Seeing the signs of Radiology

Trevor Downing, MSIV

To quote Dr. Neuffer

These are the things Radiologists come up with when they sit in the dark too long
Or something like that

Classic signs

Apple core sign

Must r/o adenocarcinoma of colon DDx:
Malignant neoplasms (adenocarcinoma, lymphoma) Benign neoplasms (villous adenoma) IBD (chronic Crohns or UC) Vascular disorders (ischemic colitis) Infections (tuberculosis, helminthoma, ameboma)

Studies of double-contrast barium enema as screening for colorectal cancer

Detects only ~1/2 of adenomas >1cm and 39% of all polyps. May miss 15-22% of colorectal cancers Use decreasing due to more accurate colonoscopy or CT colonography

Bamboo spine
Ankylosing spondylitis
Chronic inflammatory disease of the axial skeleton causing back pain and progressive stiffness of spine Peak age of onset 20-30yrs Ankylosis refers to fibrous or bony bridging of joints Part of the spondyloarthritis disorders inflammation of the entheses (insertion sites of ligaments on bones). Dx:
Clinical findings (inflammatory back pain, ROM of back) Lab testing HLA-B27 Imaging

Bamboo spine
Imaging
Abnormal SI joint on plain AP pelvic radiographs seen in longstanding disease.
Findings: joint widening, erosions, sclerosis or ankylosis

If no findings but suspicion is high then follow with MRI of pelvis. If MRI contraindicated then CT scan can detect erosions, bony sclerosis but not acute inflammatory changes

Champagne sign
Emphysematous cholecystitis
US image reveals multiple tiny echogenic reflectors within the gallbladder lumen (arrows) corresponding to gas bubbles leaving from dependent wall. Often a complication of acute cholecystitis, caused by gas forming bacteria (mostly C. perfringens, Ecoli, gut bacteria) More common in men, elderly (>60yrs) and diabetics.

Champagne sign
Emphysematous cholecystitis
Imaging
Plain films may show air in wall/lumen CT scan:
GB wall thickening >3mm Cholelithiasis Increased bile density (>20H) Loss of clear GB wall definition Pericholecystic fluid (halo)

Treatment
Percutaneous preoperative drainage + antibiotics Open cholecystectomy laparoscopic less successful

Bats wings or butterfly appearance

Congestive heart failure (HF)
Chest x-ray is often first diagnostic test
Differentiates between HF and 1 pulmonary disease (dyspnea)

Bats wings are bilateral perihilar edema Findings suggestive of HF

Cardiomegaly cardiac:thoracic width >50% Cephalization of pulmonary vessels Kerley B-lines pulmonary edema in interlobular septa Pleural effusions

Study of 880 patients showed

Cephalization, alveolar edema or interstitial edema all had >90% specificity for HF Cardiomegaly had only 50% sensitivity

Codmans triangle
Osteosarcoma
1 malignant tumor of bone malignant cells make osteoid or immature bone Uncommon tumor but #1 primary malignancy of bone in children and adolescents
Bimodal distribution - <20yrs and >65yrs

Most common sites

Children: metaphyses of long bones (distal femur 75%, proximal tibia, proximal humerus) Adults: axial skeleton

Codmans triangle
Osteosarcoma
Risks
Prior irradiation/chemotherapy Pagets disease usually osteosarcoma in pts >40yrs Chronic osteomyelitis Multiple hereditary exostoses Fibrous dysplasia Metallic implants Hereditary retinoblastoma Li-Fraumeni syndrome (p53 mutation)

Codmans triangle
Dx:
First diagnostic test usually plain radiograph
Codmans triangle new periosteal bone formation lifting the cortex. The associated sunburst appearance soft tissue ossification.

No bone findings are pathognomonic biopsy needed DDx:

Malignant bone tumors (Ewings, lymphoma, mets) Benign bone tumors (osteoid osteoma, chrondroblastoma, osteochrondroma) Non-neoplastic (osteomyelitis, eosinophilic granuloma, bone cysts)

Hamptons hump & Westermarks sign

Pulmonary embolus
Hamptons hump Pleural based, wedge shaped consolidation represents area of infarction and atelectasis Westermarks sign Area of decreased density lateral to PE represents oligemia distal to PE as well as distended/engorged pulmonary vessels.

Hamptons hump & Westermarks sign

Pulmonary embolus
Radiographic abnormalities common in PE but not helpful diagnostically

Strange signs

Anteater nose sign

Calcaneonavicular tarsal coalition
Tarsal coalition abnormal union or 2 or more tarsal bones 2 most common types
Calcaneonavicular Talocalcaneal

Causes are congenital or acquired

Acquired: trauma, infection, surgery, articular disorders

Anteater nose sign

Initial evaluation of tarsal coalition conventional radiography
Oblique, AP and lateral weight bearing views of feet CT/MRI for complicated cases or preoperative planning MRI is useful for nonosseous fibrous or cartilaginous coalitions

David Letterman sign (Aka Terry Thomas)

Scapholunate dissociation (dislocation)
Most common and significant wrist ligament injury Mechanism of injury:
Similar to scaphoid fx falling on outstretched hand (carpal loading) Common in contact sports due to jamming extended hand into other athletes

Imaging
AP radiograph scapholunate distance >3mm & flexed scaphoid. Lateral view increased scapholunate angle MRI helpful
In children: difficult to interpret due to incomplete ossification Incomplete tear of ligament

Mount Fuji sign

Tension pneumocephalus
Causes
Iatrogenic: most commonly after neurosurgical evacuation of subdural hematoma (2.5-16% incidence).
Other: skull base surgery, paranasal sinus surgery

Non-iatrogenic: head trauma, nitrous oxide anesthetic, scuba diving?

Mount Fuji sign useful test to distinguish tension from non-tension pneumocephalus
Emergency surgery vs non-operative Ishiwata study showed Mount Fuji sign positive in 4/5 patients with surgically confirmed tension pneumocephalus, not seen in any non-tension cases.

Yin-yang sign
True and false aneurysm
Yin-yang sign due to partial thrombosis of aneurysm. Contrast enhanced CT delineates lumen with active blood flow from the thrombosed portion

Utility
Two studies showed 82 & 89% of aneurysms demonstrated presence of mural thrombus. This finding particularly helpful in 2 regions of body where hard to differentiate from ddx
Brain: suprasellar meningiomas, craniopharyngiomas, hemorrhagic metastases Abdomen: cystic pancreatic tumors, islet cell tumors, solid/epithelial neoplasms, pseudocysts, gastric leiomyomas and leiomyosarcomas

However, not a specific sign for aneurysms

Rare solid or papillary neoplasms may show sign.

Throckmorton sign (John Thomas sign)

Penis points towards the side of pathology
The sign tends to be commented on by middleaged male radiologists and orthopedists suffering from Peter pan syndrome.

2 studies
Medical Journal of Australia 1998 sensitivity 70%, specificity 67% UK study sensitivity 30%, specificity 86%

Mark Morton sign is a smaller Throckmorton

References
Winawer, SJ, Stewart, ET, Zauber, AG, et al. A comparison of colonoscopy and double-contract barium enema for surveillance after polypectomy. National Polyp Study Work Group. N Engl J Med 2000; 342:1766. Toma, J, Paszat, LF, Gunraj, N, Rabeneck, L. Rates of new or missed colorectal cancer after barium enema and their risk factors: a population-based study. Am J Gastroenterol 2008; 103:3142. Klauser, A, Bollow, M, Calin, A, et al. Workshop report: clinical diagnosis and imaging of sacroiliitis, Innsbruck, Austria, october 9, 2003. J Rheumatol 2004; 31:2041. Knudsen, CW, Omland, T, Clopton, P, et al. Diagnostic value of B-Type natriuretic peptide and chest radiographic findings in patients with acute dyspnea. Am J Med 2004; 116:363. Le Vu, B, de Vathaire, F, Shamsaldin, A, et al. Radiation dose, chemotherapy and risk of osteosarcoma after solid tumors during childhood. Int J Cancer 1998; 77:370. Grimer, RJ, Cannon, SR, Taminiau, AM, et al. Osteosarcoma over the age of forty. Eur J Cancer 2003; 39:157. Papagelopoulos, PJ, Galanis, EC, Vlastou, C, et al. Current concepts in the evaluation and treatment of osteosarcoma. Orthopedics 2000; 23:858. Blakemore LC, Cooperman DR, Thompson GH. The rigid flatfoot. Tarsal coalitions. The rigid flatfoot. Tarsal coalitions. Clin Podiatr Med Surg. Jul 2000;17(3):531-55. [Medline]. Crim JR, Kjeldsberg KM. Radiographic diagnosis of tarsal coalition. AJR Am J Roentgenol. Feb 2004;182(2):323-8. [Medline]. Waters, PM. The upper limb. In: Lovell and Winter's Pediatric Orthopaedics, 6th ed, Morrissy, RT, Weinstein, SL (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p. 921. Steven J. Michel, The Mount Fuji Sign. Radiology August 2004 232:44945010.1148/radiol.2322021556 Ishiwata Y, Fujitsu K, Sekino T, et al. Subdural tension pneumocephalus following surgery for chronic subdural hematoma. J neurosurgery 1988; 68:58-61 Tommaso Lupattelli, The Yin-Yang Sign. Radiology March 2006 238:1070107110.1148/radiol.2383031884