Differential Diagnosis

in
RADIOLOGY
 Differential Diagnosis
in
RADIOLOGY
Second Edition

Sumeet Bhargava
MBBS DNB (Radiodiagnosis) MNAMS FICRI FCGP FIMSA
Assistant Professor
Department of Radiodiagnosis and Imaging
Subharti Medical College
Meerut, Uttar Pradesh, India
Satish K Bhargava
MD (Radiodiagnosis) MD (Radiotherapy) DMRD FICRI FIAMS FCCP FUSI FIMSA FAMS
Professor and Head
Department of Radiology and Imaging
School of Medical Sciences and Research
Sharda Hospital, Sharda University
Greater Noida, Uttar Pradesh, India
Formerly
Professor and Head
Department of Radiology and Imaging
University College of Medical Sciences (University of Delhi)
and GTB Hospital
Delhi, India

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Differential Diagnosis in Radiology
First Edition: 2005
Second Edition:  2014
ISBN 978-93-5152-173-0
Printed at
 Dedicated to
My loving late wife Kalpana
and my son Sumeet
whose inspiration and sacrifice have made it
possible to bring out this book
CONTRIBUTORS

Anubhav Sarikwal
Ex-Senior Resident
Department of Radiology and Imaging
University College of Medical Sciences (University of Delhi)
and GTB Hospital
Delhi, India
Ashish Verma
Assistant Professor
Department of Radiodiagnosis and Imaging
Institute of Medical Sciences
Banaras Hindu University
Varanasi, Uttar Pradesh, India
HM Kansal
Associate Professor
Department of Pulmonary Medicine
School of Medical Sciences and Research
Sharda Hospital, Sharda University
Greater Noida, Uttar Pradesh, India
Mamta Motla
Ex-Senior Resident
Department of Radiology and Imaging
University College of Medical Sciences (University of Delhi)
and GTB Hospital, Delhi, India
Nidhi Bhargava
Ex-Senior Resident
Department of Radiology and Imaging
University College of Medical Sciences (University of Delhi)
and GTB Hospital
Delhi, India
viii Differential Diagnosis in Radiology
OP Sharma
Professor
Department of Radiodiagnosis
Institute of Medical Sciences
Banaras Hindu University
Varanasi, Uttar Pradesh, India
Pardeep Kumar
Ex-Resident
Department of Radiology and Imaging
University College of Medical Sciences (University of Delhi)
and GTB Hospital
Delhi, India
Pushpender Gupta
Department of Radiology
Wake Forest Baptist Medical Center
Bouleward, Winston-Salem, NC27157, USA
Rajeev Chaturvedi
Ex-Senior Resident
Department of Radiology and Imaging
University College of Medical Sciences (University of Delhi)
and GTB Hospital
Delhi, India
Rajul Rastogi
Consultant and Head
Yash Diagnostic Center
Yash Hospital & Research Center
Moradabad, Uttar Pradesh, India
Ex-Senior Resident
Department of Radiology and Imaging
University College of Medical Sciences (University of Delhi)
and GTB Hospital
Delhi, India
 Contributors ix
Satish K Bhargava
Professor and Head
Department of Radiology and Imaging
School of Medical Sciences and Research
Sharda Hospital, Sharda University
Greater Noida, Uttar Pradesh, India
Shuchi Bhatt
Reader
Department of Radiology and Imaging
University College of Medical Sciences (University of Delhi)
and GTB Hospital
Delhi, India
Sumeet Bhargava
Assistant Professor
Subharti Medical College
Meerut, Uttar Pradesh, India
Vinita Rathi
Professor
Department of Radiology and Imaging
University College of Medical Sciences (University of Delhi)
and GTB Hospital
Delhi, India
PREFACE TO THE SECOND EDITION

Since there was an enormous demand of the book by the residents

and radiologists from all over the country, it was thought proper to
add more illustrations to better understand the various diseases.
We are confident that the second edition will be more useful to
the residents and consulting physicians in solving day-to-day
problems, so as to arrive at a correct diagnosis.

Sumeet Bhargava
Satish K Bhargava
PREFACE TO THE FIRST EDITION

The advancement in Radiology and subspecialties over a period of

two decades has tremendously enhanced this course and indepth
knowledge of image interpretation. This is particularly true in a
developing country like ours, where still majority of radiologists
practice in broader specialty and it is not always feasible to update
the knowledge because of paucity of time and availability of
literature/newer books at all places. However, an interpretation
of any radiograph is extremely essential for a radiologist to arrive
at a correct diagnosis, keeping in view various salient features
of disease entity on various imaging modalities and to exclude
other similar looking pictures. Thus, it is more important for a
trainee radiologist and a radiologist in practice to have a book,
which should be a valuable primer and also the concise and handy
reference to use in day-to-day practice. An attempt has been made
to list out as many important conditions as possible, enumerated
their salient features and important differential diagnoses so as to
arrive at a particular diagnosis.

Sumeet Bhargava
Satish K Bhargava
ACKNOWLEDGMENTS

We are grateful to our colleagues and friends, who gave timely

support and stood solidly behind us in our joint endeavor of
bringing out this book, which was required keeping in view the
wide acceptability of the ultrasound technique.
I am thankful to Shri Jitendar P Vij (Group Chairman), Mr Ankit
Vij (Managing Director), Mr Tarun Duneja (Director-Publishing),
Ms Samina Khan (PA to the Director-Publishing) of M/s Jaypee
Brothers Medical Publishers (P) Ltd, New Delhi, India, and all the
contributors, who have always been in keen desire to work with
smiling faces and with polite voices, as a result of which this book
has seen the light of the day.
CONTENTS

1. Chest 1
1.1 Lesions of Thoracic Inlet 1
Satish K Bhargava, Rajeev Chaturvedi
1.2 Mediastinal Masses 15
Satish K Bhargava, Nidhi Bhargava
1.3 Superior Mediastinal Masses—Differential Diagnosis 24
Shuchi Bhatt, Sumeet Bhargava
1.4 Differential Diagnosis of Anterior Mediastinal Mass 30
Shuchi Bhatt, Rajul Rastogi, Sumeet Bhargava
1.5 Anterior Mediastinal Mass 34
Satish Kumar Bhargava, Pardeep Kumar
1.6 D/D of Posterior Mediastinal Masses 41
Pushpender Gupta, Satish K Bhargava
1.7 Chest Wall Abnormalities 46
Rajul Rastogi, Vinita Rathi
1.8 Superior Rib Notching 50
Shuchi Bhatt, Pardeep Kumar
1.9 Inferior Rib Notching 53
Satish K Bhargava, Nidhi Bhargava
1.10 Elevation of Diaphragm 56
Nidhi Bhargava, Shuchi Bhatt
1.11 Pneumomediastinum 59
Nidhi Bhargava, Satish K Bhargava
1.12 Lung Tumors 61
Satish K Bhargava, Nidhi Bhargava
1.13 Hilar Enlargement 64
HM Kansal, Nidhi Bhargava, Satish K Bhargava
1.14 Calcification on Chest Radiograph 67
Satish K Bhargava, Nidhi Bhargava
1.15 Air-Fluid Levels on Chest X-ray 70
Satish K Bhargava, Nidhi Bhargava
xviii Differential Diagnosis in Radiology
1.16A Cavitating Pulmonary Lesions 70
Nidhi Bhargava, Satish K Bhargava
1.16B Mass within Cavity 71
Nidhi Bhargava, Satish K Bhargava
1.17 Cavitating Pulmonary Lesions 72
Pardeep Kumar, Rajul Rastogi, Satish K Bhargava
1.18A Lucent Lung Lesions 78
Nidhi Bhargava, Satish K Bhargava
1.18B Solitary Pulmonary Nodule 80
Nidhi Bhargava, Shuchi Bhatt
1.19 Solitary Pulmonary Nodule 82
Satish K Bhargava, HM Kansal, Sumeet Bhargava
1.20 Pulmonary Edema on the Opposite Side to a Pre-existing Abnormality 92
Nidhi Bhargava, Rajul Rstogi
1.21A Miliary Shadowing 101
HM Kansal, Satish K Bhargava, Sumeet Bhargava
1.21B Miliary Shadowing (0.5 to 2 mm) 105
Satish K Bhargava, Nidhi Bhargava, Sumeet Bhargava
1.22 Multiple Pinpoint Opacities 107
Sumeet Bhargava, Nidhi Bhargava, Shuchi Bhatt
1.23 Complete Opaque Hemithorax 109
Nidhi Bhargava, Vinita Rathi
1.24 Opaque Hemithorax 111
Satish K Bhargava, Pushpender Gupta, HM Kansal
1.25 Hypertransradiant Lung Field 114
Sumeet Bhargava, Satish K Bhargava, Anubhav Sarikwal
1.26 Hypertranslucent Lung Field 121
Nidhi Bhargava, Sumeet Bhargava
1.27A Honeycomb Lung 122
Sumeet Bhargava, Nidhi Bhargava, Satish K Bhargava
1.27B Honeycomb Pattern 125
Satish K Bhargava, Vinita Rathi, Sumeet Bhargava
1.28 Pleural Diseases 128
Rajul Rastogi, Sumeet Bhargava
 Contents xix
1.29 Pleural Fluid 136
Shuchi Bhatt, Nidhi Bhargava
1.30 Pleural Tumors 137
Nidhi Bhargava, Sumeet Bhargava, Satish K Bhargava
1.31 Pleural Calcification 139
Sumeet Bhargava, HM Kansal, Rajeev Chaturvedi, Satish K Bhargava
1.32 High Resolution CT-Pattern of Parenchymal Disease 141
Nidhi Bhargava, Rajul Rastogi, Satish K Bhargava
1.33 Cardiophrenic Angle Mass 142
Sumeet Bhargava, Satish K Bhargava, HM Kansal

2. Breast—Mammographic Differential Diagnosis 148

Sumeet Bhargava, Rajul Rastogi, Satish K Bhargava, Pushpender Gupta
2.1 Circumscribed Radiolucent Lesion 148

3. Cardiovascular System 170

3.1 Differential Diagnosis of Cardiovascular Disorders 170
Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
3.2 Invisible Main Pulmonary Artery 171
Sumeet Bhargava, Satish K Bhargava
3.3 Pulmonary Arterial Hypertension 174
Sumeet Bhargava, Satish K Bhargava
3.4 Enlarged Left Ventricle (ELV) 176
Sumeet Bhargava, Satish K Bhargava
3.5 Enlarged Left Atrium 180
Rajul Rastogi, Satish K Bhargava, Sumeet Bhargava
3.6 Dilatation of Pulmonary Trunk 183
Rajul Rastogi, Satish K Bhargava, Sumeet Bhargava
3.7 Enlargement Aorta 184
Sumeet Bhargava, Satish K Bhargava
3.8 Small Aorta 185
Sumeet Bhargava, Satish K Bhargava
3.9 Enlarged Right Atrium 186
Sumeet Bhargava, Satish K Bhargava
3.10 Enlarged Right Ventricle 188
Sumeet Bhargava, Satish K Bhargava
xx Differential Diagnosis in Radiology
3.11 Right Aortic Arch 191
Rajul Rastogi, Satish K Bhargava, Sumeet Bhargava
3.12 Pulmonary Venous Hypertension 193
Rajul Rastogi, Satish K Bhargava, Sumeet Bhargava
3.13 Enlarged Superior Vena Cava 194
Sumeet Bhargava, Satish K Bhargava
3.14 Cardiac Calcifications 195
Sumeet Bhargava, Satish K Bhargava
3.15 Cardiac Valve Calcifications 196
Sumeet Bhargava, Satish K Bhargava
3.16 Situs 197
Sumeet Bhargava, Satish K Bhargava
3.17 Cyanotic Heart Disease 197
Sumeet Bhargava, Satish K Bhargava

4. Soft Tissue Lesions 200

Sumeet Bhargava, Satish K Bhargava, Shuchi Bhatt
4.1 Differential Diagnosis of Soft Tissue Lesions 200
4.2 Soft Tissue Ossification 201
4.3 Linear Calcification of Soft Tissues 203
4.4 Parasitic Calcification 207
4.5 Areas of Decreased Density 210
4.6 Periarticular Soft Tissue Calcification 211
4.7 Generalized Calcinosis 213
4.8 Sheet-like Calcification in Soft Tissue 214

5. Abdomen and Gastrointestinal Tract and Hepatobiliary System 215

5.1 Dilated Esophagus 215
Rajul Rastogi, Satish K Bhargava, Rajeev Chaturvedi
5.2 Esophageal Carcinoma 221
Rajul Rastogi, Rajeev Chaturvedi, Satish K Bhargava
5.3 Thickened Mucosal Folds—Esophagus and Stomach 227
Ashish Verma, Shuchi Bhatt, Sumeet Bhargava
5.4 Thickened Gastric Folds 244
Rajul Rastogi, Satish K Bhargava, Sumeet Bhargava
 Contents xxi
5.5 Thickened Duodenal Folds 246
Rajul Rastogi, Satish K Bhargava, Sumeet Bhargava
5.6 Massively Dilated Stomach 247
Satish K Bhargava, Rajul Rastogi, Sumeet Bhargava
5.7 Target Lesions in Stomach on Barium Studies 248
Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
5.8 Gas in Gastric Wall 249
Satish K Bhargava, Rajul Rastogi, Sumeet Bhargava
5.9 Cobblestone Duodenal Cap on Barium Study 250
Satish K Bhargava, Rajul Rastogi, Sumeet Bhargava
5.10 Dilated Duodenum/Obstruction of Duodenum 251
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.11 Dilated Small Bowel/Jejunal and Ileal Obstruction 253
Rajul Rastogi, Shuchi Bhatt, Sumeet Bhargava
5.12 Strictures Small Bowel 254
Rajul Rastogi, Satish K Bhargava
5.13 Small Intestinal Stricture 255
Anubhav Sarikwal, Sumeet Bhargava
5.14 Thickened Folds in Small Bowel 262
Rajul Rastogi, Shuchi Bhatt, Sumeet Bhargava
5.15 Thickened Small Bowel Folds with Gastric Abnormality 264
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.16 Nodular Appearance of Small Bowel 264
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.17 Malabsorption 266
Satish K Bhargava, Rajul Rastogi, Sumeet Bhargava
5.18 Malabsorption 266
Sumeet Bhargava, Pushpender Gupta, Shuchi Bhatt
5.19 Protein Losing Enteropathy 276
Satish K Bhargava, Rajul Rastogi, Sumeet Bhargava
5.20 Pathologic Lesions in Terminal Ileum 276
Satish K Bhargava, Rajul Rastogi, Sumeet Bhargava
5.21 Colonic Polyps 278
Satish K Bhargava, Rajul Rastogi, Sumeet Bhargava
xxii Differential Diagnosis in Radiology
5.22 Colonic Polyps 281
Sumeet Bhargava, Satish K Bhargava
5.23 Colonic Strictures/Narrowing 284
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.24 Pneumatosis Intestinalis 285
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.25 Megacolon in Adults 287
Rajul Rastogi, Satish K Bhargava
5.26 Thumb Printing in Colon 288
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.27 Aphthous Ulcers 289
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.28 Anterior Indentation of Rectosigmoid Junction 290
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.29 Widening/Enlargement of Presacral/Retrorectal Space 290
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.30 Cystic Mesenteric Masses 291
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.31 Nonvisualization of Gallbladder on Ultrasound 292
Rajul Rastogi, Sumeet Bhargava
5.32 Gas in Biliary Tree 293
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.33 Gas in Portal Venous 294
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.34 Diffuse Hepatomegaly 295
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.35 Hepatic Calcification 296
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.36 Primary Hepatic Masses 298
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.37 Neonatal Obstructive Jaundice 300
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.38 Fetal/Neonatal Hepatic Calcification 301
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
 Contents xxiii
5.39 Diffusely Hypoechoic Liver 302
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.40 Diffusely Hyperechoic Liver (Bright Liver) 302
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.41 Focal, Hyperechoic, Hepatic Lesions 303
Rajul Rastogi, Satish K Bhargava
5.42 Focal, Hypoechoic, Hepatic Lesions 303
Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
5.43 Periportal Hyperechogenicity 303
Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
5.44 Thickened Gallbladder Wall 304
Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
5.45 Focal Hypodense Lesions on NECT Liver 305
Satish K Bhargava, Sumeet Bhargava, Rajul Rastogi
5.46 Hyperperfusion Abnormalities of Liver 306
Satish K Bhargava, Rajul Rastogi, Sumeet Bhargava
5.47 Hepatic Tumors with Vascular “SCAR” 307
Satish K Bhargava, Rajul Rastogi, Sumeet Bhargava
5.48 Diffusely Hypodense Liver on NECT 307
Satish K Bhargava, Rajul Rastogi, Sumeet Bhargava
5.49 Splenomegaly 308
Sumeet Bhargava
5.50 Splenic Calcification 308
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.51 Hyperechoic Splenic Lesion 309
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.52 Focal Hypoattenuating Lesions in Spleen 309
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.53 Pancreatic Calcification 310
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.54 Pancreatic Masses 311
Satish K Bhargava, Pushpender Gupta, Pardeep Kumar
5.55 Focal Pancreatic Masses 316
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
xxiv Differential Diagnosis in Radiology
5.56 Adrenal Mass 317
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.57 Adrenal Calcification 318
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.58 Extraluminal Intra-abdominal Gas 319
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.59 Pneumoperitoneum 320
Sumeet Bhargava, Anubhav Sarikwal, Shuchi Bhatt
5.60 Pneumoperitoneum 323
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.61 Gasless Abdomen 326
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.62 Ascites 327
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.63 Abdominal Mass in Neonates 330
Rajul Rastogi, Sumeet Bhargava
5.64 Abdominal Mass in Child 331
Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
5.65 Intestinal Obstruction in Neonates 333
Sumeet Bhargava, Rajul Rastogi, Satish K Bhargava
5.66 Abnormalities of Bowel Rotation 334
Sumeet Bhargava, Rajul Rastogi, Satish K Bhargava
5.67 Intra-abdominal Calcification in Neonates 336
Sumeet Bhargava, Rajul Rastogi, Satish K Bhargava
5.68 Hematemesis 337
Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
5.69 Dysphagia in Adults 339
Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
5.70 Neonatal Dysphagia 340
Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
5.71 Pharyngeal/Esophageal Diverticula 341
Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
5.72 Esophagitis/Esophageal Ulcers 342
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
 Contents xxv
5.73 Esophageal Strictures 347
Satish K Bhargava, Rajul Rastogi
5.74 Tertiary Contractions in Esophagus 348
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
5.75 Gastric Masses with Filling Defects 349
Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
5.76 Linitis Plastica 352
Sumeet Bhargava, Anubhav Sarikwal, Satish K Bhargava
5.77 Linitis Plastica 355
Rajul Rastogi, Shuchi Bhatt, Sumeet Bhargava
5.78 Gastrocolic Fistula 356
Rajul Rastogi, Satish K Bhargava
5.79 Retroperitoneal Fibrosis 356
Sumeet Bhargava, Shuchi Bhatt, Satish K Bhargava
5.80 Mass of Ilio-psoas Compartment 360
Satish K Bhargava, Sumeet Bhargava, Ashish Verma
5.81 Anatomy of Liver, Bile Ducts and Pancreas 362
Sumeet Bhargava
5.82 Inflammatory Bowel Disease 372
Satish K Bhargava, Pushpender Gupta, Shuchi Bhatt, Pardeep Kumar

6. Skeletal System and Joints 384

6.1 Abnormal Skeletal Maturation 384
Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
6.2 Short Limb Skeletal Dysplasia 386
Satish K Bhargava, Rajul Rastogi, Sumeet Bhargava
6.3 Short Spine Skeletal Dysplasia 389
Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
6.4 Lethal Neonatal Dysplasia 391
Satish K Bhargava, Rajul Rastogi
6.5 Dumb-bell-shaped Long Bones 392
Satish K Bhargava, Rajul Rastogi
6.6 Mucopolysaccharidoses and Mucolipidosis 393
Satish K Bhargava, Rajul Rastogi
xxvi Differential Diagnosis in Radiology
6.7 Mucolipidoses 394
Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
6.8 Generalized Osteosclerosis 394
Satish K Bhargava, Rajul Rastogi
6.9 Sclerotic Bone Lesions 396
Satish K Bhargava, Rajul Rastogi, Sumeet Bhargava
6.10 Bone Sclerosis Associated with Periosteal Reaction 402
Satish K Bhargava, Rajul Rastogi
6.11 Solitary Sclerotic Lesions with Lucent Center 403
Satish K Bhargava, Rajul Rastogi
6.12 Coarse Trabecular Pattern of Bone 404
Satish K Bhargava, Rajul Rastogi
6.13 Relationship of Metastatic Lesions to the Primary Tumors 405
Satish K Bhargava, Rajul Rastogi
6.14 Childhood Tumors Metastasizing to Bone 406
Satish K Bhargava, Rajul Rastogi
6.15 Bubbly Bone Lesions 407
Satish K Bhargava, Rajul Rastogi
6.16 Primary Bone Tumors: Clinical Features, Site of Predilection,
Radiologic Presentation 410
Satish K Bhargava, Rajul Rastogi, Sumeet Bhargava
6.17 Radiologic Characteristics of Benign and Malignant Bone Lesions 414
Satish K Bhargava, Rajul Rastogi
6.18 Subarticular Bone Lesion 414
Satish K Bhargava, Rajul Rastogi, Sumeet Bhargava
6.19 Osteolytic Defect in the Medulla 418
Satish K Bhargava, Rajul Rastogi
6.20 Lucent Bone Lesion Containing Bone/Calcium 424
Satish K Bhargava, Rajul Rastogi
6.21 Common Lytic Bone Lesions 426
Satish K Bhargava, Rajul Rastogi
6.22 Location of Some Common Neoplasms/Lesions 427
Satish K Bhargava, Rajul Rastogi
6.23 Septated Bone Lesions 429
Satish K Bhargava, Rajul Rastogi
 Contents xxvii
6.24 Moth-Eaten Bone 429
Satish K Bhargava, Rajul Rastogi
6.25 Osteopenia 429
Satish K Bhargava, Rajul Rastogi
6.26A Periosteal Reactions—Types and Conditions 437
Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
6.26B Types of Periosteal Reactions 439
Satish K Bhargava, Rajul Rastogi
6.27 Periosteal Reaction in Childhood 441
Satish K Bhargava, Rajul Rastogi
6.28 Hypertrophic Osteoarthropathy 444
Satish K Bhargava, Rajul Rastogi
6.29 Hypertrophic Osteoarthropathy 444
Satish K Bhargava, Rajul Rastogi
6.30 Bone Dysplasias Associated with Multiple Fractures 445
Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
6.31 Excessive Callus Formation 446
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.32 Bone within Bone Appearance 446
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.33 Fatigue Fractures 447
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.34 Pseudoarthrosis 449
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.35 Irregular/Stippled Epiphysis 449
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.36 Avascular Necrosis/Osteonecrosis/Aseptic Necrosis 450
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.37 Solitary Radiolucent Metaphyseal Bands 454
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.38 Solitary Dense Metaphyseal Band 454
Rajul Rastogi, Satish K Bhargava
6.39 Alternating Radiolucent/Dense Metaphyseal Bands 455
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
xxviii Differential Diagnosis in Radiology
6.40 Dense Vertical Metaphyseal Lines 455
Rajul Rastogi, Satish K Bhargava
6.41 Frayed Metaphysis 455
Rajul Rastogi
6.42 Cupping of Metaphysis 456
Rajul Rastogi, Satish K Bhargava
6.43 Erlenmeyer Flask Deformity 456
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.44 Erosion of Medial Metaphyses of Proximal Humerus 457
Rajul Rastogi, Satish K Bhargava
6.45 Abnormality Related to Clavicles 457
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.46 Rib Lesions 458
Rajul Rastogi, Satish K Bhargava
6.47 Rib Notching 459
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.48 Abnormal Shape, Size and Density of Ribs 461
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.49 Madelung Deformity 462
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.50 Carpal Fusion 462
Rajul Rastogi, Satish K Bhargava
6.51 Abnormal Digits 463
Rajul Rastogi, Satish K Bhargava
6.52 Abnormal Thumb 465
Rajul Rastogi, Satish K Bhargava
6.53 Lytic Lesions in Digits 466
Rajul Rastogi, Satish K Bhargava
6.54 Acro-Osteal Changes 467
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.55 Monoarthritis 469
Rajul Rastogi, Satish K Bhargava
6.56 Arthritis with Periostitis 471
Rajul Rastogi, Satish K Bhargava
 Contents xxix
6.57 Arthritis with Demineralization 472
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.58 Arthritis without Demineralization 472
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.59 Arthritis with Preserved/Widened Joint Space 473
Rajul Rastogi Sumeet Bhargava, Satish K Bhargava
6.60 Enlarged Femoral Intercondylar Notch 475
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.61 Plantar Calcaneal Spur 475
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.62 Chondrocalcinosis 475
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.63 Ankylosis of Interphalangeal Joints 476
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.64 Enthesiopathy 476
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.65 Sacroiliitis 478
Rajul Rastogi, Satish K Bhargava
6.66 Protrusio Acetabuli 479
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.67 Widening of Symphysis Pubis (Diastasis) 480
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.68 Fusion of Symphysis Pubis 481
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
6.69 Radiographic Finding in Degenerative,
Inflammatory and Neuropathic Arthritis 482
Rajul Rastogi, Satish K Bhargava
6.70 Comparative Features of Seronegative Spondyloarthritides 482
Rajul Rastogi, Satish K Bhargava
6.71 D/D of Dwarfism 482
Sumeet Bhargava, Satish K Bhargava
6.72 Sclerotic Lesions of Bone 489
Ashish Verma, Sumeet Bhargava
6.73 Lytic Lesion in Bone 498
Satish K Bhargava, Shuchi Bhatt
xxx Differential Diagnosis in Radiology
6.74 D/D of Generalized Osteoporosis 508
Sumeet Bhargava, Satish K Bhargava
6.75 Solitary Dense Vertebra 515
Pushpender Gupta, Satish K Bhargava
6.76 Acro-Osteolysis 517
Vinita Rathi, Sumeet Bhargava
6.77 Sacroiliitis 522
Satish K Bhargava
6.78 Bone Cyst 529
Satish K Bhargava, Anubhav Sarikwal

7. Urogenital System 544

7.1 Adult and Neonatal Kidney—Difference 544
Sumeet Bhargava, Satish K Bhargava
7.2 Smooth, Small Kidneys 544
Rajul Rastogi, Satish K Bhargava
7.3 Small, Smooth Kidneys 549
Shuchi Bhatt, Ashish Verma
7.4 Small, Irregular Kidneys 553
Satish K Bhargava, Rajul Rastogi
7.5 Large Smooth Kidneys 557
Sumeet Bhargava, Rajul Rastogi, Satish K Bhargava
7.6 Bilateral Large Smooth Kidneys 562
Sumeet Bhargava, Satish K Bhargava
7.7 Nonvisualization of a Kidney During Excretion Urography 570
Satish K Bhargava
7.8 Dilated Calyx and Dilated Ureter 575
Pardeep Kumar, Shuchi Bhatt
7.9 Gas in Urinary Tract 580
Satish K Bhargava, Sumeet Bhargava
7.10 Loss of Renal Outline on Plain Film 583
Sumeet Bhargava, Satish K Bhargava
7.11 Renovascular Hypertension 585
Sumeet Bhargava
 Contents xxxi
7.12 Renal Calcification 589
Sumeet Bhargava, Satish K Bhargava
7.13 Renal Mass 594
Sumeet Bhargava, Satish K Bhargava, Pushpender Gupta
7.14 Cystic Disease of the Kidneys 605
Sumeet Bhargava, Satish K Bhargava
7.15 Carcinoma of the Bladder 614
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
7.16 Bladder Outflow Obstruction 617
Rajul Rastogi, Shuchi Bhatt
7.17 Testicular Tumors 626
Rajul Rastogi, Shuchi Bhatt
7.18 Seminal Vesicle Calcification 630
Anubhav Sarikwal, Satish K Bhargava
7.19 Differential Diagnosis of Abnormal Nephrograms 632
Sumeet Bhargava, Mamta Motla, Shuchi Bhatt
7.20 Filling Defect in the Bladder 633
Mamta Motla, Satish K Bhargava
7.21 Carcinoma Prostate 634
Satish K Bhargava, Anubhav Sarikwal
7.22 The Prostate 644
Sumeet Bhargava, Shuchi Bhatt
7.23 D/D of Adrenal Mass 652
Sumeet Bhargava, Satish K Bhargava
7.24 Painless Hematuria 656
Satish K Bhargava, Ashish Verma

8. Head, Neck and Spine 663

8.1 Lucency in the Skull Vault—Without Sclerosis 663
Sumeet Bhargava, Satish K Bhargava
8.2 Lucency in the Skull Vault—With Surrounding Sclerosis 666
Sumeet Bhargava, Satish K Bhargava
8.3 Thickening of the Skull Vault 668
Vinita Rathi, Sumeet Bhargava
xxxii Differential Diagnosis in Radiology
8.4 Generalized Increase in Density of Skull Vault 671
Sumeet Bhargava, Satish K Bhargava
8.5 Localized Increase in Density of the Skull Vault 674
Sumeet Bhargava, Satish K Bhargava
8.6 Destruction of Petrous Bone (Apex) 677
Sumeet Bhargava, Satish K Bhargava
8.7 Basilar Invagination 678
Sumeet Bhargava, Satish K Bhargava
8.8 Hair on End Skull Vault 681
Rajul Rastogi, Satish K Bhargava
8.9 Multiple Wormian Bones 683
Sumeet Bhargava, Satish K Bhargava
8.10 Posterior Fossa Cyst and Cyst-like Masses 685
Sumeet Bhargava, Satish K Bhargava
8.11 Enlarged Sylvian Fissure/Middle Cranial Fossa of CSF Density 687
Sumeet Bhargava, Satish K Bhargava
8.12 Skull Base and Cavernous Sinus 689
Sumeet Bhargava, Satish K Bhargava
8.13 Central Skull Base Lesions 692
Sumeet Bhargava, Satish K Bhargava
8.14 Cerebellopontine Angle Mass 694
Sumeet Bhargava, Satish K Bhargava
8.15 Suprasellar Mass 698
Sumeet Bhargava, Satish K Bhargava
8.16 Sellar and Suprasellar Masses 703
Sumeet Bhargava, Satish K Bhargava
8.17 Expanded Pituitary Fossa 712
Sumeet Bhargava, Satish K Bhargava
8.18 Ring Enhancing Lesions on CECT 716
Sumeet Bhargava, Satish K Bhargava
8.19 Superior Orbital Fissure Enlargement 718
Sumeet Bhargava, Satish K Bhargava
8.20 Temporal Bone Sclerosis 725
Sumeet Bhargava, Satish K Bhargava
 Contents xxxiii
8.21 IV Disc Space Calcification 730
Satish K Bhargava, Sumeet Bhargava
8.22 Ivory Vertebral Body 731
Sumeet Bhargava, Satish K Bhargava
8.23 Atlantoaxial Subluxation 733
Sumeet Bhargava, Satish K Bhargava
8.24 Posterior Scalloping of Vertebral Body 734
Sumeet Bhargava, Satish K Bhargava
8.25 Anterior Scalloping of Vertebral Body 736
Sumeet Bhargava, Satish K Bhargava
8.26 Anterior Vertebral Body Beaks 738
Sumeet Bhargava, Satish K Bhargava
8.27 Block Vertebra 739
Sumeet Bhargava, Satish K Bhargava
8.28 Enlarged Vertebral Body 742
Sumeet Bhargava, Satish K Bhargava
8.29 Solitary Collapsed Vertebra 743
Sumeet Bhargava, Satish K Bhargava
8.30 Multiple Collapsed Vertebrae 746
Sumeet Bhargava, Satish K Bhargava
8.31 Intraspinal Mass 749
Sumeet Bhargava, Satish K Bhargava
8.32 Differential Diagnosis of Posterior Fossa Cysts 755
Sumeet Bhargava, Satish K Bhargava
8.33 Enlarged Optic Foramen 758
Pardeep Kumar, Satish K Bhargava, Rajul Rastogi
8.34 Bare Orbit/Hypoplasia of Greater Wing of Sphenoid 760
Rajul Rastogi, Shuchi Bhatt
8.35 Orbital Hyperostosis 763
Rajul Rastogi, Sumeet Bhargava
8.36 Cephaloceles 766
Sumeet Bhargava, Satish K Bhargava
8.37 Pathological Intracranial Calcification 769
Rajul Rastogi, Shuchi Bhatt
xxxiv Differential Diagnosis in Radiology
8.38 J-shaped Sella 777
Sumeet Bhargava
8.39 Cerebellar Malformations 780
Pardeep Kumar, Satish K Bhargava
8.40 Demyelinating Disorders 783
Anubhav Sarikwal, Satish K Bhargava
8.41 Prevertebral Soft Tissue Thickening 795
Pushpender Gupta, Shuchi Bhatt
8.42 Nasopharyngeal Masses 799
Pardeep Kumar, Satish K Bhargava
8.43 Laryngeal Masses 804
Satish K Bhargava, Anubhav Sarikwal
8.44 Orbital Masses 806
Rajul Rastogi, Satish K Bhargava
8.45 Ocular Masses 815
Rajul Rastogi, Satish K Bhargava
8.46 Inner Ear Masses 819
Sumeet Bhargava, Satish K Bhargava, Rajeev Chaturvedi
8.47 Middle Ear Masses 823
Satish K Bhargava, Ashish Verma, Shuchi Bhatt
8.48 External Acoustic Masses 828
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
8.49 Intramedullary Lesions 832
Rajeev Chaturvedi, Satish K Bhargava
8.50 Intradural Extramedullary Masses 838
Satish K Bhargava, Pushpender Gupta
8.51 Extradural Extramedullary Lesion 844
Rajul Rastogi, Shuchi Bhatt
8.52 D/D of Floating Teeth 851
Pushpender Gupta, Sumeet Bhargava, Satish K Bhargava
8.53 Cysts of Jaw 855
Sumeet Bhargava, Ashish Verma, Satish K Bhargava
 Contents xxxv
8.54 Loss of Lamina Dura of Teeth 860
Rajul Rastogi, Vinita Rathi
8.55 Opaque Maxillary Antrum 865
Rajul Rastogi, Satish K Bhargava
8.56 Thyroid Lesions 868
Rajul Rastogi, Shuchi Bhatt

9. Obstetrics and Gynecology 882

9.1 D/D Between Blighted Ovum and
Pseudogestation of Ectopic Pregnancy 882
OP Sharma
9.2 D/D Between Ectopic Pregnancy,
Abortion in Progress (Early Gestation) and Nabothian Cysts 883
OP Sharma
9.3 D/D Between Partial Mole, IUFD with Hydropic Placental
Degeneration, Twin Pregnancy (Mole and Fetus) 884
OP Sharma
9.4 D/D Between Pelvic Masses, Extruded Fetal
Parts With Uterine Perforation; Ectopic Pregnancy
(Postpartum/Intervention) 884
OP Sharma, Rajul Rastogi
9.5 D/D of a Presacral Fetal Mass 885
OP Sharma, Rajul Rastogi
9.6 Fetal Neck Masses 887
OP Sharma, Rajul Rastogi
9.7 D/D of Fetal Renal Cystic Diseases 888
OP Sharma, Rajul Rastogi
9.8 D/D of Various Fetal Anterior Abdominal Wall Defects 889
OP Sharma
9.9 D/D Between Renal Cyst and Hydronephrosis 890
OP Sharma, Rajul Rastogi
9.10 D/D of Cystic Adnexal Masses 890
OP Sharma, Rajul Rastogi
xxxvi Differential Diagnosis in Radiology
9.11 D/D of Benign and Malignant Ovarian Masses 891
OP Sharma
9.12 D/D of Cystic Abdominal Masses 891
OP Sharma
9.13 D/D of Non-gynecological Pelvic Masses 893
Ashish Verma, Sumeet Bhargava, Satish K Bhargava
9.14 D/D of Non-ovarian Adnexal Mass 893
Ashish Verma, Sumeet Bhargava, Satish K Bhargava
9.15 D/D of Ovarian Masses 894
Ashish Verma, Sumeet Bhargava, Satish K Bhargava
9.16 Sonographic Classification of Adnexal Masses 898
Ashish Verma, Sumeet Bhargava, Satish K Bhargava
9.17 Absent Intrauterine Pregnancy with Positive Pregnancy Test 901
Ashish Verma, Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
9.18 D/D of Thickened Placenta 903
Ashish Verma, Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
9.19 Ultrasound Signs of Chromosomal Abnormality 905
Ashish Verma, Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
9.20 D/D of Enlarged Uterus 908
Ashish Verma, Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
9.21 Cystic Structures in Fetal Abdomen 910
Satish K Bhargava, Sumeet Bhargava, Ashish Verma, Rajul Rastogi
9.22 D/D of Fetal Hydrops 912
Satish K Bhargava, Sumeet Bhargava, Ashish Verma, Rajul Rastogi
9.23 D/D of Fetal Brain and Head Abnormalities 914
Satish K Bhargava, Ashish Verma, Rajul Rastogi, Sumeet Bhargava
9.24 D/D of Brain and Head Abnormality 917
Satish K Bhargava, Ashish Verma, Rajul Rastogi, Sumeet Bhargava
9.25 D/D of Thickened Endometrium 918
Sumeet Bhargava, Satish K Bhargava, Ashish Verma
9.26 USG Signs in Abortions 920
Satish K Bhargava, Ashish Verma
 Contents xxxvii
9.27 D/D of Fetal Causes of Abnormality in Liqor Volume 922
Satish K Bhargava, Ashish Verma
9.28 D/D of Gas in the Genital Tract 928
Satish K Bhargava, Ashish Verma
9.29 D/D of Fetal Intra-abdominal Calcification 929
Satish K Bhargava, Ashish Verma
9.30 D/D of Fetal Thoracic Abnormalities 931
Satish K Bhargava, Ashish Verma

Index 935

CHAPTER 1

Chest

1.1  LESIONS OF THORACIC INLET

Anatomy of Thoracic Inlet

• Thoracic inlet/root of neck is a narrow space that serves as a
junction between the neck and the thorax
• Boundaries are:
Anteriorly:
Manubrium
Posteriorly:
First thoracic vertebra
Laterally:
First ribs.
• This area is further delineated by Sibson’s fascia which extends
from the transverse process of C7 vertebra to the medial border
of first rib
• Plane of the thoracic inlet is tilted downward anteriorly and
laterally on either side being highest medially and posteriorly
(Fig. 1.1).

Differential Diagnosis of Lesions at Thoracic Inlet

1. Congenital lesions:
Lymphangioma
Hemangioma
Cervical extension of mediastinal thymus
Thymic cyst
Vascular anomalies.
2 Differential Diagnosis in Radiology

Fig. 1.1: Thoracic inlet

2. Inflammatory lesions:
Inflammatory adenopathy—tuberculosis, mononucleosis, HIV
infection, etc.
Cervical abscess
Tubercular spondylitis with abscess
Retropharyngeal abscess with mediastinal extension.
3. Benign tumors:
Lipoma
Lipoblastoma
Schwannomas and neurofibromas
Fibromatosis.
4. Malignant tumors:
Lymphoma
Neuroblastoma
Thyroid carcinoma
Pancoast’s tumor
Lymph node metastasis
Liposarcoma
Metastasis to thoracic vertebra and ribs.
 Chest 3
5. Traumatic lesions:
Pneumomediastinum
Esophageal foreign body
Cervicothoracic hematoma.
6. Miscellaneous:
Cervical rib (Fig. 1.2)
– Thoracic outlet syndrome
– Intrathoracic goiter (Fig. 1.3).

Lymphangioma
Develops from congenital obstruction of lymphatic drainage.
Tends to surround and invade normal anatomical structures. Five
percent occur in neck (posterior triangle); 3–10% extends into

Fig. 1.2: Anteroposterior radiograph of cervical spine shows cervical rib

arising from C7 on the left side forming pseudoarthrosis with left first rib
4 Differential Diagnosis in Radiology

Fig. 1.3: Anteroposterior radiograph of chest shows superior mediastinal

widening caused by enlarged thyroid gland with a large calcification in its
right lobe

mediastinum, asymptomatic and painless masses, 90% detected

by two years of age.
Imaging: Multilocular trans-septal masses of fluid attenuation, walls
of septa-enhance (if history of surgery/infection). Occasionally
hemorrhagic areas and fluid-fluid levels are present.

Hemangiomas
Benign masses composed of proliferating endothelial cells
characteristically increase in size and gradually involute. It most
commonly occurs in the first year of life.
Imaging: Calcified phleboliths within the mass may be present.
Enhance with adjacent vascular structure and fill with contrast
over a short time.
 Chest 5
MRI: Intermediate SI on T1WI and high SI on T2WI, fatty replacement
may be present.

Cervical Extension of Mediastinal Thymus

• Due to incomplete mediastinal descent and manifests as solid
midline thymus at thoracic inlet
• Diagnosis is made on the basis of homogenous SI similar to that
of the thymus with all MR imaging sequences or connection to
the normally located thymus.

Thymic Cyst
• Caused by persistence or degeneration of the thymopharyn-
geal ducts
• 50% of cervical thymic cysts are continuous with mediastinal
masses. Most commonly seen on the left side.
Computed Tomography (CT): Well-marginated, unilocular/multi-
locular, attenuation is close to water.
Magnetic Resonance (MR): Decrease SI on T1WI and intermediate/
high SI on T2WI.
• SI on T1WI may increase if cyst contains blood/protein.
• Then septa may be present
• When these cysts occur in the neck, they are located partially
within the carotid sheath
• Most thymic cysts are congenital but they have also been
reported with infection, neoplasms, radiation therapy, trauma
and thoracotomy.

Vascular Anomalies
• Venous malformations and AVM are rarely seen in the neck
• Jugular vein thrombosis occurs after placement of a central
catheter or in association with compressive lesion and is seen
as luminal obstruction with thin rim of enhancement of the
vasa vasorum
6 Differential Diagnosis in Radiology
• Cervical aortic arch—High-positioned, usually right-sided
aortic arch. Occasionally associated with other cardiac and
vascular anomalies, patient presents with respiratory problems/
dysphagia
• A pulsatile mass is found in the neck.

Cervical Abscess
• Cervical abscesses seldom cross the thoracic inlet into the
mediastinum
• Infection in the visceral space may extend into the anterior
mediastinum, whereas infection in the retropharyngeal and
prevertebral spaces may extend into the posterior mediastinum.
Imaging is required to distinguish cellulitis and suppuration
adenopathy from the abscesses which require surgical treatment.
In suppuration-focal hypoattenuating mass with an enhancing
rim on CECT and a complete hypoechoic to anechoic mass with
a variable thick rim of solid tissue is seen on ultrasound scans. In
fluid collection—SI on MR varies according to protein content, skin
thickening and reticulated fat planes may be seen adjacent to the
abscess margins in CT and MR.

Tuberculous Spondylitis with Abscess Formation

• Infection usually starts anteriorly in the vertebral body
• In 90% cases, at least two vertebrae are affected
• Skip lesions occur in 4% cases
• Paraspinal abscesses are present in 55–90% cases
• Imaging features:
– Vertebral body destruction
– Loss of disc space
– Paraspinal abscess
– Prevertebral and epidural collections
– Paraspinal calcification.
• In the neck—dysphagia, hoarseness and lymphadenopathy are
the accompanying features.
 Chest 7
Retropharyngeal Abscess with Mediastinal
Extension

Causes of Retropharyngeal Abscess

• Tonsillar infection
• Iatrogenic/traumatic
• Perforation of pharynx.
X-ray neck soft tissue: Retropharyngeal soft tissue thickening,
forward displacement of airway.
CT/MR: Retropharyngeal collection continuing into the post-
mediastinum through the thoracic inlet.

Lipoma
• Most common cervical neoplasms of mesenchymal origin
• Typically present as painless slowly-growing masses, most
commonly occurring in posterior triangle.
CT: Homogeneous non-enhancing mass, isodense with subcutaneous
fat, usually well-encapsulated lesions (–10 to –100 HU).
MRI: SI similar to subcutaneous fat (increase on T1WI, intermediate
SI on T2WI and loss of SI on fat suppressed MR images).

Lipoblastoma
Rare, usually encapsulated benign neoplasm of the embryonal
fat. Composed of mature and immature fat and found almost
exclusively in infants (90% <3 years) and children.
Most common site—Extremities → trunk → head → neck.
CT: Fat separated by septa of soft tissue which does not enhance.
MR: Heterogeneous and have intermediate to high SI on T1WI
according to the amount of immature fat. On fat suppressed
images—area of high SI is suggestive lipoblastoma.
8 Differential Diagnosis in Radiology

Schwannomas and Neurofibromas

• Common sites are—vagus nerve, ventral and cervical nerve
roots, cervical sympathetic chains and brachial plexus
• Plexiform neurofibromas are pathognomonic of Type I
neurofibromatosis.
CT: Hypo to isoattenuating at CT. Contrast enhancement is more
often seen with schwannomas.
MR: Low to intermediate SI on T1WI and intermediate to high
SI on T2WI. They show non-uniform enhancement. Plexiform
neurofibromas usually involve cartilaginous soft tissue.
• Malignant degeneration is seen in 15–30% cases
• Tumors arising in vagus nerve displace the common carotid
and internal carotid arteries. Anteromedially and the internal
jugular vein posterolaterally
• Sympathetic chain tumors demonstrate a constant relationship
with the longus colli muscle
• Brachial plexus tumors displace the anterior scalene muscle
anteriorly.

Aggressive Fibromatosis
• Characterized by proliferation of fibrous tissue with locally
aggressive behavior and a tendency toward recurrence after
resection
• Etiology is unknown
• Appearance on MR is often infiltrative and can suggest
malignancy. Usually has decreased SI on T1 and T2WI that
permits diagnosis.

Lymphoma
• Hodgkin’s disease accounts for majority of lymphomatous
anterior mediastinal masses and the neoplastic cells typically
infiltrate the thymus
 Chest 9
• Thymic involvement is always accompanied by involvement of
mediastinal lymph node
• Lymphoma of neck involves cervical lymph node chain,
Waldeyer’s tonsillar ring and lymphoid tissue at the base of
tongue. Such lymphoma is most often of the non-Hodgkin’s
type
• Calcification and necrosis can be seen if lymphoma was treated
previously.

Thyroid Carcinoma
• Papillary carcinoma accounts for 75–90% of all the cases and is
especially prevalent in younger patients
• Medullary, follicular and anaplastic carcinoma account for 10–
25%
• Usually evaluated by ultrasound or scintigraphy. CT/MR is
required to evaluate tumoral extent when malignant tumors
are suspected
• Difficult to distinguish benign from malignant nodule because
the findings are non-specific. However, thyroid masses
with infiltrating margins that obscure soft tissue plane and
associated with adenopathy are suggestive of carcinoma
• Cold nodules on scintigraphy have a higher frequency of
malignancy
• MR is preferred as compared to CT because iodine administered
during CT can cause iodine 131 therapy to be postponed for up
to 6 months after the removal of maximum tumor volume.

Neuroblastoma
• 10–15% neuroblastomas are located in posterior mediastinum.
More than 5% neuroblastomas arise in the neck
• Arise from the renal cell rest blasts located in the adrenal gland
or sympathetic chain
• Osteochondritis and ipsilateral Horner’s syndrome are related
to lesion of cervical sympathetic nerve
10 Differential Diagnosis in Radiology
• 50% neuroblastoma shows calcification on X-ray
• 90% show calcification on CT
• MR imaging is the modality of choice for demonstrating the full
extent of mass, chest wall invasion and extra-adrenal intraspinal
involvement
• Lymph nodes involved are deep cervical lymph nodes along
the internal jugular vein, supraclavicular lymph node, scalene
nodes, and highest lymph node in superior mediastinum.

Pancoast’s Tumor
• Pancoast’s syndrome consists of a constellation of signs
and symptoms that include shoulder and arm pain in the
distribution of C8, T1 and T2 nerve roots, Horner’s syndrome
and atrophy of hand muscle
• This is caused by tumor in lung apex (squamous cell carcinoma)
which is causing invasion of the chest wall, and prevertebral
sympathetic chain or the inferior or stellate ganglion
• This tumor should be ruled out if unilateral pleural thickening
or asymmetric thickening > 5mm is noted on chest X-ray.
Metastases: (to rib and thoracic vertebra).
• Usually has a mixed pattern: Breast/lung
• Blastic—Prostate
• Lytic—Thyroid, kidney
• Vertebra—Pedicles and vertebral body are involved
• Ribs—Lesions are recognized early when the rib is expanded.

Pneumomediastinum
Air can travel from the mediastinum along the fascial planes to the
neck; subcutaneous tissue and chest wall.
Most common causes in children are asthma, aspiration of
foreign body and trauma.
 Chest 11
Esophageal—foreign body granuloma.
• Most commonly seen in infants and children
• Most common site of retention is the upper esophagus at the
thoracic inlet
• Long standing foreign body produces a granulomatous tissue
reaction that manifests as a mass
• Mediastinitis and abscess can be seen in this region as a
complication of foreign body perforation.

Cervicothoracic Hematoma

Causes
• Trauma
• Faulty placement of central catheter
• Hematomas are usually trans-spatial lesions.

Computed Tomography (CT)

• Hyperdense in acute phase
• Hypodense in chronic phase and on MR SI varies depending on
the phase.

Cervical Rib
• Seen in 1% of population
• Symptomatic in 10%
• Unilateral in 50–80%
• Cervical ribs vary in length and may be connected to the first
rib by a fibrous band
• Cervical rib may affect the brachial plexus in any one of the
following two ways:
a. May narrow the space between the posterior aspect of first
rib and anterior scalene muscle through which the nerve and
subclavian artery passes.
or
12 Differential Diagnosis in Radiology
b. Cervical rib may be situated such that a portion of the brachial
plexus must pass over it, thereby stretching the lower trunks.
• Results in cervical rib syndrome—Sensory symptoms
usually antedate motor involvement and occur along the
ulnar border of forearm and hand
• Muscle wasting of Thenar eminence.

Thoracic Outlet Syndrome

Because of compression of the subclavian artery and C8/T1 nerve.

Usual Causes
• Cervical rib
• Elongated transverse process of C7
• Fibrous band extending from transverse process of C7 to the
first rib
• Low set shoulder girdle
• Pancoast’s tumor.

Intrathoracic Goiter
Characterized by:
• Continuity with cervical thyroid gland
• Marked enhancement on CECT
• Well-defined margins
• Inhomogeneity
• Focal calcification.

CYSTIC LYMPHANGIOMA
Detected by two years of age and seen to extend from posterior
triangle multilocular cystic mass.

Thymic Cyst
Unilocular/multilocular cystic mass seen in continuation with
thymus.
 Chest 13
Cervical Abscess
Hypodense collection with enhancing rim with adjacent
reticulated fat plane.

Pott’s Spine with Abscess

Vertebral body destruction with loss of IVD space with adjacent
collection and calcification.

SOLID WITH FAT DENSITY (FLOW CHART 1.1)

Lipoma
• Painless progressive mass, well-encapsulated isointense to fat.

Liposarcoma
• Fast growing; adults
• Soft tissue admixed with fat.

Lipoblastoma
• 90% <3 years
• Areas of increase SI on T2WI
• Fat separated by septa.

Flow chart 1.1: Lesions of thoracic inlet

14 Differential Diagnosis in Radiology

SOLID WITHOUT FAT DENSITY

Schwannoma and Neurofibroma

• Plexiform neurofibroma associated with neurofibroma.

Neuroblastoma
• Arises from sympathetic chain
• Children
• Calcification present in 90%
• Horner’s syndrome.

Thyroid Carcinoma
• Mass is contiguous with thyroid and has infiltrating margins
and obscures soft tissue plane.

Pancoast’s Tumor
Mass lesion in lung apex with destruction of first rib.
• Patient presents with Pancoast’s syndrome.

Metastatic Lymph Node Mass

Primary lesion can be localized.

Others

Hemangioma
• Compressible mass lesion, multiple small cystic spaces,
phlebolith is present, vascular enhancement is present.

Cervical Rib
Extra rib is seen to arise from transverse process of C7.
 Chest 15
1.2  MEDIASTINAL MASSES (TABLE 1.1)

Mediastinum
Anterior mediastinal masses
Thyroid Tumor (Table 1.2):
1. Non-toxic enlargement of the gland.
2. Thyrotoxicosis.
3. CA thyroid.
4. Hashimoto’s disease.

Thymic Tumors
Normal thymic shadow : Triangular soft tissue mass that
projects to one side of the
mediastinum.
Prominent : • On expiratory film
• Slightly rotated film
Disappears : • Severe neonatal infection
• After major surgery
• Use of steroids.

Commonest Tumors of Mediastinum (Table 1.1)

1. Thymoma
a. Benign
b. Malignant 30%.
2. Hyperplasia of the gland.
3. Thymic cyst.
4. Thymolipoma.
5. Lymphoma.
6. Germ cell tumor.
7. Carcinoids.

Teratodermoid Tumors
• Dermoid cyst
• Teratoma
16 Differential Diagnosis in Radiology
– Benign
– Malignant
• All arise from the primitive germ cell nests in the urogenital ridge
• Dermoid cyst contains mainly ectodermal tissues.

Table 1.1: Tumors of mediastinum (both common and rare)

Common Rare
Anterior
1.  •  Tortuous innominate artery •  Innominate artery aneurysm
  •  Lymph node •  Parathyroid adenoma
  •  Retrosternal goiter •  Lymphangioma
  •  Fat deposition
2.  •  Lymph node enlargement •  Sternal mass
  •  Aneurysm of ascending aorta •  Lipoma
  •  Thymoma •  Hemangioma
  •  Teratoma
3.  •  Epicardial fat pad •  Morgagni hernia
  •  Diaphragmatic hump
  •  Pleuropericardial cyst
Middle
4.  • Lymph node enlargement •  Tracheal lesion
  • Aortic arch aneurysm •  Cardiac tumor
  • Enlarged pulmonary artery
  •  Dilatation of SVC
  •  Bronchogenic cyst
Posterior
5.  •  Neurogenic tumor
   Pharyngoesophageal pouch
6.  • Aneurysm of descending •  Neurenteric cyst
aorta •  Pancreatic pseudocyst
  •  Esophageal dilatation •  Sequestrated lung
  •  Azygous dilatation
  •  Hiatus hernia
7.  •  Neurogenic tumor •  Bochdalek hernia
  •  Paravertebral mass •  Extramedullary hemopoiesis
 Chest 17
• Solid teratoma contains tissues of ectodermal, mesodermal
and endodermal origins.
Dermoid cyst appears as a round or oval soft tissue mass,
which may show peripheral rim or central nodular calcification.
A fat fluid level or a rudimentary tooth is diagnostic radiological
sign. Teratoma appears as a lobulated soft tissue mass which on
CT shows a mass of mixed attenuation containing soft tissue, cyst
fluid, fat, calcification of bone.

PLEUROPERICARDIAL CYST
• Anterior mediastinal mass
• 75% occur in right anterior cardiophrenic angle
• Cysts have thin walls, which contain clear fluid
• These change shape with respiration.

Table 1.2: Differential diagnosis of retrosternal goitre

Non-toxic Thyro- CA Hashi-
enlargement toxicosis thyroid moto’s
of thyroid disease
A. Vocal cord – – + –
involvement
B. SVC – – + –
compression
C.  Calcification +/– – +/– –
D. Rapid increase Hemorrhage -do- ++ –
in size cyst
E. Symptom severity +/– Clinical + –
manifes-
tation
F.  Orbital lesion – + – –
18 Differential Diagnosis in Radiology

DIFFERENTIAL DIAGNOSIS OF
SOFT TISSUE LESIONS IN RIGHT
ANTERIOR CARDIOPHRENIC ANGLE (TABLE 1.4)

Morgagni Hernia
• Persistent developmental defect in the diaphragm anteriorly.
• Anterior mediastinal mass.
• May contain omentum or transverse colon.
• Appears as a soft tissue mass
• Containing either gas or air-fluid level or fat.
• Diagnosis is confirmed by barium meal and follow through or
barium enema.

MIDDLE MEDIASTINAL MASSES

Lymph Node Enlargement
Metastatic (Table 1.3)
• Intrathoracic:
– Bronchial CA
– Esophageal CA.
• Extrathoracic:
– Breast, renal
– Adrenal, testicular
– Tumors of pharynx and larynx.
Table 1.3: Metastatic lymph nodes
Head and neck squamous cell Renal cell carcinoma
carcinoma
Breast carcinoma Seminoma
Melanomas Mucinous adenocarcinoma of GIT
Neuroblastomas Nasopharyngeal carcinoma
Rhabdomyosarcomas Thyroid carcinoma
Small cell carcinoma of lung Ovarian and prostate carcinoma
Table 1.4:  Differential diagnosis of soft tissue lesions in right anterior cardiophrenic angle

Change Density Content Separate from Silhouette

shape with pericardium sign
respiration
A. Pleuropericardial + Soft tissue Fluid + +
cyst
B.  Epicardial fat pad – Fatty Fat + +
C. Partial eventration + Soft tissue Diaphragm contour + –
of right hemidia-
phragm
D. Right middle lobe – Soft tissue Lung + +
pathology
E.  Morgagni hernia – Fat if Omentum + Omentum + +
F.  Right atrial tumor – Soft tissue Soft tissue + –
G.  Pericardial lesion – -do- Soft tissue fluid – +
Chest
19
20 Differential Diagnosis in Radiology
• Lymphoma
• Leukemia
• Sarcoidosis: Bilateral hilar masses with well-defined outline.
These show egg shell calcification
• Primary tuberculous infection produces an area of consolidation
in one of the lobes with unilateral hilar mass and an associated
pleural effusion
• Low attenuation areas due to cyst formation or necrosis are
seen in lymph nodes involved with Hodgkin’s disease and
metastatic testicular or squamous cell tumors, particularly after
treatment with radiotherapy or chemotherapy.

Aortic Aneurysm (Fig. 1.4)

This produces either widening of the mediastinum or a round
or oval soft tissue mass in any part of the mediastinum with a

Fig. 1.4: Posteroanterior radiograph of chest shows aneurysm of arch of

aorta. Incidental note is made of the fibrotic changes in the left upper lobe
 Chest 21
well-defined outline. Curvilinear or peripheral calcification may be
due to syphilitic aortitis or atherosclerosis. It may cause pressure
erosion defect of the sternum or anterior scalloping of one or
two vertebral bodies. The subintimal flap and false lumen of a
dissecting aneurysm can be demonstrated by CT.

Tortuous Innominate Artery

It occurs in 20% of the elderly patients with hypertension and
produces widening of the superior part of the mediastinum on the
right without displacement of the trachea to the left.

Bronchogenic Cyst
• Middle or posterior mediastinal mass
• Majority occur around the carina in the paratracheal,
tracheobronchial or subcarinal region
• Can alter in shape on respiration
• Pericardial defect may occur in association.

Tracheal Tumors
Tracheal tumors include carcinoma, plasmacytoma. They narrow
the tracheal lumen and appear as soft tissue mass.

POSTERIOR MEDIASTINAL MASSES

Neurogenic Tumors (Table 1.5)

Table 1.5: Neurogenic tumors

Shape Calcification Dumb-bell
Neurofibroma Rounded +/– +
Neurilemmoma -do- – –
Neuroblastoma Elongated Central spicules or +
peripheral rim
22 Differential Diagnosis in Radiology

Adults
Neurofibroma
Neurilemmoma.

Children
Neuroblastoma.
• These may be asymptomatic or may produce back pain and may
even extend through an intervertebral foramen into the spinal
canal (dumb-bell tumors) to produce spinal cord compressions
• Involvement of the posterior ribs or adjacent thoracic
vertebrae—produce ribs splaying, localized pressure erosion
defect of one or two vertebral bodies and ribs notching.

HIATUS HERNIA
• Commonest cause of a mediastinal mass on a chest radiograph
in an elderly patient. It appears as a soft tissue mass with an air-
fluid level
• Lies to the left of the midline
• Contents could be liver, omentum and small intestine.

ESOPHAGEAL LESIONS
Present with dysphagia.
Pharyngoesophageal pouch: Soft tissue mass with an air-fluid level,
lies in the midline, displaces trachea forward.
Carcinoma/leiomyoma: Soft tissue mass with an air-fluid level,
behind the heart.
Achalasia: Large soft tissue mass with air-fluid level with barium
flowing in spurts. Pulmonary consolidation/bronchiectasis may be
present.
 Chest 23
PARAVERTEBRAL LESIONS
Involves the thoracic vertebrae or intervertebral disk space. They
appear as an elongated or lobulated soft tissue mass with a well-
defined outline.
Differential diagnosis would be:
• Hematoma
• Pyogenic abscess
• Tubercular abscess
• Multiple myeloma
• Lymphoma
• Metastasis
• Extramedullary hematopoiesis.

Bochdalek Hernia
• Its persistency develops mental defect in the diaphragm
posteriorly
• Occurs in the left hemidiaphragm
• Small hernias usually contain retroperitoneal fat, kidney or
spleen, that appear as a soft tissue mass in the posterior
costophrenic angle
• Larger hernias may contain jejunum, ileum and colon.

Neurenteric Cysts
Result due to partial or complete persistence of the neurenteric
canal or its incomplete resorption includes gastro-intestinal
duplication, enteric cyst, neurenteric cyst, anterior meningocele
and cysts of the canal.

Pancreatic Pseudocyst
• Posterior mediastinal mass
• Round/oval soft tissue mass behind the heart
• A left basal pleural effusion or atelectasis in the lower lobes
may result
24 Differential Diagnosis in Radiology
• Extramedullary hemopoiesis
• Appears as lobulated paravertebral soft tissue mass behind the
heart.

1.3  SUPERIOR MEDIASTINAL MASSES—

DIFFERENTIAL DIAGNOSIS

Contents
1. Trachea and esophagus.
2. Muscles—sternohyoid, sternothyroid and lower ends of longus
colli.
3. Anterior arch of aorta, brachiocephalic artery, ICC and left
subclavian artery.
4. Veins—right and left brachiocephalic vein, upper-half of SVC.
5. Nerves—vagus, phrenic, cardiac nerve, right laryngeal nerve.
6. Thymus.
7. Thoracic duct.
8. LNs—paratracheal, brachiocephalic, tuberculosis.

Criteria for Superior Mediastinum Widening

>8 cm in the transverse diameter.
>25% of the thoracic diameter at that level.
1. Retrosternal goiter: Less than 5% of enlarged thyroid in the
neck. Extend into mediastinum due to non-toxic enlargement,
thyrotoxicosis, carcinoma, Hashimoto’s disease (Table 1.3).
• Soft tissue swelling that moves on swallowing
• Dysphagia, stridor if benign, vocal cord paralysis or SVC
compression-malignancy
• Patients present soft tissue mass in anterior part;
extend down from the neck
• Outline well-defined in mediastinum but fades off into the
neck
• Displacement and compression of trachea to the left, 20%
are retrotracheal
 Chest 25

Fig. 1.5: Boundaries of superior mediastinum

• Ca++ nodules, linear or crescent pattern

• CT mass of mixed attenuation extending from one of the
lower poles of thyroid
• Radionuclide scan 99 Tc pertechnetate on 123I NaI
• MRI – Diagnostic.
2. Thymus—Normal thymus—most common in infants
• Most common in adult benign and malignant thymoma
• Associated with myasthenia gravis, red cells aplasia or
decreased granulocytes
• Plain X-ray chest –ve
• CT – Grossly asymmetrical lobular configuration.
– Homogenous with mild contrast enhancement.
– Less commonly decreased attenuation areas—
Hemorrhage/necrosis/cyst Ca++ occasionally.
• MRI = T1 = Med. SI, T2 ⇒ fat
26 Differential Diagnosis in Radiology
Thymic hyperplasia
• Seen in 2/3rd of myasthenia gravis
• CT = symmetric diffuse enlargement
• MR = same signal as normal gland
• Enlargement of thymus may also be seen in thymic cyst,
thymolipoma, lymphoma, germ cell tumor and carcinoid.
3. • Teratodermoid tumors/germ cell tumor—Extra-gonadal
germ cell tumor located within or adjacent to thymus
• Most common germ cell tumor in superior mediastinum is
dermoid cyst and benign and malignant teratoma. Chest
radiograph (CXR) may show round or oval soft mass with
well-defined border and may contain peripheral rim or
central nodules of Ca++.
• III On CT, fat fluid level, Ca++ calcifications, well-defined
border and soft tissue attenuation mass is highly suggestive
of germ cell tumor.
• Malignancy – more solid component and aggressive features.
4. • Lymph node enlargement (Fig. 1.5)
• Widened mediastinum may have lobulated margins in case
of LN enlargement
• Hodgkin/Non-Hodgkin disease—paratracheal and
tracheo-bronchial, asymmetrical widening of middle part
of superior mediastinum
– Associated feature—parenchymal lung disease
– Ca++ in LN seen after irradiation
• Tuberculosis—Unilateral paratracheal lymphadenopathy
without obvious mediastinum or pleural involvement seen
in immuno-compromised patients
• In an adult/children area of consolidation/caseation
• Fungal disease histoplasmosis, coccidioidomycosis,
blastomycosis
– Enlargement of hila or paratracheal LN
– Ca++ in healing histoplasmosis
Sarcoidosis—Bilateral lobulated hilar mass
 Chest 27

Fig. 1.6: PA radiograph of chest shows superior mediastinal widening

caused by right paratracheal adenopathy in a case of Koch’s chest

Metastasis
• Primary tumor is usually intrathoracic—Esophagus/
Bronchus
• Benign—in adult
Papilloma
Chordoma Ca++ smooth, well-defined and
fibroma < 2 cm in diameter
Hemangioma
• Mucus plug—decreased alternation, mixed with air and
will change in position and resolve after coughing
• Malignant—squamous cell carcinoma and adenoid cystic
Ca2 – Most commonly a smooth or irregular intraluminal
mass with asymmetry. Narrowing of tracheal lumen is seen.
5. Aneurysm and dissection of arch of aorta—true, pseudo, post-
traumatic atherosclerotic, post-traumatic elderly, fusiform.
• Younger, contained by adventitia only, saccular
• Clinical presentation → Asymptomatic
• Symptoms—enlarged compresses adjacent structure
• C × R = Widening with or without Ca++
28 Differential Diagnosis in Radiology
• CT = Saccular and fusiform dilatation of segment of aorta
• –>4cm; use short-axis diameter
• Ca++ in aortic wall, peripheral
• Intraluminal thrombus—crescentic/circumferential
• Displacement of adjacent structure = Trachea, bronchus
and pulmonary artery, superior vena cava, esophagus,
bony erosion, growth rate 5.6 cm/year
Aortic dissection emergency situation:
• Peak 7th–8th decade
• Most common predisposing condition is hypertension–
congenital heart disease, coarctation, bicuspid AV
• Intimal tear—blood enters into the aortic wall and creates
a false and true lumen
• CXR wide mediastinum aortic contour displaced, intimal
Ca++
• CT = Internal displacement or intimal Ca++
• Visible internal flap increased in attenuation
• High density thrombus in false lumen if actue hemorrhage
• CECT—contrast-filled true and false lumen separated by
intimal flap
• Delayed enhancement of false lumen because of slow flow
• MR—very well-demonstrate the intimal flap
• Aortography—Highly accurate.
6. • Dilatation of SVC and other veins
• Dilatation of SVC seen in raised CVP
• CCF
• Tricuspid valve disease
• Mediastinal mass
• Constrictive pericarditis
• TAPVD—Supracardiac variety. All the pulmonary veins
open into large ascending vein on the left side which is a
remnant of embryonic. Left SVC. This connects into the left
brachiocephalic vein which then passes into the right-sided
SVC and into the RA.
7. • A pharyngoesophageal pouch/Zenker’s diverticulum
• CXR = Soft tissue mass in posterior part of superior
mediastinum which contains an air-fluid level.
 Chest 29
• Soft tissue mass lies in the midline and displaces the trachea
forward
• Barium-esophagogram—confirm the diagnoses.
8. • Fat deposition—superior mediastinum widening and
epicardial fat pad seen in obese adult patients, Cushing’s
disease, steroid therapy
• CT = shows an excessive amount of mediastinal fat
9. • Tracheal mass—positive with non-specific symptoms like
cough, dyspnea, stridor, wheezing
• CXR = Not very helpful
• Benign – in adult
• Papilloma
• Chordoma Ca++ Smooth well-defined and < 2cm in
• Fibroma diameter
• Hemangioma
• Mucus plug—decrease attenuation, mixed with air and will
change in position and resolve after coughing
• Malignant—Squamous cell carcinoma and adenoid cystic
carcinoma are most common
• A smooth or irregular intraluminal mass with asymmetric
narrowing of tracheae lumen is seen.
10. • Neurogenic tumor:
• Adult—NF and schwannoma—peripheral intercostal nerve
children—ganglioneuroma and neuroblastoma—which
arise is thoracic sympathetic ganglia
• CXR—A round or oval soft tissue mass in paravertebral
gutter which usually project to one side of mediastinum
• Neuroblastoma—Central spicules or peripheral rim Ca++
splaying of posterior ribs
• Pressure erosion and defect of vertebral bodies
• Rib notching
• Enlargement of an intervertebral foramen
• CT = solid mass of soft tissue attenuation, may contain
Ca++ and involve the adjacent bone
• MRI = intraspinal extension
• MRI = transaxial SE
• GRF/phase velocity mapping.
30 Differential Diagnosis in Radiology

1.4  DIFFERENTIAL DIAGNOSIS OF

ANTERIOR MEDIASTINAL MASS
Anterior mediastinum lies anterior to anterior pericardium and
trachea. For ease of differential diagnosis, it can be divided into
three areas (Table 1.6).

Salient Features

Region 1 (Fig. 1.7)

1. Thyroid tumor (Retrosternal goiter)
– Less than 5% goiters extend into the mediastinum.
– Mostly females presenting with soft tissue swelling,
dysphagia, stridor.
– Chest X-ray shows oval soft tissue mass in superior part of
anterior mediastinum fading off into the neck.
– Well-defined smooth or lobulated.
– Central nodular, linear calcification.
– Displacement and compression of trachea.

Table 1.6: Differential diagnosis of anterior mediastinal lesion

Region 1 Region 2 Region 3
• Tortuous innomi- •  L N enlargement •  Epicardial fat pad
nate artery
• Lymph nodes •  Aneurysm of aorta • Diaphragmatic hump
•  Retrosternal goiter • Thymoma tumors • Pleuropericardial
cyst
•  Fat deposition • Teratodermoid •  Morgagni’s hernia
• Aneurysm of • Sternal mass
innominate artery lipoma
• Parathyroid •  Hemangioma
adenoma
• Cystic hygroma or
lymphangioma
 Chest 31
– CT shows mass of mixed attenuation with cysts and
calcifications, contiguous with one of the poles of thyroid.
2. Lymph node enlargement
May be due to lymphoma, metastasis or infection.
– Widening of mediastinum on chest X-ray.
– Lobulated soft tissue mass due to indentation by ribs.
– Calcification may be present.
– Lymphadenopathy elsewhere in the body.
– CT shows discrete round or slightly irregular densities of
various sizes +/– enhancement and necrosis.
3. Fat deposition
– Cushing’s disease, corticosteroid therapy.
– Widening of superior mediastinum on chest X-ray.
– CT shows excessive amount of mediastinal fat with density
– 50–100 HU.
4. Tortuous innominate artery or aneurysm
– Common in elderly.
– Widening of superior mediastinum.
– CT shows dilatation of innominate artery.
5. Lymphangioma/cystic hygroma
– Mainly in children.
– Transilluminating soft tissue swelling in the root of the neck.
– Chest X-ray shows: Oval soft tissue mass extending into the
neck.
– Alters shape on respiration but does not displace trachea.
– Ultrasound and CT shows cystic septated mass.
6. Parathyroid adenoma
– Hypercalcemia with hyperparathyroidism.
– Usually small with normal chest X-ray.
– Confirmed by radionuclide scan with 201 Tl chloride with
increased activity.

Region 2
1. Thymoma: Usually adults.
– Can present with myasthenia gravis (10–15%)
– Round oval and smooth or lobulated.
32 Differential Diagnosis in Radiology

Fig. 1.7: Diagram showing anterior mediastinal masses

– May have nodular or rim calcification.

– CT shows mixed attenuation mass with calcification and
cysts.
2. Teratodermoid tumor: Commonly dermoid cysts and benign
and malignant teratomas.
– Anterior mediastinal mass in young adult patient, dyspnea,
cough, chest pain.
– Round or oval soft tissue mass, projects to one side.
– Calcification, especially rim, fragments of bone and teeth
are diagnostic.
– Fat with fat-fluid level.
3. Lymph node enlargement.
4. Aneurysm of ascending aorta
– Widening of mediastinum or mediastinal mass.
– Well-defined outline.
– Peripheral rim of calcification.
 Chest 33
– Pulsatile mass on fluoroscopy.
– Pressure erosion of sternum.
– CT shows dilated aorta with blood of higher attenuation.
5. Sternal mass
Metastasis, plasmoacytoma, chondrosarcoma, osteomyelitis.
– Soft tissue mass with sternal destruction.
– Tumor new bone formation or lytic expansion of sternum.
– Collection in anterior mediastinum with sternal destruction
in osteomyelitis.
6. Lipomas
– Round or oval soft tissue density mass with low density.
– Alters shape on respiration.
– CT shows solid mass of fatty attenuation.
7. Hemangioma
Widening of mediastinum, round or oval soft tissue mass,
phleboliths are diagnostic.

Region 3
1. Epicardial fat pad
– Especially in obesity.
– Triangular opacity in cardiophrenic angle.
– Less dense due to fat.
– CT shows fat density and is diagnostic.
2. Diaphragmatic hump
– Localized eventration.
– Common on anteromedial portion of right dome.
– Portion of liver extends into it.
– Can be confirmed by ultrasound.
3. Pleuropericardial cyst
– Spring water cyst or pericardial diverticulum.
– 75% in Rt. anterior cardiophrenic angle.
– Round/oval/triangular soft tissue mass.
– Alters shape on respiration.
– Ultrasound or CT shows trans-sonic or cystic mass adjacent
to pericardium with density 0—20 HU.
34 Differential Diagnosis in Radiology
4. Morgagni’s hernia
– 90% in right anterior cardiophrenic angle.
– Round or oval soft tissue mass.
– Lower radiographic density than expected for its size.
– Larger hernias contain transverse colon which appears as
soft tissue mass with air-fluid level.
– Diagnosis by ultrasound, confirmed by barium meal
examination or CT.

1.5  ANTERIOR MEDIASTINAL MASS

Children
Congenital
– Normal thymus
• Sail sign +ve
• Wave sign +ve
• Notch sign +ve
– Cystic hygroma
• Cystic septated mass in neck and mediastinum
– Morgagni’s hernia
• Soft tissue density in cardiophrenic angle
– Neoplastic
– Soft tissue density mass
• With discrete L.N. +/– enhancement
+/– calcification
• LN elsewhere.

Lymphoma
• With calcifications fat, tooth, cyst
• Teratodermoid tumor
• Inflammatory
– Lymph nodes with rim enhancement
– Collection or abscess.
 Chest 35
ANTERIOR MEDIASTINAL MASS

Adults
Widening of mediastinum on X-ray with lobulated soft tissue
density mass on CT.

Lymphoma
Multiple discrete or matted LN +/– enhancement, calcification, LN
elsewhere.

Thymoma
• Soft tissue calcification cysts
• Associated with myasthenia gravis
• Teratodermoid
• Cyst calcification
• Tooth, fat, young adult.

Thyroid
• Mixed attenuation contiguous with thyroid pole
• Widening with fat density on CT
• Epicardial fat pad.

Lipoma
Widening with cystic density
Pleuropericardial cyst
• Abscess
Vascular
• Aortic aneurysm
• Hemangioma
• Mass.
36 Differential Diagnosis in Radiology

MIDDLE MEDIASTINAL MASSES

Children
1. Lymph nodes
– Neoplastic
– Inflammatory.
2. Foregut duplication cysts
– Bronchogenic cyst
– Esophageal duplication cyst
– Neurenteric cyst.
3. Cystic hygroma
4. Vascular
– Vena cava enlargement.

Adult
1. Lymph nodes
– Neoplastic
– Inflammatory
– Inhalation disease.
2. Primary tumors
– Carcinoma of trachea
– Bronchogenic carcinoma
– Esophageal tumor
– Leiomyoma, carcinoma
– Mesothelioma.
3. Vascular lesions
– Aortic aneurysm
– Distended arteries or veins.
4. Bronchogenic cyst.

LYMPH NODES
• 90% of masses in the middle mediastinum are malignant
• Paratracheal, tracheobronchial, subcarinal and broncho-
pulmonary groups. Middle mediastinal lymph node groups
 Chest 37
• Often asymptomatic, may produce cough, dyspnea and
weight loss
• It appears as widening of right paratracheal stripe, bulge
in aortopulmonary window, lateral displacement of azygo-
esophageal line, lobulated widening of mediastinum and
unilateral or bilateral lobulated hilar soft tissue mass.

Neoplastic
• Hodgkin’s disease, non-Hodgkin’s disease and the lymphatic
leukemias produce middle mediastinal lymphadenopathy,
which is often unilateral.

Hodgkin’s Disease
• On CT, nodal involvement ranges from enlarged discrete lymph
nodes to large conglomerate masses
• Thymic involvement is seen in 70% of the cases
• Involvement of superior mediastinal lymph node was seen in
98% of patients with intrathoracic disease.

Non-Hodgkin’s Disease
• Non-contiguous spread, more advanced disease, other sites
involvement more common
• Involvement of superior mediastinum in < 75% cases
• Parenchymal involvement of lungs also occurs and calcification
occasionally develops in Hodgkin’s disease after radiation
• Fungal infections like histoplasmosis, coccidioidomycosis,
blastomycosis produce hilar or paratracheal mediastinal
adenopathy with or without pulmonary involvement
• Other infective and inflammatory causes include infectious
mononucleosis, measles, whooping cough, mycoplasma,
adenovirus and lung abscess.
38 Differential Diagnosis in Radiology

Inhalation Disease
• Silicosis—egg-shell calcification
• Coal worker’s pneumoconiosis
• Berylliosis.

Foregut Duplication Cyst

Bronchogenic cyst—It is a thin-walled foregut cyst lined by ciliated
columnar epithelial cells of respiratory origin that contains viscid
mucoid material.
• Usually seen as an incidental mass in a young adult
• Rarely the cyst can become infected in children and rupture
into the bronchial tree and hemorrhage into the cyst can also
occur
• Majority occurs around carina in subcarinal region but can
occur in right paratracheal or posterior mediastinum
• Appear as well-defined round or oval soft tissue mass that can
alter in shape on respiration.
Diagnosis is confirmed by CT or MRI. CT shows a thin-walled cyst
containing fluid of either low attenuation (0–20 HU) or mucinous
material containing cysts (20–50 HU).

Esophageal Duplication Cyst

• Less common than bronchogenic cysts, usually larger and
usually situated to the right of the midline extending into the
posterior mediastinum
• May be incidental finding or produce symptoms related to
esophageal or respiratory compression. It may contain ectopic
gastric mucosa causing ulceration, hemorrhage or perforation.

Neurenteric Cyst
• Located in middle or posterior mediastinum
• Contains neural tissue and maintains a connection with spinal
canal
 Chest 39
• Commonly right-sided and associated with vertebral body
anomalies like hemivertebrae, butterfly vertebrae, and scoliosis
which are usually superior to it
• CT, MRI—for defining extent, relationship to other structure
and defining intrinsic contents that may be watery or viscous.

Cystic Hygroma
• 5% cases extend into the mediastinum from the neck
• Mostly present at birth
• Cystic with septation and some solid components on all
imaging modalities.

Thoracic Aortic Aneurysm

• Usually seen as an incidental mediastinal abnormality on a
chest radiograph in elderly patients
• It appears as either widening of the mediastinum or as a
well-defined round or oval soft tissue mass in any part of the
mediastinum often with curvilinear calcification in its wall
• Displacement of rim of calcification—aortic dissection
• Pressure erosion of sternum or vertebral bodies
• Diagnosis confirmed by CT or MRI which shows—aorta > 4
cm and containing contrast-enhanced blood in its lumen
with surrounding mural thrombus of lower attenuation and
calcification in its wall.

Other Arterial Abnormalities

• Dilatation of the main pulmonary artery due to pulmonary
artery hypertension, pulmonary valve stenosis with post-
stenotic dilatation or a pulmonary artery aneurysm also
produces an apparent left hilar mass
• A tortuous innominate artery produces widening of the
superior mediastinum on the right and an aneurysm of the
innominate or subclavian arteries produce widening of the
mediastinum on the left, often simulating a left hilar mass.
40 Differential Diagnosis in Radiology

Venous Abnormality
• Dilated superior vena cava produces slight widening of the
mediastinum on the right usually caused by congestive, cardiac
failure, tricuspid valve disease, etc.
• A persistent left-sided superior vena cava produces slight
widening of the mediastinum on the left side
• A dilated azygous vein—oval soft tissue mass in the right
tracheobronchial angle.

Metastasis
• Most mediastinal lymph node metastases arise from a primary
thoracic neoplasm, most commonly bronchogenic carcinoma
• Generally, the lymph nodes are on the same side
• In patients with central squamous cell carcinoma or small
cell carcinoma, the hilar/mediastinal mass may be the only
abnormality on plain X-ray or CT
• In patients with extrathoracic neoplasms, intrapulmonary
metastases are 10 times more common than nodal metastases.
• Most common tumors associated with nodal metastasis are:
– Genitourinary (renal and testicular)
– Head and neck
– Breast
– Melanoma
• Isolated lymph node involvement seen in 60% cases
• Hilar and right paratracheal are most commonly involved.

Inflammatory
Tuberculosis: Primary tuberculosis produces an area of consolidation
in one lobe with unilateral enlargement of the bronchopulmonary,
paratracheal and subcranial lymph node.
• Pleural effusion also occurs and complete calcification of the
lymph node may develop as healing occurs
 Chest 41

Fig. 1.8: PA radiograph of chest shows superior mediastinal and bilateral

adenopathy along with reticulonodular shadowing in bilateral lungs in a
case of sarcoidosis

Sarcoidosis (Fig. 1.8)

• Enlargement of the bronchopulmonary and paratracheal
lymph node, which usually are bilateral
• Enlarged lymph node in locations such as subcarinal, anterior
and posterior mediastinum may be seen particularly if CT is
performed.

1.6  D/D POSTERIOR MEDIASTINAL MASSES

Mediastinum (Fig. 1.9)

• Anterior—in front of the anterior pericardium and trachea
• Middle—within the pericardium including the trachea
• Posterior—lies behind the posterior pericardium and trachea
42 Differential Diagnosis in Radiology

Fig. 1.9: Shows different regions in mediastinum

DDs
Region 5. • Neurogenic tumors
• Pharyngoesophageal pouch
6. • Hiatus hernia • Neurenteric cyst
• Aneurysm of • Sequestrated lung
descending aorta segment
• Esophageal
dilatation
• Dilatation of azygous vein
7. • Neurogenic tumors • Bochdalek’s hernia
• Paravertebral mass • Extramedullary
hemopoiesis.

Neurenteric Cyst
• Partial or complete persistence of the neurenteric canal or its
incomplete resorption
 Chest 43
– Gastrointestinal reduplication
– Enteric cysts
– Neurenteric cysts
– Anterior meningocele
– Cysts of the cord
• Associated spinal anomalies
– Block vertebra
– Hemivertebra
– Butterfly vertebra
– Spina bifida
• Usually present in infants
• Respiratory distress
• Feeding difficulties
• Cysts—appear as oval or rounded soft tissue mass in posterior
mediastinum.
• Anterior meningocele: Diagnosed by CT–myelography, prone
scan
• Esophageal duplication cyst—Barium swallow—ectopic
gastric mucosa – Tc 99m positive.

Pertechnetate Scan
• Neurenteric cyst can be diagnosed by USG/CT/MRI—usually
right-sided.

Dilated Azygous Vein

• Oval soft tissue mass in right tracheobronchial angle
• Caused by—increased central venous pressure
– Superior or inferior vena cava obstruction
– Portal hypertension
– Congenital azygous continuation of IVC
– D/D—Enlarged azygous lymph node
– Azygous vein—decrease in size—in erect position
– On deep inspiration
– During maneuver.
44 Differential Diagnosis in Radiology

Esophageal Lesions
• Pharyngoesophageal pouch or Zenker’s diverticulum:
– Round mass containing air-fluid level in the superior part
of posterior mediastinum usually in the midline displaying
the trachea anteriorly
• Leiomyoma/Leiomyosarcoma—soft tissue mass
• Lower esophageal diverticulum—rounded mass with air-fluid
level behind the heart
• Dilated esophagus—Widening of the posterior mediastinum
on the right side from thoracic inlet to diaphragm with lateral
displacement of azygoesophageal line. Dilated esophagus
displaces the trachea anteriorly
• Air-fluid level with non-homogeneous mottled appearance of
food mixed with air diagnosis confirmed by barium swallow or
CT.

Paravertebral Lesions
• Traumatic wedge compression fracture of vertebral body with
paraspinal hematoma—History of trauma
• Pyogenic/tubercular paravertebral abscess—narrowing of disk
space with involvement of vertebral endplates
• Smooth fusiform bilateral or unilateral soft tissue mass
• Metastasis—bone destruction with pathological fracture
• Extramedullary hematopoiesis—lobulated mass in chronic
hemolytic anemia
• Lymphoma.

Bochdalek’s Hernia
• Developmental defect in posterolateral part of left hemidi-
aphragm
• Contents of the hernial sac includes retroperitoneal fat, kidney,
spleen, splenic flexure.
Large or small intestine, stomach, colon may also herniate
• Mediastinal shift/ipsilateral hypoplastic lung
• Thirteen pairs of ribs may be associated.
 Chest 45
Neurogenic Tumors
• Peripheral nerves
↓
I. Nerve sheath tumor
• Neurofibroma
• Schwannoma or neurilemmoma
• Neurofibrosarcoma
• Malignant schwannoma
II. Ganglion cell tumors
• Ganglioneuroma benign (> 10 years)
• Ganglioneuroblastoma (5–10 years)
• Neuroblastoma (< 5 years) (most malignant)

Fig. 1.10: Barium study radiograph shows hiatus hernia

46 Differential Diagnosis in Radiology
III. Paraganglionic nerve tissue tumors
↓ (rarest)
• Chemodectomas
• Pheochromocytomas
– 30% malignant
– Childhood or young adult patient
– Asymptomatic, back pain, spinal cord compression
– Can be multiple in the setting of neurofibromatosis—
association with lateral thoracic meningocele.
• Radiological features—Well-defined oval soft tissue mass in
paravertebral gutter
• Nerve sheath tumors—circular, calcification—rare
• Ganglion cell tumors—Elongated, central spicules or nodules of
calcification, enlargement of intervertebral foramen, scoliosis.

Hiatus Hernia
• Usually an incidental finding in an elderly patient
• Often asymptomatic
• Clinical features—dyspnea, retrosternal chest pain, epigastric
discomfort, iron deficiency anemia
• CXR—Round soft tissue mass with air or air-fluid level, behind
heart, usually to the left of midline
– Larger hernias may contain small intestine, colon, liver
– Diagnosis—confirmed by lateral chest X-ray, barium or CT.
(Fig. 1.10).

1.7  CHEST WALL ABNORMALITIES (TABLE 1.7)

Pectus Excavatum
• Most common congenital anomaly of sternum
• Decreased prevertebral space—left hand deviation of heart
with axial rotation
– Increased parasternal soft tissue in right inferomedial
hemithorax
– Lateral chest X-ray and CT quantify the severity.
 Chest 47
Table 1.7: Chest wall abnormalities
Congenital and developmental anomalies Tumors
Soft tissue tumors
•  Pectus excavatum •  Lipomas
•  Pectus carinatum •  Neurogenic tumors
•  Poland syndrome •  Hemangiomas
•  Cervical rib •  Desmoid tumors
•  Cleidocranial dysplasia – Lymphomas
•  Sarcomas
Inflammatory and infectious –  Osseous tumors
•  Pyogenic •  Osteochondroma
•  TB •  Enchondroma
•  Actinomycosis •  Osteoblastoma
•  Aspergillosis •  Chondrosarcoma
•  Myeloma
•  Plasmacytoma
Non-neoplastic osseous
•  Fibrous dysplasia
•  Paget’s disease
•  Giant cell tumor
•  Aneurysmal bone cyst

Pectus Carinatum
• Protrusion of sternum anteriorly
• May be seen in isolation or with cyanotic congenital heart
disease.

Cervical Rib
• Supernumerary rib that articulates with cervical type of
transverse process.

Cleidocranial Dysostosis
• Incomplete ossification of ribs with defective development of
pubic bones, vertebral column and long bones.
48 Differential Diagnosis in Radiology

Poland Syndrome
• Partial/total absence of greater pectoral muscle and ipsilateral
syndactyly
• Atrophy of ipsilateral fifth ribs, absence of smaller pectoral
muscle, aplasia of ipsilateral breast/nipple, simian crease of
affected extremity.

Inflammatory and Infectious Disease

• Primary infection rare and seen in diabetes mellitus,
immunosuppression, trauma and intravenous drug abusers
• Secondary infection due to disease processes in lung or to
pleurae, empyema more common
• May produce parenchymal infection, pleural effusion, chest
wall masses, rib destruction and even cutaneous fistula, air-
fluid levels may be seen in soft tissues. Patients usually have
febrile cause.

Tumors of Chest Wall

• Primarily soft tissue tumors are rare
• In adults, most common benign soft tissue neoplasm is lipoma
and most common malignant neoplasms are fibrous sarcoma
and MFH
• In children, PNET (Askian) tumor, rhabdomyosarcoma and
extraosseous Ewing’s sarcoma are most common malignant
soft tissue tumors
• Secondary tumors are more common in thoracic skeleton
• Majority of osseous lesions are in ribs, large numbers are
metastatic
• Osteochondroma is most common benign tumor of cartilage
bone. Most common malignant tumor is chondrosarcoma
• Majority of lesions arising from sternum are malignant and
represent chondrosarcoma most often
• Lesions of thoracic vertebrae are invariably metastatic
 Chest 49
• Most common tumors to produce pattern of chest wall mass
with bone destruction are metastases and small round cell
tumors (multiple myeloma), Ewing’s tumor and neuroblastoma.
The differential diagnosis in adults is metastases versus
myeloma, whereas in a child, pattern is more suggestive of
Ewing’s tumor or metastatic neuroblastoma.

Radiological Differentiation of Chest Wall Tumors

Benign
Imaging findings Tumor type
• Fat attenuation/intensity • Lipoma
• Calcification
– Skeletal
• Amorphous • Fibrous dysplasia
• Cartilaginous apical cap • Osteochondroma
– Extraskeleton, punctate • Cavernous hemangioma
• Cortical thinning—fluid- • ABC or GCT
fluid levels • Ossifying fibromyxoid
• Cortical expansion, tumor or chondromy-
sclerotic band xoid fibroma
• Rib erosion, well-defined • Schwannoma or
contours, extraskeletal non-ossifying fibroma
location
• Location at costochondral • Osteochondroma
junction
• Location in paravertebral • Ganglioneuroma or
regional paraganglioma
• Location in shoulder region • Spindle cell lipoma

Malignant
Imaging Tumor
• Fat component • Liposarcoma
• Calcification
50 Differential Diagnosis in Radiology
– Skeletal
– Rings and arcs • Chondrosarcoma
– Flocculent or stippled
– Centrally dense • Osteosarcoma
• Extraskeletal
– Heterogeneous • Ganglioneuroma or
neuroblastoma
– Speckled • Proximal type epithelioid
sarcoma
• Diffuse osteolytic changes • Myeloma
• Ill-defined mass
– Eccentric growth, in • Ewing’s sarcoma
children and young adults
– Fluid-fluid levels and • Synovial sarcoma
calcifications in
adolescents and adults
– Chronic lymphedema • Angiosarcoma
– Infiltrative growth • Malignant lymphoma
• Non-specific findings • LMS, RMS,
MFH, etc.

1.8  SUPERIOR RIB NOTCHING

Classification (Sargent et al)

1. Normal.
2. Disturbance of osteoblastic activity with decreased or deficient
bone formation
• Paralytic poliomyelitis
• Collagen diseases
– Scleroderma
– Rheumatoid arthritis
– Systemic lupus erythematosus (SLE)
• Exostosis
• Neurofibroma
• Surgery
 Chest 51
• Osteogenesis imperfecta
• Coarctation of aorta
• Marfan’s syndrome
• Radiation damage
• Quadriplegia.
3. Disturbance of osteoclastic activity with increased bone resorption
• Hyperparathyroidism
• Hypovitaminosis-D.
4. Idiopathic.

Salient Features

Poliomyelitis
• Limb deformities and muscle atrophy seen particularly
involving the pectoral muscles and shoulder girdle
• Rib notching seen in chronic cases usually involving 3rd–9th ribs
• Unilateral hypertransradiant hemithorax
• Scoliosis.

Rheumatoid Arthritis
• More common in females
• Symmetrical arthritis especially involving the MCP and PIP
joints of hands and feet and wrist
• Absence of lateral end of clavicle or pencil pointing may be seen
• Caplan’s syndrome—multiple nodules in lung
• Subcutaneous nodules.

Systemic Sclerosis
• Raynaud’s phenomenon
• Subcutaneous calcification—especially in the fingertips
• Esophageal abnormalities—dilatation, atonicity, poor or absent
peristalsis
• Symmetric erosions on superior surface, predominantly along
the posterior aspect of 3rd–6th ribs
52 Differential Diagnosis in Radiology
• Terminal phalanx resorption
• Skin thickening.

Systemic Lupus Erythematosus (SLE)

• Mostly females, butterfly rash
• Polyarthritis: Bilateral and symmetrical involving the small joints
of the hand, knee, wrist
• MCP and PIP joint involvement—no erosions
• Recurrent pleural effusion often with pleurisy resulting in
elevation of a hemidiaphragm and plate atelectasis at base.

Osteochondroma
• 10-20 years of age
• Well-defined protrusion with the patent cortex and trabeculae
continuous with that of parent bone. Cartilage cap
• Most common distal femur, proximal tibia
• Lesions arising from ribs and scapulae cause rib notching
• Diaphyseal achalasia—multiple lesions.

Neurofibromatosis
• One or more primary relatives with neurofibromas
• Café au lait spots
• Optic gliomas
• Typical bone lesions—sphenoid dysplasia
(absent greater wing or lesser wing, absent posterolateral wall
of orbit)
• Tibial pseudarthrosis
• Rib notching, twisted ribbon ribs, splaying of ribs
• Cerebral and cerebellar calcification, heavy calcification of
choroid plexus.

Marfan’s Syndrome
• Tall stature, long slim limbs
• Arachnodactyly
 Chest 53
• Joint laxity—dislocation of sternoclavicular joint and hip joint
• Scoliosis and kyphosis
• Pectus excavatum and carvinatum
• Aortic sinus dilatation and aortic regurgitation.

Osteogenesis Imperfecta
• Osteoporotic, fragile bones often with deformities secondary
to fractures and mechanical stress
• Often in infant or child with blue sclerae
• Flattened or biconcave vertebrae
• Wormian bones
• Rapid fracture healing with exuberant callus
• Wavy, thin, ribbon-like ribs with notching.

Hyperparathyroidism
• Subperiosteal bone erosion—particularly affecting the radial
side of middle phalanx of middle finger, medial proximal tibia,
lateral end of clavicle
• Diffuse cortical damage—Pepper-pot skull
• Brown tumors—mandible, ribs, pelvis
• Ribs
– Characteristically show random notching
– Coarse sclerosis of trabecular pattern of clavicles and ribs.

1.9  INFERIOR RIB NOTCHING

Unilateral
• Blalock-Taussig operation
• Subclavian artery occlusion
• Aortic coarctation left subclavian artery or anomalous right
subclavian artery.
54 Differential Diagnosis in Radiology

Bilateral
• Aorta coarctation, occlusion, aortitis
Subclavian
– Takayasu’s disease, atheroma
Pulmonary oligemia
– Fallot’s Tetralogy
– Pulmonary atresia
– Stenosis
Venous
– SVC, IVC obstruction

Table 1.8: Types of effusion

U/L, B/L Biochemical Consolidation
derangement
Transudate
Cardiac failure B/L + –
Hepatic failure B/L + –
Nephrotic syndrome B/L + –
Meigs’ syndrome U/L – –
Exudate
Infection U/L, B/L – +
Malignancy U/L, B/L – +
Pulmonary infarction U/L – +
Collagen vascular
disease – –
Subphrenic
abscess U/L – +
Pancreatitis U/L – +
Hemorrhagic
CA bronchus U/L, B/L – +/–
Trauma U/L – –
Pulmonary infarction – – +
Bleeding disorders – – –
Chylous
Obstructive thoracic
duct – – –
 Chest 55

Fig. 1.11: PA radiograph of chest shows bilateral pleural effusion causing

compression atelectasis of underlying pulmonary parenchyma (L>R)

Table 1.9: Cases of small hilum

Apparent rotation, scoliosis Volume Soft tissue Consolidation
loss
Unilateral + – –
Normal or left side lobar
collapse, lobectomy – + –
Hypoplastic pulmonary artery – _ +
McLeod’s syndrome _ _ –
Unilateral pulmonary embolus
Bilateral
Cyanotic congenital heart – – –
disease
Central pulmonary embolus – – +
56 Differential Diagnosis in Radiology
Shunts
– Intercostal-pulmonary fistula
– AV fistula
Others
– HPT
– Neurogenic
– Idiopathic.

Pleural Effusion (Fig. 1.11 and Table 1.8)

1.10  ELEVATION OF DIAPHRAGM

Small Hilum (Table 1.9)

Unilateral
• Causes above the diaphragm
– Phrenic nerve palsy
– Pulmonary collapse
– Pulmonary infarction
– Pleural disease
– Hemiplegia (Table 1.10)
- Diaphragmatic cause
– Eventration
- Causes below the diaphragm
– Gaseous distension of stomach/splenic flexure
– Subphrenic inflammation of diaphragm
– Scoliosis
– Decubitus.

Bilateral
• Poor inspiratory effort
• Obesity
Above the diaphragm
– B/L basal pulmonary collapse
– Small lungs
 Chest 57
Below the diaphragm
– Ascites
– Pregnancy
– Pneumoperitoneum
– Hepatosplenomegaly
– Intra-abdominal tumor
– B/L subphrenic abscess.

Unilaterally Elevated Diaphragm

Phrenic nerve palsy: Smooth hemidiaphragm, no movement on
respiration. Paradoxical movements on sniffing.
Pleural disease: Especially old pleural disease, e.g. Hemothorax,
empyema, tuberculosis and thoracotomy.
Splinting of the diaphragm: Associated with rib fracture or pleurisy
due to any cause.
Hemiplegia: Associated with an upper motor neuron lesion.
Eventration: More common on the left side.
Heart is shifted to the contralateral side.
Paradoxical movements on sniffing.
Gaseous distension of stomach or splenic flexure: Only the left
hemidiaphragm.

Table 1.10: Pleural lesions

Pleural calcification Local pleural mass
Old empyema Loculated pleural effusion
Old hemothorax Metastasis
Asbestosis inhalation Malignant mesothelioma
Silicosis Pleural fibroma

Talc exposure
58 Differential Diagnosis in Radiology
Subphrenic inflammatory disease: Sub-diaphragmatic abscess or
infection, inflammation.
Scoliosis: Raised hemidiaphragm on the side of the concavity.
Decubitus: Raised hemidiaphragm is on the dependent side.

Bilaterally Elevated Diaphragm

• Bilateral basal pulmonary collapse: which may be secondary to
infarction or subphrenic abscess
• Small lung due to fibrotic lung disease
• Hepatosplenomegaly in patients of lymphoma, anemia and
many infectious pathologies
• Large intra-abdominal tumors either located in the midline or
in any of the superior abdominal quadrants. Ascites in ovarian
tumor can also cause this.

Fig. 1.12: AP radiograph of chest shows honeycombing in both lungs

with reduced volume of right lung
 Chest 59
Pneumothorax
• Spontaneous
• Iatrogenic
• Traumatic
• Secondary to mediastinal emphysema
• Secondary to lung disease
– Emphysema
– Honeycomb lung (Fig. 1.12)
– Pneumonia
– Bronchopleural fistula
• Pneumoperitoneum.

Pneumomediastinum
• Lung tear
• Perforation of esophagus, trachea, bronchus, perforation of
hollow viscera.

1.11 PNEUMOMEDIASTINUM
It may be associated with pneumothorax and subcutaneous
emphysema.
1. Lung tear: A sudden rise in the intra-alveolar pressure, often with
airway narrowing, causes air to dissect through the interstitium
to the hilum and then to the mediastinum.
• Spontaneous: Following severe bout of cough or a severe
strenuous exercise
• Asthma: Usually not before two years of age
• Diabetic ketoacidosis: Secondary to severe and protracted
vomiting
• Childbirth—due to repeated Valsalva maneuvers
• Artificial respiration
• Chest trauma
• Foreign body aspiration.
60 Differential Diagnosis in Radiology
2. Perforation of esophagus, trachea or bronchus:
• Spontaneous
• Boerhaave’s syndrome
• Following severe and protracted vomiting
• Trauma
• Foreign body aspiration or inhalation
Ruptured esophagus also produces left-sided pneumothorax,
hydropneumothorax.
3. Perforation of a hollow abdominal viscus with extension of gas
via the retroperitoneum.

Right-sided Diaphragmatic Humps

At any site
• Collapse/consolidation of the adjacent lung
• Localized eventration
• Loculated effusion
• Subphrenic abscess
• Hepatic abscess
• Hydatid cyst
• Hepatic metastasis.

Medially
• Pericardial fat pad
• Aortic aneurysm
• Pleuropericardial cyst
• Sequestrated segment.

Anteriorly
• Morgagni’s hernia.

Posteriorly
• Bochdalek hernia.
 Chest 61
1.12  LUNG TUMORS
Carcinoma: Approximately 50% of lung cancers arise centrally, i.e.
in or proximal to segmental bronchi.
• Obstruction of lumen leads to collapse and often infection
• Peripheral tumors appear as soft tissue nodules or irregular
masses and invade the adjacent tissues. Signs of collapse and
consolidation may occur
• Peripheral tumors may arise in the scar. These mass les-
ions may present as hilar enlargement, airway obstruction,
peripheral mass lesion, mediastinal involvement, pleural and
bone involvement.
Alveolar cell CA: Arises more peripherally, probably from the
type II pneumocytes. It arises within the alveoli and produces
areas of consolidation.

Metastases
• Hematogenous: Breast, skeleton, urogenital
• Lymphatic: Less common, breast
• Endobronchial spread: Alveolar cell carcinoma
Metastasis is usually bilateral, affecting both lungs equally, with basal
predominance. They are often peripheral and may be subpleural.

Cavitatory Metastases
• Squamous cell carcinoma
• Sarcoma.

Calcifying Metastases
• Osteogenic sarcoma
• Chondrosarcoma
• Mucinous adenocarcinoma.

Endobronchial Metastases
• Carcinoma kidney, breast
• Large bowel.
62 Differential Diagnosis in Radiology

Lymphangitis Carcinoma
Commonest sites—Lung, breast, stomach, pancreas, cervix, prostate.
It is usually bilateral, but lung and breast cancers may cause
unilateral lymphangitis.

Hodgkin’s/Non-Hodgkin’s Lymphoma
Present as nodal enlargement, which is usually bilateral,
asymmetric and involves anterior mediastinal glands. These may
calcify following therapy. Pulmonary infiltration may appear as
areas of consolidation or areas of miliary nodules. Pleural effusion
may be present in 30% of cases.

Leukemia
Mediastinal lymph node enlargement and pleural effusion are the
commonest radiologic abnormalities.

Sarcoma
Kaposi’s sarcoma may appear as segmental or lobar consolidation.
Other primary pulmonary sarcomas include fibrosarcoma,
leiomyosarcoma—which appear as solitary pulmonary masses,
radiographically indistinguishable from a carcinoma of the lung.

Adenoma
Carcinoid accounts for approximately 90% of bronchial adenomas
and adenoid cystic tumors for about 10%. These appear as well-
circumscribed round or ovoid solitary nodules. On CT, calcification
may be seen within the tumor.

Hamartoma
They are seen in childhood as a solitary pulmonary nodule. Thirty
percent of these show calcification, often with a characteristic
‘popcorn’ appearance.
 Chest 63
Lung Abscess
Radiographically, an abscess may or may not be surrounded by
consolidation. Appearance of an air-fluid level indicates that a
communication with the airway has developed. It shows thick
irregular wall, which shows postcontrast enhancement.

Bronchiectasis
It is the irreversible dilatation of one or more bronchi and is usually
the result of severe, recurrent and chronic infection. It is frequently
basal but in tuberculosis and cystic fibrosis, it usually involves the
upper zone. Dilated bronchi produce tramline shadows or ring
shadows, and dilated, fluid-filled bronchi may cause ‘gloved friger’
shadows.

Asthma
During an attack, the chest X-ray may show signs of hyperinflation,
with the depression of the diaphragm and expansion of the
retrosternal air space. The peripheral pulmonary vessels appear
normal, but if the central pulmonary arteries are enlarged, the
irreversible pulmonary arterial hypertension is probably present.

Chronic Bronchitis
Fifty percent of these patients may have normal chest X-ray.
In patients with a plain film abnormality, the signs are due to
emphysema, superimposed infection or possibly bronchiectasis.
‘Dirty chest’ appearance is seen.

Emphysema (Fig. 1.13)

With emphysema, air trapping is present, the lung volumes
increase, the diaphragm becomes flattened, and the retrosternal
air space increases. The number and size of the peripheral vessels
decrease. Central pulmonary arteries may enlarge suggestive of
cor pulmonale.
64 Differential Diagnosis in Radiology

Bronchiolitis
It results due to infection (often in childhood) or due to inhalation of
toxic fumers, drug therapy and rheumatoid disease. Radiologically,
the appearances are most frequently of hyperinflation of lungs
and perihilar prominence and indistinctness.

1.13  HILAR ENLARGEMENT (TABLES 1.11 AND 1.12)

Unilateral Hilar Enlargement (Fig. 1.11)

Carcinoma bronchus: The hilar enlargement may be due to the
tumor itself or due to the involved lymph nodes.
Lymphoma : Unilateral is very unusual
: Anterior mediastinal nodes are
also involved
Infective : Due to the nodal enlargement
Poststenotic : Usually on the left side
dilatation of the
pulmonary artery
Table. 1.11: Unilateral
Egg shell Air broncho- LN Angio
calcification gram
Lymph Node
Carcinoma – – + –
Lymphoma – + + –
Infective
TB
Histoplasmosis – – + –
Coccidioidomycosis – –
Sarcoidosis + – – –
Pulmonary Artery
Poststenotic dilatation – – – +
Pulmonary embolus – – – +
Aneurysm + – – +
Mediastinal mass—su-
perimposed on a hilum – – – –
Perihilar pneumonia
+ +/– –
 Chest 65
Table 1.12: Bilateral
Symmetrical Occupational Lobulated
Idiopathic + – +
Sarcoidosis
Neoplastic
Lymphoma – +
Lymphangitis carcinoma- – –
–
tosis
– –
Infective
+/– +
Viruses –
– –
Primary TB –
– –
Histoplasmosis
Coccidioidomycosis –
– –
Vascular
Pulmonary arterial
hypertension +
– –
Immunological
Extrinsic allergic alveolitis
Inhalation +
– –
Silicosis
Berylliosis

Pulmonary embolus : Peripheral oligemia is characteristic

Aneurysm : In chronic pulmonary arterial
hypertension. Calcification may
also be present
Mediastinal mass : Middle mediastinum masses
may superimpose.
Perihilar pneumonia, ill-defined borders with presence of air
bronchogram.

Bilateral Hilar Enlargement

Sarcoidosis : Symmetrical, lobulated. Associated
bronchotracheal, tracheobronchial
and paratracheal lymphadenopathy
Lymphoma : Asymmetrical, but multiple sites
66 Differential Diagnosis in Radiology

Fig. 1.13: PA radiograph of chest shows bilateral pulmonary emphysema

Fig. 1.14: PA radiograph of chest shows left hilar mass

 Chest 67
Infective : Viral, mainly in children
TB-B/L is rare
Histoplasmosis pulmonary nodules
(multiple) accompany
Pulmonary arterial
hypertension : Bilaterally is rare
Peripheral oligemia is characteristic
Silicosis : Symmetrical
Pinpoint multiple pulmonary
nodules are present

APICAL SHADOWS (TABLE 1.13)

Table 1.13: Differential diagnosis of apical shadows
U/L, B/L Ellis Pleural Rib Sym-
curve outline seen destruction metry
Pleural caps U/L – – – +/–
Pleural fluid U/L or B/L + – – +/–
Bullae U/L – + – –
Pancoast’s U/L – – + –
tumor
Infections U/L or B/L – – –
– TB
Pneumotho- U/L – + – –
rax
Soft tissue B/L – – + +

1.14  CALCIFICATION ON CHEST RADIOGRAPH

Intrapulmonary (Figs 1.15 and 1.16)

Granuloma, infection
Chronic abscess
Tumor—Metastases
Hamartoma
AVM
68 Differential Diagnosis in Radiology
Hematoma
Infarct
Broncholith
Alveolar microlithiasis
Idiopathic.

Lymph Nodes
TB, histoplasmosis, sarcoidosis, silicosis.

Pleural
TB, asbestosis, talcosis
Hemothorax, empyema

Fig. 1.15: PA radiograph of chest shows multifocal pulmonary parenchy-

mal, bilateral axillary and right cervical nodal calcifications associated with
fibrotic changes in a case of healed Koch’s chest
 Chest 69

Fig. 1.16: PA radiograph of chest shows multifocal pulmonary parenchy-

mal and hilar calcifications associated with fibrotic changes in a case of
healed Koch’s chest

Mediastinal
Cardiac
Vascular
Tumors.

Pulmonary Artery
Hypertension
Aneurysm
Thrombus.

Chest Wall
Costal cartilage
Breast
Bone tumor, callus
Soft tissues.
70 Differential Diagnosis in Radiology

1.15  AIR-FLUID LEVELS ON CHEST X-RAY

Intrapulmonary
Hydropneumothorax Trauma
Bronchopleural fistula
Esophageal Pharyngeal pouch, diverticulae
Obstruction – tumor, achalasia
esophagectomy
Mediastinal Infections
Perforation – esophageal
Pneumopericardium Diagnostic, trauma
Chest wall Infection
Diaphragm Hernia, eventration, rupture

Crescent Sign
• Fungal ball
• Blood clot in tubercular cavity
• Bronchial adenoma, carcinoma
• Hamartoma
• Hydatid cyst
• Pulmonary infarct.

1.16A  CAVITATING PULMONARY LESIONS

Infection
• Staphylococcus
• Klebsiella
• Tuberculosis
• Histoplasmosis
• Amebic
• Hydatid
• Fungal.
 Chest 71
Malignant
• Primary
• Secondary
• Lymphoma.

Abscess
• Blood borne
• Aspiration
• Pulmonary infarct
• Pulmonary hematoma
• Pneumoconiosis.

Collagen Diseases
• Rheumatoid nodules
• Wegener’s granulomatosis.

Developmental
• Sequestrated segment
• Bronchogenic cyst
• Congenital cystic adenomatoid malformation
• Sarcoidosis
• Bullae, blebs
• Pneumatocele
• Traumatic lung cyst.

1.16B  MASS WITHIN CAVITY (TABLE 1.14)

1. Mycetoma—Aspergilloma
2. Tissue fragment from carcinoma
3. Necrotic lung within abscess
4. Disintegrating hydatid cyst
5. Intra-cavitatory blood clot.
72 Differential Diagnosis in Radiology
Table 1.14: Differential diagnosis of mass within cavity
1 2 3 4 5
Thick, irregular + + + – +
walled cavity
Adjacent lung + +/– + +/– +/–
parenchymal
reaction
Clinical history of of wt. Infection Infection +/–
infection loss
Mobile + +/– +/– + +
Contrast enh­ + + – +/– –
ancement in CT
of mass
Calcification – +/– – – +/– if
chronic.

1.17  CAVITATING PULMONARY LESIONS

Causes
• Malignant
– Primary
– Secondary
– Lymphoma
• Infections
– Tuberculosis
– Staphylococcus
– Klebsiella
– Amebic
– Hydatid
– Fungal
• Abscess
– Aspiration
– Blood borne
• Pulmonary infarct
• Hematoma
• Pneumoconiosis
 Chest 73
– Pulmonary massive fibrosis
– Rheumatoid nodular
– Collagen diseases
– Wegener’s granulomatosis
• Developmental
– Sequestration
– Bronchogenic cyst
– Congenital cystic adenomatoid malformation
• Sarcoidosis
• Bullae, blebs
• Traumatic lung cyst
• Pneumatocele.

Carcinoma

Primary
Very frequently cavity nodules turn out to be malignant.

Mechanism
Obstruction of an artery
(Infection of a nodule)
• In 2–10%, especially peripheral upper lobe involvement
• Most cavities are thick-walled, irregular inner surface
• Thickness > 15 mm—85–90% malignant
• Cavitation—centric or eccentric
• Multiple cavitations
• More common in squamous cell carcinoma and then may be
thin-walled.

Metastasis—Cavitation
• More common in upper lobe, may involve few nodules
• Thin or thick-walled
• Seen especially in squamous cell carcinoma—head and neck
(uncommon in adenocarcinoma—especially colon)
• Sarcoma—osteosarcoma.
74 Differential Diagnosis in Radiology

Hodgkin’s Disease
• Thick or thin-walled
• Typically in an area of infiltration
• Hilar or mediastinal LN.

Tuberculosis
• Thick-walled and smooth, sometimes fluid level
• Mainly affects upper lobes and apical segment of lower lobe
• Usually surrounded by consolidation and fibrosis
• Typically there is large cavity surrounded by smaller satellite
cavities
• Cavity walls are lined by tuberculous granulation tissue
• Cavities traversed by fibrotic remnants of bronchi and vessels
• Rasmussen aneurysm.

Staphylococcus aureus
• Mostly children, multiple
• Thick-walled cavities with a ragged inner lining
• No lobar predilection
• Associated with effusion and empyema.

Hydatid Cysts
• Complicated hydatid cyst
• Rupture into a bronchus-air crescent sign/air cap
• Water lily sign.

Aspergillosis
• Any pulmonary cavity—TB, histoplasmosis, sarcoidosis
• Forms a ball which changes position, ball is seen to be mobile
• Almost always pleural thickening related to mycetoma
• Vascular granular tissue-bleeding may occur.
 Chest 75
Abscess (Aspiration)
• Multiple or single
• Usually thick-walled
• Following aspiration
• Posterior segment or apical segment-UL
• In sitting-right lower lobe.

Pulmonary Infarct
(Infection—may be)
Primarily:
1. Septic embolus
Secondary to:
2. Initially sterile, infarct, infection
Tertiary to:
3. As aseptic cavitating infarct infected
• Aseptic cavitation is usually solitary and arises in a large
area of consolidation after about two weeks.
• Cavity has scalloped inner margins and cross cavity band
shadows/effusion.

Cystic Bronchiectasis (Fig. 1.17)

• Thin-walled lower lobes
• Air-fluid levels, peribronchial thickening and retained secretions
• Crowded vessels and retained secretions.

Sequestered Lung
• Thin- or thick-walled
• 66% in left lower lobe, 33% in right lower lobe
• Air-fluid level, surrounding pneumonia.

Wegener’s Granulomatosis
• Bilateral and widely spread
• Nodules, cavitation in some nodules (1/3)
76 Differential Diagnosis in Radiology

Fig. 1.17: PA radiograph of chest shows bilateral perihilar

cystic bronchiectasis

• Cavities are thick-walled, shaggy/irregular lining

• Become thinner with time
• After-therapy may disappear.

Rheumatoid Nodules
• Thick-walled with a smooth inner lining and well-defined
• Lower lobes and peripherally
• Become thinner with time.

Progressive Massive Fibrosis

• Predominantly in mid and upper zone
• Begin peripherally and move centrally
• Nodule formation which cavitates into thick and irregular
walled cavities in a background nodularity of pneumoconiosis.
 Chest 77
Sarcoidosis
• In early disease, necrosis of coalescent granuloma and check
valve mechanism beyond partial obstruction
• Thin-walled cavities
• B/L hilar lymph nodes.

Infected Emphysematous Bullae

• Thin-walled, air-fluid level
• Usually seen in emphysema, particularly paraseptal and scar
associated
• Apical asymptomatic and those associated with scarring
(throughout the lungs—COPD)
• Associated changes of inflammation in surrounding lung.

TRAUMA

Hematoma—peripheral
• Air-fluid level—communication with bronchus.

Traumatic Lung Cyst

• Single or multiple
• Peripheral and thin-walled
• Uni- or multilocular
• Within hours of injury.

Bronchogenic Cyst
• Medial 1/3 of lower lobes
• If ruptures into a bronchus, thin-walled, air-fluid level and
surrounding pneumonia.
78 Differential Diagnosis in Radiology

Cystic Adenomatoid Malformation

• Causes neonatal respiratory distress
• Cavities of various shapes and sizes scattered in an area of
opaque lung with well-defined margins.

1.18A  LUCENT LUNG LESIONS

Multiple Lucent Lung Lesions

Cavities
Infection
• Bacterial pneumonia
• Granulomatous infection (Fig. 1.18)
• Parasites.

Fig. 1.18: PA radiograph of chest shows right upper lobe cavitation in a

patient of Koch’s chest
 Chest 79
Neoplasm

Vascular
• Wegener granulomatosis
• Rheumatoid arthritis
• Thromboembolic or septic infarct
– Cystic fibrosis
– Tuberculosis
– ABPA
– Recurrent bacterial pneumonia.

Cysts
• Cystic bronchiectasis
• Pneumatocele
• Congenital lesions—multiple bronchogenic cysts
– Intralobar sequestration
– CCAM Type I
– Diaphragmatic hernia
• Centrilobar emphysema
• Honeycomb lung disease.

Differential Features are same as

Localized Lucent Defects (Table 1.15)
Cyst Cavity
Thin-walled Thick-walled
> 1 cm
Clear, smooth Irregular, ragged wall
Well-defined wall Adjacent lung parenchyma
May show reactive changes
+/–
+/– Air-fluid level +/–
80 Differential Diagnosis in Radiology

1.18B  SOLITARY PULMONARY NODULE

Malignant Primary
Secondary
Lymphoma
Plasmacytoma
Alveolar cell carcinoma
Benign Hamartoma
Adenoma
Connective tissue tumor
Granuloma Tuberculosis
Histoplasmosis
Sarcoidosis
Infection Round pneumonia
Abscess
Hydatid
Amebic
Fungal
Pulmonary infarct
Pulmonary hematoma
Collagen disease Rheumatoid arthritis
Wegener’s granulomatosis
Congenital Bronchogenic cyst
Sequestration segment
Congenital bronchial atresia
AVM
Impacted mucus
Amyloidosis
Intraparenchymal lymph node
Pleural Fibroma
Tumor
Loculated fluid
Non-pulmonary Skin and chest wall lesions
Artefacts
 Chest 81
Table 1.15: Localized lucent defect
Infection Location Air- Cong/ Uni/multi- Specific
fluid acq. cystic points
level
Bacterial Any zone + Acquired Multi cystic
with areas of
break-down
Granuloma- Apical + -do- +ve Fibrosis
tous and
cavita-
ting
Fungal Less likely Fungal -do- cystic
to be apical ball
Sarcoidosis Upper zone – -do- – B/L
hilar and
R para-
tracheal
LNs
Cystic bron- Lower lobes Air- Cong./ +
chiectasis fluid Acquired
level
Pneumato- In area of +/– Acquired + Staph.
cele infection infection
Sequelae
Previous
pneumonia/
posttrau-
matic hema-
toma
Intralobar Lower lobes +/– Cong. + Vascular
sequestra- drainage
tion is altered
Honey- Any zone – Acq./End +
combing state
Lung disease
CCAM Cong.
+/– Multi-cystic Cartilage
Deve-
lopment
is defec-
tive
82 Differential Diagnosis in Radiology

1.19  SOLITARY PULMONARY NODULE (TABLE 1.16)

Definition (Fig. 1.19)

Single, round intraparenchymal opacity, at least moderately well-
marginated and not greater than 3 cm in maximum diameter.

Neoplasm
• Benign—Hamartoma, inflammatory pseudotumor (Table 1.16)
• Malignant—Bronchogenic carcinoma, carcinoid tumor,
metastasis (Figs 1.20 and 1.21).

Infection
• Granuloma—Tuberculoma
• Fungal—Histoplasmoma
• Abscess
• Round pneumonia
• Parasites—Echinococcus.

Inflammatory
• Connective tissue—Wegener’s granulomatosis
– Rheumatoid nodule
– Sarcoidosis (rare).

Vascular
• Arteriovenous malformation
• Hematoma
• Pulmonary infarct
• Pulmonary artery aneurysm.

Airway
• Congenital lesion—Bronchogenic cyst
• Mucocele
 Chest 83

Fig. 1.19: PA radiograph of chest shows solitary pulmonary

nodule in right upper lobe peripherally

Fig. 1.20: PA radiograph of chest shows bronchogenic carcinoma

in right upper lobe with pulmonary metastases in left lower lobe
84 Differential Diagnosis in Radiology

Fig. 1.21: PA radiograph of chest shows multifocal

pulmonary metastases from breast carcinoma

• Infected bulla
• Pseudonodules
• ECG pads
• Cutaneous lesions
• Mole
• Nipple shadow
• Hemangiomas
• Neurofibromas
• Lipomas.

Characteristics of SPN
1. Size
• No size criteria that clearly distinguishes benign from
malignant SPN
 Chest 85
• 80% of benign SPN <2 cm in diameter
• 15% of malignant SPN <1 cm in diameter
• 42% of malignant SPN <2 cm in diameter
2. Growth
• Benign lesions—<30 days or <450 days (doubling time)
SPN with doubling time between 30 and 450 days require
further evaluation
• Doubling time for spherical lesions is defined as 25%
increase in diameter.
3. Calcification
• Approximately 1/3rd of non-calcified SPNs have calcification
on CT
• Complete/central/laminated: Granulomas
Popcorn: Hamartoma
Amorphous/Eccentric calcifications: Malignancy.
4. Fat
Fat within a smooth/lobulated SPN is suspected benignity of
hamartoma—50% show presence of fat.
5. Cavitation
Cavities with greatest wall thickness <5 mm are benign
>15 mm are malignant.
6. Air bronchogram/bubbly lucencies
• Presence of air bronchogram within SPN is suggestive
of adenocarcinoma, particularly bronchoalveolar cell
carcinoma.
• Other causes – Lymphoma, organizing pneumonia,
pulmonary infarcts and mass-like sarcoidosis.
7. Margins
• Smooth, well-defined margins symptoms of benign nodule
although 21% of malignant nodules smooth margin
• Lobulated/ill-defined/spiculated symptoms of malignant
nodule 25% of benign nodules may have undefined
margins
• Presence of a small satellite nodule surrounding the
periphery of a smooth SPN is symptom of granulomatosis
infection.
86 Differential Diagnosis in Radiology

CT Nodule Enhancement
• Enhancement <15 HU symptom of benign nodule
• False +ve: Central necrosis, mucin producing malignant
neoplasm
• Enhancement > 15 HU—Non-specific.

Pulmonary Hamartomas
• These consist of masses of cartilage with clefts lined by
bronchial epithelium which may contain large calcification
(popcorn) of fat; Age group: 45–50 years
• Triad: Pulmonary chondromas
(Carney’s triad): Gastric epitheloid leiomyosarcomas
• Functioning extra adrenal paragangliomas
• 90% peripheral and 10% within a major bronchus
• Spherical lobulated SPN with popcorn calcification, size <4 cm,
fat density positive.

Inflammatory Pseudotumor
(Plasma Cell Granuloma)
• Caused histology by mixture of fibroblasts, histiocytes,
lymphocytes and plasma cells
• Age range is wide and includes children
• SPN (2–5 cm) or as an area of consolidation, calcification is
occasionally present.
Endobronchial tumor can cause obstructive pneumonitis.

Bronchial Carcinoid
Bronchial carcinoids can invade locally, may metastasize to hilar
and mediastinal lymph nodes as well as to brain, liver and bone.
• Age: Age range is wide; Peak—5 decades.
• Clinical features—Wheeze, Cushing’s syndrome (ectopic ACTH
secretion), Carcinoid syndrome
• Hilar/parahilar mass
 Chest 87
• 80–90% Central (endobronchial)
• 10–20% Peripheral with features of bronchial obstruction,
pneumonia, Calcification +/–
• Spherical/lobular SPN (2–4 cm) smooth well-defined margin
calcification +/–.

Bronchial Carcinoma (Fig. 1.22)

• Squamous cell carainoma (30–50%)
• Adeno carainoma (30–50%)
• Undefined small cell carainoma (20–30%)
• Large cell carcinoma (10–15%)
• Peak incidence: 50 to 60 years
• Radiological features: Size > 2cm
– Undefined margins
– Umbilicated/notched margin
– Corona radiata/speculations (+)
– Pleural tail sign (+)
– Doubling time between 30 and 450 days
– Lesion crosses fissure
– Cavitation: (>15 mm thick wall)
– Calcification rare if present—eccentric
• Associated findings—Hilar/mediastinal lymph nodes, bone
mets, pleural effusion, visceral mets (+)
• Bronchoalveolar Carcinoma: Air bronchogram/bobby lucencies
– Grows slowly
– Cavitation is unusual.

Metastasis
Pulmonary metastasis is usually from breast, GI tract, kidney, testes,
head and neck tumors or from a bone and soft tissue sarcomas.
• Site: Usually in the outer portions of lung
• Radiological features (R/f )—solitary/multiple
• Spherical well-defined, occasionally irregular edge
• Calcification—unusual except metastases from osteosarcoma,
chondrosarcoma
88 Differential Diagnosis in Radiology

Fig. 1.22: PA radiograph of chest shows bronchogenic

carcinoma in right upper lobe

• Rate of growth: Variable—explosive in choriocarcinoma and

osteosarcoma
• Cavitation—unusual (squamous cell carcinoma +).

Tuberculoma
• Occurs in the setting of primary or postprimary tuberculosis
and is considered to represent localized parenchymal diseases
that alternatively activate and heal
Nodule is 10–15 mm in diameter
Situated most commonly in the right upper zone
Single or multiple (confined to a single segment)
Margins well-defined
Satellite lesions (+)
Calcification frequent
Cavitation +/–.
 Chest 89
Hydatid Cyst
Caused by tapeworm (E granulosus or E alveolaris)
• Humans are accidental host
• Infection occurs by ingestion of ova by fomites/contaminated
water.
Radiological features (R/f) Unruptured cyst: Homogenous spherical/
oval, well-defined lesion. Size 1 to 10 cm occurs particularly in
middle zone/lower zone.
Ruptured cyst: Usually associated with secondary infection
1. Meniscus sign—Pericyst—ruptures ectocyst and endocyst
intact appearance is that of an intracavitary body.
2. Disruption of inner layers:
a. Air-fluid level
b. Floating membranes (water lily, camalote sign)
c. Double wall appearance
d. Dry cyst with crumpled membranes lying at its bottom
(rising sun, serpent sign)
e. Cyst with all its contents expectorated (empty cyst sign).

Histoplasmoma
Caused by histoplasma capsulatum which is a fungus found in
moist soil and in bird or bat excreta.
Histoplasma represents a small necrotic focus of infection
surrounded by a massive fibrous capsule consisting of concentric
lamination, some or all of which may calcify.
• Sharply-defined nodular shadow
• <3 cm in diameter
• Most common site is in the lower lobe
• Satellite lesions (+)
• Calcification (+) central/eccentric
• Target lesion is pathognomonic—Homogeneous density with
central punctate deposit of calcium
• Associated findings – Calcified hilar/mediastinal lymph nodes.
90 Differential Diagnosis in Radiology

Pneumonia
Round pneumonias are usually pneumococcal which are usually
seen in children, air bronchogram.

Lung Abscess
Cavitation secondary to necrosis is seen in:
Bacterial pneumonias—Staphylococcus aureus
Gram-negative bacteria—Klebsiella pneumoniae, Proteus pseu-
domonas
Anaerobes
Amebic and fungal infections.

Cavitary Lesion with Adjacent Consolidation

Size—2 to 12 cm
Wall thickness < 15 mm
Inner aspect of cavity is smooth.

Wegener’s Granulomatosis
• Necrotizing granulomatous vasculitis
• Lungs involved in 95% cases and late renal involvement is seen
in 85% cases
• Men>Women
• Single/multiple nodules
• Size = 1 cm to several cm
• Well-defined margins
• Wax and wane
• Frequently cavitate
• Associated findings—Granulomas in upper respiratory tract
and glomerulonephritis.

Rheumatoid Nodules
Pleuropulmonary is seen in 5 to 54% cases of rheumatoid arthritis.
• Pulmonary, necrobiotic nodules are uncommon features of
rheumatoid arthritis
 Chest 91
• Associated with subcutaneous nodules
• Single/multiple
• Variable in size
• Wax and wane in size
• Cavitation (+) / (–) more common in lower lobe and in periphery.
• Similar nodule may be seen in patients of rheumatoid arthritis
who have been exposed to silica. Known as Caplan’s syndrome.

Pulmonary A-V Fistula

Congenital—50% have hereditary hemorrhagic telangiectasia
(Osler-Weber-Rendu disease)
Acquired—Liver diseases (cirrhosis), schistosomiasis and
metastatic thyroid cancer
Round/lobulated nodule
Prominent adjacent vascular shadow
Most common site—Lower lobe
Variation in size with Valsalva (size)
CT and pulmonary angiography shows the feeding artery and
vein and vascular nature of nodule.

Pulmonary Artery Aneurysm

Most pulmonary artery aneurysms are acquired as a result of septic
embolization or an extension from a pulmonary parenchymal
calcification.
• Peripheral aneurysms may mimic SPN pulsations of mass seen
on fluoroscopy
• Confirmation done by CT or pulmonary angiography.

Pulmonary Hematoma
History of (H/o) trauma (+); usually appears following resolution
of contusion.
Peripheral in location
Smooth and well-defined
92 Differential Diagnosis in Radiology
Slow resolution over several weeks
A pocket of air or fluid level (+).

Pulmonary Infarct
• Becomes visible 12–24 hours after embolic episode
• Lesions are more frequent in the lower lobe
• Hump-shaped opacity with its base applied to the pleural
surface because of partial collapse, hemorrhagic congestion
• Cavitation is rare
• Matched defect is seen on ventricular perfusion scan
• Associated pleural effusion (+).

Bronchogenic Cyst
• Peak incidence is in 2nd and 3rd decades
• 2/3rd are intrapulmonary and occur in the medial 1/3rd of the
lower pulmonary region
• Round to oval
• Smooth-walled and well-defined
• CT shows thin-walled water density cyst.

1.20  PULMONARY EDEMA ON THE OPPOSITE SIDE

TO A PRE-EXISTING ABNORMALITY (TABLE 1.17)
1. Congenital absence or hypoplasia of a pulmonary artery
2. McLeod’s syndrome
3. Thromboembolism
4. Unilateral emphysema
5. Lobectomy
6. Pleural disease.

Localized Air Space Disease

Pneumonia
Infarction
Contusion
 Chest 93
Edema
Radiation
Alveolar cell carcinoma.
Differential features are discussed in alveolar shadowing.

Unilateral Pulmonary Edema

• Pulmonary edema on the same side as a pre-existing abnormality
• Prolonged lateral decubitus

Table 1.16:  Clinical and Radiographic Criteria for Differentiating Benign

and Malignant SPN
Clinical Benign Malignant
•  Age <40 years except >45 years
hamartomas
•  Sex Female Male
•  History • High incidence of granu- • Primary lesion else-
loma in area where
•  Exposure to tuberculosis •  History of smoking
•  Skin test Positive with specific infec- Negative/positive
tious organism
Radiographic
Size Small (<2 cm) Large (>2 cm)
Location No predilection except for Predominantly on upper
tuberculosis lobes except for lung
metastases
Definition Well-defined and smooth Ill-defined, lobulated
and contour umbilicated
Calcifica- Central, laminated popcorn, Eccentric (very rare)
tion complete
Satellite More common Less common
lesion
Doubling <30 to >450 days 30 to 450 days
time
Presence (+) Symptom of hamartoma
of fat
94 Differential Diagnosis in Radiology
• Unilateral aspiration
• Pulmonary contusion
• Rapid thoracocentesis of air or fluid
• Bronchial obstruction
• Clinical history is most important in the differential diagnosis of
all the above entities.
Bronchial obstruction:
• Respiratory distress +/–
• Examination of (E/o) occlusion: It is seen in the form of luminal
obstruction, atelectasis, fissural displacement.

Alveolar Shadowing
Acute
Pulmonary edema
Cardiac
• Non-cardiac
– Hypoproteinemia
– Fluid overload
– Drowning
– Aspiration
– Inhalation
– ARDS, uremia
– Infection
• At birth
• Aspiration
• Hyaline membrane disease (Fig. 1.23)
• Alveolar
• Blood pulmonary hemorrhage
• In hematoma
• Goodpasture’s syndrome
• Pulmonary infarction.

Chronic
• Tumors
• Alveolar cell carcinoma
Table 1.17: Causes of pulmonary edema

Congenital Macleod’s Thromboem- Unilateral Lobectomy Pleural

absence or syndrome bolism emphysema disease
hypoplasia of a
pulmonary artery
Lack of soft tissue + + – – – –
outline
Prominent hilum – – + – – –
Subpleural consoli- – – + – – –
dation
Elevated diaphragm – – + – + –
Pleural reaction – – + – – +
Cavitation – – + – –
Mediastinal shift – – – + + –
Linear outline of – – – + – +
pleura
Contd...
Chest
95
Contd... 96
Location Duration Effusion LNs Air broncho-­
gram
Infection Any Rapid Reso- +/– +/– Reticulono- Peripheral,
lution dular pattern central
Hyaline Whole lung ” +/– – + – Any Usually
Membrane presents with
disease unusual fea-
tures
Aspiration Right UL in ” – – +/– During reso- Any White out
Erect Right lution lung
LL in Supine
Differential Diagnosis in Radiology

Hemor- Any – – – – – – Clinical h/o

rhage/
contusion
Alveolar Any Nonresolving ++ – + – – Clinical h/o
cell carci- Pneumonia
noma
Lymphoma ” + ++ – – Any Any

Contd...
Contd...
Location Duration Effusion LNs Air broncho-­
gram
Embolism/ Any 1-2 day – – – – Any
infarct post-trauma
resolves in
1-4 weeks
Sarcoido- UL – + – – Peripheral
sis
Löffler’s UZ Rapid – – – – Central
syndrome
Metastasis Any No +/– +/– – – Peripheral
Consolida- Follow the slow +/– – + in acute – – P/C Usually from
tion exposure in chronic chronic CA
history
Chest
97
98 Differential Diagnosis in Radiology

• Lymphoma
• Alveolar proteinosis
– Microlithiasis
• Radiation pneumonitis
• Sarcoidosis
• Eosinophilic lung.

Characteristics
• 4–10 mm diameter
• Ill-defined margins
• Coalescence
• Non-segmental.

Air Bronchogram

Common
1. Consolidation pneumonic
2. Pulmonary edema
3. Hyaline membrane disease.

Rare
1. Lymphoma
2. Sarcoidosis
3. Alveolar proteinosis
4. Alveolar cell carcinoma
5. Adult respiratory distress syndrome.

Mesothelioma
• Asymmetrical, irregular
• Thickening
• Calcification +/–
• U/L
 Chest 99

Fig. 1.23: Anteroposterior radiograph of chest in neonate shows

hyaline membrane disease

Pneumonectomy
• Rib resection +/–
• Thoracoplasty asymmetrical bony contour
• H/o present.

Pulmonary Agenesis
• Congenital anomaly
• Respiratory distress +
• Status of diaphragm.

Differential Diagnosis (D/D) Diaphragmatic Hernia

N. – Scaphoid Abdomen
Absent Bowel loops with air +/–
Opaque thorax A few lucencies +
100 Differential Diagnosis in Radiology

1 2 3 4 5 6 7 8
Location Any Peri Any Any UL Any Any Any
zone -hilar zone
Pleural effusion +/– + +/– +/– – – +/– +
Hilar enlargement +/– – – + + – +/– –
Silhouette with +/– + + +/– – – +/– +
cardiac
Diaphragm +/– – + +/– – – +/– +
LNs +/– – – + + – +/– –
Crazy pavement – – – – – + – –
pattern
White out lung – – + – – – – +
Vascular markings – + – – + – – –
visualized
Resolution + + + – + + – +

Consolidation
Air bronchogram
Confined to one segment
Air alveologram

Collapse
Vessels not seen
Crowding of fissure and ribs
Hilar and diaphragmatic displacement.

Fibrosis
Examination of (E/o) volume loss +.

Cardiomegaly
Cardiac contour conforming of uni/multi-chamber enlargement.
 Chest 101
1.21A  MILIARY SHADOWING

D/D Miliary Shadowing

Disseminated pulmonary opacities
1. Acinar
2. Interstitial
Acinar—poorly-defined, round, parenchymal opacities
• 4–8 mm in diameter
• Represent an anatomical acinus filled with fluid.

Interstitial (Fig. 1.24)

Pulmonary interstitium is a network of connective tissue fibers
that supports the lung. It includes alveolar walls, interlobular septa
and peribronchovascular interstitium.

Fig. 1.24:  Posteroanterior radiograph of chest shows bilateral

interstitial pulmonary disease
102 Differential Diagnosis in Radiology
Interstitial nodules may take various patterns.
• Linear and septal lines
• Miliary shadows
• Reticulonodular shadows
• Honeycomb shadows
• Peribronchial cuffing and ground glass pattern
Alveolar Interstitial
1. Fluffy, ill-defined Sharply-defined
2. 4–8 mm 2–4 mm
3. Coalescent Discrete
4. Segmental/lobar Widespread
5. Air bronchogram Usually 1 week
6. Time from onset of Usually more than one week
nodules is less
7. Higher density Lower density

Miliary Shadowing
It is the presence of small, discrete, rounded pulmonary nodules of
almost similar size measuring 2–4 mm in the interstitium.

Causes
1. Infectious diseases:
a. Tuberculosis
b. Fungal infections—Histoplasmosis, coccidioidomycosis,
blastomycosis
c. Chicken pox.
2. Inhalational diseases:
a. Silicosis
b. Barytosis
c. Stannosis
d. Coal miner’s pneumoconiosis
e. Berryliosis
3. Granulomatous diseases:
a. Sarcoidosis
b. Histiocytosis-X
 Chest 103
4. Metastases
5. Secondary hyperparathyroidism
6. Oil embolism
7. Alveolar microlithiasis
8. Hemosiderosis
9. Bronchiolitis obliterans.

Miliary Tuberculosis (Fig. 1.25)

• Due to hematogenous spread of infection
• May be seen in both primary and postprimary disease
• Small discrete nodules 1–2 mm in diameter, evenly distributed
throughout both lungs
• These are of soft tissue density and are well-defined
• Other tubercular manifestations as consolidation, pleural
effusion, and lymphadenopathy may be present.

Histoplasmosis
• Due to infection with histoplasma capsulatum
• Infection is usually subclinical and heals spontaneously leaving
small calcified nodules or calcified mediastinal nodes
• Infection in immunocompromised patient may produce
multiple nodules scattered throughout the lung, resulting in
miliary shadowing
• Hilar nodes enlargement is common
• Consolidation, fibrosis and cavitation may occur.

Silicosis
• Multiple nodular shadows 2–5 mm in diameter
• Affects mainly mid and upper zones, relatively sparing the
bases
• Hilar adenopathy which may calcify, fibrosis, cavitation may
occur.
104 Differential Diagnosis in Radiology

Fig. 1.25: Posteroanterior radiograph of chest shows miliary tuberculosis

Coal Miner’s Pneumoconiosis

• Small, faint nodules 1–5 mm in diameter appear in mid zone
spreading to whole lung
• Progressive massive fibrosis—mid and upper zones—in
complicated cases
• Emphysematous bullae may appear.

Sarcoidosis
• Multisystem granulomatous disorder affecting young adults
• 75–90% patients show small, rounded or irregular nodules 2–4
mm in diameter, bilaterally symmetrical with upper and mid
zone preponderance
• Bilateral symmetrical lymphadenopathy, hilar and paratracheal
• Air trapping, pleural thickening and effusion may be positive.
 Chest 105
Histiocytosis X
• Granulomatous disorder affecting young or middle-aged
adults
• Pulmonary involvement is bilaterally symmetrical
• Chest X-ray shows diffuse nodular pattern in upper and mid
zones, 1–5 mm in size. Progress of disease leads to ring shadows,
honeycombing and linear shadows.

Miliary Metastasis
• Rare cause of miliary shadowing
• Primary tumors most likely to provide miliary nodulation are
thyroid, renal carcinoma, bone sarcomas and choriocarcinomas.

Hemosiderosis
In patients with heart disease which elevates left atrial pressure,
e.g. in mitral stenosis, there is permanent miliary stippling due to
focal nature of bleeding.

Alveolar Microlithiasis
• Multiple fine sand-like calculi in the alveoli
• Produce widespread dense opacities on chest X-ray
• Clinically there is relative lack of symptoms.

1.21B  MILIARY SHADOWING (0.5 TO 2 MM)

• Soft tissue densities
• Miliary tuberculosis
• Fungal disease
• Pneumoconiosis
• Sarcoidosis
• Extrinsic allergic alveolitis
• Fibrosing alveolitis
106 Differential Diagnosis in Radiology

Greater than Soft Tissue Density

• Hemosiderosis
• Silicosis
• Siderosis
• Stannosis
• Barylosis.
Pneumoconiosis
These are diseases caused by inhalation of inorganic dusts. The
diagnosis depends on a history of exposure to the dust and an
abnormal chest radiograph and respiratory function tests.

Silicosis
• Gold-mining, sand-blasting, foundry, ceramic and pottery
workers
• Multiple, nodular shadows 2–5 mm in diameter mid and upper
zones
• Linear lines and septal lines may also be seen.

Coal Workers
• Pneumoconiosis
• Small, faint, indistinct nodules 1–5 mm in diameter appear in
the mid zones
• Coalescence of these nodules is common
• Develop bilaterally
• Fibrotic masses may calcify.

Asbestosis (Fig. 1.26)

Asbestosis mining and processing.
In construction and demolition workers, ship-building.
• Lower zones nodules
• Pleural plaque, calcification, diffuse thickening and effusion—
mid zone, bilaterally
• Pulmonary fibrosis is marked
 Chest 107
• Initially reticulonodular pattern results—which with
progression becomes coarser and there is loss of clarity of the
diaphragm and heart.

Berylliosis
In the acute stage, produces non-cardiogenic pulmonary edema,
while in the chronic stage, produces widespread non-cavitating
granulomas.

1.22  MULTIPLE PINPOINT OPACITIES

(TABLES 1.18 AND 1.19)
1. Post-lymphogram
2. Silicosis
3. Stannosis
4. Baryltosis
5. Alveolar microlithiasis.

Fig. 1.26:  Posteroanterior radiograph of chest shows calcified

pleural plaque in left hemithorax
108 Differential Diagnosis in Radiology
Table 1.18: Multiple Opacities (2–5 mm)
Remaining discrete LN Location Size
Carcinomatosis +/– Any Variable
Lymphoma + Any Same
Sarcoidosis + Mid zone Variable
Tending to confluence and varying rapidly
Multifocal pneumonia +/– Any Variable
Pulmonary edema – Perihilar Variable
Extrinsic allergic – Basal Same
alveolitis
Fat emboli – Peripheral Same

Table 1.19:Spectrum Multiple Pinpoint Opacities

1 2 3 4 5
At the termination of the + – – – –
thoracic duct
In gold miners – + – – –
Inhalation of tin oxide – – + – –
Distribution Near – – Bases and –
thoracic apices
duct spared
Kerley lines – – + – –
Inhalation of barytes – – – + –
Miliary + + + – +
Negative shadows – – – – +

Septal Lines
• Pulmonary edema
• Mitral valve disease
• Pneumoconiosis
• Lymphangitis carcinomatosa
 Chest 109

Fig. 1.27:  Posteroanterior radiograph of chest shows opaque right

hemithorax with fairly preserved hemithoracic volume

• Sarcoidosis
• Infection
• Lymphoma.

1.23  COMPLETE OPAQUE HEMITHORAX

Causes (Figs 1.27 and 1.28)

Technical Rotation, scoliosis
Pleural Hydrothorax, lung effusion
thickening, mesothelioma
Surgical Pneumonectomy, thoracoplasty
Congenital Pulmonary agenesis
Mediastinal Gross cardiomegaly, tumors
Pulmonary Collapse, consolidation, fibrosis
110 Differential Diagnosis in Radiology

Fig. 1.28:  Posteroa nterior radiograph of chest shows opacities in left

hemithorax with loss of volume with subsegmental pneumonitis in right
middle zone in a case of Koch’s chest

Diaphragmatic Hernia
Scoliosis
• Lucency on Vertebral
• Concave side Anomaly
• Rotated side Clavicular asymmetry

Effusion
• Blunted cardiophrenic angle
• Fluid along the lateral chest wall
• Silhouette with cardiac and diaphragm
• Changes with change of posture
• Thickening
– Does not follow
Ellis curve
 Chest 111
1.24  OPAQUE HEMITHORAX

Causes
• Technical Rotation, scoliosis
• Pleural Pleural effusion
– Pleural thickening
– Mesothelioma
• Surgical Pneumonectomy
– Thoracoplasty
• Congenital Pulmonary agenesis
• Mediastinal Gross cardiomegaly, tumors
• Pulmonary Collapse, consolidation, fibrosis
• Diaphragmatic hernia

Rotation
• In well-centered film, medial ends of clavicle are equidistant
from spinous process of T4/5 level
• Lung nearest to the film, less translucent.

Pleural Effusion
• A massive effusion may cause complete radiopacity of a
hemithorax
• Mediastinal shift to contralateral side
• Inversion of diaphragm
• If effusion without mediastinal shift, collapse of underlying
lung.

Exclude Carcinoma Bronchus

• Ultrasound reveals fluid in pleural cavity. In AP-CXR—with
patient supine a small effusion gravitates posteriorly—
generalized increased density with apical cap
• Erect or decubitus film confirms the diagnosis
• Pulmonary agenesis/aplasia/hypoplasia.
112 Differential Diagnosis in Radiology

Agenesis
• Complete absence of the lobe as well as its bronchus
• Absent vascular supply.

Aplasia
• No lung tissue
• Rudimentary bronchus.

Hypoplasia
• Bronchi and alveoli are present, but the lobe is under-developed
• More common on right side
• Mediastinal shifts present. Absence of a lobe is more common
than absence of whole lung
• Loss of silhouette on the right side of the heart and ascending
aorta due to deposition of extrapleural alveolar tissue
• If whole lung absent—completely opaque hemithorax with
mediastinal shift and diaphragmatic shift
• Unlike acquired pneumonectomy, gross loss of lung volume,
external diameter is not considerably less than normal side in
congenital absence
• Bronchography—diagnostic
• Scintigraphy—absent ventilation and perfusion on the affected
site
• Angiography—absent/hypoplastic pulmonary artery.

Diaphragmatic Hernia
• L > R more common in the left side
• If large hernia in early neonatal period may lead to opaque
hemithorax
• Bochdalek hernia—posterolaterally due to persistent pleurop-
eritoneal canal
• It may contain fat, omentum, spleen, kidney and bowel—
Associated with pulmonary hypoplasia and contralateral
mediastinal shift
 Chest 113
• In older age group—hemithorax not opaque due to gas in
bowel loops.

Consolidation
• Parenchymal opacification caused by replacement of air in the
distal air spaces by fluid (transudate, exudate or blood) or tissue
(e.g. bronchoalveolar cell carcinoma, lymphoma) is defined as
consolidation
• Usually no volume loss
• Expansile consolidation Pneumococcal and Klebsiella pneumonia
– Neoplasms
– Air bronchogram.

Pleural Thickening
If extensive—may lead to opaque hemithorax
• Previous thoracotomy
• Empyema
• Hemithorax
• Viewed en profile–appears as a band of soft tissue density.
• En face—ill-defined veil-like shadowing
• USG—not so sensitive pleural thickening, not reliably detected
unless 1 cm in thickness
• CT—very sensitive
• May calcify, involve visceral pleura
• If entire lung is surrounded by fibrotic pleura—Fibrothorax.

Fibrothorax is defined by Criteria

• If uninterrupted pleural density that extends over at least a
forth of the chest wall
• On CT—8 cm craniocaudal
– 5 cm laterally
– 3 mm thick
• No mediastinal shift
• Reduced ventilation due to decrease in volume
114 Differential Diagnosis in Radiology
• If on X-ray—decreased vascularity, significant ventilatory
restriction is present
• Surgical decortication is required.

Mesothelioma
More common primary pleural malignancy
• Prolonged exposure to asbestos dust—crocidolite (MC)
• Nodular pleural thickening ± hemorrhagic pleural effusion
around all or part of lung.
With central mediastinum
Volume loss due to ventilatory restriction
• Bronchial stenosis by tumor compression at hilum
• Malignant pleural thickening is nodule and extends into fissures
or over the mediastinal surface, may surround whole lung
• MRI better than CT in assessing involvement of mediastinum
and chest wall. Signal intensity slightly more than muscles on
both T1 and T2 WI.

Post-pneumonectomy
• 2–3 months after surgery
• H/o of pneumonectomy
• ± Rib resection
• ± Opaque bronchial sutures.

1.25  HYPERTRANSRADIANT LUNG FIELD

Bilateral
A. Faulty radiologic technique
• Overpenetrated films
B. Decreased soft tissues
• Thin body habitus
• Bilateral mastectomy
 Chest 115
C. Cardiac causes of decreased pulmonary blood flow
• Right to left shunts (Tetralogy of Fallot, Ebstein’s
malformation, Tricuspid atresia)
• Eisenmenger physiology
D. Pulmonary causes of decreased pulmonary blood flow
• Pulmonary embolism
• Air trapping
• Emphysema
• Bulla
• Bleb
• Interstitial emphysema.

Unilateral
A. Faulty radiologic technique
• Rotation of patient
B. Chest wall defects
• Mastectomy
• Poland syndrome (absence of pectoralis major)
C. Air trapping
• Extrinsic compression of main bronchus
• Endobronchial obstruction
• Bronchiolitis obliterans
• McLeod syndrome
• Emphysema
• Pneumothorax
D. Vascular causes
• Pulmonary arterial hypoplasia
• Pulmonary embolism
• Congenital lobar emphysema (Fig. 1.29)
• Compensatory over-aeration.

Tetralogy of Fallot
• Congenital disease presenting as left to right shunt with four
components VSD, infundibular narrowing of the right ventricular
outflow tract, right ventricular hypertrophy, overriding aorta.
116 Differential Diagnosis in Radiology

Fig. 1.29: Anteroposterior radiograph of chest shows congenital emphy-

sema of left lung with herniation to right side midline

Plain Skiagram Chest

• Boot-shaped heart
• Hypoplasia of pulmonary artery
• Pulmonary oligemia leading to translucent lungs
• Right-sided aortic arch.

ECHO
• Discontinuity between anterior aortic wall and IV septum due
to overriding aorta
• Small left atrium
• RV hypertrophy with small outflow tract
• Doppler USG can quantify severity of VSD and pulmonary
stenosis.
 Chest 117
Ebstein’s Anomaly
• Congenital disease with left to right shunt with atrialization of
right ventricle due to downward displacement of the dysplastic
incompetent tricuspid valve leading to a small right ventricle.
There is associated ASD or PDA
• Patient presents early reversal of the shunt from right to left,
leading to cyanosis.

Plain Skiagram Chest

• Massive globular “funnel-like” cardiomegaly with small pedicle
due to hypoplastic aorta and pulmonary trunk (the only CHD
with this feature)
• Extreme RA enlargement
• Dilated IVC and azygous vein
• Severe pulmonary oligemia leading to translucent lung fields
• Calcification of tricuspid valve may occur.

ECHO
• Large sail-like tricuspid valve
• RA enlargement
• Doppler USG can quantify tricuspid regurgitation.

Tricuspid Atresia
• Congenital disease with atresia of the tricuspid valve and
pronounced cyanosis at birth and is associated with ASD and
a small VSD. Pulmonary stenosis may or may not be present. It
may present with or without transposition of great vessels.

Plain Skiagram Chest

• Left ventricular contour of the heart with rounding due to both
enlargement and hypertrophy of left ventricle
• RA enlargement
• Concave pulmonary bay
• Pulmonary oligemia leading to translucent lung fields.
118 Differential Diagnosis in Radiology

Eisenmenger Physiology
• Occurs when there is reversal of left to right shunt as a
consequence of pulmonary arterial hypertension.

Plain Skiagram Chest

• Pronounced dilatation of central pulmonary arteries
• Pruning of peripheral pulmonary arteries leading to increased
translucency
• Enlargement of RV
• Return of LA and LV to normal size
• Normal pulmonary venous pressure.

Pulmonary Embolism
• The embolism is usually a result of DVT in the lower limbs
• There is a classic triad seen in 33% of cases of hemoptysis,
pleural rub and thrombophlebitis
• Hypertranslucency is seen bilaterally in cases presenting
with acute massive embolic episode, which blocks the main
pulmonary artery before the development of infarction. The
development of infarction leads to segmental, lobar or wedge-
shaped areas of consolidation. Pleural effusion is usually
present
• Unilateral hypertranslucency may occur in cases where the
embolus blocks one of the major pulmonary arteries.

Air Trapping
• There is trapping of air in the lungs due to valve mechanism
acting at the level of the trachea or major bronchi
• In children, this is usually due to a foreign body. In adults, an
endotracheal or endobronchial growth of extrinsic pressure is
the usual cause
• On plain skiagram chest, there is hypertranslucency with
evidence of increased volume like splaying of ribs, long tubular
heart, barrel-shaped chest due to increased AP diameter of the
 Chest 119
chest and depressed domes of diaphragm. These findings may
be unilateral or bilateral depending on the etiology. However,
in unilateral increase in volume, these findings are unilateral
except for the contralateral shift of mediastinum and largely
normal cardiac contour
Bulla, Blebs and Pneumatoceles: When very large, it may compress
the surrounding normal lung and may lead to either unilateral or
bilateral hypertranslucency.
Bronchiolitis obliterans: Also known as constrictive bronchiolitis or
obliterative bronchiolitis is a result of inflammation of bronchioles
leading to obstruction of bronchial lumen.
• Chest X-ray may be normal
• Hyperinflated lungs leading to increased lucency may be seen
in upto 60% of cases
• There is decrease in pulmonary blood flow
• On HRCT, there is mosaic perfusion and lobular air trapping
may be seen, bronchial wall thickening and bronchiectasis may
also be seen.
McLeod syndrome: Also known as Swyer-James syndrome, it is a
result of acute viral bronchiolitis in infancy, leading to constrictive
bronchiolitis.
• There is increased translucency of the affected lung
• Small hemithorax with decreased or normal volume of the lung
• Air trapping during expiration
• Small ipsilateral hilum
• Reduced pulmonary vasculature with pruning of vessels.
Emphysema: This term is broadly used to define pulmonary
diseases characterized by permanently enlarged air spaces distal
to terminal bronchioles accompanied by destruction of alveolar
walls and local elastic fiber network.

Plain Skiagram Chest

• Hyperinflated translucent lungs
• Low or flat hemidiaphragms
• Increased retrosternal air space
120 Differential Diagnosis in Radiology
• Barrel chest
• Pulmonary vascular pruning
• Right heart enlargement
• Bullae.
Compensatory Emphysema or over-aeration is a distinct clinical
entity where there are unilateral findings of emphysema seen due
to diseased non-functional contralateral lung.

Pneumothorax
• Can be unilateral or bilateral and is a result of collection of air in
the pleural cavity.

Plain Skiagram Chest

• There is increased translucency with loss of broncho-vascular
markings
• There is contralateral shift of mediastinum in the unilateral
types
• In tension pneumothorax, there may be inversion of diaphragm.

Congenital Lobar Emphysema

• Result of congenital insult leading to constriction of bronchi
supplying one lobe leading to air trapping and increase in
volume
• The enlarged lobe compresses the remaining normal lobes
• Contralateral mediastinal shift.

Pulmonary Arterial Hypoplasia

• Small or absent main pulmonary artery
• Concave pulmonary bay
• Pulmonary oligemia.
 Chest 121
1.26  HYPERTRANSLUCENT LUNG FIELD

Causes of Bilateral Hypertranslucency

Faulty Radiologic Technique

• Overpenetrated film.

Decreased Soft Tissues

• Thin body habitus
• Bilateral mastectomy.

Cardiac Cause
• Right to left shunt
• Eisenmengerization of left to right shunt.

Pulmonary Cause
• Decreased vascular bed
– Pulmonary embolus.
• Increase in air space
– Air trapping—asthma, acute bronchitis, emphysema
– Bullae, blebs
– Interstitial emphysema.

Localized Lucent Lung Defect

• Cavity
– Infection
– Neoplasm
– Vascular occlusion
– Inhalational – Silicosis with coal worker’s pneumoconiosis.
• Cyst
– Cystic bronchiectasis
– Pneumatocele
122 Differential Diagnosis in Radiology
– Centrilobular/bullous emphysema
– Honeycomb lung
– Diaphragmatic hernia
– CCAM Type I, CLE, bronchogenic cyst.
Hyperlucent lung: (Unilateral):
Normal Increased density contralateral lung
Overpenetrated film
Technical Overpenetrated film
Rotation, scoliosis
Soft tissue Mastectomy
Congenital absence of pectoralis major
Poliomyelitis (Poland’s syndrome)
Emphysema Compensatory: Lobar collapse,
Lobectomy
Obstructive: Foreign body, tumor
McLeod’s syndrome.
CLE
Bullous
Vascular Absent/hypoplastic pulmonary
artery, obstructed pulmonary artery
< Tumor embolus
Pneumothorax McLeod’s syndrome

1.27A HONEYCOMB LUNG

Common Rare
Histiocytosis-X Tuberous sclerosis
Scleroderma Amyloidosis
Rheumatoid disease Neurofibromatosis
Fibrosing alveolitis Lymphangioleiomyomatosis
Pneumoconiosis —
Sarcoidosis —
Similar appearance —
Bronchiectasis Connection with bronchus +
Cystic fibrosis Pancreatic anomalies +
Achlorhydria
 Chest 123
Location Upper zones Extrinsic allergic
alveolitis
Upper and midzones bases Histiocytosis
Rheumatoid
Scleroderma
Cystic bronchiectasis
Cryptogenic fibrosing alveolitis
Mid and bases Sarcoidosis

Multiple Pinpoint Opacities

Post-lymphogram : Iodized oil emboli. Contrast medium
is seen at the site of termination of
the thoracic duct
Silicosis : Located in upper and mid zones,
seen in gold miners
Stannosis : Evenly distributed throughout the lung
with Kerley A and B lines
Baryltosis : Inhalation of barytes
Very dense, discrete opacities
May be slightly larger in size
Bases and apices are spared
Alveolar : Familial, black pleura, enlarged heart
microlithiasis size is positive.

Lobar Pneumonia (Fig. 1.30)

Consolidation involving the air spaces of an anatomically
recognizable lobe. The entire lobe may not be involved and there
may be a degree of associated collapse.
1. Streptococcus pneumonia: Commonest cause, unilobar in
distribution. No cavitation. Little or no collapse. Pleural effusion
is uncommon.
2. Staphylococcus: Especially in children. Sixty percent develop
pneumatocele. No lobar predilection, effusion, empyema and
pneumothorax and bronchopleural fistulae are common.
124 Differential Diagnosis in Radiology

Fig. 1.30: Posteroanterior radiograph of chest shows

left lower lobe consolidation collapse

3. Klebsiella pneumoniae: Multilobar involvement, cavitation and

lobar enlargement is common.
4. Tuberculosis: Associated collapse is common.
Right lung is more frequently involved.
Anterior segment of the upper lobe and the medial segment of
the middle lobe are the commonest sites.
5. Streptococcus pyogenes: Lower lobe predominates, often
associated with pleural effusion.

Consolidation with Bulging Fissures

Homogeneous or inhomogeneous air space opacification with
bulging of the bounding fissures
1. Infection with abundant exudates
Klebsiella, Streptococcus pneumoniae, Tubercular bacilli
2. Abscess: When air-area of consolidation breaks down.
Common organisms include Staphylococcus aureus, klebsiella
and other gram –ve organism
3. CA of the bronchus.
 Chest 125
Lung Disease Associated with Honey Combing
Collagen Disorders
Rheumatoid lung : Basal predominance
Infiltrates and effusion are common
Scleroderma basal
Preceded by fine, linear basal streaks.
Extrinsic allergic alveolitis upper zones
Sarcoidosis sparing of extreme apices
•  Hilar lymph adenopathy
•  Egg shell calcification.
Pneumoconiosis : Mainly due to asbestosis
Cystic bronchiectasis lower and middle zones
Bronchial wall thickening
Localized areas of consolidation
Histiocytosis—mid and upper zones.
Disseminated nodules followed by honeycomb pattern
Tuberous sclerosis : Rare
Neurofibromatosis : Rib notching +
Ribbon ribs +
Scoliosis

1.27B HONEY COMB PATTERN

1. A generalized reticular pattern or miliary mottling which when
summated produces the appearance of air containing ‘cysts’
0.5–2 cm in diameter.
2. Obscured pulmonary vasculature.
3. Late appearance of radiological signs after the onset of
symptoms.
4. Complications
a. Pneumothorax is frequent
b. Cor pulmonale later in the course of the disease.
126 Differential Diagnosis in Radiology

Causes
1. Collagen diseases—Rheumatoid arthritis
Scleroderma
2. Extrinsic allergic alveolitis
3. Sarcoidosis
4. Pneumoconiosis
5. Cystic bronchiectasis
6. Cystic fibrosis
7. Drugs—nitrofurantoin, busulfan, cyclophosphamide,
bleomycin and melphalan
8. Langerhans cells histiocytosis
9. Lymphangioleiomyomatosis
10. Tuberous sclerosis
11. Idiopathic interstitial fibrosis (cryptogenic fibrosing
alveolitis)
12. Neurofibromatosis.

Rheumatoid Arthritis
• Most pronounced at the bases
• It’s severity does not parallel to that of joint involvement
• In the earlier stages, it is characterized by radiologic appearance
of patchy area of air space consolidation (multifocal ill-defined
densities)
• In the intermediate stage, there is fine reticular pattern or
reticulonodular pattern
• As the progress decreases, there is appearance of cystic spaces
of honeycomb lung
• All the above features may be preceded by basal infiltrates ±
small effusion.

Scleroderma
• Predominantly basal
• Less regular ‘honeycomb’ pattern which is preceded by fine,
linear, basal streaks, cor pulmonale is unusual
 Chest 127
• Other clinical signs which include skin changes, soft tissue
calcification, disturbances of esophageal motility and dilatation
of the esophagus
• Radiologically, an upper GIT series may demonstrate both
esophageal dilatation and decreased motility as well as small
bowel dilatation.

ASBESTOSIS
• It produces a basilar distribution that may progress from a fine
reticular interstitial pattern to a coarse interstitial pattern with
honeycombing
• The basilar reticular or honeycomb pattern is also frequently
associated with pleural thickening, pleural calcification.

Silicosis
• It has predominant upper lobe distribution
• It may be associated with hilar or mediastinal lymphadenopathy
with pleural thickening. The fine reticular pattern is seen which
progresses to honeycomb lung.

Extrinsic Allergic Alveolitis

• Predominantly seen in the upper lobes of the lung.

Sarcoidosis
Sparing of extreme apices:
• Honeycombing of the lung is usually preceded by some classic
finding including hilar adenopathy and an interstitial nodular
or fine reticular interstitial pattern
• As the interstitial disease, progresses, there is regression of hilar
adenopathy.
128 Differential Diagnosis in Radiology

Langerhans Cell Histiocytosis

• ‘Honeycomb’ pattern preceded by disseminated nodules
• May be predominantly in the mid and upper zones
• Cor pulmonale is uncommon.

Usual Interstitial Pneumonitis/

Cryptogenic Fibrosing

Alveolitis
• More marked in the lower lobes of the lungs initially and
progresses to involve the whole of the lungs
• In HRCT, there is honeycombing and fibrosis. It shows a uniform
and patchy distribution.

Tuberous Sclerosis
• Symptoms, when they appear, usually first appear in adult life
• Pneumothorax, pulmonary insufficiency and cor pulmonale
may complicate the syndrome
• The clinical and radiological manifestation of the disease in the
brain, kidneys and skin readily establishes the diagnosis.

Neurofibromatosis
• Honeycomb lung ± rib notching ribbon ribs and/or scoliosis is
seen in 10% cases but not before adulthood.

1.28  PLEURAL DISEASES

• Serous membrane which covers the surface of lung and lines
the inner surface of chest wall.

Common conditions are:

• Pleural effusion
• Pleural thickening
 Chest 129
• Pneumothorax
• Pleural masses
• Pleural calcification.

Pleural Effusion
May be transudate, exudate, pus, blood or chyle.

Transudate
Contain < 3 g/dL of protein, usually bilateral
a. Increase hydrostatic pressure
Main cause is congestive cardiac failure (CCF)—1st on right side
and then bilateral, constrictive pericarditis.
b. Decrease colloid osmotic pressure
– Decrease protein product—cirrhosis with ascites
– Protein loss/hypervolemia
Nephrotic syndrome
Overhydration
Peritoneal dialysis
c. Meig-Salmon syndrome
Ovarian fibroma, thecoma, GCT, Brenner’s tumor, etc.
– Ascites
Pleural effusion resolves with tumor removal.

Exudate
Increased permeability of abnormal pleural capillaries with release
of high-protein fluid into pleural space.
> 3 g/dL of protein.
A. Infection
1. Empyema—Pleural effusion with presence of pus. +/–
positive culture.
Micro-organisms are anerobic bacteria
Gross pus (WBC >15000/cm3)
2. Parapneumonic effusion—Less with pneumonia, abscess,
bronchiectasis.
130 Differential Diagnosis in Radiology
3. TB—Increase protein content >75 g/dL
4. Fungi and parasite—Amebiasis, secondary to liver abscess.
B. Malignant disease—Lung carcinoma (Ca), lymphoma, breast,
ovarian Ca and malignant mesothelioma. Positive cytological
result.
C. Vascular—Pulmonary embolism (15–30%)
D. Abdominal disease
Pancreatitis: Left side pleural effusion (68%),
right side (10%).
Boerhaave’s syndrome: Left side

Subphrenic Pleural effusion—79%
abscess:
Elevation and restriction of
diaphragmatic movement
Endometriosis Plate-like atelectatic or pneumonia.
E. Connective tissue disorder.
RA—UL(R>L) recurrent alternating sides relatively unchanged
in size for months.

Systemic Lupus Erythematosus (SLE)

Bilateral (B/L) in 50% (L>R), increased cardiac size.

Wegener’s Granuloma
Hemothorax
• Bleeding into the pleural space may be trauma.
• Hemophilia or excessive anticoagulation—Rare
• Pulmonary infarction—Blood stained
• Lung carcinoma—Blood stained.

Chylothorax
Chyle is milky fluid high in neutral fat and fatty acid.
Secondary to damage or obstruction of the thoracic lymphatic
vessels.
 Chest 131
Causes: Most common cause—trauma—surgery.
Carcinoma of lung, lymphoma, filariasis.

Radiological Features
Plain film: Frontal view less sensitive < Lateral view < Lateral.
decubitus view.
• Moderate effusion with mediastinum is shifted towards the
side of collapse—likely due to carcinoma of bronchus
• Empyema may be suspected by the appearance of a fluid level
• Septations.

Ultrasonography (USG)
Very sensitive, can detect few ml of fluid.
Transudate—Clear fluid separating the visceral and parietal pleura
Moving lung suspended within the pleural space.
Exudate—Echogenic fluid, containing floating particulate material,
septations or fibrin strands may be associated with pleural nodule
or thickening > 3 mm.
CT—Simple pleural effusion—Sickle-shaped disease in the most
dependent part of thorax posteriorly
• In regard to tissue density—CT is rarely helpful, however
• Exudate—>water density septation
• Parietal pleural thickening on CECT
• Extrapleural fat thickening of >2 mm
• Chylous—Decreased density than H2O.
Acute hemorrhaged—Increased density of fluid with presence
of fluid-fluid level.

Pleural Thickening
• Non-pathological
B/L apical pleural thickening, symmetrical
Elderly patient
Probably ischemia is the cause
132 Differential Diagnosis in Radiology
• Trauma: If the entire lung is surrounded by the fibrotic
Fibrothorax is secondary to organized effusion, hemothorax or
pyothorax
• Dense fibrous layer of 2 cm thickness almost always on visceral
pleura
• Frequent calcification on inner aspect of pleura.

Infection
• Chronic empyema—H/o pneumonia with presence of
parenchymal scars. Usually seen over the bases
• Frequently a thickened layer of extrapleural fat can be seen
separating the parietal and visceral layer
• Calcification may be seen.

Tuberculosis (TB)
• Lung apex
• Can be associated with apical cavity
• Calcification may be seen.

Inhalation Disorder
Asbestos exposure involves the lower lateral chest wall, basilar
interstitial disease.
Pleural plaque: Involves the parietal pleura with sparing of visceral
pleura.

Neoplasm
Asymmetric apical pleural thickening may represent Pancoast
tumor destruction of adjacent ribs and spine penetrated film will
be helpful.
• Metastasis—often nodular.
 Chest 133
Pleural Calcification
Has the same causes as pleural thickening.
Unilateral (U/L) pleural calcification—result of previous empyema,
hemothorax or pleurisy and also occur in visceral pleura associated
with pleural thickening.
• Calcification may be in a continuous sheet or in discrete plaque.
Bilateral (B/L) calcification seen in asbestos exposure, more
delicate, frequently visible over the diaphragm and adjacent to
axilla located in parietal pleura.

Pleural Masses
• Incomplete border and tapered superior and inferior borders
• Usually make obtuse angle with chest wall
• Displacement of adjacent lung parenchyma with compressive
atelectasis and blowing of bronchi and pulmonary vessels
around the mass
• Vanishing tumor and encysted pleural effusion fluid may
become loculated in interlobar fissure seen in heart failure
lateral film typical lenticular configuration. Encysted pleural
effusion—often associated with free pleural effusion
• Water density
• Neoplasm.

Benign
• Lipoma—CT detects the origin of mass of fat density.
Benign lipoma confirms fat density with few fibrin strands
• Thymolipoma, angiolipoma, teratoma, characterized by islands
of soft tissue density, interspersed with fat
• Fibroma/benign fibrous mesothelioma—Most common
benign tumor may be associated with hypoglycemia and HPOA
solitary lobulated non-calcification mass
If pedicle is seen—diagnostic, shape changes with the change
in patient’s position.
134 Differential Diagnosis in Radiology

Malignant Pleural Thickening

Bronchogenic Carcinoma: Most common cause.
When a bronchogenic carcinoma involves the pleura
diffusely with resultant pleural effusion, the tumor is considered
unresectable.

Malignant Mesothelioma
• Rare tumor
• 70% of cases—H/O asbestos exposure
• Nodular pleural thickening around all or part of lung with
pleural effusion
• Pleural—plaque
• Metastatic disease—Breast and gostrointestinal tract (GIT)
• Most common manifestation is malignant pleural effusion
• Pleural thickening is nodular and frequent. Encase the entire
lung including mediastinum
• Pleural lymphoma
• Pleural effusion
CT= localized broad-based lymphomatous pleural plaque.

Pneumothorax
Spontaneous—Most common type
M:F: 8:1, young male with tall thin stature
Due to rupture of a congenital pleural bleb, such blebs are
usually in the lung apex and may be B/L.
Iatrogenic— For example, postoperative, after chest aspiration
during artificial ventilation, after lung biopsy.
Traumatic—result of a penetrating chest wound, closed chest
trauma, associated finding like rib fracture.

Hemothorax
Surgical/mediastinal emphysema
Secondary to lung disease:
• Emphysema
• Chronic bronchitis
 Chest 135
• Common factor in an elderly patient
• Rupture of a tension cyst in Staphylococcus pneumoniae
• Rupture of a subpleural TB focus
• Rupture of a cavitating subpleural metastases
• Pneumoperitoneum—air passes through a pleuroperitoneal
foramen
• Generalized
• Localized—if pleural adhesions are present.

Open
If air can move freely in and out of pleural space during respiration.

Closed
If no movement.
Valvular: If air enters the pleural space on inspiration but does not
leave on expiration, it is valvular—as intrapleural pressure increase
it leads to development of tension pneumothorax.
Radiological features: Small pneumothorax in an erect patient
collects at the apex.
Expiratory film—useful in closed pneumothorax.
Lateral decubitus film with affected side uppermost.
Tension Pneumothorax: Massive displacement of mediastinum.
• Kinking of great veins
• Acute cardiac and respiratory embarrassment
• Ipsilateral lung may be squashed against the mediastinum and
herniate across the midline
• Depression of ipsilateral diaphragm.
Loculated pneumothorax = pleural adhesion may result in
loculated pneumothorax.
D/D—subpleural bullae, thin-walled pulmonary cavity/cyst.
Few linear strands can be seen in these but not in pneumothorax.
Hydropneumothorax containing a horizontal fluid level
(Fig. 1.31).
(See Flow chart 1.2)
136 Differential Diagnosis in Radiology

Fig. 1.31: Posteroanterior radiograph of chest shows hydropneumotho-

rax on left side with mediastinal shift to right side

1.29  PLEURAL FLUID

Radiological Appearances of Pleural Fluid

• Most dependent recess of the pleura is the posterior
costophrenic angle (100–200 mL of fluid is required to fill this).
Small effusions are hence seen earlier on a lateral film and now
on ultrasound.
• Decubitus view with a horizontal beam is being the most
sensitive view
• The effusion casts a homogeneous opacity spread upwards.
Typically, this opacity has a fairly well-defined, concave upper
edge, which is higher laterally than medially and obscures the
diaphragmatic shadow
• A massive effusion may cause complete radiopacity of a
hemithorax.
 Chest 137
• In the presence of a large effusion, lack of displacement of the
mediastinum suggests that the underlying lung is completely
collapsed
• Lamellar effusions are shallow collections between the lung
surface and the visceral pleura
• Large effusions may accumulate between the diaphragm and
the undersurface of a lung—this is called subpulmonary pleural
effusion. The apex is more lateral than normal. This collection
moves fully with changes of posture
• Empyema usually has a lenticular shape, irregular thick walls
and may compress the underlying lung
• Loculated effusions tend to have comparatively little depth,
best considerable width, rather like a biconvex lens.

Pneumothorax (Fig. 1.32)

It collects in a free pleural space in an erect patient at the apex.
On the frontal film, sharp white line of the visceral pleura will be
visible, separated from the chest wall by the radiolucent pleural
space, which is devoid of lung markings.
An expiratory film will make a closed pneumothorax easier to
see since on a full expiration, the lung volume is at its smallest,
while the volume of pleural air is unchanged.
In tension pneumothorax, the ipsilateral lung may be squashed
against the mediastinum, or herniate across the midline, and the
ipsilateral hemidiaphragm may be depressed.
Nodular extension into the fissures, pleural effusion, and
volume loss of the ipsilateral lung, all suggest malignancy.
Metastatic: The most frequent primary tumors being of the
bronchus and breast.

1.30  PLEURAL TUMORS

Benign: Mesothelioma: Well-defined, lobulated mass adjacent

to chest wall, mediastinum, diaphragm.
138 Differential Diagnosis in Radiology
Flow chart 1.2:  Pleural Lesions
 Chest 139
Lipoma: Well-defined, lobulated mass may change
shape with respiration on CT, presence of fat is
diagnostic.
Malignant: Mesothelioma: Due to prolonged exposure to
asbestosis.
Nodular pleural thickening with pleural effusion. Rib
involvement may occur, but is rare.

1.31  PLEURAL CALCIFICATION (FLOW CHART 1.3)

The common conditions are:

1. Old empyema
2. Old hemothorax
3. Asbestos inhalation
4. Silicosis.

Old Empyema and Old Hemothorax

• Calcification is irregular, resembles a plaque or sheet and is
contained within thickened pleura
• En face, it is hazy and veil-like but in profile, it is dense and
linear, paralleling the chest wall
• Usually unilateral
• Most common site: Lower posterior half of chest
• In tuberculous empyema—both visceral and parietal pleura
may be calcified, which are sometimes separated by a soft
tissue opacity which may contain fluid.

Asbestos Inhalation
• A feature of asbestosis is pleural plaque which is a well-
defined soft tissue sheet originating in the parietal pleura
(latent period is 10 years).
• Latent period for calcification to develop is 20 years
• Lesions are usually bilateral, lying in the middle zone, lower
zone and diaphragm.
When calcified, ‘holly leaf pattern’ with sharp and often
angulated outlines and often follow the margins of the ribs.
140 Differential Diagnosis in Radiology

Fig. 1.32: Posteroanterior radiograph of chest shows loculated pneumo-

thorax in left lower hemithorax causing compression atelectasis of left
lower lobe

• Usually <1 cm thick.

Diffuse pleural thickening: Unlike pleural plaques, the margins
are well-defined and tapered; may reach several cm in thickness.
Pleural effusion—Uncommon.

Malignant Mesothelioma
Latent period: 40 years
Pulmonary changes: (peripheral lower zone)
• Fibrosis
• Bronchial carcinoma
• Pseudotumor (fibrotic atelectasis).
 Chest 141
Extrathoracic Manifestation
Peritoneal mesothelioma, malignancy of upper GIT.

Silicosis
• Inhalation of silica (SiO2)
• Pleural calcification is similar to asbestosis.

Other Features
• Multiple small nodules in upper zone and middle zone
• Hilar lymph nodes with egg shell calcification
• Progressive massive fibrosis
• Caplan’s syndrome also occurs in patients with rheumatoid
arthritis and silicosis.

1.32  HIGH RESOLUTION CT-PATTERN OF

PARENCHYMAL DISEASE

Peripheral, Base
1. Cryptogenic fibrosing alveolitis
Early : Ground glass appearance
Subpleural reticular shadows
Later : Reticulations extend centrally
Chronic : Small cyst formation, commencing at
subpleural site.
2. Asbestosis
Early : Changes are seen at the lung base.
Posteriorly.
Thickened curvilinear, subpleural
lines are seen.
Thickened subpleural septal lines,
coarse parenchymal lines extending
centrally.
Chronic : Honeycombing
Rounded atelectasis with comet
tail sign
142 Differential Diagnosis in Radiology

Central Upper Fluid Zones

Sarcoidosis: Thickened bronchovascular markings with perivascular
beading present centrally.
Patchy alveolar opacification.
Subpleural and peribronchovascular nodules.

Peripheral and Central

Lymphangitis : Bronchovascular markings and septal
line thickening.
No alveolar opacification is seen.

Widespread
Lymphangio- : Characteristic widespread distribution.
leiomyomatosis More common in women.
Uniform-sized well-defined cysts with
normal parenchyma surrounding them.
Tuberous Sclerosis
Variable-sized cyst
No feminine predilection.

1.33  CARDIOPHRENIC ANGLE MASS

(FLOW CHART 1.4)

Solid
i. Fat Density
1. Epicardial Fat Pad
– Obese, Cushing’s syndrome
– Uncapsulated, homogeneous extrapleural fat.
2. Lipoma
– Uncommon, well-defined, encapsulated thin
fibrous septae.
 Chest 143
Flow chart 1.3:  Pleural Calcification

3. Liposarcoma
– Ill-defined
– Inhomogeneous.
4. Morgagni hernia.
ii. Soft Tissue
Lymph nodes
– Lymphoma
– Carcinoma—breast, lung, colon
Traumatic—Diaphragmatic hernia
– H/O trauma
– Mostly left sided
– Single entry and exit
– Barium or other studies—useful in diagnosis
Diaphragmatic hump
– Herniation of liver through the gap
– Liver scan or USG
144 Differential Diagnosis in Radiology
Fibrous tumors of Pleura
– Pleura-based, well-defined, homogeneously enhancing,
stalked.
Primary or Secondary Malignancy
– Well-defined smoothly marginated lung-based.

Cystic or Vascular
– Pericardial cyst
– Well-defined, round to oval, fluid density, non-enhancing, right
CP angle.
Hydatid cyst
– Unilocular, associated with hepatic cyst or may be bilateral
– Meniscus sign, water lily sign
– Loculated pleural effusion
– USG—makes the diagnosis
– Varices
– Delayed phase scanning is needed
– Portal hypertension, more on right
– Scimitar syndrome
– Abnormal vessel draining into IVC or hepatic vein
– Lobar agenesis or aplasia
– Accessory diaphragm, pulmonary sequestration.
Pericardial cyst
– Etiology—embryogenesis, parietal recess, diverticulum, sequelae
– 30–40 years, asymptomatic
Plain film chest—well-defined, round to oval mass
– Cardiophrenic angle mass usually right
– Changes shape with respiration and body position.

Ultrasound
Well-defined, anechoic to hypoechoic, no septae
 Chest 145
Computer Tomography (CT)
• 3–8 cm in size
• May extend into fissures
• No enhancement, no perceptible wall.

Hydatid Cyst
• Three layers—Adventitia, friable ectocyst, inner germinal layer
• Lung cyst—Unilocular, 20% bilateral, 10% associated with
hepatic cyst
• Well-defined, round-oval, homogenous masses upto 10 cm in
diameter
• Calcification is rare
• Meniscus sign, water lily sign.

Morgagni Hernia
• Defect between septum transversum and right and left costal
margins of diaphragm
• Usually asymptomatic, more common in obese people
• Right-sided, small lesions may only have omental fat, and then
it may be difficult to distinguish from epicardial fat pad
• Large lesion—colon, liver, stomach or small intestine may
herniate
• Barium study—tenting of colon or loop above the diaphragm.
CT—Omental fat, omental vessels and abdominal viscera are
seen in the mass.

Diaphragmatic Hump and Hernia

• Trauma—Hernia mostly seen on left side (posterior and central)
• Colon or less commonly stomach are the contents
• Barium—Entry and exit through the defect are closely apposed
• Obstruction is frequent probably because of angular margins
of the defect but are detected late because of subtle changes
in plain film.
146 Differential Diagnosis in Radiology
• On right side—Liver may herniate in severe trauma
• A liver scan is helpful.

Congenital Hernia
• More common on right side
• It has a hernial sac.

Scimitar Syndrome
• Presence of partial anomalous pulmonary venous return below
the diaphragm, mostly right side
• Lobar agenesis or aplasia, other systemic artery from aorta in
lower thorax or upper abdomen
• Pulmonary artery may be small or entirely absent, accessory
diaphragm, hepatic herniation, pulmonary sequestration.

Fibrous Tumors of Pleura

• Solitary, sharply-defined, sometimes lobulated soft tissue
pleural-based mass without evidence of chest wall invasion,
homogenous enhancement
• Pedicle or stalk—pathognomonic and indicator of benign
lesion, mobility
• May grow very large than obtuse or acute angle may be formed
with pleura.

Primary or Secondary Carcinoma

• Well-defined, smoothly marginated
• Lung-based
• Multiple.
Flow chart 1.4: Cardiophrenic Angle Masses
Solid Cystic
• Epicardial fat pad • Pericardial cyst
• Lymphadenopathy • Bronchogenic cyst
• Lipoma • Hydatid cyst
 Chest 147
• Carcinoma • Loculated pleural effusion
• Solitary fibrous tumor of pleura
Diaphragmatic Vascular lesions
• Morgagni hernia • Dilated RA
• Diaphragmatic hump • Varices
• Diaphragmatic hernia • Scimitar syndrome
• Nodes

Epicardial Fat Pad

• Excessive deposition of fat in mediastinum
• Obese patient
• Cushing syndrome or excessive corticosteroid intake
• Uncapsulated and extrapleural fat.

Lipoma
• Uncommon
• Well-defined, encapsulated, generally homogenous
• May contain thin fibrous septae
• Inhomogenous, poorly-defined.

Lymph Nodes
• Anterior diaphragmatic group of LN—2 nodes, <5 mm is
normal.

Causes of enlargement are:

• Unilateral or bilateral
– Lymphoma
– Lung, breast or colon cancer—metastasis.
CHAPTER 2

Breast—Mammographic
Differential Diagnosis

2.1  CIRCUMSCRIBED RADIOLUCENT LESION

(FLOW CHART 2.1)

Lipoma
• Usually solitary, presents usually in older women
• Usually have a thin capsule
• Frequently large at diagnosis
• Difficult to palpate due to soft consistency.

Oil Cyst
• Single or multiple
• Usually small 2–3 cm
• History of (H/o) trauma
– Surgical.
– Seat belt injury.
• +/– mural calcification.

Galactocele
• During lactation = Milk containing cyst caused by obstruction
of a duct by inspissated milk in a woman who has abruptly
stopped breastfeeding 2–3 cm in diameter
• Lucent or mixed density mass
• Characteristic fat-fluid level when imaged with horizontal
beam.
 Breast—Mammographic Differential Diagnosis 149
Mixed Density Lesions
• Fibroadenolipoma (hamartoma)—Mammographic appearance
is determined by the relative amount of fat and glandular tissue
• Uncommon benign tumor composed of normal or dysplastic
mammary tissue, including adipose and fibrous tissues and
ducts and lobules in varying amount
• Often large at diagnosis, often 6 cm in diameter at the time of
diagnosis
• Lack of normal architecture with lack of orientation of glandular
tissue towards the nipple results in an appearance resembling a
“slice of sausage”
• There may be a thin soft tissue density capsule visible.

Galactocele
Discussed above.

Hematoma
• H/o trauma—Blunt or surgical
• H/o anticoagulant intake
• H/o clotting abnormalities
• Medium to high density mass, often having irregular margins
• Overlying skin edema present in acute stage
• Gradual decrease in size or disappearance of the lesion on
follow-up.

Lymph Node
• Medium to low-density lesion with a fatty notch or center
• Often bilateral (B/L) and multiple
• Almost always located in the superolateral quadrant
• Pathological nodes have +/– loss of central fatty hilum,
+/– enlargement.
150 Differential Diagnosis in Radiology

Causes
• Rheumatoid arthritis: (after gold treatment ± fine dense gold
deposits
• Sarcoidosis: (+/– punctate calcification)
• Infection: Tuberculosis—(coarse calcification +/–)
• Malignancy
– Leukemia
– Lymphoma
– Metastasis from carcinoma breast carcinoma ovary. (+/-
irregular microcalcification).

Radiopaque (Soft Tissue Density Lesion)

Simple Cyst (Fig. 2.1)

• Most common cause of a circumscribed mass arising in a female
40 years or more in age

Fig. 2.1: Craniocaudal mammogram shows multiple

well-defined, simple breast cysts
 Breast—Mammographic Differential Diagnosis 151
• Sharply circumscribed low soft tissue density mass +/–
radiolucent halo (halo sign)
• Often multiple and bilateral
• Most commonly 1–3 cm in diameter
• Calcification—Uncommon rarely peripheral thin egg shell
calcification may be present
• Cyst may develop quickly prior to menses and diminish in size
just as rapidly
• USG—oval or round echo-free lesion with smooth well-defined
walls.
Strict sonographic criteria for simple cysts are:
• Well-circumscribed margins
• A bright posterior wall
• Round or oval contour
• Absence of internal echoes
• Through transmission.

Fibroadenoma (Figs 2.2 to 2.4)

• Common benign estrogen sensitive tumor composed of
fibrotic and glandular tissues in varying proportion that usually
appears in adolescent and young women before the age of
thirty years
• Usually solitary, round, ovoid or smoothly lobulated mass of
medium density
• Calcification, which is coarse, popcorn-like or primarily
peripherally distributed is characteristic
• Ultrasonography (USG): Typical appearance is of a well-
circumscribed, round or oval mass showing posterior acoustic
enhancement and with a homogenous internal echo pattern—
usually of low reflectivity compared to the surrounding breast
tissue.

Papilloma
• Usually occurs in the retroareolar region
• May cause a serous or serosanguineous nipple discharge
152 Differential Diagnosis in Radiology

Fig. 2.2: Magnified mammogram shows lobulated fibroadenoma

Fig. 2.3: Craniocaudal mammogram shows well-defined

fibroadenoma with focal calcification
 Breast—Mammographic Differential Diagnosis 153

Fig. 2.4: High resolution sonogram of breast shows well-defined

fibroadenoma with posterior acoustic enhancement

• Usually the lesion is several millimeters in size. The mammogram

may show a slight bulging of a retroareolar duct or may appear
normal
• Crescent, rosette or egg shell calcification may occur.

Phylloides Tumor (Cystosarcoma Phylloides)

• Fibroepithelial tumor which is usually large when diagnosed
• On mammography solitary large, round, oval or polylobulated
and sharply outlined lesion
• May develop plaque-like calcification
• Can recur, if not completely excised.

Metastasis
Lymphoma, and other hematologic malignancies, melanoma and
lung cancer are the three most common blood borne hematologic
154 Differential Diagnosis in Radiology
sources, followed by ovarian cancer, soft tissue sarcomas and other
gastrointestinal and genitourinary cancer.
• Seen on mammograms as discrete nodules, usually solitary
(85%) and less often multiple (15%)
• Unilateral in 75% and bilateral in 25% cases
• Diffuse involvement is much less frequent
• Majority are found in upper-outer quadrant
• Cannot be differentiated from other benign nodules, such as
cysts or fibroadenomas. However, the presence of one or more
nodules in patient with known primary should alert one to the
possibility of blood-borne metastasis
• A spiculated mass indicates the presence of a second primary
breast cancer and not metastasis
• With the exception of psammomatous calcification in
metastatic ovarian carcinoma, metastases to the breast do not
calcify.

Lymphoma
• Primary lymphoma of the breast is rare
• Secondary involvement of the breast with lymphoma is more
frequent
• The most common form of involvement is a circumscribed
mass that is well-defined or shows minimal irregularity
• Moderate to marked spiculation may or may not be present
• In the absence of known or suspected lymphoma, the
mammographic findings are non-specific
• Bilateral axillary lymphadenopathy suggests the possibility of
lymphoma

Circumscribed Malignant Lesions (Circumscribed

Carcinoma)
• Circumscribed carcinoma is a descriptive term referring to any
ductal carcinoma, that appears as a circumscribed mass on
mammogram
 Breast—Mammographic Differential Diagnosis 155

Fig. 2.5: Typical carcinoma

• Circumscribed malignant lesions are most commonly

medullary, mucinous, papillary or intracystic carcinoma, and
rarely invasive ductal carcinoma (Fig. 2.5)
• Medullary carcinomas may grow rapidly and mostly occur in
women less than 50 years old
• Mucinous and papillary carcinomas have a favorable prognosis
and mostly occur in women over 50 years
• Medullary carcinoma exhibit varying degrees of lobulations.
Invasive papillary carcinoma frequently appears as a cluster of
smooth or irregular nodules, nodules in several quadrants or as
a solitary nodule
• The outline of malignant circumscribed lesion is usually less
sharply defined than benign circumscribed masses, and
malignant lesions are typically of high soft tissue density
(Flow chart 2.1).
156 Differential Diagnosis in Radiology
Flow chart 2.1:  Circumscribed radiolucent lesion
 Breast—Mammographic Differential Diagnosis 157
Spiculated Breast Masses (Figs 2.6 and 2.7)
Invasive Carcinoma
• Approximately 95% of spiculated masses are due to invasive
breast cancer
• On mammography, there is evidence of a distinct irregular,
central tumor mass from which dense spicules radiate in all
directions
• Spicules that reach the skin or muscles cause retraction and
localized skin thickening
• This sunburst appearance is most commonly seen in scirrhous
infiltrating ductal carcinoma
• A web-like pattern of spicules may be seen with invasive lobular
carcinoma
• Most spiculated carcinomas of 1 cm diameter or more can be
demonstrated by ultrasound. The typical ultrasound features

Fig. 2.6: Mediolateral mammogram shows spiculated breast carcinoma

158 Differential Diagnosis in Radiology

Fig. 2.7: High resolution sonogram of breast shows spiculated breast car-
cinoma with posterior acoustic shadowing and internal microcalcifications

are of an echo-poor mass, with poorly-defined margins and

posterior acoustic shadowing.

Post-surgical Scar
• Surgical scar can be diagnosed from the appropriate clinical
history and physical examination, showing the position of
incision site corresponds to the position of the stellate lesion,
if necessary, by carrying out mammogram with skin marker on
the incisional skin scar
• Postsurgical scarring usually will regress with time, whereas
spiculated carcinoma usually will grow
• Postsurgical scarring will characteristically lack a central density
and will appear different on the craniocaudal and oblique
lateral views. It will have a planar configuration corresponding
to the incisional plane rather than a three-dimensional one
 Breast—Mammographic Differential Diagnosis 159
• A central lucency due to fat necrosis, when present, is a reliable
sign that a lesion is due to previous surgery.

Fat Necrosis
• Fat necrosis may assume any one of several mammographic
appearances, stellate mass, circumscribed mass, amorphous
density or architectural distortion
• When present, central lucency in the mass or lipid cysts seen
as a round lucent areas surrounded by a thin fibrotic capsule
suggests the correct diagnosis
• Fat necrosis may occur secondary to blunt trauma, surgical
procedures or on an idiopathic basis, especially in older women
who have pendulous, fatty breasts.

Radial Scar (Complex Sclerosing Lesion)

• It is characterized histologically by a fibroelastic center
surrounded by ducts and lobules arranged in a radiating
fashion
• On mammograms, the lesion is fairly small, 10 to 15 cm in
diameter. Some appear solid in the center, but in most, there is
a radiolucent center or no solid central core
• Although seen on both mammographic views, the lesion tends
to occur in one plane both on mammogram and histologic
sections. It typically varies in appearance from one projection
to another
• All patients have normal physical findings. Skin thickening and
retraction over the lesion are infrequent
• Even when the mammographic findings are suggesting a radial
scar, they are not diagnostic. Thus, biopsy is required.

Breast Abscess
• Usually caused by staphylococcus and streptococcus
• May also appear as a spiculated or poorly defined mass
160 Differential Diagnosis in Radiology
• The clinical diagnosis is usually clear, as there is pain, swelling
and erythema
• Usually retroareolar and occurs in young primiparous women
during lactation.

Sclerosing Adenosis
• It may also appear as a small stellate tumor, which may be difficult
to distinguish from radial scar or cancer on mammography
• Extra-abdominal dermoid (fibromatosis) is a rare benign
condition that can appear as a spiculated or poorly-defined
mass as on mammography
• Granular cell myoblastoma: It is a rare benign tumor that
produces a palpable lump with ill-defined stellate margins on
mammography, suggestive of malignancy.

Pseudomass (Summation Shadows)

• Overlapping glandular tissue may simulate a mass on one
projection, but no similar mass is seen on an orthogonal view
• Therefore, an area of asymmetric tissue must be identified on
two views before it can be considered abnormal.

The Edematous Breast (Fig. 2.8)

The mammographic features are:
• Skin thickening, initially affecting mainly the lower part of the
breast
• Diffuse increased density
• Coarse trabecular pattern
• Enlargement of the breast.

Differential Diagnosis
1. Carcinoma of the breast: An edematous breast may be caused
either by an advanced primary tumor, lymphatic spread from a
primary tumor or inflammatory carcinoma.
 Breast—Mammographic Differential Diagnosis 161

Fig. 2.8: Mediolateral mammogram shows breast

edema and skin edema in eryseplas

– Extension of tumor into lymphatic vessels can produce focal

skin thickening and increased density of the subcutaneous
tissue. In inflammatory carcinoma, intense edema causes
rapid enlargement and tenderness of the affected breast
with diffuse skin thickening.
2. Axillary lymphatic obstruction: Axillary lymphatic obstruction
can occur secondary to metastasis from ipsilateral breast or
contralateral breast or from non-breast. Primary advanced
gynecologic malignancies (ovarian, uterine), rarely may block
primary lymphatic drainage in the lesser pelvis, causing lymph
flow through thoraco-epigastric collaterals and overloading
the axillary and supraclavicular lymphatic drainage.
3. Postoperative axillary lymph node removal or dissection: It may
also lead to edematous breast. Edema of the breast may persist
mammographically even when it is not obvious clinically.
– If axillary lymph node dissection has been performed
for metastatic disease and skin thickening occurs, it may
162 Differential Diagnosis in Radiology
be impossible to determine whether this appearance
represents metastatic involvement of the breast or
impaired lymphatic drainage from surgery.
4. Radiation therapy: The features of edema develop progressively
following radiotherapy treatment, reaches maximum at about
6 months and has resolved approximately 18 months following
treatment.
– If skin thickening and breast edema recur after the initial
edema has resolved or decreased, recurrent carcinoma
should be considered.
5. Mastitis or breast abscess: Focal or diffuse skin thickening may
be related to lactation, skin or nipple infection with extension
into the breast or hematogenous spread of infection.
Fluid overload state: Edematous breast may develop in
patients with cardiac failure, renal failure, cirrhosis and
hypoalbuminemia. It is usually bilateral. The thickening occurs
mostly in the dependent aspect of the breast. In a bed-ridden
patient lying on one side, the skin thickening may be unilateral
and involve only the dependent breast.

BREAST CALCIFICATIONS (FIG. 2.9)

Characteristically Benign Calcification

• Egg shell calcification: It represents hollow spherical structure
with a thin calcific rim
• Can occur in:
Idiopathic fat necrosis: Small, several centimeters across
Common in large fatty breast
• Post-traumatic or post-surgical—Larger.
• Rarely in the wall of the “garden variety”, type of breast cysts
which occur in fibrocystic disease
• Tram tracks calcification: (Rail-road track calcification)
• The typical appearance of vascular calcification is that of two
parallel calcific lines, along the vessel walls
• These calcifications may be seen to be continuous with non-
calcified soft tissue shadows of the vessels
 Breast—Mammographic Differential Diagnosis 163
• Large rod-like calcification: These follow the course of the ducts
branching out in a series of orderly areas which radiate from the
retroareolar area
• These occur in the duct lumen as solid cores, and are due to
benign secretory involvement
• These are distinguishable from malignant linear calcification
by being longer, wider and more variable in width, and being
more frequently bilateral
• Popcorn calcification: It is characteristic of fibro-adenoma
• Dystrophic calcification: Dystrophic calcification resulting from
surgery and/or radiation therapy often has a bizarre or plaque-
like shape and is frequently large
• Milk of calcium: It represents calcium that layers out in the
dependent portion of tiny microcysts
• Best seen on horizontal beam lateral view—which demonstrates
a calcium-fluid level or meniscus (the tea-cup sign) while a
craniocaudal view will show a round smudge shadow often,
but not always bilateral
• Skin calcifications: There may be punctate or tiny hollow spheres
of 1–2 mm diameter each
– These occur in sebaceous glands
– Most common locations are in the periareolar, axillary and
medial breast areas.
• Sometimes may present as localized cluster of punctate
calcification, rather than diffuse calcification.
In these cases, findings that raise the possibility that clustered
calcification may be in the skin and do not require biopsy, in
comparison to clustered parenchymal calcification that do
require biopsy, include a peripheral location (frequently in the
subcutaneous tissue), or a location in the periareolar region,
axillary area or medial breast. The presence of one or more tiny
hollow spherical calcifications within the cluster also suggests
skin calcifications
• True nature can be confirmed by tangential view, which
projects the cluster in the skin
164 Differential Diagnosis in Radiology
• Pseudocalcification: These include aluminium chloride
deodorant seen in the axilla or talcum powder seen in the
inframammary area or in the medial side of breasts
• Confirmation can be obtained when necessary, by repeating
the appropriate view, after the area has been cleaned.

Calcification Suspicious for Malignancy

• Characteristics required for suspicion of malignancy:
– Linear (casting shape).
– Linear distribution.
– Segmental distribution.
– Markedly clustered distribution.
• Characteristics not specific for malignancy but increasing degree
of suspicion
– Variation in shape (pleomorphism).
– Variation in size.
– Irregular margins of individual particles.
– Irregular boundaries of areas of calcification (Fig. 2.9).

Malignant (Fig. 2.10)

• Linear (casting type).
• Linear distribution.
• Segmental distribution.
• Markedly clustered distribution.
• Pleomorphism in size and shape.
• Irregular margins of individual particles.
• Irregular boundary with areas of calcification.

Calcification
1. Microcalcification is defined as individual calcific opacities
measuring < 0.5 mm diameter.
2. Macrocalcification: Opacities > 0.5 mm diameter.
3. Microcalcification is not specific to carcinoma.
Breast—Mammographic Differential Diagnosis 165

Fig. 2.9: Types of calcification

166 Differential Diagnosis in Radiology

Fig. 2.10: Magnified mammogram shows multiple

microcalcifications in breast carcinoma

4. Microcalcification is seen in 30–40% of carcinomas on

mammography.
5. Macrocalcification may be found in carcinoma.

Definitely Benign
1. Arterial—tortuous, tramline.
2. Smooth, widely separated, some with radiolucent center.
3. Linear thick, rod-like, widespread, some with radiolucent
center.
4. ‘Egg shell’ curvilinear: Margin of cyst, fat necrosis.
5. ‘Popcorn’ in fibroadenoma.
6. Large individual calcific opacity > 2 mm, e.g. involutional
fibroadenoma.
7. ‘Floating’ calcification—seen as calcific/fluid level seen on
lateral oblique projection in ‘milk of calcium’ cysts.
 Breast—Mammographic Differential Diagnosis 167
Probably Benign
1. Widespread—one/both breasts.
2. Macrocalcification of one size.
3. Symmetrical distribution.
4. Widely separated opacities.
5. Superficial distribution.
6. Normal parenchyma.

Possibly Malignant—Biopsy is Indicated

(see Fig. 2.10)
1. Microcalcification—particularly segmental, cluster distribution
(> 5 particles in 1.0 cm3 space; of these 30% will be malignant).
2. Mixture of sizes and shapes—linear, branching, punctate.
3. Associated suspicious soft tissue opacity.
4. Microcalcification eccentrically located in soft tissue mass.
5. Deterioration on serial mammography.

Benign Conditions that Mimic Malignancy

1. Microcalcification
a. Sclerosing adenosis: One/both breasts, widely separated
opacities.
2. Suspicious soft tissue opacity
a. Fibroadenoma—when one margin is ill-defined.
b. Fat necrosis—ill-defined, sometimes with radiolucent
center.
c. Post-biopsy scar.
d. Radial scar.
e. Plasma cell mastitis.
f. Hematoma.
g. Summation of normal tissues.
h. Irregular skin lesion, e.g. wart.
168 Differential Diagnosis in Radiology

Fig. 2.11: Craniocaudal mammogram shows skin edema and

retraction of nipple in carcinoma breast

CARCINOMA

Primary Features
1. Opacity—ill-defined, spiculated outline, comet tail. Usually
dense.
2. Microcalcification—mixture of sizes, and shapes; linear,
branching, punctate cluster arrangement. Eccentric to and/or
outside soft-tissue opacity.

Secondary Features (Fig. 2.11)

1. Distortion—adjacent tissues, obliteration subcutaneous, retro-
mammary spaces.
2. Skin, nipple retraction.
 Breast—Mammographic Differential Diagnosis 169
3. Edema – all or part of breast.
4. Halo – wide around primary opacity.
5. Duct dilatation.
6. Venous engorgement.
Note: Approximately 10% of palpable carcinomas in premenopausal
women are not diagnosable on mammography.
CHAPTER 3

Cardiovascular
System

3.1  DIFFERENTIAL DIAGNOSIS OF

CARDIOVASCULAR DISORDERS
1. Pericardial effusion (Flow chart 3.1)
• Pericardial fluid >50 mL.

Causes
1. Malignancy
– Secondaries normally from breast, lung.
– May cause tamponade.
– Usually hemorrhagic.
2. Inflammatory
Bacterial, viral, tuberculous infection.
Exudative in nature.
3. Heart diseases
Cardiac failure—Transudative in nature.
Myocardial infarction—Known as Dressler’s syndrome.
4. Endocrine diseases
Myxoedema causes substantial pleural effusion, often asymp-
tomatic.
5. Collagen diseases
All collagen diseases may cause pericardial effusion [Systemic
Lupus Erythematosus (SLE) causes large pericardial effusion].
6. Uremia
18% in acute uremia.
51% in chronic uremia.
May lead to tamponade.
 Cardiovascular System 171
7. Hemopericardium
– Traumatic.
– Rupture of heart in course of myocardial infection (MI).
Dissecting aneurysm leading into pericardium
(Flow chart 3.1).

3.2  INVISIBLE MAIN PULMONARY ARTERY

Underdeveloped Main Pulmonary Artery (Table 3.1)

1. Tetralogy of Fallot
– Obstruction of right ventricular outflow tract due to
pulmonary stenosis.
– Associated ventricular septal defect (VSD) and right
ventricular hypertrophy.
– Overriding of aorta.
2. Pulmonary stenosis
– Due to reduced flow.
– Associated right ventricular hypertrophy.
– Decreased pulmonary vascularity.
3. Tricuspid stenosis
– Due to reduced blood flow into the right ventricle and
pulmonary artery.
– Enlarged right atrium.
– Hepatic congestion-anasarca.

Misplaced Pulmonary Artery

1. Complete transposition of great vessels.
– Pulmonary trunk is absent in 99%—Pulmonary artery is
located posteriorly in midline.
– “Egg on its side” appearance of heart with narrow superior
mediastinum.
2. Persistent truncus arteriosus—single artery giving rise to
pulmonary and systemic aortic stenosis (AS).
– Cardiomegaly with enlarged left atrium.
– Large aortic shadow.
– Markedly increase pulmonary blood flow.
172 Differential Diagnosis in Radiology
Flow chart 3.1:  Pericardial effusion
Table 3.1:  Causes of differential features of underdeveloped pulmonary artery
Causes of Clinical Main Heart Pulmonary Associated
underdeveloped features pulmonary shadow flow features
pulmonary artery artery
•  Tetralogy of •  Cyanosis, faint- •  Underdeve- •  RVH concave pul- •  Decreased •  Pulmonary
Fallot ing spells on loped monary bay, upward stenosis,
exertion prominence of VSD, Rt aortic
cardiac apex, cor-En- arch
sabot appearance
•  Pulmonary •  Mostly asym- •  Underdeve- •  Right ventricular •  Decreased •  Cor pulmonale
stenosis ptomatic, loped hypertrophy
cyanosis, heart
failure
•  Tricuspid •  Progressive •  Underdeve- •  Right atrial enlarge- •  Decreased •  ASD, small
atresia cyanosis from loped ment, enlarged LV VSD
birth small pulmonary bay
•  Complete trans- •  Cyanosis, sym- •  Located in •  Right heart enlarge- •  Increased •  PDA + patent
position of great ptomatic 2 wks. midline post- ment, “egg on side” forman ovale,
arteries after birth eriorly appearance VSD in 50%
•  Truncus arte- •  Cyanosis, CHF •  Arising from •  Markedly •  Rt aortic arch
riosus systolic murmur single trunk increased in 35%, forked
along with ribs
systemic
arteries
Cardiovascular System
173
174 Differential Diagnosis in Radiology

3.3  PULMONARY ARTERIAL HYPERTENSION

(FIG. 3.1)
Sustained pulmonary artery pressure >30 mm Hg (Flow chart 3.2)
1. Primary
– Idiopathic, 3rd decade M<F dyspnea, syncope.
2. Secondary
a. Parenchymal pulmonary disease:
– Cor pulmonale, chromic obstructive pulmonary disease
(COPD), chronic bronchitis, asthma, emphysema,
interstitial fibrosis.
– Alveolar hypoxia and hypercapnia—pulmonary
vasoconstriction—pulmonary arterial hypertension.
b. Congenital heart disease:
– Large left to right shunt (Eisenmenger’s syndrome)
ASD, VSD, PDA lead to increased pulmonary blood

Fig. 3.1: Posteroanterior radiograph of chest shows cardiomegaly with

enlarged pulmonary trunk and right inferior pulmonary artery in pulmonary
arterial hypertension
Flow chart 3.2:  Pulmonary arterial hypertension Cardiovascular System
175
176 Differential Diagnosis in Radiology
flow, leading to increased pulmonary resistance—PA
hypertension.
– Tetralogy of Fallot.
c. Pulmonary thromboembolism
Thrombus impacted in pulmonary arteries—rise in pulmo-
nary arterial pressure—pulmonary arterial hypertension.
– Modest increase in heart size.
– Pulmonary oligemia.
– Right ventricular enlargement.
d. Arteritides, e.g. Polyarteritis nodosa.
Narrowing of pulmonary arteries causes increase in
pressure—PHT.
Radiographic appearance of pulmonary arterial HT
1. Large triangular heart.
2. Large main and central pulmonary artery.
3. Pruning of pulmonary arteries.
4. Calcification of central pulmonary vessels.

3.4  ENLARGED LEFT VENTRICLE (ELV)

Volume Overload
1. Ventricular Septal Defect (VSD) (Fig. 3.2)
Most common congenital heart disease.
Bouts of respiratory infection, feeding problems, failure to
thrive.
Increased pulmonary vascular resistance causes left ventricle
(LV) enlargement.
2. Patent Ductus Arteriosus (PDA)
Mostly asymptomatic.
Congestive heart failure usually by 3 months of age.
Continuous murmur.
Enlarged RV, LV and LA, enlarged pulmonary artery segment
and enlarged aorta.
 Cardiovascular System 177

PA view: Chest shows prominent LT heart border (inferior part).

Rounding of LT heart border (apex of heart).
Fig. 3.2: Apex displaced inferiorly – ventricular septal defect

3. Mitral Incompetence
– Backward flow of blood from LV into LA during systole with
consequent increase in LV volume.
– LA + LV enlargement, mitral annular calcification.
4. Aortic Incompetence
– Water hammer pulse with systolic ejection and high
pitched diastolic murmur.
– LV enlargement with dilatation of aorta.

Pressure Overload
1. Aortic Stenosis
– Angina, syncope, heart failure with systolic murmur.
– Calcification of aortic valve.
– Enlarged LV with post-stenotic dilatation of ascending
aorta in 90% cases.
178 Differential Diagnosis in Radiology

Fig. 3.3: Posteroanterior radiograph of chest shows cardiomegaly with

signs of pulmonary edema, bilateral minimal pleural effusion and right fis-
sural fluid in congestive cardiac failure

2. Coarctation of Aorta
– Shelf-like narrowing of aorta usually beyond the origin of
left subclavian artery.
– Small irregular contour of upper descending aorta on X-ray.
– Rib notching.
3. Systemic Hypertension
– Due to increased resistance to blood flow.
– May lead to congestive heart failure (Fig. 3.3).
– Dyspnea on exertion, headache.

High Output States

1. Anemia.
2. AV fistula.
3. Hyperthyroidism.
Table 3.2:  Volume overload
Clinical features Chamber en- Pulmonary Pulmonary Pulmonary Associated
largement artery veins vasculature features
1.  Mitral Fatigue, exertional LA + LV Normal Mild pulmo- Normal Frequent mitral
incompe- dyspnea orthopnea nary venous annular
tence HT calcification
2.  Aortic Collapsing pulse, LV enlargement Normal Pulmonary Normal Dilatation +
incompe- early diastolic dilated aorta venous HT calcification of
tence murmur ascending aorta
3.  VSD Dyspnea, LA + LV + RV Enlarged Pulmonary Pulmonary Small aorta
syncope, venous HT plethora
chest pain, in shunt
hemoptysis reversal
4.  PDA CHF by 3 LV + LA + RV Enlarged – Increased Enlarged
months of ascending
age aorta and arch
5.  Aortic Angina, LV hypertrophy Normal Pulmonary Post-stenotic
stenosis syncope, systolic venous con- dilatation of
murmur gestion aorta
6. Coarcta- Lower extremityLV hypertro- Normal Normal – Enlarged
tion of cyanosis, phy, dilated left pulsatile collateral
aorta headache, subclavian artery in intercostal
cold extremities
and dilated as- spaces
cending aorta
Cardiovascular System

7. Cardio- Congestive cardiac LV enlargement Normal Prominent – Rib notching

myopathy failure or globular heart
179
180 Differential Diagnosis in Radiology

Myocardial Causes
1. Cardiomyopathy
– Cardiomegaly with poor contractility of ventricular wall.
– Global heart enlargement.
2. Ischemic heart disease.
Coronary artery calcification.
Left ventricular aneurysm may be present.

3.5  ENLARGED LEFT ATRIUM

Volume Overload (Table 3.2)

Mitral Regurgitation
VSD Refer to cause of enlargement of left
PDA Ventricle for salient features.
ASD with shunt reversal.

PA view: 1. Obliteration of concavity on LT RAO view: Barium swal-

heart border. 2. Double RT cardiac border. low shows LT atrial en-
3. Elevated LT carinal angle more than largement shadow or
70° and splaying of carina. 4. Prominent impression
LT atrial appendage and straigtening of LT
heart border
Fig. 3.4: Mitral valvular disease
Table 3.3:  Pressure overload
Clinical features Chamber Pulmonary Pulmonary veins Aorta Associated
enlargement artery features
Mitral Dyspnea, cough Esp. left atrial Prominent Prominent with pul- Small Ossific nod-
stenosis orthopnea appendage monary venous HT ules in lung,
RV enlarge- Kerley’s
ment LV lines
enlargement
Mitral Fatigue, exertional LA + LV Normal Prominent but mild Enlarge- Kerley’s
regurgita- dyspnea venous HT, then ment lines, less
tion MS frequent
VSD Dyspnea, syncope LA, LV, RV Enlarged Pulmonary venous Small –
chest pain hem- pulmonary HT occurs in Eisen-
optysis plethora menger’s syndrome
PDA CHF by 3 months LA, RV + LV Enlarged – Enlarged Obscured
of age aorto
pulmonary
window
Myxoma Dyspnea, weight LA, No – Pulmonary venous Small –
loss, fever, in- enlargement HT
creased ESR of left atrial
appendage
Cardiovascular System
181
182 Differential Diagnosis in Radiology

Fig. 3.5: Posteroanterior radiograph of chest shows cardiomegaly with

enlarged left atrium and its appendage in rheumatic heart disease

Pressure Overload (Table 3.3)

1. Mitral Stenosis (Figs 3.4 and 3.5)
– History of rheumatic fever.
– Shortness of breath on exertion.
– Left atrial enlargement with universal enlargement of left
atrial appendage.
– Changes in pulmonary circulation with pulmonary venous
hypertension.
2. Left Atrial Myxoma
– Dyspnea, chest pain, fever, myalgia, weight loss, raised ESR.
– Enlargement of LA, no enlargement of atrial appendage.
 Cardiovascular System 183
Secondary to Left Ventricular Failure
Radiographic features of enlarged left atrium.
1. Straightening of left heart border or discrete bulge below the
pulmonary conus.
2. Double heart shadow progressing to form the right heart
border.
3. Displacement of barium-filled esophagus backwards (in lateral
view)
4. Splaying of carina and elevated left main bronchus.

3.6  DILATATION OF PULMONARY TRUNK

1. Idiopathic
Unexplained dilatation of main pulmonary artery.
2. Pulmonary Regurgitation
– High-pitched diastolic blowing murmur.
– Enlarged RV.
3. Poststenotic Dilatation in Pulmonary Valve Stenosis
– Mostly asymptomatic.
– Enlarged pulmonary trunk and left pulmonary artery.
– Hypertrophy of RV with elevation of cardiac apex.
4. Congenital L-R shunts
– Due to volume overload in RV and pulmonary artery.
– RV enlargement.
5. Pulmonary Artery Hypertension
– Large and often triangular heart.
– Main and central pulmonary arteries are large.
– Pruning of pulmonary arteries, i.e. tapering to periphery.
6. Pulmonary Artery Aneurysm
– Can be traumatic or mycotic.
– Focally dilated main pulmonary artery with convex
pulmonary bay.
184 Differential Diagnosis in Radiology

3.7  ENLARGEMENT AORTA

1. Volume overload
a. Aortic regurgitation
– Water hammer pulse, diastolic murmur.
– LV enlargement.
b. Patent ductus arteriosus (PDA)
– Continuous murmur.
– Enlargement RV, LV and LA. Enlargement of pulmonary
artery segment, and pulmonary plethora.
2. Poststenotic dilatation in aortic stenosis
Angina, syncope.
Calcification of aortic valve.
Left ventricular enlargement.
Enlarged ascending aorta.

Fig. 3.6: Posteroanterior radiograph of chest shows aneurysm of arch of

aorta. Incidental note is made of the fibrotic changes in left upper lobe
 Cardiovascular System 185
3. Pressure overload
a. Coarctation of aorta
– Shelf-like narrowing of aorta beyond the origin of left
subclavian artery.
– Small irregular contour of upper descending aorta on
X-ray with rib notching.
b. Systemic hypertension
– May lead to left ventricular failure.
– Dyspnea on exertion.
4. Aneurysm of Aorta (Fig. 3.6)
Congenital.
Mycotic.
Syphilitic—There is widening of mediastinum.
Atherosclerotic or round or oval soft tissue mass.
Traumatic in mediastinum with or without dissecting aneurysm
with peripheral rim of calcification.

3.8  SMALL AORTA

1. Aortic Stenosis
– Angina, syncope, heart failure with systolic murmur.
– Calcification of aortic valve.
– Left ventricular hypertrophy.
2. Mitral Stenosis
– History of rheumatic fever (Fig. 3.5).
– Shortness of breath on exertion.
– Left atrial enlargement with universal enlargement of left
atrial appendage.
– Pulmonary venous hypertension with pulmonary ossific
nodules.
3. Left to Right Shunts
– Most of the blood flows into right-sided chambers and into
the pulmonary circulation causing pulmonary plethora.
– Left ventricle recovers less blood and aorta is small.
4. Hypertrophic Obstructive Cardiomyopathy
– Asymmetrical hypertrophy of the left ventricle with
difficulty in filling of LV.
186 Differential Diagnosis in Radiology
– Shortness of breath, angina, arrhythmias, jerky pulse.
– Left ventricle has a chunky outline.
5. Long Segment Coarctation of Aorta (Infantile or Tubular
Hypoplasia)
– Hypoplasia of long segment of aortic arch after origin of
innominate artery.
– Co-existent cardiac anomalies are common.
– CHF in neonatal period (in 50%).

3.9  ENLARGED RIGHT ATRIUM (TABLE 3.4)

1. Volume Overload
a. Tricuspid regurgitation
– There is systemic venous congestion and reduction of
cardiac output.
– Right-sided heart failure, hepatomegaly, ascites, and
anasarca.
– RV and RA enlargement (Fig. 3.7).
b. ASD
– Most common congenital heart defect in subjects > 20
years of age.
– Usually presents > 40 years.
Mildly symptomatic, dyspnea, fatigue, palpitations.

PA view: Prominent right Lateral view: Anterosuperior part

heart border of cardiac outline is prominent.

Fig. 3.7: Enlarged right atrium

Table 3.4:  Enlarged right atrium
Clinical features Chamber Pulmonary Pulmonary Pulmonary Associated
enlargement vasculature arteries veins features
Tricuspid Systemic venous RV and RA Normal or Normal or Normal Rt heart failure,
regurgitation congestion hepa- diminished small pleural effusion
tomegaly, ascites edema, systolic
pulsations of
liver
ASD Respiratory RA + RV Hilar dance Prominent – Loss of visuali-
infections, feeling due to → zation of SVC
difficulties, ar- pulsations of
rhythmias pulmonary
arteries
Total anoma- Cyanosis Rt ven- RA + RV figure Increased pul- – Absent Neck veins
lous pulmo- tricular heave of 8 appear- monary flow connection undistended
nary venous ance, dilated of pulmo-
return SVC nary veins
to LA
Tricuspid Fatigue refractory RA and SVC Oligemia Small with Normal –
stenosis edema, ascites, enlargement flat concave
hepatomegaly pulmonary
segment
Rt atrial Systemic venous Enlarged RA, Decreased Normal – Pulmonary em-
myxoma congestion SVC, IVC and boli may arise
azygous vein
Secondary Dyspnea, LV, LA → RV Redistribution Elevated pul- Dilatation Pleural and
to LVF orthopnea, PND and RA → of flow to up- monary arte- of pulmo- interlobar effu-
Cardiovascular System

fatigue edema, Congestive per lobes rial pressure nary veins sion
ascites heart failure with PHT
187
188 Differential Diagnosis in Radiology
– Chest X-ray hilar dance (increased pulsations of central
pulmonary arteries).
– RA and RV enlargement and pulmonary plethora.
c. Total/Partial anomalous pulmonary venous return.
– Pulmonary veins drain blood into right atrium.
– Increased pulmonary blood flow.
– ASD restores oxygenated blood to left side.
– Volume overload to RV.
Cyanosis, right ventricular heave (i.e. increased contact
of RV with sternum)
– Figure of ‘8’ or Snowman configuration of cardiac
silhouette
2. Pressure Overload
a. Tricuspid stenosis/Atresia.
– Pulmonary oligemia, small pulmonary bay.
– Right atrial enlargement, bulging the heart shadow to
the right.
b. Myxoma of Right atrium.
– Causes occlusion of tricuspid valve and RA enlargement.
– Systemic symptoms of fever, increased ESR, weight loss.
3. Secondary to Right Ventricular Failure (Fig. 3.8)
Congestive hepatomegaly, anasarca and systemic venous
distension.

3.10  ENLARGED RIGHT VENTRICLE (TABLE 3.5)

A. Volume Overload
1. ASD
– Increased amount of blood entering the right atrium
and hence right ventricle.
– Increased pulmonary flow with prominent pulmonary
arteries.
– Right atrial and right ventricle enlargement.
2. Total/Partial anomalous pulmonary venous return
– Pulmonary vein drains blood to the right atrium.
– Volume overload of right ventricle with pulmonary
overcirculation/plethora.
Table 3.5:  Enlarged right ventricle
Clinical Chamber Pulmonary Pulmonary arter- Pulmonary veins Associated
features enlargement vasculature ies features
ASD Respiratory RA + RV Overcircula- Prominent – Loss of
infections, tion visualization
feeding of SVC due
difficulty to clockwise
rotation of
heart due to
RVH
Total anoma- Cyanosis, R RA + RV “figure Increased – Absent connection Neck veins
lous pulmo- ventricular of 8” appear- flow of pulmonary veins undistended
nary venous heave ance of heart to LA
return
Tricuspid Systemic RV + RA Normal or Normal or small Normal Rt heart
regurgitation venous diminished Enlarged failure, pleural
Pulm. congestion effusions
regurgitation High pitched RV + RA Increased Enlarged – –
VSD diastolic LA, LV, RV Pulmonary Pulmonary venous
murmur dysp- plethora hypertension in Small aorta
nea, syncope, reversal of shunt
chest pain
Pulmonary Angina RV, RA Oligemia Small with con- – –
stenosis syncope cave pulm. bay
Pulmonary Syncope, RV enlarge- Clear lung Enlarged central – –
hypertension angina ment with large fields pulmonary artery
Tetralogy of shortness triangular heart with peripheral
Fallot of breath pruning
Cardiovascular System

Left heart Dyspnea, LA, LV, RV, RA Redistribution Elevated pulm. Dilatation of pulmo- Pleural and
disease orthopnea and congestive of flow to up- arterial pressure nary veins interlobar ef-
fatigue edema, heart failure per lobes with PHT fusion
189

ascites
190 Differential Diagnosis in Radiology

Fig. 3.8: Posteroanterior radiograph of chest shows biventricular enlarge-

ment in case of rheumatic heart disease with mitral stenosis and mitral
regurgitation

3. Tricuspid regurgitation
– Increased amount of blood entering RV during diastole.
– Right heart failure with systemic venous congestion.
4. Pulmonary regurgitation
– High-pitched diastolic murmur.
– Enlarged RV (Fig. 3.9).
5. VSD
– Flow of blood from LV to RV—Increased output of RV—
increased size.
– Enlarged RV, pulmonary artery.
– Pulmonary plethora.
B. Pressure Overload
1. Pulmonary stenosis.
– Increased contractility of RV—RVH.
– Pulmonary oligemia, small pulmonary bay.
 Cardiovascular System 191

PA view: Left apex of heart is Lateral view: Whole anterior part

prominent and elevated. of cardiac shadow is prominent.

Fig. 3.9: Enlarged right ventricle

2. Pulmonary hypertension.
– Increased resistance to right ventricular outflow—RVH.
– Pruning of pulmonary arteries with enlarged proximal
part.
3. Tetralogy of Fallot.
– Due to associated pulmonary stenosis.
4. VSD.
C. Secondary to Left Heart Disease/Mitral Stenosis (Fig. 3.10)
– Increased left atrial pressure—pulmonary venous
hypertension—Pulmonary arterial hypertension—RVH.

3.11  RIGHT AORTIC ARCH

1. Mirror Image Type—Brachiocephalic branches being the mirror
image of normal.
a. Tetralogy of Fallot (refer to the previous section for features)
b. Truncus arteriosus
c. Transposition of great vessels
d. Tricuspid atresia
e. Large VSD—Refer to previous section for salient features.
192 Differential Diagnosis in Radiology

Fig. 3.10: Posteroanterior radiograph of chest shows cardiomegaly with

signs of pulmonary venous hypertension in case of rheumatic heart disease

Transposition of Great Vessels

• Right aortic arch in 3%
• Pulmonary artery originating from LV and aorta from RV
• Egg on its side appearance of heart with narrow superior
mediastinum
• Right heart enlargement.
2. Right Aortic Arch with Anomalous. Left Subclavian Artery
• Bulbous configuration of origin of LSA—retro-esophageal
aortic diverticulum (from descending aorta)
• Small rounded density left lateral to trachea
• Right aortic impression on tracheal air shadow.
 Cardiovascular System 193
Causes
a. Tetralogy of Fallot
b. ASD ± VSD Refer to previous sections for
c. Coarctation salient features.

3.12  PULMONARY VENOUS HYPERTENSION

Increased pulmonary venous pressure.
Pulmonary capillary wedge pressure > 15 mm Hg.

Causes
A. Left Ventricular in Flow Tract Obstruction
1. Proximal to mitral valve—Normal left atrium
a. Total anomalous pulmonary venous return (below the
diaphragm)
– Pulmonary venous return into portal vein/IVC/
ductus venosus/left gastric vein with constriction of
descending pulmonary vein by diaphragm, enroute
through esophageal hiatus—pulmonary venous
hypertension.
– Pulmonary edema + pulmonary venous congestion.
b. Constrictive pericarditis
– Fibrous thickening of pericardium interfering with
filling of ventricular chambers.
– Dyspnea, peripheral edema, neck vein distension.
– Dilatation of SVC, azygos vein, and pulmonary
venous hypertentsion.
c. Fibrosing mediastinitis
– Widening of upper mediastinum
– Compression of SVC + pulmonary veins.
d. Primary pulmonary veno-occlusive disease
– Fibrous narrowing of intrapulmonary veins
– Pulmonary edema, pleural effusion
2. At Mitral Valve Level—Enlarged left atrium (Fig. 3.10)
a. Mitral stenosis
194 Differential Diagnosis in Radiology
– Redistribution of pulmonary blood flow to upper
lobes due to back pressure.
– Interstitial pulmonary edema and alveolar edema.
b. Left atrial myxoma
Obstructs the mitral valve with pulmonary back
pressure similar to MS.
3. Ball Valve Thrombus.
B. Left Ventricular Failure
– Increased preload, increased after load, high output failure.
– Transmission of back pressure to left atrium—Pulmonary
veins—pulmonary venous hypertension.

3.13  ENLARGED SUPERIOR VENA CAVA

A. Increased Volume of Blood Flow
1. Tricuspid regurgitation
– Systemic venous congestion and reduction of cardiac
output.
– Right-sided heart failure.
– RV and RA enlargement.
– Congestive hepatomegaly and anasarca.
2. Supracardiac total anomalous pulmonary venous return
– Pulmonary veins drain into superior vena cava.
– Superior vena cava is dilated.
B. Obstructive Causes (Superior vena cava syndrome)
1. Bronchogenic carcinoma.
Lymphoma.
Mediastinitis.
Constrictive pericarditis.
Retrosternal goiter.
Ascending aortic aneurysm.
– Head and neck edema.
– Cutaneous enlarged venous collaterals.
– Superior mediastinal widening.
– Encasement/compression/occlusion of SVC.
 Cardiovascular System 195
3.14  CARDIAC CALCIFICATIONS
A. Pericardial Calcifications
1. Idiopathic Pericarditis
– Calcification occurs at front and sides, not at back as
fluid does not collect here.
– There may be pleuropericardial adhesions roughening
the outline of heart.
2. Rheumatoid arthritis
– Pericarditis occurs in 20 to 50% cases.
– Features of bones involvement—osteoporosis, erosions.
– Pleural effusion, interstitial fibrosis.
3. Tuberculosis
– Most important infectious cause.
– Causes constrictive pericarditis.
4. Viral infection
5. Chronic renal failure
– Associated pleural effusion, ascites, pericardial
effusions.
6. Radiotherapy to mediastinum
– May lead to pericarditis, pericardial fibrosis and
calcification.
B. Myocardial Calcifications
1. Infections—viral or bacterial.
This can be suspected when CHF occurs in relation to viral
pyrexia and bacterial sepsis.
2. Myocardial aneurysm—may show wall calcification.
3. Rheumatic fever—causes myocarditis.
May produce pericardial effusion, pleural effusion.
C. Intracardiac
1. Valvular—(See in valvular calcifications).
2. Cardiac tumors—Atrial myxoma, rhabdomyoma and
fibroma.
196 Differential Diagnosis in Radiology

Fig. 3.11: Posteroanterior radiograph of chest shows situs inversus with

dextrocardia and gastric shadow under right dome of diaphragm

3.15  CARDIAC VALVE CALCIFICATIONS

1. Aortic valve
Indicates significant aortic stenosis.
a. Congenitally bicuspid valve = 70 to 85%
b. Atherosclerotic degeneration
c. Rheumatic AS
d. Syphilis.
2. Mitral valve
a. Rheumatic heart disease
b. Mitral valve prolapse.
3. Pulmonary valve
a. Tetralogy of Fallot
b. Pulmonary stenosis
c. ASD.
 Cardiovascular System 197
4. Tricuspid valve
a. Rheumatic heart disease
b. ASD
c. Infective endocarditis.

3.16 SITUS
Term describing position of atria, tracheobronchial tree, pulmonary
arteries, thoracic and abdominal viscera.
A. Situs solitus—Normal situs.
1. Abdominal
– Liver and IVC are right-sided.
2. Cardiac
– Morphologic right atrium is right-sided.
Morphologic left atrium is left-sided.
B. Situs Inversus (Fig. 3.11)
Mirror image of normal.
1. Abdominal
– Mirror image position of abdominal organs.
2. Cardiac
– Morphologic right atrium is left-sided.
– Morphologic left atrium is right-sided.
C. Situs Intermedius/Ambiguous
1. Abdominal
– Liver may be midline.
– Bowel malrotations.
2. Cardiac
– Indeterminate atrial morphology.
– Bilateral right atria/Bilateral left atria.

3.17  CYANOTIC HEART DISEASE

A. Cyanotic Heart Disease
1. Increased pulmonary flow
– Complete transposition of great arteries.
– Truncus arteriosus.
198 Differential Diagnosis in Radiology
– Total anomalous pulmonary venous connection.
– Common atrium.
– Double outlet right ventricle.
– Single ventricle without pulmonic stenosis.
2. Normal or decreased pulmonary blood flow
– Tricuspid atresia.
– Tetralogy of Fallot.
– Pulmonary arteriovenous fistula.
– Pulmonary atresia with intact interventricular septum.
– Pulmonary stenosis with right to left atrial shunt.
– Double outlet right ventricle with pulmonic stenosis.
B. Acyanotic Heart Disease (with left to right shunt)
1. Atrial level
– Atrial septal defect.
– ASD with mitral stenosis (Lutembacher’s syndrome).
– Partial anomalous pulmonary venous return.
2. Ventricular level
– Ventricular septal defect.
– VSD with aortic regurgitation.
– VSD with LV to RA shunt.
3. Aortic root to right heart shunt
– Ruptured sinus of valsalva aneurysm.
– Coronary AV fistula.
– Anomalous origin of left coronary artery from
pulmonary trunk.
4. Aortopulmonary shunt
– Patent ductus arteriosus.
– Aortopulmonary window.
5. Multiple level shunts
– ASD with VSD.
– VSD with PDA.
– Common atrioventricular canal.
C. Acyanotic without shunt
1. Left heart malformations
– Congenital left atrial inflow obstruction
 Cardiovascular System 199
a. Pulmonary vein stenosis.
b. Mitral stenosis.
c. Cor triatriatum.
– Mitral regurgitation
a. Congenitally corrected transposition of arteries.
b. Atrioventricular septal defect.
c. Primary dilated endocardial fibroelastosis.
d. Aortic stenosis/Regurgitation.
e. Coarctation of aorta.
2. Right heart malformations
– Acyanotic Ebsteins anomaly.
– Pulmonic stenosis.
– Congenital pulmonary regurgitations.
Idiopathic dilatation of pulmonary trunk.
CHAPTER 4

Soft Tissue
Lesions

4.1  DIFFERENTIAL DIAGNOSIS OF

SOFT TISSUE LESIONS
1. Increased Heel Pad Thickness
Males > 23 mm
Females > 21.5 mm
a. Acromegaly
Osseous enlargement, flared ends of long bones.
Spade-like hands, widening of terminal tufts, prognathism,
enlargement of paranasal sinuses, sellar enlargement.
Posterior scalloping of vertebrae.
b. Myxoedema
– Clinical features—fatigue, lethargy, constipation, cold
intolerance, stiffening of muscles.
– Dull, expressionless facies, periorbital puffiness.
Calvarial thickening, wedging of dorsolumbar vertebrae,
coxa vara.
c. Peripheral edema
Edema due to any reason will cause thickening of heel pad.
d. Obesity
Especially in children—heel pad is thick, because of fat
deposition.
e. Epanutin Eptoin therapy.
Erythematous eruptions, gingival hyperplasia may occur.
f. Infection/Injury
Due to pus collection or hematoma formation, heel pad
thickness may be increased.
Increased heel pad thickness (Flow chart 4.1).
 Soft Tissue Lesions 201
Flow chart 4.1:  Increased heel pad thickness

4.2  SOFT TISSUE OSSIFICATION

Formation of Trabecular Bone

1. Myositis ossificans
2. Burns
3. Paraplegia
4. Liposarcoma
5. Parosteal osteosarcoma
202 Differential Diagnosis in Radiology
6. Congenital myositis ossificans progressiva
7. Tumoral calcinosis
8. Surgical scar.

Myositis Ossificans
• Benign solitary self-limiting ossifying soft tissue mass typically
occurring in skeletal muscle
• Adolescents, young athletic adults
• Located in large muscles of extremities in 80%
• Well-defined partially ossified soft tissue mass after 6–8 weeks
• Radiolucent zone separating lesion from bone
• Periphery more denser than center.

Liposarcoma
• Second-most common soft tissue sarcoma in adults
• Age 5th-6th decade
• Usually painless, mass located in trunk, lower extremity—upper
extremity, head and neck
• Amorphous calcification.

Parosteal Osteosarcoma
• Large lobulated cauliflower-like homogeneous ossific mass
extending away from cortex
• Large soft tissue component with osseous and cartilaginous
elements
• Periphery less dense than center
• Located commonly at posterior aspect of distal femur, either
end of tibia, proximal humerus and fibula.

Burns
• Ossification in relation to joints, commonly hips, elbows and
shoulders
• May occur at sites distal to injury
• The cause is unknown.
 Soft Tissue Lesions 203
Paraplegia
• Occurs in adults with spinal lesions and children with spinal
dysraphism
• Particularly in relation to pelvis
• Woolly appearance.

Congenital Myositis Ossificans Progressiva

• Autosomal dominant or primary mutation
• Ossification in perimuscular fascia, not in muscles
• Sheets of bone in neck, thorax and limb
• Abnormally short metacarpal of thumb and metatarsal of big toe.

Tumoral Calcinosis
• Masses of bones in soft tissue near joints
• May cause discomfort and limitation of movement.

Surgical Scar
• True bone may form away from any pre-existing bone structure
or periosteum.

4.3  LINEAR CALCIFICATION OF SOFT TISSUES

1. Arterial
a. Diabetes
– Occurs commonly in calf-region.
– Associated diabetic nephropathy or cystopathy.
b. Hyperparathyroidism
– Calcification in arterial tunica media.
– Cornea, vessels, periarticular region.
– Chondrocalcinosis.
– Associated bone erosions, brown tumors.
c. Werner’s syndrome
d. Atheroma (Fig. 4.1)
204 Differential Diagnosis in Radiology
– Plaque-like calcification, linear calcification of walls.
– Commonly femoral and popliteal arteries.
2. Venous
a. Thrombosed veins.
Phleboliths are present.
b. Varicose veins.
3. Nerves
a. Leprosy
– Areas of decalcification, reticulated pattern.
– Joint space preserved.
– Absorption of nasal spine, alveolar ridge.
– Neurotrophic joints.
b. Neurofibromatosis
– Soft tissue masses.
– Optic nerve gliomas.
– Ribbon ribs, sphenoid dysplasia, and pseudoarthrosis.

Fig. 4.1:  Anteroposterior and lateral radiographs of

forearm shows arterial calcification
 Soft Tissue Lesions 205
4. Ligamentous (Fig. 4.2)
a. Tendinitis
– Pellegrini-Stieda lesion—Calcification of medial
collateral ligament of knee.
b. Ankylosing spondylitis (Fig. 4.3)
– Posterior longitudinal/anterior longitudinal ligament
calcification.
c. Fluorosis (Figs 4.4 and 4.5)
– Sacrotuberous and sacrospinous ligamentous calcifica-
tion, increased bone density.
– Interosseous membrane calcification.
d. Alkaptonuria
– Calcification in paravertebral soft tissues and tendon
insertion.
– Disk calcification.
– Massive osteophytosis.

Fig. 4.2: Anteroposterior radiograph of ankle shows soft tissue

calcification adjacent to lateral malleolus
206 Differential Diagnosis in Radiology

Fig. 4.3:  Lateral radiograph of DL spine in ankylosing spondylitis shows

anterior longitudinal ligament calcification

Fig. 4.4:  Posteroanterior radiograph of chest shows

diffuse osteosclerosis in Fluorosis
 Soft Tissue Lesions 207

Fig. 4.5: Anteroposterior radiograph of pelvis shows calcification in bilateral

sacrotuberous ligament and osteosclerosis of lower lumbar spine in Fluorosis

4.4  PARASITIC CALCIFICATION (TABLE 4.1)

1. Cysticercus cellulosae (Figs 4.6 and 4.7)
– Calcified cysts produce oval shadow 10–15 mm long and
2–3 mm broad with a translucent center.
– Number of cysts usually in hundreds.
– Arranged in direction of muscle fibers.
– May be associated with cysts in brain.
2. Loasis (Calabar swelling)
– Caused by microfilaria.
– Found in subcutaneous tissues and undergoes calcification
after death.
– Commonly in hands, in web spaces.
– Coiled thread-like opacities with amorphous calcification.
3. Guinea worm
– Calcifies after its death.
– Elongated or coiled strip of calcium density.
– May be crushed by muscle action into a round irregular
mass.
 208
Table 4.1:  Periarticular soft tissue calcification
Features Gout Sarcoidosis Secondary Hypervitami- Synovial osteo- Synovioma
HPT nosis D chondromatosis
1. Age > 40 years 20-40 years – – 20-50 years 20-50 years
2. Type of Large nodular – Periarticular, Metastatic Multiple calci- Large sphenoid
calcifi- calcification in arterial walls, calcinosis in fied bodies well defined
cation gouty tophi chondrocalci- periarticular soft tissue
nosis, viscera areas—putty- mass with
like prema- amorphous
ture falx calcification
calcification
3. Site Hands and feet, Small bones of Around hip, Periarticular + Large joints
Knee most
1st MTP most hands and feet knee, shoul- arterial walls knee > elbow >
common, hip
common ear > der, wrist + nephrocal- hip > shoulder >
ankle, elbow,
bones, tendons cinosis ankle wrist, hands,
Differential Diagnosis in Radiology

and bursae feet

4. Bone Punched out Reticulated lace- Osteosclero- Cortical + Pressure ero- Periosteal
chang- lytic bone le- like trabecular sis, especially trabecular sion of bone reaction, bone
es sions, mouse pattern in mid- axial skel- dense calva- or secondary remodelling
bite erosions with dle and distal eton, pelvis, ria widening degenerative due to pres-
overhanging mar- phalanges with ribs, clavicles, of provisional changes widen- sure invasion
gins joint space is cystic lesions Rugger-Jer- zone of calci- ing of joint of cortex and
preserved acro-osteolysis sey spine fication space and juxta-articular
accumulation of osteopenia
loose bodies
For Dermatomyositis
Scleroderma Tu- Refer to generalized calcinosis
moral Calcinosis
}
 Soft Tissue Lesions 209

Fig. 4.6:  Posteroanterior radiograph of chest shows multiple oval calcifica-

tions in soft tissues in Cysticercosis

Fig. 4.7:  Lateral radiograph of skull shows multiple calcified lesions in

Neurocysticercosis
210 Differential Diagnosis in Radiology
4. Armilifer armillatus
– Curved in one plane (comma-shaped).
– Chest and abdomen.

4.5  AREAS OF DECREASED DENSITY

1. Fat
a. Lipomas
b. Normal sites (Fig. 4.8)
– In front of lower end of humerus, below patella, in front
of Achilles tendon.
c. Lipohemarthrosis
– Following fractures.
– Particularly around knees and shoulders.
2. Gas
a. Hernias
– Containing intestine.
– Seen below inguinal ligament or in scrotum.

Fig. 4.8:  Lateral radiograph of knee joint shows infrapatellar lipoma

 Soft Tissue Lesions 211
b. Air entering from outside
i. Air bubbles near compound fractures.
ii. Fractures of PNS—air in facial soft tissues.
iii. Soft tissues of chest from lungs—after rib fractures,
laceration of lung, thoracocentesis or after surgery.
iv. From mediastinum.
c. Lower abdominal wall or thigh—following rupture of pelvic
abscess or after perforation of a hollow viscus.
d. Gas formed in tissues (Figs 4.9 and 4.10)
i. Infection in diabetes, by Clostridium welchii.
ii. Anerobic myositis.

4.6  PERIARTICULAR SOFT

TISSUE CALCIFICATION
1. Inflammatory
a. Scleroderma
b. Dermatomyositis
c. Gout.

Fig. 4.9: Anteroposterior radiograph of foot

shows aeroceles in soft tissues in gas gangrene
212 Differential Diagnosis in Radiology

Fig. 4.10: Anteroposterior radiograph of abdomen shows aeroceles with air

fluid level in right lumbar region in right paracolic abscess

2. Degenerative
– Calcium pyrophosphate dihydrate deposition disease.
3. Renal failure
– Secondary hyperparathyroidism.
4. Hypercalcemia
a. Sarcoidosis
b. Hypervitaminosis D
c. Milk alkali syndrome.
5. Neoplastic
a. Synovial osteochondromatosis
b. Synovioma.
6. Idiopathic
Tumoral calcinosis
 Soft Tissue Lesions 213
4.7  GENERALIZED CALCINOSIS
a. Collagen vascular disorders
1. Scleroderma
2. Dermatomyositis
b. Idiopathic tumoral calcinosis
c. Idiopathic calcinosis universalis.

Scleroderma
• Calcinosis of skin
• Raynaud’s phenomenon
• Esophageal dysmotility
• Sclerodactyly
• Telangiectasia.

Dermatomyositis
Inflammatory myopathy with linear and confluent calcifications in
soft tissues.
• Pointing and resorption of terminal tufts
• Respiratory muscle weakness
• Dysphagia.

Idiopathic Tumoral Calcinosis

• Progressive large nodular juxta-articular calcified soft tissue
masses
• Normal serum calcium and phosphorus and no metabolic/
renal or collagen disease
• Diaphyseal periosteal reaction with patchy areas of calcification
in medullary cavity
• Calcinosis cutis.
214 Differential Diagnosis in Radiology
Table 4.2:  Sheet-like calcification
Features Congenital myositis Dermatomyositis
ossificans progressiva
1. Type Autosomal dominant Inflammatory myopathy
2.  Calcification In perimuscular fascia Necrosis, fibrosis and
and not in muscles calcification in muscles
3. Parts Sheets of bone in neck, Extremities, elbows,
commonly thorax and limbs knees, hands abdomi-
affected nal wall and chest wall
4. Age Early childhood 5–15 yrs and 50–60 yrs
5. Bone Short metacarpal of Pointing and resorption
changes thumb and metatarsal of of terminal tufts
big toe + abnormality of
vertebrae

Idiopathic Calcinosis Universalis

• Children and young adults
• Plaque-like calcium deposits in skin and subcutaneous tissues
• Sometimes in tendons and muscles
• No true bone formation.

4.8  SHEET-LIKE CALCIFICATION IN

SOFT TISSUE (TABLE 4.2)
1. Congenital myositis ossificans progressiva.
2. Dermatomyositis.
CHAPTER 5
Abdomen and
Gastrointestinal Tract and
Hepatobiliary System

5.1  DILATED ESOPHAGUS

Normal versus Abnormal Appearance of Esophagus

Normal – 3 mm when adequately
wall thickness distended
– 5 mm when incompletely
distended
Abnormal – Greater or eccentric thickness
AP diameter esophagus – > 16 mm
Lateral diameter esophagus – > 24 mm
Abnormal – Air-filled level Obstructive
Fluid-filled lumen or
Lumen caliber > 10 mm Motility
disorders

Strictures
Smooth Irregular
Inflammatory Neoplastic
Peptic, Barrett’s Carcinoma
Scleroderma Leiomyosarcoma
Corrosive Carcinosarcoma
Lymphoma
Neoplastic Inflammatory
Carcinoma Reflux (rarely)
Mediastinal tumors Crohn’s disease
– Ca bronchus
216 Differential Diagnosis in Radiology
Leiomyoma Iatrogenic
Radiotherapy
Fundoplication
Others
Achalasia
Iatrogenic Prolonged use of nasogastric tube
Skin disorders • Epidermolysis bullosae
• Pemphigus

Peptic Stricture
• Situated most frequently in the distal esophagus near the G-E
junction
• Associated with reflux and hiatus hernia
• Most peptic strictures are circumferential. Occasionally may
be asymmetrical with radiating folds or a pseudo-diverticular
appearance
• If luminal diameter < 13 mm—Associated with dysphagia
14–19 mm – 50% cases—dysphagia.

Barrett’s Esophagus
• The normal squamous epithelium is replaced by columnar
epithelium. This usually begins in distal esophagus and
progresses proximally
• Esophagogram (non-specific)—reflux, hiatus hernia, stricture,
thickened folds, shallow ulcers and erosions
• More specific finding—(Double contrast) fine reticular mucosal
pattern distal to a stricture (seen in < 1/3rd cases)
• In Barrett’s esophagus—strictures usually develop at the
junction of squamous and columnar epithelium.

Scleroderma
• Esophageal involvement seen in 75–85% cases
• Caused by atrophy of smooth muscle and it’s replacement by
connective tissue
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 217

Fig. 5.1: Achalasia cardia—on barium study

• Radiological features: Dilatation, atonicity, poor or absent

peristalsis of gastroesophageal reflux through a widely open
G-E junction—stricture.

Other Associated Features

• Raynaud’s phenomenon
• Skin thickening
• Terminal phlalanx resorption with soft tissue atrophy
• Erosions of distal interphalangeal, first carpometacarpal,
metacarpophalangeal and metatarsophalangeal joints
• Respiratory system: Aspiration pneumonitis, interstitial lung
diseases and fibrosis in left lower zone
• Small bowel-dilated, atonic with thickened folds and pseu­do­
sacculations.
218 Differential Diagnosis in Radiology

Corrosives
• Ingestion of sodium hydroxide/acid ingestion
• Site of involvement—Aortic arch, left main bronchus and above
diaphragmatic hiatus
• Acute phase—Edema, spasm, ulceration, loss of mucosal
pattern at hold-up points
• After several weeks—smooth stricture develops—sy­mme­trical
and longitudinal.

Achalasia (Figs 5.1 and 5.2)

Esophageal motor disturbance caused by failure of lower
esophageal sphincter to relax.
• Loss of primary and secondary peristalsis
• Intermittent emptying.

Causes
Idiopathic (absence of smooth muscle ganglionic cells).
Secondary to Chaga’s disease.
Malignancy—with invasion of myanteric plexus, chest X-ray—
dilated esophagus with air-fluid level. Barium examination—
dilated sigmoid-shaped esophagus.
• “Bird Beak” appearance of distal esophagus
• Loss of primary and secondary peristalsis in distal 2/3rd of
esophagus
• Feature of esophagitis
• Intermittent spurting of barium into the stomach, stricture
classically occurs below diaphragm.

Leiomyomas
• Commonest benign esophageal neoplasm, these are usually
intramural in origin
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 219
• Barium examination: Sharply-defined smooth/lobulated defect
with superior and inferior margins that form right angles with
the luminal wall.
CT—shows the intra­luminal and extrinsic component.

Carcinoma Esophagus
Incidence, commonly seen in—Plummer-Vinson syndrome,
Barrett’s, cardiac disease, asbestosis and dye-ingestion.
(10–20%) Adenocarcinoma—Distal 1/3rd
(80–90%) Squamous (sq) cell carcinoma (ca)—Middle 1/3rd.

Types
• Polypoidal, infiltrative, ulcerative and superior spreading
• Radiological features: Irregular filling defects.

Annular/Eccentric
• Extraluminal soft tissue mass
• Proximal and distal shouldering
• Proximal dilatation
• Mucosal destruction/ulcerations
• Satellite lesions in esophagus.

Chest X-ray
• Mediastinum widening
• Tracheal deviation, anterior bowing of posterior tracheal wall
• Widened retrotracheal stripe (> 3 mm)
• Air-fluid level in esophagus.

Computed Tomography (CT)

For the extent of involvement:
Tracheobronchial, aortic, pericardial invasion, mediastinal
lymphadenopathy.
220 Differential Diagnosis in Radiology

Fig. 5.2: Achalasia cardia

Esophageal Lymphoma (Rare)

Both non-Hodgkin’s and less commonly Hodgkin’s lymphoma may
involve esophagus.

Invasion
1. Mediastinal lymph nodes with esophageal invasion.
– Extrinsic compression with irregular, serrated margins.
2. Contiguous spread of lymphoma from gastric fundus (cannot
be differentiated from carcinoma).
3. Synchronous development of lymphoma in the wall of
esophagus.
• Submucosal nodules, enlarged folds, polypoidal masses,
strictures.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 221
Secondary Esophageal Neoplasms
• Most common neoplasms that spread directly to esophagus
are gastric and bronchial carcinoma.

Others
Hypopharyngeal, thyroid and primary mediastinal.
• Esophageal invasion from neoplasmatically-laden adjacent
lymph node is more common than direct metastasis to the
esophagus. (Most common primary sites are—lungs in males
and breast in females).

Radiological Features
Extrinsic impression with regular/irregular margins and
displacement of esophagus.

Radiation Esophagitis
• Occurs when dose exceeds. 20 Gy (2000 rad) leading to
ulceration, stricture and rarely perforation.

5.2  ESOPHAGEAL CARCINOMA

Predisposing Factors
1. Achalasia 2 to 8% cases of long standing achalasia undergo
malignant degeneration because of chronic stasis induced
esophagitis.
2. Lye-like strictures (2–16%).
3. Head and neck tumors (2–8%).
4. Celiac disease.
5. Plummer-Vinson syndrome (4–16%).
6. Radiation (> 20 to 50 gray; Latent period—20 years).
7. Tylosis autosomal dominant condition characterized by hyper-
keratosis of palms and soles (95% cases > 65 years).
222 Differential Diagnosis in Radiology
8. Smoking and alcohol.
9. Barrett’s esophagitis (15%) predisposing factors for Adenocar-
cinoma.
10. Scleroderma.

Pathology

Gross
1. Infiltrating: Most common, irregular narrowing and constriction
of lumen.
2. Polypoidal: Lobulated/Fungating mass protrudes into the
lumen.
3. Superficial Spreading: Spreads superficially without invading
deeper layers.
4. Ulcerative: Flat masses in which the bulk of the tumor is replaced
by ulceration.

Histology
Squamous cell carcinoma—80–90%
Adenocarcinoma—10–20%

Japanese Society of Esophageal Disease

• Early esophageal carcinoma—Mucosa and Submucosae involved
• Superficial esophageal carcinoma—Mucosal and submucosal
involvement with lymph node metastasis
• Small esophageal carcinoma: Growth < 3.5 cm regardless of
depth of invasion of lymph node metastasis.

Distribution
• Squamous cell carcinoma has a relatively even distribution in
the upper, middle and distal third of esophagus
• 75% of adenocarcinoma arise in the distal 1/3rd at or adjacent
to the gastroesophageal junction.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 223
Routes of Spread
1. Direct Extension: Esophagus lacks mucosa, therefore, carcinoma
spreads readily into adjacent structures—thyroid, larynx,
trachea, bronchus, lungs, aorta, pericardium and diaphragm.
2. Lymphatic Extension: “Jump” metastasis can occur in the neck,
mediastinal lymph nodes in the absence of segmental lymph
node involvement because of rich inter-connecting lymphatics
in esophagus.
– Sub-diaphragmatic lymph nodes—Pericardial, lesser
curvature and celiac lymph node.
– Lymphatic metastasis can also occur within the esophagus
which presents as submucosal nodules.
3. Hematogenous metastasis: Lung, liver, adrenal, kidney, pancreas,
peritoneum and bones.

Clinical Aspects
Dysphagia, odynophagia, anorexia, weight loss, persistent
substernal chest pain, hoarseness of voice and chronic cough
(aspiration and tracheoesophageal fistula), hematemesis.

Radiographic Findings
• Early esophageal carcinoma: Double contrast esophagography
is the best radiological technique and has increased sensitivity
but less specificity.
Early esophageal Ca is seen as small protrusions < 3.5 cm which
may appear as:
• Plaque-like with central ulceration
• Sessile polyp with smooth/lobulated contour
• Focal irregularity/nodularity
• Superficial spreading carcinoma extends longitudinally in the
wall without invading beyond the mucosa/submucosa and is
seen radiographically as tiny coalescent nodules or plaques
causing nodularity/granularity.
224 Differential Diagnosis in Radiology

Advanced Carcinoma
• Chest X-ray shows mediastinal widening
• Hilar/retrohilar/retrocardiac mass
• Tracheal deviation, anterior bowing of posterior tracheal wall
• Widened retrotracheal stripe
• Air-fluid level in esophagus
• Barium studies
– Irregular narrowing, nodular or ulcerated mucosa, proximal
and distal shouldering, proximal dilatation (Fig. 5.3)
• Lobulated/fungated mass (intraluminal) usually >3.5 cm with
areas of ulceration
• Well-defined meniscoid ulcer with a radiolucent rim of tumor
surrounding the ulcer

Fig. 5.3:  Barium esophagogram in Anteroposterior projection shows es-

ophageal narrowing with proximal shouldering in a patient of esophageal
carcinoma
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 225
• Thickened, tortuous or serpiginous long filling defects because
of submucosal spread which are known as varicoid carcinoma.
– Smooth extrinsic impression with gently sloping obtuse
borders because of mediastinal lymphadenopathy.
– Satellite lesions in esophagus and stomach because of
lymphatic metastasis.
• Detection of complications on barium study.
– Esophago airway fistula—Lateral film.
– Necrotic tumor containing cavity in lung/mediastinum
communicating with the esophagus.

Computed Tomography (CT)

Best imaging modality for staging patients (Mediastinal invasion,
mediastinal adenopathy and distant metastasis)
• Criteria for tracheobronchial invasion:
– Displacement of trachea/bronchus from the spine.
– Indentation on the posterior wall of trachea/bronchus.
– Bowing of posterior wall of trachea/bronchus.
(Absence of fat plane between the trachea and/or bronchus
and esophagus cannot be used to predict invasion).
• Criteria for aortic invasion:
– Area of contact >90% or 1/4th of aortic circumference.
– Obliteration of the triangular fat space between aorta,
spine and esophagus suggests of invasion.
• Criteria of pericardial invasion:
– Presence of mass effect with concave deformity of the
heart associated with loss of normal fat plane in this region.
• Mediastinal Adenopathy
Limitations—CT cannot demonstrate lymph node metastasis
that has not caused significant lymphadenopathy
• Enlarged periesophageal lymph node cannot be detected
because they are inseparable from the primary cancer
• CT cannot differentiate benign from malignant lymphad-
enopathy.
226 Differential Diagnosis in Radiology

Sub-diaphragmatic Lymphadenopathy
Frequently the lymph nodes at or above the celiac axis are involved
(>8 mm—Enlarged).

MRI
Superior to CT in detecting mediastinal invasion.

Endoscopic Ultrasound
Advantage: Evaluates the depth of tumor invasion. Periesophageal
lymph node can also be identified.
Disadvantage: Esophageal ultrasound probe is unable to pass
through a malignant stricture.

Differential Diagnosis of Esophageal Carcinoma

Early Esophageal Carcinoma

• Squamous papilloma: Small, sessile lobulated polyp
• Candida esophagitis: Multiple plaque-like defects with
intervening normal mucosa
• Pseudomembranes/inflammatory exudates—multiple plaque-
like defects are present.

Advanced Carcinoma
• Benign stricture
– Smooth, no mucosal destruction
– No shouldering
• Esophageal varices
– On full column film the varicoid appearance disappears,
and valsalva increases the varicoid appearance
• Leiomyoma: Submucosal mass lesion with smooth margins
which forms right angle.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 227
5.3  THICKENED MUCOSAL FOLDS
ESOPHAGUS AND STOMACH
Q. What are mucosal folds?
Ans. Folds are convolutions of mucosa, made so in order to
the functional assimilative capacity of gut keeping the
structural needs to minimum. The total surface area thus
increases greatly but the length of intestine is kept to
a minimum. It consists of epithelium, lamina propria,
muscularis mucosa.
Q. Why is their demonstration so important?
Ans. Because this is the basic functional layer of GIT and most
diseases either originate or involve this layer early on.
Q. How are they radiologically demonstrated?
a. Mucosal relief.
b. Full barium.
c. Double contrast.
Ans. a and c are techniques of choice to demonstrate early
involvement and diseases of mucosa, submucosa and
even distal layers may be shown, through their effects on
mucosa and submucosa.

Thickened Esophageal Folds

Causes
1. Varices
2. Esophagitis
3. Varicoid carcinoma
4. Lymphoma.
1. Varices
→ Due To →
1. Portal hypertension: known as Uphill varices.
2. SVC obstruction: known as Downhill varices.
3. Idiopathic: due to congenital wall weakness.
→ 1. Uphill
2. Downhill Superior vena cava,
Thyroid;
228 Differential Diagnosis in Radiology
Above Bronchial; Mediastinal
↓
Azygous SVC → Heart
↓
Below/At Azygous + Hemiazygous
Azygous Periesophageal plexus
→ CF Uphill → Bleeding anemia
Downhill → SVD Syndrome; Bleed Rare.
→ Imaging: Plain X-ray → Dilated Azygous; ± Show
As posterior mediastinal mass.
→ Barium
→ Prone (RAO).
→ ± Buscopan.
→ Wait/Watch.
→ Mucosal relief.
→ Irregular serpiginous filling defects.
→ Faintly merge (D/D Ca).
→ CT → Nodular enhancing Streaks in Wall.
→ Angiography → Celiac, SMA, Portal, Splenic
→ Change with Respiration, Deglutition, Valsalva, Position.
→ TES/Doppler → Abnormal Dilated Vascular Channels Seen.
2. Esophagitis
Infectious → Candida; HSV; HIV; CMV; TB; Actinomycetes.
Non-infectious → Drugs; Caustic; RTT; NG Tube; Crohn’s; Skin
Diseases; Alcohol; GVHD.
→ Fold thickening is nodular and scalloped.
→ Associated specific findings seen:
CMV → Giant Ulcers.
Candida → Plaques.
HIV, HSV → Multiple Aphthoid Ulcers.
TB → Strictures.
Actinomyces → Sinus.
Doxycycline and Tetracyclines → Temporary superficial
ulcers.
Caustic → Long segment stricture.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 229
3. Varicoid Carcinoma
– Is basically a morphological variant seen radiologically as
fold thickening.
– It’s etiology, histopathology and management protocol are
nearly the same.
– Usually involves the lower esophagus.
4. Lymphoma
– MC secondarily involved from mediastinal nodes.
– Radiologically
→ Smooth Extrinsic Impression
Intrinsic
→ Smooth Tapered Stricture with Achalasia.
Large Mass
Varicoid (Rare).

THICKENED GASTRIC FOLDS

1. Normal variant.
2. Gastritis — alcoholic (Flow chart 5.1)
Flow chart 5.1:  Thickened Gastric Folds
230 Differential Diagnosis in Radiology
– Hypertrophic
– Antral
– Corrosive
– H pylori and other infections
– Post-radiation
– Post-freezing.
3. Peptic ulcer disease.
4. Zollinger-Ellison Syndrome (ZES).
5. Ménétrier’s disease.
6. Lymphoma.
7. Pseudolymphoma.
8. Carcinoma.
9. Varices and antral vascular ectasia.
10. Infiltrative process
– Eosinophilic gastritis
Crohn’s disease
Sarcoidosis
Tuberculosis
Syphilis
Amyloidosis.
11. Adjacent pancreatic disease
– Acute pancreatitis
Extension of Carcinoma pancreas.
1. Alcoholic Gastritis
– Due to prolonged use of large volume; corrected by
cessation.
– MCC of acute exogenous gastritis.
– Sometimes folds become so bizarre as to mimics
malignancy.
– Due to mucosal and submucosal edema.
– May progress to atrophic gastritis.
2. Hypertrophic Gastritis
– Idiopathic local/diffuse hypertrophy of mucosa and glands
without their destruction.
– Neuromuscular disorder, increased acid output, chronic
inflammation.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 231
– Increased secretions, poor coating.
– Thick (4–5 mm; N—1–2 mm), Polygonal and angular area
gastricae seen.
– Associated peptic ulcer commonly present.
3. Antral Gastritis
– Misnomer
– H pylori, alcohol, tobacco, coffee.
– ± a part of the spectrum of ulcer disease.
– ± associated with antral spasm, with ± persistent/transient
(Seen as loss of prepyloric shoulders).
– Antral granulations seen.
4. Corrosive Gastritis
– Thick folds with ulcer, atony, rigidity.
– Usually severe disease seen.
– Fixed and gaping pylorus seen due to damaged muscles.
– ± gas in the wall.
– Antrum, body and LC most affected.
– Acids more dangerous for stomach, alkaline for esophagus.
5. Helicobacter pylori (and other infections):
– Antrum and body affected more.
– If fundus also involved d/d Ménétrier’s disease.
– On CT circumferential or focal thickening are seen points
that need differentiation from malignancy.
– CMV gastritis in AIDS leads to diffuse fold thickening and
decreased distensibility.
– Other infective processes causing similar changes are
toxoplasmosis and cryptococcosis.
6. ZES and Ulcer Disease
– Body and antrum (never fundus).
– Increased acid output.
– In ZES fundic mucosa is seen in antrum.
– In ulcer disease only perilesional thickening is seen.
– In ZES large amount of gastric fluid is seen despite adequate
fasting.
232 Differential Diagnosis in Radiology
7. Ménétrier’s Disease: (known as Giant-hypertrophic Gastritis)
– Whole stomach especially fundus and body; diffuse or
focal; ESP greater curve.
– Abrupt transition between normal and abnormal folds.
– Massive hypertrophy and hyperplasia of folds (i.e. glands)
leading to brain-like appearance.
– Decrease in acid.
– Polypoidal appearance when seen end on.
– Mottle/reticular appearance due to excess mucus.
– Overall wall is thick and hypoperistalsis seen.
– May be associated with or lead to adenocarcinoma.
– ‘Pediatric Hypertrophic Gastropathy’ that presents as
hypoalbuminemia in absence of any cause, thick mucosa
and following viral infection is a distinct but related entity.
8. Lymphoma and Pseudolymphoma:
– Pseudolymphoma is a benign proliferation of lymphoid
tissue.
– Gastric lymphomas are usually nodular in type, however
other varieties may be ulcerative, polypoidal, infiltrative
(that leads to fold thickening) and mixed types.
– May lead to an associated ulcer, loss of wall pliability, lym-
phadenopathy (increased retrogastric space), splenomeg-
aly, predominant involvement of distal stomach.
9. Carcinoma (Tables 5.1 and 5.2):
– As usually misunderstood, it is not the linitis plastica
malignancies (diffuse infiltrative adenocarcinoma) that
leads to fold thickening.
Table 5.1: Differentiating features between squamous and adenocarcinoma
Squamous cell carcinoma Adenocarcinoma
Equal distribution in the Most common, situated in upper, mid
distal esophagus and lower esophagus
Rarely extends sub-dia- Frequently extends and invades cardia/
phragmatically to involve fundus
stomach
Most common type—Infil- Most common type—Polypoidal and
trating mixed polypoidal—infiltrative
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 233
Table 5.2: Differentation features of lymphoma vs carcinoma
Lymphoma Carcinoma
1. Age — Bimodal — Mid-Old
2. CF — Mass — Mass + Bleed
3. No. — Multicentric + — Rare
4. Epicenter — S/M — Mucosa
5. Distensibility — N A/E HD — (↓↓↓)
6. Caliber — N or ↓ — (↓↓↓)
7. Loss of area —+ —–
Gastricae
8. Enhancement —↑ — (↑↑↑)
9. Perigastric fat —N — Involved
10. Wall thickness — ↑↑↑↑(>3cm) — ↑↑
11. HSM —+ — ±/–
12. Lymph node ­ —+
 (Above and —±
below kidney)
13. Ext. to — ++ —±
Duodenum-
Esophagus
14. Hemorrhage and —± — +++
necrosis
15. Contour — Regular — Irregular
16. Adj. organ involve- —+ — +++
ment

– Malignancy leading to fold thickening is colloid carcinoma

or mucinous adenocarcinoma which also have specks of
calcification (Table 5.3).
– Fold thickening with normal volume and pliability is seen.
– Peristalsis is normal.
10. Varices:
– In PHT are associated with esophageal varices but if isolated
gastric varices are seen, then splenic vein thrombosis
should be suspected.
234 Differential Diagnosis in Radiology
Table 5.3: CT-differentiation of gastric adenocarcinoma from
gastric lymphoma
CT Lymphoma Adenocarcinoma
Wall thickness 4.0 cm 1.8 cm
Mean 1.1–7.7 cm 1.1–3.2 cm
Range Regular 42% Regular 27%
Contour Irregular 58% Irregular 7 3%
Extent Diffuse 80% Focal 87%
Direct spread to adjacent 42% 73%
organs
Lymph node above/below renal 42% 0%
hilum

– Multiple, curvilinear, crescentric, smooth, lobulated filling

defects with splenic impression.
– Seen mainly in fundus extending to LC.
– Charge in appearance.
– Varices in antrum and body are due to obstruction of
splenic vein proximal to patent coronary veins.
– Watermelon stomach is a distinctive form of gastric antral
vascular ectasia radiating to pylorus.
11. Infiltrative Processes:
– Conditions like eosinophilic gastroenteritis (eosinophilia
with eosinophilic infiltration and exudation), Crohn’s
disease, amyloidosis, sarcoidosis, TB, syphilis cause diffuse
rugal thickening.
12. Adjacent—Pancreatic Disease:
– Due to enzymatic mural irritation/spasm and due to
perigastric inflammation.
– Posterior wall and left coronary more.
– Is an indicator of severe pancreatic inflammation.
– Malignant infiltration causes distorted fold thickening.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 235
Thickened Duodenal Folds
1. Inflammatory disease
– Peptic ulcer disease
– Brunner’s gland hyperplasia
– ZES (Zollinger-Ellison’s syndrome)
– Duodenitis
– Pancreatitis
– Cholecystitis
– Uremia
– Tuberculosis (Fig. 5.4)
– Crohn’s disease (CD)
– Parasitoses (Giardia, strongyloides)
– AIDS
– Non-tropical sprue.

Fig. 5.4:  Barium meal follow through in anteroposterior projection shows

duodenal narrowing in a patient of duodenal tuberculosis
236 Differential Diagnosis in Radiology
2. Neoplastic
– Metastasis to peripancreatic nodes
– Lymphoma
– AIDS-related malignancies.
3. Diffuse Infiltrative Disorders
– Amyloidosis
– Whipple’s disease
– Mastocytosis
– Eosinophilic enteritis
– Intestinal lymphangiectasia.
4. Vascular Disorders
– Varices
– Mesenteric arterial collaterals
– Intramural hemorrhage
– Chronic duodenal congestion.

Fig. 5.5: Nodular and serpiginous thickening of duodenal mucosal fold

involving 2nd port of duodenum
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 237
5. Cystic Fibrosis (Mucovisciodosis)
• Peptic Ulcer Disease
– Most common cause.
– May lead to Brunner’s gland hyperplasia seen as nodular
thickening of folds known as Cobblestone appearance.
– These do not disappear on compression as compared
to simple mucosal thickening.
• ZES
– Nonbeta is left cell tumor of pancreas.
– Increased gastrin hyperstimulation of parietal cells and
hypertrophy of rugae, hyperacidity and hypervolemic
gastric secretions.

Ulcer Disease
Most common in bulb and stomach but also may occur in 2nd and
4th port of duodenum and jejunum.
Also giant ulcers due to excess acids that overwhelm the
pancreaticobiliary secretions.
Also associated dilution and dilatation.
Disease may continue even after removal of primary and
secondary or ectopic masses in stomach, duodenum, splenic hilum.
• Duodenitis
– Basically an endoscopic diagnosis.
– Thick (>5 mm) duodenal folds are very sensitive but poorly-
specific indicator (Fig. 5.5).
– Hyperacidity leads to nodularity, deformity and spiculation.
– Increased peristalsis is noted.
– However, differentiation between different causes is not
possible.
• Pancreatitis/cholecystitis
– Very important causes in everyday practice.
– Hyperirritable; poor filling; Narrow lumen; widened sweep;
– Thickening in periampullary and proximal second parts.
• Uremia and chronic dialysis
– First and second parts of duodenum show thick and
irregular folds; rigid.
238 Differential Diagnosis in Radiology
– Due to associated pancreatitis; due to associated ulcer.
• Crohn’s disease/tuberculosis
– Associated ulcers and stenosis.
– In tuberculosis associated antral/pyloric disease seen.
• Other infection
Giardiasis—Increased fluid, increased peristalsis and jejunal
involvement
Strongyloidosis—CD-like.
HIV-related cryptococcosis, MAIC, CMV-dilatation.
Non-tropical sprue—Bizarre thickening with erosions in D1 and
D2.
• Neoplastic
Lymphoma—Coarse, nodular, irregular.
Metastasies to lymph nodes—Extrinsic impression mimicking
thickened folds.
Kaposi sarcoma—submucosal infiltration.
• Varices
– Extrahepatic portal vein obstruction, intrahepatic portal
vein obstruction, splenic vein obstruction.
– Other associated varices.
1. Vertical compression on duodenum bulb 1 cm distal to
pylorus by dilated posterior superior pancreaticoduo-
denal vein.
2. Small variceal dilatation leading to Cobblestone
appearance.
3. Large serpiginous varices.
4. An isolated varix on medial descending duodenal wall.
• Mesenteric arterial collaterals
– Atherosclerotic occlusive disease leading to blocked celiac
trunk, SMA or both are the causes.
– Basically from pancreaticoduodenal arcade and gastroduo-
denal artery, which are close to medial duodenal wall
1. Serpiginous filling defects.
2. C-loop widening.
3. Nodular defects may be seen.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 239
– Sharp impression on superior aspect of D1 due to aberrant
right hepatic artery may be seen.
• Intramural bleed/congestion
– Stacked coin appearance
– Bleeding disorder, trauma, anticoagulants.
– Congestion is due to cirrhosis and CHF.
• Cystic fibrosis
– Thick, coarse mucosa.
– Nodules may be seen.
– Smudging of coating.
– Altered duodenal contour.
– D1, D2 rarely jejunum.
– Basically decreased HCO3, increased H+ leading to irritation.

THICKENED SMALL BOWEL

Folds (Flow chart 5.2 and Fig. 5.5)

1. Thickened small bowel folds with dilatation—ZES; Vascular
insufficiency; infections; amyloidosis; abetalipoproteinemia;
lymphoma; hypoalbuminemia; disease of intestinal wall and
mesentery (secondaries, TB, CD).
2. Thickened small bowel folds with gastric involvement—
lymphoma; CD; osinophilic enteritis; ZES; Ménétrier’s disease;
amyloid; Whipple’s disease; varices.
3. Thickened small bowel folds which are regular with no other
feature.
Fold thickened: Jejunum > 2.5 mm
Ileum > 2.0 mm

Fig. 5.6: Small bowel folds

Flow chart 5.2:  Thickened small bowel folds 240
Differential Diagnosis in Radiology
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 241
Hemorrhage in bowel wall: Anticoagulants, ischemic bowel
disease with infarction; vasculitis as thromboangiitis obliterans,
Henoch-Schönlein purpura, collagen vascular disease hemophilia,
idiopathic thrombocytopenic purpura; trauma; secondary
clotting disorders as secondaries, myeloma, lymphoma, leukemia,
hypofibrogenemia.
Intestinal edema: Hypoproteinemia—Cirrhosis, protein losing
enteropathy, nephrotic syndrome.
Lymphatic block: Tumor, fibrosis, lymphangitis angioneurotic
edema.
Intestinal lymphangiectasia: Primary or secondary.
Abetalipoproteinemia.
Amyloidosis.
Vasculitis.
Pneumatosis intestinalis.
Xanthomatosis.
Eosinophilic gastroenteritis.
1. Vascular insufficiency:
– Acute catastrophic
• Length
• Collaterals
• Severity
• Chronic
Arterial/veno-occlusive disease.
Systemic hypovolemia.
Thickening of folds—hemorrhage + edema.
Dilatation—adynamic idleus.
2. Disease of wall with mesentery
Thickening: Due to infiltration + Edema (Venous/
lymphatic block)
(Metastatic, granulomatous, inflammatory)
Dilatation: Mesenteric involvement leading to
areas of obstruction.
242 Differential Diagnosis in Radiology
Crohn’s disease (CD), a disease that may involve any part of GIT
from mouth to anus, has certain specific associated features like
ulcer, stricture, fistula, sinus (also tuberculosis).
  CD, however, shows a poorly distensible stomach having
irregular tubular narrowing and poor peristalsis, especially
antral. If both sides of pyloric canal are involved, a characteristic
Pseudo-Bilroth I deformity results.
3. Infectious enteritis
Non-specific fold thickening and dilatation is seen in salmonella,
strongyloidosis, candida, cytomegalovirus (CMV), cryptococcus,
Mycobacterium avium intracellulare complex (MAIC).
4. Hypoalbuminemia
– Liver and kidney disease.
– Infiltration free of cells.
– Dilatation + thickening
– Gastric fundal rugae +–
– Albumin Threshold >2.7 g%
5. Abetalipoproteinemia (Flow chart)
6. Amyloidosis and Whipple’s disease
– Show dilatation (late) with symmetric fold thickening and
thickened gastric rugae
– In amyloidosis, deposition is in between muscle fibers and
in perivascular areas.
7. Lymphoma: Submucosal infiltration.
a. Infiltrative
– Dilatation
• Due to distal narrowing
• Due to neural involvement known as aneurysmal
dilatation
• Fold thickening
• Slow passage
• Most common.
b. Exo- and endoenteric—large mass with ulcer, displaced
loops and fistula.
c. Multinodular.
d. Polypoidal.
e. Mesenteric.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 243
8. Ménétrier’s disease
– PLE with giant gastric folds.
– Regular intestinal folds.
– Altered surface metabolism.
9. Eosinophilic gastroenteritis
– Immune/allergy.
– Jejunum + distal stomach.
– Initially regular but late, irregular due to spreading of
edema.
– Eosinophilia + Eosinophilic infiltration + Eosinophilic
exudation.
– Mural thickening may be associated with obstruction.
– Good response to steroids (Only definite differential
diagnosis to Crohn’s disease).
– Folds are:
a. Distorted d.  Saw-toothed
b. Irregular e.  Rigid
c. Angulated f.  Separated
10. Xanthomatosis
– Multicentric proliferation of lipid laden cells in bowel wall.
– Regular fold thickening.
– Narrowing of stomach and colon.
11. Pneumatosis
– A mimicker and not true wall thickening.
12. Intestinal lymphangiectasias
Primary
Secondary
Obstruction
– Giant foam cells in walls.
– Diffuse regular fold thickening + loss of protein-rich
exudate in GIT + absent liver, kidney, heart disease.
Lymphangiectasias
– Thickening due to edema + lymphatic obstruction.
13. Angioneurotic edema
– AD; multifocal mucosal edema attacks.
– Focal changes, temporary during crisis, family history.
244 Differential Diagnosis in Radiology
– Regular fold thickening + mesenteric edema separated
loops.
14. Vasculitis
– Leads to infarcts, bleed, perforation, strictures associated
with fold thickening.
– HSP—Circumferential colonic wall thickening with luminal
narrowing.
15. Hemophilia
– Short-long segment fold thickening of bleed.
– Colon may be involved.
16. Idiopathic Thrombocytopenic Purpura
Acute: healthy young child, 1–2 weeks after sore throat
Chronic: Young adult female, insidiuous onset menorrhagia
– Petechiae at GUT, GIT, skin, etc.
(Flow chart)

5.4  THICKENED GASTRIC FOLDS

Gastric folds are said to be thickened when they measure >1 cm
in thickness.
1. Thickened folds in fundus and body.
– Hypertrophic gastritis
– Zollinger-Ellison syndrome
• Gastrin producing tumor
• Postbulbar ulcer in 1 and 2 part of duodenum is
suggestive
• Ulcers distal to 2nd part of duodenum are virtually
diagnostic
• Excessive acid secretion causes mucosal edema and
fold thickening
• 50% multiple and 50% malignant.
– Ménétrier’s disease
• Marked glandular hypertrophy
• Hypochlorhydria and hypoproteinemia are associated
• Course of disease is chronic and unremitting in adults
but resolution occurs in children
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 245
– Varices—associated with esophageal varices.
– Lymphocytic gastritis
• Large
• Varioli form erosions.
2. Thickened folds predominantly in antrum. (The thickened rugal
fold of more than 5 mm in antral area and of more than 1.5
cm along greater curvature. There are also prominent area
gastricae of 4–5 mm which are polygonal or regular throughout
stomach).
– Inflammatory/Infiltrative
a. Crohn’s disease
• Aphthous ulceration, fold thickening, deep ulcers,
skin lesion and scarring are observed.
b. Amyloidosis, sarcoidosis, cystic fibrosis
• Associated lung changes suggest the diagnosis in
sarcoidosis.
c. Tuberculosis: Caseous lymphadenopathy is characteristic.
d. Eosinophilic gastritis
• 50% have peripheral eosinophilia and
50% have allergic history.
e. Caustic ingestion.
f. Drugs like 5-fluorouracil.
g. Radiotherapy.
h. Watermelon stomach.
• Vascular ectasia involving submucosal vessels.
i. Acute pancreatitis.
j. Pseudolymphoma
• This is a benign reactive nodular hyperplasia.
• 70% have ulcer near the center of affected area.
3. Thickening Involving any part of Stomach
– Carcinoma
• Thickened folds are irregular with signs of mucosal
destruction
• Loss of pliability of gastric wall
246 Differential Diagnosis in Radiology
– Lymphoma
• Usually NHL
• Multifocal, usually large masses with coarse mucosal
folds which may extend along GE junction or pylorus
with preservation of wall pliability.

5.5  THICKENED DUODENAL FOLDS

1. Inflammatory
– Duodenitis
– Pancreatitis
– Crohn’s disease
• Precedes aphthous ulcer
• Duodenal cap and D2 predominantly affected
– Infections
• HIV, CMV, MAI, Cryptosporidium.
2. Neoplastic
– Zollinger-Ellison’s syndrome
• Associated ulcers are seen.
– Lymphoma
– Metastases—Rare
From melanoma, breast, ovary, etc.
3. Infiltrative disorders
– Amyloidosis – Mastocytosis
– Whipple’s disease –  Eosinophilic enteritis
–  Peripheral eosinophilia
–  History of allergy
–  Intestinal lymphangiectasia.
4. Vascular
– Varices
• Invariably associated with esophageal varices
– Intramural hemorrhage
• Trauma, bleeding diathesis
• “Stacked-coin” appearance
– Ischemia—Seen in vasculitis, collagen disease.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 247
5. Edema
– Hypoproteinemia—Nephrotic syndrome, cirrhosis, etc.
– Lymphatic obstruction
– Venus obstruction
• Budd-Chiari syndrome
• Constrictive pericarditis
– Angioneurotic edema.
6. Infestations
– Giardiasis
• Associated with hypermotility
• Spasm producing narrowing
• Associated with nodular lymphoid hyperplasia
or hypogammaglobulinemia
– Hookworm
• Ankylostoma duodenale
– Strongyloidosis stercoralis
– Tapeworm
• Tenia saginata/Tenia solium.

5.6  MASSIVELY DILATED STOMACH

Gas or food-filled stomach can be identified, with the wall of
greater curvature convex caudally with pyloric antrum pointing
cranially. Mottled translucencies can be seen due to air trapped
within food residues.

Causes
1. Paralytic Ileus
– Common in elderly
– Associated with fluid and electrolyte disturbance
– High mortality rate
a. Postoperative f. Diabetic coma
b. Trauma g. Hepatic coma
c. Peritonitis h. Uremic coma
248 Differential Diagnosis in Radiology
d. Pancreatitis i. Hypokalemia
e. Cholecystitis j. Drugs like anticholinergics.
2. Mechanical Gastric Outlet Obstruction
a. Fibrosis/scarring secondary to ulceration
b. Malignancy in antrum
c. Gastric volvulus
– Organo-axial type is usually associated with hiatus
hernia
– Elevation of left hemidiaphragm
– No gas beyond stomach
– Collapsed small bowel loops
d. Proximal small bowel obstruction
e. Bezoars
f. Infantile/adult hypertrophic pyloric stenoses
US is diagnostic.
3. Miscellaneous
– Air swallowing
– Intubation.

5.7  TARGET LESIONS IN STOMACH ON

BARIUM STUDIES (FIG. 5.7)
Appearance is due to umbilication or ulceration at the apex of
nodule.
1. Benign lesions
a. Leiomyoma—apical/central ulceration
b. Ectopic pancreatic rests
– Primitive ductal system fills with barium producing a
central niche at the apex of the tumor.
c. Neurofibroma
– May be multiple and multifocal
– Other stigmata of neurofibromatosis.
d. Acute erosive gastritis
– Ulcer surrounded by halo of edema.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 249

Fig. 5.7: “Bull’s eye” (Target) lesions in the stomach

2. Malignant lesions
a. Leiomyosarcoma
– Central ulceration but usually tumors are large
b. Lymphoma (Fig. 5.8)
c. Metastases from melanoma, carcinoid, breast, bronchus
and pancreas.

5.8  GAS IN GASTRIC WALL

1. Interstitial Gastric Emphysema
– Appear as linear or curvilinear lucent shadows along the
gastric wall.
Causes include:
– Raised intragastric pressure
– Post-endoscopy
– Peptic ulceration
– Necrotizing enterocolitis.
2. Emphysematous Gastritis
– Due to gas-forming organisms in wall
– Common in elderly, diabetes mellitus, alcohol abuse and
following corrosive ingestion.
3. Cystic Pneumatosis
– Seen in elderly
– Associated with chronic obstructive pulmonary disease
(COPD)
250 Differential Diagnosis in Radiology

Gastric adenocarcinoma polypoid type—shows abrupt narrowing of

the pyloric canal due to mural infiltration of adenocarcinoma polypoi-
dal intraluminal component
Fig. 5.8: Gastric lymphoma UGI-marked thickening of gastric ruge giving
“Cobblestone” appearance and shrunken stomach

5.9  COBBLE STONE DUODENAL CAP ON

BARIUM STUDY (FIG. 5.9)
1. Small size cap
– Erosive duodenitis
• Central fleck of barium with halo of edema
• Duodenal cap is irritable
– Benign nodular lymphoid hyperplasia
• 1–3 mm nodules involving entire duodenal loop.
– Heterotopic gastric mucosa
• 1–6 mm nodules extending from pylorus towards apex
of cap.
– Food residue/effervescent granules
• Move to most non-dependent part.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 251

Fig. 5.9: “Cobblestone” duodenal cap

2. Big polypoidal cap

– Large ulcer with surrounding edema
– Hypertrophied Brunner’s gland
• Uniform size
• Extends from pylorus to ampulla of Vater
• Associated with end-stage renal failure in 25%.
3. Crohn’s disease
– Aphthoid ulcers are seen.
4. Varices
– Base of cap is usually affected
– Decrease in erect position
– Invariably associated with esophageal varices.
5. Lymphoma.
6. Carcinoma.

5.10  DILATED DUODENUM/OBSTRUCTION OF

DUODENUM
1. Congenital causes
– Annular pancreas
– Peritoneal bands = Ladd band
252 Differential Diagnosis in Radiology
• Commonest cause in neonates
• Associated with malrotation and midgut volvulus
– Aberrant vessel
– Atresia, webs and stenosis
2. Inflammatory narrowing
– Chronic duodenal ulcer scar
– Acute pancreatitis: Phlegmon, abscess, pseudocyst
– Acute cholecystitis: Perforated gallstone
3. Intramural hematoma
– Blunt trauma (Accident, child abuse)
– Anticoagulant therapy
– Blood dyscrasias
4. Tumoral narrowing
– Primary duodenal tumors
– Tumor invasion from pancreas, right kidney, lymph node
enlargement
5. Extrinsic compression
– Aortic aneurysm
– Pseudoaneurysm
6. Miscellaneous
– Superior mesenteric artery syndrome from extensive burns,
rapid weight loss, prolonged bed-rest
• Hold-up of barium in third part of duodenum
• Delay of 4–6 hours in gastroduodenal transit
• Proximal dilatation and vigorous peristalsis with sharp
cut-off sign
• Barium passes easily in making the patient prone
• Postprandial pain relieved by lying on left side
• Decreased aorto-mesenteric angle of 6–25° as opposed
to normal of 45° as on US and decreased aorto-
mesenteric distance of 2–8 mm as opposed and normal
8–10 mm by CT
• 20% associated with duodenal ulcer
• Very-very rare in obese people.
– Bezoar
– Scleroderma
– Paralytic ileus.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 253
5.11  DILATED SMALL BOWEL/JEJUNAL AND
ILEAL OBSTRUCTION

Criteria
Jejunal diameter should not exceed 4 cm.
Ileal diameter shouldn’t exceed 3 cm on small bowel enema.
The criteria limits are 0.5 cm less on barium meal follow-through
studies.
A. Congenital
1. Ileal atresia/stenosis
2. Enteric duplication cyst—commonest ileum
– Location—antimesenteric border
3. Midgut volvulus
4. Mesenteric cyst—commonest ileum
– Location—mesenteric side
5. Meckel’s diverticulum.
B. Extrinsic bowel lesions
1. Fibrous adhesions from previous surgery/peritonitis
– Commonest cause in adults
2. Hernias (inguinal, femoral, umbilical)
3. Volvulus
4. Masses—Neoplasms, abscess.
C. Luminal occlusion (Figs 5.10A and B)
1. Swallowed foreign body, bezoar, gallstone, etc.
2. Meconium ileus
3. Intus-susception
4. Tumor, e.g. lipoma.
D. Intrinsic bowel wall lesion
1. Strictures from neoplasm, Crohn’s disease, tubercu­losis
enteritis, parasitic disease, radiotherapy, amyloidosis
2. Intramural hemorrhage—blunt trauma, Henoch-Schönlein
purpura
3. Vascular insufficiency—Arterial/venous occlusion
4. Celiac disease, tropical sprue, dermatitis herpetiformis
5. Scleroderma
6. Lymphoma.
254 Differential Diagnosis in Radiology

A B
Figs 5.10A and B:  Anteroposterior and Lateral radiograph of abdomen
showing coin as a foreign body in upper jejunal loop

E. Miscellaneous
1. Postvagotomy and postgastrectomy
2. Rapid emptying of stomach produces small bowel
dilatation
3. Extensive small bowel resection
4. Zollinger-Ellison’s syndrome.

5.12  STRICTURES SMALL BOWEL

1. Neoplasms
– Lymphoma
• Usually secondary to lymph node involvement
• Primary is usually NHL
• Associated with thick folds.
– Carcinoid
• Commonest site distal ileum
• Produces intense fibroblastic response.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 255
– Carcinoma
• Commonest site is duodenum
• Produces short segment stricture with mucosal
destruction and ulceration.
– Sarcoma
• Lympho- or leiomyosarcoma
• Thick folds with eccentric lumen.
– Metastases
– Flattened mucosal folds
2. Crohn’s Disease
– Aphthous ulcers
– Skin lesions
3. Tuberculous/Parasitic Infestation
– Long segment smooth strictures
– Multifocal
4. Ischemic
– Ulcers rare
– Evolution more rapid ± strictures
5. Radiation Enteritis
– Produce endarteritis and fibrosis
– Doses > 4500 rads
6. Enteric-coated potassium chloride tablets
7. Surgical anastomosis
8. Amyloidosis.

5.13  SMALL INTESTINAL STRICTURE

Differential Diagnosis (Flow chart 5.3)

1. Tuberculosis
2. Crohn’s disease
3. Metastatic carcinoma
4. End-stage radiation enteritis
5. Endometriosis
6. Eosinophilic gastroenteritis
Flow chart 5.3:  Small intestinal stricture 256
Differential Diagnosis in Radiology
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 257
7. Post-traumatic
8. Drug induced
9. Primary malignancy.

Tuberculosis (Figs 5.11A and B)

• Usually presents in a patient with a past or current history of
pulmonary tuberculosis, either from swallowing of sputum or
due to hematogenous spread
• Sometimes primary, as from ingestion of infected cow’s milk
• Patient presents with loss of appetite, low-grade fever or
sometimes subacute intestinal obstruction. Mantoux test may
be positive and ESR is usually raised
• Ulcerative form is most frequent, with ulcers presenting in an
axis perpendicular to the long-axis of intestines
• Hypertrophic form present with gross thickening of bowel wall
• Most common in the region of terminal ileum and cecum,
but may involve any part of the GI tract. In the ileocecal area
it usually presents with stricture and shortening of cecal pole.
Multiple strictures may be seen in the small intestines or the
whole of GI tract
• Intestinal loops may be matted as seen on fluoroscopy, USG
or CT
• Mesenteric, peripancreatic or retroperitoneal adenopathy is
seen with lymph nodes having caseous necrotic centers and
peripheral enhancement on CECT
• Ascites is usually present and is exudative with internal echoes
and thick shaggy septations/adhesions seen on USG. On CT the
ascitic fluid is of high attenuation value (20–45 HU)
• Omentum may be rolled up or may have irregular masses of soft
tissue density. Similar masses may also be seen in mesentery.

Crohn’s Disease
• A kind of regional enteritis is a disease of unknown etiology
• Presents with discontinuous (skip areas) and asymmetric
involvement of entire GI tract but most commonly involves the
small intestines
258 Differential Diagnosis in Radiology

B
Figs 5.11A and B: Barium med follow through studies with anteroposterior
projection showing ileocecal and cecal with ascending colon involvement
by tubercular process in two different patients
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 259
• There is transmural inflammation, ulceration and formation
of non-caseating granulomas and enlargement of abdominal
lymph nodes
• Patients present with colicky abdominal pains, diarrhea, low-
grade fever, weight loss and malabsorption
• There is cobblestone mucosae due to presence of abnormal
edematous, ulcerated and fissured mucosa separated by
normal uninvolved mucosa
• Perianal abscess and fistula formation is very common
• Terminal ileum alone or in combination with jejunum and
ileum is most commonly involved
• There is intense fibrosis of involved loops with formation of
‘string sign’ due to stricture formation leading to marked
narrowing of bowel loops
• There is ulceration (aphthous ulcers) and fissuring of mucosa
leading to appearances of thorns (rose thorns or raspberry
thorns) on barium studies
• Thickening of bowel loops leads to the “pseudo-kidney sign”
seen on USG
• “Creeping fat” appearances on CT are due to massive
proliferation of intestinal fat leading to separation of bowel
loops
• Multiple intra-abdominal abscesses may also be seen
• Multiple fistulous tracts (enterocolic, perianal, colovesical,
colovaginal, enterocutaneous), etc. may also be seen either on
barium studies or on CT
• Extra intestinal manifestations, such as fatty infiltration of
liver, sclerosing cholangitis, urolithiasis, digital clubbing, sero-
negative arthropathy, erythema and nodosum may also be the
presenting features.

Metastatic Carcinoma
• There is usually a history of primary carcinoma elsewhere
• Intraperitoneal spread occurs from primary mucinous cancers
of ovary, appendix, colon and breast.
260 Differential Diagnosis in Radiology

Eosinophilic Enteritis
• Patients present with relapsing attacks of gastroenteritis, there
is peripheral blood eosinophilia in 50% of cases and positive
history of atopy can be elicited
• There is formation of eosinophilic granulomas and fibrosis
• Fibrosis leads to stricture formation
• There is separation of bowel loops and sometimes ascites may
also be seen.

Post-traumatic
• The interval between trauma and onset of symptoms is usually
1 to 18 weeks
• The stenotic segment may vary in length and outline
• History may be suggestive and diagnosis is one of exclusion.

Drug Induced
• Usually due to non-enteric coated tablets of KCI and rarely
NSAIDs
• The drugs induce small bowel ischemia leading to ulceration,
then fibrosis and subsequently stricture formation
• The strictures are very short segments and diaphragm-like and
may be multiple.

Primary Malignancy
• Very rare
• May produce appearances like colonic carcinoma
• There is evidence of mucosal destruction with overhanging
edges
• Hematogenous dissemination is seen in malignant melanoma,
breast carcinoma, lung carcinoma and Kaposi sarcoma
• Direct extension may be seen in carcinoma of ovary, uterus,
prostate, pancreas, colon and kidney
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 261
• There may be a single mass protruding into the lumen of
the bowel or encircling the bowel like an annular carcinoma
leading to stricture formation
• Stricture may also form due to direct compression either by the
primary carcinoma itself or by involved nodes
• On CT, there is presence of soft tissue nodules or masses,
sheets of tissue causing thickening of bowel wall, fixation and
angulation of bowel loops and ascites.

Radiation Enteritis
• There is a history of radiotherapy done for a primary intra-
abdominal or pelvic carcinoma usually seen in women with
carcinoma of ovary, cervix, and endometrium or in patients
with carcinoma of bladder or colon
• There is a latent period of usually 1–2 years before a full-blown
picture emerges
• There is irregular nodular thickening of folds with straight or
transverse ulcers
• Bowel wall is thickened with luminal narrowing and stricture
formation
• Strictures may be multiple and can be partial or complete
• There may be shortening of small bowel
• Bowel loops may be matted together due to intense
desmoplastic reaction induced by radiation.

Endometriosis
• Rare but usually involves the rectum and colon, rarely small
intestines are involved
• There may be a history of endometriosis or colicky abdominal
pain during menstruation
• May present as an intraluminal mass or stricture of bowel wall
due to intense desmoplastic reaction invoked by periodic loss
of blood by the endometriotic deposits (Flow chart 5.3).
262 Differential Diagnosis in Radiology

5.14  THICKENED FOLDS IN

SMALL BOWEL (FLOW CHART 5.2)
Normal fold thickness—1.5–2 mm
Abnormal fold thickness—Jejunum > 2.5 mm
Ileum > 2.0 mm
Caliber—
Proximal jejunum > 3.5 cm
(4.5 cm, if small bowel enema)
Mid-small bowel > 3.0 cm
(4.0 cm, if small bowel enema)
Ileum > 2.5 cm
(3.0 cm, if small bowel enema)
Divided into two categories:
1. With dilated small bowel—common causes
– Vascular insufficiency
– Lesions of bowel and mesentery
– Z-E syndrome
– Amyloidosis
– Lymphoma
– Abetalipoproteinemia
– Extensive small bowel resection.
2. With non-dilated small bowel.

Localized (< 50% of small bowel)

Smooth and Regular

a. Vascular
Intramural hematoma
– Trauma
– Bleeding diathesis
Ischemia
– Acute—embolus, Henoch-Schönlein purpura
– Chronic—vasculitis, RT, atheroma, fibromuscular dysplasia
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 263
b. Edema
– Adjacent inflammation or mass
c. Infiltrative disease
– Early amyloidosis
– Early eosinophilic enteritis.

Irregular and Distorted

a. Inflammatory
– Crohn’s disease
– Z-E syndrome
b. Infective
– Tuberculosis
c. Neoplastic
– Lymphoma
– Carcinoid
– Melanoma or other metastases.

Generalized (> 50% small bowel involved)

Smooth and Regular

a. Vascular
– Bleeding diathesis
– Vasculitis, RT, etc.
b. Edema
– Hypoproteinemia
– Venous congestion
– Lymphatic obstruction
– Angioneurotic edema
c. Infiltrative
– Late amyloidosis
– Eosinophilic enteritis
d. Abetalipoproteinemia.
264 Differential Diagnosis in Radiology

Irregular and Distorted

a. Inflammatory
– Crohn’s disease
b. Infiltrative
– Late amyloidosis
– Eosinophilic enteritis
– Whipple’s disease
– Mastocytosis
c. Infestation
– Giardiasis
– Strongyloidosis
d. Neoplastic
– Lymphoma
e. Primary lymphangiectasia.

5.15  THICKENED SMALL BOWEL FOLDS WITH

GASTRIC ABNORMALITY
1. Lymphoma/metastases
2. Z-E syndrome
3. Ménétrier’s disease
4. Amyloidosis
5. Eosinophilic gastroenteritis
6. Whipple’s disease
7. Crohn’s disease.

5.16  NODULAR APPEARANCE OF SMALL BOWEL

1. Sand-like nodules (1 mm)
– Seen in following infiltrative disorders as:
a. Waldenström’s macroglobulinemia
– Associated with normal fold
b. Mastocytosis—associated with thick folds
c. Whipple’s disease—associated with thick folds.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 265
2. Small nodules (> 2 mm)
a. Thickened folds
1. Inflammatory – Crohn’s disease
– Cobblestone mucosa
– With skip areas
2. Neoplastic – Lymphoma.

Normal Folds
1. Inflammatory
– Nodular lymphoid hyperplasia
– Associated with hypogammaglobulinemia
– Associated malabsorption and giardiasis
2. Polyposis (Fig. 5.12)
– Peutz-Jeghers syndrome
– Autosomal dominant

Fig. 5.12:  Barium enema in anteroposterior projection showing

multiple polypoidal filling defects in the left side of colon
266 Differential Diagnosis in Radiology
– Multiple hamartomas
– May be associated with intussusception
Gardner’s and Canada-Cronkhite syndromes may occasionally
involve small bowel.
3. Lymphoma.
4. Metastases—on antimesenteric border, especially melanoma,
breast, GIT and ovary.
5. Infections as typhoid, yersinia, histoplasmosis.

5.17 MALABSORPTION
Defined as deficient absorption of any essential food materials
within the small bowel.
1. Primary
– The digestive abnormality is the only abnormality
– Celiac or tropical sprue
– Disaccharidase deficiency.
2. Secondary
– The abnormality occurs during the course of some disease.
– Enteric
– Gastric—fistula, gastrectomy, pyloroplasty
– Pancreatic—cystic fibrosis, pancreatitis, carcinoma
– Hepatobiliary
– Intra- or extrahepatic biliary obstruction.
– Acute and chronic liver disease.

5.18 MALABSORPTION

Clinical Features
• Diarrhea
• Steatorrhea
• Flatulence, abdominal distension
• Weight loss
• Other—Paresthesia, bone pain, tetany, glossitis, cheliosis,
anemia, lassitude.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 267
Blood tests: Anemia, LFT, serum iron, folic acid, albumin, vitamins
K, D and B12.
Fecal fat: 72-hour quantitative fecal fat analysis estimation of 14c in
breath after ingestion of radioactive triglyceride.
D-14[c]-xylose Breath Test: Test of choice for detecting bacterial
overgrowth.
• Gram-negative bacteria metabolize D-xylose to 14 CO2
hydrogen test for lactase deficiency
• A rise of more than 20 ppm in exhaled hydrogen above basal
level after ingestion of lactose at 1 g/kg body weight.

Barium (Fig. 5.13)

• Dilution of barium, because of hypersecretion of fluid by bowel
• Flocculation

Fig. 5.13:  Barium follow-through study in anteroposterior projection

showing signs of malabsorption
268 Differential Diagnosis in Radiology
• Segmentation of the column of barium
• Moulage sign is the appearance of barium in a featureless tube
due to effacement of mucosal folds.
Malabsorption describes impaired absorption of normal
dietary constituents, namely protein, carbohydrates, fats, minerals
and proteins.

Causes
• Mucosal
1. Coeliac disease
2. Inflammation—Tropical sprue
– Crohn’s disease
– Radiotherapy
3. Infiltrative disorder
– Whipple’s disease
– Mastocytosis
– Amyloidosis
– Eosinophilic enteritis
4. Lymphangiectasias
5. Parasites
– Giardiasis
– Strongyloidosis
6. Ischemia
• Inadequate digestion
– Postgastrectomy
– Deficiency or inactivation of pancreatic lipase
– Gastrinoma
– Disaccharidase deficiency (lactose intolerance)
• Reduced intestinal bile salt concentration
– Liver disease
– Blind loop syndrome
– Pseudo-obstruction
– Ileal resection
– Ileal inflammatory disease (Crohn’s, Tuberculosis)
– Drugs—by sequestration of bile salts
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 269
• Inadequate absorptive surface
• Intestinal resection or bypass
(Short-bowel syndrome)
• Major resection
– Severe ischemia/infarction
– Volvulus
– Trauma
• Repeated resections
– Crohn’s disease
– Peutz-Jeghers syndrome
• With or without colon: 150 cm
• With colon: 50–70 cm
• Normal ileum can assume the function of jejunum by
adaptation
• Lost ileum is metabolically irreplaceable.
• Resection of >100 cm of terminal ileum—interrupts
extrahepatic circulation of bile salt.

Barium
• Shows indication of the length of residual small bowel
• Features of adaptation—increased lumen diameter, thickened
folds, more numerous crinkled folds.
Cystic fibrosis: Exocrine pancreatic secretions are low in bicarbonate
and viscid.
Acid with pH—Maldigestion
• Duodenum—thickened or flattened folds, nodular filling
defects, and lumen dilatation with sacculations along it’s lateral
border
• In small bowel, particularly terminal ileum—Normal fold
pattern is replaced by an irregular network of curving lines.

Celiac Disease
• Antibodies to gliadin fraction of gluten HLA-DR3
• Gold standard in diagnosis—characteristic changes shown by
mucosal biopsy
270 Differential Diagnosis in Radiology
• Favorable clinical response to gluten-free diet.
• Reversal to near normalcy on follow-up mucosal biopsies.

Radiological Features
Lumen dilatation > 3 cm in followthrough:
• Increased separation or even absence of jejunal folds
• Reversal of normal fold character between the ileum and the
jejunum
• Increase in number and thickness of folds
• Mosaic mucosal pattern—network of barium containing
grooves separating areas 1–3 mm in size
• In duodenum—fewer and irregular folds
• On gluten-free diet—number of folds in jejunum returns to
normal
• Less improvement in number of ileal folds
• If bowel calibre increases while on gluten-free diet, suspect a
complication, i.e. lymphoma, carcinoma or intersusception/
intussusception (rare and non-obstructive).

Tropical Sprue
• Postinfective malabsorption with subtotal villous atrophy
• In tropical countries
• Extends throughout the small bowel
• Megaloblastic anemia, vitamin B12 and folate deficiency
• Dramatic response to broad-spectrum antibiotics and folate.
Barium: Lumen dilatation, thickened folds and flocculation.

Zollinger-Ellison’s Syndrome
• Gastric acid hypersecretion—maldigestion of fat
• Severe peptic ulcer disease—steatorrhea
• Gastrinoma—damage of jejunal mucosa.
Radiological Features (R/F)—Dilated duodenum with coarse
nodular folds with erosions.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 271
• Thickened folds increased fluid, particularly in the proximal
jejunum
• 75–80% of gastrinomas pancreas
• 15% duodenum
• Endoscopic USG > 50% of adjacent pancreatic gastrinomas
• CT/MR/somatostatin receptor scintigraphy.

Eosinophilic Gastroenteritis
• History of allergic disorders
• Diagnostic criteria
– Symptoms related to gastrointestinal tract (GIT)
– Eosinophilic infiltration of mucosa on biopsy or a character-
istic barium appearance with peripheral eosinophilia
– Exclusion of parasitic or certain extraintestinal disease like
polynodosa arteritis
• Remissions and recurrences—typical
• Predominantly mucosal
– Nausea, vomiting, diarrhea
– Fold thickening—antral
– Straight thickened folds in small bowel
– Patchy distribution
– Predominant involvement of muscularis—thickening of
muscularis with lumen narrowing—Antral
– Small bowel—segmental narrowing, not associated with
fold thickening
– Serosal—rare, ascites, pleural effusion.

Whipple’s Disease
Tropheryma whippelii.
• GIT (small bowel), heart valves, CNS, joint capsule involvement
• Lamina propria filled with macrophages containing PAS
positive residue
• Enteroclysis—Best radiological test for diagnosis of Whipple’s
disease
272 Differential Diagnosis in Radiology
• Diffuse or patchy micronodules, predominantly in the jejunum
and at the duodenojejunal junction.
Computed Tomography—Abdominal lymphadenopathy with
fatty material.

Pseudo-obstruction
Signs/symptoms of obstruction without a mechanical cause
• Primary familial de novo
– Visceral neuropathy
– Myopathy
• Dilated aperistaltic bowel loops
• Antegrade barium study to exclude mechanical obstruction
should be avoided
• To be evaluated by CT
• Secondary collagen vascular disease
– Scleroderma
– Dermatomyositis/Polymyositis
– SLE
• Amyloidosis
• Endocrine disorder: (a) Hypothyroidism (b) Diabetes.
• Neurological disease—Chaga’s disease
• Paraneoplastic visceral neuropathy—small cell lung carcinoma
• Jejunal diverticulosis
• Drugs—Narcotics, tricyclic antidepressants.

Systemic Sclerosis
• Most common cause of chronic intestinal pseudo-obstruction
• Esophagus—most common involved side, small bowel—60%
• 35% patients present with malabsorption.
R/F—aperistalsis in distal two-third of esophagus with patulous
lower esophageal sphincter and reflux esophagitis
• Involvement of 2nd and 3rd parts of duodenum and jejunum
• Hidebound appearance
• Sacculations.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 273
Amyloidosis
• Deposition of insoluble glycoprotein
• GIT involvement—more common in primary amyloidosis
• Small bowel—non-specific dilatation, fold thickening, impaired
motility, suspected of pseudo-obstruction
• Localized deposition—filling defects either macro- or
micronodular.

Bacterial Overgrowth Syndromes

Normal 104 organisms/mL, aerobic—in jejunal aspirate — >106/
mL abnormal.

Protective Mechanisms
1. Gastric acid
2. Peristalsis
3. Mucus and rapid turnover of enterocytes
4. Humoral and cellular immunity.

Causes
Stasis
• Strictures
• Diverticulosis
• Blind loop
• Bypassed bowel
• Pseudo-obstruction.

Increased Bacterial Entry

• Impaired gastric acid output—Achlorhydria, hypochlorhydria
• Gastrectomy
• Atrophic gastritis
• Omeprazole.
274 Differential Diagnosis in Radiology

Immunodeficiency
• Advanced age
• Hypogammaglobulinemia
• Malignancies
• AIDS.

Effects
• Deconjugation of bile salts
• Reduced absorption of amino acids and carbohydrates
• Bind and utilize B12.

Jejunal Diverticulosis
Most common site of small bowel diverticulae.
• Along mesenteric border
• Erect X-ray abdomen—numerous air-fluid levels in the upper
abdomen
• Supine film rounded air-filled space without valvulae
conniventes
• Barium meal followthrough/enteroclysis /CT
• Active bleeding—Tc 99m sulphur colloid scanning.

Parasitic Infestations
• Giardiasis: Villous atrophy, disruption of microvilli, bile salt
decomposition—cytotoxic T cell
• Acute self-limiting diarrhea/chronic diarrhea, malabsorption,
weight loss
• Diagnosis: Stool examination/duodenal mucosal biopsy or
duodenal aspirate
• Strongyloidosis: Increased or decreased motility, narrowing,
ulceration, thickened folds, dilatation of lumen
• Pipestem appearance of jejunum—chronic cases
• Megaduodenum
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 275
• Intestinal tuberculosis and extensive small bowel involvement
by Crohn’s disease may also lead to malabsorption syndrome
• Radiation enteropathy—damage to mucosa malabsorption.

Lactose Intolerance
Primary
Acquired
• Celiac and tropical sprue, regional enteritis, viral and bacterial
infections of GIT, giardiasis, cystic fibrosis and VC
• Bloating, cramps, flatulence following milk ingestion
• Measurement of breath hydrogen after 50 g lactose ingestion.

Lymphangiectasia
• Congenital malformation
• Blockage of lymph drainage in the mesentery or retroperito-
neum extensive abdominal or retroperitoneal carcinoma/lym-
phoma, carcinoid, cirrhosis, chronic pancreatitis, congestive
heart failure
• Enteroclysis may reveal diffuse or patchy micronodules similar
to Whipple’s with thickened, edematous folds, with increased
intraluminal fluid
• Younger patients are affected
• Mesenteric nodes are not enlarged except in patients with
secondary cause, where primary pathology may be obvious.

Mastocytosis
• Mast cell infiltration
• Urticaria
• Mucosal and submucosal infiltration with histamine release
pain, nausea, vomiting, and diarrhea
– Thickened irregular folds, diffuse mucosal nodularity, large
urticaria-like lesions.
276 Differential Diagnosis in Radiology

5.19  PROTEIN LOSING ENTEROPATHY

1. Disease with Mucosal Ulceration
– Carcinoma
– Lymphoma
– Villous adenoma
– Inflammatory bowel disease
– Peptic ulcer disease.
2. Non-ulcerative Mucosal Disease
– Celiac disease
– Tropical sprue
– Whipple’s disease
– Allergic gastroenteropathy
– Gastrocolic fistula
– Villous adenoma of colon.
3. Associated with Hypertrophic Gastric Rugae
– Ménétrier’s disease.
4. Lymphatic Obstruction
– Intestinal lymphangiectasia
– Lymphoma
– Retroperitoneal fibrosis.
5. Venous Obstruction
– Cirrhosis
– IVC thrombosis
– Constrictive Pericarditis.
6. Chronic Arterial Obstruction
– Atherosclerosis.
7. Heart Disease
– Tricuspid insufficiency.

5.20  PATHOLOGIC LESIONS IN TERMINAL ILEUM

1. Inflammatory Lesions
– Crohn’s Disease
• Asymmetric involvement with skip lesions
• Predominates on the mesenteric border
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 277
• Aphthoid ulcer—earliest sign
• Fissure ulcer
• Cobblestone pattern
• Separation of bowel loops
• Strictures and pseudosacculations
– Ulcerative Colitis
• Involves ileum in 10% of total colitis cases known as
backwash ileitis
• Dilated ileum with granular mucosa
• No ulcers
– Radiation Enteritis
• Mural thickening with symmetrical stenosis
• No ulceration or cobblestoning.
2. Infective
– Tuberculosis
• Cecum is predominantly involved
• Contraction and retraction of cecum
• Straightening of ileocecal angle
• Ulcer is uncommon.
– Yersinia
• Cobblestone mucosa with aphthous ulcers (resembles
Crohn’s disease)
• No deep fissure ulcer
• Spontaneous resolution in 10 weeks.
– Actinomycosis
• Very rare
• Predominantly cecum is involved
– Histoplasmosis
• Very rare
3. Neoplastic
– Lymphoma
• Usually non-Hodgkin’s lymphoma
• Irregular, nodular, thickened mucosa
• Irregular polypoidal mass
• Long segment annular stricture
• Multiple ulcers
278 Differential Diagnosis in Radiology
• May be difficult to differentiate from Crohn’s disease
radiologically.
– Carcinoid
• Invariably malignant if > 2 cm
• Annular fibrotic stricture
• Intraluminal filling defect
• Mesenteric mass (produces stretching, rigidity and
fixation of loops)
• Intense desmoplastic response produces stellate
arrangement of loops
– Metastases
– Ischemia
• Rare
• Thickened
• Folds, with ‘cobblestoning’ and ‘thumb-printing’
• Rapidly progressive, changes differentiate it from
Crohn’s disease.

5.21  COLONIC POLYPS

1. Polyp is a mass projecting into the lumen of hollow viscus above
the level of mucosa. Arises from mucosa but may be derived
from submucosa/muscularis propria.
a. Neoplastic—Adenomatous
b. Non-neoplastic—Hamartomatous/Inflammatory.
2. Pseudopolyp refers to island of inflamed mucosa on a
background of denuded mucosa.
a. Pseudopolyposis of ulcerative colitis
b. Cobblestoning of Crohn’s disease.
3. Postinflammatory/filiform polyps are finger-like projections of
submucosa covered by mucosa on all sides following healing
and regeneration.
1. Adenomatous polyps
A. Single: Tubular, tubulovillous, villous
– These form a spectrum both in size and degree of
dysplasia
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 279
– Villous adenoma is the largest with severest
dysplasia with highest premalignant potential
– Size: < 5 mm—0% malignant
5 mm—1 cm—1% malignant
1 cm—2 cm—10% malignant
> 2 cm—50% malignant
– Puckering of bowel wall occurs at the base of polyp.
– Villous adenomas are poorly coated because of
mucous secretion; hence are associated with
protein-losing enteropathy or hypokalemia.
Turcot’s syndrome
– Autosomal recessive
– Increased risk of CNS malignancy.
B. Multiple: Familial adenomatosis coli, adenomatosis of GIT,
Gardner’s syndrome.
– May form a part of spectrum of same disease
– Adenomas more numerous in distal colon and rectum
– Colon carcinoma develops in:
• 30% by 10 years after diagnosis
• 100% by 20 years after diagnosis.
– Carcinoma is multifocal in 50%
– Extracolonic abnormalities include:
• Hamartomas and adenomas in stomach
• Adenoma of duodenum
• Periampullary carcinoma
• Jejunal and ileal polyps
• Mesenteric fibromatosis
• Multiple osteomas in skull and mandible
• Dental abnormalities—hypercementomas, odonto-
mas, dentigerous cyst, etc.
• Epidermoid cysts in leg, face, scalp, etc.
• Pigmented lesion in fundi oculi
• Rarely thyroid carcinoma.
280 Differential Diagnosis in Radiology
2. Non-adenomatous single polyps
– Carcinoid
• Commonest in appendix
• Leiomyoma
• Lipoma
• Hemangioma, lymphangioma
• Fibroma, neurofibroma.
3. Hamartomous polyp
A. Single Juvenile polyp
– Commonest in rectum.
B. Multiple
– Juvenile Polyposis—Non-hereditary
– Peutz-Jeghers syndrome—Hereditary
– Canada-Cronkhite syndrome—Non-hereditary
– Juvenile Polyposis
• Seen in children <10 years of age.
– Peutz-Jeghers syndrome
• Autosomal dominant
• ‘Carpets’ small bowel
• Also affects colon and stomach in 30%
• Pigmentation of mucosa and skin
• Increased incidence of gastric, duodenal and
ovarian carcinoma
– Canada-Cronkhite syndrome
– Predominantly affects stomach and colon
– Increased incidence of carcinoma of colon
– Skin pigmentation, nail atrophy and alopecia are
associated features.
4. Hyperplastic polyp
A. Single/multiple—Commonest in rectum.
B. Nodular lymphoid hyperplasia.
– Seen usually in children
5. Inflammatory/postinflammatory polyp
A. Single—Benign lymphoid polyp
– Fibroid granulation polyp.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 281
B. Multiple
1. Ulcerative colitis - Polyps at all stages
2. Crohn’s disease - Less common than
ulcerative colitis
3. Schistosomiasis - Predominantly,
involves rectum
4. Amebiasis.

5.22  COLONIC POLYPS

A. Adenomatous
B. Hyperplastic
C. Hamartomatous
D. Inflammatory
E. Infective
F. Others.

Adenomatous
1. Simple tubular adenoma, tubulovillous adenoma, villous
adenoma—these three form a spectrum both in size and
degree of dysplasia. Villous adenoma is the largest, shows most
severe dysplasia and has the highest malignancy incidence.
Signs suggestive of malignancy are:
a. Size:
< 5 mm - 0% malignant
5 mm - 1 cm–1% malignant
1 to 2 cm - 10% malignant
>2 cm - 50% malignant
b. Sessile—base is greater than height
c. ‘Puckering’ of colonic wall at base of polyp
d. Irregular surface.
Villous adenomas are typically fronded, sessile and are poorly
coated by barium because of their mucus secretion. May cause a
protein losing enteropathy or hypokalemia.
2. Familial polyposis coli and Gardner’s syndrome—AD.
282 Differential Diagnosis in Radiology
Both conditions may represent a spectrum of the same disease.
Multiple adenomas of colon which are more numerous in
distal colon and rectum. Colonic carcinomas develop in early
adulthood (in 30% by ten years after diagnosis and in 100%
by 20 years). Sixty percent of those who present with colonic
symptoms already have colonic carcinomas. The carcinoma
is multifocal in 50% of cases. Extracolonic abnormalities may
occur:
a. Hamartomas of stomach (40%).
b. Gastric adenomas (more common in the Japanese).
c. Adenomas of duodenum (25%).
d. Periampullary carcinoma (12%).
e. Jejunal and ileal polyps (in 60% of patients in Japanese
literature).
f. Mesenteric fibromatosis—a non-calcified soft tissue mass
which may displace bowel loops and produce mucosal
irregularity from local invasion. USG reveals a hypo- or
hyper-echoic mass and CT a homogeneous mass of muscle
density.
g. Multiple osteomas—most frequently in the outer table of
the skull, the angle of mandible and frontal sinuses.
h. Dental abnormalities—hypercementomas, odonto­mas,
dentigerous cyst, supernumerary teeth and multiple caries.
i. Multiple epidermoid cysts—usually on legs, face, scalp and
arms.
j. Pigmented lesions of the ocular fundus: in 90% of patients
with Gardner’s syndrome and other extracolonic
manifestations.
k. Thyroid carcinoma in 0.6%.

Hyperplastic
1. Solitary/multiple—most frequently found in rectum.
2. Nodular lymphoid hyperplasia—usually children. Filling defects
are smaller than familial polyposis coli.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 283
Hamartomatous
1. Juvenile polyposis—± Familial children under 10 years.
Commonly solitary in rectum.
2. Peutz-Jeghers syndrome—Autosomal dominant. ‘Carpets’ small
bowel, but also affects colon and stomach in 30%. Increased
incidence of carcinoma of stomach, duodenum and ovary.

Inflammatory
1. Ulcerative colitis: Polyps can be seen at all stages of activity of
the colitis (no malignant potential): acute: pseudo polyps (i.e.
mucosal hyperplasia); chronic: sessile polyp (resembles villous
adenoma); quiescent: tubular, filiform (wormlike) and can show
branching pattern.
  Dysplasias in colitic colon is usually not radiologically visible.
When visible, it appears as solitary nodule, several separate nodules
(both non-specific) or as a close grouping of multiple adjacent
nodules with apposed, flattened edges (the latter appearances
being associated with dysplasia in 50% of cases).
2. Crohn’s disease—polyps less common than in ulcerative colitis.

Infective
1. Schistosomiasis—predominantly involves rectum ± strictures.
2. Amebiasis.

Others
1. Canada-Cronkhite syndrome—not hereditary.
Predominantly affects stomach and colon; but can occur
anywhere in bowel. Increases incidences of carcinoma of colon.
Other features are alopecia, nail atrophy and skin pigmentation.
2. Turcot’s syndrome: Autosomal recessive.
Increased incidence of CNS malignancy.
284 Differential Diagnosis in Radiology

5.23  COLONIC STRICTURES/NARROWING

I. Neoplastic
1. Carcinoma
– Annular/scirrhous.
– Associated with mucosal distinction.
– Short segment < 6 cm.
2. Lymphoma
– Cecum and rectum more frequently involved.
– Radiologically, polypoidal mass, diffusely infiltrative
mass or annular lesion.
3. Metastatic
– From prostate, cervix, uterus, kidney, stomach, pancreas,
etc.
II. Chronic stage of any ulcerative colitis
1. Inflammatory—are symmetrical, smooth and tapering.
– Ulcerative colitis.
– Common in sigmoid colon.
– Require >5 years.
– Malignant risk starts after 10 years and increases by
10% per decade.
– Crohn’s disease—Seen in 25% cases.
– 50% are multiple.
– Solitary rectal ulcer syndrome.
2. Infective
– Tuberculosis.
– Commonest in ileocecal region.
– Short ‘hourglass’ stricture.
– Amebiasis.
– Common in descending colon.
– Occurs in 2–8% cases.
– Multiple in 50%.
– Improvement with metronidazole.
– LGV.
– Sexually transmitted disease caused by Chlamydia.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 285
– Long and tubular stricture.
– Commonest in rectosigmoid region.
– Schistosomiasis.
– Commonest in rectosigmoid region.
– Other.
– H. zoster, CMV, strongyloidosis, etc.
3. Ischemic
– Infarction heals rapidly by stricture formation.
– Commonest site is splenic flexure.
– Have tapering ends.
4. Traumatic
– Radiotherapy.
– Latent period—several years.
– Commonest site—rectosigmoid.
– Cathartic colon.
– Pseudostricture—Changes during exam.
– Initially ascending colon is involved.
– Caustic colitis.
III. Extrinsic masses
1. Inflammation as in:
– Retractile mesenteritis
– Diverticulitis
– Pericolic abscess.
2. Deposits
– Amyloidosis
– Endometriosis
– Pelvic lipomatosis.
IV. Postsurgical
– Adhesive bands
– Surgical anastomosis.
V. Normal
– Cannon point.

5.24  PNEUMATOSIS INTESTINALIS

Also known by the name of:
• Pneumatosis cystoides intestinalis
• Bullous emphysema of intestine
286 Differential Diagnosis in Radiology
• Intestinal gas cysts
• Peritoneal lymphopneumatosis.

Causes
A. Bowel necrosis/gangrene
– Commonest cause
– There is damage and disruption of mucosa with entry of
gas-forming bacteria.
a. Necrotizing enterocolitis—in neonate.
b. Ischemia and infarction as in mesenteric thrombosis.
c. Neutropenic colitis.
d. Sepsis.
e. Volvulus.
f. Caustic ingestion.
B. Mucosal disruption
– Increased intraluminal gas pressure leads to overdistension
and dissection of gas in bowel wall.
a. Intestinal obstruction as pyloric stenosis, annular
pancreas, imperforate anus, Hirschsprung’s disease,
and meconium plug syndrome, etc.
b. Intestinal trauma as in endoscopy, rent, perforation,
bowel surgery, barium enema, penetrating and blunt
abdominal trauma, etc.
c. Infection and inflammation as peptic ulcer disease,
tuberculosis, peritonitis, Crohn’s disease, ulcerative
colitis, Whipple’s disease, etc.
C. Increased mucosal permeability
– Defects in lymphoid tissue allows bacterial gas to enter
bowel wall.
a. Immunotherapy
– Graft versus host disease
– Organ/bone marrow transplantation.
b. Miscellaneous
– AIDS enterocolitides, steroid therapy, chemo-
and radiation therapy, collagen vascular disease,
diabetes mellitus.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 287
D. Pulmonary disease
Alveolar rupture with air dissection into interstitium and
mediastinum, followed by retroperitoneal dissection and then
along vascular bundles into bowel wall.
– Chronic obstructive pulmonary disease.
– Chest trauma.
– Positive pressure ventilation.

5.25  MEGACOLON IN ADULTS

Transverse colon diameter greater than 5.5 cm is known as
megacolon.

Causes
I. Non-toxic (without mucosal abnormality)
1. Distal obstruction as by carcinoma
2. Ileus—Paralytic or secondary to hypokalemia
3. Pseudo-obstruction
– No organic lesion evident
– Few fluid levels and feces seen in rectum.
4. Purgative abuse.
II. Toxic
– Acute transmural fulminant colitis produces neuromuscular
degeneration and loss of motor tone. Mortality is 20%.
1. Inflammatory
a. Ulcerative colitis
b. Crohn’s disease
c. Pseudomembranous colitis
2. Ischemic colitis
3. Dysentery
a. Amebiasis
b. Salmonella.
288 Differential Diagnosis in Radiology

Radiological Findings
• Colonic ileus with marked dilatation of transverse colon and
few air-fluid levels
• Increasing caliber of colon on serial radiographs without
redundancy
• Loss of normal colonic haustra and interhaustral folds
• Irregular mucosal surface with pneumatosis coli
• Barium enema is contraindicated due to risk of perforation.

5.26  THUMB PRINTING IN COLON (FIG. 5.14)

This is due to thickened mucosal folds because of submucosal
edema/hemorrhage.

Causes
I. Colitides
a. Ischemic
– Commonest site is splenic flexure
– Peroral pneumocolon may obliterate it.
b. Ulcerative colitis
c. Crohn’s disease
d. Amebic colitis
e. Pseudomembranous colitis
f. Schistosomiasis
II. Neoplastic
a. Lymphoma
b. Metastases
Pseudo-thumb printing is produced by mucosal indentation by
mural air cysts. Careful examination will reveal intramural air.
III. Miscellaneous
– Endometriosis
– Amyloidosis
– Diverticulitis/diverticulosis
– Hereditary angioneurotic edema.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 289

Fig. 5.14: Shows thumb printing in colon

5.27  APHTHOUS ULCERS

These are fine erosions with a halo of edematous mucosa.

Causes
I. In colon
1. Crohn’s disease—Earliest sign
2. Amebic colitis
3. Yersinia colitis
– Produces thick mucosal folds with ulceration
– Lymphoid nodular hyperplasia
4. Salmonella, shigella infection
5. Herpes virus infection
6. Behçet’s disease
– Usually simulates Crohn’s disease
– Occasionally resembles idiopathic ulcerative proctocolitis
7. Ischemic colitis
8. Lymphoma.
II. In small bowel
1. Crohn’s disease
2. Yersinia enteritis
3. Polyarteritis nodosa.
290 Differential Diagnosis in Radiology

5.28  ANTERIOR INDENTATION OF

RECTOSIGMOID JUNCTION
1. Ascites
– Commonest cause
– Especially in erect position.
2 Abscess (pericolic).
3. Hematoma.
4. Endometriosis.
5. Surgery.
– Sling repair for rectal prolapse.
6. Tumors.
– Peritoneal metastases—Common site for gastric, colonic,
pancreatic and ovarian metastatic deposits.
– Primary pelvic tumor, especially adnexal/tubo-ovarian masses.
7. Hydatid cyst
– Metastatic from rupture of usually the hepatic cyst into
peritoneal cavity with seedlings.

5.29  WIDENING/ENLARGEMENT OF
PRESACRAL/RETRORECTAL SPACE
Normal width is < 5 mm in 95%.
Width >1 cm is considered abnormal.
I. Normal variation
– 40% cases and associated usually with obesity.
II. Rectal inflammation
1. Ulcerative colitis
– Seen in 50% cases
– Width increases as disease progresses.
2. Crohn’s colitis
3. Idiopathic proctosigmoiditis
4. Radiation therapy
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 291
III. Rectal infection
1. Proctitis (Tubercular, amebiasis, LGV, etc.)
2. Diverticulitis
IV. Rectal tumor
A. Benign B. Malignant
1. Developmental cyst 1. Adenocarcinoma,
—dermoid, enteric cyst cloacogenic carcinoma
2. Lipoma, neurofibroma 2. Lymphoma, sarcoma,
3. Epidermal cyst lymph node metastases
4. Rectal duplication 3. Prostatic, uterine, vesical,
ovarian causes
V. Body fluids/deposits
1. Hematoma
– Surgery, sacral fracture
2. Pus
– Perforated appendix, presacral abscess.
3 Serum
– Edema, venous thrombosis.
4. Fat
– Cushing syndrome, pelvic lipomatosis.
5. Amyloidosis.
VI. Sacral tumors
1. Metastases, plasmacytoma, chordoma in adults.
2. Sacrococcygeal teratoma, anterior sacral meningocele in
children.
VII. Miscellaneous
1. Colitis cystic profunda.
2. Pelvic lipomatosies.

5.30  CYSTIC MESENTERIC MASSES

I. Benign cysts
1. Pancreatic pseudocyst
– Sequelae of pancreatitis
– Cyst contents reveal P. amylase.
292 Differential Diagnosis in Radiology
2. Non-pancreatic pseudocyst
– Sequelae of mesenteric/omental hematoma/abscess.
– Thick-walled, usually septated with hemorrhagic/
purulent contents.
3. Enteric duplication cyst.
4. Enteric cyst.
5. Mesothelial cyst.
II. Masses
1. Cystic lymphangioma (commonest).
2. Pseudomyxoma peritonei.
3. Cystic mesothelioma.
4. Mesenteric cyst.
5. Mesenteric hematoma.
6. Benign cystic teratoma.
7. Cystic spindle cell tumor.
(leiomyoma/leiomyosarcoma).

5.31  NONVISUALIZATION OF GALLBLADDER

ON ULTRASOUND
1. Contracted gallbladder.
2. Chronic cholecystitis.
3. Gallbladder carcinoma.
4. Perforation of gallbladder.
5. Congenital absence of gallbladder.

Filling Defects In Gallbladder

I. Fixed
A. Single and small
1. Calculus, wall adherent.
2. Adenomyomatosis
– Usually fundal
– Stricture
– Rokitansky-Aschoff sinuses
– Visible after contraction
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 293
3. Polyp
4. Neurinoma
B. Single and large
1. Calculus
2. Tumor—Primary/Secondary
C. Multiple
1. Calculi
– 30% radiopaque
2. Cholesterolosis “strawberry” gallbladder
– Characteristic multiple mural filling defects.
II. Mobile
1. Tumefactive sludge, biliary balls
2. Blood clot
3. Calculus—usually non-shadowing.
III. “Comet-tail” defect in gallbladder
1. Rokitansky-Aschoff sinuses
2. Intramural stone
3. Cholesterolosis of gallbladder.

5.32  GAS IN BILIARY TREE

These appear as irregularly branching gas shadows not reaching
liver edge. Bile duct is outlined; gallbladder may or may not be
seen.
I. Within the bile duct
1. Incompetence of sphincter of Oddi.
(after sphincterotomy/passage of stone/patulous as in
elderly)
2. Postoperative (cholecystoenterostomy/choledochoenter-
ostomy)
3. Spontaneous biliary fistula
– Gallstone ileus = Gallstone erodes the inflamed
gallbladder wall to enter duodenum (60%) and colon
(20%)
– Duodenal ulcer perforates into bile duct
– Malignancy
– Trauma
294 Differential Diagnosis in Radiology
II. Within the gallbladder
1. All of the above
2. Emphysematous gallbladder
– Seen in diabetes due to infection by gas forming
organism.
– Air bile level seen on erect films.
– Intraluminal and intramural gas.

5.33  GAS IN PORTAL VENOUS

• Branching gas shadows within 2 cm of liver capsule
• Gas may also be seen in portal and mesenteric venous and
bowel wall
• Considered a life-threatening event and sign of bowel infarction
and gangrene, unless proved otherwise.
I. Children
1. Necrotizing enterocolitis—10% cases.
2. Umbilical vein catheterization.
3. Erythroblastosis fetalis.
4. Congenital GI obstruction: Duodenal atresia, esophageal
atresia, imperforate anus.
II. Adults
A. Intestinal necrosis (in 74% of adults)
1. Bowel infarction
2. Ulcerative colitis
3. Necrotizing enterocolitis due to mesenteric arterial
thrombosis
4. Perforated ulcer (gastric/duodenal).
B. Miscellaneous
1. Hemorrhagic pancreatitis
2. Sigmoid diverticulitis
3. Intraabdominal abscess
4. Pneumonia
5. Inadvertent gas injection during endoscopy
6. Dead fetus
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 295

Fig. 5.15:  Anteroposterior radiograph of abdomen

showing dilatation of stomach

7. Diabetes, diarrhea
8. During DCBE, especially in severely ulcerated colon
9. Acute gastric dilatation (Fig. 5.15).

5.34  DIFFUSE HEPATOMEGALY

I. Neoplastic
1. Diffuse metastases
2. Diffuse HCC
3. Lymphoma
4. Angiosarcoma
II. Metabolic/Storage
1. Fatty infiltration
2. Amyloidosis
3. Wilson’s disease
296 Differential Diagnosis in Radiology
4. Hemochromatosis
5. Glycogen storage disease
6. Lipid storage disease
7. Galactosemia
III. Congenital
– Polycystic liver
IV. Infective/inflammatory
1. Viral—infective and serum hepatitis, infectious mononu-
cleosis
2. Bacterial—Tuberculous, brucellosis
3. Fungal—Histoplasmosis
4. Protozoal—Malaria, ameba, kala-azar
5. Parasitic—Hydatid
6. Spirochetal—Syphilis
7. Other—Sarcoidosis
V. Vascular
Passive venous congestion as in
– CHF
– Constrictive pericarditis
VI. Degenerative—Cirrhosis
VII. Myeloproliferative—Myelofibrosis
Polycythemia rubra-vera.

5.35  HEPATIC CALCIFICATION

I. Multifocal and small
– Healed granulomas (Tuberculosis, histoplasmosis, brucellosis)
– Intrahepatic biliary calculi
II. Curvilinear
1. Hydatid seen in 20–30% cases
2. Congenital cyst
3. Abscess—especially amebic/old pyogenic
4. Porcelain gallbladder (Fig. 5.16)
III. Localized in mass
1. Metastatic
– Usually multifocal
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 297

Fig. 5.16:  Anteroposterior radiograph of abdomen shows

porcelain gall bladder

– Seen with mucinous carcinoma of colon, breast, stom-

ach, ovarian carcinoma, melanoma, pleural mesothe-
lioma, osteosarcoma and carcinoid
– Amorphous/flaky/stippled/granular
– May be seen following chemotherapy/RT
2. Hepatoma
– Punctate, stippled or granular.
3. Hepatoblastoma
4. Cholangiocarcinoma
IV. Sunray spiculation
1. Hemangioma/infantile hemangioendothelioma.
2. Metastatic as colloid carcinomas.
3. Rarely hepatoma.
298 Differential Diagnosis in Radiology
V. Irregular
1. Hepatic artery aneurysm.
2. Portal vein thrombosis.
3. Capsule of regenerating nodules.
4. Chronic granulomatous disease of childhood.
VI. Diffuse increased attenuation
1. Iron accumulation
– Primary/secondary hemosiderosis.
2. Copper accumulation
– Wilson’s disease.
3. Iodine accumulation
– Amiodarone therapy as an anti-arrhythmic.
4. Gold
– Gold therapy for rheumatoid arthritis.
5. Thallium
– Ingestion of rodenticides.
6. Glycogen storage disease.
7. Thorotrast.

5.36  PRIMARY HEPATIC MASSES

I. Primary benign
A. Epithelial
1. Hepatocellular
– Regenerative nodules
– Adenomatous hyperplastic nodules
– FNH
– Hepatocellular adenoma
2. Cholangiocellular
– Bile duct adenoma
– Biliary cyst adenoma
B. Mesenchymal
1. Tumor containing adipose
– Lipoma
– Myolipoma
– Angiomyolipoma
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 299
2. Tumor of muscle
– Leiomyoma
3. Tumor of vessels
– Infantile hemangioendothelioma
– Hemangioma
– Peliosis hepatis
4. Miscellaneous—Mesothelioma
C. Mixed tissue tumor
– Mesenchymal hamartoma
– Benign teratoma
D. Miscellaneous
– Adrenal rest tumor
– Pancreatic rest tumor
II. Malignant
A. Epithelial
1. Hepatocellular
– Hepatoblastoma (in pediatric age)
– HCC
2. Cholangiocellular
– Cholangiocarcinoma
– Biliary cystadenocarcinoma
B. Mesenchymal
1. Tumor of vessel
– Angiosarcoma
– Epithelioid hemangioendothelioma
– Kaposi sarcoma
2. Miscellaneous
– Embryonal sarcoma
– Fibrosarcoma
3. Tumor of muscle
– Leiomyosarcoma
– Rhabdomyosarcoma
C. Miscellaneous
– Carcinosarcoma
– Teratoma
– Yolk sac tumor
300 Differential Diagnosis in Radiology
– Carcinoid
– Squamous carcinoma
– Lymphoma.

5.37  NEONATAL OBSTRUCTIVE JAUNDICE

I. Infections
a. Bacterial
– E coli, Syphilis
b. Viral
– TORCH, HBV, Coxsackie
On USG—Liver echogenicity and size normal or increased.
TBIDA scan—May reveal delayed uptake by hepatocytes.
II. Metabolic
a. Inherited
– a-1 antitrypsin deficiency, cystic fibrosis, galactosemia,
hereditary tyrosinemia
b. Acquired
– Inspissated bile syndrome (secondary to erythroblas-
tosis): Cholestasis due to total parenteral nutrition.
III. Biliary tract abnormalities
a. Extrahepatic
– Biliary obstruction/hypoplasia/atresia.
Biliary atresia
– Correctable type with patent intrahepatic ducts
– Non-correctable type with occluded intrahepatic ducts
– Normal size, contractible gallbladder rules out the diagnosis
– Absence of small gallbladder favors the diagnosis
– Liver echogenicity on US may be normal or increased
– Normal uptake by hepatocytes but no excretion into bowel
on TBIDA scan favors the diagnosis but is not diagnostic.

Choledochal Cyst
– May present in neonate or early childhood.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 301
Todani’s Type
I. (Commonest)—Fusiform or focal dilatation of CBD
II. Diverticulum of CBD
III. C  holedochocele—outpouching of CBD in wall of
duodenum
IV. a. Dilated CBD with focal dilatation of intrahepatic ducts
b. Focal dilatation of CBD
V. Focal dilatation of intrahepatic ducts (Caroli’s disease).
TBIDA scan—Photopenic areas with delayed uptake of tracer.
Complications include calculi, pancreatitis, abscesses, cirrhosis,
portal hypertension, malignancy.
• “Bile-plug” syndrome
• Intrahepatic
– Ductular hypoplasia/atresia
– Alagille syndrome
i. Autosomal dominant
ii. Dysmorphic facies with ocular abnormalities
iii. CVS anomalies, especially pulmonary stenosis
iv. Hypoplasia of intrahepatic ducts
v. Butterfly vertebra
vi. Radioulnar synostosis.

5.38  FETAL/NEONATAL HEPATIC CALCIFICATION

I. Peritoneal—On hepatic surface
1. Meconium peritonitis
– Commonest cause of abdominal calcifications
– Solid or cystic masses with calcified walls seen on USG.
2. Ruptured hydrometrocolpos
– Appearance similar to meconium peritonitis
– Dilated fluid-filled uterus and vagina.
II. Parenchymal
1. Congenital infections
– TORCH complex
– Scattered nodular calcification
– Other stigmata of disease process.
302 Differential Diagnosis in Radiology
2. Hepatic tumors
– Hemangioma, hamartoma, hepatoblastoma, teratoma,
metastatic neuroblastoma.
III. Vascular
1. Portal vein thromboemboli
– Seen as subcapsular branching calcification
2. Ischemic infarcts
– Calcification in branching pattern distributed through-
out liver.

5.39  DIFFUSELY HYPOECHOIC LIVER

1. Acute hepatitis
– Hepatomegaly with normal echopattern.
2. Diffuse malignant infiltration
– Hepatomegaly with coarse or altered echopattern.

5.40  DIFFUSELY HYPERECHOIC

LIVER (BRIGHT LIVER)
1. Fatty infiltration Hepatomegaly Echopattern
+/– Normal
2. Cirrhosis – Coarse and
(fibrosis + fatty) nodular
(Shrunken liver
in late stage)
3. Hepatitis (Chronic) +/– Coarse
4. Infiltration/ + Coarse
deposition (Malignant,
glycogen may be
storage granuloma)
and nodular
5. Steatohepatitis + Coarse
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 303
5.41  FOCAL, HYPERECHOIC HEPATIC LESIONS
1. Metastases from GIT, ovary, pancreas, GUT.
– Usually multiple and larger than 2 cm
– Hypoechoic halo around lesions.
2. Capillary hemangioma
– Usually single and < 2 cm
– Central arteriole may be seen.
3. Adenoma
– Especially in case of associated hemorrhage.
4. Focal nodular hyperplasia.
5. Focal fatty infiltration.
– Especially around ligamentum teres and GB fossa.
6. Debris within lesions
– Abscesses and hematoma.
7. Miscellaneous
– Hepatoma, lipoma, hemochromatosis.

5.42  FOCAL, HYPOECHOIC, HEPATIC LESIONS

1. Hepatoma
2. Metastases, especially cystic from ovary/stomach
3. Lymphoma
4. Cavernous hemangioma
5. Cysts
– Hydatid
6. Abscesses
– Including complicated/infected cysts.
7. Hematoma is acute stage.

5.43  PERIPORTAL HYPERECHOGENICITY

1. Air in biliary tree
2. Recurrent pyogenic cholangitis
3. Cholecystitis
4. Schistosomiasis
5. Periportal fibrosis.
304 Differential Diagnosis in Radiology

5.44  THICKENED GALLBLADDER WALL

I. Diffuse (anterior wall > 3 mm except physiologically contracted)
A. Intrinsic
1. Acute cholecystitis
2. Chromic cholecystitis
3. Xanthogranulomatous cholecystitis
4. Hyperplastic cholecystosis
5. Sepsis
6. GB carcinoma
7. AIDS cholangiopathy
8. Sclerosing cholangitis
9. GB varices
B. Extrinsic
1. Hepatitis
2. Hypoalbuminemia
3. Renal failure
4. CHF
5. Hepatic vein obstruction
6. Benign ascites
7. Cirrhosis
8. GVH disease
9. Lymphatic obstruction
II. Focal
A. Metabolic
– Hyperplastic cholecystosis
B. Benign tumor
– Adenoma
– Neurinoma
– Papilloma
– Carcinoid
– Fibroadenoma
C. Malignant
– Adenocarcinoma
– Leiomyosarcoma
– Metastases
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 305
D. Inflammation/infection
– Polyp
– Parasitic granuloma as in ascaris, filariasis, etc.
– Retention cyst
– Xanthogranulomatous cholecystitis
E. Miscellaneous
– Impacted gallstone
– Heterotopic mucosa.

5.45  FOCAL HYPODENSE

LESIONS ON NECT LIVER
Lesions Enhancement on CECT
1. Malignant
– Heterogeneous pattern  epatoma, metastasis enhance-
H
of hemangiosarcoma, ment especially in early arterial
intrahepatic cholangio- phase
carcinoma
2. Benign
a.  Hemangioma Usually peripheral nodular en-
hancement advancing peripher-
ally; persistent enhancement on
delayed scans
b. Adenomas—Seen in Early arterial phase enhance-
young females ment which fades rapidly
c. Focal nodular hyperplasia Early arterial phase enhance-
  – Seen in young females ment which fades rapidly
  – Asymptomatic unless Central stellate scar may be seen
large
3. Cyst—Benign, simple, No enhancement but margins
hydatid, VHL, polycystic clearly demarcated; imperce-
liver disease ptible walls
4. Abscesses—Pyogenic, Peripheral enhancement with
amebic, fungal heterogeneous perilesional
enhancement due to edema in
adjacent hepatic parenchyma
306 Differential Diagnosis in Radiology

5.  Focal fatty infiltration No change but increased

  – No mass effect conspicuousness
6. Vascular
  – Infarction, hematoma, No change but increased
laceration conspicuousness
  – Hepatic artery aneurysm Intense enhancement
7.  Biliary Tree Dilatation No change
– Biloma, Caroli’s disease,
choledochal cyst

5.46 HYPERPERFUSION
ABNORMALITIES OF LIVER
There are areas of early enhancement on arterial-dominant phase
due to decreased portal blood flow/formation of intrahepatic
arterioportal shunts/increased aberrant drainage through hepatic
veins.
1. Lobar/segmental
– Portal v. thrombosis
– Obstruction by malignant neoplasm
– Ligation of arterioportal shunt
– Hypervascular GB disease
2. Sub-segmental
– Obstruction of peripheral portal branches.
– Acute cholecystitis
– FNAB
3. Generalized heterogenous
– Cirrhosis
4. Subcapsular
– Idiopathic
5. Miscellaneous
– Aberrant venous drainage as gastric or cystic veins.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 307
5.47  HEPATIC TUMORS WITH VASCULAR “SCAR”
1. FNH
2. Hepatic adenoma
3. Giant cavernous—hemangioma
4. Fibrolamellar HCC
5. Intrahepatic cholangiocarcinoma
6. Hypervascular metastases.

5.48  DIFFUSELY HYPODENSE LIVER ON NECT

1. Fatty infiltration (obesity, early cirrhosis, Cushing’s disease, late
pregnancy, CCl4 poisoning, etc.
– No change on postcontrast scans
– No mass effect on vascular channels.
2. Malignant infiltration
– Heterogenous enhancement on CECT.
3. Amyloidosis
– No change on CECT.
4. Budd-Chiari syndrome
– On CECT, non-visualized hepatic veins and/or IVC, multiple
collaterals at porta
– Hepatomegaly in acute cases
– Shrunken liver with hypertrophied caudate lobe in chronic
cases.
MRI in Important Hepatic Lesions
Lesions T1W T2W Gadolinium
1. HCC ↓, Iso, ↑ ↑ ↑
2. Metastases ↓ ­↑ ± ­↑
except melanoma
3. Melanoma metastasis ↑ ↓ ±↑
4. Hemangioma ↓ ↑ ↑
5. Adenoma ↑ ↓ –
6. FNH
Central scar ↓ ↑ ↑
margin Isointense ↑ ±↑­
308 Differential Diagnosis in Radiology
7. Regenerating ↓, Isointense ↓ –
nodules Hyperintense
8. Hemochromatosis ↓ ↓ ++ –

5.49 SPLENOMEGALY
1. Massively
– CML
• Kala-azar
– Myelofibrosis
• Gaucher’s disease
– Malaria
• Lymphoma
2. Moderately
– All the above
– Storage disorders (Niemann-Pick disease, DM)
– Hemolytic anemia (TTP, Spherocyctosis)
– Portal hypertension
– Leukemias
3. Mildly
– All of the above
– Infection
a. Viral—Infectious mononucleosis
b. Bacterial—Brucellosis, enteric fever
c. Fungal—Histoplasmosis
d. Rickettsial—Typhus
e. Sarcoidosis
f. Amyloidosis
g. Rheumatoid arthritis
h. SLE
i. Splenic trauma.

5.50  SPLENIC CALCIFICATION

I. Diffusely disseminated
1. Phleboliths
– May have central lucencies
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 309
2. Granulomas
– Commonest; multiple, small nodular
– Seen in tuberculosis, histoplasmosis and brucellosis.
II. Vascular
1. Splenic artery calcification—Curvilinear
2. Splenic artery aneurysm.
III. Calcified cyst wall (Curvilinear)
1. Congenital cyst
2. Post-traumatic cyst
3. Echinococcal cyst
4. Cystic dermoid
5. Epidermoid.
IV. Miscellaneous
1. Sickle cell anemia—fine granular
2. Pneumocystitis carinii
3. Healed abscess or infarct or hematoma.

5.51  HYPERECHOIC SPLENIC LESION

1. Granulomas
– Miliary tuberculosis, histoplasmosis
2. Phleboliths
3. Myelofibrosis
4. Gamma-Gandy nodules in portal hypertension.

5.52  FOCAL HYPOATTENUATING

LESIONS IN SPLEEN
1. Lymphoma/leukemia
2. Metastases
3. Abscesses
4. Cystic lesions
– Congenital cyst/epidermoid
– Pseudocyst (Post-traumatic)
– Cystic degeneration of infarct/hematoma
– Cavernous hemangioma/lymphangioma
310 Differential Diagnosis in Radiology

5.53  PANCREATIC CALCIFICATION

1. Chronic pancreatitis
– Numerous tiny stippled calcifications usually intra-ductal.
a. Alcoholic
• Calcification limited to head and tail.
b. Biliary
c. Idiopathic
d. Hereditary
• Autosomal dominant.
• Calcification is typically rounded and large.
• Diagnosis considered in young, non-alcoholics.
e. Pancreatic pseudocyst
• Curvilinear rim calcification is addiction.
2. Neoplastic
a. Microcystic adenoma—“sunburst” appearance
b. Macrocystic cystadenoma—amorphous and peripheral
c. Adenocarcinoma (rare)
d. Cavernous hemangioma—multiple phleboliths
e. Metastases from colon, ovarian carcinomas.
3. Hyperparathyroidism
– Similar to chronic pancreatitis
– Concomitant nephrocalcinosis or urolithiasis.
4. Cystic fibrosis
– Typically fine and granular
– Occurs late in disease and suggests advanced pancreatic
fibrosis.
5. Kwashiorkor
– Similar to chronic pancreatitis
Tropical pancreatitis appears before adulthood.
6. Intraparenchymal hemorrhage
a. Old hematoma/abscess/infarct.
7. Hemochromatosis.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 311
5.54  PANCREATIC MASSES

Focal Pancreatitis
– H/o:
• Usually in pancreatic head
• Calcification/cystic areas
• May be difficult.

Serous Cystadenoma (Microcystic)

• Benign
• F>M, 1.5:1, elderly female abdominal pain and/or mass
• Hypervascular, multilocular cystic tumor with small cyst—with
clear watery glycogen-rich fluid
• Central scar with sunburst pattern of calcification
• USG—homogenous hyperechoic solid looking encapsulated
mass.

Mucinous Cystadenoma (Macrocystic)

• Malignant/premalignant
• Uni/multilocular
• F>M, body and tail of pancreas
• Large cystic areas may contain curvilinear calcification in cyst wall
• Epigastric pain/abdominal mass.
May be difficult to differentiate from necrotic adenocarcinoma
but carcinoma has thick, irregular wall with calcification.
• Intraductal papillary mucinous tumor
– Abdominal pain/recurrent pancreatitis
– M>F
– Ductal dilatation.
• Islet cell tumors
– 80% functionally—small
– 25% nonfunctioning—large
312 Differential Diagnosis in Radiology
• Most common insulinoma
– 90% benign, 10% malignant, 90% solitary
– Whipple triad-1 decrease blood glucose, (hypoglycemia)
relief by glucose.
CT- hypervascular-arterial phase
– Post Gd. MR-Rim enhancement.
• Endoscopic—relatively hypoechoic with well-defined smooth
margins.
– 2nd MC Gastrinoma—ZES—(Acid hypersecretion diarrhea,
peptic ulcer)
– 60% multiple, 60% malignant
– Hypervascular
– Gastrinoma triangle-cystic and CD superior, 2nd and 3rd
parts of duodenum, pancreatic head and neck.

Adenocarcinoma
> 80% of all primary pancreatic neoplasms.
• M>F
• Risk factors
– Cigarette smoking
– Alcohol and coffee—not associated with increased adeno-
carcinoma.

C/F
• Pain
• Weight loss
• Jaundice—Ca head of pancreas
• Unexplained venous thrombosis
• 60% head, 13% body, 5% tail, 22% diffuse.

Imaging
• CT most popular means of determining the local tumor extent
and assessing candidates for potential curative surgery
• Should be the initial diagnostic procedure.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 313
USG
Echo poor homogenous highly attenuating masses, becoming
heterogenous as they enlarge, with irregular lobulated margins.
• Double duct sign, chain of lakes appearance of main pancreatic
duct.

Doppler
Involvement of PV, SV, hepatic and gastroduodenal arteries.

NECT
Most adenocarcinoma have attenuation pattern similar to normal
pancreas unless necrosis/cystic change present.
• Detected only as contour deformity
• Calcification usually absent.

CECT
Hypovascular, with tumor-pancreas contrast being maximum in
pancreatic phase.

Other Features
• Focal contour change with or without diescrete mass
• Focal lesion of soft tissue density in an otherwise fatty replaced
gland
• Spherical enlargement of the head
• Convex rounded border of the uncinate process
• Abrupt termination of CBD
• Double duct sign.

Criteria for Unresectability

• Tumor diameter 5 cm or more
• Extra pancreatic invasion of adjacent tissues and organs, with
the exception of the duodenum
314 Differential Diagnosis in Radiology
• Distant metastasis > nodal hematogenous
• Occlusion, stenosis or encasement of vessels portal vein SMA,
celiac trunk.

TNM staging
T Tx—Primary tumor cannot be assessed
TO—No e/o any primary tumor
T1—Tumor limited to pancreas
T1a—< 2.0 cm
T1b—> 2.0 cm
T2—extension into duodenum, bile duct or
peripancreatic tissue
T3—extension into stomach, spleen, colon or adjacent
large vessels.
N Nx—Could not be assessed
N0— –ve
N1— +ve
M Mx— could not be assessed
M0— –ve
M1— +ve
MRI Useful in tumor detection, staging, identification of level
of obstruction and site of tumor.
Gradient echo and T1W spin echo—used to evaluate
vascular invasion.
T1WI To evaluate lymphadenopathy.
T2W For hepatic metastases.
T1WI Hypointense relative to normal pancreatic parenchyma.
T2WI Variable signal intensity.
Postgadolinium-hypovascular.
MRCP Heavily T2WI-level and degree of duct obstruction.
ERCP 1.  When CT/MR findings unclear.
2.  Ductal dilatation without identification of mass.
3. To differentiate duodenal and ampullary tumors
from periampullary tumors.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 315
Endoscopic Ultrasound
• Currently under evaluation.

Advantages
• To visualize pancreas and surrounding structures with high
resolution
• To guide FNAC
• Vascular and LN invasion.

Disadvantages
• Invasive
• Operator dependence
• Inability to detect distant metastases.

Solid and Papillary Epithelial Neoplasm

• Young female: 11–47 years
84% <35 years
• Large size tumor with solid and cystic areas with well-
defined capsule in the body and/or tail of pancreas. Common
intralesional hemorrhage and necrosis
• This unusual neoplasm is considered when characteristic CT
findings are seen in young female patients.

Lymphoma
• Usually secondary to systemic disease
• Primary very rare
• Large homogenous solid mass, infrequently with central cystic
areas
• Lymphadenopathy
• Displacement and stretching of peripancreatic vessels.
316 Differential Diagnosis in Radiology

Metastasis
• Most common from melanoma—hyperintense on T1
• Also from—Breast, lung, kidney, prostate, GIT
• Multiple with H/o primary (known primary)
• If solitary, may be indistinguishable from primary.

5.55  FOCAL PANCREATIC MASSES

Lesions Features Findings on CT
I. Neoplastic
1.  Adenocarcinoma Commonest in head Isodense of NECT
and tail followed by body
calcification very rare.
Presence of metastasis
invasion of vessel
distinguish it from focal
pancreatitis
Hyper attenuating in
early arterial phase
2.  Islet cell tumor 80% are functioning, b-cell tumor–90%
except functioning benign and < 2cm
insulinomas, all are Usually isodense on
malignant : 75% of NECT with marked
nonfunctioning contrast enhancement
tumors are benign,
calcification Gastrinoma–60%
common, diagnosis malignant, marked
is usually by clinical contrast enhancement
symptomatology Associated with
and hormonal MEN-I Glucaganoma
markers – > 4 cm
3. Cystadenoma/ Usually females Multiple small cysts
carcinoma > 60 years, in head (< 2cm)
Cystadenoma Frequently calcified
Cystadenocarci- Calcification less Multiple large cysts
noma common (> 5cm) in body and tail.
4. Lymphoma Usually secondary Large homogenous
solid mass with peri-
pancreatic lymphade-
nopathy causing dis-
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 317
placement and stretch-
ing of vascular
structures

5. Solid and Rare —

papillary epithelial neo-
plasm
6. Metastases Usually form RCC, Known primary at
HCC, bronchogenic other site
breast, ovarian cancer
melanoma
II. Inflammatory
1. Focal pancreatitis Usually in head of Absence of associated
pancreas metastases and adjacent
Calcification may be invasion
seen
2. Pancreatic abscess Secondary to infected Ring enhancing
phlegmon/pseudocyst mass occurring as
complication of pan-
creatitis
3. Pseudocyst Complication of Thick wall cystic mass,
acute pancreatitis. may be multiple with
H/o acute
pancreatitis

5.56  ADRENAL MASS

Width of normal limb is < 1 cm
1. Bilateral large adrenals
– Hodgkin’s disease
– Adrenal hyperplasia
– Adrenal hemorrhage
– Wilms’ tumor
– Infection as histoplasmosis/tuberculosis
– Pheochromocytoma
– Metastases
2. Unilateral adrenal mass
– CT attenuation
< OHU = benign mass
0–15 HU = probably benign
>15 HU = indeterminate
318 Differential Diagnosis in Radiology
– On 15 minutes delayed contrast enhanced scan.
<25 HU = benign lesion
>25 HU = malignant lesion
– Size of mass
<3 cm in diameter = likely benign (90%)
>5 cm in diameter = likely malignant
Small solid mass Large solid mass Cystic masses
–  Cortical adenoma – Cortical carcinoma – Pseudocyst
usually <10HU – Pheochromocytoma (old hemorrhage
infarction)
–  Metastases usually – Neuroblastoma/
from lung, breast, ganglioneuroma
RCC, etc. – Myelolipoma – Lymphangioma/
hemangioma
– Pheochromocytoma – Metastases – True cyst
– Granulomatous – Hemorrhage – Hydatid cyst
disease
– Myelolipoma – Abscesses – Cystic degene-
  (Typically fat – Hemangioma ration of tumor/
  density) hemorrhage
– Cortical adenoma
with low density

5.57  ADRENAL CALCIFICATION

Child
1. Tumor
– Neuroblastoma (90%)
– Ill-defined, non-homogenous, stippled calcification
– Ganglioneuroma (20%)
Inhomogenous and stippled
– Dermoid (Tooth/calcified focus).
2. Vascular
– Hemorrhage (secondary to sepsis, birth trauma)
Partial or complete ring-like calcification in cyst wall formed
secondarily.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 319
3. Miscellaneous
– Wolman’s disease—AR lipidosis
Punctate cortical calcifications.

Adults
1. Tumors
– Pheochromocytoma (rare) but when present, is usually in
“eggshell pattern”
– Carcinoma—irregular and punctate
– Adenoma—punctate and small
– Ganglioneuroma—flocculent calcification.
2. Vascular
– Hemorrhage (trauma)
– Similar to that in a child.
3. Infection
– Tuberculosis, histoplasmosis, Waterhouse-Friderichsen
syndrome
– Irregular and punctate.
4. Endocrinal
– Addison disease
– Commonly due to tuberculosis.

5.58  EXTRALUMINAL INTRA-ABDOMINAL GAS

1. Pneumoperitoneum
– Gas within the peritoneal cavity.
2. Gas in bowel wall
– Pneumatosis coli
– Pneumatosis intestinalis—ischemia/infarction of bowel wall
as in necrotizing enterocolitis.
3. Gas in biliary tree
– Irregular branching gas shadows which don’t reach the liv-
er edge. It is seen in conditions as patulous sphincter, fol-
lowing passage of gallstones and following postoperative
procedures in biliary tree, enterobiliary fistulas, etc.
320 Differential Diagnosis in Radiology
4. Gas in urinary tract
– Fistula between urinary tract and intestine (Congenital,
postoperative, trauma, etc.) emphysematous pyelonephri-
tis and cystitis, etc.
5. Gas in portal vein
– Branching gas shadows which extend to within 2 cm of the
liver capsule.
– Following bowel/mesenteric infarction, air embolus
following DCBE.
6. Abscess
– Mottled gas pattern. Lack of normal mucosal/haustral
pattern help differentiate it from gas in fecal matter.
7. Necrotic tumor
– Usually in large tumors especially following treatment.
8. Retroperitoneal gas
– Secondary to bowel perforation, postoperative procedures/
diagnostic retroperitoneal air insufflation.

5.59 PNEUMOPERITONEUM
The collection of free air in the peritoneum because of a
diverse group of diseases is known as pneumoperitoneum. An
erect chest film is preferred to an erect abdominal film for this
diagnosis. With careful radiographic techniques, as little as 1 mL
of free gas in the peritoneum can be demonstrated. The views
done usually to detect this little amount of gas are either an
erect chest or left lateral decubitus abdominal film. A patient
should be at least in position 10 minutes before the radiograph
is taken so that the gas collects in the desired highest point in
the abdomen. A pneumoperitoneum can be detected in 76% of
cases using an erect chest film. However, if a left lateral decubitus
suspected of having pneumoperitoneum are critically ill, an erect
film may not be obtained. So it is important to identify the signs
of pneumoperitoneum on a supine abdomen film.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 321
Signs on a Supine Film
• Collection of gas in the right upper quadrant adjacent to liver
lying mainly in the subhepatic space and the hepatorenal or
Morrison’s pouch (doge’s sign), and is visible as an oval, linear
or triangular collection of gas
• Visualization of outer as well as inner wall of a bowel loop
(Rigler’s sign)
• Small triangular collection of gas in between three loops of
bowel (stellate triangle sign)
• Reflection of peritoneum like the falciform ligament, the
medial and lateral umbilical ligaments and the urachus can
occasionally be identified when very large amount of free gas is
present
• Very large amount of gas may accumulate beneath the
diaphragm (cupola sign) or in the center of abdomen (football
sign)
• Ligamentum teres sign is air outlining fissure of ligamentum teres
hepatis seen as vertically-oriented sharply-defined slit-like area of
hyperlucency between 10th and 12th ribs within 2.5–4.0 cm of
vertebral border, 2–7 mm wide and 6–20 mm long
• Gas bubbles may be seen lateral to right edge of liver.

Etiology
a. Disruption of wall of a hollow viscus:
– Infectious bowel diseases like typhoid, tuberculosis.
Typhoid being the commonest cause.
– Perforated gastric/duodenal ulcer.
– Blunt/penetrating trauma.
– Iatrogenic: Laparoscopy, laparotomy, leaking surgical anas-
tomosis, endoscope induced perforations, enema tip in-
jury, diagnostic pneumoperitoneum.
– Perforated appendix.
– Ingested foreign body perforation.
– Diverticulitis (ruptured Meckel’s diverticulum).
– Necrotizing enterocolitis with perforation.
322 Differential Diagnosis in Radiology
– Inflammatory bowel disease (Toxic megacolon).
– Intestinal obstruction secondarily leading to perforation.
(Figs 5.17A and B)
– Ruptured pneumatosis cystoides intestinalis with
‘balanced pneumoperitoneum’ (free intraperitoneal air act
as tamponade of pneumatosis cysts, thus maintaining a
balance between intracystic air and pneumoperitoneum.
– Idiopathic gastric perforation, i.e. spontaneous perforation
in premature infants (congenital gastric wall defects).
b. Through peritoneal surface:
– Transperitoneal manipulations like needle biopsy, catheter
placements.
– Mistaken thoracocentesis/chest tube placement.
– Extension from chest as in dissection of pneumomediasti-
num, bronchopleural fistula.
– Penetrating abdominal injury.

A B
Figs 5.17A and B:  Anteroposterior radiograph of abdomen in supine
and erect posture in a case of intestinal obstruction
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 323
c. Through female genital tract:
– Iatrogenic as in culdocentesis, Rubin test for tubal patency
and pelvic examinations
– Spontaneous as during intercourse, douching, horse-back
riding and knee-chest exercises.
d. Intraperitoneal pathologies:
– Peritonitis by gas-forming organisms
– Ruptured abscess.

Pseudopneumoperitoneum
These are processes that mimic free gas in the peritoneum:
• Pseudo wall sign: This is seen when two gas distended bowel
loops come in close apposition
• Chilaiditi’s syndrome: It is a specific radiological abnormality
seen in very thin asthenic individuals due to interposition
of colon between the liver and diaphragm leading to a false
impression of free gas. The colon can however be recognized
on careful inspection of presence of the haustral pattern
• Sub-diaphragmatic intraperitoneal fat or interposition of
omental fat between liver and diaphragm
• Curvilinear collapse: Sometimes a band of curvilinear collapse
with a crescent of normal lung between it and diaphragm may
simulate free gas
• Sub-pulmonary pneumothorax
• Uneven diaphragm
• Retroperitoneal air
• Sub-diaphragmatic abscess (Fig. 5.18).

5.60  PNEUMOPERITONEUM (FLOW CHART 5.4)

• It indicates presence of gas within the peritoneal cavity
• As little as 1 mL of free gas may be detected on erect chest or
left lateral decubitus abdominal films, but gas may take up to
10 minutes to rise
324 Differential Diagnosis in Radiology

Fig. 5.18: Posteroanterior radiograph of chest shows right subphrenic

abscess causing pneumonic consolidation with pleural effusion on right
side associated with minimal pleural effusion on left side

• On erect films, gas accumulates beneath the domes “cupola or

moustache” sign
• On supine films, gas may be seen in subhepatic space (dolfin
sign); outlining falciform ligament; outlining outer margin of
bowel wall (Rigler’s sign); and at times gas may collect in the
center of the abdomen over a fluid collection (football sign)
(Fig. 5.19).

Causes
1. Perforation
a. Peptic ulcer—75–80% shows pneumoperitoneum.
b. Inflammation toxic megacolon, diverticulitis.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 325
Flowchart 5.4: Pneumoperitoneum

c. Infarction (bowel or mesentery).

d. Obstruction (volvulus, neoplasms, etc.)
e. Pneumatosis coli/intestinalis.
2. Iatrogenic
Postprocedure (following peritoneal dialysis, endoscopy,
embolization) or postoperative. It may take 2–3 weeks for
reabsorption of air; however, serial radiographs will show a
definite decrease.
3. Associated chest conditions
a. Pneumonia.
b. Emphysema.
c. Carcinoma of lung.
d. Pneumomediastinum.
e. Intermittent positive pressure ventilation.
f. Pulmonary peritoneal fistula.
326 Differential Diagnosis in Radiology

Fig. 5.19:  Anteroposterior radiograph of abdomen in supine posture

shows diffuse pneumoperitoneum

4. Introduction per vaginum as following vaginal douches.

5. Idiopathic.

5.61  GASLESS ABDOMEN

CHARACTERIZED BY GROUND GLASS HAZI-

NESS IN ABDOMINAL RADIOGRAPH WITH NOR-
MAL PROPERITONEAL FAT LINES OR BULGING
OF FLANK LINES IN SOME CASES
In children:
a. High obstruction
– Isolated esophageal atresia.
– Duodenal atresia.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 327
– Annular pancreas.
– Hypertrophic pyloric stenosis.
– Choledochal cyst.
– Volvulus.
b. Excessive vomiting.
c. Excessive nasogastric aspiration.
d. Fluid-filled bowel loops as closed loop obstruction, bowel wash out.
e. Relative absence of bowel loops in abdomen as in congenital
diaphragmatic hernia.
In adults:
a. High obstruction
– Volvulus.
– Benign and malignant strictures.
b. Ascites
c. Pancreatitis and other acute abdominal conditions producing
excessive vomiting.
d. Fluid-filled bowel.
– Mesenteric/bowel infarction.
– Active colitis.
e. Large abdominal mass pushing and collapsing the bowel loops
laterally.
f. Normal variant.

5.62 ASCITES
It is defined as accumulation of fluid in the peritoneal cavity.
Smaller amount of fluid is first detected in pelvis.

Radiographic Signs
1. Obliteration of fat lines at the superior border of bladder.
2. Linear lucency of pelvic fat between the fluid density and bony
pelvis.
3. Symmetric densities on both sides of bladder due to fluid in
peritoneal recesses (dog’s ears) appearance.
328 Differential Diagnosis in Radiology
4. With larger amounts of fluid.
a. Elevation of both domes of diaphragm.
b. Homogenous shadow of soft tissue density called “ground-
glass appearance”.
c. Poor visualization of psoas and renal outline.
d. Obliteration of right lateral inferior margin of liver.
e. Displacement of ascending and descending colon medially
with obliteration of haustral markings and of the flank
stripes.
f. Visualization of lateral lucent band between the lateral
abdominal wall and right lobe of liver.
– Hellmer’s sign.
5. On barium study—Separation of small bowel loops is seen.
6. Ultrasonography is very sensitive in detecting ascites, even the
minute amounts, especially with a full bladder.

Technique
However, small amount of fluid collections in pelvis are more
sensitively detected by transvaginal/transrectal ultrasound than
tran­s­abdominal approach. Hyperechoic reflections are seen with
complicated ascites.
7. On CT/MRI, ascites appear as extra-visceral collection and, in
addition, may reveal the underlying cause in some instances.

Causes
1. Neonatal ascites
a. Urinary causes
– Bladder/renal rupture.
– Posterior urethral valves.
b. Chylous ascites
– Perforation of GB/CBD.
– Intestinal lymphangiectasia.
c. Hemoperitoneum
– Ruptured adrenal/spleen/liver.
– Ruptured congenital neuroblastoma.
– Ruptured hepatic tumor or hemangioma.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 329
d. Intestinal contents (Bowel perforation)
– Meconium ileus.
– Atresia.
– Stress ulcer.
e. Transudate
– Fetal hydrops.
– Cardiac failure.
– Idiopathic.
2. Adults
– Cirrhosis with portal hypertension.
– Hypoalbuminemia.
– Infectious peritonitis—particularly tubercular.
– Perforation peritonitis (Fig. 5.20).

Fig. 5.20:  Anteroposterior radiograph of abdomen in erect posture shows

pneumoperitoneum under both domes of diaphragm associated with air-
fluid levels in right abdomen
330 Differential Diagnosis in Radiology
– Tumoral ascites.
a. Malignancy
– Mesothelioma, peritoneal metastases, carcinoma of
GIT and ovary.
b. Benign
– Fibroma of ovary (Meig’s syndrome).

Increased Pressure in the Vascular System

a. CHF
b. Constrictive pericarditis.
c. Thrombosis of IVC.

Lymphatic Obstruction
a. Obstruction of visceral lymphatic drainage or of the origin of
lymphatic duct at the level of cistern of Pecquet.
b. Lymphoma.
c. Postradiotherapy.
d. Trauma.
e. Filariasis.
– Miscellaneous as myxedema, extrahepatic causes of portal
hypertension.

5.63  ABDOMINAL MASS IN NEONATE

I. Renal (55%)
1. Hydronephrosis: Dilated pelvicalyceal system. It may be
associated with hydroureter and bladder hypertrophy. It
may be due to PUJ obstruction, posterior urethral valves,
ectopic ureterocele, prune-belly syndrome and UVJ
obstruction.
2. Multicystic dysplastic kidney.
3. Infantile polycystic kidney.
4. Mesoblastic nephroma.
5. Renal vein thrombosis.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 331
6. Renal ectopia.
7. Paranephric collection (urinoma).
8. Wilms’ tumor (rare).
II. Genital (15%)
1. Hydrometrocolpos—Dilated fluid-filled vagina and/or
uterus.
2. Adnexal cysts—Follicular cysts (commonest), corpus
luteal cyst, theca lutein cyst, para-ovarian cyst, teratoma,
cystadenomas.
3. Gastrointestinal (15%) commonly associated with
obstruction.
– Duplication cyst—Commonest bowel mass.
– Mesenteric cyst.
– Meconium pseudocyst.
– Dilated bowel.
4. Non-renal retroperitoneal (10%)
– Adrenal hemorrhage—Commonly due to neonatal
stress.
– Neuroblastoma.
– Teratoma.
5. Hepato/Spleno/Biliary (5%)
– Hepatoblastoma.
– Hepatic cyst.
– Splenic cyst.
– Splenic hematoma.
– Choledochal cyst.
6. Miscellaneous
1. Urachal cyst.
2. Meningocele in lower abdomen.
3. Sacrococcygeal teratoma.

5.64  ABDOMINAL MASS IN CHILD

I. Renal 55%
1. Wilms’ tumor.
2. Hydronephrosis—due to PUJ obstruction, PU valves, reflux
disease, associated with UTI.
332 Differential Diagnosis in Radiology
3. Cyst—Multicystic dysplastic kidney, polycystic disease,
simple cysts, cystic nephroma, calyceal cyst, etc.
II. Non-renal Retroperitoneal 23%
1. Neuroblastoma.
III. Gastrointestinal 18%
1. Appendicular abscess.
2. Hepatoblastoma commonly in right lobe, 40% are bilateral
lobes and 40% calcify.
3. Hemangiomas—multiple, involving entire liver +/– CHF
and may be associated with cutaneous hemangiomas.
4. Choledochal cyst—10% present with a classical triad
of mass, pain and jaundice. Dynamic radionuclide
scintigraphy with 99Tc—TBIDA is diagnostic.
5. Omental cyst (greater omentum/lesser sac, multilocular).
6. Mesenteric cyst (between leaves of small bowel mesentery).
7. Duplication cyst.
8. Pancreatic pseudocyst.
9. Meckel diverticulum.
10. Mesenteric lymphoma.
IV. Genital
1. Ovarian cyst.
2. Teratoma.
V. Miscellaneous
Cystic lymphangioma.
DD of Wilms’ Tumor and Neuroblastoma
Wilms’ Tumor Neuroblastoma
1. Age 80%<3years 15-30% <1yr; 75% <5years
2. Site Kidneys Adrenal (40%), sympathetic
chain in abdomen (25%),
chest (15%), neck (5%),
pelvis (5%)
3. Plain Film
1.  Calcification 10% 2/3 cases
2.  Renal outline Lost or Maintained but displaced
enlarged
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 333
3.  Intervertebral Normal May be enlarged
  foramina
4.  Bone lesion Uncommon Common
4. On USG/CT/MRI
1.  Major vessels Displaced Encased
2.  Hemorrhage/ Common Uncommon
  necrosis
3.  IVC/renal Common Uncommon
  vein
  thrombosis
5. Radionuclide Not useful MIBG scanning is
scanning useful for skeletal
metastases
6. Associated Beckwith synd. Opsomyoclonus (cerebe-
syndrome (macroglossia, llar ataxia and jerky eye
organomegaly, movement), hypertension
exomphalos and +/– diarrhea due to
hemihypert- VIP secretion
rophy)
Cryptorchidism,
hypospadias,
aniridia, hemihy-
pertrophy may also
be associated

5.65  INTESTINAL OBSTRUCTION IN NEONATE

I. Duodenal—Commonest
1. Stenosis/Atresia—“Double-bubble” sign; may be associ-
ated with annular pancreas, mongolism or with other ab-
normalities of GIT.
2. Annular pancreas—May not present until adulthood.
3. Peritoneal bands—Congenital fibrous bands of Ladd con-
nect cecum to posterior abdominal wall and commonly
cross duodenum.
4. Aberrant vessel as preduodenal portal vein.
5. Congenital web.
6. Choledochal cyst.
334 Differential Diagnosis in Radiology
II. Jejunal and Ileal Obstruction.
CT is best modality for evaluation (95% accurate with 94%
sensitivity and 96% specificity).
1. Atresia/stenosis.
2. Midgut volvulus results from arrest in rotation and fixation
of small bowel in fetal life.
3. Meconium ileus—Mottled lucencies are seen due to
gas entrapment in meconium. Peritoneal calcification
secondary to perforation is seen in 30% cases.
4. Inguinal hernia.
5. Inspissated milk—dense amorphous intraluminal masses
surrounded by rim of air with or without mottled lucencies
within them. Resolves spontaneously.
6. Paralytic ileus usually due to drugs administered during
labor.
7. Enteric duplication cyst—Located on antimesenteric side,
mostly in ileum.
8. Mesenteric cyst from meconium peritonitis located on
mesenteric side.
3. Colonic
1. Hirschsprung’s disease (Fig. 5.21).
2. Small left colon syndrome.
3. Meconium plug syndrome.
4. Atresia.
5. Anorectal malformation (Fig. 5.22).
– High type—With or without sacral agenesis and gas in
bladder (due to rectovesical fistula)
– Low type—Perineal/urethral fistula may be associated.

5.66  ABNORMALITIES OF BOWEL ROTATION

1. Exomphalos
– It refers to total failure of bowel to return to the abdomen
from the umbilical cord, which are contained within a sac.
This is a midline lesion.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 335

Fig. 5.21:  Barium enema in anteroposterior projection shows anorectal

narrowing with proximal megacolon in Hirschsprung’s disease

Fig. 5.22:  Lateral invertogram shows high type of anorectal

malformation with signs of intestinal obstruction
336 Differential Diagnosis in Radiology
DD: Gastroschisis—Paramidline abdominal wall defect through
which the bowel protrudes.
2. Non-rotation
– Asymptomatic.
– Small bowel located on right side of abdomen.
– Colon located on left side of abdomen.
– Small and large bowel lies on either side of SMA with a
common mesentery.
– SMV is situated to the left of SMA.
3. Malrotation—DJ flexure lies to the right of midline and caudal
to its usual position.
– The cecum is more cephalad than normal.
Invariably complicates left-sided diaphragmatic hernia.
– SMV is anterior to SMA.
4. Reverse rotation
– Colon is dorsal to SMA with jejunal and duodenum anterior
to it.
5. Paraduodenal hernias (rare)
1. Through fossa of Landzert on left side (3/4)
– Lateral to 4th part of duodenum and behind descending
and transverse mesocolon.
2. Through fossa of Waldeyer on right side (1/4)
– Caudal to SMA and inferior to 3rd part of duodenum.
6. Extroversion of cloaca—rare
– No rotation of bowel.
– Ileum and colon open separately onto the extroverted area
in the midline below the umbilical cord.

5.67 INTRA-ABDOMINAL
CALCIFICATION IN NEONATE
1. Extraluminal
– Peritoneal calcification following fetal bowel perforation
and meconium peritonitis.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 337
2. Intraluminal
– Intestinal obstruction following imperforate anus, small
bowel atresia or Hirschsprung’s disease.
– Multifocal GI atretic sites.

5.68 HEMATEMESIS
It occurs due to upper GI bleed where the bleeding site is proximal
to the ligament of Treitz. Mortality is approximately 10%. Barium
exam should be avoided in acute cases.

Causes
I. Esophageal causes
1. Hiatus hernia (Figs 5.23A and B)
2. Esophageal varices—mortality 50%
3. Esophageal neoplasms
4. Mallory-Weiss tears—very low mortality.
II. Gastric causes—Mortality <10% if < 60 years and >35% if > 60
years.
1. Acute hemorrhagic gastritis—secondary to steroids,
NSAIDs or alcohol intake.
2. Gastric ulcers.
3. Malignancy especially leiomyosarcoma.
III. Duodenal causes
1. Blood dyscrasias.
2. Hereditary telangiectasia—autosomal dominant.
3. Connective tissue disorders as Ehlers-Danlos syndrome,
pseudoxanthoma elasticum.
IV. Visceral Artery Aneurysm.
V. Vascular Malformation.
338 Differential Diagnosis in Radiology

B
Figs 5.23A and B: Plain posteroanterior radiograph of chest and
oblique view of barium meal study shows hiatus hernia
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 339
5.69  DYSPHAGIA IN ADULTS
Difficulty in swallowing can be due to:
I. Intrinsic causes
1. Benign strictures.
– Peptic strictures due to reflux esophagitis.
– Ingestion of corrosive acids and alkalis or foreign
bodies.
– Iatrogenic following prolonged nasogastric intubation
or fibrosis secondary to radiotherapy.
– Cutaneous diseases such as epidermolysis bullosa and
pemphigus.
– Syndromes as Plummer-Vinson syndrome which
produces anterior indentation in the form of web. It is
common in females with iron deficiency anemia and
in males with postgastrectomy status. Web can occur
from C4 to D1 level. The condition is premalignant.
– Tumors as leiomyomas.
2. Malignant strictures.
– Carcinomas
– Lymphomas.
3. Miscellaneous
– Infections as moniliasis, HSV or CMV infections.
They all produce shaggy ulcerated appearance and
odynophagia (painful deglutition)
– Schatzki’s ring may produce dysphagia if internal
diameter is < 6 mm.
II. Extrinsic causes
1. Tumors
– Mediastinal lymphomas and other tumors, mediastinal
lymphadenopathy.
2. Vascular
– Aortic aneurysm.
– Aberrant right subclavian artery produces posterior
indentation (dysphagia lusoria).
340 Differential Diagnosis in Radiology
– Aberrant left pulmonary artery produces anterior
indentation.
– Right-sided aortic arch produces right lateral and
posterior indentation.
3. Pharyngeal pouch may indent the esophagus. It may
produce air-fluid level with signs of aspiration pneumonitis
on chest radiograph.
4. Goiter.
5. Enterogenous cyst lies adjacent to the esophagus. Evidence
of associated hemivertebra and anterior meningocele may
be there.
6. Prevertebral abscess/hematoma.
III. Neuromuscular disorders
1. Megaesophagus as in Chaga’s disease, achalasia cardia.
2. Systemic disease as scleroderma, myasthenia gravis.
3. Bulbar/pseudobulbar palsy.
IV. Psychiatric disorders
1. Globus hystericus.

5.70  NEONATAL DYSPHAGIA

I. Congenital anomalies
1. Cleft palate.
2. Macroglossia associated with syndromes as Pierre Robin or
Beckwith-Wiedemann syndrome.
3. Esophageal atresia.
4. Brain malformation as Chiari malformation.
5. Vascular anomalies.
– Aberrant right subclavian artery compressing the
esophagus from behind.
– Aberrant left pulmonary artery indenting the
esophagus anteriorly.
– Right-sided aortic arch producing a posterior and right
lateral indentation over esophagus.
6. Choanal atresia.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 341
II. Miscellaneous
1. Delayed/subnormal mental development.
2. Prematurity.

5.71  PHARYNGEAL/ESOPHAGEAL DIVERTICULA

Diverticulum is a blind sac or pouch arising from pharynx or
esophagus.
I. Upper third
1. Zenker’s/Pharyngoesophageal/Hypopharyngeal diverticulum.
– Present in middle-aged and elderly, especially >50
years of age.
– Arises through the posterior wall of hypopharynx usually
on the left side through Killian’s triangle (weak area
between the inferior constrictor and cricopharyngeus
sphincter).
– Causes oropharyngeal dysphagia, regurgitation, aspira-
tion and hoarseness of voice.
– May present as a mass in neck or superior mediastinal
mass on chest X-ray with or without an air-fluid level.
– It is a pulsion type of diverticulum.
2. Lateral pharyngocele
– Congenital—is remnant of 2nd branchial arch.
– Acquired—Seen in trumpeters, glassblowers.
II. Middle third
1. Traction
– Usually at the level of carina.
– Secondary to mediastinal inflammation or adenopathy
as in tuberculosis and histoplasmosis.
2. Developmental as in tracheo-esophageal fistulas.
III. Lower third
1. Epiphrenic
Causes include:
– Long standing peptic esophagitis and strictures.
– Iatrogenic—postendoscopy or surgical injury.
342 Differential Diagnosis in Radiology
– Motility disorders as diffuse esophageal spasms,
achalasia, hypertensive lower esophageal sphincter.
– Collagen disorders—Ehlers-Danlos syndrome.
IV. Miscellaneous

Esophageal

Intramural Pseudodiverticulosis
– Very rare.
– There is dilatation of submucosal glands producing numerous
tiny outpouching within the wall.
– Segmental/diffuse.
– Strictures/dysmotility of esophagus is usually associated.

5.72  ESOPHAGITIS/ESOPHAGEAL ULCERS

Signs of Esophagitis
• Fine mucosa with nodularity in double contrast studies.
• Thickening of longitudinal folds (wider than 3 mm).
• Thickening of transverse folds.
• Reduced or absent peristalsis.
1. Disease
– Reflux esophagitis

Part of Esophagus involved

– Lower third esophagus.

Features
• Blurring of squamocolumnar junction
• Fine, punctate ulcer which ultimately becomes punched out
immediately above the esophagogastric junction.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 343
Comments/Additional features
• Hiatus hernia is commonly associated.
2. Disease
– Barrett’s esophagitis.

Part of Esophagus involved

• Lower third.

Features
• Ulceration at junction of columnar and squamous esophageal
mucosa
• Fine reticular pattern of mucosa resembling area gastricae due
to islands of columnar mucosa.

Comments/Additional features
• Increased risk of carcinomatous change.
3. Disease
– Moniliasis

Part of Esophagus involved

• Any part but mainly upper-third.

Features
• Early
– Mucosal plaques
– Folds become nodular.
• Late
– Deep marginal ulceration, perforation, fistula and stricture
may occur.
344 Differential Diagnosis in Radiology

Comments/Additional features
• Common in immunocompromised.
4. Disease
– Herpetic esophagitis

Part of Esophagus involved

• Mid esophagus

Features
• Sessile filling defects
• Punched out ulcers on a background of normal mucosa
• Ultimately, diffuse ulceration.

Comments/Additional features
• Common in immunocompromised
• Oral herpetic lip-lesions suggest the diagnosis.
5. Disease
– CMV esophagitis.

Part of Esophagus involved

• Any part.

Features
• Discrete, superficial ulcer.
• Giant ulcers on a normal mucosal background.

Comments/Additional features
• Seen invariably in AIDS patients
• Endoscopic biopsy differentiates them from similar looking HIV
ulcers.
6. Disease
– Tuberculous esophagitis.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 345
Part of Esophagus involved
• Any part.

Features
• Deep ulcers and fistulas
• Scarring and stricture formation.

Comments/Additional features
• Caseating mediastinal nodes are associated.
7. Disease
– Drug-induced esophagitis.

Part of Esophagus involved

• Mid-esophagus.

Features
• Ulceration.

Comments/Additional features
• Prolonged contact with certain drugs at sites of esophageal
impression above the aortic arch or that produced by left
main bronchus, above the impression caused by dilated left
atrium and left ventricles. (Tetracycline, KCl, quinidine, aspirin,
phenylbutazone).
8. Disease
– Caustic esophagitis

Part of Esophagus involved

• Sites of anatomical holdup.
346 Differential Diagnosis in Radiology

Features
• Ulceration with mucosal sloughing
• Fibrosis, long-segment smooth strictures
• Perforation into pleural/pericardial cavity
• Ultimately, esophagus may be atonic, especially if myenteric
plexus is destroyed.

Comments/Additional features
• Dyes include sodium hydroxide and carbonate, iodine and
bleaches
• Increased risk of squamous cell carcinoma latent period =20-40
years.
9. Disease
– Radiation esophagitis.

Part of Esophagus involved

• Part included in radiation field.

Features
Doses >2500 and <4500 rads produce transient changes as:
• Mucosal granularity
• Minute ulcers
• Narrowing of lumen from mucosal edema
Doses > 4500 rads produce transient changes as:
• Severe esophagitis due to obliterative endarteritis
• Long smooth tapered strictures.

Comments/Additional features
• Drugs like adriamycin and actinomycin-D potentiate
esophagitis.
10. Disease
– Nasogastric tube esophagitis.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 347
Part of Esophagus involved
• Lower-third.

Features
• Features of peptic esophagitis.

Comments/Additional features
• Nasogastric intubation for as short as 3 days can make LES
incompetent.
11. Miscellaneous
Causes include Crohn’s disease—intramural diverticulosis.

5.73  ESOPHAGEAL STRICTURES

Inflammatory Neoplastic
1. Type – Smooth – Irregular
2. Length – Usually long – Usually short
3. Shouldering – Absent – Present
4. Mucosal fold – Usually absent – Present
destruction
5. Age-group – Early childhood, Middle-age and
young adults up to above
middle-age
6. Proximal – More Less
dilatation pronounced pronounced
7. Causes – Peptic, corrosives, Carcinoma,
achalasia, sclero- leiomyosarcoma
derma, iatrogenic postradiotherapy

Causes of Smooth Esophageal Strictures

I. Inflammatory
1. Peptic—Usually lower esophagus.
2. Scleroderma—Lower 2/3 esophagus; poor functioning LES,
hypoperistalsis produces reflux esophagitis and stricture.
348 Differential Diagnosis in Radiology
3. Corrosives—Strictures at sites of potential hold-up as aortic
arch, esophagogastric junction. Alkalis are more prone
than acids.
4. Iatrogenic—Prolonged nasogastric intubation produces
prolonged dilated LES with reflux and stricture formation
in lower third esophagus.
5. Infections as tuberculosis.
II. Neoplastic
1. Carcinoma with submucosal spread.
2. Benign tumors as leiomyoma may produce smooth,
eccentric, polypoidal mass.
3. Extrinsic mass as mediastinal lymphadenopathy and
carcinoma bronchus, etc.

Irregular Esophageal Strictures

1. Neoplastic
– Carcinoma.
– Leiomyosarcoma.
– Carcinosarcoma.
– Lymphoma.
2. Iatrogenic
– Radiotherapy.
– Postoperative: Fundoplication.

5.74  TERTIARY CONTRACTIONS IN ESOPHAGUS

These are non-coordinated, non-propulsive contractions in
esophagus seen mainly in distal 2/3 esophagus 5–10% of normal
adult in 4th–6th decade show these.

Causes include
1. Presbyesophagus
– Elderly patients with severely disordered motility due to
muscle atrophy.
– May cause chest pain or dysphagia.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 349
2. Diffuse esophageal spasm.
3. Hyperactive achalasia.
4. Neuromuscular disease.
– Diabetes.
– Parkinsonism.
– Multiple sclerosis.
– Thyrotoxic myopathy.
– Myotonic dystrophy.
5. Obstruction at the cardia.
– Neoplasm.
– Distal esophageal stricture.
– Benign lesion.
– Surgery (repair of hiatus hernia).

Findings
• Spontaneous repetitive non-propulsive contraction—“yo-yo”
motion
• Corkscrew appearance
• Compartmentalization of barium (“Rosary bead”, “Shish kebab”).

5.75  GASTRIC MASSES AND FILLING DEFECTS

1. Primary Malignant Neoplasms
a. Carcinoma
– Usually polypoidal with granular/lobulated surface.
– Sessile lesions are detected by alteration in pattern of
area gastricae or rugal folds.
– Usual site is pyloric region.
b. Lymphoma
– Mostly are NHL.
– May be polypoidal, ulcerating or infiltrative.
– Multiple polypoidal, tumor especially with central ul-
ceration giving “bulls-eye” appearance, is characteristic.
– Giant cavitating lesions with pronounced thickening of
folds is suggestive of diagnosis.
350 Differential Diagnosis in Radiology
c. Leiomyosarcoma
– Large exophytic tumors with central necrosis.
– Usual site is fundus and body.
– Association with functional extra-adrenal paraganglio-
mas and pulmonary chondromas.
d. Kaposi sarcoma
– Frequently seen in AIDS.
– Multifocal, submucosal and occasionally polypoidal
tumors.
– Associated duodenal and small bowel involvement
may be present.
e. Carcinoid
– Arise in distal antrum and along lesser curvature.
– Submucosal nodule which may be sessile or peduncu-
lated.
– Highly vascular tumor with hypervascular metastases.
2. Metastases (Secondary malignancies)
– Frequently ulcerate producing bull’s eye lesion.
– Common primaries include melanoma, bronchus, breast,
etc.
3. Benign lesions
– Polyps.
A. Type
– Hyperplastic (local glandular hyperplasia).

Features
• Usually <1 cm
• Multiple.

Location
• Fundus and body.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 351
Comments
• Commonest
• Associated with familial polyposis coli
• Associated with atrophic gastritis
• No premalignant potential.
B. Type
– Adenomatous polyps (dysplastic)

Features
• Usually >1 cm
• Often solitary with nodular surface.

Location
• Antrum.

Comments
• Associated with atrophic gastritis
• Premalignant
• May prolapse into pyloric canal to produce gastric outflow
obstruction.
C. Type
i. Villous (Hamartomas).

Features
• Usually >3 cm
• Reticular appearance.

Location
• Antrum is spared.
352 Differential Diagnosis in Radiology

Comments
• Associated with Peutz-Jeghers syndrome and Cowden’s
disease.
ii. Submucosal lesion.
Produces smooth bulge into lumen with obtuse angle with
the normal wall.
• Leiomyoma
– Commonest, difficult to separate from leiomyosarcoma.
• Lipoma
– Soft; changes shape with gastric peristalsis.
• Others
– Neurofibromas, hemangiomas, lymphangiomas, ectopic
pancreatic rests, duplication cyst, etc.
4. Extrinsic indentation
– Pancreatic tumors.
– Splenic enlargement.
– Hepatic enlargement.
– Other retroperitoneal tumors.
– Sub-diaphragmatic masses/collection.
5. Miscellaneous
Bezoars
– Mobile mass in lumen with no attachment to wall.
– Trichobezoars are commonly seen in psychiatric patients.
– Phytobezoars are the commonest.
– When large, these take the shape of stomach with contrast/
barium entering into the interstices of the bezoar.

5.76  LINITIS PLASTICA

Linitis plastica or “leather bottle” stomach is a result of submucosal
spread of pathological process, leaving in most cases an intact
mucosa resulting in a negative endoscopy. There is intense
desmoplastic reaction which leads to a rigid stomach wall and
narrow lumen. There is loss of normal mucosal pattern and
reduced capacity. The stomach wall is thickened and there is loss
of normal peristalsis.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 353
Differential Diagnosis
1. Malignancy
– Scirrhous gastric carcinoma.
– Lymphomas, both Hodgkin’s lymphoma and NHL (Non-
Hodgkin’s lymphoma).
– Metastatic involvement.
2. Inflammation
– Chronic gastric ulcer disease with intense spasm.
– Crohn’s disease.
– Sarcoidosis.
– Eosinophilic gastroenteritis.
– PAN (Polyarteritis nodosa).
– Stenosing antral gastritis.
3. Infection
– Tertiary stage of syphilis.
– Tuberculosis.
– Histoplasmosis.
– Actinomycosis.
– Strongyloidiasis.
4. Trauma
– Corrosive gastritis.
– Radiation injury.
– Gastric freezing.
5. Others
– Amyloidosis
– Pseudolymphoma
– Cystic fibrosis.

Radiological Appearance
Barium meal: There is generalized narrowing of gastric lumen
(tubular shape of stomach), with reduced capacity, the mucosa is
often nodular and fold pattern is lost. There is loss of peristalsis
appreciated on fluoroscopy.
354 Differential Diagnosis in Radiology
Ultrasound: There is evidence of wall thickening, usually more than
6 mm. No evidence of active peristalsis is seen.
CT scan: Water distension with gas effervescence is used to
demonstrate the true thickness of gastric wall, which is usually
more than 1 cm. The nodular mucosal pattern can be appreciated,
and surrounding organs and areas can be examined for associated
changes like infiltration and lymphadenopathy in cases of
malignancy. One peculiar property of linitis plastica associated
with malignancy is contrast enhancement on CECT. This helps
identify infiltrative tumors less than 1 cm in thickness.

Common Etiologies
Scirrhous gastric carcinoma: There is intense desmoplastic reaction
associated with this carcinoma. It usually involves the antrum of
stomach, but may extend to involve the entire stomach. There is
firmness, rigidity, reduced capacity and aperistalsis of involved
areas. On double contrast barium studies and CECT, there is loss of
normal mucosal fold features, with sometimes granular or polypoid
folds, and encircling growth. There is intense enhancement on
CECT and surrounding infiltration may be present.
Lymphoma: Both Hodgkin’s lymphoma and NHL may involve the
stomach either partially or diffusely. Stomach is the most common
site of GI tract lymphoma, especially NHL or extranodal Hodgkin’s
lymphoma. The flexibility of gastric wall is preserved and mucosal
folds and wall may be grossly thickened (4–5 cm). On CT, there is
homogenous overall attenuation and minimal enhancement after
contrast administration. There may be diffuse retroperitoneal and
mesenteric adenopathy.
Metastatic involvement: There is usually a history of primary
malignancy elsewhere, like malignant melanoma, breast, lung,
colon, prostate, leukemia, secondary lymphoma. Breast carcinoma
is the most common malignancy producing linitis plastica-like
appearance.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 355
Radiation injury: There is a positive history of radiotherapy received
for primary malignancy in the nearby organs. There is intense
desmoplastic reaction produced by radiotherapy leading to
effacement of gastric folds. There is a latent period of one month
to two years.
Acids: A positive history of acid ingestion can usually be elicited
and is usually found in female patients. There are associated
changes in esophagus.
Granulomatous disease: (Tuberculosis, Sarcoidosis): These may cause
changes like linitis plastica. Usually associated changes are seen in
the lungs. In cases of tuberculosis, changes may be seen in small
intestines, and abdominal lymphadenopathy may be present with
or without ascites.
Eosinophilic gastroenteritis: The patients may have a positive
history of atopy and peripheral blood eosinophilia may be seen in
50% of the cases. Ascites may or may not be present.

5.77  LINITIS PLASTICA

Disease Features Additional Points
1. Gastric Loss of wall Irregular mucosal
carcinoma pliability folds with destruction
Commonest cause
2. Lymphoma Wall pliability pre- Folds architecture
served, multifocal preserved
submucosal nodules Massive associated
Disease extent crosses lymphadenopathy
the GE junction and/
or pylorus
3. Metastases, Wall pliability Fold architecture pre-
esp. breast preserved served. Known
primary
4. Local invasion Localized mucosal Pancreatic mass with
as pancreatic destruction evidence of invasion
carcinoma into stomach
356 Differential Diagnosis in Radiology
5. Corrosives Associated with H/o ingestion
strictures. Non-
specific findings.
6. Radiation Mucosal fold H/o radiation
therapy effacement. Large exposure
antral ulcers
may be associated
7. Granulomatous Nonspecific Other stigmata
disease as findings elsewhere
Crohn’s disease Wall pliability
syphilis, preserved
tuberculosis
8. Eosinophilic Evidence of peri- Diagnosis by biopsy
gastritis pheral eosinophilia
History of allergy
Nonspecific features

5.78  GASTROCOLIC FISTULA

1. Inflammatory 2. Neoplastic
– Peptic disease with – Carcinomas of stomach,
ulcer and perforation. pancreas or colon.
– Crohn’s disease with – Metastases with perfora-
multiple fistulas and mucosal tion and fistulation.
involvement and skip areas.
– Chronic pancreatitis with
enzyme leakage or duct
rupture.
– Granulomatous infections such as
tuberculosis and actinomycosis.

5.79  RETROPERITONEAL FIBROSIS

Also known as Ormond’s disease or chronic periaortitis.
It is a rare fibrotic process frequently involving the caudal
aspect of retroperitoneum without effects on ureter, great vessels,
lymphatic and even CBD, caused by proliferation of fibroblasts,
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 357
acute infective cells and capillaries, all of which are surrounded by
collagen fibers.
In 15%—Associated with fibrotic process elsewhere in the body.

Differential Diagnosis (D/D)

Causes
A. Primary—2/3rd
Autoimmune with antibodies to ‘CEROID’ (insoluble
lipid) systemic vasculitis associated with fibrosis outside
retroperitoneum in 8–15%.
Age—Middle-aged to elderly
Sex—M:F = 2:1
Usually responsive to steroids.
B. Secondary.

Benign
• Medication 12%—Most common is Methyseurgide, but
b blocker, methyldopa, hydralazine, antibiotics and other
analgesics. Prolonged use causes abdominal, pulmonary and
endocardial fibrosis. Early withdrawal often results in regression
of the disease
• Retroperitoneal hemorrhage—because of trauma, ruptured
aneurysm or retroperitoneal surgery like translumbar
aortography and percutaneous renal biopsy
Aneurysm rupture—on CT-acute extraluminal blood is of soft
tissue attenuation with vermiform finger-like extension in the
retroperitoneum
• Post-traumatic chronic hematoma—Decreased mass with a
thick dense rim-peripheral calcification may also be seen.

Infection
Like tuberculosis, syphilis, actinomycosis, brucellosis and fungal
infection, etc. can lead to retroperitoneal fibrosis.
358 Differential Diagnosis in Radiology

Miscellaneous
Variety of intra-abdominal inflammatory conditions (diverticulitis,
appendicitis, extravasation from the urinary tract, aneurysm of
aorta and iliac artery).

Malignant
8-10%.
Primary neoplasm or metastatic disease or lymphoma can provoke
an extensive desmoplastic reaction.

Primary Retroperitoneal Tumor

Majority are malignant.
• Liposarcoma is most common
On CT—is an attenuation of fat density
• Leiomyosarcoma—large heterogeneous masses
Low attenuation component—necrosis
No fat or calcification
• MFH—Heterogeneous soft tissue, necrosis positive.

Metastasis
Metastasis from colon and breast, soft tissue, lung, kidney, prostatic
tumor incites a fibrotic reaction around itself.

Lymphoma
HL (Hodgkin’s lymphoma)>NHL (Non-Hodgkin’s lymphoma).
Enlarged lymph node may appear as discrete masses or confluent-
soft tissue obliterating the retroperitoneal fat—Loss of definition
of fat plane but not involving aorta and IVC.
• Excretory urography—ureteric obstruction
• Bilateral in 75%
• Tapering lumen or complete obstruction—usually at L4-5
• Medial deviation of ureter which is obstructed and dilated
• Other causes = Normal in 18%
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 359
– Pelvic lipomatosis.
– Following abdominoperineal resection.
– Retrocaval ureter—Right ureter passes behind the IVC at
the level of L4.
– Hypertrophy of psoas muscle of L3.
• USG—Hypoechoic smoothly marginated mass that often
appears as plaque around the distal aorta due to medial
deviation of ureter.
CT: From minimal periureteral stranding to large lobulated masses
obliterating the fat plane but not involving the aorta and IVC,
indistinguishable from bulky lymphadenopathy.
D/D features of retroperitoneal fibrosis from primary RPF tumor.
RPF: Usually located at the level of L4 and plaque-like and infiltrating
rather then nodular RPF usually surrounds the anterior and lateral
aspect of great vessels, whereas marked displacement of aorta or
IVC is seen in primary retroperitoneal tumor or in malignant LAP.
LAP in lymphoma is often-centered more cephalad in RP and may
be bulkier at the level of renal hila.
• Malignant or infective may invade and destroy adjacent bones
or organ.
NCCT: RPF—similar to that of muscle/focal or uniform hyper-
density—increase collagen.
CECT: Exuberant enhancement.
MRI: Non-malignant RPF
• Homogenous decrease signal intensity (similar to psoas muscle)
on both T1 and T2—reflects mature and quiescent phase.
• Acute benign RPF—intermediate or increase on T2—increase
cellularity and fluid.

Malignant
Heterogeneous on T2 WI.
360 Differential Diagnosis in Radiology
Both malignant and non-malignant enhancement after IV
Gadoglinium.
MRA and GRE are effective—to see the vascular involvement
and collateral vessel formation.
• Radionuclide—Ga67 uptake during active infection.

5.80  MASS OF ILIO-PSOAS COMPARTMENT

• Iliacus and psoas major muscles are chief flexors of lower limb
• Due to their common origin and insertion, both are considered
together
• Structurally, they are structures located in posterior abdominal
wall
• Psoas minor is a small muscle absent in up to 70%
• CT—Isoattenuating; minimal/nil enhancement
MRI—Intermediate (T1, T2, PD)
USG—Hypoechoic to liver/Iso—to renal medulla with linear
echogenic fascial strips
Plain X-ray—soft tissue density
• Maximally thick at L3-4. A linear area within fat about lumbar
plexus.
Pathologies/Masses
Inflammatory
Neoplastic
Pseudoaneurysm of lumbar artery
Hemorrhage
Ilio-psoas bursitis

Imaging
1. Plain X-ray
2. Retroperitoneal air insufflation and tomography
3. CT
4. MRI
5. USG
6. Indirect—IVP, aortography, IVC inferior venocavography.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 361
Salient features
1. Inflammatory—Most common
– Pyogenic/tubercular.
– Mostly secondaries—Surgery, spine, kidney, pancreas,
bowel, sometimes primary, also aortic bed.
– On CT and MRI
• Diffuse bulkiness
• Focal masses
• Iso to hypo on CT and with homogenous/rim
enhancement
• T1—iso/hypo; T2—hyper; PD—hyper
• Gas +/–
• Calcification±—tuberculosis
• Destruction and sclerosis of adjacent bone
• ± a phlegmon or an abscess.
– On USG
• Hypoechoic collection
• Bulky muscle.
– Plain X-ray-loss of psoas silhouette.
– Apart from imaging, radiologist helps in diagnosis and
intervention. We should also try and find out the source of
infection.
2. Neoplastic
– 1/3–1/4 the causes of illiopsoas masses.
– Sometimes, primary soft tissue tumor or sometimes
secondarily by invading lesion as lipoma, liposarcoma,
rhabdomyoma and sarcomas, teratoma, dermoid, etc.
– Presence of fat is a sign of fat containing mass.
– Difficult to differentiate from the above.
3. Hemorrhage
– Due to trauma, iatrogenic, graft, VWD, hemophilia.
– Expansile mass of various appearances, dual phase of
resolution is seen.
– Bone destruction is not seen.
– Slowly it resolves forming a level or low density area.
Calcifications and rim enhancement confuse it to infection.
Superinfection is rarely a problem.
362 Differential Diagnosis in Radiology
4. Bursitis
– Presents as a flocculent mass in inguinal area with
invagination towards hip.
– Communication to hip is seen in early 15% by arthrography.
– Due to rheumatoid arthritis, osteoarthritis. It is seen as
areas of fluid in all modalities.
5. Pseudoaneurysm of lumbar arteries
– Due to trauma/surgery
– Doppler USG/MRA gives good demonstration.

5.81  ANATOMY OF LIVER,

BILE DUCTS AND PANCREAS
A. Left portal vein
1. Absence of horizontal segment (0.2%)
B. Right portal vein
1. Trifurcation of main portal vein (11%)
2. Origin of RP segment from main portal vein (5%)
3. Origin of RA segment from left portal vein (4%)
4. Absence of main right, RA and RP portal segments

RAS = right anterior RPI = right posterior LMI = left median

segment inferior inferior
RAI = right anterior RPS = right posterior LMS = left median
inferior superior superior
RAS = right anterior C = caudate lobe LLI = left lateral
superior inferior
RP = right posterior L = left portal vein LLS = left lateral
segment superior

Functional Segmental Liver Anatomy

(Goldsmith and Woodburne) (Couinaud and Bismuth)
Caudate lobe
Left lobe Left lateral Left lateral superior subsegment
segment Left lateral inferior subsegment
Left medial Left medial superior subsegment
segment Left medial inferior subsegment
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 363
Right Right anterior Right anterior inferior subsegment
lobe segment Right anterior superior subsegment
Right posterior Right posterior inferior subsegment
segment Right posterior superior subsegment

Functional Segmental Liver Anatomy

Based on distribution of three major hepatic veins:
a. Middle hepatic vein:
Divides liver into right and left lobe
Also separated by main portal vein scissura (Cantlie line)
passing through IVC + long-axis of gallbladder).
b. Left hepatic vein:
Divides left lobe into medial + lateral sectors
c. Right hepatic vein:
Divides right lobe into medial + lateral sectors
Each of the four sections is further divided by an imaginary
transverse line drawn through the right + left portal vein into
anterior + posterior segments; the segments are numbered
counter-clockwise from IVC.

Hepatic Arterial Anatomy (Michel’s classification)

Type I (55%):
• Celiac trunk trifurcates into LT gastric artery + splenic artery
+ common hepatic artery
• Common hepatic artery divides into gastroduodenal artery
+ proper hepatic artery
• RT hepatic artery + LT hepatic artery arise from proper
hepatic artery
• Middle hepatic artery (supplying caudate lobe) arises from
a. LT/RT hepatic artery
b. Proper hepatic artery (in 10%)
Type II (10%):
• Common hepatic artery divides into gastroduodenal + RT
hepatic artery
364 Differential Diagnosis in Radiology
• LT hepatic artery replaced to LT gastric artery
• Middle hepatic artery from RT hepatic artery
Type III (11%):
• Common hepatic artery divides into gastroduodenal + LT
hepatic artery
• RT hepatic artery replaced to superior mesenteric artery
• Middle hepatic artery from LT hepatic artery
Type IV (1%):
• Common hepatic artery divides into middle hepatic artery
+ gastro-duodenal artery
• RT hepatic artery + LT hepatic artery are both replaced
Type V (8%):
• Accessory LT hepatic artery arises from LT gastric artery
Type VI (7%):
• Accessory RT hepatic artery arises from superior mesenteric
artery
Type VII (1%):
• Accessory RT + LT hepatic artery
Type VIII (2%):
• Combinations of accessory + replaced hepatic artery
Type IX (4.5%):
• Hepatic trunk replaced to superior mesenteric artery
Type X (0.5%):
• Hepatic trunk replaced to LT gastric artery.

Hepatic Fissures
1. Fissure for ligamentum teres = umbilical fissure = invagination
of ligamentum teres = embryologic remnant of obliterated
umbilical vein connecting placental venous blood with left
portal vein
– Located at dorsal-free margin of falciform ligament
– Runs into liver with visceral peritoneum
– Divides left hepatic lobe into medial + lateral segments
(divides subsegment 3 from 4).
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 365
2. Fissure for ligamentum venosum
= Invagination of obliterated ductus venosus
= Embryologic connection of left portal vein with left hepatic
vein
– Separates caudate lobe from left lobe of liver
– Lesser omentum within fissure separates the
greater sac anteriorly from lesser sac posteriorly.
3. Fissure for gallbladder
= Shallow peritoneal invagination containing the gallbladder
– Divides right from left lobe of liver.
4. Transverse fissure
= Invagination of hepatic pedicle into the liver
– Contains horizontal portion of left + right portal veins.
5. Accessory fissures
a. Right inferior accessory fissure
= From gallbladder fossa/just inferior to it to lateroinferior
margin of liver.
b. Others (rare).

Normal Size of Liver

Sonographic measurements along vertical (craniocaudal) axis:
a. Mid-clavicular line
< 13 cm = normal
13.0–15.5 cm = indeterminate (in 25% of patients)
> 15.5 cm = hepatomegaly (87% accuracy)
b. Preaortic line > 10 cm
c. Prerenal line > 14 cm

Normal Hemodynamics Parameters of Liver

Portal vein velocity: > 11 cm/sec
Congestion index (= cross-sectional area of portal vein divided by
average velocity): 0.070 ± 0.09
Hepatic artery resistive index: 0.60–0.64 ± 0.06
366 Differential Diagnosis in Radiology

Liver Function Tests

1. Alkaline phosphatase (AP)
Formation: Bone, liver, intestine and placenta
High increase: Cholestasis with extrahepatic biliary obstruction
(confirmed by rise in GT drugs, granulomatous disease,
sarcoidosis, primary biliary cirrhosis, primary + secondary
malignancy of liver.
Mild increase: All forms of liver disease, heart failure.
2. g-glutamyl transpeptidase (GGT)
Very sensitive in almost all forms of liver disease
Utility: Confirms hepatic source of elevated AP, may indicate
significant alcohol use.
3. Transaminases
High increase: Viral/toxin-induced acute hepatitis
a. Aspartate transaminase (AST); formerly serum glutamic
oxaloacetic transaminase (SGOT)
Formation: Liver, muscle, kidney, pancreas, RBCs
b. Alanine aminotransferase (ALT); formerly serum glutamic
pyruvic transaminase (SGPT)
Formation: Primarily in liver
• Rather specific elevation in liver disease.
4. Bilirubin
Helps differentiate between various causes of jaundice
a. Unconjugated/indirect bilirubin = insoluble in water
Formation: Breakdown of senescent RBCs
Metabolism: Tightly bound to albumin in vessels actively
taken up by liver, cannot be excreted by kidneys
b. Conjugated/direct bilirubin = water-soluble
Formation: Conjugation in liver cells
Metabolism: Excretion into bile; not reabsorbed by intestinal
mucosa + excreted in feces
Elevation:
– Overproduction: Hemolytic anemia, resorption hema-
toma, multiple transfusions
– Decreased hepatic uptake: Drugs, sepsis
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 367
– Decreased conjugation: Gilbert syndrome, neonatal
jaundice, hepatitis, cirrhosis and sepsis
– Decreased excretion into bile: Hepatitis cirrhosis,
drug-induced cholestasis, sepsis, extrahepatic biliary
obstruction.
5. Lactic dehydrogenase (LDH)
Non-specific and, therefore, not helpful
High increase: Primary or metastatic liver involvement
6. Alpha fetoprotein (AFP)
> 400 ng/mL: Strongly suggests that focal mass represents a
hepatocellular carcinoma.

Normal Size of Bile Ducts

• CBD at point of maximum diameter:
≤ 5 mm = normal; 6–7 mm = equivocal; ≥ 8 mm = dilated
• CHD at porta hepatis + CBD in head of pancreas: 5 mm
• Right intrahepatic duct just proximal to CHD: 2–3 mm
• CHD at porta hepatis + CBD in head of pancreas: 5 mm
• Right intrahepatic duct just proximal to CHD: 2–3 mm
• Cystic duct diameter: 1.8 mm
Average length of 1–2 cm
Distal cystic duct posterior to CBD (in 95%), anterior to CBD (in
5%).

Bile Duct Variants

Incidence
2.4% of autopsies;
13% of operative cholangiograms.
A. Aberrant intrahepatic duct
May join CHD, CBD, cystic duct, right hepatic duct and
gallbladder
– Anomalous right hepatic duct entering CHD/cystic duct
(4-5%)
368 Differential Diagnosis in Radiology
Complications:
1. Postoperative bile leak, if severed
2. Segmental biliary obstruction, if ligated
B. Cystic duct entering right hepatic duct
C. Ducts of luschka
• Small ducts from hepatic bed draining directly into the
gallbladder
D. Duplication of cystic duct/CBD
E. Congenital tracheobiliary fistula.
• Fistulous communication between carina and left hepatic
duct
• Infants with respiratory distress
• Productive cough with bilious sputum
√ Pneumobilia

Pancreaticobiliary Junction Variants

A. Angle between CBD + pancreatic duct:
a. Usually acute at 5°–30°
b. Occasionally abnormal at up to 90°
B. Sphincter of Oddi
• Muscle fibers encircling the CBD + pancreatic duct at
choledochoduodenal junction.
a. Choledochal sphincter = encircles distal CBD
b. Pancreatic duct sphincter (in 33% separate)
C. Types of union between CBD + pancreatic duct:
a. 2–10 (mean 5) mm short common channel (85%) with a
diameter of 3–5 mm
b. Separate entrances into duodenum
c. 8–15 mm long common channel
d. Pancreatic duct inserting into CBD > 15 mm from entrance
into duodenum
e. CBD inserting into pancreatic duct.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 369
CONGENITAL GALLBLADDER ANOMALIES

Agenesis of Gallbladder

Incidence
0.04–0.07% (autopsy)

Associated with:
Common: Rectovaginal fistula, imperforate anus, hypoplasia of
scapula + radius, intracardiac shunt.
Rare: Absence of corpus callosum, microcephaly, atresia of
external auditory canal, tricuspid atresia, TE fistula, dextroposition
of pancreas + esophagus, absent spleen, high position of cecum
and polycystic kidney.

Hypoplastic Gallbladder
a. Congenital
b. Associated with cystic fibrosis

Septations of Gallbladder
A. Longitudinal septa
1. Duplication of gallbladder
= Two separate lumens + two cystic ducts
Incidence: 1:3,000 to 1:12,000
2. Bifid gallbladder = double gallbladder
= Two separate lumens with one cystic duct
3. Triple gallbladder (extremely rare)
B. Transverse septa
1. Isolated transverse septum
2. Phrygian cap (2–6% of population)
= Kinking/folding of fundus ± septum
3. Multiseptated gallbladder (rare)
= Multiple cyst-like compartments connected by small
pores
370 Differential Diagnosis in Radiology
Cx: Stasis + stone formation
C. Gallbladder Diverticulum
= Persistence of cystohepatic duct.

Gallbladder Ectopia

Most frequent locations

(1) beneath the left lobe of the liver > (2) intrahepatic > (3) retrohepatic

Rare locations
(1) within falciform ligament (2) within interlobar fissure
(3) suprahepatic (lodged between superior surface of right hepatic
lobe + anterior chest wall) (4) within anterior abdominal wall
(5) transverse mesocolon (6) retrorenal (7) near posterior spine +
IVC (8) intrathoracic gallbladder (Inversion of liver).
Associated with: eventration of diaphragm
“Floating GB”
= gallbladder with loose peritoneal reflections, may herniate
through foramen of Winslow into lesser sac
“Torqued GB”
= results in hydrops.

Pancreas

Pancreatic development and anatomy

A. Dorsal anlage (in mesoduodenum)
Origin: Arises from dorsal wall of duodenum
– Forms cranial portion of head + isthmus + body + tail of
pancreas
– Prone to atrophy (poor in polypeptides)
√ Drains to the minor papilla through accessory duct of
Santorini.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 371
B. Ventral anlage (below primordial liver bud)
Origin: Ventral bud arises from ventral wall of duodenum
and is composed of right + left lobes (the left ventral
bud regresses completely), migrates to opposite side of
duodenum + fuses with dorsal anlage during sixth week
GA
– Forms caudal portion of the pancreatic head + uncinate
process + CBD
– Not prone to atrophy (rich in polypeptides)
√ The ventral duct of Wirsung drains with the CBD through am-
pulla of Vater and becomes the major drainage pathway for
the entire pancreas after fusion with the duct of Santorini.
C. Main pancreatic duct of Wirsung distal portion of dorsal duct
connects with ventral duct; proximal portion of dorsal duct
may disappear.
D. Accessory pancreatic duct of Santorini
= Proximal portion of dorsal duct which has not atrophied.
E. Ampulla of Vater
= Space within medial wall of second portion of duodenum
below surface of papilla of Vater.
F. Major duodenal papilla = Papilla of Vater
– Drainage of common bile duct in 100%
– Drainage of main pancreatic duct of Wirsung in 90%.
G. Minor duodenal papilla (Present in 60%)
– Drainage of accessory pancreatic duct of Santorini
– Drainage of main pancreatic duct in 10%
– Located a few cm orad to papilla of Vater.

Spleen
A. Normal size
In adults : 12 cm length, 7–8 cm anteroposterior
diameter, 3–4 cm thick; splenic index (L × W ×
H) of < 480
In children : Formula for length = 5.7 + 0.31 × age (in years)
B. Normal weight 150 (100–265) g
Estimated weight = Splenic index × 0.55
372 Differential Diagnosis in Radiology
C. CT attenuation
a. Without enhancement:
40–60 HU; 5–10 HU less than liver
b. With enhancement:
Normal heterogenous enhancement during parenchymal
phase after bolus injection (due to varying blood flow rates
through the cords of the red pulp).
D. MR signal intensity
a. on T1WI: liver > spleen > muscle
b. on T2WI: spleen > liver

Iron Metabolism
Total body iron: 5 g
a. Functional iron: 4 g
Location: Hemoglobin of RBCs, myoglobin of muscle,
various enzymes
b. Stored iron: 1 g
Location: Hepatocytes, reticuloendothelial cells of liver
(Kupffer cells) + spleen + bone marrow
Absorption: 1–2 mg/day through gut
Transport: Bound to transferrin intravascularly

Deposition
a. Transferrin-transfer to: hepatocytes, RBC precursors in erythron,
parenchymal tissues (e.g. muscle)
b. Phagocytosis by:
Reticuloendothelial cells phagocytize senescent erythrocytes
(= extravascular hemolysis); RBC iron stored as ferritin/released
and bound to transferrin.

5.82  INFLAMMATORY BOWEL DISEASE (IBD)

• The term IBD encompasses two forms of chronic, idiopathic,
intestinal inflammation—Ulcerative colitis and Crohn’s disease
• Unknown Etiology
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 373
• Ulcerative Colitis
– Diffuse inflammatory disease of unknown etiology.
– Involves primarily the colorectal mucosa.

Epidemiology
• More common than Crohn’s disease.
• Steady incidence (2–10/100,000)
• Bimodal age distribution
Peak – 15–25 years
– 50–80 years (smaller)
• Risk factors
– White –2–5 *risk
– Jewish –2–4 *risk
– Developed country
– Urban dweller
– Family H/o –30–100 *risk
– Sibling –(8.8% incidence)
– Single
– Non-smoker
– Unknown

Etiology and Pathogenesis

• Speculations
• Genetic and familial factors:
– Familial aggregation, increased frequency in monozygotic
twins
• Polygenes
• HLA—B5, BW—52, DR2
• Association with autoimmune disorder—sacroiliitis, ankylosing
spondylitis, enteropathic oligoarthritis, anterior uveitis
• Anatomic and physiological factors: Abnormal mucin
production
• Infectious factors: Chlamydia, mycobacteria, gut anerobes,
CMV, Yersinia and bacterial cell wall components have all been
proposed
374 Differential Diagnosis in Radiology
• Enteric nervous system and gut hormones: sub P and VIP =
increased release
• Psychological and stress factors: personality (neurotic,
introverts)
• Chemical mediators: Pro-inflammatory cytokines = IL-1
increased
• Environmental factors:
– Smoking: Protective
– Oral contraceptives: Increased incidence.

Diet
Cow’s milk protein, lactose intolerance, chemical food additives—
carrageenan.

Clinical findings
Variable in clinical course; waxes and wanes.
• Acute exacerbations of bloody diarrhea
• M/C clinical features—diarrhea, abdominal pain, rectal
bleeding, weight loss, tenesmus
• Vomiting, fever, constipation, arthralgias = less common.

Radiologic findings
• Plain film
– Colonic fecal residue: distal extent of fecal residue gives an
indication of the proximal extent of the colitis.
– Mucosa
- Smooth
- Granular irregular fuzzy, if ulceration = disrupted
- Intramural gas/pneumatosis
– Haustrations
- Widening of haustral cleft with loss of parallel line.
– Diameter
- Upper limit of N— 5.5 cm
= Other associated abnormalities like—Renal calculi,
sacroilitis, ankylosing spondylitis, AVN of femoral head.
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 375
– Mural thickness
- > 3 mm
= Barium enema
- To confirm clinical diagnosis
- To assess the extent and severity of disease
- To differentiate ulcerative colitis from Crohn’s disease
and other colitides
- To follow the course of disease
- To detect complications.

Findings

Acute Changes
• Mucosal granularity
– Hyperemia and accumulation of inflammatory cells in
mucosa and gradual transition.
Abnormality in quality and quantity of mucus.
• Mucosal stippling
– Due to crypt microabscesses which rupture into lumen,
cause ulcers and barium flecks to adhere.
• Collar button ulcers = crypt abscess breach the lamina propria
and muscularis mucosae and undermine submucosa
• Haustral thickening or loss = edema
• Inflammatory polyps
• Contiguous, confluent, circumferential disease.

Chronic Changes
• Haustral loss:
– Alteration in tone of the taeniae, which are relaxed
– Colonic shortening due to massive hypertrophy and
fixed shortening of muscularis mucosae (contraction)
foreshortening of the colon.
• Luminal narrowing:
– Benign strictures seen in 10% of patients
– Smooth tapering, rarely cause obstruction.
376 Differential Diagnosis in Radiology
• Sometimes reversible, usually in distal colon
• If irreversible, and located in proximal colon = suspicion of
malignancy
• Widening of presacral space
– 1–1.5 cm moderate increase
- Mural thickening due to proliferation, inflammation
and infiltration of perirectal fat.
– > 1.5 cm definitely abnormal
• Rectal value abnormality: N < 5 mm, S3-S4 level

Proctitis
• Fold thickness > 6.5 mm with or without increased presacral
space
• Absent fold with increased presacral space = absent fold with
normal presacral space = normal variant
• Backlash ilitis:
– Patulous and fixed ileocecal value that easily refluxes
with persistent dilatation of terminal ileum.
– Absent normal fold pattern with granular mucosa.
• Postinflammatory pseudopolyps.

Ultrasound
• Moderately thick hypoechoic wall
• Typical wall stratification maintained
• If extensive pseudopolyposis = wall stratification may be lost
• Loss of haustra.

Computed Tomography
• Mural thickening
• Target appearance of wall
– Due to submucosal edema (acute)
– Due to fat proliferation (chronic)
• Rectal narrowing and widening of presacral space are hallmarks
of chronic UC
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 377
• When sufficiently large, pseudopolyps can be identified on CT
• Mural thickening, unsuspected perforations and pneumatosis
can be identified on CT in patients with toxic megacolon.

MRI
• Can identify mural stratification
• Thickening and abnormal hypointensity of mucosa on T1 and
T2 WI
• Degree of mural enhancement correlates well with disease
severity (on fat suppressed gradient echo).

Scintigraphy
• Ga-67 citrate
• Indium-labelled leukocytes
• Useful when there is danger of bowel perforation and extent
and degree of disease activity must be assessed
• FDG-PET.

Prognosis
• Most patients = Mild to moderate disease
• 15 to 25% require colectomy
• Mortality
– In first 2 years of disease in > 40 years old patents
– 1/3rd colonic disease
– 1/3rd complication
– 1/3rd unrelated cause

Crohn’s Disease
• Chronic cicatrizing disorders of the alimentary tract,
characterized by granulomatous inflammation of the mucosa,
bowel wall and surrounding mesentery
• Any part of alimentary tract
• Terminal ileum and proximal colon most common site
378 Differential Diagnosis in Radiology

Epidemiology
• Uncommon disorder
• Increasing in incidence
• Bimodal age distribution—
Peak—15–25 years.
Smaller peak—50–80 years.

Risk factors
• White race
• Jewish (8-fold increase)
• Urban
• Family history positive
• Sibling with disease (30-fold increase)
• Single
• Oral contraceptive use
• Smoking (4-fold increase)
• Season (highest relapse rate autumn and winter, lowest in
summer).

Pathogenesis and Etiology

• Unknown etiology
• Genetic, environmental, infection, immunological and
psychological factors
• Increased PAF, PG and LT
• Failure of suppressor T-cell generation, coupled with
hyperactive state of helper T-cells.
• Defect in mucosal permeability = absorption of complex sugars
and macromolecules.
• Increased deposition of type-5 collagen.

Clinical features
Rectal bleeding, diarrhea, abdominal pain.
• Two type—colicky pain in lower abdomen relieved by defecation,
severe pain in right lower quadrant simulating appendicitis
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 379
• Abscess, fistula, perianal lesion
O/E—pallor, dehydration, anemia, weight loss, clubbing,
abdominal distension, tachycardia and fever
• Abdominal, tenderness, profound wasting and emaciation
• Palpable intra-abdominal mass.

Radiologic Findings

Plain film
• When confined to colon—plain film features are similar to
ulcerative colitis.
• An extended gas-filled stricture is suggestive of granulomatous
colitis.
• Small bowel obstruction.
• Evidence of—nephrolithiasis, gallstones, ankylosing
spondylitis, sacroilitis, avascular necrosis of femoral head.

Barium examination
For evaluation of small bowel, enteroclysis should be the method
of choice for the following indications:
• To demonstrate early changes
• To demonstrate the full extent and possible presence of skip
lesions, if surgery is contemplated
• To determine the cause of any clinical deterioration in previously
stable patient
• To distinguish between spasm, active stenotic disease and a
fibrous stricture
• To investigate postoperative complications of Crohn’s disease
• To definitively rule out the presence of Crohn’s disease in small
bowel
• A fluoroscopic small bowel barium meal followthrough is
adequate
• As a follow-up study in clinically stable patients with known
small bowel Crohn’s disease.
380 Differential Diagnosis in Radiology
• To investigate patients with Crohn’s disease know to involve
predominantly terminal ileum (with pneumocolon)
• To investigate possible recurrence of Crohn’s disease in the
neo-terminal ileum after ileo-cecal resection
• In patients with ileostomy—retrograde small bowel enema
is recommended for the demonstration of more distal small
bowel loops.
Early disease:
– Smooth symmetric fold thickening (obstructive
lymphedema of sub-mucosa)
– Coarse villous pattern (thickened adherent villi)
– Hyperplasia of lymphoid follicles with aphthoid ulcers.
– Shallow mucosal erosions, 1–3 mm, surrounded by small
halo of edema.

Intermediate disease
• Progressive submucosal edema with widening of base of fold
with partial or complete obliteration
• Variable submucosal infiltrate with patchy fibrosis = distortion
and interruption of fold
• Enlargement and deepening of aphthoid ulcers
• Stellate or rose-thorn appearance
• May fuse—crescenteric or linear
Typical—Long linear ulcer on mesenteric border
• Thickening, sclerosis and retraction of mesentery = straightened
mesenteric border, with redundant anti­mesenteric border
• Localized mucosal thickening or inflammatory polyps, Nodular
pattern of Crohn’s disease. (Inflammatory infiltrate with patchy
profound edema and granulation tissue).

Advanced disease
• Deep linear clefts of ulcers or fissures, axial and transaxial
fissuring
• Pseudopolyps ulceronodular or cobblestone pattern
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 381
• Antimesenteric redundancy of bowel wall disappears with
transaxial extension of ulceration
• Bowel wall thickening with inflammation and fibrosis
• Fat wrapping = Hypertrophied sub-peritoneum is tethered
towards the bowel wall by mesenteric perivascular fibrosis =
spiral CT may show parallel thickened vessels traversing this
(comb sign).
Barium enema
Early findings Late findings
• Nodular lymphoid hyperplasia • Fissures
• Aphthoid ulceration • Fibrosis
• Deep ulceration/confluent • Haustral loss
ulceration • Sacculations
• Cobblestone appearance • Postinflammatory
• Asymmetric, involvement • Pseudopolyps
• Segmental distribution • Intramural abscess
• Skip lesions stricture
• Inflammatory pseudopolyps

Anorectal disease
Fissures ulcer, abscess, fistulae, hemorrhoids.

Computed Tomography (CT)

• Bowel wall thickening
• During acute non-cicatrizing phase = stratification is maintained
—with target or double halo appearance
• With long-standing disease—transmural fibrosis—loss of
stratification
• CT may reveal—fibrofatty proliferation with creeping fat
of mesentery. Stranding of fat, lymph node in mesentery,
hypervascularity with perivascular fibrosis—comb sign
(vascular jejunization of the ileum)
• Phlegmon, abscess
382 Differential Diagnosis in Radiology

Ultrasonography (USG)
TRUS (Transrectal ultrasound)
• Mural thickening is >4 mm—loss of stratification
• Perianal and perirectal abscesses, fistulas
• Heterogeneity of the anal sphincter.

Transabdominal Ultrasound
• Thickening of colonic and small bowel wall (target or bull’s eye
appearance)
• Loss of haustrations
• Absent peristalsis
• Increase blood flow in SMA with decreased RI
• Diminished compressibility.

Magnetic Resonance Imaging (MRI)

• Can show extent and severity of inflammatory change
• Detection of perianal and perirectal fistula, sinus tracts and
abscesses.

Extraintestinal Complications of Inflammatory Bowel

Disease (IBD)
• Hepatobiliary
– Steatosis
– Cholelithiasis—impaired enterohepatic circulation of bile
salts
• Sclerosing cholangitis
– Fibrous mural thickening of bile ducts
– Focal clustering of intrahepatic (IH) ducts
– Discontinuous areas of intrahepatic (IH) biliary dilatation
without hepatic, porta hepatis or pancreatic masses.
• Cholangiography—beading, pruning
• Cholangiocarcinoma
 Abdomen and Gastrointestinal Tract and Hepatobiliary System 383
• Secondary biliary cirrhosis
• Liver abscess
• Pancreatitis

Urinary tract complications

• Nephrolithiasis—oxalate calculi
• Hydronephrosis
• Fistulas—enterovesical
• Musculoskeletal
– Arthropathy
- Ankylosing spondylitis
- Sacroiliitis
- Avascular necrosis of femoral head
- Osteomyelitis, septic arthritis
- Osteoporosis
- Psoas abscess
• Pulmonary complication
– Serositis
– ILD (interstitial lung disease)
– Bronchiolitis/Bronchiectasis/chronic bronchitis
- Necrobiotic nodules.
CHAPTER 6

Skeletal System
and Joints

6.1  ABNORMAL SKELETAL MATURATION

Skeletal Maturation Disorders

Retarded
1. Chronic ill health
– Congenital cardiac disorders.
– Chronic renal failure.
– Inflammatory bowel disease.
– Malnutrition including rickets.
– Maternal deprivation.
2. Chromosomal disorders
– Down’s syndrome.
– Turner’s syndrome.
– Trisomy 18, etc.
– Noonan syndrome.
– Prader-Willi syndrome.
3. Endocrinal disorders
– Hypothyroidism.
– Hypogonadism.
– Hypopituitarism.
– Cushing’s disease and steroid therapy.
4. Congenital syndromes
– Bone dysplasias.
– Malformation syndromes.
5. Miscellaneous
– Extreme emotional deprivation.
 Skeletal System and Joints 385
Accelerated
a. Localized
1. Local hyperemia secondary to inflammation/infection.
2. Trauma.
3. Vascular malformations (hemangioma/AVM)
4. Klippel-Trenaunay-Weber syndrome.
5. Maffucci syndrome.
6. Neurofibromatosis.
7. Macrodystrophia lipomatosa (Fig. 6.1)
b. Generalized
i. Endocrinal
– Idiopathic sexual precocity
– Hypothalamic masses
– Adrenal and gonadal tumors
– Hyperthyroidism

Fig. 6.1:  Anteroposterior radiograph of foot shows Macrodystrophia

lipomatosa involving 2nd and 3rd digits
386 Differential Diagnosis in Radiology
ii. Congenital
– McCune-Albright’s syndrome
– Cerebral gigantism
– Lipodystrophy
– Pseudohydrpoparathyroidism
– Weaver-Smith syndrome
– Marshall-Smith syndrome
iii. Miscellaneous
– Obesity in children.

Asymmetric
a. Localized Gigantism
Causes similar to localized accelerated maturation.
b. Localized Atrophy
1. Paralysis.
2. Radiation treatment in childhood.

Premature closure of growth plate

1. Localized hyperemia due to chronic inflammation as in
arthritides or infection, hemophilia.
2. Vascular malformation—AVM.
3. Trauma.
4. Radiation treatment during childhood.
5. Thermal injury—Burns and frostbite.
6. Multiple exostoses and enchondromatosis.
(Ollier’s disease)

6.2  SHORT LIMB SKELETAL DYSPLASIA

Rhizomelic
(Proximal Limb Shortening)
1. Achondroplasia
– Large skull with small base and sella and a small foramen
magnum.
 Skeletal System and Joints 387
– Short ribs with deep concavities to anterior ends.
– Decreased interpedicular distance caudally in lumbar
spine.
– Short pedicles with narrow lumbar canal.
– Posterior scalloping with anterior vertebral body beaking.
– Square iliac wings with champagne glass pelvic cavity.
– Rhizomelic micromelic with bowing of long bones (Fig. 6.2).
– Trident hands.
2. Hypochondroplasia
– Similar to achondroplasia except skull never affected.
– Height normal or mildly reduced.
3. Pseudochondroplasia
– Similar to achondroplasia.
– Except that skull is normal.
– No changes seen in first year of life.
4. Chondrodysplasia punctata
– Stippling in long bone epiphysis, spine or larynx.

Fig. 6.2:  Anteroposterior radiograph shows bowing of both

femurs with right relatively shorter than left
388 Differential Diagnosis in Radiology

Mesomelic
(Middle Segment Shortening)
1. Dyschondrosteosis
– Also known as Léri-Weill’s disease.
– Usually affects females.
– Madelung’s deformity.
– Medial aspect of proximal/distal tibia defective with or
without hypoplastic fibula.
2. Mesomelic dysplasia
– Type Langer.
– Type Reinhardt-Pfeiffer.

Acromesomelic
(Middle and Distal Segment Shortening)
1. Chondroectodermal dysplasia
– Also known as Ellis-van Creveld syndrome.
– Paired long bones are short with dome-shaped meta­
physes.
– Abnormal medial tibial plateau with defective epiphyses
laterally.
– Postaxial polysyndactyly.
– Carpal fusions seen esp. capitate and hamate with delayed
development of carpal bones.
– Partial/total absence of teeth.
– Abnormal hair and nails.
– Rib cage similar to asphyxiating thoracic dystrophy.
2. Acromesomelic dysplasia
3. Mesomelic dysplasia
– Type Nievergelt.
– Type Robinow.
– Type Werner.
 Skeletal System and Joints 389

Fig. 6.3:  Anteroposterior radiograph of foot shows polydactyly

Acromelic
(Distal Segment Shortening)
1. Asphyxiating Thoracic Dystrophy
– Also known as Jeune’s disease.
– Thorax is stenotic.
– Ribs are short and horizontal and clavicles are highly placed.
– Polydactyly (Fig. 6.3).
2. Peripheral Dysostoses

6.3  SHORT SPINE SKELETAL DYSPLASIA

Disease
1. Pseudoachondroplasia
Spinal abnormality besides short spine
– Platyspondyly with exaggerated grooves for ring
apophyses.
– C1 and C2 dislocation.
390 Differential Diagnosis in Radiology
Other features
– Short limbs.
– Marked joints laxity.
2. Spondylometaphyseal dysplasia
Like type Kozowski.
– Limb abnormalities besides spine involvement.
3. Spondyloepiphyseal dysplasia
a. Dominant variety.
– Congenita.
– Platyspondyly, maximal in thoracic spine.
Other features
– Severe tubular bone involvement.
– Retinal detachment common.
b. X-linked-tarda.
Spinal abnormality besides short spine
– Mounds of dense bone are found on superior and inferior
surfaces of the posterior part of vertebral endplates.
Other features
– Tubular bones minimally affected.
– Iliac wings are small.
– Hip degeneration frequently occurs prema­turely.
c. Recessive.
Spinal abnormality besides short limbs
– Generalized platyspondyly of least severity.
Other features
Nil
4. Diastrophic dwarfism
Spinal abnormality besides other limb abnormalities
– Interpedicular narrowing in lumbar spine.
– Progressive kyphoscoliosis.
Other features
– Delta-shaped epiphyses.
– Hitchhiker thumb.
5. Metatrophic dwarfism
Spinal abnormality besides limb abnormalities
– Hypoplastic odoentoid.
– Severe progressive scoliosis.
 Skeletal System and Joints 391
Other features
– Short limbs.
– Dumb-bell-shaped long bones.
6. Kniest syndrome
Spinal abnormality besides limb abnormalities
– Platyspondyly.
– Kyphoscoliosis.
– Interpedicular narrowing of lumbar spine.
Other features
– Dumb-bell-shaped long bones.
– Irregular epiphyses.
– Limited and painful joint movements.

6.4  LETHAL NEONATAL DYSPLASIA

1. Osteogenesis imperfecta
Type II
– Lethal in utero/early infancy.
– Sclerae are dark blue.
– Bones are grossly demineralized with thin cortices.
– Numerous healed or healing rib fractures.
Type II A – Long bones are short, broad and bowed.
– Ribs are broad with continuous beading.
Type II B – Long bones as in Type II A.
– Ribs show less or no beading.
Type II C – Long bones are thinned and show
multiple fractures.
– Ribs are too thin and beaded.
– Skull is enlarged with numerous wormian bones; Mineralization
may be retarded.
2. Thanatophoric dwarfism
– Infants are stillborn or die immediately after birth.
Rhizomelic dwarfism with bowing of long bones.
– Metaphyses are irregular.
– Epiphyses of knee absent.
– Short, wide, metacarpals and phalanges.
392 Differential Diagnosis in Radiology
– Marked platyspondyly with ‘H-shaped’ vertebra on AP view
of spine.
– Poor mineralization of pelvic bones with small square iliac
blades.
– Clover leaf skull.
– Ribs are short and flared anteriorly.
3. Chondrodysplasia punctata
– Rhizomelic type (recessive) is lethal.
– Stippling or punctate calcification of tarsus and carpus,
long bone epiphyses, vertebral transverse processes and
pubic bones.
– Long bones show gross asymmetric shortening and
metaphyseal irregularity.
4. Asphyxiating thoracic dystrophy—Patients die in infancy from
respiratory distress.
– Thorax is stenotic.
– Ribs are short and horizontal.
– Clavicles are highly placed.
5. Campomelic dwarfism
– Long bones are bowed.
6. Achondrogenesis Type I and II
7. Short rib syndromes with or without polydactyly (Type I, II, III)
8. Homozygous achondroplasia
9. Hypophosphatasia—Gross general failure of ossification of
skeleton.

6.5  DUMB-BELL-SHAPED LONG BONES

1. Metatropic dwarfism—Short spine and short limb dwarfism.
2. Pseudochondroplasia—Short limb (Rhizomelic dwarfism).
3. Kniest syndrome—Short spine and short limb dwarfism.
4. Diastrophic dwarfism—Short spine and short limb dwarfism.
5. Osteogenesis imperfecta
Type III – Sclera blue at birth but usually normal in adolescence.
– Bones are demineralized.
– Vertebral compression and kyphoscoliosis.
 Skeletal System and Joints 393
– Long bone show multiple fracture and bowing.
– Sutures are wide with multiple wormian bones.
– Dentinogenesis imperfecta.
6. Chondroectodermal Dysplasia—Acromesomelic dwar­fism with
ectodermal dysplasia.

6.6  MUCOPOLYSACCHARIDOSES AND

MUCOLIPIDOSIS (FIG. 6.4)
• They are characterized by constellation of radiological
signs related to skeletal system and share some common
characteristics as:
a. Abnormal bone texture
b. Widening of diaphyses.
c. Tilting of distal radius and ulna towards each other.
d. Pointing of proximal ends of metacarpals.
e. Large skull with calvarial thickening.

Fig. 6.4: Appendicular skeleton

394 Differential Diagnosis in Radiology
f. Anterior beaking of upper lumbar vertebrae.
g. J-shaped sella.
h. Flared ilia.
i. Fragmented femoral ossific nucleus.

6.7 MUCOLIPIDOSES
1. Type I (Neuraminidase deficiency)
2. Type II (I-cell disease)
3. Type III (Pseudopolydystrophy of Maroteaux)

6.8  GENERALIZED OSTEOSCLEROSIS

Children
i. Dysplasias
– Osteopetrosis.
– Pyknodysostosis.
– Craniotubular dysplasia.
– Craniotubular hyperostoses.
ii. Metabolic
– Renal osteodystrophy.
iii. Poisoning
– Lead = Dense metaphyseal bands.
– Flask-shaped femora.
– Fluorosis = Thickened cortex with narrow medulla.
– Ossification of tendons, ligaments and interosseous
membranes.
– Hyper- = Dense metaphyseal bands.
vitaminosis D = Widened zone of provisional calcification.
– Soft tissue calcification.
– Hyper- = Subperiosteal new bone
vitaminosis A formation.
– Reduced metaphyseal density.
 Skeletal System and Joints 395
iv. Idiopathic
– Caffey’s disease.
– Idiopathic hypercalcemia of infancy.

Adults
i. Myeloproliferative
– Myelosclerosis.
– Marrow cavity narrowed by endosteal reaction.
– Patchy lucencies due to fibrous tissue.
ii. Metabolic
– Renal osteodystrophy.
iii. Poisoning
– Fluorosis.
– Similar as in children.
iv. Neoplastic
– Osteoblastic metastases (Figs 6.5A and B).

A B
Figs 6.5A and B: Anteroposterior and lateral radiographs of LS spine
show osteoblastic metastases
396 Differential Diagnosis in Radiology

Fig. 6.6: Paget’s disease: Early long-bone changes. Lateral view of the
humerus in a middle-aged man shows an “advancing wedge” (“blade of
grass” or “flame shadow”) appearance at the end of the bone, characteris-
tic of early Paget’s disease. Since the disease process generally proceeds
from one articular end of the long bone to the other, all three phases—
early, intermediate and late—may be seen in the same bone

– Lymphoma.
– Mastocytosis.
– Sclerosis of marrow with patchy areas of lucency.
v. Idiopathic
– Paget’s disease (Figs 6.6 to 6.8).
– Coarsened trabeculae.
– Bone expansion.

6.9  SCLEROTIC BONE LESIONS

Developmental
i. Single
a. Fibrous dysplasia.
b. Bone islands (Enostosis)
 Skeletal System and Joints 397

Fig. 6.7: Paget’s disease: Late long-bone changes. Lateral view of the
tibia shows anterior bowing secondary to late-phase

– Round/Oval dense lesion in medullary location with

radiating thorn-like spicules.
– Usually <15 mm.
– Grow up to skeletal maturity.
ii. Multiple
a. Bone islands.
b. Fibrous dysplasia.
– Cyst-like lesion in diaphysis or metaphysis with
endosteal scalloping +/– bone expansion with thick
sclerotic border (rind sign)
– Age = 3 to 15 years.
c. Osteopoikilosis/Osteopathia condensans disseminata
– Dense round/oval/Lanceolate lesion arranged parallel
to long-axis of bone.
398 Differential Diagnosis in Radiology

1.  Osteoporosis circumscripta 2.  Basilar invagination

3.  Advancing wedge

Fig. 6.8: Progression of Paget’s disease: a, c and e early (osteolytic) “hot”

phase and b, d and f late (osteoblastic) “cold” phase manifestations of
Paget’s disease in (a, b) the skull, (c, d) vertebrae, and (e, f) long bones,
a. Osteoporosis circumscripta, b. “Cotton-wool” appearance. c. Biconcave
vertebra. d. “Picture frame” ivory vertebra. e. “Flame,” “blade of grass”
deformities. f. Dense, larger diameter deformities
 Skeletal System and Joints 399

Fig. 6.9: Osteoid osteoma. The frontal projection shows an enlarged,

dense right pedicle (3) and pars interarticularis (5), characteristic of oste-
oid osteoma (compare with normal pedicle on left (4 & 6).

Fig. 6.10: Osteoid osteoma

400 Differential Diagnosis in Radiology
– Seen usually at ends of long bones and around joints; in
the carpus and tarsus.
– No interval change.
d. Osteopathia striata/voorhoeve’s disease
Sclerotic striations in long bones parallel to long-axis
affecting both diaphysis and metaphyses.
e. Tuberous sclerosis
– Patchy, sclerotic lesions in skull, vertebrae, pelvis and long
bones with irregular periosteal new bone formation.

Vascular
• Bone infarcts
(Single/Multiple).
• In sickle cell anemia.
– Sclerotic lesions in femoral or humeral head in medullary
bone.
– Sharply-defined or ill-defined diffuse sclerosis.

Traumatic
• Callus (Single/multiple fracture sites)

Infective
• Sclerosing osteomyelitis of Garré.
– Localized gross sclerosis in absence of apparent bone
destruction.

Idiopathic
• Paget’s disease.
(Single/Multiple).
– Coarsened trabeculae, cortical thickening and bone
expansion.
– Encroachment of medullary cavity with epiphyseal
involvement as well.
– “Cotton-Wool spots” in skull.
 Skeletal System and Joints 401
Neoplastic
i. Single
a. Metastases.
b. Lymphoma. (De novo or after RT of a lytic lesion)
c. Osteoma.
– Usually skull, PNS and mandible.
d. Ivory or dense type; spongy or trabeculated type.
Broad-based with smooth well-defined margins.
e. Osteoid osteoma (Figs 6.9 and 6.10)
– Round/oval radiolucent lesion with dense surrounding
sclerosis with a central nidus <1 cm.
– Lesion sited in relation to cortical bone with dense
scleroses extending into medullary cavity as well.
f. Osteoblastoma
– Similar to osteoid osteoma but central radiolucency is
larger, approx. 2–10 cm in diameter.
g. Primary bone sarcoma
– Commonest being osteosarcoma.
– Wide zone of transition with periosteal reaction and
soft tissue extension.
– Healed/Healing benign or malignant bone lesions as
lytic areas following RT on CT, bone cyst, fibrous cortical
defect, etc.

A B

Figs 6.11A and B: (A) Nonossifying fibroma; (B) Osteoblastoma

402 Differential Diagnosis in Radiology
ii. Multiple
– Metastases.
– Lymphoma.
– Osteomas.
(Gardner’s syndrome).
– Osteomas, soft-tissue tumors, polyposis coli).
a. Mastocytosis
– Circumscribed areas of increased density due to thickening
of medullary trabeculae (Figs 6.11A and B).
– Coarsened appearance of bone with indistinct endosteum.
b. Multifocal osteosarcomas
– Multiple myeloma.
– in 2 to 3%.
c. Multiple healed/healing benign or malignant bone lesions.

6.10  BONE SCLEROSIS ASSOCIATED

WITH PERIOSTEAL REACTION

Traumatic
• Healing fractures with callus formation.

Neoplastic
• Metastases.
• Lymphoma.
• Osteoid osteoma/osteoblastoma.
• Osteosarcoma.
• Ewing’s sarcoma (Fig. 6.12).
• Chondrosarcoma.

Infective
• Osteomyelitis.
• Syphilis.
 Skeletal System and Joints 403
Idiopathic
i. Infantile cortical hyperostoses (Caffey’s disease)
– Age of onset is nine weeks.
– Marked periosteal proliferation and cortical thicken­ ing
beneath soft tissue swellings.
– Bones affected are mandible, ribs, scapula, ulna and any
other bone except phalanges and spine.
– In long bones, diaphysis is only involved.
ii. Melorheostosis/Leri’s disease
– Dense irregular bone running along cortex of long bone,
both externally and internally.
(Dripping candle wax appearance).
– Lower limbs are commonly involved.
– Lesions are segmental and unilateral in distribution.

6.11  SOLITARY SCLEROTIC

LESION WITH LUCENT CENTER

Neoplastic
i. Osteoid osteoma
– Central lucent center <1 cm.
ii. Osteoblastoma
– Central lucency
– 2–10 cm in diameter.

Infective
i. Brodie’s abscess
– Metaphyseal lytic lesion with surrounding sclerosis.
– Tunnelling toward epiphyseal plate is pathogno­monic.
ii. Granulomatous
(Syphilis, Tuberculosis).
404 Differential Diagnosis in Radiology

6.12  COARSE TRABECULAR PATTERN OF BONE

1. Paget’s disease
– Expansion of bone is associated.
2. Osteoporosis.
3. Osteomalacia.
4. Hemoglobinopathies
– Especially thalassemia
– Expansion of marrow cavity destroys medullary trabeculae.
5. Hemangioma
– Of vertebral bodies produces vertical coarse trabe­cular
pattern with slight expansion (caudry cloth appearance).
6. Renal osteodystrophy
– Associated sclerosis and subperiosteal bone formation is
evident.
7. Osteonecrosis
– Cystic defects with coarse trabecular pattern; perio­stitis
and increased bone density may be seen if infection is the
causative factor.
8. Fibrogenesis imperfecta ossium
– Obliteration of trabecular architecture with coarsen­ing of
remaining trabeculae.
9. Gaucher’s disease
– Associated with hypoplasia of vertebral bodies, thinning
of cortices of tubular bones and subperiosteal new bone
formation.
10. Neoplasms as chondromyxoid fibroma where new bone is
laid in pattern of coarse trabeculae.
 Skeletal System and Joints 405
6.13  RELATIONSHIP OF METASTATIC
LESIONS TO THE PRIMARY TUMORS
Location of primary tumor/variety of Characteristic of metastatic
primary tumor lesions
Lytic Blastic Mixed Expansile
1. Bronchogenic carcinoma 
2. Bronchogenic carcinoid 
3. Breast  
4. Gastric carcinoma  
5. Colon  (occa-
sionally)
6. Rectum 
7. Renal cell carcinoma 
8. Wilms’ tumor 
9. Bladder  
10. Prostate 
11. Thyroid 
12. Pheochromocytoma
13. Adrenal carcinoma 
14. Neuroblastoma 
15. Cervix  
(rarely)
16. Uterus 
17. Ovary 
18. Testes  
(rarely)
19. Squamous cell 
carcinoma of skin
20. Melanoma 
406 Differential Diagnosis in Radiology

Fig. 6.12: Ewing’s sarcoma. A permeative destructive lesion can be ob-

served in the diaphysis of the distal ulna. Fracture callus merges with a
“sunburst” periosteal reaction. The cortex on the radial aspect of the ulna
is destroyed by a soft-tissue mass growing out into the soft tissue. A short,
oblique pathologic fracture is also evident. Ewing’s sarcoma cannot be
differentiated radiologically from a nonHodgkin’s lymphoma. The latter oc-
curs in an older age group (third and fourth decades). Differentiation from
osteomyelitis can be difficult. However, unlike Ewing’s sarcoma, metaphy-
seal involvement is usually a prominent feature of childhood osteomyelitis
(See labelling on the next page in Figure 6.13)

6.14  CHILDHOOD TUMORS

METASTASIZING TO BONE (TABLE 6.13)
1. Neuroblastoma.
2. Leukemias and lymphoma.
3. Clear cell sarcoma
(Variant of Wilms’ tumor).
4. Rhabdomyosarcoma.
 Skeletal System and Joints 407

1.  Destructive lesion

2.  Soft-tissue mass
3.  Pathologic fracture
4.  Periosteal reaction
5.  Saucerization
6.  Well-organized periosteal reaction

Fig. 6.13: Ewing’s tumor

5. Retinoblastoma.
6. Ewing’s sarcoma (Figs 6.12 and 6.13).
7. Osteosarcoma.

6.15  BUBBLY BONE LESIONS

Neoplastic
Benign
1. GCT.
2. Angiomas.
3. Chondromyxoid fibroma (Figs 6.15 and 6.16).
4. Enchondroma (Fig. 6.14).
408 Differential Diagnosis in Radiology

Malignant
1. GCT.
2. Osteoblastoma.
3. Multiple myeloma.
4. Metastases (Kidney and thyroid).

Infection
1. Brodie’s abscess.
2. Coccidioidomycosis.
3. Echinococcus.

Endocrinal Fig. 6.14: Enchondroma

1. Hyperparathyroidism.

Fig. 6.15: Chondroblastoma Fig. 6.16: Chondromyxoid fibroma

 Skeletal System and Joints 409

Fig. 6.17: Aneurysmal bone cyst

Fig. 6.18: Scurvy

(a) Loss of epiphyseal density with a pencil-thin cortex (Wimberger’s
sign); (b) Dense zone of provisional calcification; (c) Metaphyseal lucen-
cy (Trummerfield zone); (d) Metaphyseal corner fracture—Pelken Spur;
(e) Subperiosteal hematoma
410 Differential Diagnosis in Radiology

Tumor-like lesions
1. Nonossifying fibroma (Fig. 6.11).
2. Aneurysmal bone cyst (Fig. 6.17).
3. Simple cyst.
Idiopathic
1. Histiocytosis X.
2. Fibrous dysplasia.

6.16  PRIMARY BONE TUMORS: CLINICAL FEA-

TURES, SITE OF PREDILECTION, RADIOLOGIC
PRESENTATION (FIGS 6.19 TO 6.27)

Fig. 6.19: Locations of tumors within a bone

 Skeletal System and Joints 411

Fig. 6.20: Patterns of bone destruction

A B C D E

Figs 6.21A to E: Types of periosteal reaction (A) Well-organized;

(B) Buttress; (C) Onion skin; (D) Codman’s triangle; and (E) Sunburst
412 Differential Diagnosis in Radiology

Fig. 6.22: Chondroblastoma Fig. 6.23: Chondromyxoid fibroma

Fig. 6.24: Osteochondroma (Exostosis)

 Skeletal System and Joints 413

Fig. 6.25: Non-ossifying fibroma (Fibrous cortical defect)

Fig. 6.26: Chondrosarcoma

414 Differential Diagnosis in Radiology

Fig. 6.27: Diaphyseal infarct. Lat-

eral view of the distal femur in a
50-year-old man shows a typical
diaphyseal infarct. This lesion,
which is remote from the knee
joint, was asymptomatic. The ab-
sence of punctate calcifications
and lobular margins differentiates
a bone infarct from an enchon-
droma

6.17  RADIOLOGIC CHARACTERISTICS OF

BENIGN AND MALIGNANT BONE LESIONS

Benign Malignant
1. Margination Well-defined Destructive, poorly-defined
2. Border Sclerotic Infiltrating
3. Periosteal reaction Less aggressive More aggressive
4. Zone of transition Narrow Wide
5. Soft tissue mass Absent Present

6.18  SUBARTICULAR LYTIC BONE LESION

Arthritides (Figs 6.28 to 6.38)

1. Osteoarthritis
– Marginal osteophytes.
– Subchondral sclerosis.
– Reduced joint space.
– Multiple cysts in load-bearing regions.
 Skeletal System and Joints 415

Fig. 6.28: Diarthrodial joint with neuropathic arthritis

Fig. 6.29: Diarthrodial joint in lupus erythematosus

416 Differential Diagnosis in Radiology
Fig. 6.30: Reiter’s syndrome.
Dorsiplantar projection of the
foot shows marked resorption
of the proximal side of the inter-
phalangeal joint of the great toe
resulting in a “mortar-and-pes-
tle” or “pencil-in-cup” deformity.
Also note the resorption at the
distal interphalangeal joint of
the fourth toe, fusion of the dis-
tal interphalangeal joint of the
fifth toe, and marginal erosion
at the proximal interphalangeal
joint of the fifth toe. Involvement
of the distal interphalangeal
joints is not uncommon in the
arthritis of Reiter’s syndrome

Fig. 6.31: Rheumatoid arthritis. Anteroposterior projection of the hips

shows concentric narrowing of both the hip joints with axial migration of
the femoral heads resulting in protrusio acetabulum (i.e. the medial wall of
the acetabulum is medial to the iliopubic line). The intense sclerosis of the
left femoral head and left acetabulum indicates secondary osteoarthritis;
however, osteophytes are absent
 Skeletal System and Joints 417
2. Rheumatoid arthritis
– Cysts at/near the regions of capsular insertion.
– Joint space narrowing.
– Juxta-articular osteoporosis.
– No sclerosis.
3. Calcium pyrophosphate arthropathy
– More collapsed and fragmented articular surface.
– Cysts larger than osteoarthritis.
– Rest similar changes as in osteoarthritis.
4. Gout
– Punched-out erosions with overhanging edge with adja-
cent soft tissue masses.
5. Hemophilia
– Erosions and subchondral cyst with periarticular osteopo-
rosis with preserved joint space until late in disease.

Neoplastic
1. Metastases/multiple myeloma.
2. Aneurysmal bone cyst.
3. GCT.
4. Chondroblastoma.
5. Pigmented villonodular synovitis.
– Mainly lower limbs especially knees.
– Soft tissue mass.
– Cyst-like defects with sharp sclerotic margins.
– Joint space destruction.

Miscellaneous
1. Post-traumatic
Especially in carpal bones.
2. Osteonecrosis
– Associated sclerosis, collapse and fragmentation of
trabeculae.
– Preserved joint space.
418 Differential Diagnosis in Radiology

1.  Subcutaneous nodule 4.  Diffuse articular loss

2.  Marginal erosion 5.  Enthesopathy
3.  Synovial hypertrophy 6.  Tendon insertion
Fig. 6.32: Diarthrodial joint with rheumatoid arthritis

3. Tuberculosis
– Completely or partially epiphyseal or partly meta­physeal.
– No sclerosis.

6.19  OSTEOLYTIC DEFECT IN THE MEDULLA

Well-Defined
i. Non-expansile
a. Marginal sclerosis
• Unilocular
– Geode (associated with arthritis).
– Healing benign/malignant osseous lesion.
– Brodie’s abscess.
 Skeletal System and Joints 419

Fig. 6.33: Osteoarthritis of spine. Lateral tomogram of an old woman

shows advanced degenerative change in the posterior apophyseal (facet)
joints of the lumbar spine. Hypertrophic bone encroaches on the central
spinal canal. Also note the spondylolisthesis at L4-L5, with calcification
in the outer fibers of the annulus fibrosus at this level. The intervertebral
discs are relatively well-maintained. Note that the spinal apophyseal (fac-
et) joints are synovial joints which may undergo degenerative change. The
resulting sclerosis and hypertrophic bone may encroach upon the central
spinal canal and produce a secondary form of spinal stenosis, as in this
patient

– Simple bone cyst.

– Enchondroma.
– Chondroblastoma.
– Fibrous dysplasia.
• Multilocular
– Fibrous dysplasia.
– Simple bone cyst.
b. No marginal sclerosis
– Metastases.
– Multiple myeloma.
420 Differential Diagnosis in Radiology

1. Synovium 3.  Articular cartilage

2.  Capsule 4.  Synovial fluid

Fig. 6.34: Normal diarthrodial joint

Fig. 6.35: Chronic tophaceous gout

 Skeletal System and Joints 421

1.  Joint-space narrowing 4.  Subchondral cyst

2.  Diffuse articular loss 5.  Subchondral sclerosis
3. Osteophytes

Fig. 6.36: Osteoarthritis of diarthrodial joint

– Eosinophilic granuloma.
– Brown tumor of hyperparathyroidism.
– Enchondroma.
– Chondroblastoma.
ii. Expansile
• Eccentric expansile
– Giant cell tumor.
– Aneurysmal bone cyst.
– Enchondroma.
– Non-ossifying fibroma.
– Chondromyxoid fibroma.
• Grossly expansile
– Malignant lesions.
– Metastases.
422 Differential Diagnosis in Radiology

Fig. 6.37: Diarthrodial joint with chronic tophaceous gout

– Plasmacytoma.
– Central chondrosarcoma.
– Telangiectatic osteosarcoma.
• Benign lesions
– Aneurysmal bone cyst.
– GCT.
– Enchondroma.
• Non-neoplastic
– Fibrous dysplasia.
– Hemophilic pseudotumor.
– Brown tumor of hyperparathyroidism.
– Hydatid disease.

Ill-defined
i. Without periosteal reaction
• Nonexpansile (Figs 6.38A and B)
 Skeletal System and Joints 423

A B
Figs 6.38A and B: Anteroposterior and lateral radiographs of lower
thigh shows nonHodgkin’s lymphoma of femur

– Metastases.
– Multiple myeloma.
– Hemangioma.
– Lymphoma.
– Malignant fibrous histiocytoma.
• Expansile
– Chondrosarcoma.
– Giant cell tumor.
– Metastases from kidney/thyroid.
– Fibrosarcoma.
ii. With periosteal reaction
– Osteomyelitis (Fig. 6.39).
– Ewing’s sarcoma.
– Osteosarcoma.
424 Differential Diagnosis in Radiology

6.20  LUCENT BONE LESION

CONTAINING BONE/CALCIUM

Neoplastic
1. Metastases, especially breast.
2. Chondroid lesions.
• Benign
– Enchondroma.
– Chondroblastoma.
– Chondromyxoid fibroma.
• Malignant
– Chondrosarcoma.
3. Osteoid lesions
• Benign
– Osteoid osteoma.
– Osteoblastoma.
• Malignant
– Osteosarcoma. Fig. 6.39: Anteroposte-
4. Fibrous tissue lesions rior radiograph of knee
• Malignant joint region shows chronic
– Fibrosarcoma. osteomyelitis of lower end
– Malignant fibrous of femur with sequestrum
formation
histiocytoma.

Miscellaneous
– Fibrous dysplasia.
– Osteoporosis circumscripta
(Paget’s disease).
– Avascular necrosis/infarction of bone.
– Osteomyelitis with sequestrum (Fig. 6.39).
– Eosinophilic granuloma.
– Intraosseous lipoma.
 Skeletal System and Joints 425

Fig. 6.40: Giant cell tumor Fig. 6.41: Nonossifying

fibroma

Fig. 6.42: Osteochondroma

(Exostosis)
426 Differential Diagnosis in Radiology

Fig. 6.43: Hemangioma of bone

Fig. 6.44: Osteosarcoma

6.21  COMMON LYTIC BONE LESIONS

With Marked Sclerosis

– Brodie’s abscess.
– Osteoblastoma.
– Osteoid osteoma.
– Stress fracture.
– Tuberculosis.
 Skeletal System and Joints 427
Multiple
– Fibrous dysplasia.
– Enchondroma.
– Eosinophilic granuloma.
– Metastases.
– Multiple myeloma.
– Brown tumors in hyperparathyroidism.

Seen in <30 years of age

– Chondroblastoma.
– Aneurysmal bone cyst.
– Infection.
– Non-ossifying fibroma (Fig. 6.41).
– Eosinophilic granuloma.
– Solitary bone cyst.

Seen on both sides of joint

– Synovioma.
– Angioma.
– Chondroid lesion.

6.22  LOCATION OF SOME COMMON

NEOPLASMS/LESIONS

Epiphysis
– Chondroblastoma.
– Giant cell tumor (Fig. 6.40).
– Intraosseous ganglion.

Metaphysis
– Nonossifying fibroma.
– Chondromyxoid fibroma.
428 Differential Diagnosis in Radiology

Fig. 6.45:  Anteroposterior radiograph of lower thigh shows osteochon-

droma arising from the lower end of femur

– Simple bone cyst.

– Osteochondroma (Fig. 6.45).
– Brodie’s abscess.
– Giant cell tumor.
– Osteosarcoma (Fig. 6.44).
– Chondrosarcoma.

Diaphysis
– Ewing’s sarcoma.
– Nonossifying fibroma.
– Simple bone cyst.
– Enchondroma.
– Fibrous dysplasia.
– Osteochondroma (Fig. 6.42).
 Skeletal System and Joints 429
6.23  SEPTATED BONE LESIONS

Lesions Type of septations

1. Aneurysmal bone cysts Delicate, horizontally-oriented
2. Chondromyxoid fibroma Coarse, thick
3. Giant cell tumor Delicate, thin
4. Hemangioma (Fig. 6.43) Striated, radiating
5. Nonossifying fibroma Lobulated

6.24  MOTH-EATEN BONE

Characterized by multiple, scattered lytic lesions of varying
sizes with no major central lesion, less well-defined/demarcated
lesional margin with larger zones of transition.
1. Neoplastic
1. Metastasis/multiple myeloma—including neuroblastoma
in child.
2. Leukemias/lymphomas.
3. Ewing’s sarcoma.
4. Osteosarcoma/chondrosarcoma.
5. Fibrosarcoma and malignant fibrous histiocytoma.
6. Histiocytosis X/Langerhans’ cell histiocytosis.
2. Infective
– Osteomyelitis.

6.25 OSTEOPENIA

Generalized (Fig. 6.46 and 6.47)

1. Osteoporosis (diminished osteoid production).
• In axial skeleton and appendicular skeleton.
– Decreased number and thickness of trabeculae.
– Cortical thinning.
430 Differential Diagnosis in Radiology

Fig. 6.46: Factors affecting resorption (Osteoclastic activity) and deposi-

tion (Osteoblastic activity) of calcium and phosphorus

– Juxta-articular osteopenia with trabecular bone pre-

dominance.
– Delayed fracture healing with poor callus forma­tion.
 Skeletal System and Joints 431

A B

Inset A Inset B

1. Medulla 5.  Spongiosa

2.  Cortex 6. Osteocytes
3.  Haversian canal 7. Marrow
4.  Lacunae with osteocytes

Fig. 6.47: Normal bone. Cross-sectional anatomy of normal adult bone in-
dicating osteocytes and their effect on bone metabolism. Inset A: Location
of osteocytes within the bone cortex. Inset B: Location of osteocytes within
the bone spongiosa. Note the conduits of metabolite transport within each
area: Haversian canals in the cortex and vascular marrow in the medulla

• In spine only.
– Diminished radiographic density.
– Increased vertical striations.
– Prominence of endplates.
– Picture framing and compression deformities with
protrusion of disks.
432 Differential Diagnosis in Radiology
a. Congenital
– Osteogenesis imperfecta.
– Turner’s syndrome.
– Homocystinuria.
– Neuromuscular disease.
– Mucopolysaccharidosis
– Trisomy 13 and 18.
– Pseudo- and pseudohypoparathyroidism.
– Glycogen storage disease.
– Progeria.
b. Idiopathic
– Juvenile : < 20 years.
– Adult : 20–40 years.
– Postmenopausal : > 50 years.
– Senile : > 60 years.
c. Miscellaneous
– Renal osteodystrophy.
– Disuse: immobilization.
– Collagen disease and rheumatoid arthritis.
– Bone marrow replacement by leukemia/lymphoma, multi-
ple myeloma/metastases.
– Drugs (Heparin, steroids, methotrexate, vitamin A)
– Radiation therapy.
d. Nutritional deficiency
– Scurvy (Fig. 6.49).
– PEM.
– Calcium deficiency (Fig. 6.48).
e. Endocrinopathy
– Hypogonadism.
– Cushing’s syndrome.
– Hyperthyroidism.
– Hyperparathyroidism.
– Acromegaly.
– Addison’s disease.
– Diabetes mellitus.
 Skeletal System and Joints 433

Fig. 6.48: Rickets

a. Widened growth plate; b. Fraying, splaying and cupping of metaphysis;
c. Thin bony spur; d. Indistinct cortex

Fig. 6.49: Scurvy; a Loss of epiphyseal density with pencil-thin cortex;

b. Dense zone of provisional calcification; c. Metaphyseal lucency; d. Pel-
ken spur; and e. Subperiosteal hematoma
434 Differential Diagnosis in Radiology
– Pregnancy.
– Mastocytosis.
2. Osteomalacia—Accumulation of excessive amounts of unca­­­­
lcified osteoid with bone softening (Fig. 6.50).
– Uniform osteopenia.
– Fuzzy indistinct trabecular detail of endosteal surface.
– Thin cortices of long bone.
– Coarsened, frayed trabe­culae decreased in number and size
– Bone deformity from softening
– Hourglass thorax
– Bowing of long bones
– Buckled/compressed pelvis
– Increased incidence of fractures, biconcave vertical
bodies
– Mottled skull and pseudofracture.

Fig. 6.50: Anteroposterior radiograph of pelvis shows pseudofracture

through ischiopubic rami and femoral neck on both sides in a case of
osteomalacia
 Skeletal System and Joints 435
Causes of Osteomalacia
• Dietary deficiency of vitamin D3 and lack of solar irradiation
• Deficiency of metabolism of vitamin D
– Chronic renal tubular disease
– Chronic administration of phenobarbitone
– Diphenylhydantoin
• Decreased absorption of vitamin D
– Malabsorption syndrome
– Partial gastrectomy
• Decreased deposition of calcium in bone
– Diphosphonates (Used for treatment of Paget’s disease)
3. Hyperparathyroidism—Increased bone resorption by osteoblasts.
Causes: Adenoma (commonest), hyperplasia, carcinoma, ectopic
hormone production, etc.
– Loss of fine trabeculae with ground glass appearance
– Subperiosteal bone resorption affecting radial side of mid-
dle phalanx of middle finger, medial proximal tibia, lateral
end of clavicle, symphysis pubis, ischial tubero­sity, medial
femoral neck, dorsum sellae, superior surface of ribs and
proximal humerus
– Cortical tunnelling producing ‘basketwork’ appearance and
‘pepper-pot’ skull
– Brown tumors in mandible, ribs, pelvis and femora
– Bone softening leading to basilar invagination, wedged or
codfish vertebra, triradiate pelvis and pathological fracture
– Soft tissue calcification
– Marginal erosion at DIP, ulnar side of base of little finger
metacarpal and hamate with normal joint space
– Chondrocalcinosis and periarticular calcification (Capsular
and tendinous).
4. Diffusely infiltrating bone disease
– For example: Multiple myeloma, leukemia, metastases.
436 Differential Diagnosis in Radiology

Localized/Regional
1. Disuse due to local immobilization secondary to fractures and
neuromuscular paralysis.
Pattern of bone loss:
– Uniform (commonest)
– Spotty (periarticular)
– Band-like (metaphyseal or subchondral)
– Endosteal cortical scalloping
– Linear cortical lucencies.
2. Sudeck’s atrophy (Reflex sympathetic dystrophy)
– Associated with post-traumatic/post-infective states, myo-
cardial infarction, calcific tendinitis, cervical spondylosis.
– Affects shoulder and hands.
– Disuse osteoporosis.
– Subperiosteal bone erosion.
– Small periarticular erosions.
3. Transient osteoporosis of hip
– Severe, progressive, osteoporosis of femoral head, neck
and acetabulum.
– Full recovery in six months.
4. Regional migratory osteoporosis
– Swelling and osteoporosis of joints of lower limbs.
– Migratory nature differentiates it from other causes.
5. Osteolytic tumor.
6. Lytic phase of Paget’s disease.
7. Inflammation—Rheumatoid arthritis, osteomyelitis, tuber­
culosis.
8. Early phase of bone infarct and hemorrhage.
9. Burns and frostbite.
 Skeletal System and Joints 437
6.26A  PERIOSTEAL REACTIONS—
TYPES AND CONDITIONS

Continuous
a. Cortex destroyed
1. Simple shell-like or expanded cortex.
2. Lobulated shell-like.
3. Ridged shell—trabeculated or soap-bubble-like.

Causes
– Giant cell tumor.
– Aneurysmal bone cyst.
– Enchondroma.
– Nonossifying fibroma.
– Chondromyxoid fibroma.
– Expansile metastases.
– Plasmacytoma.
– Central chondrosarcoma.
– Telangiectatic osteosarcoma.
– Fibrous dysplasia.
– Hemophilic pseudotumor.
– Brown tumor of hyperparathyroidism.
– Hydatid.
b. Intact cortex
1. Solid—even, uniform thickness >1 mm, persistent and
unchanged for weeks.

Patterns
– Thin—Eosinophilic granuloma, osteoid osteoma.
– Dense undulating—Vascular disease.
– Thin undulating—Pulmonary osteoarthropathy.
– Dense elliptical—Osteoid osteoma, long-standing malig-
nant disease.
– Cloaking—Storage disease, chronic infection.
438 Differential Diagnosis in Radiology
2. Unilamellar
– Osteomyelitis.
– Histiocytosis.
– Benign tumors.
– Healing fractures.
3. Multilamellar
– Osteomyelitis.
– Histiocytosis.
– Aneurysmal bone cyst.
– Ewing’s sarcoma.
– Osteosarcoma.
4. Parallel spiculated—Hair on end
– Ewing’s sarcoma.
– Osteosarcoma.
– Metastases.
– Thalassemia.
– Syphilis.
– Infantile cortical hyperostoses.

Interrupted
1. Buttressing.
– Solid periosteal bone is formed at lateral extraosseous
margin of growing bone lesion, e.g. Ewing’s sarcoma.
2. Codman’s triangle—Angular periosteal configuration with
underlying cortex.
E.g.: – Hemorrhage.
– Malignancy (osteosarcoma, Ewing’s sarcoma).
– Acute osteomyelitis.
– Fracture.
– Hemangioma.
3. Parallel or spiculated.
– Osteosarcoma.
– Ewing’s sarcoma.
– Chondrosarcoma.
– Fibrosarcoma.
 Skeletal System and Joints 439
– Leukemia.
– Metastases.
– Acute osteomyelitis.

Complex
1. Divergent spiculated.
“Sunray” appearance.
– Osteosarcoma.
– Metastases (Colorectal).
– Ewing’s sarcoma.
– Hemangioma.
– Meningioma.
– Tuberculosis.
– Tropical ulcer.
2. Combination types
– Ewing’s sarcoma.
– Osteosarcoma.

6.26B  TYPES OF PERIOSTEAL REACTIONS

Solitary and Localized

1. Traumatic.
2. Inflammatory/infective.
3. Neoplastic
– Benign.
– Malignant.

Bilateral Involvement
a. Symmetrical
1. Vascular insufficiency (Venous, lymphatic and arterial)
– Usually confined to lower limbs.
– Soft tissue swelling is seen.
– Solid, undulating periosteal reaction.
– Phleboliths seen in venous causes.
440 Differential Diagnosis in Radiology
2. Hypertrophic osteoarthropathy
– Periosteal reaction seen in metaphysis and diaphysis
of radius, ulna, tibia, fibula, less commonly femur and
humerus and bones of hands and feet.
– Thickness of periosteal reaction corresponds to the
duration of disease.
– Periarticular osteoporosis, soft tissue swelling and joint
effusions seen.
3. Pachydermoperiostosies (Fig. 6.51)
– Self-limited, familial condition, affecting boys at
puberty with predilection for blacks.
– Bones affected are radius and ulna, tibia, fibula mainly
followed by bones of hands and feet.
– Periosteal reaction is solid and spiculated and also
involves the epiphysis in addition to metaphysis and
diaphysis.

Fig. 6.51:  Anteroposterior radiograph of both the legs

showing features of Pachydermoperiostosis
 Skeletal System and Joints 441
4. Thyroid acropachy
– Solid, spiculated, lace-like periosteal reaction affecting
diaphysis of metacarpals and phalanges of hands and less
commonly of feet.
5. Fluorosis
Solid undulating periosteal reaction in long bones, flat
bone with osteosclerosis, ligamentous and intero­sseous
membranous-calcification.
b. Asymmetrical
1. Arthritides
– Rheumatoid arthritis
– Psoriatic arthropathy
2. Metastases
3. Disseminated osteomyelitis
4. Osteoporosis/osteomalacia
– Multiple fractures
5. Nonaccidental injuries
6. Bleeding diathesis
7. Hand foot syndrome (Sickle cell dactylitis)
8. Idiopathic
– Degenerative.

6.27  PERIOSTEAL REACTION IN CHILDHOOD

(FIGS 6.52A TO D)

Benign
1. Physiological
– Symmetrical involvement of diaphysis during the first six
months of life.
2. Battered child syndrome.
3. Infantile cortical hyperostoses (<6 months of age)
– Mandible, clavicles and ribs usually affected.
4. Hypervitaminosis A.
5. Scurvy/rickets.
6. Osteogenesis imperfecta.
7. Congenital syphilis
– Usually diaphyseal.
442 Differential Diagnosis in Radiology
8. Drugs like Prostaglandins E1 to treat ductus-dependent CHD.
9. Eosinophilic granuloma.
10. Osteomyelitis/trauma.
11. Sickle cell disease.
12. Kinky hair syndrome.
13. Juvenile chronic arthritis.
– Bilaterally symmetrical in the periarticular regions of
phalanges, metacarpals and metatarsals.

Malignant
1. Multicentric osteosarcoma.
2. Metastases from neuroblastoma and retinoblastoma.
3. Acute leukemia.
4. Ewing’s sarcoma.

Fig. 6.52A: Routes of bone invasion: In hematogenous osteomyelitis,

organisms gain access to bone via the nutrient arteries, which are most
numerous in the metaphysis of a growing bone
 Skeletal System and Joints 443

Fig. 6.52B: Contiguous spread from a soft-tissue infection allows the

organisms to penetrate the periosteal lining and the underlying cortex,
gaining access to the medullary cavity. Pus elevates the periosteum,
stimulating the formation of new bone (periosteal reaction)

Fig. 6.52C: A missile wound enables organisms and debris to gain entry
via a traumatic break in the skin and bone
444 Differential Diagnosis in Radiology

Fig. 6.52D: In diabetic osteomyelitis, fissures and ulcers form in the over-
lying skin secondary to diabetic vascular disease and organisms enter via
these openings. As a consequence of vascular obstruction, leukocytes,
antibodies and antibiotics fail to reach the infected focus in the bone

6.28  HYPERTROPHIC OSTEOARTHROPATHY

Pulmonary
– Carcinoma bronchus, especially oat cell carcinoma.
– Lymphoma.
– Abscess.
– Bronchiectasis.
– Metastases.

Pleural
– Pleural fibroma.
– Mesothelioma.

Cardiovascular
– Cyanotic CHD.
 Skeletal System and Joints 445
Gastrointestinal
– Ulcerative colitis/Crohn’s disease.
– Dysentery.
– Lymphoma.
– Whipple’s disease.
– Celiac disease.
– Cirrhosis.
– Nasopharyngeal carcinomas.
– Juvenile polyposis.

6.30  BONE DYSPLASIAS—ASSOCIATED

WITH MULTIPLE FRACTURES

Reduced Density
1. Osteogenesis imperfecta.
2. Achondrogenesis.
3. Hypophosphatasia.
4. Mucolipidosis II.
5. Cushing’s syndrome.

Normal Osseous Density

1. Cleidocranial dysplasia.
2. Enchondromatosis.
3. Fibrous dysplasia.

Increased Density
1. Osteopetrosis.
2. Pyknodysostosis.
446 Differential Diagnosis in Radiology

6.31  EXCESSIVE CALLUS FORMATION

Causes
1. Steroid therapy and Cushing’s syndrome.
2. Neuropathic arthropathy.
3. Osteogenesis imperfecta.
4. Nonaccidental injury.
5. Paralytic states.
6. Renal osteodystrophy.
7. Multiple myeloma.

6.32  BONE WITHIN BONE APPEARANCE

It results from endosteal new bone formation.

Causes
1. Normal
– In thoracic and lumbar spine (in infants)
– Growth recovery lines (after infancy).
2. Infantile cortical hyperostosis (Caffey’s disease).
3. Sickle cell disease/thalassemia.
4. Congenital syphilis.
5. Osteopetrosis/oxalosis.
6. Radiation.
7. Acromegaly.
8. Paget’s disease.
9. Heavy metal poisoning (Bi, Pb, Th).
10. Prostaglandin E therapy.
11. Leukemia.
12. Tuberculosis.
13. Rickets.
14. Scurvy.
15. Vitamin D toxicity.
16. Reflex sympathetic dystrophy.
 Skeletal System and Joints 447
6.33  FATIGUE FRACTURES
Normal bone subjected to repetitive stresses (none of which is
alone capable of producing a fracture) leads to mechanical failure
over a period of time (Fig. 6.53).

Radiographic signs
1. Cancellous bone
– Subtle blurring of trabecular margins.
– Faint sclerotic area due to peritrabecular callus.
– Sclerotic band (due to trabecular compression and
peritrabecular callus) perpendicular to cortex.
2. Compact bone
– Subtle ill-defined cortex.
– Intracortical lucent striations.
– Solid thick lamellar periosteal new bone formation.
– Endosteal thickening.
Fracture Related activity
1. Clay Shoveler’s fracture (frac- Clay shovelling
ture spinous process of lower
cervical/upper thoracic spine)
2. Coracoid process of scapula Trap shooting
3. Ribs Carrying heavy pack, golf,
coughing
4. Distal shaft of humerus Throwing ball
5. Coronoid process of ulna Pitching ball, throwing jave-
lin, propelling wheelchair
6. Hook of hamate Swinging golf stick/tennis
racquet/baseball bat
7. Spondylolysis (pars interarticu- Ballet, lifting heavy weights,
laris fracture) scrubbing floor
8. Femoral neck Ballet, long distance running
9. Femoral shaft Ballet, long distance running,
gymnastics, marching
Contd...
448 Differential Diagnosis in Radiology
Contd...
Fracture Related activity
10. Obturator ring of pelvis Stooping, bowling, gymnas-
tics
11. Patella Hurdling
12. Tibial shaft Ballet, jogging
13. Fibula Long distance running, jump-
ing, parachuting
14. Calcaneus Jumping, parachuting, pro-
longed standing, etc.
15. Navicular Stooping on ground, march-
ing, prolonged standing,
ballet
16. Metatarsal (commonly 2nd) Marching, prolonged stand-
ing, stamping on ground
17. Sesamoids of metatarsals Prolonged standing

Fig. 6.53:  Lateral radiograph of LS spine shows fracture through pars

interarticularis with Grade III listhesis of L5 over S1
 Skeletal System and Joints 449
6.34 PSEUDOARTHROSIS

Causes
1. Nonunited fracture.
2. Congenital in tibia and fibula—usually in neurofibromatosis.
3. Fibrous dysplasia.
4. Idiopathic juvenile osteoporosis.
5. Osteogenesis imperfecta.
6. Cleidocranial dysplasia—in femur.
7. Ankylosing spondylitis.

6.35  IRREGULAR/STIPPLED EPIPHYSIS (Fig. 6.54)

Causes
1. Normal variant
– In distal femur.

Fig. 6.54:  Anteroposterior radiograph of pelvis shows bilateral stippled

femoral head epiphysis in a patient of rickets
450 Differential Diagnosis in Radiology
2. Avascular necrosis
– Single in Perthe’s disease.
– Multiple in sickle cell anemia.
3. Hypothyroidism
– Delayed appearance and growth of ossification centers.
– Femoral capital epiphysis divided into inner and outer
half.
4. Chondrodysplasia punctata
– Stippling in long bones epiphyses, spine, larynx which
disappears by two years of age.
– Asymmetrical shortening of limbs.
5. Multiple epiphyseal dysplasia
– Delayed appearance and growth of epiphysis.
– With or without metaphyseal irregularity.
6. Spondyloepiphyseal dysplasia.
7. Hypoparathyroidism.
8. Down’s syndrome.
9. Trisomy 18.
10. Fetal warfarin syndrome
– Stippling of uncalcified epiphysis, particularly axial
skeleton, proximal femora and calcanei.
– Disappears after first year.
11. Homocystinuria
– Distal ulnar and radial epiphysis—pathognomonic.
12. Zellweger’s cerebrohepatorenal syndrome.
13. Fetal alcohol syndrome
– Mostly calcaneus and lower extremities.
14. Meyer dysplasia
– Confined to femoral heads.
15. Morquio’s syndrome
– Irregular ossification of femoral capital epiphysis.

6.36  AVASCULAR NECROSIS/OSTEONECROSIS/

ASEPTIC NECROSIS
This is the consequence of interrupted blood supply to bone with
death of cellular elements (Figs 6.55A and B).
 Skeletal System and Joints 451

Figs 6.55A and B:  (A) Anteroposterior radiograph of pelvis shows sec-
ondary degenerative changes following AVN in both the hips; and (B) An-
teroposterior radiograph of pelvis shows AVN of right hip

Causes
a. Toxic
– Steroids (>2 years of treatment)
– NSAID—Indomethacin.
– Alcohol.
– Immunosuppressives.
452 Differential Diagnosis in Radiology
b. Traumatic
– Idiopathic—Perthe’s disease (Fig. 6.56).
– Fractures—Femoral neck, talus, scaphoid.
– Radiotherapy.
– Heat-burns, electrical.
– Fat embolism.
– Frostbite.
c. Inflammatory
– Rheumatoid arthritis.
– Psoriasis.
– SLE.
– Scleroderma.
– Neuropathic arthropathy.
– Osteoarthrosis.
– Infection.
– Pancreatitis.
d. Metabolic/Endocrinal
– Pregnancy.
– Diabetes.

Fig. 6.56:  Anteroposterior radiograph of pelvis shows bony ankylosis

following Perthe’s disease in both hips
 Skeletal System and Joints 453
– Cushing’s syndrome.
– Hyperlipidemia.
– Gout.
– Hypercholesterolemia.
– Hyperuricemia.
e. Hematopoietic disorders
Hemoglobinopathies as sickle cell anemia.
– Hemophilia.
– Gaucher’s disease.
– Histiocytosis.
– Polycythemia.
f. Thrombotic/Embolic
– Dysbaric osteonecrosis.
– Giant cell arteritis.
– Endocarditis.
– Polyarteritis nodosa.
– Peripheral vascular disease.

Steinberg Classification for AVN of Hip

Stage 0 – Normal.
Stage 1 – Normal—barely abnormal trabecular pattern,
abnormal bone scan/MRI.
Stage 2A – Focal sclerosis and osteopenia.
2B – Distinct sclerosis with osteoporosis and early
crescent sign.
Stage 3A – Subchondral undermining (Crescent sign) and
cyst formation.
3B – Mild alteration in femoral head contour and
subchondral fracture with normal joint space.
Stage 4 – Marked collapse of femoral head with significant
acetabular involvement.
Stage 5 – Joint space narrowing with acetabular dege­
nerative changes.
454 Differential Diagnosis in Radiology

MR Changes in AVN (Mitchell Staging)

Stage T1WI T2WI Comments
A Increase Intermediate Fat
B Increase Increase Subacute blood
C Decrease Increase Fluid/Edema
D Decrease Decrease Fibrosis

6.37  SOLITARY RADIOLUCENT

METAPHYSEAL BANDS
It represents a period of poor endochondral bone formation.

Causes
1. Normal variant.
2. Any severe systemic illness.
3. Healing rickets.
4. Scurvy.
5. Leukemia, lymphoma.
6. Metastatic neuroblastoma.
7. Congenital infection as syphilis.
8. Growth lines.
9. Metaphyseal fracture, especially in non-accidental injuries.

6.38  SOLITARY DENSE METAPHYSEAL BAND

1. Normal variant.
2. Heavy metal poisoning (lead, bismuth, phosphorus, etc.)
3. Systemic illness.
4. Rickets (healed).
5. Scurvy.
6. Sickle cell disease.
7. Vitamin D intoxication.
8. Cretinism.
 Skeletal System and Joints 455
9. Congenital syphilis.
10. Estrogen to mother during pregnancy.
11. Leukemia.
12. TORCH infection.
13. Idiopathic hypercalcemia.
14. Radiation.
15. Osteopetrosis.

6.39  ALTERNATING RADIOLUCENT/DENSE

METAPHYSEAL BANDS
1. Growth arrest or Park’s lines.
2. Rickets, especially Vitamin D resistant.
3. Osteopetrosis.
4. Chemotherapy.
5. Chronic anemias
– Sickle cell type/thalassemias.
6. Treated leukemia.

6.40  DENSE VERTICAL METAPHYSEAL LINES

1. Congenital rubella
– Produces a characteristic “celery stalk” appearance.
2. Congenital CMV infection.
3. Hypophosphatasia.
4. Localized metaphyseal injury.
5. Osteopathia striata
– Bony exostosis may be associated.

6.41  FRAYED METAPHYSIS

1. Achondroplasia.
2. Congenital infections (Rubella, Syphilis).
3. Copper deficiency.
4. Chronic stress, e.g. wrists of gymnasts.
456 Differential Diagnosis in Radiology
5. Hypophosphatasia.
6. Metaphyseal dysostosis.
7. Rickets.
8. Scurvy.

6.42  CUPPING OF METAPHYSIS

1. Normal variant esp. distal end of ulna and proximal end of
fibula.
2. Bone, dysplasias as achondroplasia, pseudoachondroplasia, etc.
3. Rickets
– Associated with metaphyseal blurring and fraying.
4. Scurvy
– Usually follows fracture.
5. Trauma
– To growth plate; the changes will be asymmetrical.

6.43  ERLENMEYER FLASK DEFORMITY

This deformity is characterized by expansion of distal ends of long
bones, especially femora.

Causes
It includes:
1. Storage disorders as Gaucher’s disease, Niemann-Pick
disease.
2. Rickets.
3. Anemias, e.g. thalassemia with coarse trabecular pattern.
4. Fibrous dysplasia.
5. Osteopetrosis.
6. Heavy metal poisoning, e.g. lead with thick transverse
dense metaphyseal bands.
7. Metaphyseal dysplasia (Pyle’s disease)
– Rare autosomal recessive disease. Characterized by
sclerosis of skull vault and base, widening of medial ends
of clavicle and expansion of pubic and ischial bones.
 Skeletal System and Joints 457
8. Down’s syndrome.
9. Achondroplasia.
10. Rheumatoid arthritis.
11. Hypophosphatasia.
12. Diaphyseal aclasia.
13. Ollier’s disease.
14. Craniometaphyseal dysplasia
– Common, autosomal dominant condition.
15. Osteodysplasty (Melnick-Needles syndrome)
– Seen in females. Characterized by distorted irregular
ribs and sigmoid-shaped clavicles; cortical irregularity,
patchy sclerosis and bowing of bones are also seen.

6.44  EROSION OF MEDIAL

METAPHYSES OF PROXIMAL HUMERUS
• Normal variant
• Neoplastic
– Leukemia.
– Metastatic neuroblastoma.
• Storage disorders
– Gaucher’s disease.
– Hurler’s syndrome.
– Niemann-Pick disease.
• Endocrinal
– Hyperparathyroidism.
• Arthropathies
– Rheumatoid arthritis.

6.45  ABNORMALITY RELATED TO CLAVICLES

Erosion or Absence of Outer End of Clavicle

• Rheumatoid arthritis.
• Hyperparathyroidism.
• Post-traumatic osteolysis.
458 Differential Diagnosis in Radiology
• Metastasis.
• Multiple myeloma.
• Cleidocranial dysplasia.
• Pyknodysostosis.

Penciled Distal End of Clavicle

• Scleroderma.
• Hyperparathyroidism.
• Infection.
• Rheumatoid arthritis.
• Trauma.
• Progeria.

Destruction of Medial End of Clavicle

• Metastasis.
• Infection.
• Lymphoma.
• Eosinophilic granuloma.
• Rheumatoid arthritis.
• Sarcoma.
• Rarely cleidocranial dysplasia.

6.46  RIB LESIONS

Neoplastic
i. Benign
– Fibrous dysplasia (commonest).
– Eosinophilic granuloma.
– Benign cortical defect.
– Hemangioma.
– Enchondroma (at costochondral/costovertebral junction).
– Osteochondroma.
– Giant cell tumor.
 Skeletal System and Joints 459
– Aneurysmal bone cyst.
– Langerhans’ cell histiocytosis.
ii. Malignant
a. Primary
– Chondrosarcoma.
– Osteosarcoma.
– Fibrosarcoma.
– Ewing’s sarcoma.
– Multiple myeloma/plasmacytoma.
b. Secondary
• Adults
– Metastases.
– Desmoid tumor.
• Child
– Metastatic neuroblastoma.

Non-neoplastic
• Healing fractures.
• Radiation osteitis.
• Paget’s disease.
• Brown tumor of hyperparathyroidism.
• Osteomyelitis.

6.47  RIB NOTCHING

Superior Margin
i. Connective tissue disorders
– Rheumatoid arthritis.
– Scleroderma.
– SLE.
– Sjögren’s syndrome.
ii. Metabolic
– Hyperparathyroidism.
460 Differential Diagnosis in Radiology
iii. Miscellaneous
– Marfan’s syndrome.
– Restrictive lung disease.
– Neurofibromatosis.
– Poliomyelitis.
– Osteogenesis imperfecta.
– Progeria.

Inferior Margin
i. Arterial
– Coarctation of aorta (CoA) (4th–8th ribs bilaterally).
– Unilateral (U/L) and right-sided if coarctation is proximal to
left subclavian artery.
– Unilateral (U/L) and left-sided if associated with anomalous
right subclavian artery distal to coarctation.
– Aortic thrombosis.
– Pulmonary stenosis, Fallot’s tetralogy or absent pulmonary
artery (all causes of pulmonary oligemia).
– Subclavian obstruction (Post Blalock-Taussig shunt).
– Upper 3 or 4 ribs ipsilateral to operation side.
ii. Venous
– AV chest wall malformation.
– SVC obstruction.
– Pulmonary AV malformation.
iii. Neurogenic
– Neurofibromatosis.
– Intercostal neuroma.
– Poliomyelitis/quadriplegia.
iv. Osseous
– Hyperparathyroidism.
– Thalassemia.
– Melnick needles syndrome.
 Skeletal System and Joints 461
6.48  ABNORMAL SHAPE, SIZE AND
DENSITY OF RIBS
a. Ribbon ribs
– Osteogenesis imperfecta.
– Neurofibromatosis.
b. Wide/Thick ribs
– Chronic anemias.
– Fibrous dysplasia.
– Paget’s disease.
– Achondroplasia.
– Mucopolysaccharidosis.
– Healed fracture with callus.
c. Bullous costochondral ends
– Rachitic Rosary.
– Scurvy.
– Achondroplasia.
d. Short ribs
– Achondroplasia.
– Achondrogenesis.
– Thanatophoric dysplasia.
– Asphyxiating thoracic dysplasia.
– Mesomelic dwarfism.
– Short rib polydactyly syndrome.
– Spondyloepiphyseal dysplasia.
– Enchondromatosis.
– Chondroectodermal dysplasia.
e. Dense ribs
– Osteopetrosis.
– Fluorosis.
– Mastocytosis.
f. Hyperlucent ribs
– Osteopetrosis.
– Cushing’s disease.
– Acromegaly.
– Scurvy.
462 Differential Diagnosis in Radiology

6.49  MADELUNG DEFORMITY

Characterized by shortening of distal radius with posterior
subluxation of distal ulna.

Causes
• Isolated congenital
– Usually bilateral and common in females.
• Leri Weill syndrome (dyschondrosteosis)
• Turner’s syndrome.
• Post-traumatic.
• Post-infectious.

6.50  CARPAL FUSION

Isolated
i. Congenital
– Triquetral lunate (commonest).
– Capitate-Hamate.
– Trapezium.
– Trapezoid.
ii. Acquired
– Inflammatory arthritides as rheumatoid arthritis.
– Pyogenic arthritis.
– Post-traumatic.
– Postsurgical.

Syndrome Related
• Acrocephalosyndactyly (Apert’s syndrome).
• Arthrogryposis multiplex congenita.
• Ellis-van Creveld syndrome.
• Holt-Oram syndrome.
• Turner’s syndrome.
• Symphalangism.
 Skeletal System and Joints 463
6.51  ABNORMAL DIGITS
a. Brachydactyly (Shortening/Broadening of metacarpal +/–
phalanges)
– Idiopathic.
– Post-traumatic.
– Osteomyelitis.
– Postinfarction as sickle cell disease.
– Turner’s syndrome (4th +/– 3rd and 5th).
– Arthritis.
– Osteochondrodysplasia.
– Pseudo and pseudopseudohypoparathyroidism (4th and 5th).
– Mucopolysaccharidosis.
– Hereditary multiple exostoses.
– Basal cell nevus syndrome.
b. Arachnodactyly (elongated/slender)
– Marfan’s syndrome (Metacarpal index = 8.4–10.4).
– Homocystinuria.
c. Syndactyly (Fig. 6.57) (Osseous +/– cutaneous fusion of digits)

Fig. 6.57:  Anteroposterior radiograph of hand

shows syndactyly with polydactyly
464 Differential Diagnosis in Radiology

– Apert’s syndrome.
– Carpenter syndrome.
– Down’s syndrome.
– Neurofibromatosis.
– Poland syndrome.
d. Polydactyly
– Carpenter syndrome.
– Ellis-van Creveld syndrome.
– Meckel-Gruber syndrome.
– Polysyndactyly syndrome.
– Short rib-polydactyly syndrome.
– Trisomy 13.
e. Clinodactyly (Curvature of fingers in mediolateral plane)
– Normal variant.
– Clinodactyly.
– Multiple dysplasias.
– Trauma.
– Arthritis.
– Contractures (Fig. 6.58).

Fig. 6.58:  Lateral radiograph of foot shows postburn contracture

 Skeletal System and Joints 465
6.52  ABNORMAL THUMB
a. Broad
– Acrocephalopolysyndactyly.
– Acrocephalosyndactyly.
(Mitten hand and sock foot deformity)
– Rubinstein-Taybi syndrome.
– Oropalatodigital syndrome (Large cone epiphysis of distal
phalanx).
b. Large
– Klippel-Trenaunay-Weber syndrome.
– Maffucci syndrome.
– Neurofibromatosis.
– Macrodystrophia lipomatosa.
c. Short/small
– Fanconi’s anemia.
– Holt-Oram syndrome.
– Brachydactyly.
– Cornelia de Lange syndrome.
– Fetal hydantoin.
d. Absent
– Fanconi’s anemia.
– Poland syndrome.
– Thalidomide.
– Trisomy 18.
e. Triphalangeal
– Fanconi’s anemia.
– Holt-Oram syndrome.
– Blackfan-Diamond syndrome.
– Poland syndrome.
– Trisomy 13 and 21.
– Thalidomide.
f. Abnormal position
– Proximal placed (Cornelia de Lange syndrome).
– Diastrophic dysplasia and Rubinstein-Taybi syndrome.
466 Differential Diagnosis in Radiology

6.53  LYTIC LESION IN DIGITS

Well-Defined
i. Neoplastic
a. Benign
– Implantation dermoid.
– Enchondroma.
– Glomus tumor.
– Osteoid osteoma.

Malignant
• Osteoblastoma.
ii. Non-neoplastic
– Sarcoid.
– Solitary bone cyst.
– Fibrous dysplasia.

Poorly Defined
i. Neoplastic.
a. Benign
– Aneurysmal bone cyst.
– Giant cell tumor.
b. Malignant
– Metastases.
– Multiple myeloma.
– Osteosarcoma.
– Fibrosarcoma.
ii. Non-neoplastic.
– Osteomyelitis.
– Brown tumors of hyperparathyroidism.
– Hemophilic pseudotumor.
– Leprosy.
 Skeletal System and Joints 467
6.54  ACRO-OSTEAL CHANGES

Acro-Osteolysis (Fig. 6.59)

• Familial.
• Massive osteolysis.
• Essential osteolysis.
• Ainhum disease.
• Acquired.
– Psoriasis.
– Porphyria.
– Ehlers-Danlos syndrome.
– Thromboangitis obliterans.
– Ergot therapy.
– Raynaud’s disease.
– Diabetes.
– Arteriosclerosis.

Fig. 6.59:  Anteroposterior radiograph of foot shows acro-osteolysis

468 Differential Diagnosis in Radiology
– Dermatomyositis.
– PVC workers.
– Rheumatoid arthritis.
– Scleroderma.
– Leprosy.
– Syringomyelia.
– Hyperparathyroidism.

Acro-osteosclerosis
• Patchy in nature
– Incidental (Middle-aged and females)
– Rheumatoid arthritis
– Sarcoidosis
– Scleroderma
– SLE
– Hodgkin’s disorders
– Hematological disorders.

Resorption of Distal Phalanges

a. Congenital
b. Dysplasia
– Cleidocranial.
– Pyknodysostosis.
– Acro-osteolysis of Hajdu and Cheney syndrome.
– Pachydermoperiostosis.
c. Infective
– Osteomyelitis.
– Leprosy.
– Sarcoid.
d. Trauma
– Frostbite.
– Thermal injuries.
– Electrical injury.
– Amputation.
 Skeletal System and Joints 469
e. Poisons
– Ergot.
– PVC.
– Phenytoin.
– Snake/scorpion venom.
f. Metabolic
– Hyperparathyroidism and porphyria.
g. Vascular
– Scleroderma.
– Pseudoxanthoma elasticum.
– Occlusive vascular disease.
h. Neurotrophic
– Tabes dorsalis.
– Diabetes.
– Congenital in difference to pain.
– Myelomeningocele.
i. Neoplastic
– Kaposi sarcoma.
j. Miscellaneous
– Psoriasis.
– Pityriasis rubra.
– Epidermolysis bullosa.
– Reticulohistiocytosis.
– Ainhum.
– Progeria.
– Neurofibromatosis.

6.55 MONOARTHRITIS
a. Traumatic
– Associated fracture.
– Joint effusion especially lipohemarthrosis includes:
• Secondary osteoarthritis.
• Neurotrophic arthritis.
• Pigmented villonodular synovitis.
470 Differential Diagnosis in Radiology
b. Septic arthritis (Figs 6.60A to C) (Tuberculous, pyogenic.
– Periarticular erosions.
– Joint space narrowing.
– Periosteal reaction.
– Bony/fibrous ankylosis.
c. Collagen-like disease
– Rheumatoid arthritis, especially chronic juvenile arthritis.
– Rheumatic fever.
d. Sarcoidosis
– Psoriatic arthritis.
– Ankylosing arthritis.
e. Biochemical arthritis
– Gout.
– CPPD disease.
– Chondrocalcinosis.
– Ochronosis.
– Hemophilic arthritis.

A B
Fig. 6.60A: Anteroposterior radiograph Fig. 6.60B: Anteroposterior ra-
of right hip shows early phase of tuber- diograph of right hip shows late
cular arthritis phase of tubercular arthritis with
dislocation
 Skeletal System and Joints 471

C
Fig. 6.60C:  Anteroposterior radiograph of wrist shows tubercular arthritis

f. Degenerative
– Osteoarthritis.
g. Sympathetic
– In response to, e.g. tumor.
h. Neuropathic arthropathy.

6.56  ARTHRITIS WITH PERIOSTITIS

Causes
1. Juvenile rheumatoid arthritis.
2. Psoriatic arthritis.
3. Reiter’s syndrome.
4. Infectious arthritis.
5. Hypertrophic osteoarthropathy.
6. Hemophilia.
7. Uncommonly, rheumatoid arthritis.
472 Differential Diagnosis in Radiology

6.57  ARTHRITIS WITH DEMINERALIZATION

Causes
1. Hemophilia.
2. Osteomyelitis.
3. Rheumatoid arthritis, juvenile chronic arthritis.
4. Reiter’s syndrome.
5. Scleroderma.
6. SLE.

6.58  ARTHRITIS WITHOUT DEMINERALIZATION

Causes
1. Psoriatic arthritis.
2. Osteoarthritis.
3. Neuropathic arthropathy (Fig. 6.61).
4. Gout.

Fig. 6.61:  Anteroposterior radiograph of foot shows neuropathic foot

 Skeletal System and Joints 473
5. Sarcoidosis.
6. Reiter’s disease.
7. Pigmented villonodular synovitis.
8. Ankylosing spondylitis.
9. Calcium pyrophosphate arthropathy.

6.59  ARTHRITIS WITH PRESERVED/

WIDENED JOINT SPACE

Causes
1. Infective/inflammatory arthritis
– Early stage due to joint effusion.
2. Psoriatic arthropathy
– Due to fibrous tissue deposition.
3. Gout.
4. Pigmented villonodular synovitis.
5. Acromegaly
– Due to cartilage overgrowth.

Arthritis With Soft Tissue Nodules

• Gout.
• Rheumatoid arthritis.
• Pigmented villonodular synovitis.
• Reticulohistiocytosis.
• Sarcoidosis.
• Amyloidosis.

Loose Intra-articular Bodies (Figs 6.62A and B)

• Osteochondrosis dessicans.
• Synovial osteochondromatosis.
• Chip fracture from trauma (Osteochondral fracture).
• Severe degenerative joint disease (detached osteophyte).
• Neuropathic arthropathy.
474 Differential Diagnosis in Radiology

B
A B
Fig. 6.62A: Lateral radiograph of Fig. 6.62B: Lateral radiograph of
knee joint shows intra-articular knee joint shows synovial osteochon-
loose bodies dromatosis in posterior part of joint

Arthritis Mutilans
Characterized by telescoping joints due to resorption of bone
ends secondary to destructive arthritis.

Causes
1. Leprosy.
2. Diabetes.
3. Neuropathic arthropathy.
4. Rheumatoid arthritis.
5. Juvenile chronic arthritis.
6. Psoriatic arthropathy.
7. Reiter’s syndrome.
 Skeletal System and Joints 475
6.60  ENLARGED FEMORAL INTER-
CONDYLAR NOTCH

Causes
1. Hemophilia.
2. Juvenile chronic arthritis.
3. Psoriatic arthropathy.
4. Rheumatoid arthropathy.
5. Tuberculous arthritis.

6.61  PLANTAR CALCANEAL SPUR

Causes
1. Idiopathic.
2. Diffuse idiopathic skeletal hyperostosis.
3. Ankylosing spondylitis.
4. Psoriatic arthropathy.
5. Reiter’s syndrome.
6. Rheumatoid arthritis.

6.62 CHONDROCALCINOSIS
Characterized by calcification of articular or hyaline cartilage.
a. Idiopathic
b. Crystal deposition disease
– CPPD.
– Gout.
c. Metabolic
– Wilson’s disease.
– Hemochromatosis.
– Familial hypomagnesemia.
– Ochronosis.
– Diabetes.
– Hypophosphatasia.
476 Differential Diagnosis in Radiology
d. Endocrinal
– Hypothyroidism.
– Primary hyperparathyroidism.
– Acromegaly.
e. Arthropathy associated
– Rheumatoid arthritis.
– Postinfectious arthritis.
– Post-traumatic arthritis.
– Degenerative arthritis.
f. Miscellaneous
– Hemophilia.
– Amyloidosis.

6.63  ANKYLOSIS OF INTERPHALANGEAL JOINTS

Causes
1. Psoriatic arthritis.
2. Ankylosing spondylitis.
3. Still’s disease.
4. Erosive osteoarthritis (Fig. 6.63).

6.64 ENTHESIOPATHY
Characterized by osseous attachment of tendon.
Causes
1. Degenerative disorder.
2. Seronegative arthropathies as ankylosing spondylitis, Reiter’s
disease, psoriatic arthritis.
3. DISH (Fig. 6.64).
4. Acromegaly.
5. Occasionally, rheumatoid arthritis.
 Skeletal System and Joints 477

Fig. 6.63: Anteroposterior and lateral radiographs of knee joint show

features of erosive osteoarthritis

Fig. 6.64:  Lateral radiograph of cervical spine showing features of DISH

478 Differential Diagnosis in Radiology

6.65 SACROILIITIS

Unilateral
i. Infective
– Pyogenic.
– Tubercular.
ii. Degenerative
– Osteoarthrosis secondary to abnormal mechanical stress.
– Narrowing of joint space with subchondral sclerosis.
– Osteophytosis.

Bilateral
i. Symmetrical
– Ankylosing spondylitis.
– Ankylosis of joint.
– Ossification of ligaments.
– Enteropathic arthropathy as in CD, UC, etc.
– Osteitis Condensans ilii.
– Seen in young multiparous women.
– Bone sclerosis with normal joint space.
– Rheumatoid arthritis (in late stages).
– Joint space narrowing.
– Osteoporosis.
– Deposition arthropathy (gout, CPPD, ochronosis)
– Slow loss of cartilage.
– Subchondral sclerosis + osteophytosis.
– Hyperparathyroidism.
– Subchondral bone resorption.
– Widening of joint space.
– Paraplegia.
– Joint space narrowing.
– Osteoporosis.
ii. Asymmetrical
– Psoriatic arthropathy.
– Extensive erosion.
 Skeletal System and Joints 479
– Ankylosis less common.
– Reiter’s syndrome.
– Juvenile chronic arthritis.
– Gouty arthritis.
– Large well-defined erosion with adjacent sclerosis.
– Osteoarthrosis.

6.66  PROTRUSIO ACETABULI

Characterized by acetabular floor bulging into pelvis. Criteria is
acetabular line projecting medially to ilioischial line by >3 mm in
males and >6 mm is females (Fig. 6.65).

Causes

Unilateral
• Tubercular arthritis.
• Trauma.
• Fibrous dysplasia.
• Marfan’s syndrome.

Fig. 6.65:  Anteroposterior radiograph of pelvis shows protrusio

acetabuli on left side
480 Differential Diagnosis in Radiology

Bilateral
• Rheumatoid arthritis and juvenile chronic arthritis.
• Paget’s disease.
• Osteomalacia/osteoporosis.
• Ankylosing spondylitis.
• Idiopathic/familial.
• Marfan’s syndrome.

6.67  WIDENING OF
SYMPHYSIS PUBIS (DIASTASIS)

Normal Measurements
≤ 10 mm in newborn.
≤ 9 mm at 3 years of age.
≤ 8 mm at 7 years of age and over.

Congenital
i. With normal ossification
– Exstrophy of bladder.
– Epispadias.
– Hypospadias.
– Imperforate anus with rectovaginal fistula.
– Urethral duplication.
– Prune belly syndrome.
– Sjögren-Larson syndrome.
– Goltz syndrome.
ii. With poorly ossified cartilage
– Achondrogenesis/hypochondrogenesis.
– Campomelic dysplasia.
– Chondrodysplasia punctate.
– Wolf’s syndrome.
– Trisomy 9.
 Skeletal System and Joints 481
– Cleidocranial dysplasia.
– Hypophosphatasia.
– Hypothyroidism.
– Pyknodysostosis.
– Spondyloepiphyseal dysplasia.
– Osteogenesis imperfecta.
– Larson’s syndrome.
– Spondylometaphyseal dysplasia.

Acquired
– Pregnancy (resolves spontaneously by 3rd month postpartum).
– Trauma.
– Osteitis pubis (symmetrical bony irregularity with resorption
and sclerosis).
– Osteolytic metastases.
– Osteomyelitis.
– Ankylosing spondylitis.
– Rheumatoid arthritis.
– Hyperparathyroidism (subperiosteal bone resorption).

6.68  FUSION OF SYMPHYSIS PUBIS

Causes
1. Postinfective.
2. Post-traumatic.
3. Osteitis pubis.
4. Osteoarthrosis.
5. Ankylosing spondylitis.
6. Alkaptonuria.
7. Fluorosis.
482 Differential Diagnosis in Radiology

6.69  RADIOGRAPHIC FINDING IN DEGENERATIVE,

INFLAMMATORY AND NEUROPATHIC ARTHRITIS

Degenerative Inflammatory Neuropathic

1. Soft tissue swelling/ – ++ +
nodules
2. Soft tissue – ++ –
calcification
3.  Joint effusion + + ++
4. Enthesopathies – ++ –
5. Alignment + ++ ++
deformities
6. Osteoporosis – ++ –
7.  Diffuse joint loss + ++ +
8. Central/marginal – ++ –
erosions
9. Articular +/– + ++
destruction
10.  Subchondral cysts ++ +/– –
11. Osteophytes ++ – +
12. Subchondral ++ – +/–
sclerosis
13.  Vacuum phenomena ++ – +/–
++ occurs very commonly
+/– may or may not occur
+ occurs commonly
– does not occur.

6.70  COMPARATIVE FEATURES OF

SERONEGATIVE SPONDYLOARTHRITIDES

6.71  D/D OF DWARFISM

Osteochondrodysplasias—Short Limb Dysplasias

1. Rhizomelic (Proximal limb shortening)
a. Achondroplasia.
b. Hypochondroplasia.
 Skeletal System and Joints 483
c. Pseudoachondroplasia.
d. Chondrodysplasia punctata.
e. Thanatotropic dwarfism.
2. Mesomelic (Middle segment limb shortening)
a. Dyschondrosteosis.
b. Mesomelic dysplasia.
3. Acromesomelic (Middle and distal limb shortening)
a. Chondroectodermal dysplasia.
4. Acromelic (Distal limb shortening)
a. Asphyxiating thoracic dystrophy.

Short Spine Type

1. Pseudoachondroplasia.
2. Spondyloepiphyseal dysplasia.
3. Diastropic dwarfism.
4. Metatropic dwarfism.
5. Kniest syndrome.

Dysostosis Multiplex (Short Limb) + Short Trunk

– Hurler’s syndrome.
– Morquio’s syndrome.

Chromosomal Aberration
– Turner’s syndrome.

Primordial Dwarfism
Endocrine Disease
– Hypopituitarism, cretinism.
– Hypergonadism.

Metabolic Disorder
– Hypophosphatasia, rickets.
484 Differential Diagnosis in Radiology

Primordial Dwarfism
– Congenital growth disturbance, genetically trans­mitted.
– Appearance and fusion of ossification centers are normal.
– Bones are radiologically normal except that they are unusually
small.
– These patients are dwarfs at birth and never attain normal
stature.
– They are sexually normal and transmit dwarfism to their children.

Endocrine Disorders
Hypopituitarism
• Due to partial or complete lack of growth hormone
• Typical hypopituitary dwarfism is known as Lorain-Lévi dwarfism
• Patients present with short stature usually after 18 months of
age, and are usually slender and well-proportioned
• Mentality is unaffected, delayed skeletal age and sexual
immaturity
• MRI shows small sella and hypoplastic pituitary gland.

Cretinism
• Delayed skeletal maturation, i.e. delayed appearance and
fusion of ossification centers
• Dwarfism with delayed dentition, delayed closure of fontanelle,
wormian bones, fragmented epiphysis
• Kyphosis with bullet-shaped vertebrae, usually L1 and L2.

Hypergonadism
• Ovarian granulosa cell tumor in females, pineal tumors in
males, hyperfunction of adrenal cortex
• Sexual precocity with early appearance and rapid closure of
epiphysis resulting in dwarfism.
 Skeletal System and Joints 485
Turner’s Syndrome
• XO chromosome pattern
• Ovarian dysgenesis
• Short stature with retarded epiphyseal development
• Webbed neck, broad chest, pectus excavatum, cubitus valgus,
short fourth metacarpal.

Metabolic Disorders
Hypophosphatasia
• Severe forms result in dwarfism
• Lack of calcification of metaphyseal ends of long bones
• Decrease alkaline phosphatase activity.

Rickets
Causes delayed skeletal maturation, bowed legs and other
deformities and may result in short stature.

DYSPLASIAS

Rhizomelic
Achondroplasia
• Long bones are short and broad
• Small square iliac blades, horizontal acetabulia
• Lumbar canal stenosis due to decreased interpedicular distance
• Large calvarium
• Short stubby fingers.

Hypochondroplasia
• Short and broad femoral neck.
• Small iliac blades.
486 Differential Diagnosis in Radiology
• Lumbar canal stenosis.
• Skull never affected.

Pseudoachondroplasia
• Long bones are short with broad metaphysis and irregular
epiphysis
• Ilia are large, platyspondyly with central anterior tongue
• Skull normal
• Short stubby fingers.

THANATOTROPIC DWARFISM
• Rhizomelic dwarfism with bowing of long bones known as
Telephone-handle long bones (Fig. 6.66)
• Severe platyspondyly, vertebrae resemble letter H
• Short ribs, short wide metacarpals and phalanges
• Skull shows lateral temporal bulging known as clover leaf skull.

Fig. 6.66:  Anteroposterior and lateral radiographs of forearm

show bowing of both forearm bones
 Skeletal System and Joints 487
Chondrodysplasia Punctata
a. Rhizomelic
b. Non-rhizomelic.
– Asymmetric shortening of long bones with meta­physeal
irregularity.
– Stippling of carpus, tarsus and long bone epiphyses, around
joints.

MESOMELIC DWARFISM

Dyschondrosteosis (Léri-Weill Disease)

• Bilateral Madelung’s deformity
• Shortening of radius with triangular distal epiphysis
• Carpal bones wedged between radius and protruding ulna
with lunate at apex.

ACROMESOMELIC DWARFISM
Chondroectodermal dysplasia (Ellis-van Creveld syndrome)
– Short stature with short limbs.
– Shortening of paired long bones and hypoplasia of fingers
and nails.
– Hypoplastic lateral tibial plateau.
– Polydactyly is most characteristic.

ACROMELIC DWARFISM

Asphyxiating Thoracic Dystrophy

• Narrow thorax and short ribs causing respiratory distress
• Polydactyly, clavicles are highly placed.
488 Differential Diagnosis in Radiology

Short Spine Dysplasias

Spondyloepiphyseal dysplasia.
• Ovoid or pear-shaped vertebral bodies in infancy with severe
platyspondyly in later life
• Normal metaphysis
• Retarded development of symphysis pubis and femoral heads,
coxa vara.

Diastrophic Dwarfism
• Progressive kyphoscoliosis
• Hypermobile and abducted thumbs known as Hitch Hiker’s
thumb
• Delta-shaped epiphysis
• First metacarpal is oval and hypoplastic—most distinctive
feature.

Metatrophic Dwarfism
• Progressive kyphoscoliosis
• Dumb-bell-shaped long bones
• Tail-like appendage at distal end of gluteal cleft.

Short Limb + Short Trunk Dwarfs

Dysostosis Multiplex
Hurler’s Syndrome
– Macrocephaly, J-shaped sella, hook-shaped vertebral
bodies.
– Flaring of ilia, tapering of proximal ends of meta­carpals.

Hunter’s Syndrome
• Similar to Hurler’s syndrome but less severe.
 Skeletal System and Joints 489
Brailsford-Morquio’s Syndrome
• Severe platyspondyly with central protrusion
• Short and wide tubular bones
• Narrow pelvis.

Maroteaux Lamy Syndrome

Dwarfism without mental impairment similar to Hurler’s syndrome.

6.72  SCLEROTIC LESIONS OF BONE

• Bone reaction can be:
a. Offence.
b. Defence.
It can also be classified as:
1. Focal.
3. Generalized.
• Basically it is the role of osteoblasts.
↓→ Central Reactive
tumorogenic.
Periosteal Reactive
tumorogenic.
• Generic D/D of sclerotic lesion: “Vindicate”
Vascular = E.g. Hemangioma; infarcts.
Infections = E.g. Chronic osteomyelitis.
Neoplasm = E.g. Osteoma; osteoblastoma; secondaries.
Drugs/poisons = E.g. Vitamins A and D; fluorosis; oxalosis.
Idiopathic = E.g. Caffey’s; idiopathic hypercalcemia of
infancy; Paget’s.
Congenital = E.g. Bone island; osteopoikilosis;
osteopetrosis; pyknodysostosis.
Autoimmune = E.g. Mastocytosis.
Trauma = E.g. Stress fracture.
Endocrine/ = E.g. Hyperparathyroidism;
Metabolic Paget’s disease; hypoparathy­roidism, pseu-
dohypoparathyroidism and pseudopseu-
dohypoparathyroidism.
490 Differential Diagnosis in Radiology

Imaging
a. Plain X-ray and tomography.
b. CT scan.
c. MRI.
d. DEXA (i.e. Densitometry).
e. Bone scintigraphy.

Role of Radiologist
Preoperative Postoperative
1. Soft tissue extent. 1. Record site of operation.
2. Description. 2. Excision.
Biopsy specimen.
3. Pathological 3. Examination of adjacent
fracture may be seen. normal bone.
4. Aggressiveness. 4. Correlation of
Microradiographic
details to HPE.
5. Specific diagnosis if 5. X-ray diffraction to
possible. matrix.
6. Site of biopsy study. 6. Decide whether bone seaking.
7. Follow up the cases.

SALIENT FEATURES

Osteopetrosis
• Primary fetal spongiosa—Not replaced properly by adult
bone.
↓
—Grows in layers
(high in calcium Prone to secondary
and brittle) infection.
Encroaches Marrow
↓
 Skeletal System and Joints 491
Extra Medullary
Hematopoiesis
Anemia.
• 4 types:
1. AR; severe; fatal; diagnosed early.
2. AD; mild; late diagnosed A. Skull vault.
3. AR; intermediate B. Skull base +
4. Carbonic anhydrase Rugger Jersey spine.
deficiency with RTA
and basal ganglia calcification.
• Skull: Thick, sclerotic bones (especially of base) with poorly-
pneumatized sinuses and encroached foramina. Dental
abnormality.

Spine
Rugger Jersey spine with listhesis.

Extremities
Bone within bone + Erlenmeyer flask + Cigar lucencies.

Pyknodysostosis
• Autosomal-recessive; short-stature; multiple fractures with
dense bones.

Skull
Brachycephaly; persistent fontanelle and wormian sutural bones;
sclerotic skull (especially base) with facial hypoplasia; obtuse
mandible angle.

Spine
‘Standing spool’ vertebrae; listhesis, unfused neural arches and
ribs, etc. clavicle defect—lateral ends.
492 Differential Diagnosis in Radiology

Extremities
Normal modelling with patent medulla.

Fibrous Dysplasia
• Woman 10–30 years monostotic and is mostly asymmetrical,
Unilateral >> Bilateral
• Usually the lesion stops growing with age
• Radiological appearance of a cyst; cotton wool; ground glass
depends upon the degree and distribution of calcium over the
fibroid matrix. Basically it is a disease of medulla
• Spinal involvement is rare while lesion is mainly metadiaphyseal
and longitudinal with a thinned but preserved cortex
• Deformities like ‘Shepherd’s-Crook’, mask facies, proptosis
• Fractures, endocrinopathies, fibrosarcomas (1%).

Renal Osteodystrophy and Hyperparathyroidism

• 9–34% patients of ROD and rarely patients of primary and
tertiary HP show e/o sclerosis: occur because of poor renal
function (global)
• Predilection for axial skeleton and metaphysis of long bones
• Other features are that of osteoporosis, osteomalacia
• Osteitis cystica fibrosa, soft tissue changes.

Hypopseudohypo and
Pseudopseudohypoparathyroidism
• Pelvis, inner skull table, proximal femur, vertebral body and
associated with abnormal dentition and basal ganglion
calcification
• Associated features in PHP are short 4th and 5th metacarpal,
coxa vara or valga, cone-epiphysis, bowing of bones and soft
tissue calcification
• PPHP shows no radiological difference but has a normal blood
chemistry.
 Skeletal System and Joints 493
Osteosclerotic Metastasis
• Prostate; Pheochromocytoma; Pancreas, Carcinoid; Cervix;
Colon; Breast; Stomach; TCC; Testis; Medullo­
blastoma; NP;
Neuroblastoma
• Tumor new bone—Osteosarcoma TCC; Mucinous Adenocar-
cinoma.

Carcinoma Prostate
• Cortical lung.

Caffey’s Disease
• Idiopathic 9 weeks–5 months; sibling/cousin; presenting with
fever-increase ESR-pleural effusion
• Triad of hyperirritability, soft tissue swelling and bony cortical
thickening
• Patchy distribution; remission and relapses
• Soft tissue swellings—Painful; deep; proceed bony change and
unrelated to it
• A/E fibula and spine purely diaphyseal
– Rickets
– Scurvy
– Congenital syphilis.
• Periosteal reaction is associated.

Idiopathic Hypercalcemia of Infancy

• Elfin facies, failure to thrive
• Generalized bone density increased; sclerotic bands at
metaphysis
• Vitamin A excess.

Hypervitaminosis—A, D
• Basically periosteal reaction (painful), reversible; >1 year, bands
• Soft tissue calcification (in vitamin D), normal mandible.
494 Differential Diagnosis in Radiology

Fluorosis
• Usually due to excess fluorine in drinking water
• Due to increased osteoclastic activity to fluorine
• Adults>>, encroachment on medulla/foramina/spinal canal, etc.
• Membranes/Ligament ossification.

Lead
• Again due to lead in water
• Due to lead deposition + reactive changes
• Increased density + metaphyseal bands + modelling deformity.

Paget’s Disease
• Elderly; men; polyostotic (80%); fibula (rare)
• 3 phases—Lytic, mixed; sclerotic; mosaic bone with lost
corticomedullary differentiation
• Bones are large, thick, deformed, coarsened; joint deformities
• Picture frame vertebra with collapse; lost lamina dura;
hypercementosis
• Skull has a cotton-wool appearance with the lytic lesions
starting in outer while sclerosis in inner table.

Myeloma
• i.e. POEMS syndrome—seen in young men; spine, pelvis mostly
involved.

Lymphoma
• Seen in low-grade NHL and in HL (Hodgkin’s lymphoma).
• Sclerotic lesion may occur as a result of healing.

Myelosclerosis
A part of myeloid metaplasia
• A group of conditions ranging from myeloid metaplasia,
myelofibrosis to polycythemia rubra vera and CML
 Skeletal System and Joints 495
• Marrow-fibrous tissue-bone formation
• Has to be differentiated from osteopetrosis, fluorosis,
mastocytosis.

Mastocytosis
• 1/3rd cases, presenting with urticaria pigmentosa, show bone
changes
• Coarsened trabecular pattern with focal lumpy/confluent areas
of sclerosis. It may terminate as leukemia.

Bone Island and Osteopoikilosis

• Island is just a lump of bone (hamartoma). In osteopoi­kilosis,
multiple islands are seen especially in periarticular areas and
are well-defined, lanceolate, along the trabecular
• Familial and has to be differentiated from secondaries and
tuberous sclerosis which shows ill-defined patchy, cotton-wool,
flame-shaped opacities with islands.

OSTEOMA
Ivory spongy osteoid Differentiation from
Neuroblastoma, Osteomyelitis, Granu-
loma; Bleed; Stress fracture
• Small, well-defined tumor consisting primarily of well-differen-
tiated bone; skull, PNS, mandible, pressure symptoms
• Osteoid osteoma: Diaphysis of long bone; neural arch; central
nidus with surrounding sclerosis; periosteal reaction, if tumor
is near surface. Bone scintigraphy has an important role to play
(Fig. 6.67).

OSTEOBLASTOMA
• < 30 years; flat bones and vertebral appendages; some call it a
large irregular and aggressive osteoid osteoma.
496 Differential Diagnosis in Radiology

Fig. 6.67:  Lateral radiograph of thigh shows osteoid

osteoma of femur with small lucent nidus

• Large, irregular, well-defined, expansile tumor with internal

punctate calcification d/d GCT, ABC, osteoid osteoma,
osteosarcoma.

OSTEOSARCOMA (Fig. 6.68)

• Most common primary malignant bone tumor; may be
osteoblastic, chondroblastic, fibroblastic or telangiectatic
• Most common about the knee; 10–25 years; metadiaphyseal;
medulla is the site of origin
• Metastasis especially to lungs causing pneumatocele; Codman’s
triangle
• A sclerotic destructive eccentrically growing mass showing
good vascularity, differentiates other sarcomas, osteo­myelitis;
secondaries.
 Skeletal System and Joints 497

Fig. 6.68:  Anteroposterior radiograph of thigh shows

osteosarcoma of femur with pathological fracture

Rare Variants
Multifocal; diaphyseal; central; soft tissue osteosarcoma.
• Due to radiotherapy (3000 rad for 7–10 yrs)—Lytic aggre­ssive:
Radium ingestion known as secondary osteo­sarcoma.
• Other variants are parosteal and periosteal osteosarcoma.

OSTEOMYELITIS
• Especially pyogenic, syphilitic, fungal, sarcoidosis, Garre’s and
Brodie’s osteomyelitis.

BONE INFARCTS (Fig. 6.69)

• Whether septic or aseptic, an infarct leads to an irregular
sclerotic serpentine area in the medulla.
498 Differential Diagnosis in Radiology

6.73  LYTIC LESION IN BONE

Single Multiple
With Marginal Sclerosis
• Geode/subarticular • Metastasis
lucent cysts • Multiple myeloma
• Brodie’s abscess • FD (Polyostotic)
• Fibrous dysplasia • Brown tumor
• Implantation dermoid • Eosinophilic granuloma
• Neoplasm-Benign- • Metastatic neuroblastoma
osteoid osteoma
• Simple bone cyst (Fig. 6.70)
• Geode (Multiple)
• Chondroblastoma
• Enchondroma
• Adamantinoma

Fig. 6.69:  Lateral radiograph of knee shows medullary

infarcts in femur and tibia
 Skeletal System and Joints 499
Malignant
Healing benign or malignant
Without marginal sclerosis
• Eosinophilic granuloma (EG)
• Brown tumor
• Multiple myeloma (MM)
• Metastasis
• Enchondroma
• Chondroblastoma
• Metastatic neuroblastoma.

EXPANSILE BONE LESION

• Giant cell tumor (GCT)
• Aneurysmal bone cyst (ABC)
• Enchondroma

Fig. 6.70:  Anteroposterior radiograph of shoulder shows

simple bone cyst with pathological fracture
500 Differential Diagnosis in Radiology
• NOF (Non-ossifying fibroma)
• Chondromyxoid fibroma.

GEODE
• Subarticular lucent bone lesion
• Seen in osteoarthritis, rheumatoid arthritis. Calcium pyrophos-
phate deposition disease (CAPD)
• OA and CPPD = Multiple cysts in the load bearing areas of
multiple joints with surrounding sclerotic margin
• RA = No sclerosis.

BRODIE’S ABSCESS
• Localized bone infection presenting as subacute on chronic
infection
• Clinical presentation
• Site—metaphysis—diaphysis
• Radiological features—Circumscribed area of bone destruction
with a variable degree of surrounding bone reaction.

Tunneling
• CT and MR-ovoid lesion with long-axis parallel to bone
• Scintigraphy—Enhances on the delayed isotope scan
• Unknown etiology, M>F, 10–30 years.

FIBROUS DYSPLASIA (FD)

Radiological Features
• Monostotic or polyostotic (multiple bones) (Fig. 6.71)
• Location—Diametaphyseal, pelvis, femur and rib, smooth,
dense margin of varying width—‘Rind of an orange’
• Cortex—Scalloped and thinned but intact
• MRI—Fluid-filled cyst
• Mineralization/fibrous tissue.
 Skeletal System and Joints 501

Fig. 6.71: Polyostotic fibrous dysplasia

IMPLANTATION DERMOID
• Cyst lined by epidermis
• Previous history
• R/F—Well-defined round lytic lesion
• Minimal sclerosis is seen surrounding the lesion.

Age
2nd and 3rd decade, M:F = 2.5:1

Clinical Presentation
Site — Diaphysis or metaphysis of tubular bone
R/F — NIDUS—Characteristic feature—10 mm or less
surrou­nding the nidus is a region of reactive sclerosis
and periosteal new bone formation.
CT — Thin section—2 mm.
Scintigraphy—An intense focal abnormality and
intense activity persistent on delayed image.

SOLITARY BONE CYST

Unilocular: Site—proximal humerus and femur—before
epiphyseal closure calcaneum = mature skeleton
502 Differential Diagnosis in Radiology
M>F
In metaphysis may extend into diaphysis.

Radiological Features
• Area of lucency is metadiaphysis
• Overlying cortex is thinned-out, sclerotic reaction around the
margin, no calcification
• Scintigraphy—No abnormality in blood pool phase as in
aneurysm bone cyst (ABC)
• Delayed image—Increased activity around the margin.

CHONDROBLASTOMA
• Second decade of age, epiphysis or apophysis
• Frequently extend into metaphysis
• Well-defined, radiolucent, oval lesion with thin rim of sclerosis
and cortical expansion.
Stippled calcification — 25%
Adjacent periosteal reaction
CT and MR — Extension into soft tissue
Bone scan — Increased activity in blood pool phase.

ENCHONDROMA
50% Hands 20% = Femur, Humerus and Tibia
10% small bones feet
20% Flat bones
Age — 2nd and 3rd decade, flecks of calcification
within the tumor—popcorn appearance
Scintigraphy — Unremarkable
MRI — Hyperintense on T2WI (hyaline cartilage).

ADAMENTINOMA OF LONG BONES

Mid-half of tibia (femur)
Age — 10–50 (Avg. 35 years)
Sex — M:F = 5:4
 Skeletal System and Joints 503
Radiological Features
Multilocular appearance and satellite lesion are diagnostic.

Eosinophilic Granuloma
Age — 3–12 years
Site — Skull, pelvis, femur and spine. Diaphysis in
long bones 2/3rd solitary
R/F — Lucent lesion with sharply defined margins
active phase, no sclerosis
Healing phase — Peripheral sclerosis
Vertebra plana — Associated with paravertebral soft tissue
mass.

BROWN TUMOR OF
HYPERPARATHYROIDISM
Site — Metaphysis and diaphysis unusually respon­
sive to PTH solitary or multiple. Other
associated feature is resorption of bones
• Chondrocalcinosis
• Pepper pot skull
• Renal lithiasis.

MULTIPLE MYELOMA (PLASMACYTOMA)

Solitary or multiple
> 40 years, M:F =2:1
• Persistent bone pain or pathological fracture
• Radiological features—Diffuse osteoporosis
• Rounded or oval defects with sharp margin
• No marginal sclerosis
• Long bones, spine, clavicle, scapula and skull
• Laboratory investigation—Increased total serum protein, Bence
Jones proteinuria (abnormal urinary protein/hypercalcemia
increase).
504 Differential Diagnosis in Radiology

Fig. 6.72:  Anteroposterior radiograph of ankle joint

region shows osteolytic metastasis

METASTASES (FIG. 6.72)

Elderly age group : Spine, pelvis and ribs, proximal end
of humerus and femur
Females : Most common is breast
Males : Prostate, lung and kidney.
Majority are osteolytic
• Soft tissue extension is uncommon without much perio­steal
reaction, lung, breast = lytic
• Renal cell carcinoma = Solitary lesion in pelvis and lumbar
spine, if multiple < 6 in number
• Thyroid—Expansile and lytic and often solitary
• Lab-alkaline phosphatase is increased
• Serum carcinoma is increased.
 Skeletal System and Joints 505
GCT (OSTEOCLASTOMA) OR
GIANT CELL TUMOR (FIG. 6.73)
Age — 20–40 years, M>F
Site — Subarticular, bones adjacent to knee joint and wrist,
eccentric.
No calcification/ossification, no periosteal reaction.
40% — Soap-bubble pattern or trabeculations. It may produce
well-defined extension into soft tissue.
Blood pool phase of bone scan shows increased activity.

ABC (Aneurysmal Bone Cyst) (Fig. 6.74)

Age — Before epiphyseal fusion and usually central
Site — Long bones and lumbar spine. Neural arch
increase

Fig. 6.73:  Anteroposterior radiograph of wrist region shows

GCT of distal end of ulna
506 Differential Diagnosis in Radiology

Fig. 6.74:  Anteroposterior radiograph of left hip shows ABC of pubic bone

RIF — An area of bone resorption with expansion of

overlying cortex thinned out and expan­ded.
CT and MR — Fluid levels in the extravascular space.

Chondromyxoid Fibroma
Peak — 20–30 years
Site — Metaphysis, around the knee joint

Radiological Features
Eccentric space occupying lesion in metaphysis
Margins are well-defined with surrounding sclerosis, no calcification.

Bone Scan
Increased activity localized to reactive sclerosis.
 Skeletal System and Joints 507

1.  Areas of bone destruction

2.  “Sunburst” periosteal reaction
3.  “Codman triangle”
4. Circumferential soft-tissue
mass
5. Pathologic fracture through
growth plate

Fig. 6.75: Metastatic neuroblastoma. The permeative destructive lesion

throughout the entire femoral shaft in a child with metastatic neuroblas-
toma. The tumor has penetrated into the soft tissues along the distal half
of the shaft, resulting in a large, circumferential soft tissue mass. The pres-
ence of a “sun-burst” periosteal reaction and Codman’s triangles indicates
the rapidity with which the tumor has broken through the periosteum.
There is a pathologic fracture through the distal femoral growth plate

Metastatic Neuroblastoma (Fig. 6.75)

• < 5 years already known to have abdominal mass
• R/F — Multiple, often symmetric, lytic bone lesion
— Skull lesions are common
• Cranial sutural margin may be infiltrated with widening of
suture lines
• Long bones and shaft may be penetrated
• Diagnosis identification of primary tumor and raised blood
level and urinary catecholamine.
508 Differential Diagnosis in Radiology

NON-OSSIFYING FIBROMA
10–20 years, around the knee joint.

Radiological Features
• Increased radiolucency with well-defined margin in meta­
diaphysis thin zone of reactive sclerosis.
• Cortex is expanded but remains intact and thinned.

6.74  D/D OF GENERALIZED OSTEOPOROSIS

Osteopenia
Generalized or regional rarefaction of the skeleton is decrease in
bone density.

Causes of Diffuse Osteopenia

1. Osteoporosis—Diminished quantity of bone matrix but normal
mineralization of remaining bones.
2. Osteomalacia—Normal quantity of bone but defective
mineralization of osteoid.
3. Hyperparathyroidism—Increased bone resorption by osteo-
clasts.
4. Diffuse infiltrative bone diseases, e.g.
• Multiple myeloma-leukemia
• Gaucher’s disease.

Generalized Osteoporosis
1. Disorders of multiple/uncertain cause
a. Senile osteoporosis
b. Juvenile osteoporosis
c. Postmenopausal osteoporosis.
2. Endocrine
a. Cushing’s disease
b. Hypothyroidism
 Skeletal System and Joints 509
c. Hyperthyroidism
d. Hypogonadism
e. Hypopituitarism
f. Acromegaly
g. Diabetes mellitus.
3. Congenital
a. Osteogenesis imperfecta
b. Homocystinuria.
4. Nutritional disturbances
a. Scurvy
b. Protein deficiency
c. Calcium deficiency.
5. Drugs
a. Heparin
b. Steroids
c. Vitamin A.
6. Chronic diseases
a. Chronic renal disease—Renal osteodystrophy
b. Hepatic insufficiency
c. Chronic inflammatory polyarthropathies
d. GI malabsorption syndromes
e. Chronic debility or immobilization.

Osteoporosis
• No evidence of hyperparathyroidism or osteomalacia
• Evidence of conditions such as senility, immobilization,
postmenopausal state, or other causes to explain it.

Roentgenological Changes
Most prominent in axial skeleton, proximal humerus, femur, wrist
and ribs.
1. Long Bones
• Cortical thinning with irregularity of endosteal surface
• The thin cortex maintains normal mineral content and
appears dense
510 Differential Diagnosis in Radiology
• Deossification of spongy bone
• Prominence of trabeculae in lines of stress
• Delayed fracture healing with poor callus.
2. Spine (Fig. 6.76)
• Diminished radiographic density
• Vertebral end plates are thin and dense
with “Pencilling in” of vertebrae
• Irregular endosteal surface of vertebral
end plates
• Vertical striations because of the loss of
horizontal trabeculae and accentuation of
vertical trabeculae along the lines of stress
• Compression deformities with biconcave
vertebral bodies—cod fish vertebrae
• Absence of osteophyte formation.

Senile Osteoporosis Fig. 6.76: Later-

al radiograph of
Etiology DL spine shows
osteoporosis
• Reduced intestinal absorption with collapse of
• Decreased adrenal function vertebrae
• Secondary hyperparathyroidism
– There is proportionate loss of cortical and
trabecular bone.
– Fractures most commonly in femoral neck, proximal
humerus, tibia and pelvis.
– F:M=2:1.

Juvenile Osteoporosis
• Idiopathic self-limiting disorder
• Affects both sexes typically before puberty
• Clinically bone pain, backache and limp
 Skeletal System and Joints 511
• Blood chemistry is normal
• Fracture of metaphysis of long bones with minimal trauma
• Vertebral collapse, wedging and kyphosis

Postmenopausal Osteoporosis
• Affects women in 50–65 years’ age group.

Etiology
• Reduced estrogen levels
• Nutritional status, level of activity and genetic causes also
influence
• There is disproportionate loss of trabecular bone with rapid
bone loss
• Fractures commonly affect vertebrae with wedging fracture of
distal radius.

Cushing’s Syndrome
• Due to excess of adrenocortical steroids
• Negative calcium balance and hypercalciuria
• Decreased bone formation and increased resorption.

Imaging
1. Osteoporosis.
2. Exuberant callus formation causing increased density of
endplates of compressed vertebral bodies.
3. Multiple painless rib fractures.
4. Osteonecrosis.

Hypothyroidism
• Cretinism in children, myxedema in adults.
• Retarded skeletal maturation, fragmented epiphysis.
• Bullet-shaped vertebrae.
• Osteoporosis.
512 Differential Diagnosis in Radiology

Hyperthyroidism
• Increased metabolic activity with increase in bone formation
and resorption
• Bone resorption causes generalized osteopenia in skull, pelvis,
spine and long bones
• Vertebral wedging, cod fish vertebrae and kyphosis
• Pretibial myxedema.

Hypogonadism
• Due to decreased production of gonadal hormones or LH and
FSH by pituitary.
– In males—Delayed closure of epiphysis with long limbs and
short trunk.
– In females—Turner’s syndrome—short stature, cubitus
valgus, osteoporosis, short 4th metacarpal, webbed neck
and cardiovascular anomalies.

Hypopituitarism
• Deficiency of growth hormone results in cessation of
endochondral ossification
• Retarded skeletal maturation and delayed skeletal growth
• Overall reduced bone density due to reduced bone forma­tion.

Acromegaly
• Rarely causes osteoporosis
• Enlarged paranasal sinuses, prognathism and frontal bossing
• Enlargement and scalloping of vertebral bodies
• Arrow head terminal phalanges and increased heel pad
thickness.

Osteogenesis Imperfecta
• Inherited disorder of connective tissue with abnormal
maturation of collagen
 Skeletal System and Joints 513
• Classical clinical triad: Fragile long bones, blue sclerae and
deafness
• Diffuse osteopenia with thin fragile long bones, multiple
fractures and bowed bones
• Exuberant callus.

Scurvy
• Long-term deficiency of vitamin C (> 6 months)
• Children present with limb pain and irritability.

Imaging
1. Epiphysis is small and sharply marginated by a sclerotic rim.
2. Increased density of zone of provisional calcification.
3. Transverse band of lucency in metaphysis known as
Trümmerfeld zone.
4. Metaphyseal spurs—Pelkan’s spurs.

Protein Deficiency
Protein deficiency produces osteoporosis due to deficiency
of matrix production, e.g. in malnutrition nephrosis, diabetes
mellitus, Cushing’s syndrome and hyperthyroidism.

Heparin Toxicity
• Heparin has a direct local stimulating effect on bone resorption
• Large doses of heparin >15000 units/day
• Hyper-heparin states occur in Marfan’s and Hurler’s syndrome
and mast cell disease.

Renal Osteodystrophy
• Bony changes in patients suffering from chronic uremia due to
long standing renal disease.
514 Differential Diagnosis in Radiology

Imaging Features
a. Secondary hyperparathyroidism—bone resorption
b. Osteoporosis
c. Osteosclerosis—Rugger Jersey spine
d. Soft tissue calcifications.

Arthropathies (Rheumatoid Arthritis)

• May cause osteoporosis due to steroids or limitation of
movement due to pain or muscle wasting
• Erosive changes, alignment deformities and soft tissue swelling
may be found.

Disuse Osteoporosis
• Results from lack of stress and strain on bone
• Frequently caused by paralysis or body cast
• Osteoblasts remain inactive and older bone is not replaced
• Relieved when the affected part is mobilized.

Osteomalacia
• Due to vitamin-D deficiency in adults
• Defective mineralization of osteoid in mature cortical and
cancellous bone
• Pseudofractures or Looser’s zones—Bilateral symmetrical focal
accumulations of osteoid at right angles to long-axis of bones
• Intracortical resorption, osteopenia with coarse trabecular
pattern.

Hyperparathyroidism
• Affects mainly middle-aged women
• Increase in parathyroid hormone causes increase in osteoclastic
bone resorption
 Skeletal System and Joints 515
• X-ray—Subperiosteal, intra-cortical, subchondral, trabe­
cular
and subligamentous bone resorption.
– Brown tumors, Pepper-pot skull.
– Osteopenia.

Diffuse Infiltrative Disorders

For example: Multiple myeloma, leukemia and Gaucher’s disease
may cause extensive deossification because of proliferation of
plasma cells, leukemic cells or histiocytic cells in bone marrow.

6.75  SOLITARY DENSE VERTEBRA

Lymph
• Lymphoma
• Low-grade infection
• Metastasis
• Paget’s disease
• Hemangioma.

Metastasis
1. Sclerotic metastasis
• Medulloblastoma
• Bronchus
• Breast
• Bladder
• Bowel (especially carcinoids)
• Lymphoma
• Prostate.
2. Lytic metastasis—after T/F.
3. No alteration in vertebral body size.
4. Disk spaces preserved.
5. Multiple.
6. Lower thoracic and lumbar spine—Most common site.
7. Sclerotic lesions are hypointense on both T1WI and T2WI.
516 Differential Diagnosis in Radiology

Paget’s Disease
• Usually a single vertebral body is affected—lumbar spine and
sacrum
• Expanded body with thickened cortex and coarsened
trabeculations and picture-frame vertebra
• Disk space involvement is uncommon.
– Fish vertebra—due to structural weakness (biconcave)
– Involvement of posterior elements helps to differentiate
from hemangioma.

Lymphoma
• HL>NHL—40–60 years
• Normal-sized vertebral body
• Disk spaces intact
• MR—focal or diffuse hypointensity than normal marrow on T1
WI and iso- or hyperintensity than normal marrow on T2WI
• Low-grade infection
– End plate destruction.
– Disk space narrowing
– Paraspinal soft tissue mass.

Hemangioma (Figs 6.77A and B)

Prominence of the secondary bony trabeculae of the vertebral
body causing a striate or honey-comb pattern.
• Expansion +/–
• Lower thoracic and lumbar spine
• Multiple lesions in 25–30% cases
• NECT—Lucent lesion with typical ‘polka-dot’ densities in
medullary spaces
• Hyperintense on both T1 and T2WI.
• Disk space preserved.
 Skeletal System and Joints 517

A B
Figs 6.77A and B: Anteroposterior and lateral radiographs of lumbar
spine shows hemangioma of vertebra

6.76 ACRO-OSTEOLYSIS
• Loss of terminal tufts of digits
• Scleroderma/Connective tissue disease
• Psoriatic arthritis
• Reiter’s disease
• Frostbite (thumbs spared)/burns
• Leprosy
• Polyvinyl chloride exposure
• Hyperparathyroidism
• Cleidocranial dysostosis
• Progeria
• Pyknodysostosis
• Sarcoidosis.
518 Differential Diagnosis in Radiology

Cleidocranial Dysostosis
Autosomal dominant, 33% sporadic
• Skull
• Cranial dysplasia
• Wormian bones
• Basilar invagination.

Clavicles
• Aplasia/hypoplasia usually lateral portion.

Other Skeletal Abnormalities

• Small, high scapula
• Wide symphysis pubis
• Acro-osteolysis.

Hajdu-Cheney Syndrome
An osteolytic syndrome with skull deformities, characteristic
facies, osteoporosis, premature loss of teeth, joint laxity, short
stature, dissolution of the terminal phalanges, hearing loss and a
hoarse voice.
• The changes in the terminal phalanges in this condition as well
as in pyknodysostosis are pseudo-osteolysis, that is the disorder
of defective development rather than bone destruction of bone
already formed
• The patients show brachycephaly (projection of the occipital
area and a deep groove at the lambdoid sutures, both in the
occipital and parietal bones).

Progeria
An abnormal congenital condition, associated with defect in the
lamin type A gene, which is characterized by premature aging in
children, where all the changes of cell structure occur.
 Skeletal System and Joints 519
• Normal at birth
• “Wizened old man”: Alopecia, atrophy of muscles and skin
• Atherosclerosis = coronary artery disease
• Dwarfism
• Abnormal facies: Receding chin, beaked nose and exophthalmos.

Findings
• Acro-osteolysis
• Hypoplastic facial bones + sinuses
• Open cranial sutures + fontanelles, Wormian bone
• Coxa valga.

Pyknodysostosis
• Autosomal recessive
• Dense, sclerotic bones.

Features
• Open cranial sutures + fontanelles
• Wormian bones
• Dolichocephaly
• Sclerotic vertebrae
• Fractured long bones
• Short, stubby bones
• Partial agenesis/aplasia of terminal phalanges.

Psoriatic Arthritis

Types
1. True psoriatic arthritis (1/3).
2. Resembling rheumatoid arthritis (1/3).
3. Combination of psoriatic and rheumatoid arthritis (RA) (1/3).
520 Differential Diagnosis in Radiology

Findings
• No juxta-articular osteoporosis (unlike RA)
• Periosteal reaction—frequent
• Asymmetrical destruction of distal interphalangeal joints with
ankylosis
• Resorption of terminal tufts with “pencil-in-cup” deformity
• Ivory phalanges
• Destruction of first toe interphalangeal joint with periosteal
reaction and bony proliferation at distal phalangeal bone
(Pathognomonic)
• Asymmetrical syndesmophytes (lower cervical to upper lumbar
spine)
• Squaring of vertebrae in lumbar spine
• Paravertebral soft tissue calcification
• Bilateral asymmetrical sacroiliitis.

Sarcoidosis
Non-caseating granulomatous disease
• Unknown etiology
• Young adults, blacks more than whites
• Prognosis usually good
• May affect any organ
• Chest most often involved
• Diffuse pulmonary infiltrate, may resolve or progress to fibrosis
– HRCT
– Mediastinal adenopathy
– Early = septal thickening, peribronchovascular nodules,
alveolar ground glass opacity
– Late = Traction bronchiectasis, fibrosis, honey-combing
– Skeleton involved in 10%
– Differential diagnosis: Bronchial/transbronchial biopsy
(60–95% diagnostic), liver or scalene biopsy.
 Skeletal System and Joints 521
Scleroderma/Progressive Systemic Sclerosis (PSS)
• Hypertrophy than atrophy of collagen fibers
• 4–6th decade, M:F = 1:3
• Bones
– Punctate soft tissue calcification (finger tips, shoulder, hips)
– Acro-osteolysis (63%).
• Intercarpal joint space narrowing (late).
• Chest
– Evident in 10–25%
– Pulmonary fibrosis with diffuse reticulate infiltrate
– Predominantly in lower lungs.
• GI
– Esophageal dilatation and aperistalsis (>50%)
– Hiatus hernia + GE reflux + Esophagitis.

Distal Esophageal Stricture

• Gastroparesis
• Dilation and dysmotility of small bowel
• Pseudosacculations and dysmotility of colon.

Reiter’s Syndrome
• Males
• Polyarthritis
– Feet
– SI joints
– Knee/Ankles (Joint effusion)
• Urethritis
• Uveitis/Conjunctivitis.
Polyvinyl chloride may cause or feature the following:

Miscellaneous syndromes
– Acro-osteolysis
– Carcinogeneosis.
522 Differential Diagnosis in Radiology

Symptoms and Signs

– Raynaud’s phenomenon.

Cranio-mandibular Dysostosis
• Acro-osteolysis
• Arthropathy
• GI bleeding
• Micrognathia
• Short stature.

6.77 SACROILIITIS
Only anteroinferior aspects of SI joint are covered with cartilage
(1 mm hyaline cartilage on iliac side, 3–5 mm fibrous cartilage on
sacral side, with normal joint width of 2–5 mm).
• Erosions—widening of joint space
• Subchondral bone sclerosis—bony ankylosis
• Periarticular osteoporosis—Eventual return of normal bone
density.

Differential Diagnosis of Sacroiliitis

A. Bilateral symmetrical:
– Ankylosing spondylitis
– Psoriatic arthritis
– Intra-bowel disease: Crohn’s, Whipple’s
– Rheumatoid arthritis
– Deposition arthropathy, gout, CPPD
– Osteitis condensans ilii—More common in females, young,
normal joint space (Fig. 6.78)
– Hyperparathyroidism, subchondral bone resorption and
increased joint space
– Paraplegia—Decreased joint space and osteoporosis.
B. Bilateral asymmetrical
Psoriatic arthropathy—40% of cases.
 Skeletal System and Joints 523
Reiter’s Syndrome
Juvenile rheumatoid arthritis (JRA)
Osteoarthritis (OA): Smooth articular margins and well-defined,
decreased joint space, subchondral bone sclerosis, anterior
osteophytes (Fig. 6.79).
C. Unilateral (U/L)

Infection
OA—abnormal mechanical stress.

ARTHRITIS INVOLVING SPINAL COLUMN

• Ankylosing spondylitis
• Rheumatoid arthritis
• Psoriatic arthritis
• Reiter’s syndrome

Fig. 6.78:  Anteroposterior radiograph of SI joints show

idiopathic condensans ilii
524 Differential Diagnosis in Radiology

Fig. 6.79:  Anteroposterior radiograph of knee joint shows osteoarthritis

• Osteoarthritis
• DISH
• JRA (juvenile rheumatoid arthritis).

ANKYLOSING SPONDYLITIS (FIGS 6.80A AND B)

Seronegative
97% of patients for HLA B27
Age Late teens and 20’s sex—equal in both sexes,
osteopenia
SI joint Symmetrical, erosions (more on iliac side), joint
widening heals by sclerosis—joint narrowing
(whiskering), fusion.

Spinal Column
After the SI joint, begins at dorsolumbar or L-S region and then
progresses to other areas.
 Skeletal System and Joints 525
Vertebral Body Squaring
A. Osteitis and erosions adjacent to vertebral-endplate margins—
shiny or ivory corner.
B. All mineralization
Syndesmophytes—hallmark (Annulus fibrosus calcifi­cation)
= maturation leading to “Bamboo spine”, similar well-defined
ossification seen in interspinous ligament and around minor
and major joints.

Enthesitis
Shaggy or whiskered pattern at IT and GT.

A B
Figs 6.80A and B: (A) Anteroposterior radiograph of LS spine with SI
joints shows ankylosis of SI joints with bamboo spine in a case of ankylos-
ing spondylitis; (B) Lateral radiograph of cervical spine shows anterior and
posterior longitudinal ligament ossification in a case of ankylosing spon-
dylitis
526 Differential Diagnosis in Radiology

Spinal Fusion
After the calcification of IV disk.

Psoriatic Arthropathy
• 10% patients develop arthritis before skin lesions appear
• In 25%—Develops simultaneously
• 65%—Psoriasis precedes arthritis.

Clinical Features
Normal bone, mineralization.
• SI joint—Seen in 50% of patients who have polyarthritis
• B/L symmetrical in 60%, asymmetrical in 40%
• Erosion—Joint widening sclerosis. Fusion is less common than
in ankylosing spondylitis
• Enthesitis—IT and calcaneum
• Spine—Segmental, asymmetrical, can involve any region
• Paravertebral ossification—common and characteristically
symmetric, squaring of vertebral body. Atlanto-axial
subluxation in some cases.

Other Features
• Frequently affection of hands
• Sausage digit
• Erosion at DIP and IP of great toe, cup and pencil appearance
(because of osseous fusion of IP joint).
• Arthritis mutilans.

Reiter’s Syndrome
Young female, STD, characteristic triad of arthritis, urethritis and
conjunctivitis associated with HLA B27 skeletal involvement seen
eventually in 80%.
• SI joint—sacroilitis—late in case of Reiter’s disease, seen in
50% bilateral and asymmetrical. Fusion is less frequent than
ankylosing spondylitis
 Skeletal System and Joints 527
• Spine—Similar to psoriatic arthritis, except paravertebral
ossification which is asymmetrical segmental around the
dorsolumbar junction. Another feature—affects the feet rather
than hand, MTP and IP joints of great toe. Normal mineralization
• Irregular erosion and enthesitis
• Painful erosion and reactive spur very common around the
calcaneum.

RHEUMATOID ARTHRITIS (RA) (FIG. 6.81)

• 20–55 years, female more than M<G, mainly affects the small
joints
• SI joint—sacroilitis—seen in few patients, erosive process is not
as aggressive as in other joints. Bone mineralization decreased
• Spine—Most common site = upper cervical spine
• Subluxation—because of rupture of transverse ligament
• Erosion of odontoid—finally leading to fracture of odontoid
leading to basilar invagination
• Apophyseal joint and disc space—rare-eroded-fused
• Malalignment.

OSTEOARTHRITIS (OA)
(DEGENERATIVE CHANGES)
• Degenerative arthritis of synovium—elderly
• SI joint—rarely involved—smooth anterior margins, joint space
decreased, subchondral sclerosis, anterior osteo­phytes
• Spine—Space bilateral and opposing bones become narrowed
with marginal new bone formation—osteophyte— +ve and
horizontal
• Most common sites are cervical and lumbar spine (Lower
cervical—C5-C6) and C6-C7
• Vertebrae (C3 to C7) joints—narrowing of these joints with
osteophytic lipping.
528 Differential Diagnosis in Radiology

Fig. 6.81: Anteroposterior radiograph of both wrists shows

severe rheumatoid arthritis

DISH (FORESTIER’S DISEASE)

• Elderly female, M:F=3:1, HLA B 27 in some patients. Excessive
ossification found at many sites
• SI—involved, the ligamentous part of joint fusion, less common
• Spine—Cervical and lower thoracic (on right side)
• Flowing ossification of spine involving 4 or more continuous
vertebrae and hyperostosis of some ligame­ntous attachment
and around the iliac crest, ischia and above the acetabulum
• Normal vertebral and normal I/V disk space—No erosion.

Enteropathic Spondyloarthropathies
• Uncommon, Crohn’s, Whipple’s disease—may be associated
with joints, disease of secondary type.
 Skeletal System and Joints 529
1. Peripheral—ST swelling and local periostitis patients are
sero –ve and HLA B27 –ve.
2. Sacroilitis and spondylitis—identical to ankylosing
spondylitis. Do not correlate with gut disease activity!
Patients are usually male and increase positivity for HLA
B27 antigen (approx 60%).

Juvenile Rheumatoid Arthritis (JRA)

• Less than 16 years, 10%-Rh +ve, 90%-Rh –ve, osteopenia
• SI joint—B/L asymmetrical, similar to ankylosing spondylitis
• Spinal—Cervical spine under developed vertebral, increase IV
disk space
• Atlanto-axial subluxation in sero +ve patients. Other joint-
metacarpophalangeal and intercarpal joints—usual site
• Chronic synovitis and effusion—Increase of carpal bones and
epiphysis.

6.78  BONE CYST

Cyst is a well-defined lucent lesion presenting in the bone. It can
either be solitary or multiple and may be present in the epiphysis,
metaphysis or diaphysis. It can be expansile, non-expansile,
uniloculated or multiloculated.
It may or may not have a sclerotic margin. The features, however,
are not diagnostic and there is considerable overlap.

NON-EXPANSILE UNILOCULAR
CYSTIC LESIONS
• Fibrous cortical defect (Fig. 6.82)
• Non-ossifying fibroma
• Simple unicameral bone cyst
• Brown tumor of HPT
• Eosinophilic granuloma
• Enchondroma
• Epidermoid inclusion cyst
530 Differential Diagnosis in Radiology

Fig. 6.82: Fibrous cortical defect. The most common benign bone tumor, it
appears as a small oval lucency in the cortex of the posteromedial aspect
of the proximal tibial shaft

• Post-traumatic/degenerative cyst
• Pseudotumor of hemophilia
• Interosseous ganglion
• Histiocytoma
• Arthritic lesion
• Endosteal pigmented villonodular synovitis
• Fibrous dysplasia
• Infectious lesions (Brodie’s abscess)
• Metastasis.

NON-EXPANSILE
MULTILOCULAR CYSTIC LESION
• Aneurysmal bone cyst
• Giant cell tumor
• Fibrous dysplasia.
 Skeletal System and Joints 531
EXPANSILE UNILOCULAR
CYSTIC LESIONS
• Simple bone cyst
• Enchondroma
• Aneurysmal bone cyst
• Juxtacortical chondroma
• Nonossifying fibroma
• Eosinophilic granuloma
• Brown tumor of HPT
• Chondromyxoid fibroma
• Hydatid cyst
• Lipoma.

Lesions Surrounded by Marked Sclerosis

• Osteoid osteoma
• Brodie’s abscess
• Chondroblastoma
• Plasmacytoma.

Multiple Cystic Lesions

• Fibrous dysplasia
• Enchondroma
• Eosinophilic granuloma
• Metastasis
• Multiple myeloma
• Brown tumors
• Cystic angiomatosis of bone
• Gaucher’s disease.

Fibrous Cortical Defect

• Peak age 7–8 years, mostly before epiphyseal closure
• Present at metaphyseal cortex of long bones, most commonly
posterior medial aspect of distal femur
• Round to oval, average diameter of 1–2 cm
532 Differential Diagnosis in Radiology
• Extends parallel to long-axis of the bone
• Cortical thinning and expansion may occur
• Smooth well-defined scalloped margins
• Involutes over 2–4 years.

Non-ossifying Fibroma
• Much larger than fibrous cortical defect and presents at an
older age group 10–20 years
• Majority are found near knee joint, distal end of femur being
the most common site
• Sharply-defined radiolucent lesion at metadiaphysis and have a
lobulated appearance with a thin zone of reactive sclerosis
• May cause cortical expansion but the cortex remains intact
• Lesions have a tendency to regress and multiple lesions may be
associated with neurofibromatosis.

Simple Bone Cyst

• Also known as unicameral bone cyst
• Always unilocular and well-defined
• Site of origin depends on the age of presentation, prior to
epiphyseal fusion. They usually occur in the proximal humeri
and femora. After epiphyseal fusion, some lesions may occur in
bones, like calcaneum. By far, the most common site is proximal
humerus
• During the stage of skeletal maturation, the lesion is carried
from its usual metaphyseal location to diaphysis. The usual
location is thus metadiaphyseal
• The overlying cortex is often thinned and slightly expanded
with no periosteal reaction unless a fracture has occurred
• The lesions may be surrounded by a discrete sclerotic margin.

Brown Tumor of HPT

• Alike osteoclastoma and pathologically, it is due to replacement
of bone by vascularized fibrous tissue and collection of
osteoclasts
 Skeletal System and Joints 533
• Most common locations are jaw, pelvis, rib and metaphysis of
long bones
• Often eccentric and cortical in location and is most frequently
solitary but may be multiple
• They are expansile, well-marginated and cyst-like with
endosteal scalloping
• Other signs of hyperparathyroidism are present.

Eosinophilic Granuloma
• Most benign variety of histiocytosis X and, in 60–80% cases,
it is localized to bone with age incidence of 2–30 years. Most
common in 5–10 years of age. Solitary lesions are most common
but they can be multiple
• Lesions arise within the medullary canal and skull is the site in
50% of cases and that too the diploic space of parietal bone
being most frequent. The mono-ostotic involvement is most
frequent
• These are round or ovoid punched-out lesions with beveled
edges and with a sharply-marginated sclerotic rim is present
• Appearances may also be of hole within hole or that of button
sequestrum
• There may be an overlying soft tissue mass.

Enchondroma (Fig. 6.83)

• Benign cartilaginous growth in the medullary cavity. Bones
with enchondral calcification are affected, the skull is thus not
affected
• Age of presentation is 10–30 years
• An oval or round lucency is present near epiphysis with fine
marginal line with scalloped well-defined margins and ground
glass appearance
• Calcifications may be present in the lesion and there could be
bulbous expansion of the bone with cortical thinning with no
cortical breach or periosteal reaction
534 Differential Diagnosis in Radiology
• Multiple enchondromas may be seen in Ollier’s disease. In
Maffucci’s syndrome, multiple enchondroma are associated
with soft tissue cavernous hemangiomas.

Epidermoid Inclusion Cyst

• Alike implantation cyst and is most commonly seen in the age
group of 20–40 years
• Seen in superficially located bones as in the calvarium, phalanx
and foot
• These are well-defiend lesions with a sclerotic margin and
cortex is frequently expanded and thinned
• No calcifications, soft tissue mass or periosteal reaction are
noted.

Geodes
These are cystic lesions, usually subarticular in location and are
secondary to arthritis and osteonecrosis. The etiology is similar
to post-traumatic cysts and is due to bone necrosis leading to
intrusion of synovial fluid and a connection with the joint may be
demonstrated.

Intra-osseous Ganglion
• These are benign subchondral lesions without degenerative
arthritis
• Usually presents in middle age with mild localized pain
• Most common at the epiphysis of long bones
• Well-demarcated solitary lesions with a sclerotic margin and
with no communication to the joint.

Histiocytoma
• Benign fibrous histiocytoma of bone may mimic cystic lesions
• Usually presents in 23–60 years age group with localized pain
and soft tissue swelling
 Skeletal System and Joints 535

Fig. 6.83: Enchondroma

• Long bone epiphyses are typically involved

• Presents as a well-defined lesion with or without a soap-bubble
appearance and may have a sclerotic rim with no evident
periosteal reaction. It may cause cortical expansion.

Fibrous Dysplasia (Fig. 6.84)

• Most common in the first two decades of life and the lesions are
present in the medullary cavity
• Mono-ostotic variety is commoner than polyostotic variety
• Patient may present with limb length discrepancy, shepherd’s
crook deformity of femur, facial asymmetry, tibial bowing and
rib deformity
• McCune-Albright syndrome is the association of polyostotic
fibrous dysplasia with Café au Lait spots and endocrine
dysfunctions like precocious puberty and is usually seen in girls
536 Differential Diagnosis in Radiology
• Common locations are ribs, craniofacial bones, femoral neck,
tibia and pelvis
• Lesions have smooth dense margins which may be as thick as
to resemble a rind of an orange
• The bone may be expanded and the cortex scalloped but intact
• They may be multilocular and are usually diametaphyseal
• In the skull, the sclerosis may cause encroachment of neural
foramina
• There may be intralesional calcification
so much so that some lesions may have
increased density.

Brodie’s Abscess
• This is a type of subacute pyogenic
osteomyelitis usually occurring at the
metaphysis of long bones
• There is a central area of lucency surrounded
by a dense rim of sclerosis
• Lucent channel-like tortuous configurations
toward the growth plate are virtually
pathognomonic
• There may be periosteal reaction and
adjacent soft tissue swelling.

Aneurysmal Bone Cyst (Fig. 6.85) Fig. 6.84: Lateral

radiograph of arm
• Expansile lesion of bone containing thin- shows fibrous dys-
walled blood-filled cystic cavities, involving plasia of humerus
the vertebral neural arches and long bones
more commonly
• Age range is 10–30 years and female patients are affected more
often
• Purely lytic, expansile and eccentric radiolucency with soap
bubble pattern of trabeculations is seen. There may be very
slight sclerosis
 Skeletal System and Joints 537
• There may be rapid progression and the tumor may present
with a pathological fracture
• The cortex may be thinned but is intact
• Three quarters of these cysts present before epiphyseal fusion
are complete.

Osteoclastoma
• Usually occurs before epiphyseal fusion and most patients are
less than 20 years of age
• May be associated with Paget’s disease and usually present
with pain swelling and tenderness at the affected site
• It is an expansile solitary large lucent bone lesion causing
exquisite cortical thinning near the epiphysis, usually
metaphyseal in location. The long bones are most frequently
involved, usually around the knee joint
• There is a soap bubble appearance to the tumor with no evident
sclerosis or periosteal reaction unless a fracture has occurred
• There may be a soft tissue extension that characteristically has
no calcification
• When it involves vertebra, it may lead to collapse and may
involve the adjacent disks and may cross the joints.

Chondromyxoid Fibroma
• Peak age incidence 20–30 years and usually presents at the
metaphysis of long bones
• Expansile ovoid lesion with radiolucent center
• Well-defined sclerotic margin is present with no evident
periosteal reaction.

Chondroblastoma
• Peak age incidence, second decade and is usually epiphyseal in
location involving the long bones more often
538 Differential Diagnosis in Radiology

Fig. 6.85: Aneurysmal bone cyst. A large, medullary, expansile (blow out)
lucency is seen in the proximal tibial diaphysis, abutting the growth plate
(physis). The marked attenuation of the cortices, the well-organized tri-
angular periosteal reaction along the distal margin of the lesion and the
fact that the lesion is wider than the growth plate, are characteristic of an
aneurysmal bone cyst

• It is an oval-to-round eccentrically-located lucent lesion with

a well-defined sclerotic margin and may contain punctate
calcification
• The cortex is intact; however, a thick periosteal reaction may be
seen.

Plasmacytoma
• Solitary bubbly grossly expansile lesion
• Seen in 5th–7th decades of life, most commonly in thoracic or
lumbar spine.

Multiple Myeloma
• Peak age is 5th–8th decades of life. There is an abnormal B-J
protein in urine
 Skeletal System and Joints 539

Fig. 6.86: Calcaneal pitch = Calcaneal inclination angle; determines longi-

tudinal arch of foot; angle between line drawn along the inferior border of
calcaneus connecting the anterior and posterior prominences + line repre-
senting the horizontal surface

Fig. 6.87: Bohler’s angle = angle between first line drawn from posterosu-
perior prominence of calcaneus anteriorly to sustentaculum tali + second
line drawn from anterosuperior prominence posteriorly to sustentaculum
tail; measures integrity of calcaneus
540 Differential Diagnosis in Radiology

Fig. 6.88: Talocalcaneal angle on LAT view = angle between lines drawn
through mid-transverse planes of talus + calcaneus; the midtalar line par-
allels the longitudinal axis of the first metatarsal

Fig. 6.89: Intermetatarsal angle amount that 1st

+ 2nd metatarsals diverge from each other
 Skeletal System and Joints 541

Fig. 6.90: Talocalcaneal an- Fig. 6.91: Heel valgus – cannot be

gle on AP view = Kite Angle = measured directly on radiographs but
the midtalar and midcalcaneal inferred from the talocalcaneal angle
lines parallel to the 1st and 4th and estimated on coronal CT sections
metatarsals; angle is greater in
infants

• Generalized osteoporosis with multiple widespread punched-

out lesions may be seen
• There may be an associated soft tissue mass in the regions
where bone destruction has occurred
• May be associated with POEMS syndrome.
542 Differential Diagnosis in Radiology

Fig. 6.92: Angle of metatarsal heads = obtuse angle formed by lines

tangential to metatarsal heads

Metastasis
• Thyroid and kidney malignancies are the most common cause
of metatastasis that resemble bone cysts. However, lungs and
breast carcinoma may also cause such appear­ance
• Usually a history of primary can be elicited.
 Skeletal System and Joints 543

Fig. 6.93: AP pelvis view shows dislocation of hip as evident by Broken

Shenton line

Fig. 6.94: Acetabular sector angles in normal Rt hip

CHAPTER 7

Urogenital System

7.1  ADULT AND NEONATAL KIDNEY—

DIFFERENCE

Adult Neonatal
Contour Smooth Lobed
Medullary Reflectivity, –ve –ve
Cortex Reflectivity, +ve ++
Collecting system Echogenic inapparent Echo-poor apparent

7.2  SMOOTH, SMALL KIDNEYS

Unilateral Bilateral
• Ischemia due to focal Generalized arteriosclerosis
arterial disease
•  Chronic infarction Benign and malignant nephrosclerosis
•  Radiation neoplasia Atheroembolic renal disease
•  Congenital hypoplasia Chronic glomerulonephritis
•  Postobstructive atrophy Papillary necrosis
• Postinflammatory atrophy Hereditary nephropathies
•  Reflux atrophy Hereditary chronic nephritis (Alpert’s
syndrome)
Medullary cystic disease
Arterial hypotension
Amyloidosis (late)
 Urogenital System 545
SMALL, SMOOTH, UNILATERAL KIDNEY
With a small-volume collecting system.

A.  Ischemia Due to Renal Artery Stenosis

Ureteric notching is due to enlarged collateral vessels and
differentiates this from the other causes in this group.

Primary Uroradiologic Elements

Size—normal to decreased (left 1.5 cm less than right and right 2
cm shorter than left; may have less than normal increase in renal
surface area in response to contrast material or diuretics).

CONTOUR–SMOOTH (GLOBAL)

Secondary Uroradiologic Elements

• Pelvic-infundibulocalyceal system—attenuated (global)
• Notched proximal ureter (by ureteral arteries from lumbar
branches of aorta), delayed opacification time

Fig. 7.1: Normal sectional anatomy of kidney

546 Differential Diagnosis in Radiology
• Increased density of contrast material (decreased GFR allows
increased salt and water absorption)
• Delayed washout of contrast material
• Parenchymal thickness—wasted (global)
• Calcification—linear (aneurysmal or atherosclerotic in renal
hilus)
• Arteries—stenotic, aneurysmal, collateralized
• Angiography in atheromatous renal artery stenosis. There is an
eccentric narrowing of the proximal third of the renal artery
while in fibromuscular hyperplasia, there are segmental areas
of stricturing and aneurysmal dilatation affecting the distal
two-third of the renal arteries
• Color Doppler shows the increase in peak systolic velocities
to greater than 1.5 m/s, spectral broadening and increase in
maximum diastolic flow velocities.

B. Chronic Renal Infarction

Primary Uroradiologic Elements

• Size—normal to small
• Contour—smooth (global).

Secondary Uroradiologic Elements

• Parenchymal thickness wasted (global, occasionally regional)
• Nephrogram—diminished to absent contrast material density
• Echogenicity—increased.

C. Radiation Nephritis
At least 23 Gy (2300 rad) over 5 weeks. The collecting system
may be normal or small. Depending on the size of the radiation
field, both, one or just part of one kidney may be affected. There
may be other sequelae of radiotherapy, e.g. scoliosis following
radiotherapy in childhood.
 Urogenital System 547
Primary Uroradiologic Elements
• Size—normal to small
• Contour—smooth (global)
• Lesion distribution—consistent with radiation field material.

Secondary Uroradiologic Elements

• Parenchymal thickness—wasted (global, related to radiation
field)
• Nephrogram—diminished density of contrast.

D. End Result of Renal Infarction

Due to previous severe trauma involving the renal artery or renal
vein thrombosis.
The collecting system does not usually opacify during excretion
urography.

E. With Five or Less Calyces

1. Congenital Hypoplasia
The pelvicalyceal system is otherwise normal.
Primary Uroradiologic Elements
• Size—decreased
• Contour—smooth (global)
Secondary Uroradiologic Elements
• Papillae—decreased number
• Calyces—decreased number
• Small renal artery and a normal ureter.
2. With a Dilated Collecting System
Postobstructive Atrophy
• There is thinning of the renal cortex and if there is impaired
renal function, this will be revealed by poor contrast
medium density in the collecting system.
548 Differential Diagnosis in Radiology
Primary Uroradiologic Elements
• Size—small (normal or enlarged in minority of cases)
• Contour—smooth (global).
Secondary Uroradiologic Elements
• Papillae-effaced (global), may be normal in uncommon
form
• Pelvi-infundibulocalyceal system—calyces dilated (global,
may be normal in uncommon form)
Parenchymal thickness—wasted (global).
3. Postinflammatory Atrophy
Primary Uroradiologic Elements
• Size—small
• Contour—smooth (global)
Secondary Uroradiologic Elements
• Papillae—disrupted
• Parenchymal thickness—wasted (global).

SMALL, SMOOTH, BILATERAL KIDNEYS

1. Generalized Arteriosclerosis
Primary Uroradiologic Elements
• Size—normal to small
• Contour—smooth (global): May have random shallow scars.
Secondary Uroradiologic Elements
• Parenchymal thickness—wasted (global)
• Attenuation value—sinus fat increased
• Echogenicity—may be increased in sinus and renal
parenchyma.
2. Medullary Cystic Disease
• Autosomal dominant disorder
• Thin renal cortex
• Variable number of small medullary cysts up to 2 cm on CT,
US or MRI.
3. Amyloidosis, Renal Disease
• No specific radiological findings
 Urogenital System 549
• Bilateral enlargement in the presence of renal failure or
nephrotic syndrome
• The nephrogram is normal or diminished
• Renal thrombosis
• Angiography is abnormal, but findings are non-specific
• Gallium scans are extremely sensitive in the identifi­cation
of renal amyloid.
4. Papillary Necrosis
• Thinning of the cortex
• Partial sloughed papilla gives rise to density between
papilla and pyramid. A fissure forms which communicates
with central irregular cavity. In total sloughing, the
sloughed papillary tissue may (a) fragment and pass in
urine; (b) cause ureteric obstruction; (c) remain free in
calyx; and (d) remain in pelvis and form a ball calculus
• With complete detachment, loss of normal cupping of the
calyx with filling defect in the collecting system.
A Analgesics, other causes are: Adipose
D Diabetes
I Infant at shock
P Pyelonephritis
O Obstruction
S Sickle cell disease
E Ethanol

7.3  SMALL SMOOTH KIDNEYS

Smooth
• Uniform/undulating outline
• No focal indentation (especially against a calyx)
• Uniform cortical parenchymal thickness [1.5–2 cm]
• Uniform CMD (1:1/1:8)
• No focal variation in PT
• Vascularity adequate/mildly decreased
• Perirenal fascial planes uniform.
550 Differential Diagnosis in Radiology

Small
• Anatomically
• Radiography – 9–11 cm right
• USG – 11–13 cm left
• CT/MRI
• Age variation – Young
– Old
• Body surface area variation.
U/L B/L
1. Congenital 1.  Generalized arteriosclerosis
2. Postobstructive 2. CGN (Chronic
Glomerulonephritis)
3. Renal artery stenosis 3.  Chronic papillary necrosis
4. Radiation nephritis 4.  Arterial hypotension
5. Renal infarction 5.  U/L causes presenting B/L.

1. Congenital
• Quantitative decrease in renal tissue :  Quality N
• Pelvis calyceal system :  Normal
• Ureter :  Normal
• Opposite kidney :  Enlarged
• Renal artery :  Small/Normal
• Calyces <5

2. Postobstructive
• Early on the PCS +/– dilated but later it is normal
• Parenchyma is thinned
• Obstruction Acute → Increased pressure in PCS
↓ ↓
Chronic decreased blood flow
↓
decreased urine production
Slow irreversible ↓ ↓
parenchymal damage. ←Not relieved Relieved
Return to normal function
 Urogenital System 551
• Calculus, PUJ obstruction, retroperitoneal fibrosis, ureterocele,
clot, FB, bladder mass, fungus ball, stricture
• On imaging, PCSU dilated /N: Size N/decreased
• Cortex—N/decreased; nephrogram present/faint; poor
• Pyelogram—All depends upon level, severity duration.

3. Radiation Nephritis
• 2300 RAD (23 GY) for ≥ 5 weeks
• Due to small vessel disease
• PCS—N/small
• Global cortical thinning
• Delayed but dense pyelogram with delayed washout.

4. End Result of Infarction

• Global decrease in size occurs when there is injury/avulsion to
the main renal artery/segmental arteries
• Non-visualization of kidney/PCS
• Kidney decreased in size and altered appearance on CT, MR and
US.

5. Renal Artery Stenosis

• Use of IVP is nearly obsolete.
• Doppler examination – AT > .07 sec
– AT < 2 cm/sec­2
– PSV > 180 cm/sec
– AO:RA <1/2 5–3
• Captopril scintigraphy – Proposed use for
screening
• MRA/CTA – Useful corroborative
• Contrast invasive – Conventional
angiography ↓
DSA → I/A
→ I/V.
552 Differential Diagnosis in Radiology

6. Generalized Arteriosclerosis and

Arterial Hypotension
• Systemic conditions are presenting with multisystem
involvement
• Renal outline and PCS are normally seen
• Delayed appearing and increasingly dense pyelogram is seen
• Condition caused by AS is known as benign nephro­sclerosis.

7. Chronic Glomerulonephritis
• Hallmark is immediate faint and persistent nephrogram
• On USG, CMD is lost with increased echogenicity
• Diagnosis by HPE.

Chronic Papillary Necrosis

• Usually bilateral with multiple papillae affected
• Different types of appearances depending upon stage and
degree of papillary necrosis are seen
• Main causes are analgesics and diabetes.

SMALL SMOOTH KIDNEY

U/L.

Dilated PCS (Fig. 7.2)

• Postobstructive
• N/decreased function
• Thinned cortex.

Hypovolemic PCS
• RAS – Increased BP
• Radiation – H/O
• Infarction – H/O
 Urogenital System 553

Fig. 7.2: Calyces showing grades of hydronephrosis

Hypoplastic PCS
• Congenital
• Patient asymptomatic.

B/L

Systemic
• Hypotension
• Arteriosclerosis
These are systemic conditions with multisystem involvement.

Renal
• CGN –  Normal calyx
• CPN –  Abnormal calyx
• U/L causes.

7.4  SMALL, IRREGULAR KIDNEYS

• Reflux nephropathy (chronic atrophic pyelonephritis)
• Lobar infarction
• Tuberculous
• Renal dysplasia.
554 Differential Diagnosis in Radiology

Chronic Pyelonephritis/Reflux Nephropathy

A focal scar over a dilated calyx. Usually multifocal and may be
bilateral. Scarring is most prominent at the upper and lower poles.
Minimal scarring, especially at a pole, produces decreased cortical
thickness with a normal papilla (Fig. 7.3).

Primary Uroradiologic Elements

• Contour—normal (early, intermediate)
• Focal scar (late: may be multifocal)
• Lesion distribution—unilateral (may be bilateral).

Secondary Uroradiologic Elements

• Papillae—normal (early, intermediate)
• Retracted (late; focal)
• Calyces—normal (early, intermediate)
• Widened (late; focal)
• Parenchymal thickness—normal (early)
• Wasted (intermediate, late, focal)
• Focal compensatory hypertrophy
• Nephrogram—deficient enhancement (lobar, sublobar; full-
thickness; may be striated)
• Echogenicity—increased (focal)
• Increased central sinus complex.

Lobar Infarction
A broad contour depression over a normal calyx. Normal
interpapillary line.

Primary Uroradiologic Elements

Early (within 4 weeks) Late (after 4 weeks)
• Size—normal • Size—normal to small
 Urogenital System 555

Fig. 7.3: Unilateral scarred kidney

556 Differential Diagnosis in Radiology
• Contour—normal • Contour—focal scar
(may be multifocal)
• Lesion distribution— • Lesion distribution—
unilateral unilateral
(may be bilateral) (may be bilateral)

Secondary Uroradiologic Elements

Early (within 4 weeks) Late (after 4 weeks)
• Pelvic-infundibulocalyceal • Parenchymal
system—attenuated thickness—wasted
(focal, occasional) (focal) with normal
interpapillary line
• Nephrogram—absent • Echogenicity—increased
(focal, occasional, global, (focal)
rarely)

Tuberculosis
• Calcification differentiates it from the other members
• Usually hematogenous from pulmonary disease, but sometimes
secondary to tuberculous infection of the gastrointestinal tract
or bone
• Initial lesion in renal tuberculosis—small tubercles in the
glandular and cortical arterioles progress to necrotizing lesions
• Tubercles enlarge and coalesce into necrotic irregular cavities
• Ultimately, there is ulceration into the adjacent calyx, with
formation of fistulae and strictures
• The kidney becomes fibrotic and scarred
• Renal involvement is probably always bilateral; in 25% of cases,
it is unilateral
• Imaging findings are typically asymmetrical
• Renal calcification in up to 50% of cases, dense punctate
calcification associated with healed tuberculomas or renal
calculi
 Urogenital System 557
• The classical urographic finding is multifocal caliectasis, due to
irregular infundibular strictures. Parenchymal scars in advanced
cases
• Ultimately, the kidney may become small, densely-calcified,
and nonfunctioning; the so-called autonephrectomy.

Renal Dysplasia
• Developmental parenchymal abnormalities resulting from
abnormal development of the renal vasculature, renal tubules,
collecting ducts, or drainage apparatus
• Biopsy may be necessary for diagnosis
• Multicystic dysplastic kidney is due to ureteric obstruction early
in fetal life
• Usually unilateral, bilateral diseases are lethal
• Antenatal diagnosis is possible in the third trimester
• USG finding is of a multicystic mass without renal tissue
• One-third have contralateral urological abnormalities as
pelviureteric junction (PUJ) obstruction or vesicoureteral reflux
(VUR)
• Functional imaging with isotopes or IVU demonstrates lack of
function
• Arteriography outlines a small thread-like renal artery.

7.5  LARGE SMOOTH KIDNEY

Unilateral
1. Renal vein thrombosis.
2. Acute arterial infarction.
3. Obstructive uropathy.
4. Acute pyelonephritis.
5. Xanthogranulomatous pyelonephritis.
6. Miscellaneous—Compensatory hypertrophy.
  Duplicated pelvicalyceal system.
558 Differential Diagnosis in Radiology

Renal Vein Thrombosis

Common Causes in Children—Dehydration and shock, nephrotic
syndrome, cyanotic heart disease.

Adults
• Renal cell carcinoma
• Compression by tumor/lymph node or extension of thrombus
from IVC, trauma.
Secondary to Renal Diseases—Chronic glomerulonephritis,
amyloidosis.
Sudden Total Occlusion—Hemorrhagic infarct, permanent loss of
function and eventual shrinkage of kidney.
Partial Obstruction—Collaterals develop and the renal function is
undisturbed.

Primary Uroradiological Elements

• Size—normal to large
• Contour—smooth
• Unilateral.

Secondary Uroradiologic Elements

Collecting system—Attenuated, mucosal irregularity, nodula­rity,
notching. Abnormalities disappear on retrograde pyelography.
Parenchymal thickness—Expanded.
Nephrogram—Density varies from absent to normal, prolonged
corticomedullary differentiation.
Echogenicity—Variable (initial two weeks—Hypoechoic-after-hy-
perechoic).
Renal vein—Dilated, intraluminal thrombus with diminished or
absent flow.
Retroperitoneum—Dilated collaterals: Hemorrhage.
 Urogenital System 559
ACUTE ARTERIAL INFARCTION
Subtotal renal infarction is much common than infarction of the
entire organ.
Most usual cause—embolus through thrombosis, super­imposed
on underlying arterial disease, may also lead to infarction.
Primary Uroradiological Findings—large, smooth, unilateral.
Secondary Uroradiological Findings:
Collecting system—attenuated
Nephrogram—absent/diminished density, cortical rim enhance­
ment; focal nephrographic defect occurs in early subtotal
infarction.
Echogenicity—normal/reduced.
Renal angiography defines the site of arterial block.
CT—well-defined focal area of lower attenuation than that of
adjacent, normally enhancing, parenchyma.

OBSTRUCTIVE UROPATHY
Dilatation of Pelvicalyceal System
Obstructive Non-obstructive
• Congenital (e.g. PUJ, PUV) • VUR
• Acquired (stones, • Postobstructive dilatation
strictures, tumors) • Primary megaureter

IVU—Features of Acute Obstruction

• Increasingly dense nephrogram
• Modest kidney enlargement
• Delayed calyceal opacification
• Mild to moderate pelvicalectasis
• Spontaneous pyelosinus extravasation.
560 Differential Diagnosis in Radiology

Features of Chronic Obstruction

Renal Size
Partial obstruction—increased complete obstruction—small
nephrogram density—normal/decreased.
Parenchymal thickness—Reduced (crescent, rim nephro­gram).
Dilated Pelvicalyceal System—Ball pyelogram.
Ureters—Dilated/Tortuous
US—Excellent screening method.

Limitation
• Miss 1/3rd cases of acute obstruction
• Cannot differentiate extrarenal pelvis from PUJ obstruc­tion
• Unenhanced helical CT of KUB is the most sensitive technique
for diagnosing acute obstructive uropathy.

ACUTE PYELONEPHRITIS
Clinically acute pyelonephritis refers to symptom complex of
pyrexia, bacteriuria and flank pain.
IVU—Diffuse renal enlargement.
—Delayed/poor pelvicalyceal system filling of reduced density.
Severe Acute Pyelonephritis—Nephrogram may be dense,
persistent or striated.
US—Focal/generalized renal swelling, iso-/hypoechoic.
CT—Patchy enhancement with bands and wedge-shaped areas of
reduced enhancement extending from papillae to the edge of the
kidney.
Delayed scans (3–6 hours)—increased enhancement in the prior
areas.
Complication—abscess.
 Urogenital System 561
XANTHOGRANULOMATOUS PYELONEPHRITIS
• Chronic parenchymal inflammation caused by foamy
histiocytes giving a yellowish appearance to the cut-surface of
the kidney
• Usually associated with proteus infection in patients with
calculus disease.

Radiological Features
• On IVU, the pelvicalyceal system fails to fill in the presence of
good thickness of renal substance
• US—Dilated pelvicalyceal system with low level echoes, renal
parenchyma is of low echogenicity, calculus is usually present
• CT—Multiple rounded low attenuation areas of soft tissue
density surrounded by thick parenchyma
• Renal pelvis is contracted and contains calculus, asso­ciated
perinephric and psoas collection may be present.

COMPENSATORY HYPERTROPHY
• Congenital absence of kidney
• Postnephrectomy
• Diseased, poorly functioning kidney
• Maximum size of contralateral kidney is usually reached in
approximately six months.

Radiological Features
• Size of kidney increased
• Parenchymal thickness increased
• PCS and ureter appear prominent (as urine flow rate becomes
the normal from the functioning kidney).
562 Differential Diagnosis in Radiology

7.6  BILATERAL LARGE SMOOTH KIDNEYS

1. Proliferative/necrotizing disorders.
2. Abnormal protein deposition.
– Amyloidosis
– Multiple myeloma.
3. Abnormal fluid accumulation
– Acute tubular necrosis
– Acute cortical necrosis.
4. Neoplastic cell infiltration
– Leukemia.
5. Inflammatory cell infiltration
– Acute interstitial nephritis.
6. Miscellaneous
– Autosomal recessive polycystic kidney disease
– Acute urate nephropathy
– Nephromegaly associated with diabetes mellitus,
hyperalimentation and cirrhosis
– Renal vein thrombosis
– Bilateral hydronephrosis.

PROLIFERATIVE/NECROTIZING DISORDERS
• Only kidneys involved • Renal involvement is
part of multisystem disorder
– Acute – Wegener’s granulomatosis
(poststreptococcal)
• Glomerulonephritis
– (RPGN) Rapidly – Goodpasture’s syndrome
progressive
• Glomerulonephritis (GN)
– Idiopathic – Diabetic
membranous GN glomerulosclerosis
– Membrano-
proliferative GN – PAN
 Urogenital System 563
– IgA nephropathy – Allergic angiitis
glomerulosclerosis
– Glomerulosclerosis – Hemolytic uremic
associated with syndrome
heroin abuse
– Lobular GN
– Morphologic diagnosis of a specific disease within this
group is dependent on integrating light, electron and
immunofluorescent microscopic patterns of glomerular
involvement with other clinical or laboratory abnormalities.

Radiological Features
Primary uroradiologic : Large, smooth, bilateral
elements
Secondary uroradio- : Collecting system is attenuated.
logical elements
: Parenchymal thickness is
expanded. Echogenicity is
increased.
: (HUS-selective hyperecho­genicity of
cortex relative to medulla)

Amyloidosis
Caused by accumulation of extracellular eosinophilic protein
substance in various organs.
Primary—Renal involvement occurs is 35% cases.
Secondary—Secondary to chronic suppurative/inflamma­tory
disease.
Renal involvement occurs in 80% cases.
• Tuberculosis • Osteomyelitis
• Bronchiectasis • Rheumatoid arthritis
• Ulcerative colitis
564 Differential Diagnosis in Radiology

Radiological Features
Primary urological : Large, smooth and bilateral
elements
Secondary uroradio­­- : Collecting system is attenuated
logical elements : Parenchymal thickness expa­nded,
becomes wasted with time.
: Nephrogram—diminished density.
: Echogenicity—normal to increased.
: Renal vein thrombosis (occasi­onally).

MULTIPLE MYELOMA
Multiple myeloma causes renal insult in 50% cases because of
deposition—of abnormal proteins in the tubule lumina.
Renal function is also compromised by:
• Increased blood viscosity.
• Nephrocalcinosis (because of hypercalcemia)
• Bence Jones toxicity on tubules.

Amyloidosis

Radiological Features
Primary B/L large smooth kidneys.
Secondary Collecting system is attenuated.
Parenchymal thickness is expanded.
Nephrogram—diminished density.
Echogenicity—increased.
Administration of contrast material in patients with multiple
myeloma requires an awareness of potential hazards.
Dehydration should be avoided if the risk of complications is to
be minimized.

Other Radiological Features

Osteopenia with well-defined lucencies of uniform size in spine,
pelvis, skull, ribs and shafts of long bones.
 Urogenital System 565
• Vertebral body collapse +/– paravertebral shadow +/–,
intervertebral disk involvement
• Expansile ribs lesions
• Permeative mottled pattern of bone destruction present.

Extraskeletal Features
Hypercalcemia, hepatosplenomegaly, soft tissue tumors in sinuses,
submucosa of pharynx, trachea, cervical lymph nodes and GIT.

ACUTE TUBULAR NECROSIS

State of reversible renal failure with or without oliguria that follows
exposure of the kidney to certain toxic agents or to a period of
prolonged, severe ischemia.

Toxic Agents
Bichloride of mercury, ethylene glycol, carbon tetrachloride,
bismuth, arsenic, urographic contrast in particular when
administered to a patient of two pre-existing renal diseases who
has been dehydrated.

Ischemic Causes
Shock, crush injuries, burns, trans­fusion reaction, severe
dehydration, surgical procedure like renal transplantation or aortic
resection.

Radiological Features
Contrast material enhanced imaging studies should not be
performed knowingly in patients with ATN.

Collecting System
Attenuated, opacification is diminished/absent.
• Nephrogram—75% patients—immediate and persistently
dense.
566 Differential Diagnosis in Radiology
25%—Increasingly dense and persistent.
• Echogenicity: Medulla—Normal to diminished.
Cortex—Normal to increased.

ACUTE CORTICAL NECROSIS

Uncommon form of ARF in which there is death of the renal cortex
and sparing of the medulla.
• A thin rim of subcapsular tissue on the external surface of the
cortex and a thin rim of the juxtamedullary cortex are often
preserved. This fine rim of viable cortex separate the necrotic
cortex from the renal capsule externally and from the medulla
internally
• Calcification occurs at this interface which is known as—
“Tram line calcification”
• Calcification is detected microscopically at 6 days and
radiologically—at approximately 24 days (kidneys are still
enlarged).

Radiological Features
• B/L enlarged smooth kidney
• Collecting system—absent/faint opacification is effaced
• Parenchymal thickness—expanded
• Nephrogram—absent cortical nephrogram with selective
enhancement of medulla
• Calcification—cortical-diffuse or tram line
• Echogenicity—center hypoechoic (early phase)
Hyperechoic with acoustic shadow after calculus deposition.

Causes
Obstructive—premature separation of placenta, concealed
hemorrhage, septic abortion, placenta previa.
Adults—sepsis, dehydration, shock, burns, snakebite.
Children—dehydration, infection, transfusion reaction.
 Urogenital System 567
LEUKEMIA
Most common malignant cause of B/L global renal enlarge­
ment (Lymphoma occasionally produces such pattern but more
commonly causes multifocal renal enlargement). Rarely, leukemia
causes a unifocal renal mass due to chloroma, myeloblastoma or
a myeloblastic sarcoma. Enlarged kidneys can occur in leukemic
patients without leukemic infiltration because of:
• Acute urate nephropathy
• Amphotericin-induced acute interstitial nephritis
• Renal candidiasis associated with intensive chemotherapy
• Lymphocytic rather than granulocytic tumors of leukemia are
more frequently associated with renal enlargement
• Children with acute leukemia are more likely to develop
nephromegaly as compared to adults
• Peripheral WBC count can be normal or depleted at the time of
renal involvement.

Radiological Features
Primary B/L smooth enlarged kidneys.
Secondary Collecting system—attenuated.
Parenchymal thickness—expanded.
Nephrogram—diminished density.
Echogenicity—Variable.
• Focal hemorrhage, subcapsular collections, obstructive clots in
renal pelvis and other R/F in children
• Metaphyseal lucencies—distal femur, proximal tibia and distal
radius
• Permeative destruction of bone
• Osteolytic lesions—diaphysis of long bone
• Periosteal reaction—proliferation of leukemic deposits deep
to periosteum leading to subperiosteal hemorrhage. MR will
show the marrow involvement clearly.
568 Differential Diagnosis in Radiology

ACUTE INTERSTITIAL NEPHRITIS

Characterized histologically by infiltration of the interstitium
by lymphocytes, plasma cells, eosinophils and a few poly­
morphonuclear leukocytes.
Usually results as a complication of exposure to certain drugs:
Antibiotics—Methicillin, ampicillin, penicillin, ampho­tericin,
sulfonamides.
NSAIDs—Naproxen, ibuprofen.
Anticonvulsants—Phenytoin.
Antihistaminics—Cimetedine.
Cases usually evolve within a range of 5 days to 5 weeks after exposure.

Clinical Features
Fever, rash, eosinophilia, hematuria, proteinuria and azotemia.

Radiological Features
Primary B/L smooth enlarged kidneys
Secondary Collecting system—attenuated.
Parenchymal thickness—expanded.
Nephrogram—diminished density.
Echogenicity—increased.

AUTOSOMAL RECESSIVE (AR) (INFANTILE)

PCKD (POLYCYSTIC KIDNEY DISEASE)
AR PCKD characterized by dilatation of renal collecting tubules,
cystic dilatation of biliary radicles and periportal fibrosis.
AR PCKD Neonatal—Predominant renal and minimal hepatic
involvement.
Juvenile—Predominant hepatic and minimal renal involve­ment.
 Urogenital System 569
Radiological Features
Primary B/L smooth enlarged kidney.
Secondary Neonatal form: Collecting system is attenuated.
Parenchymal thickness is expanded.
Nephrogram—diminished density: Striated.
Attenuation value—less than soft tissue (unenhanced CT).
Echogenicity—diffusely increased, loss of corticomedu­llary
differentiation.
Features of pulmonary hypoplasia—small malformed thorax,
pneumothorax and pneumomediastinum.

Juvenile Form
Nephrogram : Striated.
Calcification : Nephrocalcinosis (papillae).
Echogenicity : Increased.
Misc : Hepatosplenomegaly, varices, dilated bile
ducts, increased hepatic echogenicity.

ACUTE URATE NEPHROPATHY

• Because of deposition of biurate crystals in the collecting
tubules and interstitium leading to ARF
• Seen most commonly during therapy for cancer, particularly
leukemia, malignant lymphoma.
• Myeloproliferative disorders and polycythemia vera.

Radiological Features
• Bilateral smooth enlarged kidneys
• Collecting system is normal
• Nephrogram—progressively dense
• No opacification of pelvicalyceal system
• Alkaline diuresis
• Large fluid intake
• Use of allopurinol.
570 Differential Diagnosis in Radiology

NEPHROMEGALY ASSOCIATED WITH CIRRHOSIS,

HYPERALIMENTATION AND DIABETES MELLITUS
• Nephromegaly associated with cirrhosis
• Explanation—hyperplasia and hypertrophy of renal cells
• Hyperalimentation—because of hyperalimentation, there
is increase in fluid compartment of kidney related to
hyperosmolality of the solution
• Renal enlargement reverses following cessation of therapy
• Diabetes mellitus—(in the absence of diabetic glomerulo­
sclerosis)
• Renal enlargement is due to growth hormone effect nephron
hypertrophy and glycosuric osmotic diuresis.

7.7:  NON-VISUALIZATION OF A KIDNEY DURING

EXCRETION UROGRAPHY
1. Absent kidney—Congenital absence or postnephrectomy.
2. Ectopic kidney.
3. Chronic obstructive uropathy.
4. Infection — Pyonephrosis
— Xanthogranulomatous pyelonephritis
— Tuberculosis.
5. Tumor—An avascular tumor completely replacing the kidney
or preventing normal functions of residual renal tissue by
occluding the renal vein or pelvis, e.g. renal cell carcinoma,
Wilms’ tumor.
6. Renal artery occlusion—including trauma.
7. Renal vein occlusion.
8. Multicystic kidney.

Salient Feature
Absent kidney—failure of the ureteric bud to reach the
metanephron results in renal agenesis.
 Urogenital System 571
Associated Anomalies
a. Failure of ipsilateral ureter and hemitrigone to develop
b. Adrenal agenesis
c. Absence of vas deferens, unicornuate uterus and absence or
cyst of seminal vesicle
d. VATER syndrome—vertebral and VSD
– Anorectal atresia
– Tracheal and esophageal lesions
– Radial bone anomalies
e. Contralateral renal anomalies—Renal ectopia
– Malrotation
Plain film—Absence of renal outline
Medial displacement of the splenic and hepatic flexure into
renal bed.
Compensatory hypertrophy of contralateral kidney
CT or radionuclide imaging—Definitive showing absence of
unilateral absence of renal tissue.
Other cause of atrophic kidney:
– Vesicoureteric reflux
– Infarct
– Bilateral renal agenesis associated with Potter’s syndrome
characterized by oligohydramnios, characteristic facies
and early death due to pulmonary hypoplasia.

PYONEPHROSIS
• Infection of an obstructed kidney may lead to pus developing
within the renal pelvis or calyx
• Occurs in conjunction with the presence of calculi or
undiagnosed PUJ obstruction
• Imaging features—obstructed system with particularly early or
severe loss of renal outline.
• Cross-sectional imaging shows evidence of pus and
inflammatory debris within the dilated pelvicalyceal system
(e.g. echogenic areas are USG or increased density on CT with
possible layering)
572 Differential Diagnosis in Radiology
• Xanthogranulomatous pyelonephritis
• Chronic inflammatory process in which lipid laden histiocytes
invade and replace normal renal parenchyma
• Seen in females, diabetics and infecting organism is usually E.
coli and Proteus miurabilis
• IVU—Non-functioning kidney with calculi. 80% calculi is
characteristically laminated or branched and fragmented
• Initially the kidney is enlarged and this may have a focal pattern
simulating tumor but ultimately there is marked renal atrophy
• USG and CT—Loss of normal corticomedullary differentiation
and heterogeneity, which includes debris containing cystic
areas and calculi.

Tuberculosis
IVU—Stricture affecting the calyceal neck, with the formation of
hydrocalyces.
Strictures at the PUJ and at multiple levels in the ureter.
Later the pelvis is affected and the entire kidney may become hydro-
nephrotic and non-functioning (tuberculosis auto nephrectomy).
—USG and CT demonstrates hydrocalyces and/or hydronephrosis
which may contain a considerable amount of debris, areas of
calcification and parenchymal loss.
In later stages, there is inflamed and contracted bladder.

Renal Artery Stenosis

Reduction of the internal diameter by at least 60%
– Atheroma
– Fibromuscular dysplasia
– Polyarteritis nodosa
– Takayasu’s arteritis
– Compression of the renal artery by retroperitoneal mass.
IVU—The affected kidney may be initially small and smooth.
The reduced perfusion on the affected side produces a late
nephrogram which is hyperdense.
 Urogenital System 573
Notching of the ureter due to compensatory hypertrophy of
the ureteric artery.
USG—Excludes an obvious structural abnormality or coexistent
condition that may relate to hypertension (renal scarring,
hydronephrosis, calculus disease or tumors).
Doppler—Increase in the peak systolic velocity and renal: aortic
velocity ratio of more than 3.5 or an absolute velocity of more than
180–200 cm/s.

Spectral Analysis of Intrarenal Arteries

• RAS of less than 75% is not detected by this technique
• More severe stenosis is characterized by reduction in the
ascending slope of the systolic peak which can be measured
as reduced acceleration (below 3 m/s/s), lengthened time to
systolic peak (above 0.075) and increased resistive index (above
5%) and pulsatility index (above 0.012) of the affected kidney
compared with the other side
• CT angiography
• MR angiography.

Renal Vein Thrombosis

• If thrombus is abrupt and complete, the imaging features are
similar to an arterial infarct
• Dopplar USG—It demonstrates loss of venous rather than
arterial signal.
Subacute/partial thrombosis—Smooth renal enlargement. The
IVU will show a delayed but subsequently hyperdense nephrogram
and pyelogram with either normal calyces or some evidence of
compression due to parenchymal swelling.
Notching of the ureter by dilated venous collaterals is
occasionally seen.
USG—Loss of normal corticomedullary differentiation. Diffuse
reduction in echogenicity. Thrombosis of the renal vein.
CT—Hypodense kidney.
574 Differential Diagnosis in Radiology

Multicystic Kidney
• Ureter fails to develop and is atretic while the kidney is non-
functioning
• USG or CT—The kidney is composed of non-communi­cating
cyst of varying size
• It is associated with an increased risk of contralateral
pelviureteric junction obstruction.

Renal Tumors

Wilms’ Tumor
• Present in first 3 years
• Bilateral in 5%
• Associated abnormalities—Cryptorchidism, hypospadias
hemihypertrophy, sporadic aniridia, Beckwith-Wiedemann
syndrome
• Secondaries in—liver and lung.
– Tumor thrombus in IVC or right atrium
• Plain film—Bulging flank.
– Loss of renal outline
– Enlargement of renal outline
– Displacement of bowel gas
– Loss of psoas outline

Calcification
USG—Large well-defined mass, increased echogenicity than
liver. Solid with hemorrhage/necrosis. Lack of IVC narrowing on
inspection suggests occlusion.
CT—Large, well-defined, low attenuating, heterogenous
with foci of even lower attenuation due to necrosis. Minimal
enhancement compared with the residual rim of functioning
renal tissue.
 Urogenital System 575
MRI—Inhomogenous, low signal (T1W), high signal (T2W).
Inhomogenous enhancement compared with residual renal
tissue.

Renal Cell Carcinoma

• 90% of adult malignant tumors
• Bilateral in 10% and increased incidence of bilaterality in
polycystic kidneys and von Hippel-Lindau disease. A mass
lesion (showing irregular or amorphous calcification in 10% of
cases). Calyces are obliterated, distorted and/or displaced. Half
shadow filling defect in a calyx or pelvis. Arteriography shows a
pathological circulation.

7.8  DILATED CALYX AND DILATED URETER

With a Narrow Infundibulum

1. Stricture.
2. Extrinsic impression by an artery.
3. Hydrocalycosis—congenital.

With a Wide Infundibulum

1. Megacalyces.
2. Postobstructive atrophy.
3. Polycalycosis.
4. PUJ obstruction.

DILATED URETER AND CALYCES

Vesicoureteric Reflux
Obstruction No Obstruction or Reflux
within Lumen
1.  Calculus 1. Postpartum
2.  Blood clot 2. Following relief of obstruction
576 Differential Diagnosis in Radiology
3.  Sloughed papilla 3. Urinary tract infection
4. Primary non-obstructive
ureter
In the Wall
1. Edema or stricture due
to calculus
2. Tumor
3. Tubercular stricture
4. Schistosomiasis
5. Postsurgical trauma
6. Ureterocele
7. Megaureter
Outside the Wall
1. Retroperitoneal fibrosis
2. Carcinoma of cervix, bladder or prostate
3. Retrocaval ureter.

DILATED CALYX

Stricture
• Tumor—Usually a transitional cell carcinoma presenting as a
mural growth. May be multiple
• Calculus
• Tuberculosis—Unilateral, collecting system—irregular margins,
strictures, multifocal dilatation, distinctive feature communi-
cating parenchymal cavities
• Irregularity of papillary margin (earliest)
• Calcifications, variable parenchymal thickness.

Extrinsic Impression by an Artery

• Rarely cause symptoms
• Fraley syndrome—Infundibular obstruction
• Nephralgia
• Right upper pole calyx
 Urogenital System 577
• IVP—Early opacification and delayed emptying
• Angiography—also useful.

Congenital Hydrocalycosis
• Congenital dilatation of calyx
• Diagnosis is safely made only in childhood.

Postobstructive Atrophy
• Kidney is usually small, smooth
• Effaced papillae, dilated PCS
• Parenchymal wasting
• Compensatory hypertrophy
• Megacalyces and polycalycosis
• Megacalyces—dilated Calyces ± a slightly dilated pelvis
• Polycalycosis—increased number of calyces—20–25
• Delayed visualization of calyceal system
• Cortical thickness—Normal
• Cause fetal obstruction, Boys > Girls

Calculus
• Can cause mechanical obstruction, edema or stricture
• Plain films, USG, CT—all help in diagnosis.

Blood Clot
• Volume of Blood loss is large enough
• Trauma, tumors, AVM, bleeding disorders predispose
• Usually asymptomatic, dissolve in 2 weeks
• IVP—Opaque urine, outlines the clot and may dissect
• ‘Hand-in-glove’ appearance
• USG—low-level echoes that separate sinus echoes
• CT—appearance varies with time, does not enhance
• Persistent clot—may faintly calcify.
578 Differential Diagnosis in Radiology

Sloughed Papilla
• When papillary necrosis evolves to the stage of flank necrosis,
separation occurs between viable and dead parts
• Usually in analgesic nephropathy patients
• Obstruction at infundibulum, ureteropelvic junction or ureter
• IVP—Triangle-shaped filling defect
• One or more calyces will dilate reflecting loss of papillary tip
• Calcium may deposit along the periphery
• Occasionally very dense—Indistinguishable from calculus.

PUJ Obstruction
• More common left side, 20% bilateral
• Cause neuromuscular incoordination, aberrant vessels
• During acute episode-IVU—delayed, increasing dense
nephrogram and delayed appeareance of PCS
• Calyces and dilated pelvis
• Contrast in collecting ducts—as crescents
• Ureters often not opacified
• Milder cases—difficult to diagnose.

Tumors
• Tumors are very uncommon in ureter
• TCC—renal pelvis > ureter (3:1)
• Seen in lower 1/3rd of ureter, multicentricity and bilateral, if TCC
• Filling defects on IVU, never completely surrounded by
opacified urine
• Polypoidal with smooth, irregular or lobular surface
• Squamous cell carcinoma—broad-based and flat
• Bergman’s sign—in ureteric carcinoma
—distinguishes from calculus
• USG—Similar to renal parenchyma in echogenicity
• CT—contrast enhancing mural mass projecting into lumen,
circumferential or eccentric thickening.
 Urogenital System 579
Tuberculous Stricture
• Marked irregularity of part or all of the collecting system or
ureter because of both submucosal granulomas and mucosal
ulceration
• Scars of healed tuberculous produce sharply-defined circum­
ferential narrowings at one or several sites, often with irregular
margins
• Fibrosis may progress during treatment of active tuberculous
• Pipe-stem ureter, thimble bladder.

Schistosomiasis
• Ureteral abnormalities are found in half of patients with bladder
schistosomiasis
• Early—minimal dilatation, slight mucosal irregularity and
diminished peristalsis
• Then with time—calcification, mural thickening and
straightening, beading and multiple narrowing
• Some cases—bilharzial polyps—seen as filling defects
• No increased risk of TCC.

Ureterocele (Congenital)
• Orthotopic ureterocele—best seen by IVU
• The distal ureter is dilated, projects into the lumen of bladder,
opacified bladder urine surrounds the ureterocele separated by
lucency, cobra head deformity
• An ectopic ureterocele is seen on cystography as a smooth,
non-opaque, intravesicular mass
• Ectopic ureter causes—UTI, bladder neck destruction.

Primary Megaureter
• Ureter has a normally tapered distal segment but is otherwise
dilated over a varying length, from a few centimeters proximal
to tapered end including PCS
• Tapered segment is peristaltic.
580 Differential Diagnosis in Radiology

Retroperitoneal Fibrosis
• Ureteric destruction of variable severity (75% bilateral)
• Tapering lumen or complete obstruction—L4–L5
• Medial deviation of ureters
• Retroperitoneal, periaortic mass—CT or US.

Retrocaval Ureter
• Ureter passes posterior to IVC and partially encircles it at L3–L4
with proximal dilatation
• Can cause flank pain, UTI.

Vesicoureteric Reflux
• Occurs when intramural segment of ureter in the UB is short
and the angle of insertion is wide
• VUR—decreases with age as lengthening of ureter occurs
Grading— 1. Ureter only
2. Ureter, pelvis, calyces
3. II + Mild dilatation of PCS, fornices normal
4. Moderate dilatation of PCS + Unsharp fornices
5. Gross distention + Effaced papilla.
• Small, scarred kidney.

Postpartum
• More common on right side
• Urinary tract obstruction
• Effect of P fimbriated E coli on urothelium

7.9  GAS IN URINARY TRACT

A. Gas Inside the Bladder

1. Vesicointestinal fistula.
2. Cystitis.
 Urogenital System 581
3. Following instrumentation.
4. Penetrating wounds.

Gas in Bladder Wall

Emphysematous cystitis.

Gas in Kidneys and Ureters

1. Any cause of gas in UB.
2. Emphysematous pyelonephritis.
3. Ureteric diversion.
4. Fistula with bowel.

Gas inside the Bladder

1. Vesicointestinal fistula
– Can be due to diverticular disease, carcinoma colon or
rectum or Crohn’s disease.
– Pneumaturia is the presenting complaint.
– Air visible in bladder lumen.
– Fistulous communication can be demonstrated in 70%
cases.
– Focal thickening of bladder wall due to adjacent
inflammation.
2. Cystitis
– Due to gas-forming organisms
– Especially seen in diabetics and immunocompromised.
– Usually E coli and rarely Clostridium.
3. Following instrumentation
– Cystoscopy and catheterization may lead to air in bladder
lumen.
4. Penetrating wounds
Trauma or any operative procedure may cause presence of
gas in bladder lumen.
582 Differential Diagnosis in Radiology

B. In Bladder Wall

Emphysematous Cystitis
• Uncommon complication of urinary tract infection by gas-
forming organisms
• Almost pathognomonic of poorly-controlled diabetes
• Plain film shows translucent streaks or rings of air bubbles in
bladder wall.

Intraluminal air-fluid level may be +

U/S—shows echogenic foci with distal shadowing in the area of
bladder wall thickening.

C. Gas in Kidneys and Ureters

1. Any cause of gas in urinary bladder.
2. Emphysematous pyelonephritis
– Rare fulminating form of acute pyelonephritis.
– Occurs usually in diabetics.
– Radiologically there is gas in renal parenchyma and in
perirenal tissues and pelvicalyceal system.
– Gas may have streaky/mottled/loculated pattern.
– Crescent of subcapsular or perinephric gas may also be
seen.
– Absent or decreased contrast excretion on IVP.

Ureteric Diversion into the Colon

– Ureterocolic anastomosis is performed after resection of
bladder.
– Air is seen in pelvicalyceal system and ureters.
3. Fistula
 Urogenital System 583
7.10  LOSS OF RENAL OUTLINE ON PLAIN FILM
1. Technical factors.
2. Absent kidney.
– Congenital
– Postnephrectomy.
3. Ectopic kidney.
4. Perinephric hematoma.
5. Perinephric abscess.
6. Renal tumor.

Technical Factors
• Poor radiographic technique
• Overlying fecal matter, gas-filled bowel loops obscure renal
shadows.

Congenital Absence of Kidney

• Can be unilateral or bilateral
• Unilateral renal agenesis—1:600 to 1:1000 live births
• M:F = 1.8:1
• Often associated with other anomalies of the Vater anomalies,
uterine anomalies
• Radiologically:
– Visualization of single kidney
– Colon occupies renal fossa
– Compensatory hypertrophy of normal kidney.

Postnephrectomy
History of operation, scar in lumbar region. Surgical resection of
12th rib.

Ectopic Kidney
– Kidney is normally located opposite first to third lumbar vertebrae.
– Failure of ascent of kidney from pelvis may result in ectopic
kidney.
584 Differential Diagnosis in Radiology

Fig. 7.4:  IVP radiograph shows bilateral malrotated kidneys

There may be:

a. Longitudinal ectopia—pelvic, sacral or intrathoracic kidney.
b. Crossed ectopia.
Pelvic kidney—on IVU malrotated kidneys (Fig. 7.4) with short
ureters.
• There may be associated contralateral renal agenesis, VUR
and hypospadias.
Intrathoracic kidney—is more common on the left.

Perinephric Hematoma
• Fills the entire perinephric space and displaces the kidney
• Plain film shows loss of renal and psoas outline. Kidney is
displaced anteromedially on IVU
 Urogenital System 585
• Ultrasound and CT show a perirenal collection
• Signs of trauma, e.g. fractured transverse process.

Perirenal Abscess
• Extension of acute pyelonephritis or renal abscess through the
capsule
• Loss of psoas margin and obscuration of renal contour
• Scoliosis concave to the involved side
• Gas in perirenal tissue.
IVU—shows unilateral impaired excretion; displacement of kid-
ney
US and CT—show a complex, predominantly solid and
hypoechoic mass with thick irregular wall, perinephric
collection and stranding gas within the lesion.

Renal Tumor
Tumor masses obliterate the perinephric fat planes and, therefore,
cause loss of renal outlines on plain film.
Plain film—may show soft tissue mass with calcification
IVU—shows displacement and attenuation of pelvicalyceal
system.
US—shows heterogenous mass displacing the collecting
system and extending into perinephric fat planes.
CT—shows mass of heterogenous attenuation with perinephric
extension.

7.11 RENOVASCULAR HYPERTENSION

Renovascular hypertension is defined as hypertension that
improves or resolves after correction of renal artery stenosis (RAS).

Signs of Unilateral RAS on IVU

1. Unilateral delay of one minute or more in the appearance of
opacified calyces.
586 Differential Diagnosis in Radiology
2. Small, smooth kidney
– Left more than 1.5 cm shorter than the right
– Right more than 2 cm shorter than the left.
3. Increased density of opacified calyces.
4. Ureteric notching by collateral vessels.

Signs of RAS on ACE Inhibitor Renal Scintigraphy

1. Low probability suggested by a normal study
2. Intermediate probability when:
a. Small kidney contributing < 30% of total renal function.
b. Time for maximum activity (Tmax) < 2 minutes and shows
no change following administration of ACE inhibitor.
c. B/L symmetrical cortical retention of tracer.
3. High probability when unilateral parenchymal retention is
indicated by:
a. A change in the 20-minute/peak uptake ratio > 0.15,
delayed excretion of tracer into the renal pelvis >2 minutes
or increase in the time to maximal activity Tmax of > 2
minutes or 40% after administration of ACE inhibitor
4. Decreased sensitivity when B/L renal artery stenosis, impaired
renal function, urinary obstruction or long-term ACE therapy.

Signs of Renal Artery Stenosis on

Doppler Sonography
1. Peak velocity in the renal artery >100 cm/s.
2. Renal artery velocity >3.5 × aortic velocity.
3. Tardus parvus waveform-slope of the systolic upstroke < 3 m/s2
and acceleration time (time from onset of systole to peak systole)
> 0.075.
4. Turbulent flow in the poststenotic renal artery.
 Urogenital System 587
Sign on Arteriography
• Reduction in luminal diameter > 75%
• Systolic pressure gradient across the stenosis > 15–25 mm kg or
> 20% of aortic systolic pressure
• Evidence of collateral circulation into distal vessels
• Pharmacologic manipulation of collateral vessel flow
(epinephrine restricts flow to the kidney and makes collaterals
more apparent).

CT Angiography
• Demonstrates both wall and lumen of the vessel
• Extent of plaque projecting into the vessel lumen
• Can demonstrate ostial stenosis
• Can be used to examine the patency of vessel that has been
dilated by intravascular stents
• MRA—TOF MRA—produced by unsaturated blood flowing into
the plane of imaging.

PC MRA

Causes
1. Atherosclerosis.
2. Fibromuscular dysplasia.
3. Thrombosis/Embolism.
4. Arteritis
• PAN
• TAO
• Takayasu’s disease
• Syphilis
• Congenital rubella.
5. Neurofibromatosis.
6. Trauma.
7. Aneurysm.
588 Differential Diagnosis in Radiology
8. AV-fistula.
9. Extrinsic compression.

Atherosclerosis
• 66% of renovascular causes
• Stenosis of the proximal 2 cm of the renal artery
• Less frequently the distal artery or early branches at bifurcations
• More common in males.

Fibromuscular Dysplasia
• 33% of renovascular causes
• Stenosis +/– dilatation which may give the characteristic ‘string
of beads’ appearance
• Mainly females less than 40 years
• B/L in 60% of the cases.

Takayasu’s Arteritis
• Mainly young females less than 35 years of age
• Associated with fever and increased ESR
• Mainly involves the aorta or its major branches
• Luminal narrowing, occlusion, dilatation or formation of
aneurysms
• Causes stenosis of aorta or main renal artery.

Polyarteritis Nodosa
• Usually affect medium- or small-sized vessels
• Characterized by multiple aneurysms which are sharply defined
and 2 to 3 mm wide.

Neurofibromatosis
• Coarctation of aorta
• +/– stenosis of other arteries
• +/– intrarenal arterial abnormalities.
 Urogenital System 589
7.12 RENAL CALCIFICATION
A. Calculi
B. Dystrophic calcification due to localized disease:
1. Infections.
2. Carcinomas.
3. Vascular.
4. Cysts.
C. Nephrocalcinosis (Fig. 7.6)
1. Medullary.
2. Cortical.

A. Calculi
• Stones within the collecting system
• Usually sharp in outline
• Variable in size and number
• IVP—Shows hydronephrosis if obstructing
• USG—Echogenic with acoustic shadow.

B. Dystrophic Calcification (Usually one kidney

or part of one kidney)
1. Infections
a. Tuberculosis
• Irregular, indefinite and not dense as calculi
• Usually nodular, curvilinear or amorphous mottled
calcification
• More common in cortex, in various segments
• Multifocal—ureteric, UB, vas, seminal vesicles.
b. Hydatid
• Renal involvement in 3%
• 50% of echinococcal cysts calcify
• Usually polar
• Curvilinear calcification.
590 Differential Diagnosis in Radiology
c. Xanthogranulomatous pyelonephritis
• Usually associated staghorn calculus in renal pelvis
(Fig. 7.5)
• IVP—Non-functioning/poorly functioning kidney.
– Ill-defined renal outline
• US—Nephrolithiasis
– Decreased echogenicity
– Hydronephrosis
• CT
– Calculus with poorly-functioning kidney
– Multiple non-enhancing masses (some with fat
density)
– Perinephric extension.
d. Abscess
• Calcification in wall.
• Or nodular calcification after resolution.

Fig. 7.5:  KUB radiograph shows staghorn calculus in left renal area
 Urogenital System 591
2. Tumors
a. Renal cell carcinoma
– 8–15% cases.
– Generally non-peripheral, amorphous and irregular.
b. Wilms’ tumor
– Amorphous, irregular calcification in soft tissue mass.
3. Cysts
– Due to hemorrhage or infection.
– May occur in:
• Simple cyst
• Multicystic dysplastic kidney
• Adult polycystic kidney disease.
4. Vascular
a. Subcapsular/perirenal hematoma.
b. Aneurysm of renal artery
– Curvilinear calcification or eggshell appearance.
c. Nephrocalcinosis.

Fig. 7.6:
592 Differential Diagnosis in Radiology

C. Parenchymal Calcification
Medullary Nephrocalcinosis (Pyramidal)
1. Hyperparathyroidism
– Primary >> secondary
– Commonest cause (16%)
– Other signs of HPT such as bone erosions, brown tumors,
soft tissue calcifications.
2. Renal tubular acidosis
– Commonest cause in children
– May be associated with rickets/osteomalacia
– Calcification often dense than other causes.
3. Medullary sponge kidney
– Not a true cause of nephrocalcinosis as calcification is
within ectatic ducts rather than in parenchyma.
– Numerous medullary cysts communicating with tubules
which opacify during IVU.
– Cysts contain small calculi giving bunch of grapes
appearance.
4. Renal papillary necrosis (Fig. 7.7)
Calcification of shrunken necrotic papillae.
5. Causes of hypercalcemia or hypercalciuria
a. Milk alkali syndrome
– Due to long standing calcium and alkali ingestion.
– Severe hypercalcemia, hypercalcemia, irreversible renal
failure and ectopic calcification.

Fig. 7.7: Grades papillary necrosis

 Urogenital System 593
b. Sarcoidosis
– Renal involvement in 2–5% cases.
– Associated lung involvement—hilar LN, fibro–nodular
infiltrate.
– Bone lytic lesions.
c. Hypervitaminosis D
– In excess of 50,000 U/day.
– Deossification.
– Widening of provisional zone of calcification.
– Dense calvarium.
– Metastatic calcification in arterial walls.
6. Primary hyperoxaluria
– 65% < 5 years.
– Generally diffuse and homogenous.
– Recurrent nephrolithiasis.
– Dense vascular calcification.

Cortical Nephrocalcinosis
< 5% of cases.
1. Acute cortical necrosis
– Small kidney
– Tramline/punctate calcification along margin of necrotic
tissue
– USG shows hyperechoic cortex with shadowing.
2. Chronic glomerulonephritis
– Small smooth kidneys with wasted parenchyma
– Normal papillae and calices
– Decreased density of contrast on IVU
– USG—increased echogenicity with prominent sinus fat.
3. Hemolytic uremic syndrome
– Common cause in children
– Cortical necrosis fibrosis calcification
– Clinically thrombocytopenia.
4. Alport’s syndrome
– Autosomal dominant
594 Differential Diagnosis in Radiology
– Polyuria, anemia, nerve deafness, congenital cataract,
nystagmus
– Small smooth kidneys.
5. Rejected renal transplant
– Small kidney
– Cortical calcifications.

7.13  RENAL MASS

Adult
Unilateral Bilateral
Solid
A. Tumors A. Tumors
a. Malignant: Lymphoma
Adenocarcinoma
(RCC)
– Lymphoma Metastasis
– TCC B/L malignant or benign
– Metastasis Renal tumors
– Adult
neuroblastoma B. Cysts:
b. Benign:
– AML – Adult polycystic kidney
(Angiomyolipoma) disease
– Oncocytoma
– Adenoma – Acquired cystic kidney
– Mesenchymal disease.
tumors
(Lipoma, fibroma
myoma, hemangioma)
B. Inflammatory masses:
– Acute focal pyelonephritis
– Renal abscess
– Xanthogranulomatous pyelonephritis
– Malakoplakia
– Tuberculoma.
 Urogenital System 595
Cystic
a. Simple renal cysts
b. Inherited cystic disease
• Multilocular cystic nephroma
• Multicystic dysplastic kidney
c. Focal hydronephrosis.

Children (Pediatric)
Single Multiple
• Wilms’ tumor • Multiple Wilms’ tumors
• Multilocular cystic nephroma • Angiomyolipoma
• Mesoblastic nephroma • Lymphoma
• Focal hydronephrosis • Leukemia
• Traumatic cyst, abscess • Nephroblastomatosis
• RCC • Adult polycystic kidney disease
• Intrarenal neuroblastoma • Abscesses
• Malignant rhabdoid tumor

Renal Cell Carcinoma

• Most common urological malignant lesion in adults
• M:F=2:1, 6th and 7th decades
• U/L, 2%-B/L, 9% multicentric (VHL, familial, dialysis)
• Diagnostic triad—flank pain, gross hematuria and palpable
renal mass—4–9% of patients
• Usually solid
• < 3 cm—homogenous and smooth
• Larger—necrosis and/or hemorrhage, dystrophic calcifi­cation
• Plain X-ray—normal, soft tissue mass overlying/bulging renal
outline, or loss of psoas outline
• Calcification—in 20% of RCC
(Non-peripheral or central)—87%—carcinomas
• IVP—67% sensitive in detecting solid mass lesion of the kidney
• However, cannot determine the nature of a renal mass.
596 Differential Diagnosis in Radiology

Primary Uroradiologic Elements

Size – Large
Contour – Unifocal mass
Lesion distribution – U/L

Secondary Collecting System

Focal—dilatation, displacement, attenuation.
Nephrogram : Focal replaced, irregular margin.
Attenuation : Diminished, enhances less than
normal parenchyma, unsharp
parenchymal interface with ill-
defined margin, a thick or irregular
wall, enlargement of renal vein or
IVC with or without filling defect.
Echogenicity : Variable
MR : SI similar to parenchyma on
unenha­nced T1 and T2WI, enhanc-
es with gd.
Angio : Most RCC-hypervascular, presence
of tumor vessels.
: Irregular tortuous, without normal
tapering, randomly distributed,
variable in caliber with unpredict-
able branch­ing.
Lymphoma : Primary lymphoma—rare
Usually
– Secondary hematogenous
– Direct extension.
– NHL > HL
– B/L > U/L
– Multiple nodular, diffuse
infiltration, bulky single tumor,
solitary nodule, invasion from
perirenal disease, microscopic
infiltration.
 Urogenital System 597
Earliest change: Metastatic nodules detected as nephro­graphic
defects on contrast material enhanced imaging studies, at a time
when kidneys may be normal in size and contour.

Primary Uroradiological Elements

Size : Large
Contour : Normal to multifocal masses
Lesion distribution : Bilateral.

Secondary Uroradiological Elements

Collecting system : D
 isplaced, caliectasis without pelviec­
tasis (from sinus spread)
Parenchymal : Expanded (focal)
thickness
Nephrogram : M
 ultifocal masses/attenuation value
less than that of normal tissue: minimal
enhancement with contrast material.
Echogenicity : Multifocal hypoechoic solid masses.

Transitional Cell Carcinoma

Primary involvement of PCS and ureter.
– Focal, multifocal or diffuse, transform the normally smooth
mucosa into a surface, which is irregular or nodular.
– Twice as common in renal pelvis than as in the ureter.
– B/L -10% multifocal 20–44%
– M>F, 7th decade
– Gross or microscopic hematuria flank pain.

IVP
• Primary investigative modality
• Filling defect in renal pelvis, or calyx, calyceal cut off,
infundibular narrowing, poor or non-visualization of one group
of calyces, non-functioning kidney, due to HDN.
598 Differential Diagnosis in Radiology
i. HDN
ii. Extensive destruction and replacement of renal
parenchyma
iii. Renal vein invasion.

USG
• Iso- or hypoechoic solid mass separating the central sinus
echoes.
• Focal enlargement of renal cortex if seen suggests infiltration of
renal parenchyma.

CT
Pelvis or calyceal filling defect or a solid mass in renal sinus.
• Parapelvic fat line is initially compressed by the growing mass
and, if disrupted, indicates invasion
• In large masses, a diagnosis of TCC is more likely if the mass is
centrally located, with centrifugal extension, and preservation
of renal shape
• RCC tends to be eccentric, distorted renal outline and shows
relatively more enhancement.

Metastasis
Relatively common at autopsy—seen in 20% patients
• MC sites of primary—Lung, breast, colon, malignant melanoma
• Multiple and B/L
• If single large—impossible to differentiate from primary (Renal
tumor—Biopsy indicated)
• USG—hypoechoic
• CT—small multiple solid renal lesion, < 2 cm, subcapsular in
renal cortex.
 Urogenital System 599
Angiomyolipoma (AML)
• Radiologically most common, diagnosed benign renal
neoplasm
• Hamartoma—represents excessive growth of mature fat,
smooth muscle and arteries normally present in the kidney
• F > M—Most asymptomatic
• Larger lesions—Mass, flank pain, hematuria, hypotension
• Association with tuberous sclerosis (TS)—80% of patients with
TS have AML
• X-ray—In 10% of patients shows large soft tissue mass with fat
radiolucency.

Typical Findings
Primary
Size : Large
Contour : Unifocal mass
Distribution : U/L
Secondary : Collecting system—attenuated (focal);
displaced (focal)
Nephrogram : Replaced (focal)
Attenuation value Mixed (negative and positive values) (fat)
Echogenicity : Heterogenous, often hyperechoic
MR : Signal intensity follows fat on T1 and T2WI
and fat suppressed images.

Oncocytoma
• Uncommon benign tumor arise from PCT
• 4–7% of all renal tumors
• Average size—7 cm
• Often detected incidentally as they rarely bleed or cause pain
unless extremely large.
600 Differential Diagnosis in Radiology
USG : S olid homogenous mass with central
stellate scar.
CT : Well defined solid mass with homogenous
central echo with central scar.
MR : Homogenous signal intensity. Low to
moderate on T1 and relatively high on
T2WI. Central stellate scar with well-
defined capsule.
Angio : Well-defined vascular renal tumor with
a ‘spoke-wheel’ pattern of vessels pene­
trating into the center of the tumor and
homogenous tumor blush.
Adenoma : Seen in 15% kidneys at autopsy.
: Usually as cortical subcapsular tumor.
: Arise from tubular epithelium.
: Difficult to distinguish from RCC. Natural
H/o—unknown.
Wilms’ tumor : Most common abdominal and renal
malignancy in children
: 7–8/10 children/years
: 80% in first three years
: Association with cryptorchidism, hypo-
spadias, hemihypertrophy.

Sporadic Aniridia
• 10–15% B/L
• Plain film—abdominal mass displacing adjacent structures
• Calcification—in 5%
• USG—Large well-defined mass, greater echogenicity than liver.
Solid with hemorrhage and necrosis
CT—Well-defined, low-attenuation with hemorrhage and
necrosis
MR—Inhomogenous low signal on T1 and high on T2
• Differentiation from neuroblastoma—2nd most common
retroperitoneal tumor in children.
 Urogenital System 601
Wilms’ Tumor Neuroblastoma
• Intrarenal mass with • Intraspinal extension
distorted PCS anatomy
• Vascular structures • Encased
(IVC, aorta) displaced
• Heterogenous • Solid homogenous
with areas of necrosis.
• Ipsilateral IVC/renal • Extend into chest
thoracoabdominal sign
• Vein tumor thrombus (+) • (–)
• Lung metastasis • Bone metastases
• Usually does not cross • Crosses midline
midline • Calcification more common.

Congenital Mesoblastic Nephroma

• Most common solid renal tumor in newborn—can be
diagnosed in utero-on ultrasound
• Mean age at diagnosis—3-and-a-half months, associated
polyhydramnios
US/CT—predominantly solid mass but even cystic and calcified
component can be seen
• Does not extend into IVC.

Primary
Size : Large
Contour : Infiltrative bean-shaped mass
Lesion distribution : U/L
Secondary : Attenuated, caliectasis with
collecting system pelviectasis nephrogram—replaced.
Attenuation value : Soft tissue homogenous (common)
Echogenicity : Soft tissue homogenous (common)
Others : Polyhydramnios (in utero)
602 Differential Diagnosis in Radiology

Multilocular Cystic Nephroma

• Uncommon neoplasm composed of multiple variable-sized
cysts with prominent septa
• Arises as U/L unifocal mass with the remaining portion of one
kidney uninvolved or compressed by the tumors
• Surrounded by dense fibrous capsule
• Calcification of cyst wall uncommon
• Characteristically one or more of the cysts herniate into the
renal pelvis to form filling defects.

Nephroblastomatosis
• Remnant of primitive blastoma as sheets or more discrete
nodules in cortex
• Commonly associated with Wilms’ tumor
• IVP—multifocal distortion of PCS
• CT—multiple nodules of varying sizes, situated in the peripheral
portion of the kidney, with enlargement.
• Surface—usually smooth
• Minimal contrast enhancement.

Simple Cysts/Localized Cystic Disease

Most common focal mass of the kidney
• Pathogenesis—not conclusively established
• Obstruction of renal tubule/blockage and expansion of calyceal
diverticulum (Fig. 7.8)
• Cyst fluid is serous, not urine, LDH level—lower than serum
• Usually U/L and single, most common site—polar (lower pole)
• Rarely numerous simple cysts completely replace the
parenchyma of either the entire kidney or only a portion of one
kidney—localized cystic disease composed of cluster of simple
cysts that lacks a capsule and preserves the reniform shape of
the enlarged kidney.
Cystic diseases to be distinguished from usually benign but
sometimes malignant—multiloculated cystic neoplasms (grow by
expansion and appear as ball-shaped encapsulated mass).
 Urogenital System 603

Fig. 7.8: IVP radiograph shows calyceal diverticulum

in left kidney near the upper pole

SIMPLE CYST TYPICAL FINDINGS

Primary
Size : Variable.
Contour : Unifocal mass.
Lesion distribution : Variable.
Secondary
Collecting system : Attenuated (focal), displace (focal)
Nephrogram : Displace (focal), replaced (focal),
smooth margin, ‘thin-rim sign’ when
peripheral, ‘beak sign’ when peripheral.
Calcification : Uncommon, curvilinear, peripheral.
Attenuation value : Water, no contrast enhancement.
604 Differential Diagnosis in Radiology
Echogenicity : A
 nechoic, well-defined far walls,
enhanced through sound trans­ mi­
ssion.
MR : Signal intensity parallel’s water.
Polycystic kidney : Multiple cysts in B/L kidneys.
disease

Primary
Size : Large
Contour : Multifocal masses.
Lesion distribution : B/L (may be asymmetric)

Secondary
Collecting system : Displaced, attenuated.
Nephrogram : Replaced (multiple masses with
smooth margin, varying sizes, radiolu-
cent with urography or angiography;
water density/intensity, non-enhanc-
ing with CT/MRI).
Echogenicity : Multiple fluid-filled masses.
Cyst content : Serous with urea content equal to
urine.

Acquired Cystic Kidney Disease

• Multiple renal cysts formation in patients with end stage renal
disease
• Seen in 40–50% of patients on long-term hemodialysis
• Multiple small B/L cysts involving both renal cortex and medulla
• Increased incidence of renal neoplasms
• US—B/L small kidneys with increased echogenicity with
multiple cysts
• Solid or complex renal tumor may be present
• CT—B/L small kidney, with multiple cysts
• Cyst wall calcification—common.
 Urogenital System 605
Acute Focal Bacterial Pyelonephritis and
Renal Abscess
• Usually secondary to ascending inferior gram –ve organism
• Most bacterial abscesses are associated with calculus in pelvis
or ureter
• IVP—reveals presence of focal renal mass
• USG—hypoechoic poorly-defined mass with internal echoes
• CT—low density area with patchy enhancement
• Lack of well-defined wall and central low-density differentiates
it from renal abscess.

ABSCESS TYPICAL IMAGING FEATURES

Primary
Size : Large.
Contour : Unifocal mass.
Lesion distribution : U/L.

Secondary
Collecting system : Attenuated (focal), displaced (focal).
Nephrogram : Normal (early), replaced (focal),
irregular, thick walls (late).
Attenuation value : Normal to slightly diminished before
contrast administration.
: Enhances less than normal parenchy-
ma (early) decreased and non-enhanc-
ing (late).
Echogenicity : Variable (hypoechoic (early) to
anechoic (late).

7.14  CYSTIC DISEASE OF KIDNEYS

Renal cysts : R
 epresent dilated nephrons or collecting
ducts.
606 Differential Diagnosis in Radiology
Cystic kidney : Is a kidney with 3 to 5 or more cysts.
Renal cystic disease : Refers to any disorder that results from
the presence of multiple renal cysts.
• Simple cysts
• Atypical cysts

Cystic Neoplasams
Non-genetic Conditions Imaging Features
• Cystic dysplasia or • U/L or B/L
dysplasia
• Multicystic • Diffuse or localized
dysplastic kidney
• Multilocular cyst • Size of kidneys
• Localized cystic • Extrarenal manifestations
disease of the kidney
• Parapelvic cyst
• Simple cysts
• Calyceal cysts
• Medullary sponge kidney
• Acquired cystic disease of kidney (in CRF).

GENETIC CONDITIONS

Autosomal Dominant
• Autosomal dominant, polycystic kidney disease (ADPKD)
• Tuberous sclerosis, VHL
• Medullary cystic disease
• Glomerulocystic disease.

Autosomal Recessive
Autosomal recessive polycystic kidney disease (ARPKD)
Juvenile nephronophthisis.
 Urogenital System 607

Fig. 7.9: Localized bulge of the renal outline

608 Differential Diagnosis in Radiology

Cysts Associated with Syndromes

• Chromosomal disorders
• Autosomal recessive syndromes
• X-linked syndromes.

CLASSIFICATION OF RENAL CYSTS

Renal Dysplasia
• Multicystic dysplastic kidney
• Focal segmental cystic dysplasia
• Multiple cysts associated with lower UT obstruction.

Polycystic Disease
• Childhood (AR)
• Adult (AD).

Cortical Cysts
• Simple cyst
• Multilocular cystic nephroma
• Syndromes associated with cysts
• Zellweger syndrome
• Tuberous sclerosis
• Turner’s syndrome
• VHL
• Trisomy 13
• Trisomy 18
• Hemodialysis.

Medullary Cysts
• Calyceal cyst (diverticulum) (Fig. 7.8)
• Medullary sponge kidney
• Papillary necrosis
• Juvenile nephronophthisis (medullary cystic disease MCD).
 Urogenital System 609
Miscellaneous
• Inflammatory
• Tuberculosis
• Hydatid.

Neoplastic
• Cystic degeneration of carcinoma.

Traumatic
• Intrarenal hematoma.

Extraparenchymal Renal Cysts

• Parapelvic
• Perinephric.

Simple Cysts
USG Criteria: A renal fluid collection with the following features:
• No internal echoes
• Sharply-defined distal wall
• Posterior acoustic enhancement
• Round or oval shape.

Atypical Findings in a Cyst

• Internal echoes
• Septa
• Discernible wall
• Solid components within the cyst
• Calcification.

DDx
• Hydrocalyx
• Calyceal cyst
610 Differential Diagnosis in Radiology
• Cavity
• Obstructed moiety of duplex system (upper pole)
• Hematoma
• Aneurysm or AVM.

CT Criteria
1. Sharp margination and demarcation.
2. Smooth thin wall.
3. Homogenous attenuation (0–20 HU).
4. No enhancement.
If CT findings are atypical or if patient has hematuria, non-
enhanced scan should be obtained.

MRI Criteria
1. Sharp margination and demarcation.
2. Smooth thin wall.
3. Homogenous water-like signal intensity decreases T1WI,
increases T2WI.
4. No enhancement
SS FSE sequences best suited.

ATYPICAL CYSTS
BOSNIAK classification of cystic renal masses according to CT
criteria:
Category 1: Classic simple cysts
Category 2: Minimally complicated cysts, which do not require
surgery.
• Smooth, thin (< 1 mm) septa
• Small smooth plaques of fine linear calcification in cyst wall or
septa
• High density cysts (40–100 HU)
• Can be followed with serial imaging, provided the following
criteria are met
1. Perfectly smooth, rounded, sharply-marginated homo­
genous lesions.
 Urogenital System 611
2. No enhancement.
3. At least one-fourth of the lesion’s circumference should
extend outside the kidney so that the smoothness of the
wall can be evaluated.
4. Size < 4 cm.

Cystic RCC May Rarely Show Similar CT Features

Hemorrhagic cysts on MRI – Increase T1WI,
Increase T2WI
– Do not enhance
fluid-iron levels
Category 3: Should undergo surgical exploration
• Thick, irregular mural or septal calcification
• Numerous or thick (> 1 mm) irregular septa
• Uniform or slightly nodular wall thickening
• Some category 3 lesions are benign, e.g. multilocular cystic
nephromas, hemorrhagic renal cysts
• Others are cystic RCCs.
Category 4: Clearly malignant lesions with large cystic components
which may show marginal irregularity or solid vascular elements.

POLYCYSTIC KIDNEY DISEASE

Autosomal Recessive Polycystic Kidney Disease
(ARPKD—1980-81)
Presents in childhood
1. B/L large smooth kidneys with dense striated nephrogram.
2. Markedly hyperechoic kidneys on USG with loss of CMD (small
1–2 mm cysts).
3. Associated with congenital hepatic fibrosis and portal HT.
– Dilated collecting ducts in renal medulla with relative
preservation of the renal cortex.
612 Differential Diagnosis in Radiology

Autosomal Dominant Polycystic

Kidney Disease (ADPKD)
Presents in 3rd–4th decade and terminal renal failure occurs in 10
years.
1. B/L but asymmetrical lobulated enlargement of kidneys.
2. Multiple smooth defects in the nephrogram, with elongation
and deformity of calyces giving a “spider leg” appearance. Cysts
may produce filling defects in the renal pelvis. Calcification in
cyst walls.
3. Associated with:
– Liver and pancreatic cysts
– Berry aneurysms (intracranial)
– Colonic diverticulae
– Increased incidence of RCC.
Diagnostic Criteria : (Ravine, et al. 1994)
< 30 years : Two cysts U/L or B/L
30–59 years : Two cysts in each kidney
>60 years : > Four cysts

Unilateral (Localized)
Renal Cystic Disease (URCD)
• At the most one kidney is replaced by multiple cysts. However,
the other kidney is normal
• No family history, no liver cysts, no renal failure
• Affected kidney is enlarged and may show normal function.

Acquired Cystic Kidney Disease (ACKD)

It is characterized by the development of multiple renal cysts in
patients without a history of hereditary renal cystic disease.
Diagnosis is based on detection of at least 3–5 cysts in each kidney
in a patient with CRF not due to hereditary renal cystic disease.
• Affected kidneys are usually small. However, nephromegaly
eventually develops
 Urogenital System 613
• Hemorrhagic cysts occur in about 50% of these patients
• (40–100 HU on non-enhanced scans)
• Increased incidence of small RCCs (< 3 cm).

EXTRAPARENCHYMAL RENAL CYSTS

Parapelvic cyst: (lymphatic in origin).
• Located in or near the hilum
• Does not communicate with the renal pelvis
• Simple (Multilocular; single/multiple: U/L or B/L
• May compress renal pelvis and cause hydronephrosis.

DDx
Dilated or extrarenal pelvis

Perinephric Cyst
• Secondary to trauma
• May compress the kidney, pelvis or ureter, leading to
hydronephrosis or causing renal displacement.

Multilocular Cystic Nephroma

Cystic renal mass derived from metanephric blastoma, males < 4
years; females 5th/6th decades; presents as abdominal mass.
Spectrum: Benign (Multilocular renal cyst)—Malignant
(Multilocular cystic Wilms’ tumor)
No associated anomalies.
USG: Multilocular renal mass with multiple cysts and septations.
Nonfunctioning on isotope imaging.
Hallmark on imaging in presence of a capsule.

Multicystic Dysplastic Kidney (MDK)

Two types Pelvico-infundibular atresia
Hydronephrotic type.
614 Differential Diagnosis in Radiology
In the classic Pelvico-infundibular type—No discernible renal
pelvis. Seen on imaging, kidney may be small or normal in size, or
enlarged containing multiple variably-sized non-communicating
renal cysts—No perfusion on renal scintigraphy.
In the Hydronephrotic form of MDK—Dilatation of renal pelvis
and calyces is seen with multiple non-communicating cysts.
The affected kidney may remain unchanged, but it frequently
undergoes spontaneous regression.
T2W pulse sequence can be used to diagnose MDK, especially in
utero.

Medullary Cysts
Calyceal Cyst (Diverticulum)—Small, solitary cyst communi­cating
via an isthmus with fornix of a calyx (Fig. 7.8)
Medullary Sponge Kidney—B/L in 60–80% cases.
Multiple, small, mainly pyramidal cysts which opacify during
excretory urography and contain calculi.
Juvenile Nephronophthisis (Medullary Cystic Disease)—Normal
or small kidneys, presents with polyuria. USG shows few medullary
or corticomedullary cysts with loss of CMD and increased
echogenicity.

7.15  CARCINOMA OF THE BLADDER

• Most common tumor of the gut
• TCC 90%; SCC 5%; Adenocarcinoma 2%
• Peaks in the seventh decade
• Males predominate by 3:1
• Hematuria, most common clinical presentation
• Chemical agents such as aniline, biological agents (coffee,
artificial sweeteners), radiation, chronic urothelial irritation,
and nicotine are associated with bladder carcinogenesis.
Bilharziasis is an independent risk factor
• Squamous cell carcinoma and adenocarcinoma have poor
prognosis.
 Urogenital System 615
• The lateral wall of the bladder and bladder diverticulae are
more frequently involved
• Only 60% of known bladder tumors are detected on urograms
• Bladder tumors cause non-specific intravesical filling defects
• The “Steeple sign” (Contrast trapped within the interstices of
tumor) suggests transitional cell carcinoma. Fungus balls or
mycetoma may also occasionally entrap contrast material,
but the pattern is lamellar and frequently associated with gas
formation
• CT cannot accurately depict the depth of invasion of the
bladder wall and cannot distinguish edema or inflammatory
changes from tumor. CT can accurately evaluate peri­vesical and
local pelvic extension
• MRI is superior to CT in determining local growth and detection
of bone marrow infiltration
• Stage of tumor—Single most important prognostic parameter.
Synchronous upper tract urothelial lesions must be excluded
• Clinical staging has an accuracy of 50% when compared with
that with CT (32–80%) or MRI (73%)
• Overstaging commonly occurs as a result of edema after
endoscopy and/or endoscopic resection and as a result of
fibrosis from radiation therapy
• A staging classification that incorporates the TMN and Jewett-
Strong-Marshall (JSM) system is useful
• T1A—Indicates lesions involving the mucosa and submucosa
• T2B1—Invasion of the superficial muscle layer
• T3aB2—Invasion of the deep muscular wall
• T3bC—Invasion of perivesical fat
• T4aD1—Extension to perivesical organs
• T4b—Invasion of the pelvic and/or abdominal wall
• D2—Distant metastases
• Metastases occur in approximately 11% of cases, retroperitoneal
nodes (34%); distant lymph nodes (17%); lumbar vertebrae
(13%); lungs (9%); kidneys (8%); adrenals (4%)
616 Differential Diagnosis in Radiology
• Plain radiographic findings are nonspecific, particularly the
presence of calcification. The calcification is on the surface in
TCC. Intrinsic calcifications suggest an adenocarcinoma or the
unusual cell type
• Irregular filling defects with broad base and fronds in the
bladder are seen with IVU, CT and MRI. Increased thickness
of the bladder wall in the region of the tumor should indicate
infiltration. Unusually the tumor may present as diffuse
thickening of the bladder wall
• Both CT and MRI have been shown to perform better than
cystography in the diagnosis of tumors in the bladder
diverticulae that are not depicted on cystograms because of
obstruction at the diverticular orifice
• Ultrasonography is inaccurate for diagnosing early tumor, and
it is useful in the diagnosis of obstructive uropathy. Vesical
US can be performed endoscopically during cystoscopy
or suprapubically through suprapubic approach. Tumor is
echopoor relative to the vesical wall. As the staging modality
US is invasive.
• On NECT, the TCC is iso—to hyperattenuating relative to urine.
TCCs demonstrate mild-to-moderate enhancement on CECT,
and they become hypoattenuating relative to opacified urine.
• On MRI, the tumor is hyperintense than urine but hypointense
than fat on both T-1 and PD WI; the tumor is hypointense than
urine on T2WI. Post-Gd T1WI within the first two minutes can
identify early tumors.

Differential Diagnosis
• Non-neoplastic lesions—calculi, blood clot, fungus balls,
inflammatory pseudosarcoma, cystitis.
 Urogenital System 617
Primary
• Epithelial tumors—Papilloma, SCC, adenocarcinoma, carcino-
sarcoma, undifferentiated tumors
• Mesodermal tumors—Smooth muscle—leiomyoma, leio-
myoblastoma, leiomyosarcoma; neural tumors—neurofi-
broma, neurilemmoma; vascular—hemangioma, lymphangi-
oma, hemangiosarcoma; fibrous—fibroepithelial polyp; mixed
tumors—fibromyoma, fibrolipoma, fibromyxoma; lymphoma
• Metastases or direct invasion of the uroepithelium by tumors.

7.16  BLADDER OUTFLOW OBSTRUCTION

1. Prostate • Benign prostatic hyperplasia
• Prostate cancer
• Other prostatic lesions—
Wegener’s granulomatosis
– Lymphomatoid granulomatosis
– Malignant lymphoma
2. Urethral • Congenital urethral valves
• Urethral atresia
• Urethral dysplasia
• Anterior urethral diverticulum
• Urethral stricture
• Calculus
• Meatal stenosis
3. Vesical • Acquired bladder neck stricture
• Bladder calculi
• Fungus ball
• Bladder tumors
• Neurogenic bladder
• Bladder sphincter dys-synergia
4. Miscellaneous • Ectopic ureterocele
• Prune-belly syndrome
• Hydrocolpos
618 Differential Diagnosis in Radiology

• C ervical/lower uterine segment leio-
myoma
• Vaginal carcinoma, rhabdomyosarcoma
Phimosis

BPH (Benign Prostatic Hyperplasia)

Most common cause of vesical neck obstruction in adult males.
On MCU the prostatic urethra appears elongated and compressed.
Cystogram—Floor of urinary bladder is elevated with a rounded
defect.
Trabeculations and distention of urinary bladder with/without
bladder diverticulae/bladder calculi.
IVU—Hydronephrosis /Hydroureter in advanced cases.
Distal ureters form a ‘J’ (fishhook) deformity.
US—Diffusely altered inhomogenous echopattern.
Demonstrate size and shape of gland.
Concomitant prostatic calculi + other features of obstruc­tion.
CT—Unequivocal enlargement—prostate is seen 2–3 cm or more
above the symphysis and is surrounded by the bladder.
MR—Appearance of prostate varies depending on the type of
hyperplasia.
Nodular hyperplasia—Enlarged gland with nodules of decreased
signal intensity on T1WI and of varying intensity on T2WI.
Diffuse hypertrophy—Enlarged gland with decreased signal intensity
on T1WI and homo/inhomogenous medium to high SI on T2WI.

Carcinoma of the Prostate

95% are adenocarcinoma; rarely squamous or transitional cell
carcinoma.
70% originates in periphery—C zone; 20% in transitional zone and
10% in central zone.
Screening for primary carcinoma is by digital rectal examination
and serum PSA.
 Urogenital System 619
MCU—Narrow prostatic urethra. Irregularity of urethra/floor of
bladder laterosuperior of superolateral to urethra.
Seminal versiculogram—Medial portion of seminal vesicles is
reduced in size and the lateral portion may be dilated.
US—Carcinoma is seen as hypoechoic area within the peripheral
zone which warrants a TRUS guided needle biopsy.
Feature of extracapsular invasion—Contour deformity of capsule
irregularity and duct tumor extension into periprostatic fat
CT—Used for tumor staging (nodal, visceral, bony).
Radionuclide bone scintigraphy—Accurately detects small and
early metastatic lesion.
MR—Major role is in tumor staging, especially extracapsular
extension seminal, vesicular and bladder invasion.
Signal intensity of prostate carcinoma has been variously repeated
as being of decreased, increased, and/or hetero­genous.

Congenital Urethral Valves

Almost exclusively in males.
Anterior urethral valves—Rare; Posterior urethral valves are more
common.

Posturethral Valves
Type:
1. Two mucosal folds extending from lower aspect of verumo­
ntanum to distal posterior urethra—most common.
2. Two folds extending from cephalad aspect of verumo­ntanum
to bladder neck.
3. Horizontal membrane in the region of verumontanum with
central/eccentric opening.
Antenatal ultrasound—Dilated bladder with thickened walls
with dilated posterior urethra. Dilated pelvicalyceal system and
ureter (50%).
Urinary tract rupture—Urinary ascites, paranephric urinoma.
Oligohydramnios and pulmonary hypoplasia.
620 Differential Diagnosis in Radiology
Cystic dysplasia
MCU—Dilatation of prostatic urethra upto valves
Valves may be seen as their crescenteric filling defect
Unilateral or bilateral VUR
Ring-like constriction of vesical neck (Detrusor muscle
hypertrophy)
UB—Thickened walls with trabeculations/sacculations.

Urethral Atresia
Exceedingly rare and is usually associated with renal dysplasia.

Urethral Dysplasia
• Entire urethra is dysplastic and this is associated with dysplasia
of kidneys
• Suprapubic catheter is required to outline the urethra on
MCU—thin line of contrast in the region of urethra but no
normal anatomical landmarks can be distinguished.

Anterior Urethral Diverticulum

• Saccular, wide-necked ventral expansion of the anterior urethra,
usually at the penoscrotal junction
• During micturition, the diverticulum expands with urine and
obstructs the urethra.

Urethral Stricture
Causes—infective, trauma, instrumentation.
• Most common infective cause is gonorrhea. Post-gonococcal
strictures are several cm in length and involve bulbous urethra.
Associated filling of glands of Littre and Cowper is seen during
MCU.
 Urogenital System 621
Traumatic Stricture
Most common site is both prostatic and membranous urethra.
Usually associated with pelvic fractures.

Urethral Calculus (Fig. 7.10)

• Rare and happens to be present in urethra during passage from
the bladder
• Urethral calculus is so characteristic in position that the triangle
is made from plain radiograph
• RGU and MCU provide definitive information as to the
relationship of the radiopacity to urethra
• ‘Hour glass’ calculus—occupies bladder and prostatic urethra.

Fig. 7.10: AP radiograph of pelvis shows calculus in posterior urethra

622 Differential Diagnosis in Radiology

Acquired Bladder Neck Stricture

Formation of scar tissue at vesical neck can cause the following:
Suprapubic/previous perineal/ transurethral prostatectomy.
RGU—Shows dilatation of the distensible unscarred segments
of the anterior and posterior urethra and visualization of contracted
neck of bladder.

Bladder Calculi (Fig. 7.11)

• Arise as a result of stasis, infection, FB or can descend from the
kidney
• There are usually triple phosphate stones or uric acid mixed
with urate
• X-ray—Faceted/star-shaped/laminated calculus
• US—echogenic focus with post-acoustic shadowing.
Feature of obstructive uropathy—thickened, trabeculated
urinary bladder with hydroureteronephrosis.

Fig. 7.11: AP radiograph of pelvis shows vesical calculi

 Urogenital System 623
Fungal Ball
In immunocompromized and diabetic patients, numerous hyphae
within the urinary bladder unite to form a fungus ball, leading to
bladder outlet obstruction.
• Fungus ball is associated with alternating lucent and opaque
irregular laminations owing to gas formation
• It may be seen as mobile-filling defect during IVU or
cystography.

Bladder Tumors
1. Epithelial: Most common is transitional cell carcinoma;
squamous cell carcinoma and adenocarcinoma are rare.
2. Nonepithelial:
Benign—Leiomyoma, fibroma
Malignant—Leiomyosarcoma, rhabdomyosarcoma.
Most common site—Around trigone and posterolateral wall of
urinary bladder
Cystogram—Well-demarcated filling defect with lobulated
margins
US—Non-mobile mass lesion/focal wall thickening.
CT—Useful for detection of perivesical extension, invasion.
MRI—Visceral and pelvic lymph node involvement.

Rhabdomyosarcoma
Constitutes about 1/8th of the childhood solid tumors.
• Peak period of incidence is 1 to 8 years
• Bladder is the most common site of rhabdomyosarcoma
• In males, tumor typically arises from the bladder wall or
prostate; in females from vagina
• These tumors are quite large at the time of diagnosis and the
exact site of origin of these tumors is difficult.
624 Differential Diagnosis in Radiology

Radiological Features
Lobulated soft tissue density mass in the bladder base or as
echogenic soft tissue projecting into urinary bladder on US.
Once diagnosed—Chest X-ray, 99m Tc-MDP bone scan and
CT for staging.

Bladder—Sphincter Dys-synergia
Caused by asynchronous opening of the bladder neck with the
detrusor contraction producing characteristic high-voiding
pressure and low-flow rates.

Diagnosis Established by
Videocystometrography (VCMG)
• Bladder neck opens slightly at first, but then widens further as
the detrusor pressure falls
• Eventually patients develop hypertrophied bladder which
is unable to overcome bladder outlet obstruction and
decompensated obstruction.

Neuropathic Lesions of Bladder

1. Suprasacral cord lesion
– Injuries to cerebral/pontine micturition area.
Loss of voluntary detrusor control and uncoordinated
voiding. If bladder dysuria is also positive—Detrusor
contracts against a closed sphincter.
– Diagnosis made by VCMG. On cystogram—UB is contracted,
trabeculated and thick walled “Fir Cone bladder”.
2. Damage to sacral/peripheral nerves—disrupts the vesical
parasympathetic nerve supply
– Underactive/Non-acontractile bladder muscles
– Large capacity bladder with smooth wall
Need to be evacuated by manual compression/abdominal
straining and intermittent catheterization.
 Urogenital System 625
Complication
VUR, Recurrent UTI, stone formation.

Prune-Belly Syndrome
Caused by triad of deficient abdominal musculature, undescended
testes and urinary tract dysplasia.
Proposed etiology : Fetal urethral level obstruction which resolves
in later gestation.
: Early mesenchymal develop­mental arrest.
• Protuberant abdomen.
• Small kidneys with minimal dilatation of pelvicalyceal system
• Upper ureters are mildly dilated; lower ureters are tortuous and
show disproportionate dilatation
• Posterior urethra is markedly dilated prominently with a typical
conical narrowing with poor stream in the distal urethra
• Urinary bladder is of large volume, irregularly-shaped, thin
walled and with wide neck.

Ectopic Ureterocele
• This is a saccular dilatation of the intramural portion of the
ureter as it passes through the bladder wall, which results
because of the narrowed opening of the ectopic ureter
• Ectopic ureter most commonly occurs with the upper moiety of
a kidney
• An ectopic urenterocele opening into the urethra, bladder
neck, on vestibule—results in bladder outlet obstruction.

Radiological Features
Dilated ureter with small hydronephrotic upper pole moiety.
• Ureteroceles can be seen on ultrasound and on IVU show a
characteristic ‘cobra head’ sign—caused by contrast medium
pooling in the ureterocele, which is surrounded by halo of
radiolucent ureterocele wall of bladder mucosa.
626 Differential Diagnosis in Radiology

7.17 TESTICULAR TUMORS

• Adult testes are ovoid glands measuring 3–5 cm in length, 2–4
cm in width and 2–3 cm in anteroposterior diameter. Weight
ranges from 12.5 to 19 g
• Epididymis is posterolateral to testis, 6 to 7 cm in length divided
into head (10–12 mm diameter), body (4 mm) and tail.

DD of Testicular Tumors
1. Primary testicular tumors:
A. Germ cell tumors : Seminoma
: Nonseminomatous germ cell
tumors (NSGCT)
Embryonal : Choriocarcinoma
carcinoma : Teratoma
: Yolk sac/Endodermal sinus tumor
: Tumors of more than one
histological type
: Teratoma and embryonal cell
carcinoma
: Choriocarcinoma and any other
type
B. Tumors of gonadal : Sertoli cell
stroma : Leydig cell
: Granulosa cell
: Undifferentiated
: Combination
2. Secondary testicular : Lymphoma
tumors : Leukemia
: Non-lymphomatous metastasis
(Lung and prostate)
3. Benign/miscellaneous lesions of testis:
• Tunica albuginea cyst
• Intratesticular cyst
• Tubular ectasia of rete testis
 Urogenital System 627
• Cystic dysplasia
• Epidermoid cyst
• Abscess.

Germ Cell Tumors (95%)

Clinically patient presents with a palpable painless mass, chronic
pain or sense of heaviness. Fifteen percent cases have acute
symptoms of pain following traumatic hematoma. Rarely patient
presents with signs of distant metastasis (NSGCT)
• Seminomas: Accounts for 40% of testicular tumors. Peak
prevalence is in the 4th decade
• Ultrasound: Well-circumscribed homogenous hypo­echoic mass
• Multiple calcification (1–2 mm): May be seen in 1/3rd cases
• As tumor enlarges, it becomes heterogenous (hemorrhage/
necrosis)
• Burnt-out seminoma: Primary testicular tumor is not identified
as a discrete mass despite a large tumor burden elsewhere in
the body
• Seminomas are most common tumor type in cryptorchid testis
• MR: Lobulated homogenous, intermediate SI on T2WI
• NSGCT: Peak prevalence is in the 2nd to 3rd decade
• More likely to occur as combination of different histotypes
rather than as isolated pure form
• More likely to be locally advanced and have a higher likelihood
of metastases than seminomas
• Ultrasound: Heterogenous and poorly defined
• Calcification: 50% cases
• MR: Heterogenous with areas of high and low SI or T2WI
• Endodermal sinus tumor and teratomas are the most common
tumors of infancy and early childhood.
628 Differential Diagnosis in Radiology

Stromal Tumors (3–5%)

• Twenty percent of these occur in children. Rest occurs between
20 and 50 years
• It is not possible to differentiate between the different stromal
or between stromal and germ cell tumors radiologically
• Most common stromal tumor is Leydig cell tumor
• Associated with gynecomastia (30%) (Androgen/estrogen
production)
– Impotence
– Loss of libido
– Precocious puberty.
On ultrasound, these tumors are usually small, solid and
hypoechoic.

Spread of Testicular Tumors

• Lymphatic: Upper retroperitoneal, retrocrural, mediastinal and
supraclavicular lymph node
• Pelvic lymphadenopathy is less common and is suggestive of
penetration of testicular capsule
• Hematogenous: Lung, liver, brain and bone.

Lymphomas
• Most common secondary testicular neoplasm: Peak age of
diagnosis is 60–70 years
• Testicular involvement occurs in 0.3% cases of lymphoma (NHL)
• Most common cause of bilateral testicular tumor
• Majority of lymphomas are homogenous, hypoechoic and
diffusely replace the testis. Focal hypoechoic lesions are rare.

Leukemia
• Second most common testicular metastatic tumor
• Testis acts as a sanctuary site for leukemic cells during
chemotherapy because of blood gonadal barrier that inhibits
 Urogenital System 629
concentration of chemotherapeutic agents. 64% cases of
acute leukemia and 25% chronic leukemia show testicular
involvement
• Characterized by: Diffuse infiltration producing diffusely
enlarged hypoechoic testes.

Other Metastases
Uncommon occurs from lung and prostate and rarely kidney,
stomach, colon, pancreas and melanoma.
• Commonly multiple and bilateral (15%)
• Hypoechoic but may be echogenic/complex in appearance.

Cyst of Tunica Albuginea

• Located within the tunica; usually on anterior and lateral
aspects of testes
• 5th and 6th decades
• Patient is asymptomatic, cystic lesion is 2 to 5 mm in size.

INTRATESTICULAR CYST
• Simple cyst filled with clear serous fluid that varies in size
between 2 and 18 mm.
• Probably originates from the rete testis possibly secondary to
post-traumatic/postinflammatory stricture formation.

Tubular Ectasia of Rete Testes

• Usually associated with epididymal obstruction secondary to
inflammation or traumatic lesions
• Characterized by variable-sized cystic lesion in the region of the
mediastinum testis with no associated soft tissue abnormality
and no flow on color flow Doppler imaging
• May be B/L and associated with spermatocele.
630 Differential Diagnosis in Radiology

Cystic Dysplasia
• Rare; seen in infants and young children
• Embryologic defect preventing connection of the tubules of
the rete testes and efferent ductules
• Characterized by multiple interconnecting cyst of varying size
and shape separated by fibrous stroma
• Renal agenesis/dysplasias frequently coexist with cystic
dysplasias.

Epidermoid Cyst
• Benign tumor of germ cell origin
• Occurs at any age, most frequently 2nd to 4th decades
• Well-defined hypoechoic solid masses with echogenic capsule,
internal echogenic contents may be present.

Abscess
• Results from complication of epididymo-orchitis, missed
testicular torsion, gangrenous/infected tumor, primary
pyogenic orchitis
• Common infectious causes are mumps, smallpox, scarlet fever,
influenza, typhoid, sinusitis, osteomyelitis, appendicitis
• Ultrasound—Enlarged testicle containing a fluid-filled mass
with hypoechoic/mixed echogenic areas
• Complications—Rupture-pyocele/fistula to the skin.

7.18  SEMINAL VESICLE CALCIFICATION

Seminal vesicles are paired symmetric organs, present along the
posterior aspect of prostate being separated from it by a fat plane.
These are accessory reproductive organs of males and there duct
fuses with the vas to make the ejaculatory duct which opens on
the verumontanum of posterior urethra.
 Urogenital System 631
Methods of Investigation
Plain X-ray: These may sometimes show calcifications in the
seminal vesicles, which may be confused to be of bladder origin.
The calcifications may be seen as either specks of scattered
calcification or mushroom-shaped.
USG: They appear as bilaterally symmetrical structure on
the posterior and superior aspect of prostate and are normally
heterogenous in appearance.
CT: They are seen as lobulated extraperitoneal pouches located
superior to the prostate gland between the bladder and the
rectum.
MRI: They are seen as convoluted tubular structures. The
seminal fluid within their lumen results in high-signal intensity on
T2 weighted images; these lumens are surrounded by low-signal
intensity of the tubular walls. MR imaging with endorectal coils
provides excellent images.

Differential Diagnosis
Diabetes mellitus: This is seen either as an incidental finding in a
known case of DM or may masquerade as obstruction and with
subsequent enlargement of the gland, leading either subfertility
or infertility.
Chronic infections: These include:
1. Tuberculosis.
2. Schistosomiasis.
3. Chronic UTI.
4. Syphilis.
Calcification of seminal vesicle may be seen in either of the
above diseases and is usually secondary to the involvement of
either the urinary system, i.e. the kidneys, ureters and bladder or
secondary to prostatitis. The primary changes in the above organs
give a clue to the real etiology of the calcification.
632 Differential Diagnosis in Radiology
• Tubercular seminal vesicle calcifications may present with
changes of renal tuberculosis (calcifications, calyceal cut-off
sign, calyceal diverticulae, putty kidney, multiple ureteric
strictures and a small capacity thimble bladder). Changes
of tubercular prostatitis may also be seen (abscesses,
hypoechogenicity, hemospermia calcifications)
• Schistosomiasis classically presents as bladder wall calcification,
which may extend to involve the ureters but never the PCS
(Pelvicalyceal system). This calcification may secondarily also
involve the prostate and seminal vesicle
• Idiopathic: This is by far the commonest cause of seminal vesicle
calcification, but may, however, present clinically as either
hemospermia, ejaculatory duct obstruction, sub-fertility or
infertility. The diagnosis is that of exclusion.

7.19  DIFFERENTIAL DIAGNOSIS OF

ABNORMAL NEPHROGRAMS
1. Dense persistent nephrogram with slow onset:
A. Acute ureteral obstruction
B. Acute renal failure
C. Systemic hypotension
D. Renal vein thrombosis
E. Partial renal artery occlusion
2. Dense persistent nephrogram with rapid onset:
A. Acute renal failure
B. Hypotension secondary to contrast injection
3. Persistent faint nephrogram:
A. Acute renal failure
B. Chronic renal failure
C. Acute pyelonephritis
4. Persistent dense nephrogram:
A. Contrast nephropathy
5. Rim nephrogram:
A. Severe hydronephrosis
B. Acute complete arterial occlusion
 Urogenital System 633
6. Striated urographic nephrogram:
A. Acute ureteral obstruction
B. Infantile polycystic kidney disease
C. Medullary sponge kidney
D. Medullary tubular ectasia
7. Absent nephrogram:
A. Sudden complete arterial occlusion
B. Sudden complete venous occlusion
C. Sudden complete long standing ureteral occlusion
D. Acute renal failure
E. Acute cortical necrosis
8. Inhomogenous arteriographic nephrogram:
A. Catheter induced arteriospasm
B. Small vessel disease
– Nephrosclerosis
– Necrotizing angiitis
– Wegener’s granulomatosis
– PAN—Polyarteritis Nodosa
PAN
↓
Moth-eaten nephrogram
C. Scleroderma
D. Acute renal failure
E. Acute pyelonephritis
F. Early adult polycystic kidney disease
G. Renal vein thrombosis.

7.20  FILLING DEFECT IN THE BLADDER

1. Neoplasm: Majority are transitional cell carcinoma. Other
masses simulating carcinoma of bladder include:
A. Carcinoma prostate or rectum or seminal vesicle
B. Metastasis
C. Phaeodchromocytoma
D. Leiomyoma
E. Lymphoma
F. Malackoplakia.
634 Differential Diagnosis in Radiology
2. Prostate: Seen as impression on the floor of bladder.
3. Blood clot:
– Usually post-traumatic
– Seen as filling defect.
4. Instrument:
– Urethral or suprapubic catheter
– Can be confirmed sonographically.
5. Calculus:
– Many are non-opaque
6. Ureterocele:
– Is the saccular dilatation of the intrarenal portion of a ureter
as it passes through the bladder wall. Resulting from a
narrowed opening of the ureteric orifice
7. Schistosomiasis:
– There is calcification of the bladder wall which is about 1–3
mm wide.
8. Fungal ball:
– Appearance of a gas-filled, laminated rounded mass is
diagnostic.
9. Malackoplakia:
– It is an inflammatory condition usually due to E coli
infection. Radiographically a smooth, oval or round filling
defect is seen in the bladder.
10. Endometriosis.

7.21  CARCINOMA PROSTATE

Anatomy
Prostate is a male accessory reproductive organ situated below
the base of the bladder and surrounds the prostatic urethra, which
runs through the peripheral zone. It is a pyramidal organ with its
base directed upwards. The normal gland consists of glandular and
non-glandular elements surrounded by a fibromuscular capsule.
The basic architecture of prostate can be divided as follows:
 Urogenital System 635
• Lobar anatomy: The prostate is said to be composed of anterior,
posterior and median lobes
• Zonal anatomy: This is the anatomy revealed after anatomic
dissection of prostate. It describes prostate to be composed of
the following four glandular zones surrounding the prostatic
urethra:
– Peripheral zone is the largest glandular zone containing
approx. Seventy percent of the prostatic glandular tissue
and it is this zone that is the source of most prostatic
cancers. It surrounds the distal urethral segment and is
separated from the transition zone and central zone by
the surgical capsule. It occupies the posterior, lateral, and
apical region of the prostate.
– Transition zone contains approx. 5% of prostatic glandular
tissue. It consists of two small glandular areas located
adjacent to the proximal urethral segment. It is the site of
origin of BPH. The veru montanum bounds the transition
zone caudally.
– Central zone constitutes approx. 25% of the glandular
tissue. It is located at the prostatic base. The ducts of the
vas deferens and seminal vesicles enter the central zone,
and the ejaculatory duct passes through it. It is relatively
resistant to disease processes.
• The periurethral glands form about 1% of the glandular
volume. They are embedded in the longitudinal smooth muscle
of proximal urethra
• The prostaticovesical arteries arising from the internal iliac
arteries supply the prostate. The prostate is a very vascular
structure. The lymphatic drainage of the prostate is thus via the
pelvic nodes to the internal iliac group
• Incidence: The prostate cancer is the second most common
malignancy in males being superseded only by the carcinoma
bronchus. It is said to be recognized in 35% of males above
45 years of age at autopsies. One out of 11 males will develop
prostate cancer
• Risk factors: Advancing age, presence of testes, cadmium
exposure, and animal fat intake.
636 Differential Diagnosis in Radiology
• Histopathology: The prostatic carcinoma is usually an
adenocarcinoma.

Premalignant Changes
• PIN or prostatic intraepithelial neoplasia is the lesion frequently
associated with invasive carcinoma either next to it or elsewhere
in the gland
• Atypical adenomatous hyperplasia leading to frank adeno-
carcinoma
• Spread: Mainly blood-borne along the neurovascular bundle.
• Grading: (Gleason score 2–10). This is histopathological grading
of prostatic carcinoma
– 1, 2, 3 glands surrounded by 1 row of epithelial cells.
– 4 absence of complete gland formation.
– 5 sheets of malignant cells.
• Low numbers on Gleason’s score refer to well-differentiated,
high numbers to anaplastic tumors.

Categories
• Latent: Discovered at autopsy of a patient without signs or
symptoms referable to the prostate (26–73%)
• Incidental: Discovered in 6–20% of specimens obtained during
TURP for clinically benign BPH
• Occult: Found at biopsy of metastatically involved bone lesions/
lymph nodes in a patient without symptoms of prostatic
disease
• Clinical: Cancer detected by digital rectal examination based on
induration, irregularity or nodule
• Prostate specific antigen: (PSA) is a glycoprotein produced
by prostatic epithelium and it may be elevated in cases of
carcinoma. Monoclonal radioimmunoassay is most commonly
used and the normal values range from 0.1 to 4 ng/mL
– Cancers of less than 1 mL volume usually do not elevate PSA.
– Cancers with PSA levels of <10 ng/mL are usually confined
to gland.
 Urogenital System 637
– 19% of prostate cancers do not elevate PSA.
– 16% of normal men have PSA >4 ng/mL.
– Benign conditions may also elevate PSA like BPH, prostatitis,
PIN.
– PSA levels may also be used in post-treatment screening of
patients for disease recurrence.

Staging
American urological association system modified Jeweitt-
Whitmore staging is used most commonly in the following cases:
A. No palpable lesion
A1 focal well-differentiated tumor <1.5 cm or < 5% of resected
tissue
A2 diffuse poorly-differentiated tumor >5% of chips from TURP
Specimen
B. Palpable tumor confined to prostate
B1 lesion < 1.5 cm in diameter confined to one lobe
B2 lesion > 1.5 cm involving more than one lobe
C. Localized tumor with capsular involvement
C1 capsular invasion
C2 capsular penetration
C3 seminal vesicle involvement
D. Distant metastasis
D1 involvement of pelvic nodes
D2 distant nodes involved
D3 metastasis to bones, soft tissue, organs.
American joint committee on cancer staging: AJCC or TNM
staging
T0 No evidence of primary tumor
T1 Clinically inapparent non-palpable non-visible tumor
T1a <3 microscopic foci of cancer/<5% of resected tissue
T1b >3 microscopic foci of cancer/> 5% of resected tissue
T1c tumor identified by needle biopsy
T2 Tumor clinically present + confined to prostate
T2a tumor involves half of a lobe or less
638 Differential Diagnosis in Radiology
T2b tumor involves more than half of one lobe
T2c tumor involves both lobes of any size but confined to
prostate
T3 Extension through prostatic capsule
T3a unilateral extracapsular extension
T3b bilateral extracapsular extension
T3c invasion of seminal vesicle
T4 Tumor fixed/invading adjacent structures other than seminal
vesicles
T4a invasion of bladder neck, external sphincter, rectum
T4b invasion of levator ani muscle and/or fixed to pelvic wall
N Involvement of regional lymph nodes
N1 metastasis in single lymph node < 2 cm
N2 metastasis in single node > 2 and < 5 cm/multiple lymph
nodes
Affected
N3 metastasis in lymph nodes >5 cm
M Distant metastasis
M1a non-regional lymph nodes
M1b bone
M1c other sites.

DIAGNOSTIC WORK-UP
Diagnosis is usually established by prostate biopsy guided by:
A. Digital rectal examination
B. Transrectal US
In most cases, however, the diagnosis is established by
histopathological examination of prostatic tissue obtained after
TURP. After the establishment of the diagnosis, the standard
staging work-up includes:
A. Digital rectal examination
B. Serum acid phosphatase
C. PSA levels
D. Cell ploidy
E. Bone scan
 Urogenital System 639
F. Cross-sectional imaging: It includes US, CT, MRI which
are used to determine the local extent of the tumor and
identify the operative candidates.

PROSTATE IMAGING

Ultrasound
• With the advent of high frequency transducers (5–8 MHz) and
transrectal approach, the zonal anatomy of the prostate can be
identified
• On sonography, it is more useful to separate the prostate into
a peripheral zone and inner gland which encompasses the
transition and central zone and the periurethral glandular area
• A non-glandular region on the anterior surface of the prostate
is termed the anterior fibromuscular stroma
• The surgical capsule that separates the peripheral zone from
the inner gland is identified as a hyperechoic band
• The seminal vesicles are identified as paired, relatively
hypoechoic, multi-septated structures surrounding the rectum
cephalad to the base of the prostate gland
• The anterior urethra and its surrounding smooth muscle and
glandular area appear relatively hypoechoic
• On coronal imaging, the junction of the hypoechoic periurethal
area with the verumontanum creates an appearance resembling
the Eiffel tower
• The peripheral zone has a uniform echogenicity
• The ejaculatory ducts are seen often coursing through the
central zone from the seminal vesicles and joining the urethra
at the verumontanum
• The prostate with the periprostatic fat is usually sharply
defined. Hyperechoic structures within are most characteristic
of fat, corpora amylacea, or calculi
• The sonographic appearance of most prostatic cancers is usually
hypoechoic or mixed. Small cancers are usually hypoechoic
640 Differential Diagnosis in Radiology
• The hypoechoic lesions have less stromal fibrosis and grade
lower on the Gleason grades
• Hyperechogenicity in a cancer is the result of desmoplastic
reaction; few extensive large cancers may also have hyperechoic
appearance
• A significant number of prostatic cancers are isoechoic and
thus difficult to detect and so the indirect signs like glandular
asymmetry and capsular bulging may be indicative
• When the tumor replaces the entire peripheral zone, it will often
be less echogenic than the inner gland which is the reversal of
normal echo pattern
• When the entire gland affected by hyperplasia is replaced by
tumor, the echogenicity becomes very inhomogenous
• Sonographic staging allows for separation of those patients
with macroscopic local extension into the periprostatic fat,
seminal vesicle, or local lymph nodes from those with disease
confined to the prostate gland
• Large tumors can be easily seen to extend to the outside of the
capsule as a result of loss of symmetry and capsular irregularity
• Seminal vesicle extension is defined sonographically by
enlargement, cystic dilatation, asymmetry, anterior­ displacement,
hyperechogenicity, and loss of seminal vesicle beak
• Sonographic staging is more sensitive than CT for both local
and periprostatic structures and lymph nodes.

CT SCAN
• Oral contrast opacification of small and large bowel is essential
• Positive contrast in the form of either 2% oral barium suspension
or diluted water-soluble contrast media can be used
• Negative contrast in the form of plain water can also be used
• The oral contrast can be given the night before to opacify large
bowel or an on-table contrast enema may also be used to
opacify the rectum and large bowel
 Urogenital System 641
• Contrast is also given 45 minutes before examination to opacify
small bowel. Both plain non I/V and post I/V contrast scans are
taken in spiral mode
• Prostate is visualized as a musculoglandular organ situated
between the bladder base above and the pelvic diaphragm
below
• CT cannot reliably differentiate stage A tumors from stage
B tumors. CT stage criteria are thus stage B or less, tumor
confined to prostate; stage C, extracapsular tumor extension to
involve the periprostatic fat, seminal vesicles, bladder, rectum,
obturator internus muscle; stage D1, pelvic nodes greater than
1.5 to 2.0 cm in diameter; stage D2, enlarged lymph nodes
above aortic bifurcation, bone metastasis, or extrapelvic
metastases
• CT is also not an effective technique to differentiate stage B
from stage C tumors. CT is most useful in evaluating advanced
bulky disease (stage D1 to D2) with gross objective findings
• The most common signs of advanced disease are extraprostatic
soft tissue masses invading the posterior bladder base or
seminal vesicles (stage C). Associated pelvic (stage D1) and
para aortic (stage D2) lymph node metastases are usually easy
to detect because they are large and multiple. Bone metastases
should be evaluated on appropriate window and level settings.

MRI
• The prostate gland is best studied by using endorectal coils or
by using pelvic multicoil arrangement
• T2 weighted images display the zonal anatomy of the prostate
to the best advantage; aquisition in the axial and coronal or
oblique coronal planes is usually most desirable
• T1 weighted images are important for the assessment of the
integrity of the periprostatic fat and neurovascular bundle, and
for the identification of sites of hemorrhage
• The normal prostate has a homogenous low to intermediate
signal on T1 weighted images
642 Differential Diagnosis in Radiology
• Zonal anatomy can be demonstrated on T2 images comprising
a low signal central zone and a higher signal peripheral zone
• The transition and central zone appear of similar signal intensity
and are thus termed as central gland
• The periprostatic venous plexus can be visualized as a thin rim
of higher signal intensity anterolateral to the peripheral zone
• Denonvillier’s fascia can be observed on sagittal images
separating the prostate from the rectum
• The neurovascular bundle is sited posterolaterally at 5 and
7o’clock positions on transverse section of prostate
• A normal appearing prostate gland on MRI does not exclude
the presence of tumor and heterogeneity of the gland is a
common non-specific finding
• MRI is often undertaken for staging after a positive biopsy,
which can lead to artifacts from hemorrhage and edema
• On T1 weighted images, a carcinoma is usually isointense to the
normal gland
• On T2 weighted images (including fat suppressed), the majority
of tumors appear low signal contrasted by the high-signal from
the peripheral zone, but this is not a specific finding
• Macroscopic capsular penetration can be assessed on MRI as
focal thickening or bulging of capsule
• Periprostatic infiltration can be demonstrated on T1 images as
a low signal within the periprostatic fat or as an intermediate
signal using T2 fat suppressed scans
• Extension to seminal vesicles is best demonstrated on T2
transverse and coronal scans and to rectum and bladder on
transverse and sagittal scans
• For the detection of adenopathy T1 images are required. MRI
can detect bone metastases also
• Post-contrast (Gd-chelate) enhanced imaging shows prostatic
ca. as enhancing more than the surrounding tissue but
becoming isointense on delayed scans
 Urogenital System 643
• MR spectroscopy, also known as chemical shift imaging, is an
emerging tool in the early detection of prostatic cancer. This
relies on the changes in the emitted signal produced by a
higher level of choline in carcinomas as compared to BPH
• Bone scintigraphy: This is the most sensitive method of detecting
occult bone metastases
• Screening: It is postulated that all men above the age of 50
years should be screened yearly for the presence of carcinoma
prostate by digital rectal examination and PSA levels.

Treatment
• Watchful waiting in patients with incidentally discovered
carcinoma on TURP specimens and ages above 80 years
• Radical prostatectomy for disease confined to capsule + life
expectancy of more than 15 years
• Radiation therapy either to patients with disease confined to
capsule and life expectancy of less than 15 years or to disease
outside capsule but with no spread
• Hormonal therapy (orchidectomy, diethylstilbestrol, leuprolide
acetate) for widely metastatic disease
• Cryosurgery
• Chemotherapy.

Conclusion
Prostatic carcinoma is the second most common carcinoma
affecting males. It is thus desirable to have an effective screening
program to identify the disease in its early stages. Digital rectal
examination and PSA levels in the serum are currently used as
screening procedures. Imaging only plays a secondary role in
the management in deciding the correct line of treatment and
identifying the cases fit for surgery. MRI currently is the imaging
modality of choice for staging of carcinoma prostate with USG,
especially TRUS being the second choice and CT only useful in
advanced disease and for identifying bony metastasis.
644 Differential Diagnosis in Radiology

7.22  THE PROSTATE

Normal Anatomy
Prostate gland is a flattened conical structure oriented in the
coronal plane.
• Length of normal prostate is 2.5–3 cm
• Transverse diameter at base is 4–4.5 cm
• Thickness is 2–2.5 cm.
• Normal weight is 20–25 g.

Prostatic Anatomy (Fig. 7.12)

Lobar Anatomy Zonal Anatomy
• 5 lobular divisions • 4 glandular zones
– One anterior lobe
– Peripheral zone
– One median lobe
– Transition zone
– One prostatic lobe
– Central zone
– Two lateral lobes
– Periurethral glandular area
• The concept of median • A non-glandular region on
lobe is useful in anterior surface of prostate
evaluation of patients is anterior fibromuscular
termed with BPH but this stroma
lobar anatomy is not useful
for evaluating CA prostate.

Sonographic Anatomy
• USG can differentiate prostate into a peripheral zone and inner
gland comprising transition zone, central zone and periurethral
glandular area.
 Urogenital System 645
Peripheral Zone
• Contains 70% of prostatic glandular tissue
• Occupies posterior, lateral and apical regions of prostate and
surrounds distal urethral segments
• Ducts of peripheral zone drain in distal urethra
• It is the source of most prostate cancers
• It is separated from inner gland by the surgical capsule which is
often hyperechoic due to corpora amylacea or calcifications.

Transition Zone
• Contains 5% of prostatic glandular tissue
• Located adjacent to proximal urethral segment
• Its ducts drain in proximal urethra at the level of verumo­ntanum
• Site of origin of benign prostatic hyperplasia.

Central Zone
• Constitutes 25% of glandular tissue
• Located at prostatic base
• Its ducts drain in proximal urethra
• Relatively resistant to the disease process.

Periurethral Glands
• Form 1% of glandular tissue
• Also known as internal prostatic sphincter.

Adjacent Structures
• Seminal vesicles
– Seen in bow tie configuration on transaxial view.
– Echogenicity is similar to or less than that of peripheral
zone.
646 Differential Diagnosis in Radiology
• Vas deferens
– Located anrteromedial to seminal vesicle.
Volumetric Measurement of Prostate
V = ½ (l × AP × W) where V = Volume
L = Length
AP = Anteroposterior diameter
W = Width

CT Anatomy
• Prostate gland is located just posterior to symphysis pubis and
anterior to rectum
• Homogenous soft tissue density on NCCT
• CECT—Peripheral zone may enhance to or lesser degree than
central gland
• Zonal anatomy is more evident in older patients and in patients
with enlarged gland.

MR Anatomy
• On T1 weighted segments:
– Prostate has homogenous low signal intensity similar to
skeletal muscle.
– Neurovascular bundles are seen posterolateral to prostate
gland at 5 o’clock and 7 o’clock positions.
– Zonal anatomy is not well-demonstrated on T1W segments.
– In post-gadolinium T1 weighted images, peripheral zone
has a more uniform and cause intense enhancement than
central gland.
• T2 weighted sequence
– Best for visualizing zonal anatomy.
– Peripheral zone has a higher signal than central gland due
to its more abundant glandular component and more
loosely intervening muscle bundles.
– Anterior fibromuscular band seen as low-signal structure.
 Urogenital System 647

Fig. 7.12:  Diagram of prostate zonal anatomy. A. Coronal section, mid-

prostate. B. Sagittal midline section. C. Sagittal section, lateral prostate
and seminal vesicle. D. Axial section, prostatic base. Paired ejaculatory
ducts are seen posterior to urethra and periurethral glandular area. Pe-
ripheral zone encompasses most of posterior and lateral aspects of gland.
E. Axial section, apex of gland showing mostly peripheral zone, and ure-
thral and periurethral glandular area

– True (anatomic) capsule of prostate and Denonvillier’s

fascia are seen as low-signal intensity bands.
– Surgical pseudocapsule can be seen in older patients at the
interface between transition and peripheral zones.
– Periprostatic venous plexus seen as high-signal structure
around prostate.
648 Differential Diagnosis in Radiology

– Seminal vesicles look like grapes with high-signal intensity

fluid and low-signal intensity walls.

PROSTATIC LESIONS

Agenesis/Hypoplasia
Prostatic and seminal vesicle cysts.

Congenital
• Prostatic utricle cyst
• Müllerian duct cyst
• Seminal vesicle cyst.

Acquired
• Ejaculatory duct cyst
• Retention cyst.

Infection of Prostate
• Acute prostatitis
• Chronic prostatitis
• Prostatic abscess
• Granulomatous prostatitis.

Prostatic Calculi

Tumors of prostate
– Benign
– BPH
– Malignancy
– Carcinoma.
 Urogenital System 649
PROSTATIC AGENESIS/HYPOPLASIA
• Associated with hypospadias, epispadias and exstrophy
• The only tissue visualized anterior to rectum is urethra with a
thick periurethral muscle.

PROSTATE AND SEMINAL VESICLE CYSTS

• Well-defined smooth walled anechoic structure with posterior
acoustic enhancement
• Has septations/debris, if secondarily infected.

Prostatic Cyst
Prostatic Utricle Cyst
• Always present in midline
• Usually small
• Rarely contains spermatozoa
• May contain calculus
• Associated with other anomalies
e.g. Prune belly syndrome
Hypospadias
Renal agenesis.

Müllerian Duct Cyst

• May extend from lateral to midline
• Can be large
• Never contain from spermatozoa
• Not associated with other anomalies.

Ejaculatory Cyst
• Usually small
• May contain spermatozoa
• Associated with infertility.
650 Differential Diagnosis in Radiology

Retention Cyst
• Secondary to benign prostatic hypoplasia.

PROSTATIC INFECTIONS
Acute Prostatitis
• Narrowing, elongation or straightening of prostatic urethra on
MCU
• Enlarged hypoechoic gland with periprostatic inflammation
and increased vascularity.

Chronic Prostatitis
• Reflux can be seen in prostatic ducts
• Focal areas of varying echogenicity are present with ejaculatory
duct calcification.

Prostatic Abscess
• Localized hypoechoic in peripheral gland
• Peripheral rim enhancement present on CT.

Granulomatous Prostatitis
Non-specific
• Prostatic urethra elongated in infra-verumontanum portion
(cf. BPH) is widened (cf. CA prostate).

Specific (Tubercular)
• Features of associated genitourinary tuberculosis in other
viscera
• Cavity formation in prostate with hypoechoic areas.
 Urogenital System 651
PROSTATIC CALCULI
• Bright echogenic foci in prostate with ± posterior acoustic
shadowing
• Corpora amylacea are thought to be precursor.

Types
True or Urinary calculi Exogenous calculi
Endogenous
↓ ↓ ↓
Develop from Lodged in prostatic Form in pre-existing
acini and ducts urethra abscess cavities of pros-
tate gland

BENIGN PROSTATIC HYPERPLASIA

• Criteria—Prostate gland weighing more than 40 g in older men
– Prostate is visualized in CT sections 2–3 cm or more above
pubic symphysis
• Involves transition zone and periurethral glandular tissue
• Prostatic urethra elongated and slit-like
• Enlarged prostate bulges in bladder floor with J (fish-hook)
deformity of ureters on IVU
• Secondary changes are:
– Bladder trabeculations ± diverticulae and calculi
– Hydronephrosis and hydroureter.

Carcinoma Prostate
• Involves peripheral zone in 70% cases
• Presents as hypoechoic area in peripheral zone of prostate
• Criteria for extracapsular extension:
– Contour deformity of capsule
– Irregularity
– Obliteration of Rectocapsular extension
652 Differential Diagnosis in Radiology
– Asymmetry or direct involvement of neurovascular bundle
– Focal capsular retraction or thickening
– Direct tumor extension in periprostatic fat.
• Criteria for seminal vesicular invasion:
– Loss of angle between seminal vesicle and prostate
– Direct tumor extension to seminal vesicle.
• Higher chlorine and lower citrate levels are seen in cancerous
prostate tissue on proton MR spectroscopy
• Radionuclide bone seen is useful to detect skeletal metastases.

7.23  D/D OF ADRENAL MASS

A. Neoplastic B. Others
1. Cortical 1. Granulomas
– Carcinoma – Histoplasmosis
– Adenoma – Tuberculosis
– Blastomycosis
2. Medullary 2. B/L Hyperplasia
– Neuroblastoma 3. Cysts
– Ganglioneuroma
– Pheochro- 4. Hematoma
mocytoma
3. Stromal 5. Amyloid
– Lipoma
– Myelolipoma
4. Metastasis.

CT Features S/O Adrenal Mass

1. Absence of normal adrenal gland.
2. Mass at superior level of kidneys.
3. Downward displacement of kidneys.
4. Anterior displacement of IVC, pancreas and splenic vessels.
Positive biochemical test indicating hyper­functioning of
adrenal mass.
 Urogenital System 653
Structures Mimicking Left Adrenal Mass
1. Upper pole of left kidney.
2. Gastric Diverticulum—Give oral contrast.
3. Splenic lobulations/Accessory spleen—on intravenous
contrast, it enhances to the same level as body of spleen.
4. Large mass in the tail of pancreas.
Give intravenous contrast. Pancreatic mass usually displaces
splenic vein posteriorly, whereas adrenal mass displaces it
anteriorly.

Salient Features
1. Adrenal cortical carcinoma:
– Slow growing tumor
– 50% nonfunctioning, 50% Cushing’s, Conn’s or virilizing
syndrome
– Average size 8–10 cm at diagnosis
– Average age at onset 45 years
– X-ray and IVP—Show soft tissue shadow of mass, downward
displacement of kidney calcifications
– USG—Mixed echogenicity mass with calcifications
– CT—Large mass with heterogenous enhancement
– Area of central necrosis
– Thin capsule rim, calcifications
– Liver and LN metastasis
– MRI—Mixed intensity on T1 and hyperintense on T2.
2. Adrenal cortical adenoma:
– Usually non-functioning and symptomless
– U/L, 2–5 cm
– Variable density
– Half have soft tissue density and half have low attenuation
due to higher lipid content.
(d/d with cysts which do not enhance).
654 Differential Diagnosis in Radiology

Medullary Tumors
1. Neuroblastoma
– Occur in children mostly < 3 years
– Present as abdominal mass or with secondaries
– X-ray and IVP—Soft tissue mass with downward
displacement of kidney
– Downward drooping of pelvis and calyces
– USG—Mixed density to echogenic tumor calcifications
Cystic areas of necrosis and hemorrhage
Encasement of aorta and IVC
– CT—Irregularly-shaped solid mass
– Soft tissue density with necrosis, calcifications and
hemorrhage
– Local, distant invasion
– Crossing of midline is highly suggestive
– MIBG scan shows increased uptake by primary as well as
metastatic tumors.
2. Ganglioneuroma
– More mature form of neurogenic tumor
– Children, 60% < 20 years
– Soft tissue mass with calcifications
– May invade spinal canal.
3. Pheochromocytoma
– Commonest adrenal tumor in clinical practice
– 90% arise in adrenal medulla
– 10% ectopic
– Hilum of kidney
– Aortic bifurcation
– Bladder wall
– Mediastinum
– S/S—Paroxysmal attacks of hypertension headache,
sweating, palpitation, anxiety, 50% have sustained
hypertension
– Elevated urinary VMA or metanephrine level
– Usually solitary and located on the right side.
 Urogenital System 655
– 10% cases are familial
Bilateral
“RULE OF TEN” Multiple
Extra-adrenal
Children
Malignant
– Size 2–20 cm Avg -7 cm
– X-ray and IVP—Soft tissue mass with renal displace­ment.
– CT—U/L homogenous mass >2 cm and of soft tissue
density
– Solid with or without cystic areas or entirely cystic.
– Inhomogenous with denser periphery with central necrosis
– Enhance markedly to the point of becoming isodense with
vascular structures
– MIBG method of choice in ectopic or recurrent
pheochromocytoma
– Metastasis can occur in LN, bones, liver and chest in
malignant tumor.
3. Stromal tumors
1. Lipomas and Myelolipomas
– Rare non-functioning tumors
– 1 to 2% incidence
– Usually small
– Highly echogenic on USG
– Varying proportion of myeloid and fat tissue
– Well-circumscribed mass with attenuation –30 to –140
HU with frequent foci of calcification.
4. Metastasis
– Fourth most frequently involved site of blood-borne
metastasis
– Lung > Breast > Thyroid > Colon > Metastasis
– B/L adrenal masses in a patient with known primary in
absence of hyperfunctioning suggests metastasis
– In a patient with known malignancy U/L adrenal mass
could be Mets, Carcinoma or Adenoma. So, FNAC is a must
– Metastasis produces U/L or often B/L circumscribed soft
tissue density mass.
656 Differential Diagnosis in Radiology

Granulomas
• Infections like tuberculosis, histoplasmosis and blastomycosis
result in solid or cystic mass with calcification
• U/L or B/L.

Adrenal Cysts
• Endothelial
• Pseudocyst
• Epithelial
• Parasitic (hydatid)
• Smooth marginated, well-circumscribed usually U/L, low
density mass, non-enhancing
• Rim of calcification in 15%.

Adrenal Hemorrhage
• Abdominal mass or B/L masses
• Marginal calcification
• B/L adrenal hyperplasia
• Diffuse enlargement of adrenals.

7.24  PAINLESS HEMATURIA

Definition
Blood cells in urine, whether occult or frank constitute hematuria.
Hematuria is mostly PAINLESS; PAIN is caused whenever there is
obstruction to the outflow of urine (mainly by blood clot or stone, etc).
• To define hematuria >3 RBC /HPF.

Etiology
A. Lesions in the Urinary Tract
1. Causes in kidney and pelvicalyceal system
• Polycystic kidney disease.
• Acute nephritis; Tuberculosis; Filariasis
 Urogenital System 657
• Angioma; Papilloma; (Transitional cell carcinoma) TCC;
(Renal cell carcinoma) RCC; Wilms’ tumor
• Essential hematuria.
2. Causes in ureters
• Papilloma
• TCC
• Pyeloureteritis cystica.
3. Causes in bladder
• TCC •  Bilharziasis
• Papilloma •  Filariasis
• Tuberculosis.
4. Causes in prostate
• Varices caused by BPH
• Malignancies.
5. Causes in urethra
• TCC
• Angioma.
B. Lesions in adjacent organs
– CA cervix invading the bladder
– CA rectum
– PID
– Retroperitoneal masses pressing over renal vessels.
– Several vesicle tumors.
C. Systemic causes with secondary renovascular effects
– Hematopoietic causes: Hemophilia; scurvy;
Malaria; Purpura;
Sickle cell disease.
– Congestive: Renal vein thrombosis;
Right—Heart failure.
– Infarcts: Subacute infective
Endocarditis.
Myocardial infarction.
– Collagen vascular diseases.
658 Differential Diagnosis in Radiology

D. Drugs
– Sulfonamides
– Salicylates (in large doses)
– Anticoagulants
– Phenolphthalein
– Urates
– DFM
– Chloroquine
– Pyridium
E. Hematuria-like conditions
– Porphyrinuria
– Myoglobinuria.

Clinical Features
1. Urine normal in appearance
Known as Microscopic Hematuria, i.e. > 5 RBC/HPF in 2–3
urinanalysis.
2. Urine of altered color.
3. Fever.
4. Lump and other signs and symptoms.
5. Outflow obstruction.

Pathology

Hematuria
Medical Urological
(Renal/Glomerular) (Surgical epithelial)
• Associated with cast • Associated with no cast
• Associated with • No proteinuria
proteinuria
• Dysmorphic RBC • Rounded eumorphic
(Esp. if glomerulus) • RBC
IgA nephropathy—Child • > 1/Hpf
MPGN—Adult • Abnormal
 Urogenital System 659
• Eumorphic Rounded RBC • Eumorphic
• RBC if tid • Round
• Up to 10 6/24 hrs—Normal • Regular
• But >2/Hpf—Abnormal • Smooth
• Even Hb distribution
• Dysmorphic
– Acanthocytes
– Schistocytes
– Amylocytes
– Echinocytes
– Somatocytes
– Codocytes
– Knizocytes
– It is basically the urological hematuria which is more
accessible to radiological diagnosis as the nephrological
causes are usually evaluated by laboratory methods.

Radiological Evaluation
Always ask a small question
• Is the urine bright red—Lower urinary tract origin—Gross
• Is the urine smoky—Upper urinary tract origin—Occult
Keep in mind the major causes:
1. Malignancies
2. Infections
3. Stone
4. BPH
5. Renal parenchymal lesions
6. Trauma
7. Benign idiopathic.
Always try to reach to two or three possibilities before starting
investigation.
X-ray abdomen—28
• CXR = 1.4 MSV = 28 weeks radiation
X-ray pelvis—24
• CXR = 1.2 MSV = 24 weeks
660 Differential Diagnosis in Radiology
IVU—88
• CXR = 4.4 MSV = 88 weeks
CT abdomen—176
• CXR = 8.8 MSV = 176 weeks

Plain X-ray
Abdomen:
– Calcified Nodes—tuberculosis.
– Cyst wall calcification—polycystic kidney disease.
– Evidence of mass lesion.
Chest:
– For cardiac evaluation as right heart failure is a cause.
– For looking at any tubercular focii.
Bones:
– To evaluate and correlate for hemophilia; sickle cell anemia;
scurvy; cardiovascular disease and renal osteodystrophy.

Intravenous Pyelography
– Is always the imaging modality of choice in any patient
presenting with hematuria, whether painful or painless.
– Gives a gross global idea about the structure and function of
urinary tract.
– Gives a baseline investigation for further comparison.
– Polycystic kidney disease—Swiss cheese nephrogram
– Spider web pyelogram
– Renal cell carcinoma—Distorted/Destroyed/Displaced/Delayed
– Pyelogram
– Nephrogram
• Transitional cell carcinoma—role of IVP is to r/o multi­centri­city,
to comment on function, to evaluate back pressure
• Renal vein thrombosis—increasingly dense nephrogram with
delayed pyelogram
• Tuberculosis—thimble bladder; corkscrew/pipestem ureter;
renal cavities/perirenal collection/pyelonephritis.
 Urogenital System 661
Barium Examinations
• e.g. tuberculosis
• e.g. Ca rectum.

USG +/– CD
• For general survey of KUB even before IVP
• In renovascular diseases.

CT Scan
• For retroperitoneal evaluation
• For landmarking masses
• For renovascular evaluation.

MRI
• Better imaging modality due to multiplanar capabilities.

Renal Scan
• Has only minimal corroborative role.

Arteriovenography
• Especially when intervention is contemplated.

Newer Modalities
A. MR Urography
B. CT
C. Endovesicle USG
D. Sonourethrography
E. PET.
662 Differential Diagnosis in Radiology

RGU/MCU
Definitive modality for evaluation of UB and urethral lesions

CT Urography
– Perlman, 1966
1.   Protocol—Projectional technique
A. • Conventional
• Digital
• CT scanned projectional images.
2. Protocol—Reconstructional technique
B. • 2-D
• 3-D
– Phases almost similar to liver
– For urothelial lesions conventional > CT URO.

MR Urography
1. An MRCP like technique—I.C. T2W Single/Multislice.
2. Gad + T1W.
3. Fusion
– At present reserved for patients who cannot undergo CT
URO/IVP—pregnant, pediatric, allergy, poor renal function
– Calculus detection is a limitation
– FNAC
– BX.

Conclusion
It is always essential to provide from randomizing modality, i.e. the
sound followed by IUD/CTs. Subsequence in vestigerm planned as
per case to case.
CHAPTER 8

Head, Neck and Spine

8.1  LUCENCY IN THE SKULL

VAULT—WITHOUT SCLEROSIS
1. Neoplastic Traumatic Metabolic Infective
Multiple Burr hole Hyperpara- tuberculosis
myeloma thyroidism
Mets Leptomeningeal Hydatid
Hemangioma Cyst syphilis
Neurofibroma Pyogenic osteo-
Paget’s sarcoma myelitis

Idiopathic—Osteoporosis Circumscripta
Multiple Myeloma
>40 years, Males: Females 2:1, increase of total serum protein because
of production of abnormal Ig. Leukopenia, anemia, abnormal
urine protein—Bence Jones protein—50% of hypercalcemia,
hypercalciuria, amyloidosis.

RF
Generalized decrease in bone density, localized area of lucency in
red marrow, lesion also seen in mandible, clavicle and scapula.
Adjacent soft tissue mass.
Spine—collapse with paravertebral soft tissue mass (I/V disks are
not affected).
Pedicle and post-arches are less frequently affected, proximal end
of humerus and femur are also affected.
664 Differential Diagnosis in Radiology

Hemangioma
• Well-circumscribed area of punctate or stellate rare faction
without expansion
• Prominent vascular grooves may present in the vicinity and
external carotid arteriography shows a blush.

Neurofibroma
Lucent defect in occipital bone (Adjacent to it—Lambdoid suture).
Paget’s disease in males more than females, elderly.
Most common site— Sacrum and lumbar spine
↓
Skull → pelvis → femur
Osteoporosis circumscripta occurs in the active lytic phase of
Paget’s disease.
• It starts in the lower part of the frontal and occipital region and
can cross suture line
• Destructive process affecting the outer table and sparing the
inner table.

Hyperparathyroidism
Usually pepper-pot skull. Rarely severe enough to cause overt lytic
lesions.
• Mandible is a common site for ‘brown tumors’. There may be a
loss of lamina dura
• ‘Basilar invagination’ is a common finding.

Traumatic
‘Burr hole’—H/o surgery.
Leptomeningeal cyst: Develops after head injury. If dura is torn, the
arachnoid membrane can prolapse and the pulsation of CSF can
cause progressive widening and scalloping of the fracture line.
 Head, Neck and Spine 665
Langerhans’ Cell Histiocytosis
Proliferation of histiocytic cells, particularly in the bone marrow,
the spleen, liver and lymphatic gland and lungs. Later, cells
become swollen with lipid deposit.

Eosinophilic Granuloma
Most mild expression of histiocytosis.
Age = 3 to 12 years, especially boys.
Site: any bone (1/4th in skull)
2/3rd = pelvis, skull and femur.
RF = translucent areas of bone destruction with sharply defined
margins—in active phase. Peripheral sclerosis seen in the healing
phase.
The lesion is having bevelled edges difficult to differentiate
between destruction of the inner and outer tables.
• Button sequestrum may be seen
• Other RF—spine—solitary lesion in spine, may collapse—
leading to vertebra plana
• Most common site is thoracic spine
• Paravertebral soft tissue mass present
• Disk space—maintained
• Long bones—predilection for diaphysis
• Mandible and lamina dura—osteolytic lesion leading to
‘floating teeth’ appearance.

Metastasis—In Adults
Most common site for metastasis—spine, pelvis and ribs with
proximal ends of humerus and femur and less often skull areas
correspond to sites of persistent hematopoiesis.
• Primary tumors in male—carcinoma prostate, lung and kidney
• In female = breast—2/3rd of cases of bronchial carcinoma
develop secondaries—laboratory finding
• Serum alkaline phosphatase increase in metastasis but normal
in multiple myeloma. Serum Ca++ increase
666 Differential Diagnosis in Radiology
• Ca prostate-PSA and Acid phosphatase increase
• RF = Mainly osteolytic, develop in medulla and extended in
all directions, destroying the cortex—not much periosteal
reaction
• Soft tissue extension uncommon, multiplicity in pediatric
age—especially neuroblastoma and leukemia
+/– wide suture
• Infective: Tuberculosis—osteomyelitis—skull is a rare site
• Pyogenic OM—usually direct infection from a frontal sinus or
secondary to a compound fracture
• Syphilis = moth-eaten appearance.

8.2  LUCENCY IN THE SKULL VAULT— WITH

SURROUNDING SCLEROSIS (FLOW CHART 8.1)
Fibrous Dysplasia (FD)—Unknown pathogenesis.
Replacement of medullary bone by fibrous tissue.
Age = 3 to 15 years.
Most common site—femur, pelvis, skull, mandible and ribs.
Two types = monostotic, polyostotic—lesions tend to be unilateral.
RF = Cyst-like lesion in the diaphysis or metaphysis with endosteal
scalloping +/– bone expansion.
No periosteal new bone.
Rind sign—thick sclerotic border, ground glass appearance.
Common site in skull = In skull, FD takes two main forms—sclerotic
and cystic.
Sclerotic form: More common, involves the base or facial skeletons
which are expanded and dense and sometimes showing ground
glass appearance. Most common cause of leontiasis ossea.
Cystic form: Produces a small lesion in skull vault expanding the
outer table and giving a blistered appearance.

Developmental
Epidermoid: Thin sclerotic margins with scalloping.
Most common site: Squamous portion of occipital or temporal,
although can involve any region.
 Head, Neck and Spine 667
Intramedullary in origin, so can expand and involve both inner and
outer bones. More homogenous radiolucent center.
• Meningocele: Midline defect
• Smooth and sclerotic margins with an overlying soft tissue
mass
• Most common site = occipital bone, may occur in the frontal,
parietal or basal bones
• Neoplastic Hemangioma—Rarely has sclerotic margin. Radiating
spicules of bone within it
• Langerhans’ cell histiocytosis—Only a sclerotic margin of it is in
the healing phase
• Infective—Chronic osteomyelitis: Brodie’s abscess—intra­osseous
abscess surrounded by intense sclerosis.

Mucocele of Frontal Sinus

If the ostium of sinus becomes blocked and infection does not
supervene, the sinus fills with mucus—mucus acts as slow growing
mass lesion, expanding the sinus and thinning the sinus wall—can
give rise to proptosis.

Flow chart 8.1: Lucency in skull vault with surrounding sclerosis

668 Differential Diagnosis in Radiology

8.3  THICKENING OF THE SKULL VAULT

Generalized
1. Marble bone disease
2. Dystrophia myotonica
3. Acromegaly
4. Paget’s disease
5. Cooley’s anemia.

Localized
1. Meningiomas
2. Primary osteosarcoma
3. Osteomas
4. Ossifying fibromas
5. Fibrous dysplasia
6. Leontiasis ossea
7. Hyperostosis frontalis interna.

Generalized Hyperostosis
1. Marble bone disease
– The bones of the skull base are mainly affected with
sclerosis and thickening, mainly in the anterior cranial
fossa.
– The cranium is affected to a lesser degree.
– The sphenoid and frontal sinuses and mastoids are under-
pneumatized or not at all.
– Neural foramina may encroach upon and blindne results in
serious cases.
2. Dystrophia myotonica
– They show a thickened skull vault with a small pituitary
fossa.
3. Acromegaly
– Thickened skull vault in association with the enlarged
sinuses and prognathous jaw.
 Head, Neck and Spine 669
– The vault thickening involves both tables and the diploe is
encroached upon and difficult to distinguish.
4. Paget’s disease
– Vault becomes widened and thickened, with alterations in
its bony texture. There are also osteomalacic changes and
the bones become softer and more pliable, giving rise to
platybasia with basilar invagination.
– Skull shows a typical irregular mottled texture to the
thickened bone.
5. Cooley’s anemia
– Generalized thickening of the skull with a characteristic
and diagnostic appearance.
– Widening of the diploe.
– It’s texture becomes abnormal with radiating linear
spicules of the sunray or hairbrush type. Sometimes, the
bone change in this type of anemia may be more localized,
affecting mainly the frontal region.

Localized Hyperostosis of the Skull

1. Meningiomas
These commonly invade the bony skull and produce a localized
hyperostotic reaction. The diagnosis is often suggested by the
classic meningioma site, i.e. parasagittal or sphenoidal ridge.
– Originally the hyperostosis is confined to the inner table
but later it may grow through the diploe and outer table
and present as a palpable lump.
– When protruding externally, the lesion can sometimes
show sunray spicules.
– Other radiological evidence of meningioma such as
enlarged vascular markings leading to the lesion or signs
of raised intracranial pressure may also be present.
– If the meningioma grows from the sphenoidal ridge into
the orbit, it can present with proptosis.
670 Differential Diagnosis in Radiology
2. Primary osteosarcoma
It is very rare but can give rise to localized hyperostosis often
with sun ray spicules. It is commonest as a complication of
Paget’s disease.
3. Osteomas
These can occur in the skull vault when they appear as dense
flat ivory nodules growing from the surface.
– More commonly they present as chance findings growing
from the wall of the frontal sinus.
– They are usually small—under 1 cm in size.
4. Ossifying fibroma
These are relatively rare.
– They most frequently commence in the paranasal sinuses,
particularly the antrum.
– They can produce large density calcified masses.
5. Fibrous dysplasia
– It is an important cause of localized hyperostosis involving
the skull vault, facial bones or skull base.
– It may occur as an isolated lesion or in association with
lesions in other bones (polyostotic fibrous dysplasia and
Albright syndrome).
6. Leontiasis ossea
It is a form of hyperostosis affecting the frontal bones and facial
bones and giving rise to severe facial deformity.
7. Hyperostosis frontalis interna
– Mysterious condition frequently seen in adult skulls
– Occurs almost exclusively in postmenopausal women.
– It is characterized by irregular nodular thickening of the
inner table of the skull vault, mainly the frontal bone. The
lesions are characteristically bilateral and symmetric and
spare the midline.
 Head, Neck and Spine 671
8.4  GENERALIZED INCREASE IN
DENSITY OF SKULL VAULT
Idiopathic – Paget’s disease
Fibrous dysplasia, myelosclerosis
Congenital – Osteopetrosis
Pyknodysostosis
Pyle’s disease
Metabolic – Renal osteodystrophy
Fluorosis
Neoplasm – Sclerotic metastases
Meningioma
Endocrinal – Acromegaly
Hematological – Chronic hemolytic anemia, phenytoin
therapy
• Idiopathic—Myelosclerosis—Peak age = 6th decade, cause is
unknown.
Sex = Both the sexes are equally affected.
Pathologically = Obliteration of marrow by fibrosis or bony
sclerosis—leading to normochromic and normocytic anemia.
– Hemopoiesis in spleen and liver, so they are enlarged.
RF = Bone sclerosis in 40% of cases.
Most common pattern—diffuse but may be patchy.
– Marrow diameter decreased and blurred CMD.
– Lucent areas due to fibrous tissue.
– 1/3rd cases show periosteal new bone.
Fibrous dysplasia—Two forms—sclerotic and cystic form, sclerotic
form—commoner of the two, especially in the polyostotic version.
Site—base and facial skeleton which are expanded and dense.
Most common cause of leontiasis ossea.
Lower density areas (cyst or fibrotic masses) within the sclerotic
bones—strong with evidence of fibrous dysplasia.
672 Differential Diagnosis in Radiology

Paget’s Disease
Male more than female, > 40 years.
Skull is involved in 2/3rd of cases.
Mixed pattern of sclerosis and lysis is common. An early
change is a spotty cotton wool. Increased density of bone and also
thickening of vault.
Middle and outer tables are most affected and thickened with
coarse trabeculations.

Meningioma
Sclerosis is more marked than expansion and extension from the
sphenoid bone into the facial skeleton is much less common.

Metastasis
Irregular lysis or sclerosis and multiplicity prostate and breast are
most common. Diffuse osteosclerosis is also seen occasionally in
Hodgkin’s lymphoma and leukemia and very rarely with multiple
myeloma.

Congenital
Osteopetrosis—several types. More severe types are autosomal
recessive.
– RF—Generalized increased density.
– Skull base are initially affected with sclerosis and thickening.
– Cranium is affected to a lesser degree/sphenoid, frontal and
mastoid are under pneumatized or not at all.
– Neural foramina encroached upon and blindness result in
serious cases.

Pyknodysostosis
Autosomal recessive in inheritance. Patients are usually short,
(<150 cm).
 Head, Neck and Spine 673
Skull—Brachycephaly with wide suture and persistence of open
fontanelles into adult life.

Wormian Bones
Site—Calvarium, base of skull and orbital rims are very dense.
Facial bones are small and maxilla is hypoplastic.
Mandible has no angle, it is obtuse.

Other Features
Limbs – Increased density of bones.
Thorax lateral ends of clavicle are hypoplastic.
Ribs are dense
Spine – Failure of fusion of neural arches,
spondylolisthesis
– Spoon-shaped V bodies
Hand – Acro-osteolysis with irregular distal fragments
of distal phalanges.

METABOLIC
Renal Osteodystrophy
Bony changes in patients suffering from chronic anemia due to
long standing renal disease.
• Osteosclerosis occurs in 25%
• Skull and spine are commonly involved and can look similar to
Paget’s disease.

Other Features
Secondary hyperparathyroidism—subperiosteal resorption,
subchondral resorption, brown tumors.
• Osteomalacia/Rickets
• Osteoporosis
• Aluminium toxicity
• Soft tissue calcification (vascular and periarticular)
• Fractures.
674 Differential Diagnosis in Radiology

Fluorosis
Chronic ingestion of excessive amount of fluoride results in
fluorosis.
• Osteosclerosis is seen with concentration of 8 PPM in drinking
water, calvarium is rare site.

Other Features
Osteosclerosis predominantly in axial skeleton.
• Calcification or ossification of ligaments
• Enthesiopathy.

Acromegaly
Enlarged frontal sinus, prognathism, enlarged sella, thick vault.

8.5  LOCALIZED INCREASE IN DENSITY

OF THE SKULL VAULT

In Bone
1. Neoplasm
a. Sclerotic metastases
– Most common prostate and stomach.
b. Ivory osteoma
– Commonly affects the PNS. Slow growing dense
lesion—well-defined spherical or hemispherical shape.
Mostly < 1 cm in diameter, rarely exceed 2–3 cm.
Complication—Large osteoma may interfere with drainage of
the sinus, CSF rhinorrhea, pneumocephalus or even meningitis.
c. Treated lytic metastases—especially breast—primary.
d. Treated brain tumors.
2. Paget’s disease.
3. Fibrous dysplasia.
4. Depressed fracture due to overlapping bone fragments (Fig. 8.1).
 Head, Neck and Spine 675

Fig. 8.1: Lateral radiograph of skull shows depressed fracture through

the parietal bone at the level of vertex

5. Hyperostosis frontalis interna—seen in postmenopausal

female, involves the Frontal bone.
B/L and symmetrical.
Thickening of inner table—’choppy sea appearance.’ Adjacent
to bone.
a. Meningioma: Mainly involves the inner table but if breaks
through the outer table, it may cause a ‘hair-on-end’ appear-
ance.
15%—show calcification.
Abnormal increase in vascular channel and signs of raised
intracranial pressure.
Common sites—parasagittal/olfactory grove, sphenoid ridge
and tentorium.
b. Calcified sebaceous cyst.
676 Differential Diagnosis in Radiology

A B
Figs 8.2A and B:  AP and lateral radiographs of skull show calcified
cephalohematoma along the right parietal convexity

c. Old cephalohematoma—Usually seen in the parietal region and

may be bilateral in neonate (Figs 8.2A and B).
Caused by subperiosteal bleeding during birth, does not cross
suture.
d. Tumors
– Gliomas are the most common tumors
– 5% show calcification
– Oligodendroglioma
– 50% cases calcification
– Craniopharyngioma—mainly in children, calcification in
75% cases
– Position of calcification—midline and just above the sella.

Chronic Subdural Hematoma

Calcification in the membrane.
Characteristic position adjacent to skull vault.

Basal Ganglia Calcification

B/L and symmetrical, seen in the region of basal ganglia, primary
or idiopathic—related to age, secondary—hypo-parathyroidism,
pseudohypoparathyroidism, Fahr’s syndrome.
 Head, Neck and Spine 677
Button Sequestra
EG (Esinophilic granuloma) tends to erode both tables of skull.
The outer table is more extensively destroyed at time producing
a characteristic. Double contour, with radiodense focus within the
lytic area termed as button sequestra.

8.6  DESTRUCTION OF PETROUS BONE (APEX)

Acoustic Neuroma
Arising from 8th nerve, increase in size of Internal Auditory Meatus
(> 1 cm in diameter or > 2 cm asymmetric between the two sides
(1 mm in height and 2 mm in length)
• Erosion of crista transversalis and apparent shortening of the
Internal Auditory Meatus may occur
B/h Bilateral in NF 2
• CT = Iso to brain, CECT = more enhancement
MR = FSE T2 Intermediate SI
• Congenital cholesteatoma—In the petrous apex, they form a
well demarcated expanded cystic lesion, which may enlarge to
erode the IOC and bony labyrinth
No IV contrast enhancement
MRI = T1 = low signal, T2 = high signal
Cholesteatoma tends to encase arteries without causing
obstruction
• Cholesterol granuloma is a cystic granulomatous lesion
containing hemosiderin and cholesterol deposits
CT appearance = similar to congenital cholesteatomas
MRI= high signal on both T1 and T2 due to presence of meth
Hb and other Hb break down products and increase of protein
content
• Meningioma—Tend to excite a bony proliferative response and
produce narrowing of pons acousticus internus rather than
erosion
CT = local hyperostosis and erosion of petrous bone
678 Differential Diagnosis in Radiology
• Density similar to brain tissue, often surrounding zone of low
density
CECT and MR = Contrast uptake in most cases. MR may show a
‘dural tail’ adjacent to dural infiltrate
Typically a meningioma does not enter the IOC.
• Metastasis—particularly breast, kidney and lung. Irregular
cystic defect
Pain and nerve paresis are common
• 5th nerve neuroma—are rare.
If arising from the intracanalicular or intracranial segments,
cannot be distinguished radiologically from the acoustic
neuroma.
CT = Expansion of facial nerve canal.
CECT = Enhancement.
MR = Sensitive.
• Nasopharyngeal angiofibroma
Usually large area of destruction in the floor of the middle
cranial fossa.

8.7  BASILAR INVAGINATION

Elevation of the floor of the posterior cranial fossa.
A. Primary form
– Less with nar­row foramen magnum + occi­pitalization of
atlas.
B. Secondary form
Osteogenesis imperfecta
Paget’s disease, osteomalacia.
Craniometric line used to diagnose basilar invagination or
platybasia (Fig. 8.3).
1. Wachenheim’s line (clivus canal line)
Line drawn along lines into cervical canal.
Normal odontoid tip is ventral and tangential to this line.
Odontoid tip transects the line in basilar invagination.
 Head, Neck and Spine 679

Fig. 8.3: Basal angle to measure platyplasia

2. Chamberlain’s line—joins post-pole of hard palate to opisthion.

Tip of dens lies 3–6 mm below this line. Odontoid process
bisects the line in basilar invagination.
3. MC Rae (FM line)—joint anterior and posterior edges of foramen
magnum (basion to opisthion).
Tip of dens does not exceed this line.
4. Fishgold’s bimastoid line—Line connecting tip of mastoid process.
Odontoid tip may be 10 mm above the line.

Osteogenesis Imperfecta
Due to disorder of collagen.

Four Types
Type 1 = Gracile, osteoporotic bones.
Rapid fracture healing +/– exuberant callus.
680 Differential Diagnosis in Radiology
Type 2 = Lethal perinatal.
Extremely severe osseous fragility.
Type 3 = Moderate to severe osseous fragility, severe
deformity of long bones and spine results in
severe dwarfing.
– Cystic expansion of ends of long bones.
– Wormian bones.
Type 4 = Osseous fragility with normal sclerae with
severe deformity of long bones and spine.
• Paget’s disease—Caused by excessive abnormal remodelling of
bones
Site—spine—75%, proximal femur—75%
Skull—65%
Pelvis—40%
Three stages of the disease are as follows:
1. Active (osteolytic)—skull—osteoporosis circumscripta.
2. Osteolytic and osteosclerotic areas.
3. Inactive (osteosclerotic)
• Osteomalacia—Increased uncalcified osteoid in the mature
skeleton.
Decreased bone density.
Looser’s zone—Common sites are the scapula, femoral neck and
shafts, pubic rami and ribs.
Bilateral symmetrical transverse lucent bands of uncalcified
osteoid, which, later in disease, have sclerotic margin.
– Coarsening of trabecular pattern.
– Bone softening, protrusion acetabuli, bowing of long
bones, biconcave vertebral bodies and basilar invagi­
nation.

Platybasia
Flattening of base of skull does not always accompany basilar
invagination but occur in similar situation.
The index is basal angle or sphenoid angle. Angle between roof of
sphenoid and clivus > 180°.
 Head, Neck and Spine 681
Causes
1. Osteomalacia
2. Rickets
3. Hypoparathyroidism
4. FD
5. Paget’s disease
6. Arnold-Chiari malformation.

8.8  HAIR ON END SKULL VAULT

Hemolytic Anemia
Sickle cell anemia: Develops due to abnormal hemoglobin.
RF – Deossification due to marrow hyperplasia.
– Decrease in density of bones with thickening of
trabeculae.
– ‘Hair-on-end’ skull vault (Fig. 8.4) seen in 5%, begins
in the frontal region and can affect all the calvarium
except that which is below the internal occipital
protuberance since there is no marrow in this area.
The diploic space is widened due to marrow hyperplasia.

Other Features
1. Thrombosis and infarction in diaphysis of small tubular bones
in children and in metaphysis and subchondrium of long bones
(adults).
2. Sec-osteomyelitis.
3. Abdomen—splenomegaly and splenic sequestration.

Thalassemia
• Marrow hyperplasia in thalassemia major is more marked than
in any other anemia
• Severe hair-on-end appearance
682 Differential Diagnosis in Radiology

Fig. 8.4: Hair-on-end appearance on skull vault

• Impediment of pneumatization of maxillary antrum and

mastoid sinus
• Lateral displacement of orbit, rodent facies.

Other Features
Earliest changes in small bones of hands and feet, widened
medullary spaces with thinning of cortices.
• Erlenmeyer flask deformity
• Chest
– Cardiac enlargement
– Paravertebral masses
• Abdomen
– Hepatosplenomegaly
– Gallstones
• Others
– Hereditary spherocytosis
– Elliptocytosis
 Head, Neck and Spine 683
– Pyruvate kinase deficiency
– G-6 PD deficiency.

Neoplastic
1. Hemangioma
– Mostly cavernous
– Age: 4th or 5th decade. M:F = 1:2
– Location = Vertebral body and calvarium.
RF = < 4 cm round osteolytic lesion.
Sunburst or hair-on-end and without definite margin may
occur in diploe, producing palpable lump secondary to
widening of diploe.
2. Meningioma
Only rarely, when it breaks through the outer table.
3. Metastasis
Prostatic carcinoma, retinoblastoma, neuroblastoma (skull) and
GI tract.

Cyanotic Heart Disease

• Due to erythroid hyperplasia. Hypertrophic pulmonary
osteoarthropathy may occur
• Iron deficiency anemia = severe childhood cases.

8.9  MULTIPLE WORMIAN BONES

Common in infancy but only considered significant when 6×4
mm or larger in size, >10 in number and with a tendency to be
arranged in a mosaic pattern (PORKCHOPS).
1. Pyknodysostosis: Abnormal recessive
– Short limbed dwarf with some features of osteope­trosis
and cleidocranial dysplasia.
2. Osteogenesis imperfecta.
3. Rickets in healing phase.
4. Kinky hair syndrome.
5. Cleidocranial dysplasia.
684 Differential Diagnosis in Radiology
6. Hypothyroidism/hypophosphatasia.
7. Otopalatodigital syndrome.
8. Primary acro-osteolysis/pachydermoperiostosis.
9. Down syndrome.
Osteogenesis imperfecta = Heterogenous group of a generalized
connective tissue disorder leading to a micromelic dwarfism,
caused by bone fragility, blue sclera and dentino­ genesis
imperfecta.
2 types < Congenita
Tarda—4 types—1 to 4 (I to IV)
RF Diffuse demineralization, cortical thickening, multiple
fracture, pseudoarthrosis with bowing.
• Normal exuberant callus formation
• Rib thinning or notching
• Wormian bones persisting into adulthood
• Basilar impression
• Biconcave vertebral bodies with Schmorl’s nodes
• Rickets in healing phase
– Age group: 4–18 months.
• Location metaphysis of long bones subjected to stress are
particularly involved (wrists, knees, ankles)
• RF cupping + fraying of metaphysis
• Poorly mineralized epiphyseal centers with delayed appearance
• Coarse trabeculations
• Deformities common
• Frontal bossing
• Multiple wormian bones.

Cleidocranial Dysplasia—AD
• Delayed ossification of midline structure.
a. Skull: Decreased ossification of skull.
– Wormian bones
– Widened fontanelle + sutures
– Large mandible
– Hypoplastic PNS.
 Head, Neck and Spine 685
b. Chest and upper extremity
– Hypoplasia or absence of clavicle (10%)
– Supernumerary ribs, short radius, hemivertebrae
c. Pelvis and lower extremity
– Delayed ossification of bones at symphysis pubis,
hypoplastic iliac bones.

Hypothyroidism
• Delayed skeletal maturation, fragmented stippled epiphysis
• Wide sutures/fontanelle with delayed closure
• Delayed dentition
• Delayed pneumatization of sinuses
• Wedging of D-L vertebral bodies.

Hypophosphatasia
• Autosomal recessive
• Low activity of serum, bone, liver alkaline-phosphatase
resulting in poor mineralization
• Phosphoethanolamine as a precursor of alkaline phosphatase
• Normal serum Ca++ and phosphorus
• RF moderate to severe dwarfism
• Resembles rickets
• Separated cranial sutures.

8.10  POSTERIOR FOSSA CYSTS

AND CYSTS-LIKE MASSES
• Dandy-Walker malformation (DWS) and variant
• Mega cisterna magna
• Posterior-fossa arachnoid cyst
• Enterogenous cyst
• Inflammatory
• Dermoid
• Epidermoid
• Cystic neoplasm.
686 Differential Diagnosis in Radiology

Dandy-Walker Malformation
• Atresia of embryonic roof of 4th ventricle—caused by cystic
dilatation of 4th ventricle and enlarged post fossa with
upward displacement of lateral sinuses, tentorium and torcular
herophili associated with varying degree of vermian hypoplasia
or aplasia.
Floor of 4th ventricle is present, cystically dilated 4th ventricle
balloons posteriorly.
Complete vermian absence in 25% and mild hypoplasia. The
vermian remnant typically appear as rotated and elevated above
the post-fossa cyst.
Cerebellar hemisphere—Varying degree of hypoplasia. Brain-stem
= hypoplastic or compressed.

Associated Features
CCA (corpus callosum agenesis)
Gray matter heterotopia
Clefts, polymicrogyria
Occipital cephalocele
Polydactyly and cardiac anomalies.

Mega Cisterna Magna

• Vermis and cerebral hemisphere, IVth ventricle normal
• Enlarged posterior fossa cyst can cause scalloping of occipital
and squamous base.

Posterior Fossa Arachnoid Cyst

• CSF-filled masses enclosed within split layer of arachnoid
• IVth ventricle and vermis normal but displaced
• Non-enhancing mass, parallel in CSF attenuation.

Enterogenous Cyst
• Developmental cyst (The notochord and foregut may fail to
separate during formation of definitive alimentary canal)
• Anterior to brain-stem
• IVth ventricle and vermis normal
• Equal or slightly higher attenuation.
 Head, Neck and Spine 687
Inflammatory
• IVth ventricle—Normal but may be distorted
• Enhancement after contrast administration
• Calcification common
• Slightly hyperdense to CSF.

Dermoid and Epidermoid

Both epidermoid and dermoid cysts are ectodermal inclusion
cysts.
Epidermoid—IVth ventricle is most common intra-axial site.
Dermoid—Vermis and IVth ventricle most common infra-tentorial
site.
Calcification is common in dermoid.

Cystic Neoplasm
• Site—vermis and cerebellum
• Vermis and IVth ventricle—normal but distorted
• Calcification common
• Common tumors—Cerebellar astrocytoma and ependymoma.

8.11  ENLARGED SYLVIAN FISSURE/

MIDLINE CRANIAL FOSSA OF CSF DENSITY
1. Schizencephaly open lip
2. Arachnoid cyst
3. Epidermoid
4. Cystic neoplasm
5. Infarct
6. Loculated hygroma
7. Porencephalic cyst.
Schizencephaly—(split-brain)—is a gray matter lined CSF-filled cleft
that extends from the ependymal surface of the brain, through the
white matter to the pia.
688 Differential Diagnosis in Radiology
Closed lip - cleft walls are in apposition
Two types (Type I)
- open lip—walls are separated (Type II).
clefts can be U/L, B/L or symmetrical/
asymmetrical
• Porencephalic cysts—result from insults to otherwise normally
developed brain
CSF space is lined by gliotic white matter not by dysplastic
heterotopic cortex
• Arachnoid cysts are benign, congenital, intra-arachnoidal space
occupying lesions that are filled with clear CSF-like fluid.
Age incidence—all ages, 75% occur in children; M:F = 3:1.
Location—supratentorial —50–60% = Middle cranial fossa,
10% suprasellar and quadrigeminal region.
CT—smoothly demarcated noncalcified extra-axial mass that
does not enhance.
– Pressure erosion of adjacent calvarium.
– Ipsilateral pneumosinus dilatans.
MR—Sharply demarcated extra-axial mass. Displaces or deforms
adjacent brain.
• Parallel to CSF signal intensity on all pulse sequence.
Epidermoid (i) Congenital non-neoplastic inclusion cyst.
(ii) Acquired—result of trauma.
Age and sex = peak = 4th decade, No gender predilection.
90% = intradural; 10% = intra-axial.
Most common site—basal subarachnoid space
40–50% – C–P angle cisterns.
NECT = attenuation similar to CSF, lobulated margin.
Calcification = 10–25%
Occasionally = appear hyperdense due to hemorrhage, high
protein, etc.
CECT = Most do not enhance.
MR—Confined and insinuate along basilar CSF cistern, similar
to CSF.
SSFP, MR and DWMR—to differentiate from a cyst.
Engulf the main vessels and nerve while arachnoid cyst displaces.
 Head, Neck and Spine 689
Cystic neoplasm—contrast enhancement is common.
Infarct—old chronic infarct.
• At any age
• Lined by gliotic white matter
• Changes of volume loss present
• Loculated Hygroma
– CSF density.
– Membrane can be seen on CE MR study.

8.12  SKULL BASE AND CAVERNOUS SINUS

(FLOW CHART 8.2)
Skull base is composed of the ethmoid, sphenoid, occipital bone
and paired frontal and temporal bones.
Anterior skull base lesion consists of orbital plates of ethmoid
bones.
Cribriform plate of ethmoid bone.
Flow chart 8.2: Planum sphenoidale
690 Differential Diagnosis in Radiology

Extracranial
Most arise from nose and PNS.

Benign
Mucocele—Accumulation of impacted mucus secondary to
occluded draining sinus ostium.
– If a mucocele becomes infected, it is termed as mucopyocele.
– In descending order of frequency, mucocele are found in
frontal, ethmoid, maxillary and sphenoid sinus.
Imaging—They are usually of soft tissue density mass with bone
expansion and remodelling.
Inverted papilloma (IP)—Benign, slow growing.
IP arise in the nasal vault near the junction of ethmoid and
maxillary sinuses, in the region of middle turbinate.
Imaging—A unilateral polypoidal nasal fossa soft tissue mass
widens the nasal vault, sometimes destroying the bone and
extending into the adjacent ethmoid and maxillary sinuses.
• Focal erosion of cribriform plate with cephalad extension
sometimes.
Osteoma—Benign bone tumor made up of mature cortical bone.
Frontal sinus is the most common site.
Osteoma can expand and erode the sinus wall.
Malignant sinonasal masses can cause extradural intracranial
extension.
In children—Most common extracranial malignant that involves
the skull base is rhabdomyosarcoma.
Most common soft tissue sarcoma in children.
Imaging—Bulging soft tissue mass with areas of bone destruction
T1 = Similar to mass, T2 = Hyperintense meningeal and perineural
spread are common.
Adult—98% of nasopharyngeal tumors in an adult are carcinoma.
SCC = 80%
Adenocarcinoma = 18%
Nasopharyngeal Ca = spread directly into the skull base, as well
as along muscle.
 Head, Neck and Spine 691
They extend intracranially along neural and vascular bundles
via osseous foramina.

Enthesioneuroblastoma (ENB)
Enthesioneuroblastoma or olfactory NB arises from bipolar sensory
receptor cells is the olfactory mucosa.
• Can occur at any age—Bimodal distribution
2nd
4th decade
• ENB often confined to the nasal cavity but may extend to the
PNS, orbit or brain through the cribriform plate.
Imaging— high nasal vault mass. MR—variable signal.
Moderate to inhomogenous enhancement.
• Bacterial/fungal sinusitis
• Sarcoidosis
• Sinonasal lymphoma
• Wegner granulomatosis.

Intrinsic Lesion
Fibrous dysplasia
Paget’s disease
Osteopetrosis.

Intracranial
• Most common lesion that involves the anterior skull base is
meningioma
• Planum sphenoidale or olfactory groove—site of origin
• Broad based, anterior basal subfrontal mass
• Strong and uniform enhancement
• Presence of tumor brain interface cleft
• Gray-white matter buckling
• Hyperostosis of adjacent bone
• Nasoethmoidal cephalocele—complex masses of mixed soft
tissue and CSF and are contiguous with intracranial sutures,
692 Differential Diagnosis in Radiology
typically through a widened calvarial opening. Crista galli will
be absent or eroded
• Peripherally located brain neoplasm like ganglioma causes
pressure erosion of adjacent skull.

8.13  CENTRAL SKULL BASE LESIONS

Contents are:
Upper clivus, sella turcica, cavernous sinus and sphenoid sinus.
• Osteomyelitis
– Predisposing factors—Immunocompromised states,
diabetes, chronic mastoiditis, PNS infection, trauma.
– Frontal sinusitis is very frequent leading to osteo­myelitis.
– RF loss of bone density, trabecular detail, sequestrum
formation, blurring and loss of sinus outline.
– Complication—Cerebral infarct, meningitis, subdural
empyema and brain abscess.
• Fungal sinusitis
Imaging CT—multisinus nodular mucoperiosteal thickening,
high attenuation foci within the soft tissue masses.
– Extensive lesion can produce skull base destruction.
MR—low signal on both T1 and T2, surrounded by a high
signal rim on T2.
Complication—cavernous sinus thrombosis, blood, vessel
invasion and rapid intracranial dissemination.
• Non-fungal granulomas = also have intracranial extension like
Wegener’s granulomatosis, LMG (lethal midline granulomas—
lymphoma variant).
CT—E/O mucosal ulceration and bone destruction in nasal
cavity and PNS without the ST mass, thus distinguishing from
simple malignancy.
MRI—Decreased signal on both T1 and T2.
While simple inflammatory thickening will be bright on T2.
• Primary neoplasm—Common tumors that affect the central
skull base are:
 Head, Neck and Spine 693
– Pituitary adenoma—slowly expanding that erodes the
sella turcica.
– Typically extend superiorly through the diaphragmatic
sella and laterally into the cavernous sinus.
• Sometimes may expend inferiorly and cause destruction of
central skull base
• Meningiomas of central skull base are located along the
sphenoid wing, diaphragm, sella, clivus and cavernous sinus.
   Focal lobulated or flat ‘En plaque’ mass bony destruction or
hyperostosis is occasional.
• Nerve sheath tumors—In central skull base, most often affect
the cavernous sinus and Meckel’s cave
Most common schwannoma to involve the central skull base
and cavernous sinus is trigeminal and schwannoma.
– They are encapsulated, well-delineated tumors.
– They are quite vascular and hemorrhage and necrosis may
occur.
• JNA (juvenile angiofibroma)—highly vascular, locally invasive
lesion that originates near the sphenopalatine foramen of
adolescents
Spread along neural foramina and fissure into the
pterygopalatine fossa, orbit, middle cranial fossa, sphenoid
sinus and cavernous sinus.
CT = soft tissue density mass.
Highly vascular and strongly enhancing.
• Chordoma—Slowly growing, destructive tumor, histologically
benign but locally invasive
1/3rd occur in spheno-occipital region.
Mostly occur in midline and primarily involves the clivus.
• Enchondroma—Most common benign osteocartilaginous
tumor in this location
 An expansile, lobulated soft tissue mass with scalloped en-
dosteal bone resorption, and curvilinear matrix mineralization.
The characteristic findings.
MR—iso with muscle on T1, hyper on T2
Postcontrast T1 Wt—Enhancement of scalloped margin.
694 Differential Diagnosis in Radiology
• Metastasis
Can arise via regional extension of head and neck malignancy
or hematogenous spread from extracranial primary site.
Prostate, lung and breast = MC.

diffuse/focal cystic destructive lesion.
Mixed hyperostosis and
bone destruction with an
associated ST mass. } may resemble hemangioma

Lateral orbital wall is a favorite site for prostatic metastases.

8.14  CEREBELLO PONTINE ANGLE MASSES

Cerebellopontine angle cistern lies between anterolateral surface
of the pons and cerebellum and the post surface of the petrous
temporal bone (Fig. 8.5).
Important structures within the cerebellopontine angle
cistern—5th, 7th and 8th cranial nerves.
Superior and anterior inferior cerebellar arteries
Tributaries of superior petrosal veins.
Cerebellopontine angle masses—very common in adults
Majority are extra-axial
• Arising in cerebellopontine angle cistern
– Schwannoma (acoustic)—75%
– Meningioma—8–10%
– Vascular ectasia/aneurysm—2–5%
– Epidermoid—5%
Other schwannoma.
– Arachnoid cyst.
4th ventricle/lateral recess
– Ependymoma
– CP papilloma
Brainstem/cerebellum
– Exophytic glioma metastasis
– Hemangioblastoma.
Temporal bone
– Cholesterol granuloma
– Gradenigo syndrome
 Head, Neck and Spine 695
– Paraganglioma
– Metastasis.
• Acoustic schwannoma—usually solitary, multiple seen in 5% of
cases and characteristic of NF-2
Age =5th–6th decade
with NF-2 appear earlier
Sex = M < F (1:1.5–2)
Plain X-ray = widening of IOC
Anteromedial petrous apex erosion may be enlarged foramen
ovale/rotundum/sof (superior orbital fissure) (CANAL).
CT = NECT = iso to hypodense.
CECT = almost all schwannoma enhances strongly, small tumors—
uniform
Large heterogenous pattern
Peripheral arachnoid cyst or pools of trapped CSF.
MRI = Characteristic findings of extra-axial mass.
• Distinct vascular/CSF cleft between tumor and brain
• Enlarged CP < Enlarged cerebellopontine cistern.

Fig. 8.5: Anatomic diagram depicts the cerebellopontine angle anatomy.

Lesions that arise from each component are indicated
696 Differential Diagnosis in Radiology
• Corticomedullary junction of cerebellum appears displaced
and brainstem rotated
• Ice-cream cone appearance due to intracanalicular component.
T1 = 2/3rd are hypo
T2 and PD = hyper = foci of cystic degeneration in larger lesion
• All show enhancement
• Peritumoral edema seen in 37% cases
Angio-hypo to avascular tumor.
• Draping, stretching of vessels,
• Meningioma—Posterior fossa meningioma accounts for
approx. 10% meningioma—site—post surface of petrous
temporal bone and clivus.
Arise from arachnoid cap cells.
Associated with NF-2
Sex = F > M peak—4th to 6th decades.

Plain Film
• Bone erosion and hyperostosis
• Enlarged vascular channel
• Tumoral calcification and expanded PNS (pneumosinus dilatans)
Angiography—vascular tumor
Dual supply—meningeal and cerebral artery giving a characteristic
radial or sunburst appearance.
CT—sharply circumscribed round or lobulated mass that abuts
dural surface, usually an obtuse angle.
70–75% = homogenously hyperdense.
25% = isointense
Ca++ = 20–25%
Cystic changes or necrosis = 8–23%
Peripheral edema = 60%
CECT = intense and homogenous enhancement—in 90%
MR = gray-white interface ‘buckling’ or displacement cleft or
pseudo capsule of CSF and vessels that surround the mass.
• T1 = Iso or slightly hypointense.
T2 = Variable.
 Head, Neck and Spine 697
• Epidermoid tumor—Intracranial epidermoid is cystic lesion that
insinuates along CSF cistern.
Age—20–60 years.
No gender predilection.
Location—40-50% occur at CP angle cistern.
Imaging—plain film—round on lobulated well-delineated focal
bone erosion with sclerotic margins.
Angio—Avascular mass effect.
NECT—Well-delineated lucent appearing lobulated masses
with attenuation similar to CSF.
Ca++ = 10–25%
Occasionally hyperdense on NECT.
CECT—Most do not enhance although enhancement at the
tumor margin. Epidermoid tumors encase vessel and engulf
the intracranial nerves.
MRI—Most are confined to, and insinuate along, the basilar CSF
cisterns.
SI (signal intensity) similar to CSF.
White epidermoid = iso or hyper to brain on T1 because of
increased lipid content.
SSFP (steady-state free precession) and diffusion weight MR are
helpful in differentiating the lesion with arachnoid cyst.
• VB dolichoectasia—on elongation and dilatation of
vertebrobasilar artery
• Elongation of basilar artery—if any portion of it extends lateral
to the margin of the clivus or dorsum sellae or if the artery
bifurcates above the plane of suprasellar cistern.
• Ectasia is diagnosed if the diameter of the basilar artery is
greater than 4–5 millimeters on CT.
– Angiography—non-selective angiography demonstrates
well.
– MRI and MRA give signal void on MR.
• Arachnoid cysts—are benign, congenital, intra-arachnoidal
space occupying lesions that are filled with clear CSF-like fluid.
Age—75% occur in children. F:M = 3:1. Five to ten percent of
arachnoid cysts occur in posterior fossa at < CP cerebellopontine
angle and cistern magna
698 Differential Diagnosis in Radiology
NECT—CSF density extra-axial masses do not enhance on
contrast administration.
Pressure erosion of adjacent calvarium.
Ipsilateral pneumosinus dilatans.
MRI—They parallel CSF SI on all sequences.
• Ependymoma—are slow growing lobulated neoplasms that
are often partly cystic.
Age—6 times more common in children.
Peak—1–5 years and mid 30 years.
Location—rarely arise in C-P angle cistern.
Imaging—angiography = hypovascular to extremely hypervas-
cular lesion.
CT—Iso on NECT, 50% exhibit Ca++
Mild to moderate enhancement.
MRI—lobulated ST mass hypo or iso on T1 and hyper on T2WI
Cystic portion = hypo on T1 and hyper to brain on T2WI.
• Pilocystic astrocytoma—(juvenile or cystic cerebellar)
Age—children and young adults.
Location around the 4th ventricle and cerebellar hemisphere.
Angio—avascular.
NECT—hypo or isodense mass/Ca++ seen in 10%.
Variable but strong enhancement.
Sometimes having mural nodule in a large cyst.
MR—hypo or iso on T1 and hyper on T2.
• Metastasis—1–2% of CP mass
Usually have multiple or B/L cranial nerve and leptomeningeal
lesions coexisting parenchymal lesions are identified in 75% of
these cases.

8.15  SUPRASELLAR MASS (FIG. 8.6)

Intrasellar Lesions (Pituitary)

1. Common
a. Pituitary hypertrophy
b. Microadenoma
c. Cyst (Rathke’s cleft cyst and pars intermedia cyst).
 Head, Neck and Spine 699

Fig. 8.6: Anatomic diagram depicts the sella turcica and suprasellar re-
gion as seen from the lateral view. Common lesions and their differential
diagnosis by location are indicated

2. Uncommon
a. Craniopharyngioma
b. Metastases
c. Aneurysm.

Infundibular Lesions
I. Uncommon II. Rare
a. Astrocytoma a. Hypophysitis
b. Germinoma b. Choristoma
c. Histiocytosis c. Pituicytoma
d. Lymphoma/leukemia
e. Meningitis
f. Metastasis
g. Sarcoidosis
700 Differential Diagnosis in Radiology

Suprasellar Lesions
I. Common II. Uncommon
1. Aneurysm 1. Cyst (Arachnoid, inflammatory)
2. Craniopharyngioma 2. Dermoid/Epidermoid
3. Glioma 3. Ectopic neurohypophysis
4. Meningioma 4. Hamartoma
5. Macroadenoma 5. Lipoma

Anterior 3rd Ventricle/Optic Chiasmatic Lesions

I. Common II. Uncommon
1. Glioma 1. Colloid cyst
2. Germinoma
3. Glioependymal cyst
4. Metastases

Sphenoid Sinus/Cavernous Sinus Lesions

I. Common II. Uncommon
1. Osteomyelitis 1. Chordoma
2. Meningioma 2. Histiocytosis
3. Metastasis 3. Lymphoma
4. Osteoma/osteosarcoma/
osteochondrosarcoma
5. Sarcoid
6. Schwannoma
7. Thrombus

Common Masses
• Macroadenoma (upward extension)
• Meningioma
• Aneurysm
• Craniopharyngioma
• Glioma (usually pilocystic astrocytoma).
 Head, Neck and Spine 701
Uncommon
• Lipoma
• Dermoid/Epidermoid
• Cysts (Arachnoid, Rathke’s cleft)
• Focal meningitis
• Metastasis
• Ectopic neurohypophysis.
Macroadenoma—upward extension of pituitary adenoma
through the diaphragmatic sella accounts for 1/3rd to 1/2 of all
suprasellar masses in adults.
Pituitary adenoma with suprasellar extension typically have a
figure of 8 appearance.
Mostly enhances strongly but inhomogenously.
Calcification is rare.
MRI—similar to gray matter on T1 and T2 sequences.
Hemorrhage, cyst formation can complicate the MR appearance.

Meningioma
Second most common suprasellar neoplasm in adults.
Most parasellar meningioma originate from the sphenoid ridge,
diaphragm or tuberculum sella.
NECT slightly hyperdense.
Strong uniform enhancement, but not as intense as adjacent
pituitary gland and cavernous sinus, allowing most meningioma
to distinguish from adjacent pituitary adenoma.

Craniopharyngioma
Half of all suprasellar tumors in children.
2nd peak = 4th–6th decades
90% of craniopharyngioma—exhibit calcification.
Enhanced and at least partially cystic. MRI signal intensity varies
with cyst content on T1 seq. but majority of craniopharyngioma
are hyperintense on T2WI.
702 Differential Diagnosis in Radiology
Astrocytoma—of the visual pathway, optic nerve, chiasma and
optic tracts account for 25% of pediatric suprasellar neoplasm.
CT—Iso or hypodense mass and frequent enhancement following
contrast administration.
MRI—Hypointense on T1 but hyper on T2WI.

Hypothalamoneurohypophyseal Axis Germinoma

Most are both intra- and suprasellar.
Age—most patients are <30  yrs. MR—An infiltrating mass
isointense to brain on T1, moderately hyperintense on T2 wt
images.
– Enhances strongly and homogenously after contrast
administration.
– CSF dissemination throughout the ventricular system and
subarachnoid space is common.

Epidermoid Tumor
Occasionally occurs in the suprasellar cistern.
On imaging = lobulated, irregular, frond-like surface
Appearance similar to CSF on imaging studies.

Dermoid Tumor
Well-delineated, lobulated masses that typically occur in or near
the midline. Suprasellar dermoids are uncommon.
– On imaging—Usually appear similar to fat.
– Ruptured dermoids may spill their contents throughout the
CSF spaces and elicit severe chemical meningitis.
Metastasis—to the hypothalamic—pituitary axis represents
approx. 1% of sellar—suprasellar masses. Breast cancer is the most
common site in female followed by lung, stomach and uterus.
In men, common primary tumors are neoplasm of the lung,
followed by prostate, bladder, stomach and pancreas.
MRI—ISO Isointense on T1 and hyperintense on T2WI. Moderate
enhancement following contrast administration.
 Head, Neck and Spine 703
Vascular Lesion
Vascular ectasias and supraclinoid ICA (internal carotid artery).
Aneurysms are the most common suprasellar non-neoplastic
masses in adults.
– Imaging appearance of aneurysm is variable, depending on the
presence and age of thrombus and various flow parameters.

Congenital
Suprasellar arachnoid cyst (SSAC)
Ten percent of arachnoid cysts occur in the suprasellar region.
On imaging, they appear as smoothly marginated masses that
are similar to CSF density.
SSAC—Neither calcify nor enhance.
A displaced, compressed III ventricle can be seen on MR studies.
• Rathke’s cleft cyst (RCC) is a benign epithelium lined cyst that
probably arises from remnants of Rathke’s pouch.
RCCs usually have both supra- and intrasellar components
CT and MR = Vary with cyst content.
Calcification is absent.

8.16  SELLAR AND SUPRASELLAR MASSES

Common Causes Rare Causes
1. Pituitary adenoma 1. Rathke’s cleft cyst
2. Craniopharyngioma 2. Arachnoid cyst
3. Aneurysm 3. Visual pathway glioma (VPG)
4. Suprasellar meningioma. 4. Chordoma
5. Metastasis
6. Epidermoid and dermoid
7. Teratoma
8. Germinoma
704 Differential Diagnosis in Radiology

Pituitary Adenoma
• Fifteen percent of all intracranial tumors.
• Microadenoma – <10 mm in height.
• Macroadenoma – 10 or >10 mm.

Classification
• Endocrine active—80% (Like prolactinoma, acromegaly/
gigantism, hepatosplenomegaly.
• Endocrine inactive—20%.

Plain X-ray (Fig.8.8)

Macroadenoma
• Pituitary fossa increases in size, expands and erodes. In classic
case, give ‘ballooned sella’ appearance with backward bowing
of dorsum, under cutting of anterior clinoid and downward
protrusion of floor and extension to sphenoid sinus.

Microadenoma
It produces local bulging of sellar floor or Double floor’ appearance.
In case of acromegaly—other features like thickening of skull
vault, grossly enlarged sinuses and prognathous jaw seen.

CT
The most common microadenoma and prolactinoma typically
produce some enlargement of pituitary and a discrete hypodense
region within the enhanced gland on CECT.
Other imaging findings are thinning or asymmetry of the
sellar floor, displacement of infundibulum from the midline
(infundibulum sign) and displacement of capillary tuft (tuft sign).
The macroadenoma are: isodense or slightly hyperdense mass
and enhance uniformly on CECT. Cystic or necrotic areas may be
 Head, Neck and Spine 705
seen within it. In some cases, calcification is seen in the rim of
the tumor or less commonly throughout the tumor matrix. The
adenoma usually enlarges the sella, compresses the sphenoid
sinuses or encroaches on the suprasellar cistern and may displace
the chiasm or temporal lobes. Sometimes it extends into the
anterior end of 3rd ventricle and causes hydrocephalus, rarely it
destroys the skull base degenerated to carcinoma.

MRI
The normal pituitary yields a homogenous brain-like signal in most
pulse sequences and is best shown in sagittal and coronal images.
The normal optic chiasm, carotid vessels and sphenoid sinus are
also highly conspicuous. Macroadenoma are usually of relatively
lower signal than normal brain on T1 WIS of higher signal or T2
weighted images. Regions of lower signal on T1 and higher signal
on T2 are seen within the tumor and usually represent cyst when
rounded and circumscribed and necrosis when more irregular.
Areas of recent hemorrhage found frequently and are seen as high
signal on T1W weighted images.
• Microadenoma on T1 weighted images with IV gadolinium
showing delayed enhancement of the adenoma compared to
the normal gland.

PITUITARY APOPLEXY
Pituitary tumor occasionally undergoes ischemic necrosis and
hemorrhage if the blood supply to the tumor is impaired and leads
to rapid expansion of tumor. This is known as pituitary apoplexy.
• It may also occur as a complication of pregnancy in postpartum
period called Sheehan’s syndrome.

CT
Shows hyperdensity due to hemorrhage or may show only
hypodensity in the sella with a rim or enhancement.
706 Differential Diagnosis in Radiology

MRI
It is more sensitive than CT. A subacute hemorrhage in the pituitary
gland has hyperintensity on T1 wt. and T2 wt. images.

Empty sella
A varying amount of CSF within the sella with the pituitary gland
occupying less than 50% of the volume of sella is defined as empty
sella.

Classification
1. Primary (Idiopathic): Common in females, patients are often
obese, multiparous and hypertensive.
2. Secondary:
I. After hypophysectomy or tumor removal.
II. After radiation therapy of sellar contents.
III. After infarction of pituitary gland.

X-ray
The sella often appears enlarged. The enlargement, however, is
more globular and symmetric and the cortex of the sella remains
intact.

CT (Empty Sella)
Pituitary fossa to be occupied largely by tissue of CSF or water
density rather than a normal gland. The ‘infundibulum sign’ can
be used to differentiate an empty sella from other low density
process, such as cystic tumor or an infrasellar 3rd ventricle which
displaces the infundibulum.

Craniopharyngioma
It is the 2nd most common sellar tumor and account for 3% of all
intracranial tumors. Seventy percent of cases occur before 20 years
of age.
 Head, Neck and Spine 707
X-rays
Shows suprasellar calcification, expansion of sella and/or erosion
of dorsum sellae. Such findings in a child are highly suggestive of
craniopharyngioma. However, there is often a typical deformity
of the sella which can be helpful in cases without calcification—
mostly in adults. The sella appears elongated and the dorsum may
be short and bowed forward as if pressed on from above.

CT
Suprasellar calcification is more readily identified by CT and always
suggests the diagnosis. The tumors are often cystic or partly
cystic and the cyst may be multiple or single. Calcification occurs
frequently in the wall or solid portion. After contrast injection,
there is enhancement of the outer walled solid portion. The cystic
component does not enhance.

MRI (Craniopharyngioma)
On MR with T1WI, the cystic contents are of variable signal intensity,
most often hypointense but occasionally hyperintense. On T2WI,
the cystic contents may be slightly or markedly hyperintense. On
CEMR, the solid portion and the wall enhance.

Suprasellar Meningioma
It arises on dural surface of the anterior clinoid process, diaphragm
sella, tuberculum, dorsum sellae or cavernous sinus.

X-ray
Localized hyperostotic reaction seen. Other evidence such as
enlarged vascular markings and sign of raised intracranial pressure
seen. With meningioma arising in the region of anterior clinoid, a
rare manifestation is local bone extension with pneumatization, so
called ‘BLISTERING’ seen.
708 Differential Diagnosis in Radiology

CT
Shows a well-defined and smoothly marginated iso- to hyper-
dense mass which enhances homogenously intensely on CECT.
Perilesional edema may be present. Rarely meningiomas have
cystic hypodense area within it. Globular calcification is seen in
10% of cases.
Hyperostotic bone adjacent to tumor is characteristic.

MRI
It is isointense with brain on T1WI. So, this can be missed unless
a contrast enhanced study is done. After IV gadolinium, most
meningioma are homogenously enhancing on T1WI.

ANEURYSM

X-ray
Calcifications are rare and seen as characteristic arc-like or circular
marginal calcification.

CT
It is seen as a high density suprasellar or parasellar mass and
enhances strongly related to circles of Willis on CECT. They may
have calcification in the rim, when an organized thrombus is
present. The aneurysm appears non-homogenous in CECT
because the thrombus enhances less than as the lumen and the
vessel wall.

MRI
In T1 and T2W wt. serial images, flowing blood within the aneurysm
has very low signal intensity.
Turbulent flow may produce a heterogenous signal. A thrombus
within an aneurysm usually has signal intensity higher than that of
flowing blood.
 Head, Neck and Spine 709
In T1W wt. gradient echo images, the lumen of an aneurysm
typically has high signal intensity. The vascular anatomy in the
sellar region and the presence of suspected aneurysm can be
confirmed with magnetic resonance angiography (MRA).

RATHKE’S CLEFT CYST

CT
Shows a rounded mass in the suprasellar cisterns with no
calcification. The values of density vary from that of CSF to more
solid looking.

MRI
Shows a homogenous high signal on both T1 and T2 weighted
images possibly due to altered blood in the cyst fluid.

ARACHNOID CYST
CT
The characteristic CT appearance of the cyst is a mass with CSF
density (5–15 HU) and no solid or enhancing component structure.
In MRI, the cyst has an intensity similar to or slightly higher than
the CSF in spin density and T2WI images.

EPIDERMOID AND DERMOID

CT
The tumors are usually of fatty density. But the density can be
as high as that of CSF or higher, depending on the contents. The
margin may be ill-defined and that does not enhance with contrast
medium. The presence of calcification or fat in a predominantly
cystic lesion suggests a dermoid rather than epidermoid.
710 Differential Diagnosis in Radiology

MRI
They are usually isointense with CSF on T1W wt. and isointense or
slightly brighter on T2 weighted images.

TERATOMA
X-ray
Calcification is present in 50% of mature teratoma.
Very rarely presence of dental element seen and that is the true
diagnostic feature.

CT
Shows cystic or multicystic tumor. The specific diagnosis will
depend upon recognition of multiple tissues like fat, calcified
element and dental element.

GERMINOMA (ATYPICAL TERATOMA)

CT
On CT, germinoma may be hypodense or hyperdense, homo­
genous or non-homogenous, enhancing or non-enhancing and
frequently calcified. Presence of a pineal as well as suprasellar
mass, which enhances homogenously when seen in a young male,
is characteristic of germinoma.

MRI
Germinoma is typical isointense with brain in T1WI and sometimes
hyperintense in T2WI. Fat within it has high and low signal
intensities in T1WI and T2WI respectively. Intense enhancement is
common after IV gadolinium.
 Head, Neck and Spine 711
Visual Pathway Glioma (VPG)
Usually seen in first decade of life. Six to forty-five percent of
patients with VPG have neurofibromatosis type I.

CT
It appears as an expansile mass involving the optic nerve,
chiasm and tract and/or a mass that infiltrate and expand the
hypothalamus. They are isodense to hypodense before contrast
and usually show enhancement. The optic nerve may be uniformly
enlarged with peripheral enhancement.

Chordoma
Commonly occur between 4th and 6th decades of life. They
are locally invasive, slow growing involving the clivus and the
sphenoid bone.

CT
Characteristic findings are destruction of bone in skull base
and a soft tissue mass that is often calcified and may extend to
nasopharynx.

MRI
The tumor appears as a lobulated inhomogenous mass, generally
isointense with brain on T1 wt. and of higher signal on T2-weighted
images. Calcification is seen as focal areas of signal void.

Metastasis
Metastasis to sellar region most commonly arise from lung, breast,
kidney, GI tract, lymphoma, leukemia and naso­pharyngeal tumor.
712 Differential Diagnosis in Radiology

Imaging
MRI effectively demonstrates the mass that may be invading the
pituitary fossa, cavernous sinus, sphenoid sinus and sellar cortex.
Bone destruction is better evaluated with CT.

NEUROSURGEON’S QUERIES
When a neurosurgeon preoperatively reviews a pituitary CT
scan or MRI, his interest is focused on several anatomic features
possible, considered insignificant to the radiologist. If trans
sphenoidal surgery is anticipated, imaging consideration includes
the degree of pneumatization of sphenoid sinus, location of sinus,
septa and sinonasal inflammatory disease, bony dehiscence of
the optic and carotid canals and vascular anomalies like anterior
communicating artery aneurysms or the ‘kissing’ carotids. So,
the additional information is required from imaging to help plan
surgery.

8.17  EXPANDED PITUITARY FOSSA (FIG. 8.7)

Size -N range is height = 6.5–11 mm
length = 9–16 mm
breadth = 9–19 mm.

Causes
1. Para/intrasellar mass
– Pituitary adenoma
– Craniopharyngioma
– Prolactinoma
– Meningioma
– Aneurysm.
2. Raised intracranial pressure—due to dilated 3rd ventricle.
3. Empty sella.
Primary—defect in diaphragm sella allows pulsating CSF to
expand the sella.
Patients are usually obese with hypertension and headache.
 Head, Neck and Spine 713

Fig. 8.7:  Lateral radiograph of skull shows enlarged sella

Fig. 8.8:  Erosion and osteoporosis of the sella, with no expansion

Associated with benign intracranial hypertension.

S×R = abnormal in 85%—shows symmetric expansion with no
erosion.
Secondary—pituitary tumor at treatment of a pituitary lesion
may distort the diaphragmatic sellae.

Posterior Fossa Neoplasm in Childhood

Fifty to sixty percent of pediatric cerebral tumors.
1. Cerebellar astrocytoma.
2. Medulloblastoma.
714 Differential Diagnosis in Radiology
3. Ependymoma.
4. Brainstem glioma.
5. Choroid plexus papilloma.

Cerebellar Astrocytoma
Most common posterior fossa tumor in pediatric age group. Peak
at age 10.
Location—around the 3rd or 4th ventricles.
Angiography—only an avascular mass effect.
Occasionally a mural module shows neovascularity.
CT—sharply demarcated and smoothly marginated hypo- or
isodense masses.
Calcification in 10% obstructive hydrocephalus.
CECT—strong but variable.
Some show enhancing mural nodule in a large cyst.
MR—Most cerebellar astrocytomas are cystic so, hypo- or iso-
on T1 and hyper on T2.
Mural nodule and solid T—Enhance.
Pontine and medullary gliomas—are usually diffusely
infiltrating neoplasms that are inhomogenously hypodense on
T1 and hyperdense on T2WI.
Obstructive hydrocephalus is mild or absent.
Medulloblastoma—arise from bipotential embryologic cells
located in the roof of the IVth ventricle.
Incidence—15–25% of primary brain tumor in children, 75%
occurs before 15 years and rest at age of 24–30 years.
Site—75%—in vermis.
Less common location—is lateral cerebellum seen in older
children and adults.
Extension—tend to metastasize early, widely and massively
through CSF.
Brain parenchyma metastases through Virchow Robin peri-
vascular space.
 Head, Neck and Spine 715
Imaging
Angio—hypo or avascular.
CT = midline vermian mass that displaces the IVth ventricle
anteriorly and cisterna magna posteriorly.
Hyperdense on NECT.
Obstructive hydrocephalus.
Calcification in 15%.
CECT = strong and homogenous enhancement
Atypical changes = cystic changes – 65%
isodense to brain – 3%
absent CE – 3%
MRI—Typical medulloblastoma fills the 4th ventricle and
extending inferiorly through foramen of Magendie into the
cisterna magna. Heterogenous hypointense on T1WI.
Heterogenous postcontrast enhancement.

Ependymoma
A rise from floor or roof of the IVth ventricle and protrude through
the outlet foramina into adjacent cisterns.
Incidence – 15% of posterior fossa neoplasm is childhood.
Peak age – 1–5 years, 2nd smaller peak–mid-30 years.
Site – 60% located below the tentorium.
40% above the tentorium.
90% of infratentorial occur in 4th ventricle.
Angio = variable.
CT = iso to NECT
50% = calcification
CECT = mild to moderate inhomogenous enhance-
ment
MRI = solid component hypo- or isointense on T1WI
and hyperintense on T2WI.
Choroid plexus papilloma—are one of the most common brain
tumors in children under 2 years of age.
716 Differential Diagnosis in Radiology
Location—Most common location is lateral ventricle, trigone in
children. 4th ventricle is most common site in adults.
Imaging—angiography —highly vascular neoplasm.
Enlarged choroidal artery.
CT = 75% are iso- or hyperdense to brain on NECT.
Calcification in 25%.
Tumor margins are irregular and frond-like CECT
= Intense and heterogenous enhancement.
MRI = lobulated mass isointense to brain on T1 and iso- on
slightly hyper on T2WTI.

8.18  RING ENHANCING LESIONS ON CECT

1. Primary neoplasm—GBM, meningioma, leukemia, pituitary
macroadenoma, craniopharyngioma.
2. Metastatic Ca and sarcoma.
3. Abscess—Bacterial, fungal and parasitic.
4. Empyema of epidural/subdural or intraventricular space.
5. Resolving infarction.
6. Aging hematoma.
7. Thrombosed aneurysm.
8. Radiation necrosis.
1. Primary neoplasm
High grade astrocytoma
– Anaplastic astrocytoma
Age—40–60 yrs
Location—Cerebral white matter most common.
CT—Inhomogenous/mixed density tumors on NECT. After
contrast injection, they enhance strongly but non-uniformly
and irregular rim enhancement is common.
– Peripheral edema is present.
– GBM—Most common of all primary intracranial CNS
tumors; age = 75 years.
Location—Deep cerebral white matter of frontal and temporal
lobes in most cases.
 Head, Neck and Spine 717
NECT—Heterogenous in appearance.
Ca++ —Rare
Peripheral edema
– Striking
Enhancement
– Strong but very inhomogenously thick, irregular rim
enhancement.
2. Parenchymal metastasis
Most common tumors to metastasize to brain are:
Lung
Breast
Malignant melanoma.
Age—> 40 years.
Location—Anywhere, gray-white matter junction.
NECT—Most metastases are isodense to brain, hyperdense
metastases occur in round cell tumor. Edema associated with
metastasis is striking.
CECT—both solid and ring-like enhancements with irregular
wall.
3. Abscess—Most abscesses are caused by pyogenic bacteria.
But sometimes Mycobacterium tuberculosis and fungi, such as
actinomycosis and parasites can cause abscess.
Location—gray-white matter junction—Most common
location frontal and parietal lobes are most frequent. Multiple
abscesses are uncommon except in immunocom­promised.
CT—In late cerebritis stage—An irregular enhancing rim
surrounds a central low density area edema.
Delayed scan shows contrast ‘fill in’ in the central low density
region.
An abscess rim is typically thickened near the cortex and
thinnest near the ependyma.
99mTc HMPAO—A new radionuclide imaging label for
leukocytes and radiolabeled polyclonal.
IgG (immunoglobulin/antibodies may be helpful in selected
cases.
718 Differential Diagnosis in Radiology
4. Epidural or subdural empyema
Fifty percent of cases are caused by sinusitis frontal sinus is the
most common site.
CT—Crescentic or lentiform extra-axial fluid collections that
increase density on CT, and mildly hyperintense to CSF on T2
Wt images.
Location—The cerebral convexities and interhemispheric
fissure are common site.
CECT—A surrounding membrane that enhances intensely and
uniformly following contrast administration.
5. Resolving hematoma—Between 1 and 6 weeks subacute ICH
become virtually isodense with adjacent brain parenchyma on
NECT.
      Subacute ICH show peripheral enhancement after contrast
administration because there is blood brain barrier breakdown
in the vascularized capsule that surrounds the hematoma.
6. Thrombosed aneurysm—Partially thrombosed aneurysm have a
patent lumen inside a thickened, often partially, calcified wall
that is lined with laminated clot.
The residual lumen and outer rim of the aneurysm may enhance
strongly following contrast administration.
Radiation necrosis—Extensive radionecrosis and recurrent or
persistent neoplasm produce a similar picture, i.e. an expanding
contrast-enhancing mass.
PET may be helpful for determining the extent of cerebral
gliomas as well as distinguishing radiation necrosis from
residual neoplasm.

8.19  SUPERIOR ORBITAL

FISSURE ENLARGEMENT
It is large foramen, which connects orbit with the middle cranial
fossa.
Between greater and lesser wing of sphenoid bone approximately
22 mm long, comma-shaped.
Inferomedial portion is wider, superolateral portion-thinner. Right
muscle origin divides into superior and inferior parts.
 Head, Neck and Spine 719
Sup. division—LFT [Lacrimal, frontal, trochlear] nerves.
Inf. division—Superior and inferior div. of CN III
V, Cranial nerve and nasociliary branch
Inferior and superior ophthalmic vein
Sympathetic nerve plexus
SOF is directed towards the cavernous sinus and a small amount
of fat protrudes through the SOF into the region of anterior
cavernous sinuses.

Causes
A. Congenital/Developmental
– Neurofibromatosis
– Hypoaplasia of Greater Wing (GW) of sphenoid
– Spheno-orbital encephalocele
– Orbital cysts Enterogenous cyst
Congenital
– Dermoid/teratoma
– MFD (mandibular-fascial dysostosis)
B. Infective
Tolosa Hunt syndrome/ophthalmoplegia
C. Trauma
D. Vascular causes
– Aneurysm
– AVM/CCF
– CST (cavernous sinus thrombosis)
E. Neoplasm
Extraorbital—Neurogenic tumor
Orbital—lymphoma
Capillary hemangiomas
– Parasellar chordoma
– Meningioma
– Juvenile angiofibroma
– Metastasis.
A. Neurofibromatosis-Phakomatoses
NF-1-AD—Ch. 17
NF-2-AD—Ch. 22
Skull and dural lesions are common in NF 1
720 Differential Diagnosis in Radiology
• Hypoplasia of GW of sphenoid with spheno-orbital
Encephalocele temporal lobe herniation
Proptosis (often pulsatile).

Bare Orbit Sign

• Calvarial defect due to lambdoid suture
• Dural ectasia
• Enlargement of IOC
• Plexiform neurofibromas—hallmark of NF and 1/3rd of all
patients with NF 1.
Multiple tortuous wormlike masses that arise along the axis of
a muscle or nerve.
V1 Most common site in head and neck.
• Enterogenous cysts—Rare, congenital. Cyst lined by single layer
of epithelial cells.
Cyst may be seen in anterior cranial fossa and orbit.
CT—Homogenous, well-circumscribed, hyperdense lobular,
non-enhancing.
Extension through SOF may be seen.
MR — hyper on T1
variable on T2.

Dermoid/Teratoma
Dermoid and epidermoid—among the most common orbital
tumors of childhood.
Most frequent location—superior and temporal aspects.
Although congenital, but may appear in 2/3rd disease.
Both have fibrous capsule.
CT—Well-circumscribed lesion with decreased diameter; larger
one can extend through SOF.
Dermoid Epidermoid
Calcification +ve characteristic No Ca++
signal of fat present +ve – ve
Fat-fluid level
 Head, Neck and Spine 721
MR—Decreased signal on T1 and increased on T2/FLAIR/DW.
Teratoma—Rare congenital germ cell tumor having all three
elements.
No bony invasion, but causes orbital enlargement.

Congenital Cystic Eye

Present as complex cyst occupying the orbit. CT and MR—Enlarged
orbit containing a rounded/ovoid septated cyst. Ipsilateral SOF
increased.
MR—SI of the cyst is the same as that of the normal vitreous.
A. Rudimentary connection to a thinned opposite nerve
• Primitive ectopic lens
• In colrobomatous orbital cyst—globe and optic nerve are seen
on CT and MR
• MFD—orbital defect.
Due to developmental defect affecting 1st and 2nd branchial
arches.
Maxilla and molar bones are poorly developed
Downward slopping floor of orbit
CT—Defective lateral orbital floor.
GW of sphenoid may be hypoplastic.
B. Infective
• Tolosa Hunt syndrome: Painful external ophthalmoplegia
unilateral (U/L) immediate relief following steroid treatment
Imaging—occlusion of the superior ophthalmic vein on
affected side with partial/complete obliteration of ipsilateral
cavernous sinus
• Carotid angiography/MRA—in excluding the aneurysm as a
cause of syndrome.
C. Trauma
GW of sphenoid bone—is a thinner bone—offers least
resistance to fracture.
• Neural foramina—represents weak points in the bones and
nerve within the foramen may be crushed, contused or
lacerated.
722 Differential Diagnosis in Radiology
Severe trauma can result in SOF syndrome including a
dilated pupil, ptosis with sometimes extraocular muscle
dysfunctioning.
D. Vascular
1. Aneurysm of the intracavernous part of the ICA.
– Spontaneous
– Postsurgical (pseudo)
– Sphenoid sinus infected—especially fungal, can extend
into the cavernous sinus
– Large aneurysm 1. Widening of SOF—may erode into
the floor of middle cranial fossa.
2. Pressure in nerves of cavernous sinus cause—ophthalmo-
plegia.
3. Can rupture into the sp. sinus or SA space → erosion of ant.
clinoid process.
MRA/CA—can be helpful in diagnosis.

AVM/CCF
Arteriovenous shunts in orbit are rare.
CCF-proptosis, chemosis, venous engorgement, pulsatile
exophthalmos and an auscultable bruit.
CT/MR = Proptosis
Engorgement of SOV
Increase of ipsilateral EOM.
CST (Cavernous sinus thrombosis)—arises from an infection in
an area having venous drainage to the CS.
Source of infection
CST may develop from a septic thrombophlebitis arising in the
ophthalmic vein.
Proptosis and ophthalmoplegia, meningitis, B/L CN palsies.
Thrombosed CS—Decreased attenuation non-enhancing
lateral border bow laterally.
Carotid artery within the cavernous sinus.
SOV—Markedly enlarged and often thrombosed.
MR—Enlarged vein that appears less hyperintense than the
vein on normal side.
 Head, Neck and Spine 723
CST—Causes—Engorgement of cavernous sinus and
ophthalmic veins and enlargement of EOM.

NEOPLASM
Orbital Tumors
Capillary Hemangioma
Occur in infants, during the first year of life. Increases in size for
6–10 months and through them gradually involutes may extend.
CT—poorly to well-marginated, irregular, enhancing lesions.
• Most are extraconal
Dynamic CT—intense homogenous enhancement
MR—hypointense on T1 and hyperintense on T2WI.

Lymphoma
Seventy-five percent of orbital lymphoma will have systemic
lymphoma.
• Seen in adults
• CT/MR—Homogenous areas of high density, having a sharp
margin seen either in the anterior portion of orbit, retrobulbar
area or superior orbital compartment
• Extension of extracranial tumor
• Neurogenic tumor
Schwannoma (nerve sheath tumor) arise from nerve sheath. The
nerve most commonly affected in the central skull base is the
trigeminal nerve.
Tumor can extend through the SOF into the orbit.
CT—obliteration of fat of SOF—if small.
Expanded foramen with smooth margin, if large.
Enhances after contrast administration.
Similarly neurofibroma can affect the mass.
• Parasellar chordoma arising from embryonic notochord, at any
age between 30 and 50 years
• (Male > Female)
724 Differential Diagnosis in Radiology
• CT—bone destruction as well as soft tissue mass.
Radiodense—present—represents remaining fragment of
bones.
ST—Enhances
MR—T1W wt-Soft Tissue mass—hypo- to isocystic isointense
areas (hemorrhage/mucoid material)—increased signal on
T1WI, bony fragment signal void.
T2 = High SI.

Meningioma
Can arise from any part of the sphenoid bone, from the initial site
of origin, the tumor extends along the dural surface.
Tumor grows into the orbit, causes widening of SOF—patient
presents with proptosis.
On CT—Enhancement of the soft tissue component of tumor.
Ca++ may be seen
Hyperostosis may be seen
Pneumosinus dilatans
MR—iso to brain parenchyma
GD-DTPA—Enhances homogenously
Dural tail.

Nasopharyngeal Angiofibroma—Benign Tumor

Arising adjacent to sphenopalatine foramen
• Adolescent male boy
• Nasal obstruction/epistaxis.
• Very vascular.
CT/MR
Enhances intensively
MR = T1 = Intermediate SI, high SI on T2.
 Head, Neck and Spine 725
Metastasis
Direct Encroachment
Perineural spread: Tumor can selectively follow a nerve or the
sheath of a nerve to reach and ultimately pass through a foramen.
• Adenoid cystic Ca.
Lymphoma
Melanoma
SCC
• Trigeminal nerve and its branches travel from the brain-stem
to many areas of the face, sinus and oral cavity. This nerve is
primary route for peripheral spread of tumor of head and neck
• Perineural spread along vein rare but lacrimal gland and skin
malignancy can extend along with nerve through SOF
– Enlargement of nerve and foramen
• Effacement/obliteration of the fat plane
• Enhancement of a normal-sized nerve on a Gd. enhancement
suggestive of tumor spread
Hematogenous metastases—lung, bronchus, kidney, prostate
usually causes lytic destruction.
If GW of sphenoid is affected—metastasis tends to grow in all
directions.

8.20  TEMPORAL BONE SCLEROSIS

• Otospongiosa/otosclerosis
• Fibrous dysplasia
• Paget’s disease
• Osteogenesis imperfecta
• Osteopetrosis
• Progressive diaphyseal dysplasia
• Endosteal hyperostosis
• Osteopathia striata
• Ossifying fibroma
• Meningioma
726 Differential Diagnosis in Radiology
• Metastasis
• Inflammatory lesion-chorionic mastoiditis
• Hyperparathyroidism
• Labyrinthine ossification.

D/D Temporal Bone Sclerosis

• Otosclerosis/otospongiosa
Disorder of bony labyrinth—stapes.
Adult male, peak is 2nd–3rd decades
B/L in 80% cases
• Tinnitus and hearing loss (conductive).

Pathology
Type: Fenestral or retrofenestral (cochlear)
Fenestral: Progressive connective hearing loss.
Normal tympanic membrane, no evidence of middle ear
inflammation.
HRCT = Early—small, diemineralized focus anterior to oval
window—protrudes slightly into the middle ear cavity.
• Narrowing of the oval window, thickening of the posterior
piece of the stapes, small decreased density lesion in the lateral
wall of the labyrinth.

Cochlear
Combined sensory nerve and conductive hearing loss.
CT = Demineralization of cochlear capsule and area just anterior to
the oval window—B/L symmetrical.
• ‘Double ring’ or 4th turn sign—low density demineralized
endochondral defect around the cochlea.
• Chronic/sclerotic phase—these lesions can undergo reminer-
alization and become indistinguishable from the normal dense
cochlear capsule.
MR—Both T1 and T2—very subtle signal changes in
demineralized cochlear capsule.
 Head, Neck and Spine 727
Fibrous Dysplasia
• Unknown etiology. Females more than males in the ratio of 2:1
• Pathologically: It basically involves the cancellous bone
• Mono-ostotic—at puberty
• Oligo-ostotic
• Polyostotic—Unilateral—May be seen beyond the 3rd or 4th
decade.
R/F—pagetoid—Most common >30 years—bony expansion,
area of opacity and lucency, sclerotic—temporal bone, younger,
expansile, ground glass appearance.
Cystic—younger, cystic lesion with sclerotic border.
Present as conductive hearing loss, increased size of temporal
bone, obstruction of external auditory canal, etc.
CT—Increase in bone thickness and density.
Loss of trabecular pattern.
Obliteration of the mastoid air cells and external auditory canal,
cochlear capsule may be involved.
MR—low to intermediate signal on both T1 and T2WI images
moderate to marked enhancement.

Paget’s Disease
Chronic inflammatory disorder that results in the eventual
replacement of normal bone by thickened less dense weaker bone.
> 40 years
Temporal bone—most often B/L.
Petrous pyramid, external auditory canal, middle ear, otic
capsule ossicles are rarely involved.
+– Hearing impairment—conductive or sensory nerve or mixed.
HRCT—Decreased density of bone areas may show mixed
appearance of bone thickening and sclerosis.
Mastoid process—Bone thickening, demineralization or a
mosaic pattern.
MR = Variable, T1 = decreased signal intensity.
Heterogenous high signal primary hemorrhage.
728 Differential Diagnosis in Radiology

Osteogenesis Imperfecta
(van der Hoeve’s Syndrome)
Genetic disorder of connective tissue caused by an error in type I
collagen formation.
– CT of temporal bone—proliferation of under-mineralized,
thickened bone around the otic capsule.
– Narrowing of middle ear cavity, obstruction of windows, facial
canal narrowing.
– Demineralization is much more extensive; D/D—cochlear
ossification.

Osteopetrosis
Defect in the mechanism of bone remodeling.
– Generalized increase in bone density.
– Temporal bone CT.
– Increased density of petrous pyramid and mastoid bone, lack of
pneumatization of mastoid air cells.
– IOC shortened and trumpet-shaped, ossicles may be thickened
and enlarged.

Progressive Diaphyseal Dysplasia

Rare, autosomal dominant.
Diagnosed in childhood.
CT—middle ear may be completely encased by sclerotic bone
with widespread neural foramen narrowing.

Endosteal Hyperostosis
Van Buchem’s Disease: Autosomal Recessive
Temporal bone shows a marked increase in overall size
Extensive sclerosis
Narrowing of EOC and IOC
Osteopathia striata (Voorhoeve’s syndrome)—Autosomal dominant
generalized temporal bone sclerosis.
 Head, Neck and Spine 729
Meningioma—Most meningioma arise outside the middle ear
from the meninges covering the posterior petrous bone. Some
meningioma may subsequently invade the temporal bone.
C-P angle < meningioma—can cause temporal bone sclerosis.
CT—Semicircular dural base lesion
Partially calcified and usually enhances, hyperostosis of posterior
margin of temporal bone is different but air space changes are
very sensitive.
MRI—Isointense to brain (gray matter).

Metastasis
Temporal bone is susceptible to any neoplasm that typically
metastasizes to bone.

Fig. 8.9:  Lateral oblique radiograph of mastoid shows

chronic mastoiditis with cholesteatoma
730 Differential Diagnosis in Radiology
Tumor of breast, lung, stomach, prostate, kidney.
Prostatic and stomach tumors—cause osteoblastic metastasis.
CECT = Enhancement.

Chronic Mastoiditis and CSOM (Fig. 8.9)

Following repeated bouts of osteomyelitis and accompanying
mastoid infection.
Gradual reduction in the number of mastoid aircells with
thickening of mastoid and reactive sclerosis of the bony septa.
Labyrinthine ossification: Ossification of the membranous
labyrinth may occur as a result of a previous inflammatory process,
trauma and surgery such as labyrinthectomy.
Ossification may be localized and limited to the basilar turn of
cochlear or round window niche.

8.21  IV DISC SPACE CALCIFICATION

1. Degenerative spondylosis.
Seen in nucleus pulposus.
Confined to dorsal region.
Other signs of degenerative spondylosis
– Disk space narrowing
– Osteophytosis
– Vacuum sign.
2. Alkaptonuria
Onset of arthropathy—4th decade.
– Osteophytosis.
– Disk space narrowing.
– Osteoporosis.
Calcification is in the inner fibers of annulus fibrosus. Severe
changes progress to ankylosis.
3. CPPD
Calcification seen in outer fibers of annulus fibrosus. Associated
conditions:
– Hyperparathyroidism.
– Hemoachromatosis, gout, Wilson’s disease.
– Osteophyte formation.
 Head, Neck and Spine 731
4. Ankylosing spondylitis
– Calcification in outer fibers of annulus fibrosus.
– Square vertebral bodies.
– Syndesmophytes formation.
– Ankylosis.
5. Juvenile chronic arthritis may mimic anykylosing spondylitis.
6. DISH (Diffuse idiopathic skeletal hyperostosis).
– Elderly male.
Common location—Cervical spine.
Anterior flowing osteophytes involving > 4 contiguous vertebrae.
7. Gout
May show IVD calcification
Predilection of joints of lower extremity, especially 1st metatar-
sophalangeal joints.
8. Idiopathic—Seen in children.
Cervical spine—Most often affected, may be asymptomatic or
associated with fever/neck pain persistent in adults.
9. Following spinal fusion.

8.22  IVORY VERTEBRAL BODY

Single or Multiple Very Dense Vertebrae

1. Lymphoma
2. Osteopetrosis
3. Osteoblastic metastasis
4. Paget’s disease
5. Low grade infection
6. Hemangioma
7. Trauma
8. Fluorosis
9. Myelosclerosis
10. Sickle cell disease.
1. Lymphoma—MC is HD (Hodgkin’s disease).
– Normal size vertebral body.
– Disk space intact.
732 Differential Diagnosis in Radiology
– Mediastinal, retroperitoneal RP and mesenteric lymphad-
enopathy.
2. Osteopetrosis
Defective osteoclast function with failure of proper reabsorption.
– Rugger-jersey spine—Sclerosis of both end plates of
vertebra or sandwich spine.
– Diffuse osteosclerosis.
3. Osteoblastic metastasis
– Usually primary sites are prostate, stomach and carcinoid.
– Initial lytic metastasis which after treatment has become
sclerotic.
– Normal vertebral body size.
– IVD space preserved until late.
4. Paget’s disease
– Usually a single vertebral body is affected.
– Expanded vertebral body with a thickened cortex and
coarsened trabeculations.
– IVD space normal.
5. Low grade infection
– End plate destruction.
– IVD space narrowing.
– Paraspinal soft tissue mass.
6. Hemangioma
– Sclerosis is accompanied by coarsened trabecular pattern
with prominent vertical striation.
– Expansion may or may not be there.
– IVD space—normal.
7. Trauma
With H/O trauma.
– Vertebral height is usually decreased with anterior wedging.
– IVD space—normal.
8. Fluorosis: Due to chronic fluoride poisoning.
– Generalized increase in bone density.
– Characteristic feature is calcification in the inter-rosseous
membrane.
– Thorn spine.
 Head, Neck and Spine 733
9. Myelosclerosis
Hematologic disorder of unknown etiology with gradual
replacement of bone marrow elements by fibrosis.
– > 50 years.
– Lumbar spine—most common spine to be involved.
– Rugger-jersey spine.
– Diffuse increase in density in almost all bones.
10. Sickle cell disorder
– Hematological disorder.
– Biconcarve vertebral due to depression of the central
portion of the vertebral end plate and ‘H’ shaped vertebrae.
– Due to infarction of vertebral body.

8.23  ATLANTOAXIAL SUBLUXATION

When the distance between the posterior aspect of anterior arch
of atlas and anterior aspect of the odontoid process exceed 3 mm
in adults and older children or 5 mm in younger children.

Causes
1. Trauma
– Usually associated with odontoid fracture.
2. Congenital
Occipitalization of atlas—fusion of basion and anterior arch of
atlas.
– Congenital insufficiency of transverse ligament.
– OS odontoideum/aplasia of dens.
– Down’s syndrome.
– Morquio’s syndrome
– Bone dysplasia.
3. Arthritis
Due to laxity of transverse ligament or erosion of dens.
– Rh. arthritis—associated erosion of odontoid.
– Psoriasis.
– Reiter’s syndrome
– AS—usually a late feature.
734 Differential Diagnosis in Radiology
4. Inflammatory process
Pharyngeal infection in childhood, retropharyngeal abscess,
coryza, otitis media, etc.
– Destruction occurs after 8–10 days of onset of symptoms.

8.24  POSTERIOR SCALLOPING OF

VERTEBRAL BODY (FIG. 8.10)
1. Tumors in the spinal canal.
Ependymoma—most common
Dermoid, lipoma/neurofibroma and less commonly menin-
gioma. These lesions cause raised intraspinal pressure which
leads to scalloping of vertebral body.
– Ependymoma—Usually site is lower spinal cord, conus
medullaris well demarcated/diffusely infiltrating tumor.
– Local mass with extensive areas of cystic degenerates,
hemorrhagic and Ca++ calcification.
2. Chronic-hydrocephalus (Communicating—also known as ex-
traventricular hydrocephalus.
R/F = symmetric enlargement of lateral 3rd and 4th ventricles.
– Dilatation of subarachnoid cisterns.
– Normal or effaced.
– Transependymal flow of CSF.
3. Neurofibromatosis—Scalloping is due to mesodermal dysplasia
and is associated with dural ectasia.
There may be enlargement of an intervertebral foramen and
flattening of one pedicle—‘Dumb-bell’ tumor.
4. Acromegaly
– Increased AP transverse diameter of vertebral body.
– Osteoporosis
– Spur formation
– Calcified discs
– Increased heel pad thickness, prognathism, spade-like
fingers.
 Head, Neck and Spine 735

Fig. 8.10: Posterior scalloping of vertebral bodies

5. Achondroplasia
– Spinal stenosis
– Anterior vertebral body peaks in upper lumbar spine, wide
intervertebral foramen.
– Lumbar angulation kyphosis + sacral lordosis.
6. Mucopolysaccharidoses
In Hurler and Hunter disease
In Hurler = Dorsolumbar kyphosis with lumbar gibbus
Anterior-beak at T12/L1/L2
Long slender pedicle
– Spatulated rib configuration
7. Morquio’s syndrome
– Hypoplasia/absence of odontoid process of C1-C2
instability with anterior subluxation.
– Platyspondyly
736 Differential Diagnosis in Radiology
– Ovoid vertebral body with central anterior beak at lower
thoracic and upper lumbar vertebrae.
– Widened intervertebral (I/V) disk spaces.
• Osteogenesis imperfecta
– Biconcave vertebral body.
Schmorl’s nodes.
Increased height of I/V disk space.
• Marfan’s syndrome.

8.25  ANTERIOR SCALLOPING OF

VERTEBRAL BODIES (FIG. 8.12)
1. Aortic aneurysm
– IVD space remains intact.
– Well-defined anterior vertebral margin.
– Calcification may or may not be seen.
– Usually seen in elderly patients M:F = 5:1.
– Widening of aorta; twice the size of normal aorta.

A B C D
Figs 8.11A to D: AP and lateral radiographs of spine show tubercular
spondylitis in varying stages; (A and B) early stage [end plate with discal
involvement and paravertebral collection], (C) intermediate stage [stage of
sclerosis with collapse], and (D) late stage [sclerosis with vertebral fusion]
 Head, Neck and Spine 737
2. Tubercular spondylitis (Figs 8.11A to D)
– Marginal erosion of effected vertebral bodies.
– Ivory vertebrae—Reossification as healing response to
osteonecrosis.
– IVD space destruction.
– Widening of paraspinal soft tissue mass.
– Calcification may or may not be seen.
– Usually seen is in children and adults.
– Dorsolumbar region is the most common to be involved.
Multiple contiguous involvement of multiple vertebral
segments.
– Angular kyphotic deformity in adults.
3. Lymphadenopathy
– Pressure resorption of bones results in a well-defined
anterior vertebral body margin unless there is a malignant
infiltration of bones.
– IVD space maintained.

Fig. 8.12: Anterior scalloping of vertebral bodies

738 Differential Diagnosis in Radiology
4. Delayed motor development
(Down’s syndrome)
Also k/a Mongolism – Trisomy-21.
– Atlantoaxial subluxation.
– ‘Squared vertebral bodies’ – Center high and narrow.
– Positive lateral lumbar index – (ratio of horizontal to vertical
diameter of L2).

8.26  ANTERIOR VERTEBRAL BODY BEAKS

Central Lower 1/3rd

Diagram—involves 1–3 vertebral bodies at the dorsolumbar
junction and usually associated with kyphosis.
Hypotonia is probably the factor which leads to an exaggerated
dorsolumbar kyphosis, anterior herniation of the nucleus pulposus
and subsequently an anterior vertebral body defect.
• Central beaking
1. Morquio’s syndrome
2. Psuedoachondroplasia.
• Lower 1/3rd
1. Hurler’s syndrome
2. Achondroplasia
3. Cretinism
4. Down’s syndrome
5. Neuromuscular disorder.
1. MPS
Morquio’s—central beaking at dorsolumbar vertebral body.
Hypoplasia/absence of odontoid process.
C1-C2 instability with anterior subluxation.
Platyspondyly.
Widened IVD space.
 Head, Neck and Spine 739
Hurler Syndrome
Beaking in lower 1/3rd of vertebral body
Anterior beaking at T12 /L1/L2
Long slender pedicle
IVD space—N
Spatulated rib configuration.

Achondroplasia
Beaking in the lower part of lumbar vertebral bodies, spinal
stenosis.
Wide intervertebral foramen.
Lumbar angular kyphosis + sacral lordosis.
Psuedochandroplasia.
Cretinism or hypothyroidism
• Demineralization
• Dense vertebral margins
• Delayed skeletal maturation
• Fragmented, stippled ossification
• Wide sinuses/fontanelles with delayed closure.

Down’s Syndrome
– Trisomy 21
– Atlantoaxial subluxation
– Squared vertebral bodies
– Positive lateral lumbar index (ratio of horizontal to vertical
diameter of L2)
– IVD space N.

8.27  BLOCK VERTEBRA (FIG. 8.13)

• Congenital
• Kippel-Feil syndrome
• Rheumatoid arthritis
• Ankylosing spondylitis
740 Differential Diagnosis in Radiology

Fig. 8.13:  Lateral radiograph of spine showing L4/L5 block vertebrae

• Tuberculosis
• Operative fusion
• Post-traumatic
Congenital
1.
– Segmentation failure.
– Most common site—lumbar and cervical spine.
– The ring epiphysis of adjacent vertebrae do not develop
and thus the AP diameter of the vertebrae at the site of the
segmentation defect is decreased.
– Anterior concavity.
– The articular facet, neural arches or spinous process may
also be involved.
– A faint lucency can be seen, sometimes representing
vestigeal disk.
 Head, Neck and Spine 741
2. Kippel-Feil syndrome
– Segmentation defect in cervical spine.
– Feil’s triad – low hairline
short neck
limited cervical movement.
– C2-C3 and C5-C6 are most commonly involved.
– Scoliosis >20 in >50% of patients.
– Sprengel’s shoulder–30%.
+/– omovertebral body.
– Cervical ribs.
– Facial asymmetry.
– Genitourinary abnormality—66%.
– Renal agenesis in 33%.
– Deafness in 33%.
3. Rheumatoid arthritis
Especially juvenile chronic arthritis, juvenile onset rheumatoid
arthritis.
– Angulation at fusion site.
– Posterior elements usually do not fuse.
4. Ankylosing spondylitis
Middle-aged patients
– Squaring of vertebral body because of fusion of anterior
concavity of vertebral body.
– Calcification in IVD space and ant. and postlong-ligament.
– Syndesmophyte formation—extending from one vertebral
margin to another.
5. Tuberculosis
– Usually affects young patients.
– Vertebral body collapse.
– Destruction of IVD space.
– Paraspinal soft tissue mass.
– Paraspinal calcification
– May be angulation of spine.
6. Postoperative fusion
H/O operation.
7. Post-traumatic.
742 Differential Diagnosis in Radiology

8.28 ENLARGED VERTEBRAL BODY

Generalized
1. Gigantism
2. Acromegaly.

Local—Single or Multiple
1. Paget’s disease.
2. Benign bone tumor.
a. ABC
b. Hemangioma
c. GCT.
3. Hydatid
Gigantism—Excess of growth hormone before skeletal maturity
results in gigantism.
Acromegaly—Results from excessive GH production by an
eosinophilic adenoma after skeletal maturity.
– Enlargement of spine or vertebral bodies with characteristic
posterior scalloping.
Other characteristic features are:
• Enlarged mastoid air cells and sinuses.
• Pituitary fossa enlargement.
• Spade-like fingers.
• Increased thickness of heel pad.
Paget’s disease—Especially involves the lumbar spine. Age >40 years.
• Enlargement and coarsened trabeculae.
• Cortical thickening producing picture framing.
• Can also involve the appendages and neural arch.

ABC
Age = 10–30 years.
• Usually lytic and expansile lesion but cortex intact
• Involves both the anterior and posterior elements, more
commonly shows rapid growth
 Head, Neck and Spine 743
• Thin internal strands of bone.
• Hemangioma
– Most common benign tumor of vertebral body.
Age—10–50 years.
Site—dorsal or lumbar.
Usually affects the vertebral body, but rarely involves the
posterior elements.
Prominent primary trabeculae with lytic vertebral body—
’Accordion sign’.

GCT
Involvement of the body alone is most common. Expansion is
minimal.

Hydatid
Over 40% of cases of hydatid disease in bones occur in vertebra.
• Thoracic region is most common site
• Disease tends to involve adjacent vertebrae and ribs and to
spare the I/V disks
• Cysts cause bubble-like round or lobulated circumscribed lytic
lesions in the bones with virtually no sclerotic reaction
• Adjacent soft tissue mass which tends to be extensive and
causes extradural compression.

8.29  SOLITARY COLLAPSED VERTEBRA

D/D
1. Langerhans’ cell histiocytosis
2. Neoplastic disease
Malignancy
– Metastasis
– Multiple myeloma/plasmoacytoma
– Lymphoma
Benign
– Hemangioma
744 Differential Diagnosis in Radiology
– GCT
– ABC
3. Osteoporosis
4. Trauma
5. Infection
6. Paget’s disease.

Langerhans’ Cell Histiocytosis

Eosinophilic granuloma is the most frequent cause of a solitary
vertebral plana in childhood.
• Vertebral plana is osteochondritis of vertebral body causes
increased density and collapse of vertebral body
• Adjacent disc spaces are normal or increased
• Posterior elements are usually spared
• Neoplastic disease.

Benign
Hemangioma
Most common benign tumor of spine.
Age = 10–45 years.
Site—Lumbar spine is the most common site.
Fifty percent only in the vertebral body and half may extend into
the post-element.
Size of vertebral body—Normal.
Soft tissue mass is seen in small number of patients.
R/F—Increased translucency with a characteristic fine vertical
striation.
GCT—Rarely seen in spine.
Age = 20–40 years (Mature skeleton)
R/F—A zone of radiolucency without evidence of calcification or
new bone formation.
Site = Neural arch is more commonly involved than body.
Age = 10–20 years in immature skeleton.
R/F = Area of bone resorption with slight or marked expansion.
 Head, Neck and Spine 745
Malignant Lesion
Metastasis
Breast, bronchus, prostate, kidney and thyroid account for the
majority of patients with a solitary spine metastasis.
• Focal areas of bone destruction.
• Disc spaces are preserved until late.
• Destruction of pedicle = +
• The bone may be lytic, sclerotic or mixed.

Multiple Myeloma/Plasmacytoma
• Common site for plasmacytoma
• Age = Elderly
• Osteopenia with discrete lucencies—The lucencies are usually
widely disseminated at the time of diagnosis—seen in spine,
pelvis, skull, ribs and shafts of long bones uniform in size and
are well-defined
• Vertebral body collapse occasionally with disk destruction
paravertebral shadows may or may not be seen
• Involvement of pedicle is late
Normal alkaline phosphatase level.
– Osteoporosis
Usually seen in older population.
– Generalized osteopenia.
– Coarse trabecular pattern due to resorption of secondary
trabeculae.
– Preserved I/V disk space.
3. Trauma
– IV disk spaces are usually preserved.
4. Infection
Destruction of vertebral end plates and adjacent disk spaces.
Collapse is usually accompanied by soft tissue mass.
Blurring or displacement of psoas shadows.
746 Differential Diagnosis in Radiology
5. Eosinophilic granuloma
Most common cause of a solitary vertebral plana in childhood.
Adjacent disc spaces are usually normal or increase in height.
Post elements are usually spared.
6. Paget’s disease
– Neural arch is affected in most cases, sclerosis and
expansion is seen.
– Width of body increases. Increase in interpedicular
distance. Characteristic finding of picture framing is seen
due to thickened vertebral end plates.
Collapse is common and may cause spinal nerve compression.
Vertebral enlargement distinguishes this from osteoporotic or
malignant disease.

8.30  MULTIPLE COLLAPSED VERTEBRAE

1. Osteoporosis
2. Neoplastic disease
3. Trauma
4. Scheuermann’s disease
5. Infection
6. Langerhans’ cell histiocytosis
7. Sickle cell anemia.

Osteoporosis
Decrease in bone mass
Trabeculae loss → Pencilling of vertebral bodies by the more
radiographically dense plates.
Biconcave vertebral bodies (codfish vertebrae).

Neoplastic Disease
Usually wedge fractures are seen.
Seen in osteolytic metastasis and osteolytic marrow tumors, e.g.
multiple myeloma, leukemia and lymphoma.
R/F = Altered or obliterated normal trabeculae.
 Head, Neck and Spine 747
Disc spaces are usually preserved till late.
Paravertebral soft tissue mass is more common.

Trauma
• H/O of trauma, usually lower cervical, lower dorsal or upper
lumbar
• Discontinuity trabeculae
• Sclerosis of fracture line due to compressed and overlapped
trabeculae
• Disc spaces are preserved
• Usually without soft tissue mass.

Infection
• Usually starts anteriorly beneath the end plates
• Extends beneath the anterior longitudinal ligament or into the
disc which is rapidly destroyed and loses height
• Vertebral destruction in the body above or below
• In most cases, two vertebral bodies are involved
• Collapse of vertebral body is usually accompanied by soft tissue
masses
• Blurring or displacement of psoas shadows
• Kyphosis and cord compression may also be seen
• Radiologically it is not possible to differentiate between
pyogenic and tubercular but few signs are said to be helpful.
Pyogenic is rapidly progressive while tuberculosis is slow
in progress. Pyogenic infection shows marked osteoblastic
response and tuberculosis is usually associated with large para-
vertebral abscess.
• Scheurmann’s disease (Fig. 8.14)
– Age—onset at puberty.
– Location—LT or UL (Lower thoracic or upper lumbar)
R/F= Ant. wedging of vertebral body of >5.
Increased AP diameter of vertebral body.
Slight narrowing of I/V disc space.
Schmorl’s nodes—up to 30% of cases.
End plate irregularity.
748 Differential Diagnosis in Radiology

Fig. 8.14:  Lateral radiograph of spine showing Scheurmann’s disease

Infection
Both tubercular and pyogenic can cause collapse of vertebrae.
• In Indian setting, tuberculosis is more common than pyogenic
• R/F = Destruction of end plates adjacent to a destroyed discs
Paravertebral soft tissue abscess with or without calcification.

Langerhans’ Cell Histiocytosis

Most common site is thoracic.
• Disc spaces preserved
• Rare involvement of posterior elements
• No kyphosis.
 Head, Neck and Spine 749
Sickle Cell Anemia
Characteristic step-like depression in the central part of the end
plate.

8.31  INTRASPINAL MASSES

Can be classified into three categories:
1. Extradural masses (Fig. 8.16)
2. Intradural extramedullary (Fig. 8.17)
3. Intramedullary masses (Fig. 8.18)

I. Extradural Masses
1. Prolapsed or sequestered IVD
Occur at all levels—Most common L4-L5, L5-S1 in cervical
spine—C6-C7 is most common.
Usually extradural but occasionally penetrates dura, especially
in thoracic region.
– NECT = soft tissue mass with effacement of the epidural fat
and displacement of the thecal sac.
– MR—will delineate the extent of herniated nucleus
pulposus.
2. Metastasis
Myeloma and lymphoma deposits are common.
– Associated vertebral infiltration.
– Destruction in body or neural arch may lead to collapse.
– Paravertebral mass.
– E/O primary tumor.
3. Neurofibroma (Fig. 8.15)
Solitary or multiple in neurofibromatosis.
Lateral indentation of theca at the level of the intervertebral
foramen.
– Enlarged neural foramina (Fig. 8.15).
750 Differential Diagnosis in Radiology

Fig. 8.15:  Oblique radiograph of spine showing enlarged

neural foramina in neurofibroma

4. Tumors
Hemangioma—Most common benign tumor of vertebral body.
Focal or diffuse.
Lytic lesion with prominent vertical striation.
Neuroblastoma or ganglioneuroma
– Common in pediatric population.
– Arising from sympathetic chain in paraspinal location.
Meningioma
In 85% cases, they are intradural.
15%—Extradural.
Sex = F > M, middle-aged.
Site = Thoracic spine.
 Head, Neck and Spine 751

Fig. 8.16: Imaging features of an extradural mass—The dura (small ar-

row) and spinal cord (large arrows) are displaced

5. Hematoma—May be due to trauma, dural AVM.

Anticoagulant therapy
CT and MRI show signal characteristic of blood on MR—
hyperintense on both T1 and T2WI images.
6. Abscess—Epidural abscess
Secondary to disc or vertebral sepsis, long segment extradural
mass with marginal enhancement (usually involves > 6
vertebrae).
Plain film—Osteomyelitis disc space narrowing. Myelogram, CT
myelogram—extradural soft tissue mass.
MR = Extradural soft tissue mass iso- to hypointense on T1
hyperintense on T2WI
CEMR = Diffuse homogenous or slightly heterogenous
enhancement is seen in 70% cases—phlegmonous stage or
752 Differential Diagnosis in Radiology

Fig. 8.17: Imaging findings of an extramedullary intradural mass—Mass

displaces the spinal cord and enlarges the lateral subarachnoid space. A
sharp crescenteric interface formed between mass and contrast column

thick/thin enhancing rim that surrounds a liquefied low signal

pus collection.
7. Extradural arachnoid cysts
Are CSF fluid outpouchings of arachnoid that protrude through
a dural defect.
2/3rd in lower thoracic spine.
– Long segment CSF density extradural mass.
– Widening of interpedicular distance.
– Scalloping of vertebral bodies.
– Pedicle thinning, erosion.
 Head, Neck and Spine 753

Fig. 8.18: Imaging features of an intramedullary mass—shows diffuse

cord enlargement

II. Intradural Extramedullary Masses

The common intradural extramedullary masses are meningiomas
neuromas, ependymoma, metastasis and lipoma. The tumors
present either as extradural or as intramedullary masses.

III. Intramedullary Masses

A. Tumors
1. Ependymoma—Most common intramedullary tumor in adults.
Mean age = 43 years.
Location—conus medullaris and filum terminale
Plain film—wide canal or bone destruction.
Myelography—Non-specific cord widening multi­ segmental
lesion.
754 Differential Diagnosis in Radiology
CT = Non-specific canal widening.
Scalloped postvertebral body.
Enlarged neural foramina.
MR = iso to cord on T1 and hyper on T2
2. Astrocytoma—Low grade tumors.
Most common intramedullary tumor in children.
Cervical spine is most common site.
Multisegmental involvement is the rule.
Plain film – Widened interpedicular distance with mild
scoliosis.
NECT – Widened canal, multisegmental cord enlarge-
ment
MR – Iso or slightly hypo on T1W weight images
Hyperintense on T2W weight images
Enhances following contrast administration.
3. Hemangioblastoma
75% intramedullary.
50% occur in thoracic cord.
Imaging—Dilated tortuous feeding artery and veins.
MR = Diffuse cord expansion with high signal on T2 weight
images
Cyst formation or syrinx = 50–70% of cases.
4. Dermoid—Including lipoma, teratoma
Most common site—conus medullaris.
CT and MR signal—lipomatous tissue—decreased density
signal on CT, bright signal on T1WI.
Cystic space—Decreased density on CT, increased signal
intensity on T2.
Soft tissue—Intermediate density and signal on CT and T1WI
MRI.
May enhance after contrast administration.
5. Cysts
– Congenital and acquired hydrosyringomyelia.
– Inflammatory cysts.
– Hematomyelia.
MRI = With contrast enhancement, it is helpful in differentiating
these from cord neoplasm.
All cord neoplasms will enhance while cysts do not.
 Head, Neck and Spine 755
6. Hematoma/Contusion
on CT = Only E/O cord swelling.
MR = Blood signal—Increased on T1 and T2.
7. Myelitis/Cord edema
CT = Non-specific
MR = T1 = isointense, T2 = hyperintense.
8. Infarct—Expanding in acute phase.

8.32  DIFFERENTIAL DIAGNOSIS OF

POSTERIOR FOSSA CYSTS
• Dandy-Walker malformation
• Dandy-Walker variant
• Mega cisterna magna
• Posterior fossa arachnoid cyst
• Enterogenous cyst
• Inflammatory cyst
• Cystic neoplasm
• Dermoid
• Epidermoid.

Dandy-Walker Malformation
• Failure of development of the anterior medullary velum, atresia
of the 4th ventricle outlet foramina.

Skull and Dura

• Large posterior fossa
• High tentorial insertion (Lambdoid-torcular inversion)
• High transverse sinuses.

Ventricles and CSF Spaces

• Fourth ventricle open dorsally to large posterior fossa cyst
• Hydrocephalus in 80%.
756 Differential Diagnosis in Radiology

Cerebellum, Vermis and Brainstem

• Vermian and cerebellar hemispheres hypoplasia
• Vermian remnant anterosuperiorly everted above cyst
• Cerebellar hemispheres winged anterolaterally in front of cyst
• Brainstem may be hypoplastic, compressed
• Heterotopias, cerebellar dysplasias common.
Associated CNS anomalies
Corpus callosum agenesis in 20–25%
Heterotopias, gyral anomalies, schizencephaly
Cephaloceles.

Dandy-Walker Variant
• Mild vermian hypoplasia with a variably-sized cystic space
caused by open communication of the posterior fourth
ventricle and cisterna magna through an enlarged vallecula.
(Key-Hole deformity)
• 4th ventricle is often enlarged but the posterior fossa is typically
normal size
• The inferior vermian lobules are variably hypoplastic.

Mega Cisterna Magna

• A large cisterna magna is present and may extend above the
vermis to the straight sinus
• Occasionally, posterior fossa appears enlarged with scalloping
of occipital square
• An enlarged normal cisterna magna is easily opacified following
contrast instillation into the lumbar arachnoid space.

Arachnoid Cyst
• Benign, congenital, intra-arachnoidal, space occupying lesions
that are filled with CSF-like fluid
• Occur in all ages but 75% occur in children
• 50–65%—in mid-cranial fossa
 Head, Neck and Spine 757
5–10%—posterior fossa (cerebellopontine angle and cisterna
magna)
CT smoothly demarcated, noncalcified extra-axial mass that
does not enhance
• Unless hemorrhage occurs, arachnoid cysts are similar to CSF in
attenuation
• Pressure erosion of the adjacent calvarium can occur
• Cyst may displace vermis and 4th ventricle.

Enterogenous Cyst (Neurenteric Cyst)

• This is rare intraspinal mass and even less frequent intra-cranial
lesion
• Typically intradural extramedullary posterior fossa masses
• Cerebellopontine angle and craniocervical junction.
CT—well-defined, non-calcified, nonenhancing lobulated
mass and are typically hypodense compared to adjacent brain
parenchyma.
MR—Most lesions are iso- or mildly hyperintense compared
to CSF on T1 weight images and moderate hyperintense on
proton density and T2 weight images.

Pilocytic Astrocytoma
• 5–10% of all gliomas
• Children, young adults
• Located typically around 3rd and 4th ventricles
– Optic chiasm and hypothalamus—Most common
Cerebellar vermis/hemispheres—Next.
CT—Round or oval sharply demarcated and smoothly
marginated hypo-or isodense masses
• Calcification occurs in 10%
• Some lesions enhance homogenously and solidly others have a
small enhancing mural nodule in large cyst
• Wall does not show enhancement (non-neoplastic)
758 Differential Diagnosis in Radiology
• In some, the cyst fluid enhances, with dependent layering that
creates a contrast-fluid level, particularly if delayed scans are
obtained
• Hydrocephalus may occur relatively early and moderate. Severe
if in vermis.
MR: Hypo- or isointense on T1
Hyperintense on T2
Mural nodules and solid tumors enhance strongly but somewhat
inhomogenously.

8.33  ENLARGED OPTIC FORAMEN

• Normal size—4.4–6mm
• Increased size, if diameter >7 mm
• A difference of >1mm is diagnostic.

Concentric Enlargement
1. Optic nerve glioma.
2. Neurofibroma.
3. Extension of retinoblastoma.
4. Vascular—ophthalmic artery aneurysm, AV malformation.
5. Granuloma—very rarely in sarcoidosis or pseudotumor.

Local Defect
Roof
1. Adjacent neoplasm—meningioma, metastases, glioma.
2. Raised intracranial pressure—due to thinning of floor of
anterior cranial fossa.

Medial Wall
1. Adjacent neoplasm—carcinoma of ethmoid/sphenoid.
2. Sphenoid mucocele.
 Head, Neck and Spine 759
Optic Nerve Glioma
• Occur in children, most often in association with neurofibroma-
tosis-1
• Slow growing, non-aggressive with a benign course
• Fusiform enlargement of optic nerve
• Enhance after contrast administration with variable pattern.

Optic Nerve Sheath Meningioma

• Most common in middle-aged females
• Tubular appearance on CT and MR
• Enhance more than gliomas with ‘Railroad track’ appearance
• Calcific within mass/hyperostosis around optic canal may be
seen.

NF-1 (Neurofibromatosis-1)
• In addition to optic nerve glioma may have orbital flexiform
neurofibroma
• Orbital bone changes of sphenoid, dysplastic egg-shaped
enlargement of orbital rim, bony defects in posterior orbit,
AP enlargement of middle cranial fossa, enlargement of other
cranial foramina.

Retinoblastoma
• Most common intraocular tumor in children
• Presents in first two years of life
• High density areas arising from retina
• Calcification common, subretinal fluid on MR.

AV Malformation
• Isolated anomalies are rare, usually associated with intra-cranial
AV malformation
• Usually present with orbital congestion and proptosis
• Bright enhancement on CECT, serpiginous flow, void on MR.
760 Differential Diagnosis in Radiology

Orbital Pseudotumor
• Non-specific inflammation of orbital fissures involving
predominantly fissures behind the globe
• On CT, seen as area of soft tissue density with poorly-defined
margins
• MR with fat suppression, most sensitive to detect early changes
• If discrete mass—lymphoma must be considered.

Sarcoidosis
• Rarely involves orbit
• May mimic pseudotumor.

8.34  BARE ORBIT/HYPOPLASIA OF

GREATER WING OF SPHENOID (FIG. 8.19)

Causes
• Meningioma
• Optic glioma
• Relapsing hematoma
• Metastasis
• Aneurysm
• Retinoblastoma
• Idiopathic
• Neurofibromatosis
• Eosinophilic granuloma.

Meningioma
• Most common below 40–60 years of age in females
• Arises from arachnoid granulations. Extra-axial dural-based
mass
• Associated with neurofibromatosis
• Sites
 Head, Neck and Spine 761

Fig. 8.19: ‘Bare’ orbit

– 25% parasagittal
– 20% convexity
– 15 to 20% sphenoid ridge
– 5 to 10% olfactory grooves.
• Plain film
– Hyperostosis
– Erosion
– Enlarged vascular channel
– Tumor calcification
– Pneumosinus dilatans
CT: Enhancing hyperdense mass with areas of calcification and
cystic areas with peritumoral edema.
MR: Strongly enhancing typically isointense mass with grey matter.

Optic Glioma
• Usually a tumor of childhood (2–6 years)
• Presents with unilateral loss of vision and rapidly progresses to
bilateral blindness and death within 1 or 2 years
762 Differential Diagnosis in Radiology
• CT shown homogenously enhancing well-defined fusiform
enlargement of the optic nerve. It shows characteristic kicking
and buckling (sinusoid) appearance.
MRI: Enlarged fusiform and kicked optic nerve. T1 weighted
and proton weighted images, the optic glioma will appear
isointense or slightly hypointense compared to the white
matter.
On T2 weighted images, the lesion may show greater variability
in intensity. However, it may appear hyperintense compared to the
white matter.

Retinoblastoma
• Most common intraocular tumor of childhood
CT: Moderate to markedly enhancing mass with calcification
within it.
MRI: Slightly or moderately hyperintense in relation to normal
vitreous on T1 weighted or proton weighted MR images.
On T2 weighted images, they appear as areas of markedly to
moderately low signal intensity.

Neurofibromatosis
• Two types:
1. NF-1/von Recklinghausen’s disease/peripheral NF
chromosome no. 17.
2. NF-2/Central NF/B/L acoustic schwannoma, chromosome
no. 22.
• Autosomal dominant.
• Osseous dysplasia in particular bony orbit is associated with
von Recklinghausen’s disease
• Partial or complete absence of the greater or lesser wing of
the sphenoid; the body of the sphenoid bone may be involved
producing an abnormal and dysplastic sella turcica
• Herniation of the temporal lobe of the brain of pulsating
exophthalmos.
 Head, Neck and Spine 763
• Associated hypoplasia of frontal and maxillary sinuses as well
as of adjacent ethmoid air cells.

Eosinophilic Granuloma
• Children, especially boys below 3 and 12 years of life are most
commonly affected
• The skull, pelvis and femora are most commonly affected
• There are usually solitary lytic lesions in these areas
• Spine
– Thoracic spine is usually affected.
– Vertebra plana is usually present.

Metastasis
• Lung, breast, kidney, GIT are usually affected.

Aneurysm
• Large retro-orbital aneurysm can erode the bony structures at
the back of the orbit or adjacent to the sella
• Erosion of the inferolateral margin of the optic foramen is
characteristic
• An anterior clinoid process can also be eroded, as can the bone
adjacent to it or sella.

8.35  ORBITAL HYPEROSTOSIS

Causes
• Meningioma
• Sclerotic metastasis
• Fibrous dysplasia
• Paget’s disease
• Osteopetrosis
• Chronic osteomyelitis
• Lacrimal gland malignancy
764 Differential Diagnosis in Radiology
• Langerhans cell histiocytosis
• Radiotherapy
• Hyperostosis frontalis interna.

Meningioma (Optic Nerve)

• Most often seen in middle-aged women
• Visual loss, papilledema and pallor of optic nerve head.

Plain Film
Calcification (common)
Widening of optic canal
Hyperostosis of sphenoid wing
CT: Dense sharply-defined tubular mass surrounding and paralleling
the optic nerve with enhancement (Tram-Track appearance).
• Metastasis
– Uncommon
– Neuroblastoma, carcinoid, stomach and colon
• Fibrous dysplasia
– Monostotic or polyostotic (McCune-Albright)
– Skull shows mixed lucencies and sclerosis mainly on the
convexity of the calvarium, floor of anterior cranial fossa,
sometimes affecting orbit.
– Usually involvement of other bones like femur, pelvis,
mandible, ribs is seen.

Paget’s Disease
• Rare below 40 years old
• Generalized hyperostosis of skull. Vault becomes widened and
thickened. Osteomalacic changes lead to platybasia and basilar
impression (geographic skull)
• Orbital involvement may be seen
• Picture frame vertebral body, ivory vertebrae
• Widening and coarsened trabeculations of pelvic bones.
 Head, Neck and Spine 765
Osteopetrosis
• Generalized bone thickening
• Skull—sclerosis and thickening are more prominent in
anterior cranial fossa affecting the orbital roof. Cranial nerve
compression
• Sinuses-underpneumatized
• Erlenmeyer flask deformity
• ‘Bone within bone’ appearance
• Rugger Jersey spine.

Lacrimal Gland Malignancy

• Middle-aged females
• S-shaped upper lid with eyeball displaced down and in
• Lateral rectus involvement may cause restriction of movement
• Erosion or sclerosis of orbital lateral wall may be seen
• Spread along muscle or nerve is characteristic.

Langer Cell Histiocytosis

• Long bones, pelvis, skull and flat bones
• Punched-out lesions in skull with little or no surrounding
sclerosis, bevelled edges (geographic skull)
• Orbital involvement leading to exophthalmos seen in clinical
subgroup (Hand-Schüller-Christian disease)
• Other findings like vertebral plana, rib expansion
• Hepatomegaly, lymphadenopathy, skin lesions, pulmonary
disease.

Hyperostosis Frontalis Interna

• Postmenopausal females
• Irregular nodular thickening of inner table of skull mainly
affecting frontal bones, bilateral
• May sometimes involve orbit.
766 Differential Diagnosis in Radiology

8.36 CEPHALOCELES
• A skull defect in association with herniated intracranial contents
is termed as cephalocele
• If the herniation contains solely leptomeninges and CSF, it is
termed as meningocele
• Cephaloceles, in which the protruding structures consist
of leptomeninges, CSF and brain, are termed as meningo-
encephalocele
• Incidence: Cephaloceles occur approx. 1 to 3 times in 10,000
live births
• Occipital cephaloceles predominate in individuals of white
Europeans or North American origin
• Sincipital (Frontoethmoidal) lesions are more common in
south-east Asians and aboriginal Australians
• Basal encephalocele are the rarest form of encephalocele.

Occipital and Parietal Cephaloceles (Fig. 8.20)

• Occipital cephaloceles originate between the foramen
magnum and lambda
• Brain within these cephaloceles is usually dysplastic and gliotic
cerebellum
• In severe cases, the midbrain and part of ventricular system
may also be contained within these cephaloceles
• Occipital cephaloceles can be associated with neural tube
defect such as Chiari II and III malformations, Dandy-Walker
malformations, cerebellar dysplasias, diastematomyelia,
Klippel-Feil syndrome
• Parietal cephaloceles arise from a skull defect between the
lambda and bregma
• They are commonly associated with midline anomalies such as
absent corpus callosum, Dandy-Walker malformations, lobar
holoprosencephaly and Chiari II malformations.
 Head, Neck and Spine 767

Fig. 8.20:  Lateral radiograph of skull shows deficient posterior parietal

bones with a large meningo-encephalocele

Sincipital and Sphenopharyngeal Cephaloceles

• Sincipital (frontoethmoidal) cephaloceles lie between the nasal
and ethmoid bones
• They typically show no association with neural tube defects
• Trans-sphenoidal (sphenopharyngeal) mening­oencephalocele
• These occur in association with numerous distortions of
the sellar and parasellar structures as well as endocrine
abnormalities
• They are frequently associated with callosal agenesis.
768 Differential Diagnosis in Radiology

NASAL CEPHALOCELES,
DERMOIDS AND GLIOMAS
• Nasal cephaloceles as well as nasal dermoids and nasal gliomas
occur when a dural diverticulum that traverses the prenasal
space and normally connects the superficial ectoderm of the
developing nose with the developing brain fails to regress
• Resulting anomalies range from dermal sinus, dermoid and
epidermoid to nasal cephaloceles and so-called nasal gliomas
(which are usually sequestrations of dysplastic or heterotopic
glial tissues)
• The crista galli is very important in D/D of congenital nasal
masses. If it is present but split, the mass is typically a dermoid.
If it is absent or eroded and the foramen caecum is enlarged,
the lesion is a cephalocele.

Table 8.1: Outline the site and associated anomalies of cephaloceles

Type Site Associated anomalies
Occipital Between foramen Dysplastic and gliotic cerebel-
magnum and bregma lum Chiari II and III malforma-
tions
Dandy-Walker malformation
Diastematomyelia
Klippel-Feil syndrome
Parietal Between lambda and Absent corpus callosum
bregma Dandy-Walker malformation
Lobar holoprosencephaly
Chiari II malformation
Sincipital Between nasal and No association with neural tube
ethmoid bones defects
Trans- Numerous distortion of Callosal agenesis
sphenoidal sellar and parasellar
structures and endo-
crine abnormalities
 Head, Neck and Spine 769
ATRETIC CEPHALOCELES/MENINGOCELE
• They consist of skin-covered subcutaneous lesions that consist
of meningeal and ectopic foci of glial or other CNS tissues such
as anomalous blood vessels
• They are associated with cerebro-oculomuscular (Walker-
Warburg syndrome).

8.37  PATHOLOGICAL INTRACRANIAL

CALCIFICATION
1. Neoplasms
– Glioma
– Craniopharyngiomas
– Meningioma
– Ependymoma
– Papilloma of the choroid plexus
– Pinealoma
– Chordoma
– Dermoid, epidermoid and teratoma
– Hamartoma
– Lipoma
– Pituitary adenoma (rarely)
– Metastasis (rarely)
2. Vascular
– Atheroma
– Aneurysm
– Angioma
– Subdural hematoma
– Intracranial hematoma
3. Infections
– Toxoplasmosis
– CMV inclusions
– Herpes
770 Differential Diagnosis in Radiology
– Rubella
– Tuberculosis
– Pyogenic abscess
– Cysticercosis
– Hydatid cyst
– Paragonimus abscesses
– Trichinosis
– Torulosis
– Coccidioides
4. Metabolic and Miscellaneous
– Idiopathic basal ganglia calcifications
– Hypoparathyroidism
– Pseudohypoparathyroidism
– Tuberous sclerosis
– Sturge-Weber syndrome
– Neurofibromatosis
– Lissencephaly
– Fahr’s syndrome
– Cockayne’s syndrome
– X-radiation and methotrexate
– Hemodialysis
– Lead poisoning
– Co-poisoning

Normal Intracranial Calcification (Fig. 8.21)

1. Pineal
2. Habenula
3. Choroid plexus
4. Dura (Falx; Tentorium; over vault)
5. Ligaments (Petroclinoid and interclinoid)
6. Basal ganglia and dentate nuclei
7. Pituitary gland
8. Lens
 Head, Neck and Spine 771

Fig. 8.21:  Radiograph of the PNS region showing

calcification in falx cerebri

Tumors
Gliomas
Commonest cerebral tumor
• Calcification is visible on skull films as little as 5%
• Slow growing and less malignant tumor are most likely to
calcify
• Oligodendroglioma calcify in 50% of cases
• Posterior fossa gliomas calcify in 20% of cases
• Few punctate dots to a large calcified nodule or linear streaks to
large amorphous calcification.
772 Differential Diagnosis in Radiology

Craniopharyngiomas
• Present mainly in children
• Calcification
– Midline and just above the sella
– Few punctate dots to a densely calcified mass
– Sella is bent forward
– If the tumor is cystic, curvilinear calcification may be seen.

Meningiomas
• Calcification on plain film in about 10% of cases
• Calcification is ball-like and amorphous and in a characteristic
parasagittal or other typical meningioma sites
• Other radiological organs include bony hyperostosis where the
tumor is involving the vault or sphenoid ridge and increased
meningeal vascular markings leading up to the site of
attachment.

Dermoids
• Commonest in the posterior fossa or near the base of the skull
• Arcs of calcification
• Associated with a characteristic small central defect in the
occipital bone.

Epidermoids
• These are much less likely to calcify
• Occasionally show small arc calcifications which can be multiple.

Teratomas
• Found mainly in the pineal and suprasellar regions in children
• They frequently contain calcification and rarely the recognition
of a dental element may establish on the plain film.
 Head, Neck and Spine 773
Pineal Tumors
• Calcification in the pineal area, abnormal in extent, particularly
in a child.

Ependymomas
• Occur mainly in posterior fossa in children
• In adults occur in supratentorial compartment
• Calcification is unusual but can occur and be quite dense.

Choroid Plexus Papilloma

• Mainly in children
• Show calcification in one of the cases in 4
• Characteristic site is lateral or 4th ventricle.

Lipoma
• Occur in relation to corpus callosum
• Large lesions show a highly characteristic marginal calcification
(‘bracket sign’).

Chordomas
• Irregular calcification in minority of cases
• They grow from the clivus and other radiological features such as a
soft tissue mass projecting into the nasopharynx or basal erosion.

VASCULAR LESIONS

Aneurysms
• Characteristic arc-like or circular marginal calcification
• Most occur in the region of the circle of willis and a linear ring or
arc of calcification
774 Differential Diagnosis in Radiology
• Mostly small (under 1 cm in diameter)
• Occasional calcification is seen in the margins of fusiform
carotid siphon or basilar aneurysms.

Angioma
• Consists of scattered flecks of calcium associated with the
presence of one or more ring or arc shadows
• The latter arc in the walls of aneurysmal dilatations of vessel on
the venous side of the angioma.

Chronic SDH
• Calcification in membrane.

Intracerebral Hematoma
Irregular calcification but has no diagnostic features.

Atheromas
• Linear fleck in atheromatous carotid siphons and may be quite
extensive
• Atheromatous calcification at the carotid bifurcation in neck.

Infections and Infestations

Tuberculoma
• Calcification on plain film is rare
• Seen in patients successfully treated for tuberculosis and
meningitis
• Small nodules in the healed basal exudate at the base of the
brain.

Toxoplasmosis
• Most human infestation is derived from cats
• Pregnant carrier can infect the fetus in utero
 Head, Neck and Spine 775
• Widespread granuloma with calcifications, severe brain atrophy
with ventricular dilatation and bilateral choroido-retinitis
• Calcification in congenital toxoplasmosis is characteristic
consisting of multiple scattered flecks in the cortex and linear
streak in the basal ganglia.

CMV
• There is a severe intrauterine brain infection
• Microcephaly, a characteristic widespread periventricular
calcification
• Calcification is stippled, bilateral and symmetric.

Cysticercosis
• Human autoinfection with the tapeworm Taenia solium
• Muscle mass is mainly affected and the calcified cysts present a
diagnostic picture
• There is characteristic picture of scattered calcified nodules.

Paragonimus Westermani
• This trematode infection is acquired from crabs or crayfish
• Brain lesions are usually in the parietal region and give rise to
extensive ‘roof bubble’ calcification in cyst measuring 3 to 4 cm
in diameter.

Metabolic and Miscellaneous

Basal Ganglia Calcification
• Chance of finding in the X-ray of adult skull
• B/L and symmetrical and commences in the region of the head
of caudate muscles. The globus pallidus, putamen and lateral
part of thalamus may be involved. The dentate nuclei in the
posterior fossa may be affected with or without supratentorial
calcification. The latter is hazy or punctate in type
776 Differential Diagnosis in Radiology
• Most cases are primary or idiopathic and the condition is
related to age
• Secondary cases are due to hypoparathyroidism, either
spontaneous or following thyroidectomy.

Hyperparathyroidism
• Extensive calcification in falx and tentorium in patients with
CRF and on long-term hemodialysis.

Neurofibromatosis
Extensive calcification of the choroid plexus of the 3rd and lateral
ventricles.

Tuberous Sclerosis
• Multiple areas of dysplasia in the brain may contain calcifications
• On the plain film, these appear as scattered discrete nodule of
varying sizes.

Sturge-Weber Syndrome
• Occipital cortical calcification described as ‘Tram line’
• The parallel lines represent the sulci seen end on since the
calcification lies in the atrophic cortex
• Calcification is U/L and occipital region.

Lissencephaly
• Rare anomaly
• Characteristic small (3 mm) calcified nodule in the septum
pellucidum and just behind the foramen of Monro.
 Head, Neck and Spine 777
8.38  J-SHAPED SELLA (FIG. 8.22)

Common
• Normal variant
• Mild arrested hydrocephalus
• Optic chiasm glioma.

Less Common
• Achondroplasia
• Congenital hypothyroidism
• Hurler’s syndrome
• Neurofibromatosis
• Pituitary tumor
• Intrasellar arachnoid cyst
• Suprasellar tumor.
The normal pituitary fossa in lateral skull radiography can vary
considerably in size. A length of 11–16 mm and a depth of 8–12
mm are regarded within the normal limits.

Fig. 8.22: J-shaped sella

778 Differential Diagnosis in Radiology
J-shaped sella is an elongated sella with a shallow anterior
convexity which represents an exaggeration of the normal slight
impression of sulcus chiasmaticus.

Optic Nerve Glioma

• Appear as fusiform enlargement of optic nerve with secondary
involvement of the chiasm or may envelop the chiasm and
spread secondary to the optic nerve
• X-ray—Classically, demonstrate a J-shaped sella, optic foramina
> 7 mm or a difference of > 2 mm
CT and MRI—provide the exact localization
• Usually isodense, and may show enhancement, especially the
posterior lesions
• Calcifications can be seen
• Eighty-five percent cases seen before 15 years of age.

Hurler’s Syndrome
• Caused by deficiency of enzyme alpha-1-uronidase
• Excess urinary excretion of dermatan sulphate and heparan
sulphate
• Macrocephaly, thick vault with ground glass opacity, J-shaped
sella
• Chest—wide ribs, wide, short clavicles
• Spine—odontoid hypoplasia, ovoid hook-shaped vertebral
bodies, inferior beaking of vertebral bodies
• Pelvis—iliac wings flared with constricted iliac bones, small
irregular tumoral capital epiphysis
• Metacarpals—short and wide with proximal coning
• Genu valgum.

Hydrocephalus
• Bulging fontanelles, sutural diastasis
• Copper beaten skull
 Head, Neck and Spine 779
• Usually seen in arrested hydrocephalus, i.e. when the enlarge-
ment of ventricles stops due to compensatory mechanisms but
they may undergo decompensation.

Hypothyroidism (Cretinism)
• Delayed skeletal maturation
• Fragmented, stippled epiphysis
• Wide sutures, fontanelles with delayed closure
• Delayed dentition
• Hypertelorism, wormian bones
• Delayed/decreased pneumatization of sinuses and mastoids
• Calvarial thickening/sclerosis—Adulthood
• Hypoplastic phalanges of 5th finger.

Achondroplasia (Autosomal Dominant)

• A skeletal dysplasia with short limbs and a characteristic facial
appearance and body habitus
• Skull—Large skull vault, brachycephaly, short skull base, small
foramen magnum, hydrocephalus
• Spine—Platyspondyly, wide disc spaces, narrow spinal canal
with lumbar spinal canal stenosis, thoracolumbar kyphosis
• Square iliac wings, horizontal acetabular roofs
• Long bone shortening, particularly femur and humerus
• Trident hand.

Neurofibromatosis
• One or more relatives, primarily with NF
• Optic gliomas (MC CNS tumor in NF-1)
• Typical bone lesions—sphenoid dysplasia or tibial pseudo-
arthrosis
• Twisted ribbon ribs; splaying of ribs
• Heavy calcification of choroid plexus
• Café-au-lait spots.
780 Differential Diagnosis in Radiology

Arachnoid Cyst (Leptomeningeal Cyst)

• Benign, congenital, intra-arachnoidal SOL, i.e. filled with clear
CSF-like fluid
• Mainly seen in middle cranial fossa but may involve sella
• CT—Smoothly demarcated, non-calcified extra-axial mass that
does not enhance.

Findings on Skull X-ray

• Copper beaten skull
Bulging fontanelle, sutural – Hydrocephalus
diastasis
• Optic foramina >7 mm
or a difference of >2 mm – Optic glioma
• Associated sphenoid dysplasia – Neurofibromatosis
• Large skull vault, brachycephaly,
short skull base, small – Achondroplasia
foramen magnum
• Macrocephaly, thick
vault with ground glass
opacity, odontoid hypoplasia – Hurler’s syndrome
• Wide sutures, fontanelles with
delayed closure, wormian – Hypothyroidism
bones, hypertelorism, calvarial
thickening decreased pneu-
matization of mastoid and sinuses

8.39  CEREBELLAR MALFORMATIONS

Differential Diagnosis
1. Chiari IV malformations
2. Joubert’s syndrome
3. Rhombencephalosynapsis
4. Tecto-cerebellar dysraphia
5. Lhermitte-Duclos disease
 Head, Neck and Spine 781
Chiari IV Malformations
• Absent or severely hypoplastic cerebellum
• Small brainstem
• Large posterior fossa, CSF fluid spaces.

Joubert’s Syndrome
• Autosomal recessive presents with marked global
developmental delay and neonatal breathing abnormalities
• Dysgenetic vermis that appears split, segmented or disorgan-
ized
• The inferior and superior cerebellar peduncles are often small
• The fourth ventricle roof appears superiorly convex on sagittal
MR scans
• No hydrocephalus
• Associated with callosal dysgenesis, congenital retinal
dystrophy, occulomotor abnormalities, polydactyly, cystic
kidney.

Rhombencephalosynapsis
• Presentation is with mental retardation and severe ataxia
• Vermian agenesis or hypogenesis
• Midline fusion of cerebellar hemispheres and peduncles
• Apposition or fusion of dentate nuclei
• Variable fusion of colliculi
• Keyhole fourth ventricle
• Associated with ventriculomegaly, absent septum pellucidum,
anterior commissure hypoplasia, fused thalami, schizencephaly,
cephalocele.

Tectocerebellar Dysraphia
• Vermian hypoplasia or aplasia
• Occipital cephalocele
782 Differential Diagnosis in Radiology
• Dorsal traction of brainstem
• The hypoplastic cerebellar hemispheres are rotated lying
ventrolateral to brainstem.
Lhermitte-Duclos disease: Also known as dysplastic gangliocytoma
of cerebellum.
• Gross thickening of cerebellar folia with or without mass effect
• Mimics posterior fossa neoplasms
• On CT, there are poorly delineated hypo- or isodense posterior
fossa lesions that do not enhance
• Mass effect and displacement of fourth ventricle may occur
• Calcification and hydrocephalus may be present
• On MR decreased signal non-enhancing mass is seen on T1
weighted images and a very characteristic laminated folial
pattern of increased signal intensity is seen on T2 weighted
images
• Usually an isolated abnormality.

Miscellaneous
Dandy-Walker Complex
• Failure of development of anterior medullary velum (roof of
fourth ventricle) or atresia of foramina of Luschka and Magendie
• Large posterior fossa
• High tentorial insertion
• High transverse sinus
• The fourth ventricle communicates with a posterior fossa cyst
• Hydrocephalus
• Vermian or cerebellar hemispheric hypoplasia
• Anterolaterally winged cerebellar hemispheres in front of the cyst
• Brainstem may be hypoplastic and compressed
• Heterotopias and cerebellar dysplasias are common
• Associated with corpus callosum agenesis.
 Head, Neck and Spine 783
Dandy-Walker Variant
• Mild vermian hypoplasia
• Communication of fourth ventricle to cisterna magna with
enlargement of fourth ventricle
• Posterior fossa size is normal.

8.40  DEMYELINATING DISORDERS

• Two main categories
– Dysmyelinating disorders—primary abnormality of
formation of myelin
– Demyelinating—result of myelin loss after its normal
formation.
• General imaging features
– Hypodense on CT
– Hypointense on T1WI
– Hyperintense on T2WI
– Acute lesions may show focal contrast uptake.

Demyelination
• Multiple sclerosis
• ADEM (Acute disseminated encephalomyelitis)
• Infections
– Congenital or perinatal
– CMV
– Rubella
– HSV
• Acute encephalitis
– HSV
– Mumps
– Rubella
– Measles, chicken pox
– AIDS encephalitis
784 Differential Diagnosis in Radiology
– PML
– SSPE
– CJD
• Toxic/Metabolic
– Osmotic demyelination
– Wernicke’s
– Marchiafava-Bignami syndrome
• Vascular
– Subcortical arteriosclerostic encephalopathy
– HIE.

Radiation and Chemotherapy

Dysmyelination
• Metachromatic leukodystrophy
• Krabbe’s disease.

Paroxysmal Peroxisomal Disorders

• ALD
• Zellweger’s syndrome.

Amino Acid Metabolism

• Canavan’s disease.

Mitochondrial Dysfunction
• Leigh’s disease
• MELAS syndrome
• MERRF syndrome
• Kearns-Sayre syndrome.

Unknown
• Alexander’s disease
• Pelizaeus-Merzbacher disease.
 Head, Neck and Spine 785
DEMYELINATION
• Multiple sclerosis
• Unknown etiology—Autoimmune mediated demyelination
• Most common demyelinating disorder, except for age-related
vascular demyelination
• 20–40 years F>M, 1.7–2:1
• Location: Ovoid periventricular lesions, oriented parallel to long
axis of the brain and lateral ventricles
Demyelination around subependymal and deep white matter
medullary veins.
– Calloso-septal interface.
• Infratentorial with 10% in adults.
(Posterior fossa)—more commonly involved in children and
adolescents
• C/F
– Prolonged relapsing-remitting disease.

Imaging
• CT
– May be normal
– Iso- to hypodense lesions on NCCT
– Variable contrast enhancement—both nodular and rim-like
• MRI, iso- to hypointense on T1WI, lesion within lesion
appearance (beveled appearance)
– Hyperintense on T2WI
• Criteria
– Presence of three or more discrete lesions, > 5 mm in size,
characteristic location with compatible clinical H/O
– Oblong lesions at colloso-septal interface are typical with
characteristic periventricular extension into adjacent white
matter, called Dawson’s finger
– Variable and transient CE, only during active demyelinating
stage.
786 Differential Diagnosis in Radiology

Acute Disseminated Encephalomyelitis

• Immune mediated response to a preceding viral infection or
vaccination
• Any age, mostly children and young adults
• Abrupt onset, with monophasic course, neurological symptoms
characteristically develop 1 to 3 weeks after infection
• Multifocal subcortical hyperintense foci on T2WI
• Deep white matter, brainstem and cerebellum can be affected
• Occasionally basal ganglia involvement occurs
• Typically bilateral, but asymmetric
• Usually non-hemorrhagic
• Some but not all lesions enhance, often contrast enhancement.

INFECTIOUS
Congenital and Perinatal Viral Infections
CMV
• Most common cause of congenital infections
• >60% of infected fetuses have multisystem involvement
• Most common intracranial abnormalities 70%
• Cardiac abnormalities and hepatosplenomegaly—(HCM) 1/3rd
cases
• C/F
– Prematurity, hepatosplenomegaly, jaundice, thrombocyto-
penia, chorioretinitis, during newborn period
– Seizures, mental retardation, optic atrophy, sensorineural
hearing loss
– Hydrocephalus—later manifestations.
• Imaging
– X-ray—Microcephaly with egg-shell like periventricular
calcification, due to widespread periventricular tissue
necrosis with subsequent dystrophic calcification.
• USG
– Ventriculomegaly with periventricular calcification.
 Head, Neck and Spine 787
• CT
– Hydrocephalus, atrophy, periventricular calcification.
• MRI
– Migrational anomalies, encephalomalacia, ventriculomeg-
aly, delayed myelination, subependymal periventricular
cysts and calcification.
• Rubella
– Interferes with multiplication of cells located in germinal
matrix—Microcephaly, delayed myelination, vasculopathy
with perivascular necrosis in basal ganglia, periventricular
region and cerebral white matter.
• Parenchymal calcification.
• Other
– Cataract, glaucoma chorioretinitis, microphthalmia cardiac
malformations
– Deafness.

Herpes Simplex Encephalitis (HSE)

Most common viral encephalitis
• Neonatal HSE is caused by HSV-2
• In older children and adults, HSV-1
• HSV causes fulminant hemorrhagic necrotizing meningoen-
cephalitis.
• Neonatal HSV-2 infection is a diffuse non-focal infection
HSV-1- Limbic system predilection.
– Temporal lobe, insular cortex, subfrontal area, the cingulate
gyrus
– ‘Sequential bilaterality’.
• C/F
– Altered mental states, seizures, fever, headache.
• CT
– Normal or Low density lesion in temporal lobe with mild
mass effect
– Hemorrhage—if present highly s/o HSE—usually seen later
in the course of disease.
788 Differential Diagnosis in Radiology
• CECT
– Ill-defined patchy or gyriform contrast enhancement.
• Neonatal HSE-2
– Strikingly increased density of cortical grey matter, and
diffuse low attenuation in the white matter.
• MR
Decrease—T1WI
Increase—T2WI
– In limbic system, with sequential bilaterality with variable
Contrast enhancement and subacute hemorrhage
• Encephalomalacia, atrophy and dystrophic calcification late
sequelae.

HIV ENCEPHALOPATHY
Progressive subcortical dementia-subacute encephalitis
• Develops in 60% of AIDS patients.
• CT
– Most common finding—Atrophy
– Multifocal hypodense areas in deep white matter.
• MR-T2WI
– Ill-defined diffuse or confluent patches of increased signal
intensity in the deep white matter
– Most common site—frontal lobes, often—B/L and symmetric
– Grey matter—typically spared
– No contrast enhancement.
• PML
Group B human papovavirus (JC virus)
– Infects and destroys oligodendroglia—demyelination
– Adults immunocompromised patients, extremely rare in
children
– Periphery to central progression, subcortical areas first to
be affected
– Typically bilateral and asymmetric
– Posterior centrum semiovale—most common site
– Rarely, unilateral, thalamic and basal ganglia lesions.
 Head, Neck and Spine 789
• SSPE
– Rare progressive encephalitis (subacute sclerosing
panencephalitis) that develops several years after mea-
sles infection
– Affects children and young adults.
• C/F
– Behavioral abnormalities, myoclonus, tremors and seizures.
NCCT—hypodense lesion in subcortical and periventricular
white matter basal ganglia
– Generalized atrophy.
• T2W MRI
Multifocal, hyperintensities in cerebral white matter and basal
ganglia.

Osmotic Demyelination
• Alcoholics
• Malnourished or chronic debilitated adults
• Rapid correction of hyponatremia
• Hypernatremia
• Myelinolysis with selective neuron sparing
• MC site—central pons (CP myelinolysis)
• Extrapontine sites:
– Putaminal, caudate, midbrain, thalami, subcortical white
matter
• NCCT—hypodense, hypointense on T1WI, hyper on T2WI
• CE—Most lesions do not enhance, some show variable CE
• Transverse pontine fibers are most severely affected with
sparing of corticospinal tracts.

Marchiafava-Bignami Disease
• Chronic alcoholism
• Corpus callosum demyelination and necrosis, with or without—
cerebral hemispheric white matter and other commissural
fibers may be affected.
790 Differential Diagnosis in Radiology
• Wernicke’s encephalopathy—Nutritional thiamine deficiency—
chronic alcoholics
• TRIAD—Ophthalmoplegia, ataxia, confusion
• Involves both grey and white matter
• Characteristic topographic distribution. Periventricular regions,
mammillary bodies
• Periaqueductal grey, midbrain reticular formation and tectal
plate
• Postcontrast enhancement—may or may not be present
Radiation and chemotherapy—cyclosporin A, methotrexate,
cytarabine, 5-FU
• Small and medium-sized vessel injury
• Predominant involvement of deep white matter with relative
sparing of the cortex and underlying subcortical arcuate fibers
• Widespread perivascular calcification condition known as
mineralizing angiopathy (MA), typically occur in children
receiving irradiation and chemotherapy for acute leukemia
• MC site—basal ganglia and junction of the cortex with
subcortical white matter.

Vascular Lesions
HIE: Premature infants—Periventricular leukomalacia (PVL)
ischemic infarction
• Isolated PVL reflects second or early third-trimester injury
• CF—spastic diplegia, non-progressive but permanent.
• MR—peritrigonal hyperintensities focal ventricular
enlargement with irregular ventricular contour, atrophy of
posterior corpus callosum
• B/L, and asymmetric
• Term infants: Predominant involvement of cortex and
subcortical white matter, with common involvement of deep
grey matter nuclei
• Children and adults: Watershed infarction, with B/L selective
neuronal necrosis in basal ganglia, thalami, hippocampus,
parahippocampal gyrus, cerebellum and brainstem.
 Head, Neck and Spine 791
Subcortical Arteriosclerotic Encephalopathy:
(Binswanger’s Disease)
• Patients with chronic hypertension
• Dementia, spasticity, seizures, gait apraxia, incontinence
• Multifocal white matter lesions in periventricular and deep
white matter, extending peripherally with increasing severity
• Associated with lacunar infarcts in central grey matter and
atrophy.

DYSMYELINATION (LEUKODYSTROPHIES)
• Disorders of children
• Present with variable mental retardation.

Metachromatic Leukodystrophy
Most common hereditary (AR) leukodystrophy.
• Lysosomal disorder, deficiency of -Aryl sulfatase-A, AR
– Symmetric demyelination with subcortical U-fiber sparing
– Cerebellum—often atrophic
• Anterior white matter is most severely affected
• CT
– Moderate ventricular enlargement
– Hypodensity in white matter, progressing anterior to
posterior with no contrast enhancement
• MR
– Increased T2, with arcuate fiber sparing initially
– Increased intensity in cerebellar white matter
– Thalamic hypointensity, mild to extreme.

Krabbe’s Disease (Globoid Cell Leukodystrophy)

• Deficiency of galactocerebroside b-galactosidase, AR
• Cerebral atrophy with small brain, extensive symmetric
demyelination of the centrum semiovale and corona­radiata
with subcortical arcuate fiber sparing
792 Differential Diagnosis in Radiology
• Cerebellar white matter is affected to a lesser degree
• Parieto-occipital lobes may be selectively involved early in
disease
• NCCT
– Periventricular white matter hypodensity
– Thalami and basal ganglia-hyperdense
– Corona radiata, cerebellum—also are hyperdense
• MR
– Periventricular white matter hyperintensity on T2WI
– Late onset disease may show changes limited to posterior
hemispheric white matter
• Cerebral atrophy.
Adrenoleukodystrophy
Single peroxisomal enzyme deficiency—Acetyl coenzyme-A
synthetase
• X-linked recessive
• Three types
– ALD
• Rare neonatal form
– AMN
Neonatal ALD-AR
– ALMN
• Multiple enzyme deficiency
• Ventricular enlargement, cerebral atrophy.
– First involvement of occipital lobes and splenium-B/L
– Centrifugal and anterior extension symmetrical
• ALD–3 months–1 year of age
– Sparing of subcortical white matter early in disease.
• AMN–20–30 years
– Auditory pathway involvement common
– Typically three zones
• Innermost central and posterior zone with necrosis, gliosis and
sometimes calcification
 Head, Neck and Spine 793
• Intermediate zone of active demyelination and inflammatory
change
• Peripheral zone of demyelination with inflammatory change.
CT
Large symmetric hypodensity in parietoccipital region ±
calcification (peritrigonal)
– After contrast enhancement, in advancing rim with more
peripheral non-enhancing edematous zone.

MR
• Central necrosis, zone of decreased intensity on T1WI and
increased intensity on T2WI
• Intermediate zone shows contrast enhancement
• Peripheral zone of decreased T1 and increased T2 signal intensity
• Abnormal signal in lateral geniculate bodies, auditory pathways,
corpus callosum splenium and corticospinal tracts.

AMN
Symmetric hyperintensity in posterior limb of internal capsule
Zellweger’s (cerebrohepatorenal syndrome)—Autosomal recessive,
multiple peroxisomal enzyme deficiency.
• Neuronal migration disorders with heterotopic grey matter
pachygyria, polymicrogyria, with white matter hypomyelination
Leigh’s disease: (Subacute necrotizing encephalopathy)
• Multiple mitochondrial enzyme deficiencies, automatic
recessive
• Involvement of both grey and white matter
• C/F—hypotonia, seizure, vomiting, loss of head control,
respiratory failure
• CT—hypodensity in caudate and putamen, no contrast
enhancement
• MR—symmetric hyperintensity in globus pallidus putamen,
caudate, periventricular white matter and peri-aqueductal
grey.
794 Differential Diagnosis in Radiology

MELAS SYNDROME
Cerebral infarcts—occipital lobes most common site
• Focal cortical and brainstem white matter changes with basal
ganglia calcification with or without cerebral and cerebellar
atrophy.

MERRF SYNDROME
Kearns-Sayre syndrome
• Childhood/adolescence AD
• Progressive external ophthalmoplegia
• Pigmentary retinal degeneration
• Heart block/increased CSF protein/cerebellar dysfunction
• White matter disease with cortical and/or cerebellar atrophy,
and calcification in basal ganglia or deep white matter.

LEUKODYSTROPHIES—DISTINCTIVE FEATURES
• Complete/near complete lack of myelination
– Canavan’s disease
– Pelizaeus-Merzbacher disease
• Frontal white matter most involved—Alexander’s disease
• Occipital white matter most involved—ALD
• Macrocephaly
– Alexander’s disease
– Canavan’s disease
• High density basal ganglia-Krabbe’s disease
• Enhancement following contrast enhancement
– Alexander’s disease
– ALD
• Stroke
– Leigh’s syndrome
– MELAS syndrome
– MERRF syndrome
 Head, Neck and Spine 795
8.41  PREVERTEBRAL SOFT TISSUE THICKENING
(Cervical Region)
Normal Values of Prevertebral Soft Tissue
Level Thickness (in mm)
C1 10
C2 5
C3 7
C4 7
C5 20
C6 20
C7 20
• Weight and age variation
• Flexion and extension < 1 mm variation

Fascial Spaces in Prevertebral Region

Retropharyngeal space between buccopharyngeal fascia
anteriorly and alar fascia posteriorly.
Laterally—Cloison sagittale.
Retroesophageal space: Continuation of the above space in mid
and lower neck surrounds the esophagus.
Danger space— Ventrally– alar fascia
Dorsally– prevertebral fascia
From skull base down to posterior mediastinum.
Prevertebral space between prevertebral fascia and vertebrae
from skull base to coccyx.

Causes of Prevertebral Soft Tissue (Cervical Region)

• Retropharyngeal space
– Lymphadenopathy
– Abscess
– Cellulitis
– Edema
796 Differential Diagnosis in Radiology
– Hematoma
– Lipoma
– Hemangioma
– Tortuous carotid artery
– Extension of goiter
• Prevertebral space
– Abscess
– Phrenic nerve—Schwannomas
– Mesenchymal tumors of muscles
• Extension of tumors like nasopharyngeal or esophageal
carcinoma or lymphoma.

Retropharyngeal Lymph Adenopathy

• Lateral group is involved more than median group
• Reactive, suppurative, metastatic, lymphoma—4 main
categories:
Metastasis nasopharynx, oropharynx, nasal cavity and
hypopharynx (unresectability of primary tumor)
CT—Inflammed lymphoid tissue enhances homogenously
or heterogenously or may appear edematous with decreased
attenuation and mild delayed peripheral enhancement, nodal
edema or suppuration.

Retropharyngeal Cellulitis and Abscess

• Retropharyngeal infections result from suppurative lymph-
adenitis, associated tonsillitis, pharyngitis, sinonasal infection,
otitis media, etc.
• Fever, sore throat, swelling, stridor, odynophagia, trismus
• Plain film
– Widening of retropharyngeal soft tissue
– Loss of cervical lordosis
– Occasionally air in retropharyngeal soft tissue.
 Head, Neck and Spine 797
CT is used to differentiate adenitis, abscess and cellulitis.
• Like lymphadenopathy, abscess is also characterized by low
attenuation and ring enhancement but the margins no longer
confine to nodal morphology (skull base to T4)
• So CT gives invaluable information but it is not entirely accurate
• US
– Differentiate between abscess and adenitis
– Guidance for intraoperative aspiration and drainage
• Diagnosis of cellulitis on CT is made when edema of soft tissues
and obliteration of fat planes without rim enhancement
• Necrotizing cellulitis: Extensive stranding of subcutanous fat
planes
• Complications
– Airway obstruction
– Displacement and compression of internal carotid artery
– Internal jugular vein-compression/thrombophlebitis.

Retropharyngeal Edema
• Usually seen following radiation therapy in patients with head
and neck cancer
• May also follow trauma or infection of oropharynx or vertebral
column.

Hemangioma
These are vascular nests subdivided in three types:
1. Capillary
2. Cavernous
3. Mixed type.

On CT and MRI
• Intensively enhance after contrast injection
• Phleboliths
798 Differential Diagnosis in Radiology

Lipoma
• Predominantly found in posterior cervical space but may occur
in RPS
• Seen as fat density, well-defined encapsulated on CT and MR
• Lipomas tend to enlarge with weight gain but do not decrease
with weight loss.

Tortuous Carotid Artery

• A tortuous common or internal carotid artery may present
submucosal mass displacing the posterior pharyngeal wall
• Palpation may not be feasible, pulsation overlooked
• CT diagnosis is straightforward.

Extension of Thyroid Masses

Pretracheal space communicating with retropharyngeal space
between levels of thyroid cartilage and inferior thyroid artery can
extend through this space.

Prevertebral Abscess
• Abscess in prevertebral space is usually from osteomyelitis of
vertebral bodies
• Displaces RPS anteriorly and carotid sheath laterally.

Tumors
• Masses arising from prevertebral muscles are mesenchymal in
origin
• Erosion of vertebral body—malignant
• Rhabdomyosarcoma—mostly from pharyngeal mass
• In children—Rhabdomyosarcoma and neuroblastoma
• Nasopharyngeal lymphoma or minor salivary gland malignancy
may directly invade.
 Head, Neck and Spine 799
8.42  NASOPHARYNGEAL MASSES
Nasopharynx is a space situated posterior to the posterior nares
and bounded superiorly by the floor of the middle cranial fossa
and posteriorly by the base of skull and laterally by the pharyngeal
musculature, the mandible and the parotid.

Methods of Investigations
Plain X-ray soft tissue neck: This is now only sometimes used as
a lateral projection of the pharynx. The film is placed against
the shoulder and the central ray is centered at the angle of the
mandible.

Computed Tomography
CT is now the optimum method of imaging; it shows not only the
outlines of the nasopharynx but also the soft tissue structures of
the infratemporal fossa and parapharyngeal space. The scan can
be done in axial views and sagittal and coronal reconstructions
can be done or direct coronal scanning can be done. Both pre-
and post-contrast scans should be undertaken. The role of CT for
lesions in this region may be defined as follows:
1. Used as a complement to direct examination.
2. To assess the size, situation and relations of a well-defined mass
for prospective surgical removal, or the extent of local and deep
infiltration for radiotherapy planning.
3. To assess the relationship of the mass with great vessels and the
parotid gland on post-contrast scans.

Magnetic Resonance Imaging

Now the imaging investigation is of choice, but careful selection
of cases is necessary. It shows the major vessels of neck without
contrast enhancement and clearly depicts the soft tissue anatomy
in multiplanar projections. T1 weighted sequences have the best
800 Differential Diagnosis in Radiology
spatial resolution and give a strong signal from fat in the tissue
planes. However, T2 weighted protocols are most useful for
showing muscle invasion by carcinomas. A standard head coil is all
that is used for the assessment of nasopharynx.

Differential Diagnosis of Nasopharyngeal Masses

1. Meningoceles
2. Adenoid hyperplasia (Fig. 8.23)
3. Antrochoanal polyps
4. Infections
5. Juvenile angiofibroma
6. Chordomas
7. Carcinomas

Fig. 8.23:  Radiograph of nasopharynx showing adenoid hypertrophy

 Head, Neck and Spine 801
8. Lymphoma
9. Extension of neoplasms (sphenoid/ethmoid carcinoma, parotid
tumor).

Meningoceles
These present as a smooth well-defined mass in an infant or a young
child posterior to and projecting into the nasopharynx. These
are rare manifestations and are usually associated with a defect
in the skull base. These masses may show fluid or CSF density of
intracranial contents. These are best shown by coronal CT or MRI,
which will differentiate meningocele from an encephalocele.

Adenoid Hyperplasia
• Presents in younger age group with nasal blockage and
recurrent attacks of rhinitis
• There is a verrucoid polypoidal mass in the nasopharynx with
no evidence of bone involvement or mucosal invasion
• CT and MRI best delineate the size, volume and extent of the
lesion.

Antrochoanal Polyp
• These are antral polyps which outgrow from the antrum and
present in the nasopharynx
• They are smoothly outlined pear-shaped masses in the
nasopharynx
• They are associated with partial or complete opacification of the
antrum but with no evidence of bone destruction or erosion.
However, thinning of bones, secondary to the expansile nature
of the mass, may be seen
• On CT they present as hypodense soft tissue masses. On MR
they have high homogenous signal on T2-weighted sequences.
CT and MR can elegantly define the origin of mass from the
maxillary antrum and will also define the extent of the mass.
802 Differential Diagnosis in Radiology

Infections
• Abscess in the parapharyngeal spaces may present in the
nasopharynx posterior to the mucosal lining presenting
clinically as masses in the nasopharynx with or without
associated changes of inflammation on the overlying mucosa
and the patient may show signs of toxemia
• The abscesses are usually secondary to infection extending
either from the parotid glands, the sinuses and hematogenous
spread from a distant location
• On CT they are seen as well-defined walls of necrotic masses
with enhancement of walls on CECT. Associated changes may
be seen in the nearby structures from which the abscess has
originated.

Juvenile Angiofibroma
• Commonest benign tumor in pubescent males presents
classically with epistaxis and nasal obstruction and a dark red
or ulcerated mass in the nasal cavities and postnasal space
• CT and MR clearly define the extent and origin of the lesion
• The mass arises at or close to the base of the pterygoid lamina,
thus bone erosion at this site is probably a pathognomonic feature
• The tumor not only spreads into the nose and PNS but
has a special tendency to spread laterally through the
pterygomaxillary fissure and anterior bowing of the posterior
wall of the antrum, an important differentiating feature. It
causes destruction of the adjacent bones
• Neglected cases may also show extension into the orbit,
sphenoid sinus and the cranial cavity
• There is considerable contrast enhancement on CECT and MR
may show presence of flow voids as well as marked enhancement
after gadolinium, which is characteristic to the tumor.
 Head, Neck and Spine 803
Chordomas
• These are midline tumors arising from commonly the clivus,
but may also arise from basisphenoid and present as postnasal
mass
• They are usually found in patients of older age group
• They present on CT as a large soft tissue mass in the postnasal
space associated with destruction of the basisphenoid and
flecks of calcifications. There is usually an associated intracranial
mass.

Carcinomas
• Eighty percent of the carcinomas are squamous cell type.
When they are large and exophytic, they present as a mass in
the postnasal space. Usually, however, they infiltrate into the
base of skull so that the patient presents with a cranial nerve
lesion or with enlarged neck glands. Serous otitis media due
to blockage of Eustachian tubes may be another presenting
complaint
• There is erosion of the floor of middle cranial fossa
• There is obliteration of the lateral pharyngeal recess (fossa of
Rosenmüller)
• CT and MR may also show the obliteration of soft tissue planes
suggestive of invasion
• Extension in the cranial cavity and evaluation of neck glands by
CT and MR help in staging the tumor. In cases of adenocystic
carcinoma, MR may also show perineural spread, which is
characteristic to the tumor.

Lymphomas
• In the postnasal space, these tumors tend to grow in a
bulky circumferential pattern without early invasion of the
parapharyngeal spaces
• CT and MR show bulky masses in the postnasal space with
homogenous attenuation or intensity.
804 Differential Diagnosis in Radiology

Extension from Nearby Structures

This is usually due to the spread of pathological process in the
nearby structures like in cases of sphenoid or ethmoid carcinoma
or parotid masses. CT and MR will show the presence of primary
pathology elsewhere and its extension in the postnasal space.

8.43  LARYNGEAL MASSES

Causes
Malignant Benign
Carcinoma Papillomas/Polyps
Chondrosarcomas Laryngocele/Mucocele
Salivary gland tumors Hemangioma
Metastases Cartilage tumors
Miscellaneous Salivary gland tumors

Malignant Lesions
• Carcinoma: Masses in the larynx are usually malignant, and
virtually all are squamous cell carcinomas.
– M:F is 5:1, almost always associated with tobacco and
alcohol.
– Peak incidence is 7th decade.
– Divided into the supraglottic, glottic and subglottic
(infraglottic) types.
– Role of radiologist is to describe the deep extension, the
relationship of the mass to the surrounding structures, and
lymphadenopathy. Pay particular attention to: laryngeal
cartilage invasion, transglottic extension, extension into
adjacent fascial spaces, especially parapharyngeal space
and carotid space, regional lymph nodes including internal
jugular chain of nodes and the midline Delphian node. Be
observant for possible lung metastasis or secondary lung
primary. Needle biopsy of suspicious deep masses may be
necessary under imaging guidance.
 Head, Neck and Spine 805
– Pitfalls of CT include the inability to reliably differentiate
inflammation and edema from tumor, to accurately identify
the subsite involvement in the presence of anatomic
distortion from large tumors, and to clearly define margins
in the absence of well-developed fat planes.
– MRI has an advantage of multiplanar display especially
in determining subglottic extension and in identifying
the pre-epiglottic spread. MRI also has difficulty in
differentiating edema from tumor but is superior to CT in
detecting cartilage invasion.
• Chondrosarcomas are slowly growing neoplasms
– Present usually in the 6th and 7th decades
– Cricoid cartilage is usually involved (80%) followed by
thyroid cartilage.
– Lesions in virtually all patients demonstrate coarse or
stippled calcifications.
– Features differentiating from carcinomas include older
age at diagnosis, absence of smoking history, and
predominately calcified tumor matrix.
• Minor salivary gland tumors as adenocystic carcinomas have
been reported. They are indistinguishable from the laryngeal
carcinomas but should be considered in patients with laryngeal
mass and no history of smoking or drinking.
• Metastases to the larynx usually occur in the terminal stages
of the disseminated malignancy. Primary tumors include
melanoma (30%), renal cell carcinoma (15%). Site of deposit
include supraglottic (40%), subglottic (20%), glottic (5%) and
multifocal (35%).
• Rare tumors include fibrosarcomas, liposarcomas and
lymphomas.

Benign Lesions
• Papillomas constitute 80% of the benign mucosal tumors and
are the commonest pediatric laryngeal tumors. These appear
as multiple nodular excrescences on the false and true cords
producing contour abnormalities of the mucosal surfaces
806 Differential Diagnosis in Radiology
• Small cystic lesions can arise in the vallecula or epiglottic
surface secondary to the obstruction of minor salivary gland
• Vocal cord polyps can arise secondary to vocal abuse
• Laryngoceles are the air-filled diverticulae arising from the
saccule of the laryngeal ventricle. They are common in
musicians who play wind instruments. They are associated with
airway obstruction, pyoceles and vocal cord paralysis. 25% are
bilateral. These are of three types:
– Internal: when confined within thyroid lamina
– External: lesions that pierce the thyroid membrane
– Mixed: combination of the internal and external
• Laryngeal mucocele is a fluid-filled laryngocele that arises
secondary to a small ventricular cancer obstructing the saccule
• Subglottic hemangioma is the commonest laryngeal and upper
tracheal neoplasm in the newborn and the young infant.
It appears as a well-defined mass in the posterior or lateral
portion of the subglottic airway
• Chondromas arise from the hyaline or elastic cartilages of the
larynx
• Chondrometaplasia is a condition in which nodules of cartilage
arise in the soft tissues of the larynx. Lesions arising in the
close vicinity of the laryngeal cartilages may be difficult to
differentiate from chondromas or chondrosarcomas on
imaging
• Schwannomas typically involve the sensory nerves such as the
internal branch of the superior laryngeal nerve and usually
arise in the 4th to 6th decades as a palpable mass
• Minor salivary gland tumors as pleomorphic adenomas have
been reported
• Rare tumors include paragangliomas, atypical carcinoid tumor,
amyloidosis, etc.

8.44  ORBITAL MASSES

The pediatric patient with an orbital tumor differs substantially
from the adult patient with a much greater incidence of congenital
 Head, Neck and Spine 807
lesions, higher frequency of infection, and unique benign and
malignant tumors involving the orbit.

Pediatric Orbital Tumors

• Most common orbital masses are cystic lesions of the orbit,
mainly dermoids
• Vasculogenic lesions are the second most common
• Others include inflammatory lesions, fat-containing lesions,
lacrimal gland masses, lymphoid tumors and leukemia, optic
nerve and meningeal tumors, osseous and fibro-osseous
masses, rhabdomyosarcoma, and metastatic lesions
• Common malignant processes include rhabdomyosarcoma,
metastatic disease, lymphomas and leukemia
• Most orbital tumors in children are benign.

Cystic Lesions
Dermoid Cysts
• Arise from trapped embryonic ectoderm in the suture lines
between the orbital bones
• Classified into juxtasutural sutural, and soft-tissue types
• Most common type—juxtasutural in the superotemporal and
superonasal quadrants
• Presents as painless mass in superotemporal area at the lateral
portion of the eyebrow
• Usually unattached to overlying skin, mobile, smooth and non-
tender
• CT scan reveals a well-circumscribed lesion with a low-density
lumen.

Teratomas
• Congenital germ-cell tumors arise from primordial germ cells
with ectodermal, mesodermal and endodermal components.
808 Differential Diagnosis in Radiology
• Typically present at birth, with no bone invasion, often cause
orbital enlargement
• Large intraconal masses cause massive proptosis.

Vasculogenic Lesions
Capillary Hemangioma
• One-third are diagnosed at birth, and over 90% are visible by 6
months of age
• Most common presentation—superficial involvement
appearing as tumor and telangiectatic vessels in the skin that
with time develops the typical strawberry-like appearance
• Deeper lesions may appear as raised soft, purplish nodules
• Deep orbital involvement may present solely with proptosis
and no skin changes
• Orbital hemangiomas frequently produce proptosis, globe
displacement and enlarge with Valsalva’s maneuvers or crying
• The typical course is—normal appearance at birth, lesion first
noticed at one month, enlarging till 1 to 2 years followed by a
stabilization and spontaneous involution by age 4 to 8 years of
age
• Best evaluated with CT or MRI—a diffusely infiltrating non-
encapsulated mass, conforming to the surrounding orbital
structures. No bony erosion, although expansion of the orbit is
possible
• Ultrasonography is also a valuable noninvasive test.

Lymphangiomas
• Benign congenital malformation—may affect the conjunctiva,
eyelids or deep orbit
• Classically, viewed as separate from the vascular system,
although some overlap has been noted
• Typically, the tumor is identified within the first two decades of
life
 Head, Neck and Spine 809
• Present as slow enlargement with increasing proptosis over
many years, or one of sudden proptosis from intralesional
hemorrhage (chocolate cyst)
• The classic lesion is a smooth, pink-orange mass (Salmon patch)
under an intact conjunctiva
• CT scan shows a homogenous mass with well-defined borders
that does not destroy surrounding structures or bone
• Most lesions are extraconal and in the superior orbit.

Orbital Meningiomas and Schwannomas

• Most common during the fourth to seventh decade of life.
Primary orbital meningiomas arise from the optic nerve, 70%
invade the orbit from the cranium infiltrative, and enhancing.
The classic “railroad track” describes calcifications of the tumor
along the optic nerve in the subarachnoid space
• MRI is used to evaluate intracranial extension, showing a
hyperintense tumor after contrast administration
Schwannoma or neurilemmoma is a benign, non-invasive,
peripheral nerve tumor
• They are relatively rare; usually occur in adults from age 20 to 70
years
• CT shows well-circumscribed, homogenous, elongated ovoid
mass displacing the surrounding structures
• MRI—the tumor is hypointense on T1WI and hyperintense on
T2WI
• The tumor is extraconal when associated with the IV cranial
nerve, but is more commonly intraconal.

CAVERNOUS HEMANGIOMA
(ENCAPSULATED VENOUS MALFORMATION)
• Most common vascular and the most common primary
intraconal orbital lesion in adults
• Average age of onset is around 40 years
810 Differential Diagnosis in Radiology
• Commoner in women (70%) than men (30%) and is generally
unilateral
• Present with a slowly progressive painless proptosis over
several years
• These do not enlarge with Valsalva
• CT or MRI reveals a well-defined mass with an oval shape
• Most are intraconal, but occasionally extraconal
• On CT they are homogenous with increased density
• On MRI they are homogenous and isointense to muscle, on
T1WI and hyperintense on T2WI
• Following contrast addition, the lesions enhance inhomo-
geneously.

METASTATIC TUMORS
• Breast carcinoma is commonest metastatic tumor in women
followed by lung carcinoma
• In men, the most common are lung and prostate
• The average age at presentation is the 7th decade, most being
female (due to the higher incidence of breast metastasis)
• On CT, the most common finding is a well-defined, contrast
enhancing, intraconal mass
• The orbital bony walls are also a common site for metastasis,
especially with prostate cancers
• These tumors may show expansion during an acute upper
respiratory infection
• Superficial lesions are more common and have a better
prognosis for vision than deeper lesions. No enlargement of the
tumor with Valsalva maneuvers
• Imaging studies include CT and MRI, which both show
the multicompartmental nature of the venous-lymphatic
malformations
• MR imaging is preferred over CT because it delineates the
internal structure of the cysts.
 Head, Neck and Spine 811
MISCELLANEOUS
Rhabdomyosarcoma
• Most common orbital malignant tumor found in children
• Presents early in the first decade with rapid unilateral proptosis
and displacement of the globe
• CT scan shows an irregular tumor with moderately well- defined
margins, soft tissue attenuation, and often evidence of bony
destruction (50%)
• MR imaging demonstrates a signal similar to muscle on T1 and
higher than muscle on T2 weighted images.

Optic Nerve Gliomas

• Often associated with neurofibromatosis type I (18 to 50% of
cases), often bilateral
• Mean age of presentation is about 8 years
• Typical presentation is proptosis and visual loss or visual field
changes
• Appear as fusiform enlargement of the optic nerve which is
isodense to brain on CT
• Intracranial extension into the optic canal and chiasm is best
evaluated with MRI.

Fibrous Dysplasia
• Most frequent fibro-osseous tumor seen exclusively in children
in the first two decades of life
• Replacement of normal bone with collagen, fibroblasts, osteoid
and giant cells
• Two types of fibrous dysplasia: polyostotic (Albright’s syndrome)
and monostotic
• Polyostotic fibrous dysplasia involves multiple bones, not
generally the orbit, abnormal skin pigmentation and precocious
puberty
812 Differential Diagnosis in Radiology
• Monostotic fibrous dysplasia occurs most often in the bones of
the face
• The orbital roof is the most common site of orbital involvement
• Usual presentation—adolescent child with proptosis, globes
and orbit displacement and facial asymmetry
• The CT shows thickened abnormal bone with sclerotic lesions
with a ‘ground-glass’ appearance
• Biopsy is usually necessary to confirm the diagnosis and to rule
out more aggressive lesions.

Metastatic Tumors
• Neuroblastoma is the most frequent metastatic orbital disease
in children
• Others include Ewing’s sarcoma, leukemia and lymphoma
• Neuroblastoma is common in children, majority occurring
before age 5 (median 22 months).

Adult Orbital Tumors

In the adult population, the more common types of orbital
tumors vary significantly from children. The most common tumor
includes carcinomas (paranasal sinus, secondary and metastatic),
inflammatory masses (pseudotumor), lacrimal gland tumors,
cysts, lymphomas, meningiomas, and vascular tumors (cavernous
hemangiomas). Secondary tumors commonly invade the orbit
and include mucoceles, squamous cell carcinoma, meningioma,
vascular malformations and basal cell carcinoma.

Paranasal Sinus Masses

Mass in the paranasal sinuses has the potential to extend into the
orbit. The most common mass lesion of the orbit originating in the
sinus is the mucocele.
Mucocele results from obstruction of a sinus ostium leading to an
enlarging fluid-filled sinus, which eventually may erode through
the orbital bony wall.
 Head, Neck and Spine 813
• The median age of presentation is around 50 years
• Most arise from the ethmoid and frontal sinus
• Patients will present with unilateral proptosis with globe
displacement away from the mass, lid swelling and sometimes
a palpable mass
• CT scan reveals a well-defined homogenous mass extending
into the orbit through a bony defect associated with an
opacified sinus cavity.

Neoplasms of the Paranasal Sinuses

• Benign tumors push the periorbital structures aside, while
malignant lesions invade the periosteum
• Most common malignancy is squamous cell carcinoma
• Disease is usually advanced at presentation with orbital
invasion in almost 2/3rd of the patients
• Adenocarcinoma arising from the ethmoid sinuses is frequently
associated with wood workers
• Adenoid cystic carcinomas show perineural spread via the
infraorbital nerve
• Locally invasive neoplasms as esthesioneuroblastoma and
benign paranasal neoplasm as inverted papilloma may also
extend into the orbit
• Evaluation best done radiologically with CT scan, because of
the ability to detect early lesions and note bony destruction
with either orbital or intracranial extension
• MRI scans are useful in detecting intracranial extension and
distinguishing certain neoplastic diseases from one another.

ORBITAL PSEUDOTUMOR
(IDIOPATHIC ORBITAL INFLAMMATION)
• An inflammatory condition of the orbit of unknown etiology
• Common cause of proptosis from the 2nd to 7th decade of life
• Multifocal involvement is common and any orbital structure
may be involved
814 Differential Diagnosis in Radiology
• Onset of symptoms is acute, however, subacute or chronic
forms have been described
• The typical symptom is dull orbital pain, which is worse with
eye movement
• Proptosis is the most common finding
• CT findings show hazy enlargement of affected structures with
enhancement after intravenous contrast injection
• MR T1-weighted images show lesions with similar signal to
muscles that enhance with contrast. T2-weighted images have
increased signal similar to or greater than fat.

Lacrimal Gland Tumors

• About half are epithelial neoplasms, while the other half are in
lymphoproliferative disorder
• Lymphoid lesions include benign lymphoid hyperplasia,
malignant lymphoma and leukemias. Lymphoid lesions appear
as smooth enlargement of the gland on CT scans
• Epithelial neoplasms appear irregular on CT and include
pleomorphic adenomas (benign), adenocystic carcinoma,
adenocarcinoma, mucoepidermoid carcinomas, and
undifferentiated carcinomas
• The most common of epithelial lesions is the pleomorphic
adenoma (benign mixed tumor) which occurs primarily
between the ages of 20 and 50 years
• Most common malignant epithelial neoplasm is adenoid cystic
carcinoma
• CT scans will often show bony destruction and infiltration of
the lacrimal mass.

Lymphoid Tumors
• Orbital lymphomas may be primary or associated with systemic
disease
• Most orbital lymphomas are localized to the orbit but many
patients develop systemic lymphoma over time
 Head, Neck and Spine 815
• Orbital lymphoma is an adult disease usually presenting
between the ages of 50 and 70 years
• Usually an anterior mass, enlarges slowly, causing progressive
painless proptosis over months.

8.45  OCULAR MASSES

Melanoma
• Arise from choroid in elderly
• Commonest malignancy in adults
• Highly invasive with extraocular spread as well
• Ultrasound typically shows raised echogenic focus along post
wall of vitreous chamber (collar button)
• On MRI, melanotic type shows increased T1W and decreased
T2W while amelanotic type is isointense to soft tissue
• Trans-scleral and perineural spread is common.

Retinoblastoma
• Commonest malignancy in childhood
• 1/3rd are B/L with autosomal dominant inheritance
• Trilateral retinoblastoma when B/L tumor associated with
pineal tumor
• Highly malignant and aggressive with trans-scleral and
hematogenous spread
• US shows highly echogenic mass with DAS
• CT is modality of choice and shows dense calcification in a
retinal based soft tissue mass
• Any calcification within the globe on CT scans in pediatric
patient should be considered retinoblastoma unless proved
otherwise
• MRI is superior to CT in evaluation of trans-scleral or perineural
spread or in evaluation of pineal region for additional masses.
816 Differential Diagnosis in Radiology

INTRAORBITAL CALCIFICATION
Causes
1. Cataract
2. Retinoblastoma
3. Parasitic infection
– Hydatid cyst
– Cellulosae cysticercosae
4. Phleboliths
– Hemangioma
Arteriovenous malformation
Venous varix
5. Orbital meningioma
6. Others
– Adeno and cystic carcinoma of lacrimal gland
Neurofibroma
Rhabdomyosarcoma.
• Cataract
Immature cataract—scattered opacities are separated by clear
zones: Mature cataract—totally opaque cortex is noted on
ultrasound.
• Retinoblastoma
– Most frequent intraocular tumor of childhood.
– 85% are < 3 yrs ; 20–40% have B/L tumors.

Classified as
Grade-1: Solitary/multiple, < 4 disc dram in size at or behind
equator
Grade-2: Solitary/multiple; 4-10 disc dram
Grade-3: Anterior to equator or solitary > 10 disc dram
Grade-4: Tumors that are multiple and extend up to or a serrata
Grade-5: Tumors that involve half of the retina or presence of
vitreous seeds.
• Most children present with leukokoria/white pupillary reflex.
R/F: Irregular intraocular mass, 90% cases show calcification
on CT.
 Head, Neck and Spine 817
Endophytic extension
– Projects into vitreous
Exophytic extension
– Subretinal space – Radio-opaque density
Contrast enhancement is variable.
Orbital and intracranial extension.

Orbital Meningioma
Primary: Optic nerve sheath
Secondary: Originates from greater wing of sphenoid with
temporal and orbital extension.

Optic Nerve Meningioma

• Adults: 3rd–5th decades.
R/F:
– Tubular/Fusiform thickening of optic nerve.
– Homogenous contrast enhancement.
– Tram track sign: Hyperdense mass surrounding hypodense
optic nerve.
– Calcification +ve
– Optic canal widened by mass or narrowed by hyperostosis
– Intracranial ext +/–.

Hemangioma
Capillary Hemangioma
• Tumor of early childhood; involutes spontaneously by
6–7th year
• Forms a soft bluish mass which may involve any part of orbit.
US—well-defined anterior soft lesion with small irregular
echoes. Calcification +/–.
CDFI—high flow within immature vessels.
818 Differential Diagnosis in Radiology

Cavernous Hemangioma
Commonest benign retrobulbar tumor 3–4th decade.
Usually it lies within the muscles’ core and displacing the optic
nerve.
R/F: Honeycomb pattern of altered strong and weak signals on
ultrasound.
CT: Homogenous mass (hyperdense) with smooth margin
showing uniform contrast enhancement.
Phleboliths +
Expansion of the orbital wall +
Arteriovenous Fistula (Carotid Cavernous Fistula)
Post-traumatic/postsurgical
Spontaneous
• Atherosclerosis
Osteogenesis imperfecta
Ehlers-Danlos syndrome
Pseudoxanthoma elasticum
• Clinically patient presents with pulsatile exophthalmos
R/F: Dilated superior ophthalmic vein which cannot be com-
pressed
• Reverse flow in the superior ophthalmic vein which is
arterialized
• Increased size of extraocular muscles
• Angiography required for endovascular treatment
• Phleboliths +/–.

Orbital Varices
Varix becomes prominent on prone position, compression of
jugular veins and Valsalva’s maneuver.
• Ultrasound shows soft echofree lesion with phleboliths
• CDFI may demonstrate movements of blood flow as
malformation fills with blood or empties
• Orbit may be expanded.
 Head, Neck and Spine 819
CT shows nodular/serpiginous mass, containing phleboliths,
with marked contrast enhancement.
MRI—Vase stream with signal void or flow related enhancement
or echo rephasing due to slow flow.
Permanent signal may indicate a clot.

Rhabdomyosarcoma
• Highly malignant tumor; most frequent in childhood.
R/F—Seen as a well-defined mass in a muscle or adjacent to it.
– Mass may include the lacrimal gland with osseous and
extraorbital invasion
– Calcifications are frequently seen after radiotherapy.
• Adenocystic Carcinoma of Lacrimal Gland
Most common malignant lacrimal gland tumor.
R/F—Enlarged gland with irregular serrated bodies, bony
erosion of orbital roof.
Presence of calcific deposit.
• Hydatid Cyst
Can be seen in the retrobulbar region.
R/F—Spherical/oval mass of low reflectivity/low density.
Enhancement of walls +ve
Calcification +ve
Cellulosae cyst
• Intraocular (vitreous/subretinal space)
• Extraocular (EOMS, eyelid, lacrimal gland, optic nerve)
R/F—Cystic lesion with an eccentrically placed hyperdense
scolex showing ring enhancement.
In the later stages, nodular calcification is seen.

8.46  INNER EAR MASSES

• The Temporal Bone
– Petrous Part 1
– Squamous Part 2
– Tympanic Part 3
– Mastoid Part 4
820 Differential Diagnosis in Radiology
– Styloid Process 5
– Zygomatic Process 6
• Houses the structures of middle and inner ears (Fig. 8.24)
– Cochlear apparatus
(for Hearing)
Vestibular apparatus
(for equilibrium)
• The Bony Case is known as Ottic Capsule or Bony Labyrinth while
the Functioning Inner Organ System is known as Membranous
Labyrinth (Fig. 8.25).

METHODS OF IMAGING
1. Plain X-ray, e.g. Stenvers’ view
2. Tomography of temporal bone

Fig. 8.24: Structures of middle and inner ears

 Head, Neck and Spine 821
3. CT scan
– Axial especially bony
Coronal labyrinth
4. MRI
– Axial especially membranous
Coronal labyrinth

Masses
Inflammatory
• Granulomatous labyrinthitis
• Labyrinthitis ossificans
• Sarcoid granuloma Fig. 8.25: Bony
Cholesteatoma/cholesterol granuloma. Labyrinth

Neoplastic
• Schwannoma
• Lipoma
• Arachnoid cyst
• Epidermoid cyst
• AVM
• Hemangioma
• Meningioma
• Lymphoma
• Metastasis
• Temporal bone tumors.

Miscellaneous
• Intralabyrinthine hemorrhage
• Vestibular aqueduct syndrome (VAS).
822 Differential Diagnosis in Radiology

Salient Features

Inflammatory
• Labyrinthitis is a term used to describe inflammation of inner
ear
• Viral; Bacterial; Autoimmune
• Tympanogenic; Meningogenic; Hematogenic; Post-traumatic;
Iatrogenic; Tympanogenic may be associated with Cholesteatoma
• B/L >> U/L: A cholesteatoma may occur here per se
• On CT and especially MR, membranous labyrinth shows faint
and segmental enhancement (as compared to schwannoma
which shows complete and well-defined enhancement)—
acute and subacute
• Associated enhancing granuloma and facial nerve
enhancement may be seen
• In late stages when treatment failure occurs, a fibrous and very
late bony labyrinth, also known as labyrinthitis ossificans, is
seen. The imaging pattern corresponds accordingly, i.e.
Fibrous:  hypointense on T1WI; minimal/No enhancement;
– hypointense on T2 WI and T2GRE.
– isodense on CT.
Calcified – hypointense on T1, T2 WI with no enhancement.
– hyperdense on CT.

Intralabyrinthine Bleed
• Coagulopathy, trauma, tumor
• Rare
• Hyper on CT and T1.

Vestibular Aqueduct Syndrome

• Most common cause of congenital sensorineural hearing loss
diagnosed by imaging
• On imaging, a large endolymphatic duct and sac are seen.
Associated deformity of cochlear modiolus is present
 Head, Neck and Spine 823
Schwannoma
• Of 8th cranial nerve known as Acoustic Neuromas are usually
combined intra- and extracanalicular (i.e. CP angle) but may
sometimes be purely intracanalicular
• Sometimes purely intralabyrinthine schwannomas may be
seen
• Slow-growing non-calcifying masses, larger in females
• When small, they are uniformly isodense (CT), isointense (T1
and T2) while enhance uniformly but as the size increases, areas
of necrosis and cyst formation may also be seen.
Other Neoplasia: But these are not stressed as they are not primary
inner ear conditions.
• The appearances are general with the epicentre of lesion being
the only feature helping in predicting an inner ear origin, e.g.:
Lipoma : Hyperintense on T1, T2WI hyper, while
hypodense on CT, no enhancement
Arachnoid cyst : Follows fluid signal
Epidermoid : Follows with specific changes
Bone tumors : Bony changes
Vascular tumors : Extreme vascularity.

8.47  MIDDLE EAR MASSES (TABLE 8.2)

Congenital
• Aberrant Internal Carotid Artery
– Vascular tympanic membrane.
– Pulsatile tinnitus.
– Imaging reveals a tubular soft tissue mass entering
middle ear cavity posterolateral to cochlea, crossing
mesotympanum along cochlear promontory, extending
anteromedially to become continuous with horizontal
portion of carotid canal.
– Protrusion into middle ear without bony margin.
824 Differential Diagnosis in Radiology
• Dehiscent Jugular Bulb
– Vascular tympanic membrane.
– Pulsatile tinnitus.
– Imaging reveals a soft tissue mass contiguous with jugular
foramen and there is absence of a bony plate separating
jugular bulb from posteroinferior middle ear.

Inflammatory
• Cholesteatoma
– Tumor-like mass of exfoliated keratin within a sac of
stratified squamous epithelium.
– Cholesteatoma is usually an acquired disease (secondary
cholesteatoma), but can be congenital (primary
cholesteatoma).
– Acquired cholesteatoma result from in-growth of squamous
epithelium through marginal tympanic membrane
perforations, from retraction pockets or from in-growth
into the middle ear of the basal layer of the tympanic
membrane and are usually related to chronic otitis media.
– High resolution CT is an excellent technique for showing
the location and extent of the lesion prior to surgery.
– On CT images, cholesteatoma usually presents as a more
or less rounded soft tissue mass, often centered within the
epitympanic recess and lesions are commonly associated
with erosion of the lateral epitympanic wall (more
specifically the scutum) and the ossicular chain.
– Associated findings are thickening of the tympanic
membrane and inflammatory polyps in the medial part of
the external auditory canal.
– MRI may provide additional information, as the
signal characteristics and/or enhancement pattern of
cholesteatoma are characteristic being low-signal intensity
on T1-weighted and a high-signal intensity on T2-weighted
images.
 Head, Neck and Spine 825
• Cholesterol Granuloma
– Expansile lesion arising from a pneumatized cavity which
becomes closed; the subsequent decrease in air pressure
causes edema, fluid accumulation and intralesional
bleeding; that promotes granulomatous reaction leading
to neovascularity and continuing hemorrhage.
– In the middle ear cavity, they usually arise in the context
of chronic otitis media; on otoscopy, this may give rise to
a blue tympanic membrane, suggesting the presence of a
vascular mass lesion.
– On CT images, a well-demarcated expansile lesion is seen,
indistinguishable from cholesteatoma.
– MR characteristics of cholesterol granulomas are
hyperintensity on both T1- and T2-weighted images (this
being due to their hemorrhagic components).
• Granulation Tissue
– Vascular reparative tissue, commonly seen in the middle
ear and mastoid, in conjunction with other diseases (such
as cholesteatoma) or in isolation.
– It may produce a bluish discoloration of the tympanic
membrane, causing clinical doubt as to the presence of a
true hypervascular lesion.
– On CT, granulation tissue causes opacification (linear
stranding) of the middle ear and mastoid without erosive
changes.
– On MRI, pronounced enhancement is seen after injection
of gadolinium.
– In rare cases, granulation tissue itself may behave
aggressively and cause bone erosion.

Neoplastic
Benign Tumor
• Glomus Tumor/Chemodectomas/Nonchromaffin
Paragangliomas/Glomerulocytomas (slow growing vascular
lesion arising from glomus body).
– Glomus tympanicum at the cochlear promontory.
826 Differential Diagnosis in Radiology
Table 8.2:  Middle ear masses
Tumor Location Imaging Comments
Aberrant in- Posterolat- Enhancing mass Protrusion in
ternal carotid eral to cochlea on postcontrast middle ear cavity
artery crossing mes- images and without a bony
otympanum continuous with margin
along cochlear carotid canal
promontory
Dehiscent Posteroinferior Enhancing mass Absence of bony
jugular bulb middle ear contiguous with plate between
jugular bulb jugular bulb and
middle ear
Cholestea- Usually in the Hypointense on Erosion of the
toma epitympanic T1W and hyper- epitympanic wall,
recess intense on T2WI esp. the scutum
and ossicles
Cholesterol Non-specific Hyperintense on Associated with
granuloma T1W and T2WI CSOM
Granulation Non-specific Linear strand- No bony erosive
tissue ing of middle changes
ear cavity with
enhancement
on postcontrast
images
Glomus tym- Cochlear Enhancing mass Inferior wall of
panicum promontory on postcontrast middle ear cavity
images with remains intact
erosion and
displacement of
ossicles
Glomus At the jugular Enhancing mass Destruction of
jugulare foramen on postcontrast inferior wall of
images with middle ear cavity,
destruction of roof of jugular
ossicles and fossa and bony
posteromedial spur separating
surface of pe- vein from carotid
trous bone artery

Contd...
 Head, Neck and Spine 827
Contd...
Tumor Location Imaging Comments
Meningioma Non-specific Enhancing mass Sclerosis of adja-
with remodeling cent bone
of bone
Malignant Non-specific Enhancing mass Histopathology is
masses as on post-contrast confirmative
squamous images with
cell carci- destruction of os-
noma, rhab- sicles and other
domyosar- adjacent bones
coma

• Appears as a globular soft tissue mass with intense post-

contrast enhancement
• It may cause erosion and displacement of the ossicles; however,
the inferior wall of the middle ear cavity is left intact.
– Glomus jugulare at the jugular foramen
• It causes invasion of the middle ear from below and destroys
the bony roof of the jugular fossa and bony spur separating
vein from the carotid artery
• There is intense postcontrast enhancement, destruction of
ossicles (usually incus), otic capsule and posteromedial surface
of the petrous bone
• MR imaging shows ‘salt and pepper appearance’ due to multiple
small tumor vessels
• Angiography is also diagnostic
• Malignant transformation with metastases to regional nodes is
seen in 2–4% cases
• Facial Neuroma
– It appears as a tubular mass in enlarged/scalloped facial
canal
• Choristoma
– Ectopic mature salivary tissue
828 Differential Diagnosis in Radiology
• Meningioma
– Extracranial meningiomas are rare
– Extracranial meningiomas are formed by direct extension
outside the skull of a primary intracranial meningioma, by
metastasis from a malignant intracranial meningioma, or
from extracranial arachnoid cell clusters which accompany
certain cranial nerves outside the cranium
– The imaging characteristics are similar to those of
intracranial meningioma: An enhancing mass lesion with
remodeling of the bone is seen; the neighboring bone may
appear very sclerotic.

Malignant Tumor
• Squamous Cell Carcinoma
– Appears as a soft tissue mass with variable enhancement
on postcontrast images.
– Destruction and displacement of ossicular chain and
adjacent bones.
• Metastases
• Rhabdomyosarcoma
– Commonest soft tissue tumor in children
– Appears as a bulky soft tissue mass with uniform postcontrast
enhancement producing bony destruction as well
– MR is the imaging modality of choice with the tumor
being intermediate in signal intensity on T1W images and
hyperintense on T2W images.
• Adenocarcinoma (rare), adenocystic carcinoma.

8.48  EXTERNAL ACOUSTIC MASSES

Causes
1. Keratosis obturans
2. Ext. auditory canal cholesteatoma
3. Malignant external otitis
 Head, Neck and Spine 829
4. Benign tumors
– Exostosis
– Osteomas
– Epidermoid/primary congenital
– Cholesteatoma.
5. Malignant tumors
– Squamous cell carcinoma
– Basal cell carcinoma
– Ceruminoma
– Rare
– Metastasis, myeloma.
– Osteosarcoma, chondrosarcoma.
6. Histiocytosis
7. Some middle ear masses may also extend.

Keratosis Obturans
• Usually occurs in individuals <40 years
• H/O sinusitis/bronchiectasis [Results in reflux sympathetic
stimulation of ceruminous gland of external auditory canal
(EAC)]
• Keratin plugs occlude the medial portion of EAC and the
adjacent bony canal is diffusely widened (Reflux hyperemia).

EAC Cholesteatoma (0.1 to 0.5% in EAC)

• Usually occurs in individuals >40 years
• Unilateral, chronic, associated with otorrhea
• Localized erosion of the canal wall with elevation of epidermis
by cholesteatoma embedded in the bony wall
• Formation of sequestrum and sinus tracts may be present
• Most common site is along the posteroinferior wall of EAC but
lateral to temporomandibular joint
• Exact cause—Unknown; periostitis of the bony canal.
830 Differential Diagnosis in Radiology

Malignant External Otitis

• Disease of elderly who are diabetic/immunocompromised
• Causative agent is usually pseudomonas, Staphylococcus and
Aspergillus
• Often begins in an insidious fashion at the osseocartilaginous
junction as a focal area of ulceration and osteitis of EAC. TM is
resistant to the infectious process
• Infection may spread—Parotid gland, TMJ, soft tissue of neck,
skull base/involvement of mastoid, petrous apex and middle
ear may also occur
• Intracranial extension can occur through the petro-occipital
synchondrosis
CT: Bone destruction and sequestrum, soft tissue edema.
Abscess in parapharyngeal spaces, intra-cranial invasion
MRI: Superior to CT for detection of marrow invasion and soft
tissue changes
In III WBC and Tc-99m SPECT—Best imaging approach to assess
the post-therapeutic response.

Exostosis
• Most common benign tumor of EAC
• Arises in the medial aspect of the osseous portion of the EAC
near tympanic annulus
• Seen in patients with prolonged exposure to cold sea water,
swimming pool water
• Seen as sessile multinodular bony masses. Unilateral or bilateral.

Osteomas
• Less common than exostosis
• Mastoid is the most common extracanalicular site
• Seen as solitary, U/L pedunculated growths of mature bone
located in the outer portion of the EAC.
 Head, Neck and Spine 831
Squamous Cell Carcinoma
• Most common malignant tumor of the ear
• H/O chronic external otitis is usually positive
• Tumor destroys the adjacent bone in the EAC and middle ear
and invades the surrounding tissue
• The most important CT finding suspected of carcinoma is
erosion of the walls of EAC/middle ear by a soft tissue mass in a
patient who does not have a history of cholesteatoma
• Predictor of poor outcome
– Extensive tumor, 8th nerve involvement, cervical/
periparotid LN.

Ceruminomas
Apocrine glands within the EAC are known as ceruminous glands.
Tumors arising from ceruminous glands:
• Ceruminous adenoma
– Rare–5th to 6th decade
• Pleomorphic adenoma
CT: soft tissue mass without bony destruction.
• Adenoid cystic carcinoma
• Mucoepidermoid carcinoma
• Ceruminous adenocarcinoma
• Most common.
CT findings are similar to squamous cell carcinoma except that
metastases to regional lymph nodes are more common.

Metastasis
• Hematogenous: Breast, prostate, lung, kidney and thyroid
• Direct spread: Skin, parotid, nasopharynx, brain and meninges
• Systemic involvement: Leukemia, lymphoma and myeloma
• These lesions present as diffuse/focal osteolytic destructive
pattern.
832 Differential Diagnosis in Radiology

Epidermoidomas
(Primary Congenital Cholesteatoma)
• Consists of masses of ectodermal rests (different from true
cholesteatomas whose formation is a reaction to inflammation
and trapped squamous epithelium)
• Seen as a soft tissue mass with widening of EAC.

Histiocytosis
• Primarily affects the pediatric age group
• In the temporal bone, EAC and mastoids are commonly
involved
• Patients present with otalgia and draining ear
• Cases are diagnosed only after treatment with antibiotic first to
cure a suspected middle/external ear infection
• Early imaging findings mimic inflammatory diseases beveled.
Bony destruction pattern is usually geographical with edge.
Enhancement of soft tissue may be homogenous or peripheral.

8.49  INTRAMEDULLARY LESIONS (FIG. 8.26)

• Intramedullary lesions are lesions of spinal cord.
• Tumors
– Most are malignant.
– 90–95%.
• Gliomas
– >95%
• Ependymomas
– Low-grade astrocytomas
– Oligodendroglioma.
• Less common
– Hemangioblastomas
– Paragangliomas
– Lipoma
– Epidermoid—rare
– Gangliocytoma
 Head, Neck and Spine 833

Fig. 8.26: Intramedullary lesions

– Metastasis
• Non-neoplastic cystic lesions
– Hydrosyringomyelia
– Hematomyelia
• Inflammatory diseases
– Multiple sclerosis
– Transverse myelitis
– Tuberculoma—rare
– Cysticercosis
– Intramedullary abscess
– Sarcoidosis.
• Infarct

Ependymoma
• Most common spinal cord tumor overall
• Most common intramedullary tumor in adults
• Arise from ependymal cells.
834 Differential Diagnosis in Radiology

Intramedullary
Most common—Cellular type—circumscribed, sharply.
• Most common site—cervical cord
• Mean age 43 years
– Cystic degeneration
• F>M
– Hemorrhage
• Typically—symmetric cord expansion
• Myxopapillary type exclusively in conus and filum terminale
• Mean age 28 years
– Slow growing, filling and expanding lumbosacral spinal
cord
– M > F hemorrhage and cystic degeneration—common
• C/F—back or neck pain, leg or sacral pain
• X-ray: Widened canal or bone destruction in 20%
• Myelography
– Nonspecific cord widening
– Multisegmental lesion
– Small conus medullaris or filum terminale lesions
– Well-delineated intradural mass with contrast meniscus
• CT
– Non-specific canal widening
– Posterior scalloping
– Neural foraminale enlargement.
• MRI
– Iso on T1 and hyper on T2
– Hypointensity at tumor margin on T2WI
– Cyst formation, hemorrhage, necrosis
– Enhance strongly following contrast administration.

Astrocytomas
• Second most common spinal cord tumor overall
• Most common cord tumor in children
• Usually low grade-fibrillary astrocytomas
• Anaplastic astrocytomas and glioblastoma multiforme
 Head, Neck and Spine 835
• Mean age at presentation –21 years (9 years–70 years).
• M=F
• Most common site—Cervical cord, and thoracic cord
– Multisegmental involvement
• Most common clinical feature—Pain
– Sign and symptom of neurological dysfunction, often
absent early in disease.

X-ray
• May be normal
• Widened interpedicular distance.

Myelography
• Nonspecific cord enlargement
• Canal widening
MRI—iso to hypo on T1, hyper on T2, enhance after contrast
• Intratumoral cyst formation and associated syrinx are common.

Hemangioblastoma
• 1–5% of cord tumors • 75% intramedullary
• Fourth decade • 1
 0–15% combined intra- and extra-
medullary (intradural)
• Most common site • Thoracic cord, cervical cord
(50%) (40%)
• Highly vascular nodule with an extensive cyst that diffusely
enlarges the cord with prominent leptomeningeal vessels.

C/F
• Sensory changes—typically impaired proprioception
• 1/3rd—associated with VHL disease
• Myelocord expansion with prominent dilated tortuous vessels
seen in 50% patients
836 Differential Diagnosis in Radiology
• Angiography—highly vascular mass with dense prolonged
tumor blush with prominent vessels
MR-cord expansion with high signal intensity on T2WI with
strong CE with prominent foci of high velocity signal loss.
• Cyst formation and syrinx—50–70%.

Oligodendroglioma
• Nonglial neoplasms
– Ganglioglioma
– Schwannoma—rare.

Lipoma
• Rare
• May be associated with dysraphism
• CT—fat density
• MR—high signal intensity on T1WI.

Epidermoid
• Rare
• Congenital or iatrogenic
• Usually oval-shaped lesions with variable signal intensity
depending upon contents.

Syringohydromyelia
• Fluid-filled cavity usually centered on the central canal +
extending into dorsal column through the white commissure.
• Cylindrical—involve most of the cord. May enlarge the cord
• Fusiform—usually segmental.
– 80% associated with Chiari-I malformation
– Most of the rest are idiopathic.
• Post-traumatic.
• Postarachnoiditis
 Head, Neck and Spine 837
• Above and below intramedullary tumors especially
hemangioblastoma
• Well shown by MRI—signal characteristics similar to CSF
• IV Gd may be necessary to exclude tumor in idiopathic cases
• Plain CT—May or may not reveal dilatation of central canal
• CT myelo early and delayed imaging after contrast administration
(6 or 10 hours)—Helps in diagnosis.

Hematomyelia
+ May or may not be associated with subarachnoid hemorrhage.
• Trauma
• SVM
– Spinal cord AVM most common course of nontraumatic
spinal hemorrhage
• Anticoagulant therapy
• Hemorrhage into cord tumor, syrinx, or hemorrhagic area may
be associated with inflammatory myelitis.
MRI—Aside from intramedullary hematoma and their primary
causative lesions, may show superficial hemosiderosis, seen as a
coat of marked hypointensity on T2WI.

Intramedullary Abscesses
• Very rare
• Usually associated with dermal sinuses
• Enhancement of the meninges after IV gadolinium contrast
can be helpful to indicate inflammation in some of the rare
conditions
• Enhancement is not seen with multiple sclerosis or acute
transverse myelitis
• Metastatic disease to the cord
– Rare
– Variable incidence—0.9%–8.5%
– Most common primary lung 40–85% of total metastatic
lesions
838 Differential Diagnosis in Radiology
• Breast carcinoma, melanoma, lymphoma, colonic Ca, kidney Ca
• Thoracic cord > cervical > lumbar
C/F Pain, weakness, paresthesias, bowel and bladder dysfunction
• Rapid clinical progression as compared to primary cord tumors
• Plain X-ray and myelography—usually normal
• Vertebral metastasis may or may not be associated
• MR—hypointense on T1 and hyperintense on T2—with or
without cord widening
• Usually central—hypointensity, on T1 which may be confused
with syrinx
• Contrast enhancement is present.
Note: Size of metastasis is disproportionately small compared to
the amount of the edema.

Infarction
• Usually involves long segment of the cord
• Shown only by MRI
• Usually intensified centrally
• Particular clinical setting
MC—after
– Thoracoabdominal aortic aneurysm repair
– Thrombosis of dural AVF and their draining veins.

8.50  INTRADURAL EXTRAMEDULLARY

MASSES (FIG. 8.27)
Intradural extramedullary masses arise inside the dura but outside
the spinal cord. Nerve sheath tumors and meningiomas account
for 80–90% of such masses. Other tumors are uncommon and
include paraganglioma, epidermoid, dermoid, arachnoid cysts and
meningoceles, lipoma, sarcoma, metastases and non-Hodgkin’s
lymphoma.
From a radiological point of view the classical myelographic
criteria are:
 Head, Neck and Spine 839

Fig. 8.27: Intradural extramedullary masses

• Widening of the subarachnoid space on the side of the mass

• Contralateral displacement of the cord and nerve roots away
from the mass
• Delineation of the mass by a sharp meniscus of contrast
abutting the lesion.
Nowadays, MRI is the modality of choice and clearly shows not
only the signs of cord displacement and CSF space widening but
also the lesion itself. Plain films may show bony changes when the
tumor has enlarged the spinal canal, erosion of the pedicle with
widening of the neural foramen, scalloping of the vertebral body.

Nerve Sheath Tumors

Nerve sheath tumors usually arise from dorsal roots, rarely
are entirely intramedullary, presumably from aberrant nerve
roots. They include schwannomas, neurofibromas and rare
ganglioneuromas and neurofibrosarcoma.
840 Differential Diagnosis in Radiology
Clinical symptoms are often similar to those of a disk herniation,
with pain and radiculopathy. When they compress the spinal cord,
myelopathic signs may be present.
• Nerve sheath tumors are the commonest intradural
extramedullary mass (25–30%) and are primarily seen in
middle-aged adults between the ages of 20 and 50 years, with
no predilection for either sex
• Schwannomas (Synonyms—neurinoma/neurilemmoma) are
typically lobulated, encapsulated masses; nerve fibers do not
course through them. They are slightly more common than
neurofibromas
• Neurofibromas are unencapsulated, typically fusiform and less
well-defined lesions. Nerve fibers course through them
• Nerve sheath tumors are variable in location: 70% are intradural
extramedullary, 15% are “dumb-bell” shaped tumors, and 15%
are extradural
• These lesions typically enlarge the adjacent neural foramen;
calcification within them is rare
• They are typically (75%) isointense on T1WI and the vast
majority is hyperintense on T2WI; virtually all exhibit marked
and homogenous enhancement with Gadolinium
• Other nerve sheath tumors such as ganglioneuroma or
neurofibrosarcoma are rare
• Multiple intraspinal neurofibromas and schwannomas are
pathognomonic of NF1 and NF2 respectively. Malignant
degeneration of neurofibromas and rarely schwannomas may
occur in NF.

Meningiomas
Meningiomas arise from arachnoid cluster cells located at exit
zones of nerve roots or entry zones of arteries. Slowly progressive
myelopathy is the most common clinical presentation with motor
and sensory deficits, sphincter dysfunction and pain.
• Meningiomas are second to nerve sheath tumors, in frequency,
accounting for 25% of all spinal tumors. They are, however,
 Head, Neck and Spine 841
much less common than intracranial meningiomas, the ratio
being 1:8
• Peak incidence is in the fifth and sixth decades. More than 80%
occur in women
• The thoracic spine is the most common site (80%) followed by
the cervical spine (15%). The lumbar spine is an uncommon
location
• Meningiomas may rarely calcify and can be seen also on plain
films and at CT
• On MRI, they are isointense on both T1- and T2-weighted
images and enhance markedly
• Most spinal meningiomas are benign and slow-growing
neoplasm. Ninety percent of spinal meningiomas are intradural,
whereas 5% each are “dumb-bell” shaped or extradural lesions
• Plain films are usually normal. Bone erosion is uncommon
(15%). Calcification is rare (1–5%)
• MR scans may demonstrate broad-based dural attachment; a
“dural tail” sign in some cases. Occasionally, densely calcified
meningiomas are markedly hypointense on MR and show only
minimal contrast enhancement
• A rare variant of spinal meningioma is meningiomatosis
characterized by diffuse involvement of the meninges
by the tumor. MR imaging demonstrates thick or nodular
enhancement, but is nonspecific. This variant carries a dismal
prognosis
• Another rare type of meningioma is angioblastic meningioma,
a significantly more aggressive type that carries the potential
for extraneural metastases and possibly subarachnoid seeding.
These contain a dense capillary bed and varied cellular element
including xanthomatous features with intracellular fat. This
results in varied signal intensity on T1WI, depending on the
amount of fat present, and generally increased signal on T2WI
because of the rich capillary bed.
842 Differential Diagnosis in Radiology

Embryonal Tumors
Embryonal tumors are a less common group, with the exception
of lipomas, which are probably the most common. Lipomas,
dermoids and epidermoids may present as primary intramedullary
mass lesions at the level of the spine. They are most frequently
recognized as intradural intramedullary lesions at or near the
conus medullaris in conjunction with dysraphic complexes.
• Lipomas
– Are characterized by the high-signal intensity on T1WI
which is less intense with more T2-weighting.
• Epidermoid cysts
– Are lined only by superficial epidermal contents of the skin
and are filled with keratinized debris and cholesterol.
– They are congenital or may be acquired as a result of
subarachnoid implantation of epidermal elements
following lumbar puncture or spinal surgeries.
– They are found in thoracic spine.
– They have signal characteristics that follow CSF on T1- and
T2WI and are detected on PD and FLAIR images on the
basis of their ‘cottage cheese’ appearance.
• Dermoid cysts
– Are lined by simple or stratified squamous epithelium
containing hair follicles, sweat glands, and sebaceous cysts
that secrete fatty material into the cyst.
– Approximately 80% are isolated masses and the rest are
associated with dorsal dermal sinuses.
– They display a variety of non-characteristic signal intensity
patterns with MR not only among different lesions but also
within the same tumor. This may be related to the physical
state (solid vs liquid) and lipid content (cholesterol vs fatty
acid) of the cyst.
 Head, Neck and Spine 843
Paragangliomas
• Usually found in the cauda equina and filum terminale
• They are usually isointense to spinal cord on T1WI and
hyperintense on T2WI. MRI may show a ‘salt-and-pepper’
appearance because of multiple areas of flow voids secondary
to hypervascularity.

Arachnoid Cysts
• Are common in mid and lower thoracic region, most commonly
located posterolaterally, displacing the cord anteriorly and
compressing it.
• They are believed to result from the proliferation of arachnoid
adhesions caused by trauma, hemorrhage, inflammation or
congenital abnormalities. They are accurately characterized
noninvasively by MRI.

Metastases
• May be in the form of single or multiple nodules or diffuse
subarachnoid seeding
• Medulloblastoma in pediatric age group and ependymomas
and glioblastoma in adults are the commonest intracranial
tumors producing CSF seeding followed by pineoblastoma,
germinoma, retinoblastoma and choroid plexus carcinoma.
Extracranial tumors seeding the meninges include the
carcinoma of the lung and breast, leukemia, lymphoma and
melanoma
• The overall sensitivity of unenhanced and enhanced MRI in
detecting intradural extramedullary metastases is only 19%
and 36% respectively in patients with CSF cytological findings
positive for neoplasia. So the CSF examination remains the gold
standard (despite the fact that the single CSF specimen is only
50% sensitive to drop metastases).
844 Differential Diagnosis in Radiology

Cysticercosis
• A parasitic infestation that can result in cysts within the
subarachnoid space
• Most cases are associated with extraspinal involvement
• These are most commonly seen in the thoracic region
• MRI reveals lesion with typical cyst-like intensity
• In addition, nonspecific cord changes resulting from arachnoiditis
can be seen characterized by an enlarged cord with irregular
margins on T1WI and focal increased signal on T2WI.

Lateral Thoracic Meningoceles

• Seen in association with NF-1 and Marfan’s syndrome
• They represent CSF outpouchings that extend into and enlarge
the neural foramina, containing both the dura and arachnoid,
and follow CSF signal intensity on MRI. No enhancement is seen
on postcontrast images.

Spinal Subdural Empyema

• Collection of pus in the subdural space
• It is a very rare event
• Different factors including the absence of veins, the filter action
of the epidural spinal space, and the centripetal direction of
spinal blood flow have been suggested to explain the rarity of
this event as compared to spinal epidural empyemas on the
one hand and to intracranial subdural empyemas on the other.

8.51  EXTRADURAL EXTRAMEDULLARY

LESION (FIG. 8.28)

Epidural Space
• Space between dura mater and bone
• Contains epidural venous plexus, lymphatic channels
connective tissue and fat.
 Head, Neck and Spine 845

Fig. 8.28: Extradural extramedullary lesions

• Classic myelographic feature is displacement of the thecal

sac away from bony walls of the spinal canal with extrinsic
compression
• If block-interface between lesion and contrast column is poorly
defined with “feathered” appearance of level of obstruction
• MR scan clearly shows the dura draped over the mass
• Crescent of epidural fat can be seen capping the lesion.

D/Ds
• Disk Disease
– Bulging disk
– Disk protrusion
– Herniated nucleus pulposus
– Sequestrated nucleus pulposus
• Inflammation
– Epidural abscess
846 Differential Diagnosis in Radiology
• Hematoma
– Post-traumatic
– Spontaneous
• Tumors
a. Benign
Nerve sheath tumor
Meningioma
Hemangioma
Epidural lipomatosis
Angiolipoma
Cysts
– Arachnoid cysts
– Synovial cysts
b. Malignant
Metastasis
– Adult
• Breast
• Lung
• Prostate
Lymphoma
– Children
• Ewing’s sarcoma
Neuroblastoma
Ewing’s sarcoma

Disk Bulge
• Loss of turgor of nucleus pulposus and loss of elasticity of
annulus fibrosis → disk bulges
• Decreased height of intervertebral disk space.

X-ray
• Vacuum sign
• Endplate sclerosis/osteophyte
 Head, Neck and Spine 847
NECT/MR
• Loss of (normal) posterior disk concavity
• Diffuse, non-focal protrusion of disk material beyond the
adjacent vertebral endplate.
Disk protrusion → Focal incomplete extension of contents of
nucleus pulposus through an incomplete tear of annulus fibrosis.
Disk herniation → Herniation of nucleus pulposus through an
annular defect causes focal protrusion of disk material beyond the
adjacent endplate.
Free disk or sequestrated disk → Disk material migrates inferiorly,
superiorly, medially or laterally.

Epidural Abscess
• Hematogenous dissemination → staphylococcus access
I. Phlegmonous stage: Thickened inflamed tissue with
granulomatous material and embedded micro­abscesses.
II. Frank abscess—with collection of liquid pus
Clinical features → Fever, local tenderness
• Predisposing condition → diabetes, IV drug abuse
Imaging → X-ray →
• Osteomyelitis
• Disk space narrowing
CT/MR/Myelo/CT myelo → extradural soft tissue mass with
extradural block
CE → Diffuse homogenous or slightly heterogeneous → 70% →
Phlegmonous stage.
• Thick/thin rim enhancement, 30% frank necrotic abscess

Epidural Hematoma
• Most common cause
– Trauma
• Spontaneous →
– Anticoagulation
– Vigorous exercise
848 Differential Diagnosis in Radiology
– Hypertension
– Vascular malformation
– Postsurgical
– Collagen vascular disorders
• Most common site → Upper thoracic region, in dorsolateral
aspect of spinal canal
CT → high density lentiform collection located adjustment to
neural arch
MRI → investigation of choice.

Hemangioma
• Slow growing benign neoplasm, 4th to 6th decades
• Most common site—vertebral body, 10–15% → Posterior
elements
• Most epidural → secondary to expansion of intraosseous lesion
• 1% → completely extraosseous.

C/F
• Most → Asymptomatic
• Pain → Due to pathological fracture
• Epidural mass
X-ray → Lytic lesion with honeycomb trabeculations or thick
vertical striation.
NCCT → Lytic lesion with typical Polka-dot densities in medullary
space
Myelo/CT myelo → Epidural mass
MR → Hyperintensity on T1WI and T2WI with foci of very low SI,
suggestive of thickened vertical trabeculae.
Show—Contrast enhancement.

Epidural Lipomatosis
• Excessive deposition of unencapsulated fat in epidural space
• Part of—Morbid obesity
– Associated with central or truncal lipomatosis
 Head, Neck and Spine 849
• M>>F
• 60% thoracic spine 40% in lumbar spine
Clinical features—weakness back pain
• Radicular pain, numbness
Myelo → (Normal) to extradural blocks
CT/MR→ Increased extradural fat with diminished subarachnoid
space.

Spinal Angiolipoma
Very rare—Mature adipose tissue with blood vessels
• Fifth decade, F > M
• MC → Thoracic spine
• Dorsal or dorsolateral to cord
Myelo → Extradural mass or block
CT → Low to intermdiate density, epidural mass showing contrast
enhancement
MR → Iso to hyper on T1 and hyper on T2
• Diffuse homogenous contrast enhancement → Typical.

Cysts
Extradural arachnoid cysts → CSF filled-out pouching of arachnoid
that protrude through dural defect.
• 2/3rd → Mid to low thoracic level
• 20% → Lumbosacral region
• Imaging studies show → long segment CSF equivalent
extradural mass that causes spinal cord
Compression or myelographic block
• Secondary bony changes → Widened interpedicular distance
• Scalloping of vertebral bodies
• Pedicle thinning/erosion
• Synovial (juxta-articular) cysts—Rare
– Associated with facet degeneration
850 Differential Diagnosis in Radiology

Malignant Lesions
Metastasis
• In adults from → Breast
– Lung → 50%
– Prostate
Other from → Lymphoma, Melanoma, Renal cancer, Sarcoma and
Multiple myeloma
In children
• Ewing’s sarcoma
• Neuroblastoma
• Pediatric tumors → invade via neural foramen causing a
circumferential cord compression
• Adult → initial site is in vertebral body with secondary
involvement of epidural space
• Lower thoracic and lumbar spine
X-ray →
• Pedicle destruction
• Multifocal lytic vertebral body lesion
• Sclerotic lesion → Breast/prostate
• Indistinct posterior vertebral body margin
• Paraspinal soft tissue mass
• Myelography—extradural blocks
• Bone scintigraphy → Sensitive
• NCCT → Lytic/blastic lesion, with epidural soft tissue mass
• Intrathecal contrast required to delineate precise extent of
lesion
• MR → exquisitely delineates epidural and paraspinal soft tissue
involvement
• Low signal on T1 and high signal on T2.

Lymphoma—NHL → 85%
• HL → Less common
• 40–60 years, M>>F
• Spinal extradural mass with nonspecific imaging findings
 Head, Neck and Spine 851
• NHL → can cause bone destruction and hyperostosis
• Epidural extension best delineated on MRI
• Ewing’s sarcoma → Children second decade M > F
• Non-specific findings
• Eroded vertebral body with paraspinal soft tissue mass
• Hypo- to isointense T1WI and hyperintense on T2WI.

8.52  D/D OF FLOATING TOOTH

Definition
The term “floating tooth” applies to a state where there is no
supporting bone or periodontal structures, the tooth, however,
maintaining it’s normal position.

Causes
A. Infective pathology
– Chronic osteomyelitis
– Acute osteomyelitis
B. Osteonecrosis
C. Malignant pathology
– Osteosarcoma
– Local extension of malignancy in nearby structures
– Burkitt’s lymphoma
– Histiocytosis
– Metastasis especially from lung, breast, kidney
– Multiple myeloma.
D. Others
– Fibrous dysplasia
– Cementoma and cemento-ossifying dysplasia
– Ossifying fibroma
– Hyperparathyroidism
– Severe periodontal disease.
852 Differential Diagnosis in Radiology

Salient Features
A. Acute Osteomyelitis
– Iatrogenic, traumatic, extension of pulpal infection or acute
exacerbation of chronic process
– Various forms may be seen as acute periapical abscess,
subacute abscess or Gum boil or chronic apical infection
– On Imaging: Earliest feature seen is widened periodontal
space (but this is non-specific)
– After 7–14 days definitive features like blurring of trabecular
pattern, loss of lamina dura and finally a periapical abscess
are seen. Associated sequestra and periosteal reaction may
be seen. MR shows marrow changes early or in association
to bony changes.
B. Chronic Osteomyelitis
– A persistent low-grade infection or an untreated or
inadequately treated infection
– It is usually the chronic suppurative osteomyelitis that
leads to “floating tooth”
– This is simply a more protracted form of the above disease
process and shows similar features.
C. Osteonecrosis
– Irradiation of developing tooth leads to hypoplasia of
both primary and secondary dentition. Also it leads to an
associated mandibular hypoplasia
– It further leads to reduction in salivary gland function and
more acidic, dry environment leading to increased chances
of dental infection
– Direct cell death caused by radiation leads to osteoporosis,
bone resorption, pathological fracture and associated
infection in a devitalized bone.
D. Osteosarcomas and other primary bone malignancies
– Osteosarcomas of jaw are rare lesions but have a very similar
appearance to that seen elsewhere. The age of occurrence
is 30–40 years and the prognosis is much better.
 Head, Neck and Spine 853
– Ewing’s sarcoma has an epidemiology and appearance
similar to that at other sites.
E. Metastasis
– Four times more common in mandible (posterior esp.) than
maxilla
– Breast, kidney, lung, colon, prostate, thyroid.
a. Localized lucent lesion
b. Moth-eaten lesion
c. Permeative lesion
F. Direct invasion
– Squamous cell carcinomas. Salivary gland tumors and
lymphomas can invade the dental sockets by direct
invasion.
G. Multiple myeloma
– Seen more commonly in mandible than metastasis.
– 30% of all cases involve the mandible.
– Skull >> mandible.
– Appearance is similar.
H. Burkitt’s lymphoma
– A condition occurring in maxillary bone/jaws of children in
equatorial Africa
– Probably Epstein-Barr virus
– Leads to large soft tissue mass with involvement of all
adjacent structures
– New bone formation may be seen.
I. Langerhan’s cell histiocytosis
– Multifocal resorptions of periapical bone and may be also
the tooth root
– Children <5 years, most common
– >50% of cases have jaw/dental involvement
– Hand-Schüller-Christian disease is the condition most
commonly forming such an appearance
– Geographic skull and vertebra plana are other associated
findings.
854 Differential Diagnosis in Radiology
J. Hyperparathyroidism
– Subperiosteal bone resorption (Lamina dura being
one such bone area) is a pathognomonic sign of
hyperparathyroidism
– Loss of lamina dura is always associated with changes in
hand and feet, Brown’s tumor, etc.
– These, though specific, are poorly sensitive indicators of
disease
– Now seen rarely due to early diagnosis and treatment.
K. Fibrous dysplasia
– A homogenous, hyperdense, enhancing and greatly
expansile lesion totally replacing the normal bone
– Both polyostotic and mono-ostotic forms involve mandible
and maxilla but mono-ostotic form involves maxilla slightly
more
– Craniofascial fibrous dysplasia is a specific form involving
>1 bone on one side
– Cherubism is a familial form of fibrous dysplasia involving
predominantly the mandible but also the maxillary
tuberosity.
L. Ossifying fibroma
– Mandibular molar/premolar region of women in 3rd/4th
decade
– Well-defined, well-circumscribed, expansile
– Initially lucent but later may become opaque
– If a lot of cementum is present, then maybe known as
cemento-ossifying fibroma.
M. Cementoma-cemento-ossifying dysplasia
– Are periapical lucent lesions that may lead to floating teeth.
– Cementoma is due to benign fibrous proliferation of
periodontal membrane that later becomes ossified.
 Head, Neck and Spine 855
8.53  CYSTS OF JAW
Classified into (Fig. 8.29):
1. Cysts of dental origin
a. Developmental
– Odontogenic keratocyst (Primordial cyst)
– Dentigerous cyst (follicular cyst)
b. Postinflammatory
– Radicular (apical) cyst.
2. Nondental/Developmental or fissural cyst
– Medial mandibular
– Medial maxillary
– Nasopalatine
– Globulomaxillary
3. Non-epithelialized bone cyst
– Simple bone cyst
– Aneurysmal bone cyst.

Odontogenic Keratocyst
• Follow cystic degeneration, enamel arises before the tooth is
formed, so cyst replaces the tooth
• More common in young men but seen in all ages

Radicular cyst Dentigerous cyst Primordial cyst

At apex of carious Related to crown Replacing the tooth
tooth of unerupted tooth
Fig. 8.29:  Types of cysts
856 Differential Diagnosis in Radiology
• Cortex is thinned and axial view shows expansion in buccal-
lingual plane
• Most common in posterior mandible and usually monolocular
• Usually keratinized and may react unless removed completely.

Dentigerous Cyst
• Cystic degeneration of enamel after formation but before
eruption of tooth
• Cyst related to crown of an unerupted tooth
• Seen in adolescents and young adults
• Permanent mandibular third molar and maxillary canine are
affected
• Usually unilocular
• If multiple, may be associated with Gorlin’s syndrome.

Radicular (Apical) Cyst

• Most common jaw cyst
• Lies directly upon the apex of a tooth
• Follow inflammation of bulb and apical bone
• Unilocular cyst with dense opaque margin continuous with
lamina dura or at periphery of cyst. Within the cyst, lamina dura
is destroyed
• Usually <1.5 cm and associated with carious teeth
• It persists after dental extraction—Residual cyst.

Medial Mandibular
Medial Maxillary
• Similar in appearance to radicular cyst but with normal teeth.

Nasopalatine
• Usually seen due to failure of obliteration of nasopalatine ducts
behind the central incisors.
 Head, Neck and Spine 857
Globulomaxillary
• These look like inverted pear and lie lateral of upper lateral
incisor and canine, the roots of which are diverged.

Simple Bone Cyst

• Usually follows trauma and is known as traumatic cyst
• In young patients, in posterior aspect of body of Mandible
• Diagnosis is usually histologic.

Aneurysmal Bone Cyst

• Not common in jaws
• Diagnosis is histologic.

Differential Diagnosis
Location
1. Lateral
More common
2. Medial/Midline
– Fissural or developmental
– Usually rare

Cystic Lesions of the Jaw

Benign
Dental origin
Developmental
Odontogenic Keratocyst (Primordial Cyst)
• Monolocular cyst that forms from cystic degeneration of tooth
enamel before tooth is formed
• Cyst replaces the tooth
• Common in young men and in posterior mandible
• Cyst demonstrates expansion with cortical thinning.
858 Differential Diagnosis in Radiology
Dentigerous Cyst (Follicular Cyst)
• Monolocular cyst related to the crown of unerupted tooth
• Common in adolescents/young adults and the permanent
mandibular third molar and maxillary canine are commonly
affected
• Multiple such cysts are associated with Gorlin’s syndrome.

Postinflammatory
Radicular Cysts (Apical)
• Unilocular cystic lesion associated with apex of a diseased tooth
• Dense sclerotic margins of the cyst are continuous peripherally
with lamina dura but, within the cyst, lamina dura is destroyed.
Non-dental
Developmental/Fissural cysts
– These occur at sites of fusion of embryonic processes and
include:
• Medial mandibular
• Medial maxillary
• Nasopalatine duct cyst
– Seen in 4th to 6th decades
– Asymptomatic cyst near anterior palatine papilla.
• Globulomaxillary cyst
– Seen between the lateral incisor and canine
• Nasolabial cyst arises in the soft tissues between the nose
and upper lip with resorption of adjacent maxilla.
Non-epithelialized bone cysts
Simple bone cyst
Traumatic cyst
• Seen in young patient following trauma
• Common in posterior part of body of mandible
• Are vaguely spherical but well-defined with thin sclerotic
margin
• May extend upward displacing the vital teeth.
 Head, Neck and Spine 859

B
Figs 8.30A and B: PA and lateral radiographs of mandible showing
ameloblastoma with floating tooth appearance
860 Differential Diagnosis in Radiology
Aneurysmal Bone Cyst
• Well-defined multilocular expansile cystic lesion uncommonly
seen in jaws
• May be secondary to fibrous dysplasia.
Brown Tumors
• Seen in hyperparathyroidism
• Commonly involves mandible
• Arises as a cystic lesion unrelated to tooth
• Associated loss of lamina dura.
Giant Cell Reparative Granuloma of Jaffe
• Soft tissue mass appearing like cyst with well-defined margin
• Common between 7th year and early 20s.
Malignant
• Ameloblastoma (Figs 8.30A and B)
• Common in middle-aged males in molar region of mandible
• Lesions are cystic, multilocular, expansile with thinning of
cortex with peripheral satellite defects.
Giant Cell Tumor
• Multilocular cystic lesion with expansion
• Rare in the jaws.
Burkitt’s Lymphoma
• Jaws are frequently affected with deformed face
• Multilocular cystic destruction beginning around the roots of
the tooth
• A “sun ray” type periosteal reaction may be associated
• Seen in childhood.

8.54  LOSS OF LAMINA DURA OF TEETH

Lamina dura is a layer of compact bone that lines the tooth
socket and provides anchorage for the fibers of the periodontal
membrane.
 Head, Neck and Spine 861
Causes
Generalized Localized
1. Endocrine/Metabolic 1. Infection
– Osteoporosis 2. Neoplasms
– Hyperparathyroidism – Leukemia
– Cushing’s syndrome – Multiple myeloma
– Osteomalacia – Metastases
2. Paget’s disease – Burkitt’s lymphoma
3. Scleroderma – Langerhan’s cell
Histiocytosis

Osteoporosis
• There is reduced bone mass of normal composition secondary
to either osteoclastic (85%) or osteolytic (15%) resorption
• Incidence is 7% of all women between 35 and 40 years of age
and 1 in 3 women of greater than 65 years of age.

Hyperparathyroidism
• Loss of the lamina dura surrounding the roots of the teeth is
an early manifestation of hyperparathyroidism, with alterations
in the jaw trabecular pattern characteristically developing next.
Not all teeth are affected
• There is a decrease in trabecular density, and blurring of the
normal pattern produces a “ground glass” appearance on the
radiograph
• With persistent disease, other osseous lesions develop, such
as the so-called “Brown tumor” of hyperparathyroidism. The
name of this lesion is derived from the color of the gross tissue
specimen, which is usually dark reddish-brown due to the
abundant hemorrhage and hemosiderin deposition within the
tumor
862 Differential Diagnosis in Radiology
• Radiographically, Brown tumors are unilocular or multilocular
well-demarcated radiolucencies, which commonly affect
the mandible, clavicle, ribs and pelvis. They may be solitary,
but more often are multiple. The long-standing lesions may
produce significant cortical expansion
• The value of loss of lamina dura as a radiodiagnostic sign is
poor
• All patients have hand changes, i.e. subperiosteal bone
resorption.

Cushing’s Syndrome or Hypercortisolism

• It results from a sustained increase in blood glucocorticoid
levels. This can be due to either corticosteroid therapy or
endogenous overproduction from the adrenal gland. Excess
ACTH from a pituitary tumor also causes hypercortisolism and
Cushing’s disease
• Associated osteoporosis is seen in the jaws. Pathological
fractures of the mandible, maxilla or alveolar bone may occur.
• Lamina dura may be poorly visualized or absent.

Osteomalacia
• There is accumulation of excessive amounts of uncalcified
osteoid with bone softening and insufficient mineralization of
osteoid
• There is poor visualization of the lamina dura.

Paget’s Disease
• In the jaw, bone enlargement and sclerosis are usually seen
• Irregular dense sclerotic patches may form on teeth, if any are
present or merely in what had been the teeth-bearing bone
• Mandible usually remains normal, either jaw can become very
large indeed
 Head, Neck and Spine 863
• Infection is the commonest complication and may be the
presenting lesion, especially in the mandible.

Scleroderma
• Also called progressive systemic sclerosis, it is a generalized
disorder of connective tissue of unknown cause.
• Many of the diverse clinical manifestations in this disease are
represented on radiographs as atrophy and calcification of
soft tissue and bone resorption. Frequently the abnormalities
predominate in the phalanges of the hand, although diffuse
subcutaneous calcification, widespread peri-articular
calcification, and bone resorption are encountered at other
sites, such as the mandible, the ribs and the clavicles. Joint
alterations include erosive arthritis and intra-articular calcific
collections
• On radiographs, hand alterations include soft tissue resorption of
the fingertips, subcutaneous calcification and bone destruction.
Erosion of the phalangeal tufts leads to pencilling, sometimes
with destruction of much or the entire distal phalanx
• Thickening of the periodontal membrane and mandibular
resorption may result in loss of the lamina dura and loosening
of the teeth
• Erosions may also occur on the superior aspect of multiple ribs.
In the spine, paraspinal calcification may be evident
• Joint involvement may be seen in the PIP and DIP joints, the
first CMC joints, the elbow, the inferior radioulnar joints of the
wrist, MCP and MTP joints, knee and hip
• Incidence is lower than in the axial skeleton.

Burkitt’s Lymphoma
• Occurs throughout the world but especially in equatorial Africa,
where it accounts for 50% of all childhood malignancies
• Jaws are frequently affected which deforms the face
• Lesions are multifocal
864 Differential Diagnosis in Radiology
• Destruction of bone begins around the roots of teeth, which
are then exfoliated
• New bone formation in these lesions gives a coarse, spiculated,
sun ray appearance.

Langerhan’s Sun Ray Histiocytosis

• LCH represents a spectrum of clinical disorders ranging from
a highly aggressive and frequently fatal leukemia-like disease,
affecting infants to a solitary lesion of bone
• The presence of alveolar bone loss in young children with
precocious exfoliation of primary teeth should suggest the
possibility of LCH. LCH can also occur in adolescents and adults
• Of the bones of the jaw, the mandible is the most frequently
involved. The presenting signs usually include pain, swelling,
ulceration and loose teeth
• Radiographically, the teeth often appear to be floating in air
surrounded by large radiolucent regions. This is due to rapid
alveolar bone loss
• The term ‘eosinophilic granuloma of bone’ is used when solitary
lesion is found, but multiple lesions may develop later
• Forming tooth-buds may be destroyed.

Infection
• Apical tooth abscess is the commonest cause of loss of lamina
dura
• Hyperemia and trabecular destruction are responsible.

Neoplasms

Leukemia
• Diffuse osteopenia is the commonest pattern, which is
responsible for the poor visualization of lamina dura
• Leukemic lines, which are the transverse radiolucent
metaphyseal bands can be seen in the long bones
• Associated periostitis of long bones infrequently encountered.
 Head, Neck and Spine 865
Multiple Myeloma
• The incidence of jaw involvement in multiple myeloma averages
about 15% and involvement of the mandible is commoner than
in metastases
• These lesions cause swelling of the jaws, pain, numbness,
mobility of teeth, and pathologic fracture
• Punched-out lesions of the skull and jaw are characteristic
radiographic findings
• This malignancy is associated with diffuse osteoporosis which
also contributes to the loss of lamina dura.

Metastases
• Overall, the most common primary site for metastases to the
jaw is the breast. In men, the lung is the most common primary
site for jaw metastases. The molar region of the mandible is the
most common bony site for metastasis.

8.55  OPAQUE MAXILLARY ANTRUM

Traumatic Inflammatory/ Neoplastic Miscellaneous

Infective
Fracture Sinusitis Carcinoma Fibrous dysplasia
Overlying Allergy Lymphoma Cysts
Soft tissue
Swelling
Postoperative Pyocele Mucosal Wegener’s Granulo-
(Caldwell-LUC) (Rare) Polyp matosis
Epistaxis Technical (Over-tilted
view)
Barotrauma Anatomical (Aplasia,
Sloping antral wall)
866 Differential Diagnosis in Radiology

Sinusitis
• Acute sinusitis produces an air-fluid level
• Chronic sinusitis can be due to aspergillosis, mucormycosis,
tuberculosis and syphilis. Fungal sinusitis is commonly seen in
diabetes mellitus. These produce hyperdense sinus secretions
as seen on CT usually with bone destruction.

Cysts in Antrum
• Mucous retention cyst
– Common complication of chronic sinusitis
– Maxillary sinus is the commonest site
– Often arises in the floor
– Commoner than polyp but cannot be differentiated from it
on imaging.
• Dentigerous cyst
– It is related to the crown of the unerupted tooth
– Expands into the floor of the antrum
– Involved tooth may be displaced into the antrum.

Neoplasms
• Polyps (Fig. 8.31)
– Complication of chronic sinusitis
– May extend up to the posterior choanae (antrochoanal
polyp)
– CT shows soft-tissue dense, minimally to mildly enhancing
masses
– MRI reveals hyperintense masses on T2WI
• Carcinoma
– Associated bony destruction is seen
– Soft-tissue mass extending beyond the limits of the antrum
– Calcification seen in cases of squamous cell carcinoma.
 Head, Neck and Spine 867

Fig. 8.31:  PA radiograph of PNS shows bilateral chronic

maxillary sinusitis with antral polyp on the right side

Wegener’s Granulomatosis
• Autoimmune disease
• Usually presents at 40–50 years of age
• Early mucosal thickening progresses to a mass with bone
destruction.

Fibrous Dysplasia
• There is sclerosis of the facial bones with or without expansion
(leontiasis ossea)
• Involvement of the face is usually asymmetrical
• Involvement of the skull may be seen.
868 Differential Diagnosis in Radiology

8.56  THYROID LESIONS

Increased Uptake of Radiotracer

• Grave’s disease
• Toxic multinodular goiter
• Toxic solitary nodule
• Dyshormonogenesis
• Hashimoto’s thyroiditis
• Following recovery from subacute thyroiditis or antithyroid
drug therapy.

Grave’s Disease
• It is a very common cause of hyperthyroidism
• The disease tends to occur in a younger age group than does
toxic nodular goiter
• The scan findings are quite characteristic. The radioiodine
uptake is considerably elevated with 24 hours uptake values
considerably in 60 to 80% range and sometimes higher
• If dynamic range acquisition is performed following intravenous
pertechnetate administration, very intense flow to the thyroid
will be seen
• The distribution of tracer within the thyroid is typically very
homogenous
• Routine thyroid imaging demonstrates an enlarged gland,
that is usually rather symmetric. An enlarged pyramidal lobe is
frequently present.

Toxic Multinodular Goiter

• Toxic multinodular goiter is a common cause of hyperthyroidism
in older individuals with a peak incidence in the fourth and fifth
decades, which is later than that of Grave’s disease
• The scan usually demonstrates irregular enlargement of the
thyroid without a prominent pyramidal lobe
 Head, Neck and Spine 869
• Tracer distribution within the gland is very heterogenous with
varying regions of uptake present
• Frequently discrete hot and cold regions can be identified even
in the presence of hyperfunctioning nodules, the remainder of
the thyroid may not be suppressed because of the autonomy
present within it.

Hashimoto’s Thyroiditis
It is a chronic inflammatory process of the thyroid
• F > M, may occur at any age, with peak incidence in fourth and
fifth decades
• The gland typically is enlarged with patchy traces distribution
throughout the gland.
A prominent pyramidal lobe is frequently seen
• Hashimoto’s thyroiditis commonly leads to hypothyroidism
• Radioiodine uptake is variable, but is frequently low
• In some instances, Hashimoto’s thyroiditis is associated with
thyrotoxicosis (called Hashitoxicosis) and they may demonstrate
markedly increased radioiodine uptake.
Dyshormonogenesis: In the presence of defective thyroid hormone
production.

Increased TSH Levels

• Increased TSH levels may lead to adenomatous hyperplasia of
thyroid, associated with hot thyroid nodule on thyroid scan
• These TSH dependent lesions will involute following
administration of exogenous hormones.

Toxic Solitary Nodule

• It may be TSH dependent (adenomatous hyperplasia) or
independent (adenoma)
• Adenomatous hyperplasia if associated with increased TSH
levels
870 Differential Diagnosis in Radiology
• Toxic adenoma is associated with decreased TSH level, with
partial or total suppression of remainder of gland
• Rarely malignant thyroid nodule may show increased tracer
uptake.

Hot Thyroid Nodule

• A hot nodule concentrates traces more rapidly than does the
adjacent normal thyroid
• They are seen in 8% of Tc-99m pertechnetate scans.

Causes
1. Adenoma
a. Autonomous adenoma
• Hot nodule
• TSH independent
• Associated with decreased/normal TSH level
• Patient can be hyperthyroid or euthyroid
• Partial or total suppression of remainder of gland.
b. Adenomatous hyperplasia
• Hot nodule
• TSH dependent
• Associated with increased TSH level secondary to
defective thyroid hormone production.
Note: These nodules can be further evaluated by performing
a suppression test. By following administration of exogenous
thyroid hormone:
• An autonomous nodule deep in the lobe will become visible
as extranodular uptake is suppressed, and the nodule may be
more easily palpable as the gland shrinks
• Any TSH-dependent lesion will involute with exogenous
hormone administration. Although the nodule may not be
visible on scan, its diminution in size, or actual absence on
palpation at the time of follow-up may be just as diagnostic.
Those nodules that persist following suppression without
activity present are treated as cold nodules.
 Head, Neck and Spine 871
2. Thyroid carcinoma (extremely rare)
– Shows discordant uptake.
Note: Any hot nodule on Tc-99m scan must be imaged with I-123
to differentiate between benign or cancerous lesion.

Discordant Nodules
• Most cold nodules lack the ability to either trap or organify iodine.
In a small percentage of tumors, however, the organification
is blocked, but the trapping function is intact, such a nodule
will be hyperfunctioning on Tc-99m pertechnetate scan and
hypofunctioning on I-131 scan, which indicates reduced
organification capacity
• A nodule that is hot on technetium scanning reflecting trapping,
but cold on iodine scanning because of absent organification,
may represent either a benign or malignant lesion
• Malignant
– Follicular/papillary carcinoma
• Benign
– Follicular adenoma/adenomatous hyperplasia.

Cystic Lesions of Thyroid

• Thyroglossal duct cysts
– Appears in the midline along the migratory path of the
embryonic thyroid gland anywhere from the foramen
cecum at the base of the tongue to the lower neck
• Characteristically moves with protrusion of tongue and
swallowing.
– Usually cystic, these thyroglossal duct cysts can become
infected and develop increased echogenicity but rarely
develop thyroid papillary carcinoma
– On CT, most cysts are isodense to water. However, they may
be hyperdense when there is high protein content
– MR imaging—hypointense on T1WI and hyperintense on
T2WI. When cyst contents are proteinaceous, the cyst may
be hyperintense on T1WI and intermediate to hyperintense
on T2WI
872 Differential Diagnosis in Radiology
– Characteristically shows thin peripheral rim enhancement
of cyst well. Thick peripheral enhancement is unusual
unless cyst is secondarily infected.
• Simple cyst
– True epithelial cysts are rare (<1% of all thyroid masses)
– They are smooth-walled anechoic masses with posterior,
acoustic enhancement.

Degeneration of Adenomatous Nodules

• Most cystic thyroid masses are degenerating adenomatous
nodules
• These are not true epithelial-lined cysts
• May contain bloody fluid, chocolate-colored fluid or
xanthochromic fluid, depending on the age of the degeneration
of the blood products
• On USG-anechoic with thin walls and posterior acoustic
enhancement
• The presence of a ‘Comet-tail sign’ on USG has been said to be
highly specific sign of benign colloid nodule
• Low density on CT and hyperintense on T2WI and decreased or
increased signal intensity on T1WI
• Increased signal intensity on T1WI is related to the presence of
hemorrhage, colloid or increased protein content.

Cystic Papillary Carcinoma

• Any cystic thyroid mass with a solid component must be
approached with suspicion for malignancy (especially papillary
carcinoma) although a completely cystic nodule with uniformly
thin walls is almost always benign
• Cystic papillary carcinomas show a predominantly liquid con-
tent, with one or more solid, irregularly marginated projection
in the lumen, each generally containing microcalcifications and
central branching blood supply.
 Head, Neck and Spine 873
Thyroid Abscess
• Less common
– Clinical features of fever, pain, tenderness.
– Ultrasound—ill-defined/well-defined hypo to anechoic
lesion with thick irregular shaggy wall with internal debris.

Cold Nodules
• All nodules that cannot be demonstrated to function are
considered cold.
• Causes
A. Benign tumor
– Non-functioning, adenoma
– Cysts (11-20%)
– Involuting nodule.
B. Inflammatory mass
– Focal thyroiditis
– Granuloma
– Abscess
C. Malignant tumors
– Carcinoma
– Lymphoma
– Metastasis.
• All thyroid carcinomas will be cold, as will be lymphoma and
metastatic disease. Many benign nodules, as enlisted above,
will also be cold. Because of the relative frequencies of these
abnormalities, the vast majority of cold nodules are benign.
Although the specificity of finding a cold nodule on scan is low,
it does permit trial of the patient into a diagnostic pathway
in which tissue diagnosis is needed to exclude the presence
of malignancy. The true incidence of carcinoma in non-
functioning nodules is difficult to determine, but probably lies
somewhere near 6 to 20% range
• However, in an attempt to provide more definitive diagnosis,
the following feature may be helpful:
874 Differential Diagnosis in Radiology
– Ultrasound can easily identify a cystic lesion as a well-
defined anechoic lesion, with thin wall showing posterior
acoustic enhancement. The presence of a Comet-tail sign
on ultrasound has been said to be a highly specific sign of
a benign colloid nodule
• There are no specific imaging features to differentiate the
varying inflammatory processes that affect the thyroid gland.
Acute suppurative thyroiditis is rare, particularly affecting
the children. It may be associated with fourth branchial cleft
anomaly. The patient will present with painful thyroid swelling
and fever. Abscess formation is common and the role of
ultrasound is to confirm this, demonstrate it’s boundaries and
it’s relationship to the major neck vessels.
• Papillary carcinoma
– F>M, younger age group
– Slow growth with good prognosis
– USG characteristics
• Hypoechoic (90%)
• Microcalcifications (85–90%)
• Hypervascular (90%) with widespread internal flow.
– Nodal metastasis (50–55%), which can show the same
features as the primary lesion
– Can be echofree, owing to serous cystic contents.
• Follicular carcinoma
– F>M, older age group
– Nonspecific feature that suggests follicular carcinoma
are irregular tumor margins, a thick, irregular halo, and a
tortuous or chaotic arrangement of internal blood vessels
on color or power Doppler.
• Sonographic features of medullary carcinoma are similar to
that of papillary carcinoma (low reflectivity, irregular margins,
microcalcifications and hypervascularity)
• Anaplastic carcinomas are often associated with papillary
or follicular carcinomas, and presumably represent a
differentiation of the neoplasm. They tend not to spread
 Head, Neck and Spine 875
via lymphatics, but are prone to local aggressive invasion of
muscles and vessels. Low reflectivity and signs of invasion or
encasement of large blood vessels and neck muscles are the
most distinctive sonographic features of anaplastic carcinomas.
– When they are not adequately imaged and staged with
ultrasound, CT or MRI scans are performed to define the
extent of the disease.

Lymphoma
• Accounts for about 4% of all thyroid malignancies
• Mostly of non-Hodgkin’s type, affects older female
• The typical finding is a rapidly growing mass which may cause
symptoms of obstruction such as an dyspnea and dysphagia
• Seventy to eighty percent of cases arise from a pre-existing
chronic thyroiditis (Hashimoto’s disease), with subclinical or
overt hypothyroidism
• More commonly present as a solitary mass, but multiple
nodules may be seen
• On USG-lymphoma of thyroid appears as an echo-poor lobu-
lated mass, that is nearly avascular. Large areas of cystic necrosis
may occur, as well as encasement of adjacent neck vessels
• Diffuse involvement may cause thyroid enlargement with little
detectable abnormality, or a heterogenous pattern may be
seen in the adjacent thyroid parenchyma due to associated
chronic thyroiditis
• There may be associated cervical lymphadenopathy.

Metastasis
• Metastatic disease involving the thyroid is uncommon
• The common primary sites include melanoma, breast and renal
cell carcinoma.
876 Differential Diagnosis in Radiology

DECREASED OR NO UPTAKE OF RADIOTRACER

A. Blocked trapping function
1. Iodine load (most common)
2. Exogenous thyroid hormone (replacement therapy)
B. Blocked organification
1. Antithyroid medication/goitrogenic substances
C. Diffuse parenchymal destruction
1. Subacute/chronic thyroiditis
D. Hypothyroidism
1. Congenital hypothyroidism
2. Surgical/radioiodine ablation
3. Thyroid ectopia.

Iodine Load
• Previous administration of iodine-containing medications
is the most common extrinsic factor for decreased uptake of
radiotracer. Extrinsic iodine administration will depress the
thyroid uptake for a variable period, regardless of the thyroid’s
functional status
• If thyroid uptake is markedly reduced because of previous
iodine exposure, little diagnostic information can be obtained
from the scan. Therefore, all the patients should be screened
prior to radioisotope administration.

Exogenous Thyroid Hormone

• It is another frequent cause of decreased tracer uptake. In
some cases, thyroid suppression scans are intentionally
performed in the evaluation of nodules. At other times,
however, unintentional thyroid suppression scans are likely
to be performed, either because of patients’ confusion about
discontinuing medication
• Administration of thyroid hormone (factitious hyperthyroidism)
 Head, Neck and Spine 877
• Very rarely, functioning ectopic thyroid tissue, such as struma
ovarii or functioning metastatic thyroid cancer will cause
thyroid suppression
• Antithyroid drugs—Antithyroid drugs, such as Propylthiouracil
(PTU), or methimazole, block organification and will decrease
radioiodine uptake.
However, pertechnetate uptake will not be affected and useful
information can be obtained from Tc-99m scans in selected
instances.

Subacute Thyroiditis
• Supposed to be caused by viral infection
• These patients usually present with a painful, tender and
enlarged thyroid, and signs of hyperthyroidism are frequently
present secondary to an outpouring of thyroid hormone into
the blood) from the inflamed thyroid
• The natural history is variable, but over the subsequent weeks
to months, the hyperthyroid phase is succeeded by euthyroid
and sometimes hypothyroid stages, before the gland recovers
and functioning returns to normal
• Initially the gland is inflamed and functions poorly with very
low radioiodine uptake, as the patient progresses through the
hypothyroid and recovery phases, the radio-iodine uptake
gradually increases to the normal range in some patients
transiently rising above normal.

Congenital Hypothyroidism
• Scintigraphy is helpful by demonstrating the absence of thyroid
tissue, which is the underlying problem in 30-40% of cases
• Ectopic thyroid tissue may be seen in 40-50% of cases, most
commonly seen as a nodule or mass at the base of the tongue
• In the latter case, increased tracer uptake is present at the
foramen caecum of the tongue and there is absence of the
normal uptake in the neck.
878 Differential Diagnosis in Radiology

Ectopic Thyroid
• Ectopic thyroid tissue may lie along the line of thyroglossal
duct cyst or adjacent to it
• The presence of ectopic thyroid tissue decreases tracer uptake
in the normal thyroid gland. The ectopic thyroid tissue may co-
exist with normal thyroid gland, and, in some cases, the ectopic
tissue may be the only functioning thyroid gland
• Most commonly ectopic thyroid tissue presents in childhood as
nodule or mass at the base of the tongue.

Solid Thyroid Nodule

A. Benign
– Adenomatous hyperplasia (50%)
– Follicular adenoma (20%)
– Ectopic parathyroid adenoma
– Hemorrhage/hematoma: Frequently associated with ad-
enomas
– Abscess
B. Malignant
– Thyroid carcinoma
– Lymphoma
– Metastasis from breast, lung, kidney, malignant melanoma
C. Hürthle cell tumors.

Adenomatous Hyperplasia
• Most commonly observed pathology of thyroid gland
• May be familial (disorders of hormonogenesis)
– Iodine deficiency (endemic)
– Compensatory hypertrophy (secondary to hypoplasia of
one lobe or partial thyroidectomy)
• F>M: 3:1
• May be diffuse or nodular
• Diffuse hyperplasia results in enlargement of one on both lobes
 Head, Neck and Spine 879
• Nodular hyperplasia is usually seen as multiple discrete
nodules, varying greatly in number and size, separated by
normal parenchyma
• The typical hyperplastic nodule is of the same reflectivity as
the normal gland, with a regular and complete peripheral halo,
which is probably caused by perinodal blood vessels and mild
edema or compression of adjacent normal parenchyma.

Adenoma
• Adenomas represent 5–10% of all nodular diseases of the
thyroid
• F:M = 7:1
• A minority of adenomas is hyperfunctioning, develops
autonomy, and may cause thyrotoxicosis (Plummer’s disease)
• Follicular adenomas, which are much more frequently
encountered than non-follicular adenomas, are true thyroid
neoplasms, characterized by compression of adjacent tissue
and fibrous encapsulation
• Thyroid adenomas may be of low, normal or increased
reflectivity usually with a thick and smooth peripheral echo-
poor halo, owing to the fibrous capsule and blood vessels
• Often vessels pass from the periphery to the center of the
lesion, creating a “spoke and wheel” appearance.
Malignant lesions are discussed with cold thyroid nodules.

Hürthle Cell Tumors

• Very rare
• They have been considered benign lesions in the past but may
exhibit malignant characteristics with metastatic spread to
lymph nodes and lung. This is seen more frequently (80%) in
lesions measuring greater than 4 cm in diameter
• These lesions are of mixed echogenicity on USG, usually solid
and often ill-defined with no calcification
880 Differential Diagnosis in Radiology
• Currently no single ultrasound criterion can distinguish benign
from malignant thyroid nodules with complete reliability.
However, some features almost unique for benign goitrous
nodules are:
• A thoroughly cystic appearance
• Moving Comet-tail artifact
• Fluid-fluid levels
• Widespread cystic appearance in isoechoic or highly echogenic
nodules
• Highly reflective nodules
• A perilesional thin, uniform thickness, echo-poor halo
• Well-defined and regular margins
• Peripheral egg-shell-like or large coarse calcifications
• A perilesional blood flow pattern
• If most of these signs are found in a thyroid nodule, the
diagnosis of benign disease is highly reliable
• Conversely the possible ultrasound signs for malignancy are:
– Low reflectivity
– Irregular margins
– Thick irregular halo
– Intranodular blood flow pattern
– Microcalcification
– Hypervascularity
– Invasion of vessels and adjacent structures
– Vessel encasement
• The most reliable of these signs for detecting malignancy are
microcalcifications and the infiltration of structures adjacent to
the thyroid gland.

Thyroid Calcifications
• Calcifications can be seen in both benign and malignant lesions
of thyroid
• Benign calcifications are seen as stromal calcifications in
adenoma or in patients with multinodular goiter
 Head, Neck and Spine 881
• Benign calcifications are peripheral or egg-shell-like, usually
coarse and scattered throughout the gland, unlike the clustered
fine calcifications (microcalcifications) which are more typical
of malignant nodules
• Microcalcifications (<1 mm) occur in 54% of thyroid neoplasms,
and are most commonly seen in papillary carcinoma of thyroid.
Microcalcifications can also be seen in medullary carcinoma of
thyroid.
CHAPTER 9

Obstetrics and
Gynecology

9.1  D/D BETWEEN BLIGHTED OVUM AND

PSEUDOGESTATION OF ECTOPIC PREGNANCY

Blighted ovum Pseudogestation of

ectopic pregnancy
(Fig. 9.1)

1.  Uterine size Usually normal May be enlarged

2. Gestation sac with Present Absent

double decidual
sac sign

3.  Yolk sac +/– Absent

4.  Fetal node Absent Absent

5.  Other criteria GS size MSD >2 cm Adnexal mass

with no yolk sac; MSD
>2.5 cm with no fetal
node; Rate of increase
in MSD <1 mm/day

6. Peritrophoblastic Present Absent (Present

flow around uterus (PSV >21 cm/sec) around adnexal
mass)
 Obstetrics and Gynecology 883

Fig. 9.1:  Pseudogestation with free fluid

9.2  D/D BETWEEN ECTOPIC PREGNANCY,

ABORTION IN PROGRESS (EARLY GESTATION)
NABOTHIAN CYSTS

Ectopic pregnancy Abortion in Nabothian cysts

progress
1.  Pregnancy test +ve +ve –ve
2.  Uterine size May be increased May be Normal; cervix
increased may be bulky
3. GS/double de- Absent Present Absent
cidual sac sign
in uterus
4. Fetal node in Absent Present Absent
uterus yolk sac
5.  Cervical os Closed Open Closed
6.  Adnexal mass Present Absent Absent
(Except
for Corpus
luteum cyst)
884 Differential Diagnosis in Radiology

9.3  D/D BETWEEN PARTIAL MOLE, IUFD WITH

HYDROPIC PLACENTAL DEGENERATION, TWIN
PREGNANCY (MOLE AND FETUS)

Partial mole IUFD with hy- Twin pregnancy

dropic placental
degeneration
1. Uterine Corresponds to May be smaller for Larger for dates
size dates dates
2. Placental Normal tissue Normal tissue with One normal
appear- with many small few cystic lesions placenta and
ance cysts (<15mm) one with multiple
cystic lesion
3. Fetus Abnormal either Fetus and placen- One normal fetus
(structur- blended /adja- ta seen separately seen/2 fetal poles
ally) cent to placental seen
tissue
β-hCG
4.  Highter than Lower than Very much higher
levels normal for GA expected for GA for GA

9.4  D/D BETWEEN PELVIC MASSES, EXTRUD-

ED FETAL PARTS WITH UTERINE PERFORA-
TION; (FIG. 9.2) ECTOPIC PREGNANCY
(POSTPARTUM/INTERVENTION)

Pelvic Extruded fetal parts Ectopic pregnancy

abscess
1. Uterine Normal/ Small for GA with May be enlarged
size enlarged breach in uterine wall
2. USG- Complex Fetal bones with Adnexal mass which
appear- echogenic acoustic shadowing is heterogenous
ance mass
3. β-hCG Falling titers Falling titers/normal Higher than GA
level for GA
4. Uterine Empty/Pus Fetal parts/only liqor Pseudosac (Fluid in
cavity uterine cavity)
 Obstetrics and Gynecology 885

Fig. 9.2: Perforation of lower uterine segment with

extension of fetal bones into cul-de-sac

9.5  D/D OF A PRESACRAL FETAL MASS

Causes
1. Sacrococcygeal teratoma.
2. Chordoma.
3. Anterior myelomeningocele.
4. Neurenteric cyst.
5. Neuroblastoma.
6. Sarcoma.
7. Lipoma.
8. Bone tumor.
9. Lymphoma.
10. Rectal duplication.
Differentiation between sacrococcygeal teratoma/anterior
myelomeningocele and other presacral masses is easily achieved
by biochemical tests as amniotic fluid alpha-fetoprotein and
acetylcholinesterase levels are increased in the former two.
886 Differential Diagnosis in Radiology

Sacrococcygeal Anterior sacral

teratoma myelomeningocele
1. USG- Soft tissue mass with Soft tissue mass with nerve
Appear- calcified foci roots and spinal cord travers-
ance –  Mixed and solid (85%) ing the mass, devoid of any
–  Cystic (15%) calcifications
2. Liqor Polyhydramnios (2/3) Polyhydramnios
volume Oligohydramnios (1/3)
3. Fetal Normal/destroyed Defect in spine with widened
spine spinal canal diameter
4. Location Most commonly, dorsal Presacral
to spine (47%); Presacral
only in 10%
5. Ass­ NF-I; Marfan’s syndrome, Spinal dysraphism, sacral
ociated Partial sacral agen- agenesis, dislocation of hip,
anoma- esis’ imperforate anus, hydronephrosis, Potter’s
lies stenosis, tethered spinal syndrome imperforate anus,
cord, GU tract/colonic fetal hydrops, placentomegaly,
anomalies curvilinear sacrococcygeal
defect

Fig. 9.3:  Cystic hygroma

 Obstetrics and Gynecology 887
9.6  FETAL NECK MASSES

Causes
1. Neural tube defects
– Occipital cephalocele
– Cervical
– Myelomeningocele
2. Cystic hygroma (Fig. 9.3)
3. Teratoma (Dermoid)

Neural Cystic defects Teratoma

tube hygroma

1. USG- Soft tissue Multiseptate, Complex mass

Appearance mass anechoic mass containing echo-
with thick midline genic components,
septum some with acoustic
shadowing; pre-
dominantly solid on
10–31% and purely
cystic in 9–15%

2. Skull and Present Absent Absent

spine defects

3. Other Brain Chromosomal Associated with

associations anomalies defects as Trisomy thyroid gland
21; Turner’s
syndrome, fetal
hydrops; may
be associated
with fetal alcohol
syndrome and
multiple pterygium
syndrome
888 Differential Diagnosis in Radiology

9.7  D/D OF FETAL RENAL CYSTIC DISEASES

Multicystic Obstructive Autosomal Autosomal
dysplastic cystic renal recessive dominant
kidney dysplasia polycystic polycystic kid-
(MCDK) kidney disease ney disease
(ARPKD) (ADPKD)
1. Renal Usually Variable (nor- Enlarged Enlarged
size enlarged mal, increased,
decreased)
2. Reni- May be May be Preserved Preserved
form deformed deformed
shape
3. Renal Multiple of Multiple in sub- May be seen, May be seen,
cyst variable capsular region/ usually too usually too
size cortex small to be small to be
resolved by resolved by
ultrasound ultrasound
4. Dilated Absent May be present Absent Absent
PC sys-
tem
5. Lateral- Unilateral Usually Bilateral Bilateral
ity 80% Bilat- 20%
eral Bilateral
6. Normal Absent Usually present Present but no Present but
renal around the cyst CM differentia- no CM dif-
paren- with some corti- tion ferentiation
chyma cal parenchyma

7. Inherit- Sporadic NA Autosomal Autosomal

ance recessive dominant (so
one of the
parents is
affected)
8. Associa- Contralat- Most commonly With hepatic May be a part
tion eral reveal with urethral fibrosis, pulmo- of VHL, tuber-
abnormali- obstruction nary hypo- ous sclerosis
ties as UPJ plasia, Jeune’s
obstruc- syndrome,
tion, Meckel-Gruber
agenesis, syndrome
hypoplasia,
MCDK
 Obstetrics and Gynecology 889
9.8  D/D OF VARIOUS FETAL ANTERIOR
ABDOMINAL WALL DEFECTS
Gastroschisis Omphalocele Limb body Bladder/
wall cloacal
complex exstrophy
1. Location of –R
 t. para- Midline cord Lt. side Midline,
defect umbilical insertion site lateral defect infraum-
bilical
2. Size of Small Variable Large Variable
defect (2–4 cm) (2–10 cm)
3. Covering- Absent Present Present, Variable
membrane Contiguous
with placenta,
Umbilical
cord absent
4. Contents Usually small Usually liver Evisceration Blad-
bowel and at but at times of abdominal der wall
times large with bowel viscera espe- eviscera-
bowel, stom- cially liver tion with
ach and solid or without
viscera bowel
5. Bowel com- Present Absent Absent Absent
plication (usually),
including Present with
thickening ruptured
of wall and membrane
dilatation
6. Cardiac Rare Common Common Uncom-
anomalies mon
7. Other Rare Common Common GUT and
anomalies (Related) to –Limb de- spinal
GUT, CNS, fects anomalies
musculo- –Internal
skeletal organ mal-
formation
–Scoliosis
–Craniofacial
anomalies
8. Chromo- Common — Variable
somal (Trisomy
abnormali- 13,18,21)
ties
890 Differential Diagnosis in Radiology

9.9  D/D BETWEEN RENAL CYSTS AND

HYDRONEPHROSIS

Renal cyst Hydronephrosis

1. Size Variable size Uniform size
2. Alignment Nonspecific Aligned anatomically
3. Communica- Absent Communicate with dilated
tion renal pelvis
4. Shape Round to oval Tapering toward renal pelvis
5. Reniform May be distorted Usually preserved
contour of
kidney
6. Renal paren- May be present/ Present peripherally
chyma absent depending
on location

9.10  D/D OF CYSTIC ADNEXAL MASSES

1. Ovarian Causes
a. Physiological ovarian cyst
b. Functional/retention cyst
c. Endometrioma
d. Dermoid cyst
e. Serous/Mucinous cystadenoma/cystadenocarcinoma
f. Hyperstimulation cysts
g. Massive ovarian edema.
2. Tubal Causes
– Hydro/Pyosalpinx.
3. Tubo-ovarian
– Abscess
– Ectopic pregnancy.
4. Miscellaneous
– Peritoneal inclusion cyst
– Para-ovarian cyst.
 Obstetrics and Gynecology 891
9.11  D/D OF BENIGN AND MALIGNANT
OVARIAN MASSES

Benign Malignant
1. Size Small;<5 cm Large; >10 cm
2. Contour Well-defined with thin walls Ill-defined with thick
walls
3. Internal arc­ Cystic with thin septations Solid/Complex with
hitecture solid mural or papil-
lary projections with
thick septations
4. Doppler Absent flow or high resist- Vascular nodules with
ance flow nodules may be high resistance flow
avascular
5. Associated — Ascites; peritoneal
findings implants

9.12  D/D OF CYSTIC ABDOMINAL MASSES

Normal Ovaries
a. Normal Tubes
i. Peritoneal inclusion cyst
• USG—multiloculated cystic adnexal mass with intact
ovary and mid-septations and fluid.
ii. Para-ovarian (Paratubal cyst)
• USG—Cystic
• Mass frequently located superior to uterine fundus
adjacent to ovary.
b. Abnormal Tubes
• Hydro-Pyosalpinx
• USG—Cystic tubular mass with somewhat folded confi­
gura­tion and well-defined echogenic wall; anechoic
contents in hydrosalpinx and echogenic debris seen in
pyosalpinx.
892 Differential Diagnosis in Radiology

Abnormal Ovaries
Physiological
• Cysts (Unilocular)
– < 2.5 cm in diameter
– Sequential changes are most common.

Tubo-ovarian Abscess
• Complex multiloculated mass with irregular margins, variable
septation with scattered internal echoes and DAS.

Functional Cysts
• (Unilocular), unilateral
• >2.5 cm in diameter
• Changes seen over few next MC
• Low-level reticular echoes may be seen in hemorrhagic cysts
• Theca lutein cysts are bilateral multilocular cysts.

Massive Ovarian Edema

• Ovarian edema from partial or intermittent torsion
• Large multicystic adnexal mass is seen on USG.

Endometrioma
• Unilocular asymptomatic cystic lesion with homogenous
low-level echoes that rarely show significant changes with
menstrual cycles.

Dermoid
• Cystic anechoic to echogenic mass with dermoid plug, hair
fluid/fat fluid level with foci of calcification.
 Obstetrics and Gynecology 893
Cystadenoma/Cystadenocarcinoma
• Uni/Multilocular/Bilateral cystic masses with thin/thick
septations with mural nodules and low resistance flow in
malignant masses with presence of ascites and peritoneal
spread.

9.13  D/D OF NON-GYNECOLOGICAL PELVIC

MASSES
These arise most commonly secondary to surgery involving either
GIT and urinary tract.

D/D of Postoperative Pelvic Mass

Abscesses Hematoma Lymphoceles/ Urinoma/
Seroma
• Ovoid, anechoic • Spectrum of find- • Cystic anechoic col-
masses with thick ings from an- lection
irregular wall with echoic to echogenic • Fluid cytology helps in
posterior acoustic masses with DAS diagnosis
enhancement and variable ap-
with clinical pearance with time
symptomatology

9.14  D/D OF NON-OVARIAN ADENEXAL MASS

a. Functional cysts
– Follicular cyst
– Corpus luteal cyst
– Hemorrhagic cyst
b. Ovarian remnant syndrome
c. Paraovarian (Peritubal) cyst
d. Peritoneal inclusion cyst
e. Endometriosis
f. PCOD
g. Massive edema
894 Differential Diagnosis in Radiology
h. Inflammatory T-O mass
i. Postoperative lymphocele, seroma, urinoma
j. Bowel masses presenting as adenexal.

9.15  D/D OF OVARIAN MASSES

Ovarian Masses are Classified Histologically

1. Epithelial Tumors
– Serous
– Mucinous
– Mesonephroid (clear cell)
– Endometrioid
– Brenner’s
– Mixed
– Undifferentiated
– Unclassified.
2. Sex Cord (Gonadal stromal) Tumors
– Granulosa cell tumor, theca cell tumor
– Androblastoma (k/a Sertoli-Leydig cell tumor)
– Gyndandroblastoma
– Unclassified
3. Lipid (Lipoid) Cell Tumor
4. Germ Cell Tumors
– Dysgerminoma
– Endodermal sinus tumor
– Embryoma
– Polyembryoma
– Choriocarcinoma
– Teratoma
– Mixed
5. Gonadoblastoma
– Pure
– Mixed with dysgerminoma
6. Soft tissue tumors
 Obstetrics and Gynecology 895
7. Unclassified
8. Secondaries
9. Tumor-like conditions.

SALIENT FEATURES
A. Epithelial Tumors
– Constitute 95% of all malignant neoplasms of ovary
– Most common are serous and mucinous cystadeno­carcinomas
– Postmenopausal women
– Spreads transcoelomically along the direction of ascitic fluid
circulation
– Right subphrenic and right paracolic gutters are early sites of
spread
– Eighty-five percent have peritoneal deposits at presen­tation
– Para-aortic and pelvic are the first lymph nodes to be involved
One of the few primaries to have splenic secondaries.

On USG
• First modality used to detect, confirm the presence, and
characterize a pelvic mass. It’s high sensitivity (97.3%) makes it
an ideal screening tool in high-risk groups
• Malignant masses are large, bilateral, complex, with thick walls,
thick septa and have mural nodules. Conversely is true for
benign.

On Color Doppler
• Increased abnormal neovascularity
RI < .4; PI < 1 (but these are not highly specific signs)

On CT Scan
• Mainstay of preoperative assessment
• The appearance is similar to that seen on USG. The solid
component enhances on administration of IV contrast. Solid
896 Differential Diagnosis in Radiology
looking non-enhancing areas have either blood or thick mucin.
Calcification is better detected
• Spread to adjacent—Organ is well documented but distant
and especially peritoneal spread is difficult to interpret.
Conventional scanners detect less than 50% of metastases less
than 5 mm
• Peritoneal deposits may present as small focii of new peritoneal
calcification, multiple nodular lesion in omental fat, omental
cake, nodules surrounded by bowel loops and thickening along
vessels and lymphatics
• Pseudomyxoma peritoneii occurring due to rupture of
mucinous tumors present as high density fluid loculi on the
serosal surfaces of organ, indenting them.

On MRI
• Basic morphological features are same but it is better in
determining the origin, characterization and land masking the
spread due to multiplanner capability and better soft tissue
contrast.

B. Germ Cell Tumors

– 5–15% of ovarian malignancies
– Seen in young and adolescent: Peak = 16–20 years mostly <30
years
– Most common pediatric ovarian tumor
– Most common is dysgerminoma (the counterpart of seminoma)
– U/L, solid, well-defined, large (since aggressive). Dysgerminoma
is multiloculated with vascular fibrous septa in between
– Calcification seen in teratoma and dysgerminoma.
Usually extends directly but metastasis to nodes, lung and liver
is more common than epithelial tumors.
 Obstetrics and Gynecology 897
C. Stromal/Sex Cord Tumors
– 3–6% of ovarian malignancies
– Most common is Granulosa cell tumors
– Almost always malignant
– Hormone (Estrogen) secreting
– Postmenopausal or prepubertal age groups
– Quite variable in appearance.

D. Metastasis
– 15% of all ovarian malignancies
– Stomach, colon, breast, lung, gallbladder, pancreas

Flow chart 9.1:  Ovarian mass

898 Differential Diagnosis in Radiology
– Krukenberg’s tumor is a specific term used to describe a
secondary having sarcomatous stroma interspersed between
mucin-secreting-Signet ring cells. Usually the primary site is
stomach
– Large, B/L, indistinguishable from primary
– Presence of associated deposits in liver, lung are so strong
indicators that the ovarian mass is secondary
– Ovary is most common genital organ to receive leukemic
deposits
– Maybe involved in diffuse non-Hodgkin’s lymphoma.

Features of Malignancy
1. RI < 0.4
2. PI < 1.0
3. Thick septa >3 mm
4. Mural nodule
5. Complex cyst
6. Large size >10 cm
7. Ascites
8. Metastasis/peritoneal implants.

9.16 SONOGRAPHIC CLASSIFICATION OF
ADENEXAL MASSES

Simple Cyst
Always Benign
1. Simple ovarian cysts
– Folicular cyst
– Corpus luteal cyst
– Hydrosalpinx
– Cystadenoma.
2. Nongynecological
– Of GI origin
– Bladder diverticulum.
 Obstetrics and Gynecology 899
Solid Masses
Benign
1. Pedunculated fibroid.
2. Torsion.
3. Brenner’s tumor.
4. Fibroma/thecoma.

Malignant
1. Germ cell tumor.
2. Endometrioid carcinoma.
3. Granulosa cell tumor.
4. Metastasis.

Nongynecological
1. Lymphadenopathy.
2. Bladder tumor.
3. GI tumor.

Complex Cyst
Benign
1. Cyst with low-level echoes
– Endometrioma
– Hemorrhagic cyst
– Cystadenoma.
2. Cyst with hyperechoic component
– Cystic teratoma.
3. Cyst with solid components
– Tubo-ovarian abscess
– Cystadenoma
– Cystic teratoma
– Fibrothecoma
– Peritoneal inclusion cyst.
900 Differential Diagnosis in Radiology

Malignant
1. Mucinous/serous cystadenocarcinoma.
2. Clear cell carcinoma.
3. Endometrioid carcinoma.
4. Granulosa cell tumor.
5. Cystic teratocarcinoma.
6. Metastasis.

Nongynecological
– Abscess
– Hematoma
– Lymphocele.

MRI Classification of Adenexal Masses

A. LOW T1 + LOW T2 : a. Leiomyoma
b. Fibroma/thecoma
B. LOW T1 + HIGH T2 : a. Functional cyst
b. Peritoneal inclusion cyst
c. Cystadenoma
d. Hydrosalpinx
C. HIGH T1 : a. Dermoid
b. Endometrioma
c. Hemorrhagic cyst
d. Proteinaceous material
D. Heterogenous : a. Malignancies
b. Simple cyst with
hemorrhage
c. Tubo-ovarian abscess
d. Ovarian torsion
e. Ruptured ectopic
pregnancy
 Obstetrics and Gynecology 901
9.17  ABSENT INTRAUTERINE PREGNANCY
WITH POSITIVE PREGNANCY TEST

Causes
1. Ectopic pregnancy.
2. Very early intrauterine pregnancy.
3. Recent abortion.
4. Molar pregnancy/gestational trophoblastic neoplasia.

Salient Features
1. Ectopic Pregnancy:
• Specific feature: Live embryo in the adenexa.
• Nonspecific features (Need β-hCG correlation):
– Empty uterus
– Pseudogestational sac in uterus
– Particulate ascites
– Adenexal mass
– Ectopic tubal ring
• Nonsupportive features:
– Live intrauterine pregnancy
– Peritrophoblastic flow
– Intradecidual sign/double decidual sac sign
• Slow rising β-hCG, i.e. doubling time <2 days.
2. Very Early Intrauterine Pregnancy:
• Pregnancy test becomes positive at approximately 23 days
while the earliest sonographic sign of pregnancy, i.e.
intradecidual sign is detected at approximately 25 days.
During this window period of 2 days, confusion may occur.
• It is always wise to screen after 72 hours in case of any
confusion.
3. Recent Abortion:
In case of positive pregnancy test with USG showing no
intrauterine pregnancy serial monitoring of β-hCG should be
902 Differential Diagnosis in Radiology
Flow chart 9.2:  Absent Intrauterine pregnancy with positive pregancy test

done. In cases of abortion, a falling titer is seen in maternal

serum.
4. Gestational Trophoblastic Neoplasia:
Uterus is enlarged with cavity filled with multiple small vesicles
and soft-tissue nodules. Fetal parts and myo­metrial invasion
may or may not be seen. β-hCG levels are quite high.
 Obstetrics and Gynecology 903
Flow chart 9.3:  Thickned placenta

9.18  D/D OF THICKENED

PLACENTA (FLOW CHART 9.3)

Causes
1. Maternal diabetes. 2. Rhesus Isoimmunization.
3. Fetal hydrops. 4. Triploidy.
904 Differential Diagnosis in Radiology
5. Intrauterine infections. 6. Maternal severe anemia.
7. Fetal anemia. 8. Fetal hydrops.
9. Homozygous alphathalassemia. 10. Placental tumors.
11. Retroplacental/Placental bleed.

Salient Features
• Placenta (Figs 9.4 to 9.6) is called thickened when it measures
>4 cm in thickness at the cord insertion
• Most of the above causes are better evaluated by micro­scopic
and biochemical evaluation of maternal blood
• Karyotyping is an essential step in evaluation
• USG has a corroborative role in evaluating structural abnor-
malities in above conditions, e.g. fetal hydrops chromosomal
abnormalities.

Fig. 9.4:  Placenta and membranes in twin pregnancies

 Obstetrics and Gynecology 905

Fig. 9.5:  Abnormalities of the placenta

Fig. 9.6: Placental hemorrhage

9.19  ULTRASOUND SIGNS OF CHROMOSOMAL

ABNORMALITY (FLOW CHART 9.4)

Generalized Signs Which are

Important Even if Isolated
1. Borderline ventriculomegaly.
2. Posterior fossa abnormality.
3. Cystic hygroma.
4. Nuchal fold thickness.
5. Nuchal translucency.
6. Atrioventricular septal defects.
906 Differential Diagnosis in Radiology
7. Double outlet right ventricle.
8. Omphalocele.
9. Duodenal atresia.
10. Echogenic bowel.
11. Genitourinary abnormality.
12. Nonimmune hydrops.

Important Specific Signs

Trisomy 21
1. Cystic hygroma.
2. Nonimmune hydrops.
3. Nuchal thickening.
4. Hydrothorax.
5. Gut atresias.
6. Protruding tongue.
7. Cleinodactyly.
8. Increased distance between 1st and 2nd toes.

Trisomy 18
1. IUGR.
2. Single umbilical artery.
3. Cystic hygroma.
4. Microcephaly/Dolichocephaly.
5. Mega cisterna magna.
6. Omphalocele.
7. Renal dysplasias.
8. Rocker bottom feet.

Trisomy 13
1. Cyclopia.
2. Anophthalmia.
3. Cleft lip/palate
4. Low set deformed ear.
 Obstetrics and Gynecology 907
Flow chart 9.4:  USG sign of chromosal abnormality approach
908 Differential Diagnosis in Radiology
5. Holoprosencephaly.
6. Duplicated kidney.
7. Polydactyly.
8. Rocker bottom feet.

Triploidy
1. Early onset IUGR.
2. Myelomeningocele.
3. Agenesis of corpus callosum.
4. Micrognathia.
5. Sloping forehead.
6. Postaxial Polydactyly/syndactyly.
7. Molar placenta.
8. Renal cortical cyst.

Turner’s Syndrome
1. Cystic hygroma.
2. Nonimmune hydrops.
3. Brachycephaly.
4. Small mandible.
5. Coarctation of aorta.
6. Horse-shoe kidney.
7. Cubitus valgus.
8. Short stature.

9.20  D/D OF ENLARGED

UTERUS (FLOW CHART 9.5)

Causes
1. Pregnancy 2. Leiomyoma
3. Carcinoma endometrium 4. Hemato/pyometria
 Radiological Differential Diagnosis Obstetrics and Gynecology 909
Flow chart 9.5:  Enlarged uterus

5. Gestational trophoblastic 6. Puerperal uterus

neoplasia
7. Ectopic pregnancy 8. Soft tissue sarcomas
9. Adenomyosis

Salient Features
• Most common cause of enlarged uterus in childbearing age is
pregnant and puerperal uterus, both of which may be evaluated
by proper history and signs of pregnancy
• In older females, malignancy is an important considera­tion
• In young congenitally malformed uterus hemato/pyometria
may be seen.
910 Differential Diagnosis in Radiology
Flow chart 9.6:  Approach to a cyst lesion in fetal abdomen

9.21  CYSTIC STRUCTURES IN

FETAL ABDOMEN (FLOW CHART 9.6)

Causes
1. Renal – Multicystic dysplasia and other cystic
diseases
 Obstetrics and Gynecology 911
– Hydronephrosis
– Megacystis
2. GI – Duodenal obstruction
– Jejunal obstruction
3. Ovarian – Simple cyst
– Complex cyst associated with torsion.
4. Mesenteric cyst
5. Hepatic cyst
6. Pancreatic cyst
7. Lymphangioma
8. Urachal cyst.

Salient Features
• Renal: If multiple cysts with a distorted kidney and absent renal
parenchyma are seen, it suggests MCDK. If enlarged echogenic
kidneys are seen, it could be either ADPCKD or ARPCKD which
are difficult to separate out by USG
• GI: A double bubble sign with polyhydramnios shows duodenal
obstruction while multiple air fluid levels indicate jejunal
obstruction
• Ovarian: 97% are benign functional cysts due to hormonal
stimulation. These are simple cysts located eccentrically in
pelvis with a normal GI and urinary system
• Megacystis is caused by posterior urethral valves; urethral atre-
sia /stricture; prune-belly syndrome; primary mega­cystis; cloa-
cal malformation; megacystis-microcolon-intestinal-hypoperi-
stalsis syndrome (MMIHS)
• Meckel-Gruber Syndrome: Polycystic kidney (100%); polydactyly
postaxial (55%); occipital cephalocele (60-85%)
• Cystic lesions are usually indeterminate in appearance and
correlation to associated features is helpful in final diagnosis
• Cyst in association with echogenic bowel can be pan­creatic
cysts in cystic fibrosis.
912 Differential Diagnosis in Radiology

9.22  D/D OF FETAL HYDROPS (FLOW CHART 9.7)

Causes
A. Immune Hydrops
– Rh (D) incompatibility.
– Other blood group antigens incompatibility, e.g. kell.
B. Nonimmune Hydrops
1. Fetal Causes:
a. Idiopathic (15–20%)
b. Infections
– CMV; HPVB19; Rubella; Coxsackie; Syphilis; Listeria;
Toxoplasma.
c. Cardiovascular
– Malformations; arrhythmias; high output failure.
d. Neck/Thorax abnormalities
– Cystic hygroma; diaphragmatic hernia; congenital
cystic adenomatoid malformation; pulmonary se-
questration.
e. Gastrointestinal abnormalities
– Cirrhosis; hepatitis; atresias; volvulus; meconium
peritonitis.
f. Urinary tract abnormalities
– Congenital nephrotic syndrome; prune-belly syn-
drome; polycystic kidney.
g. Anemias
– Alpha-thalassemia; HPVB19 infections G-6-P
deficiency; Twin-Twin Transfusion syndrome.
h. Chromosomal abnormality
– 45,X; Trisomy 13,18,21; Triploidy.
i. Genetic disorders
– Gaucher’s; Hurler’s; MPS; Sialoidosis; Achondro­
plasia; achondrogenesis; thanatophoric dysplasia;
Jeune’s dystrophy; Osteogenesis imperfecta;
Arthrogryposis Multiplex Congenita; Pena-Shokier
syndrome; Neu-Laxova syndrome;
 Obstetrics and Gynecology 913
Flow chart 9.7:  Approach to a cast of fetal hydrops

2. Maternal Causes:
– Severe diabetes.
– Severe anemia.
– Severe hypoproteinemia.
3. Placental
– Chorioangioma.
– Venous thrombosis.
– Cord torsion, knot, tumor.
914 Differential Diagnosis in Radiology

Salient Features
• Hydrops is defined as an abnormal accumulation of serous fluid
in atleast two body cavities or tissues
• Sonographic features:
a. Ascites.
b. Pleural effusion.
c. Pericardial effusion.
d. Subcutaneous edema.
e. Placental edema.
f. Alteration in arterial/Venous Doppler.
g. Alteration in fetal well-being.
• Pseudoascites is a hypoechoic rim seen peripherally in
abdomen (<2 mm) due to muscle layer
• Subcutaneous edema is best evaluated over the scalp and head
• Pattern of fluid collection helps in D/D:
Immune hydrops – Ascites first
Thoracic pathology – Pleural fluid first
Anemia – Ascites first
Meconium peritonitis – Fluctuant ascites with
echogenic bowel
Parvovirus infection – Tense ascites with
echogenic bowel

9.23  D/D OF FETAL BRAIN AND

HEAD ABNORMALITIES

Causes
1. Abnormalities of dorsal induction:
– Anencephaly
– Encephalocele/iniencephaly
– Spina bifida/Chiari II malformation
– Caudal regression.
 Obstetrics and Gynecology 915
2. Abnormalities of ventral induction:
– Holoprosencephaly
– Dandy-Walker malformation.
3. Neuronal proliferation/differentiation:
– Macrocephaly
– Microcephaly
– Vascular malformations/tumors.
4. Abnormalities of migration:
– Agenesis of corpus callosum
– Schizencephaly/lissencephaly
– Polymicrogyria/pachygyria.
5. Acquired injuries:
– Porencephaly
– Aqueductal stenosis.
6. Unclassified.

Salient Features
• Abnormalities are classified according to the time of their origin:
Dorsal induction – 4th to 7th week.
Ventral induction – 5th to 10th week.
Neuronal proliferation
and differentiation – 2nd to 3rd month.
Neuronal migration – 3rd to 5th month.
Acquired injury – 3rd to 4th month.
• Anencephaly
– Absence of cranial vault, cerebral hemispheres, diencephalic
structures and their replacement by flattened amorphous
neurovascular.
– Mass known as area coxbiovasculosa.
– Diagnosed earliest by confidence (100%) at 14th week
– Acrania: Absent vault.
– Exencephaly: Brain matter is recognizable.
– Cranioschiasis: Cranial abnormality with spinal dysraphism.
• Encephalocele
– Is a pouch containing CSF, meninges and brain matter
while cranial meningocele has no brain parenchyma.
916 Differential Diagnosis in Radiology
– 75% Occipital;13% frontal; 12% parietal.
– Seen in Meckel-Gruber syndrome.
• Lemon skull
– Bifrontal indentation is seen in 1% normal fetus, few
dwarfism and spina bifida.
• Strawberry skull
– A skull having reduced OFD, flattened occiput and pointed
frontal area. Seen in trisomy 18.
• Clover leaf skull
– Seen in thanatophoric dwarfism and craniosynostosis.
• Ventriculomegaly
– Occipital horn >10 mm
– Ventricle to choroid ratio > 3 mm
– Anterior horns > 20 mm (under 24 weeks)
– VHR = 74% at 16th week
– 35% at 25th week.
• Banana sign
– Compressed moulded cerebellum about brainstem, seen
in spinal dysraphisms.
• Iniencephaly
– A condition where occiput and cervical spine are involved
together in dysraphism. Child is in a “star-gazing” position
and spinal segmentation abnormality is present.
• Holoprosencephaly
– Results from incomplete cleavage and/or diverticulation of
forebrain into cerebral hemispheres.
– May be lobar, semilobar or alobar upon the severity of the
disease.
– Associated with midline facial defects.
• Dandy-Walker malformation
– A condition where a malformed posterior fossa cyst
communicating with fourth ventricle due to vermian
agenesis and hydrocephalus is seen.
– In D-W variant less severe degrees of abnormality is seen.
• Hydranencephaly is the most severe degree of porence­phaly
or brain destruction where almost the whole of cerebral
 Obstetrics and Gynecology 917
parenchyma is absent. Mostly due to early and total occlusion
of supraclinoid carotids.
• Schizencephaly
– Characterized by slits lined by gray-matter in brain
parenchyma communicating brain surface to ventri­cles.
• Lissencephaly (agyria)
– Abnormal neuronal migration from germinal matrix to
surface leads to absence of convolution formation or
formation of broad Gyri (Pachygyria)
• Corpus callosum agenesis
– Callosal development occurs between 12 and 20 weeks.
Any insult leads to total/partial lack of formation of this
commissure.
– Frontal horns are Steer-horn shaped with probst bundles
lying medial to them.
– Colpocephaly and Sun-ray appearance of gyri radiating to
ventricles is seen.

9.24  D/D OF BRAIN AND HEAD ABNORMALITY

1. Anencephaly D/D amniotic band syndrome
a. Amputation of other parts.
b. Membranes in liqor.
c. Asymmetric cranial defects.
d. D/D large encephaloceles.
2. Encephaloceles
– D/D cystic hygroma.
– D/D hemangioma.
– D/D teratoma.
– D/D scalp edema.
– D/D branchial cleft cyst.
All the above do not have a cranial defect with protrusion of
CSF, brain and meninges.
3. Holoprosencephaly
– D/D severe hydrocephalus.
918 Differential Diagnosis in Radiology
– Rim of parenchyma and vessels present.
D/D hydranencephaly. Both of the above do not have
associated facial defects.
4. Dandy-Walker malformation
– D/D Variant (Dandy-Walker)
a. Less severe anomaly and hydrocephalus.
– D/D Arachnoid cyst.
a. No communication to ventricles.
b. No associated anomaly.
5. Hydranencephaly D/D severe hydrocephalus.
– D/D alobar holoprosencephaly
– D/D massive congenital subdural collection.
– D/D postanoxic/infective encephalopathy.
All the above have thinned or injured brain parenchyma seen
to varying degrees.

9.25  D/D OF THICKENED

ENDOMETRIUM (FLOW CHART 9.8)

Causes
1. Early intrauterine pregnancy/abortions.
2. Ectopic pregnancy.
3. Estrogen excess, e.g. polycystic ovary syndrome.
4. Endometrial carcinoma/hyperplasia.
5. Endometrial polyp.
6. Hormonal replacement
– Therapy in postmenopausal females.
7. Endometritis.

Salient Features
• Normal thickness Phase
3–5 mm Proliferative
Upto 14 mm Secretory
• Early Intrauterine Pregnancy
– With thickened endometrium and increased peritro­
phoblastic flow look for intradecidual and double decidual
sac signs.
 Obstetrics and Gynecology 919
Flow chart 9.8:  Thickened endometrium

• Ectopic Pregnancy
– Pseudogestation sac is an artefact due to minimal uterine
collection with thickened endometrium under hormonal
influence seen in these cases
• Endometrial Carcinoma
– In old ladies
– <4 cm thickness is normal 4–8 is equivocal and needs
histopathological correlation while >8 mm is suggestive
of malignancy. Associated myometrial invasion is seen in
advanced cases
• Endometrial polyp is a focal thickening seen best by
sonohysterography, very minimal if any risk of malignancy is
associated
• Endometrial hyperplasia is said to occur when gland to stroma
ratio exceeds that in normal proliferative endometrium. It is
divided in hyperplasia with and that without cellular atypia.
920 Differential Diagnosis in Radiology
Nearly 1/4 progress to carcinoma if atypia is present. Occurs due
to persistent hyperestro­genemia as in estrogen therapy, PCOD,
granulosa/theca cell tumors, obesity and persistent anovulatory
cycles. Endometrium appears thickened with few cystic areas.

9.26  USG SIGNS IN ABORTIONS (TABLE 9.1)

Abortion
(Fetal wastage before viability period)

Induced
• Legal.
• Illegal (Septic).

Spontaneous
1. Missed
2. Incomplete
3. Septic
4. Threatened
5. Inevitable
6. Complete.

Salient Features
a. Missed Abortion: Usually between 8 and 14 weeks.
– Dead fetus retained inside uterus for more than four weeks.
– No fetal heartbeat with
CRL > 5 mm (TVS)
CRL > 9 mm (TAS)
– Gestational age discordant to menstrual age.
– Sac > 25 mm with no evidence of fetus.
– Distorted sac configuration/shape.
– Low down location.
– Internal debris within the sac.
 Obstetrics and Gynecology 921
– Discontinuous/irregular/thin (<2 mm) peritrophoblastic
reaction and inadequate flow.
– Subchorionic collections.
b. Threatened Abortion:
– First trimester bleed with a live fetus.
– Clinical triad of bleeding, cramp, closed cervix.
– 1/2 progress to spontaneous abortion, 1/2 develop
normally.
c. Inevitable Abortion:
– Gestational sac with fetus having become detached from
implantation site and spontaneous abortion likely to occur
in the next few hours.
– Cervix is dilated.

Table 9.1:  USG D/D of Abortions

Points Missed Incomplete Inevitable Threat- Septic
ened
1. Shape of Crumpled Irregular/ Irregular Well- ±
GS non- non- defined
identifiable identifiable
2. Site of GS US/LS US/LS LS US US/LS
3. Collection Solid mass ± + ± +
around GS forms
4. Peritro- Not Not present Poor Present Not
phoblastic present present
reaction
and vascu-
larity
5. Status of Dead/non- Dead/ Dead Live Not
fetus identifiable non- present
identifiable
6. Cervix Closed Partially open Open Closed Closed
7. Abdomino Not Not present Not Not Present
pelvic signs present present present
of infec-
tion
922 Differential Diagnosis in Radiology
– Abnormal shaped sac.
– Low-lying sac.
– Collection suggestive of blood seen around the sac.
– Trophoblastic reaction unsatisfactory.
d. Incomplete Abortion:
– Consists basically of retained products of conception in the
uterus.
– The product is usually heterogenous unidentifiable
material and/or collection.
– Associated with bulky uterus and irregular endometrium.
– May lead to endomyometritis, DIC, septic shock.
e. Septic Abortion:
– Usually a consequence of illegal abortion.
– It is very important to look for any foreign body in the
uterus/abdomen.
– Associated uterine perforation, signs of localized/diffuse
abdominal sepsis and pelvic sepsis may be seen.

9.27  D/D OF FETAL CAUSES OF

ABNORMALITY IN LIQOR VOLUME

Causes
A. Oligohydramnios: (Flow chart 9.9):
– Fetal demise/IUD
– Renal/bladder abnormalities
– PVU
– Prune belly syndrome
– ARPCKD
– BRA
– IUGR
– Postdated pregnancy.
B. Polyhydramnios (Flow chart 9.10):
– Cardiovascular decompensation
– Diaphragmatic hernia
– Anencephaly/other severe cranial anomalies especially
ONTD
 Obstetrics and Gynecology 923
– Obstructive malformations of GIT, e.g. TOF, duodenal
stenosis/atresia
– Bone dysplasias.
– Neuromuscular abnormalities.
– Chromosomal abnormality, e.g. trisomy 18.

Salient Features
• Amniotic fluid assessment
Single pocket AFI
Oligohydramnios <2 cm <7
Reduced 2–3 cm 7–10
Normal 3–8 cm 10–17
More than average > 8–12 cm 17–25
Polyhydramnios >12 cm >25
• Fetal demise:
– Fetal wastage, after the time significant liqor production is
seen, leads to slow resorption of liqor.
– Urine production status at 9 weeks and renal function starts
at 11 weeks. At 12 weeks, urine accumulates at the rate of 5
cc per day.
• Signs of IUD are:
1. Spalding’s sign
– Overriding of skull bones.
2. Gas in vessels.
3. Sometimes associated hydrops.
4. Extended limbs/lost tone.
5. Absent-cardiac activity.
6. Gas in abdomen.
• IUGR:
– Weight of neonate below 10 percentile of the expected
fetal weight for that age.
– Usually detected after 32-34 weeks, i.e. the age of maximum
fetal growth.
– May be due to uteroplacental insufficiency that leads to
asymmetric IUGR.
924 Differential Diagnosis in Radiology
– Asymmetric IUGR is early onset and leads to concordant
reduction of all parameters.
– Criteria for IUGR:
Sensitivity Specificity
– Advance placental grade 62% 64%
– FL/AC (increased) 34–49% 78–83%
– TIUV (decreased) 57–80% 72–76%
– Small BPD 24–88% 62–94%
– Slow increase in BPD 75% 84%
– Low EFW 89% 88%
– Decreased AFV 24% 98%
– Increased HC/AC 82% 94%
– Biophysical profile <6 = Equivocal
<4 = Fetal compromise
– Doppler indices
– Uterine artery—S/D >2.3, difference of the two sides
>1, RI > .6
– MCA–RI < .7
– Umbilical artery–RI – > .7
• Postdated Pregnancy/Large for Dates:
– When weight is > 90th percentile for the expected fetal weight.
– Also when weight > 4000 gm.
– Sonographic criteria.
LGA Sensitivity Specificity
– AD/BPD (increase) 46% 79%
– FL/AC (decrease) 24–75% 44–93%
– AFV increase 12–17% 92–98%
– Pondrel index increased 13–15% 85–98%
– High EFW 20–74% 93–96%
– Growth score increased 14% 91%
Macrosomia
– FL increased 24% 96%
– AC increased 53% 94%
– High EFW 11–65% 89–96%
– BPD increased 29% 98%
 Obstetrics and Gynecology 925
Flow chart 9.9:  Approach to a pointing with oligohydramnios
926 Differential Diagnosis in Radiology
Flow chart 9.10:  Approach to a pointing with polyhydramnios

– Renal/bladder abnormality: Any cause of reduction of

urine formation as in renal (B/L) agenesis, ARPCKD or of
obstruction to outlet of urine as in prune-belly syndrome,
urethral atresia/stenosis, posterior urethral valve can lead
to oligohydramnios. Look for signs of Megacystitis, i.e. UB
>8 mm, hydronephrosis, i.e. Pelvis > 6 mm, abnormal renal
parenchyma, dilated ureter and urethra.
• Polyhydramnios occurs when either increased production or
decreased fetal Gullping of liqor is seen.
• Cardiovascular decompensation:
Bradycardia – <100 BPM of >10 sec.
Tachycardia – >180 BPM.
PSVT – 180-300 BPM with conduction rate 1:1.
Flutter – 300-400 BPM with conduction rate 2:1/4:1
Fibrillation – >400 BPM
 Obstetrics and Gynecology 927
Flow chart 9.11:  Gas in genital tract

• Diaphragmatic hernia:
Cystic areas in thorax with small abdomen. Absent fundic
bubble, GB with portal vein pointing up
• Double bubble and triple bubble sign of duodenal and jejunal
atresia should be looked for
• Skeletal dysplasia, chromosomal abnormalities detection have
been described elsewhere.
928 Differential Diagnosis in Radiology

9.28  D/D GAS IN THE GENITAL

TRACT (FLOW CHART 9.11)

Causes
1. Fistula between genital tract and gastrointestinal tract
– Congenital
– Postinflammatory, e.g. tuberculosis, Crohn’s disease
– Due to infiltrative malignancies.
2. Postintervention
– Hysterosalpingography
– Hysteroscopy
– Pervaginal examination
– Tubal insufflation
– Laparoscopy.
3. Gas-forming infection.
4. Post-traumatic.

Salient Features
• Fistula between GUT and GIT occur most commonly due to
inflammatory conditions like Crohn’s disease and tuberculosis.
In such cases, it is usually the small bowel that communicates
with uterus
• Congenital fistulas occur between lower genital tract and
terminal GIT leading to rectovaginal and rectouterine fistulas.
These occur early during the course of develop­ment due to
closely associated origin of both the above
• Malignancies of uterus, cervix, vagina, rectum, recto­sigmoid
and anal canal lead to fistula formation between them. Feculant
material is also seen passing from genital tract
• Contrast studies from both tracts are good for depiction of site
of communication
• MRI is fast picking up in demonstration of fistula
• Gas-forming anerobic and gram-negative infections are usually
uncommon but occur in cases of immuno­compromised, states
as diabetes, AIDS, chemo­therapy and systemic diseases
 Obstetrics and Gynecology 929
• Trauma to genital tract may be due to vehicle accident, due to
obstetric intervention or prolonged labors.

9.29  D/D OF FETAL INTRA-ABDOMINAL

CALCIFICATION (FLOW CHART 9.12)

Causes
A. Peritoneal:
– Meconium peritonitis.
– Plastic peritonitis with hydrometrocolpos.
B. Tumors:
– Hemangioma.
– Hemangioendothelioma.
– Hepatoblastoma.
– Metastatic neuroblastoma.
– Teratoma.
C. Infections:
– Toxoplasma.
– Cytomegalovirus.

Salient Features
• Meconium Peritonitis:
– Occurs due to meconium exiting from the bowel lumen,
due to perforation, causing sterile chemical peritonitis.
– Perforation occurs due to valvulus, jejunal/ileal atresia,
meconium ileus.
– Immediately ascites occur following which linear streaky or
spotty calcification occurs.
– Pseudocyst formation may also occur.
– Calcified meconium balls in/out the lumen may also be seen.
• Infections like toxoplasma and CMV lead to calcifications in
liver, spleen and also intracranial calcification.
• Hemangiomas may occur at multiple sites in fetal body and
may be associated with calcification.
930 Differential Diagnosis in Radiology
Flow chart 9.12:  Intra-abdominal fetal calcification

• Hemangioendothelioma and hepatoblastomas

– Common fetal hepatic tumors which show areas of specky
linear calcification associated with vascular spaces showing
high velocity Doppler shifts.
• Hepatoblastoma is the most common hepatic tumor (Primary)
in young and nearly all present before the age of five. Associated
with hemihypertrophy, 11p13 chromosome and Beckwith-
Wiedemann’s syndrome. Serum AFP levels are almost always
elevated. Shows lumpy calcification.
• Neuroblastoma is the most common neonatal tumor usually
occurring in the adrenal gland. It is an echogenic mass,
heterogenous in appearance. It commonly metastasizes to
placenta, liver and subcutaneous tissues with the metastasis
appearing echogenic calcified. Hydrops may commonly occur.
• Teratomas and dermoids are common fetal tumors occurring in
retroperitoneal and gonadal locations most commonly. These
show solid and cystic areas with areas of calcification.
 Obstetrics and Gynecology 931
9.30  D/D OF FETAL THORACIC
ABNORMALITIES (FLOW CHART 9.13)

Causes
1. Pleural effusion.
2. Congenital diaphragmatic hernias.
3. Pulmonary hypoplasia.
4. Pulmonary sequestration.
5. Pulmonary cystic adenomatoid malformation.
6. Congenital bronchogenic cyst.
7. Bronchial/laryngeal atresia.
8. Thymic enlargement.
9. Cystic hygroma.
10. Teratoma.
11. Enteric cysts.
12. Neuroblastoma.

Salient Features
• Pleural effusion
– May be isolated or occur as a result of generalized fetal
hydrops.
– Fluid collects as a cresentric rim around lungs forming a
‘Bat-Wing-appearance’ of lungs floating in fluid.
– U/L—congenital adenomatoid malformation (CAM), dia-
phragmatic hernia, sequestration, pulmonary hypoplasia.
– B/L—infections, CHF, Turner’s, Down’s, pulmonary lym-
phangiectasia.
– Long-lasting larger effusions may lead to pulmonary
hypoplasia.
– May be treated by thoracocentesis.
• Diaphragmatic Hernias
A. Bochdalek hernia
– Posterolateral in location.
– Left>>right.
932 Differential Diagnosis in Radiology
– Small intestine (88%), stomach (60%), colon (56%), liver
(51%), spleen (45%).
– Detected by sonography at 17 weeks.
– Mediastinal deviation seen by change in position and
axis of heart.
– Hollow viscera may be seen with AC <5th percen­tile
and polyhydramnios.
– Absence of GB in abdomen.
– Umbilical vein displaced up.
B. Morgagni Hernia
– Anteriorly behind the sternum.
– Right>>> left.
– Omentum, colon, liver, stomach, small bowel.
– May be covered by peritoneum and pleura or only
pleura or none at all. If pericardium is also absent, it lies
in direct contact to heart.
C. Eventration of Diaphragm
– Due to absent muscle fibers in the diaphragm.
– U/L asymptomatic.
– B/L may cause pulmonary hypoplasia.
– B/L associated with trisomy 13 and 18, CMV infection, Ru-
bella infection and arthrogryposis multiplex congenita.
• Pulmonary hypoplasia
– U/L—rare, may be simulated by discordant rate of growth
of both lungs. Due to thoracic masses.
– B/L—commoner, due to restricted chest cage as in
thanatophoric dwarfism, Jeune’s asphyxiating dystro-
phy, achondrogenesis and all causes of early onset severe
oligohydramnios.
Chest area − heart area
– × 100
Chest area
is accurate (85% sensitive and specific) in diagnosis, as
correlated to age.
 Obstetrics and Gynecology 933
Flow chart 9.13:  Fetal thoracic abnormalities

• Cystic adenomatoid malformation (CAM)

– Are hamartomas in lung divided by Adzich in Macroscopic
(cysts >5 mm) and Microscopic (<5 mm)
– Macroscopic type has better prognosis and is less
commonly associated with hydrops.
– Size of the mass may decrease over time
– Has to be D/D from diaphragmatic hernia, bronchial cyst,
cystic dilatation of esophagus, pericardial teratoma.
• Pulmonary sequestration
– Is a segment or part of lung not communicating at the
usually bronchovascular tree.
934 Differential Diagnosis in Radiology
– Appear as solid echogenic masses inside (Intralobar
sequestration) of the lung. Usually in basal parts.
– Extralobar may occur inside the diaphragm, peri­cardium,
hila, mediastinum.
– In 50% malformations of sternum and diaphragm are seen
but no major anomaly is seen.
– D/D to diaphragmatic hernia, CAM and lobar emphysema.
– A supplying vessel from aorta is the most confirmatory
sign.
• Upto 27 weeks, the thymus enlarges and appears as echogenic
mass (from 14 weeks); after 27 weeks, it becomes hypoechoic
• Cystic hygroma (lymphangiomas) is cystic (Predomi­nantly) and
solid dumb-bell mass extending in the mediastinum
• Teratomas usually arise from pericardium and are surrounded
by pericardial fluid (diagnostic point). Appearance is the same
as in adults
• Neuroblastomas are echogenic masses with echolucent centers
lying in the paravertebral area
• Enteric cysts lined by GI mucosa are also seen in posterior
mediastinum.
INDEX

Page numbers followed by f refer to figure and t refer

to table respectively.

A focal bacterial pyelonephritis

and renal abscess 605
Abdominal mass in interstitial nephritis 568
child 331 obstruction 559
neonate 330 prostatitis 650
Abnormal pyelonephritis 560
digits 463 tubular necrosis 565
nephrograms 632 urate nephropathy 569
ovaries 892 Adamentinoma of long
shape, size and density of bones 502
ribs 461 Adenocarcinoma 312
skeletal maturation 384 Adenoid
thumb 465 hyperplasia 801
Abnormalities of hypertrophy 800f
bowel rotation 334 Adenoma 62, 879
placenta 905f Adenomatous hyperplasia 878
Abscess 71, 75, 301, 630 Adrenal
Achalasia 22, 218 calcification 318
cardia 220f, 221f cysts 656
Achondroplasia 485, 739, 779 hemorrhage 656
Acoustic neuroma 677 mass 317, 652
Acquired Adrenoleukodystrophy 792
bladder neck stricture 622 Adult
cystic kidney disease 604, 612 and neonatal kidney 544
Acromelic dwarfism 487 orbital tumors 812
Acromesomelic dwarfism 487 Advanced
Acro-osteolysis 467, 467f, 517 carcinoma 224, 226
Acro-osteosclerosis 468 disease 380
Acute Agenesis 112, 648
arterial infarction 559 of gallbladder 369
cortical necrosis 566 Aggressive fibromatosis 8
disseminated Air
encephalomyelitis 786 bronchogram 98
936 Differential Diagnosis in Radiology
fluid levels on chest X-ray 70 Areas of
trapping 118 bone destruction 507
Alveolar decreased density 210
microlithiasis 105 Arterial
shadowing 94 calcification 204f
Alveolitis 128 hypotension 552
Amino acid metabolism 784 Arteriovenography 661
Amyloidosis 273, 563, 564 Arthritides 414
Anatomy of Arthritis
liver, bile ducts and pancreas 362 involving spinal column 523
thoracic inlet 1 mutilans 474
Aneurysm 708, 763, 773 with demineralization 472
of arch of aorta 20f, 184f with periostitis 471
Aneurysmal bone cyst 409f, 505, with soft tissue nodules 473
536, 538f, 857 without demineralization 472
Angioma 774 Asbestos inhalation 139
Angiomyolipoma 599 Asbestosis 106, 127
Angle of metatarsal heads 542 Ascites 327
Ankylosing spondylitis 206f, 524, 525 Aseptic necrosis 450
Ankylosis of Aspergillosis 74
interphalangeal joint 476 Asphyxiating thoracic
Anomalies of cephaloceles 768f dystrophy 487
Anorectal disease 381 Aspiration 75
Anterior Asthma 63
indentation of rectosigmoid Astrocytomas 834
junction 290 Atheromas 774
longitudinal ligament Atherosclerosis 588
calcification 206f Atlantoaxial subluxation 733
mediastinal Atresia of external auditory
lesion 30t canal 369
mass 30, 32f, 34, 35 Atretic cephaloceles/
scalloping of vertebral meningocele 769
bodies 736, 737f Atypical cysts 610
urethral diverticulum 620 Autosomal
vertebral body beaks 738 dominant 606, 612, 779
Antrochoanal polyp 801 dominant polycystic kidney
Aortic aneurysm 20 disease 612
Aphthous ulcers 289 recessive 568, 606
Apical shadows 67, 67t polycystic kidney
Aplasia 112 disease 611
Appendicular skeleton 393f Avascular necrosis 450
Arachnoid cyst 709, 756,
780, 843
 Index 937
B Bone
cyst 529
Bacterial overgrowth syndromes 273 destruction 411f
Bare orbit 761f dysplasias 445
sign 720 infarcts 497
Barium 267, 269 island and osteopoikilosis 495
Barrett’s esophagus 216 scan 506
Basal ganglia calcification 676, 775 sclerosis associated with
Basilar invagination 398, 678 periosteal reaction 402
Benign within bone appearance 446
and malignant ovarian Bony
masses 891 ankylosis 452f
lesions 805 labyrinth 821f
prostatic hyperplasia 618, 651 Boundaries of superior
tumor 825 mediastinum 25f
Berylliosis 107 Bowing of both forearm bones 486f
Biconcave vertebra 398f Brailsford-Morquio’s syndrome 489
Bilateral Breast
chronic maxillary sinusitis 867f abscess 159
hilar enlargement 65 calcifications 162
interstitial pulmonary carcinoma 84f, 166f, 354f
disease 101f edema 161f
large smooth kidneys 562 Brodie’s abscess 500, 536
malrotated kidneys 584f Bronchial carcinoid 86, 87
perihilar cystic Bronchiectasis 63
bronchiectasis 76f Bronchiolitis 64
pulmonary emphysema 66f Bronchogenic cyst 21, 77, 92
stippled femoral head Brown tumor of
epiphysis 449f hyperparathyroidism 503
Bilaterally elevated Bubbly bone lesions 407
diaphragm 58 Bull’s eye lesions in stomach 249f
Bile duct variants 367 Burkitt’s lymphoma 863
Binswanger’s disease 791 Button sequestra 677
Bladder
calculi 622
outflow obstruction 617 C
tumors 623 Caffey’s disease 493
Blighted ovum 882 Calcaneal pitch 539f
Blood Calcification 164, 574
clot 577 in bilateral sacrotuberous
tests 267 ligament 207f
Bochdalek’s hernia 23, 44 Calcifying metastases 61
Bohler’s angle 539f
938 Differential Diagnosis in Radiology
Calculi 589 Cervicothoracic hematoma 11
Calculus 577 Chest
in posterior urethra 621f wall 69
Capillary hemangioma 723, 808, 817 abnormalities 46, 47t
Carcinoma 22, 61, 73, 168, 803 X-ray 219
of bladder 614 Choledochal cyst 300
of breast 168f Chondroblastoma 408f, 412f,
of esophagus 219 502, 537
of prostate 493, 618, 634, 651 Chondrocalcinosis 475
Cardiac valve calcifications 196 Chondrodysplasia punctata 487
Cardiophrenic angle mass 142, 146 Chondromyxoid fibroma 408f, 412f,
Cardiovascular disorders 170 506, 537
Carpal fusion 462 Chondrosarcoma 413f
Cast of fetal hydrops 913 Chordoma 711, 773, 803
Causes of Choroid plexus papilloma 773
bilateral hypertranslucency 121 Chromosomal aberration 483
diffuse osteopenia 508 Chronic
osteomalacia 435 bronchitis 63
prevertebral soft tissue 795 glomerulonephritis 552
pulmonary edema 95f mastoiditis 729f, 730
retropharyngeal abscess 7 obstruction 560
smooth esophageal strictures osteomyelitis 424f
347 papillary necrosis 552
Cavernous prostatitis 650
hemangioma 809, 818 pyelonephritis 554
sinus lesions 700 renal infarction 546
Cavitating pulmonary lesions 70, 72 subdural hematoma 676
Cavitatory metastases 61 tophaceous gout 420f, 422f
Celiac disease 269 Chylothorax 130
Central Circumferential soft-tissue mass 507
skull base lesions 692 Circumscribed
upper fluid zones 142 carcinoma 154
Cephaloceles 766 malignant lesions 154
Cerebellar radiolucent lesion 148, 156
astrocytoma 714 Cirrhosis 241, 301
malformations 780 Classification of renal cysts 608
Cerebellopontine angle masses 694 Cleidocranial
Cerebellum 756 dysostosis 47, 518
Cervical dysplasia 684
abscess 6, 13 Coal miner’s pneumoconiosis 104
extension of mediastinal Cobblestone duodenal cap 251f
thymus 5 on barium study 250
rib 11, 14, 47
 Index 939
Codman’s triangle 411f, 507 Cranio-mandibular dysostosis 522
Cold nodules 873 Craniopharyngioma 701, 706, 772
Collagen Crescent sign 70
diseases 71 Crohn’s disease 257, 377
disorders 125 Cupping of metaphysis 456
Collagen vascular disease Cushing’s syndrome 511, 862
haemophilia 241 Cyanotic heart disease 197, 683
Colonic Cyst of tunica albuginea 629
polyps 278, 281 Cystadenocarcinoma 893
strictures/narrowing 284 Cystadenoma 893
Common lytic bone lesions 426 Cystic
Commonest tumors of abdominal masses 891
mediastinum 15 adenomatoid malformation 78
Compensatory hypertrophy 561 bronchiectasis 75
Complete opaque hemithorax 109 disease of kidneys 605
Complex dysplasia 630
cyst 899 fibrosis 269
sclerosing lesion 159 hygroma 39, 886f
Computed tomography 5, 11, 145, lesions 807
219, 225, 376, 381, 799 of jaw 857
Congenital of thyroid 871
absence of kidney 583 lymphangioma 12
and perinatal viral infections 786 mesenteric masses 291
cystic eye 721 neoplasm 606, 687
emphysema 116f papillary carcinoma 872
gallbladder anomalies 369 structures in fetal abdomen 910
hernia 146 Cysticercosis 209f, 775, 844
hydrocalycosis 577 Cystosarcoma phylloides 153
hypothyroidism 877 Cysts 79, 849
lobar emphysema 120 in antrum 866
mesoblastic nephroma 601 of jaw 855
myositis ossificans progressiva
203
urethral valves 619 D
Congestive cardiac failure 178f Dandy-Walker
Corpus callosum 369f complex 782
Cortical malformation 686, 755
cysts 608 variant 756, 783
nephrocalcinosis 593 Degeneration of adenomatous
Cotton-wool appearance 398f nodules 872
Craniocaudal mammogram 152f, Demyelinating disorders 783
168f Demyelination 783, 785
940 Differential Diagnosis in Radiology
Dense metaphyseal bands 455 Distal
Dentigerous cyst 856 esophageal stricture 521
Dermatomyositis 213 interphalangeal joint 416f
Dermoid 687, 892 Disuse osteoporosis 514
cysts 807 Down’s syndrome 739
tumor 702 Dumb-bell-shaped long bones 392
Destruction of Duodenal tuberculosis 235f
medial end of clavicle 458 Dyschondrosteosis 487
petrous bone 677 Dysmyelination 784, 791
Dextrocardia 196f Dysostosis multiplex 483, 488
Dextroposition of pancreas 369 Dysplasias 485
Diabetes mellitus 570 Dystrophic calcification 589
Diabetic
osteomyelitis 444f
vascular disease 444f E
Diaphragmatic Early esophageal carcinoma 226
hernia 99, 110, 112 Ebstein’s anomaly 117
hump and hernia 145 Ectopic
Diaphyseal infarct 414 kidney 583
Diarthrodial joint 415, 418f, 422f pregnancy 883
in lupus erythematosus 415f thyroid 878
Diastrophic dwarfism 488 ureterocele 625
Diffuse Edematous breast 160
articular loss 418, 421 Ejaculatory cyst 649
cord enlargement 753f Elevation of diaphragm 56
infiltrative disorders 515 Embryonal tumors 842
osteosclerosis in fluorosis 206f Emphysema 63, 119
pneumoperitoneum 326f Emphysematous cystitis 582
Diffusely hyperechoic liver 302 Empty sella 706
Dilatation of Empyema 57
pulmonary trunk 183 Encapsulated venous
stomach 295f malformation 809
Dilated Enchondroma 408f, 502, 533, 535f
azygous vein 43 Endobronchial metastases 61
calyx 575, 576 Endocrine
duodenum 251 disease 483
esophagus 215 disorders 484
PCS 552 Endometrioma 892
ureter 575 Endometriosis 261
and calyces 575 Endoscopic ultrasound 226, 315
Discordant nodules 871 Endosteal hyperostosis 728
Disk bulge 846
 Index 941
Enlarged diverticula 341
left duplication cyst 38
atrium 180 lesions 22, 44
ventricle 176 lymphoma 220
optic foramen 758 strictures 347
right ulcers 342
atrium 186, 186f, 187t Esophagitis 342
ventricle 188, 191f, 189t Ewing’s
superior vena cava 194 sarcoma 406f
Sylvian fissure 687 tumor 407f
uterus 908, 909 Excessive callus formation 446
vertebral body 742 Exocrine pancreatic secretions 269
Enlargement aorta 184 Exogenous thyroid hormone 876
Enterogenous cyst 686, 757 Exostosis 412f, 425f, 830
Enteropathic Expanded pituitary fossa 712
spondyloarthropathies 528 Expansile
Enthesioneuroblastoma 691 bone lesion 499
Enthesitis 525 unilocular cystic lesions 531
Eosinophilic Extension of thyroid masses 798
enteritis 260 External acoustic masses 828
gastroenteritis 271, 355 Extradural
granuloma 503, 533, 665, 763 extramedullary lesion 844, 845f
Ependymoma 715, 773, 833 masses 749
Epicardial fat pad 147 Extraintestinal complications of
Epidermoid 687, 709, 836 inflammatory bowel
cyst 630 disease 382
inclusion cyst 534 Extraluminal intra-abdominal
tumor 702 gas 319
Epidermoidomas 832 Extramedullary intradural mass 752f
Epidural Extranodal Hodgkin’s
abscess 847 lymphoma 354
hematoma 847 Extraparenchymal renal
lipomatosis 848 cysts 609, 613
space 844 Extrathoracic manifestation 141
Epiphysis 427 Extremities 491, 492
Epithelial tumors 895 Extrinsic allergic alveolitis 127
Erlenmeyer flask deformity 456
Erosion of medial metaphyses of
proximal humerus 457 F
Erosive osteoarthritis 477f Fat necrosis 159
Esophageal Fatigue fractures 447
carcinoma 221, 224f, 226
942 Differential Diagnosis in Radiology
Fetal in genital tract 927, 928
abdomen 910 in kidneys and ureters 581, 582
causes of abnormality in liqor in portal venous 294
volume 922 in urinary tract 580
hydrops 912 inside bladder 580, 581
intra-abdominal Gaseous distension of stomach 57
calcification 929 Gasless abdomen 326
neck masses 887 Gastric masses 349
renal cystic diseases 888 Gastrocolic fistula 356
thoracic abnormalities 931, 933 Germ cell tumors 627, 896
Fibroadenoma 151 Germinoma 710
Fibromuscular dysplasia 588 Giant cell tumor 425f, 505
Fibrosis 100 Gliomas 771
Fibrous Globoid cell leukodystrophy 791
cortical defect 413f, 530f, 531 Grades
dysplasia 492, 500, 535, 727, of hydronephrosis 553g
811, 867 papillary necrosis 592f
of humerus 536f Granulomas 656
tumors of pleura 146 Granulomatous
Floating tooth 851 disease 355
Fluorosis 494, 674 prostatitis 650
Focal Grave’s disease 868
hypoattenuating lesions in
spleen 309
pancreatic masses 316 H
pancreatitis 311 Hajdu-Cheney syndrome 518
Foregut duplication cyst 38 Hamartoma 62
Foreign body granuloma 11 Hashimoto’s thyroiditis 869
Forestier’s disease 528 Haversian canal 431
Formation of trabecular bone 201 Heart border 186
Frayed metaphysis 455 Heel valgus 541f
Fungal ball 623 Hemangioblastoma 835
Fusion of symphysis pubis 481 Hemangioma 4, 14, 516, 664,
744, 797, 817, 828
G of bone 426f
of vertebra 517f
Galactocele 148, 149 Hematemesis 337
Gallbladder ectopia 370 Hematoma 77, 149
Gas Hematomyelia 837
in biliary tree 293 Hematuria 658
in bladder wall 581 Hemiplegia 57
in gastric wall 249 Hemolytic anemia 681
 Index 943
Hemorrhage in bowel wall 241 Hypertranslucent lung field 121
Hemosiderosis 105 Hypertransradiant lung field 114
Hemothorax 57, 134 Hypertrophic osteoarthropathy 444
Henoch-Schönlein purpura 241 Hypervitaminosis 493
Heparin toxicity 513 Hypochondroplasia 485
Hepatic Hypofibrogenemia 241
arterial anatomy 363 Hypophosphatasia 485, 685
calcification 296 Hypoplasia 112, 646, 649
fissures 364 of greater wing of sphenoid 760
tumors with vascular scar 307 Hypoplastic
Herpes simplex encephalitis 787 gallbladder 369
Hiatus hernia 22, 45f, 46, 338f PCS 553
Hilar enlargement 64 Hypoproteinemia 241
Hirschsprung’s disease 335f Hypothalamoneurohypophyseal axis
Histiocytoma 534 germinoma 702
Histiocytosis 105, 832 Hypothyroidism 511, 685, 779
Histoplasmoma 89 Hypovolemic PCS 552
Histoplasmosis 103
HIV encephalopathy 788
Hodgkin’s I
disease 37, 62, 74 Idiopathic
lymphoma 354 calcinosis universalis 214
Honeycomb lung 122 hypercalcemia of infancy 493
Hot thyroid nodule 870 orbital inflammation 813
Hunter’s syndrome 488 thrombocytopenic purpura 241
Hurler’s syndrome 739, 778 tumoral calcinosis 213
Hürthle cell tumors 879 Implantation dermoid 501
Hyaline membrane disease 99f Infected emphysematous bullae 77
Hydatid 743 Infection of prostate 648
cyst 74, 89, 145 Inferior
Hydrocephalus 778 margin 460
Hydropic placental rib notching 53
degeneration 884 Inflammatory
Hyperechoic and infectious disease 48
hepatic lesions 303 bowel disease 372
splenic lesion 309 pseudotumor 86
Hyperostosis frontalis interna 765 Infrapatellar lipoma 210f
Hyperparathyroidism 53, 514, Infundibular lesions 699
664, 776 Inhalation
Hyperperfusion abnormalities disease 38
of liver 306 disorder 132
Hyperthyroidism 512 Inner ear masses 819
944 Differential Diagnosis in Radiology
Intermediate disease 380 Juvenile
Intestinal angiofibroma 802
edema 241 osteoporosis 510
lymphangiectasia 241 rheumatoid arthritis 529
obstruction 322f
in neonate 333
Intra-abdominal K
calcification in neonate 336 Keratosis obturans 829
fetal calcification 930 Koch’s chest 27f, 68f, 69f, 78f, 110f
Intra-articular loose bodies 474f Krabbe’s disease 791
Intracerebral hematoma 774
Intradural extramedullary
masses 753, 838, 839f L
Intralabyrinthine bleed 822
Lacrimal gland
Intramedullary
malignancy 765
abscesses 837
tumors 814
lesions 832, 833f
Lactose intolerance 275
masses 753
Langer cell histiocytosis 765
Intramural pseudodiverticulosis 342
Langerhans’
Intraorbital calcification 816
cell histiocytosis 128, 665,
Intra-osseous ganglion 534
748, 774
Intrasellar lesions 698
sun ray histiocytosis 864
Intraspinal masses 749
Large smooth kidney 557
Intratesticular cyst 629
Laryngeal masses 804
Intrathoracic goiter 12
Lateral thoracic meningoceles 844
Intravenous pyelography 660
Left
Invasive carcinoma 157
hilar mass 66f
Invisible main pulmonary artery 171
lower lobe consolidation
Irregular esophageal strictures 348
collapse 124f
Ischemic bowel disease with
Leiomyoma 22, 218
infarction 241
Leptomeningeal cyst 780
Ischiopubic rami 434f
Léri-Weill disease 487
Ivory vertebral body 731
Lesions of thoracic inlet 1, 13
Lethal neonatal dysplasia 391
J Leukemia 62, 241, 567, 628, 864
Leukodystrophies 791, 794
Japanese Society of Esophageal Linear calcification of soft
Disease 222 tissues 203
Jejunal diverticulosis 274 Linitis plastica 352, 355
Joint-space narrowing 421 Lipoblastoma 7, 13
Joubert’s syndrome 781 Lipoma 7, 13, 35, 147, 148,
J-shaped sella 777f 773, 798, 836
 Index 945
Liposarcoma 13, 202 Magnetic resonance imaging 382,
Liver function tests 366 799
Lobar Malignant
infarction 554 external otitis 830
pneumonia 123 lesion 745, 804, 850
Lobulated fibroadenoma 152f mesothelioma 134, 140
Localized pleural thickening 134
air space disease 92 tumor 828
hyperostosis of skull 669 Marchiafava-Bignami disease 789
lucent Marfan’s syndrome 52
defect 81t Maroteaux Lamy syndrome 489
lung defect 121 Massive ovarian edema 892
Loose intra-articular bodies 473 Massively dilated stomach 247
Loss of Mastocytosis 275, 495
epiphyseal density 409 McLeod syndrome 119
lamina dura of teeth 860 Medial
renal outline on plain film 583 mandibular 856
Lower end of femur 428f maxillary 856
Lucency in skull vault 663, 666 wall 758
Lucent Mediastinal masses 15
bone lesion containing bone/ Mediastinum 15, 41
calcium 424 Mediolateral mammogram 157f,
lung lesions 78 161f
Lung Medullary
abscess 63, 90, 125 cysts 608, 614
tumors 61 tumors 654
Lymph node 36, 68, 147, 149 Mega cisterna magna 686, 756
enlargement 18 Melanoma 815
Lymphangiectasia 275 Melas syndrome 794
Lymphangioma 3, 808 Meningioma 672, 701, 724, 760,
Lymphangitis 764, 772, 840
angioneurotic edema 241 Meningoceles 801
carcinoma 62 Merrf syndrome 794
Lymphatic obstruction 330 Mesothelioma 98, 114
Lymphoid tumors 814 Metabolic disorder 483, 485
Lymphoma 8, 34, 35, 154, 241, 315, Metachromatic leukodystrophy 791
354, 358, 494, 516, 628, 723, Metaphyseal
803, 850, 875 corner fracture 409
lucency 409, 433f
Metastatic
M carcinoma 259
Macroadenoma 704 lymph node 18t
Macrodystrophia lipomatosa 385f mass 14
Madelung deformity 462
946 Differential Diagnosis in Radiology
neuroblastoma 507, 507f myeloma 503, 538, 564, 663,
tumors 810, 812 745, 865
Metatrophic dwarfism 488 opacities 108t
Michel’s classification 363 pinpoint opacities 107, 123
Microadenoma 704 wormian bones 683
Middle Myelography 835
ear masses 823, 826t Myeloma 241, 494
mediastinal masses 18, 36 Myelosclerosis 494
Midline cranial fossa of CSF Myositis ossificans 202
density 687
Miliary
metastasis 105 N
shadowing 101, 102, 105 Nabothian cysts 883
tuberculosis 103, 104f Nasal cephaloceles 768
Misplaced pulmonary artery 171 Nasopalatine 856
Mitochondrial dysfunction 784 Nasopharyngeal
Mitral angiofibroma 724
regurgitation 180, 190f masses 799, 800
stenosis 190f Neonatal
valvular disease 180f dysphagia 340
Mixed density lesions 149 hepatic calcification 301
Monoarthritis 469 obstructive jaundice 300
Morgagni hernia 18, 145 Neoplasms of paranasal sinuses 813
Moth-eaten bone 429 Neoplastic disease 746
Mucinous cystadenoma 311 Nephroblastomatosis 602
Mucocele of frontal sinus 667 Nephrotic syndrome 241
Mucolipidosis 393 Nerve sheath tumors 839
Mucopolysaccharidoses 393 Neurenteric cyst 23, 38, 42, 757
Müllerian duct cyst 649 Neuroblastoma 9, 14
Multicystic Neurocysticercosis 209f
dysplastic kidney 613 Neurofibroma 664
kidney 574 Neurogenic tumors 21, 21t, 45
Multifocal pulmonary Neuropathic
metastases 84f arthritis 415f
parenchymal and hilar foot 472f
calcifications 69f lesions of bladder 624
Multilocular cystic nephroma Nodular appearance of small
602, 613 bowel 264
Multiple Non-expansile
collapsed vertebrae 746 multilocular cystic lesion 530
cystic lesions 531 unilocular cystic lesions 529
lucent lung lesions 78
 Index 947
Non-gynecological pelvic tumors 723
masses 893 varices 818
Non-Hodgkin’s Osmotic demyelination 789
disease 37 Osteoarthritis 524f, 527
lymphoma 62 of diarthrodial joint 421f
of femur 423f of spine 419f
Non-ossifying fibroma 401, 413f, Osteoblastoma 401, 495
425f, 508, 532 Osteochondrodysplasias 482
Non-ovarian adenexal mass 893 Osteochondroma 52, 412, 425f
Normal Osteoclastoma 537
bone 431 Osteogenesis imperfecta 53, 512,
diarthrodial joint 420f 679, 728
hemodynamics parameters of Osteoid osteoma 399f, 496f
liver 365 Osteolytic
intracranial calcification 770 defect in medulla 418
osseous density 445 metastasis 504f
ovaries 891 Osteoma 495
size Osteomalacia 434, 514, 862
of bile ducts 367 Osteomas 830
of liver 365 Osteomyelitis 450, 497
Osteopenia 429, 508
Osteopetrosis 490, 728, 765
O Osteophytes 421
Obstruction of duodenum 251 Osteoporosis 508, 509, 746, 861
Obstructive uropathy 559 circumscripta 398, 398f, 663
Ocular masses 815 Osteosarcoma 426f, 496
Odontogenic keratocyst 855 of femur 497f
Oligodendroglioma 836, 925 Osteosclerosis 394
Oncocytoma 599 of lower lumbar spine in
Opaque fluorosis 207f
hemithorax 111 Osteosclerotic metastasis 493
maxillary antrum 865 Ovarian mass 894, 897
Optic
glioma 761 P
nerve 764
glioma 759, 778, 811 Paget’s disease 396f-398f, 494, 516,
meningioma 817 672, 727, 764, 862
sheath meningioma 759 Painless hematuria 656
Orbital Pancoast’s tumor 10, 14
hyperostosis 763 Pancreas 370
masses 806 Pancreatic
meningioma 809, 817 calcification 310
pseudotumor 760, 813
948 Differential Diagnosis in Radiology
development and anatomy 370 Periurethral
masses 311 glands 645
pseudocyst 23 glandular 647f
Pancreaticobiliary junction Pertechnetate scan 43
variants 368 Perthe’s disease 452
Pancreatitis 301 Pharyngoesophageal pouch 22
Papilloma 151 Phrenic nerve palsy 57
Paragangliomas 843 Phylloides tumor 153
Paragonimus westermani 775 Pilocytic astrocytoma 757
Paranasal sinus masses 812 Pineal tumors 773
Paraplegia 203 Pituitary
Parasitic adenoma 704
calcification 207 apoplexy 705
infestations 274 Placental hemorrhage 905f
Paravertebral lesions 23, 44 Plain
Parenchymal calcification 592 skiagram chest 116-120
Parosteal osteosarcoma 202 X-ray 660, 704
Paroxysmal peroxisomal Plantar calcaneal spur 475
disorders 784 Planum sphenoidale 689
Partial mole 884 Plasma cell granuloma 86
Pectus Plasmacytoma 503, 538, 745
carinatum 47 Platybasia 680
excavatum 46 Pleural
Pediatric orbital tumors 807 diseases 128
Pelken spur 409, 433f fluid 136
Pelvic masses 884 lesions 57t, 138
Penciled distal end of clavicle 458 masses 133
Pencil-thin cortex 409 thickening 113, 131
Peptic stricture 216 tumors 137
Perforation of lower uterine Pleuropericardial cyst 17
segment 885 Pneumatosis intestinalis 285
Periarticular soft tissue Pneumoconiosis 106
calcification 208f, 211 Pneumomediastinum 10, 59
Perinephric Pneumonectomy 99
cyst 613 Pneumonia 90
hematoma 584 Pneumoperitoneum 320, 323, 325
Periosteal reaction 407, 437, 441 Pneumothorax 59, 120, 134, 137
Peripheral Poland syndrome 48
blood eosinophilia 355 Poliomyelitis 51
zone 645 Polyarteritis nodosa 588
Periportal hyperechogenicity 303 Polycystic
Perirenal abscess 585 disease 608
 Index 949
kidney 369f massive fibrosis 76
disease 568, 611 systemic sclerosis 521
Porcelain gall bladder 297f Prostate 644
Portal hypertension 301 and seminal vesicle cysts 649
Positive pregnancy test 901, 902 imaging 639
Posterior Prostatic
fossa abscess 650
arachnoid cyst 686 agenesis 649
cysts 685, 755 calculi 648, 651
neoplasm in childhood 713 cyst 649
mediastinal masses 21, 41 infections 650
scalloping of vertebral lesions 648
bodies 734, 735f utricle cyst 649
Postmenopausal osteoporosis 511 Protein
Postnephrectomy 583 deficiency 513
Postobstructive atrophy 577 losing enteropathy 241, 276
Postoperative pelvic mass 893 Protrusio acetabuli 479, 479f
Post-pneumonectomy 114 Prune-Belly syndrome 625
Post-surgical scar 158 Pseudoachondroplasia 486
Posturethral valves 619 Pseudoarthrosis 449
Pott’s spine with abscess 13 Pseudogestation of ectopic
Premature closure of growth pregnancy 882
plate 386 Pseudomass 160
Presacral fetal mass 885 Pseudo-obstruction 272
Pressure overload 181t Pseudopneumoperitoneum 323
Prevertebral Psoriatic
abscess 798 arthritis 519
soft tissue thickening 795 arthropathy 526
Primary Pubic bone 506f
bone tumors 410 Pulmonary
congenital cholesteatoma 832 arterial
hepatic masses 298 hypertension 174, 174f, 175
malignancy 260 hypoplasia 120
megaureter 579 artery 69, 173t
retroperitoneal tumor 358 aneurysm 91
uroradiologic elements AV fistula 91
545-547, 554, 596 diseases 119
Proctitis 376 embolism 118
Progeria 518 hamartomas 86
Progression of Paget’s disease 398f hematoma 91
Progressive infarct 75, 92
diaphyseal dysplasia 728 parenchyma 55f
venous hypertension 192f, 193
950 Differential Diagnosis in Radiology
Pyknodysostosis 491, 519, 672 Rhabdomyosarcoma 623, 811, 819
Pyonephrosis 571 Rheumatic heart disease 182f, 190f,
192f
Rheumatoid
R arthritis 51, 126, 416f,
Radial scar 159 418f, 514, 527
Radiation nodules 76, 90
enteritis 261 Rhombencephalosynapsis 781
esophagitis 221 Rib
injury 355 lesions 458
nephritis 546, 551 notching 459
Radicular cyst 856 Rickets 433f, 485
Rathke’s cleft cyst 709 Right
Reflux nephropathy 554 aortic arch 191
Reiter’s syndrome 416f, 521, 523, 526 paracolic abscess 212f
Renal sided diaphragmatic humps 60
artery stenosis 545, 551, 572 Routes of
calcification 589 bone invasion 442f
cell carcinoma 575, 595 spread 223
cystic disease 612
cysts and hydronephrosis 890 S
dysplasia 557, 608
infarction 547 Sacroiliitis 478, 522
mass 594 Sarcoidosis 41, 77, 104, 127,
osteodystrophy 492, 513, 673 355, 520, 760
scan 661 Sarcoma 62
size 560 Scheurmann’s disease 748f
tumor 574, 585 Schistosomiasis 579
vein thrombosis 558, 573 Schwannoma 823
Renovascular hypertension 585 and neurofibroma 8, 14
Resorption of distal phalanges 468 Scimitar syndrome 146
Retention cyst 650 Scleroderma 126, 213, 216, 521, 863
Retinoblastoma 759, 762, 815 Sclerosing adenosis 160
Retrocaval ureter 580 Sclerotic
Retroperitoneal fibrosis 356, 580 bone lesions 396
Retropharyngeal lesions of bone 489
abscess with mediastinal Scoliosis 58
extension 7 Scurvy 409f, 513
cellulitis and abscess 796 Secondary
edema 797 collecting system 596
lymph adenopathy 796 esophageal neoplasms 221
Retrosternal goitre 17t uroradiologic elements 545-547,
554, 556, 558, 597
 Index 951
Sellar and suprasellar masses 703 mass 407
Seminal vesicle calcification 630 ossification 201
Senile osteoporosis 510 Solid
Septal lines 108 and papillary epithelial
Septated bone lesions 429 neoplasm 315
Septations of gallbladder 369 masses 899
Sequestered lung 75 thyroid nodule 878
Seronegative spondyloarthritides with fat density 13
482 without fat density 14
Serous cystadenoma 311 Solitary
Severe rheumatoid arthritis 528f bone cyst 501
Sex cord tumors 897 collapsed vertebra 743
Short dense
limb dysplasias 482 metaphyseal band 454
limb skeletal dysplasia 386 vertebra 515
spine pulmonary nodule 80, 82, 83f
dysplasias 488 radiolucent metaphyseal
skeletal dysplasia 389 bands 454
Sickle cell anemia 749 Sonographic classification of
Signs of adenexal masses 898
esophagitis 342 Spectral analysis of intrarenal
malabsorption 267f arteries 573
pulmonary edema 178f Spectrum multiple pinpoint
Silicosis 103, 106, 127, 141 opacities 108t
Simple Sphenoid sinus 700
bone cyst 499f, 532, 857 Sphincter dys-synergia 624
breast cysts 150f Spiculated breast
cyst 150, 602, 603, 609, 898 carcinoma 157t, 158f
Sinusitis 866 masses 157
Situs 197 Spinal
inversus 196f angiolipoma 849
Skeletal maturation disorders 384 column 524
Sloughed papilla 578 fusion 526
Small subdural empyema 844
aorta 185 Spine 491
bowel 262f Spleen 371
folds 239f Splenic
hilum 55t, 56 calcification 308
intestinal stricture 255, 256 flexure 57
smooth kidney 549, 552 Splinting of diaphragm 57
Smooth hemidiaphragm 57 Spongiosa 431
Soft tissue Sporadic aniridia 600
lesions 200
952 Differential Diagnosis in Radiology
Spread of testicular tumors 628 Systemic
Squamous cell carcinoma 831 lupus erythematosus 52, 130
Staphylococcus aureus 74 sclerosis 51, 272
Steinberg classification for AVN of
hip 453
Stippled epiphysis 449 T
Strictures small bowel 254 Takayasu’s arteritis 588
Stromal tumors 628 Talocalcaneal angle 540f, 541f
Structures Tectocerebellar dysraphia 781
mimicking left adrenal mass 653 Temporal bone sclerosis 725, 726
of middle and inner ears 820f Tendon insertion 418
Sturge-Weber syndrome 776 Teratodermoid tumors 15
Subacute thyroiditis 877 Teratoma 710, 772, 807
Subarticular lytic bone lesion 414 Testicular tumors 626
Subchondral Tetralogy of Fallot 115
cyst 421 Thalassemia 681
sclerosis 421 Thanatotropic dwarfism 486
Subcortical arteriosclerotic Thickened
encephalopathy 791 duodenal folds 235, 246
Subcutaneous nodule 418 endometrium 918, 919
Sub-diaphragmatic esophageal folds 227
abscess 58 gallbladder wall 304
lymphadenopathy 226 gastric folds 229, 244
Subperiosteal hematoma 409, 433f mucosal folds esophagus
Subphrenic inflammatory disease 58 and stomach 227
Sunburst periosteal reaction 507 placenta 903
Superior small bowel folds 240, 264
margin 459 Thoracic
mediastinal masses 24 aortic aneurysm 39
orbital fissure enlargement 718 inlet 2f
rib notching 50 outlet syndrome 12
Suprasellar Thoracotomy 57
lesions 700 Thromboangiitis obliterans 241
mass 698 Thumb printing in colon 288
meningioma 707 Thymic cyst 5, 12
Swyer-James syndrome 119 tumors 15
Synovial Thymoma 35
fluid 420 Thyroid
hypertrophy 418 abscess 873
osteochondromatosis 474f calcifications 880
Synovium 420 carcinoma 9, 14
Syringohydromyelia 836 lesions 868
 Index 953
TNM staging 314 U
Tortuous
carotid artery 798 Ucolipidoses 394
innominate artery 21 Ulcer disease 237
Toxic Underdeveloped main
multinodular goiter 868 pulmonary artery 171
solitary nodule 869 Unilateral
Toxoplasmosis 774 hilar enlargement 64
Tracheal tumors 21 pulmonary edema 93
Transabdominal ultrasound 382 scarred kidney 555f
Transitional cell carcinoma 597 Unilaterally elevated diaphragm 57
Transposition of great vessels 192 Upper jejunal loop 254f
Traumatic Ureteric diversion into colon 582
lung cyst 77 Ureterocele 579
stricture 621 Urethral
Tricuspid atresia 117, 369 atresia 620
Tropical sprue 270 calculus 621
Tubercular arthritis 470f, 471f dysplasia 620
Tuberculoma 88, 774 stricture 620
Tuberculosis 57, 74, 132, 257, 355, Urinary tract complications 383
556, 572 Usual interstitial pneumonitis 128
Tuberculous
spondylitis 6
stricture 579
V
Tuberous sclerosis 128, 776 Van Buchem’s disease 728
Tubo-ovarian abscess 892 Van Der Hoeve’s syndrome 728
Tubular ectasia of rete testes 629 Vascular
Tumoral calcinosis 203 anomalies 5
Tumors 578, 771, 798 lesion 703, 773, 790
of chest wall 48 Vasculitis 241
of mediastinum 16t Ventricles and CSF spaces 755
of prostate 648 Ventricular septal defect 177f
Turner’s syndrome 485, 908 Vertebral body squaring 525
Twin pregnancy 884 Vesical calculi 622f
Types of Vesicoureteric reflux 575, 580
calcification 165f Vestibular aqueduct syndrome 822
cysts 855f Videocystometrography 624
effusion 54t Villous adenomas 281
periosteal reaction 411f, 439 Visual pathway glioma 711
Typical carcinoma 155f Volume overload 179t
954 Differential Diagnosis in Radiology

W X
Wegener’s Xanthogranulomatous
granuloma 130 pyelonephritis 561
granulomatosis 75, 90, 867 X-ray neck soft tissue 7
Whipple’s disease 271
Widened growth plate 433
Widening of symphysis pubis 480 Z
Wilms’ tumor 574 Zollinger-Ellison’s syndrome 270
Wimberger’s sign 409
Wormian bones 673