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Ideberg classification of intraarticular glenoid fractures

Kuhn classification of acromion fractures

Thompson classification of scapula fractures

Zdravkovic and Damholt classification of scapula fractures

Classification of acromioclavicular joint injury

Neer classification of distal clavicle fractures

Allman classification of clavicle fractures

Foreign body

Foreign body

Grading of muscle injuries

Delayed onset muscle soreness

Delayed onset muscle soreness (DOMS)

MR grading of muscle injury

Non accidental trauma / child abuse

Common sites of fracture

Mondor disease

Superficial thrombophlebitis Just under the skin Clinically visible Should distinguish from dilated ducts with intraduct content Vein cannot be compressed due to thrombosis Often not detected on mammogram

Sternalis muscle

Rare variant Triangular or round in shape Seen medially adjacent to sternum Look for it in the CC view of mammogram Knowledge of this is imperative to rule out a mass

Poland syndrome

Varying degress of hypoplasia or even absence of Costosternal component of pectoralis major Serratus anterior External oblique Costal cartilages May be associated with syndactyly, other upper limb deformities Ipsilateral breast maybe hypoplastic or absent

Polythelia, polymastia

Polythelia: accessory nipples Polymastia: accessory breasts

Levels of axillary lymph nodes

Level I Inferior and lateral to pectoralis minor Level II Rotter nodes – beneath pectoralis minor Level III Superior to pectoralis minor Level I and II usually removed in full dissection

Paget disease of the nipple

Carcinoma in situ from nipple epidermis Nipple areola thickening and retraction No obvious findings in ultrasound Abnormal nipple enhancement in post Gd MRI

Ductal carcinoma in situ

Malignancy from epithelial cells of terminal duct lobular unit No basement membrane invasion Calcification is the most common finding – fine linear or branching, tend to be a cluster seen accompanying dilated ducts which have indistinct walls. Associated mass suggests invasion

Phyllodes tumor

Can be benign or malignant Arises from periductal stroma The papillary growth pattern is the origin of the name ‘Phyllodes’ (leaf-like in Greek) Large rapidly growing without calcifications. Calcifications when present (rare) are large and chunky Difficult do distinguish from a highly cellular fibroadenoma The clefts in the papillary growth appear as cystic spaces onContinue reading “Phyllodes tumor”

Fibromatosis of breast

Aggressive growth of fibroblasts and myofibroblasts Arises typically from pectoralis fascia Hence the mass is often seen closely related to pectoralis major Large spiculated dense lesion Hypoechoic on ultrasound, hypointense on MR sequences with variable enhancement post contrast MRI best for delineating extent prior to excision

Pseudoangiomatous stromal hyperplasia (PASH)

Benign lesion Myofibroblastic hyperplasia Round or oval shaped 5-10 cm sized well defined lesion Very slow growing No typical echogenicity or enhancement patterns Core biopsy diagnostic

Papilloma breast

Benign proliferation of duct epithelial and myoepithelial cells 70% lesions central, involves main ducts in subareolar region 30% occurs in peripheral breast, in terminal duct lobular units Lesion is occult usually in mammography Ultrasound and galactography are high yielding Use generous gel, roll nipple to the side, and use an angled view to evade theContinue reading “Papilloma breast”

Fibrocystic change of breast

A mixture of cysts, fibrosis and adenosis Diffuse involvement of both breasts Scattered calcifications, varying densities of glandularity, temporally changing cysts Cysts can be macro, cluster of micro, regional or diffuse This condition make it harder to detect any new onset malignancy and these patients should be monitored more closely

Fibroadenoma breast

Most common benign tumor Adult and juvenile form Contains stromal and epithelial element Well circumscribed, oval  lesions with edge shadowing, posterior enhancement on ultrasound, wide than tall. Hypermobile under the ultrasound probe Isointense to breast in T2 and can be seen to rapidly enhance post i.v. contrast administration Calcifications are commonly seen, causing edge shadowingContinue reading “Fibroadenoma breast”

Fibroadenolipoma breast

Breast-within-breast Pseudoencapsulated lesion containing varying levels of glandularity and fat Benign Can occur at any site in breast or in ectopic breast

Diffuse calcifications in breast

Random distribution of calcifications in both breasts Often benign Differentials Adenosis: premenopausal Sclerosing adenosis: postmenopausal Fibrocystic disease Skin calcifications Very rarely extensive DCIS

Vascular calcifications

Benign Atherosclerotic changes in intima media Serpiginous, linear and plaque type Sometimes dot-dash appearance Snake-skin, patchy marble appearance

Secretory calcifications in breast

Duct ectasia with secretory deposits Benign calcifications Large rod shaped / cigar shaped Show a ductal pattern radiating from nipple 3-10 mm long Tends to be bilateral and extensive

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Oil Cyst

Liquefied fat Can be seen in any part of breast Most common in subareolar region Range from few mm to cm in size Mammography Oval to round lucent smooth border lesion Develops rim calcification over time Calcification can be rim, egg-shell or coarse In early stages, same as surrounding fat and difficult to detect UltrasoundContinue reading “Oil Cyst”

Well Defined Margins

A descriptor terminology used in lesion characterization in imaging When at least 75% of the margins can be clearly distinguished from surrounding tissue

MRI – The Reporting Room

Ultrasound – The Reporting Room

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Precession

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Net magnetization vector

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MR active nucleus

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PD weighted imaging

Manipulating TR and TE helps us to weight the contrast of the image to a certain parameter while diminishing the impact of other parameters In PD weighting, the intrinsic contrast of tissues is accentuated. This is done by reducing the T1 and T2 effects on imaging A long TR reduces T1 effects, a short TEContinue reading “PD weighted imaging”

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T2 weighting

Manipulating TR and TE helps us to weight the contrast of the image to a certain parameter while diminishing the impact of other parameters In T2 weighting, the T2 relaxation time of tissues is accentuated and the T1 effects decreased How we achieve this is by using a long TE – which allows both fatContinue reading “T2 weighting”

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T1 weighted imaging

Manipulating TR and TE helps us to weight the contrast of the image to a certain parameter while diminishing the impact of other parameters In T1 weighting, the T1 relaxation time of tissues is accentuated and the T2 effects decreased How we achieve this is by using a short TR – which prevents fat orContinue reading “T1 weighted imaging”

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T2 decay

Decay of NMV in the transverse plane in an exponential manner Occurs due to spin-spin interactions The intrinsic magnetic fields of nuclei causes loss of coherence, resulting in dephasing It is intrinsic to tissue Time taken for 63% of the transverse magnetization to be lost due to dephasing This dephasing occurs during TE – theContinue reading “T2 decay”

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T1 recovery

Also known as spin lattice energy transfer It is the time taken to for the spins to dissipate energy so that they regain their longitudinal magnetization It is an exponential process It is tissue specific Defined as time taken for 63% of the longitudinal magnetization to be recovered The time taken for this extends fromContinue reading “T1 recovery”

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Pulse sequence

Series of RF pulses, gradients and intervening time periods Time period determines image weighting Sequence is needed to produce signals sufficient enough to form an image Changing TE and TR enables forming different types of contrast Spins are rephased using 180 degree RF pulse – conventional spin echo, fast or turbo spin echo, inversion recovery,Continue reading “Pulse sequence”

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T1 recovery and T2 decay

T1 recovery Once RF is applied, spins move to high energy states. Once RF is removed, they transfer this energy to the lattice, called the spin lattice energy transfer. Slowly the spins magnetic moments move from high energy to low energy state NMV recovers and realigns to external field. This relaxation is called T1 recovery.Continue reading “T1 recovery and T2 decay”

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Free induction decay and T2* decay

Free induction decay Apply an RF pulse, achieve desired resonance and flip angle, then RF pulse is removed Signal induced in receiver coil begins to decrease in amplitude This signal decrease is due to Relaxation Field inhomogeneity and susceptibility T2* decay Dephasing due to spin-spin interactions and field inhomogeneities together

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Brownian motion, behavior of fat and water in mri

Brownian motion Each substance contains molecules that are constantly in motion This motion has rotational and transitional components The faster the motion within, the harder it is to release energy to its surroundings Behavior of fat and water in MRI Fat Molecules closely packed together Slow rate of molecular motion Low inherent energy, hence canContinue reading “Brownian motion, behavior of fat and water in mri”

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TR, TE and flip angle

Repetition time (TR) Time between one RF pulse to the next Measured in milliseconds (ms) Time to echo (TE) Time between RF excitation pulse and collection of signal Measured in milliseconds (ms) Flip angle Angle through which NMV moves due to an RF pulse

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Signal intensity in MRI

Depends on the magnitude of coherent transverse magnetization Larger the transverse magnetization, higher the signal intensity

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Contrast-to-noise ratio (cnr)

Difference in signal between two adjacent areas Larger the difference, better the CNR

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Resonance, radiofrequency pulse, receiver coil, free induction decay

When a frequency same as the object is applied, it goes through an energy transition. This is called resonance. This frequency applied is called a radiofrequency pulse (RF pulse) This is usually at 90 degrees to external magnetic field RF pulse is applied at the specific Larmor frequency of hydrogen, only hydrogen spins resonate WhenContinue reading “Resonance, radiofrequency pulse, receiver coil, free induction decay”

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Larmor frequency

Each MR active nucleus spins on its own axis When put in an external magnetic field, it develops a secondary spin. This is called precession Magnetic moments of the MR active nucleus follows a circular path around the external magnetic field The speed with which the moments spin around the magnetic field is called theContinue reading “Larmor frequency”

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Magnetic flux density

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Ferromagnetic substances

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Diamagnetic substances

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Precession

Each MR active nucleus spins on its own axis When put in an external magnetic field, it develops a secondary spin. This is called precession Magnetic moments of the MR active nucleus follows a circular path around the external magnetic field

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Net magnetization vector

Two theories – classical and quantum theory Classical theory Based on the direction of magnetic moments Parallel alignment: magnetic moments align parallel to external magnetic field Anti-parallel alignment: magnetic moment align opposite to external magnetic field At room temperature, more moments are aligned parallel and as a result, there is a net magnetization vector parallelContinue reading “Net magnetization vector”

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MR active nuclei

Nuclei having odd number of protons Have odd mass number Examples: hydrogen 1, carbon 13, nitrogen 15, oxygen 17, fluorine 19, sodium 23 Hydrogen 1, also known as protium is the active nuclei used in MRI. It’s mass and atomic number is 1.

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Motion in an atom

Electrons spinning on their own axis Electrons orbiting the nucleus Nucleons spinning in their own axes

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Ion and Ionization

Ion Atoms with deficit or excess number of electrons Ionization Process of removing electrons from an atom

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Stable atom

Number of negative charged electrons equals number of positively charged protons

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Isotope

Atoms of the same element but has different mass numbers

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Mass number

Sum of neutrons and protons in the nucleus of an atom

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Atomic number

Refers to number of protons in the nucleus

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Atom

Contains the following particles Protons: in the nucleus. Have positive charge Neutrons: in the nucleus. No charge Electrons: orbits the nucleus. Have negative charge

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Faraday’s law of induction

Change in magnetic flux inside a closed circuit induces and electromotive force This force is proportional to rate of change of magnetic field, area of circuit and number of turns in the coil of wire

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Paramagnetic substances

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Magnetic susceptibility

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Induced electric current

Magnetic fields can generate electric currents When a magnet is moved in and out of a circuit, an electric current is induced till the motion stops.

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Fleming’s right-hand rule

A moving charge or an electric current can generate a magnetic field Point your right thumb along the direction of the current, then the curled fingers will point to the direction of the magnetic field

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Magnetic flux density

Magnets have two poles: north and south The magnetic field produced by the magnet produces lines of force that runs from south pole to the north Number of these lines per unit area is called magnetic flux density

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Magnetic Flux

Magnets have two poles: north and south The magnetic field produced by the magnet produces lines of force that runs from south pole to the north

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Ferromagnetic substances

Have a strong net magnetic moment of their own When placed in an external magnetic field, they strongly align and strengthen the external field. Even when the external field is removed, they retain their magnetization Permanent magnets, example: Iron

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Diamagnetic substances

They have no net magnetic moment When placed in an external magnetic field, they generate a small magnetic moment that opposes the external field, show negative magnetic susceptibility Examples: water, inert gases

CT Scan – The Reporting Room

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Paramagnetic substances

Substances with unpaired electrons in the atom They generate a small magnetic field of their own When an external magnetic field is applied, the magnetic field of the substance aligns with the external field resulting in a local increase in the magnetic field Oxygen, ions of iron, magnesium, gadolinium

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Magnetic susceptibility

The configuration of electrons in an atom decides the impact an external magnetic field has on the nucleus of the atom With respect to MRI, based on the susceptibility, substances are classified as paramagnetic, diamagnetic or ferromagnetic

Radiographs – The Reporting Room

The Reporting Room

Here we look at cases as we do in clinical practice, providing minimal clinical information, doing a film reading in a normal reporting format, describing findings, coming to a conclusion, listing differentials and suggestive next steps in management. This is a roadmap to approaching films and can help inculcate a way of thinking to reachContinue reading “The Reporting Room”

NI-RADS ACR Neck Imaging Reporting and Data Systems

Lumbosacral transitional vertebra

Case report

Learn in 60 seconds

60 second videos on social media to learn something new in a short and sweet package.

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Basics of T1 and T2 weighted imaging

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Rotator cuff anatomy

Skyline view radiography of knee

Hydrops fetalis

Simple bone cyst

Non ossifying fibroma

Lumbarized S1 vertebra

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Single umbilical artery

Two vessel cord One umbilical artery and one umbilical vein In isolation, no adverse clinical outcome When accompanied by other anomalies, 50% chance for trisomy 13 and 18 IUGR in 15% cases Imaging Free loop of cord with 2 vessels 70% absent left umbilical artery Single umbilical artery is larger in size than 3 vesselContinue reading “Single umbilical artery”

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Shoulder radiography projections checklist

Shoulder survey Anteroposterior 15 degrees erect or supine Superoinferior (axial) Inferosuperior (axial) Anteroposterior outlet projection Lateral oblique outlet projection Shoulder joint trauma Anteroposterior erect Anteroposterior supine  Lateral oblique Y projection Recurrent dislocation  Anteroposterior (lateral humerus) Anteroposterior (oblique humerus) Anteroposterior (modified) – Stryker Inferosuperior  Calcified tendons  Anteroposterior  Anteroposterior with medial rotation of humerus Anteroposterior with lateralContinue reading “Shoulder radiography projections checklist”

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Typical lumbar vertebra

Primary sclerosing cholangitis

Post transplant renal artery stenosis

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Osteochondroma

Optic drusen

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Vein of Galen malformation

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Vein of Galen malformation

Aneurysmal dilatation of median prosencephalic vein of Markowski due to arteriovenous fistula that occurs in 6-11 weeks of gestation  30% of all pediatric vascular malformations M:F = 2:1 Most common extra cardiac cause of high output cardiac failure Presents with heart failure or hydrocephalus  Two types: choroidal and mural. Choroidal has feeders from pericallosal, choroidalContinue reading “Vein of Galen malformation”

Myxopapillary ependymoma

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