APID REVIEW SHAHID HUSSAIN SHERIF A. A. LATIF ADRIAN D. HALL Rapid Review of Radiology Shahid Hussain MA, MB, BChir, MRCP, FRCR Consultant Radiologist Heart of England NHS Foundation Trust, Birmingham) UK Sherif Aaron Abdel Latif MB, ChB, MRCS, FRCR Consul tant Dudley Group of Hospitals NHS Foundation Trust, West Midl ands, UK Adrian David Hall MB, ChB, MRCP, FRCR Consultant Radiologist Dudley Group of Hospitals NHS Foundation Trust, West Midlands, UK MANSON PUBLI SHING ----------Dedications _ To .. , ... m S.L _ To..,. .,,"" -.I J.oJ, my Il ...... -.I t..bf I) ... , t;"rl"lh, 0 lOI ,n'n .. "'.'g_h "" fnon "" .. ,,, .. ,m. "'''"H"'ly. Iu", il\;,idy "",,1,,,.1 r""" of f""" ,,,,,hipk ,oJ 'h,,,,, ", .. Iu"'ly i< ",""",. " "., .. , """'. ' f>< 1M .... .." ,,,. "'f"'''' nl ... ...J .'nm' .... " ;t!I "".m< ,no" ""F"''''''_ ''I''",'-'I!y .. ...... , bm,,", ...... ),"' Ik ," .. I=. mJ "" b .. ,.,j J ;,if."h< J;(J.,,,", ;'I . ...... n' . "" ""mh, n,;,< " h'"" ...... , .... ," .. ,h" I .. 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Ifro\! arc sure of the diagnosis, dispatch the film promptly with your preprepared 'speech' so that you can progress to the next case as soon as possible. Of course there may be 'Aunt Minnie' cases that yOll haven't secn and rhis may present a problem, Such cases arc often not amenable to working out the diagnosis - you either know it or you don' t . The only thing ro do is be methodical in your analysis and description of the findings so that at the very least you can suggest whether you feci an abnormali ty is li kely 10 be lo ngstanding and benign or orhenvise, and make appropriate suggestions on how you would proceed. The 'test of observation' Here, there is an abnormality prescnt that once seen, may wclllcad to an easy diagnosis. The abnormality is subtle or hidden however, such that it tests the candidate's perception and approach [Q a case. Perceptual abi lity, however, is variabl e, not only between people bur also in the same obscn'er on diflcrcllt days (this is particularly [rue in examinat:ions where anxiety levels arc high). You must therefore be systematic in analysing each film if there is no ob\'ious abnormality [ 0 sec on firsr inspection. There arc mall Y diflerent s}'srcmatic approaches and it is beyond [he scope of this discussion to be morc prescriptive. Howcver, make sure you haye a system and usc it. Moreover, describe the process you are going through aloud in the viva so that the examiner knows that you arc practising safe radiology. The 'jigsaw puzzle' This type of case presents several findings that once identified and considered together, lead to a specific or differential diagnosis. This nOt only tCSts perceptual skill and systematic approach, but also the abili ty ro mentall y 'cross-reference' se\'eral diflcrential diagnosis lists for the various abnormalities identified, to find thc 'best fit' diagnosis. Whenever producing a differential diagnosis in an exami nation or real life, it is \'ital to produce a sensible list, not just a recital oflong lists learnt from books. To do this, you must use all clues available from the clinical histOry and film, and combine this information with knowledge of the incidence of each possibility in a given patient population. Generalln1rodueti on Th. ' di."" ,,,J",,, "'&1< ",",< "'h,, , n., "f'"" ,>I"I'r 10" W''''' "" 'h< "'" 0"'''' '''''''' ,h .. In ' I>< '"" ,' ,.. ,I' '" .. " .00 ' hD n .. I"",,"t1' " ,I>< ,,( ,I>< ,x...,'irtion. '1'1)' to .xo' Oy ",1-..", in"""''' .... ,n th< """"YIp""'" roo-lins'I", " i"."" ... ;',., ,h,.,h " .... 'h, I .......... 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S, mp!n"" o.:lu,1< ""r"o" " J [1. in til", ''I\"' ... of """ ...d """,ul..-;",,",ulo_ ", ... 1 .. ;n"",;,;.1 ",""'0'1\', K.'''''), A .... ' 1,lI ';" ,11.-0 " .. cr. '!>.,mpo f1>< """" I"'!y ' " '" ....... .... , Iw", .. ,,., ........... ,,1 1\"' rI>'" . nor"h), , hot ;, oft,,, 1''''''0' .. Ipnplo",IY' ;" Uk< 1>['m. "&""" ........ ! ....... im*" l.< .... '" roIJ. p'" """,001)"_ 1lx rit-hl .".""",,, 011"1"" ;" , ..... H. oot i''''K' to "'f'I'd," be"",,, it no< hold," 1' ,11< h,.." "-'Ii" k.be < ;n-,,,, . ,,,d ... ; ;n", ... J I.nt '''' ' mtu& .. ".lIono i2b. b._I > Diff er.nti, 1 di . gno." 0, """" "I tI ... "';, ".,k, . It, : _ 'mi.-" rh, .. , NoJ " I" "b. ""'"",,,,,1 _ r"" ",.,,";.. , w ""-",,rr. >,r".u'. ANSWER 29 ObSflrv lon.12So, 29bl '1".'" "" I cr ... "' ,h. ,h,,' .h",, ">1,,, or '''!'' .. ,1\tl," .... ",,' j ."uIJ fi, . ;o h oJf 1"""""'0< ... ,,""" 1"''''Ok ,,, "'I'< t,,'"'' 1'''1'''",,-'-''' tin" ,.JO>Iof!r " ..... .nJ .. rut""!.. .... ",;nm ,," the Qf If>< R.r,-.J .0/' k",)_ Woh in .. ioJ, 01" ",.eo h,,-, 1>" 1''''''"1< l""''' )' "" I'''' l'" p...-.J "1""'"". 'I' , I", ( ",;, ' to< . , ... m'''I ",,,, .om;"" "'" hijd'" Y"" mU>! I" . , ifd"" '''' ,*,>"." ""'o.m,h'r to ,,' .... ."f"" .... Tl",,,,:. ",,'n)' dofl3 em in diameter with :a paucity of gas in the large bowel. Other appe:af3nces C:all be of: 'String of beads' sign due to small:airfluid b 'c!s in fluid filled obstructed loops of small bowel (47b). Absence of gas in the small bowel due to compleTe obstruction and complete fluid filling ofJoops (47e). 47b Plain abdominal radiograph demonstrating the 'string of beads' sign. Small bowd can be differemi:ated from large bowcJ using: the following fe:afUTes: Presence of"al"ulae conni\'entes which extend :across the width of the bowel. Colonic haustf3 do not tran:rse the whole lumen. Dilated bowc! located in the centf31 abdomen f3ther than the peripher)' (47d). Diameter of loops is l!cia., skin piglllcOI'3.tion and nail atrophy. Practical t ips Images should oc carefull y inspected for a coexist colo nic tumour as well as cxtr:acolonic mali gnan . Intussusceprion in adults indi cates an underhing. bowel pathology, whereas in children if can be idiopathi c. Further management Surgical referral is required for prophylact ic cokcr is referr.tl for genetic screening of rclati\es. Further reading Galiatsatos P, Foulkes WD (2006). Familial adcnOmatOllS polyposis. AmeriCfm jOllrnnl of Gnstrotllurology 101(2): 385-398. Abdominal Imaging Cases 50, 51 91 92 Answers 50, 51 Abdominal Imaging ANSWER 50 Observations (50a) This single TI weighted coronal image shows a striking reduction in signal intensity throughout the H"cr parenchyma. This is likely 10 indicate iron overload. II is notable t hat the spkcn retains normal signal intensity so the li\'(:r is most likely due to hacmo-chromatosis. Diagnosis i-Iacmochromarosis. Discussion Pri mary hacmochrOlTl3[Qsis is an aurosomal recessive condition characterized by increased absorption and ckposition of iron within several organs illCluding [iva, pancreas, heart and pituitary gland. Patients arc usuall)' lsymptom:ttic until the 2nd dCC3dc, then they present with a varied clinical picture due [0 iron deposition in: Skin - h)'PCrpiglllcllt:ttion. U\'er - cirrhosis. lu:p:uomegaly. l)allcrc3S - diabetes. Heart - arrhythmias. dilated cardiomyopathy. Ml1sculoskclet31 - arthralgi:t. Pituira.ry - piruir-J.ry r.,ildrc with signs of impotence, atrophr. hair loss. Radiologically, imaging of the abdomen shows marked abllormality oCthe livcr. Accumulation of iron rcsults in the liver being of ditl'usel)' reduced signal on ;vIRl. The degree of iron deposition has been shown to correlate with the l\oIlU appearances. Uncnh:lIlced CT of the li\'cr demonstrates increascd :lUenuation ( >75 HU). Follow-up in these patients is important due to the hepatic complicati on" of cirrhosis :tnd the ;nc.rc;eed risk. Oh hepatocellular carcinoma. Art.hropatAy of haemochromatosis is similar to that of calcium pyrophosphate deposition disease. calcinosis is a tcamre. T}VicaJl)', appearances arc of squaring of the mctacarpal he.lds due TO flatTening and peripheral small, hook-like SpUTS ( SOb). Osteopenia is also common. ANSWER 51 Observations (51 a, 51b) 1111:1ges arc control and delayed prone abdominal radiographs fro111 an [VU series. The control fi lm shows medi all y located appearance ofbolh kidneys and although the superior poles of both arc identifiable, inft:rior poles are not. The delayed IVU image (S ib) shows Illedial location of the pell'icalyeeal systems, which are anteriorly orientated. No filling defects arc identified. Di agnosis Horseshoe kidney, Practical tips l\'l ultiplc transfusions for chronic haematological disordCG C:lnlead to iron overload, i.e. transfusion siderosis. j\IRJ wi ll show hypointensity in the liver find spleen in t condition. This helps diflerenti:lle it from haemo. eh romatosis where the spleen shows normal signal MIU. Further management In thc course offollow-up, ultl'J.sound monitoring may useful due to [he high risk of dC\'cloping cirrhosis hepatocellularcarcin0111a. SOb Radiograph of both hands shows fl atteni ng of the 2nd and 3rd metacarpal heads with loss of joint space, giving a squared appearance. Early spur formation is seen on the lateral aspect of the 2nd metacarpal of left hand. Discussion This is t he most COlllmon fusion abnormality of kidneys. It is 1110re cOIll111only found in male patients has an incidence of I in 300. The kidneys arc joined tht:ir lower poles in 90% of Ca$CS, by a parcnehymal/fi isthmus band ( SI c). The long axis of the medially oricntated with anterior rotation, such th.;n renal pclvisesi are anteriorly located. Thc condiri complicated by urinar), stasis with renal stone fornua. infection and reflux. Vesieoureteric reflux hydronephrosis sd:ondary to ureteropelvic jlln obstruction arc common. There is :I reported Abdominal Imaging Case 52 enec of rCIl::ai adenocarcinoma, transitional cell m ~ and Wilms' rumour. In :I.ddition the kidnc" is cptib1c to injury following abdominal traUffi3. oc kidney is associated with: ourin:u)' ab'normaJitics: hypospadia, hidism, urctcr,ll duplication, bicornuate 'Jscular abnormalities . . al tips .an IVU, check for filling defeCTs, which could nt a retl;11 calculus or transi tional cell - ~ o l d male willI weight loss. 51c Axial CT image demonstrates the horseshoe kidney with a narrow isthmus of tissue extending anterior to the aorta and IVC. 93 94 Answer 52 Abdominal Imaging ANSWER 52 Observations (S2a) Single AI' radiograph of the abdomen shows a metallic stem within the (cmtal pel\'is, which presumably lies inlhc rectum or distal sigmoid colon. [t is likel y thaI Ihis stent has been inserted to rdicve symptolllS from a (olarectal 1'lI1l1our. The rest of the bowd gas pattern is unremarkable wi t h no ("vidence of obslnlction. There arc, however, amorpholl s, poorly marginated areas of calcification seen in the region of the liver and thc.:sc likely rcpn:scm calcified liver Illct:mascs. Ultrasound or cr should be undcrt3kcn, and a contrast cnl13nccd CT (52b) of this patient docs confirm the presence of calcified liver Diagnosis Stcntcd rcct:l[ tumour with calcified liver mctast:tscs. Differential diagnosis For calcified [h'cr mctast:J.scs: Muci nous adenocarcinomas - colon, rectum, ovarian, brc:l5[ and s[Omach. Osteosarcoma. Endocrine pancreatic carcinoma. Medul lal)' carcinoma ofthr roid. LUllgcancer. Discussion Colorcct:ll carcinoma is the third most COlllmon cancer diagnosed in the de"eloped world. Rectum and sigmoid arc the most common si tes of1csions. When' surgical resection is not possible or appropriate, stems can provide symptomatic relief and prel'ent obstruction. The liver is the most common site for metastatic spread after regional lymph nodes, Practical tips As with all radiographs that show e\'idence of likel y primal)' malignancy. once thi s has been noted, look carefull y for metastat ic disease elsewhere on the film, coloreetal cancers metastasize to the li\'er due [0 the ,"enous drainage of bowel l"i a the portal \'enous system. Howe\,er, t he \'enOliS drainage of the-rectum interfuces with the systemic venous drainage- . the 3nal canal and thus pulmonary metastases are said 10 be more likely in rectal cancer than other colonic tumours. In reality, pullnonal)' metastases arc nOt :m uncommon finding in colon or rectal cancer. Further management TNi\'1 ( tumour- node- met astases) staging lllust be accomplished as lor most tumours. Tumour staging rectal cancer is done with MR.I (52c) (along with loc.ll nodal staging). The primary reason for MRl is ro as proximity of nUll our to the llle$Oreetal fuscia - this is thr. plane along which the surgeon dissects in a [ot"J.imcsorc excision (TME) procedure. This boundary is rhus referm. 10 as the eireumfercmial resection margin (CRM), Ifloc.. tumour spread extends close to it, the surgical margin Il\.Io well be contaminated with tumour wi th the attendant . oflocal recurrence. ldent if)'ing patients where the CR.:\! threatened in thi s way means they can be selected preoperati\'e radiotherapy or chemotherapy to reduce r risk. Di stal nodal disease and metastases can be ass!: with CT or MRI but if the chest is al so to be imaged exclude pulmonary metastases, CT is required for 1 component at least. 52c Thin T2 weighted image shows a circumferential rectallumour with wall breach at the left anterolateral wall (12-2 o'clock) consistent with this being a T3 tumour. SE 53 c ry 35-year-old female presented \ \ ~ t h inal pain and per rectal bleeding .3 months. Abdominal Imaging Case 53 95 96 Answer 53 Abdominal Imaging ANSWER 53 Observations (53a, 53b) Plain abdominal film of adult patielll shows marked wall thickening of the transverse colon wi th thlllllb-printing. The sigmoid loops show no such abnormalities and the rc(mlll contains fucccs. The double contr:lSt b:lIium enema film confirms extensive mucosal ulccrmion and a somewhat cobblestone "ppcaranee rhat extends from caecum 10 the descending colon. The colon distal to this is 1l0fllllL The appearances :Ire in keeping with colitis, and sparing or the more distal colon makes Crohn's disease morc likely than ulcerative colilis. It is not:lblc that the sacroiliac joints arc normal. Diagnosis Crohn'sdiscasc. Differential diagnosis For [emlina] ileal disease: TB - uSlIllly has morc severe il\\'olvement of the caecum ( 53c). Thnc is oHen evidence of pulmonary TB. Radiation ileitis. Ycrsinia. 53c T8 can also affect the bowel and appearances can mimic those of Crohn's disease. Caecal involvement with features of stri ctu ring and ulceration is more common than terminal ileal involvement. For thumb printing: Inflammatol)' colitis - Crohn's, uJccl""Jtive colitis ( UC). Ischaemiccolitis. Infectious colitis/pseudomembranous colitis Divcrticulitis. Othcr causcs: cndometriosis, am)'loidosis, hereditary angioncurotic ocdcma, lymphoma. Discussion Crohn's disease is a chronic, inflammatory, granulomatOUl disease that can aflcct any part of thc bowel trona oesophagus to recrum. Small bowel is most imolved and the tcrminal ileum is iJwolvcd in ovcr 95% cases (531). I'rcscnt:ltion is usually in the 2nd-4th decldo with s)'ml)\ollls uf abdominal pain, diarrhoea, pcr ren bleeding, weight loss and fearurcs ofmabbsorption Radiological fcatures arc: Aphthous ulccrs - shallow ulccrs with surrounding oedema. Fissures, and fistulae - Crohn's is the third most (0111111011 cause offisrulae aftcr idiopathic causa and di\crticulitis. Thc tistulae can be bctwcen loops Ner 53 Abdominal Imaging I, between inflamed bowel loops and otntcr nal "iscera, c.g. colo\'cskal or from bowel to tone mucosa - longirudinal and transverse Sl!'par.ttcd by ocdematous mucosa, ning of small bowcllolds. lion of small bowclloops due to inflammation or:dcmaofwalL gr:lIl ubrity with < I 111m rounded mucosal 'yps - inflammatory or mucosa. - often multiple. Jc:sjons willI discontinuous disease 3TC seen in of eases. g fea tures (53e) are dcmollstr:ltcd in this case of _ male patient who has had a pre\'ious Terminal ileal C- image shows recurrence of disease in the ina I ileum post surgical resect ion. There is bowel wall thickening and oedema with alery change in the surroundi ng ti ssues. resection for Crohn's disease. There is noll' recurrence of disease in the ncotcrminal ileum with features of: Thickening of the bowel wall. M3rkcd stranding of the surrounding (,1[ due to inflammation. Engorged and dilated mesenteric \'csscls rclerrcd to as the 'comb sign' due 10 the similarity in appear:lllce to the teeth of a comb. Skip lesions with tWO imoked segments shown on this single axial image. MR imaging (small bowel emerograph}') fearures arc demonstrated in Figures 53f- 53i . The fat suppressed coronal/axial images ( 53f, 53g) show bowd wal l lhickening in the proximal ileum. (eOlu. ) 53f (coronal ), 53g (axial) fat suppressed images showing bowel wall thickening of a loop of proximal ileum. Dynamic images are obtained and viewed in cine mode to see how this focus of bowel contracts. 97 98 Answer 53 Abdominal Imaging The pre- :md post-contrast TI weighted corOlll! images (S3h, 53i) show cnhancmlcnt of an involvc.d loop of small bowel in the central lower abdomen. Treatment is both medical and surgical, with a high rate of fCCllTrcncc cI'cn alter resection (almost 40%), p;'1rticubrly in the ncotCfminal ileum following distal ileal resections Practical tips Terminal ileal involvement, skip lesions and multiple strictures arc the best signs for Crohn's disease. When assessing colonic disease, rememocr that UC aimosl always involves the rectum and has a continuou' distribmion withom skip lesions. Ho\\"cler, if a UC patient has had steroid enemas, the rectum may look nonmtl. Always look for signs of complications of Crohn's, i.e adenocarcinoma ( risk increased up to 20-lold), lymphoma, toxic meg:lcolon, pertoration, abscess, fistulae. Always look for signs of extrailltestinal manifestations 53h (pre-contrast), 53i (post-contrast) coronal images of the colon showing enhancement in the thickened small bowel loops in the lower abdomen. of disease all the film. Check lor sacroiliac joint disease, gallstones, hypcnrophic osteoarthropathy. Always look for signs of drug rfcatmcnr of disease on the film. Check femoral heads lor evidence of ;t,,:tscuhr necrosis from steroid trcatmclH. Further management Initial diagnosis in suspecTed cases is often confirmed with a Slllall oo\\'d barium study (iollow through Of emerod)'sis). Sometimes a more aCUTe presentation with abdominal pains mal' lcad to the diagnosis fi m being suggested by CT. Capsule is a !1!:'1 illl"estigationllm Illay also first identify disease. OIKt" the diagnosis is made, follow-up imaging with MRI idea}.as this iucurs no rndiation risk oin what afC trequcntly young patients. CT imaging remains equally useful, howelcr, when complications stich A abscess arc suspccll:d. Trealllll:m includes medical and surgical discipli nes.. SE 55 Dry '::9-year-old male presented with ivc d}'sphagia. Abdominal Imaging Cases 54, 55 99 100 Answers 54, 55 Abdominal Imaging ANSWER 54 Observations (541 Single image from a double conrr3st barium meal examination shows multiple, small dense foci ofconlr:J.$t wit hin t he aIHrulll and bod\' of the slOmach. These are surrounded by a lucent halo' rcprc.scming oedema. There is some irregular thickening of the gastric folds, with thc target lesions appearing to be orientated along these. Diagnosis Erosive gastritis. Different ial diagnosis For aphthous ulccr:Hion: Erosi l'C gastritis. Crohn's di sc;lSC. Ihriurnprccipiralcancf.ICts . For gastric fold thickening: Erosil'c S;lstritis. Zollinger- Elli son syndrome. Crohn'sdisease. Malign:lIlc), - lymphoma, carci noma. Benign rcani,'e lymphoid hyperplasia, Mcncuier'sdiseasc, ANSWER 55 Observations (55) Si ngle image trom a barium swall ow examination shows a lesion in the lower oesophagus, just superior to the gastro-ocsophageal junction, The lesion is well defined with ;1 smooth edge, indenting lhe oesophageal IUlllen, No ulceration Of infiltration is seen. Appearances suggest a benign intramural mass, most likely a leiomyoma. Diagnosis Lciomroma orthe oesophagus. Differential diagnosis For smomh ocsophagel1 mass lesion: Neurofibroma. Li poma. Hacmatoma, e.g. from instmmemation. Dupl ication q'5t - can simulate an intramur::J.I mass, Di scussion This is dIe mOst common benign tumour of the oesophagus. It is usuall y fou nd in young adul ts, being slightl y more common in males. Growth is slow and Discussion Gastritis often has t his apht hoid appearance ,,;da ":lriolirorm ulcers, consisting or a tin)' dense focus barium surrounded by a radiolucent halo or oedema a ;rnrget lesion' appearance. Lesions arc usually multiple. The lntrum is preferentially affected wit h spread towarQ. the fundus, lesions appearing (Q be longitudin oriemated along the rugal rolds, Causes: In 50% or cases, no caus.ati,'e abnormality is identi fi Peptic discasc, Dmgs - aspirin, NSAIDs, steroids, Alcohol. Infenion - herpes simplex, cytomcgalO\'irus (CM\' . C(mdidn, Crohn's disease - lI slIall )' there arc signs ofCrohn's disease in other locations, most commonly the terminal ileum. Practi cal tips On the cont raSt examination look for features in oesophagus of an infecti,'c cause for the gamic appca or for oesophageal varices pointing TO alcohol as undcrlringcause. Further management Gastroemerology referral with a ,'iew (Q endoscopy. presentation is with dysphagia, odynophagia and pos.. haematelllesis. Radiol ogical features are: Well defined, large, smooth intramural mass extending into the oesophageallulllcn. Forms an obtuse angle wilh lhe adjacent mucosa-good sign ofa benign lesion. Usuall), found in the mid and lowef oesophagus, Calcification is sometimes seen and is vi rruall v diagnostic si nce it is the only oesophageal ealcif)' . Ukerationisrarc. May be multiple in -3%. Uniform contraSt enhancement on CT, Practical tips Smooth, wdl defined, slow growi ng oesophageal afC likely 10 be benign. Further management Gastroenterology referral \\;th a I';ew to direct ,;su wi th endoscopy. Abdominal Imaging Case 56 101 Answer 56 Abdominal Imaging ANSWER 56 Observations 156a, 56b) The All postmicturition imlge (56b) from 3n rvu series shows billteral dilat3tion of the disra.1 ureter with 3 cobra. held' lppelrlnce. There is a surrounding thick I1llo of lucency within the bbdder, represcnting oedema. These 3ppeara.nces are of bilatera.l ureterocelcs. The control film (56a ) demonsnates bilateral calculi in the peh'is that lie within these ureteroceles. Diagnosi s Bilatcra.l ureterocdes. Differential diagnosis I:or radiolucent bladder filling defects on lVU: Ureterocele. Hiaddertllmour. Radiolucent calculus. 102 Sloughed renal plpilla. Gas secondary to fistula, cystitis, idiopathic causes and trauml. Island prostate - enl3rged central zone Cln appear as ~ ccntra.l bladder lucency. Di scussion A simple or ort horopic ureterocele is a congenira.1 prolapse of the dist;!l ureter lnd its orifice into the bbddcr. It usu311y an incidental ti nding in adu\[s and is bilatera.l in third of C3ses. Figure 56c shows how a ureterocele c produce l less spedfk type of filling defect when t.b.:. bladder is full and Figure 56d shows the typical ultra.sound. 3ppelra.nce. The main complication is of obstructi which can cause collecting system dibtatian and rc failure. There is also an increased risk of stone forma ' and it is therefore imperative to check the control film e,"ery patient-as in this case! 56d US image of the bladder s hows protrusi on of the distal ureter int o the bladder, indi cating that these are orthotopic ureteroceles and not pseudoureteroceles. Abdominal Imaging Case 57 urcrcrocclcs can haxc a similar appearance and d bv obslrucl;on of:l normal ufetef. Dificrcll-bcn\:ccn the tWO types can be made using or oblique films, which show no prmnlsion of into t he bladder lumen with pscudourc[crocelcs. of pscudourcfcrocclcs include: .Jana ahhe distal ureter secondary to impacted infection, r tumour (56c:) , to check the comrol film of an IVU. management I asymptomatic ureterocele Ill;l}' not require recurrent urinary tract infcnion ( UTI ), calculi, obsrruct;vc uropathy arc indi cations for surgical 56e Single axial T2 weighted image of the pelvis shows a pseudoureterocele secondary to a large bladder tumour. 103 104 Answer 57 Abdominal Imaging ANSWER 57 Observations 157a) This frorHa] chest radiograph of an adult patient shows an added com'ex soft tissue density along the right mediastinal border and behind the heart. There is no normal gastric :ti l' bubble beneath the left hcmidiapllf:l.grn. The findings suggest dilatation of the ocsoph:agus secondary to chronic distal ohstrunion, most likely due to achalasia. A barium swallow would confirm. Diagnosis Achalasia. Differential diagnosis Secondary achalasia due to a stricture at the gastro-oesophageal junction, There will be normal pcristalsis however. Chagas' disease is esselltially the same as achalasia but the neurenteric plexus damage is due 10 Trypmlosomfl cYII::.iinfcction. Discussion Achalasia is a lllmilily disorder that is idiopathic in aetiology, characterized br degeneration of Auerbach' s plexus. This results in a fai lure of relaxation of the caudal oesoph:lgus at the g:lstro-oesophageal sphincter. Presentation is with progressivc dysphagia. investi gat:ioe. is with a contrast swallow examination (57b), which mat" show featufes of: 'Vigorous achalasia' - multiplc tert iary contractions in the distal oesophagus Gill be the earliest sign. 'Bird's beak' deformity - symmetrical sLenotic segment of oesophagus at the gastro-ocsophageal junction. Imaging the patient erect allows best demonstration with contraSt forcing its way through the gastro-oesophageal sphincter when the hydrostatic pressure of the barium column in the oesophagus is sufiiciemly high. l'vlcga-oesophagus - dilatation of the oesophagus ttui call involve its emire length. Relaxation ofthe lo\\"er oesophageal sphinCler can be induced with amyl niTraTe inhalation. Achabsia is complicated by an increased risk of d e v c l ~ an oesophageal squamous cell carcinoma. Practical tips Check lungs for pulmonary changes of previous aspiration. Check for evidence of pulmonary metastases from secondary oesophageal malignancy (or indeed if the di!:ncd oesophagus is due to a primary malignancy rather than achalasia). Further management The condition is fi.lrther im'estigated with pressure measurements (manomet!)') and endoscopy. Treatment is most commonly by pneumatic di latalil: of the gastro-ocsophageal sphincter. Surgical mrotomy is considered where there is disease 57b Two images from a barium swall ow examination show a dilated oesophagus contai food debris, which 'narrows down to form the classical ' bird's bea'k' appearance at the gastro-oesophageal junction. Abdominal Imaging Case 58 105 106 Answer 58 Abdominal Imaging ANSWER 58 Observations (58a, 58b, SSc) Three im;lgcs from an JVU se ries arc provided bur no control film (which would normally be assessed prior 10 interpretation of the post -contrast films ). [Illages show uni lateral increasingly dense and persistent ncphrogr:un on the right'. The right kidney shows uniform smooth reduction in size when compared to the lefr. There is delayed excretion of comrasr by t he right kidney on the 10 minute fi lm ( 58e). These appcar:lI1ccs suggest unibtcTll right renal :trtcry stenosis. The young age of the patient makes fibromuscuhr dysplasia more likely than atherosclerosis as the underlying pathology. Diagnosis Renal artery stenosis. Differential diagnosis For persistent dense ncphrogram: UnilaTeral: Obstruction - acute obstruction is the most common cause of this sign. Renal artery stenosis/ ischaemia. Renal vein thrombosis. Acutc bacterial pyelonephritis. Acute papillary necrosis. Bi lateral: H}'potension/shock. Aelile tubular necrosis. Acute glomerulonephritis . Causes of un ilatera I change involving both kidneys. Discussion 'Illere arc two main causes of renal artery stenosis: Atherosclerosis (80- 90%) - usually in the proximal 2 cm of the renal artery; afrects older population >50 years; more common in men; bibteral in one-third. Fibromuscular dysplasia ( 10-20%) - usually in the mid and distal renal arter)'; allccts young adults and .::hildrcn; more common in women; bilateral in two-thirds. Less common causes include vasculiti s, arterial dissection and thromboembolic disease. Hypertension in neurofibromatosis is a consequence 01 phaeochromocytoma and/ or renal artery stenosis, .11smooth stenosis seen in proxim:al ren:al :arter)'. In this p:arielU, a renal angiogram was performed and showed a smooth n:arrow stenosis in the mid portion of rhe right rena! artery (58d) and this would be in keeping with the underl ying diagnosis of fibromuscular dysplasia of the renal ;lrter'\' . The of renal artCr)' stenosis is systemic hypertension as a result of o\'er;lCtivit}, of the renin-angiotensin system. Treatment is aimed :at medically controlling hypertension and with renal arter)' Practical tips If there is bilateral delayed persistent nephrogram with absent or decreased excretion, then the patient t..... needs to be immediatclv checked to ensure that contrast anaphylactic sh"ock has not occurred. Magnetic resonance or CT is the prcli:rred ilwesrig;lti on tor thi s condition in the moc\ernera. Further management Attempted renal arter)' angiography and angioplasry arc usually S8d Single image from a renal angiogram showing a stenosis in the mid portion of the right renal artery. Abdominal Imaging Case 59 107 108 Answer 59 Abdominal Imaging ANSWER 59 Observations (59a, 59b) Single image from a barium follow-through examination shows smooth thickelled small bowel folds. Selected axial images from an IV comrast enhanced CT scm of the abdomen again dcmonsrr.l1cs smooth thickening ofbowcl folds in dilated loops offluid-fillcd small bowel. In addition, there is thrombus seen in the mid superior mesenteric vcill. Diagnosis Small bowel ischaemia secondary to superior mesenteric vein (SMV) thrombosis. Differential diagnosis For smooth thickened folds' Haemorrhage. Ischaemia: Acute - embolus, Hcnoch-Schonlcin purpura ( HSP). Chronic - vasculitis, thromboangiitis obliterans, radiother.lPY Oedema cirrhosis, nephrotic syndrome, protein-losing enteropathy. Angioneurotic oedem,\. Lymphatic obstruction lymphoma, mesenn:ric fibrosis, intestinallymphangiecrasia. Discussion Small bowel/mesenteric ischaemia can present very acutdy with symptoms of acute abdominal pain, ,'omiling, diarrhoea and recral blecding. This is usually due ro arterial thrombus, dissection or acute ,"enous Obstruction. Chronic ischaemia usually due to chronic arterial thrombus has a more indolent symptomatology with longstandi ng grumbling abdominal cramps, postprandial pain, wei ght loss and malabsorption. Other causes of ischaemia include \"asculitis, bowel obstruction, radiotherapy and aCUle: abdominal inflammation, e.g. pancreatitis, appendicitis. Radiologi cal features of acure small bowel ischaema include: Bowel \\'all thickening/oedema. Enhancement pattern of the bowel wall can be incre3sed or decreased (5ge). Stranding of the surrounding f.1L Pneuillatosis intestinal is, which is a late sign and indicati\'e of necrotic bowel. Free imra-abdominal gas due to perforation of necrosed bowel. Portal venous gas is seen in preillorbid patients. In chronic ischacmia, there call be additional complicati of strictures (which tend to be long, smooth a symmetrical), ulceration and atrophic valvulae connivenro. The splenic flexure and the proximal descending colon most cOlllmonly affected due to the transition fr superior to inferior mesenteric arterial suppl y at this poiIIL Practical tips Look careftilly for linear gas shadows within the bowel wall indi cative ofinrramllfal gas. Portal vein gas is usually seen in the pcriphery of the liYcr as well as centrally, in contrast to biliary gas, which is usually only central. This is a prcmorbid sip in adults. Further management hll'cstigation with CT C:tll both diagnose and complications of ischaemia. 59c Axial CT image of the abdomen shows dilated fluid-fi ll ed loops of non-enhancing ischaemic small bowel. SE 61 - tory 57 -year-old m:alc prcscillcd with 'Cr abdomi nal pain. Abdominal Imaging Cases 60, 61 109 110 Answers 60, 61 Abdominal Imaging ANSWER 60 Observations (60) Single oblique radiograph of the pelvis from an IVU shows a small, shrunken, spastic trabeculated bladder with multiple diverticula, with a superiorly pointed dome. This is the so called 'pinc trce' appearance of a neurogenic bladder. Diagnosis Neurogenic bladder. Differential diagnosis For Slllall bladder: Infection - schistosoilliasis/TB. Iatrogenic - postsurgery/ radiotherapy. Neurogenic. Transitional cell carcinoma (TCC) - awmilletric bladder contraction with thick wall and filling defects. Extrinsic compression - usually gi\'es a pear shaped bladder appearunee. ANSWER 61 Observations (61) Single image from a barium enema examination demonstrates a well defined, Sillooth, eccentric filling deft."(;t in the distal sigmoid colon. This appears to be extraluminal in origin and lies on the mesenteric aspect of the bowcl A similar lesion is seen in the pouch of Douglas. Multiple lesions centred in an intrJperitone3110carion suggest the diagnosis ofimraperitone31 metaS[3Ses. Diagnosis Colonic mctastascs. Discussion Tumours to the mesentcry via four rolltcs: Direct invasion along thc mesenteric \'essels and fut -scen wi th gastric, pancreatic, colonic and biliary cancers; 40% of patients with adenocarcinoma of the pancreas have tumour cxtending along the mcscntcric root at diagnosis Extension mesenteric 1}'mph3tics - colonic, ovarian, breast, lung, c3rcinoid and melanoma cancers C3n spread to mesenteric lymph nodes, though lymphomJ is morc common. Haematogenolls spread - commonly from melanoma, hrCJS! :lild lung prim3ries, met3st'3ses invoke lhe anti mesenteric bordcr of the bowd via sm311 arteries. They can act as the lead point tor intussusception. Up to 7.5% ofmehnoma paticnts show st1l311 bowel involvcment Discussion Bladder innervation is by the parasympathetic nervC$ 52-54. Injury to these nerves causes denervation oftbc detrusor muscle, giving this appearance of a shrunken. heavily trabeculated bladder, with an irregular thicken wall and multiple diverticula. Causes include: Congenital anomalies - myelomeningocele, spina bifida. Spin:!1 trauilla. Diabetes mellitus. Infection - syphilis, herpes. .Spinal neoplasm Practical tips Inspect IVU films carefully to look for asp' abnormality, which can help to determine the cause of the bladder abnormality. Further management In the absence of an easily identifiable cause, lumbo spine MIU can be useful. Intraperitoneal seeding - brc:lst, 0\'3rian, panctc:lOi: and gastric tumours arc the most common primaries responsible for intraperitone31 'drop' seeding. "Thot lesions involve the mesenteric borders. Appcaranas arc of a focal mass or ditfuse stellate appearance 011 CT, but on double contrast barium im3ging, Jppcarances arc of a foc31 extrinsic indentation of bowel. This involves the pouch of Dougl3s (50'\ commonly the superior/anterior border of the sigmoid. Thc distal ileum and mediJI border ofd:.: caecum arc also often invoked Practical tips The most common underlying calise lor malignant diseJse is ovarian cancer. Further management Clinical review of patient to tty and loc3lize a likely tumour. CT sC3nning will confirm peritone31 Illay well reycal the primary tumour. Further reading Shcth S, Horton KNt, Garland [\tR, Fishman EK _ l'vlcsenteric neopl3sms; CT appe3rances of priffiX"l and secondary tumors and diffcrcntial RndioGmphics 23: 457-473. SE 62 ory 46-year-old Icmalc , recentl y ted to the UK from Africa, - med with symptoms of urinary ncy and urgency. E 63 ry diabetic presented with and abdominal pain. Abdominal Imaging Cases 62, 63 111 11 2 Answer 62 Abdominal Imaging ANSWER 62 Observations (62a) This single coned view of the pekis shows curvilinear wall calcifi catio n of a relatively normal capaci ty bladder, No calcifiGlrion of the lower ureter.; is seen. No discontinuity in thc calcifi cation is.scen. TIle history of residence in Africa raises the possibilities of bladder TB and schistOsomiasis. The absence of gross bladder contraction makes the laner more likcl}" but it would also be helpful to re,;ew a full length alxlominal film Practical tips Schistosomiasis il1\'ol\'("s bbdder and lower ureters and results in a calcified, nonshrunken bladder. Tn involves rhe kidneys and spreads via the ureters ro involve rhe bl:ldder. It is very unusual to have isolated bladder involvcment with TB and the degree of bladder contraction is more marked than in schistosomi:lsis Transitional cell ::r Discontinuity of calcitic at ion in the bladder wall should arouse suspicion of bladder cancer, Diagnosis SchistOsomiasis. Different ial diagnosi s For calcified bladder wall: Cancer - prirnaril}' transitional cdl carcinoma (TCC) but also other rarer bladder tlImour.;. Radi otherapy. Inlection - Tn and schistosomiasis. , . . . SChlstOSOlmaSIS IS one of the mOSt common paraslilc infcctions, affecting 8% of the global population. Schistosolllff l)(Illllntobi lllll is the female parasitc whi ch aflccts the genitourinary system. Unlike TB, which tends to affect thc kidneys first and then spreads caudally, schistosomiasis has a re,'erse involvement and uSlIall}' is confined to bladder and lower ureters. (Another case of bladder schi stOsomiasis [62b] is shown - note the absence of upper tract calci fication that one might sec in TB.) Classically, the patient presents wi th urinary frequenc)" urgency and dysuria. Imaging findings arc of: Calcification of the bladder - which results in reduced bladder filling capaci ty and increased posnnicturi tion residual volume. Calcitlcation of the lower uret ers. Lower ureteric strictures. Ureteritiscystica. Complications of disease aAccting the genitourinary system incl ude: Cystitis. Vesicourelerie reflux and subsequent pyelonephritis. Increased risk of squamous cell carci noma of the bladder. Other systems can be affected: Li\'er - oval mi gration results in portal hypertension and subsequent oesophageal varices. Respiratory system - diffuse granulomatous lung lesions. Further management Followup in these patients is required since the latency fw development of squamous cel l carcinoma of the bladder can be lip to 30- 35 rears. 62b Calcification of the bladder is seen in schistosomiasis wi th absence of upper tract calcification to help differentiate from TB. Abdominal Imaging Case 64 R 63 tions (63) biominal radiograph demonstrates gas within the ~ . i l y c c a l system and upper ureter. No intra-a1 renal gas is seen. No gas is seen in the right or in the bladder. _ nie - uri nary diversion procedures . .' tract fistula to bowel due to innalllillation, Crohn's, diverticulitis or spreadi ng malignancy. mamU5 pyelitis is a condition in which infective produce gas, which is confined within the renal :cc,aI system. In emphysematous pyelonephritis, gas \\ithin the renal parenchyma - a lifcthrcatcnirrg JII'l that requi res prompt di:agnosis and tn:amlcnt. E 64 ;uold female presented with lIUlCty and epigastric pain. There is an increased incidence of these conditions in patients with diabetes mellitus and women arc three times more: cOlllmonly affected than men. Esc/)ericbia coli is the causative organism in 70% of cascs with Klehsiell", Proteus, Candida and PseudomOllflsorganisms also being found. In emphysematous pyelonephritis, small gas bubbles arc initially seen on plain radiographs in\"ol\'ing lhe renal parenchyma; this progresses to give a di ffuse mottling in morc ad,'anced disease and then progresses to produce a crescent of perinephric gas when there is extension into the perirenal fill. Practical tips CT is the best imaging modality for assessing extent and location of gas. Further management Depends on ca use but obviously infective causes require prompt, appropriate antibiotic treatment. Further reading Joseph RC, Amendola MA, Artze ME, et al. (1996 ). Genitourinary tract gas: imaging evaluation. RadioGrapbies 16: 295-308. 113 11 4 Answer 64 Abdominal Imaging ANSWER 64 Observations (64a) Single image from :t double contrast barium meal cx:ulIi nati on shows :t lI'ell defined smooth walled ovoid mass lesion in l he gastric JllIfIlm. A central smooth ulcer is present and no calcification is seen. Diagnosis Leiomyoma of the stomlcn. Differential diagnosis Fortargc! lesions: Ncurofibrolll3. Lipoma (64b). Ectopic pancreatic rest. MCl'3stascs - cOlll mon ly breast, IUll g, renal and mali gnant melanoma. Hacm3ngioma Di scussion This is the second mOST common benign gastric tumour after gastric Ukc ocsophagcallciomyoma, these aTC slow growing lesions and arc usually asymptomatic umil they incn:asc in size, when there may be epigastric p:lin and. bleedi ng. The gastric antrum and pylorus arc l he m common si tes "flected. The majority of these lesio extend imraluminally (60%) and form well defi ned 0\' defects. They arc more likely ('Q ulcerate than ocsophag leiomyoma with ulcerat ion scen in up to 50%. Calcifica . is rare. Complications include: Bleeding. Obstmction. Intussusception - tumour can act as a lead point. Malignant degeneration - in up to 15-20% m cases. Practical tips Smooth, well defined, slow growing gastric lesions likely to be benign. Further management Although radiological appcarances suggest this to be benign lesion, referral for +/- biopsy should made. 64b Axi al CT image demonstrating a well defined, smooth, rounded lesion in the stomach, which has clearly the same attenuation as intra/extraabominal fat. This has appearances of a gastric lipoma. Abdominal Imaging Cases 65, 66 IJ8jorcnsenllsUler) 11 5 11 6 Answer 65 Abdominal Imaging ANSWER 65 Observations (65a) Single image from a double contrast bariulll enema exami nation shows :abnormalitv of the colon that extends from the rectum [0 the mid rrans\'crsc colon. There aTe (C3IUTes ofJuminal narrowing with mucosal irregularity, granulari t y ;1 11(\ shallow ukcr:ltion. The disease process appears cOll tinuous along the 3.flcctcd segment's with no fil rthcr lesions seen. Noml:!l appearances of the ikocacc:L1 region. Normal sacroiliac joints. T hc appearanccs arc in keeping with a colitis, most likely ulccrntive colitis. Diagnosi s Ulcc:rnti,'c colitis ( UC). Di scussion Ulcerat ivc coli ti s is an idiopathic bowel disease \Iith invokemcnt predominamly of the mucosa and su bmucosa or thc l:t rge bowel. There arc tWO peaks of prcscntltion - 3rd-5th dccades and 7th- 8th dccldes. The most commo n presentation is with blood)' diarrhoel and abdominal plin. The rectum is almost always involved (96% of cases) with continuous, and of the colon more proxlillally. The tcrmlllalrku1l1 IS 111I"01\'ed in 10- 25% due 10 backwash ileitis. In acute infl ammation there arc findings of: 65b Single axial CT image shows continuous thickening of the colonic wall invol ving sigmOid colon. The surrounding fat is 'dirty' !i ncreased attenuation) due to inflammatory change. Appearances are of an acute active colitis though the appearances here are not specifi c for an underlying cause. of bowd W:I!l (65b). Significant bowel wall thickening can 1c3d to tht: classical 'thumb-printing' appearance. Widening ar t hc presacral space. Fine ll1ucS.11 granularity. Superficial ulceration. I'scudopolyps - islands of oedematous mucosa. Collar button ulcers (65c). Appcal'Jnces in the chronic stage: Colon becomes ri gid with llllllinainarrowing due [( chronic inilamm:ltion, and loss or haustrations -'le3clpipc' colon. Coorsc grnnul:tr mucosa. Inflam1l13tory polyps. Ibck\\'ashilcitis. Abdominal Imaging n is complicated by: n from toxic in 5- 10% - thc ..:ommon cause of death (65d). .ldCIlOCarcinQm3 - this complicates Lip to 5% with risk highest when there is or onsct at a young age( Ii,'er activity) while benign lesions do not (crt ures. !f rou see such features, then indic3te the degree of urgency required in seeking neurosurgical evaluation and intervention. Assess the enhancement pattern of the lesion. This is often nonspecific but certai n patterns such as the intense, homogeneous enhancement of meningioma allow a confident di agnosis. CT AND MRI NECK Cross-sectional imaging of the neck requires excellent an3tomical knowledge! Familiarize with the anatomical divisions of the upper aerodigesth'e traer, the fascial Sp3Ces ofthe neck along which tumour and infection track, and the nodal stations of the neck. With this knowledge, you can make a meaningful interpretation for the E?-..TT surgeon. T2 weighted scans with fu! suppression arc particularly useful to eV31uate at first inspection if these arc avail3ble, for detecting both primary pathologr and 147 eNS, Head and Neck Imaging nodal disease. Thereali-cr, sinmltaneous examination of the Tl weighted scans can help to better delineate the precise anatomical location of disease. Look at the sofi- tissues of the anterior cen'ical space. which should be no greater than a third of the width ofa vertebral bod" for C I- 3 and no more than the width ofa \'ertebr:al body for C4-7. Check the imen'al between the anterior arch of atlas and the RADIOGRAPHS greater There arc a very limited number of pathologies that arc On the AP film :J]ook for misalignment of the likely to be shown on a skull radiograph: vertebral spinous processes in a \'Crtical plane, which Trauma As well as skull fractures, check for indirect signs of fixture such as fluid leyels in sinuses and intracranial air. Remember 10 look at all the bones on the film - the fracture of would suggest a flcet joint dislocation. Ensure that the AP 'peg' view adequately excludes a C2 peg fracture. odontoid peg at the edge of the lateral skull film is a basic exam type of case. When you arc suspicious of an unstable fracture, nak this clear so that adequate steps arc taken to prote ... , the cervical spine until such time as this has been confirmed or excluded with CT. Calcification Know the normal intracranial calcifications such as pineal and choroid plexus so that you can ditlerentiatc from pathological calcification such as that associated with meningioma. When assessing thoracic and lumbar films, carefully chco. alignment and \'ertebral body height. On the AP fil m the thoracic spine, look for widening of the paravcrte stripe suggestive ofhaematoma. Mali gnancy Pi tuitary Bony involvement is one of the most common sites Size and shape of the pituitarr fossa should be assessed. metasratic tumour spread along with the lungs and Ihu Vaul t Several diffuse processes have characteristic changes on the spinous process for lytic deposits. As ever, pay attention skull radiograph and make for 'spot diagnoses', e.g. the soft tissues - a paravertebral soft tissue mass may acromegaly, fibrous dysplasi;l, th3lassacmia, you to a subtle bony lesion. Do not lorget that \\ hyperparathyroidism ;md myelon13. mrcloma classically produces focal bony lucencies Spine As always, there arc many potential pathologies to sec on plain fi lms of the spine but trauma, infection and neoplasia arc particularl y common. Tra uma possible resulting vertebral collapse, a significant nu . of cases show only diffuse oSleopenia, which can III osteoporOSIs. Infection When ;lssessing cen'ical spine films' -0. First ensure that the complete cervical spine has been imaged down to C7- Tl level Spinal infection is usually centred on the disc and the there will be a reduction in disc height with i1l\'olvc of the superior endplate of the vertebral body belo\\ inyohement of the inferior endplate of the vertebral above. Added sofi- tissue d\le to abscess is likely to be and in the cervical spine will be seen as a preyertebral tisslle Im.SS on the lateral cervical spine film; in the [h spine this will be seen as a widening of the paravert stripe; and in the IUl11b::lf region there may be a 148 On the lateral film, look at the anterior spinal, posterior spinal and spinolalllinar lines to ensure continuity (I.e. imaginary lines drawn along the anterior and posterior vertebral body cortices and along the anterior limits of the spinous processes). abscess eNS, Head and Neck Imaging ~ d presented with bilateral dcafilcss. Cases 86, 87 149 150 ANSWER 86 Observations (86a) Single high-resolution axial CT image of the skull at the level of the petrous bone. There is bilateral enlargement of t he vestibular aqueduct. Preci se measurements have not been documented but the aqueducts afC dearly signifi cantly wider than the horizontal semici rcular canal seen on the right. Diagnosis Enlarged vestibular aqueduct syndrome. Discussion Enlarged vestibubr aqueduct syndrome presents clinicall)' with sensorineural hearing loss. Hearing is usuall y prescnt :\f birth and then deteriorates from age of -3 years. Deterioration is often in a manner, associated with episodes of minor head trauma. There is a suggestion of an inherited recessive genetic link and 50% of cases arc bilateral. A degree of cochlear dysplasia is present in 75% of cases. The normal endolymphatic duct ori ginates from the vestibule, via the common crus and extends posterolaterally in the bony vestibular aqueduct to t he endolymphatic S.1C. The endolymphatic sac on the posterior aspect of the petrous temporal bone. Enl arged vestibular aqueduct syndrome is diagnosed when the diameter at irs midpoint exceeds 1.5 mm. Figure 86b indicates the dil:J.ted aqu in rhiscase. Diagnosis of the condition is important due to the _ results achie\'cd with cochlear implantation. Practical tips A quick assessment of the vestibular aqueducts can made by comparing the diameter at midpoint to thc= diameter of the adjacent posterior semicircular the aqueduct should not be larger. When identified, check the cochlea for e"idence of dysplasia. Further management Advise on a\'oiding head trauma where possible, no contact sports. Hearing can be improved with cochlear implants. Further reading Dahlen RT, Harnsberger HR, Gray SD etal. ( 1997). Overlapping thin-section f.1st spin-echo MR oftht large \'estibular aqueduct syndrome. American jOltrlml of Neuroradiology 18: 67- 75. Valvassori GE ( 1983). The I:J.rge vcstibul:J.r aqueduct associated anomalies of the inner car. Otola171lgo _ C/illicsofNortbAmeriCll 16: 95- 101 . 86b Axial CT image demonstrating an enlarged vestibular aqueduct. eNS, Head and Neck Imaging Case 88 187) que image from a parotid sialogr-anl with no iiIm provided for comparison, The parotid duct is calibre with no obstructing stones or stricture. florid pUllerate dilatation of the ___ ""'I" ",,,,,,,,1,, and acini in keeping with punctate recurrent sialadcnitis is llSU;\lIy associated with ,[rietll Tc causing duct obstruction. These causes, Me rare in children and chronic infhlmmation is JlTl monJy idiopathic in nature. The parotid is more than the submandibular gland, perhaps due par.l tivcly smaller salivary Olltput. Clinically, present with repeated artacks of swelling of tile associated fevcr. Age of onset is typically 3- 6 symptoms usually rcsoh'ing sponranl"Ously after Althollgh sialography is the primary method of diagnosis, US is useful for tollow-up as it avoids thc radiation burden and invasive nature of sialography. At US, the gland is swollen with :I hettrogencous appearance and multiple hypo25 tllm) (98c). Prcm:lture ostcO:lrthritis (OA). Pract ical tips Normal dimcnsions of thc pituitary fossa on lateral films arc a length of < 15 mill and height of < 12 mm. Further management !\'ianagcmcnr of this condition is both medical (soma statin/brolllocriptine ) and surgical ( trallssphe n hypophysectomy). 98d Radiogra of the hand shows marked soft tissue enlargement givi ng it a sp like appearanc:e. In addition th is widening of terminal tufts. 98e Soft tissue lateral radiograph demonstrates thickening of the heel pad, which measures >25 mm in thickness. . eNS. Head and Neck Imaging Case 99 -. weighted axial (top left). thin section T2 weighted axial orbits (top right), axial and coronal T2 weighted I MR images. 171 172 Answer 99 eNS. Head and Neck Imaging ANSWER 99 Observations (99) The axial images of the orbit show fusitorm enlargement of the posterior right optic l1en'e, which also il1\"okes both sidcs of the optic chiasm. The coronal scan confirms thickening of the posTerior aspect of bOTh optic nen'es. Axial T2 weighted images also show a round tixus of high signal in The right cerebellar hemisphere and a second lesion in the posterior aspen of right midbrain that produces convexity to the margins of the cerebral peduncle. The appearances arc likely to indicate optic nerTe glioma involving the chiasm and both opril": nen'es along with hamartomas in the cerebellum and midbrain due to neurofibromatosis type I. No cutaneous neurofibromas arc seen on these images. Diagnosis OpTic chiasm/nen'e glioma due LO neurofibromatosis type 1 ( NFl ). Differenti al diagnosis ror optic nerve thickening: Optic nen'e glioma - 80% under 20 yean, variable enhancement, calcifjcation I""Olre, buckling of nen"e, of len asymptomatic. 'Meningioma of optic nem: - middlc aged women, 'tramtrack' enhancemelll, calcification in 20- 50%, st raight nen"e, visual impairment early. Sarcoidosis. Multiplcsclcrosis Lymphoma, kukaemia and metastatic disease. Intracranial hypertension - enlarges the perineural CSFspace. Discussion Opt ic nen'e glioma typically presents in childhood, only 20% manifesting beyond the age of 20. Rclati\"cly slow growing and benign ill children, lesions presenting in adults often show morc rapid malignant growth with intracranial spread. Though often asymptom:uic, prescntaTion can bc with visual loss and strabismus. BHater:!1 tumours herald NF l . The tumour causes fusiform or tubular cnlargement of the optic nen"e sheaTh complex and shows variable enhancement with IV contrasT. The majority of lesions occurring in the orbital portion of the nene do not extend intracranillly. Some optic nen'c gliomas haxc ext!: associated thickening of rhe surrounding meninges, Ie ar.lchnoidal hyperplasia, which is often seen in patients 'Il NF - on T2W MIU, Ihis is seen as:I ccntrallow-si tumour surrounded a higher-signal rim that call M like a dilated perineural CSF space. p. Approximately 25% of paticlHs with optic glioma NFl and it is one of the diagnostic critcri:l listcd for condition, of which two or more arc required: six or IDI 'cafe-au-lait' patches; twO or morc Lisch nodules; rn more neurofibromas or one plexiform ncurofibr axillary freckling; optic glioma; bone pseudarthrosis; fint degree relati,'c with NFl} In this the coexisting lesions in the cerebell um and midbrJin one to the overall diagnosis of NF l . These high T2 toci arc seen in the brainsl'em, basal gangl ia, cerci peduncles, cerebellum and the stLprarenrorb.1 whi Te They arc usually thought of lS I lnd often decrease in size with . to in the cerebmm, and telling the difference be i enlarges O\'er time or shows possibility of astrocytoma must be considered. choroid plexus calcification and hydrocephalus aqucduct stenosis arc other intrncranial features . NFl is sporadic in 50% and autosomal dominant' (chromosome 17). Practical tips Tl weighted post-contraSt scans of the orbit sh be performed with fut suppression in view of the adjacemorbitai fur. Meningioma is the main differential diagnosis for optic ncn'e thickening and the features liSTed abo-may help distinguish the tWO. Whenever NFl enters t he diflcrential for anv I""Oldiological study, al\\':lYs check for evidence of cutaneous nodules that 'clinch t hc diagnosis'. Further management Treatment depcnds on the size ofnrl1lour along \\ age and gener:!] condition ofthc patient. Options surgcry, radiotherapy and chemotherapy. eNS. Head and Neck Imaging Case 100 173 174 Answer lOa eNS, Head and Neck Imaging ANSWER 100 Observations 1 11008) Axial T2 weighted image demonstrates high signal in the lateral aspect of right medulla. This is bright on dIe DWI indicating restricted water molecule: diffusion probably from cell swell ing due to leutc inf:lfction. Together with the clinical details, findings arc consistent with syndrome due to infurction in the territory of the right posterior inferior cerebellar artery ( PICA). Observations 2 (100b) These axial and coronal 1'2 weighted images show a focus ofincrcascd signal in the right side of the midbr:l.in. Then: is no associated mass dice! and the lesion lies in the region of the red nucleus. The clinical symptoms arc compatible with 3n infurct affecting the red nucleus and causing Claude's syndrome. Diagnosis' Right PICA infarction (Wallenberg's syndrome). Diagnosis 2 Ri ght midbrain infarction :lflccting the red nucleus (Claude's syndrome ), Di scussion There arc various specific panems ofbrainstem infarction, oftell having unusual eponyms. Othe rs include Weber's, Nodlnagel's, "< LP f,_ ' .. " '-T "",,"d, "" ,1.1.,,,.1 k ... II h, fn ... ,'" """" ,,,' ... ..!"''''' " "u)' "" ...... ""."" '"6 ,'n" Chapter 4 MUSCULOSKELETAL IMAGING ,'1.",10 "r ,II< ", .... 11< ,.,..,,, mJ ,I>", ,bn' ..... I. y. , 01;11"., ,lW""'S .,,,,,,1 ioontl). ,"" "''' ''''f')' n..", '" k""", ,'-' ""',, .. "I "'"'' or ..... "' ...... ,,, ., ... ,;]", '" p,(>.i",,,. ,,",1< .. ,in 'h"" or" " . Agg, " , ive V$ benign "'''' ""f'O'""'" ' 0 d.""" '"." '"""' "((,.,,, 1-..", b " . S"" ,b, u,., "(lull ."""i" ..... ' Mull,,,,,,n,,,J "", ..... < '. ,,,,,,,,," ... 1 1'n .." ,",' " ." \\,,11 d< ",,'''' ,,,",,,! . , .. I>< pin' .00 ,;"u, 'ul>< "')' I>ph ,I"n ....... ".,.. .... '" of"'" 1""'"".1 ""'''r"Y'" of,h< ' J 0. bian "".o, ..... , "ok .h'on'''' .. f, ", '''''''. m",1 "'1''''''''' ...J "",.I ; ,t,,,">1 .. pt ... It h ... """".' wn< 0/'" . ... " .,.,. To. .. ;" p .. f,on .. >< '''' ,,, 'f'('w"h '", po>bift U""", J 'P;p")"')' 0, .. ,i>< '!' ol40, "","'" .. ...J m)"lom, ,""""", < .... "' h,,., 't'-f."""< m "''''W,,,i .. r,,,.,,,! .. ",;0.1 'h" ...... mun ",.,,"'" ' "'h .. "''''''''''' " ... " .. , k _!\S,,,.i,,, """' ... 0000. "",0,.1 J","""""'/h",')',h""'Sh. ,it< """'"'''' of Im",n .. , J, 'I' . " I ",J '" on '00' 1", ... .1 .. .", .... ron< I;". p....-lr .I, r"" .. ,"UK;"' )_ I.,"''' ("' u ]';"1. ,",all hk, 00 I"""", .. k ooru,t .. >one lesion! 11 Sd AP pelvis in a female with widespread lytic metastases and a pathological fracture of the left femoral neck. Note the cortical destruction and the wide zone of transition of the majority of the lesions. Case 116 209 "" Answer 116 MuScul oskelet al Imagi ng ANSWER 116 ObservatlonS II I"'1 ' i'h,,,, "m.",1 h"d " """"inS in ,hi. r""n'. Aot"Ion! woh "",r.IKon in 'h, m"lh", 'h, " .. ",p;'o", n.. .!'" ,ut hr ,0"" .... IIed 'i9mokl 0010". Answer 117 MuSculoskeletal Imaging ANSWER 117 ObH fVlti ons ll l1,1 ' Ib AI' """v'rio .... """",.1 ,10k"", ,I., .. oftt.. gI,>",.1 rlu, """,,10 >1"'" ";,10 ,h. " ",, in ,10, ",it",,,;.-., 0(,10" 1< .. fi"",,_ Alk",J ""k"" ,,,1h)'k ' ! 10, 'prm .. ' "J.";,-,,, in 'l"phr".1 "" ,I'>< I' '''''''I!'-'I''> d" '0 ' I'>< ..... ";,-,,, in i, , lip" m,,,,, ,,,,,,,,,,,,IT TI>< I ... oll< " .""" ...... , h;,J ,I ... ,h;,J rro,;",,1 ;.,,t 'f'>< " .... -.l 'l'in< '" _ .. ,10< .. ';"'" 0 1'-"'< pili< .. ,, Dlsc bulon 'A"n' M;.,m,, ...... -. 0' .1", f,brod)'('lo ... ""i,'.,,", h;', " " Prof"'"'' di",... ,h"",,,ri,,J b, n ,",,,b,,io", of fo"obl .. ,k p",'lf""io" 10 ""ilk""", .nd or' "-,k,, 1 m""k. I .. , " ,oJ,,", ,"J ' .... """,_ IUo.I ivIoP< >I It",,,,,, II.:: ,;..""" ' " mn> of ... fro. G"'" ..... ,ok'",""n O" ;(ON "';"'''' < uf ,0..""", oi"nrni . ."'-1 ""I 0 ..... 1 "'''php'' of 'h, "bi. "" ,I>< ""'" "''''''''''' .,." "'""h,J. n, wr.1 ...J , .... >1 bun" '" ""k" """mool, 1 .. , h..-"" .... ,, .rl" ... .uK' i. ,,f. "."ol "," .. fI ... " ",y ,,,,,,,""J,J h)' , .k" .. ,;., " I ,,,,,,i,, ,\ lu",. , ..... ou. ,h.."", 1 ,,,"...J, ti", ,I, 1'1", I,,,lwog,",m,"," "],," ->< .. h J,mmd joJ ""y 1"""' "" ,",,,,oJ ",,,mh . P.lo:Iic.l tipo Guo, II "' "It," h" .. ,,1 . , ,r.. '" '''ri>1' ml>:, ,h." ., ,h" "''''"''' 'I' f-i')'< ,I ..... "' ",1,,1, .. ll""'",, GC!' ... h,M"," ,,,,), ..,. Lit, ., R",. . -, .""', .... "I>< 1oJ n' , .1",)' l.ook m. ""'ill"')' < I< bio" moo' " .. .. , .');"t f>< , . ... , ,;.,, ... "" J .. o1 " ," "'. h .. '" ,If"" 'n" of ,I" , ibO . tlK " "" im" hum"u, .. ,d ' h, ,ibtll" bu' " .. In " ' h,, "'.,,"_ Tho ,II< "'"'' '""moo .... n of, l .. k .. g boo .. ,,,-,, ,H'"h),,,;.!.m mJ ,],,,.Id ,100 b< .""";&,,.1 . Dilllneai. Imill ,;.. . ,,,,,",,,,ion i> .."n ., 10'" vf """",,nO< , i,l",y me'.'., .. ". CASE 148 HISlory " 00)- I""'ntN _ . .., ... """" dU""8 'h< "OS"'-Case 148 264 ANSWER 148 Observations (148a) There is an area of dense sclerosis aflccting the shaft or the femur with associated cOrtical thickening. Within this is an area of ccmral111cency. This likely represents a nidus and the tcatufcs arc therefore consistent with all osteoid osteoma. Depending 011 other clinical features, infection might be considered as a diHcrential diagnosis. Diagnosis Osteoid osteoma. Differential diagnosis Infixtion. Eosinophilic granuloma. Discussion Osteoid osteoma is a rclati\'cly common, benign skeletal neoplasm composed of woven and osteoid bone, with loose intervening fibrovascular tissue. The lesion itself rarely exceeds 1.5 em in maximum dimension and there arc three main types: cortical, cancelloll s and subperiosteal. Cortical lesions arc the most common and have characteriseic findings. Radiographs show dense reactive sclerosis that aHccts the sha'ft of a long bone, especially the tibia alld femur. The lesion itself, howc"er, is a radiolucent area within this area of osteosclerosis known as the nidus. This is more clearly set::n on tht:: CT images of the same patit::nt (148b). Cancellous osteoid osteomas have a sitc predilection for the femoral neck, posterior clements of the spine and the small bones of the hands and feet. By comparison, the sclerosis associated with a cancellolls lesion is usually mild or moderate and may be distant from t he lesion. C the classical cortical osteoid osteoma, the cancellous may not necessarily be situated at the centrc oj sclerosis, making treatment more diflicult. The subperiosteal type is rarest, and typically I the medial aspect of the femoral neck or in the feet. It produces a soft tissue mass immediately adjao:::a the affected bone rather than osteosclerosis. Can ... and subperiosteal osteoid osteonlI, Stull M, Gilkey F, Moser R (199 1). Osteoid osteoma. RndioGrnpbjCJ 11 (4): 67 1- 696. 265 266 Answer 149 Musculoskeletal Imaging ANSWER 149 Observations (149a) There is all extensive, cxpansik [liceill lesion involving the length orlhe lett humerus, pn:dominJntl)' the mctlphyscs and diJphysis. RClllo0. iot in cth log. iO..,en in thi. achondropl.stic wit h I",ing of motap hv " ","'pot' oppO"' "' . 1511 R..ti"llraph of ,h. h.od d.mon.".ot;"g ""bbV 'ub" l .. -. Case 152 m Answer 152 MusculoskeletlOllmllglng ANSWER 152 Obso",atlonsI 15h) 1)""",1I)'" ... N,u"-",,,h\\ ' .S, .nJ of r"'g,rtip " >10; Si> ;,. ,I., "n" "".I '" ,."'''',, .. , m "(,,,. ,jh' .. ,"' .... 'u"" n",,,, '" m .. ,)' "'"'," ,",If 1'" ".'" "k' ... " .. >.I ,"''' '" I""d. 'I'h< ,Iu-r, m.in r,",m. , ,; .. ''''' "" .. I 'un, ""1""'"'" ,"d I"", .. ;""b. (i". " 'he h.,,) 1',no.,,,1 .",,,",,, .. "," ",",lIy ,,,n " ,h. of ... Pr,Cl lc.' l ip. So ... .. "ki",'"." in "' ... but ,',. ...., t... .. ,n .. ml>t" - k"" h 'n"" " Ml h"'I"'hy .-.1',1 ""'f"h"'"S'" "on ,"J ' I"""i in " 'I" "'';-'''''';1)'. .\I"" of ,h. orh .. Ii,,," .ikrt "'" '"Ii. """'rook,m. Ji>I", ,""""00 Jo.....nr,.oo ,10, ""1'''' .. .. ' 0 ,'" "cl .... J ""."J " ,,,- ..... Th,,, "" """.1 """'1, ,, ANSWER 154 ObH rvllionsl l!;4) T, ,-,", ""il .... "f, lo< IA he .... u,,. of. " ,,,b,, ot.,,,. Th< ""m IiJ.dy "'" i" ,kaJ .. , ",I;,,,}, ,,,/I'I,,,J ,,", b .. i, 01 ", P"'''''''''' fu.",", ,,( ' hi","", ... ,,,,d , I, "' .. , i'r, 1'.-."""",0' " .... h m.,i>I '" .... ' ' 0" " .. m ... Abo""" .. ,' ""', ,t.. ,,,"" "n."""," ,,, " , t.', mi"" QhI ... , 'h< e, "", oJ, ,, ", "",,,,",I;; '" ,n,h .. ",,,, J""N, Th j_ ,"., "" '""", ""'" t h< 0 , nJ d.",-" ""mi." .... , CASE 157 History An r""'"' f"t\>N< ,n" .. "", , oJ , )\" .... Iy otT",, ,iI< .. h'lf "f , t.. "'" ond , .... '" ""b,S J p0. " >I.", 11.1 IT >I", ,"''' , r" ..... ' ''1 """, .J" >0" 0>0" I. ,11t. l1 ... fn' , .... ," " " , t.. h ....... ","",mt.., ")"'>iJ oy ;, I""o,"!o, ;,h ' h h Hoarathyroidism in 3% ofc:lscs. Figure 160c a pathological fracture through a bro\\TI 160b Left hand radi ograph demonstrating lucent bands of resorption across the mid-portions of the distal phalanges of the first three digits. Radiological features of h),pcrparathyroidism arc 10110ws: BOlle resorption: Radial aspect middle ph,)Janx of211d and 3rd fingers ( 160 .. ). Terminal phalangeal tufts ( 160b). Disral end of cla\"idcs and superior aspect of ribs onCXIL "ledial aspect proxill1:l1 tibia ( 160c). I'Ikdial tcmorll and humeral necks. La.mina dura of skull :Illd teeth producing 'fl teeth' , 'Pepper-pot' skull due to trabecular n:sorplion ( 160d). Pseudo-widening of joillls, e.g. sacroiliac jointi.. cro5ions of the h;lIlds. Bone softening: Wedged Iertebrae. Kyphoscoliosis. Bowing of long bones. Brown tumour ( 160e). Osteosclerosis (marc common in seconda/"}' h)"l>erp;lralhrroidism). 'Rugger jersey' spine. Soft tissuc calei/ication: Periarticular. Chondroc:llcinosis. Anerial. Ren:ll c:llculi. 1\ ledullary nephrocalcinosis. ""'l t 160c AP radiograph of both knees demonstrates subperiosteal resorption at the medial aspect of both tibial metaphyses. Answer 160 MuSculoskeletal Imaging Pro.li"", lip On CXk .. '"Or< do< '0 "'-" """",,t>. On "n h>l. .. , ron"""" JiUJ."- c .. 1>< "n .-.f 'h' ,'"' , ... " J", ,fl 160y "''11",,1 If>"'" of 'h< r""hl",id tl .. J . """ d in"," .nJ '"'" ......... di,I .. , ... 1> .. ""'no tot""" " "",,,,,,oJ ,,,,,'Mi, ''>I < rm"u", inf",' ., ... 1> to I"";""""""" kukom.J .. i . "" "I " jo,)' ,,,hj! o'-'h, ""'''' of ' h, mit< h,," b", ko", Hu k n o .. h , .. 11,,,,, '" '''' "'1';,,,,"1' .-.i,, , ANSWER 162 ObSflovltions l 1621 ' I'h.", ... " of,'. """,n,1 ,","IT Th. , "'j' .,"" '" "",, ;, ,h" ".." Funll .. man. lI_ment ) " m ",'Um," ' ' '1'';'''' OI ...... lon A''''''"''''' ""''''0" "f,i-.< " .";,1 ''''''''';'' '"M ... , J if th", ;, """'"'"5 0,,10 ," m .. "< SA ,.(,1>< ,"J "'''""'' .... ...-n; d(;DH. .II"" ..... i ,,"'"" .\I ..., ,., '"" 'W-' rt< .. "" ... kl'l' "' ... ""'"",, Ii>< ' " , 0I, .,,01 ' '''''in wll'p",J ".u,int '" 'p;, '''''Y f'" h, , .... ,0< "". 11 In 'irh" '5""''''' l'i"" "r ..... ,' '"" 'II'"'" "I" "","m .00 ... .... " , ,,>vum "" 101. p""ufnO' ho," ... ",.-.lO,V '0 ""nlilotion ""' .. py. No" the bubbly i" .. , odioting ro "'" lung 0o"",h.",,,,,, m t< 'OIh, " nn m l l.'d). managoment T,,,,,,,,,", .. ,,,j,,. .. < "''''I'"'llUL A ... no"" b< .. ,"'''' ''''''''I'h'F'' "'''' .. ...J Jri, oI T' lF, TIt, ""'.;. ,",ul" ;" ",,",I.'g " ,J .. ,.", . i,,,1 ,-" .. k, .. 1"""'" ""'h" int" "'"H",h ..,.j ,10,,, tn. n:_,", uf , ", ,,",.-d_ ... ,,;M'''' ul "''' TOF ""0"' """'I'h,.,>1 ''',''; 00 . " roo", ,,, r""'"' '" 1,.oL J",,,,kJ ....... h of p""im>L '"""Ph"", ,nJ , k .. ,,,,.,,n,,,,,. m",)' ..... ," " '" '" "ft,n .,,,,,,,,,ol by ,nul' ;rl< .... .. , hl ;' ;'" i""l"dio'li ," .. ul",,,,,,,,,f. CT. ."d n", k " . "''''1''-.-'' ;n. rET/CT. d " r '" (,>o;u", "'" "'".,, ", .. " < .... - '0"'1" " ;, no< d;"m.,d. MAMMOGRAPHY Unto mo.1 I""", ) ' Of'''' , b, '''I' .. f ,lw im,. < , .. ' ' .. m"ti, I I " """) " 'h, """"'m .,(", "",,&,. On ..... 'I lO ..... in.,oo. " .. ,," of"" ptoJ on"" I< "", .. 1.1 ... " 1< ... " 1_ 1 ... ,,.i,;'. , n< ""oeM of ,n "X'U"" f .. ,I>0'1)' "'''oJ,,, to ;"'"'" ., .... " ' j\< dgnr>r. A '"uU m"',, .. ,ru. ';1 ,,, " ,,10k , b.'I"Y. m.) '" _I",,, ,I" J..., ..... ""." ,. ... "''',, .... ft " ,,,',,' f""< ",m""",, of ,I>< ngh' h...,.. '1' 10< ..... " ".",", 1. Th, ''''P'''"'U' m ... in 'h, "rP" inn" b,..>t Iokd)' "'pm,"" "nil'''.1 < .. " .. 0"'., Diegno.i. ,,,,,,,,,on. '.u. ,m i" ,h. ,,1' ( II RT) "",,,k,, . ", ... "J "" "")' ""r b< 0 ' o, , .-.,,,,,,, I , I.e]. d"m' """""n. ,i,. (I>c ' sn _ '0" m,," ... oJ .. , , .. l;l """'_"PI',,,,")i"" I U ..,I- ... / -.. '"";j'!..-ii._ /'2. , , 1 " .." j " H 1- 2 i1 " . . . ' . ". '" It""' '- , H: ..'l1 ." "J " , 01- = ' ... -'! .. -, '1" ." p_ H!l: -! .. ,,- ' Ii ;; '" . , ' . ' ' i: ,. , r. " l " "-;" . :: ._ .. .. _. i-f'" c.. __ ..; ... _ "'"" N .. ,,",,-,, - .. - -ls rL a l .,- . '; -r.- 0 ". ' ' ., " . . .... ,.;:.-... ,, " . , ,,,t .... _,,",,- -: .;::.;; :;,; -1" "' ." ",.- "-'" "'-:, ... -" ,".. '1 ;ci";;' " " ... 5'"" _ ,. -4 Ld t" .... '. 0..,. ;;"1' ",,, ,. . -,. i- "' _ I;; 1:;;; " ",,,-" ;. "' .... .... . .. ,_ N w ,. " " ::'i-i'" , ! >',-,"--I Z .. "; ' '''-;.!i''' - - . ,. ... "'=' ''. , ' l "k' .. -!fir' - ' g "- 3 "" ",. ' i .;'" .. .... , " " 0 .", - " " .. . -H.n,-a,-e. n (,': ;.h {H . >;. ," -",- -, - .. ';" ,.ii'" ",:rl ,!. =,o.ii. _ . .,.;! 7'1;",,,'" ." - ----" '; [!.' ,. .; _.,_ r .. '" 1. '"; - ";; ;." -< v,> .. '" ;: ... .. _, .,. .... - ', z-. - ;;. Q ; i "" ""- , ' . " .- .-" " '" "''' ..... ", ... ... sn iJ"'I'''hk .... 1. 7 ,J",,>l ,J, ... " . ... .-"''''' '" [5M ,""I .... "'" 9. ,""r,1 '''w J,."", II mrtnl,oI""""'r II I ""I" io' , ."",1,,, IT>< Il 0, Il,. 18 . "') ," """"k. ' p"" .,id ,in", Ill', '' I M< "oh: ,;", "." ........ '" '"""'rk .-,irh)". ... d,'rl..... I." ... 97 I ... m)"Kanl,a1 ",J"" """,," .. i. 81 .. " III P"'l"",i," I H ",;I ... ""II",,tJ ...... , 118 "",1 ",g'''. \\"" ''''(. .!. ""' .... 'i,,'S """",,,,it.. ,,,7 "'...,,, .. J",,.k,,, j ", .. " I .l ... ...... iom "'";''' 00 ')"0""",, "" .." .... n.m ",u. 17J ,,,.Js' I',,,m",, .. itr "''-'', " ... .01 ;1",, ". C"-",,, ' , J '" '" " ""ph"""",,,,,, 17,. "'p""".k .. ,,;'. ",".1 m...JuU")" " General Index ""Un,","''''''' 17, III ,,"""',""' .. a1,.... lJl 127 . 8 exit. 27 I. '!,p< 1 11I.ll7 ..... , 'J"} .... ;" ..... Iuk, ')'p< l ,,,, .. M .. W" "" """",,,I m;Y""'" . ""'S,"i1.d .. 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