HAPPY NEW YEAR 2015

What is outside is harder to change than what is inside? Follow the path of least resistance.

Paulo Coelho

ADENOMYOMATOSIS OG GALL BLADDER

MCQ ----NUCLEAR IMAGING

1. First-line technique for evaluating myocardial perfusion, viability and function is

a.Echo
b.Nuclear cardiac imaging
c.CMR
d.MDCT

e.X ray



2.All are true regarding nuclear cardiac imaging except
a. Resting perfusion abnormalities occur in areas supplied by a very severe (>85%) stenosis
b. stress is often used to increase sensitivity for rate-limiting stenoses
c. adenosine / dipyridamole/dobutamine are used in stress test.
d.current indications for pharmacological perfusion imaging include left bundle branch block and fixed rate pacemaker

e. SPECT may have better specificity than Rubidium-82 for detecting coronary artery disease

ANS---

1.---b
2----e

ANS-----e
Rubidium-82 may have better specificity than SPECT for detecting coronary artery disease.

 Many regard PET (using rubidium-82 to assess flow and FDG to assess glucose metabolism) as the best method for determining myocardial viability. Others believe that DE-MRI is equivalent or even superior to PET for assessing myocardial viability, and has superior spatial resolution.(Grainger)

Post by Dr.Nagendra Kumar Sinha.

COMET-TAIL ARTEFACT IN GALL BLADDER

• Adenomyomatosis is a benign condition characterized by hyperplastic changes of unknown etiology involving the gallbladder wall and causing overgrowth of the mucosa, thickening of the muscular wall, and formation of intramural diverticula or sinus tracts termed Rokitansky Aschoff sinuses.
• Three types 

                      a.generalised 

                      b.segmental/annular

                       c.fundal 

• Comet tail artefact due to cholesterol crystal in Rokitansky Ascoff sinuses is highly specific for Adenomyomatosis
• Rokitansky-Aschoff sinuses gives gives CT ROSARY SIGN 
•  Fuid filled intramural diverticula appear as pearl necklace sign on MRI
• 
  

FUNDAL VARIETY OF ADENOMYOMATOSIS

MCQ FRCR ----cardiac stress testing

454.All are true regarding cardiac stress testing except
a. used to determine the functional consequences of CAD
b. Exercise, pacing, cold pressor testing are used as stress 
c. Perfusion defects are seen after  the development of ischaemia
d. dobutamine/dipyridamole / adenosine are used as pharmacological agent for stress testing

e. the end-point of the test is usually the appearance of new wall motion abnormalities or a new perfusion defect.

cervical lymph node ---usg

 Common locations of metastatic, lymphomatous and tuberculous nodes in the neck
                                                                                                         Commonly involved nodal groups
Metastases from oropharynx, hypopharynx, larynx carcinomas -----Internal jugular chain
Metastases from oral cavity carcinomas ---------------------------------SubmandibularUpper cervical
Metastases from infraclavicular carcinomas-----------------      Supraclavicular fossa Posterior triangle
Metastases from nasopharyngeal carcinoma -------------------Upper cervical,Posterior triangle
Metastases from papillary carcinoma of the thyroid------------ Internal jugular chain
Non-Hodgkin’s lymphoma ------------------------------Submandibular,Upper cervical.Posterior triangle
Tuberculosis ------------------------------------------------------Supraclavicular fossa,Posterior triangle




. Classic US criteria used in differentiating benign vs. malignant lymph nodes.
Criterion Benign Malignant
B scan criteria                                                                      BENIGN -----MALIGNANT
Size               ------------------------------------------------------- small--------- large
shape----------------------------------------------------------------- oval---------- rounded
hilum -----------------------------------------------------------------present-------- absent
echogenicity --------------------------------------------------moderate or low ------marked hypoechoic
margins ---------------------------------------------------------sharp ----------------------irregular, blurred,
Structural changes---------------------------------------------------absent----------- present
– focal cortical nodules
– intranodal necrosis
– reticulation
– calcification
– matting

Soft tissue edema --------------------------------------------------may be present---------- absent
Doppler criteria
Flow--------------------------------------------------------- absent------------------ present
Vessel location ----------------------------------------------central ------------------peripheral
Vascular pedicles---------------------------------------- single -----------------------multiple
Vascular pattern--------------------------------------- regular------------------------ chaotic
Impedance values--------------------------------------------- low--------------------- high




BENIGN LYMPH NODE



benign lymph node



lymphoma





Malignant lymph node

Use of MR to Identify Brown Fat Could Fuel Obesity Therapies

MIKE BASSETT is a writer based in Holliston, Mass., specializing in health and medicine.

December 01, 2014

The first MR imaging study to show “brown fat” in a living adult could help researchers develop therapies to battle obesity.

BY MIKE BASSETT

Use of a novel MR imaging technique to detect the presence of brown fat in humans could help researchers develop therapies to battle obesity and related illnesses including diabetes.

“We’ve demonstrated for the first time that we can use a form of MRI to actually show brown fat (brown adipose tissue, or BAT) and discern it from white fat (white adipose tissue, or WAT),” said Thomas Barber, Ph.D., associate professor of clinical endocrinology and honorary consultant endocrinologist, University of Warwick, University Hospitals Coventry and Warwickshire NHS Trust. “This is the first study that has used MRI to show brown fat in a living human.”

The study by Dr. Barber and colleagues was published in the January 2014 issue of the Journal of Clinical Endocrinology and Metabolism.

White fat has been associated with weight gain, while brown fat helps regulate body weight due to its ability to use energy and burn calories. “If you have a sugar cube size of brown fat, and activate it for a year, you could burn through three or four kilograms of white fat in that time,” Dr. Barber said. “You don’t need a lot of brown fat to have a very attractive method of producing weight loss.”

According to Dr. Barber, the study of brown fat was “revolutionized” five years ago with the publication of a study in the New England Journal of Medicine by Wouter D. van Marken Lichtenbelt, Ph.D., and colleagues, who determined that “the amount of brown adipose tissue is inversely correlated with body mass index, especially in older people, suggesting a potential role of brown adipose tissue in adult human metabolism."

Brown fat was previously thought to be relevant only in small mammals and infants. “This, therefore, opened the possibility for further study of brown fat in human adults and potentialtherapeutic avenues,” Dr. Barber said.

Until recently, PET/CT had been the standard approach for assessing brown fat tissue in adult humans, but that modality is limited in determining how many adults have brown fat and, if so, how much fat each adult possesses. “PET allows detection of BAT in vivo, but is hampered by various factors including the requirement that the BAT be metabolically active in order for the radiotracer to be taken up,” said study author Terrance Jones, Ph.D., a clinical research fellow in radiology at the University of Warwick.

Other study authors include Professor Charles Hutchinson, B.Sc., M.B.Ch.B., M.D., Sarah Wayte, Ph.D., and Narendra Reddy, M.D., M.R.C.P.

Dr. Jones added that BAT is also sensitive to external factors, most notably temperature.

For those reasons, PET/CT is not very useful in determining the prevalence of BAT in adult humans. For example, Dr. Barber cited some PET/CT studies showing that brown fat is found in just 5 to 10 percent of subjects, and others involving multiple scans that point to a presence brown fat in as many as 50 percent of subjects. “With PET/CT, the question is how many of us have brown fat tissue,” Dr. Barber said. “We don’t really know the answer. It could be that all of us have some brown fat; it could be that a minority of us do.”

Knowing the answers to these questions could be of great value, Dr. Barber said, as they could affect research on brown fat-related therapies used to battle obesity.

MR Advantages Could Aid Future Research

Researchers found that MR imaging has imporant advantages over PET/CT. Along with having no ionizing radiation, MR imaging provides superior spatial resolution, which could potentially allow for identification of small brown fat deposits, Dr. Jones said. MR imaging can also differentiate between BAT and WAT based on the difference in water content between the two tissue types, allowing researchers to identify both active and inactive brown fat. PET/CT only identifies brown fat when it is active.

“Identifying BAT using MR has capitalized on the biochemical and morphological differences between BAT and WAT,” Dr. Jones said. The application of iterative decomposition of water and fat with echo asymmetry and least-squares

estimation (IDEAL) enables MR imaging to distinguish between BAT and WAT, as shown in previous studies.

In the team’s proof-of-concept study, they visually identified BAT on anatomical fat-only spin-echo MR images in a single adult with a large volume of BAT. They reported moderate inter- observer variability and provided PET/CT, histological and immunohistochemical confirmation. “When applied to a wider sample, visual identification tended to underestimate BAT on MR compared with PET/CT,” Dr. Jones said. “However MRI has the advantage of being able to acquire multiple data points in experiments where precise estimation of BAT volume is required.”

It is noteworthy that the proof-of-concept study was performed on a subject who happened to have an abundance of active brown fat that appeared on the original PET/CT, which was performed for clinical reasons, Dr. Barber said. “This needs to be tested on many more subjects so we can examine its reproducibility, its reliability and validate some of the findings we showed in the original study,” he said.

The ultimate aim of the research is to identify a way of quantifying BAT so that it can be used to assess the efficacy of future therapies based on brown fat and to shed light on the nature of brown fat itself.

“We are hoping additional research will help us answer questions like how many of us have brown fat,” Dr. Barber said. “For those of us who do have brown fat and it’s not activated, why isn’t it activated? Are we missing something that’s not activating our existing brown fat? Hopefully, this MRI technique will help us address these questions.”

FRCR -----cardiac anatomy in image

SOURCE----http://www.ncbi.nlm.nih.gov/pmc

FRCR MCQ -----CARDIOVASCULAR MODULE

350.All are true except

a. there is usually mirror image branching of the aortic arch

 in right-sided aortic arch with associated CHD

b. A dilated ascending ‘aorta’, rising high in the mediastinum 

is seen typically in persistent arterial truncus or tetralogy of 

Fallot 

c. Rib notching noted in persistent cervical arch 

(pseudocoarctation)

d. figure of 3 indentation deformity of the left border of the

 oesophagus is noted in coarctation of aorta

RADIOLOGY MCQ -----Figure of 8

438. Figure of 8  is noted in
a.TOF
b.UCTGA
c. total superior anomalous pulmonary venous drainage(Type 1)
d. Ebstein's anomaly

d. Uhl's disease

ANS----C----total superior anomalous pulmonary venous drainage(Type 1)













www.improbable.com

RADIOLOGY MCQ----OLIGAEMIA

341. Central cyanosis may be present within a few hours

 after birth in

a. tetralogy of Fallot

b. uncorrected transposition of great arteries (UTGA).

c. common atria and common ventricles 

d. PDA

e. persistent truncus arteriosus

434.All are causes of oligaemia except
A Ebstein's anomaly
b. Tetralogy of Fallot
c. Uncorrected transposition of the great arteries with atrial or venous septal defect
d. Uhl's disease

e. persistent truncus --Type IV


341.---b
434.---c

Table   -- INCREASED PULMONARY PERFUSION (PLETHORA)

Level of shunt	Anomaly
Atrium	Ostium primum defect[*]
	Ostium secundum defect[*]
	Sinus venosus defect
	Anomalous pulmonary veins[†]
Atrioventricular valves	Endocardial cushion defects
	Ostium primum defect[*]
	Muscular ventricular septal defect (VSD)[*]
Ventricles	Membranous VSD[*]
	Bulvar VSD[*]
	Double outflow ventricle
	Single ventricle
Aorta	Patent arterial duct[*]
	Aortopulmonary window
	Common arterial trunk (persistent truncus arteriosus)[†]
	Coronary artery-to-right heart fistula
	Uncorrected transposition of the great arteries with atrial or venous septal defect

*	Most common causes of plethora without cyanosis;
†	most common causes of plethora with cyanosis.

  -- DECREASED PULMONARY PERFUSION (ANOMALY)

Level of abnormality	Anomaly
Tricuspid valve	Tricuspid atresia
	Tricupid stenosis
	Ebstein's anomaly
Right ventricular outflow	Pulmonary infundibular stenosis (severe)
	Pulmonary valvar stenosis (severe)
	Tetralogy of Fallot
	Uhl's disease (right ventricular hypoplasia)
Pulmonary arterial	Pulmonary artery or trunk atresia
	Right or left pulmonary artery interruption
	Peripheral pulmonary artery interruption or stenosis
	Common arterial trunk (persistent truncus) (Type IV)
	Transposition (ventriculo-arterial discordance) with pulmonary valve stenosis
	Eisenmenger reaction (lung periphery only) REF -- Adam: Grainger & Allison's Diagnostic Radiology, 5th ed. CHAPTER 23 – Congenital Heart Disease: General Principles and Imaging

FRCR ----cardiac artefact

Q1 There is an artefact in aorta   left sided image (above and below) on MDCT  cardiac scan.What is that artefact?
Q2 How was that artefact removed (no artefact on right sided image ,above and below)?











ANS
Q1.Pulsatility artefact (duoble lumen of aorta in above image  ,step artefact on down image)
Q2.---By use of ECG gating and taking the image at end-diastole (when cardiac pulsation is least)

FRCR ----ANATOMY

FRCR  ----ANATOMY

Q1.Name of investigation?

Q2.Structure seen in the image?

Q3.Name the structure shown by black arrow?

Q4.Name the structure shown by white arrow/?

ANS ---Q1.---MRA

             Q2.---LEFT VENTRICLE IN END SYSTOLE

             Q3------PAPILLAR MUSCLE

             Q4.-----MITRAL VALVE

RADIOLOGY MCQ ---PG AND FRCR ---‘black bronchus’ sign

280.All are true regarding ground glass opacity except
a.increase in lung density
b.presevation of bronchoalveolar  markings on CT
c. obscuration of  vessel markings on chest x ray
d. indicate disease within the airspaces only  

e. ‘black bronchus’ sign
ANS---d---
Ground glass opacity  indicate disease within the airspaces and/or the interstitium.It may or may not be an associated  with air bronchogram. In cases of uncertainty, comparison of the (air) density within airways with that of lung parenchyma (the ‘black bronchus’ sign) may be useful, normally the two densities are roughly comparable. .(CHAPTER 21 – Airspace Diseases,Adam: Grainger & Allison's Diagnostic Radiology, 5th ed)




IMAGE SOURCE--www.learningradiology.com

‘crazy-paving’ pattern on CT

278.All are true regarding airspace diseases except
a. Wegener's granulomatosis  may show  cavitation  on CT scan
b. In cryptogenic organizing pneumonia, areas of consolidation  most pronounced in the periphery and lower zones of the lungs
c. in chronic eosinophilic pneumonia, the changes tend to be in the upper zones and  parallel to the chest wall
d. transient and migratory opacities , unaccompanied by significant constitutional disturbance favour  diagnosis of an eosinophilic pneumonia.

e. ‘crazy-paving’ pattern on CT is noted in alveolar proteinosis.



278.----b---In cryptogenic organizing pneumonia, areas of consolidation  are most pronounced in the periphery and upper zones of the lungs.(CHAPTER 21 – Airspace Diseases,Adam: Grainger & Allison's Diagnostic Radiology, 5th ed)












www.casesjournal.com

RADIOLOGY MCQ ---PG AND FRCR ----TUBES AND LINES

255.Correct positions of tubes and lines are all except
a. Endotracheal tube---3–8 cm above carina
b. Swan–Ganz catheter----  superior vena cava
c. Central venous pressure catheter----Superior vena cava
d. Peripherally inserted central catheter line---Superior vena cava

e. Pleural tubes----In pleural space via mid axillary line, 6th to 8th rib spaces.
ANS---- Swan–Ganz catheter----Right or left pulmonary artery. (CHAPTER 20 – Thoracic Trauma and Related Topics ,Adam: Grainger & Allison's Diagnostic Radiology, 5th ed).

ENDOTRACHEAL TUBE 



source --www.med-ed.virginia.edu

SWAN -GANZ CATHETER


source --www.med-ed.virginia.edu

Syndesmophyte

Syndesmophyte 

Bilateral ,symmetrical,thin intervertebral connections noted in ankylosing spondylitis.Represent ossification of the outermost lamellae of annulus fibrosis.

Syndesmophytes noted at multiple levels produce BAMBOO SPINE.






IMAGE SOURCE ----www.mypacs.net

RADIOLOGY MCQ --AIPGMEE AND FRCR---SULCUS SIGN

241. An abnormally deep costophrenic sulcus sign is noted in

a.pneumothorax in supine position

b.pleural effusion in supine position

c.pleural effusion in decubitus position

d.pneumothorax in standing position

e.collapse of lower lobe

ANS----a

 With supine radiographs, air collects anterior to the lung and there is no visible lung edge. In this situation a pneumothorax can produce an unusually sharp mediastinal border and hemidiaphragm and an abnormally deep costophrenic sulcus.

Image source ---www.resus.com.au

RADIOLOGY MCQ /AIPGMEE AND FRCR/Erasmus syndrome

233. Erasmus syndrome refers to

a. the association of silicosis and rheumatoid arthritis

b. the association of silicosis and systemic sclerosis

c. the association of CWP and rheumatoid arthritis

d. the association of Berrylosis and rheumatoid arthritis

e. the association of CWP and systemic sclerosis

RADIOLOGY MCQ --AIPGMEE AND FRCR---HRCT SARCOIDOSIS

217.All are HRCT finding of sarcoidosis except

a. peribronchovascular,subpleural distribution

b. perilymphatic distribution

c. small well-defined nodules (1-5mm)

d. fibrosis

e.a mid and lower zone distribution

ANS-----e---mid and upper zone distribution

IMAGE SOURCE ---www.radiologyassistant.nl

RADIOLOGY MCQ --AIPGMEE AND FRCR---EGGSHELL CALCIFICATION

215.Causes of eggshell nodal calcification are all except

a. Sarcoidosis

b. Silicosis

c. tuberculosis

d. Lymphoma (postirradiation)

e. Amyloidosis

ANS ---C----TUBERCULOSIS 

Causes of eggshell nodal calcification are  sarcoidosis. silicosis, 

lymphoma (postirradiation),amyloidosis, histoplasmosis,

 blastomycosis. (Chapter 19,  High-Resolution Computed 

Tomography of Interstitial and Occupational Lung Disease ,Adam:

Grainger & Allison's Diagnostic Radiology, 5th ed)

IMAGE SOURCE----www.meddean.luc.edu

RADIOLOGY MCQ /AIPGMEE AND FRCR/HALF-LIVES

32.Correct matching of half lives is/are

a.fluorine -18---110 min

b.technetium-99m---6hrs

c.iodine-123----13hrs

d.molybdenum-99---67hrs

e.indium-111---67hrs

RADIOLOGY MCQ --AIPGMEE AND FRCR--The lotus root sign

The lotus root sign 

De Quervain disease is stenosing tenosynovitis of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons in the first extensor compartment of the wrist


Hiranuma classification. 
(a) Normal type of de Quervain disease (Hiranuma type I). APL and EPB run in the same sheath. 
(b) Complete septation (Hiranuma type II). APL and EPB run in separate tendon sheaths.
 (c) Incomplete septation (Hiranuma type III). APL and EPB run in separate tendon sheaths in only the distal portion.
 (d) EPB-lacking type (Hiranuma type IV). Tendon sheath is normal but lacks EPB.



\
 (a) Photograph of the sliced lotus root. (b) Photographic negative of a transverse US image shows the lotus root sign. This sign suggests three or more tendon slips in one compartment. Negatively inverted tendon slips look like holes of the sliced lotus root.



a.


b.



SOURCE ---http://pubs.rsna.org/doi/suppl/10.1148/radiol.11102458