diagnostic imaging in critical care

A PROBLEM BASED APPROACH

Diagnostic Imaging in Critical Care: A problem based approach provides an up to date

educational resource which will enable clinicians practising or training in intensive
care, emergency medicine or anaesthesia to interpret patients’ imaging investigations.
The book is based on a series of problems about critically ill patients. The problems,
which are of varying degrees of difficulty, begin with a brief clinical history and an
image or series of images; questions are asked about the images and answers are pro­
vided on the facing page. There are two sets of radiological images for each problem
- one set is in the book as part of the problem, and the second set is on the DVD - and
offer a full set of high quality images such as a reporting radiologist would review (the
same images seen on the digital X-ray system used in the authors’ clinical practice).
The book will also be useful for doctors from a broad range of specialties whose
patients come to the ICU, including surgeons and physicians, as well as radiology
trainees.

FEATURES
• problems arranged in chapters based on anatomical region being imaged
• plain X-ray, CT, MRI and ultrasound images from the full spectrum of disease
processes seen in the critically ill adult
• DVD supports the entire set of problems with high quality images similar to
those used in real life
• DVD enhances learning in allowing readers to scroll through sequential images
giving an appreciation of 3D anatomy

Chris Joyce Associate Professor, Department of Anaesthesiology & Critical Care,

University of Queensland; Director of Intensive Care, Princess Alexandra Hospital,
Brisbane, Australia
Nivene Saad Staff Radiologist, Princess Alexandra Hospital, Brisbane, Australia
Peter Kruger Senior Lecturer, Department of Anaesthesiology & Critical Care,
University of Queensland; Deputy Director of Intensive Care, Princess Alexandra
Hospital, Brisbane, Australia
Carole Foot Staff Specialist, Intensive Care, Royal North Shore Hospital, Sydney,
Australia
Nikki Blackwell Senior Staff Specialist, Intensive Care, Prince Charles Hospital,
Brisbane; Consultant, Critical Care, Medecins Sans Frontieres, Paris, France; Senior
Lecturer, University of Queensland, Brisbane, Australia

CHURCHILL
LIVINGSTONE
ISBN 978-0-7295-3878-7
diagnostic imaging
1 in critical care
A PROBLEM BASED APPROACH

Chris Joyce
Nivene Saad
Peter Kruger
Carole Foot
Nikki Blackwell
diagnostic imaging
in critical care
A PROBLEM BASED APPROACH

Chris Joyce
Nivene Saad
Peter Kruger
Carole Foot
Nikki Blackwell

CHURCHILL
LIVINGSTONE

Sydney Edinburgh London New York Philadelphia St Louis Toronto

ELSEVIER

Churchill Livingstone
is an imprint of Elsevier

Elsevier Australia. ACN 001 002 357

(a division of Reed International Books Australia Pty Ltd)
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©2010 Elsevier Australia

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This publication has been carefully reviewed and checked to ensure that the content is as
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and/or damage to persons or property arising from any error in or omission from this publication.

National Library of Australia Cataloguing-in-Publication Data

Diagnostic imaging in critical care : a problem based approach / Chris Joyce ... [et al.].

ISBN: 978 0 7295 3878 7 (pbk.)

Includes index.
Bibliography.

Diagnostic imaging.
Clinical medicine.

Joyce, Chris.

616.0754

Publisher: Sophie Kaliniecki

Developmental Editor: Sabrina Chew
Publishing Services Manager: Helena Kiijn
Editorial Coordinator: Eleanor Cant
Edited by Mark Snape
Proofread by Kerry Brown
Design and typesetting by Pindar NZ, Auckland, New Zealand
Index by Max McMaster
Printed by 1010 Printing International Limited
CONTENTS

About the authors vi

Reviewers vi
Acknowledgements vii
Introduction vii
Acronyms vii

CHAPTER 1 Chest 1
CHAPTER! Abdomen and pelvis 141
CHAPTER 3 Head 209
chapter 4 Neck and back 275
CHAPTER 5 Limbs 343
chapters Imaging modalities 371

Appendix 377
Index 381

V
About the authors Acknowledgements
Chris Joyce
Dr Daniel Mullany contributed images, critiqued the problems and helped with the annotations on the
MB ChB, PhD, FJFICM, FANZCA
DVD. Dr Judith Bellapart contributed images for the problems on transcranial Doppler and provided
Associate Professor, Department of Anaesthesiology and Critical Care, University of Queensland, Brisbane, advice on these problems. Our thanks to the radiographers, sonographers and PACS support personnel of
Australia
Princess Alexandra hospital who helped with image acquisition and optimisation, and to Wendy Schipper
Director of Intensive Care, Princess Alexandra Hospital, Brisbane, Australia
who assisted with the preparation of the manuscript.
Nivene Saad
MB BCh, MS, MD, FRANZCR
Staff Radiologist, Princess Alexandra Hospital, Brisbane, Australia Introduction: including how to use this book and DVD
This book is based on a series of problems about critically ill patients. Plain X-ray, CT, MRI, and ultra­
Peter Kruger sound images from the full spectrum of disease processes seen in the critically ill patient are included. The
MBBS, BSc(Hons), FJFICM, FANZCA problems are arranged in five chapters based on the region of the body being imaged (Chest, Abdomen and
Senior Lecturer, Department of Anaesthesiology and Critical Care, University of Queensland, Brisbane, Pelvis, Head, Neck and Back, and Limbs). Each chapter starts with a section of applied anatomy related to
Australia imaging that region, except for the Limbs chapter. The final chapter is basic information about the imag­
Deputy Director of Intensive Care, Princess Alexandra Hospital, Brisbane, Australia ing modalities presented in this book. Whether this is read first, last or when questions about the imaging
modality are raised by the problems is up to the reader.
Carole Foot For each problem, there are two sets of radiological images. One set is in the book as part of the problem
MBBS(Hons), FACEM, FJFICM, MSc(International Health Management) and, because of space, is limited to only those images necessary to solve the problem. The second set is con­
Staff Specialist Intensive Care, Royal North Shore Hospital, Sydney, Australia tained on the DVD and comprises a full set of high-quality images such as a reporting radiologist would
review. Each problem consists of a brief clinical scenario, the two sets of images and a series of questions.
Nikki Blackwell Answers to the questions (including our interpretation of the images) are provided in the book, along with
MBBS, BSc (Hons), FRCP, FRACP, FAChPM, DTMH, FJFICM a set of learning points.
Senior Staff Specialist, The Prince Charles Hospital, Brisbane, Australia While the book can be used independently of the DVD, the learning experience will be enhanced by
Consultant Critical Care, Medecins Sans Frontieres, Paris, France reviewing the full set of images on the DVD when the problem is done. The DVD images are the same
Senior Lecturer, University of Queensland, Brisbane, Australia images seen on the digital X-ray system used in our clinical practice. This provides high-quality images on
a computer screen that could never be achieved with printed reproductions. It also allows the user to scroll
through MRI or CT images, which gives an appreciation of the three-dimensional anatomy that cannot
Reviewers be obtained from images in a book or on film printouts. Annotations on the DVD images illustrate the
Gerard Ahern findings that we have made in our interpretation of the images. The DVD images can be viewed with these
MBBS annotations switched on or off.
We hope that you find learning from this book as fulfilling as we have found the challenges of caring for
Prosector & Postgraduate Anatomy Coordinator, Monash University, Melbourne, Australia
the patients whose images are presented in this book.
Honorary Senior Fellow in Anatomy, University of Melbourne, Australia
Honorary Associate Professor, Oceania University, Apia, Samoa
Lecturer & Tutor, Royal Australasian College of Surgeons
Examination Contributor, Australian Medical Council Acronyms
AP Anteroposterior
Nicholas Barnes ARDS Acute respiratory distress syndrome
MB ChB, FJFICM CXR Chest X-ray
Clinical Director, Critical Care, Waikato Hospital, Hamilton, New Zealand DISH Diffuse idiopathic skeletal hyperostosis
GCS Glasgow coma scale
Benjamin Harris Gd Gadolinium
MBBS, BSc(Med), PhD, FRACP HIDA Hepatobiliary iminodiacetic acid (scan)
Respiratory Physician, Royal North Shore Hospital, Sydney, Australia HRCT High resolution computerised tomography
Research Fellow, The Woolcock Institute of Medical Research, Sydney, Australia ICU Intensive care unit
IV Intravenous
Tim Harris IVC Inferior vena cava
FACEM, FCEM, DipImmCare, Dip O&G, BM, BS, BMedSci NG Nasogastric
Consultant, Emergency Medicine and Prehospital Care, Royal London Hospital and London HEMS, UK PA Posteroanterior
Head of Research, School of Emergency Medicine and Department of Emergency Medicine, Royal London PCP Pneumocystis pneumonia
Hospital, London, UK TB Tuberculosis
TPN Total parenteral nutrition
Morry Silberstein
MBBS, MD, DRACR, FRANZCR
Associate Professor, Radiology, Monash University, Melbourne, Australia

vi vii
2 Diagnostic imaging in critical care 1 • Chest 3

APPLIED ANATOMY
Lobes and fissures of the lung
(Figures 1.1,1.2 and 1.3)
In the right lung, there are two fissures. The greater
or oblique fissure runs obliquely forwards and
downwards from approximately the T4 vertebra
posteriorly, then passes through the hilum to con­
tact the front of the diaphragm 0-3 cm behind the
anterior costophrenic recess. This greater fissure
separates the lower lobe from the upper and mid­
dle lobes. The horizontal fissure runs horizontally
and laterally at the level of the hilum and separates
the upper from the middle lobe. The lower lobe lies
against the diaphragm, the middle lobe lies against
the heart, while the upper lobe lies against the supe­
rior mediastinum.
In the left lung, there is only one fissure, the FIGURE 1.2 Upper lobes.
FIGURE 1.3 Middle and lower lobes.
oblique fissure. This fissure separates the lower lobe
from the upper lobe. The part of the left upper lobe
analogous to the right middle lobe is the lingula, the right upper mediastinal border and the creation Mediastinal borders (Figure 1.4)
but there is no fissure separating it from the rest of of a border at the horizontal fissure. The right side of the mediastinum is the -venous”
the upper lobe. The lower lobe lies against the dia­ With a left upper lobe process there is a loss of side and, from above down, is formed by the bra­
phragm. The lingula lies against the heart and the both the left upper mediastinal border and the left chiocephalic vein, the superior vena cava (SVC),
remainder of the upper lobe lies against the upper cardiac border. If the process is constrained to the the azygous vein, the SVC and the right atrium.
mediastinum. lingula, only the left cardiac border is lost. The left or “arterial” side of the mediastinum is
This explains the X-ray appearances when indi­ With a right middle lobe process, there is loss formed by the subclavian artery, the aortic knuckle,
vidual lobes are opacified. The normal borders of the right cardiac border and creation of a new the pulmonary artery, the left atrium and the left
between an affected lobe and adjacent soft tissue border at the horizontal fissure. ventricle. Understanding this anatomy facilitates
density mediastinal structures are lost (silhouette With a lower lobe process on either the right or determining which is the abnormal structure when
sign), while new borders are created where the left, there is loss of the diaphragmatic border. Note there is an abnormal mediastinal or cardiac outline
opacified lobe lies against normal lung at fissures. that the opacification can extend well above the on the chest X-ray.
With a right upper lobe process there is loss of level of the horizontal fissure, up to T4.

FIGURE 1.4 Mediastinal borders and position of venous

FIGURE 1.1 The normal fissures and borders of the lung. RIWL = Right middle lobe; RUL = Right upper lobe. and arterial anatomical structures.
4 Diagnostic imaging in critical care 1 Chest 5

PROBLEM 1.01
A
1. Right upper lobe. 3. Consolidation.

2. Findings that support involvement of the right 4. Opacification without any evidence of shift of
upper lobe are: structures supports consolidation. An alter­
• opacification in right upper zone native process is collapse, which would be
• loss of right upper mediastinal border supported by the presence of the tip of the
• creation of a new border at horizontal endotracheal tube at the carina. The lack of
fissure shift of structures argues against collapse unless
it is incomplete.

Learning point
Each lobe of the lung has a characteristic pat- allows identification of the site of a pathological
tern of opacification. Loss/creation of borders process.

This 64-year-old man presented with shortness of

breath for 24 hours. On admission to hospital, he
Q Which lobe is abnormal?
1.
had hypoxaemic respiratory failure. 2. What findings support this?
3. What is the likely process in the affected lobe?
4. What evidence supports this being the
process?
6 Diagnostic imaging in critical care

PROBLEM 1.02

This 61-year-old man presented with unstable

angina. He was found to have critical stenosis of 1. Which lobe is predominantly abnormal?
the left main coronary artery and had emergency 2. What is the likely process affecting that lobe?
coronary artery bypass grafting yesterday. 3. What findings support this?
 1 • Chest 7

A
1. The left lower lobe. There is also patchy opaci­ 3. Findings which support this are:
fication elsewhere in both lungs, likely to be • increased cardiac density
atelectasis. • loss of diaphragmatic border
With complete collapse of the left lower
2. Collapse, with some additional element of lobe, the bronchus is typically shifted down­
pleural effusion. wards, a sign that is not present on this image.

Learning point
Left lower lobe collapse is very common following
cardiac surgery.
8 Diagnostic imaging in critical care 1 • Chest 9

PROBLEM 1.03
A
1. Lobes that are involved in the process are: patchy density behind the heart and partial
• Lingula and left lower lobe are involved in loss of the left hemidiaphragm.
the process.
♦ Lingular involvement is evidenced by loss of 2. The likely process is consolidation, which,
the left cardiac border, with adjacent perihi- in this context, is probably due to aspiration.
lar opacification. Collapse needs to be considered, but there is no
• Left lower lobe involvement is evidenced by obvious shift of structures.

Learning point
Knowledge of the anatomy will enable delinea­
tion of which lobes are involved in a pathological
process.'

This 25-year-old woman was an unrestrained

front seat passenger during a high-speed motor
Q
1. Which lobes are involved in the process?
vehicle collision. She sustained a severe head 2. What is the likely process?
injury, with a GCS of 3 at the scene. She is thought
to have aspirated prior to intubation.
10 Diagnostic imaging in critical care 1 • Chest 11

PROBLEM 1.04
A • upward shift of the horizontal fissure
The tip of the pulmonary artery catheter appears
to be in the proximal pulmonary artery. The These features are not suggestive of pulmonary
appearances in the right upper lobe suggest col­ infarction.
lapse, as evidenced by: The endotracheal tube is not too low. Indeed, it
• homogenous opacification in the right upper is too high, suggesting that it is unlikely to be the
zone immediate cause of the collapse.
• loss of right upper mediastinal border
• creation of a new border at the horizontal
fissure

Learning point
Pulmonary collapse creates traction forces on right upper lobe bronchus and/or shift to the
adjacent structures, often shifting them towards right of the trachea and other upper mediastinal
the area of collapse. structures. Hyperinflation of the rest of the right
With right upper lobe collapse, it is common to lung may occur as it expands to fill up the space
find the horizontal fissure shifted upwards. There left by the collapsed right upper lobe.
may also be upwards shift of the right hilum and

This 32-year-old man presented with septic shock.

A pulmonary artery catheter was inserted to
Q
What do you think?
guide management. Your junior medical staff are
concerned that the findings on this image suggest
the pulmonary artery catheter may have caused a
pulmonary infarct.
 12 Diagnostic imaging in critical care 1 • Chest 13

PROBLEM 1.05
A
Two evident pathological processes are: • left upper lobe fibrosis: the left lung hilum is
• hyperinflated lungs suggestive of emphysema: abnormally elevated, suggesting a loss of lung
normally, there are six ribs visible anteriorly volume in the left lung apex. There are increased
above the diaphragm and ten posteriorly. In reticular markings in the left apex. The differ­
this film, there are seven ribs visible anteri­ ential diagnosis of unilateral upper lobe fibrosis
orly above the diaphragm and ten posteriorly; includes lung carcinoma, tuberculosis, trauma,
the mediastinum is narrow and elongated and radiation therapy or previous pneumonia
the diaphragm flattened. Lung markings are (Dahnert, 2007).
reduced bilaterally with emphysematous bullae
at both apices.

Learning point
The left hilum is normally only slightly higher
than the right. Changes in position of structures
may give a clue to otherwise subtle pathology.

This is the preoperative chest X-ray of a 65-year-

old man with a 50-year history of heavy smoking.
Q
What two pathological processes are evident?
He is scheduled to have major ENT surgery for a
squamous cell carcinoma of the tongue.
—
14 Diagnostic imaging in critical care 1 • Chest 15

PROBLEM 1.06
A
1. The differential diagnosis of a unilateral opaque pneumonectomy. If the process involved
hemithorax includes: tumour or pleural fluid causing this extent of
100/3.2 • consolidation opacity, there would usually be contralateral
• pleural fluid mediastinal shift but, occasionally, second­
• tumour ary lung collapse means this does not occur.
MOBILE SUPINE • pneumonectomy Consolidation will often produce air broncho­
• collapse grams, but these are not always seen. There are
small lucencies in the right hemithorax, which
2. Consolidation, with or without pleural may represent air bronchograms or early
effusion. abscess formation.
This patient had a staphylococcal pneumo­
3. In a case like this, it is not certain what process nia with no effusion.
is present. Isolated collapse is unlikely as there
is no mediastinal shift. There is no evidence 4. CT scan will be the most helpful. Ultrasound
of surgical clips or rib resection to suggest will demonstrate if an effusion is present.

Learning point
On a plain chest X-ray, it is not always possible to
make a definitive diagnosis. Other investigations
may be needed.

This 18-year-old woman had fevers for one week

then became short of breath yesterday. She now 1. What is your differential diagnosis?
presents to hospital with hypoxaemic respiratory 2. What is the most likely cause?
failure. 3. Why do you favour this diagnosis?
4. What further investigation would help resolve
the diagnosis?
16 Diagnostic imaging in critical care 1 • Chest 17

PROBLEM 1.07 A
1. In this chest X-ray, there is pleurally based 2. Findings that support this diagnosis are:
opacification of the right hemithorax with • homogenous opacification of the right side
contralateral mediastinal shift. The most likely of the chest
cause of this is a collection of pleural fluid • mediastinal shift away from the pathology
under tension. Other possibilities include a (contralateral shift)
pleurally based tumour, such as a mesothe­ • no signs of bony trauma to suggest a
lioma or metastases. haemothorax

Learning point
The direction of shift of the medistinal structures In contrast, with processes that produce mass
is a due to the underlying pathology. With patho­ effect (pleural collections, most tumours), the
logical processes that produce loss of lung volume shift is away from the affected area. Consolidation
(collapse, fibrosis, pneumonectomy), there is does not usually produce significant shift of
shift of the structures towards the affected area. structures.

This 70-year-old man presented with hypotension

and dyspnoea. He gave a history of progressive 1. What is the most likely cause of the opaque
fatigue and shortness of breath over the previous right hemithorax?
two weeks. 2. What findings on the X-ray support your
diagnosis?
18 Diagnostic imaging in critical care 1 • Chest 19

PROBLEM 1.08
A
1. Prior pneumonectomy. • surgical clips in region of left hilum
• hyperinflation of right lung, which herniates
2. Findings on the X-ray that support this diag­ across the midline to the left side
nosis include: • shift of mediastinal structures towards the
• narrowing of intercostal space between the pathology (ipsilateral shift)
sixth and seventh left ribs posteriorly • abrupt cut-off of left main bronchus
• homogeneous opacity in left hemitho­
rax with loss of diaphragmatic and cardiac
borders

Learning point
The clinical history, including past surgical
procedures, is important when generating the
differential diagnosis of appearances on imaging.

This 54-year-old man was in a car crash today,

sustaining lower limb fractures. You are shown 1. What is the most likely cause of the opaque left
this chest X-ray by a resident working on the hemithorax?
surgical ward. He wants to know what size chest 2. What findings on the X-ray support your
drain to insert. diagnosis?
20 Diagnostic imaging in critical care 1 • Chest 21

PROBLEM 1.09
A
1. Collapse of the left lung. • narrowing of rib spaces in left hemithorax
• mediastinal shift towards the pathology
2. Findings that support this diagnosis include: • abrupt cut-off of left main bronchus
• homogeneous opacity in left hemitho­
rax with loss of diaphragmatic and cardiac
borders

Learning point
Lung collapse is associated with shift of the medi­
astinal structures towards the side of pathology.

This 43-year-old man sustained a C5 vertebral

injury during a car crash. He has been in the ICU 1. Why is there an opaque left hemithorax?
for seven days and is quadriparetic. 2. What findings on the X-ray support your
diagnosis?
22 Diagnostic imaging in critical care

PROBLEM 1.10

This 63-year-old man has had increasing short­

ness of breath for two months, associated with Suggest a differential diagnosis.
malaise and four kilograms of weight loss.
 1 • Chest 23

A
The entire right hemithorax is opacified. The calcifications and an oesophageal stent. The most
opacification is homogeneous with no visible lung likely diagnosis is mesothelioma. Clues are the
markings present. There is some mediastinal shift presence of pleural calcification (consistent with
to the opposite side. The differential diagnosis for prior asbestos exposure) and less mediastinal shift
these findings include: than expected with this amount of pleural opaci­
• pleural fluid fication. The latter is due to the fibrotic nature
• neoplasm of the tumour, resulting in volume loss of the
• pneumonia with empyema involved hemithorax. If this was all pleural fluid,
Other findings present on this image are more mediastinal shift would be expected.
a smaller left pleural effusion, left pleural

Learning point
The cause of an opaque hemithorax cannot X-ray. Other imaging, such as CT or ultrasound,
always be determined with certainty by a chest may be required.
24 Diagnostic imaging in critical care 1 Chest 25

A
The gas exchange is poor because: • Most of the left hemithorax is opacified, but
• The entire right hemithorax is homogeneously the opacification is non-homogeneous, with air
opacified and no underlying lung markings are bronchograms, and appearances suggestive of
seen. There is an abrupt cut-off of the right alveolar shadowing. This would be consistent
main bronchus, likely to be due to a mucus with pneumonia, but the differential diagnosis
plug or blood clot obstructing the bronchus. is broad.
The mediastinum is shifted to the right. This is • There is a paucity of lung vessels in the left
in keeping with collapse of the right lung. The costophrenic recess, but no other sign of a
endotracheal tube is just above the carina. pneumothorax.

Learning point
Multiple processes may contribute to impaired
gas exchange.

This 60-year-old woman presented with hypox­

aemic respiratory failure and was intubated in Why is the gas exchange so poor?
the emergency department 12 hours ago. The
gas exchange has deteriorated over the last two
hours.
26 Diagnostic imaging in critical care 1 • Chest 27

PROBLEM 1.12
A
1. Findings on this film include: 2. The differential diagnosis for interstitial lung
• increased peripheral interstitial markings in infiltrates includes (Dahnert, 2007):
a coarse reticular pattern throughout both • cardiogenic and non-cardiogenic pulmonary
lung fields oedema
• apical pleural thickening • interstitial pneumonitis
• tenting of the right hemidiaphragm • infection
• irregular pleuropericardial interface • lymphangitis carcinomatosis
• reduced lung volumes • drug reactions
• the apparent shift of the trachea is caused by • autoimmune diseases
rotation, not a pathological process • sarcoidosis
• increased cardiothoracic ratio • mineral dust inhalation
• extrinsic allergic alveolitis (hypersensitivity
pneumonitis)
This patient had sarcoidosis, which was
proven on lung biopsy.

Learning point
The differential diagnosis for interstitial infil­ are usually thin, regular, basal and subpleural
trates on a chest X-ray is broad. The duration (Kerley B lines). Chronic reticular infiltrates
of symptoms may be helpful in narrowing the are usually coarse, with peribronchovascular or
differential. peripheral subpleural distribution.
Reticular infiltrates in acute pulmonary oedema

This 68-year-old woman was referred to ICU with

respiratory failure and a five-month history of 1. Describe the findings on this film.
increasing shortness of breath with a dry cough. 2. What is your differential diagnosis?
28 Diagnostic imaging in critical care

PROBLEM 1.13

This previously well, 35-year-old female presents

to the emergency department with a three-day his­ 1. Describe the findings on this film.
tory of shortness of breath. She is now dyspnoeic 2. What is your differential diagnosis?
at rest and hypoxic despite high-flow oxygen via
face mask.
 1 Chest 29

A
1. There is widespread diffuse opacification of lung is abutting air-filled bronchi, giving the
both lung fields with relative sparing of the appearance of air bronchograms.
apices and lung peripheries. The opacifica­
tion has a “fluffy” or “cotton wool” appearance 2. The differential diagnosis should include:
typical of alveolar opacification. Air bron­ • cardiogenic pulmonary oedema
chograms are seen bilaterally, there is loss of • non-cardiogenic pulmonary oedema
the cardiac borders and medial parts of both (e.g. ARDS, aspiration pneumonitis)
hemidiaphragms. • pneumonia
This is a good example of how borders are • pulmonary haemorrhage (including pulmo­
only seen between tissues of different densities. nary contusion)
The diaphragmatic and mediastinal borders • primary alveolar proteinosis
are lost because the air spaces in the lung have Alveolar cell carcinoma and lymphoma
filled with fluid and are now the same density may produce alveolar opacification, but this is
as the adjacent tissues (silhouette sign). New typically more localised.
borders have been created where fluid-filled

Learning point
The differential diagnosis for alveolar infiltrates
on a chest X-ray is broad. Diagnoses other than
heart failure must be considered.
30 Diagnostic imaging in critical care 1 • Chest 31

PROBLEM 1.14
A
On the right side, there is: fluid so, in the supine position, pleural fluid lies
• homogenous opacification throughout the posterior and to the sides of the lung giving this
entire hemithorax characteristic appearance.
• underlying lung markings that appear normal On the left side, there is:
• a rim of opacity around the periphery of the • loss of the diaphragmatic border
lung • retro cardiac opacification
• loss of mediastinal and diaphragmatic borders • haziness at the base, outside of the cardiac
• mediastinal shift to the left shadow
These findings are consistent with a moderate These findings suggest left lower lobe collapse,
to large pleural effusion. Lung floats on pleural probably with a small left pleural effusion.

Learning point
The appearance of a pleural effusion on a supine
X-ray is different from that on an erect X-ray.

This 42-year-old man complained of mild short- CJ

ness of breath, but otherwise felt well. What processes are evident on the X-ray that may
explain the shortness of breath?
32 Diagnostic imaging in critical care 1 • Chest 33

PROBLEM 1.15
A
On the right side, there is: On the left side, there is:
• dense opacification at the base with haziness • loss of the diaphragmatic border
extending up to the midzone • retrocardiac opacification
• fluid extending into the horizontal fissure • haziness at the base and obliteration of the
• an abnormal contour of the “diaphragmatic costophrenic angle
border” which is flattened and the apex shifted • mediastinal shift to the left
laterally These findings suggest left lower lobe collapse
These findings are consistent with a moder­ with a small left pleural effusion. This is the same
ate right, predominantly subpulmonic pleural patient as in Problem 1.14, but imaged in an erect
effusion. position.

Learning point
Pleural fluid moves with gravity as the patient
changes position.

This 42-year-old man is mildly short of breath. Q

What processes are evident on the X-ray that may
explain the shortness of breath?
34 Diagnostic imaging in critical care 1 Chest 35

PROBLEM 1.16
A
There is a left apical pneumothorax, Closer examination of the left upper zone
Air is lighter than lung so tends to collect in reveals that the upper mediastinal border and
non-dependent areas of the pleural cavity: the aortic knuckle are much sharper than on the
apex in the erect patient and anteriorly in the right side. This is because, on the right, the inter­
supine patient. face is between air-filled lung and “tissue density”
A relatively subtle pneumothorax can easily mediastinum while, on the left, it is between free
be missed if the lung edge is not clearly visible. pleural air and mediastinum. This is strong ancil­
It is important when reviewing chest X-rays to lary evidence of a pneumothorax. In addition,
look globally at the film before focusing on the there is an absence of vascular markings in the
detail, otherwise relatively obvious findings can hyperlucent area. Closer inspection reveals a lung
be missed. On a global inspection of this film, two edge, although this could easily be missed without
findings are evident: the global inspection.
• The left upper zone is darker than on the right Other findings on the film include:
side. As the right upper zone appears normal, • sternal wires
this suggests hyperlucency in the left upper • mitral valve replacement (the three struts are
zone. visible)
• Cardiomegaly. • linear atelectasis in the left lower lobe

Learning point
It is important to stand back and look at the
X-ray globally to avoid missing obvious pathol­
ogy because of a focus on detail.

This is a routine erect postoperative film of

a 60-year-old woman who had a mitral valve What abnormality is present that may need
replacement and coronary artery bypass grafting intervention?
performed yesterday.
36 Diagnostic imaging in critical care 1 • Chest 37

PROBLEM 1.17
A
On the left side, there is: lung edge. In the supine position, air will collect
• extensive surgical emphysema in the subcutane­ anterior to the lung as this is the non-dep endent
ous tissues of the chest wall and in the pectoral area of the pleural cavity.
muscles On the right side:
• a deep sulcus sign at the costophrenic angle • a lung edge is seen
• a lucency over the upper abdomen, not • the cardiac and diaphragmatic borders are very
explained by any normal structure sharp, suggesting pleural air
• a lobular mediastinal-based shadow inferome- • there is lucency over the liver
dial to the cardiac apex is due to a new border This demonstrates the presence of significant
forming between displaced pericardial fat and residual pneumothorax despite what appears to
the adjoining pneumothorax be an appropriately placed chest drain.
• mediastinal shift to the right Sternal wires are present, suggesting a previous
These findings strongly suggest a left tension sternotomy.
pneumothorax despite the absence of a visible

Learning point
In the supine position, a lung edge may not be An inferior pneumothorax may produce a
visible, even with a tension pneumothorax. Other sharp outline of the pericardial fat, also known as
features of a pneumothorax must be sought. a “pericardial fat tag” sign (Ziter, 1981).

This 40-year-old man was admitted to the ICU

following a polypharmacy drug overdose. There What problems does the X-ray demonstrate?
was some difficulty with inserting the central
venous catheter. The patient now has a high
arterial-alveolar oxygen gradient.
38 Diagnostic imaging in critical care

PROBLEM 1.18

This 40-year-old man with a severe head injury ■' 9

has been in the ICU for four days. He has sud- Describe the findings on this film,
denly become hypotensive and hypoxic.
 1 • Chest 39

A • the left lung is partially collapsed

The findings on this film include:
• left-sided tension pneumothorax (evidence for • the left-sided central line, endotracheal and
this includes a visible lung edge with no lung nasogastric tubes are well positioned
markings beyond the edge; mediastinal shift to • a fine-bore pleural drainage catheter adjacent
the right; depression of the left hemidiaphragm to the lung edge. This is best appreciated in the
with a deep sulcus sign) DVD images.
• a small amount of subcutaneous emphysema

Learning point
The presence of a pleural drainage catheter does
not exclude a significant pneumothorax.
40 Diagnostic imaging in critical care 1 • Chest 41

PROBLEM 1.19
A
Pneumonia is the most likely diagnosis. There is Fungal infection can cause nodular opacities and
patchy alveolar opacification throughout most of this immunosuppressed patient is at increased
the right lung field, with alveolar nodules as well risk. Metastatic disease could be considered, but is
as areas of confluent homogeneous consolidation. unlikely because of the unilateral appearance and
There is some perihilar opacification on the left. the confluent homogeneous component.

Learning point
Although some chest X-ray features may suggest Alveolar nodules appear on the chest X-ray as
particular causative organisms in a patient with ill-defined opacities greater than 1 cm in size.
pneumonia, they cannot provide certainty in
diagnosis.

This 35-year-old man had a liver transplant two

years ago. He presents with a 36-hour history of What is the likely diagnosis?
fever and rapidly progressive shortness of breath.
42 Diagnostic imaging

PROBLEM 1.20
 1 • Chest 43

This 66-year-old homeless alcoholic man had a Q

three-week history of fever and cough. What is the most likely diagnosis?

A
There is a cavity in the apical segment of the throughout the rest of the right lung. This sug­
right lower lobe with a fluid level within it. In gests a pneumonic process, which could be either
this clinical scenario, this is highly suggestive of the cause or the result of the abscess.
an abscess. There is extensive patchy opacification

Learning point
The apical segment of the right lower lobe is a
very common site for aspiration. It is likely that
this lung abscess is the result of aspiration.
44 Diagnostic imaging in critical care 1 • Chest 45

PROBLEM 1.21 A
1. There is a large pleurally based collection, 2. A CT scan should be performed to confirm
which has not been adequately drained by the diagnosis of empyema and to check the
an appropriately placed chest drain. In this position of the intercostal catheter. Empyema
clinical scenario, the likely diagnosis is empy­ would be supported by the presence of thick­
ema. Parapneumonic effusion should also be ened, contrast-enhancing, parietal pleura. If
considered. empyema is confirmed and the intercostal
catheter is appropriately positioned, surgical
decortication should be considered.

Learning point
Empyemas are often loculated and, therefore, may
not adequately drain with an intercostal catheter.

This 49-year-old woman presented with a two-

week history of productive cough, fever and 1. What diagnosis is suggested by this image?
worsening shortness of breath. 2. How will you manage this problem?
46 Diagnostic imaging in critical care

PROBLEM 1.22

This 30-year-old man lived in India until two

months ago. He now presents with fever and What is the most likely diagnosis?
shortness of breath.
 1 • Chest 47

A
Miliary tuberculosis. The differential diagnosis of miliary nodules
There are small, well-defined nodular opacities, includes (Dahnert, 2007):
the size of millet seeds, throughout the lung fields; • infection (tuberculosis or histoplasmosis)
this is the pattern of interstitial nodular opacity. • neoplasia (renal cell carcinoma, thyroid or tes­
In contrast, alveolar nodular opacities are larger ticular cancers, melanoma deposits)
and less defined. There is a thin-walled cavity in • pneumoconiosis (silicosis)
the right upper zone. • sarcoidosis

Learning point
The incidence of tuberculosis and other infec­ local environment is admitted to hospital, exotic
tious diseases varies widely from one community diseases need to be considered.
to another. When a patient from outside of the
48 Diagnostic imaging in critical care 1 • Chest 49

PROBLEM 1.23
A
The devices present are: located just distal to the left subclavian artery.
• well-positioned endotracheal tube. The tip is This corresponds to the tip being just above
between the medial ends of the clavicles, well the left main bronchus, in the second or third
clear of the carina, at around the T4 level. left intercostal space anteriorly. The balloon is
• well-positioned right-sided central venous line. inflated and is projected as a linear lucency in
The tip is just above the level of the bronchus in the left paraspinal region. This should not be
the line of the superior vena cava. mistaken for a pneumomediastinum.
• pulmonary artery catheter. The tip appears • mitral valve prosthesis
to lie in the main pulmonary artery or right • two surgical drains, which are likely to be medi­
ventricular outflow tract. The pressure trace astinal and pericardial
should be reviewed and, if it suggests right ven­ • sternal wires aligned vertically
tricular placement, then the catheter should • pads for external defibrillation or pacing
be advanced. The tip of a pulmonary artery • monitoring leads and ECG dots overlying the
catheter should not extend laterally beyond the chest
medial third of either hemithorax. There is a double right-heart border, consis­
• intra-aortic balloon pump, which is positioned tent with left atrial enlargement from mitral valve
slightly high. The radio-opaque tip should be disease.

Learning point
You need to systematically identify each device
and check that the position is correct.

This 68-year-old woman had high-risk elective

cardiac surgery 24 hours ago.
Q
Comment on the devices present.
50 Diagnostic imaging in critical care 1 • Chest 51

PROBLEM 1.24 A
The feeding tube has been inserted into the right There are bilateral interstitial infiltrates and
main bronchus. It should be removed immedi­ pleural effusions with fluid in the horizontal fis­
ately. The majority of misplaced feeding tubes go sure. The right-sided central venous line and the
into the right main bronchus. endotracheal tube are in acceptable positions.

Learning point
It is important to inspect the position of lines,
tubes and other devices on chest X-ray images.

This 64-year-old man has respiratory failure Q

from chronic obstructive airways disease and car- What are the findings on the image?
diac failure. He is slow to wean from mechanical
ventilation.
52 Diagnostic imaging in critical care

PROBLEM 1.25
 1 • Chest 53

A
The findings on the film are: • The right internal jugular central venous cath­
• At the right lung base, there is hazy opacifi­ eter is well positioned.
cation with loss of the hemidiaphragm. The • The sternal wires are normally aligned.
horizontal fissure is normally positioned. These • There are three ring-like structures seen near
findings are suggestive of pleural fluid. the centre of the heart shadow. These represent
• The medial part of the left hemidiaphragm mitral and aortic valve replacements and a tri­
is unclear and there is increased retrocardiac cuspid valve annuloplasty ring.
opacity with some air bronchograms. In this • The endotracheal tube is slightly low in
clinical context, this most likely represents position.
atelectasis although consolidation is possible.
• Two surgical drains are present, one of which
appears to be kinked.

Learning point
Different prosthetic valves have different appear­ orientated in a more vertical direction, facing
ances on the chest X-ray and some are not obliquely up and to the right. This gives them an
radio-opaque. Mitral and tricuspid annuloplasty ovoid (in profile) appearance. They are higher
rings form an incomplete circle and so can be dis­ than mitral or tricuspid prostheses and tend to be
tinguished from valve replacements. . smaller in size. The perceived direction of blood
With cardiac disease, the position and orienta­ flow across the valve is towards the ascending
tion of valves may change as the cardiac chambers aorta.
change their size and position. It is often not pos­ Mitral valve prostheses are lower and more to
sible to be certain which valve has been replaced the left than aortic and oriented in a more hori­
from the chest X-ray appearance. There are, how­ zontal anteroposterior direction. This gives them a
ever, some useful clues based on orientation, valve more circular (en face) appearance. The perceived
orifice appearance, perceived direction of blood direction of blood flow is towards the apex.
flow and position (Foot, 2006). Tricuspid valve prostheses are aligned in a more
Compared to other valves, aortic valve pros- medial-lateral direction and lie to the right of the
theses tend to have the opening of their ring mitral valve, below the level of the aortic valve.
54 Diagnostic imaging in critical care 1 • Chest 55

PROBLEM 1.26 A
The endotracheal tube is in the right main bron­ there is at least a partial collapse of the right upper
chus. The left hemithorax is opacified, with shift lobe, suggesting the endotracheal tube is occlud­
of the mediastinum to the left, which are features ing the right upper lobe bronchus.
consistent with left lung collapse. In addition,

Learning point
An opaque hemithorax following trauma is not
always due to haemothorax.

This 42-year-old woman was admitted to ICU fol- VJ

lowing surgery for multiple trauma. This supine What is the most likely cause of the opaque left
chest X-ray was taken 15 minutes later. A hae- hemithorax?
mo thorax has been diagnosed and preparations
are being made for inserting a chest drain.
56 Diagnostic imaging in critical care 1 • Chest 57

PROBLEM 1.27 A
The lungs are hyperinflated with flattened dia- The patient is most likely difficult to wean
phragms, consistent with chronic obstructive because of chronic obstructive airways disease,
airways disease. The bilateral midzone opacities
are due to breast implants.

Learning point
Breast implants maybe confused with pulmonary­
based opacities.

Two weeks ago this 5 7-year-old woman was 4

admitted to ICU with hypercapnic respiratory Why is this patient difficult to wean from mechan-
failure. ical ventilation?
58 Diagnostic imaging in critical care 1 Chest 59

PROBLEM 1.28
A
There are bilateral calcified pleural plaques with pulmonary fibrosis, which in the presence of
marked pleural thickening on both the diaphrag­ pleural plaques is likely to be due to asbestosis. No
matic surface and chest wall. These are strongly rib fractures or other evidence of chest trauma is
suggestive of asbestos exposure. There is under­ seen. The endotracheal tube is well positioned.
lying interstitial opacification consistent with The chest drain has been inserted too far.

Learning point
Not all pleurally based opacities are a haemotho­
rax or pleural effusion.

This 62-year-old man fell three metres while ( |

working on a building site. He landed on his head What pathological process does this image
and has been unconscious since then. A drain was suggest?
inserted into the right chest because a haemo tho­
rax was thought to be present, but nothing has
drained.
60 Diagnostic imaging in critical care 1 • Chest 61

PROBLEM 1.29
A
1. There is a large, well-defined mass lesion 2. Three possible causes for this appearance are:
extending from the left hilar region. • neoplasm: primary or secondary
• infection: pneumonia, abscess, hydatid cyst
• pulmonary artery aneurysm
The patient had a bronchial carcinoma.

Learning point
Routine X-rays may reveal unexpected but impor­
tant findings.

This is the routine postoperative X-ray of a

63-year-old man who had elective coronary artery 1. Describe the major abnormality.
bypass grafting for stable angina with triple vessel 2. List three possible causes for this appearance,
coronary artery disease.
62 Diagnostic imaging in critical care

PROBLEM 1.30

This 79-year-old man suddenly developed severe

central chest pain following an alcoholic binge. What is the most likely diagnosis?
 1 • Chest 63

A
The findings on the X-ray are: • atelectasis within the left lower lobe
• loss of the left costophrenic angle, suggesting a The combination of pleural effusion and medi­
small pleural effusion astinal air is highly suspicious of a rupture of the
• mediastinal air, outlining the left side of the oesophagus.
aorta from the top of the arch to below the
diaphragm

Learning point
There is a characteristic appearance of a ruptured
oesophagus on a chest X-ray.
64 Diagnostic imaging in critical care 1 • Chest 65

PROBLEM 1.31
A
There is air under the left hemidiaphragm, as
well as a small left pleural effusion. He has septic
encephalopathy complicating a perforated viscus.

Learning point
Don’t forget to look below the diaphragm.

This 75-year-old man was found at home confused "

and agitated. He was given sedation in the emer­ Can you suggest a diagnosis?
gency department because of severe agitation,
then became obtunded and required intubation.
66 Diagnostic imaging in critical care

PROBLEM 1.32

This 68-year-old woman is booked for a needle

biopsy of the mass in the right midzone. Is this an appropriate course of action?
 1 • Chest 67

A
The appearances on the X-ray are those of a Other findings on the X-ray include the pres­
“pseudotumour” caused by encysted fluid in the ence of a mitral valve replacement (seen as three
oblique fissure. There is no indication for needle dots to the left of the lower sternal wire) and cal­
biopsy. cification in the aortic arch.

Learning point
Encysted fluid collections in a fissure are often in either the horizontal or oblique fissure. A lateral
called “pseudotumours” and are easily confused chest X-ray will confirm the oblong configuration,
with neoplasms if you are not aware of their char­ with the long axis of the opacity aligned along the
acteristic appearance. Pseudotumours may occur course of the fissure.
68 Diagnostic imaging in critical care 1 •. Chest 69

PROBLEM 1.33
A
There are rounded opacities at both hila. The right mediastinal lymphadenopathy includes sarcoi­
paratracheal stripe is thickened. These findings dosis, tuberculosis, lymphoma, lung carcinomas
suggest hilar and mediastinal lymphadenopa­ and other cancers. There is also minimal patchy
thy, respectively. The differential diagnosis for opacification at the right base.

Learning point
Not all mediastinal lymphadenopathy is caused
by malignancy.

This 38-year-old woman presented with a four-

week history of malaise, cough and shortness of Suggest a differential diagnosis,
breath.
70 Diagnostic imaging in critical care

PROBLEM 1.34

This previously well, 2 8-year-old woman devel­

oped respiratory failure 48 hours after having What is the likely cause of her respiratory failure?
open reduction and internal fixation of a femoral
fracture.
 1 • Chest 71

A
There are widespread patchy alveolar infiltrates Without the clinical history, the differential diag­
throughout both lungs. The cardiac size is nor­ nosis would be broad and include cardiogenic
mal. Acute respiratory distress syndrome (ARDS) and non-cardiogenic pulmonary oedema, pneu­
caused by fat embolism syndrome or aspiration monia, pulmonary haemorrhage and primary
is the most likely cause of her respiratory failure. alveolar proteinosis.

Learning point
The chest X-ray must be interpreted in conjunc­
tion with the clinical context.
72 Diagnostic imaging in critical care 1 • Chest 73

PROBLEM 1.35
A
The lower and mid zones of the right chest are These findings suggest a traumatic diaphrag­
opacified, with gas density structures seen within matic hernia with bowel herniation into the right
this area. There are multiple old rib fractures from chest.
previous trauma. There is pleural calcification on
the right, which in this clinical context is likely to
be due to previous haemothorax.

Learning point
Following chest trauma, it can take several years previous empyema or haemothorax. Bilateral
for a significant diaphragmatic hernia to develop. pleural calcification usually indicates asbestos
Unilateral pleural calcification may be due to exposure.

This 75-year-old man complained of increasing

dyspnoea over the last six months. Ten years ago, What is the likely cause of the dyspnoea?
he had a motor vehicle accident requiring ICU
admission for two weeks.
74 Diagnostic imaging in critical care 1 • Chest 75

PROBLEM 1.36
Although there is left lower lobe collapse, this is is not seen. This could be an unstable spinal
not the most important finding on the X-ray. At fracture and he should not be allowed to sit up.
T4/5 level, there is an alteration in the height of Incidentally, there is also an azygous lobe, which
the vertebral bodies and the intervertebral space is a normal anatomical variant.

Learning point
Don’t forget to look at the bones on the chest
X-ray.

L
r
This 26-year-old man presented following a
motorbike crash. He is increasingly short of breath
Q
Are you going to let him sit up?
and now desaturating on high-flow mask oxygen.
He wants to sit up so it is easier to breathe.
76 Diagnostic imaging in critical care

PROBLEM 1.37

This 42-year-old man was involved in a high- ' I

speed car crash and was intubated on the scene What features on the image may have contributed
for severe respiratory distress. to the respiratory distress?
 1 • Chest 77

A
There are multiple fractured ribs bilaterally, so is also an opacity in the right midzone, consis­
pain may have been a factor. On the left side, tent with a pulmonary contusion. Finally, there
there are anterior and posterior fractures, which is surgical emphysema and a chest drain on the
would be consistent with a flail chest, but this right side, suggesting that there may have been a
cannot be diagnosed by imaging alone. There pneumothorax.

Learning point
Flail chest is a clinical diagnosis, not a radiologi­
cal one.
78 Diagnostic imaging in critical care 1 • Chest 79

PROBLEM 1.38
A
The findings on the image include a pleural fluid likely source of the haemothorax is the spinal
collection on the left, gastric distension and a fracture. Other possible sites of bleeding are a
spinal fracture-dislocation at around the T6/7 ruptured aorta, the lung or the chest wall.
level. There are no obvious rib fractures. The most

Learning point
Haemothorax may complicate a thoracic spinal ruptured aorta. The haematoma can extend into
fracture. It is very common to have a haematoma the extrapleural space, producing the appearance
adjacent to the fracture, which may track through of a pleural cap, or rupture into the pleural cavity,
the mediastinum giving appearances similar to a producing a haemothorax.

This 28-year-old man had a motorbike crash on

the freeway. At the scene, he complained of dif- What is the likely source of the haemothorax?
ficulty breathing.
80 Diagnostic imaging in critical care 1 • Chest 81

PROBLEM 1.39
A
1. Aortic coarctation. • bilateral rib notching from the third to the
eighth ribs
2. Findings on the X-ray that support your • aortic knuckle is small and abnormally
diagnosis: shaped

Learning point
Subtle signs on the X-ray are easily missed unless • lines and tubes (devices)
the X-ray is systematically examined. A good • lungs
scheme for systematic examination of a chest • mediastinum
X-ray is: • bones
• general overview • other soft tissues

This 25-year-old man has chronic hypertension. Q

1. What is the diagnosis?
2. What findings on the X-ray support your
diagnosis?
82 Diagnostic imaging in critical care 1 • Chest 83

PROBLEM 1.40
A
1. Abnormalities on this chest X-ray include: diagnosis of aortic disruption but are not pres­
• endotracheal tube ent on this X-ray include:
• bilateral chest drains (two on right) • fracture of first or second rib
• lower thoracic scoliosis, which raises the • left haemothorax
question of a spinal fracture • loss of paratracheal stripe
There are a number of findings on this X-ray As is commonly encountered in the ICU,
suggesting aortic disruption (Clarke, 1997): the patient is significantly rotated on this
• displacement of trachea and NG tube to image, which must be considered when inter­
right preting the image.
• wide upper mediastinum
• left pleural cap 2. CT angiography, transoesophageal echocar­
• loss of aorto-pulmonary window (the space diography or digital subtraction angiography
on the left mediastinal border between the would be acceptable for investigation of a
aortic knuckle and the pulmonary artery) possible traumatic rupture of the aorta. MR
• indistinct outline of aortic knuckle angiography may be used, but the requirement
• depression of left main bronchus for a prolonged investigation in a suboptimally
Other features that would suggest the monitored environment limits its usefulness.

Learning point
There is a classic constellation of signs on the
chest X-ray associated with aortic injury.

This 2 9-year-old man was the driver in a

high-speed car crash. 1. List the abnormalities on this chest X-ray.
2. What further investigation will you do?
84 Diagnostic imaging in critical care 1 • Chest 85

PROBLEM 1.41
A
1. There is a superior mediastinal mass. The dif­ elongated and there is an upper thoracic sco­
ferential diagnosis for this includes: liosis, convex to the left.
• lymphoma
• teratoma 2. Conditions associated with thoracic aortic
• thymoma aneurysms include (Dahnert, 2007):
• thyroid • Marfan syndrome and other connective tis­
• thoracic aortic aneurysm sue disorders
In this case, the presence of sternal wires, • hypertension
surgical staples and visible aortic root replace­ • tertiary syphilis
ment graft favour a thoracic aortic aneurysm. • previous trauma
The border of the “mass” is also contiguous • infection
with the aortic wall inferiorly, hence con­ • seronegative arthritides
firming its aortic origin. The thoracic cage is

Learning point
Thoracic aortic aneurysms in young adults are
usually due to Marfan syndrome.

This 3 3-year-old man presented with sudden Q

onset of chest pain. 1. Describe the findings on the film.
2. What diseases are associated with this
appearance?
86 Diagnostic imaging in critical care 1 • Chest 87

A
The central pulmonary arteries are enlarged of pulmonary hypertension, such as recurrent
and there is peripheral pruning of the pulmo­ pulmonary emboli, need to be excluded. The
nary vasculature. The cardiac shadow and the peripherally inserted central venous catheter is
lung fields appear normal. This suggests pri­ well positioned.
mary pulmonary hypertension, but other causes

Learning point
Peripheral pruning describes an abrupt change in Before making a diagnosis of primary pulmo­
calibre between the lobar pulmonary arteries and nary hypertension, other causes of pulmonary
their segmental branches. It gives the appearance hypertension need to be excluded.
of a “pruned” tree.

This 25-year-old man presented with shortness of

breath and reduced exercise tolerance, which has What is the likely diagnosis?
developed progressively over the last six months.
88 Diagnostic imaging in critical care 1 • Chest 89

PROBLEM 1.43
A
The key findings are: These findings suggest left atrial enlargement
• mild cardiomegaly and mitral valve disease. There is no evidence of
• an abnormally straight left heart border pulmonary oedema on this film.
• splaying of the carina to over 90 degrees
• a double right-heart border

Learning point
Knowledge of normal anatomy of the heart assists
with interpreting the X-ray in cardiac disease.

This 62-year-old woman presented with reduced ' £

exercise tolerance and episodic shortness of What is the most likely diagnosis?
breath, which had been slowly worsening over the
last three months.
90 Diagnostic imaging in critical care 1 • Chest 91

A
The sternal wires are not lined up in the centre mediastinitis are highly likely. There is also blunt­
of the chest, which suggests sternal dehiscence. ing of the left costophrenic angle due to a small
Not all sternal dehiscence is caused by infection pleural effusion.
but, in this clinical context, wound infection and

Learning point
Risk factors for sternal dehiscence include bilat­ ventilation (Losanoff, 2002).
eral internal mammary artery grafts, diabetes, Don’t forget to look at medical devices such as
smoking, obesity and prolonged postoperative sternal wires.

This 62-year-old diabetic man developed fever,

shortness of breath and severe chest pain five days What is the major abnormality?
after coronary artery bypass surgery.
92 Diagnostic imaging in critical care

PROBLEM 1.45

This 59-year-old woman underwent coronary Q

artery bypass grafting yesterday. There was sig- What is the likely diagnosis?
nificant bleeding out of the mediastinal drains
initially but this settled after a few hours.
Extubation occurred uneventfully this morning.
 1 • Chest 93

A
There is an opaque left hemithorax with mediasti­ If these X-ray abnormalities occurred several
nal shift to the right. The most likely diagnosis is days after surgery, then chylothorax from damage
massive haemothorax. The bleeding did not stop, to the thoracic duct should be considered.
but the drains were blocked and hence a large vol­
ume of blood accumulated in the pleural cavity.

Learning point
Blood does not always come out of the chest
drains.
94 Diagnostic imaging in critical care

PROBLEM 1.46
 1 • Chest 95

This 68-year-old woman is scheduled for elective £

hip surgery tomorrow. You have been asked to What do you think?
look at the X-ray because of concerns about the
appearances at the right lung base.

A
The anteromedial part of the right hemidiaphragm
is elevated, consistent with a focal eventration of
the diaphragm. There is no need to defer surgery.

Learning point
With eventration of the diaphragm, there is an respiratory compromise. The most common posi­
upward displacement of abdominal contents tion is anteromedial on the right side (Dahnert
secondary to a thin hypoplastic diaphragm. It 2007).
is usually asymptomatic but, if large, can .cause
 1 • Chest 97
96 Diagnostic imaging in critical care

PROBLEM 1.47 A
On an appropriately inflated chest X-ray, 10 ribs diaphragm. This chest is significantly underin­
should be visible above the diaphragm posteriorly flated, making the vessels appear more prominent
and the ends of six ribs anteriorly. In this image, than they would if the film was adequately inflated.
only seven ribs are visible posteriorly above the No significant pathology is present.

Learning point
Technical aspects that need to be considered with • patient position (erect, supine or decubitus)
interpreting a chest X-ray include: • amount of rotation
• correct patient I time I date • positioning of patient on film
• direction of X-ray beam (PA, AP or lateral) • amount of inflation and exposure

This 29-year-old man was admitted to ICU fol- C)

lowing open reduction and internal fixation of What do you think?
multiple lower limb fractures. Concerns have
been raised that his X-ray has prominent lung
markings and that he may have fluid overload or
fat embolism syndrome.
 1 • Chest 99
Diagnostic imaging in critical care

This 25-year-old woman received a blow to . Q

PROBLEM 1.48
the head with a transient loss of consciousness. What is the likely cause of the appearances on the
Review was requested by the neurosurgical team X-ray?
because they think the patient may have aspirated.
The patient looks and feels well.

Pectus excavatum. The lateral film shows the middle lobe process, a typical appearance with
lower sternum impressing into the chest cavity. pectus excavatum. The heart may be displaced to
There is an accentuated downward course of the the left, mimicking cardiomegaly, but this is not
anterior portions of the ribs. The PA film shows demonstrated in this example (Dahnert, 2007).
an indistinct right heart border mimicking a right

Learning point
Pectus excavatum may be confused with pneu­
monia on the chest X-ray.
100 Diagnostic imaging in critical care 1 • Chest 101

PROBLEM 1.49 A
There is an azygous lobe, which is a normal ana­ shadow inferomedially. This is the azygous vein,
tomical variant. It is more obvious on this image which is somewhat distended, perhaps because of
because there is fluid within the azygous fissure. replete volume status.
The azygous fissure also harbours a tear-shaped

Learning point
Knowledge of anatomical variants is important in
interpreting radiological images.

This 79-year-old man was electively admitted ( _

to the ICU following major abdominal surgery. What do you tell them?
Your junior medical staff are concerned about the
appearance of the right upper lobe on his post­
operative X-ray.
102 Diagnostic imaging in critical care 1 • Chest 103

PROBLEM 1.50 A
The dialysis catheter is in an acceptable position different. It follows the left mediastinal border
with the tip near the junction of the superior vena then turns more medially. The tip appears to be
cava (SVC) and right atrium. It is usually recom­ behind the heart. The most likely explanation for
mended that the optimal position of a central this appearance is that the patient has a double
venous catheter is with the tip at the level of the SVC system and the pacing wire has been placed
carina, just above the right main bronchus, which in the left SVC with the tip within the coronary
places it above the pericardial reflection. Some cli­ sinus. Arterial placement is unlikely, as the wire
nicians prefer that the catheter is inserted further, appears to pass lateral to the descending aorta.
with the tip at the junction of the right atrium Extravascular placement is possible, but the
and the SVC. appearance is typical for a device in a left SVC.
The position of the pacing wire is somewhat

Learning point
A double SVC system is a normal variant found the left usually drains into the coronary sinus. A
in 0.3% of the population. It is more common in single, left-sided SVC is another variant (Minniti,
people with congenital heart disease. The SVC on 2002).

This 60-year-old man has endstage renal failure 1 )

and went to the operating theatre to have a dialysis Comment on the position of the dialysis catheter
catheter inserted. He became severely bradycardic and pacing wire.
intraoperatively and a temporary transvenous
pacing wire was inserted. Capture was achieved
with the pacing, though the stimulation threshold
was high.
 1 • Chest 105
104 Diagnostic imaging in critical care

PROBLEM 1.51 A
1. Traumatic aortic injury. Other signs of aortic injury (Ng, 2006) that
are not present on this image are:
2. Findings on the CT scan which support your • luminal thrombus
diagnosis: • periaortic contrast extravasation (extrava­
• mediastinal haematoma sation outside the aortic adventitia, into
• irregular aortic contour the mediastinal tissues, suggesting active
• intimal flap bleeding)

Learning point
CT assessment for possible aortic trauma requires traumatic aortic injury seen on imaging is at the
arterial phase images. The commonest site of ligamentum arteriosum.

This patient was the front seat passenger in a

motor vehicle crash today. 1- What diagnosis is
2. What findings on the CT scan support your
diagnosis?
 1 Chest 107
106 Diagnostic imaging in critical care

A
1. There is a Stanford type A aortic dissection. and the right common femoral artery have
not perfused with contrast (the images in the
2. The following complications are visible: book do not demonstrate these findings).
• The right common carotid artery has not • These images are not standard mediasti­
opacified with contrast. This demonstrates nal windows, but have been modified to
that the dissection has compromised flow to more clearly demonstrate the pathological
this vessel. process.
• There is a moderate pericardial effusion, but The DVD images have a chest X-ray with
no clear evidence of chamber compression. features of an aortic dissection, including a
• The left kidney is not perfused. widened upper mediastinum.
• On the DVD images, the left subclavian artery

Learning point
Type A aortic dissections involve the ascend­ unless complications develop.
ing aorta, whereas type B dissections do not When a dissection is demonstrated on imag­
(Golledge, 2008). Distinguishing the two types is ing, the complications of the dissection need to be
important, as type A dissections are managed sur­ assessed radiographically and clinically.
gically but type B dissections are not operated on

This 77-year-old woman presented with sudden

onset of severe chest pain. 1. What is the cause of her chest pain?
2. What complications have ensued?
 1 • Chest 109
108 Diagnostic imaging in critical care

PROBLEM 1.53 A
1. There is a saddle embolus, seen in the main 2. Heparinisation and supportive care are indi­
pulmonary artery, and both right and left main cated. As the patient is haemodynamically
branches. On the DVD extensive involvement unstable, consideration should be given to sur­
of more distal arterial branches is also seen. gical or catheter embolectomy if it is available.
Thrombolysis is contraindicated by the recent
hip surgery.

Learning point
CT pulmonary angiography is a sensitive investi­
gation for large proximal pulmonary emboli, but
less so for small peripheral emboli.

This 72-year-old woman had a hip replacement >■

two weeks ago. She has been admitted to the ICU 1. What is the cause of the shock?
with chest pain and shock. 2. How will you manage this patient?
 1 • Chest 111
110 Diagnostic imaging in critical care

PROBLEM 1.54 A
1. Two pathological processes seen on these artery originating directly from the aorta,
images are: seen posterior to the left subclavian artery
• A small area of contrast extravasation in the (image b).
region of the ligamentum arteriosum, con­
sistent with aortic disruption. This is seen on 2. The dilemma in this case is the desirability of
the CT angiogram (image d) and the digital anticoagulation for the pulmonary embolus,
subtraction angiogram (image c). but the contraindication of this by the rup­
• A filling defect in the pulmonary artery to tured aorta. Management undertaken was
the right lower lobe, suggesting a pulmonary insertion of a stent to the aortic injury, and an
embolus (image e). IVC filter for prevention of further pulmonary
The anatomical variant is a left vertebral embolic events.

Learning point
The chest X-ray in a patient with traumatic aortic abnormality. Multiple problems are common in
rupture may be normal. critically ill patients.
Don’t stop looking when you find the first

This 28-year-old man was the driver of a car that Q

crashed one week ago. 1. List two pathological processes and one ana­
tomical variant seen on these images.
2. Outline your management plan.
 1 • Chest 113
112 Diagnostic imaging in critical care

PROBLEM 1.55 A
There is an aberrant right subclavian artery, which
passes posterior to the trachea and oesophagus.

Learning point
Knowledge of common anatomical variants may be misinterpreted as a posterior mediastinal
is important when interpreting scans. On a mass.
non-enhanced scan, an aberrant subclavian artery

This 28-year-old-man was an unrestrained back Q

seat passenger in a high-speed car crash. "What anatomical variant is present?
 1 • Chest 115
114 Diagnostic imaging in critical care

A
There is a left-sided tension pneumothorax with the pleural cavity. The right lung has dependent
significant depression of the diaphragm but only atelectasis and there is patchy peripheral alveolar
minor mediastinal shift. The left lung is col­ opacification.
lapsed and there is a small amount of fluid in

Learning point
CT provides significantly more information precise anatomic diagnosis must be balanced
about the causes of abnormal gas exchange than against the risks of transport to the CT scanner.
the chest X-ray. However, the benefits of a more

This 19~vear-old woman crashed her car on the

way to work. She was intubated and ventilated What factors are contributing to her poor gas
in the emergency department. A chest drain was exchange?
inserted before she was taken to the CT scanner.
She has just arrived in the ICU.
116 Diagnostic imaging in critical care

PROBLEM 1.57

This 25-year-old woman received multiple stab

wounds to the chest during a domestic dispute. Describe the findings on these images.
She presented to the emergency department in
respiratory distress with a sucking chest wound.
An occlusive dressing has been placed over the
wound and an intercostal catheter inserted.
 1 • Chest 117

A
A stab wound is seen to enter the right chest wall in the right chest wall. A large right haemopneu­
just lateral to the sternum (image a). It transects mothorax has not been adequately drained by the
the right internal mammary artery (image b) and intercostal catheter and there is partial collapse of
the laceration extends into the right middle lobe the right lung. The chest drain has been inserted
where there is associated pulmonary contusion too far and is resting adjacent to the posterior
(images c and d). Other wounds can be seen on mediastinum. On the DVD images, it can be seen
the DVD images, but these do not appear to enter that the chest drain is kinked.
the thoracic cavity. There is surgical emphysema

Learning point
If there is one stab wound, there are often more. damage to them is not obvious on CT images.
These should be actively searched for both clini­ Organs may move with respiration or be dis­
cally and on imaging. placed by the injury, so lacerations to deeper
Stab wounds usually have a linear track, which structures do not always lie immediately below
is often evident on CT imaging. Structures adja­ the surface wound on the CT images.
cent to this track may have been injured, even if
 1 • Chest 119

A
There is a fluid collection in the right pleural No loculations are seen to explain why the fluid is
space with a contrast-enhancing rim around not draining. The gas could be due to gas-forming
it and gas within it. It has not been adequately organisms or was introduced during intercostal
drained by the intercostal catheter. In this clinical catheter insertion. The underlying lung is densely
context, this is strongly suggestive of empyema. consolidated.

Learning point
Empyemas are often loculated and may not not demonstrate septation. Ultrasound is more
respond to simple chest drainage. CT often does sensitive for detecting loculations.

i
120 Diagnostic imaging in critical care

This 62-year-old man gave a history of mal- ’

aise and lack of energy for one month. He was Why is this patient hypotensive?
referred to the outpatient department by his fam­
ily doctor because of deteriorating renal function.
When reviewed in outpatients he was found to be
hypotensive. No cause for the hypotension was
immediately apparent.
A
There is a large pericardial effusion posterior In this image, there are also moderate bilateral
and medial to the heart. Chamber compression pleural effusions with a small amount of adjacent
is difficult to assess on CT but, with such a large atelectatic lung. The irregularity in the descend­
effusion, tamponade must be considered. ing aorta is atheroma, not dissection.

Learning point
CT is a good modality for detecting pericardial difficult with echocardiography. On the other
effusions. It can distinguish between a pericar­ hand, echocardiography can assess the haemody­
dial fat pad and pericardial fluid, which may be namic effects of an effusion, which CT cannot.
 1 Chest 123
122 Diagnostic imaging in critical care

PROBLEM 1.60 A infection (Staphylococcus aureus, Klebsiella pneu­

There are bilateral perihilar ground-glass infil­
trates. In this immunocompromised patient, this monia and Nocardia commonly form cavities),
could represent Pneumocystis jiroveci or viral infec­ or fungal infection (Aspergillus or Cryptococcus).
tion, although the differential diagnosis is broad. This is unlikely to be neoplastic due to the visible
There is a right posterolateral area of con­ air bronchograms traversing the lesion. In neopla­
solidation. There is a cavity within the area of sia, the traversing bronchi are usually compressed
consolidation (image b). In an immunocom­ and occluded.
promised patient, this could represent bacterial

Learning point
A ground-glass infiltrate is a hazy increased In contrast, consolidation is increased attenu­
attenuation that does not obscure visibility of the ation that obscures the underlying vasculature,
underlying vascular structures. It is a non-specific usually producing air bronchograms (Gotway,
finding that can be due to volume averaging of 2005). The terms “consolidation” and “alveolar
abnormalities too fine to be resolved with high infiltrates” are synonymous. It is a finding that
resolution CT, an alveolar process, an interstitial indicates the air within alveoli has been replaced
process or a combined alveolar and interstitial by a substance such as oedema fluid, blood, pus
process (Gotway, 2005). or cells.

This 58-year-old woman had cough and increas­

ing shortness of breath over 48 hours. There was Describe the changes seen on the CT scan.
a past history of chronic liver disease and steroid
therapy.
 1 • Chest 125
124 Diagnostic imaging in critical care

PROBLEM 1.61 A
There is widespread bilateral consolidation with Bilateral pleural effusions are also present.
some peripheral sparing. In this clinical con­ Promyelocytic leukaemia (M3 type acute myel­
text, the differential diagnosis includes ATRA oid leukaemia) is commonly treated with ATRA
syndrome, cardiac failure, infection (bacterial, (All-trans-Retinoic Acid).
fungal, PCP, viral), pulmonary haemorrhage and
fluid overload.

Learning point
The differential diagnosis for consolidation is and the distribution of the consolidation seen on
broad and depends on both the clinical scenario the CT scan.

This 32-year-old man with acute myeloid leukae- O

mia (M3 type) had chemotherapy recently and What is your differential diagnosis?
developed rapidly worsening hypoxaemic respi­
ratory failure.
 1 • Chest 127

A
There is widespread ground-glass opacifica­ In addition, there are multiple enlarged medi­
tion throughout both lungs, with some patchy astinal lymph nodes.
consolidation in the right perihilar region. These could be reactive to infection or caused
There is a small right pleural effusion. The dif­ by sarcoidosis, lymphoma or metastatic disease.
ferential diagnosis for this includes pulmonary The combination of the ground-glass opaci­
oedema, atypical infection (including viral and ties and the lymphadenopathy would favour
Pneumocystis jiroveci), pulmonary haemorrhage infection.
and hypersensitivity pneumonitis. On the DVD images, some of the lymph nodes
have calcification within them.

Learning point
The significance of ground-glass opacification of the opacification on the CT and the presence or
depends on the clinical scenario, the distribution absence of other findings on the CT.

This 45-year-old woman had been well until she

developed increasing shortness of breath two days
Q
What is your differential diagnosis?
ago.
 1 • Chest 129
128 Diagnostic imaging in critical care

PROBLEM 1.63 A
1. There are centrilobular nodules in both lower bronchus is larger than that of the accompany­
lobes. In the left lower lobe, a classic “tree­ ing lobular artery, suggesting bronchiectasis.
in-bud” pattern is seen. In both lungs, there
are areas where the diameter of the lobular 2. Bronchiectasis with concomitant infection.

Learning point
Lung nodules are discrete opacities ranging in size • random: caused by haematogenously dissemi­
from 2 to 30 mm. Depending on their distribu­ nated infections (tuberculosis, fungal or viral)
tion relative to the secondary pulmonary lobule, and neoplasms
they are subdivided by their appearance on chest A tree-in-bud pattern is a form of centrilobular
CT scan into (Gotway, 2005): nodular pattern, almost always due to infection.
• centrilobular with or without tree-in-bud con­ It is caused by clogging of the bronchioles by
figuration: causes include infective diseases, inflammatory material. It has a branching pat­
aspiration, hypersensitivity pneumonitis and tern, likened to that of a budding tree (Gotway,
vasculitis. These nodules are less defined than 2005).
the perilymphatic and random ones
• perilymphatic: causes include sarcoidosis,
lymphangitis carcinomatosis and lymphopro­
liferative diseases

This 27-year-old man presented with a five-day

history of productive cough and increasing short- 1. Outline your findings on
ness of breath. 2. Suggest a diagnosis.
 1 • Chest 131
130 Diagnostic imaging in critical care

PROBLEM 1.64 A
1, The chest X-ray images show bilateral patchy • chronic eosinophilic pneumonia
consolidation and bilateral pleural effusions. • hypersensitivity pneumonitis
The CT images show bilateral patchy consoli­ • drug reaction
dation and ground-glass opacification, mainly • vasculitis (Wegener's granulomatosis, sys­
in the periphery of the lungs. There is no septal temic lupus erythematosus, Churg-Strauss
thickening or traction bronchiectasis. The CT syndrome)
confirms the presence of pleural effusions. • sarcoidosis
• thromboembolic disease, with multiple pul­
2. The differential diagnosis in this patient is monary infarcts
broad and should include: • atypical pulmonary oedema
• infections not covered by standard antibiot­ • bronchoalveolar carcinoma
ics for community-acquired pneumonia (e.g. This patient underwent open lung biopsy
Mycobacterium tuberculosis, Coxiella burnetii that demonstrated BOOP. There was a good
[causes Q fever], viruses) response to steroid therapy.
• bronchiolitis obliterans organising pneumo­
nia (BOOP)

Learning point
The differential diagnosis for consolidation is infarct and sarcoidosis (Gotway, 2005). Several of
extensive. Narrowing the differential diagnosis these conditions are steroid responsive, so recog­
requires careful integration of the clinical history nising this pattern of peripheral consolidation is
and imaging features. The distribution of the find­ important.
ings on the CT may be helpful. In particular, the The terms BOOP and cryptogenic organising
finding of peripheral consolidation should trig­ pneumonia are used interchangeably. For defini­
ger consideration of certain specific diagnoses: tive diagnosis, a lung biopsy is required, preferably
BOOP, chronic eosinophilic pneumonia, atypical via video-assisted thoracoscopy. BOOP is usually
pulmonary oedema, Churg-Strauss syndrome, steroid responsive, but may relapse when steroids
drug reactions, pulmonary contusion, pulmonary are stopped.

This 5 8-year-old woman presented with a non-

productive cough, malaise and weight loss for 1. What are the findings on the images?
eight weeks. She is becoming increasingly short of 2. What is your differential diagnosis?
breath. There has been no improvement despite
two courses of antibiotics appropriate for com­
munity acquired pneumonia.
 1 • Chest 133
132 Diagnostic imaging in critical care

PROBLEM 1.65 A
There are multiple cystic areas within the lung, are strongly suggestive of usual interstitial pneu­
typical of “honeycomb” lung cysts. There is monia (UIP). Dilated corrugated bronchi with
extensive thickening of intralobular and inter­ absence of peripheral tapering are seen. This is
lobular septae, architectural distortion and typical of traction bronchiectasis, which is com­
traction bronchiectasis. The traction bronciecta- mon in fibrotic lung disease. No ground-glass
sis is most prominent at the bases. These features opacification or consolidation is seen.

Learning point
In a patient with interstitial pneumonia, the are spaced 10-20 mm apart. In this way, approxi­
presence of ground-glass opacification often mately 10% of the lung is sampled (Gotway,
reflects active inflammation (alveolitis) and some 2005). The sections are processed using a sharp
reversibility. or “bone” algorithm to enhance the detection of
Interlobular septae border the secondary edges. No intravenous contrast is administered.
pulmonary lobules. They are best identified in HRCT is indicated when interstitial lung
the lung apices and bases along the subpleu- disease is suspected, as it visualises the lung inter-
ral regions. They are 1-2.5 cm long, often in a stitium better than conventional CT. There are
polyhedral arrangement. One feature that distin­ limitations to the technique, as mediastinal and
guishes them from blood vessels is that they may hilar structures are poorly visualised and small
This 55-year-old man complained of increasing 1 reach the pleural surface, whereas blood-vessels lung nodules are readily missed.
shortness of breath for several months. Recently, What disease process is suggested by these HRCT do not. Intralobular septae lie within the second­ Conventional CT requires the administration
ary pulmonary lobule and appear as ground-glass of contrast to highlight mediastinal structures.
he developed hypoxaemic respiratory failure scans? opacity; individual intralobular septae cannot be The entire thorax is imaged with no skip areas
requiring urgent admission to the ICU. seen on HRCT (Gotway, 2005). and slices are 5-10 mm thick. It is indicated in
High Resolution CT (HRCT) obtains very thin trauma, neoplasia and complicated infections.
(1 mm) axial sections of the chest. The sections
■ .-4-a

1 • Chest 135
134 Diagnostic imaging in critical care

PROBLEM 1.66 A
1. There is interlobular interstitial septal thicken­ is present. No honeycombing or traction bron­
ing in the apices (image a) and bases (image chiectasis is seen to suggest a chronic process.
d) and intralobular interstitial thickening in a
perihilar distribution (images b and c). There 2. In this clinical context, the most likely diagno­
are patches of ground-glass opacification and sis is cardiogenic pulmonary oedema.
bilateral pleural effusions. Peribronchial cuffing

Learning point
Intralobular and interlobular interstitial septal should also be considered, including dust-related
thickening is common in the idiopathic intersti­ diseases, sarcoidosis, pulmonary haemorrhage,
tial pneumonias. It may also occur in pulmonary alveolar proteinosis and chronic hypersensitivity
infections, especiallyPneumocystisjiroveci, pulmo­ pneumonitis (Webb, 2006).
nary oedema and lymphangitis carcinomatosis. Peribronchial cuffing implies fluid is present
The differential diagnosis for interlobular in the peribronchovascular interstitium. This sign
interstitial thickening includes the above con­ may be seen on plain X-ray or CT scan.
ditions, but a broad range of other conditions

This 48-year-old woman developed chest tight- 0

ness and shortness of breath earlier today. 1. Outline your findings on the HRCT.
2. What is the most likely diagnosis?
 1 • Chest 137
136 Diagnostic imaging in critical care

PROBLEM 1.67
A
These images demonstrate a large pericardial effu­ even on the dynamic images shown on the DVD.
sion. The inferior vena cava is dilated (>2.0 cm; Further information is required to fully assess for
image d), consistent with pericardial tamponade. tamponade physiology.
No obvious chamber compression is apparent,

Learning point
Distinguishing between pericardial and pleu­ Echocardiographic features of tamponade
ral fluid can be difficult on echocardiographic physiology include (Otto, 2004):
images. The pericardium and pericardial space lie • dilated inferior vena cava that does not collapse
between the descending aorta and the left atrium with respiration
in the parasternal long axis view, while the pleu­ • right ventricular diastolic collapse
ral space does not. Fluid separating the aorta and • reciprocal variation in right and left ventricular
left atrium must lie in the pericardial space (see volumes with respiration
image a). • respiratory variation in right and left ventricu­
Pericardial tamponade is a clinical diagnosis. lar diastolic filling
The echocardiogram is helpful to confirm the These features have only been validated in the
presence of a pericardial effusion and may suggest spontaneously breathing patient and are less use­
tamponade physiology, but the imaging features ful during mechanical ventilation.
must be put into the clinical context.

This 38-year-old man has been unwell for the

Is the cause of the hypotension apparent on these
last six weeks with malaise and lethargy. He now
images from a transthoracic echocardiogram?
presents with hypotension, requiring vasopressor
therapy.
 1 • Chest 139
138 Diagnostic imaging in critical care

PROBLEM 1.68 A
The liver is located on the right of the image and a large pleural effusion. Within the echo-free
is of normal texture. To the left of the liver is an space an echogenic mass is seen, consistent with
echo-free space up to 14 cm deep, consistent with atelectatic lung.

Learning point
A plain chest X-ray does not always answer the size of a pleural effusion and whether locula-
the clinical question of whether there is suffi­ tions are present or not. It can be performed at
cient pleural fluid present to warrant drainage. the bedside, which is a significant advantage over
Ultrasound can rapidly and non-invasively assess CT for the critically ill patient.

This 52-year-old man was admitted to the ICU C)

following severe abdominal trauma. Two weeks Describe the findings on this ultrasound image,
later he has been slow to wean from mechani­
cal ventilation. Chest X-ray shows changes at the
right lower zone, but it is uncertain whether the
main problem is effusion or collapse.
140 Diagnostic imaging in critical care

REFERENCES tion of median sternotomy: a comprehensive review.

Clarke GM. Chest injuries. In Oh TE, ed. Intensive care Eur J Cardiothorac Surg 2002; 21: 831-9
manual. 4th edn. Oxford: Butterworth-Heinemann; Minniti S, Visentini S, Procacci C. Congenital anomalies
1997 of the venae cavae: embryological origin, imaging
Dahnert W, ed. Radiology review manual. 6th edn.
Philadelphia: Lippincott Williams and Wilkins; 2007
features and report of three new variants. Eur Radiol
2002; 12:2040-55 CHAPTER 2
Foot CL, Coucher J, Stickley M, Mundy J, Venkatesh B. The Ng CJ, Chen JC, Wang, LJ, et al. Diagnostic value of the
imaginary line method is not reliable for identification helical CT scan for traumatic aortic injury: correlation
of prosthetic heart valves on AP chest radiographs. with mortality and early rupture. J Emerg Med 2006;
Crit Care Resusc 2006; 8:15-18 30: 277-82

ABDOMEN
Golledge J, Eagle KA. Acute aortic dissection. Lancet 2008; Otto CM. Textbook of clinical echocardiography. 3rd edn.
372: 55-66 Philadelphia: Saunders; 2004
Gotway MB, Reddy GP, Webb WR, Elicker BM, Leung Webb WR. Thin-section CT of the secondary pulmonary
JW. High-resolution CT of the lung; patterns of dis­ lobule: anatomy and the image - the 2004 Fleischner
ease and differential diagnoses. Radiol Clin North Am lecture. Radiology 2006; 239: 322-38

AND PELVIS
2005;43: 513-42 Ziter FM, Westcott JL. Supine subpulmonary pneumotho­
Losanoff JE, Richman BW, Jones JW. Disruption and infec­ rax. Am J Roentgenol 1981; 137: 699-701

141
142 Diagnostic imaging in critical care 2 • Abdomen and pelvis 143

APPLIED ANATOMY Retroperitoneal structures in the

upper abdomen (Figure 2.2)
Free fluid and gas (Figure 2.1) The coeliac axis (CA) and the superior mesenteric
Free fluid accumulates in the dependent parts of artery (SMA) are the first two anterior branches of
the peritoneal cavity, where it may be seen on CT or the abdominal aorta. To help identify the pancreas,
ultrasound. Dependent areas in the supine patient duodenum, blood vessels and other structures,
include the pelvis, the paracolic gutters, the hepato­ the origin of these vessels should be identified. As
renal recess (Morrison’s pouch) and the perisplenic they arise from the aorta in close proximity to each
space. Within the pelvis, fluid tends to accumulate other, they should be followed distally to ensure
in the rectouterine pouch (of Douglas) in females, they have been correctly identified.
the rectovesical pouch in males or laterally in the
paravesical space in both genders. Identifying the duodenum
In contrast, free intraperitoneal gas rises to the The duodenum is a C-shaped tube passing from
least dependent part of the abdomen. This is usu­ the stomach to the duodenojejunal flexure. Once
ally in the midline anteriorly, or anterior to the the stomach is identified on the CT, the course of
liver. Free gas may be better appreciated on lung the duodenum can be followed by scrolling through
the images. This is helped by positive identification
windows.

Free gas

Perisplenic fluid
(trace only)

Fluid in right Fluid in left

paracolic gutter paracolic gutter

FIGURE 2.2 Retroperitoneal structures in the upper abdomen.

BD = Bile duct; PV — Portal vein; HA = Hepatic artery; IVC = Inferior vena cava; Ao = Aorta; SV — Splenic vein; SA = Splenic artery;
SMV = Superior mesenteric vein; LRV = Left renal vein; SMA = Superior mesenteric artery; IMA — Inferior mesenteric artery; Duo =
Duodenum. This patient has had a cholecystectomy.

Fluid in*
of the third part of the duodenum. Firstly, find passing from the spleen to join with the superior
the origin of the SMA. Next identify the left renal mesenteric vein (SMV) behind the neck of the pan­
vein, which lies between the aorta and the SMA as creas, forming the portal vein. The splenic artery
it passes from the left kidney to the IVC. The third follows the superior border of the pancreas from
Uterus part of the duodenum is inferior to this, between the CA to the spleen. The pancreatic head lies in
the aorta and the SMA. The inferior border of the the concavity of the duodenum. The pancreas is
Fluid
duodenum is adjacent to the origin of the inferior obliquely oriented in the retroperitoneum, with its
mesenteric artery (IMA). The IMA is not always head lower than its tail. The tail is seen first close to
visible on venous-phase CT. the splenic hilum. Following it inferiorly will help
Rectum
identify the neck, head and uncinate process.
Identifying the pancreas
Between the origin of the CA and the SMA, the Structures passing to the porta
aorta is crossed by the pancreas and the splenic hepatis (Figure 2.3)
vein (SV). The SV runs posterior to the pancreas, The right and left hepatic ducts join to form the
FIGURE 2.1 Free fluid and gas.
144 Diagnostic imaging in critical care
2 • Abdomen and pelvis 145
branches for the left and right lobes of the liver. The
relations in the free border of the lesser omentum
are portal vein behind, bile duct in front and to the
right, and hepatic artery in front and to the left.

Adrenal glands (Figure 2.4)

The adrenal glands lie anterosuperior to the upper
part of each kidney. On the right side, the gland
lies posterolateral to the IVC and posteromedial to
tlie liver. On the left side, the gland lies lateral to
the left crus of the diaphragm, and posterior to the
pancreas and splenic vessels.
Arterial supply of the gut
The coeliac axis supplies the gut from the lower
oesophagus to the entry point of the bile duct into
the duodenum, the liver (with the portal vein), the
pancreas and the spleen. The SMA supplies the gut
from the entry point of the bile duct into the duo­
denum to the splenic flexure. The IMA supplies the
gut from the splenic flexure to the anal canal.
FIGURE 2.3 Structures passing to the porta hepatis.
PV = Portal vein; IVC = Inferior vena cava; Ao — Aorta;
HA — Hepatic artery.
Lateral recess of peritoneal cavity and
retroperitoneal spaces (Figure 2.5)
The peritoneum of the lateral abdominal wail
common hepatic duct, which in turn joins with reflects at the lateral recess of the peritoneal cavity
the cystic duct to form the bile duct. The bile duct (paracolic gutter), then passes over the front of the
passes down the free edge of the lesser omentum descending (or ascending) colon and kidney. The
where it is accompanied by the portal vein and depth of the lateral recess is variable and it may
hepatic artery. It then passes behind the first part extend behind the colon, or even posterolateral to
of the duodenum, between the second part of the kidney. DC = Descending Colon
the duodenum and the pancreas, to join with the The anterior and posterior layers of the renal
(Gerota’s) fascia fuse laterally to form the latero-
— Peritoneum
pancreatic duct at the ampulla of Vater and enter
the posteromedial aspect of the second part of the conal fascia, which blends in the flank with the •....... Lateroconal Fascia
duodenum. Unless it is dilated, the entire course of peritoneal reflection of the lateral recess of the - — Renal Fascia
the bile duct may not be seen on CT scan. peritoneal cavity. The retroperitoneum is divided FIGURE 2.5 Lateral recess of the peritoneal cavity and retroperitoneal spaces.
The portal vein forms behind the neck of the into three spaces by the renal fascia. The perire­
pancreas, and the hepatic artery is a branch of the nal space is bounded anteriorly by the anterior
coeliac axis. They both pass up the free edge of the renal fascia and posteriorly by the posterior renal The anterior pararenal space is bounded by the
lesser omentum with the bile duct, then divide into fascia. It contains the kidney and adrenal gland. peritoneum anteriorly, the anterior renal fascia
posteriorly and the lateroconal fascial laterally. It
contains the retroperitoneal portions of the duo­
denum and colon, and the pancreas. The posterior
pararenal space lies behind the posterior renal fas­
cia and the lateroconal fascia. It contains no organs
(Dodds, 1986).

Pelvic organs (Figure 2.6)

Assessment of the abdominal scan should include
the soft tissues of the pelvis. It is not uncommon
for inexperienced doctors to interpret a CT scan as
showing a pathological mass when the appearance
is actually that of a normal uterus. FIGURE 2.6 Pelvic organs.

FIGURE 2.4 The adrenal glands. IVC = Inferior vena cava; Ao = Aorta.
 2 • Abdomen and pelvis 147
146 Diagnostic imaging in critical care

PROBLEM 2.01 A
A markedly distended loop of bowel extends tube” or a “coffee bean”. The rest of the large
from the pelvis to the upper abdomen, tapering bowel is also distended, though less markedly, and
inferiorly. No haustra are visible in this segment the haustral pattern is retained. These features are
of bowel. It has the appearances of a “bent inner typical of a sigmoid volvulus.

Learning point
The vast majority of cases of volvulus involve either majority of cases of sigmoid volvulus, though CT
the caecum or the sigmoid colon (Matsumoto, may be required if the diagnosis is uncertain.
2004). Abdominal X-ray is diagnostic in the

This 79-year-old woman presented with genera- —r

lised abdominal pain and vomiting. What is the likely problem?
 2 • Abdomen and pelvis 149
148 Diagnostic imaging in critical care

A
The plain film shows a large bowel loop in the pel­ demonstrates the “whirl sign” just anterior to the
vis, with haustral creases and an air fluid level. It iliac vessels. This sign is the direct visualisation of
has the appearance of a “coffee bean”, on both the the twisted segment of bowel. The coronal view
plain film and the coronal image of the CT. No demonstrates the origin of the distended loop
other distended loops of large bowel are visible. from the right iliac fossa adjacent to the proxi­
The CT scans confirm this, but also show mul­ mal ascending colon. These findings are typical of
tiple loops of normal sigmoid colon in the pelvis caecal volvulus.
(image d), excluding a sigmoid volvulus. Image c

Learning point
The vast majority of cases of volvulus occur the volvulus, both from above and below. When
either in the caecum or the sigmoid colon. Both this tapered bowel is filled with contrast, it has
are characterised on CT by (Matsumoto, 2004; the appearance of a bird’s beak (not seen in the
Moore, 2001): images from this problem)
• a very distended segment of large bowel folded • spiralling of collapsed loops of bowel and ves­
back on itself so that the twisted loop forms sels at the site of the twist (known as the whirl
two compartments with a central double wall sign)
ending at the apex of the twist. This is the “cof­ In the case of sigmoid volvulus, the proximal
fee bean” sign, and is well demonstrated.on large bowel is distended, while small bowel disten­
the plain film example of a sigmoid volvulus sion may or may not occur. With caecal volvulus,
(Problem 2.01) there is no proximal large bowel to distend.
• progressive tapering of the bowel leading up to

This 54-year-old man presented with vomiting t|

and abdominal pain. Soon after these images were What diagnosis is suggested by these images?
acquired, he vomited, aspirated and required
intubation and ventilation.
150 Diagnostic imaging in critical care

PROBLEM 2.03
 2 • Abdomen and pelvis 151

This 69-year-old woman was receiving mechanical .

ventilation for community acquired pneumonia What problem do these images suggest?
when she developed generalised abdominal pain
and hypotension.

A
The supine film (image a) shows surgical clips in of pneumoperitoneum are relatively subtle and
the right upper quadrant and multiple gas-filled could easily be missed on the supine film.
loops of small and large bowel. In some of the The left lateral decubitus film (image b) clearly
bowel loops, both inner and outer aspects of the demonstrates a moderate-sized pneumoperito­
bowel wall can be seen (Rigler’s sign). This sug­ neum. Free gas is seen lateral to the liver, extending
gests a visceral perforation, unless there has been caudally to the iliac crest.
a recent laparotomy. In this case, the appearances

Learning point
Often it is impractical to perform erect chest and non-dependent part of the abdomen and, in the
abdominal films in critically unwell patients. Left left lateral position, this is lateral to the liver.
lateral decubitus abdominal X-rays are much Gas may persist in the peritoneal cavity for up
more sensitive than supine abdominal films for to a week following laparotomy.
detecting pneumoperitoneum. Gas rises to the
 2 • Abdomen and pelvis 153
152 Diagnostic imaging in critical care

PROBLEM 2.04 A
There are multiple distended loops of small and The caecal dilatation would be in keeping with
large bowel. The caecum is grossly dilated. Air is caecal volvulus, but the distal large bowel disten­
seen in the rectum. There is a high risk of per­ sion and presence of gas in the rectum make this
foration with this degree of caecal dilatation, but unlikely. In this clinical context, the most likely
there is no direct evidence of perforation on this diagnosis is pseudo-obstruction.
image.

Learning point
Acute intestinal pseudo-obstruction presents Distinguishing pseudo-obstruction from
with a similar clinical and radiological picture to mechanical large bowel obstruction may be dif­
large bowel obstruction. Characteristically, the ficult. Flexible colonoscopy and sometimes a
caecum, ascending colon and transverse colon are barium enema may be required if the diagnosis is
dilated, but the dilatation may extend as far dis­ unclear on imaging.
tally as the sigmoid colon. The presence of air in If the diameter of the caecum exceeds 12 cm,
the rectum is common with pseudo-obstruction, there is a high risk of perforation and decompres­
but rare with complete mechanical obstruction sion should be considered (Batke, 2008).
(Batke, 2008).

This 77-year-old man has been ventilated since

undergoing cardiac surgery two weeks ago. He "What problem does this image suggest?
has had increasing abdominal distension and has
not yet passed a bowel motion.
11
2 • Abdomen and pelvis 155
154 Diagnostic imaging in critical care

PROBLEM 2.05 This 76-year-old woman presented with abdomi-. Q

nal pain and vomiting. What problem do these images suggest?

A
There are dilated loops of small bowel, with mul­ findings denote an early, or partial, distal small
tiple air-fluid levels. A “string of pearls” sign is bowel obstruction. No evidence of bowel infarc­
present on the erect projection (see the Learning tion or perforation is seen.
point below for a description of this sign). A small Incidentally, there is also marked scoliosis of
amount of gas is seen in the hepatic flexure and the spine.
descending colon, which are not dilated. These

Learning point
Characteristic features of small bowel obstruction more central. Secondly, the mucosal folds have a
include distended (> 3 cm) loops of small bowel, different appearance. Specifically, the plicae cir­
multiple air fluid levels, thickening of the small culates (valvulae conniventes) of the small bowel
bowel wall and collapse of the colon. There may extend across the full diameter of the bowel while
be small bubbles of gas contained within the pli­ the haustra of the colon do not.
cae circulares, giving the appearance of a “string When the imaging suggests small or large
of pearls”, which is accentuated when a large vol­ bowel obstruction, features of perforation (free
ume of fluid residue is present in the small bowel gas) or gut infarction (pneumatosis intestinalis
(Nicolaou, 2005). and/or gas in the portal vein) should be looked
Small bowel may be distinguished from large for (Nicolaou, 2005). Hernial orifices should also
bowel by two features. Firstly, large bowel is at the be assessed for incarcerated bowel, both clinically
periphery of the abdomen, while small bowel is and radiologically.

I
J
 2 • Abdomen and pelvis 157
156 Diagnostic imaging in critical care

PROBLEM 2.06 A
This image has multiple features of a large pneu­ subhepatic space and outlining of the falciform
moperitoneum, including the “football sign” ligament by air. Visceral perforation with sepsis is
Rigler’s sign, interloop triangular lucency (just the likely cause of this patient’s shock state.
above the tip of the 12th left rib), air in the

Learning point
Many signs of pneumoperitoneum have been • interloop triangular lucency: this is a triangular
described on the supine abdominal X-ray. Some collection of gas between two loops of bowel
of the more useful ones are (Khan, 2008): and the abdominal wall.
• Rigler’s sign: both inner and outer borders of • subhepatic air: gas in the right upper quadrant
the bowel are well defined. This is caused by the outlines the inferior border of the liver. It may
normal interface between the inner aspect of also be seen as an inverted V in the ligamentum
bowel wall and luminal gas, and the abnormal teres notch between the left and right lobes of
interface between the outer aspect of bowel wall the liver.
and gas in the peritoneal cavity. • falciform ligament outlined by air: the falciform
• football sign: in which air seems to outline the ligament may be outlined by air and visible as
entire peritoneal cavity with a football shape. a vertical soft tissue density between the umbi­
This represents a large air collection within the licus and the notch between the left and right
greater sac. . lobes of the liver.

“S'S .... a«.<-» -B««

shock.
 2 • Abdomen and pelvis 159
158 Diagnostic imaging in critical care

PROBLEM 2.07 A
Within the peritoneal cavity, there is a moderate is fluid around the spleen, but there is no splenic
amount of free fluid, and free gas is seen anteri­ injury identified on these images. The perisplenic
orly. In the absence of a recent laparotomy, these fluid could indicate a splenic injury that is below
findings are strongly suggestive of hollow visceral the resolution of CT scan to detect or it could be
perforation. The wall of the sigmoid colon and part of the free peritoneal fluid, which is seen in
the descending colon is thickened and there is gas multiple locations throughout the abdomen. On
within the mesentery (well seen on the lung win­ the DVD images, there is an incidental right adre­
dows, image f), suggesting a colonic injury. There nal lesion.

Learning point
Lung windows may help to demonstrate subtle
evidence of intra-abdominal free gas.

This 28-year-old-man developed lower abdomi- Q,

nal pain following a car crash earlier today. What injury is suggested by these images?
160 Diagnostic imaging in critical care

PROBLEM 2.08 A
There is a laceration through the spleen with a splenic injury. Two ribs on the left have minimally
surrounding haemorrhage. A small area of con­ displaced anterior fractures. More rib fractures
trast extravasation is noted at the splenic hilum. are demonstrated on the DVD images.
These features are consistent with a grade IV

Learning point
The organ injury scale of the American Association parenchymal haematomas, lacerations and
for the Surgery of Trauma is used to grade injury injury to the vessels supplying the spleen, with
to individual organs (Tinkoff, 2008). It may be or without devascularisation. As the spleen is not
used for a range of organs, including liver, spleen necessary for survival, splenic injuries are graded
and kidneys. Grades I to V represent increas­ from I to V (see Appendix 1 for details).
ingly severe injuries in salvageable patients, while Splenic injuries are often associated with lower
grade VI represents an unsurvivable injury. rib fractures on the left side.
Splenic injuries may include sub capsular or

This 65-year-old man fell while crossing the road

earlier today. He complains of left upper quad-
J injuries are demonstrated on these images?
CWhat
rant abdominal pain, with tenderness over the
adjacent chest wall.
 T
2 • Abdomen and pelvis 163
162 Diagnostic imaging in critical care

PROBLEM 2.09 A
There are two large subcapsular haematomas of a grade III liver injury. There is also a large hae­
the liver, seen best on the axial images. On the moperitoneum and, on the parasagittal images,
parasagittal image, a relatively small laceration of a retroperitoneal haematoma inferior to the kid­
the posterior aspect of the liver is seen. Contrast ney can be seen. On the DVD images, there is a
extravasation is seen on the arterial phase image, vertical shear injury to the pelvis with extensive
suggesting active bleeding. This is consistent with retroperitoneal haematoma.

Learning point
Subcapsular haematomas appear as elliptical low-attenuation areas in the parenchyma of the
collections of low attenuation between the liver liver. Lacerations appear as linear or branch­
capsule and the enhancing liver parenchyma. They ing low-attenuation areas in the parenchyma.
can be differentiated from free peritoneal blood Contrast extravasation on arterial phase images
in the perihepatic space because they indent or indicates active haemorrhage (Yoon, 2005). Liver
flatten the underlying liver margin. Parenchymal injuries are graded from I to VI (see Appendix 1
haematomas or contusions are irregular, focal, for details) (Tinkoff, 2008).

hypotensive again, and is confused and agitated.

This 29-year-old woman was involved in a high­
speed car crash two hours ago. She was hypotensive
on presentation and initially responded to intra­
venous fluid resuscitation. She has now become Describe the injuries.
 2 • Abdomen and pelvis 165
164 Diagnostic imaging in critical care

PROBLEM 2.10 This 64-year-old woman was in a high-speed car. Q

crash earlier today. She complains of abdomi­ What injury is demonstrated by these venous
nal and back pain. Macroscopic haematuria was phase images?
noted when a urinary catheter was inserted.

A
The upper half of the right kidney has multiple the perinephric space. On the images in the DVD,
deep lacerations, extending through the corti- free fluid is seen within the peritoneal cavity in the
comedullary junction into the collecting system. pelvis. These findings are consistent with a grade
The renal artery and vein are well opacified with IV renal injury. The venous phase images shown
contrast and the renal parenchyma is enhancing in the book cannot exclude urine extravasation,
with contrast. There is a large haematoma in the but the delayed phase (pyelographic) images on
retroperitoneum surrounding the right kidney, in the DVD show no evidence of this.

Learning point
Renal injuries may include contusions, lacerations a contrast study with both early phase (to assess the
and injury to the renal vasculature. Renal injuries renal vasculature and parenchyma) and delayed
are graded from I to V (see Appendix 1 for details) phase images (to assess the collecting system)
(Tinkoff, 2008). should be obtained. This allows any extravasation
For full assessment of a renal injury by CT, of urine to be identified.
 2 • Abdomen and pelvis 167
166 Diagnostic imaging in critical care

PROBLEM 2.11 A
There are multiple distended loops of small bowel. This transition is adjacent to the right ingui­
The large bowel is not dilated. There are also non­ nal region and bowel is seen in a femoral hernia
distended collapsed loops of small bowel in the adjacent to the femoral vessels in image d. This
right iliac fossa (image b), with a transition from patient has an incarcerated femoral hernia caus­
dilated to collapsed small bowel seen in image c. ing a small bowel obstruction.

Learning point
A transition point between dilated and collapsed transition point should be sought. This requires
bowel confirms the presence of a mechanical a systematic process of following the bowel up
bowel obstruction and defines the site of obstruc­ from the rectum, examining in turn the sigmoid,
tion (Nicolaou, 2005). descending, transverse and ascending colon, then
Whenever distended bowel is present, such a finally the small bowel.

This 72-year-old man complained of vomiting Q

and abdominal pain. His abdomen was markedly What cause of this patient s abdominal symptoms
distended. do these images suggest?
 2 • Abdomen and pelvis 169
168 Diagnostic imaging in critical care

A
The caecum, ascending colon and transverse transition point. The small bowel is also mildly
colon are all dilated, while the descending and dilated. There are no obvious liver metastases or
sigmoid colon are collapsed. A transition from lymphadenopathy and there is no evidence of
dilated to collapsed large bowel is seen in image ischaemia or perforation.
a, in the distal transverse colon near the splenic The problem suggested by these images is a
flexure (best appreciated on the DVD images, large bowel obstruction. The most likely cause is
which allow the large bowel to be followed along bowel cancer.
its entire length). There is mural thickening at this

Learning point
The small bowel may or may not be dilated in The upper limit of normal colon size is 6 cm,
large bowel obstruction, depending on the com­ though the caecum may be up to 9 cm (Dahnert,
petence of the ileocaecal valve. 2007).

This 76-year-old woman required admission to 1 )

ICU for management of acute renal failure from What problem do these images suggest?
dehydration. The history revealed several days of
abdominal pain and vomiting.
 2 • Abdomen and pelvis 171
170 Diagnostic imaging in critical care

nnciDl Cft/I T IX A
There is marked thickening of the large bowel is likely, but pseudomembranous colitis should be
wall, involving the descending, ascending and considered.
transverse colon and the caecum. The small Of concern, there is gas in the bowel wall (image
bowel is normal distally and slightly distended c), and the enhancing mucosa of the ascending
proximally (seen on DVD images). These appear­ colon is discontinuous (image b) with surround­
ances suggest that the main problem is colitis, ing fluid. This is suspicious of a perforation but,
with typhlitis (inflammation of the caecum). In as no free gas is seen on these images, the presence
this clinical context, neutropenic typhlitis/colitis of a perforation is uncertain.

Learning point
In patients with neutropaenic typhlitis, CT is peritonitis or abscesses.
helpful to confirm the diagnosis and identify Uncomplicated typhlitis is treated with anti­
problems that may need surgical management. biotics and supportive management.
Such problems include perforation leading to

foundly leucopenic and febrile with abdominal

pain and distension.
 1 • Abdomen and pelvis 173
172 Diagnostic imaging in critical care

PROBLEM 2.14 A
There is gas in the substance of the liver. It has a the ascending colon. It is seen both in the depen­
branching linear pattern and is seen peripherally dent and non-dependent parts of the bowel wall,
in the liver, consistent with portal venous gas. Gas suggesting that it is submucosal rather than lumi­
is also seen within the superior mesenteric vein. nal. In this clinical context, these findings would
In addition, there is an area of low attenuation be consistent with necrotising enterocolitis or
in the posterior aspect of the right hepatic lobe mesenteric vascular occlusion causing infarcted
(image b), which may represent early abscess for­ gut. The relative sparing of the transverse and
mation. There is extensive air within the wall of descending colon would favour gut infarction.
both small and large bowel, most prominent in

Learning point
The differential diagnosis for gas with a branch­ accumulate in the large central bile ducts near the
ing linear pattern within the liver includes portal hilum.
venous gas and pneumobilia. The flow of portal Pneumatosis intestinalis (gas in the bowel wall)
venous blood is from the hilum outwards, and may be primary (which is both idiopathic and
portal venous gas is seen branching to within benign) or secondary. Secondary causes include
2 cm of the periphery of the liver. In cases where it bowel necrosis, a range of non-necrotising bowel
is more centrally distributed, the continuity of the diseases (bowel obstruction, Crohn’s disease,
gas filled branches with the contrast-containing ulcerative colitis), immunosuppression, abdomi­
branches of the portal vein may be apparent. The nal trauma and pulmonary barotrauma (Dahnert,
flow of bile is from the periphery to the porta 2007; Knechtle, 1990).
hepatis and, with pneumobilia, gas tends to

This 66-year-old man developed central abdomi-

nal pain two days ago. The pain has become
C)
What problem do these images suggest?
progressively worse and he has now developed
septic shock with severe lactic acidosis.
 2 • Abdomen and pelvis 175
174 Diagnostic imaging in critical care

A
The wall of the sigmoid colon is thickened and fluid and gas with some rim enhancement. The
at least one diverticulum is seen. Adjacent to the most likely cause of these findings is diverticulitis
thickened area of colon is a collection containing with localised perforation and abscess formation.

Learning point
When a collection suggestive of an abscess is iden­ diverticulitis, gangrenous cholecystitis, pancreati­
tified on a CT scan, the rest of the scan should be tis, mesenteric ischaemia with gut infarction and
reviewed for possible causes of intra-abdominal other gastrointestinal tract perforations.
abscess. Common causes include appendicitis,
 2 • Abdomen and pelvis 177
176 Diagnostic imaging in critical care

PROBLEM 2.16 This 44-year-old man presented with right lower

quadrant abdominal pain and is now waiting for
Q
What diagnosis do these images suggest?
surgery. He is known to have Cl esterase inhibitor
deficiency and an ICU bed has been requested for
postoperative monitoring.

A
The appendix is markedly enlarged (15.9 mm) image d, where it may be compared with the adja­
and contains a calcified appendicolith. There is cent terminal ileum. These findings are strongly
periappendiceal fat stranding, suggesting inflam­ suggestive of appendicitis. There is no evidence of
mation. There is contrast enhancement of the perforation.
appendiceal wall, which is best appreciated in

Learning point
The CT findings of appendicitis include,(Curtin, • presence of a calcified appendicolith
1995; Jain, 2006): • perforation suggested by the presence of a peri-
• circumferential and symmetric wall thicken­ caecal phlegmon or abscess formation
ing with a “two wall” diameter > 6 mm. If the Other findings that may be found with perfo­
lumen is filled with fluid, the walls may not be ration include extraluminal air and thickening of
distinguishable from the luminal contents; in the adjacent caecum or terminal ileum. A con­
this circumstance, a diameter of up to 10 mm glomerate of inflamed and adherent bowel loops
may be normal. may obscure the inflamed appendix in some
• enhancement of the appendiceal wall with IV cases.
contrast
• periappendiceal inflammation with fat
stranding
 2 • Abdomen and pelvis 179
178 Diagnostic imaging in critical care

A
The head of the pancreas appears normal. There There is no evidence of local complications of
is an inflammatory mass (phlegmon) centred on pancreatitis, such as fluid collections, pseudocysts,
the body and tail of the pancreas. Most of the pan­ abscesses, pseudo aneurysm or haemorrhage.
creas enhances well, but the tail does not enhance There are no gallstones seen on these images and
normally, suggesting pancreatic necrosis. There the bile ducts are not obviously dilated.
are inflammatory changes in the surrounding fat
(fat stranding) with associated thickening of the
perirenal (Gerota’s) fascia.

Learning point
The role of CT in acute pancreatitis is: fluid collections and gas in the tissues, both
• diagnostic pancreatic and peripancreatic)
• grading of severity 2. the amount of necrosis on contrast enhanced
• identification of complications CT
The severity of pancreatitis may be graded Gallstones are a common cause of pancreatitis.
on CT. The Balthazar Severity Index (Balthazar, A large proportion of gallbladder stones are not
1990) has two components, which are combined visible on CT. Ultrasound is a better modality for
to give a total score: detecting gallstones.
I. the findings on unenhanced CT (inflammation,

This 50-year-old alcoholic man was admitted to

the ICU with severe abdominal pain, tachycardia What pathological process is suggested by these
and hypotension. images?
 2 • Abdomen and pelvis 181
180 Diagnostic imaging in critical care

PROBLEM 2.18 A
Within the liver there is a linear branching problem is obstruction of the common bile duct
hypodensity, which lies adjacent to, but not within, by a calculus that was not removed at the time of
the portal venous branches. This represents cholecystectomy. Biliary stones are often difficult
dilated intrahepatic bile ducts. The extrahepatic to see on CT, as they may be poorly calcified or
bile duct is markedly dilated and, at its distal display a soft tissue density as in this case.
end (image d), it contains a large calculus. The

Learning point
Biliary calculi may be missed at the time of
cholecystectomy.
 2 • Abdomen and pelvis 183
82 Diagnostic imaging in critical care

PROBLEM 2.19 A
There is a large multiloculated fluid collection in consistent with obstruction. There is no parenchy­
the retroperitoneum, involving the lower pole of mal gas to suggest emphysematous pyelonephritis.
the left kidney and extending down to the pel­ The left psoas muscle is involved in the process.
vis. There is rim enhancement and gas is seen These findings are consistent with pyelonephritis
within the collection. The left kidney is swollen complicated by intrarenal, perinephric and psoas
and abnormal and there is calyceal dilatation abscess.

Learning point
When a patient with acute pyelonephritis has The CT may be normal with uncomplicated
severe sepsis, imaging should be performed to look pyelonephritis. Findings that suggest pyelone­
for complications that require surgical treatment. phritis include renal enlargement, focal swelling,
These include emphysematous pyelonephritis thickening of Gerota’s fascia and perinephric fat
(urgent nephrectomy), ureteric obstruction (stent stranding. A patchy or striated nephrogram with
or percutaneous nephrostomy) and perinephric wedge areas of decreased attenuation is also sug­
abscess (percutaneous or surgical drainage). gestive of the diagnosis in the correct clinical
context (Dahnert, 2007).

This 18-year-old
back pain, manrigors.
fevers and gave aAtone-week history
presentation of
to the Q
What problem is suggested by these images?
emergency department, he was in septic shock.
 2 • Abdomen and pelvis 185
184 Diagnostic imaging in critical care

PROBLEM 2.20 A There is also gas within the gallbladder.

There is a large lesion in the liver, which contains
gas and an air-fluid level. The gas in the liver sub­ These findings suggest a liver abscess and bil­
stance has a branching linear pattern and does iary sepsis with emphysematous cholecystitis. The
not extend to within 2 cm of the periphery of the liver lesion could be a tumour but, given the other
liver. It is separate from the adjacent branch of findings, this is less likely.
the portal vein and consistent with pneumobilia.

Learning point
Gas in the biliary tree is most commonly due to include biliary tract disease, infection of organs
surgery or instrumentation of the biliary tree. with portal venous drainage (including appendi­
Other causes include an incompetent sphincter of citis) and haematogenous spread during systemic
Oddi (sphincterotomy or passage of a gallstone), bacteraemia. Non-pyogenic liver abscess may be
trauma, gallstone ileus, duodenal ulcer perforat­ due to amoebic or fimgal infections. Abdominal
ing into the bile duct, and severe biliary sepsis with CT and biliary tract ultrasound are helpful in
emphysematous cholecystitis (Dahnert, 2007). delineating underlying causes of pyogenic liver
Common causes of pyogenic liver abscess abscesses (Dahnert, 2007).

This 65-year-old man gave a one-week history yfoat problem do these images suggest?
of right upper quadrant pain. On presentation,
he was jaundiced and rapidly developed septic
shock.
 2 • Abdomen and pelvis 187

A
There are large fluid collections in the right sub- most likely bile (see Chapter 6: Imaging modali­
phrenic and subhepatic spaces, with compression ties, p 374). In this clinical context, these findings
of the liver substance. Both demonstrate rim are suggestive of a bile leak, with secondary sub-
enhancement. The density of the collections is phrenic and subhepatic collections of infected
10—15 Hounsfield units, consistent with fluid and bile.

Learning point
When a collection is seen on CT, measuring its its composition (see Chapter 6: Imaging modali-
density in Hounsfield units may help determine ties, p 374 for more details).

managed with biliary reconstruction ten days ago.

She now has abdominal pain and sepsis.
 2 • Abdomen and pelvis 189
188 Diagnostic imaging in critical care

PROBLEM 2.22 A
There is a large (9.9 cm transverse diameter) calcification in its wall. There is retroperitoneal
FR 22Hz
FR 22Hz
RS abdominal aortic aneurysm seen on both the haemorrhage adjacent to, and partly involving,
RS
ultrasound and CT images. On the ultrasound the left psoas muscle. There is a crescentic luminal
C 55
images, there is a cresentic hypoechoic area adja­ thrombus, corresponding to the hypoechoic area
P Low
Res cent to the patent lumen. It is uncertain on these on the ultrasound. No free intraperitoneal blood
images whether this represents a rupture of the is seen on the images in the book, though a small
aneurysm or thrombus within its lumen. amount of pelvic fluid is seen on the DVD images.
On the CT images, the aneurysm extends These findings suggest retroperitoneal rupture of
up to the level of the renal arteries and there is the aneurysm and urgent surgery is indicated.

Learning point
•> Dist When the diagnosis of ruptured abdominal aortic is stable, CT is preferred as it will provide more
:: Dist
aneurysm is suspected, an abdominal ultrasound information about the anatomy and pathologi­
can be performed rapidly by the bedside with­ cal process, even in the absence of IV contrast
out delaying emergency surgery. If the patient administration.

This 70-year-old man had a new onset of back

pain. The blood pressure and heart rate were nor-
Q,
Does this patient neeu an g
operation?
p
mal. A non-tender pulsatile mass was palpable in
the abdomen, consistent with a known abdomi­
nal aortic aneurysm. This was being monitored
with serial imaging by the vascular surgeons.
 2 • Abdomen and pelvis 191
190 Diagnostic imaging in critical care

PROBLEM 2.23 A
A multilocular cystic lesion is seen within the The differential diagnosis for the CT findings
right side of the pelvic cavity, with a thin enhanc­ would include tubo-ovarian abscess, pyosalpinx,
ing wall. Inflammatory change and fat stranding is or acute haemorrhage/infection in a pre-existing
seen adjacent to this mass. It is intimately related ovarian cyst. Ovarian carcinoma would be less
to the right fallopian tube and ovary. likely, particularly in this clinical context.

Learning point
Gynaecological infection should be considered mandatory when the clinical presentation is one
in the differential diagnosis of severe sepsis in a of sepsis with no obvious site.
woman of reproductive age. Pelvic examination is
 2 • Abdomen and pelvis 193
192 Diagnostic imaging in critical care

PROBLEM 2.24 A
On the CT, the uterine cavity is enlarged and fluid There are low-level internal echoes, consistent
filled. While this would be normal in the early with complex fluid. The outline of the cavity is
postpartum period, by five weeks postpartum irregular, as is the interface between the endome­
the size of the cavity should be almost normal. trium and myometrium. In this clinical scenario,
The endometrium is thickened and has enhanced the findings of both the ultrasound and the CT
with contrast. are strongly suggestive of retained products of
On the transvaginal ultrasound, the uterine conception.
cavity is enlarged and contains hypoechoic fluid.

Learning point
Sepsis from retained products of conception can
occur following caesarean section and these are
best imaged with ultrasound.

UTERUS- Long l •

|9C3 6*
| drfloO

jlSfps

8*

Transvaginal ultrasound
Dfctl A 28.5 mm Dist? A 48.6 mm Dist3
Volume

This 39-year-old woman delivered a healthy baby Q

by caesarean section five weeks ago. She has been What cause for her sepsis is suggested by these
admitted to the ICU with septic shock. images?
 2 • Abdomen and pelvis 195
in critical care

PROBLEM 2.25 A
There are fractures of the right L4 and L5 trans­ rupture. On the DVD (not seen on images in the
verse processes. There is a vertical shear fracture book), there is also a left L2 transverse process
of the right sacral ala and marked diastasis of the fracture and a minimally displaced fracture of the
symphysis pubis. The sacroiliac joints are intact left superior pubic ramus.
with no diastasis. Extravasation of contrast from These features suggest a vertical shear injury
the urinary system is seen from the urethra (on to the pelvis with associated bladder and urethral
the retrograde urethrogram), but there is also con­ injury.
trast in the peritoneal cavity indicating a bladder

Learning point
Pelvic fractures are classified according to the fractures through the sacrum and pubic rami.
patterns of force creating the injury, into four There may be fractures of the acetabular roof,
categories: anteroposterior (AP) compres­ symphysis pubis diastasis and vertical iliac wing
sion (characterised by external rotation of the fractures. Displacement of the hemipelvis is in a
hemipelvis), lateral compression (characterised vertical direction (Young, 1990).
by internal rotation of the hemipelvis), vertical Bladder and urethral injury is common with
shear and complex (a combination of more than major pelvic injury. Bladder rupture maybe either
one pattern of force) (Young, 1986; 1990). into the peritoneal cavity or extraperitoneal. The
Vertical shear injuries usually result from a commonest site of traumatic urethral rupture is
fall. The sacrum is driven down between the iliac in the membranous urethra, as this is a relatively
wings. Typical findings include vertical (sagittal) fixed site.

This 46-year-old man fell from a six metre high Q

scaffold. A pelvis X-ray and retrograde ure- What injuries do the images demonstrate?
throgram were performed in the emergency
department with a subsequent CT scan.
 2 • Abdomen and pelvis 197
196 Diagnostic imaging in critical care

PROBLEM 2.26 A
There is wide diastasis of the symphysis pubis, arteries. On the DVD, the astute reader may note
well in excess of 2.5 cm. Both sacroiliac joints are pin tracts in the ilium from previous instru­
widened anteriorly. No bony fractures are seen. mentation, a lytic lesion in the left ilium, which
These findings are in keeping with an AP com­ may be a cyst or enchondroma, and bilateral hip
pression injury. osteoarthritis.
There is incidental calcification in the iliac

Learning point
AP compression injury commonly occurs in a on the dashboard), though anterior acetabular
motor vehicle crash. Typically, the anterior pelvis fractures may occur (Young, 1990).
is disrupted, which causes either symphysis dia­ If the ligaments of the symphysis pubis are
stasis or vertical (sagittal) fractures of the pubic completely divided, but this is the only injury, the
rami. When the trauma is more severe, there is amount of diastasis is limited to 2.5 cm because of
splaying of the anterior pelvis, with external rota­ the posterior ligamentous structures. Symphysis
tion of one or both hemipelvises. If this occurs, pubis diastasis of greater than 2.5 cm implies
the sacroiliac joint on the side of the rotated additional injury to the posterior ligaments of the
hemipelvis is disrupted, with the posterior part of pelvis (Young, 1990).
the sacroiliac joint acting as a hinge. Sacral frac­ An important feature distinguishing AP from
tures are rare and iliac wing fractures ape not part lateral compression injury is that the pubic rami
of this injury pattern. Fractures of the posterior fractures are vertical (sagittal) in an AP compres­
acetabulum are common (often due to posteriorly sion injury but horizontal (coronal) in a lateral
directed forces from the flexed femur impacting compression injury (Young, 1990).

This 74-year-old man was injured in a high-speed Q

car crash earlier today. His pelvis feels unstable on Describe
D.. the pelvic injury.
clinical examination.
 2 • Abdomen and pelvis 199
198 Diagnostic imaging in critical care

A
There are horizontal (coronal) fractures of both sacroiliac joint is disrupted, with predominantly
inferior pubic rami. There is also a fracture of the posterior widening. The left hemipelvis is rotated
superior ramus on the left. The symphysis pubis internally, hinging on the anterior aspect of the
is disrupted such that the right pubic bone lies sacroiliac joint. These features are in keeping with
in front of the left, with slight overlap. The left a lateral compression injury.

Learning point
Lateral compression injuries typically cause hori­ of this joint acting as a pivot or obliquely frac­
zontal (coronal) fractures of the pubic rami and turing the ipsilateral iliac wing. If enough force
impacted fractures of the sacrum may occur. is applied the contralateral hemipelvis may rotate
When the trauma is more severe the affected externally. There may be fractures of the medial
hemipelvis rotates internally, either disrupting the acetabulum, with central hip dislocation (Young,
ipsilateral sacroiliac joint with the anterior aspect 1990).

This 36-year-old woman survived a single vehicle What mechanism of injury do these images
rollover car crash, in which two people died. She
is complaining of severe pain in her lower abdo­ suggest?
men and groin.
 2 • Abdomen and pelvis 201
200 Diagnostic imaging in critical care

PROBLEM 2.28 A
The right sacroiliac joint is disrupted, with both lateral compression. The superior ramus fracture
anterior and posterior widening. There is some on the left is vertical (parasagittal), in keeping
posterior displacement of the hemipelvis, but with AP compression. On the other hand, the
minimal rotation. This pattern would be in keep­ fracture on the right is in the axial plane.
ing with an AP compression component to the Features of more than one injury pattern are
injury. However, there is also an oblique fracture present (AP compression and lateral compres­
of the iliac wing, which is not typical of an AP sion), so this is classified as a “complex pattern”
compression injury and more in keeping with a injury.
lateral compression injury. There is also a large retroperitoneal haematoma
There are fractures of all four pubic rami. On in the region of the right iliacus muscle, adjacent
the DVD, it can be seen that the inferior rami to the sacroiliac joint injury.
fractures are horizontal (coronal), in keeping with

Learning point
Not all pelvic injuries fit into the simple classi­ has elements of more than one of these patterns
fication of AP compression, lateral compression (Young, 1990).
and vertical shear. One in four pelvic injuries

This 57-year-old man was in a high-speed car What is the likely mechanism of injury to the
crash. He was intubated at the scene because of
severe respiratory distress. pelvis?
 2 • Abdomen and pelvis 203
202 Diagnostic imaging in critical care

PROBLEM 2.29 A
There is marked thickening of the gallbladder In image d, there are small echogenic foci in
Map 5 GB
wall, which is hypoechoic between its inner and the non-dependent gallbladder wall. While the
Map 3 GB 170dB/C2 outer aspects indicating oedema. There is a large appearance could be confused 'with gallstones,
170dB/C2 Persist Olt
PersistOff 2DOpt:FSCT calculus at the neck of the gallbladder and also gallstones move with gravity and should be
2DOpt:FSCT
Fr RaterSurv
Fr Rate:Surv
SonoCT"’
several smaller calculi in the dependent aspect of dependent. This finding suggests adenomyo-
SonoCT"' the body of the gallbladder. There is also sludge matosis, which can also cause thickening of the
seen within the gallbladder. These findings are gallbladder wall.
-5
-5
strongly suggestive of acute calculous cholecys­ There is no extra-hepatic biliary duct dilatation
titis. Pericholecystic fluid is commonly seen with (upper limit of normal 5 mm with gallblad­
cholecystitis, but is not demonstrated in these der present, 8 mm following cholecystectomy)
t NECK
images. (Dahnert, 2007).
1.82cm
0.52cm

a b Learning point
Ultrasound is a better investigation than CT for • air in the gallbladder wall (suggests emphyse­
biliary disease. It has the added advantage that the matous cholecystitis)
images can be acquired at the bedside, avoiding Interpretation of ultrasounds for assessing
transport of the critically ill patient. If ultrasound biliary disease may be complex in critically ill
is equivocal, HIDA radioisotope scan is an alterna­ patients; patients that are starved or on TPN often
tive investigation, though its role in the critically have sludge in the gallbladder.
ill patient is not well established. When patients with cholecystitis have no gall­
Features of acute cholecystitis on ultrasound stones in the gallbladder, they have acalculous
include (Dahnert, 2007): cholecystitis. This condition accounts for around
• thickening of the gallbladder wall (upper limit 10% of cases of cholecystitis and has a higher
of normal 3 mm) morbidity and mortality than calculous chole­
• distension of the gallbladder (diameter > 4 cm, cystitis. The incidence is higher in critically ill
length > 10 cm) patients (Kimura, 2007; Yasuda, 2007).
• pericholecystic fluid
• sonographic Murphy sign (pain when probe is
pushed onto the gallbladder)

This 40-year-old woman presented with right £

upper quadrant abdominal pain and was admit- What pathological process do these ultrasound
ted to the ICU with septic shock. images of the gallbladder suggest?
 2 • Abdomen and pelvis 205

This 69-year-old man presented with lethargy and

malaise and was found to be in acute renal failure. What condition is demonstrated by these
An ultrasound of the renal tract was performed. images?

A
On the right side, there is significant calyceal dila­ though hydronephrosis may occur in the absence
tation and associated dilatation of the extrarenal of obstruction. These findings alone cannot
pelvis and ureter. The kidneys are of normal size explain the acute renal failure, as renal failure
(9-12 cm in longitudinal axis) (Barozzi, 2007). should not develop with a normally functioning
The residual volume in the bladder is normal. The non-obstructed kidney on one side.
left kidney and ureter are normal. These findings
are in keeping with right ureteric obstruction,

Learning point
Obstruction must be excluded in patients with Examples of this include (Klahr, 2007; Kulkarni,
acute renal failure, as it is readily treatable. 2005):
Ultrasound is the imaging modality of choice to • acute obstruction, if the patient is volume
assess for obstructive uropathy. Typically, it dem­ depleted and has a low urinary output
onstrates dilation in the calyces or renal pelvis • when the urinary system is encased in retro­
(Klahr, 2007). peritoneal tumour or fibrosis, although there
Significant obstruction may occur without is often dilated ureter proximal to the area of
urinary system dilatation in some conditions. encasement
 2 • Abdomen and pelvis 207

A
1. This is a normal FAST scan. ongoing haemorrhage into the abdomen, the
volume of blood may have reached a point
2. Yes, the clinical scenario is highly suggestive where it can be detected by FAST scan.
of significant haemorrhage. If there has been

Learning point
The Focussed Assessment with Sonography in FAST scans are good at detecting major
Trauma (FAST) scan consists of perihepatic intra-abdominal haemorrhage, but poor at detect­
(includinghepatorenal pouch), perisplenic, pelvic, ing visceral perforation. A normal FAST scan at
and pericardial views. Depending on the expertise presentation does not rule out intra-abdominal
of the sonographer, these four “P” views may be bleeding, because early after injury the volume of
supplemented by further views. Supplementary blood in the peritoneal cavity may be too small
views allow more detailed assessment of organs to see. If there is continued bleeding, the volume
and examination of other sites in which free fluid of blood may increase to a point where it can be
collects such as the paracolic gutters, but this detected by sonography. Serial FAST scans have a
takes longer in what may be a time-critical situa­ higher sensitivity for intra-abdominal injury than
tion (Kirkpatrick, 2007). a single scan (Kirkpatrick, 2007).

This 21-year-old man was a passenger in a high­ 1. What is your interpretation of these images?
speed car crash. This FAST scan was done 10 2. Is there any point in repeating the FAST scan?
minutes after arrival in the emergency depart­
ment because of hypotension. The hypotension
responded to intravenous fluids, but 30 minutes
after arrival the patient has become hypotensive
again.
208 Diagnostic imaging in critical care

REFERENCES Klahr S. Chapter 25: Urinary tract obstruction. In: Schrier

Balthazar EJ, Robinson DL, Megibow AJ, et al. Acute RW, ed. Diseases of the kidney & urinary tract. 8th
pancreatitis: Value of CT in establishing prognosis. edn. Philadelphia: Lippincott, Williams and Wilkins;
Radiology 1990; 174(2): 331-6 2007: 689-716
Barozzi L, Valentino M, Santoro A, et al. Renal ultrasonog­ Knechtle SJ, Davidoff AM, Rice RR Pneumatosis intesti-
raphy in critically ill patients. Crit Care Med 2007; nalis: surgical management and clinical outcome. Ann
35(5 Suppl): S198-205 Surg 1990; 212(2): 160-5
Batke M> Cappell MS. Adynamic ileus and acute colonic Kulkarni S, Jayachandran M, Davies A, et al. Non-dilated
pseudo-obstruction. Med Clin North Am 2008; 92(3): obstructed pelvicalyceal system. Int J Clin Pract 2005;
649-70 59(8): 992-4
Curtin KR, Fitzgerald SW, Nemcek AA, et al. CT diag­ Matsumoto S, Mori H, Okino Y, et al. Computed tomo­
nosis of acute appendicitis: Imaging findings. Am J graphic imaging of abdominal volvulus: pictorial
Roentgenol 1995; 164(4): 905-9 essay. Can Assoc Radiol J 2004; 55(5): 297-303
Dahnert W, ed. Radiology review manual. 6th edn. Moore CJ, Corl FM, Fishman EK. CT of cecal volvulus:
Philadelphia: Lippincott Williams and Wilkins; 2007 Unraveling the image. Am J Roentgenol 2001; 177(1):
Dodds WJ, Darweesh RM, Lawson TL, et al. The retroperi­ 95-8
toneal spaces revisited. Am J Roentgenol 1986; 147(6): Nicolaou S, Kai B, Ho S, et al. Imaging of acute small-bowel
1155-61 obstruction. Am J Roentgenol 2005; 185(4): 1036-44
Jain RK, Jain M, Rajak CL, et al. Imaging in acute appen­ Tinkoff G, Esposito TJ, Reed J, et al. American association
dicitis: a review. Indian J Radiol Imaging 2006; 16(4): for the surgery of trauma organ injury scale I: spleen,
523-32 liver, and kidney, validation based on the national
Khan AN, MacDonald S, Chandramohan M. trauma data bank. J Am Coll Surg 2008; 207(5):
Pneumoperitoneum, emedicine. In Lamki N, Coombs 646-55
BD, Gay SB, Krasny EM, Lin EC. eds. WebMD: Yasuda H, Takada T, Kawarada Y, et al. Unusual cases of
2008. Available: http://emedicine.medscape.com/ acute cholecystitis and cholangitis: Tokyo guidelines. J
article/372053-overview; accessed 7 May 2009 Hepatobiliary Pancreat Surg 2007; 14(1): 98-113
Kimura Y, Takada T, Kawarada Y, et al. Definitions, Yoon W, Jeong YY, Kim JK, et al. CT in blunt liver trauma.
pathophysiology, and epidemiology of acute cholangi­ Radiographics 2005; 25(1): 87-104
tis and cholecystitis: Tokyo guidelines. J Hepatobiliary Young JW, Resnik CS. Fracture of the pelvis: Current con­
PancreatSurg 2007; 14(1): 15-26 cepts of classification. Am J Roentgenol 1990; 155(6):
Kirkpatrick AW. Clinician-performed focused sonography 1169-75
for the resuscitation of trauma. Crit Care Med 2007; Young JW, Burgess AR, Brumback RJ, et al. Pelvic frac­
35(5 Suppl): SI62-72 tures: Value of plain radiography in early assessment
and management. Radiology 1986; 160(2): 445-51
210 Diagnostic imaging in critical care
3 • Head 211
Basal ganglia and thalamus
APPLIED ANATOMY The components of the basal ganglia are the cau­ Maxillary sinus
Ethmoid sinuses
Structures seen on cranial CT scan date nucleus and the lentiform nucleus (consisting Middle cranial
of the putamen and globus pallidus). The caudate fossa
(Figure 3.1) nucleus lies lateral to the anterior horn of the lat­ Sphenoid sinus
eral ventricle and is separated from the lentiform
Brainstem nucleus by the anterior limb of the internal cap­
The brainstem consists of the medulla oblongata, sule. The lentiform nucleus is closely applied to the Prepontine
pons and midbrain. The internal structure of the lateral aspect of the internal capsule. cistern__
brainstem is poorly seen on CT because of the The thalamus lies lateral to the third ventricle. It Medulla
beam-hardening artefact (seen as linear streaks and oblongata
is separated from the lentiform nucleus by the pos­ Cerebellopontine
bands) caused by the adjacent petrous bones. As terior limb of the internal capsule (Harnsberger, cistern --------------
the midbrain passes through the tentorial hiatus, 2006). Pons
it lies posteromedial to the uncinate process of the
temporal lobe (uncus). With intracranial hyper­ White matter structures
4th ventricle
tension, the uncus may herniate, compressing the Fibres pass between the brainstem and the cortex Foramen Mastoid
midbrain. magnum air cells
in the internal capsule and optic radiation. They Cerebellum
diverge to form a radiating white matter mass, the
CSF spaces corona radiata, which lies lateral to the lateral ven­
Posterior
The basal cisterns are expansions of the subarach­ cranial fossa
tricles (Harnsberger, 2006). Frontal sinus Suprasellar cistern
noid space at the base of the brain and around In the centre of each cerebral hemisphere, above (contains circle of Willis)
the brainstem. The suprasellar cistern is superior the level of the lateral ventricle, lies a mass of white Pituitary fossa
Sylvian
to the pituitary gland and anterior to the mid­ matter, known as the centrum semiovale. The cor­ fissure
Basilar
brain. The quadrigeminal cistern lies posterior to pus callosum connects the cerebral hemispheres. artery,
the midbrain. The ambient cistern wraps around It forms the roof of the lateral ventricle and the
the pituitary gland and midbrain, connecting the anterior wall of the anterior horns of the lateral
suprasellar and quadrigeminal cisterns. The pre- ventricles (Nakano, 1995). Uncus
pontine cistern lies directly anterior to the pons,
Temporal horn
and the paired cerebellopontine cisterns lie antero­ Lobes of the brain (Figure 3.2) lateral ventricle
lateral to the pons and anterior to the adjacent part To identify the boundaries of the lobes, the central
of the cerebellum. The premedullary and cerebel­ sulcus and the Sylvian fissure should be sought. The
lomedullary cisterns have a similar relationship to central sulcus is best identified on sagittal images,
the medulla oblongata and adjacent cerebellum. and on axial images it is identified in the superior Ambient
The cisterna magna lies posterior to the medulla cuts. It is the longest and most prominent sulcus Pons cistern
oblongata, anterior to the occipital bone, and infe­ and lies in the posterior half of the image. In older
rior to the cerebellar vermis (Harnsberger, 2006). people with some cerebral atrophy, it is usually eas­ Basal Caudate nucleus Midbrain
Within the foramen magnum, the medulla ily seen, but in young people, it may not be visible. ganglia Lentiform j Anterior horn Quadrigeminal
oblongata is separated from the occipital bone by The Sylvian fissure is usually easily seen in both age nucleus lateral ventricle cistern
cerebrospinal fluid within the cisterna magna. The
groups. Anterior part of
cerebellar tonsils are not normally seen at this level. The frontal lobe is the anterior part of the cere­ corpus callosum
If there is intracranial hypertension (or a Chiari bral hemisphere and rests in the anterior cranial Sylvian fissure Lateral
malformation) the tonsils may herniate down into fossa. It lies in front of the central sulcus and above ventricle
Internal
the foramen magnum and appear posterolateral to the Sylvian fissure. The temporal lobe rests in the capsule
the medulla oblongata. Intracranial hypertension middle cranial fossa and lies below the Sylvian fis­ Corona
may also efface or obliterate the basal cisterns. sure, which separates it from the frontal lobe. Deep radiata
The ventricular system consists of the fourth to the Sylvian fissure, adjacent to the frontal and
ventricle, which lies between the pons/medulla temporal lobes is the insula. The occipital lobe is
oblongata and the cerebellum, the slit-like third the posterior part of the cerebral hemisphere and
ventricle, and the paired lateral ventricles. The third rests on the tentorium cerebelli. The parietal lobe 3rd ventricle
and fourth ventricles communicate via the cere­ lies posterior to the central sulcus, which separates
bral aqueduct, while the third and the two lateral it from the frontal lobe, and anterior to the pari­
ventricles communicate by the Y-shaped interven­ etooccipital sulcus, which separates it from the
tricular foramen of Monro. Each lateral ventricle Optic '
occipital lobe. radiation Occipital horn
has a body, an anterior horn an occipital horn, and lateral ventricle Posterior part of
a temporal horn. Dilatation of the temporal horn is Thalamus
corpus callosum
an early sign of hydrocephalus.
F|GURE 3.1 Structures seen on cranial CT scan.
212 Diagnostic imaging in critical care 3- • Head 213

^°ntal ,obe ; central sulcus Anterior choroidal arteries

" Anterior cerebral arteries
- - Parietal lobe Sylvian fissure
Occipital lobe * *1%% parieto-occipital sulcus ------------- Middle cerebral arteries
Posterior cerebral arteries
■: > Insular cortex
=== : Other areas supplied by the posterior circulation
Temporal lobe

figure 3.3 Vascular supply of the brain. Adapted from Moeller and Reif, 2000.
FIGURE 3.2 Lobes of the brain. Adapted from Moeller and Reif, 2000.

Vascular territories (Figure 3.3) the anterior circulation. The vertebral arteries join are joined by two posterior communicating arter­ The commonest distribution is described here
to form the basilar artery. The branches of the ver­ ies (PCOM), one of which passes from the carotid (Carpenter, 1991; Berman, 1980; Hayman, 1981;
The brain in entirely supplied by blood from
branches of the two vertebral and two carotid arter­ tebral and basilar arteries give rise to the posterior artery to the posterior cerebral artery on each side, Berman, 1984).
circulation. The anterior and posterior circulations lhe distribution of blood supply is highly variable.
ies. The branches of the carotid artery give rise to
214 Diagnostic imaging in critical care

Anterior circulation Posterior circulation

The intracranial branches of the carotid artery that Each of the two vertebral arteries gives rise to an
supply the brain are the posterior communicating anterior and posterior spinal artery (which join
artery, the anterior choroidal artery, and its two ter­ with the corresponding vessel from the other side),
minal branches: the middle cerebral artery (MCA) and a posterior inferior cerebellar artery. The basi­
and the anterior cerebral artery (ACA). lar artery gives rise to the superior and anterior
The anterior choroidal artery supplies the inferior cerebellar arteries. These vessels supply
amygdala in the temporal lobe, the ventrolateral the medulla oblongata, pons and midbrain, as do
part of the thalamus, the posterior limb of the smaller branches of the vertebral and basilar arter­
internal capsule and the most rostral part of the ies. The cerebellar vessels supply the corresponding
midbrain. parts of the cerebellum.
The MCA supplies the lateral and superior sur­ The terminal branches of the basilar artery are
face of the cerebral hemisphere, except for a strip the two posterior cerebral arteries. On each side,
over the vertex (supplied by ACA), the occipital the posterior cerebral artery (PCA) supplies the
pole and inferomedial temporal lobe (supplied by occipital poles and most of the undersurface of the
PCA). The lateral lenticulostriate branches of the temporal lobe except for its tip, which is supplied
MCA supply most of the lentiform nucleus and the by the MCA. Branches of the PCA supply the mid­
superior aspect of the internal capsule. brain and most of the thalamus.
The ACA supplies the medial hemispheric With the exception of the most rostral part of the
surface except for the occipital lobe. The medial midbrain, the entire blood supply for the medulla
lenticulostriate branches of the ACA supply the oblongata, pons, midbrain and cerebellum comes
caudate nuclei, the anteromedial aspect of the len­ from the posterior circulation.
tiform nucleus and the anterior limb of the internal
capsule. The ACAs are joined by the anterior com­ Watershed areas
municating artery. Vascular watershed areas exist at the boundary of
the main arterial territories (MCA, PCA and ACA).
These areas are vulnerable to hypoperfusion dur­
ing hypotensive episodes.
 3 • Head 217
216 Diagnostic imaging in critical care

A
1. There is a large hyperdense extra-axial col­ No fractures are identified on the image in the
lection in the right frontal region. It is convex book, though a small temporal fracture can be
towards the brain substance, an appearance seen on the DVD images.
typical of an extradural haematoma. The het­
erogeneous density within the lesion suggests 2. Urgent surgical evacuation of the extradural
acute and ongoing bleeding. There is signifi­ haematoma.
cant midline shift, with subfalcine herniation.

Learning point
Identifying mass lesions that need urgent surgical
evacuation is the main reason for performing CT
head scans in severe head injuries.

While intoxicated with alcohol, this 21-year-old

1. What are the findings on the CT scan?
man jumped off a roof. His GCS was 13 on pre­ 2. What intervention is required?
sentation, but fell to 8 prior to intubation.
 3 • Head 219
218 Diagnostic imaging in critical care

PROBLEM 3.02 A
There is a large right-sided hyperdense extra-axial midline shift. There is a haemorrhagic cerebral
collection, concave towards the brain substance, contusion underlying the haematoma. The left-
an appearance typical of an acute subdural hae­ sided soft tissue swelling over the occipital region
matoma. There is significant mass effect. The suggests a coup-contrecoup injury.
ipsilateral ventricle is compressed and there is

Learning point
The age of an intracranial haemorrhage can be is ongoing active bleeding, it may be heterog­
estimated by its appearance (Osborn, 2004). enous, which is known as the “swirl sign” (see
Unclotted blood is hypodense. Clotted blood is extradural in Problem 3.01).
initially hyperdense, but gradually becomes less • A subacute haemorrhage (3 days to 3 weeks) is
dense over several weeks as the blood compo­ isodense to the cerebral parenchyma and is the
nents break down. most difficult to see.
• A “hyperacute” haemorrhage (< 6 hours) has • A chronic haemorrhage that has not resorbed
a significant hypodense component, due to is hypodense to the brain, and may reach CSF
unclotted blood. A fluid level may develop as density. When new hyperdensity is present
the cellular and serous components separate. within such a collection it suggests acute-on-
• An acute haemorrhage (6 hours to 3 days) is chronic haemorrhage (see Problem 3.03).
typically homogeneously hyperdense. If there

This 51-year-old woman fell down stairs and QCT scan.

struck her head. Her GCS was 6 when the para­
medics arrived.
 3 • Head 221
220 Diagnostic imaging in critical care

PROBLEM 3.03 A
There is a large right-sided hypodense extra-axial the collection, suggesting some acute-on-chronic
collection, concave towards the brain substance. component. The ventricular system is promi­
This appearance is typical of a chronic subdural nent, but there appears to be generalised cerebral
haematoma. There is significant mass effect, with atrophy. Furthermore, the temporal horns are
effacement of the ipsilateral sulci, compression of not dilated and the basal cisterns are not effaced,
the ipsilateral ventricle and midline shift. which both argue against hydrocephalus.
There is a small hyperdense component within

Learning point
Dilated ventricles are not always due to
hydrocephalus.
 3 • Head 223
222 Diagnostic imaging in critical care

PROBLEM 3.04 A
1. The scans show extensive subarachnoid haem­ 2. Hydrocephalus and cerebral oedema. There
orrhage with an intraventricular component. is reduced grey-white differentiation and the
The 3D reconstruction of the CT angiogram image at the level of the foramen magnum
shows two aneurysms, one on the left middle shows herniation of the cerebellar tonsils.
cerebral artery near its trifurcation and the
other at the tip of the basilar artery.

Learning point
One of the early signs of hydrocephalus is that becoming crescentic rather than having their nor-
the temporal horns of the lateral ventricles dilate, mal slit-like appearance.

This 42-year-old
at home woman was found unconscious
by her daughter. 1« What is the cause of the patient s condition.
2. What complications have occurred?
 3 • Head 225
224 Diagnostic imaging in critical care

A
1. There is hyperdensity in the left thalamus and 2. The size of the thalamic haemorrhage has
posterior limb of the internal capsule, consis­ increased and there is intraventricular exten­
tent with a small acute thalamic haemorrhage. sion. Transtentorial uncal herniation is seen,
denoted by compression of the ipsilateral
cerebral peduncle by the medial aspect of the
temporal lobe. Significant hydrocephalus is
also present.

Learning point
Predisposing factors for thalamic bleeds include
hypertension and anticoagulant therapy.

This 65-year-old woman presented with mild

1. What caused the initial hemiparesis?
right hemiparesis and a GCS of 15 (images a 2. Why has the clinical deterioration occurred?
and b). Forty-eight hours later, her GCS fell to 5
(images c and d).
 3 • Head 227
226 Diagnostic imaging in critical care

PROBLEM 3.06 After a sudden onset of headache at work, this

26-year-old man rapidly became unconscious.
Q K
What pathological process does the scan
demonstrate?

A
There is a large haematoma within the left frontal shows an arteriovenous malformation, arising
lobe, with significant mass effect producing mid­ from the anterior cerebral vessels.
line shift. There is extension of the haemorrhage
into the ventricular system. CT angiography

Learning point
CT angiography should be considered when the which other forms of angiography are compared,
initial CT study shows non-traumatic intracranial CT angiography using the modern generation of
haemorrhage. While digital subtraction angiog­ scanners performs almost as well as DSA and is
raphy (DSA) is still the “gold standard” against relatively non-invasive.

3D CT angiogram
CT angiogram
MIPS
 ■3 • Head 229
228 Diagnostic imaging in critical care

PROBLEM 3.07 A
There is a hyperdense area in the right cerebellar A history of predisposing factors for cerebellar
hemisphere, representing an acute haemorrhage. haemorrhage, such as hypertension and anti­
There is intraventricular extension, with blood coagulant therapy, should be sought. Trauma is
seen in the dependent areas of the ventricular sys­ unlikely with this pattern of haemorrhage.
tem, and moderate hydrocephalus.

Learning point
Posterior fossa haemorrhage may cause hydro­ need decompression with an external ventricu­
cephalus by either directly compressing CSF lar drain but, in the presence of posterior fossa
outflow from the ventricles or by extending into hypertension, there is a risk of ventricular decom­
the ventricular system, leading to obstruction of pression producing transtentorial herniation of
CSF outflow by blood. The hydrocephalus may posterior fossa contents (“reverse coning”).

This 69-year-old man complained of a severe Q

headache. The level of consciousness fell rapidly What is the cause of the clinical picture?
and his GCS was 6 by the time he arrived in the
emergency department.
230 Diagnostic imaging in critical care . 3 • Head 231

PROBLEM 3.08 A
There are bilateral hypodense areas in the lenti- appearance, typical of the basal ganglia infarction
form nuclei. This gives a characteristic “owl’s eyes” caused by hypoxia.

Learning point
The basal ganglia are particularly sensitive to
hypoxia. Severe hypoxia may cause basal ganglia
infarction.

This 38-year-old man had an unexpectedly dif­

ficult airway to intubate during induction of What significant abnormality is present on this
anaesthesia for elective surgery. There was a CT scan?
prolonged period of severe hypoxia. Forty-eight
hours later, he was agitated and confused when
sedation was ceased.
 3 • Head 233
232 Diagnostic imaging in critical care

PROBLEM 3.09 A
There is hypodensity within the occipital lobe and artery territory infarction. There is also a separate
the inferior and medial parts of the right temporal area of hypodensity within the left parietal lobe.
lobe. This is typical of a right posterior cerebral

Learning point
Infarction in the territory of the distal posterior
cerebral artery often causes homonymous hemi-
anopia without hemiparesis (Smith, 2005).

This 54-year-old
ing aortic valve replacement. On to
man was slow wake follow-
examination, he Q.
Which vascular territory is affected?
appears to be moving all limbs symmetrically.
 3 • Head 235

A
There is hypodensity of the medial aspect of the immediate postoperative period, the problem is
left frontal and parietal lobes. This pattern is typi­ likely to be vasospasm rather than a misplaced
cal of anterior cerebral artery territory infarction. clip. There is also a small area of hypodensity on
As the clinical features were not present in the the medial aspect of the right frontal lobe.

Learning point
With an anterior cerebral artery territory infarct,
leg weakness is often the predominant feature
(Smith, 2005).

Five days ago, this 3 2-year-old woman had a What is the likely cause of this clinical picture?
grade I subarachnoid haemorrhage. The next day,
an anterior communicating artery aneurysm was
clipped. Weakness developed in her right leg 48
hours ago. Today, she has become progressively
obtunded.
 3 • Head 237
236 Diagnostic imaging in critical care

A
Over most of the left hemisphere, there is a subtle of the basal cisterns and herniation of the cer­
hypodensity with complete loss of grey-white ebellar tonsils into the foramen magnum. These
differentiation. The occipital lobe, and the medial findings are consistent with a left middle cere­
part of the frontal and parietal lobes are spared. bral artery territory infarct with significant mass
There is evidence of mass effect and intracranial effect.
hypertension including: midline shift, obliteration

Learning point
CT features suggesting elevated intracranial pres­ The features of uncal herniation are:
sure include: • shift of the brainstem and distortion of adja­
• effacement of basal cisterns cent cisterns
• loss of grey-white differentiation • dilation of contralateral temporal horn
• loss of sulci • compression of the posterior cerebral artery
• midline shift as it crosses the tentorium, causing a posterior
• herniation of cerebellar tonsils into the fora­ cerebral artery territory infarct (Osborn, 2004)
men magnum
• uncal herniation

Forty-eight hours ago, this 58-year-old woman Are there any findings on this scan that could
had a mitral valve repair. Off sedation, she has
a GCS of 7 (E2, VI, M4) and is not moving her explain the clinical features?
right arm or leg in response to pain.
 3 • Head 239
238 Diagnostic imaging in critical care

PROBLEM 3.12 A
There is generalised cerebral atrophy, consistent do not explain the clinical picture. No cause for
with advancing age. A small area of hypodensity the altered level of consciousness is evident on
is present in the region of the right corona radi- this CT scan. Sedation often has prolonged effects
ata. On the DVD, it is seen to extend into the basal in the elderly.
ganglia. This is a lacunar infarct. These findings

Learning point cerebral arteries and are particularly common in

Lacunar infarcts are small, deep subcortical elderly patients with hypertension and diabetes,
infarcts less than 1.5 cm in size. They usually occur which are associated with severe atherosclerosis
in the basal ganglia, thalamus, internal capsule, of small vessels and small vessel cerebral dis­
corona radiata and brainstem. They are caused by ease. Lacunar infarcts are often asymptomatic
occlusion of deep penetrating branches of major (Norrving, 2008).

This 68-year-old
injuries sustained
manfrom
when he fell chest
a ladder. was limb
He and slow Q
What is the likely cause of this clinical picture?
to wake when sedation was withdrawn.
 3 • Head 241
in critical care

PROBLEM 3.13 One week ago, this 38-year-old man was stabbed
in the groin, sustaining a lacerated femoral artery
Q
Are there any findings on this scan that could
that required emergency repair because of exsan­ explain the clinical features?
guinating haemorrhage. He now has resolving
acute renal failure. Sedation was ceased 48 hours
ago, but he is still unresponsive. There are no
localising signs.

A
There are multiple bilateral hypo dense lesions areas between the territories of the major vessels,
involving both the grey and subcortical white but not exclusively so.
matter. They are predominantly in watershed

Learning point
Prolonged severe hypotensive insults- may result 2. Internal border zone infarctions between the
in watershed infarcts. territory of the penetrating arteries arising
Watershed infarcts occur in areas with rela­ from the superficial pial plexus and the terri­
tively poor blood supply, at the boundary between tory of the deep penetrating arteries arising
the territories of cerebral arteries. Two forms of from the basal cerebral arteries. These infarcts
watershed infarction may occur: lie in the corona radiata and the centrum
1. Cortical border zone infarctions between the semiovale adjacent to the lateral ventricles
territories supplied by the anterior, middle, (Bladin, 1993).
and posterior cerebral arteries.
 3 • Head 243
242 Diagnostic imaging in critical care

PROBLEM 3.14 A
There is a well-circumscribed, hyperdens e mass There is homogeneous contrast enhancement of
adjacent to the falx cerebri (dural based), with a the mass. These findings are highly suggestive of
small area of calcification. There is no significant a meningioma.
mass effect and minimal surrounding oedema.

Learning point
New onset epilepsy often has a structural intrac­
ranial cause. It requires investigation with CT and,
if no diagnosis is apparent on CT, with MRI.

This 69-year-old
a prolonged manseizure.
epileptic was admitted to ICU
There was after
no previ- Q
Why does this patient have epilepsy?
ous history of seizures.
 • 3 • Head 245
244 Diagnostic imaging in critical care

PROBLEM 3.15 A
There is a large, left-sided, mixed-density fronto­ uncinate process of the temporal lobe displacing
temporal lesion with variable enhancement and the brainstem to the right. Contralaterally, there is
extensive surrounding vasogenic oedema. There obstructive dilatation of the lateral ventricle. The
is significant mass effect with midline shift. On appearances of the lesion are most suggestive of a
the side of the lesion, there is sulcal effacement, primary malignant brain tumour, such as a glio­
effacement of the lateral ventricle, subfalcine blastoma multiforme.
herniation and transtentorial herniation of the

Learning point
Patterns of brain herniation include (Ropper, There are two types of cerebral oedema (Osborn,
2005): 2004):
• uncal transtentorial herniation: the uncinate 1. cytotoxic: intracellular oedema caused by cell
process of the temporal lobe herniates into the swelling with an intact blood-brain barrier.
anterior part of the opening of the tentorium Cytotoxic oedema affects predominantly grey
cerebelli. matter, with subsequent loss in the grey-white
• central tentorial herniation: there is symmet­ matter differentiation. It generally accompa­
rical downward movement of the thalamic nies stroke and hypoxia and gives a pattern of
region through the opening of the tentorium “restricted diffusion” on MRI sequences (see
cerebelli. - • Chapter 6: Imaging modalities, p 375).
• subfalcine herniation: there is displacement of 2. vasogenic: extracellular oedema caused by
the cingulate gyrus under the falx and across loss of integrity of the blood-brain barrier.
the midline. Vasogenic oedema predominantly affects white
• foraminal herniation: there is downward herni­ matter and spreads along white matter tracts,
ation of the cerebellar tonsils into the foramen accentuating the grey-white matter differen­
magnum. tiation. It generally accompanies inflammatory
disease and brain tumours. It does not give
a pattern of “restricted diffusion” on MRI
sequences.
 3 -• Head 247
246 Diagnostic imaging in critical care

PROBLEM 3.16 A
1. Otitis media and mastoiditis resulting in Image c shows a hypodense lesion adjacent
subdural empyema. Image a shows the right to the tentorium cerebelli, while image d shows
external auditory canal and middle ear filled rim enhancement of the lesion with contrast.
with fluid. The right mastoid bone is eroded,
suggesting the presence of mastoiditis. Image 2. Management should include antibiotics,
b shows a fluid-filled middle ear and erosion myringotomy and debridement of the affected
of the tegmen tympani (bony plate divid­ area of the mastoid, with drainage of the sub­
ing middle ear from cranial cavity), which is dural empyema.
pathognomonic of cholesteatoma.

Learning point
Examination of the ears is an important part of
assessing the patient with an altered level of con­
sciousness, especially if there is clinical suspicion
of sepsis.

This 17-year-old woman was brought to me 1. What is the likely cause of this illness?
emergency department by her mother. On exami­ 2. Outline the important aspects of manage­
nation, she was febrile and confused.
ment.
248 Diagnostic imaging in critical care

This 76-year-old man presented with fever, M

neutrophil leukocytosis and an altered level of What does the scan demonstrate?
consciousness. There were no focal neurological
signs.
 3 • Head 249

A
There is a ring-shaped hyp er dense lesion in the enhances with contrast. This is consistent with a
right periventricular white matter. The lesion rim cerebral abscess.

Learning point
Common causes for a rim-enhancing lesion parenchyma, such as glioma, and infections (e.g.
are cerebral abscess, tumours of the brain toxoplasmosis).
250 Diagnostic imaging in critical care

PROBLEM 3.18

This 53-year-old man sustained severe chest J

trauma in a motor vehicle crash. There was pro- What does the scan demonstrate?
longed entrapment at the scene. The GCS is 3
despite minimal sedation.
 3 • Head 251

A
There is generalised loss of grey-white differ­ septum pelhicidum is present. This is a congenital
entiation, consistent with cerebral oedema. The variant where the septum pellucidum is a cystic
basal cisterns are not effaced and there is no ton­ structure containing CSF; it is seen best in the
sillar herniation. An incidental finding of a cavum DVD images.

Learning point
Significant hypoxic cerebral damage can be pres- abnormality on an acute CT scan is diffuse cere-
ent with an initially normal scan. The commonest bral oedema.
 3 • Head 253
252 Diagnostic imaging in critical care

A
There are mixed-density lesions in the left frontal level in a sinus may indicate an occult fracture. A
and temporal lobe, consistent with cerebral con­ small area of calcification is seen anterior to the
tusions. There is no significant mass effect. There quadrigeminal cistern, adjacent to the midbrain.
is a fluid level in the right maxillary sinus, but no This is consistent with pineal gland calcification.
fracture is seen. In the context of trauma, a fluid

Learning point
Frontal and temporal lobes are common sites of
traumatic contusions.

This 25-year-oid man was punched in the face What intracranial pathology is shown on th
during an altercation at a nightclub. He was
intubated because of agitation and confusion. scan?
 ’3 • Head 255
254 Diagnostic imaging in critical care

PROBLEM 3.20 A
There are multiple, small hyperdense lesions, There is a fracture of the lateral wall of the right
predominantly within the white matter and the maxillary sinus, with an associated fluid level in
grey-white junction. These are petechial haemor­ the sinus (haemosinus).
rhages, consistent with diffuse axonal injury.

Learning point
Diffuse axonal injury is suggested by multiple in the acute phase (Osborn, 2004). MRI scan­
petechial haemorrhages on the CT scan, classically ning is not without risk in the critically ill patient.
at the grey-white interface, along the corpus cal­ This risk must be balanced against the likelihood
losum and within the white matter. MRI will give of the information from the MRI providing real
better information about the extent and nature of clinical benefit.
the injury, but is unlikely to change management

This 23-year-old man crashed his motorbike at

What injuries are identified on the scan?
high speed. He had a GCS of 5 at the scene.
256 Diagnostic imaging in critical care

This 65-year-old man was the unrestrained driver

in a high-speed motor vehicle crash. Describe the facial fractures.
 • Head 257

A
There are extensive facial fractures. The fractures and the right side of the frontonasal junction is
pass through the pterygoid process bilaterally, disrupted. There is also a sagittal fracture of the
extending horizontally through the walls of the hard palate. These findings are in keeping with a
maxillary sinuses and into the lateral margins of LeFort I fracture bilaterally and a LeFort II frac­
the nasal aperture bilaterally. On the right side the ture on the right. On the images in the book, the
inferior orbital rim is fractured and this extends right globe of the eye does not look entirely nor­
into the anteromedial orbital wall. The frontal mal. The axial brain images on the DVD confirm
process of the maxilla is fractured on the right that the globe is ruptured.

Learning point
A LeFort fracture has two components (Jeffrey, anterolateral wall of the nasal fossa, the medial
2007). Firstly, there must be disruption of the and lateral walls of the maxillary sinus, and the
pterygomaxillary junction with fractures of the nasal septum are fractured. The characteris­
pterygoid processes and/or pterygoid plates. tic feature separating this type from the other
Secondly, there must be discontinuity between the LeFort types is a fracture of the lateral margin
skull and portions of the face (maxilla), which is of the nasal aperture.
usually manifest clinically by mobility of the face. • Type II: the fracture separates the midface
Other maxillary fractures that may be confused from the skull and is the commonest of the
with LeFort fractures include zygomaticomaxil­ three types. The inferomedial orbital rim, the
lary complex fractures, nasoethmoid fractures and anteromedial orbital wall and the frontonasal
midface smash fractures. These fracture patterns junction are fractured. The characteristic fea­
do not involve the pterygoid processes or plates, ture of type II is a fracture of the inferior orbital
unless there is a coexisting LeFort fracture, but rim.
this combination is common. Isolated pterygoid • Type III: the fracture separates the entire face
plate avulsion may occur with severe mandibular from the skull and is the least common type.
trauma. The frontonasal junction, the medial and lat­
LeFort fractures may be (Jeffrey, 2007): eral orbital walls and the zygomatic arches are
• Type I: the fracture is horizontally oriented, fractured.
separating the palate and maxillary alveolus Combinations of more than one type of LeFort
from the remainder of the face and skull. The fracture are common.
258 Diagnostic imaging in critical care

PROBLEM 3.22

T2 FLAIR T2 FLAIR

T2 FLAIR
 - 3 • Head 259

This 75-year-old man was admitted to the ICU ( )

with low grade fever, an altered level of conscious­ What diagnosis does the scan suggest?
ness and repeated seizures.

A
The T2-weighted images show increased signal shows increased signal in the affected area. It
(whiter areas) within the right temporal lobe, is more typical that herpes encephalitis shows
extending into the insula and frontal lobe inferi­ reduced signal (restricted diffusion), particularly
orly. There is reduced signal in these areas in the in the early stages. However, the pattern is vari­
T1-weighted images. The lesion does not enhance able and the finding of increased ADC signal does
with contrast. These findings are strongly sugges­ not rule out the diagnosis in the presence of other
tive of herpes encephalitis. typical features.
The apparent diffusion coefficient (ADC) map

Learning point
MRI is the imaging technique of choice for herpes patchy gyral or cisternal contrast enhancement
encephalitis. Typically with herpes encephalitis, may occur. Diffusion weighted imaging may be
there is a hyper intense T2 signal in the tempo­ more sensitive for early herpes than T2-weighted
ral lobes, inferior frontal lobes and insula. It has images (Dahnert, 2007).
a predilection for the medial temporal lobes and See Chapter 6: Imaging modalities, p 375 for
the basal ganglia are usually spared. The T1 sig­ further explanation of terms used.
nal is hypointense, consistent with oedema. Mild
260 Diagnostic imaging in critical care

PROBLEM 3.23
 3 • Head 261

This 46-year-old woman presented with quadri­

paresis and respiratory failure. One year ago, she
Q
What pathological process is demonstrated in
developed severe weakness in her right arm that these images?
resolved over a period of two months.

A
There are multiple areas of increased intensity suggestive of multiple sclerosis. For this patient,
on the T2-weighted and the T2-FLAIR images in dissemination in time is demonstrated by the two
the cerebral white matter and the spinal cord. In attacks and dissemination in space is demon­
this clinical context, these findings are strongly strated by the MRI.

Learning point
To diagnose multiple sclerosis, there must be at perpendicular to the ventricles. They involve
least one clinically apparent neurological distur­ regions such as the corpus callosum and the cer­
bance consistent with the multiple sclerosis and ebellar peduncles. They show well in T2-weighted
evidence that the disease process is disseminated images. When gadolinium enhancement is pres­
in both space and time. This evidence may be clin­ ent, this suggests active inflammation (Dahnert,
ical or based on MRI findings (Polman, 2005). 2007).
The lesions in multiple sclerosis are character­ See Chapter 6: Imaging modalities, p 375 for
istically adjacent to the ventricles and oriented further explanation of terms used.
 3 • Head 263
262 Diagnostic imaging in critical care

PROBLEM 3.24 A
The cerebellar tonsils extend well below the level oblong hypointense lesion within the spinal cord;
of the foramen magnum and have an elongated consistent with hydromyelia (dilatation with CSF
pointed shape. The fourth ventricle is corre­ of the central canal of the cord). These features
spondingly elongated. At the C2 level, there is an are in keeping with a Chiari 1 malformation.

Learning point
With a Chiari 1 malformation, the following find­ The most reliable diagnostic criterion is her­
ings may be observed on MRI: niation of the cerebellar tonsils by at least 5 mm
• displacement of the cerebellar tonsils below the below the foramen magnum, in the absence of an
level of the foramen magnum intracranial mass lesion (Dahnert, 2007).
• pointed and/or peg-like tonsils The level of the foramen magnum is measured
• narrow posterior cranial fossa on the sagittal T1 image. It is defined as a line
• elongation of the fourth ventricle, which between the front. (basion) and the back (opis-
remains in the normal position thion) of the foramen magnum. The signal of
• hindbrain abnormalities cortical bone, not marrow, must be used to define
• obstructive hydrocephalus these landmarks.
• associated abnormalities such as syringomy­
elia or hydromyelia and skeletal abnormalities
(Dahnert, 2007)

This 48-year-old woman suffered from episodes What disease process is suggested by the image?
of syncope for two weeks. During a syncopal epi­
sode in the emergency department, she became
apnoeic and required manual ventilation by
facemask.
 3 • Head 265
264 Diagnostic imaging in critical care

This 59-year-old woman had a rapid onset of v*

quadriparesis. A CT scan of her head and cervi- Why has this patient become quadriparetic?
cal spine was normal. A provisional diagnosis of
Guillaine-Barre syndrome has been made.

A
On the T2-FLAIR image, there are multiple areas The other clue to the pathology is the absence
of increased intensity within the pons and mid­ of a flow void in the basilar artery, which appears
brain. On the diffusion weighted image, these hyperintense on the FLAIR sequence. This is
same areas are of increased intensity while, on the strongly suggestive of basilar artery thrombosis,
apparent diffusion coefficient map, they appear either as a primary event or secondary to dissec­
hypointense. This is a pattern of reduced diffu­ tion or embolism. This could be confirmed with
sion, suggesting cytotoxic oedema from acute MR angiography.
ischaemia in these areas. On the DVD images, See Chapter 6: Imaging modalities, p 375 for
there are other similar areas consistent with acute further explanation of terms used.
posterior circulation ischaemia.

Learning point
CT has a low sensitivity for brainstem ischae- swelling, sulcal effacement and loss of grey-white
mic events because of the high incidence of differentiation. MRI has a high sensitivity and
bone-related artefact in the posterior fossa and specificity for detecting this disease process,
inability to elicit ancillary signs such as cerebral
 3 • Head 267
266 Diagnostic imaging in critical care

A
There is abnormal T2 signal in the left basal in the left middle cerebral artery territory. On the
ganglia and adjacent cortex on the left. On the DWI image, there are some foci of reduced sig­
corresponding areas of the diffusion weighted nal, which suggest some petechial haemorrhage
image (DWI), there is increased signal and, in the within the infarct. This is best seen on the gradi­
apparent diffusion coefficient (ADC) map, there ent echo sequence.
is reduced signal. This suggests acute ischaemia

Learning point
With cerebral ischaemia or acute infarction, there becomes hyperintense. At around 7-10 days, the
is a pattern suggestive of cytotoxic oedema. That ADC map becomes bright, allowing the age of the
is, intensity is high on the DWI and reduced on infarct to be estimated (Rajeshkannan, 2006).
the ADC map before any changes are visible on See Chapter 6: Imaging modalities, p 375 for
T2-weighted images. The T2-signal subsequently further explanation of terms used.

This 42-year-old man developed an acute right What pathological process is suggested by these
hemiplegia. He required mechanical ventilation
after a massive aspiration episode resulted in images?
hypoxaemic respiratory failure.
268 Diagnostic imaging in critical care

PROBLEM 3.27
 3 • Head 269

This 20-year-old woman presented with severe v £

headache and subsequent seizures. What pathological process is demonstrated by
these images?

A
The CT images are hyperdense in the positions of transverse sinus and the right sigmoid sinus. The
the right transverse sinus, superior sagittal sinus MR venogram shows flow defects in the superior
and straight sinus. This suggests thrombosis of sagittal sinus, right and left transverse sinuses,
these vessels. and right sigmoid sinus. The left sigmoid sinus is
The coronal T2 images show normal flow relatively normal. Despite this extensive cerebral
voids in cortical vessels. However, there is abnor­ venous sinus thrombosis, there is no evidence of
mal signal and absence of flow voids in the infarction.
positions of the superior sagittal sinus, the right

Learning point - •
A hyperdense appearance of an artery or vein on MRI is the imaging modality of choice for
non-contrast CT suggests vascular thrombosis. cerebral venous thrombosis. MR venography
Filling defects may be demonstrated on contrast demonstrates flow defects in the affected veins,
enhanced CT. On both Tl- and T2-weighted MRI while the other imaging sequences assess for the
images, the features suggesting arterial or venous presence of venous infarction. Venous infarction
thrombosis are the absence of normal flow voids is characteristically haemorrhagic and does not
and the presence of abnormal signal within the conform to the territories of the arterial supply.
affected vessels.
270 Diagnostic imaging in critical care 3 • Head 271

PROBLEM 3.28 A
The transcranial Doppler (TCD) study three days
The TCD study five days after admission shows
after admission is normal. There is systolic and
a marked increase in the mean flow velocity in the
diastolic flow signal above the baseline (towards MCA (above the baseline). The Lindegaard ratio is
the transducer) from the left MCA. There is simi­ moderately elevated at 5.4. The pulsatility index is
lar flow pattern below the baseline (away from
normal. These findings suggest vasospasm in the
the transducer). With a sample depth of 60 mm MCA. The flow velocity remains normal in both
during a MCA study (temporal window), this the ACA (below the baseline) and the extracranial
indicates that the sample volume is at the bifurca­ internal carotid.
tion of the MCA and ACA, respectively.

Learning point
The Lindegaard ratio (LR) is a parameter derived conditions. In the setting of a high flow veloc­
from TCD recordings. ity, a LR < 3 suggests the problem is hyperaemia,
while a LR > 3 suggests the problem is vasospasm
Lindegaard ratio = (White, 2006).
Mild vasospasm is suggested by a LR of 3-6.
mean velocity in MCA Severe vasospasm is suggested by a mean velocity
mean velocity in ipsilateral extracranial carotid artery in the MCA > 200 cms-1 or a LR > 6. An increase
in systolic velocity > 50 cms’1 over 24 hours
High flow velocities in the MCA (mean velocity predicts the onset of delayed ischaemic deficit
in MCA >120 cms“l) may be due to hyperaemia (White, 2006).
cerebral artery (ACA). Hence, forward flow in the or vasospasm. The LR is used to distinguish these
After having a grade 1 aneurysmal subarachnoid
haemorrhage, this 24-year-old woman developed MCA is above the baseline and forward flow in
a right hemiparesis on day seven after admission. the ACA is below the baseline.
The transcranial Doppler studies shown use a
window in the temporal region to study the left Q
What pathological process is demonstrated by
middle cerebral artery. The sample volume for the
pulse-wave Doppler study is placed at the junction these transcranial Doppler studies?
of the middle cerebral artery (MCA) and anterior
 3 • Head 273
272 Diagnostic imaging in critical care

PROBLEM 3.29 A
There is a “reverberant flow” pattern, in which during diastole and there is no sustainable cere­
there is forward flow during systole and back­ bral perfusion (Moppett, 2004).
ward flow during diastole. This indicates that the
cerebral blood flow during systole is not retained

Learning point
Transcranial Doppler (TCD) is a useful ancil­ circulation. It is normal in vasospasm, but rises
lary investigation in the setting of suspected with elevation in the intracranial pressure. Values
brain death. When the clinical criteria for brain over 1.5 are abnormal.
death cannot be used, TCD may assist with the
Three days after admission timing of definitive studies such as four-vessel Pulsatility index =
angiography.
Site: Basilar artery The pulsatility index (PI) is a parameter derived (Peak systolic velocity - end diastolic velocity)
Depth: 90 mm; Scale: 4000 Hz; Gain: 55°/o
from TCD recordings. The PI is an index of the mean velocity
+ve -ve vascular resistance of the more distal cerebral
Peak velocity (cms-1) 81 51
Mean velocity (cms-1) 13 23
Pulsatility index 6 2.0

This 19-year-old motorcyclist was admitted with a What does this transcranial Doppler study
severe head injury. On day three following admis­
sion, his pupils have become fixed and dilated. demonstrate?
The image shown is from a transcranial
Doppler study, using a window through the fora­
men magnum to study the basilar artery. Forward
flow in the basilar artery is above the baseline.
274 Diagnostic imaging in critical care

REFERENCES Moeller TB, Reif E (eds). Pocket atlas of sectional anat­

Berman SA, Hayman LA, Hinck VC. Correlation of CT omy: CT and MRI. 2nd edn. Stuttgart, Thieme; 2000
cerebral vascular territories with function. I: Anterior Nakano S, Yokogami K, Ohta H, et al. CT-defined large
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253-7
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Hayman LA, Berman SA, Hinck VC. Correlation of CT Cerebrovascular diseases. In: Kasper DL, Braunwald
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276 Diagnostic imaging in critical care 4 • Neck and back 277

Computed tomography (CT) is the preferred

imaging modality for assessment of suspected spi­
nal injuries in critically ill trauma patients, with
supplementary MRI used when spinal cord or
ligamentous injury is suspected. This chapter will
focus on these imaging modalities.

APPLIED ANATOMY
Craniocervical junction
The skull base, atlas (Cl) and axis (C2) form the
craniocervical junction that in conjunction with
associated ligaments, acts as a single functional
unit. Classification of injury is based on anatomi­ FIGURE 4.2 Craniocervical junction: Axial image.
cal site. Injury patterns include occipitocervical AD = Atlantodental space.
dissociation, occipital condyle fracture, atlas frac­
FIGURE 4.3 Craniocervical junction: Coronal views.
ture, atlantoaxial rotatory instability, atlantodens
• no subluxation or widening of the atlanto- CO = Occipital condyle; CO/1 = Atlanto-occiptal joint; Cl /2 = Cl /2 facet joint; C2/3 = C2/3 facet joint; Peg = Odontoid peg; Dashed
instability, odontoid fracture and traumatic spon­ line indicates lateral borders of lateral masses of Cl and C2.
dylolisthesis of the axis (Torretti, 2007). occipital joints
On sagittal CT images (Figure 4.1), check for the • facet joints between C1/C2 and C2/C3 are
following normal features: aligned
On .axial images (Figure 4.2), check for the fol­ On coronal images (Figure 4.3), check for the
• space between anterior arch of Cl and the odon­ odontoid peg to the medial aspect of the occipi­
toid peg (atlantodental space) should be < 3 mm lowing normal features: following normal features: tal condyles
• space between anterior arch of Cl and the odon­ • space between odontoid peg and lateral mass of
in an adult and < 5 mm in a child • the posterior longitudinal ligament that runs
• anterior cortex of the odontoid peg and poster­ toid peg should be < 3 mm Cl is the same on both sides
• Cl is symmetrically aligned around the odontoid posterior to the vertebral bodies and extends as
ior cortex of anterior arch of Cl are parallel • there is no subluxation or widening of the the tectorial membrane to insert into the basion
• anterior aspects of the laminae of C1-C3 form a peg atlanto-occipital joints
• the anterior longitudinal ligament that runs
• no significant rotation of C0/1 or Cl/2 (up to 15 • the facet joints between C1/C2 and C2/C3 are
straight line, the spinolaminar line anterior to the vertebral bodies and extends as
• bodies of C2 and C3 are in alignment, with a degrees of Cl/2 rotation may be normal) aligned
the anterior atlanto-occipital membrane to insert
• absence of soft tissue swelling • the edge of the lateral mass of Cl does not over­ into the basion
normal disc space
hang C2 at the facet joint • the transverse atlantal ligament that extends
The major ligaments of the craniocervical junc­ between the lateral masses of Cl, passing poste­
tion are (Torretti, 2007):
rior to the odontoid peg
• the paired alar ligaments that extend from the

FIGURE 4.1 Craniocervical junction: Sagittal and parasagittal images.

AD — Atlantodental space; SLL = Spinolaminar line; CO = occipital condyle; CO/1 = Atlanto-occiptal joint; Cl/2 = Cl/2 facet join ,
„

= C2/3 facet joint.

 4 • Neck and back 279
278 Diagnostic imaging in critical care

FIGURE 4.7 Columns of thoracic spine.

AC = Anterior column; MC = Middle column; PC = Posterior
column.

On axial images (Figure 4.6), check for the fol­

FIGURE 4.6 Subaxial cervical spine: Axial images. lowing normal features:
E) = Facet joint. • no soft tissue swelling
• facet joints aligned
• no significant rotation
Lower (subaxial) cervical spine Thoracolumbar spine (Figure 4.7)
Classification of injury is based on the mechan­ Classification of injury to the thoracolumbar spine
ism of injury. Common injury patterns include is based on the three column concept. Common
distractive flexion, compressive flexion, lateral injury patterns include compression fractures,
flexion, vertical compression, distractive extension burst fractures, flexion distraction (seat-belt type)
and compressive extension injuries (Allen, 1982; injuries, and fracture dislocations (Denis, 1983).
Torretti, 2007). The anterior column is formed by the anterior
On sagittal reconstructions (Figure 4.4), check longitudinal ligament, the anterior half of the ver­
for the following normal features: tebral body and the anterior armulus fibrosus. The
• anterior and posterior vertebral body lines and middle column is formed by the posterior longitu­
spinolaminar line are uninterrupted dinal ligament, the posterior half of the vertebral
• vertebral body height is the same anteriorly and body and posterior annulus fibrosus. The posterior
posteriorly column is the posterior osseous arch, the supras­
• no prevertebral swelling pinous and interspinous ligaments, the ligamentum
• no widening of distances between spinous flavum, and the facet joint capsule.
processes The features sought on sagittal, coronal and
• facet joints aligned, appearing as stacked axial images of the thoracolumbar spine are similar
parallelograms to those described for lower cervical spine injuries.
• disc spaces intact The pattern of injuries differs between these two
On coronal images (Figure 4.5), check for the sites.
following normal features: *
• height of each side of the vertebral body is the
same
• disc spaces are intact
• facet joints are aligned

FIGURE 4.5 Subaxial cervical spine: Coronal images. FJ - Facet joint.

 4 • Neck and back 281

This 21 -year-old man was knocked over by a wave CJ

while swimming in the surf four hours ago. He Describe the injury,
hit the back of his head on the sea floor. He has
weakness and abnormal sensation in all limbs.
The clinical signs suggest an incomplete spinal
cord injury.

A
On the AP view, the main abnormality is a nar­ 50% shift of the body of C4 on C5 with angul­
rowing of the C4/5 interspace. On the lateral view, ation at this level. These features are typical of a
there is disruption of the anterior and posterior bilateral facet joint dislocation. This is a severe
vertebral body lines and the spinolaminar line at form of a distractive flexion injury, often assoc­
the C4/5 level. The inferior facets of C4 lie in front iated with spinal cord injury.
of the superior facets of C5. In addition, there is

Learning point
Recognition of a bilateral facet joint dislocation be distinguished from it on plain X-rays. On the
is important, as it is one of the few true surgical AP image the spinous processes below the dislo­
emergencies related to spinal injury. The dis­ cation do not align with those above it and the
location may be reduced with traction or open interspinous gap is widened. The lateral image
reduction. If reduction cannot be achieved with may show the facet joint dislocation but this is
traction, then immediate open reduction should better seen on oblique views. At the level of the
be considered, particularly if the neurological dislocation there is usually around 25% shift
signs are normal or incomplete (Thumbikat, forward of the superior vertebral body on the
2007). inferior one. Traction is used to reduce unilateral
A unilateral facet joint dislocation is a less facet joint dislocations but, even if this is unsuc­
severe form of distractive flexion injury than a cessful, emergency surgery is seldom required
bilateral facet joint dislocation and can usually (Thumbikat, 2007).
 4 • Neck and back 283

This 52-year~old man was an unrestrained pas­

senger in a high-speed car crash today. He has
Q
Describe the findings on the plain films and the
multiple limb injuries and a major pelvic injury. CT scan.
He was intoxicated with alcohol and had a GCS
of 12.

A
The plain films show no clear evidence of bone The CT scan presents a very different picture.
injury. At the antero-inferior border of the C5 The image in the book shows a bilaminar fracture
and C6 vertebral bodies, there are small, well- at the C7 level, with anteropulsion of the fracture
corticated bone fragments that have the appear­ fragments into the vertebral canal. This indicates
ance of osteophytes. With the inclusion of a a compressive extension injury, which is poten­
Swimmer view (image c), the alignment at the cer- tially unstable. The images in the DVD show a
vicothoracic junction is seen to be appropriate. similar injury at the C6 level.

Learning point
The best approach to clearing the cervical spine CT scan. When multiple trauma patients are
in the patient with multiple trauma remains con­ imaged with CT scan, 6% have discoligamentous
troversial. In this group of patients, plain X-rays injuries that are not detected (Platzer, 2006).
miss a significant proportion of bony cervical The consequences of a missed cervical spine
spine injuries. In a study of patients with mul­ injury are potentially devastating. There is a rel­
tiple trauma, a single cross table lateral view atively high incidence of missed fractures when
missed 37% of significant bony cervical spine plain radiography alone is used to image the cer­
injuries, a three-view series (AP, lateral, peg view) vical spine in patients with multiple trauma. CT
missed 10%, while cervical spine CT missed none is the imaging modality of choice in this group
(Platzer, 2006). of patients, with supplementary MRI when spinal
Ligamentous injuries are not well imaged with cord or ligamentous injury is suspected.
284 Diagnostic imaging in critical care

PROBLEM 4.03
 4 • Neck and back 285

This 66-year-old man underwent elective coro­

nary artery bypass grafting earlier today. He was
Q
1. Describe the findings on these images.
extubated four hours after the procedure, but 2. What particular risk does reintubation pose
now requires reintubation because of atelectasis for this patient?
and sputum retention. These images were taken
preoperatively because of a history of rheumatoid
arthritis.

A
1. The major finding on these images is marked These features are typical of severe rheumatoid
atlantoaxial subluxation that occurs when arthritis. One feature of rheumatoid arthritis
the neck is flexed. There is loss of the corti­ in the neck that is not seen on these images is
cal outline of the upper part of the odontoid fusion of the posterior elements of the spine.
peg. This amount of subluxation is indirect
evidence of rupture of the transverse atlantal 2. There is a risk of cervical spinal cord injury
ligament. There is osteoporosis of the spine. with intubation.

Learning point
Rheumatoid arthritis can have an important • The range of motion of the neck may be limited
impact on airway management (Matti, 1998). by fibrosis and ankylosis.
• Cervical spine involvement may produce sub- • Temporomandibular joint involvement may
luxation at the atlanto-occipital joint or at lead to poor mouth opening.
subaxial joints. If this is present, manipulation • Cricoarytenoid joint arthritis may narrow the
of the position of the head during airway man­ laryngeal inlet.
agement may produce spinal cord compression
or vertebrobasilar ischaemia,
 4 • Neck and back 287
286 Diagnostic imaging in critical care

PROBLEM 4.04 A
There is a right occipital condyle fracture. The The coronal views on the DVD show a fracture
position of the fracture suggests that it may be an dislocation of the right mandibular ramus,
avulsion fracture at the insertion of the alar liga­
ment. In the images provided, Cl is not displaced
in relation to the occipital condyle.

Learning point
Common fracture patterns of the occipital con- fractures related to the alar ligament (Anderson,
dyle include crush fractures, fractures that are 1988).
extensions of basal skull fractures and avulsion

This 19-year-old woman fell off a horse while Q

Describe the injury.
show jumping. She was confused and combative
on arrival at hospital.
 4 • Neck and back 289

PROBLEM 4.05 A
There are fractures of the anterior arch of Cl in peg extending into the body of C2 with posterior
the mid line and the posterior arch on the left displacement of the peg (type 3 odontoid frac­
side. In the coronal image, the right lateral mass ture). The spinolaminar line is disrupted at the
of Cl overhangs C2, consistent with expansion of Cl/2 level. There is posterior displacement of Cl
the Cl ring. on C2 at both Cl/2 facet joints.
There is a fracture at the base of the odontoid There are extensive arthritic changes.

Learning point
Odontoid fractures are classified as type 1 (tip of When the Cl ring is broken, it usually fractures
odontoid), type 2 (junction of dens and body) in at least two places.
and type 3 (extending into the body of C2)
(Anderson, 1974).

This 79-year-old front seat passenger was uncon-

scious at the scene following a high-speed car Describe the injury,
crash.
 4 • Neck and back 291
290 Diagnostic imaging in critical care

A
There is a traumatic spondylolisthesis of C2 and c) and an avulsion fracture of the right
(Hangman’s fracture) with a fracture through occipital condyle (image e), though these frac­
the pedicles bilaterally. The anterior aspects of tures are relatively subtle on these sections (best
the posterior arch of Cl, C2 and C3 do not align seen on the full set of images on the DVD, which
correctly (disruption of the spinolaminar line). also show fractures of the lateral masses of Cl). A
The astute interpreter will also note that there are well corticated detached osteophyte is seen at the
fractures of the posterior arch of Cl (images a anterosuperior corner of C6.

Learning point
Injuries of the craniocervical junction often
involve more than one anatomical site.

This 41-year-old man was a driver involved in a

high-speed car crash in which two people died at Describe the injury pattern.

the scene.
 4 • Neck, and back 293
292 Diagnostic imaging in critical care

PROBLEM 4.07
A
There is rotatory subluxation of Cl on C2 (up congruent with that of C2. This combination of
to 15-20 degrees of rotation of Cl on C2 is nor­ findings is highly suspicious of a ligamentous
mal). The posterior cortex of the anterior arch of injury, and spinal precautions, including the cervi­
Cl and the anterior cortex of C2 are not paral­ cal collar, should remain in place until the injuries
lel on the midline sagittal image (image c). In the are further delineated. The coronal images on the
right parasagittal view (image d), the facet of C2 DVD show a tiny avulsion fracture of the right
is displaced forwards on Cl, and the intervening occipital condyle.
facet joint is widened posteriorly. In the coronal There is a fracture of the T1 spinous process,
view, the lateral masses of Cl are asymmetrically which is separate to the craniocervical junction
aligned around the peg. The left atlantoaxial joint injury.
is widened and the right lateral mass of Cl is not

Learning point
Significant injuries to the craniocervical junction suspicion is required. MRI is more sensitive than
can occur without bony injury. A high index of CT for detecting unstable ligamentous injuries.

This 17-year-old man sustained multiple trau­ Cm the spinal collar be removed?
matic injuries in a single vehicle roll-over crash.

I
 4 • Neck and back 295
294 Diagnostic imaging in critical care

PROBLEM 4.08
A
The most significant abnormality is widening subluxation of Cl on C2 is noted on the right
(vertical distraction) of the posterior aspect of the parasagittal reformatted images (image a), where
atlanto-occipital joints bilaterally, which indicates the lateral mass of C2 is not aligned with that of
type 2 occipitocervical dissociation. Cl. This rotatory subluxation of Cl on C2 is best
There is an avulsion fracture of the right occip­ appreciated in the axial images on the DVD.
ital condyle (seen on DVD images only). Rotatory

Learning point
Occipitocervical dissociation (also known as distraction of atlanto-occipital joint > 2 mm), or
atlanto-occipital subluxation) is easily missed on type 3 (posterior dislocation) (Torretti, 2007). It
plain radiography, and is potentially fatal. It may is frequently associated with significant injury of
be type 1 (anterior subluxation), type 2 (vertical the craniocervical junction or brain stem.

This 25-year-old man hit the median barrier on a Describe the injury pattern.
motorway and was found eight metres away from
his motorbike.
 4 • Neck and back 297

A
No fractures are present. Three congenital anom­ expanded. Secondly, there is an os odontoideum,
alies of the craniocervical junction are present on a condition where the dens is separated from the
the scan. Firstly, there is a deficiency of the poste­ body of C2 (Truumees, 2008). The edges of this
rior arch of Cl. This is not a fracture, as the bony ossicle are well corticated and the position that
ends are well corticated and rounded. In addi­ it has separated from C2 would be unusual for
tion, the lateral mass of Cl does not overhang a fracture. Thirdly, there is a congenital defect of
that of C2, which suggests that the Cl ring is not the anterior arch of Cl.

Learning point
Knowledge of common congenital anomalies may
avoid misdiagnosis and incorrect management.

This 29-year-old man was injured in a high-speed

car crash. Concerns have been raised that there What do you think of the images?
may be a fractured odontoid peg and a Jefferson
fracture of Cl.
 4 • Neck and back 299
imAOirW ifl critical care

Following a high-speed car crash, this 52-year old

woman was tetraplegic with a C7 neurological
Q
Describe the injury.
level.

A
This is a distr active flexion injury at the C6/7 level. In image b, one vertebral body appears anterior
There is a greater than 50% shift of C6 forward on to the other, indicating significant subluxation.
C7 (image c), with a facet joint dislocation on the Similarly, in image d, two posterior arches are
left (images e and f) and fractures of the articular visible. There is an uncovered facet, also termed
processes of C6 and C7 on the right (images a, b, “bare facet” or “naked facet”, on the left in image b,
d). indicating a facet dislocation (McConnel, 1995).

Learning point
Distractive flexion injuries range from facet sub- dislocation to bilateral facet joint fracture or dis-
luxation, through unilateral facet 'fracture or location (Allen, 1982).
 4 Neck and back 301
300 Diagnostic imaging in critical care

PROBLEM 4.11 A
There is loss of anterior height and a “beak-like” inferoposterior aspect of C4 relative to C5. The
appearance of the anterior aspect of the C4 ver­ vertebral arch is intact. This is consistent with a
tebral body. There is a vertical fracture of C4 grade 4 compressive flexion injury.
vertebral body and mild displacement of the

Learning point
With stage 1 compressive flexion injury, there is displacement of the inferoposterior aspect of
blunting of the anterior-superior vertebral mar­ the vertebral body < 3 mm. When this displace­
gin. With stage 2, there is a beak-like appearance ment relative to the vertebra below is > 3 mm, it
to the anterior vertebral body with loss of ante­ becomes stage 5. Occasionally, a fracture of the
rior vertebral height and an oblique contour. laminae due to distraction may occur, though this
With stage 3, there is a fracture extending from is not typical. Retropulsion of fragments does not
the anterior surface of the vertebral body into occur (Allen, 1982).
the disc space. With stage 4, there is posterior

This 34-year-old man was cutting down a tree,

which fell on the back of his head while he was Describe the injury.
trying to avoid it.
 4 • Neck and back 303
302 Diagnostic imaging in critical care

PROBLEM 4.12
A
There is a stage 1 distractive extension injury at displacement of the cephalad vertebrae into the
the C5/6 level. There is widening of the disc space spinal canal. On the DVD, a number of additional
anteriorly with an avulsed inferior corner frag­ injuries may be seen, including fractures of the
ment from C5 vertebral body. There is no loss occipital and hyoid bones, and a fracture of the
of height of the posterior vertebral bodies or fourth rib.

Learning point
Distractive extension injuries are classified as and the cephalad vertebrae are displaced into the
stage 1, in which there is abnormal widening of the spinal canal (Allen, 1982). Patients with ankylo­
disc space (representing disruption of the ante­ sing spondylitis and diffuse idiopathic skeletal
rior longitudinal ligament and disc) or stage 2, hyperostosis are at risk of these injuries with min­
in which the posterior ligaments are disrupted imal trauma (Torretti, 2007).

This 73-year-old woman was hit by a truck while

crossing the road. She has been unconscious since Describe the injury.
the time of injury.
 4 • Neck and back 305
304 Diagnostic imaging in critical care

A
There are bilateral fractures of the C7 vertebral extends into both the lamina and pedicle. This
arch. On the left the fracture involves the articular pattern is consistent with a compressive exten­
process and extends into the lamina. On the right, sion injury.
the fracture involves the articular process and

Learning point
With compressive extension injury, there is dam­ combination of these. With more severe injuries,
age to the vertebral arch but the body of the the affected vertebra may be displaced anteriorly
affected vertebra remains intact. The vertebral arch relative to the subjacent vertebra and the antero-
fractures may be unilateral or bilateral, involv­ superior aspect of the subjacent vertebra may be
ing the pedicle, articular process, the lamina or a sheared off (Allen, 1982).

This 42-year-old man crashed his motorcycle (

when riding home from a party while intoxicated Describe the injury pattern,
with alcohol.
 4 • Neck and back 307
306 Diagnostic imaging in critical care

PROBLEM 4.14
A
There is a comminuted fracture of the body of vertebral arch of C5 and C6 are seen. This pattern
C7, with loss of height of the vertebral body and is consistent with a vertical compression injury.
fractures of the elements of the posterior verte­ On the axial images on the DVD, there is some
bral arch. There is significant retropulsion of asymmetry of Cl around the odontoid peg. In
bone fragments into the vertebral canal (which the absence of other findings suggesting an injury
does not occur with compressive flexion injuries). to the craniocervical junction, the significance of
There is kyphosis at the C7 level. In the images this finding is uncertain. MRI may be helpful to
on the DVD (but not the book) fractures of the exclude ligamentous injury.

Learning point
Vertical compression injuries are classified as both endplates are involved. In stage 3 lesions, the
stage 1, in which there is a central fracture of either vertebral body is fragmented with fragments dis­
the superior or inferior endplate with a “cupping” placed in multiple directions. The vertebral arch
deformity of the endplate. In stage 2 injuries, may or may not be involved (Allen, 1982).

This 20-year-old man was one of the drivers in

Describe the injury pattern.
a high-speed, multiple vehicle crash. He is now
quadriplegic with a C7 neurological injury level.
 4 • Neck and back 309
308 Diagnostic imaging in critical care

PROBLEM 4.15
A
1. All the vertebral bodies are fused together, through the C6/7 disc. There is anterior dis­
given the appearance of a piece of bamboo. placement of C6 on C7 with some narrowing
This appearance is typical of ankylosing spon­ of the vertebral canal. The facet joints are also
dylitis, in which the facet joints also become involved, hence the fracture involves all three
fused. In addition, the annulus fibrosus, the columns.
anterior longitudinal ligament and the inters-
pinous ligament calcify. 3. Patients with severe ankylosing spondylitis are
often extremely difficult to intubate by con­
2. The fused vertebral column has fractured ventional means.

Learning point
Patients with ankylosing spondylitis, or diffuse from extension injury (Torretti, 2007). Ankylosing
idiopathic skeletal hyperostosis (DISH), are at spondylitis patients may develop unstable stress
high risk of unstable cervical fractures, usually fractures with no history of significant trauma.

This 61-year-old man hurt his neck when he Q

1. What condition does he have that predisposed
slipped and fell over earlier today. Now he is
quadriparetic and required emergency tracheos­ him to a neck injury?
2. What injury has he sustained?
tomy because of respiratory distress. 3. Why was a tracheostomy used to secure his
airway?
 Diagnostic imaging in critical care 4 • Neck and back 311

PROBLEM 4.16 A
1. There is extensive ossification along the ante­
suggestive of diffuse idiopathic skeletal hyper­
rior aspect of five contiguous vertebral bodies, ostosis (DISH).
together with bridging osteophyte formation.
The disc spaces are preserved and there is no
2. Patients with DISH who have neck pain after
ankylosis of the facet joints. Minimal ossifi­
minor trauma require MRI, even if no frac­
cation of the posterior longitudinal ligament
tures are identified on CT or plain radiography
is also noted on the axial image and is better (Torretti, 2007).
seen on the DVD images. These features are

Learning point
DISH predisposes to vertebral fractures due to with relatively minor trauma, due to narrowing
the rigidity of the spine. Cord injury may occur of the spinal canal.

old man slipped over in the bathroom * )

This 59-year-<________
and hit his forehead. He initially complained ofr 1. What condition is present?
2. What are the impheations of this condition for
some neck pain, then became progressively con­
your management in this clinical scenario?
fused and agitated. A CT scan of the head shows
minor frontal contusions.
 4 • Neck and back 313
312 Diagnostic imaging in critical care

PROBLEM 4.17
A
There is anterior wedging of the body of a mid- is intact. This is a typical compression fracture.
thoracic vertebra. The height of the vertebral There is generalised osteopaenia, which is a predis­
body posteriorly is maintained but there is around posing factor to vertebral compression fractures.
20% loss of height anteriorly. The vertebral ring

Learning point
With a compression fracture, the anterior column may partially fail in distraction (Denis, 1983).
fails under compression. The middle column Compression fractures may be anterior (ante­
remains intact and acts as a hinge. The posterior rior flexion mechanism) or lateral (lateral flexion
column is usually intact but with severe injuries it mechanism) (Denis, 1983).

back pain.
 4 • Neck and back 315

A
There is a comminuted fracture of the L4 verte­ of fragments into the vertebral canal, which is
bral body with significant loss of height of both almost completely obliterated. There is a vertical
anterior and posterior aspects of the vertebral fracture of the lamina. This pattern is typical of a
body. There is an increase in the interpedicular burst fracture.
distance (seen best in image c) with retropulsion

Learning point
With burst fractures of the thoracolumbar spine, similar findings in the posterior vertebral body.
there is failure in compression of the anterior and Characteristically, the pedicles are spread apart
middle columns, but not the posterior column. by the posterior vertebral body fracture. There is
Failure in compression of the anterior column commonly a vertical fracture of the lamina, and
is shown by fracture of the cortex of the ante­ splaying of the facet joints, without which there
rior vertebral body, which loses height. Failure in could not be significant widening of the inter-
compression of the middle column is shown by pedicular distance (Denis, 1983).

This 19-year-old man fell three metres off scaf­

folding while trying to attract the attention of his Describe the injury pattern.
friend on the ground. He now has cauda equina
syndrome.
 4 • Neck and back 317
516 Diagnostic imaging in critical care

A
1. There is marked widening of the interspinous “Chance” fracture. Schmorl’s nodes are noted
interval at the T12/L1 level. A horizontal frac­ along the endplates of L4 but are of no clinical
ture line is seen through the vertebral body of significance.
LI, which extends through the pedicles and
articular processes of Ll, with widening of the 2. There is a high incidence (around 60%) of
fracture line posteriorly. There is no sublux­ intra-abdominal injury in association with
ation or dislocation. This is a “seat belt type” flexion-distraction injuries (Anderson, 1991).
or “flexion-distraction” injury, in this case a

Learning point
With seat belt type (flexion distraction) injuries bone, through the ligaments or a combination of
of the thoracolumbar spine, there is failure in the two. When injury is through the bone at one
distraction of the middle and posterior columns, level, it is known as a “Chance” fracture (Denis,
with either no injury to the anterior column or 1983).
minor compression. The injury may be through

This 18-year-old woman was a back seat passen­

1. Describe the injury pattern.
ger in a car crash. In the emergency department, 2. What other injuries is the patient at high risk
her GCS was 10 and she was moving all four
limbs. Intubation was required for management of?
of agitation.
 4 • Neck and back 319
Diagnostic imaging in critical care

PROBLEM 4.20 A
There is a flexion rotation fracture dislocation at lesion, with rotation and just under 50% lateral
the T7-T9 level. The body of T8 is severely com­ displacement. There is a fracture of the left fourth
minuted with retropulsion of fragments into the rib and bilateral pleural fluid. On the DVD, addi­
spinal canal, which is almost completely oblit­ tional injuries may be seen, including multiple rib
erated. The bodies of T7 and T9 are anteriorly and transverse process fractures.
wedged. There is a kyphosis at the level of the

Learning point
The main characteristic of a fracture dislocation Fracture dislocations of the thoracic spine
injury is failure of all three columns, leading to occur with high energy trauma. Other associated
translational deformity (subluxation or dislo­ injuries should be actively sought.
cation), which may be in the sagittal or coronal
plane.

T8 level

found to be paraplegic Q
This 26-year-old man was Describe the injury.
at the scene following a motorcycle crash.
 4 • Neck and back 321
320 Diagnostic imaging in critical care

A
There is a flexion-distraction dislocation at the the Tll/12 level. The body of T12 is compressed
T11/12 level. The body of T11 is shifted anteriorly anteriorly, with some comminution of its supe­
on the body of T12. There is a bilateral poste­ rior endplate. There is also a minimally displaced
rior facet joint dislocation (seen on DVD) and fracture of the anterosuperior aspect of LI.
marked widening of the interspinous interval at

Learning point
Fracture dislocations involve all three columns,
making them extremely unstable injuries, com­
monly associated with neurological damage
(Denis, 1983).

This 30-year-old woman was a restrained back

seat passenger during a car crash. Prior to intuba­ Describe the injury pattern.
tion, she was moving her arms but not her legs.
 4 * Neck and back 323
322 Diagnostic imaging in critical care

A
There is discontinuity of the pars interarticularis disruption are corticated with marked sclerosis.
of L5 bilaterally, associated with a small amount This is consistent with minor spondylolisthesis
of anterior shift of L5 on Si. This process is caused by spondylolysis. It is unrelated to the
chronic, as the parts of the bone adjacent to the recent traumatic episode.

Learning point
Spondylolysis is a defect in the pars interarticularis to another (spondylolisthesis). The L5/S1 inter­
of a vertebra. It may or may not be accompanied space is the commonest site of spondylolisthesis
by the forward translation of one vertebra relative (Froese, 2006).

This 28-year-old man was intubated and sedated "What is the abnormal finding on these images?
for major chest trauma sustained in a high-speed
car crash.
324 Diagnostic imaging in critical care

PROBLEM 4.23

This 23-year-old man presented with fever, sore

throat and stridor. You are called to the emer- What diagnosis does this image suggest?
gency department because of concerns about
airway obstruction.
 4 • Neck and back 325

A
Posterior and slightly inferior to the hyoid bone, thyroid lamina is consistent with thickened
at the level of the laryngeal inlet, is a soft tissue oedematous mucosa overlying the arytenoids and
mass extending into the anterior aspect of the air­ the aryepiglottic folds. The AP image on the DVD
way. It has the appearance of the tip of a thumb. shows the incidental finding of bilateral cervical
This appearance is typical of epiglottitis. A more ribs.
inferior nodular opacity superimposed on the

Learning point
Suspected adult, epiglottitis is usually assessed If the patient is at risk of airway obstruction,
by fibreoptic endoscopy or, if urgent intubation any imaging undertaken before the airway is
is required, by direct laryngoscopy. If fibreoptic secured should be done in an area with resuscita­
endoscopy is not available, a lateral neck X-ray tion facilities, not unmonitored in the radiology
may help confirm the diagnosis. department.
 4 Neck and back 327
326 Diagnostic imaging in critical care

A
There is a hypodense, multilocular collec­ These findings are consistent with Ludwig’s
tion within the right submandibular space. The angina, which is a severe soft tissue infection of
normal soft tissue planes are indistinct due to the floor of the mouth.
inflammatory changes. There is marked narrow­
ing of the airway by swelling, A tracheostomy tube
is in-situ.

Learning point
In severe soft tissue infections of the neck, CT is obstruction, the airway should be secured prior
useful to assess whether there are collections pres­ to imaging. The CT scanning suite is not the best
ent that can be drained. place to manage a difficult airway that becomes
When infection causes significant upper airway completely obstructed.

Emergency cricothyroidotomy was performed on ( |

this 66-year-old man for acute airway obstruc- What is the likely diagnosis?
tion. The anterior neck was grossly swollen
and inflamed. He was febrile with a neutrophil
leucocytosis.
 4 • Neck and back 329
328 Diagnostic imaging in critical care

PROBLEM 4.25 A
There is a large, soft tissue mass in the anterior thyroid malignancy. Other possibilities would be
neck and upper mediastinum with associated multinodular goitre and autoimmune thyroiditis
lymphadenopathy. A normal thyroid gland is not but these conditions would not explain the patho­
seen. There is compression of the trachea and logically enlarged lymph nodes.
the veins of the neck and upper mediastinum. The apparent hypodensity in the lower media­
The right brachiocephalic vein is markedly com­ stinum is caused by beam-hardening artefact from
pressed. The most likely explanations for these dense contrast in the left brachiocephalic vein.
findings would be a lymphoma or a primary

Learning point
Malignancy may present in an advanced state with some of the malignancies that present in this way
compression of vital structures in the neck and/or are eminently curable. In particular, teratomas
upper mediastinum. When confronted with this and lymphomas may be exquisitely sensitive to
clinical scenario, it should be remembered that chemotherapy.

This 62-year-old
ing with rest. had
stridor atman notedneck
obvious
He was swell-
to develop Q
Suggest a differential diagnosis,
respiratory distress when supine.
 1
4 • Neck and back 331
330 Diagnostic imaging in critical care

PROBLEM 4.26 A
There is extensive oedema in the cord around the and anterior to the anterior longitudinal ligament
C3-5 level. Particularly at the C3/4 level, there is superior to this level. There is increased T2 signal
narrowing of the canal (images a, b and c). There intensity in the soft tissues adjacent to the spinous
is extensive osteophyte formation anteriorly. processes from C2 to C6. These features suggest a
There is increased signal intensity in the C3/4 disc, hyper extension injury.

Learning point
Central cord syndrome may result from an exten­ complex and a bulging ligamentum flavum, in the
sion injury due to cord compression between absence of any fractures.
a hypertrophied spondylotic disc-osteophyte

his face today. Q . .

This 71-year-old man fell onto
He now has clinical features of central cord syn­ Describe the injury.
drome. CT scan shows degenerative changes but
no fractures.
 4 • Neck and back 333
332 Diagnostic imaging in critical care

PROBLEM 4.27
A
There is a cervical epidural collection extending contrast sequence. The cord is displaced and com­
over several vertebral levels. Compared to the pressed by the collection. These findings would be
cord, it is T1 isointense and T2 hypoin tense. most consistent with an epidural haematoma.
There is peripheral enhancement on the post

Learning point
MRI is the modality of choice for evaluating a subacutely. Gradient-echo may demonstrate
spinal epidural haematoma, as it provides infor­ blooming of haemorrhage.
mation regarding location, extent, degree of cord A low T2 signal rim to the collection favours a
compression and acuteness of the haematoma. haematoma over an abscess while peripheral lin­
Signal characteristics can vary but are ear post-contrast enhancement would favour an
isointense to the adjacent cord acutely, with con­ abscess over a haematoma. The clinical scenario
version to hyper in tensity in the subacute stage and MR characteristics should allow accurate
on T1-weighted images. On T2-weighted images, diagnosis in most cases.
the majority of the signal abnormality is hetero­ See Chapter 6: Imaging modalities, p 375-6 for
geneously hypointense acutely and hyperintense further explanation of terms.

C5 level
T1 Fat Sat + GD

This 67today,
paresis -year-old manishad
which morerapid onsetonofthe
marked quadri-
right What is the most likely reason for the neurologi­
than the left and is accompanied by incomplete cal symptoms?
sensory loss at C6 and below.
 4 • Neck and back 335
334 Diagnostic imaging in critical care

PROBLEM 4.28 A
The axial T1 fat saturation images show absence cerebellar artery, is well demonstrated in the max­
of the normal flow void in the left vertebral artery. imum intensity projection images.
The absence of arterial flow in the left vertebral See Chapter 6: Imaging modalities, p 375 for
artery and its branch, the left posterior inferior further explanation of terms.

Learning point
Vertebral artery dissection can produce a wide syndrome may occur from posterior inferior cer­
spectrum of clinical manifestations from being ebellar artery involvement.
asymptomatic to brain death. Lateral medullary

T1 Fat Sat

T1 Fat Sat

This
lated 43-year-old-woman
by her family doctorhad her neck
24 hours ago. manipu-
She now _ of the symptoms,
What is the likely explanation
has vomiting, vertigo and nystagmus.
 4 • Neck and back 337
336 Diagnostic imaging in critical care

PROBLEM 4.29 A
There is a long segment of increased T2 signal would be similar, but these diagnoses are unlikely
in the thoracic cord. There is no cord expansion. without risk factors such as recent aortic surgery.
The spinal canal is not narrowed. There is an incidental thoracic scoliosis, mak­
The most likely diagnosis is transverse myeli­ ing it impossible to visualise the entire thoracic
tis. Other possible causes include cord ischaemia, cord on one image.
infarction or multiple sclerosis. If the MRI of the The T2 hypointense areas seen within the CSF
head is normal, multiple sclerosis is unlikely. The are due to CSF flow artefact.
MRI findings in cord ischaemia or infarction

Learning point
Expansion and contraction of the intracranial Signal intensity may be increased or reduced and
vessels associated with the cardiac cycle results the artefacts are typically seen in the lateral ven­
in pulsatile expansion and contraction of the tricles just superior to the foramen of Monro, the
brain. This produces to-and-fro movement of fourth ventricle and within the cervical and tho­
CSF, which may cause CSF flow artefacts on MRI. racic spinal canal.

T3 level

This previously well 21-year-old woman What is the most likely diagnosis.
developed paraplegia over the last 72 hours. She
has a sensory level at T6.
338 Diagnostic imaging in critical care

PROBLEM 4.30

This 49-year-old man presented in septic shock. O

Staphylococcus aureus was isolated from blood What source of sepsis is seen on these images?
cultures. No source of infection was apparent
clinically.
 4 • Neck and back 339

A
The T1 sagittal sequence demonstrates mar­ small non-enhancing areas, consistent with an
row oedema of the L3 and L4 vertebral bodies, epidural abscess.
which enhances on the post-contrast sagittal T1 There is abnormal enhancement of the psoas
fat saturated sequence. The intervening disc dis­ muscles bilaterally, which is more pronounced on
plays a bright T2 signal, consistent with oedema the right and is consistent with inflammation. A
of the nucleus pulposus. No disc enhancement non-enhancing central component would suggest
is seen. These findings, as well as loss of end­ an intramuscular abscess. Although no abscess is
plate definition, are consistent with discitis and demonstrated on the images shown in the book, a
osteomyelitis. small 4 mm abscess is shown on the post-contrast
An anterior epidural lesion is noted at the L3/4 sequence in the DVD.
level, compressing the thecal sac. Within it are

Learning point
In the patient with staphylococcal bacteraemia include epidural abscess, psoas abscess and
with no obvious source, common occult sites of endocarditis.
infection that may need surgical management
 4 • Neck and back 341
340 Diagnostic imaging in critical care

PROBLEM 4.31
A 2. Other useful information these images provide
1. The findings which identify which of the ves­ to the person undertaking cannulation are:
sels is the vein are: • The anatomical relation between the artery
• The vein is thin walled and ovoid. The artery and the vein. In this patient, the vein lies in
is thick walled and round (image a). front of and to the right of the artery.
• The vein collapses with external pressure, • The vein is patent, of normal size, and suit­
while the artery does not (image b). able for cannulation.
• Flow in the vein is continuous with pulse­ • Visualisation that the needle is directed
wave Doppler (image c), while arterial flow towards the vein while it is being inserted
is pulsatile (image d). (image e).
• Confirmation that the guidewire is correctly
placed within the vein (image f).

External pressure applied

Learning point
When central venous catheterisation is performed shortens the time of the procedure
via the internal jugular vein, real-time ultrasound reduces the number of failed attempts
guidance (Maecken, 2007): reduces the rate of complications

- 100

50

, tfufcwfive Qoppfer

idevvire insertion

This 35-year-old man was admitted to ICU with Q

1. What findings on these images identify which
abdominal sepsis. It was decided to insert a right 12 1
internal jugular central venous catheter using of the vessels is the vein?
2. Apart from the position of the vein, what other
real-time ultrasound guidance. These ultrasound useful information have these images provided
images are shown in the order that they were to the person undertaking cannulation?
obtained during the procedure.
342 Diagnostic imaging in critical care

REFERENCES Maecken T, Grau T. Ultrasound imaging in vascular access.

Allen BL, Ferguson RL> Lehmann TR, et al. A mechanistic Crit Care Med 2007; 35(5 Suppl): S178-85
classification of closed, indirect fractures and dislo­ Matti MV, Sharrock NE. Anesthesia on the rheumatoid
cations of the lower cervical spine. Spine 1982; 7(1): patient. Rheum Dis Clin North Am 1998; 24(1):
1-27-
Anderson LD, D’Alonzo RT. Fractures of the odontoid
19-34
McConnel CT. The “open” exit foramen: A new sign of
unilateral interfacetai dislocation or subluxation in
CHAPTER 5
process of the axis. J Bone Joint Surg Am 1974; 56(8):
1663-74 the lower cervical spine. Emerg Radiol 1995; 2(5):
Anderson PA, Montesano PX. Morphology and treat­ 296-302
ment of occipital condyle fractures. Spine 1988; 13(7): Platzer P, Jaindl M, Thalhammer G> et al. Clearing the
cervical spine in critically injured patients: A compre­

LIMBS
731-6
Anderson PA, Rivara FP, Maier RV, et al. The epidemi­ hensive C-spine protocol to avoid unnecessary delays
ology of seatbelt-associated injuries. J Trauma 1991; in diagnosis. Eur Spine J 2006; 15(12): 1801-10
31(1): 60-7 Thumbikat P, McClelland MR. Acute injury to the spinal
Denis F. The three column spine and its significance in the cord. Surgery (Oxford) 2007; 25(10): 413-19
classification of acute thoracolumbar spinal injuries. Torretti J, Sengupta D. Cervical spine trauma. Indian
Spine 1983; 8(8): 817-31 J Orthopaed 2007; 41(4): 255-67
Froese BB. Lumbar spondylolysis and spondylolisthesis, Truumees E. Os odontoideum. emedicine. In Riley
emedicine. In Slipman GW, Talavera F, Foye PM, LH, Talavera F, Shaffer WO, Patel D, Keenan MAE,
Allen KL, Cailleiet R, WebMD, 2006, Available: http:// WebMD, 2008, Available: http://emedicine.medscape,
emedicine.medscape.com/article/310235-overview; com/article/1265065-overview; accessed 7 May 2009
accessed 7 May 2009

343
344 Diagnostic imaging in critical care

PROBLEM 5.01

When this 40-year-old man was admitted to ICU O

with status epilepticus, some bruising was noticed What problem do these images show?
around his left shoulder.
 5 '• Limbs 345

A
The AP view looks relatively normal although appearance. The trans-scapular view clearly dem­
there are some subtle abnormalities. Due to inter­ onstrates a posterior dislocation of the shoulder.
nal rotation, the humeral head has a “light bulb” There is also an impaction fracture of the neck of
appearance, instead of a normal “hockey stick” the humerus.

Learning point
Posterior dislocation of the shoulder is an uncom­ cannot be externally rotated from this position
mon injury, which is often missed. Classically, the (Limb, 2005).
history is one of seizures or electrocution but this On the AP projection, the dislocated humeral
injury may result from a fall on an outstretched head may appear to line up normally with the
arm. A clinical pointer towards this injury in glenoid fossa. The abnormalities in this view are
the unconscious patient is that the arm is typi­ subtle, and often missed. The dislocation will be
cally held adducted and in internal rotation and obvious in a trans-scapular view (Limb, 2005).
346 Diagnostic imaging in critical care
5 • Limbs 347

PROBLEM 5.02 A
On the AP view, the lunate (middle bone, proxi­ somewhat anteriorly The lunate retains its nor­
mal row of three carpal bones) appears triangular mal relation to the distal radius, while the capitate
and overlaps the other carpal bones. There is loss and other carpal bones are dislocated posteriorly.
of the normal smooth carpal arcs of the proximal These findings are typical of a perilunate disloca­
and distal articular surfaces. On the lateral view, tion (Kozin, 1998). The ulnar styloid tip is also
the lunate has rotated so that its concave sur­ fractured.
face (usually articulated with the capitate) faces

Learning point
Perilunate dislocations are commonly missed, clinical examination. Delayed treatment may
even when wrist X-rays are obtained. In the result in significant long-term functional limita­
unconscious patient who cannot complain of tion due to arthritis or median nerve palsy (Kozin,
pain, there may be no obvious abnormality on 1998).

This 47-year-old man was an unrestrained pas-

senger in a high-speed car crash and sustained What injury do these images show?
multiple traumatic injuries. Bruising and swelling
around the right wrist was noticed at ICU admis­
sion following an emergency laparotomy
348 Diagnostic imaging in critical care

PROBLEM 5.03

This 17-year-old man sustained major chest and O

abdominal trauma in a high-speed car crash. His What injury is seen on these images?
right wrist was swollen and tender.
 5 • Limbs 349

A
There is an undisplaced fracture through the waist
of the scaphoid.

Learning point
Initial plain X-rays often miss scaphoid fractures, neurological injury, long-term functional limi­
especially when acquired only in an AP projec­ tations are determined mainly by orthopaedic
tion. An AP view in ulnar deviation demonstrates injuries. Missing a seemingly minor injury in a
these fractures to a better advantage. CT and MR patient with life-threatening chest and abdomi­
scans have a much higher sensitivity than plain nal injuries may result in significant long-term
X-ray for this injury. morbidity.
When patients survive major trauma without
350 Diagnostic imaging in critical care

PROBLEM 5.04__________________________________________________________________

This 70-year-old man was in a high-speed car ' ’

crash and is ventilated because of chest injuries. What injury is shown on these images?
On the ward round, it is noted that there is swell­
ing of the foot and bruising of the medial side of
the plantar aspect of the midfoot.
 5 • Limbs 351

A
In the AP view (image a): In the oblique view (image b), there is lateral
• the second to fifth metatarsals are displaced displacement of the second to fifth metatarsals
laterally resulting in loss of alignment of:
• the medial borders of the second metatarsal • the lateral borders of the lateral cuneiform and
and the middle cuneiform do not align, due to the third metatarsal
lateral shift of the metatarsal • the medial borders of the fourth metatarsal and
• the space between the first and second metatar­ the cuboid
sals is widened (normal < 2 mm) In the lateral view (image c):
• the base of the second metatarsal is fractured, • the second metatarsal is displaced dorsally in
and a “fleck” sign is present (best appreciated on relation to the middle cuneiform
the DVD images). The fleck sign is an avulsion These findings are typical of a Lisfranc injury.
fragment adjacent to the base of the first meta­ Incidental calcification of the dorsalis pedis artery
tarsal, pathognomonic of a Lisfranc fracture is noted.

Learning point
The Lisfranc ligament links the medial cuneiform Lisfranc injury is very poor, the diagnosis is
to the base of the second metatarsal. When it is important to make. Clinical findings may include
disrupted, the lateral four metatarsals can sublux midfoot swelling (especially dorsal), with pain to
laterally in relation to the tarsal bones and the palpation in the tarsometatarsal area and ecchy-
first metatarsal (Sands, 2004). mosis on the medial side of the plantar aspect of
Since the natural history of an untreated the midfoot (Sands, 2004).
352 Diagnostic imaging in critical care 5 • Limbs 353

A
There is a comminuted fracture of the calcaneus,
best seen on the lateral view (image b). It appears
to involve the subtalar joint.

Learning point
When a calcaneal fracture results from a fall from forces. These include contralateral calcaneal
a significant height, it is often associated with fracture, vertical shear fracture of the pelvis and
other injuries produced by axial compression spinal burst fracture.

bruising around her left ankle and proximal foot

This 45-year-old woman was working on a
were noted at the time of admission to intensive
construction site. She fell six metres and was
unconscious at the scene. On arrival at the emer­ care.
gency department, she was intubated because of
agitation and confusion. The CT head scan shows Q
Describe the injury.
minor frontal cerebral contusion. Swelling and
354 Diagnostic imaging in critical care 5 • Limbs 355

A
There are comminuted fractures of the tibia and artery but there is an abrupt cut off at this level.
fibula, with significant deformity at the fracture The vessels distal to this level are not seen. These
sites. Normal contrast opacification of the arterial findings are consistent with a traumatic occlusion
system is seen down to the level of the popliteal of the popliteal artery.

Learning point
When major limb fractures are present, the the problem, then vascular reconstruction maybe
integrity of the circulation distal to the fracture required.
should be carefully examined. If the circulation is CT angiogram or digital subtraction angio­
compromised, the first step is to reduce any dislo­ gram are the best modalities to assess vascular
cation or gross deformity. If this does not correct integrity following trauma.

This 35-year-old pedestrian was struck by a car,

injuring his left leg. His left foot is pale, with no Describe the findings on this digital subtraction
pulses and abnormal sensation. angiogram.
 5 • Limbs 357
356 Diagnostic imaging in critical care

PROBLEM 5.07 A
There is a fracture of the calcaneum. Gas can be gas. The distribution of gas is far more extensive
seen within the soft tissues of the foot and lower than could be attributed to air entering the tissues
leg, particularly on the dorsal and lateral aspect from an open wound, and is strongly suggestive
of the foot. The Achilles tendon is outlined by of gas gangrene.

Learning point
With early surgical debridement and prophylac­ has a role in determining the extent of severe soft
tic antibiotic therapy for open wounds, severe tissue infection but should not delay surgery.
clostridial soft tissue infections are now rare. MRI

Two days ago, this 60-year-old man fell off a lad- Q

What problems do these images suggest?
der and sustained an open injury to the left heel.
He is now complaining of severe pain over his
entire foot.
358 Diagnostic imaging in critical care 5 • Limbs 359

PROBLEM 5.08 A
There is a small, metallic foreign body just dis­ phalangeal joint which is widened. Cortical
tal to the metatarsophalangeal joint, between the erosion is also seen in the middle phalanx of the
proximal phalanges of the second and third toes. right third toe. These findings are consistent with
The adjacent soft tissues are markedly swollen. cellulitis and osteomyelitis caused by a foreign
Multiple lucencies are seen within the second and body. Vascular calcification suggests that arterial
third proximal phalanges with cortical erosion. insufficiency could be a contributing factor.
This process extends into the third metatarso-

Learning point
Osteomyelitis may be due to haematogenous • joint involvement (septic arthritis is common)
spread (common in children) or to direct spread • periosteal new bone deposition
from a contiguous focus of infection (common • detached segments of necrotic bone known as
in adults). Foci of infection from which direct sequestra
spread commonly occurs include open fractures, Bone scintigraphy scans and MRI are highly
diabetic wound infections or surgical treatment sensitive for detecting early osteomyelitis. MRI
of closed injuries (Pineda, 2006). provides additional information about the extent
Plain X-rays are often normal in early acute of the infection and involvement of adjacent soft
osteomyelitis. As the disease progresses, findings tissues. CT is less sensitive for early disease but
may include (Dahnert, 2007; Pineda, 2006):' may provide addition information about bony
• localised soft tissue swelling adjacent to the anatomy (Pineda, 2006).
affected area
• features of bone destruction, such as cortical
erosions or radiolucent areas within the bone

This 50-year-old man presented to the emergency (J

department with septic shock. He gave a history What problem do these images suggest?
of six weeks of pain and swelling in the sole of his
right foot, at the base of the second and third toes.
On examination, this region was swollen, tender
and erythematous.
360 Diagnostic imaging in critical care
 5 .• Limbs 361

This 57-year-old man fell off his pushbike two admitted to the emergency department with sep­
months ago. He sustained a wound on the medial tic shock.
aspect of his upper left leg that required debri­
dement and hospitalisation for two weeks. Last
week, he developed pain in his left knee and now
Q
What diagnosis is suggested by these images?
cannot weight bear on his left leg. He has been

A
On the AP view (image a), there is widening of erosion of the subchondral cortex of the tibia and
the joint space, seen best on the medial aspect of femur, and blurring of the joint margins. In this
the joint. On the lateral view (image b) there is clinical context, this is highly suggestive of sep­
fluid in the suprapatellar pouch. These findings tic arthritis. There is a lucent area in the proximal
are typical of knee joint effusion. tibial shaft, with overlying soft tissue abnormality,
On the medial aspect of the knee joint, there is suggestive of osteomyelitis.

Learning point
In early septic arthritis, X-rays are usually normal knee and the elbow but are much less apparent in
but may show a joint effusion. Joint space nar­ other joints. An effusion in the elbow is indicated
rowing due to destruction of articular cartilage on plain X-rays by the appearance of triangu­
and osteopaenia around the joint may develop lar radiolucencies anterior and posterior to the
rapidly. Erosion of the articular cortex and reac­ distal humerus (often called “sail signs”). These
tive bone sclerosis occur after 8-10 days (Dahnert, represent intra-articular fat pads that have been
2007; Wilson, 2004). displaced by the effusion.
On plain X-ray, effusions are readily seen in the
362 Diagnostic imaging in critical care

PROBLEM 5.10

This 25-year-old man gave a history of a pain­ developed blisters. He now has septic shock and
ful black area the size of a small coin developing acute renal failure.
on the skin of the anteromedial aspect of his left .
thigh last night. When he woke this morning, he
felt unwell. The skin lesion was larger and had What diagnosis do these images suggest?
 5 • Limbs 363

A
Intermuscular and intramuscular gas is present, small areas of muscle. On image d, there is more
which is seen as areas of low signal on all three extensive muscle involvement. On the post-GD
sequences. The axial T1 image shows skin thicken­ contrast sequence a small area of intramuscular
ing (best seen posteromedially) and subcutaneous contrast enhancement is seen (image b), corre­
fat stranding (best seen anteriorly). The axial T2 sponding to an area of oedema (image c) on the
Fat Saturation images show extensive oedema of T2 sequence. These findings are typical of necro-
the skin and subcutaneous tissues. On image c, tising fasciitis.
the oedema involves the fascial planes and a few

Learning point
Necrotising fasciitis is characterised clinically by and broad-spectrum antibiotics are required. The
necrotic or blistering skin lesions with systemic role of imaging in this condition is limited, as the
illness and pain out of keeping with the physi­ priority is urgent surgical intervention. In the
cal signs. Large areas of soft tissue and muscle occasional case where imaging is required, MRI is
are often involved. Early aggressive debridement the modality of choice.
364 Diagnostic imaging in critical care 5 Limbs 365

PROBLEM 5.11
A
There is a wound on the anterior aspect of the left attenuation of intramuscular fat planes (image
thigh, which contains packing. There are multi­ b). There is surgical emphysema in the deep tis­
ple metallic foreign bodies scattered through the sues. Surgical clips are seen on the anterior aspect
soft tissue of the thigh. The largest of these is in of the right thigh, consistent with the saphenous
the subcutaneous tissue overlying the left gluteus vein donor site. There is flow in the left femoral
maximus muscle. Haematoma of the left gluteus arterial graft. The patency of the graft is con­
maximus and the adductor muscles is denoted by firmed in the full set of images on the DVD.

Learning point
With gunshot wounds, it is common that there than the diameter of the projectile would
will be significant tissue damage at sites remote suggest.
from the linear track between entry and exit • Bullets often fragment with impact and each
wounds. fragment may damage the tissues through
• Transfer of kinetic energy from a bullet may which it traverses.
result in tissue disruption significantly greater

This 45-year-old man was shot in the upper thigh performed and the wound was packed. These
during an armed robbery. On arrival at hospital, images were obtained following the operation.
he was immediately taken to the operating theatre
for exsanguinating haemorrhage. A saphenous
vein reconstruction of his femoral artery was
Q . .
Describe the findings on these images.
366 Diagnostic imaging in critical care 5 * Limbs 367

PROBLEM 5.12
A
There is an echo free cavity measuring 4.37 X in relation to the size of the artery, and to-and-fro
2.55 x 2.97 cm in the right groin, adjacent to the flow is demonstrated on the Doppler waveform in
profunda femoris artery. Swirling colour flow this region. These findings are typical of a pseudo­
is recorded within the cavity and there is high- aneurysm and, in this clinical context, represent a
velocity colour flow within a tract between the complication of the cardiac catheterisation.
cavity and the artery. The width of the communi­
cation between the artery and the cavity is small

Learning point
A pseudoaneurysm is a pulsatile haematoma interventional procedures that use a femoral
that communicates with an artery through a arterial access site. It is more common when the
disruption in the arterial wall (Kronzon, 1997). puncture site is at, or distal to, the bifurcation of
Pseudoaneurysm complicates 0.1-0.2% of diag­ the common femoral artery (Lenartova, 2003).
nostic coronary angiograms and 1-2% of cardiac

This 60-year-old woman underwent elective cor­

onary angiography with angioplasty and stenting What problem do these images of a duplex scan
one week ago. The procedure was uneventful and of the right groin demonstrate?
she continues to take aspirin. She now presents
with a pulsatile mass in the right groin, adjacent
to the catheter insertion site.
368 Diagnostic imaging in critical care

PROBLEM 5.13

No external pressure External pressure applied.

6.0- 6.0-
LT LEG CFV NON COMP
FR16Hz M2M3 I
+38.51
P1

2D
53%
C50
P Low
Gen

CF
63%
3500Hz
WF 175Hz
Med -38.5
cm/s

6.0"
LT LEG CFV NON COMP

This 45-year-old man was in a car crash eleven

days ago. He sustained injuries to his chest and What are the findings on these ultrasound images
abdomen, as well as a left tibial fracture, which of the left common femoral vein?
was treated with open reduction and internal
fixation. He continues to require mechanical ven­
tilation. On the ward round today, his left leg was
found to be much more swollen than yesterday.
 5 • Limbs 369

A
The lumen of the common femoral vein is filled There is no flow seen within the vein on colour
with a strongly echogenic mass. The vein is not Doppler imaging. These findings are typical of a
compressed when external pressure is applied. common femoral vein thrombosis.

Learning point
Duplex ultrasonography combines 2D imaging Alternative imaging techniques include:
and colour Doppler imaging and is the inves­ • indirect CT contrast venography: intravenous
tigation of choice for suspected deep venous (IV) contrast is injected at a site away from the
thrombosis (DVT). It allows correct diagnosis of affected limb. This can be performed at the same
other conditions that may mimic DVT, such as time as CT pulmonary angiography, without
Baker’s cyst, calf haematoma and popliteal artery the need for additional contrast (Orbell, 2008).
aneurysm. When assessing for DVT in the lower • direct CT contrast venography: LV contrast
limb, it is less sensitive in the calf than for more injection into affected limb
proximal veins. Significant limitations are that • MRI venography
ultrasound may not image the iliac veins well, it • contrast venography: IV contrast is injected
may be impractical to study patients in plaster into the affected limb
casts and it is of little value for detecting a new
thrombosis in a post-phlebitic limb (Orbell,
2008). .
370 Diagnostic imaging in critical care

REFERENCES Limb D, McMurray D. Dislocation of the glenoid fossa.

Dahnert W, ed. Radiology review manual. 6th edn. J Shoulder Elbow Surg 2005; 14(3): 338-9
Philadelphia: Lippincott Williams and Wilkins; 2007. Orbell JH, Smith A, Burnand KG, et al. Imaging of deep
Kozin SH. Perilunate injuries: Diagnosis and treatment. J vein thrombosis. Br J Surg 2008; 95(2): 137-46
Am Acad Orthop Surg 1998; 6(2): 114-20
Kronzon I. Diagnosis and treatment of iatrogenic fem­
Pineda C, Vargas A, Rodriguez AV. Imaging of osteomyeli­
tis: current concepts. Infect Dis Clin North Am 2006;
20(4): 789-825
CHAPTER 6
oral artery pseudoaneurysm: a review. J Am Soc
Echocardiogr 1997; 10(3): 236-45 Sands AK, Grose A. Lisfranc injuries. Injury 2004; 35
Lenartova M, Tak T. Iatrogenic pseudoaneurysm of femo­ (Suppl 2): SB71-6
ral artery: Case report and literature review. Clin Med Wilson DJ. Soft tissue and joint infection. Eur Radiol 2004;

IMAGING
Res 2003; 1(3): 243-7 14 (Suppl 3): E64—71

MODALITIES

371
372 Diagnostic imaging in critical care

are usually obtained with the beam directed in a

PLAIN X-RAYS posteroanterior (PA) direction and the image recep­
X-rays are. a form of electromagnetic radiation. tor placed against the front of the chest. Mediastinal
They , can be generated in the vacuum within structures are located anteriorly, close to the image
an X'-ray tube by bombarding a tungsten target receptor, so there is minimal magnification of these
(anode) with electrons from a filament of tung­ structures. With portable X-ray imaging, the beam
sten wire (cathode). The electrons are accelerated is directed in an antero-posterior (AP) direction
towards the target by the high potential difference and the image receptor placed against the back of
between the anode and cathode (Long, 2006). the chest. As the mediastinal structures are now
The path of the X-ray beam is from the beam further from the image receptor, there is significant
source (X-ray tube), through the tissues being magnification of them, which produces apparent
imaged, to an image receptor. The image recep­ widening on the AP image. This appearance may
tor may be either a traditional film-based system be compounded by gravitational effects. The PA
or a filmless computed radiography system. The image is acquired in the erect position, so gravity
film-based system consists of a film holder (cas­ narrows and elongates the mediastinum. The AP
sette), an intensifying screen coated with phosphor, image is often acquired with the patient supine, in
which fluoresce when exposed to X-rays, and the which case this effect is absent.
film. The film is developed after image acquisition
and then viewed directly. The computed radiogra­
phy system consists of a sealed cassette containing
phosphor material. After image acquisition, the ULTRASOUND
cassette is scanned with a laser system and viewed
on the computer screen of a Picture Archiving and Tissue imaging
Communication System (Long, 2006; Novelline, Pulses of ultrasound are generated by a piezo­
2004). electric crystal and enter the body, travelling at a
The attenuation of X-rays by tissues depends on velocity of approximately 1540 ms-1 in soft tissues.
both their density and thickness. X-rays often pass Ultrasound pulses are reflected from tissue inter­
through multiple tissues and the image formed faces and the reflected pulse returns to the crystal,
represents the sum of all the densities interposed where it generates an electrical signal. Image gen­
between the beam source and the image receptor. eration is based on the time delay between sending
The appearance of tissues on images allows them the pulse and receiving reflections from the tissue
to be classified into the four basic radiographic interfaces. Deeper structures have a longer time
densities of air, fat, water (or soft tissue) and bone delay than superficial structures. The time delay
(Erkonen, 2005). between transmitting the pulse and receiving the
Tissues must be of different density for the reflected signal, and the assumed velocity of ultra­
boundary between the two tissues to be seen on sound in the tissues, is used to calculate the depth
an X-ray image. Consider the boundary between (Anderson, 2007).
the heart and the lung. On the plain X-ray image, With M-mode ultrasound, the ultrasound pulse
this boundary is normally seen as a distinct cardiac is directed along a single line through the struc­
border because the water density heart lies against tures of interest. The display shows tissue depth on
the air density lung. Consolidated lung has water the y-axis and time on the x-axis. The brightness of
density. Therefore, if the lung adjacent to the heart any point on the display is determined by the inten­
becomes consolidated, the cardiac border becomes sity of the corresponding reflected signal. M-mode
indistinct and may not be apparent on the image. allows a rapid sampling frequency, providing good
Similarly, air filled bronchi cannot be seen within temporal resolution of rapidly moving structures
normal air density lung but, if the lung becomes (Anderson, 2007).
consolidated, the bronchi may be seen as air 2D ultrasound images may be generated by either
bronchograms. a phased array or a linear array transducer. With a
As the X-ray beam travels from the beam source phased array transducer, the beam is swept across a
to the image receptor, its cross-sectional area tomographic plane to produce a sector-type image.
increases and its intensity reduces in keeping with Each sweep of the ultrasound beam generates an
the inverse square law. Because the object being image and the frequency of the sweeps determines
imaged is closer to the beam source than the image the image frame rate on the video display. With a
receptor, the image is magnified. The magnifica­ linear array transducer, multiple parallel beams in
tion depends on both the distance from object to a tomographic plane produce a rectangular image.
image receptor and the distance from beam source With both transducer types, the display shows the
to image receptor (Long, 2006). Chest X-ray images tomographic plane with the brightness of any point
 6 • Imaging modalities 373

determined by the intensity of the corresponding, interest. The transducer generates pulses of ultra­
reflected signal (Feigenbaum, 2005; Otto, 2004). sound at a set frequency and records the reflected
Standard ultrasound imaging is based on the signal, assessing the change in frequency between
fundamental frequency generated by the trans­ the two. This time, however, recording of the signal
ducer. As the ultrasound wave propagates through only takes place at the time delay corresponding
the tissues, harmonic frequencies are generated, to the depth of the area of interest, so the veloc­
which may be used to generate images that are ity recorded is the velocity of that area only. Thus,
often superior to standard images (Otto, 2004) pulsed wave Doppler gives spatial resolution while
The frequency of the transmitted pulse is CW Doppler does not. PW Doppler is usually set up
important in determining image quality. Image using 2D ultrasound so that the area of interest can
resolution is better with high frequencies, while be visualised and the window set accordingly. There
depth of penetration is better with low frequencies. is a limitation imposed by the PW nature of this
There is a trade off between these two factors. In technique. The changes in frequency used to gener­
general, superficial structures are best imaged with ate velocity information become ambiguous if they
high frequencies, while deeper structures are best are greater than half the pulse repetition frequency
imaged with low frequencies (Anderson, 2007). (Nyquist limit). This means that PW Doppler can
A basic artefact of ultrasound tissue imaging only be used to examine relatively low blood flows,
is acoustic shadowing. This is where an intensely while assessment of high velocity turbulent jets
echogenic structure blocks propagation of the requires CW techniques (Anderson, 2007).
ultrasound wave, producing an echo-free shadow The technique of PW Doppler may be extended
distal to the structure. This artefact may be useful to multiple areas of interest. This allows a colour
(e.g. giving a characteristic appearance with- echo­ flow map to be generated and superimposed on a
genic gallstones) or interfere with image generation 2D ultrasound image of the anatomical structures.
(e.g. image degradation deep to bone or gas) (Otto, This technique is termed colour flow imaging.
2004). Conventionally, blue is used to display flow away
from the transducer and red for flow towards it.
Doppler ultrasound This can be remembered with the mnemonic:
When ultrasound waves are reflected from an BART (Anderson, 2007).
interface moving towards the transducer, there is
an increase in frequency of the waves. The opposite
is true when the interface is moving away. This is
a manifestation of the Doppler effect, easily exem­ COMPUTED
plified by the fall in frequency of the sound from
the siren of a passing ambulance. Doppler ultra­ TOMOGRAPHY
sound may be used in a continuous wave (CW) or In the current generation of CT scanners, the X-ray
pulsed wave (PW) modality. These are often used tube rotates in a circle around the patient while the
to examine blood flow, with the interface being the patient is moved continuously through the gantry.
red blood cell membrane (Anderson, 2007). The X-ray tube follows a helical path relative to
With CW Doppler, the ultrasound beam is the patient. Multiple rows of detectors are located
directed along a single line. The transducer gen­ in the gantry opposite the X-ray tube, allowing
erates a continuous wave of ultrasound at a set rapid data acquisition. At the time the scan is per­
frequency and records the reflected signal. The formed, the technician sets a range of parameters
peak change in frequency between the generated suitable for the examination being conducted and
and reflected frequency measures the maximum these parameters define the resolution of the scan
velocity directed towards (or away from) the (Hofer, 2005).
transducer. This technique allows assessment of The raw dataset acquired is used to reconstruct
the maximum velocity with no limitation on how a matrix of voxels (cuboid volume elements). Each
high this is, but lacks spatial resolution. The maxi­ voxel is assigned a value calculated from the attenu­
mum velocity could have been generated anywhere ation of the X-rays passing through it. This value
along the beam path. Conventionally, the display corresponds to the average density of the tissue
shows movement towards the transducer as a posi­ in the voxel. The voxels are arranged in a series of
tive velocity above the baseline and away from the slices, that are 1 voxel thick. These slices can then
transducer as a negative velocity below the baseline be displayed as a 2D image with the brightness of
(Anderson, 2007). each pixel dependent on the attenuation value of
With PW Doppler, a small window is set as the corresponding voxel (Hofer, 2005).
the area of interest. The ultrasound beam is again Conventionally, the basic axial 2D image is dis­
directed along a single line through the area of played as if the patient is supine and the observer
374 Diagnostic imaging in critical care

TABLE 6.1: Typical densities of a range of tissues, level of the tissue being examined. Typical windows
in Hounsfield units. Adapted from Hofer, 2005. used are “soft tissue”, “bone”, “lung” and “brain”.
In addition to the axial 2D reconstruction, it is
Tissue Density (HU) possible to generate other reconstructions from the
Bone (compact and spongy) > WO raw dataset, which help appreciate the anatomy
in three dimensions. This post processing is done
Clotted blood 80 ± 10
after the patient leaves the CT suite. Multiplanar
Blood 55 ± 5 reconstruction (MPR) simply reconstructs the raw
Solid abdominal organs 30-80 dataset into a new matrix of voxels, with the slices
arranged in a different plane. Typical planes are
Liver 65 ± 5 axial, sagittal and coronal. Oblique reformats may
Spleen/muscle/lymphoma 45 ± 5 also be performed in any plane (Pavone, 2001).
Maximal Intensity Projection (MIP) is used to
Exudate 25 ±5 depict 3D “voxel” information on a 2D image. For
Transudate 18 ± 2 each pixel, the value to be displayed is calculated
by evaluating each of the voxels lying along a line
Fat/connective tissue -15 + 65
perpendicular to the screen (analogous to the view­
Fat -90+10 er’s line of sight), and displaying the maximum
Water density fluids 0-10 voxel value on the line. The angle of view may be
changed by rotating the image, giving a further 3D
perspective. This technique is useful for displaying
contrast enhanced blood vessels both on CT and
is standing at the patient’s feet. The patient’s right MRI (Pavone, 2001).
side is on the left-hand side of the screen and vice Surface-shaded display shows the surface of
versa; anterior is on top of the screen and posterior a structure that has been defined by having den­
at the bottom. To gain an appreciation of the 3D sity above a set value of Hounsfield units. The
nature of the anatomy, images are scrolled through appearance is enhanced by a hypothetical source
on a computer screen, allowing structures such as of light that the computer uses to create shading.
blood vessels to be followed as they pass between The image generated may be rotated, allowing the
slices (Hofer, 2005). entire surface of the structure to be examined. This
The attenuation value of a voxel is related to the technique is useful for displaying bony structures
average density of the tissue in it. When a single (Pavone, 2001).
structure does not occupy the full volume of a Volume rendering is a more complex and
voxel, partial volume effects occur, which may computationally costly method of displaying 3D
result in poor definition of the borders of a struc­ information. A wide variety of applications include
ture. This explains the poor definition of sites such CT angiography and virtual colonoscopy (Pavone,
as the poles of the kidney (Hofer, 2005). 2001).
The density of a structure on the CT scan can CT scans are often combined with the intrave­
be measured. This can provide useful diagnostic nous injection of an iodinated contrast medium.
information, such as allowing a pleural effusion to Contrast administered intravenously distributes
be distinguished from a haemothorax. Care must rapidly throughout the extracellular space (except
be taken to include several voxels in the region of for the central nervous system) and is excreted by
interest to avoid errors due to statistical fluctua­ the kidneys. The time between intravenous con­
tions and to avoid partial volume effects. Density is trast injection and data acquisition determines
measured in Hounsfield units (HU), a scale where the pattern of contrast enhancement. As the time
water is 0 HU and air is -1000 HU. Typical densi­ from injection progresses, contrast is seen within
ties for tissues are given in Table 6.1. The density the arteries (arterial phase), then the tissues (late
of almost all soft tissue organs lie in the 10-90 HU venous phase), then in the urinary collecting sys­
range (Hofer, 2005). tem (delayed phase). Intravenous administration
A modern computer screen can display 256 of iodinated contrast media is associated with
shades of grey but the human eye can only distin­ dose-dependant nephrotoxicity, particularly in
guish approximately 20. If the full range of tissue patients with impaired renal function (Adam,
densities (-1000 to +1000 HU) were to be displayed 2008).
on the computer screen, it would not be possible
to distinguish between many tissues of interest. For
this reason, it is necessary to display only a small
range (window) of densities, centred on the density
 6 • Imaging modalities 375

the tissue and the T2 value of the tissue. Mobile

MAGNETIC fluid environments (e.g. CSF) are associated with
long T2 values (high intensity on image), while less
RESONANCE IMAGING mobile fluid environments (e.g. white matter) are
Protons have charge and spin, hence act as small associated with short T2 values (low intensity on
magnets. When they are exposed to a strong mag­ image). Lesions in the CNS that have high water
netic field they tend to align with the magnetic field content or have disruption of the structure of the
and their axes of rotation wobble at the same fre­ tissue at a cellular level will have a high T2 signal
quency (Larmor frequency). The wobbling of the (Schild, 1990).
axes of rotation of the individual protons are out of Fast spin echo (FSE) allows rapid image acqui­
phase with one another. If they are then exposed to sition, thereby minimising movement artefact
a strong radiofrequency (RF) pulse of an appropri­ and gives a different contrast pattern to other
ate frequency, their alignment will change and the sequences (Blink, 2004). It is useful for examining
wobbling of the axes of rotation of the protons will the spinal cord in trauma, assessing for oedema or
move into phase. When the RF pulse stops, the pro­ haematoma.
tons release energy as radio frequency waves (the Fat-suppressed images may be obtained for
signal) then move back into alignment with the Tl- and T2-weighted sequences. This is useful for
magnetic field and the wobbling of the axes of rota­ imaging bony structures, where fat from marrow
tion once again becomes out of phase. The rate of may obscure pathology.
return to the baseline state is characterised by two
independent processes, each with their own time (2) Gradient echo (GRE) sequences
constant. T1 is the “longitudinal relaxation time With these sequences, there is rapid image acquisi­
constant” and relates to the rate at which the pro­ tion and images maybe Tl-weighted, T2-weighted
tons move back into alignment with the magnetic or PD (Blink, 2004).
field. T2 is the “transverse relaxation time constant” The fast spoiled gradient echo (FSPGR) sequence
and relates to the rate at which the wobbling of the is highly sensitive for detecting tissue containing
axes of rotation move out of phase (Schild, 1990). iron or calcium, which will both produce a mark­
The preceding paragraph describes the basic edly hypointense signal. It is useful for assessing
principles of MRI, but the practical application is haematoma or examining the bones.
considerably more complex. Sequences use mul­
tiple RF pulses, with varying frequency, direction, (3) Inversion recovery sequences
and other parameters, in order to generate images Two sequences commonly used are (Blink, 2004):
with different characteristics. A detailed explana­ • Fluid attenuated inversion recovery (FLAIR)
tion of how these images are generated is beyond sequence, which eliminates the signal from CSF.
the scope of this book but a simplified overview It is sensitive to oedema and inflammation.
may be helpful. One issue is that different MRI • Short Tl inversion recovery (STIR) sequence,
manufacturers use different names to describe very which eliminates the signal from fat tissue. This
similar sequences. MRI sequences may be categor­ is useful when high signal from fat in the marrow
ised into four broad groups. may obscure pathology such as subtle traumatic
bone marrow oedema.
(1) Spin echo sequences
These are the most frequently used sequences. They (4) Diffusion weighted imaging (DWI)
include the standard Tl-weighted, T2-weighted DWI assesses the movement of protons due to
and proton density (PD) images. diffusion over a short time. If there is restricted
With a PD image, the effects of T1 and T2 are diffusion, the signal is of high intensity. If there is
eliminated so the intensity of signal depends on the unrestricted diffusion (e.g. CSF), there is low inten­
density of protons in the tissue (Blink, 2004). sity signal. Unfortunately, the signal on DWI is not
The intensity of the signal in a T1-weighted just produced by the diffusion characteristics, but
image depends on both the density of protons in also changes in parallel with the T2 and PD of the
the tissue and the Tl value of the tissue. Tissues tissue. To eliminate these confounders, an apparent
in which the protons are tightly bound (e.g. fat) diffusion coefficient (ADC) map is generated. The
are associated with short Tl values (high intensity ADC signal is low with true restricted diffusion.
on image), while tissues in which the protons are Using a combination of these sequences, vasogenic
loosely bound (e.g. CSF) are associated with long oedema (intensity high on T2, high on DWI and
Tl values (low intensity on image) (Schild, 1990). high on ADC map) may be distinguished from
The intensity of the signal in a T2-weighted cytotoxic oedema (intensity high on T2, high on
image depends on both the density of protons in DWI, and reduced on ADC map) (Mikulis, 2007).
376 Diagnostic imaging in critical care

Gadolinium contrast with oedema (fractures, tumours or infections),

Gadolinium (Gd) is a paramagnetic substance the marrow becomes darker (hypointense). On
that acts., ds a contrast agent by markedly short­ T2 sequences, the CSF is bright (myelographic
ening Tl when it is present. Gd-based contrast effect), as is any marrow oedema. T2 sequences
distributes throughout the extracellular fluid, are good for depicting cord injury.

Appendix
and does not cross the normal blood-brain bar­ • Axial Gradient echo as FSPGR to assess for hae­
rier. In pathological conditions in which the matoma, and optimise visualisation of bony
blood-brain barrier breaks down, there is marked structures.
hyper-intensity (enhancement) of affected areas on
Tl-weighted images (Roberts, 2007). REFERENCES
Gd administration may be combined with a fat- Adam A, Dixon AK, Grainger RG, et al (eds). Grainger &
suppressed sequence (Tat sat’), which eliminates Allison's diagnostic radiology. A textbook of medical
the normally bright Tl signal from the protons in imaging. Philadelphia; Elsevier: 2008
fat. This may be useful in the diagnosis of infec­ Anderson B. Echocardiography: The normal examina­ AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA ORGAN INJURY
tions such as epidural abscess or neoplasia. tion and echocardiographic measurements. Brisbane: SCALE - SPLEEN, LIVER AND KIDNEY*
In patients with both acute and chronic renal MGA Graphics; 2007
failure (GFR <30 mL/min), Gd contrast admin­ Bhave G, Lewis JB, Chang SS. Association of gadolinium SPLEEN
istration is associated with nephrogenic systemic based magnetic resonance imaging contrast agents
fibrosis and should be avoided if possible (Bhave, and nephrogenic systemic fibrosis. J Urol 2008; 180(3): Grade Injury Type Description of Injury
2008). There is some evidence that Gd contrast 830-5; discussion 835 1 Haematoma Subcapsular (< 10% surface area)
may have nephrotoxic effects (Perazella, 2007). Blink EJ. An easy introduction. Basic MRI physics for any­
one who has not a degree in physics. Available: http:// Laceration Capsular tear (< 1 cm parenchymal depth)
MRI sequences for neurological www.mri-physics.com; accessed 7 May 2009 II Haematoma Subcapsular (10% to 50% surface area); intraparenchymal (< 5 cm in diameter)
imaging Erkonen WE.’ Chapter 1: Radiography, computed
The exact sequences used will vary depending on tomography, magnetic resonance imaging, and ultra­
Laceration Capsular tear (1-3 cm parenchymal depth that does not involve a trabecular vessel)
the clinical question and the region of the body sonography: Principles and indications. In: Erkonen III Haematoma Subcapsular (> 50% surface area or expanding); ruptured subcapsular or
being examined. A range of sequences are cho­ WE, Smith WL, eds. Radiology 101. The basics and parenchymal haematoma; intraparenchymal haematoma (a 5 cm or expanding)
sen that provide complementary information. fundamentals of imaging. 2nd edn. Philadelphia: Laceration > 3 cm parenchymal depth or involving trabecular vessels
Sequences that are commonly used for imaging the Lipincott Williams and Wilkins; 2005: 3-15
brain and spinal cord are described below, Feigenbaum H, Armstrong WF, Ryan T. Chapter 2: Physics IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation
and instrumentation. In: Feigenbaum H, Armstrong (> 25% of spleen)
MRI sequences for brain imaging WF, eds. Feigenbaum’s echocardiography. 6th edn. V Haematoma Completely shattered spleen
• Axial Tl-weighted spin echo (Tl): shows fluid Philadelphia: Lippincott Williams and Wilkins; 2005:
Laceration Hilar vascular injury devascularises spleen
signal hypointense to that of normal brain. 11-45
Subacute blood, proteinaceous material and fat Hofer M, ed. CT teaching manual. A systematic approach
signal are hyper-intense relative to the brain. LIVER
to CT reading. New York: Thieme Medical Publishers;
• Axial T2 FLAIR: nulls the normally bright T2 2005 Grade Injury Type Description of Injury
signal of CSF (becomes black), while other Long BW, Frank ED, Ehrilich RA, eds. Radiography essen­
parenchymal fluid appears bright (as in oedema 1 Haematoma Subcapsular (< 10% surface area)
tials for limited practice. 2nd edn. St. Louis: Saunders;
or tumour). 2006 Laceration Capsular tear (< 1 cm parenchymal depth)
• Axial DWI and ADC: depict restricted diffusion Mikulis Df, Roberts TP. Neuro MR: Protocols. J Magn II Haematoma Subcapsular (10% to 50% surface area); intraparenchymal (< 10 cm in diameter)
in acute infarcts, abscesses and some hypercellu- Reson Imaging 2007; 26(4): 838-47
lar neoplasms. These sequences are used to look Novelline RA, ed. Squire’s fundamentals of radiology. Laceration Capsular tear (1-3 cm parenchymal depth, < 10 cm in length)
for acute infarcts. Cambridge: Harvard University Press; 2004 ill Haematoma Subcapsular (> 50% surface area of ruptured subcapsular or parenchymal
• Axial gradient echo: is highly sensitive for blood, Otto CM, ed. Textbook of clinical echocardiography. 3rd haematoma); intraparenchymal haematoma (> 10 cm or expanding)
which appears markedly hypo-intense in signal. edn. Philadelphia: Saunders; 2004
Laceration > 3 cm parenchymal depth
It generally overestimates the actual haematoma Pavone P, Luccichenti G, Cademartiri F. From maximum
size (blooming effect). intensity projection to volume rendering. Semin IV Laceration Parenchymal disruption involving 25-75% hepatic lobe or 1-3 Couinaud's segments
Ultrasound CT MR 2001; 22(5): 413-19 V Laceration Parenchymal disruption involving > 75% of hepatic lobe or> 3 Couinaud's segments
MRI sequences for spinal cord Perazella MA, Rodby RA. Gadolinium use in patients with within a single lobe
imaging kidney disease: A cause for concern. Semin Dial 2007;
• Tl- and T2-weighted spin echo with and with­ 20(3): 179-85 Vascular Juxtahepatic venous injuries (i.e. retrohepatic vena cava / central major hepatic veins)
out fat suppression. Fat suppression improves Roberts TP, Mikulis D. Neuro MR: Principles. J Magn VI Vascular Hepatic avulsion
the ability to assess inflammatory processes in Reson Imaging 2007; 26(4): 823-37
fatty tissues. Tl sequences highlight the nor­ Schild HH, ed. MRI made easy (well almost). Berlin:
mally slightly hyperintense vertebral marrow, so Nationales Druckhaus; 1990

377
378 Appendix 1

KIDNEY
Grade Injury Type Description of Injury
1 . Contusion Microscopic or gross haematuria, urologic studies normal
Haematoma Subcapsular, non-expanding without parenchymal laceration
II Haematoma Non-expanding perirenal haematoma confined to renal retroperitoneum
Laceration < 1.0 cm parenchymal depth of renal cortex without urinary extravasation
111 Laceration > 1.0 cm parenchymal depth of renal cortex without collecting system rupture or
urinary extravasation
IV Laceration Parenchymal laceration extending through renal cortex, medulla and collecting system
Vascular Main renal artery or vein injury with contained haemorrhage
V Laceration Completely shattered kidney
Vascular Avulsion of renal hilum that devascularises kidney
Advance one grade for bilateral injuries up to grade III

* Tinkoff G, Esposito TJ, Reed J, et al. American association for the surgery of trauma organ injury scale I: spleen, liver, and
kidney, validation based on the National Trauma Data Bank. J Am Coll Surg 2008; 207: 646-55
Index
abdominal aortic aneurysm, 188 and fever, 246, 247, 259
rupture, 189 and headache, 228
abdominal distension neutrophil leucocytosis and fever, 248
and no bowel motion, 152 and repeated seizures, 259
and pain, 170 alveolar cell carcinoma, 29
abdominal injuries, car crashes, 159, 161,165, 207 alveolar infiltrates, 29,123
abdominal pain alveolar nodular opacities, 47
central, and septic shock, 172 alveolar nodules, 41
and distension, 170 alveolar opacification, 29,115
following car crash, 158 alveolar proteinosis, 135
generalised, and vomiting, 146 ambient cistern, 210
and hypotension, 151 American Association for the Surgery of Trauma, organ
left upper quadrant, 160 injury scale, 161
lower, and sepsis, 190 amoebic infections, 185
right lower quadrant, 177 amygdala, 214
right upper quadrant, and septic shock, 184, 202 angina, unstable, 6
and sepsis, 186 anlde injury, after fall from height, 352
and septic shock, 174 ankylosing spondylitis, 303, 309
and shock, 156 difficult intubation, 309
tachycardia and hypotension, 178 annulus fibrosus, calcification, 309
and vomiting, 148,155,166,168 anterior annulus fibrosus, 279
abdominal scan, 142-5 anterior cerebral artery (ACA), 214
abdominal sepsis, 340 Doppler studies, 270
abdominal trauma, 173 anterior cerebral artery territory infarction, 235
aberrant right subclavian artery, 113 anterior choroidal artery, 214
acalculous cholecystitis, 203 anterior circulation, 212,214
acetabular roof fractures, 195 anterior column (thoracolumbar spine), 279
acute calculous cholecystitis, 203 anterior communicating artery aneurysm, clipped, 234
acute intracranial haemorrhage, 219 anterior compression spinal fractures, 313
acute myeloid leukaemia (M3 type), 124,125 anterior cranial fossa, 210
acute-on-chronic intracranial haemorrhage, 219 anterior longitudinal ligament, TH, 279
acute posterior circulation ischaemia, 265 calcification, 309
acute pulmonary oedema, reticular infiltrates, 27 increased signal density anterior to, 331
acute renal failure, 205 anterior pararenal space, 145
and Gd contrast administration, 376 anterior renal fascia, 144,145
septic shock and thigh skin lesion, 362 anterior spinal artery, 214
acute respiratory distress syndrome (ARDS), 71 anterior vertebral body
acute right hemiplegia, 266 failure in compression of anterior column, 315
acute subdural haematoma, 219 fracture of the cortex, 315
acute thalamic haemorrhage, 225 anteroposterior compression pelvic fracture, 195,197
adductor muscles, haematoma, 365 aortic arch calcification, 67
adenomyomatosis, 203 aortic coarctation, 81
adrenal glands, 144 aortic contour, irregular, 105
adrenal lesions, 159 aortic disruption, 83, 111
air bronchograms, 29, 53,123 management, 111
airway management, and rheumatoid arthritis, 285 aortic dissection, 107
airway obstruction, 324, 325, 326, 327 aortic injury, traumatic, 105
altered level of consciousness aortic valve protheses, 53
after sedation in the elderly, 239 aortic valve replacement, 53

379
380 Index

apical pneumothorax, 35 biliary sepsis, 185

apparent diffusion coefficient (ADC) maps, 259,265,267, biliary tract disease, 185
375 biliary tree, gas in, 185
appendicitis,' 175,177,185 bladder rupture, 195
CT findings, 177 bowel cancer, 169
appenditolith, calcified, 177 bowel necrosis, 173
arterial-alveolar oxygen gradient, high, 36 bowel obstruction, 173
arterial insufficiency, 359 large bowel, 153,169
arterial supply of the gut, 144 small bowel, 155,167
aryepiglottic folds, oedamatous mucosa overlying, 325 brachiocephalic vein compression, 329
arytenoids, oedamatous mucosa overlying, 325 brain, vascular territories, 212-14
asbestosis, 59,73 brain death, 273
ascending colon brain herniation, patterns, 245
dilation, 169 brain imaging, MRI, 376
gas, 173 brain lobes (CT scan), 210,212
thickening, 171 brain parenchyma tumours, 249
Aspergillus, 123 brainstem, 210
aspiration, 8,9,71,99 brainstem ischaemia, 265
and lung abscess, 43 breast implants, 57
atelectasis, 53,139,285 bronchi, dilated corrugated, 133
dependent, 115 bronchial carcinoma, 61
linear, 35 bronchiectasis, 129
atheroma, 121 traction, 133
atlanto-occipital joint, widening, 295 bronchiolitis obliterans organising pneumonia (BOOT), 131
atlanto-occipital subluxation, 295 bronchoalveolar carcinoma, 131
atlantoaxial joint, widening, 293 burst fractures of thoracolumbar spine, 315
atlantoaxial rotatory stability, 276
atlantoaxial subluxation, 285 Cl
atlantodens instability, 276 anterior arch congenital defect, 297
atlas fracture, 276 anterior arch fracture, 289
ATRA (All-trans-Retinoic Acid) syndrome, 125 asymmetry around odontoid peg, 307
autoimmune thryoiditis, 329 Jefferson fracture, 296
axial DWI and ADC, 376 positive displacement, 289
axial gradient echo, 376 posterior arch deficiency, 297
axial T1-weighted spin echo (Tl), 376 posterior arch fracture, 291
axial T2 FLAIR, 376 rotary subluxation, 293,295
axonal injuries, diffuse, 255 Cl esterase inhibitor, 177
azygous fissure, 101 C2
azygous lobe, 75,101 os odontoideum, 297
traumatic spondylolisthesis, 291
back injuries C2 facet, displacement, 293
car crashes, 165,302,306, 316,320, 322 C2 to C6 spinous processes, increased T2 signal intensity,
fall from scaffold, 314 331
motorbike crash, 304 C3/4, oedema in the cord around, 331
back pain, mid-thoracic, 312 C3/4 disc, increased signal intensity, 331
bacterial infections, 123,125,338 C4, inferoposterior aspect displacement, 301
Baker’s cyst, 369 C4 facet, angulation, 281
Balthazar Severity Index, 179 C4 vertebral body, vertical fracture, 301
basal cisterns, 210 C4/5
obliteration, 237 distractive flexion injury, 281
basal ganglia, 210 interspace narrowing, 281
abnormal T2 signal, 267 C5 facet, angulation, 281
basal ganglia infarction, 231 C5 vertebral body, avulsed inferior corner fragment, 303
basilar artery, 212,214 C5/6, distractive extension injury, 303
absence of flow void, 265 C6, bilaminar fracture, 283
aneurysm, 223 C6/7
transcranial Doppler study, 272 disc fracture, 309
basilar artery thrombosis, 265 distr active flexion injury, 299
bile duct, 144 C7
bile duct injury, iatrogenic, 186 bilaminar fracture, 283
bile leak, 187 comminuted fracture, 307
biliary calculi, 181 kyphosis, 307
 - Index 381

C7 vertebral arch, bilateral fractures, 305 cerebral hemispheres, 210,214

caecal dilation, 153,169 cerebral ischaemia, 265, 267
caecal thickening, 171 cerebral oedema, 223,251
caecal volvulus, 147,149,153 cytotoxic, 245,265,267
calcaneal fractures, 357 vasogenic, 245
comminuted, 353 cerebral venous sinus thrombosis, 269
contralateral, 353 cerebral white matter, increased intensity on T2-weighted
calcification of the aortic arch, 67 and T2-FLAIR images, 261
calcified appendicolith, 177 cervical epidural collection over several vertebral levels, Tl/
calculous cholecystitis, 203 T2-weighted images, 333
calf haematoma, 369 cervical spine injuries
car crashes in multiple trauma, imaging modality, 283
abdominal injuries, 159,161,165,207 through intubation, 285
back injuries, 165,302,306,316,320,322 “Chance” fracture, 317
chest injuries, 104,110,112,114 chest drains, 59,83,93,117
facial injuries, 156 chest injuries
foot injuries, 350 after fall from ladder, 258
head injuries, 250,272 car crashes, 104,110,112,114
neck injuries, 290,291,292,296 chest pain
pelvic injuries, 196,198,200,283 and shock, 108
“seat belt type” injuries, 317 and shortness of breath, 90
and tetraplegia, 299 sudden onset, 84,106
and unconsciousness, 288,302 chest stab wound, 116,117
wrist injuries, 347,348 chest tightness, and shortness of breath, 134
see also motorbike crashes chest X-rays
cardiac failure, 50,125 systematic examination scheme, 81
cardiac surgery, 52 technical aspects to be considered when interpreting, 97
devices, 48,49,53 Chiari 1 malformation, 263
and lower lobe collapse, 7 cholecystectomy, 180,181
cardiogenic pulmonary oedema, 29,71,135 and iatrogenic bile duct injury, 186
cardiomegaly, 35,99 cholecystitis
carotid artery, 212 acalculous, 203
intracranial branches, 214 acute calculous, 203
cauda equina syndrome, 314 emphysematous, 185,203
caudate nucleus, 210 gangrenous, 175
cavum septum pellucidum, 251 cholesteatoma, 247
cellulitis, caused by foreign body, 359 chronic eosinophilic pneumonia, 131
centra] chest pain, severe, 62 chronic hypersensitivity pneumonitis, 135
central cord syndrome, 330,331 chronic hypertension, 80
central sulcus, 210 chronic intracranial haemorrhage, 219
central tentorial herniation, 245 chronic obstructive airways disease, 50,57
central venous catheter placement, 103 chronic renal failure, and Gd contrast administration, 376
central venous line, 49,51 chronic reticular infiltrates, 27
centrilobular nodules, 129 chronic subdural haematoma, 221
tree-in-bud pattern, 129 Churg-Strauss syndrome, 131
centrum semiovale, 210 chylothorax, 93
infarcts in, 241 cisterna magna, 210
cerebellar heamorrhage, 229 clostridial soft tissue infection, foot, 357
cerebellar peduncles, lesions, 261 coeliac axis (CA), 142,143
cerebellar tonsils, 210 colitis, 171
displacement, 263 ulcerative, 173
herniation into the foramen magnum, 223,237 collapse, 9,21,25,115
cerebellar vessels, 214 lower lobe, 7,75
cerebellopontine cistern, 210 upper lobe, 11,31,33, 55
cerebellum, 210,214 common bile duct, obstruction by calculus, 181
cerebral abscess, 249 common femoral vein thrombosis, 369
cerebral aqueduct, 210 common hepatic duct, 144
cerebral atrophy, 239 community-acquired pneumonia, 130,131,151
generalised, 221 complex pelvic fractures, 195,201
cerebral circulation, “reverberant flow” pattern, 273 compression spinal fractures, 315
cerebral contusions, 253 anterior, 313
haemorrhagic, 219 lateral, 313
382 Index

compressive extension injury, 279, 283,305 discitis, 339

compressive flexion injury, 279,301 distal cerebral circulation, vascular resistance,
stages, 301 273
computed tomography (CT), 373-4 distractive compression injuries, 279
consolidation, 5,9,15, 53,123,125,127,131 distractive extension injury
contralateral calcaneal fracture, 353 at C5/6,303
contralateral shift, 17 classification, 303
contrast venography, 369 distractive flexion injury, 279
cord infarction, 337 at C4/5,281
cord ischaemia, 337 at C6/7,299
corona radiata, 210 diverticulitis, 175
hypodensity, 239 Doppler ultrasound, 373
infarcts in, 241 dorsalis pedis artery calcification, 351
coronary angiography, 366 double superior venous cava system, 103
and subsequent pseudoaneurysm, 367 drug reaction, 131
coronary artery bypass surgery, 6, 34,60,90,92 duodenal ulcer perforation, 185
coronary artery stenosis, 6 duodenum, 144
corpus callosum, 210 identifying, 142-3
lesions, 261 duplex ultrasonography, 369
cortical border zone infarctions, 241 dyspnoea, 72,73
coup-contrecoup injury, 219
Coxiella burnettii, 131 ECG dots, 49
cranial CT scan, structures seen, 210,211 elbow joint effusion, 361
craniocervical junction, 276-8 emphysema, 13
axial image, Tl^-1 subcutaneous, 39
congenital anomalies, 297 surgical, 37,77
coronal views, 2T1 emphysematous cholecystitis, 185,203
major ligaments, 277 emphysematous pyelonephritis, 183
parasaggital image, 276 empyemas, 45,73,119
sagittal image, 276 subdural, 247
craniocervical junction injuries, 291,307 encephalopathy, septic, 65
craniocervical junction ligament injuries, 293 encysted fluid collection in a fissure, 67
cricothyroidectomy, 326 endocarditis, 339
Crohn’s disease, 173 endometrium, thickening, 193
Cryptococcus, 123 endotracheal tube, 49, 51,53, 55, 59,83
CSF flow artefacts, 337 enterocolitis, necrotising, 173
CSF spaces, 210 epidural abscess, 339
CT scans, 373-4 epidural haematoma, 333
CW (continuous wave) Doppler, 373 epiglottitis, 325
cystic duct, 144 epilepsy, new onset, 242, 243
cytotoxic cerebral oedema, 245, 267 eventration of the diaphragm, 95
from acute ischaemia, 265 exsanguinating haemorrhage, 364
extradural haematoma, 217
deep vein thrombosis (DVT), 369 extrahepatic bile duct, dilation, 181
descending colon extrarenal pelvis and ureter, dilatation, 205
collapse, 169
thickening, 171 facet joint capsule, 279
dialysis catheter, placement, 102,103 facet joint dislocation, 299
diaphragm bilateral, 281,299,321
depression, 115 unilateral, 281,299
focal eventration, 95 facet joints, fusion, 309
diaphragmatic border facial fractures, 256-7
abnormal contour, 33 facial injuries
loss of, 29,31 after altercation, 253
diaphragmatic hernia, traumatic, 73 car crashes, 156
diffuse axonal injury, 255 falciform ligament outlined by air, 157
diffuse idiopathic skeletal hyperostosis (DISH), 303, 309, fall down stairs, and mid-thoracic back pain, 312
311 fall from height, ankle injury, 352
management, 311 fall from horse, neck injuries, 286
diffusion weighted imaging (DWI), 259, 375 fall from ladder
digital subtraction angiogram, 355 with chest and limb injuries, 238
direct CT contrast venography, 369 and open injury to heel, 356
 Index 383

fall from scaffold glioblastoma multiforme, 245

with back injuries, 314 glioma, 249
with head injuries, 194 globus pallidus, 210
falx cerebri, hyperden.se mass adjacent to, 243 gluteus maximus haematoma, 365
fasciitis, necrotising, 363 goitre, multinodular, 329
FAST (Focussed Assessment with Sonography in Trauma) gradient echo (GRE) sequences (MRI), 375
scan, 207 grey matter, bilateral hypodense lesions, 241
fast spin echo (FSE), 375 grey-white differentiation, loss of, 223,237,251
fast spoiled gradient echo (FSPGR) sequence, 375 grey-white junction, hyperdense lesions, 255
fat embolism syndrome, 71,96 groin, pulsatile mass, adjacent to catheter insertion site, 366
feeding tube, inserted in right main bronchus, 51 ground-glass opacification, 127,131,133,135
femoral artery, saphenous vein reconstruction, 364,365 Guillain e-Barre syndrome, 265
femoral artery access site, and pseudoaneurysm, 367 gunshot wounds, 365
femoral hernia, incarcerated, 167 upper thigh, 364
fever gut, arterial supply, 144
and abdominal pain and distension, 170 gut infarction, 173
and altered level of consciousness, and repeated seizures, gynaecological infections, 191
259
and confusion, 246 haemoperitoneum, 163
and cough, 43,44 haemorrhagic cerebral contusion, 219
and malaise following pneumococcal pneumonia, 118, haemothorax, 54, 55, 58, 59, 73
119 causes, 78,79
neutophil leucocytosis and altered consciousness, 248 intercostal catheter, 117
rigors and back pain, 182 massive, 93
and shortness of breath, 14,40,44,46,90 Hangman’s fracture, 291
sore throat and stridor, 324 hard palate, sagittal fracture, 257
fibrotic lung disease, 133 head injuries
fibula, comminuted fracture, 355 after being hit by falling tree, 300
flail chest, 77 after fall, 220
flexion-distraction dislocation of thoracolumbar spine, 321 after falling down stairs, 218
flexion-distraction injuries of thoracolumbar spine, 317,319 after jumping off roof, 216
fluid overload, 96 car crashes, 250,272
foot, clostridial soft tissue infection, 357 motorbike crash, 254
foot injuries headache
after fall from ladder, 356 and declining consciousness, 228
car crashes, 350 and subsequent seizures, 269
“football sign” (large pneumoperitoneum), 157 sudden, and unconsciousness, 227
foramen magnum, 210 heel open injury, after fall from ladder, 356
foraminal herniation, 245 hemidiaphragm
fourth ventricle, 210 air under left, 65
elongation, 263 depression with deep sulcus sign, 39
fracture dislocation injuries of thoracic spine, 319 elevated, 95
free fluid, 142,159 loss of, 53
free intraperitoneal gas, 142,151,159 hemiparesis, 224,225, 270
frontal lobe, 210 hemipelvis
haematoma, 227 displacement, 201
hypodensity, 235 rotation, 197,199
traumatic contusions, 253 hemiplegia, acute right, 266
frontonasal junction disrupture, 257 hemithorax
frontotemporal lesion, mixed-density, 245 opacification, 25,31
fungal infections, 123,125,185 opaque, 15,17,19,21,23,54,55,93
hepatic artery, 144
gadolinium (Gd) contrast, 376 herpes encephalitis, 259
gallbadder, 202,203 high resolution CT, 132,133
gas in, 185 hilar lymphadenopathy, 69
gallbladder wall, thickening, 203 hip osteoarthritis, bilateral, 197
gallstone ileus, 185 histoplasmosis, 47
gallstones, 179, 203 hollow visceral perforation, 159
gangrenous cholecystitis, 175 homonymous hemianopia without hemiparesis, 233
gas exchange, impaired, 24,25,113,115 horizontal fissure, upward shift, 11
gas gangrene, 357 Hounsfield units, for tissue density measurement, 187,374
gastric distension, 79 humeral head, internal rotation, 345
384 Index Index 385

hydatid cyst, 61 intracranial haemorrhage lateroconal fascia, 144,145 lymphaginitis carcinomatosis, 135
hydrocephalus, 210, 221,223, 225, 229 age estimation, 219 LeFort fractures, 257 lymphoma, 29, 69, 85,127, 329
hydromyelia, 26.3 non-traumatic, 227 classification, 257
hydronephrosis, 205 intracranial hypertension, 210,237 left atrial enlargement, 49,89 M-mode ultrasound, 372
hyoid bone intracranial pressure, CT features, 237 left common femoral vein, 368 macroscopic haematuria, 165
' fractures; 303 intrahepatic bile ducts, dilation, 181 echogenic mass, 369 magnetic resonance imaging (MRI), 375
. soft tissue mass posterior to, 325 intralobular interstitial thickening, 135 left hemisphere, hypodensity, 237 for brain imaging, 376
"hyperacute” intracranial haemorrhage, 219 intralobular septae, 133 left hepatic duct, 143 diffusion weighted imaging (DWI), 375
hypercapnic respiratory failure, 56 intramuscular abscess, 339 left main bronchus, abrupt cut-off, 19,21 gadolinium contrast, 376
hyperextension injury, 331 intramuscular gas, 363 left middle cerebral artery territory infarct, 237 gradient echo (GRE) sequences, 375
hyperinflation of lung, 19 intrarenal abscess, 183 left posterior inferior cerebellar artery, absence of flow, inversion recovery sequences, 375
hyperlucency, upper zone, 35 intraventricular extension, 229 335 for neurological imaging, 376
hypersensitivity pneumonitis, 127,131 intubation left subclavian artery, 107 spin echo sequences, 375
chronic, 135 in ankylosing spondylitis, 309 left upper quadrant abdominal pain, 160 for spinal cord imaging, 376
hypertension, chronic, 80 and cervical spinal cord injury, 285 left vertebral artery, 111 mandibular ramus fractures, 287
hypoperfusion, 214 difficult, 230 absence of normal flow, 335 Marfan syndrome, 85
hypotension, 120,121,136,137,206, 214 in epiglottitis, 325 leg injuries, no pulse and abnormal sensation, 355 mass effect, 219, 221, 227,237,245
and abdominal pain, 151 inversion recovery sequences (MRI), 375 leg weakness, after anterior communicating artery aneurysm mastoiditis, 247
confusion and agitation, 162 ipsilateral cerebral peduncle compression, 225 clipped, 234 maxillary fractures, 257
tachycardia and abdominal pain, 178 ipsilateral shift, 19 lentiform nucleus, 210 maxillary sinus
hypoxaemic respiratory failure, 4,14,24,124,132,266 ipsilateral sulci effacement, 221 bilateral hypodense areas, 231 fluid level in, 253,255
hypoxia, 230,231 ipsilateral ventricle compression, 219, 221 lesser omentum, 144 lateral wall fracture, 255
ligamentum ar ter iosum, 105 mechanical bowel obstruction, 167
iliac artery calcification, 197 jaundice, and septic shock, 180 contrast extravasation near, 111 mechanical large bowel obstruction, 153
iliac wing fractures Jefferson fracture of Cl, 296 ligamentum flavum, 279 . mechanical ventilation, difficulty weaning from, 50, 56, 57,
oblique, 201 limb injuries, after fall from ladder, 258 138
vertical, 195 Klebsiella pneumonia, 123 Lindegaard ratio (LR), 271 mediastinal air, 63
imaging modalities knee joint, erosion of subchondral cortex of tibia and femur, lingular involvement, 9 mediastinal borders, 3
computed tomography, 373—4 361 Lisfranc injury, 351 loss of, 11,29,31
magnetic resonance imaging, 375-6 knee joint effusion, 361 liver mediastinal haematoma, 105
plain X-rays, 372 knee pain, and septic shock subsequent to leg wound, 361 arterial phase image, contrast extravasation, 163 mediastinal lymph nodes, enlarged, 127
ultrasound, 372—3 kyphosis, 307,319 parenchymal haematomas, 163 mediastinal lymphadenopathy, 69
immunocompromised patient, 123 subcapsular haematomas, 163 mediastinal mass, superior, 85
immunosuppression, 173 LI vertebral body liver abscess, 185 mediastinal shift, 17,19,21, 25, 31, 37, 93
incomplete spinal cord injury, 281 horizontal fracture line, 317 liver injury, grade III, 163 mediastinum, upper, vein compression, 329
indirect CT contrast venography, 369 minimally displaced fracture of the anterosuperior lobes of the brain (CT scan), 210,212 medulla oblongata, 210,214
inferior mesenteric artery (IMA), 143 aspect, 321 lower abdominal pain, and sepsis, 190 melanoma deposits, 47
inferior pubic rami, horizontal (coronal) fracture, 199, 201 L2 transverse process fracture, 195 lower cervical spine, classification of injury, 278-9 meningioma, 243
inferior vena cava, dilation, 137 L3/4, anterior epidural lesion, 339 lower lobes, 3 mesenteric ischaemia with gut infarction, 175
inferomedial temporal lobe, 214 L3/4 vertebral bodies, marrow oedema, 339 cavity in apical segment, 43 mesenteric vascular occlusion, 173
inflated chest X-rays, ribs showing, 97 L4 vertebral body, comminuted fracture, 315 centrilobular nodules, 129 mesothelioma, 17, 23
insula, 210 L4/5 transverse process fractures, 195 collapse, 7, 31, 33, 75 metastatic disease, 41,127
intercostal catheter, 45,116,117,119 L5> pars interarticularis discontinuity, 323 involvement in pathological process, 9 metatarsal, second, fractured with “fleck” sign, 351
interlobular interstitial septal thickening, 135 L5/S1 interspace, as site of spondylolisthesis, 323 lower thoracic scoliosis, 83 metatarsals, second to fifth, lateral displacement, 351
interlobular septae, 133 lactic acidosis, 172 Ludwig’s angina, 327 metatarsophalangeal joint, metallic foreign body distal to,
interloop triangular lucency, 157 lacunar infarcts, 239 luminal thrombus, 105 359
intermsuscular gas, 363 laparotomy, and free gas, 151 crescentic, 189 mid-thoracic back pain, 312
internal border zone infarctions, 241 large bowel distension, 153 lunate rotation, 347 mid-thoracic vertebra, anterior wedging, 313
internal capsule, 210, 214 large bowel loop lung midbrain, 210,214
hyperdensity, 225 “coffee bean” appearance, 147,149 collapse, 7, 9,21, 25, 55,115 increased intensity, 265
internal jugular central venous catheterisation, 53 distension, 153 lobes and fissures, 2 middle cerebral artery (MCA), 214
insertion using real-time ultrasound guidance, 340, gas-filled, 151 mediastinal borders, 3 acute ischaemia, 267
341 large bowel obstruction, 153,169 opacification, 5,7,29 aneurysm, 223
interspinous ligaments, 279 large bowel wall, thickening, 171 lung abscess, 43 Doppler studies, 270,271
calcification, 309 lateral compression pelvic fractures, 195,197,199 lung carcinomas, 69 vasospasm, 271
interstitial lung infiltrates, 27, 51 lateral compression spinal fractures, 313 lung cysts, “honeycomb”, 133 middle column (thoracolumbar spine), 279
interstitial pneumonia, 133 lateral flexion injury, 279 lung hilum, elevation, 13 middle cranial fossa, 210
interventricular foramen of Munro, 210 lateral medullary syndrome, 335 lung nodules, 129 middle lobes, 3
intimal flap, 105 lateral ventricles, 210 lymphadenopathy midface smash fractures, 257
intra-abdominal abscess, 175 effacement, 245 anterior neck, 329 midfoot swelling and bruising of medial side of plantar
intra-abdominal haemorrhage, 207 obstructive dilation, 245 hilar, 69 aspect, 350
intra-aortic balloon pump, 49 with temporal horn dilation, 223 mediastinal, 69 midline shift, 217,227,237,245
386 Index

miliary nodules, differential diagnosis, 47 odontoid fractures, 276,289

miliary tuberculosis, 47 classification, 289
mitral valve disease, 49,89 odontoid peg, 276, 277
mitral valve' prosthesesj 49,53 asymmetry of Cl, 307
mitral valve replacement, 34, 35, 53, 67 fracture, 289, 296
monitoring leads, 49 oesophageal rupture, 63
motorbike crashes oesophageal stent, 23
back injuries, 304 opacification
head injuries, 254 alveolar, 29
neck injuries, 294 hemithorax, 25,31
paraplegia after, 318 homogeneous, 17
and shortness of breath, 74,78 lungs, 5, 7, 29
mouth floor, soft tissue infection, 327 perihalar, 9
MR venography, 269, 369 opaque hemithorax, 15,17,19,21, 23, 54, 55, 93
MRI, 375-6 optic radiation, 210
multinodular goitre, 329 orbital rim fractures, 257
multiple sclerosis, 261, 337 organ injury scale, 161
Mycobacterium tuberculosis, 131 os odontoideum, 297
myelitis, transverse, 337 osteoarthritis, hip, 197
osteomyelitis, 339, 361
nasoethmoid fractures, 257 caused by foreign body, 359
neck, soft tissue mass with associated lymph adenopathy, osteopaenia, generalised, 313
329 osteophyte formation, 311, 331
neck injuries osteoporosis, of the spine, 285
after fall, 308 otitis media, 247
car crash, 290, 291 ovarian carcinoma, 191
fall from horse, 286 ovarian cyst, acute haemorrhage/infection in, 191
motorbike crash, 294 “owl’s eyes” appearance (basal ganglia infarction),
neck manipulation, vomiting, vertigo and nystagmus, 231
334
neck pain, after fall, 310 pacing wire, placement, 102, 103
neck swelling pads for external defibrillation or pacing, 49
and inflammation, 326 paired alar figaments, 277
and soft tissue infections, 327 pancreas, 144
with stridor or respiratory distress, 328 identifying, 143
necrotising enterocolitis, 173 pancreatic necrosis, 179
necrotising fasciitis, 363 pancreatitis, 175
needle biopsy, 66,67 grading, 169
neoplasms, 47,67,123 paraplegia, with sensory level at T6,336
primary or secondary, 61 parapneumonic effusion, 45
nephrogenic systemic fibrosis, 376 parenchymal haematomas
neurological imaging, MRI, 376 liver, 163
neutropenic typhlitis, 171 spleen, 161
neutrophil leucocytosis parietal lobe, 210
fever, and altered level of consciousness, 248 hypodensity, 233,235
and grossly swollen and inflamed neck, 326 parieto-occipital sulcus, 210
Nocardia, 234 pars interarticularis discontinuity, 323
nodular opacities, 47 PD (proton density) images, 375
non-cardiogenic pulmonary oedema, 29,71 pectus excavatum, 99
non-pyogenic liver abscess, 185 pelvic cavity, multilocular cystic lesions, 191
pelvic fractures
occipital bone, 210 anteroposterior compression, 195,197
occipital bone fractures, 303 classification, 195
occipital condyle, avulsion fracture, 287,291,293, complex, 195, 201
295 lateral compression, 195,197,199
occipital condyle fractures, 276 vertical shear, 195,353
occipital lobe, 210 pelvic injuries, car crashes, 196,198,200,283
hypodensity, 233 pelvic organs, 145
occipital poles, 214 pelvis, vertical shear injury, 195
occipitocervical dissociation, 276,295 perforated viscus, 65
classification, 295 periaortic contrast extravasation, 105
occult fractures, 253 periappendical fat stranding, 177
 Index 387

peribronchial cuffing, 135 posterior column (thoracolumbar spine), 279

pericardial effusion, 107,121,137 posterior communicating arteries, 213,214
pericardial tamponade, 137 posterior dislocation of the shoulder, 345
pericholecystic fluid, 203 posterior fossa haemorrhage, 229
perihalar ground-glass infiltrates, 123 posterior inferior cerebellar artery, 214
perihalar opacification, 9 absence of flow, 335
perilunate dislocations, 347 posterior longitudinal ligament, 277
perilymphatic nodules, 129 minimal ossification, 311
perinephric abscess, 183 posterior osseous arch, 279
perinephric fat stranding, 183 posterior pararenal space, 145
peripheral pruning, 87 posterior renal fascia, 144
perirenal (Gerota’s) fascia, thickening, 179 posterior spinal artery, 214
perirenal space, 144 posterior vertebral body, 315
perisplenic fluid, 159 premedullary cistern, 210
peritoneal cavity prepontine cistern, 210
free fluid, 142 primary alveolar proteinosis, 29, 71
lateral recess, 144-5 primary pulmonary hypertension, 87
periventricular white matter, hyperdense lesion, productive cough
249 fever and shortness of breath, 44
petechial haemorrhages, 255,267 and shortness of breath, 128
pineal gland calcification, 153 promyelocytic leukaemia (M3 type acute myeloid
plain X-rays, 372 leukaemia), 125
pleural calcifications, 23,73 proximal phalanges, cortical erosion, 359
pleural drainage catheter, 39 proximal pulmonary artery, 11
pleural effusion, 15,23,31, 33, 51, 63, 65, 91,121, proximal tibial shaft, lucent area, 361
139 pseudoaneurysm, 367
bilateral, 121,131,135 pseudo-obstruction, 153
subpulmonic, 33 pseudotumours, 67
supine vs erect X-ray, 31,33 psoas abscess, 183,339
pleural fluid, 17,53,79,115,119,319 psoas muscle, 183
pleural plaques, 59 abnormal enhancement, 339
pleural tumours, 17 retroperitoneal abscess, 189
pneumatosis intestinalis, 173 pterygoid process, fracture of, 257
pneumobilia, 173,185 pubic rami
pneumococcal pneumonia, fever following, 118, displaced 195
119 fractures, 199,201
pneumoconiosis, 47 horizontal (coronal) fractures, 199,201
Pneumocystis jiroveci, 123,127,135 vertical fractures 201
pneumocystis pneumonia, 125 pulmonary arteries, enlargement, 87
pneumonectomy, 19 pulmonary artery aneurysm, 61
pneumonia, 25,41, 61, 71, 99 pulmonary artery catheter, 10,11,49
community-acquired, 130,131,151 pulmonary artery defect, 111
pneumococcal, 118,119 pulmonary barotrauma, 173
pneumocystic, 125 pulmonary contusion, 77,117
staphylococcal, 15 pulmonary emboli, 87,109, 111
usual interstitial, 133 management, 109, 111
pneumonitis, hypersensitivity, 127,131 pulmonary fibrosis, 59
pneumoperitoneum, 151,157 pulmonary haemorrhage, 29, 71,125,127,135
pneumothorax pulmonary hypertension, primary, 87
apial, 35 pulmonary infarct, 10
tension, 37,39,115 pulmonary oedema, 127
pons, 210,214 atypical, 131
increased intensity, 265 cardiogenic, 29,71,135
popliteal artery, traumatic occlusion, 355 pulsatility index (PI), 273
popliteal artery aneurysm, 369 putamen, 210
porta hepatis, 143-4 PW (pulsed wave) Doppler, 373
portal vein, 144 pyelonephritis
portal venous gas, 173 acute, with sepsis, 183
posterior annulus fibrosus, 279 complicated by intrarenal, perinephric and psoas
posterior cerebral arteries (PCA), 214 abscess, 183
posterior cerebral artery territory infarction, 233 pyogenic liver abscess, 185
posterior circulation, 212,214 pyosalpinx, 191
388 Index

Q fever, 131 sacral ala, vertical shear fracture, 195

quadrigeminal cistern, 210 sacroiliac joint
calcification anterior to, 253 disruption, 199,201
quadriparesis,’261, 265' widening, 197
and incomplete sensory loss at C6 and below, saddle embolus, in main pulmonary artery, 209
<332 “sail signs” (elbow effusion), 361
quadriplegia, 308 saphenous vein reconstruction, femoral artery, 364, 365
sarcoidosis, 27,47,69,127,131,135
random nodules, 129 scaphoid fractures, 349
reintubation,-285 Schmorl’s nodes, 317
renal artery, 165 scoliosis, 155
renal cell carcinoma, 47 lower thoracic, 83
renal failure, acute, 205,362 thoracic, 337
renal (Gerota’s) fascia, 144 “seat belt type” injuries, 317
thickening, 183 sedation
renal injury, grade IV, 165 effects in the elderly, 238, 239
renal parenchyma, 165 and unresponsiveness, 241
renal vein, 165 sepsis
respiratory distress and abdominal pain, 186
and emergency tracheostomy, 308 five-weeks post-partum, 192
and neck swelling, 328 from retained products of conception, 193
severe, 76,77 and lower abdominal pain, 190
respiratory failure, 26, 50, 70, 71, 261 septic arthritis, 361
retained products of conception, and sepsis, 193 septic encephalopathy, 65
reticular infiltrates, acute pulmonary oedema, 27 septic shock, 10,338
retrocardiac opacification, 31,33,53 and abdominal pain, 174
retroperitoneal fluid collection, 183 back pain, fever and rigors, 182
retroperitoneal haematoma, 163,165, 201 and central abdominal pain, 172
retroperitoneal rupture of the abdominal aortic aneurysm, five-weeks post-partum, 192
189 and jaundice, 180
retroperitoneal spaces, lateral recess, 144-5 and pain in knee subsequent to leg wound, 361
retroperitoneal structures, upper abdomen, 142-3 and right upper quadrant abdominal pain, 184,202
rheumatoid arthritis, 285 and swelling of sole of foot and base of toes, 358
and airway management, 285 thigh skin lesion and acute renal failure, 362
rib fractures, 77,161 shock
fourth, 303,319 and abdominal pain, 156
right common carotid artery, 107 causes, 108,109,157
right common femoral artery, 107 shortness of breath, 28,30,31,32,33,68,122,126
right hepatic duct, 143 and chest pain, 90
right internal jugular central venous catheter, 53 and chest tightness, 134
insertion using real-time ultrasound guidance, 340, and desaturating on high-flow mask oxygen, 74
341 and fever, 14,40,44,46, 90
right internal mammary artery, 117 and hypoxaemic respiratory failure, 132
right lower quadrant abdominal pain, 177 motorbike crash, 74, 78
right main bronchus and non-productive cough and weight loss, 130
abrupt cut-off, 25 and productive cough, 44,128
feeding tube inserted in, 51 and reduced exercise tolerance, 86,88
right posterior cerebral artery territory infarction, shoulder, posterior dislocation, 345
233 shoulder bruising, 344
right sigmoid sinus, absence of flow void, 269 sigmoid colon
right subclavian artery, aberrant, 113 collapse, 169
right transverse sinus thickened, 175
absence of flow void, 269 sigmoid volvulus, 147,149
hyperdense region, 269 small bowel
right upper quadrant abdominal pain, and septic dilation, 169
shock,184,202 distension, 171
Sigler’s sign, 151,157 small bowel loop
rim-enhancing lesion, 249 distension, 153,167
rupture of abdominal aortic aneurysm, 189 gas-filled, 151
rupture of the aorta, 79, 83 “string of pearls” sign, 155
rupture of the oesophagus, 63 small bowel obstruction, 155,167
rupture of the transverse atlantal ligament, 285 sphincter of Oddi, incompetent, 185
 Index 389

spin echo sequences (MRI), 375 superior mesenteric artery (SMA), 142,143,144
spinal arteries, 214 superior pubic rami
spinal burst fractures, 315, 353 displaced fracture, 195
spinal collar, removal, 292,293 fracture, 199
spinal cord, increased intensity on T2-weighted and vertical fracture, 201
T2-FLAIR images, 261 superior saggital sinus
spinal cord imaging, MRI, 376 absence of flow voids, 269
spinal cord injury, incomplete, 281 hyperdense region, 269
spinal epidural haematoma, 333 superior venous cava
spinal fractures, 83 double, 103
thoracic, 75, 79 single, left-sided, 103
unstable, 75 suprapatellar pouch, fluid in, 361
spinal injuries, CT imaging, 276-9 suprasellar cistern, 210
spinolaminar line, 276 supraspinous ligaments, 279
disruption, 281,289,291 surgical drains, 49, 53
spleen surgical emphysema, 37, 77
parenchymal haematomas, 161 Sylvian fissure, 210
subcapsular haematomas, 161 symphysis pubis
splenic hilum, contrast extravasation, 161 diastasis, 195,197
splenic injuries, 159 disruption, 199
grade IV, 161 syncope episodes, 262
splenic vein (SV), 143 systemic lupus erythrematosus, 131
spondylolisthesis, 323
spondylolysis, 323 T1 spinous process, fracture, 293
stab wounds, chest, 116,117 • T1-weighted images, 385
Stanford type A aortic dissection, 107 T2-weighted images, 385
Stanford type B aortic dissection, 107 T7 vertebral body, anterior wedging, 319
staphylococcal pneumonia, 15 T7-T9, flexion rotation fracture dislocation, 319
Staphylococcus aureus, 123 T8 vertebral body, comminution with retropulsion of
in septic shock, 338 fragments, 319
status epilepticus, 344 T9 vertebral body, anterior wedging, 319
sternal dehiscence, risk factors, 91 Tll/12
sternal wires, 35,37,53,91 flexion-distraction dislocation, 321
straight sinus, hyperdense region, 269 posterior facet joint dislocation, 321
subacute intracranial haemorrhage, 219 T12 vertebral body, anterior compression, 321
subararchnoid haemorrhage, 223,234 T12/L1, widening of interspinous interval, 317
grade 1 aneurysmal, 270 tachycardia, abdominal pain and hypotension, 178
subaxial cervical spine tamponade, 121
axial images, 279 pericardial, 137
classification of injury, 279 temporal lobe, 210,214
coronal image, 278 hypodensity, 233
parasagittal image, 278 T1-weighted images, signal level, 259
sagittal image, 278 T2-weighted images, signal level, 259
subcapsular haematomas transtentorial herniation of uncinate process, 245
liver, 163 traumatic contusions, 253
spleen, 161 tension pneumothorax, 37,39,115
subclavian artery, aberrant, 113 tentorium cerebelli, 210
subcortical white matter, bilateral hypodense lesions, 241 hypodense lesion adjacent to, 247
subcutaneous emphysema, 39 teratoma, 85
subdural empyema, 247 testicular cancer, 47
subdural haematoma tetraplegia, following car crash, 299
acute, 219 thalamic haemorrhage, acute, 225
chronic, 221 thalamus, 210, 214
subfalcine herniation, 245 hyperdensity, 225
subhepatic air, 157 thigh
subhepatic space, fluid collection, 187 foreign bodies, 365
submandibular space, hypodense, multilocular collection, 327 gunshot wound, 364,365
subphrenic space, fluid collection, 187 oedema of skin and subcutaneous tissues, 363
subpulmonic pleural effusion, 33 thigh skin lesion, septic shock and acute renal failure, 362
subtalar joint, 353 third ventricle, 210
sucking chest wound, 116,117 thoracic aortic aneurysm, 85
sulcal effacement, 245 thoracic cord, increased T2 signal, 337
390 Index

thoracic scoliosis, 83, 337 uncal herniation

thoracic spinal fractures, 75, 79 features, 237
thoracolumbar spine­ transtentorial, 225,245
burst fractures, 315 unconsciousness, 222,244
classification of injury, 279 after sudden headache, 227
columns, 279 and car crash, 288, 302
flexion-distraction dislocation, 321 transient, after blow to head, 99
flexion-distraction injuries, 317, 319 unstable spinal fracture, 75
fracture dislocation injuries, 319 upper abdomen, retroperitoneal structures, 142-3
thromboembolic disease, 131 upper lobe fibrosis, 13
thryoiditis, autoimmune, 329 upper lobes, 2,100
thymoma, 85 collapse, 11
thyroid cancer, 47,85 upper zone, hyperlucency, 35
thyroid malignancy, 329 ureteric obstruction, 183,205
tibia, comminuted fracture, 355 urethral rupture, 195
tibial fracture, and subsequent swelling, 368 urine extravasation, 165
tibial shaft, proximal, lucent area, 361 usual interstitial pneumonia, 133
tissue density measurements, Hounsfield units, 187,374 uterine cavity, hypoechoic fluid, 193
tracheal compression, 329 uterus, 145
tracheostomy
and respiratory distress, 308 vascular territories, 212-13
in severe ankylosing spondylitis, 309 affected, 232,233
tracheostomy tube, 327 vascular thrombosis, 269
traction brochiectasis, 133 vascular watershed areas, 214
transcranial Doppler studies vasculitis, 131
basilar artery, 272 vasogenic cerebral oedema, 245
junction of MCA and ACA, 270,271 vasospasm, in middle cerebral artery, 271
Lindegaard ratio (LR), 271 venous infarction, 269
pulsatility index (PI), 273 ventricular decompression, 229
transtentorial herniation of posterior fossa contents, 229 ventricular system, 210
transtentorial uncal herniation, 225, 245 vertebral arteries, 212,214
transverse alantal ligament, 277 vertebral artery dissection, 335
rupture, 285 vertebral bodies, ossification, 311
transverse colon vertebral body lines, disruption, 281
dilation, 169 vertebral compression fractures, 313
thickening, 171 vertical compression injuries, 279, 307
transverse myelitis, 37 classification, 307
traumatic aortic injury, 105 vertical fracture of the lamina, 315
traumatic occlusion of the popliteal artery, 355 vertical shear pelvic fractures, 195,353
traumatic spondylolisthesis viral infections, 123,125,127
of the axis, 276 visceral perforation, 151,157
ofC2,192 hollow, 159
tricuspid valve annuloplasty ring, 53 volvulus
tricuspid valve prostheses, 53 caecal, 147, 149,153
tuberculosis, 68 sigmoid, 147,149
miliary, 47
tubo-ovarian abscess, 191 watershed areas, 214
type A aortic dissection, 107 watershed infarcts, 241
type B aortic dissection, 107 Wegener’s granulomatosis, 131
typhlitis, neutropenic, 171 white matter, hyperdense lesions, 255
white matter structures, 210
ulcerative colitis, 173 wrist injuries, car crashes, 347,348
ulnar styloid tip fracture, 347
ultrasound X-rays, 372
Doppler, 373
tissue imaging, 373-4 zygomaticomaxillary complex fractures, 257