysts. This rise with timeor
dialysis with about 90% in patients after 5
year of dialysis. The thing to know is:
Increased risk of malignancy with dialysis.

Aunt Minnie 161

 ,a -
0

Split Function:
- Right 100%
- Left 0%

Lithium Nephropathy "History of Bi-Polar Disease"

• Occurs in patients who take lithium

long term.

• Can lead to diabetes insipidus and

renal insufficiency.

• The kidneys are normal to small in

volume with multiple (innumerable)
tiny cysts, usually 2-Smm in
diameters.

• These "microcysts" are

distinguishable from the larger cysts
associated with acquired cystic
disease of uremia.

Aunt Minnie 162

CASE 74 - HISTORY OF UNPROTECTED SEX WITH
MULTIPLE ANONYMOUS PARTNERS

1. What is the diagnosis?

A. Pyelonephritis
B. Pyonephrosis
C. Disseminated PCP
D. HIV Nephropathy

2. What other finding (not well seen on this case) has been classically described with this
diagnosis?
A. Cortical Calcifications
B. Medullary Calcifications
C. Extra fat in the renal sinus
D. Loss of fat in the renal sinus

3. In the same patient population (same demographic risk factors) what would punctate
cortical calcifications make you think of?
A. Xanthogranulomatous Pyelonephritis
B. CMV Infection
C. PCP Infection

Aunt Minnie 163

 CASE 74 - HIV NEPHROPATHY

HIV Nephropathy

Common cause of chronic renal failure in HTV

positive patients.

Essential Trivia:

- lfyou see BIG BRIGHT Kidneys in a

patient with HIV, then this is the answer.

- Loss of the renal sinus fat appearance has also

been described (it s edema in the fat, rather
than loss of the actual fat).
1. What is the diagnosis?
A. Pyelonephritis
- There wil I / may be a history of proteinuria
B. Pyonephrosis
C. Disseminated PCP (they typically present in nephrotic
D. HIV Nephropathy syndrome).

2. What other finding (not well seen on - The biopsy results will show 'focal segmental
this case) has been classically described glornerulosclerosis '
with this diagnosis ?
A. Cortical Calcifications
- The prognosis typically suck
= B. Medullary Calcifications
C. Extra fat in the renal sinus
D. Loss of fat in the renal sinus Other AIDS Related Renal Trivia:

3. In the same patient population ( same - Disseminated PCP in HIV patients can result
demographic risk factors) what would in punctate (primarily cortical) calcifications.
punctate cortical calcifications make
you think of?
-TB: The most common extrapulmonary site
A. Xanthogranulomatous
of infection i the urinary tract. The features are
Pyelonephritis
papillary necrosis and parenchymal destruction.
B. CMV Infection
You can have extensive calcifications. Basically
C. PCP Infection
you end up with a shrunken calcified kidnev
"putty kidney." "I his end stage appearance is
e sentially an auto nephrectomy.

Aunt Minnie 164

 CASE 75 - PELVIC PAIN

1. What is the diagnosis?

A. Hutch Diverticulum
B. Bladder Ears
C. Cloacal Malformation
D. Bladder cancer
=
2. What cell type ?
A. Transitional Cell
B. Adenocarcinoma
C. Squamous Cell
D. Rhabdomyosarcoma

3. Schistosomiasis is a common cause of bladder cancer world wide. What is the cell line
for those bladder cancers?
A. Transitional Cell
B. Adenocarcinoma
C. Squamous Cell
D. Rhabdomyosarcoma

Aunt Minnie 165

CASE 75 - Li RACHAL ADENOCARCINOMA

Urachal Adenocarcinoma

The urachus is the umbilical attachment of the

bladder (initially the allantois then urachus).

Essential Trivia:

- It usually atrophies and becomes the

Midline Mass, Coursing umbilical ligament (as the bladder descends
towards the umbilicus into the pelvis).

1. What is the diagnosis? - A persistent patent urachus can result in urine

A. Hutch Diverticulum
flow from the bladder to the umbilicus (and
B. Bladder Ears
C. Cloacal Malformation then likely someone's unsuspecting face).
D. Bladder cancer
- There i a spectrwn of these things from:
2. What cell type ? patent -> sinus -> diverticulum -> Cyst.
A. Transitional Cell
B. Adenocarcinoma - Th y can get infected.
C. Squamous Cell
D. Rhabdomyosarcoma
- Really the main thing to know i · that they get
3. Schistosomiasis is a common cause of adenocarcinoma�
bladder cancer world wide. What is the
cell line for those bladder cancers? - It s midline and they get adenocarcinoma
A. Transitional Cell
B. Adenocarcinoma - Bladder Cancer Key Trivia:
C. Squamous Cell
D. Rhabdomyosarcoma
- Typical= Transitional Cell
- Schisrosomiasis = Squamous
- Urachus = Adenocarcinoma
- KidN = Rhabdomyosarcoma

Aunt Minnie 166

CASE 76 - PELVIC PAIN (HISTORY OF BREAST CA)

1. What is the diagnosis? 3. A post menopausal patient, presents

A. Normal Proliferative Phase Uterus with a history of bleeding. Her
B. Normal Secretory Phase Uterus Endometrial thickness is measured at
C. Adenomyosis 4mm. What is the likely cause for her
D. Tamoxifen Related Changes bleeding?
E. N abothian Cysts A. Cancer
B. Endometrial Polyp
2. The GYN resident is very concerned for C. Atrophy
an underlying polyp, what would be the D. Endometrial Hyperplasia
best way to tell if one is hiding in there?
A. Intra-operative D&C 4. Endometrial Hyperplasia seen in the
B. Repeat Ultrasound with patient in setting of an ovarian mass is the classic
prone position multiple choice trick for?
C. Repeat Ultrasound with provocative
maneuvers (have her bare down) A. Granulosa Cell Tumor
D. Repeat Ultrasound as a B. Brenner Tumor
sonohysterogram C. Ovarian Fibrothecoma
D. Ovarian Fibroma

Aunt Minnie 167

CASE 76 - TAMOXIFEN RELATED CHANGES

Tarnoxifen

Thi i what the uteru ofTamoxifen patient

looks like.

Essential Trivia:

- Tamoxifen is a SERM (acts like estrogen in the

pelvi , blocks the estrogen effects on the
breas t).

- It's used to treat hormonally responsive breast

I. What is the diagnosis?
A. Normal Proliferative Phase Uterus
cancer, but increases the risk of endometrial
B. Normal Secretory Phase Uterus cancer.
C. Adenomyosis
D. Tamoxifen Related Changes
E. Nabothian Cysts - Normally post menopausal endometrial tis ue
2. The GYN resident is very concerned for shouldn't be thicker than 4mm but on
an underlying polyp, what would be the best Tamoxifen the endom trium gets a pass up to
way to tell if one is hiding in there?
A. Intra-operative D&C Smm, although the exact number at which you
B. Repeat Ultrasound with patient in should recommend a biop . y is allusive.
prone position
C. Repeat Ultrasound with provocative
maneuvers (have her bare down)
D. Repeat Ultrasound as a - It eems that most people agree that
sonohysterogram endometrial cancer typically presents with
3. A post menopausal patient, presents with a bleeding, and therefore bleeding patients with
history of bleeding. Her Endometrial thickened endometriurn should probably
thickness is measured at 4mm. What is the
likely cause for her bleeding? undergo a biopsy.
A. Cancer
B. Endometrial Polyp
C. Atrophy - If you are wondering if a polyp is hiding you
D. Endometrial Hyperplasia can get a sonohysterogram ( ultrasound after
4. Endometrial Hyperplasia seen in the instillation of saline).
setting of an ovarian mass is the classic
multiple choice trick for?
Classic Imaging Findings:
A. Granulosa Cell Tumor *tumor makes
estrogen which thickens endometrium - Thickened Irregular Appearance of the
B. Brenner Tumor Endometrium
C. Ovarian Fibrothecoma
D. Ovarian Fibroma - Subendometrial cysts,
- Development of endometrial poly p (30%).
Aunt Minnie 168
CASE 77 - PELVIC PAIN

1. What is the diagnosis?

A. Adenomyosis
B. Adenomyomatosis
C. Endometrial hyperplasia
D. Endometrial cancer

2. What measurement is used to define this pathology on MRI?

A. Thickness of the lower uterine segment
B. Number of ovarian follicles
C. Thickness of the junctional zone
D. Thickness of the posterior uterine wall

3. What part of the uterus tends to be most heavily afflicted, what part tends to be spared?
A. Posterior Wall is Favored, Anterior Wall is Spared
B. Cervix is favored, Posterior Wall is spared
C. Inferior wall is favored, Cervix is spared
D. Posterior Wall is Favored, Cervix is spared.

Aunt Minnie 169

CASE 77 - ADENOMYOSIS

Adenomvosis
"'

Endometrial tis ue that has migrated into the

myometrium

Essential Trivia:

- Most commonly in multiparous women of

reproductive age, especially if they've had a
history of uterine procedure (Caesarian section
dilatation and curettage).
1. What is the diagnosis?
A. Adenomyosis - First Line therapy is typically GnRH agonists -
B. Adenomyomatosis to mess with the normal cyclical hormone
C. Endometrial hyperplasia induced proliferation.
D. Endometrial cancer

- Doe (probably) respond to uterine artery

2. What measurement is used to
define this pathology on MRI? embolization, although hysterectomy is
A. Thickness of the lower uterine con. idered the definitive treatment for severe
segment cases.
B. Number of ovarian follicles
C. Thickness of the junctional Classic Imaging Findings:
zone
D. Thickness of the posterior
Ultrasound:
uterine wall
• Heterogeneous uteru (hyperechoic
3. What part of the uterus tends to be adenomyosis, with hypoechoic mu cular
most heavily afflicted, what part hypertrophy
tends to be spared? • Enlargement of the po terior wall spares cervix.
A. Posterior Wall is favored,
Anterior Wall is spared
MRI
B. Cervix is favored, Posterior Wall
• Thickening of the j unctional zone of the
is spared
C. Inferior wall is favored, Cervix uterus to more than 12 mm (normal is< 5mrn).
is spared 1 he thickening can be either focal or diffuse.
D. Posterior Wall is favored, • Small high T2 signal regions corresponding to
Cervix is spared. regions of cystic change

Aunt Minnie 170

CASE 78 - HISTORY WITHHELD

1. What is the diagnosis?

A. Ovarian Torsion
B. Polycystic Ovarian Syndrome (betcha this chick has a mustache)
C. Theca Lutein Cysts
D. Hemorrhagic Cyst

2. What measurement is used to define this pathology on MRI?

A. On birth control
B. On fertility meds ( clomid)
C. Has some bizarro encephalopathy (anti NMDA)
D. Has gastric cancer

3. Let's say she is pregnant ... what's probably true about this pregnancy?
A. Totally normal single gestation
B. Oh it's doomed for sure, probably trisomy 13
C. Multiple Gestations - possible reality tv show in her future

Aunt Minnie 171

CASE 78 - THECA LUTEIN CYSTS

Theca Lutein Cysts

Thi is a type of functional cyst related to

overstimulation from b-HCG.

Essential Trivia:

- What you see are large cysts (- 2-3 cm)

and the o ary has a typical multilocular
cystic "spoke-wheel · appearance.

- Clinical history might be hypereme is

gravidarum - all that b-HCG causes
1. What is the diagnosis? nausea.
A. Ovarian Torsion
B. Polycystic Ovarian Syndrome (betcha Think about 3 thing ·:
this chick has a mustache)
• Multifetal pregnancy,
C. Theca Lutein Cysts
• Gestational trophobla tic disease
D. Hemorrhagic Cyst
(moles), and
2. What measurement is used to define this • Ovarian Hyper. timulation syndrome.
pathology on MRJ?
A. On birth control Ovarian Hyperstimulation syndrome.
B. On fertility meds ( clomid) - Thi is a complication as ociated with
C. Has some bizarro encephalopathy (anti
fertility therapy (occurs in like 5%).
NMDA)
They will show you the ovarie · with
D. Has gastric cancer
theca lutein cysts then ascites, and
3. Let's say she is pregnant ... what's pleura] effusions. They may al o ha e
probably true about this pregnancy? pericardia] effusions. Complications
A. Totally normal single gestation include increased risk for ovarian torsion
B. Oh it's doomed for sure, probably (big ovaries). and hypovolemic shock.
trisomy 13
C. Multiple Gestations - possible reality
tv show in her future (followed by a
divorce)

Aunt Minnie 172

CASE 79 - PELVIC PAIN

1. What is the diagnosis?

A. Cervical Cancer
B. Nabothian Cyst(s)
C. Vaginal Leiomyoma
D. Skene Gland Cyst

2. What's the stage?

A. Stage 1
B. Stage 2a
C. Stage 2b

3. What is the typical cell type?

A. Transitional Cell
B. Adenocarcinoma
C. Squamous Cell
D. Rhabdomyosarcoma

Aunt Minnie 173

CASE 79 - CERVICAL CANCER

Cervical Cancer

Essential Trivia:

- H's usually squamous cell

related to HPV (like 90% .

- The big thing to know is

parametrial invasion stage llb).

- Violation of the normal T2 dark

line around the cervix =
parametrial in asion

- Stage Ila or below is treat d

with surgery. Once you have
parametrial invasion (stage llb)
Stage II-A or involvement of the lower l/3
-No Parametrial Enlargement
of the vagina it's gonna get
Stage 11-B chemo/ radiation
-Parametrial Enlargement

- What is this Parametrium ? The

parametrium is a fibrous band
that s parate the supravaginal
1 . What is the diagnosis? cervix from the bladder. It
A. Cervical Cancer
B. Nabothian Cyst(s) extends between the layer of
C. Vaginal Leiomyoma the broad ligament. The uterine
D. Skene Gland Cyst
artery runs inside the
2. What's the stage? parametrium. hence the need for
A. Stage I chemo - once invaded.
B. Stage 2a
C. Stage 2b

3. What is the typical cell type?

A. Transitional Cell
B. Adenocarcinoma
C. Squamous Cell
D. Rhabdomyosarcoma

Aunt Minnie 17 4
 CASE 80 - CHEST PAIN

RT AN.1. ERIOR
. . LT

1. What is the tracer (his kidneys are hot)?

A. Gallium
=
B. MIBG
C. Iodine
D. MIBI

2. What makes uptake of this tracer intense?

A. Blood Flow, and Mitochondria
B. Blood Flow, and Glucose Metabolism
C. Blood Flow and Functionality of the Na/K Pump

3. Bony Uptake of this tracer is considered bad (cancer)?

A. Iodine
B. MIBG
C. Octreotide
D. All of the above

Aunt Minnie 175

CASE 80 - THE INCIDENTAL CANCER

Incidental Cancer

..••
Watch your back ... the tiger i · in th tall
grass .

Essential Trivia:

- Sestami bi - Thi tracer is used for

parathyroid imaging cardiac imaging and
Axillary Nodes Like this are
NOT normal! breast specific gamma imaging.

- It work, by having affinity for high blood

flow and mitochondria.

- Lymph Nodes - Any lymph nodes seen on

1. What is the tracer (his kidneys are hot)?
A. Gallium *won't have spleen uptake BSGl (Brea t Specific Gamma Imaging).
B. MIBG *won't have kidney uptake Cardiac 'tudies using MJBI, or
C. Iodine * won't have heart uptake Parathyroid studies should be considered
D. MIBI cancer till proven otherwise. You 11 need
to recommend omething el e -
2. What makes uptake of this tracer
ultrasound first (probably) then eventual
intense?
biop y.
A. Blood Flow, and Mitochondria
B. Blood Flow, and Glucose Metabolism
C. Blood Flow and Functionality of the - As a re, ident I had an elderly attending
Na/KPump who wouJd always give the same an wer,
when I would ask what I hould do with
3. Bony Uptake of this tracer is considered an incidental finding. He would look at
bad (cancer) ?
me through his thick orange cataracts and
A. Iodine
B. MIBG say ' Biopsy the Mother Fucker!" ... He
C. Octreotide also gave good advice on women.
D. All of the above
- Bad Bones - You should NEVER , ee bone
uptake on MlBG I-1"' I. or Octreotide
scan . If you .ee this you are dealing
with bone mets till proven otherwise.

Aunt Minnie 176

CASE 81 - COUGH - CD4 COUNT 30

1. What is the tracer ? 4. What is the "critical organ"

A. Gallium for this tracer?
B. MIBG A. Bladder
C. Iodine B. Stomach
D. MIBI C. Kidney
D. Colon
2. What is the mechanism of this tracer?
A. Mimics Iron
B. Mimics Bilirubin
C. Mimics Potassium
D. Mimics Calcium

3. For PCP pneumonia, uptake is classically ?

A. More intense than the liver
B. Less intense than the liver
C. More intense than the kidneys
D. Less intense than the kidneys

Aunt Minnie 177

 CASE 81 - GALLIUM SCAN - PCP

PCP (Pneumocy tis)

Most common opportunistic pulmonary

infection found in HIV patients (in the
United State ).

Essential Trivia:

- An elevated serum lactate

dehydrogenase level i very sen itive for
PCP (and very non-specific, so family
1. What is the tracer ? medicine docs probably love it).
A. Gallium
B. MIBG
- The sensitivity of Gallium scanning for
c. Iodine
the evaluation of P P in HJ V patients
D. MIBI
has been reported to be as high as
2. What is the mechanism of this tracer? 90-95%.
A. Mimics Iron
B. Mimics Bilirubin - Classic Findings: Diffuse
C. Mimics Potassium heterogeneous pulmonary activity
D. Mimics Calcium
which is more intense than the liver

3. For PCP pneumonia, uptake is classically?

= A. More intense than the liver - Gallium Mechani srn: The body handles
B. Less intense than the liver Ga+3 the same way it would Fe+3 -
C. More intense than the kidneys which as you may remember from step 1
D. Less intense than the kidneys gets bound (via lactoferrin) and
concentrated in areas of inflammation
4. What is the "critical organ" for this tracer?
infection and rapid cell division.
A. Bladder
Therefore it's a very non- pecific way to
B. Stomach
C. Kidney look for infection or tumor.
D. Colon
- "Critical Organ' -The organ that would
first be subjected to radiation in exce s
oftbe maximum permissible amount.
For Gallium this is the colon.

Aunt Minnie 178

CASE 82 - CONFUSION

1. What is the energy of the tracer? 4. What part of the brain is classically
A. 140 preserved with neurodegenerative disorders?
B. 511 A. Cingulate Gyrus
C. 173 & 247 B. Motor Strip
D. 365 C. Rectus Gyrus
D. Hippocampus
2. What is the diagnosis?
A. Alzheimers
B. Vascular Dementia
C. Picks Disease
D. Dementia with Lewy Bodies

3. What part of the brain atrophies first with this diagnosis?

A. Cingulate Gyrus
B. Motor Strip
C. Rectus Gyrus
D. Hippocampus

Aunt Minnie 179

CASE 82 - ALZHEIMERS

Alzheimer Disease (AD)

The most common cause of dementia in

the elderly

Essential Trivia:

- The characteristic progressive atrophy

pattern begins in the medial temporal
lobes (bilateral hippocampi).

-PET-FDG as a tracer - Progre sive

decrease in gluco e metaboli m has been
shown to corre pond to underlying
neuronal degeneration in specific
patterns - this is exploited for dementia
imaging.

l . What is the energy of the tracer?

A. 140
- Decreased FOG for AD is in an "ear
B. 511 - * positron emission from FDG muffs" appearance - involving the
C. 173 & 247 inferior frontal lobe, and posterior
D. 365
temporal i parietal region. The cingulate
2. What is the diagnosis? gyrus is NOT spared.
A. Alzheimers
B. Vascular Dementia
C. Picks Disease - The motor cortex is classically spared
D. Dementia with Lewy Bodies
with neurodegenerative disorders (not
3. What part of the brain atrophies first with this nece .. arily with multi-intact dementia).
diagnosis?
A. Cingulate Gyrus
B. Motor Strip - There are kind of new tracers for AD
C. Rectus Gyrus imaging (none of which will be paid for
D. Hippocampus
by insurance that tag the amyloid and
4. What part of the brain is classically preserved tau protein . The mo t famous is the
with neurodegenerative disorders? Amyloid plaque ensitive agent
A. Cingulate Gyrus
B. Motor Strip "Pittsburgh compound B'' or C11-PiB.
C. Rectus Gyrus
D. Hippocarnpus

Aunt Minnie 180

DEMENTIA IMAGING - ESSENTIAL TRIVIA

Multi-Infarct Dementia

• This is the second most

common cause of dementia.

• Cortical infarcts and lacunar

mtarcts are seen on MRI.

• PET-FDG will demonstrate

multiple scattered areas of
decreased activity

Decreased Uptake in
Multiple Vascular Territories

Dementia with Lewy Bodies

• This is the third most common

cause of dementia (second
most common
neurodegenerative ).

• Very similar clinical picture to

the dementia seen with
Parkinsons, with the major
difference being that in DLB,
the dementia comes first.

• The hippocampi remain

normal in size (unlike AD).

• PET-FDG will show decreased

uptake in the lateral occipital
cortex, with sparing of the
mid posterior cingulate
gyrus {Cingulate Island)

Preservation of the Decreased Uptake in the

Cingulate Gyrus Lateral Occipital Cortex

Aunt Minnie 181

 Picks I Frontotemporal
Dementia
Decreased
Uptake in the • The 3rd most common
Frontal Lobes neurodegenerative disorder.

• Atrophy and Decreased FOG

patterns vary on the subtype
but typically involve the frontal
lobe and anterior temporal
lobes.

• Depression can be a mimic -

for the same decreased FOG
pattern.

Huntingtons

• Inherited (Autosomal Dominant -

Atrophy of the Triplet Repeat) -
Caudate Heads neurodegenerative disorder
caused by the loss of neurons in
the basal ganglia (especially the
caudate nucleus)

• Characteristic pattern of atrophy

in the caudate head - results in
a "box like" configuration of the
frontal horns; which people try
and quantify with measurements.

• There is also atrophy and

increased T2 signal in the
putamen.

• Not surprisingly, FOG-PET will

show low activity in caudate
nucleus and putamen

Aunt Minnie 182

 CASE 83 - HEADACHE

CISTERNOGRAM

ANTERIOR
RLAT

1. What is the tracer (most likely)?

A. Gallium
B. MIBG
C. Indium - DTPA
= D. MIBI

2. What is the diagnosis?

A. Normal Pressure Hydrocephalus
B. Meningitis
C. Pseudotumor Cerebri

3. Can this study distinguish between communicating and obstructive (non-

communicating) hydrocephalus ?
A. Yup
B. Nope

Aunt Minnie 183

CASE 83 - NORMAL PRESSURE HYDROCEPHALUS (NPH)

Normal Pressure Hydrocephalus

NPH i an idiopathic decrease in the

absorption of CSF. Secondary causes can
Persistent occur - the main one being meningitis and
Tracer in the ubarachnoid hemorrhage.
Lateral Vents

Essential Trivia:

- NJ>H is clinically Wet, Wacky. and Wobbly

(incontinent. confused and ataxic) clinically.

RLAT
- The classic CT findings is "ventricular
enlargement out of proportion to atrophy" on

1. What is the tracer (most likely)? CT.

A. Gallium
B. MIBG C F Imaging:
C. Indium - DTPA
D. MIBI - Tracer (most commonly ln-DTPA) is
injected intrathecal. You then watch to see if
2. What is the diagnosis?
it flows uormally.
A. Normal Pressure Hydrocephalus
B. Meningitis
C. Pseudotumor Cerebri - The major rule to remember that at 24 hours
it should clear from the basilar cisterns
3. Can this study distinguish between and be over the cerebral convexities
communicating and obstructive (non-
communicating) hydrocephalus ?
- Another finding sometimes de cribed is the
A. Yup
early detection of tracer into the lateral
B. Nope
ventricles - causing a heart shape (instead
of the normal trident).

- The cistemogram cannot di tinguish

communicating vs noncommunicating types
of hydrocephalus ( unless you want to inject
tracer directly into the lateral ventricles).

Aunt Minnie 184

 CASE 84 - PRE-NATAL CHECK UP

1. What is the diagnosis?

A. Gastric Outlet obstruction
= B. Colonic Atresia
C. Duodenal Atresia
D. Malrotation

2. What is a common associated finding on pre-natal ultrasound?

A. Polyhydramnios
B. Oligohydramnios
C. Renal Atresia
D. Limb abnormalities

3. Is this diagnosis typically ?

A. Solitary Atresia
B. One of multiple Atresias

Aunt Minnie 185

CASE 84 - DUODENAL ATRESIA

Duodenal Atresia

One of the most common cau es of neonatal

bowel ob truction,

Essential Trivia:

- "Double Bubble" - Because the atretic

portion is u ually just distal to the ampulla
of Vater, you do still have the first portion of
the duodenum. The double bubble
appearance represents a dilation of th
stomach and this proximal duodenum.

1. What is the diagnosis?

- The double bubble appearance can be seen
A. Gastric Outlet obstruction
B. Colonic Atresia with annular pancreas but this takes time to
C. Duodenal Atresia develop, and is typically not seen
D. Malrotation immediately after birth.

2. What is a common associated finding - The degree of distention will be more

on pre-natal ultrasound?
pronounced than with midgut lvulus
A. Polyhydramnios
(which i a more acute proces - a ssociated
B. Oligohydramnios
C. Renal Atresia with malrotation).
D. Limb abnormalities
- Just like a plain film of the belly this can be
3. Is this diagnosis typically ? . een on pre-natal US (or MRJ). On prenatal
A. Solitary Atresia Ultrasound. the double bubble will not be
B. One of multiple Atresias
present till late 2nd or 3rd trimester.

- Polyhydramnios is an associated pre-natal

finding.

- Thought to be secondary to failure to

canalize during development (often an
isolated atresia).

Aunt Minnie 186

CASE 85 - PRE-NATAL CHECK UP

1. What is the diagnosis?

A. Aqueductal stenosis
B. Neonatal Brain Tumor-probably ATRT
C. Choroid Plexus Cyst
D. Holoprosencephaly

2. When this finding is made in isolation, what is it's significance?

A. The kid is screwed - very specific congenital malformation
B. The kid is screwed - very specific for fetal alcohol syndrome
C. The kid will probably be fine - this is very common in the general population

3. What is the main syndrome I pathology this is associated with?

A. Trisomy 21
B. Trisomy 18
C. Trisomy 13
D. Turner's Syndrome

Aunt Minnie 187

CASE 85 - CHOROID PLEXUS CYST

Choroid Plexus Cyst

' oft sign' of chr mosome abnormalitie .

Essential Trivia:

- Benign and often transient finding seen in

about 1 % of pregnancies.

- This is one of thos incidental findings that

in isolation means nothing. It upposed
to make you look closer for other findings.
1. What is the diagnosis?
A. Aqueductal stenosis - Trisomy 18 is the primary testable
B. Neonatal Brain Tumor - probably association. Here are the high yield
ATRT points:
C. Choroid Plexus Cyst
D. Holoprosencephaly
• CP Cyst by itself gives you about a l %
2. When this finding is made in isolation, ri k ofTrisomy 18
what is it's significance? • CP yst with other anomalous gives
A. The kid is screwed - very specific you about a 4% risk ofTrisomy 18
congenital malformation • The risk for Trisomy 18 is the same
B. The kid is screwed - very specific for regardles · of whether you have one
fetal alcohol syndrome
cyst or multiple.
C. The kid will probably be fine - this
• About 50% ofTrisomy 18 babies have/
is very common in the general
population had choroid plexus cysts.

3. What is the main syndrome I pathology - Other association: trisomy 21, Turner's
this is associated with? _ ndrome, and Klinefelter's
A. Trisomy 21
B. Trisomy 18
C. Trisomy 13
D. Turner's Syndrome

Aunt Minnie 188

CASE 86 - PRE-NATAL CHECK UP (9 WEEKS)

1. What is the diagnosis?

A. Gastroschisis
B. Omphalocele
C. Totally normal at this gestational age

2. GastroschisisALWAYS occurs on?

A. The right side
B. The left side

3. Which has more associated syndromes ?

A. Omphalocele
B. Gastroschisis

4. Maternal serum AFP will be elevated with?

A. Omphalocele
B. Gastroschisis
C. Both

Aunt Minnie 189

CASE 86 - NORMAL MIDGUT HERNIATION

Normal Midgut Herniation

A normal thing that look · like an omphalocele to

the un-initiared.

Essential Trivia:

- Normal Embryology:
- At week 6: The midgut forms a 'U haped
loop .. which herniates through the umbilical
nng.
- At week 11: The midgut n rmally rotates 270
1. What is the diagnosis? degrees counterclockwise around the sup ri r
A. Gastroschisis mesenteric artery and returns to the abdominal
B. Omphalocele cavity,
C. Totally normal at this gestational - **Normalfrom week 6 - week 11
age

- This mimic the appearance of an omphalocele,

2. Gastroschisis ALWAYS occurs on?
A. The right side
B. The left side
Omphalocele - This is a congenital midline defect,
with herniation of gut at the base of the umbilical
3. Which has more associated
cord.
syndromes?
A. Om phalocele
Trivia to know:
B. Gastroschisis
• It DOES have a surrounding membrane
(gastroschisis does not), so AFP not elevated.
4. Maternal serum AFP will be elevated
• Associated anomalies are common (unlike
with?
gastroschisis)
A. Omphalocele
• Trisomy 18 is the most common associated
B. Gastroschisis
chromosomal anomaly
C. Both
• Other associations: Cardiac (50%), Other GI,
CNS, GU, Turners, Klinefelters, Beckwith-
Wiedemann.
• Outcomes are not that good, because of associated
syndromes.
• Umbilical Cord Cysts (Allantoic Cysts) are
associated.

Aunt Minnie 190

CASE 87 - PRE-NATAL CHECK UP (7 WEEKS)

1. What is the diagnosis?

A. Dandy Walker Malformation
B. Hydrocephalus ( aqueductal stenosis)
C. Total normal at this gestational age

2. The Rhombencephalon forms what?

A. The Thalamus
B. The Midbrain
C. The Hindbrain ( cerebellum, Pons, & medulla)
D. The cerebral hemispheres

3. In a Dandy Walker malformation, what is the relationship between the Torcula and the
Lambdoid suture?
A. The Torcula is elevated above it
B. The Torcula is depressed below it
C. They line up perfectly

Aunt Minnie 191

CASE 87 - NORMAL CYSTIC RHOMBENCEPHALON

Normal Cystic Rhombencephalon

A normal thing. that look Like a scary CNS

problem.

Essential Trivia:

- Normal Embryology:
- The rhombencephalon is a primary
brain "vesicle" that will go on to form
the hindbrain (Cerebellum, pons
medul1a)
- Between week 6 and 8 this has a normal
1. What is the diagnosis? cystic appearance, with the cavity
A. Dandy Walker Malformation forming a normally proportioned 4th
B. Hydrocephalus (aqueductal stenosis) ventricle by week 11.
C. Total normal at this gestational age - **Normalfrom week 6 - week 8

2. The Rhombencephalon forms what?

- This is ometimes confused (by the un-
A. The Thalamus
B. The Midbrain initiated) as a Dandy Walker Malformation,
C. The Hind brain ( cerebellum, Pons, &
medulla)
D. The cerebral hemispheres
Dandy Walker

3. In a Dandy Walker malformation, what is

The results of a mal-developed roof to the 4th
the relationship between the Torcula and the
ventricle.
Lambdoid suture?
A. The Torcula is elevated above it
Classically there are 3 findings to know:
B. The Torcula is depressed below it
(1) Hypoplasia of the vermis
C. They line up perfectly
(2) Cystic dilation of the 4th Ventricle
(3) Torcular-Lambdoid Inversion (torcula
above the lambdoid suture because of
elevation of the tentorium).

W'TF is the Torcula? - It's a fancy word for

the confluence of the venous sinuses

Aunt Minnie 192

CASE 88 - PRE-NATAL SCREEN

1. What is the diagnosis?

A. Hydrocephalus
B. Hydranencephaly
C. Holoprosencephaly

2. What is the most common congenital cause ofthis ?

A. Stroke
B. Sickle Cell
C. Fetal EtOH Syndrome
D. Aqueductal Stenosis

3. The absence of a cortical mantle (not seen in this case) would suggest ?
A. Hydrocephalus
B. Hydranencephaly
C. Holoprosencephaly

Aunt Minnie 193

CASE 88 - HYDROCEPHALUS (AQUEDUCTAL STENOSIS)

Aqueductal Stenosis

One of the most common cause of

congenital obstructive hydrocephalus.

Essential Trivia:

Aqueductal Steno ·i :

- Cau ·e can be congenital (from web or

scarring) acquired (from tumors) or
intrinsic (from infection or blood).

Fetal Hydrocephalus
1. What is the diagnosis?
A. Hydrocephalus
B. Hydranencephaly - Typically defined as lateral ventricle size
C. Holoprosencephaly greater than 15mm

2. What is the most common congenital - "Dangling horoid Sign" - thi is when
cause of this ? you have choroid separated more than
A. Stroke
3mm from the margin of the ventricle
B. Sickle Cell
C. Fetal EtOH Syndrome
D. Aqueductal Stenosis - Up to 80% have associated anomalies.

3. The absence of a cortical Strategy for

LOTS of CSF Y?7 Hydrocephalus
mantle (not seen in this case)
would suggest ? YES ,/;! Faix?
A. Hydrocephalus
� NO Holoprosencephaly
B. Hydranencephaly Cortical Mantle
C. Holoprosencephaly
Hydranencephaly

Aunt Minnie 194

CASE 89 - TROUBLE BREATHING

1. What is the diagnosis?

A. Sinonasal Polyposis
B. Choanal Atresia
C. Allergic Sinusitis
D. Holoprosencephaly.

2. What is the most "classic" clinical history?

A. Respiratory Distress when running
B. Respiratory Distress when Feeding
C. Respiratory Distress when laying flat
D. Recurrent Fever I Ear Infections

3. What other findings might you look for?

A. Coloboma (weird looking eyes)
B. Vertebral Body Malformations
C. Limb Abnormalities (Radial Ray)
D. Severe white matter disease

Aunt Minnie 195

 CASE 89 - CHOANAL ATRESIA

Bony Obstruction of the Choanal Atresia

choanal opening
Congenital lack of formation of the choanal
Air Fluid Level above
obstruction point openings.

Medial Bowing of the Essential Trivia:

posterior medial sinus
-Two type : Bony 90%) and Membraneous (10%)

1. What is the diagnosis?

A. Sinonasal Polyposis -It usually unilateral (65%)
B. Choanal Atresia
C. Allergic Sinusitis
-The classic hi tory is either (a) failure to pa. s the
D. Holoprosencephaly.
= NG tube, or (b) respiratory distress while feeding-
2. What is the most "classic" clinical can't breathe through nose and you have a bottle I
history?
A. Respiratory Distress when running nipple in your mouth.
B. Respiratory Distress when
Feeding
C. Respiratory Distress when laying -Don t forget that infants are obligate nose
flat breathers
D. Recurrent Fever I Ear Infections

3. What other findings might you look -There is a known association with early
for? pregnanc use of antith roid drugs
A. Coloboma (weird looking eyes)
B. Vertebral Body Malformations
C. Limb Abnormalities (Radial Ray) -There are multiple syndromes associated with this
D. Severe white matter disease - the big one to know is CHARGE (Coloboma,
Heart Defects Atresia - Choanal, Retardation,
Genital Issues. Ear Problems)

Aunt Minnie 196

CASE 90 - BELLY LOOKS BIG

I. What is the diagnosis?

A. Hepatoblastoma
B. Infantile Hemangioendothelioma
C. Mesenchymal Hamartoma
D. HCC (Fibrolamellar)

2. Which is true regarding the age group this tumor is found in?
A. Never seen before 6 months
B. Most commonly seen between age 0-2
C. Most commonly seen between age 5-10
D. Most commonly seen in teenagers

3. What lab would you expect to be elevated?

A. AFP
B. Endothelial Growth Factor
C. Neither

Aunt Minnie 197

CASE90-MESENCHYMALHAMARTOMA

[Link] Hamartoma

�ystic tumor seen in the liver of neonates

Essential Trivia:

- Its one of the 3 tumors you think about in

the liver of a 1 year old (the other two are
hepatoblastoma and infantile
hemangioendoth lioma),
Cystic Septated Mass in the Liver

- This tumor can be distinguished from tho. e

2. because its very cyst like.
1. What is the diagnosis?
A. Hepatoblastoma
B. Infantile Hemangioendothelioma - ome people don t even consider this a
C. Mesenchymal Hamartoma tumor, but more of a developmental
D. HCC (Fibrolamellar) anomaly.

2. Which is true regarding the age group - Symptom (and possible d sath) occur from
this tumor is found in? the mass effect this thing delivers.
A. Never seen before 6 months
B. Most commonly seen between age
0-2 - AFP i · usually negative (classically elevated
C. Most commonly seen between age with hepatoblastoma)
5-10
D. Most commonly seen in teenagers lassie Look:
- Large mostly cy tic septated mass in the
3. What lab would you expect to be liver of a kid ( 2 or younger).
elevated?
A. ·AFP
B. Endothelial Growth Factor DDx:
C. Neither - Hepatoblasloma - Same Age Group But
more solid. and has elevated AFP

- Infantile Hemangioendothelioma - Sarne

Age Group but looks like a vascular lesion
(not a cyst). Also ha') elevated endothelial
growth factor.
Aunt Minnie 198
CASE 91 - INFERTILITY WORKUP

1. What is the diagnosis?

A. Arcuate Uterus
B. T Shaped Uterus
C. Septate Uterus
D. Bicomuate Uterus

2. Is there an increased risk of infertility /fetal loss?

A. Yes
B. Not Usually

3. Which of the following statements is TRUE?

A. DES use was associated with a Bicomuate Uterus
B. Arcuate Uterus has an increased risk of fetal loss
C. Septate Uterus has a NORMAL fundal contour
D. Bicomuate Uterus has a NORMAL fundal contour

Aunt Minnie 199

 CASE 91 - SEPTATE UTERUS

Septate Uterus

· terine Mal formation characterized by

a residual eptum.

Essential Trivia:

- This one has two endometrial canals

separated by a fibrous (or muscular)
septum.

- Fibrous vs Muscular can be

determined with MR1 and thi
distinction changes surgical
1. What is the diagnosis? management (different approaches).
A. Arcuate Uterus
B. T Shaped Uterus
- Septum is a normal developmental
C. Septate Uterus
structure that is suppose to resorb
D. Bicomuate Uterus
(usually resorbing from inferior to
2. Is there an increased risk of infertility/fetal superior).
loss?
_,
A. Yes - There is an increased risk of
B. Not Usually infertility and recurrent
spontaneous abortion (felt to be
3. Which of the following statements is TRUE?
secondary to implantation on the
A. DES use was associated with a Bicomuate
Uterus ** "I-Shaped" septum).
B. Arcuate Uterus has an increased risk of fetal
loss ** Nope it's a normal variant lassie Description:
C. Septate Uterus has a NORMAL fundal - Normal Fundal Contour+ Septum
contour - 1 Uterus, I. Cervix 2 Ovaries ---
D. Bicomuate Uterus has a NORMAL fundal
otherwise normal.
contour **Nope

Aunt Minnie 200

CASE 92 - INFERTILITY WORKUP

1. What is the diagnosis?

A. Arcuate Uterus
B. T Shaped Uterus
C. Septate Uterus
D. Bicomuate Uterus

2. Is there an increased risk of infertility/fetal loss?

A. Yes
B. Not Usually

3. When you have a mullerian duct anomaly, you should also remember to look at?
A. The heart
B. The pancreas
C. The kidneys
D. The liver

Aunt Minnie 201

 CASE 92 - BICORNUATE UTERUS

Bicornuate Uterus

Ut rine Malformation chara .terized by

a "heart shape" . with two horns to the
uterus.

Essential Trivia:

- Thi comes in tw flavor (one cervix

unicollis, two cervix bicollis). There
will be separation of the uteru by a
deep myometrial cleft.

Bicornuate vs Septate
1. What is the diagnosis?
- This require some kind of cross
A. Arcuate Uterus
sectional imaging (you can't tell by
B. T Shaped Uterus
C. Septate Uterus HSG). Yi u distinguish the two by the
D. Bicornuate Uterus apex of the fundal contour:
- Apex of Fundal Contour> 5mm
2. Is there an increased risk of infertility/fetal Abov T ubal Ostia = Septate
loss? - Apex of Fundal Contour < 5mm
A. Yes
_J Above Tubal Ostia = Bicornuate
B. Not Usually

3. When you have a mullerian duct anomaly, you - The risk of fetal loss i much le s
should also remember to look at? than septate, and for th most part not
A. The heart a major issue.
B. The pancreas
C. The kidneys - There is a 25% chance of an
D. The liver
associated longitudinal vaginal
septum

Classic Description:
- ABnonnal Fundal Contour (external
fundal indentation> Icm)
- Can have one or two cervixes (uni or
bi-collis)
Aunt Minnie 202
UTERINE MALFORMATIONS - ESSENTIAL TRIVIA

Lack of Development

Essential Trivia:

• Endornetrial tissue in a
rudimentary horn ( communicating
or not - increases the risk of
miscarriage and uterine rupture

• 40% of these chicks will have

renal issues ( usually renal
Unicornuate Unicornuate agenesis) ipsilateral to the
- with Non-Communicating rudimentary horn.
Rudimentary Horn

Lack of Resorption

Essential Trivia:

• The Arcuate Uterus is just a

concavity to the fundus. It's a
normal variant, and has no
significance clinically.

• Septate Uterus has a normal fundal

contour, and a known increased
risk for fetal loss I infertility.
Septate Arcuate

Lack of Fusion
Essential Trivia:

• Didelphys - if no vaginal
septum, it's typically
asymptomatic

• T Shaped - This is seen in

daughters of patient's who
took DES ( synthetic
estrogen) in the 1940s.
They also get vaginal
Didelphys Bicornuate T-Shaped clear cell CA.

Aunt Minnie 203

 Bicornuate vs Septate

Bicornuate

• "Heart Shaped" - Fundal contour is le,ss

than Smm above the tubal ostia

• No signif'icant infertility issues

• Resection of the "septum" results in poor

outcomes

Vs
Septate

• Fundal contour is Normal ; more than Srnrn

above the tubal ostia

• Legit infertility issues

• Resection of the septum can help

Bicornate vs Didelphus

Bicornuate

• "Partial Fusion"

• 2 uteri, 1 or partial 2 cervix, 1 vagina

• Vaginal Septum about 25% of the time

• Clinically - between unicornuate I normal

Vs
Didelphys

• NO Fusion

• 2 uteri, 2 cervix, 2 upper 1/3 vagina

• Vaginal Septum about 75% of the time

• Clinically - like unicornuate

Aunt Minnie 204

CASE 93 - HISTORY WITHHELD

1. What is the diagnosis?

A. Gastric Volvulus
B. Duodenal Web
C. Hypertrophic Pyloric Stenosis
D. Annular Pancreas

2. What is the classic clinical history?

A. Vomiting (Bilious)
B. Vomiting (Non-Bilious)
C. Constipation

3. What age do you see this pathology?

A. You can see it immediately after birth
B. Between 1 week and 3 weeks (rare after 1 month)
C. Between 3 weeks and 3 months
D. Most commonly seen between age 3 and 6

Aunt Minnie 205

CASE 93 - HYPERTROPHIC PYLORIC STENOSIS

Hypertrophic Pyloric Stenosis

Thickening of the gastric pyloric

musculature which can result in
progressive obstruction

Essential Trivia:

- tep I buzzword is "non-bilious

vomiting."

- Docs NOT occur at birth or after 3

months. There is a pecific age range
2-12 weeks (peak at 3-6 weeks).
1. What is the diagnosis? **just think 3wks to 3 months
A. Gastric Volvulus
B. Duodenal Web
riteria is 4mm and 14mm (4mm
C. Hypertrophic Pyloric Stenosis
single wall l4mm length).
D. Annular Pancreas

2. What is the classic clinical history? - The primary differential is

A. Vomiting (Bilious) pyloro 'pa sm (which wiJl relax during
B. Vomiting (Non-Bilious) exam).
C. Constipation

- The most common pitfall during the

3. What age do you see this pathology?
exam i gastric o er distention, which
A. You can see it immediately after birth
B. Between 1 week and 3 weeks (rare after 1 can lead to di placement of the
month) antrum and pJ torus- leading to false
C. Between 3 weeks and 3 months negative.
D. Most commonly seen between age 3 and 6
- Fal e positive can result from off axis
mea urement.

- The phenomenon of' paradoxial

aciduria 'has been described, and i a
common buzzword.

Aunt Minnie 206

CASE 94 - BELLY PAIN

1. What is the diagnosis?

A. Anterior Urethral Valves
B. Posterior Urethral Valves
C. Membranous Urethral Stricture
D. Hutch Diverticulum

2. Who do you see this pathology in?

A. Baby Boys
B. Baby Girls
C. Both Baby Boys and Girls
D. Presents in Boys when they start to toilet train (around age 2)

3. Most cases are ?

A. Sporadic
B. Syndromic

Aunt Minnie 207

 CASE 94 - POSTERIOR URETHRAL VALVES

Posterior Urethral Valves

Mo t common congenital ob. tructive lesion of

the urethra

Essential Trivia:

- A thick valve like membrane which gets left

behind in a failure of regres ion of the
mesonephric duct. It's located at the
vemmontanum - distal prostatic urethra.

I. What is the diagnosis?

A. Anterior Urethral Valves - Only seen in male infants
B. Posterior Urethral Valves
C. Membranous Urethral Stricture
D. Hutch Diverticulum - Pre-natal US may show oligohydramnios
( when severe)
2. Who do you see this pathology in?
A. Baby Boys
B. Baby Girls - V UG (Voiding Cystourethrogram) is the
C. Both Baby Boys and Girls
best test. The be t phase during this test is
D. Presents in Boys when they start to toilet
train (around age 2) the micturition phase. You need a lateral
(or oblique view) to actually see the urethra.
3. Most cases are?
A. Sporadic
= B. Syndromic Ways this can be shown:
• VCUG demonstrating the Valve (as in this
case)
• Neonatal Hydro - prenatal US (3rd
trimester)
• Neonatal Hydro - prenatal MRJ (3rd
trimester)
• "Keyhole Sign" - dilation of the posterior
urethra can cause a "key hole· like
appearance on US.

Aunt Minnie 208

CASE 95 - HISTORY WITHHELD

1. What is the diagnosis?

A. Normal Study
B. Thymus is enlarged (possibly rebound)
C. Lymphoma
D. Pneumomediastinum

2. Which of the follow is true ?

A. Thymic hyperplasia is COLD on PET, Lymphoma is HOT on PET
B. Thymic hyperplasia is HOT on PET, Lymphoma is HOT on PET
C. Thymic hyperplasia is COLD on PET, Lymphoma is COLD on PET
D. Thymic hyperplasia is HOT on PET, Lymphoma is COLD on PET

3. Which is true regarding the fat pads of the elbow?

A. The Anterior fat pad should never be visible
B. The Posterior fat pad can sometimes be seen, but the anterior fat pad should never
be seen.
C. A false positive posterior fat pad sign can occur from improper positioning

Aunt Minnie 209

CASE 95 - SPINNAKER SAIL SIGN - (PNEUMOMEDIASTINUM)

Spinnaker Sail Sign

A sign of pneumomediastinum

Essential Trivia:

- This occurs when the thymus i outlined by

air and displaced lateralJy.

Other Sail Signs:

- Elbow Sail Sig11 - Joint Ejfusion
1. What is the diagnosis? - Pearls: Anterior Fat Pad sometimes een
A. Normal Study as a thin sliver. The posterior fat pad
B'. Thymus is enlarged (possibly should never be seen (if the elbow is
rebound)
correctly positioned, as a true lateral).
C. Lymphoma
D. Pneumomediastinum Joint effusion can float the fat pads out,
creating the appearance of a sail - an
2. Which of the follow is true ? indicating an occult fracture.
A. Thymic hyperplasia is COLD on
PET, Lymphoma is HOT on PET - Adult Chest Sail Sign (retrocardiac sail) -
B. Thymic hyperplasia is HOT on
Left Lower Lobe Collapse. ColJapse of the
PET, Lymphoma is HOT on PET
LLL can create a triangular · ail like' d n. ity
C. Thymic hyperplasia is COLD on
PET, Lymphoma is COLD on PET behind the heart.
D. Thymic hyperplasia is HOT on PET,
Lymphoma is COLD on PET Thymic Rebound -
- The thymu shrinks during tress and then
3. Which is true regarding the fat pads of "rebounds' bigger than it was before (usually
the elbow?
taking around 9 months). Classic times when
A. The Anterior fat pad should never
this occurs, are post cherno, or after hanging
be visible
B. The Posterior fat pad can sometimes out in the NI U (getting tressed out).
be seen , but the anterior fat pad
should never be seen. - The trick question is this can be P T Avid,
C. A false positive posterior fat pad and mimic lymphoma. Suppo ·edly you can
sign can occur from improper tell them apart by morphology (the thymus
positioning
will till drape over the heart whereas
lymphoma is a ball).

Aunt Minnie 21 o
CASE 96 -LEG PAIN

Zoomed from Box

1. What is the diagnosis? 3. Which is true ?

A. Chondrosarcoma A. The mineralization pattern of
B. Osteosarcoma osteosarcoma goes from peripheral to
C. ABC central
D. Myositis Ossificans B. The mineralization pattern of myositis
ossificans goes from peripheral to central
2. Which typically has the best
prognosis? 4. If this patient had a pneumothorax -what
A. Conventional (Intrameduallary) would you say the likely cause was?
Type
B. Periosteal A. Family medicine trying to put a central line in
C. Parosteal on the floor
D. Telangiectatic B. Bleb rupture- (assuming the patient smokes)
C. Metastatic Disease to the lung
D. Chemotherapy induced pneumothorax

Aunt Minnie 211

CASE 96 -CODMAN'S TRIANGLE - OSTEOSARCOMA

Essential Trivia:

- There are a bunch of subtypes, but for the

purpose of this discussion there are 4.
Conventional lntrarnedullary (85%), Parosteal
( 4 % ), Periosteal ( l % ) Telangiectatic (rare).
Codman triangle - With
aggressive lesions, the - All the subtypes produce bone or osteoid from
periosteum does not have time neoplastic cells, and prefer the femur.
to ossify completely , so only
the edge of the raised
periosteum will ossify - creating - Most are idiopathic but the testable causes are:
the appearance of a triangle. Pagets, Prior Radiation, and Bone Infarct.

1. What is the diagnosis? Pearls Per Sub-Type:

A. Chondrosarcoma - Conventional Iotramedullary- Most Comm n.
B. Osteosarcoma typically higher grade than urface types. Occur
C. ABC
between age 10-20.
D. Myositis Ossificans

2. Which typically has the best - Parosteal- 'BULKY" surface le ion. Typically low
prognosis? grade. Seen in middle aged adults.
A. Conventional (lntrameduallary)
Type - Periosteal - Surface lesion but less bulky. Worse
B. Periosteal prognosis than parosteal (but better than
C. Parosteal
conventional type). een in ages 15-25.
D. Telangiectatic

3. Which is true ? - Tclangiectatic- Will have fluid-fluid levels on MRI.

A. The mineralization pattern of Kinda look like an AB . Progn is is imilar to
osteosarcoma goes from that of the conventional type. Average age is 20.
peripheral to central
B. The mineralization pattern of
myositis ossificans goes from High Yield Trivia:
peripheral to central • Osteosarcoma met to the lung is a
4. If this patient had a pneumothorax - ' classic" ( frequently te ted) cause of occult
what would you say the likely cause pneumothorax.
was?
• "Rever e Zoning Phenomenon" - more
A. Family medicine trying to put a dense mature matrix in the center less
central line in on the floor peripherally (opposite of myositis
B. Bleb rupture - (assuming the patient
smokes) ossificans ).
C. Metastatic Disease to the lung • Secondary Osteosarcomas - From Pagets.
D. Chemotherapy induced
tend to be very high grade

Aunt Minnie 212

CASE 97- DAILY NICU CXR

1. What is the most likely cause of the finding?

A. Prostaglandin Therapy
B. Stress from the NICU
C. Chronic Steroid Use
D. Langerhans Cell Histiocytosis

2. Which of the follow is true regarding Physiologic Periostitis of the Newborn?

A. It occurs in a newborn
B. It occurs in the femur before the tibia
C. It occurs in the metaphysis (never the diaphysis)

3. Where is the classic location for the erosion lesion seen in congenital syphilis?
A. The medial proximal tibia
B. The lateral proximal tibia
C. The lateral distal femur
D. The medial distal femur

Aunt Minnie 213

CASE 97 - PERIOSTEAL REACTION
(PROSTAGLANDIN THERAPY)

Periosteal Reaction

It's a nonspecific finding of periosteal irritation.

Essential Trivia:

- Prostaglandin Therapy- Prostaglandin El and E2

(often used to keep a PDA open) can cause a
periosteal reaction. The cla sic trick is to show a
chest x-ray with stemotomy wires (or other hints of
congenital heart). and then periosteal reaction in the
arm bone
1. What is the most likely cause
of the finding? Other Causes:
A. Prostaglandin Therapy
B. Stress from the NICU
- "Physiologic Periostitis of the Newborn" - should
c. Chronic Steroid Use
D. Langerhans Cell never happen in a newborn. You see it around 3
Histiocytosis months. There are 3 'Nots" of this Physiologic
Periostitis. (1) NOT before I month, (2) NOT in the
2. Which of the follow is true tibia before the femur, (3) NOT Metaphysis (should
regarding Physiologic Periostitis be diaphysis).
of the Newborn?
A. It occurs in a newborn
- Periosteal Reaction in the Jaw is Caffeys disease (for
B. It occurs in the femur
before the tibia (proximal multiple choice), and bisphosphonate therapy for
before distal) Osteogenesis Imperfecta in the real world.
C. It occurs in the metaphysis
(never the diaphysis) - TORCHS like Rubella and Syphili • can cause it.
Remember "Celery stalk" for rubella, and medial
3. Where is the classic location
proximal metaphy is of the tibia (Wimberger) for
for the erosion lesion seen in
Syphilis
congenital syphilis?
A. The medial proximal tibia
B. The lateral proximal tibia - Never forget that child abuse can present as a
C. The lateral distal femur p riosteal reaction (healing fracture)
D. The medial distal femur
- Neuroblastoma mets
Aunt Minnie 214
CASE 98 - WALKING FUNNY

1. What is the diagnosis?

A. Sinding-Larsen Johansson
B. Blounts
C. Congenital Syphilis
D. Congenital Rubella

2. What is the other name for this?

A. Tibia Valga
B. Tibia Vara

3. Which of the follow is true?

A. It's rarely bilateral
B. It's usually seen before age 2
C. When seen in adolescents - it's usually a fat kid
D. It's associated with delayed ambulation ("late walkers")

Aunt Minnie 215

CASE 98 - BLOUNT DISEASE

Blount Disease (Tibia Vara)

Growth disorder of the tibia. which re, embles

a 'bowed leg. '

Essential Trivia:

- Yarns angulation occurring at the medial

aspect of the proximal tibia (varus bowing
occurs at the rnetaphy is not the knee).

- Thi is often bilateral, and NOT often een

1. What is the diagnosis? before age 2 (two sides, not before two).
A. Sinding-Larsen Johansson
B. Blounts - Later in the disease progre sion the medial
C. Congenital Syphilis metaphysis will be depressed and an osseous
D. Congenital Rubella outgrowth clas ically develops.

- You can ee it in two different age groups;

2. What is the other name for this?
A. Tibia Valga (a) early - which is around age 3 and (b) late
B. Tibia Vara - which is around age 12.

3. Which of the follow is true? - The early type i . een in early walkers"
A. It's rarely bilateral - Possible mechanism is stress on a bone
B. It's usually seen before age 2
that's not ready to hare weight
C. When seen in adolescents - it's
usually a fat kid
D. It's associated with delayed - The late type is seen in fat kid
ambulation ("late walkers") - Possible mechani mis too much Burger
King and Taco Bell

Aunt Minnie 216

CASE 99 - THIS KID HATES TO PLAY OUTSIDE

1. What is the diagnosis?

A. Ellis-Van Crevald
B. Rickets
C. Achondroplasia
D. Congenital Rubella

2. Can this disorder occur in a newborn?

A. Yup
B. Nope

3. Which of the following is true?

A. This kid is at increased risk for SCFE
B. The disorder is typically least prominent at the growth plates
C. Leg Bowing classically begins before ambulation
D. The bones are paradoxically increased in strength

Aunt Minnie 217

 CASE 99 - RICKETS

Rickets

Metabolic condition that occurs from a

lack of Vitamin O (or the inability to use it
correctly).

Essential Trivia:

- Targets the most rapidly growing bone

(knees and wrist , with features most
prominent at the areas of growth (growth
Cupping along the Physeal Region plates).

OT seen in newborns; the Mother's

Vitamin D is still doing it's thing.
1. What is the diagnosis?
A. Ellis- Van Crevald
B. Rickets - If you see what looks like rickets on x-
C. Achondroplasia ray in a newborn the answer i '
D. Congenital Rubella 1.--Jypophosphatasia

2. Can this disorder occur in a newborn? - These kid are at increa ed risk for
A. Yup
SCFE ( and other fractures)
� B. Nope * when x-ray features are seen
on a newborn the answer in
Hypophosphatasia
'las ic F indings:
3. Which of the following is true? - "Cupping I Fraying" of the physeal
A. This kid is at increased risk for SCFE margins.
B. The disorder is typically least prominent - Bowing of the knees - especially once
at the growth plates
the kid starts walking.
C. Leg Bowing classically begins before
- Involvement of the anterior ribs ends
ambulation
D. The bones are paradoxically increased in 'Rachitic Rosary'
strength

Aunt Minnie 218

CASE 100 - BELLY PAIN ( 3 MONTH OLD)

1. What is going on here?

A. Looks normal to me
B. Heterotaxia
C. Malrotation
D. Biliary Atresia

2. What if this kid came in with bilious vomiting ?

A. "Clinical Correlation" , could be viral
B. Could be obstructed needs an Upper GI
C. Could be obstructed needs a water soluble enema
D. Could be obstructed needs a CT

3. What surgical procedure is done on these kids ?

A. Lecompte maneuver
B. Kasai Procedure
C. Ross Procedure
D. Ladds Procedure

Aunt Minnie 219

CASE 100 - MALROTATION

SMA & SMV Reversal - Malrotation

The SMA is normally on the ame .ide as the Aorta

(artery with artery). When you seen it reversed - think
Malrotation.

Essential Trivia:

- Normally the developmental rotation of the gut places

the ligament ofTrietz to the left of the spine (at the
level of the duodenal bulb).

- These patients are at increased risk for mid gut

volvulus, and internal hernias.

- If ou see the appearance of malrotation and the

clinical history is bilious vomiting then you mu t
1. What is going on here? uspect midgut volvulus.
A. Looks normal to me
B. Heterotaxia
- In an older chid (or even adults) ob truction +
c. Malrotation
D. Biliary Atresia malrotation is from kinking from a "Ladds Band" -
which is a stalk of peritoneal ti .sue.
2. What if this kid came in with
bilious vomiting ?
A. "Clinical Correlation" , - The "Ladds Procedure' is done to prevent volvulus. ft
could be viral inv Ives cutting out the Ladds band and stimulating
B. Could be obstructed needs
adhe ion formation to tac the bowel down.
an Upper GI
C. Could be obstructed needs a
water soluble enema
D. Could be obstructed needs a
CT

3. What surgical procedure is

done on these kids ?
A. Lecompte maneuver
B. Kasai Procedure
C. Ross Procedure
D. Ladds Procedure
Normal - Duodenum Ma/rotation
crosses the midline at
level of bulb
Aunt Minnie 220
 RANDOM PEDS - ESSENTIAL TRIVIA

Timed Trivia

Airway/Lungs:
• Croup - Peaks around 1 year
• Epiglottis - Peaks are 3.5 years
• Transient Tachypnea - Should resolve by day 3
• Respiratory Distress Syndrome (Hyaline Membrane) - seen in kids « 32 weeks
• Extralobar Sequestration presents early b/c of heart disease association
• lntralobar Sequestration presents later with recurrent pneumonia

Adrenals/Kidneys/Testicles
• Neuroblastoma - you can be born with
• Wilms tumor - you can NOT be born with (shows up around age 1)
• Kidney Tumors (aqe « 1) think Nephroblastornatosis - the wilms precursor, and
Mesoblastic Nephroma
• Torsion of the Testicular Appendages - most common cause of acute scrotal
pain in age 7-14.

GI:
• Hypertrophic pyloric stenosis - NOT in newborn ; think 3 weeks - 3 months
• lntussusception - think 3 months - 3 years
• NEC occurs 90% of the time within the first 10 days of life
• Liver Tumors (age < 1) think Hemangioendothelioma , Hepatoblastoma, and
Mesenchymal Hamartoma

Bones:
• Remember the elbow ossifications occur in a set order (CRITOE), Capitellum
(Age 1 ), Radius (Age 3), Internal (medial epicondyle - Age 5), Trochlea (Age 7),
Olecranon(Age 9), and External (lateral epicondyle -Age 11 ).
• Blouts occurs around age 3 (or less commonly in fat adolescents)
• Congenital Syphilis - Bony changes do NOT occur until 6-8 weeks of lite
• Congenital Rubella - Bony changes occur in the first week of life
• Caffey's Disease (if it were real) would occur in the first 6 months of life
• Physiologic Periostitis ot the Newborn - doesn't occur till around 3 months
• Perthes occurs around age 6
• SCFE occurs around age 12
• Bony changes of Rickets are NOT seen in a newborn, if it looks like Rickets in a
newborn the answer is Hypophosphatasia

Neuro:
• Germinal Matrix Hemorrhage is only seen in premature infants - never after 36
weeks

Aunt Minnie 221

When You See This - You Gotta Look There

VACTERL

V - Vertebral Anomalies (37%)

A -Anal (imperforate anus) (63%)
C- Cardiac (77%)
TE - Tracheoesophageal Fistula ( 40%)
R - Renal (72%)
L - Limb (radial ray) - 58%

Wilms Associations

Beckwith-Weidemann:
-Big Tongue, Omphalocele, Hemihypertrophy

WAGR
-Wilms. Aniridia, Genital, Growth Retardation

Other associations:
- Hepatoblastoma
Ii

CHARGE Syndrome

•Coloboma of the eye,

-Heart defects,
•Atresia of the choanae,
•Retardation of growth and/or development,
•Genital and/or urinary abnormalities,
•Ear abnormalities/deafness.

Multi-Cystic Dysplastic Kidneys

• 50% have a UPJ Obstruction on the other

side

• If you see a UPJ Obstruction, Look for

"Crossing Vessels," as a possible cause

Aunt Minnie 222

CASE 101 - PALPABLE BUMP

1. What is the diagnosis? 3. What subtype of IDC is associated

A. Lipoma with Radial Scar?
B. IDC A. Mucinous
C. Island of Normal Breast Tissue B. Medullary
D. Hamartoma C. Papillary
D. Tubular
2. Lets say this was biopsied and the path
showed Pseudoangiomatous Stromal
Hyperplasia, what is the prognosis?
A. Certain Death
B. Might be ok, with Chemo and Radiation
- stage the axilla
C. Should be fine , it's a benign entity

Aunt Minnie 223

 CASE 101 - HAMARTOMA

Hamartoma

Benign fat containing mass.

Essential Trivia:

- There are fi e classic fat containing

lesions. all of which are benign. The oil
cyst I fat necrosis hamartoma.
galactocele lymph nodes and lipoma.

- Of these 5, only oil cyst/fat necrosis and

1. What is the diagnosis? I ipoma are considered "pure fat
A. Lipoma containing .. masses.
B. IDC
C. Island of Normal Breast Tissue Hamartoma
D. Hamartoma
- The buzzword is "breast within a
2. Lets say this was biopsied and the path
breast.'
showed Pseudoangiomatous Stromal
Hyperplasia, what is the prognosis?
A. Certain Death - They have an Aunt Minnie appearance
B. Might be ok, with Chemo and Radiation on mammography although they are
=
- stage the axilla difficult to see on ultrasound (they blend
C. Should be fine , it's a benign entity into the background).

3. What subtype of IDC is associated with

Radial Scar?
A. Mucinous Other Trivia
B. Medullary
C. Papillary • Pseudoangiomatous Stromal
D. Tubular Hyperplasia = Benign thing with a scary
sounding name

• Tubular JDC - Spiculated cancer. with a

good prognosis. and an association with
radial car

Aunt Minnie 224

CASE 102 - "HIGH RISK" SCREENER

1. What BI-RADS approved vocabulary word would you use for this?
A. Linear I Segmental - Non Mass Like Enhancement (NMLE)
B. Clustered Ring - Non Mass Like Enhancement (NMLE)
C. Irregular Mass
D. Oval Mass

2. What is this "classic" for ?

A. Fibroadenoma
B. ILC
C. IDC
D. DCIS

3. To be considered "high risk" enough to get screening MRI, what must you chance of
Breast CA be?
A. Lifetime Risk Greater than 5%
B. Lifetime Risk Greater than 10%
C. Lifetime Risk Greater than 20-25%
D. Lifetime Risk Greater than 50 %

Aunt Minnie 225

CASE 102 - DCIS

DCIS

The "earlie t form of breast cancer.' It can't kill

you but the side-effects from the chemo might.

Essential Trivia:

- "Cancer" is confined to the ducts

1. What BI-RADS approved DCIS on Mammogram

vocabulary word would you use
for this? - Usually a suspicious calcification pattern (fine
A. Linear I Segmental - Non linear branching or fine pleomorphic)
Mass Like Enhancement
(NMLE)
B. Clustered Ring - Non Mass Like - 8% of DCIS will present as a mass without
Enhancement (NMLE) calcifications
C. Irregular Mass
D. Oval Mass DCISOnMIU

2. What is this "classic" for ?

- Clumped, ductal, linear or segmental non-mass
A. Fibroadenoma
likely enhancement.
B. ILC
C. IDC
D. DCIS - Kinetics are typically NOT helpful for DCIS.

3. To be considered "high risk" Screening Trivia

enough to get screening MRI, what
must you chance of Breast CA be?
• People with a lifetime risk greater than 20-25%
A. Lifetime Risk Greater than 5%
qualify for screening MRI.
B. Lifetime Risk Greater than 10%
C. Lifetime Risk Greater than
20-25% • Anything that gets you more estrogen increase
D. Lifetime Risk Greater than 50 your risk (obesity, liver damage - leading to less
% estrogen metabolism).

• 20Gy of Radiation to your chest a a kid buys

you a screening MRI - at 25 or 8 years after
exposure (*which ever is longer)

Aunt Minnie 226

CASE 103 - SCREENING MAMMOGRAM

1. What is the "next step" ?

A. Put the patient in ultrasound
B. Get spot compressions
C. Put the patient in the consultation room (" the room of tears'')
D. Look to see if the patient has ever had a chest CT

2. This finding can ONLY be made on ?

A. Screening Mammograms
B. Diagnostic Mammograms
C. ACCView
D. An Ultrasound

3. Which of the following is true

A. It's twice as likely to be bilateral
B. It's twice as likely to be unilateral
C. When present it's unilateral just as often as it is bilateral
D. It's NEVER unilateral

Aunt Minnie 227

CASE 103 - STERNALIS MUSCLE

Stemalis
1. What is the "next step" ?
A. Put the patient in ultrasound
Variant chest wall muscle, that mimics a
B. Get spot compressions
C. Put the patient in the consultation room mass on mammograms.
("the room of tears")
D. Look to see if the patient has ever had Essential Trivia:
a chest CT
- It's a non-functional muscle next to the
2. This finding can ONLY be made on ?
sternum that can simulate a mass.
A. Screening Mammograms
B. Diagnostic Mammograms
C. ACCView - It is ONLY SEEN ON THE CC VIEW.
D. An Ultrasound
- It's unilateral twice as often as bilateral
3. Which of the following is true (when it occurs - which is about 5% of
A. It's twice as likely to be bilateral the time).
B. It's twice as likely to be unilateral
C. When present it's unilateral just as often
as it is bilateral - Handling this in real life i all about the
D. It's NEVER unilateral old gold. Find that thing on the priors
(even better is a en. cc only, never on
theMLO.

Aunt Minnie 228

CASE 104 - CHEST PAIN

1. What is the major risk for for this? 5. Which of the following classically
A. Atherosclerosis originates from the FALSE lumen?
B. Hypertension A. Right Renal
B. Left Renal
2. How would you grade this? C. SMA
A. Standford A D. Celiac
B. Standford B
C. Standford C

3. What is the difference is management between type A and type B?

A. A is surgical , B is medical
B. A is medical , B is surgical

4. When might this thing get a stent graft?

A. If in involves more than 5cm of the descending thoracic aorta
B. If it persists for longer than 3 months, without thrombosing
C. If the patient has persistent pain despite anti-hypertensive therapy
D. If the flap extends into the SMA or Celiac Trunk

Aunt Minnie 229

CASE 104 - AORTIC DISSECTION (TYPE B)

Aortic Dissection

Most common of the acute aortic syndromes,

where blood dissects into the potential space
between the intima and media

Essential Trivia:

- Caused by Hypertension (70%) - Other

cause, include cocaine use marfans and
pregnancy.

1. What is the major risk for for this? - Stanford A: Proximal to the left subclavian
A. Atherosclerosis artery takeoff
B. Hypertension
- Stanford B: Distal to the left subclavian
2. How would you grade this? artery takeoff
A. Standford A
B. Standford B
C. Standford C - True Lumen: Typically smaller, surrounded
by intimal calcifications
3. What is the difference is management
between type A and type B?
A. A is surgical , B is medical - False Lumen: TypicaIJy bigger, and the
B. A is medical, Bis surgical
origin of the left r nal artery.
4. When might this thing get a stent graft?
A. If in involves more than 5cm of the
descending thoracic aorta Treatment:
B. If it persists for longer than 3 months, - Type A is surgical. Type B i medical (anti-
without thrombosing
hypertensives).
C. If the patient has persistent pain despite
anti-hypertensive therapy
D. If the flap extends into the SMA or Celiac - Type B can get an. endograft if it
Trunk
considered "unstable '
5. Which of the following classically originates - Persistent or recurrent pain despite
from the FALSE lumen ?
A. Right Renal adequate anti-hypertensive therapy
B. Left Renal - Acute xpansion of the false lumen
C. SMA
- Periaortic or mediastinal hematoma
D. Celiac
( contained rupture)
- Visceral. renal or limb malperfusion
syndrome

Aunt Minnie 230

CASE 105 - STENT GRAFT FOLLOW-UP

Arterial Phase Delayed Phase

1. What is going on here?

A. There is enhancing scar in the graft
B. There is enhancing tumor in the graft
C. The graft is infected
D. The graft is leaking

2. What is the most common type of endo-leak?

A. Type lA
B. Type 2
C. Type 3
D. Type4

3. Which endoleak(s) is considered "high pressure" and must be fixed?

A. Type lA
B. Type lB
C. Type 2
D. Type 3
E. Type 4
F. Type 2 and Type 3
G. Type 1 and Type 2
H. Type 1 and Type 3

Aunt Minnie 231

CASE 105 - ENDOLEAK

Filling of Sac Essential Trivia:

on Delayed
- Type l: Leak at the top (A) or the bottom (B) of
the graft. They are typically high pressure and
require intervention ( or the sac will keep growing).

- Type 2: Filling of the sac via a feeder [Link] i

the MOST COMMON type. and is usually seen
after repair of an abdominal aneurysm. The most
likely culprits are the IMA or a Lumbar artery.
1. What is going on here?
A. There is enhancing scar in the They often spontaneously resolve but may require
graft treatment. Typically you follow the sac size and if
B. There is enhancing tumor in the
graft it grows you treat it.
C. The graft is infected
D. The graft is leaking
- Type 3: This is a defect/fracture in the graft. It is
2. What is the most common type of usually the result of pieces not overlapping.
endo-leak?
A. Type lA
B. Type2 - Type 4: This is from porosity of the graft.(' 4 is
C. Type 3 from the Pore '). It 's of historic signi ficance. and
D. Type4
doesn't happen with modern grafts.
3. Which endoleak(s) is considered
"high pressure" and must be fixed?
A. Type IA - High Pressure: Type 1 and Type 3 are considered
B. Type IB high pressure, because they communicate directly
C. Type 2
D. Type 3 with systemic blood flow.
E. Type 4
F. Type 2 and Type 3
G. Type I and Type 2
H. Type 1 and Type 3

Type I
�R
Type Iii Type IV
Aunt Minnie 232
CASE 106 - "MY LEG HURTS"

1. What is going on here?

A. The right iliac vein is compressing the left iliac vein
B. The right iliac artery is compressing the right iliac vein
C. The right iliac artery is compressing the left iliac vein
D. The left iliac artery is compressing the left iliac vein

2. Is there an Eponym for this?

A. Dodd-Frank Syndrome
B. Miller-Fisher Syndrome
C. May-Thurner Syndrome
D. Marcus Gunn Phenomenon

3. What is the treatment?

A. Thrombolysis Only
B. Thrombolysis + Angioplasty (no stent)
C. Thrombolysis + Stent
D. Surgical Re-implantation

Aunt Minnie 233

CASE 106 - MAY-THURNER SYNDROME

Right Iliac Artery Left Iliac Vein

Essential Trivia:

1. What is going on here?

- A syndrome re suiting in DVT of the left common
A. The right iliac vein is
compressing the left iliac vein iliac vein.
B. The right iliac artery is
compressing the right iliac - The pathology is compression of the left common
vem iliac vein by the right iliac artery.
C. The right iliac artery is
compressing the left iliac
- Why the lei? Although both left and right
vein
common iliac veins lie deep to the right common
D. The left iliac artery is
compressing the left iliac vein iliac artery the left has a more transverse course
and is predi posed to compression (the right has a
2. Is there an Eponym for this? more vertical course and is therefore not as
A. Dodd-Frank Syndrome predisposed).
B. Miller-Fisher Syndrome
C. May-Thurner Syndrome
- Can you get it on the right? Yes but it's rare and
D. Marcus Gunn Phenomenon
unlikely to show up on a multiple choice test
3. What is the treatment?
A. Thrombolysis Only - Treatment is thrombolysi · and stenting.
B. Thrombolysis + Angioplasty
(no stent) - If they show you a swollen left leg, this is
C. Thrombolysis + Stent probably the answer.
D. Surgical Re-implantation

Aunt Minnie 234

 CASE 107 - "PRETTY SURE IT'S .JUST A BAKERS CYST"

1. Where should you look next ?

A. The brain - for berry aneurysms
B. The liver - for findings or cirrhosis
C. The abdominal aorta - to see if its aneurysmal
-. D. The kidneys - to check for RCCs

2. What is the most dreaded complication of this finding?

A. An acute limb (foot)
B. Stroke - from DVT
C. PE - from DVT

3. Popliteal Entrapment most commonly occurs secondary to?

A. Compression from the medial head of the gastrocnemius
B. Compression from the lateral head of the gastrocnemius
C. Compression from the semimembranosus
D. Compression from the popliteus

Aunt Minnie 235

CASE 107 - POPLITEAL ANEURYSM

Popliteal Aneurysm

This is the most common peripheral

arterial aneury m (2nd mo t common
overall to the aorta).

Essential Trivia:

- The main issue with these thing is

distal thromboembolism. which can
be limb threatening.

- There is a strong and frequently

tested association with AAA.

1. Where should you look next ? - 30-50% of patients with poptiteal

A. The brain - for berry aneurysms
aneurysms have a AAA
B. The liver - for findings or cirrhosis
C. The abdominal aorta - to see if its
aneurysmal - 10% of patients with AAA have
D. The kidneys - to check for RCCs popliteal aneurysms

2. What is the most dreaded complication of this - 50-70% of popliteal aneury m. are
finding? bilateral
A. An acute limb (foot)
B. Stroke - from DVT
- The most dreaded complication of a
C. PE - from DVT
popliteal artery aneurysm is an acute
3. Popliteal Entrapment most commonly occurs limb from thrombosi and distal
secondary to? embolization of thrombus pooling in
A. Compression from the medial head of the the aneurysm.
gastrocnemius
B. Compression from the lateral head of the
Popliteal Entrapment -- Symptomatic
gastrocnemius
compre ·sion or occlusion of the
C. Compression from the semimembranosus
D. Compression from the popliteus popliteal artery due to the
developmental relationship with the
medial bead of the gastrocnemius (less
c mmonly the popliteus).

Aunt Minnie 236

 CASE 108 - CHEST I ARM PAIN

1. What is the diagnosis?

A. Cogan Syndrome
B. PAN (polyarteritis nodosa)
C. Wegeners
D. Giant Cell Arteritis

2. What is the most likely age of the patient ?

A. Less than 30
B. Between 3 0-5 0
= C. Older than 70

3. Where else in the body does this commonly effect?

A. Renal Arteries
B. Temporal Arteries
C. Infra-renal aorta
D. Iliac Arteries

Aunt Minnie 237

CASE 108 - GIANT CELL ARTERITIS

Giant Cell Arteritis

Thi - is the most common primary system

vasculitis

Essential Trivia:

- This vasculitis loves old men usuaJly

70-80).

- This vasculitis involves the aorta and its

major branches particularly those of the
external carotid (temporal artery).
1. What is the diagnosis?
A. Cogan Syndrome
- This can be shown in two way : (I) an
B. PAN (polyarteritis nodosa)
C. Wegeners ultrasound of the temporal artery,
D. Giant Cell Arteritis demonstrating wall thickening or (2) CTA I
MR.A or even angiogram of the arm pit area
2. What is the most likely age of the (Subclavian/ Axillary/ Brachial),
patient? demonstrating wall thickening, occlusions
A. Less than 3 0
dilations, and aneurysm.
B. Between 30-50
C. Older than 70
- Think about it as the part of the body that
3. Where else in the body does this would be compressed by crutches ( old men
commonly effect? need crutches).
A. Renal Arteries
B. Temporal Arteries - Trivia worth knowing is that (I) � SR and
C. Infra-renal aorta
CRP are mark dly elevated, and (2) that
D. Iliac Arteries
the disease responds to steroids.

- Gold Standard · for diagnosis is temporal

artery biop ·y (although it's often negative).

Aunt Minnie 238

CASE 109 - MRI PHYSICS (CASE 1)

1. What is the artifact?

A. Partial Volume
B. Truncation
c. Motion (Pulsation)
D. Chemical Shift

2. Which direction is this artifact occurring?

A. Phase encoding
B. Frequency encoding

3. If this artifact was obscuring a finding in the liver, what could you do?
A. Increase the matrix
B. Decrease the bandwidth
C. Move the patient from the 3T to a 1.5 T
D. Switch the phase encoding and frequency encoding directions

Aunt Minnie 239

CASE 109 - PULSATION ARTIFACT

Pulsation Artifact

A type of motion artifact.

Essential Trivia:

- Motion artifact can be seen with both

voluntary and involuntary (cardiac,
respiratory) movements.

- Motion creates difference between frequency

encoding (which is fast) and phase encoding
1. What is the artifact? (which is slow). You will see ghosting or
A. Partial Volume smearing - primarily in the phase encoding
B. Truncation
direction. You can also see the classic
c. Motion (Pulsation)
pulsation arti fact from the aorta.
D. Chemical Shift

2. Which direction is this artifact - In abdominal imaging the phase encoding

occurring? step is done in the AP direction (because this
A. Phase encoding is usually the thinner part of the patient, and
B. Frequency encoding phase encoding is time intensive). This can
be witched to move the artifact off the area
3. If this artifact was obscuring a finding
of interest.
in the liver, what could you do?
A. Increase the matrix
B. Decrease the bandwidth
C. Move the patient from the 3T to a 1.5
T
D. Switch the phase encoding and
frequency encoding directions

Aunt Minnie 240

CASE 110 - MRI PHYSICS (CASE 2)

1. What is the artifact?

A. Susceptibility
B. Truncation
c. Zipper
D. Chemical Shift

2. This artifact will be better (less severe) on?

A. Spin Echo Sequences
B. Gradient Echo Sequences

3. Which of the follow is true, regarding this artifact?

A. Better on In-Phase Imaging (relative to out of phase)
B. Better on Out of-Phase Imaging (relative to in phase)
C. Equal on both In-Phase and Out of Phase Imaging

Aunt Minnie 24 i
CASE 110 - SUSCEPTIBILITY ARTIFACT

Susceptibility Artifact

Artifact seen in substances that can be

magnetized by the external field (metal, &
calcium hydroxyapatite are the big ones).

Essential Trivia:

- A less prominent version occurs at tissue

interfaces (bone and muscle or air and
bone). The classic location for this is the
transition from paranasal sinus to skull base.
1. What is the artifact?
A. Susceptibility - Generally speaking susceptibility affects all
B. Truncation pulse sequences, but is most severe with
C. Zipper
GRE images and least severe with SE
D. Chemical Shift
(because of the 180 degree refocusing pulse
2. This artifact will be better (less severe) - to lose those T2* effects).
on?
A. Spin Echo Sequences - Susceptibility artifact worsens on in phase
B. Gradient Echo Sequences imaging relative to out of phase. This has
nothing lo do with the phase of water and
3. Which of the follow is true, regarding
fat, Instead it bas everything to do with in
this artifact?
phase being done later. The longer TE, the
A. Better on In-Phase Imaging (relative
to out of phase) more susceptibility. Remember. air will do
B. Better on Out of-Phase Imaging the same thing.
(relative to in phase)
C. Equal on both In-Phase and Out of Making it better:
Phase Imaging • Using SE and FSE instead ofGRE.
• Use a wider receiver bandwidth.
• Align the longitudinal axis of a metal
implant with the axis of the main field.
• STIR does way better than frequency
selective fat suppression.

Aunt Minnie 242

 CASE 111 - MRI PHYSICS (CASE 3)

1. What is the artifact?

A. Aliasing
B. Truncation
C. Zipper
D. Chemical Shift (type 1)
E. Chemical Shift (type 2 - india ink)

-'
2. This artifact occurs in the?
A. Frequency Encoding Direction
B. Phase Encoding Direction

3. This artifact increases with

A. Decreased Field Strength (worse on T 1.5 relative to T3)
B. Increased Gradient Strength
C. Narrower read out bandwidth

Aunt Minnie 243

CASE 111 - CHEMICAL SHIFT ARTIFACT - TYPE 1

Chemical ShiftArtifact - Type J

Artifact seen at fat - water interfaces

Essential Trivia:

- The chemical environments of fat and water

are different for protons. This causes these
protons to precess at different rates, and
results in an error during read out (frequency
encoding) direction.

- The type 1 artifact re ults from a shift in the

spatial location of fat voxel . Because of
their different environment (and precession
speed), voxels containing fat will not have
the expected resonance frequency and will
be spatially misregistered, causing a shift in
Frequency Encoding Direction the spatial location in the frequency-encode
direction. This artifact appears as a white (or
dark) band at the interface between fat and
1. What is the artifact? water.
A. Aliasing
B. Truncation Most Testable Facts:
c. Zipper - This "type 1 ' artifact can occur on gradient
D. Chemical Shift (type 1) or spin echo sequences (Type 2 in only seen
E. Chemical Shift (type 2 - india ink)
on gradient).

2. This artifact occurs in the ?

A. Frequency Encoding Direction - Chemical shift increases with field strength
B. Phase Encoding Direction (it s not seen below 1 T)

3. This artifact increases with - Chemical shift decreases with increa ed

A. Decreased Field Strength (worse on gradient strength
T 1.5 relative to T3)
B. Increased Gradient Strength
C. Narrower read out bandwidth - Chemical shift decreases with a wider read
out bandwidth

Aunt Minnie 244

 CASE 112 - MRI PHYSICS (CASE 4)

1. What is the artifact?

A. Aliasing
B. Truncation
C. Zipper
D. Chemical Shift (type 1)
E. Chemical Shift (type 2 - india ink)

= 2. This artifact can be seen on

A. Gradient Echo
B. Spin Echo
C. Both

3. This artifact occurs in the "?" direction

A. Phase encoding
B. Frequency Encoding
C. Both

Aunt Minnie 245

CASE 112 - CHEMICAL SHIFT ARTIFACT - TYPE 2 "INDIA INK"

Black Line Circumferential Chemical Shift Artifact-Type 2

at Fat interfaces

Artifact seen at fat - water interfaces

Essential Trivia:

- The chemical environments of fat and water are

different for protons. This causes these protons to
precess at different rates.

4.4 msec

More Classic Look - lf a spoiled GRE is performed when the protons are
- Around the Kidney on Out Phase spinning with each other (about 4.4 msec at l .5T)
voxels containing both fat and water will cancel out
producing a black line.
1. What is the artifact?
A. Aliasing
B. Truncation - This type of chemical shift artifact shows a black
C. Zipper
D. Chemical Shift (type 1) line in all directions of the fat-water interface
E. Chemical Shift (type 2 - india (both the frequency-encode and phase-encode
ink)
direction · as it i independent of spatial encoding.
2. This artifact can be seen on
A. Gradient Echo
B. Spin Echo
- This occurs on GRE only, as the 180 degree
C. Both refocusing pulse of a spin echo sequence
minimizes the phase shift.
3. This artifact occurs in the"?"
direction
A. Phase encoding
B. Frequency Encoding
C. Both

Aunt Minnie 246

 CASE 113 - MRI PHYSICS (CASE 5)

1. What causes this artifact ?

A. Field of view is too narrow
= B. Abrupt change in signal
C. T2* effects
D. Overlapping signal from adjacent slices

2. The tech calls you about this artifact, what should you tell him?
A. Switch the patient to a 3T
B. Use a gradient technique instead
C. Use a STIR technique instead
D. Increase the slice gap

3. What else could be done to improve this artifact?

A. Use sequences with a lower TE
B. Use a lower bandwidth
C. Use a smaller field of view
D. Use a smaller matrix

Aunt Minnie 247

CASE 113 - MAGNETIC INHOMOGENEITY (BAD FAT-SAT)

Metal F' d Up Your Fat Sat

Artifact mimics edema in bones

Essential Trivia:

- A metal object will become magnetized from

the external field. Th" difference between the
magnetized metal and adjacent wiJl cause local
Same Knee distortions (T2*) in the magnetic field.
-STIR Used Instead

Why is the fat sat not working around the

1. What causes this artifact? metal?
A. Field of view is too narrow • As described in Ca 112 Fat and Water
B. Abrupt change in signal
c. T2* effects resonate at different times. Because of thi
D. Overlapping signal from adjacent separation in frequencies, it is possible to
slices
aturate just one (and not the other).
2. The tech calls you about this artifact,
what should you tell him?
A. Switch the patient to a 3T
B. Use a gradient technique instead
C. Use a STIR technique instead
D. Increase the slice gap

3. What else could be done to improve this

artifact?
A. Use sequences with a lower TE
B. Use a lower bandwidth
C. Use a smaller field of view
D. Use a smaller matrix • With a magnetic field di tortion (from metal)
there is a preces. ionaJ frequency shift. So the
time targeted to the normal peak of fat mis 'e ·
Things to Make it Better:
and you get incomplete saturation.

• The easiest fix, is to use STIR instead

of T2F when deaJing with metal.
• Using Spin Echo - NOT Gradient
• Using Spin Echo sequences with:
Relatively low TE
High bandwidth,
Larger Field of View and
Higher Matrix
.i:
Aunt Minnie 248
CASE 114 - MRI PHYSICS (CASE 6)

1. What causes this artifact ?

A. Field of view is too narrow
B. Proximity to the coil
C. Abrupt change in signal
D. T2 * effects

2. The tech calls you about this artifact, what should you tell her?
A. Switch the patient to a 3T
B. Use a gradient technique instead
C. Use a STIR technique instead
D. Reposition the patient with additional padding between the breast and the coil

3. Is this artifact related to fat suppression technique?

A. Yup
B. Nope

4. In general, when dealing with breast MRI - which magnet has better fat suppression?
A. 1.5 T
B. 3 T

Aunt Minnie 249

 CASE 114 - "SIGNAL FLARING" ARTIFACT (COILING BURNING)

Signal Flaring

Artifact creates the appearance of poor fat sat.

Essential Trivia:

- Proximity to the coil elements can cause a very bright

signal (it's not a true fat sat issue). You see this in
two main places ( l) in the breasts as shown in this case,
and (2) on prostate MRl when using an endorectal
coil ... my JOd this endorectal coil, have you ever seen
1. What causes this artifact ? one of those?
A. Field of view is too narrow
B. Proximity to the coil
C. Abrupt change in signal - Getting the breast away from the coil is the cure and
D. T2 * effects the easiest way to do this is with padding and
2. The tech calls you about this
repositioning.
artifact, what should you tell her?
A. Switch the patient to a 3T
Fat Sat in the Breast - General Points
B. Use a gradient technique
instead - Most breast MRJ is done with 1.5 T, because you can
C. Use a STIR technique get a more uniform field relative to 3T. Most of the
instead
D. Reposition the patient with time if there are fat sat is. ue the first thing breast MRI
additional padding people will do is move the patient to the 1.5.
= between the breast and the
coil
- But Prometheus, isn't the separation ofpeaks better on
3. Is this artifact related to fat
a 3Tcompared to a 1.517 Shouldn t this make it easier
suppression technique?
A. Yup lo fat sat? Yes thats true, but the inhomogeneity in the
B. Nope field still make the images dirty. People who were
4. In general, when dealing with smart enough to not go to med school (Physicists) are
breast MRI - which magnet has working on fixing this, as the improved signal to noise
better fat suppression?
A. 1.5 T of a 3T offers breast imagers the chance to perform
B. 3 T even more unnecessary biop ies.

- If the patient is already on a 1.5T and there is still poor

fat sat, 'shimming" the magnet to improve
inhomogeneities in the field i · probably the next move.

Aunt Minnie 250

CASE 115 - MRI PHYSICS (CASE 7)

Axial - Through the cervical cord

1. Is there a syrinx?
A. Yes
B. No

2. What can you do to make this better?

A. Increase the bandwidth
B. Increase the pixel size
C. Larger Field of View
D. Increase the Matrix

3. What is the improvement pay off?

A. Increased acquisition time
B. Issues with achieving a good fat sat
C. More susceptibility artifact
D. More signal & less noise

Aunt Minnie 251

CASE 115 - TRUNCATION ARTIFACT (GIBBS)

Gibbs I Truncation

Artifact mimics a yrinx

Essential Trivia:

- The transformation of K space through inverse

fourier transform ideally (but never) resulting
in a block of data. Ripples in this data -
especially at abrupt intense tissue changes
result in the appearance of line .

- You classical1y see these at high contrast

interface (skull -brain, Cord-CSF, and
meniscus/fluid). The CSF-Cord interface is the
most classic - mimicking a syrinx.

"Ripples" at the brain f - If prompted I would say the cause is limited

bone interface, is the sampling of free induction decay.
other classic location
- It can be seen in both the frequency encoding
1. Is there a syrinx? and phase encoding directions but i more
A. Yes commonly seen in the phase encoding because
B. No many times a phase encoding matrix that is
smaller than the readout matrix is selected to
2. What can you do to make this better?
reduce time.
A. Increase the bandwidth
B. Increase the pixel size
C. Larger Field of View - Making it better:
D. Increase the Matrix - Short answer = more matrix.
- Long answer= Decreasing the bandwidth
3. What is the improvement pay off? or decreasing pixel size (more PE steps
A. Increased acquisition time
less FOV. more matrix).
B. Issues with achieving a good fat
sat
C. More susceptibility artifact - Improvement penalty: Increased acquisition
D. More signal & less noise time and reduced per-pixel signal to noise.

Aunt Minnie 252

CASE 116 - MRI PHYSICS (CASE 8)

1. What is the artifact? 4. This artifact typically effects?

A. Aliasing A. Fat people with ascites
B. Truncation B. Skinny people without much
c. Dielectric muscle
D. Zipper C. Very heavily muscled people
E. Herringbone D. Elderly with poor bone density

2. The tech calls you about this artifact, what

should you tell her?
A. Switch the patient to a 3T
B. Use a gradient technique instead
C. Use a STIR technique instead
D. Application of dielectric pads
E. Reposition the patient

3. Which of the follow is true?

A. This is often better on a 3T
B. This is often better on a 1.5T

Aunt Minnie 253

CASE 116 - DIELECTRIC EFFECT I STANDING WAVES

Difilectric Effect

Artifact puts a black spot over the liver

Essential Trivia:

- Biologic tissue have a dielectric constant that

results in reduction of wavelength by the
i11 er e of some constant. Interactions can
cause local eddy currents ill the imaged tis ues.
1. What is the artifact?
A. Aliasing
- Since RF waves are shorter at 3T - the effects
B. Truncation
c. Dielectric are worse with a stronger magnet.
D. Zipper
E. Herringbone - You also see this worsen with large bellies.
especially if they have a cites. Larger body
2. The tech calls you about this artifact, parts (the abdomen) are primarily affected.
what should you tell her?
A. Switch the patient to a 3T
- Classic Look I Location: Dark signal in the
B. Use a gradient technique instead
C. Use a STIR technique instead central abdomen over the left lobe of the liver.
D. Application of dielectric pads
E. Reposition the patient Making it better:
• Application of dielectric pads - placed between
3. Which of the follow is true? patient and anterior body array coil
A. This is often better on a 3T
B. This is often better on a [Link]
• Parallel RF transmission (SEN E) - RF pulses

4. This artifact typically effects? from a et of coils· each coil sends an

A. Fat people with ascites independent RF pulse. Gives you a longer
B. Skinny people without much pulse.
muscle
C. Very heavily muscled people
D. Elderly with poor bone density

Aunt Minnie 254

 CASE 117 - MRI PHYSICS (CASE 9)

1. What is the artifact?

A. Aliasing
B. Truncation
=
c. Dielectric
D. Zipper
E. Herringbone

2. The tech calls you about this artifact, what should you tell him?
A. Switch the patient to a 3T
B. Decrease the pixel size
C. Close the door
D. Reposition the patient
E. Use a STIR technique instead

Aunt Minnie 255

CASE 117 - ZIPPER ARTIFACT

Zipper Artifact

Artifact creates a 'zebra stripe" across the

patient.

Essential Trivia:

- There are lots of random stray RF signals

(radio tv etc ... ). Remember that the RF
pul e is a "radio- wave."

- Anyway, if you have defective or inadequate

1. What is the artifact? shielding you can get a "zipper" of high
A. Aliasing signal - 1-2 pixels in width running across
B. Truncation
the image.
C. Dielectric
D. Zipper
E. Herringbone - This typically extends in the phase encoding
direction. Although this is controversial, and
2. The tech calls you about this artifact, not likely tested.
what should you tell him?
A. Switch the patient to a 3T Classic Scenarios:
B. Decrease the pixel size
- Anestbe ia left the pulse ox monitor in the
C. Close the door
room.
D. Reposition the patient
E. Use a STIR technique instead - The tech left the door open.

Making it helter:
- Try closing the door (if its open).
- Remove all electronic devices from the
room.
- Call the tech people to repair the faulty RF
shielding.

Aunt Minnie 256

CASE 118 - MRI PHYSICS (CASE 10)

1. Based on the TR and TE above, what kind 3. What kinds of tissues are
of sequence is this? susceptible to this artifact?
A. Spin Echo Tl A. Fat
B. Spin Echo T2 B. Water
C. Proton Density C. Tightly bound collagen (tendons
D. GRE Tl weighted & cartilage)
E. GRE T2 weighted D. Any of these can be involved.

2. Attention to the supraspinatus foot print. 4. What angle must the tissue be in
What other sequence would you want to check relationship to the main magnetic
before you called this high signal field?
tendinopathy? A. 15 Degrees
A. Tl B. 25 Degrees
B. T2 C. 55 Degrees
C. Proton Density D. 7 5 Degrees
D. GRE

Aunt Minnie 257

CASE 118 - MAGIC ANGLE

Magic Angle

Artifact creates the appearance of

tendinopathy on Short TE sequences

Essential Trivia:

- Thi is an MSK artifact seen with

1. Based on the TR and TE above, what kind of tendons (and sometimes cartilage).
sequence is this?
A. Spin Echo Tl
B. Spin Echo T2 - You see this with short echo time
C. Proton Density
D. GRE Tl weighted (TE sequences where the focus
E. GRE T2 weighted forms an angle of 55 degrees with
2. Attention to the supraspinatus foot print. What the main magnetic field (magic angle
other sequence would you want to check before you phenomenon).
called this high signal tendinopathy?
A. Tl
B. T2 - This will NOT be seen in T2
C. Proton Density sequences (with long TE).
D. GRE

3. What kinds of tissues are susceptible to this - This phenomenon, is reduced at

artifact?
A. Fat higher field trengths due to greater
B. Water shortening of T2 relaxation times.
C. Tightly bound collagen (tendons &
cartilage)
D. Any of these can be involved.
What is a short I long time?
4. What angle must the tissue be in relationship to
the main magnetic field? - For Spin Echo:
A. 15 Degrees - Short TR < 700ms
B. 25 Degrees
C. 55 Degrees - Long TR> 2000 ms
D. 75 Degrees - 'hort TE < 25ms
- Long TE> 60m"

- For GRE:
T1 = Short TR, Short TE - Short TR < SOms
T2 = Long TR, Long TE - Long TR > 100 ms
- Short TE < 5 m
PD = Lonq TR, Short TE - Long TE> l Oms

Aunt Minnie 258

 CASE 119 - NUCLEAR MEDICINE PHYSICS (CASE 1)

l
I

1. What causes this artifact ?

A. Wrong Gamma Energy Window
B. Septal Penetration
C. Field is not uniform
D. Image Linearity Problem
E. Center of Rotation is Off

= 2. What could you do to eliminate this error?

A. Switch the energy window
B. Use a higher energy collimator
C. Reset the Ion Chamber
D. Reposition the patient

3. What pattern have the collimator holes been arranged in this case?
A. Pentagonal
B. Square
C. Hexagonal
D. Heptagonal

Aunt Minnie 259

CASE 119 - STAR ARTIFACT - SEPTAL PENETRATION

Star Artifact

This star shaped artifact can obscure

underlying faint metastases

Essential Trivia:

- This occurs when the high energy

photons ( typically from 1-131, 364
keV) break through a medium
J trength collimator.

- The single answer cause for this i ·

"septa} penetration"

- A thicker collimator would reduce

the artifact.

- The "star" shape, is simply a result

of the arrangement of collimators, in
this case a hexagonal shape.

I. What causes this artifact ?

A. Wrong Gamma Energy Window
B. Septa) Penetration
C. Field is not uniform
D. Image Linearity Problem
E. Center of Rotation is Off

2. What could you do to eliminate this error?

A. Switch the energy window
B. Use a higher energy collimator
C. Reset the Ion Chamber
D. Reposition the patient

3. What pattern have the collimator holes been arranged in this case?
A. Pentagonal
B. Square
C. Hexagonal
D. Heptagonal

Aunt Minnie 260

CASE 120 - NUCLEAR MEDICINE PHYSICS (CASE 2)

• L R

LPO RT LATERAL
RPO POSTERlOR

AAO LT LATERAL ANTERIOR

1. Is there a PE ?
A. Yup
B. Nope
C. I always read these as indeterminate

2. What causes this appearance?

A. Pulmonary Hyperemia
B. Multifocal PE
C. Clumping of the MAA
D. Shunting ofMAA
E. Wrong tracer

3. What is a common cause of "pulmonary hyperemia" ?

A. Hypervascular Tumor
B. Pulmonary AVM
C. Pulmonary Embolism
D. There are no causes of pulmonary hyperemia

Aunt Minnie 261

CASE 120 - CLUMPED MAA

[Link]� [Link].

Clumped MAA

This artifact creates the appearance of

pulmonary hyperemia.

Essential Trivia:
POSTERIOR
- MMA clumps together creating a large ball
of intense signal

1. Is there a PE ? - MAA is very "sticky" and even the smallest

A. Yup amount of blood aspirated into the syringe
B. Nope can cause this appearance.
C. I always read these as indeterminate
** this is also true - Even though the appearance looks like
'hyperemia" in the lungs there are no
2. What causes this appearance?
A. Pulmonary Hyperemia causes of pulmonary hyperemia.
B. Multifocal PE
C. Clumping of the MAA - Tumors tend to get their blood from
D. Shunting of MAA bronchial arteries and even then the blood
E. Wrong tracer to a tumor is much less than the normal
pulmonary blood flow.
3. What is a common cause of"pulmonary
hyperemia" ?
A. Hypervascular Tumor
B. Pulmonary AVM
C. Pulmonary Embolism
D. There are no causes of pulmonary
hyperemia

Aunt Minnie 262

CASE 121- CT PHYSICS (CASE 1)

1. What causes this artifact ? 3. With this artifact, is the average energy
A. Preferential removal of the higher energy higher or lower ?
photons A. Higher
B. Preferential removal of the lower energy B. Lower
photons
C. The mA is set too high
D. The slices are too thin

2. What could you do to eliminate this error?

A. Turn the mA down
B. Remove the filter
C. Reposition the patient
D. Tum the kV down

Aunt Minnie 263

CASE 121 - BEAM HARDENING (ARMS ARE DOWN)

Beam Hardening

This artifact creates streaks and bands, obscuring

lots of stuff and making "cannot exclude" a
prominent phrase in the report.

Essential Trivia:

- As the x-ray beam passes through an object the

lower energy photons are removed preferentially
leaving a "harder beam" with an increased
average energy.

1. What causes this artifact ? - 111 this case the patient's arms were left down by
A. Preferential removal of the those lazy no good techs. X-ray which pass
higher energy photons
through the dense arms lose their lower energy
B. Preferential removal of the
lower energy photons photons (making them "harder"). X-rays that
C. The mA is set too high don't pass through the arms (the ones that pass
D. The slices are too thin anterior and posterior) will have a lower average
energy. The result of these two groups mixing is
2. What could you do to eliminate this dark bands I streaks appearance. The tech
this error?
was placed in the stocks (pillory) for this offense.
A. Turn the mA down
B. Remove the filter
C. Reposition the patient Fixing Beam Hardening:
D. Tum the kV down • Increase [Link] energy (tum the kV Up!)
• Filtration - Pre hardening of the beam to remove
3. With this artifact, is the average lower energy components before it hit the
energy higher or lower ? patient, and/or the addition of a bow-tie filter.
A. Higher * Removal of lower • Calibration Correction - Using a phantom to
energy photons, increases the
allow the detector to compensate for hardening
AVERAGE energy.
B. Lower effects.
• Correct Software -An iterative correction
algorithm can be u ed.
• Avoidance - Tilt the gantry or position the patient
to avoid areas the cause hardening.

Aunt Minnie 264

 CASE 122 - CT PHYSICS (CASE 2)

=
1. What is this artifact?
A. Helical Artifact
B. Spiral Artifact
C. Ring Artifact
D. Incomplete Projection Artifact

2. What causes this appearance?

A. mA is too high
B. Metal on the slice above ( or below)
C. Defective Detector
D. Overscanning

Aunt Minnie 265

CASE 122 - RING ARTIFACT

Ring Artifact

This artifact create a spiraled ring u ually on

multiple slices.

Essential Trivia:

- If one of the detectors 'drifts" in it's calibration a

projection error will occur, which get propagated
during the back projection process. The result is
a ring artifact.
1. What is this artifact?
A. Helical Artifact - This artifact is seen primarily with 3rd
B. Spiral Artifact Generation CT scanners.
C. Ring Artifact
D. Incomplete Projection Artifact - Fixing Ring Artifact - Recalibrate your dinosaur
detector, or replace the broken part.
2. What causes this appearance?
A. mA is too high
B. Metal on the slice above ( or
below)
C. Defective Detector
D. Overscanning

Aunt Minnie 266

CASE 123 - ULTRASOUND PHYSICS (CASE 1)

*Both Residents were placed in the stocks (pillory) for such disgraceful ultrasounding

1. What should Resident 1 have done better?

A. Turned up the gain
B. Turned down the gain
C. Centered his focal zone
D. Used a low frequency probe

2. What should Resident 2 have done better ?

A. Narrowed the focal zone
B. Turned down the gain
C. Used the compound imaging feature
D. Used the harmonic imaging feature

3. Axial Resolution depends on?

A. The depth of the object you are focusing on
B. The Spatial Pulse Length
C. Time Gain Compensation
D. Receiver Focusing

Aunt Minnie 267

CASE 123 - IMAGE OPTIMIZATION - FOCAL ZONE

Optimizing the Image

In most mammo divisions, bad technique from a

resident will result in placement in the stocks (and
possible castration).

Correct Technique: Narrow Essential Trivia:

focal zone, centered over the
object of interest Focal Zone (the point where the beam is most narrow,
and has maximum intensity).

1. What should Resident 1 have - Classic teaching was to place the focaJ zone behind
done better? the object, but that only held up for equipment that is
A. Turned up the gain now in the Smithsonian. Mottern devices have
B. Turned down the gain
multiple focal zones, so it's ok to land it right on the
C. Centered his focal zone
area of interest.
D. Used a low frequency probe

2. What should Resident 2 have Resolution (the ability to resolve to adjacent objeets):
done better ?
A. Narrowed the focal zone - High Frequency transducer have high resolution but
B. Turned down the gain less tissue penetration, you should use them for
C. Used the compound imaging
superficial stuff.
feature
D. Used the harmonic imaging
feature - Axial Resolution - for optimal axial resolution you
need the returning echoes rto be separate and not
3. Axial Resolution depends on? overlap. The minimum required separation between
A. The depth of the object you two reflectors is l/2 the spatial pulse length (SPL)
are focusing on otherwise the returning echoes will overlap.
B. The Spatial Pulse Length
C. Time Gain Compensation
- Lateral Resolution - this does best with a nice
D. Receiver Focusing
narrow beam (remember it's the mo t narrow at the
focal zone). Cranking the gain will actually make
this worse. because that widens the beam. Another
testable pearl is that lateral resolution worsens with
depth (which makes ense because the beam diverges
after the focal zone in the "far zone").
Aunt Minnie 268
CASE 124 - ULTRASOUND PHYSICS (CASE 2)

1. This artifact is caused by what "false assumption" ?

A. All echoes originate from within the main beam
B. All echoes return to the transducer after a single reflection
C. The speed of sound in human tissue is constant - 1540 mis
D. Acoustic energy is uniformly attenuated

2. Why do you put gel on people's skin before you ultrasound?

A. Makes their skin soft
B. Decreases the reflection
C. Decreases the refraction
D. Decreases the impedance

3. What factors determine refraction?

A. Speed Change and Angle of Incidence
B. Speed Change and Absorption of Sound (how much is turned to heat)
C. Frequency Change and Angle of Incidence
D. How non-specular (bumpy) the surface is

Aunt Minnie 269

CASE 124 - MIRROR IMAGE ARTIFACT

Mirror Image Artifact

Artifact generated by a repeat echo.

Essential Trivia:

- A 11 ultrasound artifacts are the result of a

violation of a display assumption (the rules
the machine uses to make a picture). In this
case, the assurnpti n is that a11 echoes return
to the transducer after a single reflection.

- Probe

I Potent Reflector
I
- In this case, the ultrasound beam pas es
through a highly reflective surface (the
diaphragm). then gets repeatedly reflected
between the back side of the reflector and
the adjacent tructure. This is displayed as a
I "
Trapped Echos duplication equidistant from but deep to the
strongly reflective interface.

- Reflection: Ultrasound energy gets reflected

1. This artifact is caused by what "false at a boundary between two tissues because
assumption" ?
A. All echoes originate from within the main of the differences in the acoustic impedances
beam
of the two tissues. A large difference in
B. All echoes return to the transducer after a
single reflection 'stiffness" result in a large reflection of
C. The speed of sound in human tissue is constant
- 1540 mis energy.
D. Acoustic energy is uniformly attenuated

2. Why do you put gel on people's skin before you - Impedance is the stiffnes s, and is defined by
ultrasound? the density x peed of sound in that object.
A. Makes their skin soft
B. Decreases the reflection Air pockets (eliminated by g •I) will create a
C. Decreases the refraction large impedance difference (Jots of
D. Decreases the impedance
hadowing),
3. What factors determine refraction?
A. Speed Change and Angle of Incidence
B. Speed Change and Absorption of Sound (how - Refraction is influenced by the angle of
much is turned to heat)
C. Frequency Change and Angle of Incidence incidence and the speed change (as stated in
D. How non-specular (bumpy) the surface is nells law).

Aunt Minnie 270

CASE 125 - ULTRASOUND PHYSICS (CASE 3)

1. This artifact is caused by what "false assumption" ?

A. All echoes originate from within the main beam
B. All echoes return to the transducer after a single reflection
C. The speed of sound in human tissue is constant - 1540 mis
D. Acoustic energy is uniformly attenuated

2. What is the minimal distance needed for axial resolution?

A. One Spatial Pulse Length
B. Two Spatial Pulse Lengths
C. One Half Spatial Pulse Length
D. One Quarter Spatial Pulse Length

3. Does this thyroid nodule need a biopsy?

A. No - it's benign
B. Yes - there are no imaging features to predict benign vs malignant
C. Yes - the body division is broke

Aunt Minnie 271

 CASE 125 - COMET TAIL ARTIFACT

Comet Tail Artifact

Another Artifact generated by a repeat echo.

Essential Tri\'ia:

- 111is artifact is a fonn of reverberation artifact.

Rev rberation occurs when the sound wave
ncounters two parallel highly reflective urfaces,
the echoes generated from a primary ultrasound
beam are repeatedly reflected back and forth (like a
1. This artifact is caused by what game of pong) before eventually returning to the
"false assumption" ?
transducer for detection. This L recorded and
A. All echoes originate from within
the main beam
display ed a multiple echoes.
B. All echoes return to the
transducer after a single - This time our two parallel highly reflective
reflection surfaces are clo er together which means the
C. The speed of sound in human sequential echoes are closely spaced. The space
tissue is constant - 1540 mis between them may be less than 112 the patial pulse
D. Acoustic energy is uniformly
length (SPL) - which as mentioned above was the
. attenuated
minima] distance needed for axiaJ resolution. As a
2. What is the minimal distance result, the displayed echoes will look like a
--. needed for axial resolution? triangle, instead of linear Jines.
A. One Spatial Pulse Length
B. Two Spatial Pulse Lengths - Wiry a triangle and not a square ? The later echoe ·
C. One Half Spatial Pulse Length
get attenuated and have decreased amplitude, This
D. One Quarter Spatial Pulse
decreased amplitude is manifested on the display
Length
as decreased width. So you get a tapering triangle
3. Does this thyroid nodule need a ( or comet tail).
biopsy?
A. No - it's benign - Comet Tai] Artifact from micro crystals in colloid
B. Yes - there are no imaging is a classic feature of thi benign nodule. I would
features to predict benign vs
onlj biopsy it if th chairman was putting pressure
malignant
on me to generate money for the di ision ... uh I
C. Yes - the body division is broke
mean for good patient care. You aren't gonna find
cancer in it.

Aunt Minnie 272

This vs That 1
TMis vs THAT

This vs That 2
 CASE 1 - "HEADACHE"

-----, 1. Which is Which ?

A. (1) Meningioma, (2) Epidermoid, (3) Schwannoma
B. (1) Epidermoid, (2) Meningioma, (3) Schwannoma
C. (1) Meningioma, (2) Schwannoma, (3) Epidermoid
D. (1) Meningioma, (2) Schwannoma, (3) Arachnoid Cyst

2. How can you tell an epidermoid from an arachnoid cyst?

A. The Epidermoid Enhances
B. The Epidermoid Restricts
C. The Epidermoid will be T2 Bright

3. How can you tell a meningioma from a schwannoma?

A. The schwannoma will enhance more homogeneously
B. The schwannoma will calcify more
C. The schwannoma will invade the IAC

This vs That 3
CASE 1 - CEREBELLOPONTINE ANGLE ("CPA") MASSES

1. Which is Which ? Meningioma vs Schwannoma

A. (1) Meningioma, (2)
Epidermoid, (3) Schwannoma
- Both enhance, but the meningioma tends to do it
B. (1) Epidermoid, (2)
more homogeneously.
Meningioma, (3) Schwannoma
C. (1) Meningioma, (2)
Schwannoma, (3) - Both can calcify but the meningioma tends to do it
Epidermoid more often.
D. (1) Meningioma, (2)
Schwannoma, (3) Arachnoid -Thc Schwannoma tends to invade the IAC. This
Cyst
can be also be shown with a non-contrast CT -
with a widened "trumpet shaped" pours acousticus
2. How can you tell an epidermoid
from an arachnoid cyst?
A. The Epidermoid Enhances Epidermoid vs Arachnoid Cyst
B. The Epidermoid Restricts
C. The Epidermoid will be T2 - Both are T2 Bright (iso-intense to CSF)
Bright - There is a zebra called a "white
epidermoid" that is dark on T2 - but this i.
3. How can you tell a meningioma
not gonna show up on a multiple choice
from a schwannoma ?
A. The schwannoma will enhance te. t, it's too obscure even for this test.
more homogeneously
B. The schwannoma will calcify - ONLY Epidermoid wiU be dirty - but not black on
more FLAJR (the CSF in the arachnoid cyst will
C. The schwannoma will invade suppres)
the IAC

- ONLY Epidermoid will restrict on Diffusion

This vs That 4
CASE 2 - "UGLY BABY"

1. Which is Which ?
A. (1) Lobar Holoprosencephaly, (2) Alobar Holoprosencephaly
B. (1) Lobar Holoprosencephaly, (2) Semi-lobar Holoprosencephaly
C. (1) Alobar Holoprosencephaly, (2) Semi-lobar Holoprosencephaly
D. (1) Semi-lobar Holoprosencephaly, (2) Alobar Holoprosencephaly

2. What is classically absent in Lobar Holoprosencephaly?

A. The thalamus
B. The cerebellum
C. The septum pellucidum
D. The falx

3. What is the most common genetic abnormally associated with Holoprosencephaly?

A. Trisomy 21
B. Trisomy 18
C. Trisomy 13
D. DiGeorge Syndrome

This vs That 5
CASE 2 - "HOLOPROSENCEPHALY SPECTRUM"

What do they have in common?

The e are all midline cleavage errors. The brain i
supposed to have two hemispheres.
1. Which is Which ?
A. (I) Lobar Holoprosencephaly, (2)
Alobar Holoprosencephaly How does the cleavage normally go down?
B. (I) Lobar Holoprosencephaly, (2)
Semi-lobar Holoprosencephaly Remember that the corpus colosseum forms front to
C. (1) Alobar Holoprosencephaly, back? Well. the cleavage occurs just in the opposite
(2) Semi-lobar
Holoprosencephaly way - back to front - sorta sounds like a rap ong.
D. (I) Semi-lobar The most mild forms will have a cleaved posterior a
Holoprosencephaly, (2) Alobar
and fused anterior.
Holoprosencephaly

2. What is classically absent in Lobar Lobar (mild):

Holoprosencephaly?
A. The thalamus - Just 'Think Absent Septum Pellucidum
B. The cerebellum - If there i a fusion, it' gonna be Anterior/Inferior
C. The septum pellucidum
D. The falx
Semi-Lobar (Probably retarded, but not a mon ·ter):
3. What is the most common genetic
abnormally associated with
- Just Think Fusion of the 1 halami
Holoprosencephaly? - Olfactory bulbs are trashed - don 't bother to stop
A. Trisomy 21 and smell the roses
B. Trisomy 18
C. Trisomy 13 - Posterior brain should be normal
D. DiGeorge Syndrome
Lobar (Possibly a one eyed cyclops monster):
- Just think single big ventricle with an absent falx
- Cortical mantle is present
This vs That 6
CASE 3 - EPILEPSY (DEMONIC POSSESSION)

1. Which is Which ?
A. (1) Open Lip Schizencephaly (2) Porencephaly
B. (1) Closed Lip Schizencephaly (2) Porencephaly
C. (1) Porencephaly, (2) Open Lip Schizencephaly
D. (1) Porencephaly, (2) Closed Lip Schizencephaly

2. How do you distinguish Schizencephaly from Porencephaly

A. Porencephaly patient's parents won't have insurance
B. Schizencephaly - the cleft should enhance
C. Schizencephaly - the cleft should restrict
D. Schizencephaly - the cleft should be lined with grey matter

This vs That 7
CASE 3 - OPEN LIP SCHIZENCEPHALY VS PORENCEPHALY

1. Which is Which ? Schizencephaly.

A. (1) Open Lip Schizencephaly (2)
Porencephaly
Migrational disorder that results in a grey matter
B. (1) Closed Lip Schizencephaly
(2) Porencephaly lined cleft that will extend through the entire
C. (1) Porencephaly, (2) Open Lip hemisphere.
Schizencephaly
D. (1) Porencephaly, (2) Closed Lip It comes in two main flavors:
Schizencephaly (1) Closed Lip - cleft walls appose each other
- more common in bilateral cases
2. How do you distinguish
(2) Open Lip - cleft walls are . eparated by CSF
Schizencephaly from Porencephaly
A. Porencephaly patient's parents - more common in uni lateral cases
won't have insurance ** actually
the schizencephaly kid is more Highly Testable Associations:
likely to have uninsured parents - • Optic Nerve Hypopla sia (30%)
as there is a known association • Absent Septum Pellucidum (70%)
with abandoned children and use
of "street drugs" during
pregnancy.
B. Schizencephaly - the cleft should Porencephaly
enhance
C. Schizencephaly - the cleft should This is basically an in-utero stroke resulting in
restrict encephalomalacia. The cleft will be lined with
D. Schizencephaly - the cleft white matter.
should be lined with grey matter

This vs That 8
CASE 4 - DECREASED LEVEL OF CONSCIOUSNESS

1. Which is Which ?
A. (1) Herpes Encephalitis, (2) Also Herpes 3. How can you distinguish Herpes
Encephalitis - incidental lung CA Encephalitis from an MCA infarct?
B. (1) Herpes Encephalitis, (2) Zinc Toxicity A. Herpes will NOT restrict
C. (1) Herpes Encephalitis, (2) Limbic Diffusion, the stroke will
Encephalitis B. Herpes will be bright on FLAIR,
D. (1) Herpes Encephalitis, (2) Toxoplasmosis the stroke will not
C. The MCA stroke will commonly
2. Which is the "most sensitive" sequence for involve the basal ganglia, Herpes
diagnosis of case 1 ? will not
A. T2 D. The MCA stroke will spare the
B. Tl grey-white interface, Herpes will
C. FLAIR not
D. Diffusion

This vs That 9
CASE 4 - HSV ENCEPHALITIS VS LIMBIC ENCEPHALITIS

HSV Encephalitis:

- Serious business and potentially fatal

- Sw Hen (unilateral or bilateral) medial

temporal lobe, which will be T2 bright.

- Earliest sign is actually restricted

diffusion - related to vasogenic edema.

- Blooming on gradient means it's bleeding

(common in adults, rare in neonate form).
1. Which is Which ?
A. (1) Herpes Encephalitis, (2) Also
Herpes Encephalitis - incidental lung - Spares the basal ganglia (di tinguishes it
CA from MCA stroke).
B. (1) Herpes Encephalitis, (2) Zinc
Toxicity
C. (1) Herpes Encephalitis, (2) Limbic
Encephalitis
D. (1) Herpes Encephalitis, (2) Limbic Encephalitis:
Toxoplasmosis

2. Which is the "most sensitive" sequence - Paraneoplastic syndrome that look alot
for diagnosis of case 1? like HSV - often involving the mesial
A. T2
B. Tl temporal lobes, with bright signal on T2.
C. FLAIR
D. Diffusion - It' bilateral about 60%
3. How can you distinguish Herpes
Encephalitis from an MCA infarct? - Tends to have a less acute time course
A. Herpes will NOT restrict Diffusion, the compared to H V
stroke will
B. Herpes will be bright on FLAIR, the
stroke will not - HSY is more likely to have a fever
C. The MCA stroke will commonly (although cancer can cause one)
involve the basal ganglia, Herpes
will not
D. The MCA stroke will spare the grey- - Small cell I ung CA is the classic cause
white interface, Herpes will not

This vs That 10
CASE 5 - HEADACHE

I. Which is Which ?
A. (1) Intracranial Hypertension (2) Intracranial Hypotension
B. (1) Intracranial Hypotension (2) Intracranial Hypertension

2. Dural Venous Sinuses Do What with What ?

A. Shrink with Hypertension, Expand with Hypotension
B. Shrink with Hypotension, Expand with Hypertension
C. Always stay constant in volume

3. What do you think Case 1 looks like?

A. Skinny 70 year old woman
B. Fat teenage boy
C. 45 Year old homeless man (with terrible BO)
D. Fat Middle Aged Woman

This vs That 11
CASE 5 - INTRACRANIAL HYPER VS HYPOTENSION

Monro-Kellie Doctrine:

The Monro-Kellie doctrine is the idea that the head is a closed shell, and that the
three major components: (1) brain, (2) blood - both arterial and venous. and (3)
CSF. are in a state of dynamic equilibrium. As the volume of one goes up, the
volume of another goes down.

lntracrainal Hypertension

Findings follow the equilibrium idea:

• Ventricles become slit like,
• Pituitary shrinks (partially empty sella),
• Venous sinuses appear compressed.
• Vertical tortuosity of the optic nerves
and flattening of the posterior sclera.

Pseudotumor Cerebri: Classic scenario

of a fat middle aged women with a
headache.

lntracrainal Hypotension

Findings follow the equilibrium idea:

• Volume of venous blood will increase
to maintain the equilibrium.
• The result is meningeal
engorgement {enhancement),
distention of the dural venous-sinuses
{concave appearance of the
transverse sinus), prominence of the
intracranial vessels and
• Engorgement of the pituitary.
• The development of subdural
hematoma and hygromas is also a
classic look (again, compensating for
1. Which is Which ?
A. (1) Intracranial Hypertension (2) lost volume).
Intracranial Hypotension
B. (1) Intracranial Hypotension (2) Intracranial 3. What do you think Case 1 looks
Hypertension like?
A. Skinny 70 year old woman
2. Dural Venous Sinuses Do What with What ? B. Fat teenage boy
A. Shrink with Hypertension, Expand with C. 45 Year old homeless man
Hypotension (with terrible BO)
B. Shrink with Hypotension, Expand with Hypertension D. Fat Middle Aged Woman
C. Always state constant in volume

This vs That 12
CASE 6 - IV DRUG USER ... ALSO LIKES UNPROTECTED SEX
WITH MULTIPLE ANONYMOUS PARTNERS

1. Which is Which ?
A. (1) HIV Encephalitis, (2) Progressive Multifocal Leukoencephalopathy (PML)
B. (1) Progressive Multifocal Leukoencephalopathy (PML), (2) HIV Encephalitis

2. How do you tell these two apart?

A. HIV Encephalitis will be asymmetric
B. PML will involve the cortical U Fibers
C. PML will have normal Tl signal
D. HIV lesions will enhance

This vs That 13
 CASE 6 - HIV ENCEPHALITIS VS PML

HIV Encephalitis

• This is actually pretty common and affects

about 50% of AIDS patients.
• CD4< 200.
• What you are going to see is symmetric
increased T2 / FLAIR signal in the deep
white matter.
• T1 will be normal.
• These tend to spare the subcortical U-
fibers (PML will involve them).

PML

• This is caused by the JC virus.

• CD4 less than 50.
• Asymmetric T2/FLAIR hyperintensities out
of proportion to mass effect - buzzword
• Corresponding T1 hypointensity
(remember HIV was T1 normal)
• The lesions have a predilections for the
subcortical U-fibers.

1. Which is Which ?
A. (1) HIV Encephalitis, (2) Progressive Multifocal Leukoencephalopathy (PML)
B. (1) Progressive Multifocal Leukoencephalopathy (PML ), (2) HIV Encephalitis

2. How do you tell these two apart?

A. HIV Encephalitis will be asymmetric
B. PML will involve the cortical U Fibers
C. PML will have normal Tl signal
D. HIV lesions will enhance

This vs That 14
 CASE 7 - MOM THINKS VACCINES CAUSE AUTISM

1. Which is Which ?
A. (1) CMV (2) Toxoplasmosis
B. (1) Toxoplasmosis, (2) CMV
=
2. How do you tell these two apart?
A. Toxo is more common
B. Toxo famously has polymicrogyria
C. Toxo has hydrocephalus
D. CMV famously has brain atrophy in the frontal lobes
E. CMV has less calcifications - more ischemia I Vasculopathy

3. Which of the follow is true?

A. HSV targets the same locations within the brain - regardless of virus subtype (I or II)
B. Rubella has more calcifications than other TORCHS
C. HIV tends to cause brain atrophy (frontal lobe)
D. CMV classically spares the germinal matrix

This vs That 15
 CASE 7 - TORCH - - CMV VS TOXOPLASMOSIS

CMV:

• This is the most common TORCH (by far!,

it's 3x more common than Toxo - which is
the second most common).
• It likes the germinal matrix and causes
periventricular tissue necrosis.
• Classically Periventricular calcifications .
• CMV has the highest association with
polymircogyria .

Toxo:

• This is the second most common TORCH.

It's seen in women who clean up cat shit.
• The calcification pattern is more random,
and affects the basal ganglia (like most
other TORCH infections).
• The most likely test question =
hydrocephalus.

CNS TORCH - What you need to remember

• CMV = Most Common Periventricular Calcifications Polymicrogyria

• Toxo = Hydrocephalus, Basal Ganglia 'alcifications
= • Rubella = Va iculopathy I lschemia. High T2 signal - le s Calcifications
• HSV = Hemorrhagic Infarct, and lead to bad encephalomalcia
(hydranencephaly)
• IDV = Brain Atrophy in frontal /obe.

1. Which is Which ? 3. Which of the follow is true?

A. (1) CMV (2) Toxoplasmosis A. HSV targets the same locations within
B. (1) Toxoplasmosis, (2) CMV the brain - regardless of virus subtype (I
or II)
2. How do you tell these two apart? B. Rubella has more calcifications than
A. Toxo is more common other TORCHS
B. Toxo famously has polymicrogyria C. HIV tends to cause brain atrophy
C. Toxo has hydrocephalus (frontal lobe)
D. CMV famously has brain atrophy in the D. CMV classically spares the germinal
frontal lobes matrix
E. CMV has less calcifications - more
ischemia I Vasculopathy

This vs That 16
 CASE 8 - HEADACHE

1. Which is Which ?
A. (1) Pilocytic Astrocytoma (2) Oligodendroglioma
B. (1) Hemangioblastoma (2) Pilocytic Astrocytoma
= C. (1) Pilocytic Astrocytoma, (2) Hemangioblastoma
D. (1) Central Neurocytoma, (2) Xanthogranuloma

2. Which is true ?
A. Pilocystic Astrocystomas are seen more with NF 2
B. Pilocystic Astrocystomas are seen more with NF 1
C. Pilocystic Astrocytomas are WHO Grade 4
D. Pilocystic Astrocystomas rarely arise from midline structures

3. Which is true?
A. Hemangioblastomas are seen with Tuberous Sclerosis
B. Hemangioblastomas are seen with Von Hippel Lindau
C. Hemangioblastomas are seen with NF 2
D. Hemangioblastomas are seen with Gorlin Syndrome

This vs That 17
CASE 8 - POSTERIOR FOSSA CYST WITH A NODULE -
PILOCYSTIC ASTROCYTOMA VS HEMANGIOBLASTOMA

Pilocystic Astrocytoma:

• Most common primary brain tumor of childhood.

• They are WHO 1 - although they do demonstrate
enhancement (just the nodule). "This is an important
exception to the rule that low grade intra-axial things
don't enhance.
• Classically in midline structures (optic nerve/chiasm)
and cerebellum.
• NF-1 Patients get these in the optic nerve bilaterally
• The syndromic (NF1) optic gliomas are pilocystic
astrocytoma - WHO 1, and have a good prognosis.
• The sporadic optic nerve gliomas are GBMs (WHO
4) and they fucking destroy you.

Hemangioblastoma:

• Most common posterior fossa mass in a young

adult.
• About 50% of patients with VHL get these
• About 25% of the time you see one of these, the
patient has VHL.
• Remember you can also get these things in your
spine.
• Because they happen more in VHL patients a
testable association is the pheochromocytoma
Cyst + Nodule in an Adult

1. Which is Which ?
A. (1) Pilocytic Astrocytoma (2) Oligodendroglioma
B. (1) Hemangioblastoma (2) Pilocytic Astrocytoma
C. (1) Pilocytic Astrocytoma, (2) Hemangioblastoma
D. (1) Central Neurocytoma, (2) Xanthogranuloma

2. Which is true ?
A. Pilocystic Astrocystomas are seen more with NF 2
B. Pilocystic Astrocystomas are seen more with NF 1
C. Pilocystic Astrocytomas are WHO Grade 4
D. Pilocystic Astrocystomas rarely arise from midline structures

3. Which is true ?
A. Hemangioblastomas are seen with Tuberous Sclerosis
B. Hemangioblastomas are seen with Von Hippel Lindau
C. Hemangioblastomas are seen with NF 2
D. Hemangioblastomas are seen with Gorlin Syndrome

This vs That 18
CASE 9 - "GOTTA BUMP ON MY NECK"

1. Which is Which ?
A. (1) Thyroglossal Duct Cyst (2) Brachia! Cleft Cyst
B. (1) Brachial Cleft Cyst (2) Thyroglossal Duct Cyst

2. Is there anything else #2 could be? 3. You scroll through #1 and

A. Nope - it's in a classic location notice some solid components.
B. Could be a floor of the mouth cancer met ... but only What is the patient at risk for?
if he's old and smokes A. N eek Hematoma
C. Could be a floor of the mouth cancer met, even in a B. Hypothyroidism
younger non-smoker C. Thyroid Storm
D. Could be a peri-tonsillar abscess - probably should D. Papillary CA
drain it.

This vs That 19
CASE 9 - CYSTIC NECK MASS
- BRACHIAL CLEFT CYST VS THYROGLOSSAL DUCT CYST

Thyroglossal Duct Cyst

• Most common midline congenital neck mass

• Found along the tract left by the thyroid gland after

descent from the toramen cecum at the tongue base

• The main thing to know (other than its midline

position) is that it can get cancer - usually papillary
"the popular" subtype. If you see solid components,
it has to get a cancer workup.

Brachial Cleft Cyst

• There are a bunch of types - but type 11 is by far the

most common and makes up like 95%.

• They can mimic a necrotic level 2 lymph node.

• The most important thing to remember is that in an

adult with a new neck mass (unless it's midline, or
clearly a goiter) they have sec nodal mets until
proven otherwise. Why? Because HPV related
floor of the mouth cancer can (and does) occur in
people in their 20s. The idea that only old smokers
get mouth cancer is incorrect.

1. Which is Which ?
A. (1) Thyroglossal Duct Cyst (2) Brachia) Cleft Cyst
B. (1) Brachial Cleft Cyst (2) Thyroglossal Duct Cyst

2. ls there anything else #2 could be?

A. Nope - it's in a classic location
B. Could be a floor of the mouth cancer met... but only if he's old and smokes
C. Could be a floor of the mouth cancer met, even in a younger non-smoker
D. Could be a peri-tonsillar abscess - probably should drain it.

3. You scroll through #I and notice some solid components. What is the patient at risk for?
A. Neck Hematoma
B. Hypothyroidism
C. Thyroid Storm
D. Papillary CA

This vs That 20
CASE 10 - "MY EAR HURTS"

I. Which is Which ?
A. (I) Cholesteatoma (2) Cholesterol Granuloma,
B. (1) Cholesterol Granuloma, (2) Cholesteatoma

2. The pathology is #2 likely started at ?

A. Pars Flaccida
B. Pars Tensa

3. What is true about these two pathologies on Diffusion Weighted Imaging?

A. (I) Will Restrict, (2) Will NOT Restrict
B. (1) Will Restrict, (2) Will Also Restrict
C. (1) Will NOT Restrict, (2) Will Restrict
D. (I) Will NOT Restrict, (2) Will Also NOT Restrict

This vs That 21
CASE 10 - "CHOLESTEATOMA VS CHOLESTEROL GRANULOMA

Cholesterol Granuloma

• The most common primary petrous apex lesion.

• Mechanism is likely obstruction of the air cell, with

repeated cycles of hemorrhage and inflammation
leading to expansion and bone remodeling.

• On MRI it's gonna be T1 and T2 bright. The bright

T1 signal makes it unique.

Cholesteatoma

• This is basically an epidermoid ( ectopic epithelial

tissue).

• This one is an acquired type (pars flaccida - from

the upper floppy part of the ear drum).

O In the petrous apex they are more likely to be

congenital.

Soft tissue in the "Attic" I • They are typically slow growing, and produce bony
Epitympanum. There is changes similar to cholesterol granuloma.
erosion of the scutum
• The difference is their MRI findings; T1 dark, T2
bright, and restricted diffusion.

1. Which is Which ?
A. (1) Cholesteatoma (2) Cholesterol Granuloma,
B. (1) Cholesterol Granuloma, (2) Cholesteatoma

2. The pathology is #2 likely started at ?

A. Pars Flaccida
B. Pars Tensa

3. What is true about these two pathologies on Diffusion Weighted Imaging?

A. (1) Will Restrict, (2) Will NOT Restrict
B. (1) Will Restrict, (2) Will Also Restrict
C. (1) Will NOT Restrict, (2) Will Restrict
D. (1) Will NOT Restrict, (2) Will Also NOT Restrict

This vs That 22
CASE 11 - "HOARSENESS"

1. Which is Which ?
3. Which of the following
A. (1) Vocal Cord Paralysis (2) Vocal Cord Tumor
has the BEST prognosis?
B. (1) Vocal Cord Tumor (2) Vocal Cord Paralysis
A. Supraglottic CA
B. Glottic CA
2. In the setting of left sided vocal cord paralysis, the
C. Infraglottic CA
"next step" is ?
A. BrainMRI
B. NM Bone Scan
C. CT Abd and Pelvis
D. CT Chest

This vs That 23
CASE 11 - VENTRICLE DILATION - CANCER VS PARALYSIS

Vocal Cord Paralysis

• The vast majority of cases are secondary to

problems with the recurrent laryngeal nerve (which
innervates nearly all the laryngeal muscles

• When it's left sided you need to look at the AP

window next - for a mass compressing the recurrent
laryngeal nerve.

• There are Two Key Imaging Features:

• (1) Atrophy of the Thyroarytenoid muscle which
Paralysis = Same Side Dilation makes up the bulk of the true cord
• (2) Dilation of the Laryngeal Ventricle - on the
same side as the paralyzed cord.

Laryngeal CA

• The role of the Radiologist is to help stage

• Laryngeal cancers are subdivided into (a)

supraglottic, (b) glottic, and (c) subglottic types.

• Glottic SCC has the best outcome (least

lymphatics), and is the most common (60%)

• Subglottic is the least common (5%), and can be

clinically silent till you get nodes

Mass = Other Side Dilation • The laryngeal ventricle will dilate with a cancer, but
this time it's gonna be on the opposite side.

I. Which is Which ?
A. (1) Vocal Cord Paralysis (2) Vocal Cord Tumor
B. (I) Vocal Cord Tumor (2) Vocal Cord Paralysis

2. In the setting of left sided vocal cord paralysis, the "next step" is ?
A. Brain MRI
B. NM Bone Scan
C. CT Abd and Pelvis
D. CT Chest

3. Which of the following has the BEST prognosis?

A. Supraglottic CA
B. Glottic CA
C. Infraglottic CA

This vs That 24
 CASE 12 - "BUMP ON MY FINGER"

1. Which is Which ?
A. (1) Glomus (2) Fibroma
B. (1) Giant Cell Tumor (2) Glomus
C. (1) Glomus, (2) Giant Cell Tumor
D. (1) Fibroma, (2) Giant Cell Tumor

2. How do you tell them apart?

A. Glomus is T2 Dark
B. Fibroma is T2 Bright
C. Giant Cell Tumor will Bloom on Gradient
D. Glomus will only enhance peripherally.

This vs That 25
CASE 12 - FINGER MASSES - GLOMUS VS GCT OF TENDON

Glomus (Glomangioma)

• Benign Vascular Tumor (best thought of as a

hamartoma).

• Almost always found in the finger

• Classic Imaging Features:

• T2 BRIGHT
• AVID contrast enhancement

Giant Cell Tumor (of the tendon)

• Benign lesion arising from the tendon

sheath.

• It is basically PVNS.

• They favor the palmar tendons

• Classic Imaging Features:

• T1 and T2 Dark Oust like a fibroma)
• GAE - Blooms (fibromas won't bloom)

1. Which is Which ?
A. (1) Glomus (2) Fibroma
B. (1) Giant Cell Tumor (2) Glomus
C. (1) Glomus, (2) Giant Cell Tumor
D. (I) Fibroma, (2) Giant Cell Tumor

2. How do you tell them apart?

A. Glomus is T2 Dark
B. Fibroma is T2 Bright
C. Giant Cell Tumor will Bloom on Gradient
D. Glomus will only enhance peripherally.

This vs That 26
 CASE 13 - "SHOULDER PAIN"

1. A mass would have to be centered where to cause the atrophy pattern in "l" ?
A. Suprascapular Notch
B. Spinoglenoid Notch
C. Quadrilateral Space
D. Brachia! Plexus
=
2. A mass would have to be centered where to cause the atrophy pattern in "2" ?
A. Suprascapular Notch
B. Spinoglenoid Notch
C. Quadrilateral Space
D. Brachial Plexus

3. Which muscle(s) are innervated by the axillary nerve?

A. Supraspinatous
B. Infraspinatous
C. Teres Minor
D. Teres Major
E. Subscapularis
F. "A& B"

This vs That 27
CASE 13 - INNERVATION OF THE ROTATOR CUFF

Suprascapular Notch:
-Suprascapular Nerve traveling
to the Surpraspinatus
-A hit here will de-innervate both
the Supra S. and the Infra S.

I Spinoglenoid Notch:
I -Suprascapular Nerve traveling
I to the lnfraspinatous
II -A hit here will de-innervate only
I the Infra S.

Infra S.
I Quadrilateral S-pace
i -Axillary Nerve traveling to the
Teres Minor
-A hit here will de-innervate the
Teres Minor
Triceps
Lateral

1. A mass would have to be centered where to cause

the atrophy pattern in "1" ?
A. Suprascapular Notch
B. Spinoglenoid Notch
Fatty
C. Quadrilateral Space
D. Brachia) Plexus Atrophy of
lnfra-
2. A mass would have to be centered where to cause Spinatous
the atrophy pattern in "2" ?
A. Suprascapular Notch
B. Spinoglenoid Notch
C. Quadrilateral Space
D. Brachia) Plexus

3. Which muscle(s) are innervated by the axillary

nerve?
A. Supraspinatous
B. Infraspinatous
C. Teres Minor Fatty
D. Teres Major
Atrophy
E. Subscapularis
F. "A & B" of Teres
Minor

This vs That 28
 CASE 14 - "SHOULDER PAIN"

1. Which is Which ?
A. (1) ALPSA, (2) PERTHES
B. (1) PERTHES, (2) GLAD
C. (1) GLAD, (2) ALPSA
D. (1) Bony Bankart, (2) GLAD

2. Which of the following is typically NOT association with shoulder instability?

A. Bankart
B. ALPSA
C. PERTHES
D. GLAD

This vs That 29
 CASE 14 - GLENOID LABRUM - ALPHABET SOUP
- PERTH ES vs GLAD

j
(( I
)
> > , > •
GLAD PERTHES ALPSA Bankart "Bony" Bankart

Least Severe

!GLAD: PERTH ES: � ALPSA:

t - Impaction injury - Lifting of the Anterior Labral
with a cartilage anterior inferior Periosteal
I defect. labrum off the Sleeve Avulsion.
I - There will be an edge of the 1j1 - The anterior
I associated
superficial
glenoid, with
medial
inferior labral is
torn off the
anterior inferior displacement of glenoid but
labral tear the sleeve remains stuck to
- NOT associated periosteum the periosteum.
with underlying - You have loss of - It can heal in this
instability the normal folded off position
stabilizing effects - requiring
_, of the inferior surgery to fix.
glena-humeral

1. Which is Which ?
A. (1) ALPSA, (2) PERTHES
B. (1) PERTHES, (2) GLAD
C. (1) GLAD, (2)ALPSA
D. (1) Bony Bankart, (2) GLAD

2. Which of the following is

typically NOT association with
shoulder instability?
A. Bankart
B. ALPSA
C. PERTHES
D. GLAD **aren't you glad it's
Lifted Labrum, with Cartilage Defect with just a glad.
Displacement of the Detached Labrum
Sleeve Periosteum
This vs That 30
CASE 15 - ARM PAIN

1. Which is Which ?
A. (1) Galeazzi Fx, (2) Monteggia Fx
B. (1) Monteggia Fx, (2) Galeazzi Fx

2. What The F' is an "Essex- Lopresti" Fx?

A. Comminuted fracture of the radial head with a dislocation at the DRUJ
B. Comminuted fracture of the proximal ulnar with a dislocation at the DRUG
C. Fracture of the ulnar shaft with dislocation of the radial head
D. Fracture of the distal radius with dislocation of the DRUJ

This vs That 31
CASE 15 - EPONYMOUS FRACTURES

---------------
r Monteggia Fracture (MUGR)
J

Fracture of the Ulna + Radial Head Dislocation

- The direction in which the apex of the ulnar
fracture points is the same direction as the
radial head dislocation (usually anterior)
- Fracture classification is based on the direction
of radial dislocation (usually anterior).

Galeazzi Fracture (MUGR)

- Fracture of the Distal Radius +

DRUJ (distal-radial ulnar joint)
Dislocation
- Classification is based on dorsal vs
volar displacement of the distal
radius

Essex-Lopresti

- Comminuted Fracture of
Radial Head+ DRUJ
Dislocation

1. Which is Which ?
A. (1) Galeazzi Fx, (2) Monteggia Fx
B. (1) Monteggia Fx, (2) Galeazzi Fx

2. What The F' is an "Essex- Lopresti" Fx?

A. Comminuted fracture of the radial head
with a dislocation at the DRUJ
B. Comminuted fracture of the proximal ulnar
with a dislocation at the DRUG
C. Fracture of the ulnar shaft with dislocation of
the radial head
D. Fracture of the distal radius with dislocation
of the DRUJ

This vs That 32
CASE 16 - COUGH

•
** Case "2" - Different
Patients with the same "sign"

1. Which is Which ?
A. (1) Halo Sign, (2) Reverse Halo (Atoll) Sign
B. (1) Reverse Halo (Atoll) Sign, (2) Halo Sign

2. What is the classic single answer diagnosis for #1 ? 3. What is the classic single
A. Cryptogenic Organized Pneumonia (COP) answer diagnosis for #2 ?
B. Angioinvasive Aspergillosis A. Cryptogenic Organized
C. Sarcoid Pneumonia (COP)
D. Pulmonary Lymphoma B. Angioinvasive
Aspergillosis
C. Sarcoid
D. Pulmonary Lymphoma

This vs That 33
CASE 16 - HALO SIGNS - HALO VS REVERSE HALO (ATOLL)

Halo

- Consolidative opacity - with a

ground glass halo

- The ground glass part is suppose

to represent the hemorrhage I
invasion into surrounding tissue

- It has a DDx in real life. But on

multiple choice it's Invasive
Aspergillosis (or other bad
fungal infections).

Reverse Halo (Atoll)

- Central ground glass with rim of

consolidate opacity.

- It has a DDx in real life. But on

multiple choice it's Organizing
Pneumonia (COP). *Cryptogenic
when cause not known.

- Classic causes of organizing

pneumonia include drugs
(amiodarone), & collagen
vascular disease.
1. Which is Which ?
A. (1) Halo Sign, (2) Reverse Halo (Atoll) Sign
B. (1) Reverse Halo (Atoll) Sign, (2) Halo Sign

2. What is the classic single answer diagnosis for # 1 ?

A. Cryptogenic Organized Pneumonia (COP)
B. Angioinvasive Aspergillosis
C. Sarcoid
D. Pulmonary Lymphoma

3. What is the classic single answer diagnosis for #2?

A. Cryptogenic Organized Pneumonia (COP)
B. Angioinvasive Aspergillosis
C. Sarcoid
D. Pulmonary Lymphoma

This vs That 34
 CASE 17 - COUGH

=
•
1. Which is Which ?
A. ( 1) Lymphangiomyomatosis (LAM), (2) Langerhans cell histiocytosis (LCH)
B. (1) Langerhans cell histiocytosis (LCH), (2) Lymphangiomyomatosis (LAM)

2. Which of the follow is true? 3. Which of the following classically

A. LAM has thick walled cysts spares the costophrenic angles ?
B. LCH has thin walled cysts A. Hypersensitivity Pneumonitis
C. LCH is seen more in people who smoke B. LAM
D. LAM has a strict lower lobe C. NSIP
predominance D. UIP
E. LCH has an association with tuberous
sclerosis

This vs That 35
CASE 17 - CYSTIC LUNG DISEASE - LAM VS LCH

Pulmonary Langerhans Cell

Histiocytosis (LCH)

-Young Adult (20-30s) Smokers

- Starts out with upper lobe predominant

centrilobular nodules - which then cavitate
into bizarre thick walled cysts.

- *Thick Walled Cysts + Nodules - upper

lobe predominant

Sparing of the costophrenic angles - only

seen with LCH and Hypersensitivity
CPA Pneumonitis
Sparing
- Resolves about 50% of the time, if they
quit smoking.

Lymphangiomyomatosis (LAM)

- Women of child bearing age

- Association with Tuberous Sclerosis

(gamesmanship is to show an AML of the
kidney first)

- *Thin walled cysts, diffuse distribution

- They are known to develop

chylothorax

1. Which is Which ?
A. (1) Lymphangiomyomatosis (LAM), (2) 3. Which of the following
Langerhans cell histiocytosis (LCH) classically spares the costophrenic
B. (1) Langerhans cell histiocytosis (LCH), (2) angles?
Lymphangiomyomatosis (LAM) A. Hypersensitivity
Pneumonitis
2. Which of the follow is true? B. LAM
A. LAM has thick walled cysts C. NSIP
B. LCH has thin walled cysts D. UIP
C. LCH is seen more in people who smoke
D. LAM has a strict lower lobe predominance
E. LCH has an association with tuberous sclerosis

This vs That 36
 CASE 18 - COUGH

Lower Lobe
Predominant

1. Which of the following has an upper lobe predominance ?

A. Asbestosis
B. Rheumatoid Lung
-. c. Ankylosing Spondylitis
D. Sarcoid

2. Which of the following has a lower lobe predominance ?

A. CF
B. RB-ILD
C. Primary Ciliary Dsykinesia
D. Silicosis

3. Which of the following has a lower lobe predominance ?

A. Primary Lung Cancer
B. Progressive Massive Fibrosis
C. Emphysema (Centrilobular)
D. Scleroderma

This vs That 37
CASE 18 - UPPER VS LOWER LOBE DISTRIBUTION

Upper Lobe Predominant Lower Lobe Predominant

Most inhaled stuff (not asbestosis). Coal Asbestosis ** the exception to the upper
Workers, and Silicosis. This includes lobe predominant rule for inhaled crap.
progressive massive fibrosis.

CF Primary Ciliary Dsykinesia

RB-ILD (remember it has an association Most Interstitial Lung Diseases (UIP,

with smoking) NSIP, DIP)

Centrilobular Emphysema Panlobular Emphysema (Alpha 1)

Ankylosing Spondylitis Rheumatoid Lung

Scleroderma ( associated with NSIP)

Sarcoid

Most Primary Lung Cancers (more Most Hematogenously Spread Metastatic

exposure to air born toxins - cigarette Cancers (more bloodflow to the bases)
smoke etc .. .)

1. Which of the following has an upper lobe predominance?

A. Asbestosis
B. Rheumatoid Lung
C. Ankylosing Spondylitis
D. Sarcoid

2. Which of the following has a lower lobe predominance?

A. CF
B. RB-ILD
C. Primary Ciliary Dsykinesia
D. Silicosis

3. Which of the following has a lower lobe predominance?

A. Primary Lung Cancer
B. Progressive Massive Fibrosis
C. Emphysema (Centrilobular)
D. Scleroderma

This vs That 38
CASE 19 - COUGH

II

II
I. Which distribution of nodules is which ?
A. (1) Random, (2) Centrilobular, (3) Perilymphatic
B. (1) Random, (2) Perilymphatic, (3) Centrilobular
C. (1) Perilymphatic, (2) Centrilobular, (3) Random
D. (1) Centrilobular, (2) Random, (3) Perilymphatic

2. Which of the following classically has a perilymphatic distribution ?

A. Sarcoid
B. Hypersensitivity Pneumonitis
C. Endobronchial Infection
D. Hematogenous Spread of Cancer

3. Which of the following classically has a centrilobular distribution?

A. Sarcoid
B. Systemic Fungal Infection
C. Hypersensitivity Pneumonitis
D. Lymphangitic Spread of Cancer

This vs That 39
CASE 19 - NODULE PATTERNS

Diffuse without Random

Predominance

Pleural Nodules

Subpleural & i.....i�Perilymphatic

Peribronchovascular

I No Pleural Nodules 1-l ----1•�1 Centrilobular

Perilymphatic Random Centrilobular

Sarcoid - *Most Classic Miliary TB - *Most Classic Hypersensitivity Pneumonitis -
*Most Classic

Silicosis Disseminated Fungal Infection Resp Bronchiolitis (RB-ILD)

Lymphangetic Spread CA Hematogenous Spread CA Infectious Diseases

(Endobronchial Spread)

1. Which distribution of nodules is which ?

A. (1) Random, (2) Centrilobular, (3) Perilymphatic
B. (1) Random, (2) Perilymphatic, (3) Centrilobular
C. (1) Perilymphatic, (2) Centrilobular, (3) Random
D. (1) Centrilobular, (2) Random, (3) Perilymphatic

2. Which of the following classically has a perilymphatic distribution?

A. Sarcoid
B. Hypersensitivity Pneumonitis
C. Endobronchial Infection
D. Hematogenous Spread of Cancer

3. Which of the following classically has a centrilobular distribution?

A. Sarcoid
B. Systemic Fungal Infection
C. Hypersensitivity Pneumonitis
D. Lymphangitic Spread of Cancer

This vs That 40
CASE 20 - BELLY PAIN

1. Which is which ?
A. (1) Hepatic Steatosis (2) Hemochromatosis
B. ( 1) Hemochromatosis (2) Hepatic Steatosis

2. Which should be acquired first?

A. Out of phase imaging
B. In phase imaging
C. Makes no difference

3. Iron causes a signal drop out by?

A. Causing T2 * effects
B. Elongates Tl signal
C. Increasing local eddy currents in the imaged tissues
D. Worsening sample size limitations

This vs That 41
CASE 20 - SIGNAL DROP-OUT; FATTY LIVER VS IRON LIVER

[Link] Crash Course

- When iron is present in high concentrations it essentially becomes a small magnet ("Iron
is Paramagnetic"). The presence of a magnet within the magnet changes the field
surrounding it (makes the field dirty). This results in a shortening of lots of stuff, the most
testable is due to T2 star (remember those are the ones from a non-uniform field). An
easy way to think about this is it you had a totally uniform field T2 would equal T2*.

- The longer you wait to image something, the more noticeable the effects of T2* are going
to be. Think about two runners at the starting line, one is fat & one is from Kenya. If you
took a picture 0.5 seconds into the race they would be close together, but if you waited 10
seconds the distance between them would be huge. T2* is the Kenyan and Iron laden
livers have more T2* .... so the longer the echo time, the darker iron looks (why it's dark on
in-phase , which is traditionally done later - as shown below).

- Lets briefly review in and out of phase imaging. This is basically two gradient sequences
done with different echo times, based on the precession speed of water and fat (which are
different). At different echo times fat and water can be seen on opposite sides (out of
phase), or perfectly lined up (in phase). When opposed, the signals drop out. This is why
fat drops out on out of phase imaging.

- Now, because this lining up and not lining up is occurring over and over again (every 2.2
msec at [Link]) you can wait and do the out of phase at 6.6msec. BUT, if you do that, and
you are dealing with an iron laden liver the T2* effects will be even more pronounced (the
Kenyan runner will be way away) and will not be able to tell if you have signal drop out
from fat, or signal drop out from iron.

1. Which is which ? [Link] causes a signal drop out by?

A. (1) Hepatic Steatosis (2) Hemochromatosis A. Causing T2 * effects
B. (1) Hemochromatosis (2) Hepatic Steatosis B. Elongates Tl signal
*Fat dark on OUT ofphase, Iron dark on IN phase C. Increasing local eddy currents in the imaged
tissues
2. Which should be acquired first ? D. Worsening sample size limitations
A. Out of phase imaging
B. In phase imaging
C. Makes no difference

This vs That 42
 CASE 21 - BRONZE SKIN

** ARROWS ON PANCREAS

1. Which is which ?
A. (1) Primary Hemochromatosis (2) Secondary Hemochromatosis
= B. (1) Secondary Hemochromatosis (2) Primary Hemochromatosis

2. How can you tell them apart ?

A. The liver is involved in primary but not secondary
B. The pancreas is involved in secondary but not primary
C. The spleen is involved in secondary but not primary

3. What "internal control" can be used to evaluate for iron overload in the liver?
A. The pancreas
B. The paraspinal muscles
C. The vertebral bodies
D. The large bowel

4. How is iron quantification accomplished?

A. Using Spin Echo Sequences with a specific TR
B. A double inversion protocol is done, with a specific TI
C. GRE Sequences with progressively longer echo times
D. It's done with diffusion set at varying Bo values.

This vs That 43
 CASE 21 - HEMOCHROMATOSIS - PRIMARY VS SECONDARY

Primary

- Autosomal Recessive Condition

- Seen mostly in white Europeans
- You see the manifestations later in women,
because they self treat by having bloody periods
- It can cause cirrhosis, heart failure, arthritis, bronze
skin, and pancreas failure ("bronze diabetes")

Signal Drop out in Pancreas - On Imaging:

- The liver signal drops out (darkens) on delayed
sequences - typically in phase)
- The liver will be darker than the paraspinal
muscles (which is never normal).
- Pancreas can be involved (Pancreas for Primary)
- Spleen is spared.

Secondary

- From frequent blood transfusions (usually)

- All the same stuff from primary ( drop out on in
phase, liver darker than spine muscles) PLUS you
have a dark spleen. Spleen for Secondary.

I. Which is which ? 4. How is iron quantification accomplished?

A. (I) Primary Hemochromatosis (2) Secondary A. Using Spin Echo Sequences with a
Hemochromatosis specific TR
B. (1) Secondary Hemochromatosis (2) Primary B. A double inversion protocol is done,
Hemochromatosis with a specific TI
C. GRE Sequences with progressively
2. How can you tell them apart ? longer echo times ** more drop out
A. The liver is involved in primary but not secondary with progressive echo time
B. The pancreas is involved in secondary but not primary D. It's done with diffusion set at varying Bo
C. The spleen is involved in secondary but not values.
primary

3. What "internal control" can be used to evaluate for iron

overload in the liver?
A. The pancreas
B. The paraspinal muscles
C. The vertebral bodies
D. The large bowel

This vs That 44
CASE 22 - HEPATITIS C - AFP RISING

1. Which is which ?
A. (1) Regenerative Nodule (2) Dysplastic Nodule
B. (1) Dysplastic Nodule, (2) HCC
C. (1) Dysplastic Nodule, (2) Regenerative Nodule

2. How can you tell them apart ?

A. Dysplastic Nodules are T2 Bright
B. Regenerative Nodules enhance
C. HCC is T2 Bright

3. What if you saw large (4cm) enhancing nodules in a patient with Budd Chiari?
A. They are cancer until proven otherwise
B. Probably benign

This vs That 45
 CASE 22 - LIVER NODULES

•
T1 T1 T1

••
•• •
• •
• •• •• •
T2 T2 T2

••
••
• •
Regenerative
Nodule

Regenerative: Dysplastic:
I - Most Common
!
- Rrogressive
I Cirrhosis Associated architectural
iI
Nodule derangement on
, - Usually numerous histology
I - Histologically their -T2: Dark - especially
j function is normal, when low grade.
they are just scarred The higher grade
up ones will have mildly
' - T2; DARK increased signal
I - T1 : Variable - but - T1 : Variable - but
think about them think about them
being T1 dark being T1 Bright
1 - C+: Enhance the - C+: Enhance the
same as liver same as liver
·�------
1. Which is which?
------------
A. (]) Regenerative Nodule (2) Dysplastic Nodule
B. (1) Dysplastic Nodule, (2) HCC I Budd Chiari Nodules
C. (I) Dysplastic Nodule, (2) Regenerative Nodule
' Large Multiple Nodules in
2. How can you tell them apart ?
A. Dysplastic Nodules are T2 Bright
I characteristic
Budd Chiari livers are
of
B. Regenerative Nodules enhance
C. HCC is T2 Bright regenerative nodules
(hyperplastic). They can
3. What if you saw large (4cm) enhancing nodules in a patient with enhance, but don't
Budd Chiari ? washout out quickly like
A. They are cancer until proven otherwise an HCC.
B. Probably benign

This vs That 46
CASE 23 - BELLY PAIN

1. Which is which ?
A. (1) Serous Cystadenoma (2) Mucinous Cystic Neoplasm (MCN)
B. (1) Mucinous Cystic Neoplasm (MCN) (2) Serous Cystadenoma
C. (1) Solid Pseudopapillary Neoplasm (SPN), (2) Serous Cystadenoma

2. Generally Speaking ...

A. Serous Cystadenoma is seen in grandmas, MCNs are seen in moms
B. MCNs are seen in grandmas, Serous Cystadenoma is seen in moms
C. SPNs are seen in teenage asian boys

3. Which is true ?
A. Serous Cystadenoma is malignant until proven otherwise
B. MCNs are usually in the body/tail
C. SPNs do NOT enhance
D. MCNs have no malignant potential

This vs That 47
CASE 23 - CYSTIC PANCREATIC LESIONS-

Solid Pseudopapillary
• Daughter Lesion
• Solid and cystic parts
• Enhances like a hemangioma
• Capsule

•
I
Mucinous Cystic
Mother Lesion
• Premalignant
• Body I Tail - 95%
• Unilocular with thick
wall separations

• Benign
• Microcystic, with central calcifications

1. Which is which ?
A. (I) Serous Cystadenoma (2) Mucinous Cystic Neoplasm (MCN)
B. (1) Mucinous Cystic Neoplasm (MCN) (2) Serous Cystadenoma
C. (1) Solid Pseudopapillary Neoplasm (SPN), (2) Serous Cystadenoma

2. Generally Speaking ...

A. Serous Cystadenoma is seen in grandmas, MCNs are seen in moms
B. MCNs are seen in grandmas, Serous Cystadenoma is seen in moms
C. SPNs are seen in teenage asian boys ** asian or african american teenage girls

3. Which is true?
A. Serous Cystadenoma is malignant until proven otherwise
B. MCNs are usually in the body/tail
C. SPNs do NOT enhance
D. MCNs have no malignant potential

This vs That 48
 CASE 24 - BELLY PAIN

I. Which is which ?
= A. (1) Crohns (2) Ulcerative Colitis
B. (1) Ulcerative Colitis (2) Crohns

2. Ulcerative colitis "always" involves the ?

A. Terminal Ileum
B. Splenic Flexure
C. Rectum
D. Small Bowel

3. Which is true?
A. Primary Sclerosing Cholangitis is more common with Crohns
B. Gall Stones are more common with Crohns
C. Fistula are more common with UC
D. Crohns has a higher malignant risk compared to UC
E. UC has a malignant risk (higher than gen pop) when limited to the rectum only

This vs That 49
CASE 24 - INFLAMMATORY BOWEL DISEASE

Crohns

- Typically seen in a young adult (15-30), but has a

second smaller peak 60-70.
- Discontinuous involvement of the entire GI tract
(mouth-> asshole).
- Stomach, usually involves antrum (Ram's Horn
Deformity).
- Small bowel is involved 80% of the time, with the
terminal ileum almost always involved (Marked
Narrowing= String Sign).
- After surgery the "neo-terminal ileum" will
frequently be involved.
Epic String Sign - Strictured Tl -Complications include fistulae, abscess,
gallstones, fatty liver, and sacroiliitis.

Ulcerative Colitis

- Similar dual peak age breakdown

- Involves the rectum 95% of the time, and has
retrograde progression.
- Terminal ileum is involved 5-10% of the time via
backwash ileitis (wide open appearance).
- It is continuous and does not "skip" like Crohns.
- It is associated with Colon Cancer, Primary
Sclerosing Cholangitis, and Arthritis (similar to
Ankylosing Spondylitis).
- Cancer risk is only above general population when
disease progresses to the splenic flexure.
-On Barium, it is said that the colon is ahaustral,
Ahaustral - Lead Pipe Colon with a diffuse granular appearing mucosa. "Lead
Pipe" is the buzzword (shortened from fibrosis).

1. Which is which ? 3. Which is true?

A. (1) Crohns (2) Ulcerative Colitis A. Primary Sclerosing Cholangitis is more
B. (1) Ulcerative Colitis (2) Crohns common with Crohns
B. Gall Stones are more common with Crohns
2. Ulcerative colitis "always" involves the ? C. Fistula are more common with UC
A. Terminal Ileum D. Crohns has a higher malignant risk compared
B. Splenic Flexure to UC
C. Rectum E. UC has a malignant risk (higher than gen pop)
D. Small Bowel when limited to the rectum only ** only when
it extends past the splenic flexure.

This vs That 50
CASE 25 - BELLY PAIN

1. Which is which ?
A. (1) Endometrioma (2) Hemorrhagic Cyst
B. (1) Hemorrhagic Cyst (2) Endometrioma
C. (1) Dermoid, (2) Endometrioma
D. (1) Endometrioma, (2) Dermoid

2. Which is the correct rare malignant transformation pairing?

A. Endometrioma -> Clear Cell CA, Dermoid -> Adenocarcinoma
B. Endometrioma -> Clear Cell CA, Dermoid -> Squamous Cell CA
C. Endometrioma -> Squamous Cell CA, Dermoid -> Adenocarcinoma
D. Endometrioma -> Transitional Cell CA, Dermoid-> Squamous Cell CA

This vs That 51
 CASE 25 - OVARIAN MASS - MRI DIFFERENTIAL

Endometrioma

Dermo id

Endometrioma

•
T1 J
Bright
·� - A known cause of pelvic pain
'
:
. - T1 Bright (from blood), Fat Sat don't do shit, T2 will be
dark. This is the so called "shading sign"
- They can become cancer (clear cell), but it's rare. If they
T2 are big (like 9cm) and seen in an older women - then
Shading
. they are at higher risk.

Dermoid

- Most common ovarian neoplasm in patients « 20.

- Hyperechoic solid mural nodule - is classic on ultrasound
- T1 & T2 Bright (from fat), and will suppress on fat sat.
= - They can become cancer (squamous), but it's rare. Risk
factors are similar - large size, and advanced patient
age.
- Bilateral about 10% of the time.

1. Which is which ?
A. (1) Endometrioma (2) Hemorrhagic Cyst
B. (1) Hemorrhagic Cyst (2) Endometrioma
C. (1) Dermoid, (2) Endometrioma
D. (1) Endometrioma, (2) Dermoid

2. Which is the correct rare malignant transformation pairing?

A. Endometrioma -> Clear Cell CA, Dermoid -> Adenocarcinoma
B. Endometrioma -> Clear Cell CA, Dermoid -> Squamous Cell CA
C. Endometrioma -> Squamous Cell CA, Dermoid -> Adenocarcinoma
D. Endometrioma -> Transitional Cell CA, Dermoid -> Squamous Cell CA

This vs That 52
 CASE 26 - STINKY BREATH

1. Which is which ?
A. (1) Killian Jamieson Diverticulum (2) Zenker Diverticulum
B. (1) Traction Diverticulum (2) Zenker Diverticulum
C. (1) Epiphrenic Diverticulum (2) Killian Jamieson Diverticulum
D. (1) Zenker Diverticulum (2) Traction Diverticulum
�

2. Most likely cause?

A. (1) Esophageal motor disorder (failure of cricopharyngeus muscle to relax),
(2) Granulomatous Disease
B. (1) Granulomatous Disease, (2) Esophageal motor disorder failure of cricopharyngeus
muscle to relax),

3. Where does the Zenker Diverticulum occur?

A. Just Above the cricopharyngeus muscle
B. Lateral to the suspensory ligaments of the esophagus inserting on the cricoid cartilage
C. Killian's Triangle (Dehiscence)
D. Just above the gastroesophageal junction

This vs That 53
CASE 26 - ESOPHAGEAL DIVERTICULA

Zenker Diverticulum

- These are the posterior ones

- They occur between the oblique and horizontal
fibers of the esophageal wall, known as a Killian
dehiscence or triangle.
- If the cricopharyngeus muscle refuses to relax, a
lot of pressure is generated - this results in
herniation through the weak Killian Triangle.
- Why won't it just relax? Most people say that it's
from a hypertrophied morphology secondary to
chronic reflux.
- Just remember reflux -> Killian Dehiscence.
- These things are classified as "pulsion"
diverticulum ( The Round Kind).
- A true pulsion diverticulum contains no muscle in
their walls) with a peristaltic contraction.

Traction Diverticulum

- The Triangle Kind

- Historically these were caused by TB - and that's
probably still the case outside the US. Other
inflammatory disease (Histo) or radiation can do it
as well. Think about it as a scarring I tethering.

I. Which is which ?
A. (1) Killian Jamieson Diverticulum (2) Zenker Diverticulum
B. (I) Traction Diverticulum (2) Zenker Diverticulum
C. (1) Epiphrenic Diverticulum (2) Killian Jamieson Diverticulum
D. (1) Zenker Diverticulum (2) Traction Diverticulum

2. Most likely cause?

A. (1) Esophageal motor disorder (failure of cricopharyngeus muscle to relax), (2) Granulomatous
Disease
B. (1) Granulomatous Disease, (2) Esophageal motor disorder failure of cricopharyngeus muscle to relax),

3. Where does the Zenker Diverticulum occur?

A. Just Above the cricopharyngeus muscle
B. Lateral to the suspensory ligaments of the esophagus inserting on the cricoid cartilage
C. Killian's Triangle (Dehiscence)
D. Just above the gastroesophagealjunction

This vs That 54
CASE 27 - DECIDED TO HAVE "ONE MORE", TO TRY AND
SAVE THE MARRIAGE

1. Which is which ?
A. (1) Monochorionic (2) Dichorionic
B. (1) Dichorionic (2) Monochorionic

2. Which one of these would be susceptible to "Twin-Twin Transfusion" Syndrome ?

A. (1)
B. (2)

3. Which of the following is true regarding the Umbilical Artery Systolic I Diastolic Ratio?
A. The ratio should increase with gestational age
B. The ration should always be more than 3 at 34 weeks
C. High Resistance patterns are seen with IUGR
D. Reversed diastolic flow is associated with favorable outcomes

4. Which of the following is true regarding Fetal Middle Cerebral Artery Assessment?
A. The fetal MCA should be low resistance, with normal antegrade flow in diastole
B. Checking fetal MCA resistance is done for the workup of fetal anemia & twin-twin
transfusion
C. Fetal MCA SID Ratio should always be lower than the Umbilical Artery S/D ratio

This vs That 55
CASE 27 - TWINS - PLACENTA MORPHOLOGY

Twin-Peak Sign:

- A beak-like tongue between the two

membranes of a dichorionic (2
placentas) diamniotic (2 sacs)
fetuses.
- This excludes a monochorionic
pregnancy.
- This is the good one.

T- Sign:

- This is essentially the absence of

the twin peak sign. You don't see
chorion between membrane layers.
- T sign = monochorionic (1
placenta) pregnancy.
- These are susceptible to lots of bad
things from "blood sharing" -
including twin-twin transfusion.

1. Which is which ? Fetal Doppler Trivia

A. (1) Monochorionic (2) Dichorionic
B. (1) Dichorionic (2) Monochorionic
- Umbilical Artery:
2. Which one of these would be susceptible to "Twin-
- The ratio of systolic to diastolic
Twin Transfusion" Syndrome ? pressure (SID) should decrease
A. (1) with age.
B. (2) - The general rule is 2-3 at 32
weeks. The ratio should not be
3. Which of the following is true regarding the Umbilical
more than 3 at 34 weeks.
Artery Systolic I Diastolic Ratio ?
A. The ratio should increase with gestational age - Elevation shoald make you fhink
B. The ration should always be more than 3 at 34 weeks llJGR or pre-eclarnpsia
C. High Resistance patterns are seen with IUGR
D. Reversed diastolic flow is associated with favorable - MCA SID Ratio:
outcomes - Usually done to monitor anemia
4. Which of the following is true regarding Fetal Middle
(from a variety of causes)
Cerebral Artery Assessment ? - Normal Fetal MCA is high
A. The fetal MCA should be low resistance, with normal resistance. If it turns low
antegrade flow in diastole resistance the head is attempting
B. Checking Fetal MCA resistance is done for the fo "spare itself' - thats bad.
workup of fetal anemia & twin-twin transfusion
- As a general rule the MCA SID
C. Fetal MCA SID Ratio should always be lower than
the Umbilical Artery S/0 ratio should always be higher than the
umbilical one

This vs That 56
CASE 28 - NICU BABY ... PROBABLY NAMED "MIRACLE"

1. What happened to his lungs on Day 2?

A. He developed full on pulmonary edema - tell the intern to give him lasix
B. He developed bilateral interstitial pneumonia -tell the intern to give him ABx
C. This is normal given the procedure he had in the interval (between Day 1 & 2)

2. What is the "primary risk" of the therapy shown in "Day 2" ?

A. Pneumonia
B. NEC
C. Intracranial Hemorrhage
D. Anastomotic Breakdown

3. What is the reason a daily CXR is done after this therapy ?

A. Look for catheter migration (in or out)
B. Detection of subtle pneumonia
C. Detection of interstitial pulmonary edema
D. Because all health care resources are free and unlimited.

This vs That 57
 CASE 28 - ECMO

ECMO
(Extracorporeal Membrane Oxygenation)

- ECMO is a cardiopulmonary bypass technique used to support patients with severe

respiratory or cardiac failure (usually both) unresponsive to conventional ventilatory
support.

- The standard indications for the use of ECMO include meconium aspiration (for
which it actually has pretty good outcomes), primary pulmonary hypertension,
congenital diaphragmatic hernia, and the most common reason in the US which is
the desire to run the NICU bill up as high as possible to burden the parents not only
with the inevitable death of their child but also with an un-payable multi-million dollar
bill, which will then add to the rising cost of health care and the need to reduce
physician salaries (white at the same time raising hospital administrator salaries).

- The main role of the radiologist when reading these daily NICU films is to check for
catheter migration - both in and out. The carotid catheter should terminate over the
arch, and the jugular catheter should terminate over the right atrium.

- Generalized lung opacification (white out) is typical and expected when the patient
is placed on ECMO - as shown on this case. This occurs because of the changes in
pulmonary hemodynamics and physiology from the abrupt change in airway
pressure. Remember the lungs are getting by passed.

- Systemic anticoagulation is required for ECMO. Additionally, there is a known

continuous consumption of platelets that occurs in these patients. These two factors
= make the baby high risk for hemorrhage. As a result, these kids qet daily head
ultrasounds to monitor for this complication (plus the risk of stroke from having their
jugular and carotid ligated on one side).

1. What happened to his lungs on Day 2?

A. He developed full on pulmonary edema - tell the intern to give him lasix
B. He developed bilateral interstitial pneumonia -tell the intern to give him ABx
C. This is normal given the procedure he had in the interval (between Day 1 & 2)

2. What is the "primary risk" of the therapy shown in "Day 2"?

A. Pneumonia
B. NEC
C. Intracranial Hemorrhage
D. Anastomotic Breakdown

3. What is the reason a daily CXR is done after this therapy?

A. Look for catheter migration (in or out)
B. Detection of subtle pneumonia
C. Detection of interstitial pulmonary edema
D. Because all health care resources are free and unlimited.

This vs That 58
 CASE 29 - NICU BABY ... ALSO NAMED "MIRACLE"

.
...
..
..
..
•.
.. ••... ....
..

1. Which is Which ?
A. (1) Umbilical Arterial Catheter, (2) Umbilical Venous Catheter
B. (1) Umbilical Venous Catheter, (2) Umbilical Arterial Catheter

= 2. How can you tell them apart?

A. The venous catheter first goes down, then up
B. The arterial catheter first goes down, then up

3. Which is true about positioning of Umbilical Arterial Catheters?

A. L 1 is the ideal location
B. It should always be above the renals (T6-Tl 0)
C. It should always be below the renals (L3-L5)
D. It can be above (T68-Tl 0) or below (L3-L5) the renals

This vs That 59
CASE 29 - UMBILICAL CATHETERS

UAC

- In order to avoid
placement into (and
T6-T10 thrombosis of)
aortic branches, the
catheter should be
either in a high
SMA& Celiac position (T6-T10)
Renals above the celiac,
mesenteric and
OK renal arteries or in a
low position (L3-L5)
below the inferior
Umbilical mesenteric artery.
Arteries
heads south
first towards
the Internal
Iliac

uvc
- Position at the right
atrium is ideal.

- Placement in the
Umbilical left portal vein can
Vein heads cause a liver infarct
north
towards the
ductus
venosus

3. Which is true about

1. Which is Which ? positioning of Umbilical
A. (1) Umbilical Arterial Catheter, (2) Umbilical Venous Arterial Catheters ?
Catheter A. L 1 is the ideal location
B. (1) Umbilical Venous Catheter, (2) Umbilical Arterial B. It should always be above
Catheter the renals (T6-T1 0)
C. It should always be below
2. How can you tell them apart? the renals (L3-L5)
A. The venous catheter first goes down, then up D. It can be above (T6-T10)
B. The arterial catheter first goes down, then up or below (L3-L5) the
renals

This vs That 60
 CASE 30 - CARDIAC WORKUP

=
1. Which will have more cardiac malformations ?
A. (1)
B. (2)

2. Which is true regarding the IVC positioning ?

A. (1) will have azygous continuation of the IVC, (2) will have reversed aortic/lVC position
B. (1) will have reversed aortic/lVC position, (2) will have azygous continuation of the IVC

3. Which is true regarding lung fissures ?

A. (1) will have two left fissures, (2) will have one right fissure
B. (1) will have one right fissure, (2) will have two left fissures

This vs That 61
CASE 30 - HETEROTAXIA SYNDROMES

uvc
- The major game played on written tests is "left side vs right side."

- So what the hell does that mean?

- I like to start in the lungs. The right side has two fissures (major and minor). The
left side has just one fissure. So if I show you a CXR with two fissures on each
side, (a left sided minor fissure}, then the patient has two right sides. Thus the
term "bilateral right sidedness."

- What else is a right sided structure?The liver. So, these patients won't have a
spleen (the spleen is a left sided structure). The opposite is true, bilateral left sided
patients have polysplenia.

- What about the IVG? Its usually a right sided structure, so it flips in a bilateral right
sided situation.

Bilateral Right Sided Bilateral Left Sided

Increased Cardiac Malformations Less Cardiac Malformations

Reversed Aorta I IVC Azygous Continuation of the IVC

1. Which will have more cardiac malformations ?

A. (1)
B. (2)

2. Which is true regarding the IVC positioning?

A. (1) will have azygous continuation of the IVC, (2) will have reversed aortic/lVC
position
B. (1) will have reversed aortic/IVC position, (2) will have azygous continuation of the IVC

3. Which is true regarding lung fissures ?

A. (1) will have two left fissures, (2) will have one right fissure
B. (1) will have one right fissure, (2) will have two left fissures

This vs That 62
CASE 31 - HIP PAIN I LIMP

II
1. Which is Which ?
A. (1) SCFE, (2) Perthes,
B. (1) Perthes, (2) Development Dysplasia
C. (1) SCFE, (2) Development Dysplasia
D. (1) Development Dysplasia, (2) Perthes

2. Which is true about the classic age for these ?

A. (1) Around 6, (2) Around 12
B. (1) Around 12 (2) Around 6

3. Which of these is bilateral more often?

A. (1)
B. (2)

4. Which is true regarding the treatment of SCFE?

A. You should relocate it first, then pin it
B. You should just pin it, don't relocate it
C. You should never pin it. .. just relocate it

This vs That 63
CASE 31 - THE PEDIATRIC HIP - SCFE VS PERTHES

Slipped Capital Femoral Epiphysis (SCFE)

- This is a type 1 salter harris,

- Unlike most SH1 s, this guy has a bad prognosis if
not fixed.
- The classic history is fat black adolescent (age
12-15) with hip pain.
- It's bilateral in 1 /3 of cases (both hips don't usually
present at same time).
- The frog leg view is the money - think about this
view on "next step" type questions.
- They pin these to stop further slippage, but they do
NOT move the epiphysis back into place
"Klein's Line" - Should intersect
(supposedly that causes AVN and chondrolysis).
the femoral head ... this one
clearly doesn't

Legg-Calve-Perthes

- This is AVN of the proximal femoral epiphysis.

- Favors white males around age 5-8.
- It's bilateral about 10% of the time.
- The subchondral lucency (crescent sign) is best
seen on a frog leg.
- Other early signs include an asymmetric small
ossified femoral epiphysis.
- MRI has more sensitivity. The sequella of a
Flattened collapsed femoral collapsed femoral head is easier to see. Loss of
Head, with widened femoral normal bright T1 marrow.

1. Which is Which ?
A. (1) SCFE, (2) Perthes, 4. Which is true regarding the treatment of
B. (1) Perthes, (2) Development Dysplasia SCFE?
C. (1) SCFE, (2) Development Dysplasia A. You should relocate it first, then pin it
D. (1) Development Dysplasia, (2) Perthes B. You should just pin it, don't relocate it
C. You should never pin it ... just relocate it
2. Which is true about the classic age for these ?
A. (I) Around 6, (2) Around 12
B. (1) Around 12 (2) Around 6

3. Which of these is bilateral more often?

A. (1)
B. (2)

This vs That 64
 CASE 32 - BELLY PAIN

1. Which is Which ?
A. (1) Wilms, (2) Neuroblastoma
B. (1) Neuroblastoma, (2) Wilms
=
2. Which is true ?
A. Neuroblastoma has a better prognosis when it occurs in the chest (versus the abdomen)
B. Wilms tumors calcify more than Neuroblastoma
C. Wilms tumors are seen in a younger population compared to neuroblastoma
D. You can NOT be born with a neuroblastoma
E. If you can't decided between adrenal hemorrhage vs neuroblastoma on ultrasound - the
next best step should be biopsy.

3. What is true about Neuroblastoma "Stage 4S"?

A. Seen in an older population (age 4 and up)
B. Has distal mets to the skin, liver, and bone marrow and has the worst prognosis
C. Has distal mets to the skin, liver, and bone cortex and has an excellent prognosis
D. Has distal mets to the skin, liver, and bone marrow and has an excellent prognosis

This vs That 65
CASE 32 - CLASSIC PEDIATRIC TUMORS -
NEUROBLASTOMA VS WILMS

Neuroblastoma
Staging Trivia: Crossing the Midline is bad
- Prognosis Trivia: Thoracic Primary does better than
Abdomen Primary
- Staging & Prognosis Trivia: Stage 4S is Bone
MARROW, Liver, and Skin - it's seen in kids c 1 year
old and has a pretty good prognosis.

Wilms

- "Solid Renal Tumor of Childhood'

Lots of Associations: Omphaloceles, Hepatoblastomas,
Beckwith Weidemann (Overgrowth Syndromes)
- There are two Wilms Variants, the essential trivia is:
- Clear Cell - Likes to Met to Bones
- Rhabdoid - Terrible Prognosis, associated with high
grade brain tumors

Neuroblastoma Wilms
Usually less than 2 (you can have it in utero) Usually around age 4 (NEVER before 2 months)

Calcifies like 90% Calcification is rare

Encases Vessels . Invades Vessels

Poorly Marginated Well Circumscribed

Mets to Bone Does NOT usually met to bone (exception is the

wilms variant 'clear cell'> which loves bone).
I . Which is Which ?
A. (1) Wilms, (2) Neuroblastoma 3. What is true about Neuroblastoma
B. (I) Neuroblastoma, (2) Wilms "Stage 4S" ?
A. Seen in an older population (age
2. Which is true ? 4 and up)
A. Neuroblastoma has a better prognosis when it B. Has distal mets to the skin,
occurs in the chest (versus the abdomen) liver, and bone marrow and has
B. Wilms tumors calcify more than Neuroblastoma the worst prognosis
C. Wilms tumors are seen in a younger population C. Has distal mets to the skin,
compared to neuroblastoma liver, and bone cortex and has
D. You can NOT be born with a neuroblastoma an excellent prognosis
E. If you can't decided between adrenal hemorrhage D. Has distal mets to the skin,
vs neuroblastoma on ultrasound - the next best step liver, and bone marrow and
should be biopsy. has an excellent prognosis

This vs That 66
 CASE 33 - BELLY PAIN

1. Which is Which ?
A. (1) Small Left Colon Syndrome, (2) Hirschsprung
B. (1) Colonic atresia, (2) Small Left Colon Syndrome
=
C. (1) Hirschsprung Disease, (2) Meconium Ileus

2. Which is true?
A. Small left colon is seen in the children of diabetic mothers
B. Meconium Ileus is not specific to any diagnosis, (it's seen with multiple entities)
C. In Hirschsprungs - the rectum is bigger than the sigmoid colon
D. Heal Atresia is typically a failure to cannulate

3. Which of the following can be "cured" with an enema?

A. Hirschsprung Disease
B. Small Left Colon Syndrome
C. Ileal Atresia
D. Acting Like a Huge Asshole

This vs That 67
CASE 33 - Low OBSTRUCTION IN A NEONATE

Enema Finding = Long Micro Colon

- Meconium lieus-ONLY in patients with CF. The
pathology is the result of tenacious meconium causing
obstruction of the distal ileum. Contrast will reach ilea/ loops,
and demonstrate multiple fiHing defects (meconium).
- This can be addressed with an enema.

- Distal lleal Atresia - This is the result of intrauterine

vascular insult. Contrast will NOT reach ilea/ loops.
- This needs surgery.

Enema Flndin9 = Caliber Change

- Small Left: Transient "Functional" obstruction, seen in
babies of diabetic mothers, or moms who got Mag Sulfate
(for eclampsia)

- Hirschsprung: The rectum (poop bucket) should always be

bigger than sigmoid colon. In Hirschsprungs it is NOT.
"Recto-Sigmoid Ration < 1"
- Another key finding is a sawtooth appearance of the rectum.
- Ox is from biopsy.

I. Which is Which ? Hirsonsprung

A. (1) Small Left Colon Syndrome, (2) Hirschsprung
B. (I) Colonic atresia, (2) Small Left Colon Syndrome
C. (1) Hirschsprung Disease, (2) Meconium lieus

2. Which is true ?
A. Small left colon is seen in the children of diabetic
mothers
B. Meconium Ileus is not specific to any diagnosis, (it's seen
with multiple entities) ** only CF
C. In Hirschsprungs - the rectum is bigger than the sigmoid
colon** S>R
D. Ilea! Atresia is typica11y a failure to cannulate =u» a
vascular insult (usually)

3. Which of the following can be "cured" with an enema?

A. Hirschsprung Disease
B. Small Left Colon Syndrome
C. Ilea! Atresia
D. Acting Like a Huge Asshole * Although an enema is often therapeutic, there is no cure for this condition

This vs That 68
CASE 34 - I TOLD THE ED I ONLY READ THESE AS
INTERMEDIATE, THERE IS REALLY NO POINT IN ORDERING
THE STUDY, BUT HERE IT IS ... THEY NEVER LISTEN.

"PowerSoribe Intermediate"

"B"

"A"

1. Which projection is "A"

A. RAO
B. LAO
C. Anterior
D. Right Lateral

2. Which projection is "B"

A. LPO
B. RPO
C. Posterior
D. Right Lateral

3. How big are the MAA particles for the perfusion part of the VQ?
A. 5 Microns
B. 100 Microns
C. 250 Microns
D. 1000 Microns

This vs That 69
CASE 34 - VQ ANATOMY & TRIVIA

RPO vs LPO:

The posterior views look very

similar. Just Remember the
heart shadow is on the left
(mostly}, so look for the faint
attenuation of tracer (white)
outline of the heart. The right
RPO LPO posterior oblique view won't
have it.

RAO vs LAO:

I like to think of the anterior

oblique views as "almost a
CXR." You can see a lot more
heart shadow compared to a
posterior oblique view.

I use the same thinking about

the heart to distinguish R vs L.
The LAO has a larger heart
shadow (tracer attenuation)
than the right.
1. Which projection is "A"
A. RAO
B. LAO
C. Anterior
D. Right Lateral

2. Which projection is "B"

A. LPO
B. RPO
C. Posterior
D. Right Lateral
A capillary is about 10 micrometers.
You need your particles to stay in
3. How big are the MAA particles for the perfusion the lung, so they can't be smaller
part of the VQ? than that. You don't want
A. 5 Microns them to be so big they block
B. 100 Microns arterioles (150 micrometers).
C. 250 Microns
D. 1000 Microns So the answer is 10-100 microns

This vs That 70
 CASE35-RENALTRANSPLANT

•• II

• 30MI:N JOMI:N II
1. Which is Which ?
A. (1) Cyclosporin Toxicity, (2) ATN
=
B. (1) Acute Rejection, (2) ATN
C. (1) ATN, (2) Acute Rejection
D. (1) ATN, (2) Cyclosporin Toxicity

2. How does one distinguish ATN from Cyclosporin Toxicity ?

A. Flow
B. Perfusion
C. Excretion
D. How long post op they are

3. You get a DMSA scan to evaluate for pyelonephritis. Which of the following is true?
A. Scar and Pyelo Look totally different on DMSA
B. The critical organ for both MAG-3 and DMSA is the bladder
C. Gentamicin does NOT cause problems with DMSA scans
D. Areas of infection appear "cold" (photopenic) on DMSA

This vs That 71
CASE 35 - RENAL TRANSPLANT - RELATED TRIVIA:

I Normal Perfusion Delayed Excretion ATN vs Rejection

ATN:
- Usually in the first week after transplant.
and is more common in cadaveric
donors.
- There will be preserved renal perfusion
with delayed excretion in the renal
parenchyma
- ATN usually gets better.
Shitty - Cyclosporin toxicity can also look like
Perfusion Delayed Excretion ATN (normal perfusion, with retained
tracer) but will NOT be seen in the
z immediate post op period.
0
-I-
o Rejection
w
-, - Will have poor perfusion, and delayed
w excretion.
a: - A chronically rejected kidney won't really
take up the tracer.

DMSA
1. Which is Which ?
A. ( 1) Cyclosporin Toxicity, (2) ATN
B. (1) Acute Rejection, (2) ATN
• Tc-DMSA- is cortically bound, and used
C. (I) ATN, (2) Acute Rejection
D. (I) ATN, (2) Cyclosporin Toxicity for structure more than function.
• The critical organ is the kidney (different
2. How does one distinguish ATN from than MAG-3 - which is the bladder).
Cyclosporin Toxicity ?
A. Flow • Pyelo vs Scar: It's all timing. Both are
B. Perfusion photopenic (cold), but scar is a chronic
C. Excretion finding and pyelo is acute. "Clinical
D. How long post op they are
Correlation"
3. You get a DMSA scan to evaluate for
pyelonephritis. Which of the following is • Nephrotoxic drugs like Gentamicin &
true? Cisplatinum are known to inhibit the
A. Scar and Pyelo Look totally different on uptake of DMSA.
DMSA
B. The critical organ for both MAG-3 and
DMSA is the bladder
C. Gentamicin does NOT cause problems
with DMSA scans
D. Areas of infection appear
"cold" (photopenic) on DMSA

This vs That 72
CASE 36 - HISTORY WITHHELD

Ill II
1. Which is Which ?
A. (1) Normal (2) Diffuse Mets - "Superscan"
B. (1) Diffuse Mets "Superscan", (2) Normal
C. (1) Hyperparathyroidism "Superscan", (2) Diffuse Mets "Superscan"

2. How does one distinguish a "metabolic" vs "metastatic" Superscan ?

A. Extremity Involvement (intensity)
B. Tracer in the bladder
C. Skull Involvement (intensity)
D. They can't be distinguished on the scan, you need blood work

3. Tracer in bone on which of the following is NORMAL?

A. MIBG
B. 1-131
C. Octreotide
D. Gallium

This vs That 73
 CASE 36 - SUPERSCAN(S)

"Metabolic Super Scan"

• You don't see the kidneys (seen in both types).
• The skull seems unusually hot.
• Classic multiple choice answer is= Hyperparathyroidism
• Other things that can do this: renal osteodystrophy,
pagets, or severe thyrotoxicosis.

"Metastatic Super Scan"

• You don't see the kidneys (seen in both types).
• The skull takes up tracer just like the other bones
• Classic multiple choice answer = Breast or Prostate CA

1.
A.
B.
Which is Which ?
(1) Normal (2) Diffuse Mets - "Superscan"
(1) Diffuse Mets "Superscan", (2) Normal
BAD BONES
C. (1) Hyperparathyroidism "Superscan", (2)
The metastatic super scan is not
--. Diffuse Mets "Superscan"
unique to Tc MOP. Remember
2. How does one distinguish a "metabolic" vs thyroid CA and Neuroblastoma will
"metastatic" Superscan ? go to bones.
A. Extremity Involvement (intensity)
B. Tracer in the bladder It is NEVER normal to see bone
C. Skull Involvement (intensity)
uptake on:
D. They can't be distinguished on the scan, you
need blood work

3. Tracer in bone on which of the following is

MIBG
NORMAL? Octreotide
A. MIBG
B. 1-131 1-131
C. Octreotide
D. Gallium * "Poor mans bone scan"

This vs That 74
CASE 37-TERRORISTS HAVE ATTACKED!!

I. Which is Which ?
A. (1) Geiger Muller Counter (2) Ion Chamber
B. (1) Ion Chamber, (2) Gieger Muller Counter

2. Which of these devices would you want to use for higher doses (the terrorist attack)?
A. (1)
B. (2)

3. Hospital administration needs someone to assist the National Guard in checking the
radiation levels after Al-Qaeda attacked the hospital with a "dirty bomb." The Chairman
called down and asked your Attending to do it, but your attending thinks it would be a good
learning experience for you ... the Trainee. On the way to ground zero, you encounter a
smiling medical student (who is wearing one of those dorky short white coats). You ask him
ifhe would like a good learning experience. He says yes out of fear (secretly he hates
learning, he only went into medicine to keep his Indian parents from disowning him). You
hand him device "l ", and he enters the radioactive room. The device clicks once, then stops.
What does this mean ?
A. He is probably gonna die of acute radiation poisoning.
B. He is totally gonna be fine.

This vs That 75
CASE 37 - TOOLS THAT TECHS USE (AND DOCTORS DON'T)
BUT ARE FOR SOME REASON TESTABLE.

"Geiger-Mueller Counter"
• How it works: It has a gas filled chamber, with a HIGH voltage
applied from an anode to cathode. Radiation causes the
conduction of an electric current, which can be measured.

• A single ionization can result in a "Townsend Avalanche'', which

really increases the sensitivity. The downside of this is that it takes
time to dissipate.
*Very Sensitive
• Dead Time - The GM Counter can get over-run by high levels
*Problems with High Levels
because of the need for things to dissipate. If the meter clicks
once then stops ... that means it's flooded, and it's probably dead
time - for the person holding the probe.

"Ionization Chamber"
• How it works: It has a gas filled chamber, with a LOW voltage
applied from an anode to cathode. Radiation causes the
conduction of an electric current, which can be measured.

• Because of the low voltage applied it has no avalanche effect and

is therefore less sensitive at very low levels. The upside is that it
does not encounter "dead time" tissues, and it superior for very
high levels of radiation (like Dirty Bombs).
*Less Sensitive
*No Problems with High
Levels

I. Which is Which?
A. (1) Geiger Muller Counter (2) Ion Chamber
B. (]) Ion Chamber, (2) Gieger Muller Counter

2. Which of these devices would you want to use for higher doses (the terrorist attack)?
A. (1)
B. (2)

3. Hospital administration needs someone to assist the National Guard in checking the radiation
levels after Al-Qaeda attacked the hospital with a "dirty bomb." The Chairman called down and
asked your Attending to do it, but your attending thinks it would be a good learning experience for
you ... the Trainee. On the way to ground zero you encounter a smiling medical student (who is
wearing one of those dorky short white coats). You ask him if he would like a good learning
experience. He says yes out of fear (secretly he hates learning, he only went into medicine to keep his
Indian parents from disowning him). You hand him device "1 ", and he enters the radioactive room.
The device clicks once, then stops. What does this mean ?
A. He is probably gonna die of acute radiation poisoning.
B. He is totally gonna be fine.

This vs That 76
 CASE 38 - THERE ARE TWO PACKAGES TO CHECK IN

1. Which is true ?
A. No special instructions are needed for a "Yellow II" package
B. The surface dose rate of a "Yellow III" should not exceed 200 mrem/hr
C. Packages should be checked in within 5 hours of receipt
D. A "common carrier" is a truck that carries different kinds of radiopharmaceuticals

=
2. What is that square box under the word "radioactive"? (I put an arrow on it)
A. It's the dose of the pharmaceutical (in mCu)
B. It's the surface dose at the time of check in ("Check Index")
C. It's the surface dose at the time of shipping ("Shipping Index")
D. It's the dose at 1 meter at the time of shipping ("Transportation Index")

3. Which is true ?
A. The T.I. for "1" should not exceed 1 mR per hour
B. The T.I. for "2" should not exceed 1 mR per hour
C. If the allowable limit is exceeded, you only need to contact the NRC
D. There is a Yellow 1.

This vs That 77
CASE 38 - RECEIVING RADIOACTIVE MATERIAL

Testable Trivia:

- Whose job is it to check in the package ? - A Tech ... not a Radiologist

- Who will be tested on obscure trivia applicable to a task they have never done, and will never
do ? - The Radiologist

- How long do you have to check in the package ? 3 hours

- What are the limits? There are 3 classes. "White 1", "Yellow 2', and "Yellow 3." Yes, I said
"Yellow 3," these assholes couldn't just pick another color. There is no "Yellow 1"

Limits are as follows:

• White 1: No special handling, surface dose rate c 0.5 mrem/hr, 1 meter O mrem/hr
• Yellow 2: Surface dose rate « 50 mrem/hr, 1 meter< 1 mrem/hr
• Yellow 3: Surface dose rate c 200 mrem/hr, 1 meter< 10 mrem/hr

- The box under the word radiation is for the "transportation index," This is the dose rate
measured at 1 meter at the time of shipping.

Limits are as follows:

• White 1 : There is no T. I. because the rate at 1 meter will be so low.
• Yellow 2: The T.I. ls « 1.0 mR per hour.
• Yellow 3: The T.I. is> 1.0 mR per hour.

- If the package is over the limit you have to contact (1) NRG, and (2) the Shipper

- "Common Carrier" is someone who caries both radioactive packages and regular stuff

1. Which is true ?
A. No special instructions are needed for a "Yellow II" package
B. The surface dose rate of a "Yellow III" should not exceed 200 mrem/hr
C. Packages should be checked in within 5 hours ofreceipt
D. A "common carrier" is a truck that carries different kinds of radiopharmaceuticals

2. What is that square box under the word "radioactive"? (I put an arrow on it)
A. It's the dose of the pharmaceutical (in mCu)
B. It's the surface dose at the time of check in ("Check Index")
C. It's the surface dose at the time of shipping ("Shipping Index")
D. It's the dose at 1 meter at the time of shipping ("Transportation Index")

3. Which is true?
A. The T.I. for "1" should not exceed 1 mR per hour
B. The T.I. for "2" should not exceed 1 mR per hour
C. If the allowable limit is exceeded, you only need to contact the NRC
D. There is a Yellow 1.

This vs That 78
CASE 39 - SHIT! I DROPPED IT ....

1. Which of the following is true, regarding major vs minor spills ?

A. Activity level greater than 10 mCi ofTc-99m is considered a major spill.
B. Activity level greater than 100 mCi ofTl-201 is considered a major spill.
C. Activity level greater than 1 mCi of In-111, is considered to represent a major spill.
D. Activity level greater than I mCi of Ga-67, is considered to represent a major spill.

2. Which of the following is true?

A. You should clean up a major spill, then call the Radiation Safety Officer (RSO) to Check
your work
B. You should let the RSO clean up the major spills

3. Which is true?
A. Agreement states can have less strict rules than the National Agency
B. Agreement states can be more strict than the National Agency

This vs That 79
 CASE 39 - RADIATION SAFETY I CONTAMINATION

Testable Trivia:

- The "NRC" is the governing body that has been charged with the task of enforcing all these
various directives. It is possible for individual states to reach an agreement with the Federal
Government to enforce these rules on their own. These are called "Agreement States", and
the main thing to know is that they can be more strict, but not less strict than the national
agency.

- Spills can be broken into major and minor spills

- Major Spills:
• Activity level greater than 100 mCi of Tc-99m is considered a major spill.
• Activity level greater than 100 mCi of Tl-201 is considered a major spill.
• Activity level greater than 1 O mCi of ln-111, is considered to represent a major spill.
• Activity level greater than 10 mCi of Ga-67, is considered to represent a major spifl.
• Activity level greater than 1 mCi of 1-131 is considered to constitute a major spill.

- Radiation Safety Officer (RSO) needs to be notified immediately when a major spill occurs, to
direct the decontamination process. You can clean up the Minor Spills Major Spills are
cleaned under the direction of the RSO.

1. Which of the following is true?

A. Activity level greater than 10 mCi of Tc-99m is considered a major spill.
B. Activity level greater than 100 mCi of Tl-201 is considered a major spill.
C. Activity level greater than 1 mCi of In-111, is considered to represent a major spill.
D. Activity level greater than 1 mCi of Ga-67, is considered to represent a major spill.
=
2. Which of the following is true?
A. You should clean up a major spill, then call the Radiation Safety Officer (RSO) to Check
your work
B. You should let the RSO clean up the major spills

3. Which is true ?
A. Agreement states can have less strict rules than the National Agency
B. Agreement states can be more strict than the National Agency

This vs That 80
CASE 40 - MORE STUFF TECHS 00

1. Which is Which ?
A. Radionuclide Purity = How much Al is in the Tc, Chemical Purity = How much Mo is in
the Tc, Radiochemical Purity = How much Free Tc
B. Radionuclide Purity = How much Mo is in the Tc, Chemical Purity = How much Al is in
the Tc, Radiochemical Purity = How much Free Tc
C. Radionuclide Purity = How much Free Tc, Chemical Purity = How much Al is in the Tc,
Radiochemical Purity = How much Mo is in the Tc

2. Which of the following is true?

A. You test Chemical Purity with pH paper
B. You test Radionuclide Purity with Thin Layer Chromatography
C. You test Radiochemical Purity with a Dose Calibrator

3. Which is of the follow is true regarding Radionuclide Purity ?

A. The limit is 0.15 microcuries of Mo per 1 millicurie of Tc
B. The limit is 0.15 millicuries of Mo per 1 millicurie of Tc
C. The limit is 0.15 millicuries of Mo per 1 microcurie ofTc

This vs That 81
CASE 40 - TC PURITY

Tc99 is produced from a "generator" of Molybdenum (which has a much longer half
life than Tc). The generator is basically a tube with Moly stuck to Aluminum walls.
As the Moly breaks down into Tc it becomes less sticky. If you run water over it, the
Tc will wash off the Aluminum column. Because of this process, there is the
potential to have contamination from both Moly, and washed off Aluminum. This is
tested for, and therefore you are likely to be tested on how it's tested for.

Vocab What is it? Tested? Limit?

Tested in a dose
Radionuclide How much Mo 0.15 microcuries of Mo per 1
calibrator with lead
Purity in the Tc? millicurie of Tc
shields;

Chemical How much Al Tested with pH

< 10 micrograms Al per 1 ml
Purity in the Tc? paper
• 95% Na99mTc04
Tested with Thin • 92%for 99mrc sulfur
Radiochemical How much
Layer colloid (MAA)
Purity Free Tc?
Chromotography • 91 % for all other Tc
radiopharmaceuticals

1. Which is Which ?
A. Radionuclide Purity = How much Al is in the Tc, Chemical Purity = How much Mo is in the Tc,
Radiochemical Purity= How much Free Tc
B. Radionuclide Purity= How much Mo is in the Tc, Chemical Purity= How much Al is in the
Tc, Radiochemical Purity = How much Free Tc
C. Radionuclide Purity= How much Free Tc, Chemical Purity= How much Al is in the Tc,
Radiochemical Purity= How much Mo is in the Tc

2. Which of the following is true?

A. You test Chemical Purity with pH paper
B. You test Radionuclide Purity with Thin Layer Chromatography
C. You test Radiochemical Purity with a Dose Calibrator

3. Which is of the follow is true regarding Radionuclide Purity?

A. The limit is 0.15 microcuries of Mo per 1 millicurie of Tc
B. The limit is 0.15 millicuries of Mo per l millicurie of Tc
C. The limit is 0.15 millicuries of Mo per l microcurie of Tc

This vs That 82
CASE 41 - LABELS ON THE AXIS OF A GRAPH ARE A LUXURY

1. Which is Which ?
A. "1" is Beta Plus "2" is Beta Minus
B. "1" is Beta Plus, "2" is Electron Capture
C. "1" is Beta Minus, "2" is Beta Plus
D. "l" is Electron Capture, "2" is Beta Plus

2. Which of the following is true?

A. Beta Minus is seen with Neutron Excess
B. Beta Plus is seen with Neutron Excess
C. Electron Capture is seen with Neutron Excess

3. Which of the following is true?

A. Beta Plus occurs in the setting of insufficient energy (less than 1.02 Me V)
B. Beta Plus occurs in the setting of insufficient energy (less than 511 keV)
C. Electron Capture occurs in the setting of insufficient energy (less than 1.02 Me V)
D. Electron Capture occurs in the setting of insufficient energy (less than 511 keV)

4. What is the best shield against a beta emitter?

A. Lead
B. Plastic

This vs That 83
CASE 41 - TRANSMUTATION GRAPHS I TRIVIA

Beta Minus Decay

\----
• Seen with Neutron Excess.
>, • A neutron is converted to a proton, then emits an electron
,._
Ol (beta particle) and antineutrino.
Q)
c • Worthless for imaging, but can harm DNA.
w
• Used for Radionucleotide Therapy with 32P, 89Sr, 90Y,
1311, and 153Sm
Atomic Number

Beta Plus Decay

>, • Seen with Proton E>ecess (Neutron Deficiency).
,._
Ol
• A proton is "transformed" into a neutron. (Trivia to know=
Q)
c you need 1.02MeV for this to occur}
w
• A positron (beta particle) is then emitted which collides into
a real [Link] mutual destruction emits two 511 keV
photons which come out 180 degrees apart.
Atomic Number • Used for PET

Electron Capture

I/
• Also Seen with Proton Excess (Neutron Deficiency).
• This occurs in the setting of insufficient energy (remember
beta plus needs 1.02MeV).
• A proton eats (captures) an electron and then turns into a
neutron. The neutron (formerly a proton) then burps (emits)
characteristic radiation
Atomic Number • Used for most Diagnostic Imaging

1. Which is Which ?
A. "l" is Beta Plus "2" is Beta Minus
B. "1" is Beta Plus, "2" is Electron Capture
C. "l" is Beta Minus, "2" is Beta Plus
D. "!" is Electron Capture, "2" is Beta Plus

2. Which of the following is true?

A. Beta Minus is seen with Neutron Excess
B. Beta Plus is seen with Neutron Excess
C. Electron Capture is seen with Neutron Excess

3. Which of the following is true?

A. Beta Plus occurs in the setting of insufficient energy (less than 1.02 Me V)
B. Beta Plus occurs in the setting of insufficient energy (less than 511 keV)
C. Electron Capture occurs in the setting of insufficient energy (less than 1.02 MeV)
D. Electron Capture occurs in the setting of insufficient energy (less than 511 keV)

4. What is the best shield against a beta emitter?

A. Lead * (NOT LEAD because it will create Bremmstahlung x-rays).
B. Plastic

This vs That 84
 CASE 42 - I .JUST LOOK AT THE COLOR PICTURES

II
=
1. Which is Which ?
A. "1" is Uncorrected, "2" is Corrected
B. "1" is Corrected, "2" is Uncorrected

2. Is PET Attenuation depth dependent ?

A. Yes, it's depth dependent - just like CT
B. No, it's depth independent

3. Which is true regarding a Pacemaker ?

A. It will look HOT on the corrected PET
B. It will look HOT on the uncorrected PET
C. It will look COLD on both corrected & uncorrected

This vs That 85
CASE 42 - ATTENUATION CORRECTION

Uncorrected Corrected
• DARK Skin • LIGHT Skin
• DARK Lungs • LIGHT Lungs

Attenuation Correction
• The CT part of PET-CT is performed for two main reasons: (1) so that you can see
where things are and (2) for attenuation correction.

• Attenuation correction is a correction for the different levels of attenuation a photon

might undergo as it tries to get out of the body to the detector. Think about traveling
through bone vs traveling through lung.

• The classic trick is the pacemaker (metal) making something appear really really hot -
when attenuation is corrected for. This is why you always look at the uncorrected data,
when reading a PET.

1. Which is Which ?
A. "1" is Uncorrected, "2" is Corrected
B. "1" is Corrected, "2" is Uncorrected

2. Is PET Attenuation depth dependent ?

A. Yes, it's depth dependent - just like CT
B. No, it's depth independent

3. Which is true regarding a Pacemaker?

A. It will look HOT on the corrected PET
B. It will look HOT on the uncorrected PET
C. It will look COLD on both corrected & uncorrected

This vs That 86
 CASE 43 - EVAL FOR RUPTURE

1. Which is Which ?
A. "1" is Intra Capsular Rupture "2" is Extra Capsular Rupture
B. "I" is Extra Capsular Rupture, "2" is Intra Capsular Rupture
= C. "I" is an example of "Radial Folds", "2" is Intra Capsular Rupture
D. "I" is Intra Capsular Rupture, "2" is an example of"Radial Folds"

2. Which of the following is true?

A. You can have isolated intra capsular rupture, but you cannot have isolated extra capsular
rupture
B. You can have isolated extra capsular rupture, but you cannot have isolated intra capsular
rupture
C. You can have isolated intra and extra capsular rupture

3. What is the typical sequence for evaluating implants?

A. Heavy Tl weighting with Fat Sat
B. Heavy T2 weighting with Fat Sat
C. Heavy T2 weighting with both Fat and Water Sat
D. Diffusion

This vs That 87
 CASE 43 - IMPLANT RUPTURE

: Radial Folds �ntracapsular Rupture: Extra & lntracapsular

! - Guys like squishy boobs. I-
The "capsule" is not part of - You can NOT have
1
The bigger and the I the implant. It's th� fibrous isolated extra capsular
squishier the better. !
coat your body makes (the silicone: It has to
- Therefore, implants are not outer black line iA my make it through the
bound tightly - so they can I diagram). implant shell first.
be squishy. - Silicone can rupture - Silicone outside the
i - Because they are loosely through the shell of the capsule can create a
bound the shell in-folds implant, but stay confined "snow storm" look on
creating radial folds inside the fibrous coat - this ultrasound. It can also
I - The folds always attach is intra-capsular rupture. infiltrate lymph nodes
i to the shell* - irhe classic sign is the and do the same
- The folds are thicker than flo�ting .. linguine" - as in (snow storm nodes).
a rupture, because they these case.
represent both layers.

1. Which is Which ?
A. "1" is Intra Capsular Rupture "2" is Extra Capsular Rupture
B. "1" is Extra Capsular Rupture, "2" is Intra Capsular Rupture
C. "1" is an example of "Radial Folds", "2" is Intra Capsular Rupture
D. "1" is Intra Capsular Rupture, "2" is an example of "Radial Folds"

2. Which of the following is true?

A. You can have isolated intra capsular rupture, but you cannot have isolated extra capsular
rupture
B. You can have isolated extra capsular rupture, but you cannot have isolated intra capsular rupture
C. You can have isolated intra and extra capsular rupture

3. What is the typical sequence for evaluating implants ?

A. Heavy Tl weighting with Fat Sat
B. Heavy T2 weighting with Fat Sat
C. Heavy T2 weighting with both Fat and Water Sat - "Silicone Sequences" are usually heavily T2-
weighted, with both fat and water suppression. Silicone will be bright white on these sequences
D. Diffusion

This vs That 88
CASE 44 - MALE MAMMOGRAM (UGH, THE HORROR)

1. Which is Which ?
A. "1" is Gynecomastia "2" is Pseudo - Gynecomastia
B. "1" is Gynecomastia "2" is Breast CA
C. "1" is Breast CA "2" is Gynecomastia

2. Which of the following is true?

A. Males who have had gender reassignment (on hormones) should get screening
mammograms
B. BRCA 1 is more common than BRCA 2 - in men with breast CA
C. Klinefelter patients have increased risk for Breast CA.
D. Gynecomastia is typically eccentric to the nipple

This vs That 89
CASE 44 - THE MALE BREAST

Gynecomastia
• This is a non-neoplastic enlargement of the
epithelial and stromal elements in a man's breast

• Just think flame shaped, behind nipple, bilateral but

asymmetric, and can be painful.

• Associated with a variety of conditions

(spironolactone, psych meds, marijuana, alcoholic
cirrhosis, testicular cancer).

• NEVER evaluate it on ultrasound. Always get a

mammogram. It will look scary on US - don't let
this trick you.

Male Breast CA
• It's uncommon in men, and very uncommon in
younger men (average age is around 70).

• BRCA 2 is the more common than BRCA 1 in men

• It's always ductal (usually IDC-NOS), it' cannot be

lobular because the male breast doesn't have
lobules.

-On mammography it looks like a breast cancer, if it

was a woman's mammogram you BR-5 it. On
ultrasound it's the same thing, it looks like a BR-5.

• Things that make you think it's breast cancer:

Eccentric to Nipple, Unilateral, Abnormal Lymph
nodes. Calcifications

1. Which is Which ?
A. "I" is Gynecomastia "2" is Pseudo - Gynecomastia
B. "1" is Gynecomastia "2" is Breast CA
C. "I" is Breast CA "2" is Gynecomastia

2. Which of the following is true?

A. Males who have had gender reassignment (on hormones) should get screening mammograms
8. BRCA I is more common than BRCA 2 - in men with breast CA
C. Klinefelter patients have increased risk for Breast CA.
D. Gynecomastia is typically eccentric to the nipple

This vs That 90
CASE 45 - "SCREENING" MRI

1. Which is Which ?
A. "1" is on Tamoxifen "2" is off Tamoxifen
B. "1" is off Tamoxifen "2" is on Tamoxifen

2. When should you do a screening breast MRI?

A. Early in the menstrual cycle (day 7-20)
B. Late in the menstrual cycle (day 15-30)
C. Timing of cycle doesn't matter

3. What is the exception to the "T2 Bright things are benign" in the breast rule ?
A. JDC
B. Radial Scar
C. Colloid Cancer

This vs That 91
CASE 45 - "SCREENING" MRI

Background Parenchyma Enhancement (BPE):

• Is it normal ? - Yes

• Where is it most common ?- Posterior Breast in the upper outer quadrant

• Why that location ? It's all based on vascular supply to the breast. Enhancement occurs
peripheral to central (retro-areolar area enhances last). This is called "picture
framing." Although enhancement of the nipple is still considered normal - a common
trick is to try and get you to call nipple enhancement Paget's Breast... don't fall for that
bush-league shit.

• How do you reduce it?- Do the MRI during the first part of the menstrual cycle (day
7-20). - Optimal is around week 2. They say background uptake is highest weeks 1
and 4.

• What does Tamoxifen do?- Tamoxifen will decrease background parenchyma uptake.
Then it causes a rebound.

1. Which is Which ?
A. "1" is on Tamoxifen "2" is off Tamoxifen ** Rebound Effect
B. "1" is off Tamoxifen "2" is on Tamoxifen

2. When should you do a screening breast MRI ?

A. Early in the menstrual cycle (day 7-20)
B. Late in the menstrual cycle (day 15-30)
C. Timing of cycle doesn't matter

3. What is the exception to the "T2 Bright things are benign" in the breast rule ?
A. IDC
B. Radial Scar
C. Colloid Cancer ** also called mucinous.

This vs That 92
CASE 46 - FAMILY MEDICINE HEARD A NECK BRUIT

I. Which is Which ?
A. "I" is the internal carotid, "2" is the external carotid
B. "I" is the external carotid "2" is the internal carotid

2. Which is true?
A. In the internal carotid the diastolic velocity NEVER returns to baseline
B. In the external carotid color flow is continuous through the cardiac cycle
C. In the internal carotid there should be maintained high resistance
D. The internal carotid can be identified by looking for branching vessels

3. What does the "TT" stand for on "I" ?

A. It's the Sonographers initials
B. It describes a confirmatory maneuver for this vessel
C. Patient has had tentanus toxoid
D. Patient has elevated thrombin time

This vs That 93
CASE 46 - CAROTID ULTRASOUND - INTERNAL VS EXTERNAL

External Carotid

• Flow to muscles of the face is optional (doesn't need to

be on). Therefore you can have:

• High Resistance
• High Systolic Velocity
• Diastolic velocity approaches zero baseline
• Color flow is intermittent during the cardiac cycle

• Temporal Tap - This is a point of trivia, that I guess one

can perform. It is a technique Sonographers use to tell
the external carotid from the internal carotid. You tap the
temporal artery on the forehead and you see ripples in
the spectrum.

• Branches - Looking for branches is another

confirmation test to tell internal vs external.

Internal Carotid

• The brain is always on. Therefore you need:

• Low Resistance
• Low Systolic Velocity
• Diastolic velocity NEVER approaches zero baseline
(unless the patient is brain dead)
• Color flow is continuous during the cardiac cycle

1. Which is Which ?
A. "l" is the internal carotid, "2" is the external carotid
B. "1" is the external carotid "2" is the internal carotid

2. Which is true ?
A. In the internal carotid the diastolic velocity NEVER returns to baseline
B. In the external carotid color flow is continuous through the cardiac cycle
C. In the internal carotid there should be maintained high resistance
D. The internal carotid can be identified by looking for branching vessels

3. What does the "TT" stand for on "l" ?

A. It's the Sonographers initials
B. It describes a confirmatory maneuver for this vessel * temporal tap
C. Patient has had tentanus toxoid
D. Patient has elevated thrombin time

This vs That 94
CASE 47 - FAMILY HISTORY OF ANEURYSM

1. Which is Which ?
A. "1" is Marfans, "2" is Loeys-Dietz
B. "1" is Loeys-Dietz "2" is Marfans

2. Which is true ?
A. "2" often presents with a dislocated lens ( ectopia lentis)
B. Of the two, "1" has the greater risk of rupture ( occurs at smaller diameter)
C. "2" often has a birth history of cleft palate
D. "1" Classically spares the aortic sinus

3. What is the buzzword used to describe #1 's aorta?

A. Tulip Bulb
B. Flower Pot
C. The "Abraham Lincoln"
D. Dropping Lilly

This vs That 95
 CASE 47 - CONNECTIVE TISSUE DISORDERS
MARFANS VS LOEYS-DIETZ

Marfans

• Inherited (AD) Connective tissue disorder

• Caused by retarded Fibrillin (micro-fibrils)

• Think About Marians With:

• "Annulo-Aortic-Aneurysm" - with dilation starting in the
aortic sinus progressing into the sinotubular junction
then the annulus - Tulip Bulb Appearance
• This style of dilation leads to aortic valve regurg
• Aneurysms occur early in life (classic before age 50)
• Calcification of the mitral annulus before age 40
• Dilation of the main PA before age 40
• Also, these are tall goofey looking dudes with ugly
Dilation Favors the Root pectus deformities

Loeys-Dietz

• Inherited (AD) Connective tissue disorder

,
• Caused by retarded CeH Signaling (TGF-13)

• Think About Loeys-Dietz With:

• Crazy looking tangled vertebral arteries
• "Roller Coaster Loops" in the vessels of the neck
• Classic Triad: Aneurysms, Hypertelorism ("Crazy Eyes")
=
and a Cleft Palate (sometimes Bifid Uvula).

• Trivia: Unlike Marians does NOT have an association

with lens dislocation (ectopia lentis)
Roller Coaster Loop • Trivia: Will rupture I dissect earlier than Marfans.
Think about this as the bad ass cousin of Marians.

I. Which is Which ?
A. "1" is Marfans, "2" is Loeys-Dietz
3. What is the buzzword
B. "]" is Loeys-Dietz "2" is Marfans
used to describe #I's aorta ?
A. Tulip Bulb
2. Which is true ?
B. Flower Pot
A. "2" often presents with a dislocated lens (ectopia lentis)
C. The "Abraham
B. Of the two, "1" has the greater risk of rupture (occurs at
Lincoln"
smaller diameter)
D. Dropping Lilly
C. "2" often has a birth history of cleft palate
D. "I" Classically spares the aortic sinus

This vs That 96
CASE 48 - HYPERTENSION

1. Which is Which ?
A. "I" is FMD "2" is Atherosclerosis
B. "1" is Atherosclerosis "2" is FMD

2. Which is the preferred treatment for each ?

A. "1" Gets Angioplasty+ Stent, "2" Gets Angioplasty but no stent
B. "l" Gets Angioplasty but no Stent, "2" Gets Angioplasty+ Stent
C. They both get Angioplasty + Stent
D. I'm not doing IR! I hate procedures! Why do you think I went into Radiology !?

3. The disease process in "2" is most likely to involve what other vessels?
A. The Aortic Root
B. The Iliacs
C. The Subclavian
D. The Femoral Artery

This vs That 97
CASE 48 - RENAL ARTERY - ATHEROSCLEROSIS VS FMD

Atherosclerosis

• This is actual disease of the aorta that involves the

ostia of the renal arteries. This is why the disease is
very proximal (close to the aorta).

• The patient is gonna be old (or a fat diabetic smoker

who strongly believes he's entitled to free treatment).

• It's somewhat controversial, but lets just say if you

have a significant pressure gradient most people
believe that Angioplasty + Stent is the right answer.

Fibromuscular DyspJasia

• Nonatherosclerotic vascular disease, primarily

affecting the renal arteries of young white women.

• Tends to involve the middle part of the vessel (not

proximal like athero).

• Has a "string of beads" appearance.

• Renal arteries are the most commonly involved

(carotid #2, iliac #3)

• They are predisposed to spontaneous dissection

• Treatment = Angioplasty WITHOUT stenting.

I. Which is Which ?
A. "1" is FMD "2" is Atherosclerosis
B. "1" is Atherosclerosis "2" is FMD

2. Which is the preferred treatment for each ?

A. "1" Gets Angioplasty+ Stent, "2" Gets Angioplasty but no stent
B. "1" Gets Angioplasty but no Stent, "2" Gets Angioplasty+ Stent
C. They both get Angioplasty+ Stent
D. I'm not doing IR! I hate procedures! Why do you think I went into Radiology!?

3. The disease process in "2" is most likely to involve what other vessels?
A. The Aortic Root
B. The Iliacs
C. The Subclavian
D. The Femoral Artery

This vs That 98
 CASE 49 - ARTHROGRAM TIME

1. Where is the ideal puncture site for an arthrogram on "1" ?

A. Triangle
B. Square
C. Hexagon
= D. Star

2. Where is the ideal puncture site for an arthrogram on "2" ?

A. Triangle
B. Square
C. Hexagon
D. Star

3. What is the correct mix to put in shoulder ?

A. 12 total cc (4cc Lidocaine, 7cc Visipaque, and only about lee Gd).
B. 12 total cc ( 4cc Lidocaine, Sec Visipaque, and only about O. lee Gd).
C. 6 total cc (2cc Lidocaine, 4cc Visipaque, and only about [Link] Gd).
D. 30 total cc (5cc Lidocaine, 15cc Visipaque, and only about lOcc Gd).

This vs That 99
 CASE 49 - ARTHROGRAM TIME

Target

Target
Head/Neck\
"-,.0 Junction

Target: Junction between the middle and Target: Lateral Femoral Head Neck
inferior thirds of the humeral head - 2mm Junction
inside the cortex
Cocktail: Around i4cc total (4cc Lidocaine,
Cocktail: Around i2cc total (4cc iOcc Visipaque, and only about 0. i cc Gd).
Lidocaine, Sec Visipaque, and only about
[Link] Gd).

1. Where is the ideal puncture site for an arthrogram on "1" ?

A. Triangle
--=
B. Square
C. Hexagon
D. Star

2. Where is the ideal puncture site for an arthrogram on "2" ?

A. Triangle
B. Square
C. Hexagon
D. Star

3. What is the correct mix to put in shoulder ?

A. 12 total cc (4cc Lidocaine, 7cc Visipaque, and only about lee Gd).
B. 12 total cc (4cc Lidocaine, Sec Visipaque, and only about [Link] Gd).
C. 6 total cc (2cc Lidocaine, 4cc Visipaque, and only about O. lcc Gd).
D. 30 total cc (Sec Lidocaine, 15cc Visipaque, and only about lOcc Gd).

This vs That 100

CASE 50 - SOME FAT DIABETIC WITH A 100 PACK YEARS
HAS A COLD LEG .... IR TO THE RESCUE

��-------),1-------::::=::--�
�

�-
/
1. What is a "French" ?
A. 1 mm
B. 3mm
C. 0.3 mm
D. A cowardly rude European

2. What sized guide wire will fit in a 5F Catheter ?

A. 3F
B. 4F
C. 5F
D. 6F

3. Which is true ?
A. "French" refers to the inner diameter of a sheath, not a catheter
B. "French" refers to the inner diameter of a catheter, not a sheath
C. "French" is a "French" - always means the inner diameter, regardless of catheter or
sheath

4. How many French is a standard 0.038 wire?

A. 3 F
B. 4 F
C. 5 F

This vs That 101

CASE 50 - ANGIO SIZING BASICS

Basic Trivia:

• 3 French = 1 mm , so 1 French is 1 /3 of a mm or 0.3mm.

• Guidewire terminology "0.038, 0.035 ... etc ... " are actually given in INCHES
• 0.038 (inches) is about 3 French

Catheters: Sheath:

• The "French Size" refers to the OUTER • The "French Size" refers to the INNER
diameter. diameter.
• The wall of the device is about 1-2 French • A 5F introducer (sheath) can accept a
• An 0.038 Wire (3F) will fit in most 5F 5F Catheter
catheters. • The wall of the device is about 1-2
French
• Therefore a 5F introducer (sheath)
makes a 6-7F sized hole (about 2mm)
hole in the patient's skin

This would be a This would be

SF Catheter a 3F Sheath

1. What is a "French" ? 3. Which is true?

A. Imm A. "French" refers to the inner diameter of
B. 3mm a sheath, not a catheter
C. 0.3 mm B. "French" refers to the inner diameter of a
D. A cowardly rude European catheter, not a sheath
C. "French" is a "French" - always means the
2. What sized guide wire will fit in a SF Catheter ? inner diameter , regardless of catheter or
A. 3 F sheath
B. 4 F
C. 5 F 4. How many French is a standard 0.038 wire?
D. 6F A. 3 F
B. 4 F
C. 5 F

This vs That 102

This vs That 103
Anatomy Quiz ?.
What is that?
What attaches there?
What goes through that?

Anatomy 1
CASE 1 - THE SKULL BASE (PART 1)

1. What is "A" ?
A. Superior Orbital Fissure
B. Internal Auditory Canal
C. Foramen Rotundum
D. Pterygopalatine Fossa (PPF)

2. What is "B" ?
A. Inferior Orbital Fissure
B. Foramen Ovale
C. Foramen Rotundum
D. Pterygopalatine Fossa (PPF)

3. What passes through "B"?

A. CNVl
B. CNV2
C. CNV3
D. CN6
E. CN4

Anatomy 2
CASE 1 - THE SKULL BASE {PART 1)

1. What is "A" ? 3. What passes through "B "?

A. Superior Orbital Fissure A. CNVl
B. Internal Auditory Canal B. CNV2
C. Forarnen Rotundum C. CNV3
D. Pterygopalatine Fossa (PPF) D. CN6
E. CN4
2. What is "B" ?
A. Inferior Orbital Fissure
B. Foramen Ovale
C. Foramen Rotundum
D. Pterygopalatine Fossa (PPF)

Anatomy 3
CASE 2- THE SKULL BASE (PART 2)

1. What is "A" ? 3. What passes through "A"?

A. CNVI
A. Foramen Spinosum
B. CNV2
B. Foramen Ovale
C. CNV3
C. Foramen Rotundum
D. CN6
D. F oramen Lacerum
E. CN4
2. What is "B" ?
A. Forament Spinosum 4. What passes through "B"?
B. F oramen Ovale A. CNVI
C. Foramen Rotundum B. CNV2
D. F oramen Lace rum C. CNV3
D. Middle Meningeal Artery
E. Nothing

Anatomy 4
 CASE 2- THE SKULL BASE (PART 2)

1. What is "A" ?
A. Foramen Spinosum
Forameo Contents
B. Foramen Ovale
C. Foramen Rotundum
D. Foramen Lacerum F oramen Ovale CN V3, and Accessory
=
J\[Link]
2. What is "B" ?
A. Forament Spinosum Foramen Rotundum CN V2 ("R2V2"),
B. Foramen Ovale
C. Foramen Rotundum Superior Orbital CN 3, CN 4, CN Vl, CN6
D. Foramen Lacerum Fissure
3. What passes through "A"? Inferior Orbital CN V2
A. CNVI Fissure
B. CNV2
C. CNV3 F oramen Spino sum Middle Meningeal Artery
D. CN6
E. CN4 Jugular Foramen Jugular Vein, CN 9, CN 10, CN
11
4. What passes through "B"?
A. CNVl Hypoglossal Canal CN12
B. CNV2
C. CNV3 Optic Canal CN 2, and Opthalmic Artery
D. Middle Meningeal Artery

Anatomy 5
CASE 3 - THE SKULL BASE (PART 3)

1. What is "A" ?
A. Superior Orbital Fissure
B. Internal Auditory Canal
C. Foramen Rotundum
D. Pterygopalatine Fossa (PPP)

2. What is "B"?
A. Inferior Orbital Fissure
B. Vidian Canal
C. F oramen Rotundum
D. Pterygopalatine Fossa (PPP)

3. What is "C" ?
A. Forament Ovale
B. Vidian Canal
C. F oramen Rotund um
D. Pterygopalatine Fossa (PPP)

4. All 3 Le Fort Fractures involve fracture of the?

A. Pterygoid Plate
B. Lateral Orbital Wall
C. Zygoma
D. Inferior Orbital Wall

Anatomy 6
 CASE 3 - THE SKULL BASE (PART 3)

High Yield Point:

Notice that Ovale Runs up

and down (vertical)

Where as Rotundum runs in

a more horizontal plane.

1. What is "A" ? 3. What is "C" ?

A. Superior Orbital Fissure A. Forament Ovale
B. Internal Auditory Canal B. Vidian Canal
c. Foramen Rotundum C. F oramen Rotundum
D. Pterygopalatine Fossa (PPF) D. Pterygopalatine Fossa (PPF)

2. What is "B" ? 4. All 3 Le Fort Fractures involve fracture

A. Inferior Orbital Fissure of the?
B. Vidian Canal A. Pterygoid Plate
C. F oramen Rotund um B. Lateral Orbital Wall
D. Pterygopalatine Fossa (PPF) C. Zygoma
D. Inferior Orbital Wall

Anatomy 7
CASE 4- THE SKULL BASE (PART 4)

1. What is "A" ?
A. Superior Orbital Fissure
B. F oramen Ovale
C. Foramen Rotundum
D. Pterygopalatine Fossa (PPF)

2. What is "B" ?
A. Inferior Orbital Fissure
B. Vidian Canal
C. Foramen Rotundum
D. Pterygopalatine Fossa (PPF)

3. What is "C" ?
A. Forament Ovale
B. Vidian Canal
C. Foramen Rotundum
D. Pterygopalatine Fossa (PPF)

Anatomy 8
CASE 4 - THE SKULL BASE (PART 4)

1. What is "A" ? Pterygopalatine Fossa (PPF)

A. Superior Orbital Fissure
B. F oramen Ovale This is a 3 dimensional box that acts as a
C. Foramen Rotundum gateway, 'Or intersection between the nasal
D. Pterygopalatine Fossa (PPF) cavity, infra t ernporal fos a. pharynx, orbit
and middle cranial fossa through multiple
2. What is "B" ? passages.
A. Inferior Orbital Fissure
B. Vidian Canal *Don't try and memorize all the stuff that
C. Foramen Rotundum goes in and out of it. just realize a bunch of
D. Pterygopalatine Fossa (PPF) stuff does and be able to recognize the big
ones (Rotundum, Orbital Fissures,
3. What is "C" ? Sphenopalatine, & Vidian).
A. Forament Ovale
B. Vidian Canal
C. Foramen Rotundum
D. Pterygopalatine Fossa (PPF)

Anatomy 9
CASE 5 - THE SKULL BASE (PART 5)

I. What is "A" ?
A. Superior Orbital Fissure
B. The Cavernous Sinus
C. The Pituitary Fossa
D. Pterygopalatine Fossa (PPF)

2. What does NOT run through the Cavernous Sinus?

A. CN3
B. CN 4
C. CNVI
D. CNV2
E. CNV3

3. What cranial nerve in the Cavernous Sinus does NOT run along the wall
A. CN3
B. CN 4
C. CNV3
D. CN6

Anatomy 10
 CASE 5 - THE SKULL BASE (PART 5)

,
.. ... ·· ········ ·· ...'..
,,,...

� .., l... :
,-.2 ..{k�- "° \
.,. . \. "" ,,.' ..··/
. ..
·� f
:
��,.,'·
\·
,,
.

.
··•.
..�.··�·
.
.
..

.
. �·
,·
.
.,.
't·
Sphenoid ·:.,,.
Sinus 6 •
.. ,, . o<J• •
·· ...
• • ,.. •

}' \\' £ . - •
• •.•. .I.... u. "J ..,. ••

1. What is "A" ? Cavernous Sinus:

A. Superior Orbital Fissure
B. The Cavernous Sinus The question is going to be, what' s in it
C. The Pituitary Fossa (probably asked as what is NOT in it).
D. Pterygopalatine Fossa (PPF) CN3 4, CN VI, CNV2. CN6. and the
carotid. CN2 and CN V3 do NOT run
2. What does NOT run through the
through it.
Cavernous Sinus?
A. CN3 The only other anatomy trivia I can
= B. CN4
think of is that CN6 runs next to the
C. CN Vl
D. CNV2 carotid, the rest of the nerves are along
E. CNV3 the wall. This is why you can get lateral
rectus palsy earlier with cavernous
3. What cranial nerve in the Cavernous sinus pathologies.
Sinus does NOT run along the wall
A. CN3
B. CN4
C. CNV3
D. CN6

Anatomy 11
 CASE 6 - THE SKULL SUTURES

1. What is "A" ?
A. Metopic
B. Coronal
C. Sagittal
=
D. Lambdoid

2. Premature closure of "B" results in?

A. Brachycephaly (with a Harlequin Eye)
B. Turricephaly
C. Trigonocephaly
D. Dolichocephaly

3. Premature closure of"?" is the most common form of Craniosynostosis?

A. A
B. B
c. c
D. D
E. E

Anatomy 12
CASE 6 - THE SKULL SUTURES

Lambdold
�

1. What is "A" ?
A. Metopic Premature Suture Closure
B. Coronal
C. Sagittal Sagittal Dolichocephaly
D. Lambdoid (long and skinny).
*most common
2. Premature closure of "B" results in?
A. Brachycephaly (with a Harlequin Metopic Trigonocephaly
Eye) (pointed forehead)
B. Turricephaly
Coronal Brachycephaly (also
C. Trigonocephaly
gets orbit issues
D. Dolichocephaly
"harlequin-eye).
Often with
3. Premature closure of"?" is the most
associated
common form of Craniosynostosis?
syndromes.
A. A
B. B Unilateral Plagiocephaly
C. C (sagittal) Lambdoid
D. D
E. E Bilateral Lambdoid Turricephaly

Anatomy 13
 CASE 7 - THE SAGITTAL BRAIN

1. What is "A" ?
A. Pituitary
B. Mammillary Body
C. Optic Chiasm
D. Hypothalamus
=
2. What is "B" ?
A. Pituitary
B. Mammillary Body
C. Optic Chiasm
D. Hypothalamus

3. Is it ever normal for the anterior pituitary to be bright?

A. Nope
B. It should always be bright
C. Yup, it's supposed to be bright in babies.

4. What is "C"?
A. Neurohypophysis
B. Adenohypophysis

Anatomy 14
CASE 7- THE SAGITTAL BRAIN

1. What is "A" ?
A. Pituitary
B. Mammillary Body
c. Optic Chiasm
D. Hypothalamus

2. What is "B" ?
A. Pituitary
B. Mammillary Body
C. Optic Chiasm
D. Hypothalamus

3. Is it ever normal for the anterior pituitary to be bright?

A. Nope
B. It should always be bright
C. Yup, it's supposed to be bright in babies. * under the age of 2, it can be

4. What is "C" ?
A. Neurohypophysis * The posterior pituitary
B. Adenohypophysis

Anatomy 15
CASE 8 - TEMPORAL BONE (PART 1)

1. What is "A" ?
A. Superior Turn Semicircular Canal
B. Basal Tum of the Cochlea
C. Middle Tum of the Cochlea
D. The Vestibular Aqueduct

2. What is "B"?
A. The Oval Window
B. The Round Window
C. The Vestibular Aqueduct
D. The Facial Nerve

3. What is "C" ?
A. The Oval Window
B. The Round Window
C. The Vestibular Aqueduct
D. The Facial Nerve

4. What attaches to the oval window?

A. The Malleus
B. The Incus
C. The Stapes

Anatomy 16
CASE 8 - TEMPORAL BONE (PART 1)

1. What is "A" ?
A. Superior Turn Semicircular Canal
B. Basal Turn of the Cochlea Round Window and Oval Window
C. Middle Turn of the Cochlea
D. The Vestibular Aqueduct I used to get these mixed up all the time
when I was in training.
2. What is "B" ?
A. The Oval Window The way I remember which is which, is
B. The Round Window that the foot print of the stapes is oval, and
C. The Vestibular Aqueduct the, tapes attaches to the oval window. I
D. The Facial Nerve find the easiest way to find the stapes is to
look for the "elbow" appearance of the
3. What is "C" ?
Lenticular. process of the inc us (on
A. The Oval Window
coronal). which will hook up to the stapes.
B. The Round Window
C. The Vestibular Aqueduct
The Round Window is at the base of the
D. The Facial Nerve
basal tum of the cochlea (the thing that
4. What attaches to the oval window? looks like a smiley face on axials).
A. The Malleus
Just remember one - and know that the
B. The Incus
C. The Stapes other one is the other one.

Anatomy 17
CASE 9 - TEMPORAL BONE (PART 2)

1. What is "A" ?
A. Prussak's Space
B. Pyramidal Eminence
C. Aditus Ad Antrum
D. The Vestibular Aqueduct

2. What is "B" ?
A. Pyramidal Eminence
B. Cochlear Promontory
C. Modiolus
D. Scutum

3. What is "C" ?
A. The Incus
B. The Malleus
C. The Stapes

4. What is "D" ?
A. Horizontal I Lateral Semicircular Canal
B. The Vestibule
C. Middle Tum of the Cochlea

Anatomy 18
CASE 9 - TEMPORAL BONE (PART 2)

1. What is "A" ? Re evant Anatomy for the

A. Prussak's Space
Acqiired Cholesteatoma
B. Pyramidal Eminence
C. Aditus Ad Antrum Acquired Cbole t atoma is a bunch of exfoliated skin
D. The Vestibular Aqueduct
debris growing in the wrong place. It creates a big

2. What is "B"? inflammation ball which wrecks the temporal bone

A. Pyramidal Eminence and the ossicles.
B. Cochlear Promontory
You ha:ve two part to the ear drum, a flimsy whimpy
C. Modiolus
D. Scutum part "Pars Flaccida" , and a tougher part ·•Par· 1 ensa."
The flimsy Flaccida is at the top and the tensa is at
3. What is "C" ? the bottom. If you "acquire" a hole with some
A. The Incu inflammation I infection involving the pars flaccida
B. The Malleus you can end u.p with this ba11 of epithelial crap
C. The Stapes
growing and causing inflammation in the wrong place
(typically Prussak' space) ..
4. What is "D" ?
A. Horizontal I Lateral
The first thing it erodes is the scutum. Then you have
Semicircular Canal
erosion and displacement of tile adjacent ossicles
B. The Vestibule
C. Middle Tum of the Cochlea (incus and malleus). 'Eventually. you can have
involvement of the semi-circular canal (most
commonly at the lateral I horizontal portion).

Anatomy 19
CASE 10 - TEMPORAL BONE (PART 3)

1. What is "A" ?
A. Facial Nerve (CN 7)
B. Cochlear Nerve
C. Superior Vestibular Nerve
D. Inferior Vestibular Nerve

2. What is "B" ?
A. Facial Nerve (CN 7)
B. Cochlear Nerve
C. Superior Vestibular Nerve
D. Inferior Vestibular Nerve

3. What is "C" ?
A. Facial Nerve (CN 7)
B. Cochlear Nerve
C. Superior Vestibular Nerve
D. Inferior Vestibular Nerve

4. What is "D" ?
A. Facial Nerve (CN 7)
B. Cochlear Nerve
C. Superior Vestibular Nerve
D. Inferior Vestibular Nerve

Anatomy 20
CASE 10 - TEMPORAL BONE (PART 3)

\. �--.

Superior CN7
Vestibular .,..... _; (Facial )
Nerve i&111, � 1I
1

Anterior
..

•·
The Mnemonic is
"Zup, Coke Down" - to
remember that the Facial

i
Inferior
'Cochlear
Nerve
Nerve (Cn 7) is superior. to
the Cochlear Nerve

Vestibular
Nerve

1. What is "A" ?
A. Facial Nerve ( CN 7)
B. Cochlear Nerve
C. Superior Vestibular Nerve
D. Inferior Vestibular Nerve

2. What is "B" ?
A. Facial Nerve (CN 7)
B. Cochlear Nerve
C. Superior Vestibular Nerve
D. Inferior Vestibular Nerve

3. What is "C" ?
A. Facial Nerve (CN 7)
B. Cochlear Nerve
C. Superior Vestibular Nerve
D. Inferior Vestibular Nerve

4. What is "D" ?
A. Facial Nerve (CN 7)
B. Cochlear Nerve
C. Superior Vestibular Nerve
D. Inferior Vestibular Nerve

Anatomy 21
CASE 11- CERVICAL LYMPH NODES

1. What Level is "A"?

A. Level2
B. Level 3
C. Level 4
D. Level 5

2. What level is "B" ?

A. Level 2
B. Level3
C. Level 4
D. Level 5

3. What land mark distinguishes between a Level 2 and Level 3?

A. Lower Border of the Hyoid
B. Lower Border of the Cricoid
C. The Stemocleidomastoid (SCM)
D. The Posterior Border of the Submandibular Gland

Anatomy 22
CASE 11- CERVICAL LYMPH NODES

1. What Level is "A" ?

A. Level 2 *Probably a 2B because
Posterior Border
its behind the jugular vein Submandibular
Jugular Fossa
B. Level 3 Gland
C. Level 4
D. Level 5

2. What level is "B" ?

A. Level2
B. Level 3 "you can still see Lower Border
oflfyoid ___,.
Cricoid
C. Level 4
D. Level5 of Cr/cold

3. What land mark distinguishes

between a Level 2 and Level 3?
A. Lower Border of the Hyoid
B. Lower Border of the Cricoid
C. The Stemocleidomastoid (SCM)
D. The Posterior Border of the
Submandibular Gland

Anatomy 23
CASE 12 - VASCULAR (CNS - PART 1)

1. What is "A" ?
A. Posterior Inferior Cerebellar Artery (PICA)
B. Posterior Cerebral Artery (PCA)
C. Middle Cerebral Artery (MCA)
D. Superior Cerebellar Artery (SCA)
E. Pontine Artery

2. What is "B" ?
A. Posterior Inferior Cerebellar Artery (PICA)
B. Posterior Cerebral Artery (PCA)
C. Middle Cerebral Artery (MCA)
D. Superior Cerebellar Artery (SCA)
E. Anterior Inferior Cerebellar Artery (AICA)

3. What is "C"
A. Posterior Inferior Cerebellar Artery (PICA)
B. Posterior Cerebral Artery (PCA)
C. Middle Cerebral Artery (MCA)
D. Superior Cerebellar Artery (SCA)
E. Anterior Inferior Cerebellar Artery (AICA)

Anatomy 24
CASE 12 - VASCULAR (CNS - PART 1)

AP Run Vert Lateral Run Vert

1. What is "A"?
A. Posterior Inferior Cerebellar Artery ACA

(PICA)
B. Posterior Cerebral Artery (PCA) MCA

C. Middle Cerebral Artery (MCA)

D. Superior Cerebellar Artery (SCA)
E. Pontine Artery

2. What is "B" ?
A. PICA
B. PCA
C. MCA
D. SCA Anterior
E. Anterior Inferior Cerebellar Inferior
Cerebellar
Artery (AICA) Artery (AICA)

3. What is "C" PICA origin is

variable, sometunes
A. PICA coming aff tne Basilar
B. PCA
C. MCA
D. SCA
E. AICA

Anatomy 25
CASE 13 -VASCULAR (CNS - PART 2)

1. What is "A"?
A. Posterior Communicating Artery (PCOM)
B. Anterior Cerebral Artery (ACA)
C. Middle Cerebral Artery (MCA)
D. Superior Cerebellar Artery (SCA)
E. Ophthalmic Artery

2. What is "B" ?
A. Posterior Communicating Artery (PCOM)
B. Anterior Cerebral Artery (ACA)
C. Middle Cerebral Artery (MCA)
D. Superior Cerebellar Artery (SCA)
E. Ophthalmic Artery

3. What is "C"
A. Posterior Communicating Artery (PCOM)
B. Anterior Cerebral Artery (ACA)
C. Middle Cerebral Artery (MCA)
D. Superior Cerebellar Artery (SCA)
E. Ophthalmic Artery

Anatomy 26
CASE 13 - VASCULAR (CNS - PART 2)

Lateral Run Internal Carotid AP Run Internal Carotid

1. What is "A" ?
A. Posterior Communicating Artery (PCOM)
B. Anterior Cerebral Artery (ACA) Ophthalmic Artery - Arises right
above the Clinoid Segment (CS)
C. Middle Cerebral Artery (MCA)
of the internal carotid - just
D. Superior Cerebellar Artery (SCA) above that bump thingy. It is the
E. Ophthalmic Artery first intracranial vessel heading
in the anterior directiorn (which
2. What is "B" ? makes it testable). "Just above
A. Posterior Communicating Artery (PCOM) the dural ring" is a buzzword.
B. Anterior Cerebral Artery (ACA)
The Posterior Communicating
C. Middle Cerebral Artery (MCA) (PCOM) - is the vessel heading
D. Superior Cerebellar Artery (SCA) ppsterior at about the level of the
E. Ophthalmic Artery ophtlilalmic.

3. What is "C" The so called ''Fetal PCOM"

occurs when the PCOM is larger
A. Posterior Communicating Artery (PCOM)
than the PCA. This becomes
B. Anterior Cerebral Artery (ACA) -Al clinically relevant when you see
C. Middle Cerebral Artery (MCA) an anterior circulation stroke that
D. Superior Cerebellar Artery (SCA) also seems to involve the
E. Ophthalmic Artery posterior circulation.

Anatomy 27
CASE 14 - VASCULAR (CNS - PART 3)

1. What territory is the stroke in "A" ?

A. Posterior Communicating Artery (PCOM)
B. Anterior Choroidal Artery
C. Middle Cerebral Artery (MCA)
D. Anterior Cerebral Artery (ACA)
E. Artery of Percheron

2. What territory is the stroke in "B"?

A. Posterior Communicating Artery (PCOM)
B. Anterior Choroidal Artery
C. Middle Cerebral Artery (MCA)
D. Anterior Cerebral Artery (ACA)
E. Artery of Percheron

3. How old (roughly) is a stroke that restricts diffusion, but is NOT bright on FLAIR?
A. 0-6 hours
B. 6-24 hours
C. 24 hours -1 week

Anatomy 28
CASE 14 - VASCULAR (CNS - PART 3)

Lenticulostriate
ACA Anterior
MCA Choroidal

PCA
PCA

1. What territory is the stroke in "A" ?

A. Posterior Communicating Artery
(PCOM) Findings on MRI do change with the age of
B. Anterior Choroidal Artery the stroke. Diffusion restricts early, and
*originates off the /CA (usually) lasts, but the key to tell if the stroke is acute
C. Middle Cerebral Artery (MCA) is the absence of FLAIR signal. This
doesn't always hold up in the real world,
D. Anterior Cerebral Artery (ACA)
but for the purpose of multiple choice - no
E. Artery of Percheron FLAIR is always acute.

2. What territory is the stroke in "B" ?

A. Posterior Communicating Artery 0-6 hours 6-24 hours 24 hours
(PCOM) -1 week
B. Anterior Choroidal Artery Diffusion Bright Bright Bright
C. Middle Cerebral Artery (MCA)
D. Anterior Cerebral Artery (ACA) FLAIR NOT Bright Bright
E. Artery of Percheron BRIGHT
Tl Iso Dark Dark, with
3. How old (roughly) is a stroke that Bright
restricts diffusion, but is NOT bright on Cortical
FLAIR? Necrosi
A. 0-6 hours
T2 Iso Bright Bright
B. 6-24 hours
C. 24 hours -1 week

Anatomy 29
CASE 15 - VASCULAR (CELIAC AXIS)

1. What is "A" ?
A. Right Gastric Artery
B. Left Gastric Artery
C. Phrenic Artery
D. Celiac Trunk

2. What is "B" ?
A. Proper Hepatic Artery
B. Common Hepatic Artery
C. Right Gastric Artery
D. Gastroduodenal Artery (GDA)

3. What is "C" ?
A. Superior Pancreaticoduodenal
B. Gastroepiploic Artery
C. Common Hepatic
D. Gastroduodenal Artery (GDA)

Anatomy 30
CASE 15 - VASCULAR (CELIAC AXIS)

'Superlo
Right J'
&astroepiplolc
Pancreatlcodqodenal Left
&astroeplplolc

1. What is "A" ?
A. Right Gastric Artery
B. Left Gastric Artery
C. Phrenic Artery
D. Celiac Trunk

2. What is "B" ?
A. Proper Hepatic Artery
B. Common Hepatic Artery
C. Right Gastric Artery
D. Gastroduodenal Artery (GDA)

3. What is "C" ?
A. Superior Pancreaticoduodenal
B. Gastroepiploic Artery
C. Common Hepatic
D. Gastroduodenal Artery (GOA)

Anatomy 31
CASE 16 -VASCULAR (SMA)

1. What is "A" ?
A. Right Gastric Artery
B. Inferior Pancreaticoduodenal
C. Replaced Hepatic Artery
D. Right Colic Artery

2. What is "B"?
A. Marginal Artery of Drummond
B. Arc of Riolan
C. Arc of Buhler
D. Pancreatic-Duodenal Arcarde

3. The Arc ofRiolan is a collateral pathway from?

A. Right Colic of the SMA to the Left Colic of the IMA
B. Middle Colic of the SMA to the Left Colic of the IMA
C. Superior Pancreatic Duodenal to the Inferior Pancreatic Duodenal
D. Superior Rectal of the IMA to the Internal Pudendal (Internal Iliac)

Anatomy 32
CASE 16-VASCULAR (SMA)

SMA Trivia
1. What is "A" ?
A. Right Gastric Artery The Right Hepatic Artery arising from
B. Inferior Pancreaticoduodenal the SMA - "replaced" - is the most
C. Replaced Hepatic Artery common variant of the hepatic arterial
D. Right Colic Artery anatomy, occurring at 10-15% of the
time.
2. What is "B" ?
A. Marginal Artery of Drummond The Arc ef Riolan is an important
B. Arc of Riolan collateral between the SMA and IMA -
occurring via rhe middle colic (SMA)
C. Arc of Buhler
and the left colic (IMA).
D. Pancreatic-Duodenal Arcarde
The Marginal Artery of Drummond is
3. The Arc ofRiolan is a collateral pathway from? another important SMA to IMA
A. Right Colic of the SMA to the Left Colic of [Link] anastomosis C>fi the
the IMA terminal branches of the lleocolic. right
B. Middle Colic of the SMA to the Left Colic colic and middle colic arteries of the
of the IMA SMA, and of the left colic and sigmoid
C. Superior Pancreatic Duodenal to the Inferior branch s of the IMA. form a continuous
Pancreatic Duodenal arterial circle or arcade al ng the inner
D. Superior Rectal of the IMA to the Internal border of the colon.
Pudenda! (Internal Iliac).

Anatomy 33
CASE 17-VASCULAR (UPPER EXTREMITY)

1. What is "A" ?
A. Radial Artery
B. Ulnar Artery
C. Interosseous Artery
D. Brachial Artery

2. What is "B" ?
A. Radial Artery
B. Ulnar Artery
C. Interosseous Artery
D. Brachial Artery

3. What is "C" ?
A. Radial Artery
B. Ulnar Artery
C. Interosseous Artery
D. Brachial Artery

Anatomy 34
CASE 17 - VASCULAR (UPPER EXTREMITY)

1. What is "A" ?
Conventional Anatomy
A. Radial Artery
B. Ulnar Artery
C. Interosseous Artery
D. Brachia! Artery

2. What is "B" ?
A. Radial Artery
B. Ulnar Artery

-,
C. Interosseous Artery Snuff Box Tendons
D. Brachia! Artery
��
3. What is "C" ? Ulna Artery
A. Radial Artery
B. Ulnar Artery
C. Interosseous Artery
D. Brachia} Artery

Upper Extremity Trivia

• The Axillary Artery

becomes of the brachia! Common Variant (12%) Radial Artery
High Radial Take Off * High Take Off
artery .at the lateral
margin of the teres
�
major,

• Usually, the ulnar artery

is larger than the radial
and gives off the Brachia/
common interossecus=- Snuff Box Tendons

-,
Artery
which then splits off to
form anterior and
posterior branches. Ulna "Artery

• The superficial palrnar

arch is from the ulna A.

• The deep palmar arch is

from the radial A.

Anatomy 35
 CASE 18 -VASCULAR (LOWER EXTREMITY)

1. What is "A"?
A. Common Femoral Artery
--. B. Superficial Femoral Artery
C. Profunda Femoris
D. Inferior Epigastric Artery

2. What is "B" ?
A. Anterior Tibial
B. Posterior Tibial
C. Peroneal Artery
D. Tibioperoneal Trunk Artery

3. What is "C" ?
A. Anterior Tibial
B. Posterior Tibial
C. Peroneal Artery
D. Tibioperoneal Tmnk Artery

Anatomy 36
CASE 18 - VASCULAR (LOWER EXTREMITY)

Lower Extremity Trivia

1. What is "A" ?
A. Common Fem oral Artery • Once the inferior epigastric comes off (level
B. Superficial Femoral Artery of the inguinal ligament) you are dealing with
C. Profunda Femoris the common femoral artery (CEA).
D. Inferior Epigastric Artery
• The superficial femoral becomes the popliteal
2. What is "B" ? when the vessel emerges from Hunter's
A. Anterior Tibial �ADDuctor) canal.
B. Posterior Tibial
C. Peroneal Artery • The first branch off of the pop) iteal artery is
D. Tibioperoneal Trunk Artery the anterior tibial.

3. What is "C" ? • The anterior tibial courses anterior and

A. Anterior Tibial lateral, then it transverses the interosseous
B. Posterior Tibial membrane, terminating as the dorsalis pedis.
C. Peroneal Artery
D. Tibioperoneal Trunk Artery • The most medial artery in the leg is the
posterior tibial (felt at the medial malleolus).

Anatomy 37
CASE 19 - VASCULAR (FEMORAL ACCESS)

1. Which one is the Femoral Artery?

A. A.
B. B.

2. When treating a femoral artery pseudo aneurysm with thrombin, it is important to"?"
A. Aspirate blood first into the syringe before injecting the thrombin
B. Confirm the cavity size is less than lcm before injecting the thrombin
C. Give no more than 100 units
D. Give between 500 and 1000 units

3. A "High Stick" above the inguinal ligament classically carries a risk of?
A. Retroperitoneal Bleed
B. AV Fistula
C. Occluding branching vessels with your sheath
D. Fascia} compartment syndrome

4. A "Low Stick" close to or at the femoral bifurcation classically carries a risk of?
A. Retroperitoneal Bleed
B. AV Fistula
C. Fascial compartment syndrome
D. Post thrombotic syndrome

Anatomy 38
CASE 19 - VASCULAR (FEMORAL ACCESS)

NAVEL towards the Navel

N-A-V-E-L

0
Nerve, Artery, Vein, Empty, lymph

Fem9ral Acoess Trivia

1. Which one is the Femoral Artery?
A. A. • The ideal location is over the femoral head
B. B. (which gives you something to compress
against), distal to the inguinal ligament I
2. When treating a femoral artery pseudo epigastric artery and proximal to th common
aneurysm with thrombin, it is important
to"?" femoral bifurcation.
A. Aspirate blood first into the syringe
before injecting the thrombin ** never • If you stick: too high (above inguinal
do this - it will clot in the syringe ligament): You risk retroperitoneal bleed
B. Confirm the cavity size is less than
lcm before injecting the thrombin • If you stick too low, you risk AV Fistula
C. Give no more than 100 units
D. Give between 500 and 1000 units
• If vou stick at the bifurcation: Y0u risk
"
3. A "High Stick" above the inguinal occluding branching vessels with your sheath.
ligament classically carries a risk of?
A. Retroperitoneal Bleed
B. AV Fistula Pseudoaneurysm Treatment
C. Occluding branching vessels with your
sheath • A lot of the time. small (<3cm) will undergo
D. Fascial compartment syndrome
spontaneous thrombosis.
4. A "Low Stick" close to or at the femoral
bifurcation classically carries a risk of? • The Thrombin Dose is between 500-1 000
A. Retroperitoneal Bleed units, injected into the apex of the cavity.
B. AV Fistula
C. Fascial compartment syndrome • Contraindications would include: infected
D. Post thrombotic syndrome
. kin. distal ischemia, a large neck (risk of
propagation), and a small sac size ( < I cm)

Anatomy 39
CASE 20 - CARDIAC (PART 1)

1. What is "A" ?
A. Pulmonary Vein
B. Pulmonary Artery
C. IVC
D. Coronary Sinus

2. What is "B" ?
A. Crista Terminalis
B. Papillary Muscle
C. Moderator Band
D. Tricuspid Valve

3. The Morphologic Right Atrium is Defined by?

A. The absence of a draining pulmonary vein
B. The absence of an emerging pulmonary artery
C. The moderator band
D. The attachment of the IVC

4. The Morphologic Right Ventricle is Defined by?

A. The absence of a draining pulmonary vein
B. The absence of an emerging pulmonary artery
C. The moderator band
D. The attachment of the IVC

Anatomy 40
CASE 20 - CARDIAC (PART 1)

Coronary Sinus
1. What is "A" ?
A. Pulmonary Vein
• The main draining vein of the
B. Pulmonary Artery myocardium. It runs in the AV groove
C. IVC on the posterior surface of the heart and
D. Coronary Sinus enters the right atrium near the tricuspid
2. What is "B" ?
valve
A. Crista Terminalis
B. Papillary Muscle • The persi tent left SVC classically
C. Moderator Band drains into the coronary sinus
D. Tricuspid Valve

3. The Morphologic Right Atrium is Defined by?

A. The absence of a draining pulmonary vein Trivia
B. The absence of an emerging pulmonary
artery • The Right Atrium is defined by the IVC
C. The moderator band
D. The attachment of the IVC
• The Right Ventricle is defined by the
4. The Morphologic Right Ventricle is Defined moderator band.
by?
A. The absence of a draining pulmonary vein • The moderator band is a muscular band
B. The absence of an emerging pulmonary that extends from the ventricular septum
artery
c. The moderator band to the anterior papillary muscle. It
D. The attachment of the IVC carries with it the right bundle branch of

Anatomy 41
 CASE 21 - CARDIAC (PART 2)

1. What is "A" ?
A. A clot
B. A tumor - probably a myxoma
C. A tumor - probably an elastofibroma
D. Coumadin Ridge

2. What is "B" ?
A. Aclot
B. Papillary Muscle
= C. Crista Terminalis
D. Chiari Network

3. The papillary muscles of the mitral valve inserts on the"?", and the papillary muscles of
the tricuspid valve insert on the "?"
A. MV = Septum, TV = Lateral and Posterior Walls
B. MV = Lateral and Posterior Walls, TV = Septum
C. MV = Septum, TV = Septum
D. MV = Lateral Walls, TV= Lateral Walls

Anatomy 42
 CASE 21 - CARDIAC (PART 2)

Coumadio Ridge
1. What is "A" ?
A. Aclot • The ridge of atrial tissue separating the
B. A tumor - probably a myxoma
C. A tumor - probably an elastofibroma
left atrial appendage from the left upper
D. Coumadin Ridge pulmonary vein.

2. What is "B" ? • This structure is often mistaken for

A. A clot thrombus and resulted in patient being
B. Papillary Muscle
C. Crista Terminalis
prescribed anticoagulation therapy with
D. Chiari Network warfarin (Cownadin).
=
3. The papillary muscles of the mitral valve
in_serts _on the"?", and the papillary muscles of the Crista Terminalis
tricuspid valve insert on the "?"
A. MY = Septum, TV = Lateral and Posterior • A frequently tested normal structure
Walls (it s not a clot or a tumor).
B. MV = Lateral and Posterior Walls,
TV= Septum • It is a muscular ridge that runs from
C. MY = Septum, TV = Septum
D. MY= Lateral Walls, TV= Lateral Walls
the entrance of the superior- to that of
the inferior vena cava.

Trivia

• The tricuspid papillary muscles insert on the septum

• The mitral valve papillary muscles insert into the lateral and posterior walls as well as the
apex of the left ventricle (not the septum).

Anatomy 43
 CASE 22 - ABDOMINAL ULTRASOUND

1. What is "A"? 4. What is "D" ?

A. IVC A. Left Renal Vein
=
B. Aorta B. Right Renal Vein
c. Celiac Artery C. Splenic Vein
D. Vertebral Body D. Splenic Artery

2. What is "B" ? 5. What is "E" ?

A. IVC A. Hepatic Artery
B. Aorta B. Hepatic Vein
C. Celiac Artery C. Portal Vein
D. SMA D. Common Bile Duct

3. What is "C" ?
A. IVC
B. Aorta
C. Right Renal Artery
D. SMA

Anatomy 44
CASE 22 - ABDOMINAL ULTRASOUND

1. What is "A" ?
A. IVC 4. What is "D"?
B. Aorta A. Left Renal Vein
C. Celiac Artery B. Right Renal Vein
D. Vertebral Body C. Splenic Vein
D. Splenic Artery
2. What is "B" ?
A. IVC 5. What is "E" ?
B. Aorta A. Hepatic Artery
C. Celiac Artery B. Hepatic Vein
D. SMA C. Portal Vein
D. Common Bile Duct
3. What is "C" ?
A. IVC
B. Aorta
C. Right Renal Artery
D. SMA

Anatomy 45
 CASE 23 - THE PROSTATE

1. What is "A" ?
A. Central Gland
B. Peripheral Zone
C. Bright Zone
D. Fibromuscular Zone

2. What is "B" ?
A. Central Gland
=
B. Peripheral Zone
C. Bright Zone
D. Fibromuscular Zone

3. What is "C" ?
A. TheApex
B. The Base

4. Prostate Cancer is typically"?", and found in the"?"

A. T2 Dark - in the Central Gland
B. T2 Dark - in the Central Zone
C. T2 Bright - in the Peripheral Zone
D. T2 Dark - in the Peripheral Zone

Anatomy 46
CASE 23 -THE PROSTATE

1. What is "A" ? Trivia

A. Central Gland
• The terms "central gland.. and "central zone"
B. Peripheral Zone
can be used as distractors. There is a difference >
C. Bright Zone
so be careful.
D. Fibromuscular Zone

2. What is "B" ? fransltlo al

A. Central Gland Centra� Zone
B. Peripheral Zone GlandL
Central
C. Bright Zone
D. Fibromuscular Zone
Zone

3. What is "C" ? • Central GLAND= Central Zone+ the

A. TheApex Transitional Zone
B. The Base
• Central Gland is where is the BPH nodules live.
4. Prostate Cancer is typically"?",
and found in the "?" • Peripheral Zone is where the Cancer lives
A. T2 Dark - in the Central Gland (usually). It is typically T2 dark, enhances,
B. T2 Dark - in the Central Zone restricts diffusion, and ha rapid wash out
C. T2 Bright - in the Peripheral kinetics.
Zone
• The Rare Central Gland Cancer is supposed to
D. T2 Dark - in the Peripheral
look like "Smudged Charcoal" on T2
Zone

Anatomy 47
 CASE 24 - MSK (THE PELVIS)

1. What attaches at "A" ? 3. What attaches at "C" ?

=
A. ADDuctors A. Sartorius
B. Iliopsoas B. Rectus Femoris
C. Gluteal Muscles c. ADDuctors
D. Tensor Fascia Lata D. Iliopsoas

2. What attaches at "B" ? 4. What attaches at "D"?

A. ADDuctors A. Sartorius
B. Hamstrings B. Rectus F emoris
C. Sartorius C. ADDuctors
D. Abdominal Muscles D. Iliopsoas

Anatomy 48
CASE 24 - MSK (THE PELVIS)

1. What attaches at "A"? 3. What attaches at "C" ?

A. ADDuctors A. Sartorius
B. Iliopsoas B. Rectus Femoris
c. Gluteal Muscles C. ADDuctors
D. Tensor Fascia Lata D. Iliopsoas

2. What attaches at "B"? 4. What attaches at "D"?

A. ADDuctors A. Sartorius
B. Hamstrings B. Rectus F emoris
C. Sartorius C. ADDuctors
D. Abdominal Muscles D. Iliopsoas

Anatomy 49
CASE 25 - MSK (THE SHOULDER)

1. What is "A"?
A. Supraspinatous (SS)
B. Infraspinatous (IS)
C. Teres Minor (TM)
D. Subscapularis (Sub S)

2. What is "B"?
A. Supraspinatous (SS)
B. lnfraspinatous (IS)
C. Teres Minor (TM)
D. Subscapularis (Sub S)

3. What is "C"?
A. The Subscapularis Tendon
B. Labral Fragment
C. Middle Glenohumeral Ligament
D. Long Head of Biceps Tendon

4. If the long head of the biceps attaches to the glenoid at 12 o'clock, what attaches at 6
o'clock?
A. The Short Head of the Biceps
B. The Triceps

Anatomy 50
 CASE 25 - MSK (THE SHOULDER)

1. What is "A" ? ·e,\e

c.\'3,��
A. Supraspinatous (SS)
B. lnfraspinatous (IS)
C. Teres Minor (TM)
D. Subscapularis (Sub S)

I
2. What is "B" ?
A. Supraspinatous (SS)
B. Infraspinatous (IS)
= C. Teres Minor (TM)
D. Subscapularis (Sub S)

3. What is "C" ?
A. The Subscapularis Tendon
B. Labral Fragment
C. Middle Glenohumeral Ligament
D. Long Head of Biceps Tendon

4. If the long head of the biceps attaches to the glenoid at 12 o'clock, what attaches at 6
o'clock?
A. The Short Head of the Biceps
B. The Triceps

Anatomy 51
CASE 26 - MSK (THE WRIST)

1. What is "A" ?
A. Scaphoid
B. Capitate
c. Hamate
D. Trapezoid

2. What is "B" ?
A. Radial Nerve
B. Ulnar Nerve
C. Median Nerve
D. Musculocutaneous Nerve

3. What is "C" ?
A. Listers Tubercle
B. Radial Styloid
C. Ulnar Tubercle
D. Os Styloideum

4. Which of the following does NOT pass through the carpal tunnel
A. Flexor Dig. Profundus
B. Flexor Dig. Superficialis
C. Flexor Pollicis Longus
D. Flexor Carpi Ulnaris

Anatomy 52
CASE 26 - MSK (THE WRIST)

Hamate
Radius

Hook of --- �··\.·

Hamate •• . e
F!exor Te()(Jons

Trivia
1. What is "A"?
A. Scaphoid • The hook of tho barnate is right next to
B. Capitate the ulnar nerve I artery. Therefore
C. Hamate
D. Trapezoid fracture or repetitive trauma can cause
adjacent injury (ulnar nerve palsy or
2. What is "B" ? pseudo-aneurysm). This is sometimes
A. Radial Nerve seen in bike riders - the so called
B. Ulnar Nerve
C. Median Nerve "handle bar palsy", where the ulnar
D. Musculocutaneous Nerve nerve is compressed between the handle
bar and the hamate hook within
3. What is "C" ? "Guyon s Canal."
A. Listers Tubercle
B. Radial Styloid
C. Ulnar Tubercle • The 3rd xtensor compartment
D. Os Styloideum "Extensor Pollicis Longus" - wraps
around "Lister's Tubercle" on it's way to
4. Which of the following does NOT pass the thumb.
through the carpal tunnel
A. Flexor Dig. Profundus
B. Flexor Dig. Superficialis • Flexor tendon and the median nerve go
C. Flexor Pollicis Longus through the carpal tunnel. The ones that
D. Flexor Carpi Ulnaris don't arc: Flcxor Carpi Ulnaris,
Flexer Carpi RadiaUs, Palmaris
Longos (if you have one).

Anatomy 53
CASE 27 - MSK (THE ANKLE)

1. What is "A" ?
4. Is it ever normal for the Flexor
A. Flexor Digitorum Longus Hallucis Longus to have extra fluid
B. Flexor Hallucis Longus in the sheath?
C. Peroneus Brevis A. Nope
B. Yup
D. Peroneus Longus

2. What is "B" ?
A. Flexor Digitorum Longus
B. Flexor Hallucis Longus
C. Peroneus Brevis
D. Peroneus Longus

3. What is "Henry's Knot"?

A. Crossing of Flexor Hallucis over Flexor Digitorum
B. Crossing of Flexor Hallucis over The Posterior Tibial
C. Crossing of the Flexor Digitorium Longus over Flexor Digitorium Brevis
D. None of the Above

Anatomy 54
CASE 27 - MSK (THE ANKLE)

Tibialis Anterior
A bunch of extensor
tendons no one

-·
gives a shit about �

!, Tibia
/Fibvia
....... . Tibialis Posterior "Tom"
Flexor Oigitorum
Peroneus Longus "Dick"
Long us Tibial Nerve
Flexor Hallucis Longus "Harry"
Plantaris
Achilles
I. What is "A" ?
A. Flexor Digitorum Longus
B. Flexor Hallucis Longus Ankle Trivia
C. Peroneus Brevis
D. Peroneus Longus
• Achilles Tendon has NO tendon Sheath
2. What is "B" ?
A. Flexor Digitorum Longus • It may be pos ible to plantar flex with a
B. Flexor Hallucis Longus tom Achille , as urning your plantari ts
C. Peroneus Brevis
D. Peroneus Longus still intact

3. What is "Henry's Knot" ? • Henry s Knot is a "Harry Dick ., - refers

A. Crossing of Flexor Hallucis over Flexor
Digitorum
to the cro s of Hallucis over Digitorum
B. Crossing of Flex or Hallucis over The Posterior
Tibial • Flexor Hallucis Longus bas a
C. Crossing of the Flexor Digitorium Longus over communication with the ankle joint 20%
Flexor Digitorium Brevis
D. None of the Above of the time, so an effusion in the tendon
heath can be normaJ
4. Is it ever normal for the Flexor Hallucis Longus to
have extra fluid in the sheath?
A. Nope
B. Yup

Anatomy 55
CASE 28 - NUKES (MYSTERY WHOLE BODY SCAN 1)

1. What scan is it?

A. Gallium
B. Indium - WBC
C. MIBG
D. I would ask the tech what tracer they injected. If they said "I don't know", I would fire
them on the spot, and have security remove them from the hospital immediately.

2. This tracer mimics the physiologic behavior of?

A. Iron
B. WBC
C. Potassium (Na/K pump)
D. Calcium

3. What is the half life of this tracer?

A. 74 Hours
B. 72 Hours
C. 78 Hours

Anatomy 56
CASE 28 - NUKES (GALLIUM SCAN)

HOT WBC

,./ Spleen Liver= Sulfur

8 ones-. ? Spleen Colloid

C()[Link]

Kidneys
No
Bones
Heart
No MIBG
Kidneys 1-123
No
Bones
MIBG
Liver
No 1-131
Heart

I. What scan is it? Gallium Trivia

A. Gallium
B. Indium - WBC • Handled by the body like Fe+3 - which gets
C. MIBG bound (via lactoferrin) and concentrated in
D. I would ask the tech what tracer they
injected. If they said "I don't know", I areas of inflammation and infection.
would fire them on the spot, and have
security remove them from the hospital • Ifs the "poor mans bone scan."
immediately.
• The clas ic use is for spinal osteomyelitis
2. This tracer mimics the physiologic (it's way better than In-WBC in the spine).
behavior of?
A. Iron
B. WBC • Renal uptake can he normal up to 24 hours.
C. Potassium (Na/K pump) after than - think about interstitial nephritis
D. Calcium
• Has 4 photo peaks (roughly 100. 200, 300,
3. What is the half life of this tracer? 400).
A. 74 Hours
B. 72 Hours
C. 78 Hours • Made via electron capture (GIIn.

Anatomy 57
 CASE 29 - NUKES (MYSTERY WHOLE BODY SCAN 2)

Anterior Posterior

1. What scan is it?

A. Gallium
= B. Indium - WBC
C. MIBG
D. I would ask the tech what tracer they injected. If they said "I don't know", I would fire
them on the spot, and have security remove them from the hospital immediately.

2. What are the photon peaks of this tracer?

A. Single Peak at 81
B. Four Peaks at 93, 184, 300, & 393
C. Two Peaks at 1 73 & 24 7
D. Single Peak at 365

3. What is the half life of this tracer?

A. 67 Hours
B. 73 Hours
C. 8 Days

Anatomy 58
 CASE 29 - NUKES (INDIUM-WBC)

Indium Trivia
1. What scan is it?
A. Gallium
• Tagged onto a Neutrophil - they travel to
B. Indium - WBC areas of infection I inflammation and the
_I C. MIBG RES (why the spleen i HOT)
D. I would ask the tech what tracer
they injected. If they said "I don't • Indium can actually be hooked onto lots of
know", I would fire them on the
stuff (Octreotide, DTPA, etc ... )
spot, and have security remove
them from the hospital
immediately. • You can also do WBC scanning be using Tc
(instead on Indium). Both will have hot
2. What are the photon peaks of this spleens but the Tc tudy looks cleaner and
tracer?
becau c of its higher counts.
A. Single Peak at 81
B. Four Peaks at 93, 184, 300, & 393
C. Two Peaks at 173 & 247 • Tc -WBC labeling is preferred for small
D. Single Peak at 365 parts (hand and feet) and . mall people
(kids).
3. What is the half life of this tracer?
A. 67 Hours
B. 73 Hours
• ln-WBC is gonna be way better for bowel
C. 8 Days pathology (inflammatory or infected), as Tc
has normal bowel uptake (Indium does not).

Anatomy 59
 CASE 30 - NUKES (MYSTERY WHOLE BODY SCAN 3)

1. What scan is it?

A. Sulfur Colloid
B. MIBG
=
C. Iodine 131
D. I would ask the tech what tracer they injected. If they said "I don't know", I would fire
them on the spot, and have security remove them from the hospital immediately.

3. What is the halflife of this tracer?

A. 13 Hours
B. 13 Days
C. 8 Hours
D. 8 Days

3. Which is true regarding breast feeding?

A. You can resume breast feeding 24 hours after I-131
B. You can resume breast feeding 3 days after 1-123
C. You can resume breast feeding immediately after Tc-99m

Anatomy 60
CASE 30 - NUKES (IODINE -131)

HOT WBC
Salivary Gland
Uptake
Spleen Liver= Sulfur
k Bones ? Spleen Colloid

COLD Gallium

f
GI uptake (bowel) Heart
Kidneys

No
No
Bones

MIBG
- From Excretion
Kidneys 1-123
No
Bones
Liver
MIBG
Post Thyroidectomy No 1-131
(why there is no thyroid) Heart
No
Liver Iodine

I. What scan is it? Iodine Trivia

A. Sulfur Colloid
B. MIBG
• 1-131 is cheap but has a longer half life (8
c. Iodine 131
D. I would ask the tech what tracer they days), and is high energy (364)
injected. If they said "I don't know", I
would fire them on the spot, and have • 1-123 is more expensive. but has a horter half
security remove them from the hospital lifo ( 13 hours), and a more ideal energy (159)
immediately.
• Tc99m can also be used to image the thyroid,
3. What is the half I ife of this tracer?
A. 13 Hours but is not organified, so it just diffuses in and
B. 13 Days out of the thyroid - this cau es more
C. 8 Hours background uptake.
D. 8Days
• Any bone uptake should be considered a met
3. Which is true regarding breast feeding?
A. You can resume breast feeding 24 with 1-123 and 1-131.
hours after 1-131
B. You can resume breast feeding 3 • The shadow of the heart on a grey lung
days after 1-123 should make you think lung mets.
C. You can resume breast feeding
immediately after Tc-99m
• Uptake in the liver can bes en post l-13 l
ablation tr atrnent.

Anatomy 61
Index 1
CASE INDEX

Index 2
 Aunt Minnie's
1) CADASIL
2) Agenesis of the corpus callosum (ACC)
3) Jouberts
4) Central Pontine Myelinolysis
5) Hypothalamic Hamartoma
6) Artery of Percheron Infarct
7) Superficial siderosis (SS)
8) Skull Base Fibrous Dysplasia
9) NF-2
10) Esthesioneuroblastoma
11) Inverting Papiloma
12) Labyrinthitis Ossificans
13) Endolymphatic Sac Tumor
14) Large Vestibular Aqueduct Syndrome (LVAS)
15) Superior Canal Dehiscence (SCD)
16) Otospongiosis
17) Retinoblastoma
18) Spinal Ependymoma
19) Tethered Cord with Lipoma
20) De Quervain's tenosynovitis
21) Kohlers
22) Juvenile Rheumatoid Arthritis
23) Psoriasis Arthritis
24) Gout
25) Erosive OA
26) Systemic Lupus Erythematosus Arthritis
27) Osteochondral Lesion
28) Synovial Osteochondromatosis
29) Pagets
-I 30)
31)
Particle Disease
Polyethylene Wear
32) Partial UCL Tear - T Sign
33) Aneurysmal bone cysts (ABC)
34) Bucket Hand Meniscal Tear - Double PCL sign
35) Discoid Meniscus
36) Split Brevis
37) Posterior Tibial Tendon Tear
38) Adhesive Capsulitis
39) Buford Complex
40) Calcific Tendonitis
41) Anisotropy - Ultrasound Artifact
42) SLAC wrist
43) Displaced medial humeral epicondyle fracture
44) Arrhythmogenic right ventricular cardiomyopathy (ARVC)
45) Car Triatriatum Sinistrum
46) Coronary Artery Aneurysm
47) Non-compaction cardiomyopathy (NCC)

Index 3
48) lschemia on Cardiac MR I
49) Myocarditis
50) Sinus of Valsalva Aneurysm
51) Ebsteins Anomaly
52) Tetralogy of Fallot
53) Total anomalous pulmonary venous return (TAPVR)
54) UIP
55) NSIP
56) Fibrosing Mediastinitis
57) Kaposi Sarcoma
58) Pulmonary Alveolar Proteinosis (PAP)
59) Tracheobronchopathia Osteochondroplastica (TBO)
60) HOT Quadrate Syndrome
61) Bud Chiari
62) Duodenal Hematoma
63) CF Pancreas (SOS)
64) Gamma Gandy Bodies
65) Rectal CA - T3 staging
66) Appendix Mucocele
67) Biliary Cystadenoma
68) Shock Bowel
69) Typhlitis
70) Pheochromocytoma
71) Xanthogranulomatous Pyelonephritis (XGPN)
72) Autosomal Dominant Polycystic Kidney Disease (ADPCKD)
73) Multilocular Cystic Nephroma
74) HIV Associated Nephropathy (HIVAN)
75) Urachal Carcinoma
76) Tamoxifen Uterus
77) Adenomyosis
78) Theca Lutein Cysts
79) Cervical Cancer
80) MIBG with Breast CA
81) Gallium Pneumonia (PCP)
82) FOG Brain Alzheimers
83) Normal pressure hydrocephalus
84) Duodenal Atresia
85) Choroid Plexus Cyst
86) Mid Gut Herniation
87) Cystic Rhombencephalon
88) Aqueductal Stenosis Congenital Hydrocephalus
89) Choanal Atresia
90) Mesenchymal Hamartoma
91) Septate Uterus
92) Bicornuate Uterus
93) Pyloric Stenosis
94) Posterior Urethral Valve (PUV)
95) Neonatal Pneumomediastinum and the Spinnaker-Sail Sign
96) Osteosarcoma

Index 4
97) Prostaglandin Therapy
98) Blount's disease
99) Rickets
100) Malrotation
101) Breast Hamartoma
102) NMLE (DCIS) on MRI
103) Sternalis Muscle
104) Type B Aortic Dissection
105) Stent Graft Endoleak
106) May-Thurner syndrome
107) Popliteal Artery Aneurysm
108) Giant cell arteritis
109) MRI Artifact 1 - Pulsation
110) MRI Artifact 2 - Magnetic Susceptibility
111) MRI Artifact 3- Cs -1
112) MRI Artifact 4 - CS -2
113) MRI Artifact 5- Fat inhomogeneity
114) MRI Artifact 6- Coil Flair
115) MRI Artifact 7 -Gibbs
116) MRI Artifact 8 - Dielectric Artifact
117) MRI Artifact 9 - Zipper
118) MR I Artifact 1 O - Magic Angle
119) Star Artifact
120) NM colloid clump VQ
121) Beam Hardening Artifact
122) Ring Artifact
123) Ultrasound QC - Focal Zone Wrong
124) Ultrasound Artifact - Mirror Image
125) Ultrasound Artifact - Comet Tail

Index 5
This vs That

1) Acoustic Schwannoma vs Meningioma vs Epidermoid

2) Holoprosencephaly Spectrum
3) Schizencephaly vs Porencephalic Cyst
4) Herpes Encephalitis vs Limbic Encephalitis
5) lntracranial Hypotension vs lntracranial Hypertension
6) HIV Encephalitis vs PML
7) CMV calcifications vs Toxoplasma calcifications
8) JPA vs Hemangioblastoma
9) Thyroglossal Duct Cyst vs Brachia! Cleft Cyst
10) Cholesteatoma vs Cholesterol Granuloma
11) Vocal Cord Paralysis vs Tumor
12) Glomus vs Giant-cell tumor of the tendon sheath (GCT-TS)
13) lnfraspinatus vs Quadrilateral Space Atrophy
14) Perthes vs GLAD
15) Monteggia Fx vs Galeazzi Fx
16) HALO vs Reverse Halo Sign
17) LAM vs LCH
18) Upper vs Lower Lobe Predominant
19) Pulmonary Nodule Patterns
20) Hemochromatosis vs Fatty liver
21) Primary vs secondary hemochromatosis
22) Dysplastic Nodule vs HCC
23) Pancreatic serous cystadenoma vs Mucinous Cystadenoma (MCN)
24) Crohns vs Ulcerative Colitis
25) Endometrioma vs Dermoid on MRI
26) Traction vs Pulsion Diverticulum
27) T sign vs Twin Peak Sign
28) Pre vs Post ECMO
29) UAC vs UVC
30) Polysplenia vs Asplenia
31) SCFE vs Perthes
32) Wilms vs Neuroblastoma
33) Hirschsprung's disease (HD) vs Meconium lleus
34) VQ anatomy Projections
35) Renal Transplant Rejection vs ATN - on MAG 3
36) Super Scans - Metabolic vs Mets
37) Geiger Muller Counter vs Ionization Chamber
38) Yellow 1 vs Yellow 2
39) Major Spill vs Minor Spill
40) Radiochemical Purity vs Chemical Purity
41) Decay Line Diagrams
42) PET corrected vs uncorrected
43) Breast Implants on MRI - Radial Folds vs lntracapsular Rupture
44) Male Gynecomastia vs Male Breast CA
45) Breast MRI - Tamoxifen on Vs Tamoxifen Off - Rebound Effect
46) Carotid Doppler - Internal Carotid vs External Carotid
47) Marfans vs Loeys-Dietz syndrome
48) Renal Artery Angiograms: Atherosclerosis vs FMD
49) Arthrogram - Shoulder vs hip
50) Catheter Basics - Inner vs Outer Diameter (Sheath vs Catheter)

Index 6
Anatomy

1) Skull Base - Part 1

2) Skull Base - Part 2
3) Skull Base - Part 3
4) Skull Base - Part 4
5) Skull Base - Part 5 (Cavernous Sinus)
6) Skull Sutures
7) Sagittal Brain MRI -
8) Temporal Bone - Part 1 (CT)
9) Temporal Bone - Part 2 (CT)
10) Temporal Bone - Part 3 (MR I)
11) Cervical Lymph Nodes
12) Vascular (CNS - Part 1)
13) Vascular (CNS - Part 2)
14) Vascular (CNS - Part 3)
15) Vascular (Celiac Axis)
16) Vascular (SMA)
17) Vascular (Upper Extremity)
18) Vascular (Lower Extremity)
19) Vascular (Femoral Access)
20) Cardiac (Part 1)
21) Cardiac (Part 2)
22) Abdominal Ultrasound
23) Prostate MRI
24) MSK - Pelvis
25) MSK - Shoulder
26) MSK - Wrist
27) MSK - Ankle
28) Nukes Mystery Whole Body Scan 1
29) Nukes Mystery Whole Body Scan 2
30) Nukes Mystery Whole Body Scan 3

Index 7
 Blank on Purpose For Note Writing:

Index 8
Blank on Purpose For Note Writing:

Index 9
Blank on Purpose For Note Writing:

Index 10
 If you want a thing bad enough to go out and fight for it,

To work day and night for it,

To give up your time and your peace and your sleep for it;

And all that you dream and you scheme is about it;

If life seems all empty and useless without it,

If gladly you'll sweat for it and fret for it

And lose all you terror of the opposition for it

If you'll simply go after the thing that with all your capacity,

Strength and sagacity; faith, hope, and confidence, & stern pertinacity;

If neither cold poverty famish nor gaunt

Nor sickness or pain to body or brain can turn you away from it

If dogged and grim, you besiege and beset it, you'll get it!

-LB

Index 11