U of MN Answers
Glenn shunt: End-to-side shunt between distal end of RPA and SVC. Used for management of tricuspid atresia. Reserved for patients in which total correction is not possible.
Fontan procedure: Two parts of the procedure: 1) External conduit from RA to PA trunk and 2)Closure of ASD: floor constructed from flap of atrial wall and roof from a piece of prosthetic material. Used in patients with tricuspid atresia.
Blalock-Taussig shunt: end-to-side anastomosis between SCA to PA, performed ipsilateral to innominate artery/opposite to where the arch lies. The modified Blalock-Taussig shunt uses synthetic graft material such as Polytetrafluoroethylene or PTFE (also known as Gore-tex) for construction of the shunt, in an end-to-side anastomosis between SCA and ipsilateral branch of PA. Used in patients with tetralogy of Fallot or tricuspid atresia with pulmonic stenosis.
Rastelli procedure: External conduit (Dacron, also known as polyester) with porcine valve connecting RV to PA trunk. Used in Transposition of the great vessels.
Waterston-Cooley shunt: side-to-side anastomosis between ascending aorta and RPA. If done extrapericardially called Waterston, if done intrapericardially called Cooley. Used in tetralogy of Fallot. Not done anymore, because it is difficult to take down.
Pott shunt: side-to-side anastomosis between descending aorta and left LPA. Used in tetralogy of Fallot. Not done anymore because it is difficult to take down.
Both types of aneurysms can rupture (true aneurysms rarely or infrequently do so according to Dähnert) and lead into tamponade. It is more frequent in false aneurysms. False aneurysms can be the result of localized/contained rupture of a true aneurysms, as well as trauma, pericarditis and AMI.
Both types of aneurysms can calcify. Calcifications in a true aneurysms (rare according to Dähnert) are typically located in the anterolateral wall or near the apex whereas those in a false aneurysm are typically located along the posterior (inferior or diaphragmatic) or posterolateral wall.
Both types of aneurysms can occur in the inferior or inferoposterior wall according to Dähnert, although false aneurysms are more frequently located in the posterolateral or diaphragmatic wall of the LV.
Both can be surgically repaired (see attached references, from several papers).
I could not find an association between these 2 types of aneurysms and atherosclerotic disease (namely, aneurysms of other arteries, including AAA, thoracic and popliteal). But, looking at this question from a different perspective, atherosclerosis can cause myocardial infarction, which in turn can lead to formation of either true or false aneurysm in the heart.
In PV stenosis, PV pressures are higher than those in the RV (pressures in the LA should be normal).
In aortic coarctation, pressures in the LV are high (like in aortic stenosis, but pressures in the aorta are also high proximal to the area of coarctation (accounting for the elevated pressure peak in the aorta seen in the figure). Beyond the coarctation, pressure in the aorta is low (due to pressures being distributed into aortic arch branches and collateral formation).
E. In aortic stenosis there is a pressure gradient between a higher pressure in the LV and a lower pressure in the aorta distal to the stenotic valve.
Transposition of the great vessels is the most common cause of cyanosis and increased pulmonary blood flow in the newborn. It is the most common cause of cyanotic congenital heart disease with increased pulmonary blood flow. The most common overall causes of congenital heart disease with cyanosis are: Tetralogy of Fallot (especially true in the child (defined as age > 1 year) and then Transposition of the great vessels. However, tetralogy of Fallot and transposition of the great vessels account for 8% and 10% of congenital heart disease respectively.
GI bleeding scans need a rate of minimum 0.1 mL/min for detection (0.05 mL/min according to Dähnert) (compared to a minimum of 0.5 mL/min for angiography). Tagged red cell studies are more sensitive than sulfur colloid studies. Sulfur colloid has several disadvantages: Bleeding must be active at time of administration (with tagged cell study, bleeding may or may not be active, and allows detection over a long period of time), it is cleared very rapidly form blood by the RES (not allowing for imaging over a long period, although that is an advantage in the unstable patient in which rapid diagnosis is needed, since the whole study only takes 20 min versus 1h for tagged cell study), and it is not useful for upper GI bleeding (interference from high activity from liven and spleen) or bleeding near hepatic/splenic flexures of colon. Twenty four hour image in a tagged red cell study may be useful to see movement of tracer/change in appearance of tracer, consistent with bowel peristalsis. In fact, up to 33% of studies may become positive only after 12-24 h. Single best answer would be: To identify a GI bleed (the key word here is ACTIVE BLEEDING, which was not put in the distracter) the tracer must be seen in the bowel and move antegrade and/or retrograde with peristalsis. It is essential for diagnosis that the activity moves within bowel. Fixed activity is unlikely to represent active bleeding. (tracer accumulates with time, conforms to bowel anatomy and then moves). Tagged red cell studies are longer to prepare and perform, and have the potential for false positive results from 1)misinterpretation of normal variants or pitfalls 2) Free Tec 99m pertechnetate and 3) misinterpretation of delayed images.
The left gastroepiploic artery is a branch of the splenic artery.
Advantages of MRI: Allows imaging of entire aorta from the aortic valve to the aortic bifurcation (precise knowledge of extension of dissection) which is useful for surgical planning and for follow-up of stability Versus progression after either surgical or medical treatment; detects aortic valve regurgitation; allows evaluation of blood flow in the true and false channels; multiplanar capabilities. Comparing MRI, CT and TEE (transesophageal echo) for ascending aorta: sensitivities of 100%, 82.6% and 96.4%; and specificities of 98.6%, 100% and 85.7% respectively. Overall sensitivities and specificities:
MRI 98.3% 97.3%
TEE 97.7% 87.1%
CT 93.8% 76.9%
TTE (transthoracic echo) 59.3% 83%
The higher specificity of MRI compared for TEE (for the ascending aorta is important since the presence of involvement of the ascending aorta mandates for surgical management. MRI can be performed in the emergency setting, for patients requiring monitoring, or connected to a ventilator.
The false lumen can fill with contrast on a CT study, and this may be simultaneous with flow in the true lumen or delayed, depending on flow characteristics.
The internal carotid is involved more frequently than the external carotid, in fact, it is the most frequently affected vessel in the neck. (The order of involvement counting all arteries of the body is: renal artery by far the most common, internal carotid, external iliac). Involvement begins approximately 2 cm distal to the bulb in most cases, and rarely affects the bulb.
According to Osborne, the false lumen may rarely fill. In the overwhelming majority of cases, the dissection is seen angiographically as a narrowing of the true lumen, with no visualization of the false lumen nor of an intimal flap of dissection.
The string of beads is the most common angiographic sign of FMD, in cases of FMD of the media, which is the most common variety. The other Two varieties can also be seen (fibroplasia of the intima or of the adventitia, in which cases, isolated short narrowings or long smooth narrowings can be noted angiographically).
Again, according to Osborne, although rare, the intracranial vessels can be affected by FMD.
FMD is bilateral in 60-75%.
Stenting is the treatment of choice for dissection after PTCA. This is the single best answer. Conditions for stenting include a significant pressure gradient or flow-limiting dissection (flow is asymmetric, slower in relation to the uninvolved site). Not all dissections need to be stented, particularly small or nonflow limiting ones.
The size of the balloon is determined by the diameter of the adjacent noninvolved vessel, without correction for magnification on the films
Surgery has better long term patency results than percutaneous interventions for infrainguinal vessel disease, due mainly to the smaller size of these vessels. Stents can be done in these vessels, Mostly when patients are not good surgical candidates.
The risk of rupture of this size aneurysm is 75%. The survival rate on the other hand is only 6% (deaths due to rupture or other cardiovascular events).
The renal arteries can be revascularized at the time of aneurysm repair. Technically, this is more demanding, but nonetheless can be done.
This, according to Rutherford, in a series of 450 autopsy cases. In this series, the major vessel branches least affected were in order inferior mesenteric artery, right subclavian artery and celiac artery. The most affected branches were in order right common iliac, left common iliac, left common carotid, left subclavian and left coronary (same incidence for these 2 latter vessels), left renal, right renal.
This is probably the best answer. Again, as for question 25, stenting is indicated for failures of PTA, namely: flow limiting dissections, long dissections, dissections with significant pressure gradients.
This is probably the best answer. If the patient is a good surgical candidate, surgery should be performed for failure of PTA in the popliteal artery. If the patient is not a surgical candidate, then most anything can be done, including stenting. Also, we have to remember that percutaneous interventions do not preclude future surgery, and can be repeated after they fail.
Similar to 26F.
39. True. It means dissection, PSA formation or acute thrombosis at the treated site.
(25/10 mean 15, according to Amplatz and Moller Radiology of Congenital Heart Disease 1992, 12 ± 2 in adults according to Jay H. Stein Internal Medicine, and 15-30/4-12 with a mean of 9-18 according to Harrison’s Principles of Internal Medicine 13th edition 1994.
A wave 8 ± 3, v wave 8 ± 3 and mean 7 ± 2 in adults, according to Stein. a wave 3-15, v wave 3-15 and mean of 2-10 according to Harrison’s.
AAA are more common in white males.
It depends on the range of size of the AAA. 5-6 cm 25%, 6-7 cm 35%, 7.1 cm 75%. This according to Rutherford.
"The blood pool has a homogeneous high-signal intensity throughout most of the cardiac cycle on cine-MR. Regurgitation through either the atrioventricular or semilunar valves is associated with a high velocity jet which causes a signal void within the otherwise high-signal-intensity chamber."
"The blood pool is generally a signal void (spin echo), which provides high contrast between blood and the myocardial wall. When the evaluation of cardiac structure is desired, the ECG gated spin-echo technique, which provides static images with high signal-to-noise ratios, is used. When the primary goal is to assess cardiac contractile function, cine-MR (gradient echo) is used."
49. Priscoline (tolazoline): "Alpha-2 selective antagonist... Tolazoline is similar to phentolamine... Phentolamine causes a reduction in peripheral resistance through both alpha-receptor blockade and an additional nonadrenergic action on vascular smooth muscle."
Ergotamine: "The action of ergot alkaloids on vascular smooth muscle is drug-, species-, and vessel-dependent, so few generalizations are useful. Ergotamine constricts most human blood vessels in a predictable, prolonged, and profound manner."
50. Vasopressin: "Mode of Action: Causes smooth-muscle contraction in the gastrointestinal tract and vascular bed (capillaries, small arterioles, vessels). Short-acting, rapid response. Indications: Intra-arterial infusion for the control of GI bleeding. Decreases flow in mesenteric, gastric, and splenic arteries, but increases flow in the hepatic arteries. Dosage: Infuse with a constant arterial infusion pump at an initial rate of 60 ml/hr (0.2 units/min) for 20-30 minutes. If bleeding continues with the initial rate of infusion, double the infusion rate to 0.4 units/min and infuse for another 20-30 minutes. If bleeding is not controlled, increasing the dose rate is not beneficial and alternative methods should be considered..."
Nitroglycerine: "Mode of Action: Relaxes smooth muscle; a short-acting vasodilator. Indications: Vasodilator during PTCA to prevent or treat vasospasm caused by catheter wire manipulation. Dosage: During angioplasty, 100-200 micrograms (bolus directly into artery that is to undergo angioplasty..."
"A few imperfect valves are found in the azygous vein, but its tributaries are provided with complete valves."
(assuming this means coronary sinus). "It (the coronary sinus) ends in the right atrium between the opening of the IVC and the right atrioventricular orifice, its opening displaying a semilunar flap, the valve of the coronary sinus."
"Both sets (the deep and superficial veins of the upper extremity) are provided with valves, which are more numerous in the deep than in the superficial system."
(No formally named vein, but likely refers to the pampiniform plexus and testicular veins.) False. "The testicular vein and the pampiniform plexus are devoid of valves except for an occasional one at their termination in the IVC or the left renal vein."
"Location of dissection (following helical flow pattern):
- on anterior + right lateral wall of ascending aorta just distal to aortic valve (65%).
- on superior + posterior wall of transverse arch (10%).
- on posterior + left lateral wall of upper descending aorta distal to left subclavian artery (20%).
- more distal aorta (5%) usually terminating in left iliac artery (80%) right iliac artery (10%) (involvement of left renal artery in 50%).
1) Retrograde dissection
a) aortic valve malfunction
b) occlusion of coronary artery (8%)
c) rupture into pericardial sac/pleural space: 70% mortality
d) rupture into RV, LA, vena cava, pulmonary artery producing large L-to-R shunt
2) Occlusion/transient obstruction of major aortic branches (30%)
3) Rupture of aorta
4) Development of saccular aneurysm requiring surgery (15%)
"... rim of calcium in fibrotic wall (chronic) rare..."
"Location: a) left anterior + anteroapical: readily detected (anterior + LAO views); b) inferior + inferoposterior: less readily detected (steep LAO + LPO views)."
"...Prognosis: rarely ruptures..." (Need to distinguish true aneurysm from false aneurysm. The false aneurysms have a high risk of delayed rupture, which is infrequent in true aneurysms.)
Sensitivity: Not found; Specificity: 67%.
"Extent of injury:
1) Complete tear (85%) with exsanguination before reaching a hospital
2) Incomplete rupture (15%)
a) transverse intimal tear
b) tear of intima + media with subadventitial accumulation of blood (40%) = false aneurysm
c) aorta goes on to rupture completely within 24 hours in 50% of patients.
Earliest and most specific signs:
- deviation of nasogastric tube to right of spinous process at T4 (67%)
Likely not sensitive as 28% of patients have a normal admission CXR (radiographic signs may not develop until 6-36 hours). Remember, there are no plain CXR findings of aortic injury (since aortic integrity is maintained by intact adventitia)! The source of mediastinal bleeding are the azygous, hemiazygous, paraspinal, and intercostal vessels!"
"The most common and almost universal finding is small, 1-5 mm nodules, usually with irregular margins."
"There are areas of low attenuation with ill-defined margins. However, when areas become 1-2 cm in diameter, it is not unusual for part of their border to become well defined. Other signs of emphysema include bullae, pruning and attenuation of vessels, and vascular distortion. It may be possible, especially when HRCT is used in patients with mild or mild-to-moderate disease, to distinguish among the various types of emphysema."
"The principal findings are cysts and nodules, often in combination, giving a characteristic appearance. When only one type of lesion is present, it is more commonly cyst than nodule... Walls are usually hairline, although in a few patients they are several millimeters thick."
Decreases alveolar wall tension.
Produced by Type II pneumocytes.
Used to treat meconium aspiration; "Oxygen, antibiotics, ECMO, liquid ventilation."
Guess; couldn't find.
Produced by Type II pneumocytes.
"Respiratory Distress Syndrome, a distinct pathologic entity, is due to a deficiency of pulmonary surfactant. Surfactant is a phospholipid complex synthesized by the Type II pneumocyte, which coats the alveolar lining cells and prevents atelectasis by lowering surface tension in alveoli."
66. FVC = FVC = (Forced) Vital Capacity
67. TLV = Total lung volume
68. ERV = Expiratory Reserve Volume
69. TV = Tidal Volume
70. RV = Residual Volume
71. FRC = Functional Residual Capacity
72. TLC = Total Lung Capacity
73. IC = Inspiratory Capacity
74. EC = Expiratory Capacity (not a usually defined volume)
A. False. "Patients with P. carinii or CMV pneumonia are usually chronically ill. The early radiographic findings are central interstitial infiltrates; this pattern may rapidly evolve into confluent airspace disease."
B. False. "... primarily extranodal, ... solitary/multiple well defined pulmonary nodules often coexistent with pleural effusion +/- axillary / supraclavicular / cervical / hilar adenopathy, ... alveolar infiltrates, paraspinal masses...."
C. True. "LIP usually has an insidious clinical onset with only mild cough and dyspnea; radiographically there are diffuse reticulonodular densities."
D. False. "... adenopathy, pulmonary infiltrates, nodules, miliary disease..."
"Kaposi's sarcoma in the lungs often leads to extensive interstitial disease with severe impairment of diffusing capacity and may result in massive pulmonary hemorrhage. Pulmonary Kaposi's sarcoma must be differentiated from P. carinii pneumonia, since both can present with fever and interstitial patterns on CXR. Pleural effusions and bilateral lower lobe infiltrates are much more common in Kaposi's sarcoma."
"Kaposi's sarcoma, however, is the most common malignancy in AIDS patients, and cutaneous Kaposi's sarcoma is frequently the initial manifestation of the disease."
"It appears that pulmonary Kaposi's sarcoma is rare in the absence of cutaneous involvement."
A. True. "Regional lymphadenopathy (axillary, head and neck, inguinal) is the predominant clinical feature of CSD; affected nodes are often tender and occasionally suppurate. Between 25% and 60% of patients report a primary cutaneous inoculation lesion (0.5- to 1-cm papule or pustule) at the site of a cat scratch or bite. The skin lesions typically develop 3 to 10 days after injury and precede the onset of lymphadenopathy by 1 to 2 weeks. Low-grade fever and malaise accompany lymphadenopathy in up to 50% of patients; headache, anorexia, weight loss, nausea and vomiting, sore throat, and splenomegaly may develop. In addition, short-lived, non-specific maculopapular eruptions, erythema nodosum, figurate etythemas, and thrombocytopenia purpura have been observed... Unusual manifestations of CSD, which occur in up to 14% of patients, include Perinaud's oculoglanular syndrome (6%), encephalopathy (2%), hepatic granulomas (0.3%), osteomyelitis (0.3%), and pulmonary disease (0.2%)... The story of CSD took a significantly divergent path with the recognition that opportunistic infections were an important consideration for patients infected with human immunodeficiency virus (HIV). Bacillary angiomatosis (BA), a newly recognized disease characterized by cutaneous and subcutaneous vascular lesions containing bacillary organisms visualized by Warthin-Starry silver staining, was described predominantly among HIV-infected patients; however, bacterial isolates were not made or identified... Because silver staining and electron microscopy of both BA and CSD tissue sections revealed bacillary organisms indistinguishable from one another, several authors suggested that BA might represent disseminated CSD in the immunocompromised host. In addition, several anecdotal reports of BA described a history of cat contact preceding the onset of disease."
B. False. "The skin lesions of Kaposi's sarcoma... ultimately evolve into nodules. Oral mucous membranes are also involved frequently as are the lower extremities, particularly the soles of the feet... Although any organ system can be involved in the disseminated form of Kaposi's sarcoma, lymph nodes, gastrointestinal tract, and the lungs are most commonly involved."
C. True. "Mild, self-limited infections may come to medical attention because of case clusters or hypersensitivity reactions: erythema nodosum, erythema multiforme, toxic erythema, ... Reactivation with dissemination in later years occurs occasionally, especially if Hodgkin's disease, non-Hodgkin's lymphoma, renal transplantation, AIDS, or other immunosuppression has supervened... With time, lesions appear in the bone, skin, SQ tissues, meninges, joints, and other sites."
"Pulmonary edema may be seen during or immediately following treatment of acute upper airway obstruction. The proposed mechanism involves the creation of markedly negative intrathoracic pressure by attempts to inspire against an extrathoracic airway obstruction, producing transudation of fluid into the lung. There are no distinguishing radiographic features."
Right atrium (RA)
A. Mean pressure 0-8 mm Hg.
B. Waveform analysis:
1. A wave - RA contraction.
2. X descent - RA relaxation and downward movement of AV junction.
3. C wave - upward movement of the tricuspid valve (TV) toward RA during ventricular systole - not always present.
4. V wave - passive venous filling of RA during RV systole while TV is closed.
5. Y descent - Rapid RA emptying following opening of TV.
Right Ventricle (RV)
A. Pressure 15-30 / 0-8 mm Hg.
B. Waveform analysis:
1. Isovolumetric contraction.
3. Isovolumetric relaxation.
4. Rapid ventricular filling.
5. Reduced ventricular filling/diastasis
Pulmonary Artery Pressure (PAP)
A. Pressure 15-30 / 4-12 mm Hg, mean 9-18 mm Hg.
B. Waveform analysis:
Pulmonary Capillary Wedge Pressure (PCWP)
A. Mean pressure 2-10 mm Hg.
B. Waveform analysis:
1. A wave - LA contraction.
2. X descent - LA relaxation and downward movement of AV junction.
3. C wave - upward movement of the mitral valve (MV) toward LA at the onset of LV systole - not always present.
4. V wave - passive venous filling of LA during LV systole while MV is closed.
5. Y descent - Rapid LA emptying following opening of MV."
"Functional renal impairment is unusual at the time of diagnosis, occurring in only about 10% of patients... A majority (85%) develop renal disease..."
"The mean age at presentation is in the 5th decade, with a wide range: 8 to 75 in one series."
"Upper airway involvement, with sinusitis, rhinitis, and otitis is the most common clinical feature at presentation, encountered twice as often as lung and systemic symptoms."
"Cavitation of the nodules and consolidations are seen in approximately 40% of the cases at initial examination."
Asbestosis presents usually with lower lobe disease. GG density, interstitial thickening by both CT, HRCT, and plain film begin in peripheral, particularly lower lobe, in the lung.
Lymphangioleiomyomatosis is most similar radiographically to Eosinophilic Granuloma. Fine reticular, nodular or reticulonodular opacities initially, often symmetric, either generalized or basally predominant, then progressing to a coarse, irregular pattern. Cysts, bullae, and honeycombing then follow with concomitant increase in lung volumes. HRCT shows multiple thin-walled cysts uniformly distributed in otherwise normal lung. Also, female patients, young, frequent PTX.
Ground glass is parenchymal
Kerley A lines radiate from hila to deep central portions of the lung.
Kerley B lines are interlobular septae perpendicular to pleura, peripherally.
Visceral pleural thickening is peripheral.
Peribronchial thickening is described as intraparenchymal.
AP film 150 -- poor visualization of basal disease. Arch poorly defined. Apparent superior mediastinal widening, left heart border indistinct, left hilum projected caudally hidden by heart.
Cirrhosis, nephrotic syndrome and CHF are common causes of transudates.
Residual volume is left over after forced expiration. FRC is the lung volume remaining after normal expiration. FRC-RV = expiratory reserve volume. VC is the volume between a maximum inspiration and maximum expiration or IRV + TV + ERV.
Bleomycin toxicity is augmented by oxygen toxicity.
Bleomycin toxicity is augmented by rad tx.
Type II regenerate.
113. Silicosis is in the upper lungs. Micronodules in the upper two-thirds of the lungs progressing to progressive massive fibrosis.
114. Centrilobular emphysema (a.k.a. centriacinar) is selective dilatation of central elements of the acinus in the upper zones and lower lungs.
Asbestosis is lower lung predominance.
IPF predominates in lower lung zones.
115. Sarcoidosis is usually reticulonodular (75-90%) or alveolar (10-20%) opacities in the middle or middle/upper zone predominance.
Pneumococcus pneumonia is likely in sickle cell and post-splenectomy.
Silicosis is a factor in reactivation tuberculosis.
Mycetoma formation is a common complication of sarcoid. Sarcoid is the second-most common predisposing condition to mycetoma following TB.
Pseudomonas infections (and Staph Aureus) are common problems in cystic fibrosis.
CF is not associated with reflux.
CF is associated with intussusceptions. Yes, rectal prolapse, meconium ileus and equivalent, thickened folds and small colons.
If meconium ileus/equivalent is mechanical.
Alpha-1 antitrypsin is a cause of pan-acinar emphysema leading to increased lung compliance.
Mirizzi's syndrome is characterized by cystic duct/GB neck stone with erosion into CHD with proximal ductal dilatation. CBD is normal. May also be caused by carcinoma.
Kawasaki's disease is characterized by fever, rash, node swelling in neck, and red lips/oral mucosa. Complications include GB hydrops and arterial aneurysms (esp. coronary).
Adenomyomatosis is characterized by mucosal wall hypertrophy and thickening, and intramural diverticula (Rokitansky-Aschof sinuses). May be diffuse.
The triad is Conn's syndrome of hyperaldosteronism. The most common cause in adults is a hyperfunctioning adrenal adenoma; in children, adrenal hyperplasia.
C (and B).
Early LGV (caused by chlamydia) shows edema, granular mucosa and limited distensibility of the rectum. Chronic LGV can show sinuses and fistulae.
D (and C).
An ulcerative disease of the colon (right > left) toxic megacolon is listed as a complication in Dahnert. Granular mucosa can be seen.
Bechet's disease is characterized by aphthous ulcers in the oral mucosa and ring ulcers in colon and TI. Shares some features with Crohn's.
Uncinate process passes between aorta and SMV along with third duodenum and left renal vein.
The caudate lobe is located medial and superior to the MPV.
The right renal artery is behind the IVC.
A. Hematomas were the most common major complication of adrenal biopsies in one series. Other complications include PTX and pancreatitis.
Falciform ligament divides left medial and lateral segment.
Right hepatic vein divides right anterior and posterior segments.
Middle hepatic vein divides right and left lobes of the liver.
The ligamentum teres is the remnant of the fetal umbilical vein, and continues from the free end of the falciform ligament to the umbilicus.
In the acute pancreatitis setting, a phlegmon (acute fluid collection of enzyme-rich pancreatic fluid) may occur in up to 40% of patients. Of these, 50% should resolve spontaneously; the rest can develop into pseudocysts (encapsulated collection of fluid). Of these pseudocysts, 50% resolve spontaneously, 20% are stable, and 30% may cause other complications. Pseudocysts < 5 cm should be monitored rather than aspirated due to the spontaneous resolution rate. Also, aspiration risks superinfection - 10% of cases. Pseudocysts > 5 cm are good candidates for drainage, with 90% success rate.
Ranson's criteria is a group of findings that serve as a scoring system to predict the morbidity and mortality of an acute pancreatic attack. The system is about 80% accurate in predicting a severe from a mild course. Three or more positive criteria predict a complicated course (severe pancreatitis); mortality rises when score is 4 or greater.
On Admission Within 48 Hours
Age > 55
Hemocrit down > 10%
WBC > 16K
BUN rise > 5 mg/dl
Glucose > 200 mg/dl
Calcium > 8 mg/dl
LDH > 350 IU/L
Art PO2 < 60 mm Hg
AST > 250 IU/L
Base deficit > 4 mEq/L
Fluid deficit > 6 L
APACHE II criteria (not listed here) Consider > 8 severe pancreatitis.
141. True. Non-enhancing parenchyma during bolus injection = pancreatic necrosis. Twenty-nine percent of acute pancreatitis shows no change in size/appearance. Accuracy of detection for pancreatic necrosis 80-90%.
142. True. In acute pancreatitis, the pancreas can become edematous. The common bile duct can be compressed and narrowed, leading to common bile duct stricture.
A) Whipple disease: intestinal lipodystrophy - systemic multifocal disease ? s/p infection with bacterium. M 9:1 F, 40s, Caucasian - migratory arthralgias/non-deforming arthritis, malabsorption, steatorrhea, abdominal pain, fever and lymphadenopathy.
B) Jejunal adenocarcinoma - Adenocarcinoma accounts for 25% of the small bowel malignancies (carcinoid is about 50%; lymphoma about 20%; Leiomyosarcoma about 10%). Ileum is most commonly involved (41%), followed by jejunum (36%), then duodenum (18%). Eighty percent have pain due to intermittent obstruction, 50% have a palpable mass, and 50% have GI blood loss. Intussusception is possible, but likely to be transient. Plus, growing Ca would create other obstructive problems.
C) Pancreatitis - Mild pancreatitis presents with pain, vomiting and tenderness. Intravascular volume depletion can exceed 30% due to peripancreatic fluid sequestering and vomiting. Volume depletion can cause a host of more severe symptoms. Severe, acute pancreatitis is manifested by more dramatic symptoms and signs, including hypovolemic shock, renal failure, pulmonary insufficiency, and ARDS, sepsis, GI hemorrhage, flank ecchymosis (Grey-Turner sign), and periumbilical ecchymosis (Cullen sign). Patients do not present with diarrhea or intussusception.
D. Sprue - The classic disease of malabsorption, patient gets villous atrophy and elongation of the crypts of Lieberkuhn. Disease divides into two categories: tropical and nontropical. Tropical sprue is thought to be a bacterial infection that can affect any age group. Found in India, the Far East and Puerto Rico, it presents with hepatosplenomegaly and glossitis. This can be cured with folic acid and antibiotics. Nontropical sprue (or celiac disease, or Gluten-sensitive enteropathy) is characterized by malabsorption resulting from atrophy of intestinal villi. It may be hereditary, detected in 15% of first-degree relatives. Small bowel dilatation is the hallmark of the disease. Patients get hypersecretion-related findings on SBFT exams, including flocculation and moulage sign. There is "jejunization" (increased v. conniventes folds) of ileal loops which is a reactive response to the decreased jejunal mucosal surface - this is a specific sign. Twenty percent of patients get transient, nonobstructive intussusception without anatomic lead point. Diarrhea and steatorrhea is "classic", but found in a minority of patients.
All choices are various pancreatic islet cell tumors derived from APUD (amine precursor uptake and decarboxylation) cell lines. Prevalence 1:100,000. Eighty-five percent are functional, 15% are nonfunctional/below threshold of deductibility. Sixty to ninety percent will metastasize to liver and regional lymph nodes. Calcification is suggestive of malignancy.
A) Glucagonoma - Derived from ALPHA - pancreatic islet cells. Associated with necrolytic erythema migrans (erythematous macules/papules on lower extremity, groin, buttocks and face). Also diarrhea, weight loss, anemia and glossitis. Malignant transformation > 80%.
B) VIPoma - Rare islet cell solid tumor which releases Vasoactive Intestinal Peptides -- > relaxes vascular smooth muscles. Associated with: WDHA syndrome (old term) = Watery Diarrhea, Hypokalemia and Achlorhydria. -- Or WDHH syndrome (same thing, new term) = Watery Diarrhea, Hypokalemia and Hypochlorhydria. AKA "pancreatic cholera" or Verner-Morrison syndrome. Malignant transformation > 60%.
C) Insulinoma - Most common functioning islet cell tumor. Single benign adenoma - 80-90%; multiple adenomas - 5-10%. Malignant transformation - 5-10%.
D) Somatostatinoma - Derived from DELTA islet cells, somatostatin suppresses release of insulin, glucagon, gastric acid, growth hormone, TSH, pepsin and secretin. Malignant transformation 50-90%.
E) Gastrinoma - Second-most common functioning islet cell tumor. In alpha/delta cells. Only one I found where men > women. Associated with Zollinger-Ellison syndrome. Malignant transformation > 60%.
VIPoma - rare islet cell solid tumor which releases vasoactive intestinal peptides -- relaxes vascular smooth muscles. Associated with WDHA syndrome (old term) = Watery Diarrhea, Hypokalemia and Achlorhydria. -- Or WDHH syndrome (same thing, new term) = Watery Diarrhea, Hypokalemia and Hypochlorhydria. AKA "pancreatic cholera" or Verner-Morrison syndrome.
Carcinoid - Most common primary tumor of appendix and small bowel. Appendix > small bowel with a preference for tip of appendix. Tumor releases ACTH, histamine, bradykinins, kallikrein and serotonin. Serotonin (5-hydroxy tryptamine) is converted to 5-hydroxyIndole acetic acid (5-HIAA) by one pass through the liver, then pissed away. Carcinoid syndrome is caused by excessive serotonin release which has bypassed the liver (therefore not from the bowel or SMV would have delivered the blood back to the liver). Carcinoid syndrome must be from liver mets on the hepatic vein side, or primary lung/ovarian neoplasms.
MEN III - Multiple endocrine neoplasm IIB was renamed MEN III (while MEN IIA remains MEN II). MEN III is also called mucosal neuroma syndrome as it involves the gastrointestinal tract with multiple submucosal ganglioneuromatoses which can act as a lead point for intussusception. MEN II and MEN III (or old IIA and IIB) are autosomal dominant. Both involve medullary carcinoma of the thyroid (so release of calcitonin), and pheochromocytoma. MEN II involves parathyroid adenomas - III does not; III involves GI mucosa - II does not.
No serosa. The esophagus has a tunica adventitia as it's outermost covering. The serosa is a thin connective tissue layer and mesothelium that covers the bowel where the tract is attached to the body via a mesentery (visceral peritoneum). The esophagus is comprised of a mucosal layer: epithelium, laminae propria and muscularis mucosa, followed by a muscular layer of circular, then longitudinal muscle, covered with connective tissue or adventitia in the thorax.
D or E.
Pneumoperitoneum may occur from a large list of sources, including a spectrum from blunt trauma to 'orogenital insufflation'
A) "Rigler's sign" - After Leo Rigler, is gas on both sides of the bowel lumen. This usually requires > 1,000 cc of gas to be detected. This is also known as the "Wall sign" or "Bas-relief sign".
B & C) The falciform ligament is the most common structure to be outlined with a large amount of gas. The lateral umbilical ligaments may show up as an "inverted V sign" and the urachal ligament may also be seen with a large amount of free air.
D) "Cupola sign" refers to air trapped along the anterior central tendon of the diaphragm (the cupola of the diaphragm) in a supine film. Dahnert considers this a reliable sign for small gas collections. Also known as the "saddlebag" or "mustache" sign.
E) Free air at the edge of the liver is also referred to (in a number of texts) as a reliable sign of a small amount of intraperitoneal gas. The "Doge's cap sign" is a small collection of gas in Morrison's pouch. Also, air can outline the ligamentum teres (post. free edge of the falciform ligament) and present as a linear slit of hyperlucency between the 10th and 12th ribs, 2-4 cm to the right of the vertebral border.
Note: In all of the texts that I could find, not one listed one sign as the most common presentation for a small amount of air. The falciform ligament was listed as the most common structure outlined for a large amount of air.
Fifty-three percent of internal hernias are paraduodenal. Of these 53% three-quarters are through the fossa of Landzert on the left side, one-quarter are through the fossa of Waldeyer on the right side. Therefore, left > right. Incidentally, M>F 3:1.
Left side herniation occurs 75% of the time. Small bowel loops enter the paraduodenal folds where the duodenum exits from its fixed retroperitoneal position. They protrude further posteriorly and to the left, essentially herniating into descending and distal portions of the transverse mesocolon. Twenty-five percent are on the right side where small bowel herniates into the ascending mesocolon. So, infra greater than supra by 3:1.
Five to ten percent of all internal hernias occur through defects in the mesentery of the small bowel. These have no limiting sac, but are functionally similar to true internal hernias. Nearly 35% of transmesenteric hernias affect the pediatric age group, which means that 65% occur in adults. Therefore, the answer is true.
Having said that, the transmesenteric hernia constitutes the most common type of internal herniation in the pediatric population. These are frequently found in infants with atretic bowel regions. A causal relation to prenatal intestinal ischemic accident seems likely. But nearly 35% affect pediatric population (most common type in peds).
Fossa of Landzert is on the Left side.
Focal nodular hyperplasia - second-most common benign tumor of the liver. A rare benign congenital hamartomatous malformation or reparative process in areas of focal injury. May develop as hyperplastic response due to underlying congenital AVMs. Composed of abnormally arranged hepatocytes, bile ducts and fibrous septa. Lesion does have Kupffer cells , which allow for sulfur colloid uptake in nukes scan (70% with normal - increased uptake / 30% with decreased uptake). Look for central fibrous scar. No portal triads or central veins.
There is no definite association with oral contraception except incidence is at least 3:1 female > male and occurs in child-bearing decades (3rd to 5th). Eleven percent of cases involve women on OCPs - FNH is associated with hepatic hemangiomas (23%) if OCPs are used.
Rupture with hemoperitoneum is one of the complications - increased incidence with women on OCPs.
156. False. No malignant association.
Isolated gastric varices is a specific sign for splenic vein occlusion. Gastric varices are usually associated with esophageal varices and are secondary to portal hypertension. The presence of isolated gastric (gastric without accompanying esophageal) varices is specific for splenic vein occlusion. Most commonly, this is secondary to pancreatitis or pancreatic carcinoma. Gastric varices are usually noted in the fundus, and vary in size with respiration or positioning.
Desmoplastic fibroma = intraosseous desmoid tumor - rare, locally aggressive benign neoplasm of bone with borderline malignancy resembling soft tissue desmoids. #107 reported in the world literature. > 50% are in a long bone, 25% are in the mandible. Residual column of bone with "pseudotrabeculae" are classic (91%).
Lymphoma (8%), commonly diffuse and nodular. Adenocarcinoma of small bowel in 6%. Squamous cell carcinoma of esophagus and pharynx in 6%.
A low score has a better prognosis.
A high score has a bad prognosis.
Biliary cystadenoma = bile duct cystadenoma - a rare, benign, multilocular cystic tumor with well defined, thick capsule containing proteinaceous fluid that originates in the bile ducts, probably from ectopic rests of primitive biliary tissue. Eighty-five percent intrahepatic ducts, 15% extrahepatic. Right lobe > both > left. Malignant transformation into cystadenocarcinoma.
US: Ovoid, complex mass with irregular margins and +/- septations.
CT: Multiloculated mass of near water density with septations. Contrast enhancement in walls and internal septations.
MRI: Multiloculated mass. Signal varies based on protein content of cysts.
Associated with migratory arthralgias and nondeforming arthritis.
Z-E syndrome is due to overproduction of gastrin by pancreas (90%) via non-beta (i.e., not insulin) islet cell tumor. The remaining 10% come from antral gastrin cells in the stomach - pseudo Z-E syndrome.
The pancreas serves as an exocrine and endocrine organ. The exocrine portion releases proenzymes (trypsinogen, proelastase, etc.) into the pancreatic duct which in turn releases it into the duodenum. The endocrine function centers around clusters of cells in the islets of Langerhans. These divide into alpha cells which secrete glucagon, and beta cells, which secrete insulin.
AKA "neutropenic colitis" or "ileocecal syndrome" and is an acute infection of the cecum. "Typhlon" is Greek for cecum. Typhlitis is acute inflammation of cecum, appendix, and occasionally terminal ileum. It is caused by leukemic/ lymphomatous infiltrate, ischemia or focal pseudomembranous colitis. Causative organisms include E. Coli, Pseudomonas, Candida, Klebsiella, CMV, B. Fragilis and Enterobacter. It is common in childhood leukemia, aplastic anemia, lymphoma, and immunosuppressive therapy or patients with a neutropenia.
For Couinaud's, start at 1 with caudate lobe, go directly medial and begin counting clockwise.
Sixty percent of renal stones spontaneously pass. The remainder require intervention. ESWL (extracorporeal shock wave lithotripsy) can treat 80%. Percutaneous nephrolithotomy and lithotripsy are still indicated in: large stones (>3 cm), staghorn calculus, cysteine stones, infected stones, children, patients with complete obstruction, and the morbidly obese. In patients with a large staghorn calculus and little residual function, nephrectomy may be the only choice.
Eighty percent of kidney stones are calcium oxalate.
Staghorn calculi are formed of struvite (magnesium ammonium phosphate). This forms in the presence of urea-splitting bacteria like proteus mirabilis. Staghorn calculi are hard to treat, often infected, and more likely to cause sepsis.
Stones less than 3 cm should be treated with ESWL.
Cysteine stones respond poorly to ESWL.
ESWL is not indicated in children.
UPJ obstruction is an indication for percutaneous nephrolithotripsy.
C (maybe A, but not B).
All three listed can cause delayed persistent nephrograms. Initial IVP was normal. A 28-year-old, even post-partum, would have gotten a UA and a UPT for flank pain. If the UA was positive, she may go into imaging to rule out obstruction, but the diagnosis is made. Therefore, "B" is out. She is post-partum, so has a risk factor for ATN. Seventy-five percent have an initial, abnormal IVP, but if hers was normal, she may be in that 25% that have increasing dense nephrograms. "A" may be correct.
Finally, contrast nephropathy seems likely, as she had a normal IVP, but now has swollen (dilated) kidneys and persistent nephrogram. If UA was negative, she may go to pelvic ultrasound and barium enema. So, I think the best answer may be "C"
A) Acute tubular necrosis is due to a temporary reversible marked reduction in tubular flow rate. This can be due to drugs or ischemia. Major trauma, massive hemorrhage, and post-partum hemorrhage and hypovolemia or shock can all cause ATN. Kidneys become smooth and large 2nd to edema. IVP: Immediate - can see diminished/absent opacification of the collecting system. Seventy-five percent with immediate persistent dense nephrogram, 25% with increasingly dense delayed nephrogram.
B) Acute bilateral pyelonephritis - Episodic bacterial infection from infected urine from lower tract. Reflux or ascending bacteria (think P-fimbriated E. Coli). Ten to twenty percent can be hematogenously spread (Gram + cocci). Seventy-five percent have normal urogram, can have delay of contrast excretion, or narrowing of collecting system due to edema. Can also see immediately persistent dense nephrograms (rarely mucosal striations or "tree barking"), or patchy areas of decreased nephrodensity. In severe pyelonephritis, can actually get nonvisualization of the kidney. Nonobstructive ureteral dilation is rare, but does occur (due to endotoxins), can also see generalized renal enlargement or focal swelling.
C) Contrast induced renal failure = contrast nephropathy. Contrast causes renal vasodilation followed by vasoconstriction. This can lead to ATN-like symptoms and persistent nephrogram on plain films. Serum creatinine is expected to rise over the first complication - also do not exceed 4 ml contrast/Kg body weight of patient.
D. After 3-6 months of age, UTIs occur predominantly in females. Fecal bacteria (E. Coli predominantly) is most common infecting organism. Propagation from bladder to kidney by reflux which is common in patients with recurrent UTIs (70% of patients < 1 year-old / 10% of patients @ 12 year-old / 5% in adults). Bladder infection may precipitate reflux by weakening a marginally competent UVJ. UVJ matures and strengthens in older children, therefore decreased incidence of UTIs as child ages.
Objective in imaging children is to diagnose reflux, existing renal scarring, and structural/functional abnormalities that may predispose to reflux (particularly those requiring surgical intervention). Investigation is indicated in all children after the first documented renal infection. Approaches differ, though. It is hard to argue against ultrasound as an initial modality. It is quick, noninvasive, offers anatomical information, and can be done during active infection. However, ultrasound is limited to upper tracts, and the lower ureters and bladder must also be assessed for abnormalities. VCUG should be performed in all patients less than 5 years old. Girls have such low incidence of obstructive urethral pathology that scintigraphic cystography may be performed instead. In males, however, incidence of obstructive pathology is high, and VCUG cannot be substituted. Since active infection may alter the normal competence of the UVJ valves, this can be performed to evaluate for reflux once the acute phase has cleared. Scintigraphic cystography is very sensitive in detecting reflux, and can also be used as a follow-up exam. Traditionally, VCUG and IVP were the initial imaging modalities of choice. Caffey reports many radiologists reserve IVP for additional evaluation when greater than Grade 2 reflux is identified on VCUG. CT is the wrong choice for initial evaluation.
Except when a particular calyx must be entered for stone removal, the needle is best directed toward a lower or midnephric posterior calyx. Puncture into an anterior calyx makes guidewire and catheter placement extremely difficult, if not impossible, because of the acute angle that must be negotiated between the entry site and the renal pelvis.
These questions were tough. I did the best I could, but they remain open to interpretation. But first, a story...
Once upon a time...
IV contrast agents divide into high osmolar contrast agents (HOCAs or Ionics), and low osmolar contrast agents (LOCAs or nonionics). All consist of iodinated (radiodense portion) benzene ring derivatives. All HOCAs are ionic. They are organic acids consisting of an anion (the radiodense iodinated benzene ring part) and a cation (positively charged, either meglumine or sodium). The nonionics do not require the accompanying cations to be stable and therefore have lower osmolality.
Ionics are 6-8 times greater than the osmolarity of blood, while nonionics are only 2-3 times more osmolar. Increased osmolality is associated with increased side effects (up to six times greater for minor side effects and nine times greater for major effects.
The two major ionic agents or HOCAs are both "tri-iodinated" (three iodine molecules on the ring) and differ only in the R group portions. Diatrizoate (Hypaque) and iothalamate (Conray) are the anionic portions that combine with sodium or meglumine to form the injectable HOCAs. Both diatrizoate (Hypaque) and iothalamate (Conray) have mild anticoagulating properties. In the old days, when these were used for angiography, catheters were not flushed between runs. The new nonionics do not have these anticoagulant properties, so today we flush often.
Sodium salts result in better renal opacification than meglumine compounds, and mixing meglumine and sodium together offers less risk of ventricular fibrillation than sodium alone (possibly because it decreases the osmolality). Diatrizoate sodium is associated with a higher incidence of neurotoxicity than meglumine or combination of products.
Increased osmolality is associated with increased side effects including cardiac arrhythmias (ventricular fibrillation). Increased osmolality also leads to crenulated RBCs, i.e., hyperosmolar solution being injected. Consider Answer F. Peripheral vasoconstriction may refer to hypovolemic shock. Consider Answer A.
D? or C, or A, or F...
Increased sodium... Sodium is one of the cations used in ionic contrast agents (Hypaque and Conray). Sodium is preferred over meglumine for IVP studies as it creates better renal opacification. Sodium contrast agents also dissociate better than meglumine salts and thus sodium compounds have higher in-vivo osmolalities - which may account for higher complication rates. "Increased Na+" may = increased osmolality, and therefore increased side effects. Consider answers B, F, and A. Also, one study on a group of kids with brain tumors found that several had seizures after receiving diatrizoate sodium, the incidence of which was lessened when with meglumine - again possibly due to decrease in osmolality. No contrast will cross the intact BBB (Answer C). However, investigators speculated that BBB was already affected by illness, which allowed contrast to cross. Therefore, likely not Answer G (alters BBB), and not truly Answer C (crosses BBB).
Increased sodium means increased osmolality which is more likely to be the problem. I do remember learning that increased sodium is bad for blood pressure - so Answer D (HTN) must be correct - unless, of course, the diuretic effect removes volume and neutralizes the sodium effect... You be the judge.
E... or A, or B, or F...
Both diatrizoate (Hypaque) and iothalamate (Conray) are HOCAs or "ionic" agents. Ionic contrast agents have mild anticoagulating properties, so correct answer may be E. Of course, ionic agents are also higher in osmolality so everything I said for the previous two answers may apply here, too.
See answer for #176
Process of elimination. Nonorganic iodine from IV contrast may collect in the thyroid - decreasing uptake on a nuclear medicine exam due to iodine load. Sodium iodine, i.e., I123, may also be taken into salivary glands and stomach, where it is trapped but not organified. I suspect this holds for the parotid gland, too. At any rate, I could find nothing else that made better sense. If you to, please get back to me.
Bladder is the most frequent site of urinary involvement.
Malakoplakia is not a premalignant condition.
It is associated with chronic urinary tract infection, often E. coli, greater than 90%.
More common among immunocompromised patients.
The bladder is the most common site of urinary tract involvement.
Diabetes mellitus predisposes towards malakoplakia.
E. The most common cause of lateral displacement of the middle one-third of the ureter is retroperitoneal lymph node enlargement.
Normal prostatic utricle is narrow at its orifice in the verumontanum.
Seminal vesicle cysts involve one or more of the lateral convolutions of the seminal vesicle. (Some B)
Cysts that arise in or near the midline of the prostatic base include utricle, Müllerian duct cyst and ejaculatory duct cysts.
Müllerian duct cysts most commonly occur in the midline just above the prostate.
B. Approximately 40% of all ureteral strictures in the United States are caused by gonorrhea, while the remainder are caused by other diseases such as chlamydia, mycoplasma, TB, schistosomiasis, tumor, trauma, or iatrogenic injury. Gonococcus infects the glands of Littre. Fibrous scarring is most prominent in the bulbous urethra, where glands of Littre are most abundant. Strictures are typically several centimeters long.
Common associations include PID, infertility, ectopic pregnancy, tubal dilation and obstruction.
Of 49 articles reported one article that SIN is associated with other tubal abnormalities such as hydrosalpinx and tubal occlusion.)
Most authors use the double-layer endometrial measurements obtained with transvaginal ultrasound imaging with the endometrium imaged sagittally.
If the endometrial thickness is found to be less than 4 mm, the bleeding can be attributed to endometrial atrophy.
Differential of endometrial thickening of greater than 8 mm includes hyperplasia, polyp and malignancy.
Tamoxifen has both antiestrogenic and estrogenic effects. The latter effects on the endometrium, with increased incidence of endometrial hyperplasia and carcinoma.
Chorionic villi juxtaposed to the myometrium.
Chorionic villi invade myometrium.
defined as through myometrium or penetrating myometrium (usually into bladder).
201. No definition found.
More than 95% of prostate neoplasms are adenocarcinoma which typically arise in the peripheral zone.
Cystitis glandularis, cystica or follicularis is found in 75% of patients with pelvic lipomatosis.
Captopril prevents conversion of Angiotensin I to Angiotensin II by inhibition of ACE.
Fifty percent will show normal sonographic findings while the remainder will demonstrate increased cortical echogenicity with normal sized or enlarged kidneys.
Renal insufficiency may be the first manifestation of HIV infection.
Radiographically with MRI, nephromegaly with loss of corticomedullary distinction on T1-weighted images has been found as a nonspecific finding. Histologically, a variety of glomerular lesions, including focal and segmental glomerulosclerosis with mesangial deposits of complement C3, Igm or IgA as well as tubular atrophy have been found. However, these findings are also nonspecific. Consequently, the AIDS nephropathy can be distinguished from some but not all causes of end-stage renal disease.
It occurs four times more frequently in girls than boys.
The upper pole ureter inserts medially and caudally to the ipsilateral normal ureteral orifice and is almost always associated with a ureterocele (Weigert-Meyer Rule).
Ectopic ureteroceles invariably are associated with the upper pole of a duplex collecting system and usually cause obstruction of the upper pole collecting system and ureter. They may cause VUR into the lower pole's ureter.
Generally, this is true. However, large ectopic ureteroceles may directly compress and obstruct the ipsilateral lower pole orifice. Likewise, it may extend across the midline and obstruct the contralateral ureteral orifice or prolapse into the bladder with subsequent bladder outlet obstruction.
The most common cause of lateral displacement of the middle third of the ureters is retroperitoneal lymph node enlargement. An abdominal aortic aneurysm also may displace the mid-ureters laterally. Consequently, AAA is the best single answer.
Renal cysts increase proportional to duration of dialysis. Multiple small cysts are seen on CT.
(However, Dahnert characterizes the cyst size as multiple 0.5-2 cm cysts bilaterally. Best answer is still B.)
Robbins defines Leydig cell tumor as a non-germ cell tumor by the WHO Pathologic Classification of testicular tumors.
Few extratesticular masses are neoplasms. There is increased risk of malignancy when a mass is found to be intratesticular.
They are elevated in most germ cell testicular tumors and are secreted/ produced by the tumors themselves. In this case, elevated levels may be secondary to intratesticular tumor. However, following orchidectomy, persistent elevations indicate Stage II or extratesticular disease.
Retroperitoneal nodal involvement often appears first at the approximate level of the renal hila on the left and slightly lower on the right. Inguinal and inferior iliac nodes are usually spared.
Dunnick reports association with obstruction, infection, and renal calculi. Kirks mentions obstruction, increased incidence in Wilms tumors, renovascular hypertension, and adenocarcinoma in patients with horseshoe kidneys.
Idiopathic uric acid lithiasis occurs in patients with normal serum urate levels but persistently low urine PH.
Secondary gout is rarely a cause of radiographically apparent disease.
The kidney is the second-most common site of tubercular infection after the lungs, and the most common finding in renal TB is infundibular stenosis. Other causes of infundibular stenosis are brucellosis, found primarily in meat packers or people who ingest unpasteurized cow's milk, and fungal infections. Urothelial tumors can cause a desmoplastic reaction in the renal sinus and give a similar picture.
In chronic reflux or chronic pyelonephritis, the upper and lower pole cortex is most susceptible to the damage caused by pyelotubular backflow. The theory is that the papillae in these regions are more likely to be compound, with circular orifices to the ducts of Bellini. In the interpolar region, the papillae are simple, with slit-like orifices which impede the retrograde flow of urine. The ultimate result of intrarenal reflux is parenchymal scarring and cortical thinning.
The same process as seen in infundibular stenosis can progress to amputated calices.
Congenital megacalicosis is nonprogressive caliceal dilatation caused by hypoplastic medullary pyramids. It is usually unilateral. The kidney is usually enlarged with prominent fetal lobulation and a mosaic arrangement of polygonal, faceted calices.
Two ducts empty into the sump of the bulbous urethra. These are long ducts of the pea-sized glands of Cowper, which lie on either side of the membranous urethra, within the urogenital diaphragm. Cowper's glands also secrete mucous during sexual stimulation.
(The other glands providing mucous are the glands of Littre, which line the anterior urethra.)
"The indications for stone removal include recurrent UTI, progressive renal damage, urinary obstruction and persistent pain. Removal of struvite stones is the treatment of choice."
(Surgical intervention is not indicated for uric acid stones.)
Yes, they are all true statements, but the Meyer-Weigert rule is pretty limited. It states only what is written under C above.
Dunnick states that, "Otherwise healthy patients with uncomplicated pyelonephritis seldom need a radiologic workup if they respond to antibiotic therapy within 72 hours. If there is no response to therapy, urography is probably the most cost-effective initial examination."
Having said that, I'm going with A. It's an eight-year-old girl in whom the risks of radiation and of contrast administration are probably the major considerations. There is evidence that ultrasound in children demonstrates an increase in renal size as much as two standard deviations over normal in acute inflammatory disease, making it more sensitive for the detection of pyelonephritis in children than it is in adults. This effect is most pronounced in younger children, but eight isn't ancient.
"A chemical phlebitis may develop... most likely as the result of prolonged contact of the contrast medium with the venous endothelium... markedly reduced by using diluted contrast..." Sounds like it's true.
Chlamydia trachomatis immuotypes L1, L2, and L3 cause lymphogranuloma venereum. The disease is characterized by a transient genital lesion followed by lymphadenitis and possibly rectal strictures. The inguinal and subinguinal nodes may become matted, undergo suppuration, and form multiple sinuses. Dahnert says it causes narrowing and straightening of the rectosigmoid, widening of the retrorectal space, ulcerations of the mucosa, paracolic abscesses, and fistula. Males are more likely to be infected 3.4:1. Antibiotics used to treat chlamydia are useful if scarring hasn't set in. Chlamydia is not a retrovirus.
The uterus forms from paramesonephric ducts (Müllerian ducts). The Müllerian ducts form the uterus, fallopian tubes, and upper two-thirds of the vagina in females. The utricle is a remnant of the Müllerian duct. The other male structure which derives from the Müllerian duct is the appendix testis.
The seminal vesicle forms from a distal diverticulum of the mesonephric (Wolffian) duct. Ejaculatory ducts arise from the mesonephric duct, specifically the Wolffian duct.
The urethra forms from urogenital sinus endoderm in males and females, except at the very distal end of the male urethra (the navicular fossa), which is derived from surface ectoderm.
ACE inhibitors prevent the conversion of angiotensin I to angiotensin II in the lungs by angiotensin converting enzyme. The actions of angiotensin II include constriction of efferent postglomerular arterioles which increases intraglomerular capillary hydraulic pressure and GFR; systemic arteriolar constriction, aldosterone release, and induction thirst. Angiotensinogen is converted to angiotensin I under the auspices of renin, and the other three (B-D) are just the opposite of what one would expect from ACEI.
Cystinuria is a rare autosomal recessive inborn error of metabolism characterized by impaired reabsorption of dibasic amino acids from the renal tubule and GI tract. X-ray examination reveals a slightly dense, laminated calculus. Management is medical, and includes hydration to decrease the total concentration of cystine in the urine, alkalinization of the urine with oral sodium bicarbonate or potassium citrate to increase its solubility, direct irrigation of the stone with alkaline solution, administration of cystine binding drugs such as penicillamine, and dietary restriction of methionine, a cystine precursor.
A 2.6 cm stone is not going to pass the UPJ, at which the ureter is relatively narrow. Hydration is probably a good idea, but waiting for the stone to pass isn't. Partial nephrectomy should only be used in patients with severe obstruction and parenchymal damage in whom the recovery of renal function in the resected segment is expected to be minimal. Percutaneous removal was the method of choice before the advent of widely available ESWL.
Staghorn struvite calculi must be removed, or the patient can be expected to experience significant morbidity as a result of persistent urinary tract infection. Cystograms are useful in evaluating the lower urinary tract and determining whether reflux is present. IVP is essential to evaluate the uninvolved kidney and determine whether there are surgically correctable anatomic abnormalities in the involved kidney. Medical therapy with antibiotics is useful pre- and postoperatively as an adjunct to surgery. Struvite stones fragment well with ESWL.
According to Dahnert (page 403), exposure without a grid is 25kV, and with a grid is 26-27kV. Tube output is 80-100mA, molybdenum target material with characteristic emission peaks of 17.9+19.5keV. keV 1/3 - 1/2 kVp
Phantom imaging is performed monthly. According to the Primer (page 659), some mammographers advocate more frequent evaluation of phantoms, since they test the entire imaging system.
LCIS is usually mammographically occult. Invasive lobular carcinoma will present as architectural distortion in 18-30%. A spiculated mass is seen in 16-28%, asymmetric opacity in 8-19%, round, well-circumscribed mass in 1%, and microcalcifications in 0-24%. It's the type of breast cancer that is most frequently missed (19% false-negative rate). You're most likely to miss it, but if there's a likely mammographic presentation, it's architectural distortion.
It's the number of correct results in all tests, or the number of correct results divided by the total number of tests.
It's the ability to detect disease, or the probability of having an abnormal test result in the presence of disease.
It's the ability to identify the absence of disease, or the probability of having a negative test when there is no disease.
It's the likelihood that a positive test really indicates the presence of disease.
B indicates the negative predictive value, or the probability that there is really no disease in the case of a negative test.
Fibroadenomas are not typically described as being spiculated. Dahnert mentions a hyalinized fibroadenoma with fibrosis (page 398), but you'd think the pathologist might mention the hyalinization and fibrosis (maybe the Board question-writer wouldn't). There are references to malignancy occurring within fibroadenomas, since they contain epithelial tissue. This occurrence is extremely rare, but so are spiculated fibroadenomas. Repeat the core.
The ductal lobular unit consists of the extralobular terminal duct and the terminal lobule. It is the site for fibroadenoma formation, epithelial cyst formation, apocrine metaplasia, adenosis, epitheliosis, ductal carcinoma in situ, lobular carcinoma in situ, and infiltrating ductal or lobular carcinoma. As for papilloma, the more common form of papilloma occurs centrally in the subareolar ducts and does not occur in the ductal lobular unit. However, peripheral multiple papillomas occur in the terminal ductal lobular unit, and they're really rare... just rare enough to show up on Boards.
Place the tip of the needle/core device at the periphery of, but not into the lesion. The theory is that actively growing/spreading tumor should be more peripheral.
Why would anyone get a mammogram of a woman in such CHF that her breasts are edematous? That being said, it's still probably A. I couldn't find a reference.
The only mention of a specific cell type I could find is this one. It's intracystic papillary carcinoma in situ. In pneumocystography, 2% of cysts will be found to have tumor, and 1% malignant tumor.
Tubular carcinoma is well-differentiated and the most benign of all breast carcinomas. Ductal carcinoma in situ is cured in nearly all women with a modified mastectomy, but the Primer asserts that papillary has a slower growth rate and better survival statistics. The others are less easily dealt with. Medullary carcinoma is the fastest growing. Lobular is multicentric in 70% and most frequently leads to invasive disease. Papillary has a 90% five-year survival rate after mastectomy.
Medullary presents typically as a well-defined round-to-oval noncalcified uniformly dense mass. Tubular is usually spiculated. Ductal presents typically as branching calcifications. Lobular is usually architectural distortion. Inflammatory is diffusely increased density with skin thickening.
Apocrine metaplasia is virtually always benign.
Atypical hyperplasia increases the risk for developing carcinoma, and the more atypical, the greater the risk.
Adenosis alone is a nonproliferative lesion and carries no increased risk of breast cancer.
Sclerosing adenosis increases the risk 1.5-2 times. Also, in this slightly increased group: papilloma with fibrovascular core, papillary hyperplasia.
Duct ectasia is another nonproliferative lesion. Others include macro- and microcysts, fibrosis, hyperplasia of more than 2, but not more than 4 epithelial cells deep, mastitis, squamous metaplasia.
Lobular carcinoma. Architectural distortion is the second most likely after, "You missed it on the mammo".
True - focal post-surgical scarring.
• Most common pattern is asymmetric density without definable margins.
• Second most common = spiculated mass.
• Micro Ca++ in 25%, but one-half within adjacent benign tissue.
Excisional biopsy warranted because many subsequently prove to be breast Ca at excision.
Carcinoma = TDLU (intralobular portion); fibroadenoma = connecting tissue surrounding acini within lobule; papilloma = major ducts.
Mammogram = well circumscribed smooth, round/oval mass. Frequently ill defined margin. Calcification not important factor. Ultrasound = well circumscribed, lobulated, hypoechoic, heterogeneous. May show posterior acoustic enhancement.
1) Hyperplasia, moderate or florid: 1.5 - 2 x risk;
2) atypical hyperplasia, ductal or lobular: 4 - 5 x risk;
3) papilloma with fibrovascular core: 1.5 - 2 x risk;
4) Lobular carcinoma in situ = 15% risk for either breast of developing invasive carcinoma over next 20 years (30% overall) (9 x risk).
"Trans-scaphoid perilunate dislocation". Most common fracture associated with carpal dislocation.
Flexor hallicus longus. Tibialis posterior tendon runs underneath the medial malleolus. Flexor dig. longus runs at or below medial edge of sustentaculum tali. Peroneus longus and brevis run along lateral aspect of ankle.
291. A, C.
293. C, A.
294. D, C.
295. D, C.
297. D, C.
Legg Calve Perthes: Usual age = 5 - 8 y (range: 3 -1 2 y)
Slipped capital femoral epiphysis: Age 10 - 15 y
Transient toxic synovitis: Age < 10 y
Caffey disease: Infantile cortical hyperostosis Age < 6 mos.
Suprascapular notch contains suprascapular nerve, which supplies infraspinatus muscle. Infraspinatus atrophy occurs with ganglion cysts of the suprascapular notch, or spinoglenoid notch.
Median canal contains median nerve, flexor digitorum superficialis and profundus, and flexor pollicus.
Associations with SLAC: CPPD - 70%. Increase scapholunate distance 70%.
305. 45-year-old male playing basketball has sudden onset of severe foot pain. Most likely cause:
A. Posterior tibial tendon rupture
B. Achilles tendon rupture
C. Deltoid ligament rupture
D. Flexor digitorum longus rupture
Reference: Greenspan, Orthopedic Radiology, 1997, page 9.29.
306. Myositis ossificans A. Calcifies from outside in
307. Periosteal osteosarcoma B. Mature bone centrally
308. Central osteosarcoma C. Medullary band destruction
"Myositis ossificans is characterized by immature bone centrally and mature ossification peripherally."
Reference: Greenspan, Orthopedic Radiology, 1997, pages 18.8-18.10.
309. Best sign of loosening of a non-cemented total hip arthroplasty:
A. Sclerosis around the femoral shaft tip
B. Absorption of bone adjacent to the medial femoral neck
C. Periosteal reaction adjacent to the lateral femoral shaft
D. Lateral migration of the femoral shaft
Reference: Primer of Diagnostic Imaging, page 221.
310. CPPD A. Involves the second and third digits of the hand
311. Amyloid B. Osteoarthritis of unusual joints
312. PVNS C. Marked swelling about multiple joints
313. Synovial chondromatosis D. Hemosiderin in synovium
References: Brower, Arthritis in Black and White, 1997, pages 343-358; Greenspan, Orthopedic Radiology, 1997, pages 14.13-14.14, 15.35-15.37.
314-318. True/False - Concerning congenital dysplasia of the hip:
314. More common in males than females
315. After treatment with spica cast, an AP radiograph with straight leg is best to evaluate
316. Labrum is more echogenic than femoral head
317. Delayed ossification of femoral head occurs
318. Acetabular angle greater than 30 indicates good covering of the femoral head
314. False. Female:Male = 8:1.
315. Probably true.
317. True. Delayed ossification is sign of CDH.
318. False. Normal angle <30.
References: Greenspan, Orthopedic Radiology, 1997, pages 27.3-27.10; Kirks et al., Practical Pediatric Imaging, 1997, pages 465-472.
|Following answers provided by Kevin Lobo, M.D.|
319-322. True/False - Tibial plateau fracture is associated with:
319. Anterior compartment syndrome
320. Peroneal nerve injury
322. Ganglion cyst formation
319. True. Increased pressure in compartment bounded by tibia, fascia, and interosseous membrane.
Reference: Resnick, page 780.
321. True. Nonunion is rare after low energy plateau injuries but can be seen with severe comminution, unstable fixation, failure of bone graft, or infection.
322. True (?). Could not find a reference. However, plateau fractures are associated with ligament/meniscal injury which is associated with ganglion.
There are different classifications:
Müller - 4 types
Reference: Primer, page 370.
Schatzker - 6 types
Reference: Dahnert, page 61.
Lateral plateau fractures (80%) are most common. Medial fractures (10%) are associated with greater force and higher incidence of associated injuries. Both plateaus (10%).
Extent of fracture may be underestimated by plain films; can use tomograms or CT.
- Malunion (common)
- 2 DJD (common)
- Ligament/meniscal injury
- Peroneal nerve injury
- Popliteal artery rupture
References: 1) Resnick; 2) Fractures in Adults, Rockwood C, Volume II, pages 1919-1954.
323-325. True/False - Regarding the axis vertebral body:
323. High (Type II) fractures are associated with nonunion
324. Hangman's fracture often decompresses the spinal canal
325. Low (Type III) fractures are unstable
323. True. Nonunion occurs in two-thirds of high dens fractures and 100% if >5 mm of displacement. Ununified fracture called os odontoideum and indicates atlantoaxial instability.
Reference: Harris, page 441.
324. Hangman's fracture usually not associated with neurologic deficit because of small cord/canal ratio (1:3) and because of "auto-decompression" of canal.
Reference: Harris, page 379.
Effendi classification: Type I - minimal displacement; Type II - displaced with abnormal disc; Type III - displaced, C2 body is flexed, bilateral C2-3 facet dislocation.
325. True. Low dens fractures are unstable because the dens, atlas, and occiput can move as a unit separate from the axis.
Reference: Harris, page 443.
Reference: Radiology of Acute Cervical Spine Trauma, Third Edition, Harris J.
326. Which of the following fractures is most likely to cause neurologic injury (Single best answer)?
C. Flexion injury with a teardrop fragment
D. Extension injury with a teardrop fragment
E. Burst fracture
Answer: A. Flexion teardrop. Most devastating cervical injury compatible with life, characterized by anterior cord syndrome - complete, immediate quadriplegia with loss of pain, touch, temperature (anterior column) and retention of position, vibration (posterior column). All ligaments disrupted, completely unstable.
Reference: Harris, page 283.
Extension teardrop: Ant. inf. fragment height width, unstable in extension due to disruption of ALL, stable in flexion.
Hangman's: See question #315.
Burst fracture: Deficit ranges from transient parasthesia to permanent quadriplegia, but usually of lesser magnitude than flexion teardrop.
327. Adult pitcher with medial elbow pain. (Single best answer):
A. Radial head fracture
B. Ulnar nerve entrapment
C. Biceps tendinitis
D. Medial epicondyle fracture
E. Olecranon fracture
Answer: B. Ulnar nerve entrapment. Nerve trapped in fibro-osseus tunnel posterior to medial epicondyle between two heads of flexor carpi ulnaris. "Cubital tunnel syndrome" - MRI - increased signal and enlargement of nerve.
Reference: Andrews JR, Am J Sports Med 1995; 23(4):407-413. Review of 72 professional baseball players undergoing elbow arthroscopy or surgery. Diagnoses: Postmedial olecranon osteophyte (65%); ulnar collateral ligament injury (25%); ulnar neuritis (15%).
328. The most likely cause of death in a patient with a pelvic ring fracture:
B. Pulmonary embolus
C. Fat embolus
E. Genitourinary injury
Answer: A. Hemorrhage.
Reference: Poole GV, et al. Ann Surg 1991; 213(6):532-538.
236 pelvic fractures, 18 died: 1 from pelvic hemorrhage; 1 from PE; 4 from sepsis/organ failure; 1 from pulmonary injury; 6 from hemorrhage from other sites; 5 from head injury.
Note that death from pelvic hemorrhage is uncommon, although hemorrhage from all sites together was the most common cause of death.
329-332. True/False - Regarding Legg-Calve-Perthes disease and diagnostic bone scans:
329. Bone scans are less sensitive than plain films
330. A joint effusion will cause a false-positive result
331. Joint aspiration will cause a false-negative result
332. Increased activity is the earliest sign on bone scans
329. False. Bone scan is more sensitive early-on.
330. False (?). Unable to find reference.
331. False (?). Unable to find reference.
332. False. Decreased activity is the earliest sign due to impairment of blood supply.
333. Order of distal humeral ossification centers (Single best answer):
A. CRITOE (find ages)
Answer: A. CRITOE.
Capitellum 1 year
Radial head 5 years
Internal (medial) 7 years
Trochlea 10 years
Olecranon 10 years
External (lateral) 11 years
(1-2 years earlier in females)
334. A 40-year-old with homogeneous 2 cm density in the proximal humerus with hex______ borders blending with adjacent bone. Mild increase uptake on bone scan.
C. Enostosis (bone island)
D. Osteoid osteoma
Answer: C. Enostosis (?).
Metastasis: Purely sclerotic metastasis - prostate; can also be seen in bronchial carcinoid, bladder, stomach, medulloblastoma and neuroblastoma.
Osteosarcoma: Usually in younger patients, but can occur in middle age, e.g., intraosseous low grade osteosarcoma, usually large metaphyseal purely sclerotic lesion; however, would expect marked increased uptake.
Reference: Resnick, page 1005.
Enostosis: Discrete margins with radiating spicules, usually normal bone scan, frequent in all age groups.
Reference: Resnick, page 1211.
Osteoid osteoma: Usually has central lucent area and intense uptake.
335. Signs of loosening of femoral prosthesis (Single best answer):
A. Sclerosis at tip of femoral comp.
B. Resorption of medial femoral neck/shaft
C. Heterotopic bone formation
D. Cement fracture
E. Cement bone 2 mm lucency involving 50% of interface
Answer: D. Cement fracture. This is definite evidence of loosening.
Heterotopic bone formation is of unknown etiology.
Medial bone resorption is likely related to stress shielding.
Choice E is evidence of possible loosening.
Reference: Resnick, chapter 20.
336. True/False - Amyloidosis causes marked thickening of the soft tissues (this was a musculoskeletal question).
Answer: True. Amyloid deposition can cause scleroderma-like skin changes, prominent skin nodules (especially at the olecranon, hands), and extensive infiltration about the shoulders resembling shoulder pads.
Reference: Resnick, page 605.
337. True/False - CPPD has a propensity for involvement of the second and third metacarpels.
Answer: True. Changes in the hand in CPPD predominate at the MCP joints with changes most frequent at the 2nd and 3rd MCP. In hemochromatosis, the 4th and 5th MCPs are involved more commonly than in CPPD.
Reference: Resnick, page 473.
338. Middle-aged patient with a round, sclerotic density in the proximal humerus which fades into the surrounding bone. Lesion measures approximately 1-2 cm. (Single best answer):
A. This lesion will be very hot on bone scan
B. This lesion will be mildly hot on bone scan
C. Lesion will not be seen on bone
D. Lesion will be photopenic
E. Patient will have a superscan
Answer: C. Same as #334; likely bone island. May show some uptake but "scintigraphy in cases of bone islands usually yields normal results."
Reference: Resnick, page 1211.
339. Know the ulnar carpal impaction syndrome.
Answer: Almost always associated with positive ulnar variance and chronic impaction of the ulnar head against the triangular fibrocartilage and the ulnar-sided carpal bones resulting in deterioration of the triangular fibrocartilage, chondromalacia of the lunate and ulnar head, and attrition of the luno-triquetral ligament. Findings include sclerosis, cysts, and osteophytes of the lunate, triquetrum, and ulnar head, and communicating defects of the TFC and disruption of the lunotriquetral interosseus ligament on arthrography. Treatment is with ulnar recession arthroplasty.
References: 1) Resnick, page 820; Radiology 1996; 201(2):495-500.
340-343. True/False - Concerning aggressive fibromatosis:
340. Commonly erodes bone
341. Is well defined
342. Is homogeneous on MR
343. 20% of aggressive fibromatosis metastasize to lung
340. True or False? Both Resnick and Enzinger say "may cause pressure erosion or superficial cortical defects."
References: 1) Resnick; 2) Soft Tissue Tumors, F. Enzinger.
341. False. Poorly defined with invasion of fat or muscle; however, can be lobulated and well defined.
References: 1) Resnick; 2) Soft Tissue Tumors, F. Enzinger; 3) Dahnert, page 53.
342. False. Iso to muscle on T1. Variable on T2, can have mixed areas of cellularity (increased T2) and fibrosis (decreased T2).
References: 1) Resnick; 2) Soft Tissue Tumors, F. Enzinger; 3) Dahnert, page 53.
343. False. No cases of metastasis documented in the literature.
References: 1) Resnick; 2) Soft Tissue Tumors, F. Enzinger.
Note: Aggressive fibromatosis is also called extra-abdominal desmoid, extra-abdominal fibromatosis. Peak incidence is 25-35 years, F > M. Shoulder > chest > thigh > mesentery > neck.
References: 1) Resnick; 2) Soft Tissue Tumors, F. Enzinger.
344. Tarsalcoalition - What is the age of presentation?
397. The middle subtalar joint is involved A. Calcaneonavicular
Answer: Symptoms usually appear in 2nd or 3rd decade at the time of ossification of fibrous coalition. Calcaneonavicular (50%); talocalcaneal (35%); talonavicular (uncommon).
Reference: Resnick, page 1174.
345. True/False - Pes cavus is associated with tarsalcoalition.
Answer: True. Association with painful pes planus with peroneal spasm is well recognized.
Reference: Resnick, page 1174.
346. Drawing of anterior cerebral artery circulation - asked to label:
A. Anterior choroidal artery
B. Sylvian point
C. Ophthalmic artery
D. Anterior temporal artery
E. Recurrent artery of Heubner
Answer: ICA has four segments:
Cervical - Usually no branches.
Petrous - Branches rarely seen on angio
- Vidian (pterygoid)
Cavernous - Meningohypophyseal trunk
Supraclinoid - Ophthalmic
- Superior hypophyseal (usually not seen)
- Post. communicating
- Anterior choroidal
Recurrent artery of Heubner - Superior branch of the A. segment and supplies the caudate head and ant-inf internal capsule.
Anterior temporal artery - M1 segment trifurcates to anterior branch, posterior branch, and anterior temporal artery.
Sylvian point - On the AP view, the frontal and parietal branches of the MCA pass medially then laterally. The most superomedial point in their course is the Sylvian point.
347. The most common primary cerebral hemispheric tumor in children:
Answer: A. Supratentorial tumors in children: Astrocytoma (37%); meningioma (3%); hemangioblastoma uncommon in children and supratentorial; ependymoma (5%); P.N.E.T. (2.5%).
Reference: Dahnert, pages 168-169.
348. Posterior fossa tumor in a child with a cystic component (Single best answer):
A. Juvenille pilocystic astrocytoma
Answer: A. JPA is the most common pediatric infratentorial neoplasm (33%) and 60-80% of these will be cystic.
- Brainstem glioma (16-21%) (may be cystic = more aggressive)
- Medulloblastoma (26-31%) (10% are cystic)
- Ependymoma (6-14%) (small cystic-necrotic areas in 15-50%)
- Hemangioblastoma (uncommon)
Reference: Dahnert, Neuro Requisites.
349-355. True/False - Shear injury involves:
349. Brain stem
350. Splenium of corpus callosum
351. Subcortical white matter
352. Caudate nucleus
353. Temporal lobes
354. Gray white matter
349. True. The dorsolateral midbrain is involved in the most severe cases of DAI.
350. True. Splenium of corpus callosum (and posterior body) are commonly affected by DAI.
351. True. Patients with the mildest form of DAI have injury in the subcortical white matter of the frontal and temporal lobes.
353. True (See #351).
354. False. Cortex is spared.
Reference: Neuro Requisites, Brant & Helms, pages 57-60.
356. The most echogenic structure in a neonatal head ultrasound:
A. Cingulate gyrus
B. Corpus callosum
C. Caudate head
D. Vermis of cerebellum
Answer: C or D.
Caudate head - echogenic
Vermis of cerebellum
Corpus callosum - echopenic
Cingulate gyrus - Hypoechoic
Thalamus - hypoechoic
357. Right paracentral disc at L4/5. Most likely cause:
A. Right L5 radiculopathy
B. Right L4&5 radiculopathy
C. Right L4 radiculopathy
D. Bilateral L5 radiculopathy
Answer: L4 root is unlikely to be affected unless the L4-5 herniation is lateral, both L5 roots are unlikely to be involved by a paracentral disc.
Reference: Resnick, page 370.
358. At what age will the white matter of children have an adult pattern of myelination on imaging studies?
A. 4 weeks
B. 4 months
C. 8 months
D. 12 months
E. 2 years
F. 4 years
G. 8 years
Answer: E. Adult myelination by 18 months.
References: Brant & Helms, page 196; Primer, page 455.
359. High parietal/convexity punctate bleeds in an older adult is most likely caused by:
Answer: B. Amyloid. Older patient with multiple punctate bleeds. Pattern of bleeds doesn't fit with infarct or tumor. Contusion usually occurs in frontal or anterior temporal lobes. Amyloid accounts for 31% of lobar bleeds in adults.
Reference: J Med Dent 1997; 44(1):11-19.
360-364. True/False - Orbital pseudotumor
360. Cannot be identified on CT
361. Associated with pseudotumor cerebri
362. Is painless
363. Treatment is radiation therapy
364. Rarely sensitive to steroids
360. False. CT may show increased density of retro-orbital fat, thickening of sclera, enlargement of lacrimal gland, retrobulbar mass, or enlarged EOMs.
362. False. Causes unilateral painful exophthalmos, decreased ocular motility, chemosis.
363. True or False (?). Steroids are the first line of Tx; however, radiation therapy is 77% effective in cases of steroid failure.
Reference: Int J Radiat Oncol Biol Phys 1990; 18(2):407.
364. False. Usually has rapid onset and good response to steroids; however, there is a more chronic form with fibrosis less responsive to steroids.
|Following answers provided by G. Michael Werdick, M.D.|
365. A 45-year-old patient with history of dry mouth for one year and history of enlarged, painless parotid glands. MRI shows cysts in bilateral parotid glands. (Single best answer):
B. Sjogren's syndrome
C. Lymphoepithelial cysts
D. Adenoid cystic carcinoma
Answer: A. Benign lymphoepithelial cysts are a feature of AIDS. Other possibilities include Warthin tumor and metastatic disease.
366. Which of the following are associated with Chiari I?
D. Agenesis of corpus callosum
E. Beaked tectum
Answer: C. Twenty to thirty percent of Chiari I are associated with syringohydromyelia. A, D, E are seen in Chiari II. See Question #368 below for a complete list.
367. A 40-year-old woman presents with acute headache and seizures. T2 MRI shows increased signal in the medial temporal lobe and cingulate gyrus with no enhancement (Single best answer):
B. Low grade glioma
C. Herpes encephalitis
D. Multiple sclerosis
E. HIV encephalitis
Answer: C. Herpes simplex is the most common cause of fatal endemic encephalitis. Asymmetric involvement of the temporal lobes, cingulate gyrus, insula, orbitofrontal regions are characteristic. Gliomatosis cerebri is diffuse infiltration of tumor seen as high T2 of a hemisphere with relatively little mass effect.
368-373. Matching - Diagram of an AP projection of an ICA injection:
368. Recurrent artery of Heubner
369. Anterior choroidal artery
370. Medial temporal artery
371. Sylvial point
372. Ophthalmic artery
373. Anterior temporal artery
See following diagrams for a complete list:
374. Normal adult myelination pattern is reached at what age? (Single best answer):
A. 4 months
B. 8 months
C. 1 year
D. 2 years
E. 5 years
Answer: "Myelination begins in the fifth fetal month and continues throughout life, being nearly complete at age 2 years." - Anne Osborne.
375. Young woman with worst headache of life and intrasellar/suprasellar mass with fluid/fluid level in it - Most likely lesion is (Single best answer):
B. Pituitary adenoma
E. Rathke's cyst
Answer: History is typical for leaking aneurysm. Fluid/fluid level may be due to intramural thrombus.
376. Patient presents with an infrahyoid mass beneath the strap muscles (Single best answer):
A. Thyroglossal duct cyst
B. Brachial cleft cyst
C. Cystic hygroma
D. Glomus tumor
Answer: A. Thyroglossal duct cysts are midline neck masses. Sixty-five percent are below the hyoid, 25% at the hyoid. Brachial cleft cysts are typically masses anterior to the sternocleidomastoid, fluid filled, but may become secondarily infected or drain to the skin. Cystic hygromas are congenital lymphangiomas, seen in utero or < 1 year, associated with Turner's. Glomus tumors are from paraganglion cells of the carotid body, very vascular and lateral in the neck.
377. Know all the differences between Chiari I and Chiari II.
Chiari I Chiari II
Tonsils below for. magnum Tonsils below for. magnum
Normal brain stem location Beaking tectum
Syrinx in 20-75% Towering cerebellum
Associated with Klippel-Feil Scalloped petrous bone
Associated with C1, C2 Myelomeningocele
IV vent compression
Small post fossa
Agenesis of corpus callosum
Enlarged massa intermedia
Enlarged for. magnum
378. True/False - Carotid dissection requires immediate surgery.
Answer: False. Some may be managed nonoperatively.
379. True/False - Carotid dissection is most commonly caused by penetrating trauma.
Answer: False. Blunt.
380. Patient with punctate parasagittal hemorrhages on CT scan. (Single best answer):
A. Superior sagittal sinus thrombosis
B. Transverse sinus thrombosis
C. Shear injury
D. Epidural hematoma
E. Subarachnoid hemorrhage
Answer: A. Cortical and subcortical hemorrhages can sometimes be seen adjacent to the occluded sinus.
381. True/False - Chiari I patient has a large head size.
Answer: False. They are often asymptomatic.
382. True/False - Chiari II patient has a large head size.
Answer: False, although lacunar skull and small posterior fossa are characteristic.
383. UVA questions regarding a focal 1.5 cm four lateral disc at L4-5. Which nerve root is affected?
C. L4 & 5
Answer: In the lumbar region, central disk herniation compresses the root below; lateral disk herniation compresses the root above.
384-387. True/False - Concerning carotid dissections in the neck.
384. Angiography demonstrates both the false and true lumens typically
385. May present with ocular symptoms and headache
386. May present with the Horner syndrome
387. May present with pupillary dilatation
384. False. Angiography demonstrates both the false and true lumens typically (29%).
385. True. May present with ocular symptoms and headache.
386. True. May present with the Horner syndrome
387. False. May present with pupillary dilatation.
388-389. Match disseminated necrotizing leukoencephalopathy, PML, and rubella with rapid correction of sodium, measles vaccine, treatment with intrathecal chemotherapy and radiation therapy to the brain, and immunocompromised state.
388. Subacute sclerosing panencephalitis
389. Central pontine myelinolysis
Disseminated necrotizing leukoencephalopathy
Treatment with intrathecal chemotherapy
PML Immunocompromised state
Measles Subacute sclerosing panencephalitis
Central pontine myelinolysis Rapid correction of sodium
390. Adult patient with unilateral papilloma and calcification in posterior globe:
B. Choroidal angioma
D. Uveal melanoma
E. Phthisis bulbi
Answer: Correct answer: A.
(B: Noncalcified, most common adult benign globe tumor.)
(E: Small, contracted globe.)
391-393. Matching - Regarding tendons of the foot:
391. Tibialis post A. Most common for rupture
392. Flexor halluces longus B. Passes under sustentaculum tali
393. Flexor digitorum longus C. Inserts on navicular
394. Arthritis A. Sprue
395. Lymphoma B. Mastoiditis
396. Sclerotic bones C. Whipple's
395. A (Seen in 8% of sprue).
Differential for dense bones: Renal osteodystrophy, sickle cell, myelofibrosis, osteopetrosis, pyknodysostosis, mets, mastocytosis, Paget's, athletes, fluorosis.
Reference: Helms, page 958.
397-399. Which of the following would result in decreased LVEF in a MUGA?
397. Underestimate background
398. Underestimate ESV
399. Include RA in EbV
397. Falsely low.
398. Falsely high.
399. Falsely high.
Remember the equation EF = EDV - ESV/EDV - Background. The background is subtracted in the numerator.
400-402. True/False - Regarding lung perfusion scans:
400. Minimum of 200,000 particles are needed for a diagnostic study
401. A defect may be secondary to lung cancer
402. Delivers 5 rads to the lungs
400. False. 60,000 - 40,000.
401. True. Defect may be secondary to lung cancer.
402. False. < 1 rad.
403. A 35-year-old female with paroxysmal hypertension, history of thyroid surgery. The best initial imaging study:
Answer: A. This patient has MEN II with pheochromocytoma, medullary carcinoma of the thyroid, and hyperparathyroidism. MIBG is the agent for pheo.
404. During a dipyridamole stress study of the heart, a patient has severe angina. You should:
A. Continue the exam
B. Stop the study, give the patient nitroglycerine
C. Stop the study, give the patient aminophylline
D. Stop the study, give the patient adenosine
E. Continue the study, but give the patient nitroglycerine
Answer: C. Aminophylline will reverse the effects of dipyamidole.
405. Gallium negative study in a 35-year-old male AIDS patient who has bilateral, patchy infiltrates on chest x-ray. Most likely etiology:
C. Kaposi's sarcoma
D. Bronchogenic carcinoma
Answer: C. Ga is avid for nearly all inflammatory conditions including PCP and sarcoid.
406. One hour after a HIDA study, bowel is visualized. Next step is (Single best answer):
A. Give glucagon
B. Give cholecystokinin
C. Stop exam
D. Give morphine
E. Have patient eat a fatty meal
Answer: D. Morphine will increase sphincter of Oddi pressure and may indicate chronic cholecystitis if gallbladder fills late.
407. A 40-year-old female with tachycardia, sweating and hypertension. What is the most appropriate next study?
Answer: A. Imaging agent for pheo.
408. On SPECT, patient with Alzheimer's will have the following pattern:
A. Increased uptake in temporal lobes
B. Decreased uptake in parietal lobes
C. Decreased uptake in occipital lobes
A. Increased occipital uptake
C. Increased parietal and temporal uptake
D. Decreased parietal and temporal uptake
E. Increased frontal uptake
Answer: D. Seen in 80% of cases. May also be seen in Parkinson's. Increased frontal uptake is seen in Pick's disease.
|Following answers provided by Jeffrey Kuo, M.D.|
409. Best nuclear medicine test for pheochromocytoma:
A. Tc-99m sestamibi
B. I-131 MIBG
C. In-III octreotide
D. I-123 MIBG
E. Tc-99m pertechnetate
Answer: B or C. Sensitivities for I-131 MIBG and In-111 octreotide are approximately equal (88% and 96% respectively). In-111 octreotide is a more convenient agent. With I-131 MIBG, need to pretreat patient with Lugol's solution or potassium iodide.
410. Mechanism of clearance of DTPA during a VQ scan (Single best answer):
A. Alveolar capillary clearance
B. Renal excretion
C. Biliary excretion
D. Mucociliary clearance
E. Lacrimal drainage
Answer: A, if they mean clearance from the lungs; B if they mean clearance from the body. DTPA aerosol particles cross alveolar-capillary membrane with half-life of one hour; enter the pulmonary circulation and from there are rapidly cleared by the kidneys.
Reference: Mettler, Nuclear Medicine Imaging, page 144.
411. Concerning radionuclide ventriculography - Know the equation for determining ejection fraction and whether increasing or decreasing background increases or decreases the ejection fraction.
Answer: EF = End diastolic counts - end systolic counts
End diastolic counts - background counts
Increase BG causes increase ejection fraction. Decrease BG causes decrease ejection fraction.
Reference: Mettler, Nuclear Medicine Imaging, page 128.
412. True/False - The ejection fraction increases when the left atrium and left ventricle overlap.
Answer: False. Inaccurate definition of aortic or mitral valve planes with resultant inclusion of portions of either ascending aorta or left atrium in the left ventricular region of interest leads to underestimation of left ventricular ejection fraction.
Reference: Mettler, Nuclear Medicine Imaging, page 128.
413. Gallium scan in patient with AIDS is positive. What disease can be excluded?
Answer: A. The lack of uptake of gallium in Kaposi's sarcoma may make gallium 67 imaging useful in differentiating between infection and sarcoma in these patients.
Reference: Mettler, Nuclear Medicine Imaging, page 260.
414. Sulfa colloid scan with hot spot least likely:
B. SVC obstruction
D. Regenerating nodule with cirrhosis
Answer: E. Focal areas of increased uptake can result from 1) increased flow to an area, resulting in more radiocolloid delivered to normally functioning Kupffer cells or; 2) normal flow to an area of increased density of Kupffer cells. FNH has increased uptake from both vascular nature of the tumor and an increased density of functioning Kupffer cells. SVC obstruction causes increased radionuclide delivery to the quadrate lobe. Budd-Chiari causes a relative increase in uptake in the caudate than the remainder of the liver. Cirrhosis causes relative decrease in uptake in more severely affected areas and regenerating nodules will appear relatively increased in uptake. Adenomas are made up almost exclusively of hepatocytes are typically seen as cold defects.
Reference: Thrall, The Requisites, Nuclear Medicine, pages 216-218.
415. Trisomy 13 A. Brachycephaly
416. Chiari II B. Scaphocephaly
417. Coronal suture closure C. Microcephaly
418. Sagittal suture synostosis D. Macrocephaly
419. Apert's syndrome E. Microcrania
420. Dandy Walker F. Macrocrania
415. C. DDX of microcephaly: Intrauterine infection, toxic agents, drugs, hypoxia, radiation, maternal phenylketonuria, premature craniosynostosis, chromosomal abnormalities, Meckel-Gruber.
Reference: Dahnert, page 226.
416. G. Enlargement of occipital homs and atria due to maldeveloped occipital lobes.
Reference: Dahnert, page 199.
417. A. Coronal synostosis is the second-most common type and results in plagiocephaly when unilateral ("harlequin eye") and brachycephaly when bilateral.
418. B. Sagittal suture craniosynostosis is the most common type and results in dolichocephaly = scaphocephaly = elongation of the skull in the AP dimension.
419. C and E. Apert syndrome is AD. Oxycephalic skull (premature closure of sagittal, coronal, and lambdoid sutures), hypoplasia sinuses, fusion of phalanges, metacarpals, carpals, absence middle phalanges.
420. B and D. Large skull secondary to hydrocephalus and dolichocephaly.
Reference: Dahnert, page 203.
421. Five-day-old full-term baby underwent cardiac angiography for evaluation of VSD and coarctation of the aorta. Two to three days later, an x-ray showed dilated bowel with pneumatosis. Most appropriate action:
A. Repeat the film in 24-48 hours
B. Barium enema to find perforation
C. Contrast-enhanced abdominal CT scan
D. Decubitus film to look for free air
E. Aortic ultrasound to detect thrombosis
F. Cross-table lateral to rule out free air
Answer: D. The major concern is for ischemic bowel/necrotizing enterocolitis. The only true radiograph indication for surgery is perforation. If a perforation is suspected, a left lateral decubitus film is preferred over the supine cross-table lateral exam. Barium is contraindicated. Remember that gas in the portal system does not imply a bad outcome as is does in the adult.
Reference: Blickman, Pediatric Radiology, The Requisites, page 63-65.
422. The most common type of tracheo-esophageal abnormality:
A. Distal fistula with esophageal atresia
B. Proximal and distal fistulas
C. H-type fistula
D. Proximal and distal atresia without fistula
E. Distal atresia and proximal fistula
Answer: B. Most common is EA and distal fistula (82%), then EA without fistula (9%), no EA with H-type fistula (6%), EA and two fistulas (2%), proximal fistula and distal EA (1%).
Reference: Blickman, Pediatric Radiology, The Requisites, page 71.
423. The lowest level of the tip of the conus in the normal neonate:
D. L422 E. S1
Answer: C. Tethering of the cord id caused by primary shortening of the filum terminale or is secondary to dysraphic changes preventing the normal "ascent" of the conus medullaris above L2-3. In an infant, US may demonstrate low termination of the conus below L2 or L2-3.
Reference: Blickman, Pediatric Radiology, The Requisites, page 228.
424. Two-year-old female with first UTI. Next test (Single best answer):
A. VCUG or RNC
B. Renal US
Answer: A. At Children's Healthcare Minneapolis, everyone gets a VCUG first. Some folks at Fairview argue that a RNC is okay as an initial study for a girl as it is more sensitive and has less radiation exposure. VCUG must be done in all males to look for urethral pathology (e.g., PUV).
425. A newborn presents with failure to thrive, difficulty feeding, and intermittent cyanosis. Failure to pass NG tube and normal CXR. What test would you order next?
A. Chest CT
B. Upper GI
D. Renal ultrasound
E. Pulmonary function tests
Answer: B. The main concern is for a tracheo-esophageal abnormality. A carefully performed UGI is the study of choice.
426. Most common type of TE fistula is (Single best answer):
A. Distal fistula/proximal atresia
B. Esophageal atresia, no fistula
C. H-type fistula
Answer: ? (Question was not answered.)
427. Hemangioblastoma A. Sturge-Weber
428. Venous angioma B. Von Hippel-Lindau
429. Port wine stain C. Osler-Weber-Rendu
430. Telangiectasia D. Other phakomatoses
427. B. Von Hippel-Lindau is AD (chromosome 3) consisting of retinal, cerebellar and visceral angiomatous lesion including hemangioblastomas.
428. A. See below.
429. A. Sturge-Weber is characterized by facial port wine stain in VI distribution, leptomeningeal venous angiomas, subpial tramlino calcifications.
430. C. Autosomal dominant inheritance and manifests as cutaneous and mucous membrane telangiectasias, AVM, and aneurysm.
431-433. True/False - Wilms tumor:
431. Associated with hereditary aniridia
432. Associated with Beckwith-Wiedemann syndrome
433. Most common pediatric tumor to invade IVC
431. False. Wilms tumor is associated with sporadic aniridia, hemihypertrophy, Drash syndrome, and GU anomalies.
Reference: Dahnert, page 713.
432. True. Beckwith Wiedemann syndrome = EMG syndrome = exophthalmos, macroglossia, gigantism + hepatomegaly, hyperglycemia from islet cell hyperplasia.
Reference: Dahnert, page 713.
433. True. Wilms tumor is most common abdominal neoplasm in children from 1-8 y.o. and third-most common malignancy in childhood after leukemia and brain tumors. Four to ten percent invade IVC/RA.
Reference: Dahnert, page 713.
434. True/False - Celiac sprue is associated with transient intussusception.
Answer: True. Transient nonobstructive intussusception (20%) without anatomic lead point.
Reference: Dahnert, page 626.
435. True/False - Cystic fibrosis is associated with meconium plug syndrome.
Answer: False. Meconium plug syndrome is neonatal low colonic obstruction due to colonic inertia, usually in full-term babies. It is associated with diabetic mothers and mothers treated with MgSO4 for preeclampsia.
Reference: Dahnert, page 616.
436. Expected time that corpus luteum should no longer be present (Single best answer):
A. 5 weeks of pregnancy
B. 10 weeks of pregnancy
C. 15 weeks of pregnancy
D. 20 weeks of pregnancy
E. 24 weeks of pregnancy
Answer: D. Corpus luteum of pregnancy can grow up to 15 cm. Maximum size at 8-10 weeks. Usually resolves before 20 weeks of GA.
Reference: Dahnert, page 743.
437-441. True/False - High output heart failure in utero:
437. Decrease size umbilical vein
438. Increase placental thickness
440. Increased fetal movement
441. Skin thickening
437. False. Findings in hydrops include anasarca = skin edema (skin thickness > 5 mm), ascites, pleural effusion, increased diameter of umbilical vein, polyhydramnios, placentomegaly > 6 cm, pericardial effusion, hepatosplenomegaly.
Reference: Dahnert, page 749.
442. Most common sonographic evidence of malignant thyroid lesion:
A. Poorly defined margins
B. Peripheral calcification
C. Increased Doppler flow
Answer: D. Thyroid cancer is typically hypoechoic and has poorly defined margins. One feature that should prompt particular concern is microcalcifications, because these are more predictive of cancer than is any other sonographic finding.
Reference: (Kurtz, Ultrasound Requisites, page 451.)
443-445. True/False - Regarding power Doppler
443. Depends on signal amplitude
444. Color indicates flow velocity
445. Provides same information as color Doppler regarding direction of blood flow
443. True. Instead of displaying the mean Doppler frequency shift, power Doppler images display the integrated power of the Doppler signal. It is theoretically velocity and Doppler angle independent and not subject to aliasing.
Reference: Rubin, Radiology 1994; 190:853-856.
446-448. True/False - Re: endometrial stripe thickness:
446. EM polyps can mimic thickening
447. Best measured n coronal plane
448. Best measured in sagittal plane
446. True. DDX of thickening: EM polyp, hyperplasia, endometriosis, endometrial carcinoma. Tamoxifen, met, mole, incomplete abortion, submucosal leiomyoma.
Reference: Dahnert, 728.
449-451. True/False - Concerning Tamoxifen effects on the endometrium:
449. Causes endometrial polyps
450. Antiestrogenic affect on the endometrium
451. Thin endometrium may cause bleeding when the endometrial stripe measures less than 4 mm thick
449. True. An increased incidence of endometrial changes including hyperplasia, polyps, and endometrial cancer has been reported with Tamoxifen likely secondary to partial estrogenic properties.
451. False. The statement is true in that endometrial atrophy can result in uterine bleeding, but Tamoxifen results in more proliferative changes on endometrium.
452. When does the corpus luteum of pregnancy disappear?
A. 5 weeks
B. 10 weeks
C. 15 weeks
D. 20 weeks
453. Measure endometrial stripe transverse/coronal.