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Case Presentations: Chest Radiology

Jan 12 | 1:30 PM

IRIA, Kerala, brings an amazing session for radiology residents and aspiring consultants, join us for an interesting chest radiology case presentation, with Dr. Aparna Irodi, Professor, Department of Radiology, CMC Vellore, let us brush up on some fantastic concepts and discover some new ones.

[Music] very good evening to all and a warm welcome to today's session on radiology residence academic program 2022 organized by ira kerala chapter so we'll start off today's program with an opening remark and welcome speech by dr vedic head of the department who rcc the chief academic coordinator of this program as well i invite dr venu to give his welcome speech okay good evening to all and uh so the academic being actually plans two programs every week on wednesdays and on saturdays on saturdays faculty teaching program and on wednesday's residence program so first program we already had last saturday and this wednesday actually we have got resilience program and today actually we have got one evening faculty dr abernathy medical college below and we know that the cases from christian medical college it will be very much fantastic and truly and also maybe rare cases also may be there and anyway we are eagerly waiting for those cases to see and uh very warm welcome to dr aparna is a multi-talented personality with great interests academically and socially and it's the mastermind of this whole event i invite you man okay thank you thank you dr uh dr venu good evening dr aparna also good evening i'm very happy to be in this platform because i'm used to this and i inaugurated this uh platform about six months back and i'm very happy to get this platform again to teach the students and i'm very happy that we have got a wonderful team as we are going to conduct pg discussions uh every wednesday in this platform so i request all the residents to be online to see variety of cases which will be very helpful for them during the examinations so this wednesday program will be very much benefited by all the residents throughout the state and nation also so i welcome all of you uh be attentive throughout the session thank you thank you tara i think dr richard maxwell dynamic state secretary iris for the felicitation all the best wishes to the program and maybe i will join at the end of it thank you thank you so we are beginning the questions so we have four cases for discussion and we have two candidates and uh dr aparna would be showing the first set of cases to dr aisha and dr jessica will be doing the second set for the final apg over here good evening so let me just give a disclaimer before we start so i didn't uh given the interesting or exotic cases i just put like exam type of cases all right so uh we'll uh start with the discussion so you can describe um as we go and i think i'll be showing the images because uh i think that's how this works all right yes [Music] okay so can you start describing this yes ma'am uh this is a frontal stereograph of a mature skeleton patient there is a well defined uh opacity noted in the left side of [Music] otherwise there is no obvious external or clavicular abnormalities based on all these features are the possibilities that this opacity or religion must be a mediastinal lesion coming to each compartment uh since uh it is a interface with the left cardiac border is not well visualized so the load sign is positive possibly the legion must be in the anterior mediastinum [Music] or in other ways uh the ilr vessels are seen approximately more than one centimeter distance uh from the lateral margin of the opacity so this must be an anterior mediastinal uh lesion rather than a cardiometallic so this must be anti-difference delusion remarkable soft tissue shadows visualize parts of abdomen as well as the bony frameworks grossly [Music] okay okay uh that was a that was a good description uh only a few points i want to add one was the azygo esophageal recess i don't think that is displaced again if you're like you're contradicting your statements as i use the facial resources is an anterior structure or posterior structure so then you're kind of contradicting what you're saying right so i in fact i am not even sure clearly okay so silhouette sign is positive for hard border right yes that is lost that is we call it a silhouette sign positive is there a silhouette sign negative for any structure okay then [Music] anything else descending thoracic iota right that is also clearly seen so all these points together is adding to say its anterior mediastinum right so uh that would that kind of description would be even better so you could say silver sign positive for left-hand border negative for descending thoracic iota so and it has a broad contact with the mediastinum so i think it's a mediastinal lesion likely to be in the anterior mediastinum two more points that you could add is before you uh conclude on this chest x-ray like you stopped describing so i realized you finished what you wanted to say about the x-ray so one thing is uh tell any relevant negative so wherever you are seeing any lesion uh you have to tell any relevant negative so what relevant negative points is important in this since you're thinking anterior mediastin what are your uh okay [Music] but trying to differentiate so one thing is trying to say what is the etiology second thing look for any complications such kind of things so any etiology what are the causes of mediastinal anterior terminal lesions [Music] what are the differentials okay thyroid is unlikely in this patient it's really low down but it could be an ectopic thyroid okay [Music] malignant kind of germ cell tumors so out of these anything that you can um characterize based on only chest x-ray areas and calcifications of this calcium okay so that is the only thing that you may be able to see so it will be good if you could say that i'm looking for calcifications i don't see any or i do see some where the high limb just about the high lump area is c some calcific areas all right so that is one point you should remember always any relevant negative towards the etiology and towards any complications so for example suppose say there is a vowel obstruction that you are seeing on abdominal radiograph so you look for any hernia so you say i'm looking for a honey i don't see hernia then i'm looking for free air because i'm looking for any perforation so there is no free air so when you say all those relevant negatives it gives a good impression all right so after you finish this description with the relevant negative next thing you should have said is the differentials i am considering are teratoma germ cell tumor lymphoma thymoma but this is a young patient thymoma is seen in older age groups so that is less less lower on the line and you should say what you want to do next so you should say i would like to do a contrast in hand ct to further characterize the lesion all right okay so we'll go to the city so i think these i had given you scrollable images that we are not able to see on this so we'll see the static images okay can you describe the ct what kind of seat is this the contrast are axial sections so uh there is a well-defined length in the anterior mediastinum enhancements and fat containing areas as well as some areas of calcifications and the lesion uh is having a different fat plain with the chest wall and in some areas with arthrophyota as well i don't see any obvious bone bone abnormalities there is no other opacity in the ammeter and the lung fields okay so uh what is this you can uh just to speed it up i'll tell you um [Music] okay so then like this loss of plane with iota if you say that then are you trying to say it's inoperable so we should be careful before saying that is he looking like a benign turret or mana why should it have a loss of plane with iota you should be careful in exam you should be careful in your regular reporting also because it makes a big difference for the patient if you're saying that the surgeon may think it is some infiltrative lesion which is lost plane with iota and all systems so be careful when you're saying that okay yeah okay so this is a typical teratoma so don't tell any differentials or anything just say this is a definite tyrotoma anything else you're seeing on these any other finding you saw there's another similar morphology i'm sorry i can't point it out but uh just have a look at the pectoralis minor so you should be specific where in the chest so sometimes this teratomas can rupture all right so that is for one extra brownie point so teratoma everybody will identify so if you have identified this you will get some little extra points so it has ruptured into the chest wall it can rupture into the pleural space uh it can rupturing to the bronchus such things yeah okay so one last question for this case uh do you know how how do we classify the mediastinal compartments on cross sectional imaging do you know any named thing compartments what are they called an anterior middle and posterior is called what are the nails prevascular compartment visceral compartment okay so where is this in which compartment is this region [Music] okay so whatever is anterior lateral to pericardium is previous prevascular whatever is medial and posterior to the pericardium is visceral up to one centimeter from the vertebral body and behind that is paravertible okay good uh well done i'll just show one companion case so where is this lesion okay just just quickly this companion case what's the difference between that first case that we saw in this one um i think this is a software density legion which is about broadband and the same uh up to the angle of contact but here this load sign is done yeah yeah so i i think you can say a silhouette sign is lost or you can say cellular sign is negative don't say interface is clear or not clear because there may not be an interface it's totally posterior right it's not in contact with the heart that is why you are not seeing you are seeing the hard water clearly and one more finding you can see that you can see that intercostal space is widened and there is scalloping of that rib that is the posterior end of the rib that is also indicating its posterior mediastinum so in this you describe as broad base to the mediastinum with the um silhouette of the heart border preserved and widening of the intercostal space with scalloping of the rib likely to be a posterior media standard lesion a common is differential would be a neurogenic tumor and i would like to do a mri to look for intra spinal extension in here the major relevant negative that you can say is you're looking at the vertebral bodies intervertebralis this could even be a paravertebral abscess right so tell those kind of relevant negatives so you can be ready for this kind of things in the exam think of what all relevant negatives have to say like suppose you say rcc then you have to like renal cell carcinoma the negatives will be whether there is renal vein invasion whether there is uh lymph nodes such things all right so you'll be ready for all those things so again just showing the first one is the posterior mediastinum where silhouette sign is negative for left heart border but positive for the descending thoracic areata so it's a posterior mediastinal second one is an anterior mediastinal lesion where silhouette sign is positive for hard border that is heart border is lost whereas the descending thoracic iota the silhouette is preserved that means its anterior mediastinum okay so this was the posterior image standard lesion it was a nausea tumor with intra spinal extension that we can see on the mri okay shaq you want to continue with this one yes this is a 48 year old patient presented the complaints of pain in the leg and this is a radiograph of a ankle with a leg with the ankle uh ap other than the lateral view i can see the diaphragm there is there is no uh aggressive periosteal reaction and there is no extension into the ankle joint there is no obvious quantity or austenite matrix okay let's since we don't have much time let me just uh cut it short do you think it's an aggressive lesion or non-aggressive lesion [Music] okay uh what are the points towards non-aggressive and is there any point towards aggressive uh cortical bone distribution aggressively but uh aggressive periosteal reaction okay when do you see the periosteal reaction only when there is time for it to form right yeah so what point is saying that it is aggressive here cortical breakdown yeah the cortex is fully destroyed right okay okay so let's see the mr what do you think on this let's see this is the coronal yeah it's okay don't uh don't have to describe the signal intensity at all what do you think of the lesion this is not contrast anyway do you think it's aggressive or not aggressive aggressively so what will you like to do next i'm based on the morphology and the age of the patient uh the differential start one of the possibilities okay okay very good so this is what i wanted in some exams will keep like this they will not give the whole set of study like for example even the anterior mediastinal mass they may only give you the x-ray and they'll want they'll expect you to ask the further what has to be done so this one actually is a typical cookie bite metastasis yeah okay so acryl metastasis so distal so most of the primaries will give rise to the metastasis in the axial skeleton right so ca lung is one which gives rise to this accurate metastasis two in in the peripheral bones and this is a typical cookie bite metastasis it really looks like a bite of a coquino so once you see this you have to think of ca lung only and you have to ask for the chest x-ray like in some exams especially i've seen in dnb sometimes in md also some examples want to do like this so they may give this you describe everything and say i will look at the chest x-ray last for a chest x-ray to be [Music] any other findings okay why do you think left-hand adaption is salivated okay what is causing be there foreign because this whatever you're seeing in the left lung upper zone that is unlikely to cause uh chronic no policy but probably there are notes that's why there is convexity of the uh ap window yeah so this is just this ct i'll just quickly show so that was the mass in the left upper lobe that is the big mass and there were nodes in the ap window here and uh anterior mediastinum along the arch so that is the expected location of the phrenic nerve that's why there is renicknow policy and in this ap window recurrent laryngeal now also goes so always look for vocal cord policy in this we have not covered but if it is covered you look for it all right okay well done shall we move to dr jessica for her cases thank you thank you so i was given a case of a 35 year old who presented with companies of cough and was treated empirically with att and was not resolving chest radiograph frontal projection uh shows a homogeneous obesity involving the right mid as well as the lower zone uh the cellular sign is positive for the right uh right heart border as well as the right uh hemi director uh the right uh pulmonary a descending parliamentary artery is not visualized the right uh hilum is also unremarkable the rest of the lung field right lung fields as well as the left lung fields appears to be normal uh the in the left uh the sending parliamentary artery as well as the left hemi diaphragm is also visible there is no other obesity within bilateral lung fields visualized bones as well as the soft tissues appears to be normal uh so from the given radiograph my possible diagnosis would uh differentiates would be of an underlying lung mass causing collapse of the right lower low okay so some things uh you told about right hard border being lost as well as a diaphragm right yes ma'am so why is hard water also lost if it is only lower lobe um i'm both the lower as well as the right middle loop okay so most likely it's middle and low low both are collapsed right but why did you say collapse what made you say collapse ma'am collapse consolidation uh okay i agree to the collapse but i want you to substantiate with why you're saying that uh there is volume loss on the right side compared to why how are you seeing volume loss there is a mild drip crowding as well as the right pulmonary artery as well as the right highlight is not well visualized north will visualize this because of the lesion being there more than that it is the there is mild uh medicinal shift to the right right yes ma'am cardia is like so that is indicating the volume loss so that you could have brought out that also to substantiate your that there being collapse so where do you expect the lesion to be now that you're saying that it is likely middle and lower low collapse it might involve the uh right um means uh the right bronchus intermedius or uh involving the bronchus yeah which bronchial bronchus intermedius is correct so you should say likely there may be some lesion in the bronchus intermediates or this whole thing may be some kind of lesion involving the entire those middle and lower low but then if it was holding this lesion there would have been more volume and it should have caused medicine shift to the opposite side so likely there is a collapse and we are looking for any central mass right yes okay okay the actual sections post contrast images uh shows uh relatively uh where a well-defined oval shaped lesion involving the uh right uh right main stem bronchus uh ender bronchial uh component as well as there is an external bronchial or there is parenchymal component involving the right perihelion as well as the right medial segment uh can i just interrupt you if you say main bronchus is involved how is the upper lobe still looking normal is only seen in the right main bronchus but there is no cut off of the right main bronchus but another external uh parenchymal component which is uh involving the right bronchus intermediates and causing cut off of the right bronchus intermedius and there is a lower loop collapse okay so mainly the lesion is in the bronchus intermediates but may be minimally projecting into the main bronchus right it's mainly the main lesion is in the bronchus intermedius uh again i'm sorry i'm not able to point out uh hopefully everybody is able to appreciate the uh lesion in the bronchus intermediates um so you can start seeing from these images onwards uh you can see that it is how is the lesion it's quite a little bit enhancing type of lesion right yes now you can see it centrally on all these images it is there centrally and all these images centrally okay go on then what is happening uh then the lesion is uh the lesion is um having an enter bronchial component into the right right uh bronchus intermediate and there is cut off of the right main uh right bronchus intermediate and causing collapse of the right middle as well as a lower lobe okay maybe we will just show the lung wind also to everybody before we yeah so here we can see now you can see that up in the first image you can see the karina next image you can see the upper low bronchus taking off and next image you can see the tip of the lesion which is just about projecting into the right main bronchus and then you can see that the bronchus intermedius is fully cut off right bronchus intermedius is fully cut off and then we can see the middle and lower lobe collapsed okay so normally how will the collapsed lung look uh it'll have a bronchograms it'll collapse the lung they need not have air bronchograms no in the malignancy how do you differentiate collapsed lung versus the mass so what is happening here is these the whatever the collapsed lung is actually looking very hypodense right so what we are seeing lower density areas is actually like fluid bronchograms all these low density areas are dilated fluid filled bronchi because of the chronic obstruction so normally when there is a collapsed lung that the collection will be very brightly enhancing so when there is a mass and collapse lung that is how we differentiate mass will usually be hypodense whereas the collapse lung will be brightly enhancing whereas here this collapsed lung is actually like a drowned lung where it has got lot of air sorry fluid bronchograms and dilated fluid filled bronchi uh dr jessica are you back yes ma'am okay okay any other findings you saw in this patient uh mammal uh aberrant writes a claviness okay okay and this one here uh it has there is a liver cyst also involving the exactly okay sorry how will you confirm whether it is assist uh remember you can do a further imaging by using a pet scan to confirm that it is a liver cyst uh do you need a pet scan to confirm that it is assist no ma'am uh you can check the attenuation of the cyst using the hu value okay post contrast images usually the system will not enhance okay this is a low density lesion you are seeing it already just do an ultrasound uh don't say pet for that all right so this is what another finding that dr jessica has pointed we can see the aberrant right subclavian artery so from that is the last artery arising from the arch and then it is causing posterior to the esophagus which we can see in the last image the fourth image and then the third image we can see how it's coursing posterior and in the first image you can see that going up and then you can see it uh in all these images i hope everyone is able to identify that so that is evident right subclavian artery um okay somebody is asking about mass versus collapsing i'll explain that again uh so basically these kind of some extra findings may be there which if you identify will again give you some little extra brownie points but um you did a good description that was good so this question that uh dr viddush is asking to explain mass versus collapse so usually when there is a malignancy say say lung with a collapse the collapsed lung will usually be very brightly enhancing whereas the mass will be hypodense that is how we may be able to differentiate between the collapsed lung and mass but here what is happening is because it's like a chronic collapse we have said that it's a long-standing thing that all this bronchi are filled with fluid so all these are fluid bronchograms so it's like a drowned lung which filled with all the uh mucus and secretions are all pent up and filled and dilated bronchi that is why it's looking very high potency that's what i was trying to say so what do you think this lesion is uh dr jessica and what will you do next um i think if this lesion is considering the age of the patient and uh the well-defined uh homogenously enhancing lesion it could be a carcinoid bronchial carcinoid yeah so most likely this is a carcinoid because it's quite enhancing lesion and it's a young patient and it's a long standing history i told you already patient has taken some att and all that so if it was malignancy it would have worsened more you know and so it's likely to be a carcinoid and what will you do next um you can uh uh you can do a bronchoscopy and you can do a histopathology of the lesion or okay excellent so uh bronchoscopy and biopsy can be done although they would previously they were scared that it may bleed etc they will be able to control the bleed and we can biopsy it and delta t pet scan is one good way of imaging these carcinoids all right so let's move on to your next case so this is a 50 year old who has a lot of dyspnea let's go to the chest x-ray just a gesture to grab frontal projection of a 50 year old male which shows bilateral bilateral enlarged palm descent main as well as a descending pulmonary arteries uh there is um prominence of bilateral upper lobe pulmonary weights as well as there is few linear uh radiopacitis involving the right uh lower zones uh rest of the lung fields appears to be normal uh the bilateral uh hyperdomes of the hemidiaphram obvious normal there is mild cardiomegaly other than that there is no obvious mass lesions or visualize bones as well as the soft tissue supposed to be normal okay you you summarize and conclude what you're trying to say uh i think of i think it's cardiomegaly with uh enlarged parliamentary arteries so features of parliamentary artillery hypertension okay now many things that you're saying a little bit contradictory one is uh how do you say there is cardiomegaly by checking the cardiothoracic ratio okay [Music] yeah i don't think there is significant cardiomegaly okay maybe it's a borderline heart okay all right so one is you said that hilar and lush and the descending pulmonary arteries dilated when do you say it's dilated uh when it is more than 17 am okay what is more than 17 mm descending pulmonary art okay second point is you said about the upper lobe veins being prominent and something you described like curly b lines right okay so uh that i don't uh curly b lines i don't really think there are any uh i agree that some vessels are looking a little prominent in the upper lobes so uh usually we don't see both these like this happening together but in which condition can you see that what is upper lobe vessels being prominent indicate what i was trying to say is upload the vessels being prominent indicates like we are trying to say its pulmonary venous congestion right but at the same time when we are saying pulmonary arteries are dilated we are saying trying to say its pulmonary arterial hypertension so only one condition that can give both is when there is like a mitral stenosis so we will try to look for whether there is any double atrial shadow or whether any central cardiac density to say whether there is any left atrial dilatation we will try to look for whether there is carinal widening whether there is lifting above the left main bronchus so all those will be the relevant negatives so we will say that there is no double lateral shadow there is no widening of the carina normal angle so that's what i was trying to say so uh i don't think the current is vital so normal carinal angle is 60 to 75 degrees so here that we are not really seeing left atrial dilatation features but definitely primary arteries are looking dilated another point will be whether it will be um arteries dilated and peripheral pruning so peripherally we are not seeing the pulmonary artery so all those are indicating there is pulmonary hypertension how do we differentiate whether this is a lymphadenopathy causing hilar enlargement versus dilated pulmonary arteries so we can use this um hilar convergence sign which is whether if the vessels are going towards the dilated or enlarged highland that means it is pulmonary artery whereas if the vessels are the pulmonary vessels are going towards the waste of the heart instead of this abnormal bump that means it is something else like lymphadenopathy so here we can see the vessels are directly leading into the dye into that tyler bump so this is um pulmonary arteries dilated and this is pulmonary hypertension another thing if you look the both the lungs are looking quite hyper inflated with the flattening of the domes so there is emphysema so that could one be one cause right so you can say you there is primary hypertension it could even be core pulmonary because i see that the lungs are hyperinflated so i am considering these options now all right so dr jessica is back again okay the scrolling images we are not able to see let's see the static images where dr jessica what did you see on the ct um there is a dilated main parliamentary artery as well as a segmental enter branches of parameters were diluted uh the diameter of the palmetto tree was more than 42 m main parmantiyati was more than 42 mm okay so this is what she's trying to say so main pulmonary artery and all the right and left pulmonary arteries are dilated so that is confirming what you saw on the x-ray so you think there is pulmonary hypertension okay once you see that what are you uh what else you want to do now um check for the causes of pulmonary artery hypertension okay very good so in addition to that pulmonary artery being dilated what are you seeing in these images [Music] ah there is um right ventricular as well as right atrial enlargement is there okay very good so there is rarv dilatation also again consistent with the pulmonary hypertension probably right heart is going into failure right yes okay okay so next uh point is we're trying to establish a cause right so what all causes are you looking for okay so one point we thought about on the x-ray was whether there was hyperinflation so whether it could be copd causing or pulmonal so if we look at this on the lung in the lung windows we are seeing some kind of inhomogeneous attenuation which sometimes we can see with primary hypertension itself but we are not seeing gross emphysema or bronchial wall thickening right um so we're not seeing raw copd may be some degree but the degree of primary hypertension with 45 millimeters of pulmonary artery uh diameter and this much of ra rv dilatation is out of proportion to whatever we are seeing in the lungs so basically what i was trying to show here is let me just show so these images if you all can zoom and see [Music] we can see uh yes dr jessica did are you back did you did you find any cause for the primary hypertension so what all will you look for so when we said already about the lung to look for any causes in the lungs like copd ild etc so in this patient there was some bronchitis and some little bit of inhomogeneity but we didn't see any gross things so in the uh pulmonary arteries itself whatever one main thing we want to look for is thromboembolism right so chronic thromboembolism you may see pregnancy just as webs or linear filling defects so other things that we want to look for is any left to right shunts so this one i just wanted to show this for that because this thing many people miss this finding so if you look at it on this image you can see one vein the pulmonary vein which is going and draining into the svc i'm really sorry i can't point out but uh i hope you're able to see i have one image with some arrows i'll show that also and [Music] see this image here you can again in the right upper lobe you can see this pulmonary vein which is draining into the svc can you see that primary vein just anterior to the pulmonary artery which is draining into svc and one more so basically it's right upper lobe and right middle lobe veins this is the other one which are draining into the svc and if we see in this image what we are seeing here sorry in this image is a sinus venous type of asd let me just show one zoomed images of that okay so here we can see this is the right apollo primary vein draining into svc and here you can see another vein which is also right upper brain only are both draining into the svc and slightly lower level what we see here is the sinus venous type of asd so this can be missed on echocardiogram it's very important for us to identify this because it can be missed and i've seen many people missing this that's why i just put this case this may not be a typical exam case but i just wanted to eat pulmonary hypertension can come to discuss all the causes all the findings etc so that is why i just put this case so remember that every case of primary hypertension look for any type of shunts so sometimes you may see ap windows sometimes you may see pda also which can be missed on echo especially in adult patients so always look for any asd vst pda ap window this kind of sinus windows asd which can be missed all right so let's now go quickly to the spotters uh spotters are like actually just very typical cases and it's more like a rapid fire let me see where yeah here uh doctor y shark maybe you can do the first seven and uh dr jessica can do the next date quickly and then we'll just go through it first i will not interrupt you you just keep doing quickly okay [Music] yeah dr divya is asking so this was a case of ice and manga it had not yet gone into ice and manga if there was icing mango patient would have had cyanosis at the time patient didn't have cyanosis [Music] okay dr vaishak shall we go ahead yes okay just keep telling okay no it's just it's spotters no description and we will do it like a rapid fire next [Music] if you don't get it immediately you can pass it and we can come back quickly once next [Music] next [Music] [Music] okay so why chuck you've seen your seven jessica are you able to see now yes mommy yes okay your turn now partially anomaly [Music] next text system cactus um [Music] abpa next [Music] memphis next medallion calcium and all findings put together [Music] next clam next okay you take a few seconds because there are many images [Music] what are you seeing on the ct what are you seeing on the hand x-ray same patient this is [Music] um okay [Music] okay let once last quickly we'll go through first okay uh dr vicer this one you called as pneumothorax it's pneumothorax but you should have said tension pneumothorax right why because we're seeing the mediastinal shift and flattening of the diaphragm so you have to use the word tension in mother ex it's medical emergency if it's like viva and all you should say i'll immediately call or even put in a chest tube or something all those things what is this just a companion case [Music] this is a hydro pneumothorax you can see the air fluid level in the lower zone and a little bit of uh right lower and a little bit of air in the chest wall correct so right hydropneumothorax what was this you did not get it yeah you said about a bad swing but [Music] you are seeing the findings only on the right side right and can you see something in the right close on some roundish thing okay so basically when you see this kind of unilateral one is it can be unilateral pulmonary edema which can be different causes like unilateral pulmonary vein may be obstructed or it may be like re-expansion edema after drainage of a plural effusion but here other thing to consider is lymphangitis so this is a mass in the right lower zone with the lymphangitis carcinomatosis in the right lung here's another example basically here you can see right breast there is mastectomy and in the lung we are seeing the tiny nodules and reticulations so this is lymphangitis carcinomatosis so you in that septal thickening you can get smooth or nodular and smooth septal thickening is edema so this is a typical edema where you can see the smooth interlobular septal thickening there is small bilateral pleural effusion that is calcification of the mitral valve and you can see in the x-ray also the typical left lateral dilatation uh with the widening of the carina uplifting of the bronchus double atrial shadow all those things so smooth uh so this is mitral stenosis with pulmonary edema so smooth uh interlocus apple thickness edema whereas nodular thickening is lymphangitis yes this one you got it so this is a ruptured hydrated cyst with the folded membrane seen within it uh and many numerous signs are described so for example it's good to know all these signs so onion peel sign water lily sign serpent sign cotton will sign in ultrasound where you can see the folded membranes and there are many more signs so please read up all the signs this is another example just to show you the folded membranes in a ruptured hydrate it's just and you can get this crescent sign also where air is tracking between the pericyste and ectocyst okay i think this one also you did not get basically this is the alveolar micro lithius is very typical appearance very dense kind of opacities so you can get reticular nodular very dense opacities and the pleura will look at dark so this is alveolar another very gross example where the whole lung is so dense that the pleura is looking really dark somebody is asking about aspergillus i don't know for which case sorry i missed that query so this one again i think you did not get it so basically if suddenly if you don't see anything look at all your review areas can you see anything in the review area what are the review area hidden areas so episodes costophrenic angles retro diaphragmatic retrocardiac hylar all these areas are the review areas [Music] so here can you see anything in one of your review areas yeah can you see anything review areas [Music] yeah somebody's saying so left left epicon pancos tumor you're seeing right so there is a lesion there in the left epical region and the rib is also eroded the second rib is eroded so i think there was a question about why the hydrated is not a aspergilloma you can see the folded membrane see the membranes it's not a rounded ball no it's membranes that are folded all right again you can see if you see in the mediastinal window also you can see this is another case where you can see the folded membranes okay so we are back to this so this is a typical pancreas tumor where you can see in the left superior sulcus lesion with the rib being eroded just few other examples of hidden area lesions so here you can see something in the retrocardiac region all right so this was a small adenocarcinoma which can be easily missed if you don't look re look at your review areas here there is a bigger retro cardiac lesion again when it is big also sometimes we can easily miss it so always re look at your review areas in the exam and also in real life please re-look at the review areas here is a right panco's tumor this was a patient who had one cerebellar lesion so always this this also can come in exam like this where they'll you you'll have to ask for i will review the chest x-ray to look for whether thinking of metastasis like the cookie bite one so here this was a chest x-ray of this patient with the brain lesion so here again you can see actually in the epical region there is a module and there is also right paratrooking adenopathy so if you don't look closely we can easily miss that all right so here there is a retro diaphragmatic module this was a patient with osteosarcoma this is a metastasis in the retro diaphragmatic so all these are your review areas see another example of a cookie bite metastasis in the humerus and where is the primary you can see in the left retrocardiac area can you see that there retrocardiac and partly retro diaphragmatic so that is a primary with the cookie bite metastasis this you answered correctly very good so pulmonary embolism in the second image you can see the embolism and in the rest of the images you can see the infarct so this is a typical appearance when you see little triangular thing with this kind of central like some loosen c some areas of breakdown think of pulmonary embolism and even if it is not done as a ctpa you look for pulmonary artery defects so this is pulmonary embolism within fact so other things that can give so in the in fact you can see that feeding our tree sign so other things like malignancies can have that kind of cavitating lesions this is an adenocarcinoma with that pseudo cavitation the bubbly area seen in that last image are there differentials for cavitating lesions so what is this uh i think both of them are offline so this is yeah correct vaginas granulomatosis so multiple and sinusitis think of vaginas granulomatosis or granulomatosis with polyangitis is the correct name now for vaginas metastasis is typically from squamous cell carcinoma and what is this [Music] can you see the absence around the left uh in front of the left scapula yeah so there was an abscess there and from there septic emboli have come all right so all those are differentials for the multiple cavitating lesions so septic emboli yeah this one again you did not get so this is the basically again just applying the silhouette signs so silver sign for the heart border is lost so this is a right middle oblation so likely to be a consolidation it's a child so it's a right middle loop consolidation all right yes so this is similar area lesion here the right heart border is preserved but the diaphragm is lost so this is lower lobe so first image is right middle loop second image is right overload all right clear so that is the right lower lobe again seen on ct yeah this one dr vaishak you got it right so this is a left upper loop collapse so again everybody keep this picture in mind so when you see this kind of a veil like opacity just loss of left hard border left upper loop collapse this is a very typical appearance and why do we see it like that because the upper lobe collapses against the anterior chest wall all these are examples of upper lip collapse just keep all these pictures in mind because left upper collapse can be an exam case so if you have to describe it you have to say like male like capacity loss of hard border my diatic nucleus seen and because that uh that is a luffy shell sign then i will do ct to look for any obstructing lesion this is typical of couple of collapse i look at the lateral view to look for confirm it and i'll do ct to look for obstructing lesions like that you have to describe for the exam all right what is this left lower low collapse why [Music] a triangle opacity involving the uh yeah yeah no i agree why is it collapsed [Music] it is left level of collapse in the retrocardiac opacity can you see any cause [Music] what is the age of the patient yes yes can you see the eyes no there is a foreign body no can you see it yes just just be on the current now one linear thing it's a child so foreign body so look for that for so children always look for that foreign body okay so left loop collapsed [Music] which loop what is this see the lateral view also middle lock see a right hand motor is lost left headboard is so clearly seen now this is right middle of collapse right here border is lost on the pa view and on the lateral view you can see that triangular opacity which is overlapping the heart shadow so this is typical right middle of collapse okay right middle low collapse so all the different lobes collapse so this is left lower low because the first one is left lower low because diaphragm is lost but heart is preserved then next is left upper low bright upper lobe is clear this is right lower low because diaphragm is lost but heart is preserved right middle of only a small part of the heart is lost so that is right middle of the last one is left lower lobe with some bronchitis all right [Music] okay this one you got it so basically central cystic bronchitis is cystic and varicoid with your chord impaction giving that finger in glove appearance so this is typical abpa abp or allergic bronchopulmonary aspergillus is another example multiple finger in glove and if you see in mediastinal window you will see the high attenuation that mucous plug will have higher attenuation or ham or high density mucus plugging so that is abpa another example so other things that can look similar what is this [Music] this is basically bronchial entries here again this is one it will be one single area where we are seeing that mucus plugging give them giving that finger in glove and surrounding that you can see that big area of air trapping okay so this is typical appearance of bronchial atresia always but you have to make sure that there is no obstructing lesion causing that all right so this is bronchi electricity yeah what was this again you both passed it you want to take it again [Music] what are we seeing both lower zones we are seeing some yes correct so your small cystic kind of things with their fluid levels so what do you think that could be like cystic bronchitis right why is there cystic bronchitis sorry anything you're seeing basically can you see the marker side marker there is a side marker [Music] right so this is cartagena syndrome this is how it will be so this can be put in the exam like this or they may give you the x-ray and without seeing the marker you may put it up in the wrong way yeah if if this vitus inverses was not the cystic fibrosis would be a good differential somebody has put that as the cystic fibrosis differential that would be a good differential if this cytosine versus facade okay this one [Music] yeah this is medullary nephrocalcinosis is there then what is in the lungs [Music] what type of nodules are these [Music] we are seeing tiny nodules what is the distribution of nodules [Music] is it random is it paralymphatic is it central lobular yes and what type of yeah this is typical perilymphatic basically you're seeing peri bronchial and perivascular nodules so that is perilymphatic distribution and you see calcified mediastinal nodes some of them are like eggshell classification so putting everything together dr hayman has got it right so this is sarcoidosis all right so why do you get medullary in afrocations in sarcoidosis because there is associated with hypercalcium okay they can hypodecisis patients can have hypocalcemia so what are the causes for medullary in africanuses renal tubular acidosis medullary sponge kidney hyperparathyroidism any causes for hypocalcemia like sarcoidosis and actual calcification you can get in sarcoidosis silicosis histoplasmosis tb etc all right this one you got it so nice uh so a lot of volume loss so big cavity with the big fungal ball filling the cavity so intra cavity fungal ball this is a big uh thin wall cavity the small fungal balls sometimes this also can be kept and people get confused now this one you did not get anybody wants to take this one so when you don't see anything in the quick review quick look one is to look at all the review areas that is your hidden areas which we already mentioned small pneumothorax all this yeah can you see the inferior rib notching [Music] yeah so typical inferior rib notching at multiple levels and in fact you can see that three sign of the iota also here there is one narrowing just beyond that and then there is mild dilatation if you look closely you can zoom and see that you can see uh so very sorry that i can't point out but you can see that notching and you can see the three sign so on the barium you can see inverted three sign and if you get this for exam all the different types of quantitation will be asked and when will you get unilateral drip notching and all those questions will be asked so you can read up all that what are the associations will be asked what is this showing so basically this patient had actually come for a renal artery doppler saying there is hypertension so we are seeing bilateral dam [Music] dampening in both main renal arteries so once we see that we have to consider quantitation look at the x-ray and we can see the quantitation so all the three sign other associations bicast pediatric valve berry aneurysm sternus syndrome etc all right so this is what is the answer for 11 what was 11 11 is sarcoidosis that's what we said basically there is perilymphatic modules there is eggshell calcification so even without the kidney picture it is sarcoidosis typical sarcoidosis and the kidney has medullary in afrocalcinosis because of the hyper calcium associated with sarcoidosis uh lch no y lch nothing related to lch is there in this okay this one or for this you are asking the lch no so basically this is a typical appearance of silicosis or coal workers pneumoconiosis with the progressive massive fibrosis what are we seeing numerous tiny nodules in both lungs and in the parahylar and upper zones we are seeing this conglomerate opacities so what does that conglomerate opacity these nodules are coalescing informing the progressive massive fibrosis once we are seeing more than one centimeter sized opacity that is progressive massive fibrosis as they conglomerate they migrate from the periphery to center and they leave behind peripheral areas of emphysema that is what we are seeing peripherally there is emphysema and there is parahylar these conglomerate opacities and there is no induced diffusely and these conglomerate opacities are often said to have this lenticular shape paralleling the pleura all these are typical description of silicosis or coal workers pneumoconiosis with progressive massive fibrosis keep this picture in mind again can come as water or case okay silicosis with pmf what is this this is asbestosis basically silicosis and coal workers most of the occupation will be upper or predominant one of the occupation which is lower low predominant is asbestos so here you can see bilateral pleural plaques which are calcified so this was the last thing do you want to take it again what is in the lungs okay okay very good so lungs are showing ild which is like an nsip pattern so there is reticulations and ground glass with extreme subplural sparing and the esophagus is dilated so both those together is itself saying scleroderma but what is in the hand and we are saying across your eyes is acrostiolysis is there and cutaneous calcifications are there so all together is what yeah but any syndrome you are somebody saying [Music] uh that is one of the components what is the syndrome yeah who said why doctor weisha did you say yeah chris syndrome what is chris can you tell me can you tell me all the because it was crest program i wanted to put this as the last case yeah yeah calcium phenomena [Music] excellent okay i think we are done with all the spotters also thank you i don't know whether we exceeded time no no no no no no that is a fantastic question it is yeah especially the spots and then i think you handle the platform very well so that's another great thing yeah but thank you doctor dr vaishak and jessica you did well you did really well thank you i think you can introduce yourself are you online my name is jessica uh i'm a finally post graduate from moacc medical college call in duty and dr vaisha i am i mean final year i'm the restaurant i'm studying in government medical college okay nice to have you here very well done so i'll be just showing some cases for this and the first fight to dr jessica so is she still online yes ma'am so like um yeah so i'd be showing some questions like you know five spots to you and then to dr vaisha so unlike uh how dr aparna did like you know i'll be asking you questions then and there so be prepared for that so this would be a false key style so there are overlaps and it's just a recap for those who are online yeah jessica i think this is for you and that's a recap so the questions to you are what is your diagnosis and name the sign a wheel sign or left upper lip collapse yeah um [Music] love the shield sign okay and um so what does this word mean with the shell because we have been hearing it for quite a long time uh meaning an inverted squad sword okay and where do you see the signal over here um yeah so next slide please next slide next one so this is where you see the air sickle sign close to the arch of iota okay next slide please and so what is the diagnosis here soya james and here if you look at it uh closely what is your finding and then you can come to the diagnosis involving the right upper loop all right i'm sorry left upper loop sorry ma'am left upper loop yeah a left upper zone yeah uh causing uh mediastinal shift uh to the right side okay so i think you have picked up the findings so what is your diagnosis uh can be a large emphysematic bully or can okay so can you come up with a different kanjinitolobar emphysema okay so uh i know that you've said like it's a bully so clo and then what are the other differentials on it um in a child so i think you come up with the diagnosis it's actually clo so what are the common sites of cll the left upper lobe is our most common side and then followed by next next side middle opera right yes you're right right is the main complication that it causes whenever there is a congenital lobe or over inflation how does a child present with uh child presence with um breathing difficulties fine why why does it occur uh there is a media standard shift and compression of the trachea yeah it compresses the because when it is in the upper side like it compresses the rest of the lung and then it can cause symptoms so what is the cause of contamination as the name suggests it's congenital so it's because of some cartilage lacy or hyperplasia could be idiopathic as well so and what is the treatment that you offer for them low back to you yeah it's surgery and it's look at me i think like you know you know the answers so that you can come up with the answers fast this will so next slide please next slide and the next slide i think you have answered all the questions and then so this is case number three and so this is a 40 year old male patient with dysphagia so what is the diagnosis i think the next image also you can show that shows some zoomed images so maybe the next slide please yeah stop with that so so nsi nsip pattern with uh dilated esophagus so scleroderma yeah yeah you have seen one case so so can you just tell me the lung findings that can occur in scleroderma um interstitial lung disease yeah yeah the patterns uh nsip pattern yeah and then then it progresses to uh in a separate pattern of fibrosis yeah this uip pattern can have a uip pattern as well as an sip pattern so dr aparna has already told us about the other system involvement as well so can you name any other one plain radiographic finding which involves a musculoskeletal system osteoart acrolysis yeah and then can you tell me two findings in barium study of esophagus now that our patient presented with dysphagia um one is uh in barium you will have the high bound sign in uh the abdomen as well as on yeah i was asking about the findings in esophagus uh dilated acid figures yes yes and there'll be mortality disorder and there'll be widening of the g junction as well yes especially below the level of diabetic arch so next ah next slide please and then the next one so next one yeah next one next yeah and this is the case number four this is post-transplant scenario with this nia so [Music] you can just go through the images and tell me your findings as well as diagnosis when the next image because it shows some zoomed pictures yeah commonly occurs in a trans transplant scenario renal transplant pcp pneumonia yeah pneumocystis gene yeah you're right come up with that confidence so what type of an organism is it is it a fungus it is a viral is it a virus or is it a bacteria and what are the findings you get on it's a like fungus so what are the findings that you could get bilateral uh bilateral uh ground glassing uh as well as giving a crazy baby pattern also a perihelion is enough yes yes yes yes and and how do you treat it what is the drug of choice next slice please okay next slide please next slide please so those are the ct findings as jessica the slide before please just show me the slide before this niveda just show me the slide before this yeah so the ct finding says she had rightly enumerated that ground glass pattern then reticular opacity is plus septal thickening giving a crazy pattern and metal cells can occur also the treatment of this like trimethoprim sulphur methoxy combination and next slide please and this is the next slide please and this is the radiograph following uh treatment so there is clearance of the opacity so and case number five and jessica this is going to be a last case it's number five next slide please now that we have seen everything like this is a 21 year old male uh who is instantly detected to have this on routine health check so can you name the relevant radiological sign that will help in the diagnosis and this is for the benefit of all that in these yeah this question was given to the case was given to actually so i thought i'll guess you so why do you say so i was just asking about the relevant radiological sign that would help in diagnosis so uh the hilar mobility sign yeah so how does it help you here no it is really saying can you just describe the sign for the benefit of the others i think some network issues [Music] this has been described in detail so the fill out the seal out sign also helps us helps us in disregard so actually this is a posterior mediastinal mass this is a proven ganglion neuroma and you can also see the widening of the neural foramen with erosion so our next slide please next slide next one next one i think jessica you are back 23 year old male patient who presented with recurrent episodes of knees so what is your diagnosis under [Music] cystic bronchitis yes just describe all the findings because dr parana uh cystic bronchi this is mucus plug yeah what do you call the nucleus what is it uh fingers yeah finger in glow and then how does it appear on um ct plane ct this is plane cp so what do you call it um mucous plugs uh yeah yeah yeah yeah can you uh can you uh let's describe it uh in a bit more detailed manner so this is called the high attenuation mucous this is bilateral bronchitis next image please and my next image please stop anywhere next image next one next one next one and yeah so ah you can just go back can you just go back yeah so i think that is a high attenuation central bronchitis involving the segmental and sub segmental bronchi and you can also see maker impaction name bronchocell so this is referred to as a finger in globe sign and you can also see the high attenuation mucous synthesis because the presence of calcium salts and metals ions of iron and manganese like thin fungal hypha next slide please next slide please so this allergic bronchopulmonary aspergillosis occurred due to hypersensitivity to fungal antigen next slightly so and initially it would appear with fleeting opacities uh then it can the disease can remit the disease can reappear and then can finally cause fixed pulmonary opacities and leads on pain stage lung disease so early diagnosis would hold the development of chronic diseases and in stage five process okay next slide please next slide so why shack because he's completely gone offline so this is also to you nivedida so this is another post plainer transplant so i chose two scenarios one for you and the other for vaisha so let's is presented with breathlessness and fever and haemophilus is again post renal transplant scenario next slide next slide so can you describe the findings and give your diagnosis as well as the um media still window which shows radio pct with yeah involving um that is um radiating plural attacks radiating to the pleura there is linear radio obesity described well so what is your diagnosis lung mass invasive aspergillosis [Music] like how does it look like no there is no yeah but it is not a cavitation so most likely a lung must uh like a next slide please next slide please negotia yeah this is typical of much okay so this is the typical reverse halo sign or the tool sign so ah and and the micro is one of the most common cause of reverse hallucin in an immunocompromised hospice so what you see here is a central lucency and then you can see a render soft tissue in the periphery very much resembling a burstness so it is called the bird's nest sign a troll sign and this is very classic of mucur and on the contrary what you have said is an aspergillosis so it's very difficult to differentiate that but in invasive energy invasive aspergillus what you see is ground glass infiltrates the periphery of condition denoting and invasion so there are so there are so much of overlaps between the imaging findings but then whenever there is sinusitis or another patient is on work on a prophylaxis developing fungal infection you have to think about next slide please next slide so niveda can you just identify the there are so many tubes in situ i have shown arrows at two areas so can you tell me the procedure and can you tell me the device where i have put the arrows so can you tell me what procedure the patient is undergoing can you tell me something about the tubes [Music] so actually this is a case of covich pneumonia with the diffuse alveolar damage so [Music] asking you about it so you can see a tube tube here and then yeah almost in the position of a center line and then you can see another uh one here so this is uh uh go with the pneumonia with the diffuse alveolar damage so this patient is also more circuit okay this patient is more circuit so you do it for um for us uh cardiopulmonary bypass technique and then there are two axis paths and you know arterial and we know venus so what i have shown here is aveeno venus so where you have two cathedrals like you can see one above and one below so one is to take blood out the below one is to take blood out and other it gets oxygenated and then the top one where you see it um at the place at the junction of svc and array is actually the uh inflow catheter so this is how ecmo is done so i just wanted to make you familiar with the present event so that's why i put it as a slide and next slide please next slide slide next slide next one next one so this is number nine and this is just a spot so can you tell me what it is name the sign and the cause so this is a classic focal hotspot sign so this is because of auto systemic venus chanting so liver you can see a focal area of enhancement in the periphery and this is because of superior vena caval obstruction have also the initial images what you can see is the lung mass which is seen around infiltrating the superior vena cava causing superior vena cava obstruction so in a success scenario you may find the hot spot sign is due to photosystemic venus shanti and the last case so uh pressure this is going to be the last case for you so so we have described it after a number of times today but still this is a 56 year old lady with shortness of breath so what do you see here next next slide please speak loudly and what do you see here what is the cause of lower low collapse yeah so what could it be [Music] collapse second due to any bronchogenic malignancy yeah um i think this is can you see something protecting into the bronchus yes one endogenous lesion is there it is not yeah yeah can you name one common ender bronchial lesion carcinoid is one thing can also be benign cases [Music] benign lesions but uh carcinoid is also uh most common thing yeah yeah i think you have to say like if you're seeing an endo bronchi lesion especially this if it is enhancing you have to say that it's a carcinoid so and the other central lesions if you are asked about i think uh you have to um say that the common are the central lesions malignant ones are redundant so the last question for the session is what is deep neck and we are stopping with that next slide please uh what is deep net so it stands for diffuse idiopathic pulmonary neuroendocrine cell hyperplasia where you can see small nodules scattered in the lung parenchyma especially when there is a setting of carcinoid tumor so i think i will stop really wonderful kara okay i think we can end the session yeah yeah yeah yeah so i take this opportunity to thank all who have attended this handmade is even possible special thanks to dr aparna i think she has already left so who found her time and mr decision to come over here and this was very useful session to that in this and the pds i also thank the periods we have all endeared for the session and their big thanks thank you to the organizers dr gomez without whom support this wouldn't have been materialized and also i thank them associates and for all the support given so that the program could happen and i also thank all the residents and the radiologists who have attended the session so i think i can declare can i declare the session close thank you thank you sir we are closing the session and thank you you

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Dr. Murtuza Zozwala & 906 others

SPEAKERS

dr. Aparna Irodi

Dr. Aparna Irodi

Professor, Department of Radiology, CMC Vellore | General Secretary, Society for Chest Imaging and Intervention (SCII)

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dr. Aparna Irodi

Dr. Aparna Irodi

Professor, Department of Radiology, CMC Vello...

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