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Aquifer Radiology Final Aquifer -

Radiology Actual Exam Questions With

Answers Latest Updated 2024

spine sign - Correct Answer if vertebrae appear more white on lateral projection, there may be a consolidation/pneumonia in a lower lobe (positive spine sign) vertebrae should appear black (lucent) Silhouette sign for: R heart border L heart border hemidiaphragms lower descending aorta - Correct Answer RML consolidation lingual consolidation (LML) lower lobe consolidation LLL consolidation air bronchograms - Correct Answer represent air-filled airways surrounded by lung consolidation; the air can be seen since the air in the alveoli has been replaced with an alveolar filling process not seen in pneumonia ground glass appearance and increased interstitial markings - Correct Answer atypical bacterial and viral organism pneumonia blood vessels that are not obscured by CT mycoplasma pneumonia can produce - Correct Answer Kerley B lines (thickening of interlobular septa that will touch the pleura-- blood vessels won't touch the pleura) what do you see on a radiograph of a consolidaiton - Correct Answer blood vessels are obscured by CT and air bronchograms are more common when do you follow up on pneumonia patients - Correct Answer over 40 history of recurrent pneumonia smoker at any time symptoms that won't resolve what can a portable x-ray evaluate - Correct Answer line and tube placement lungs

complications of central lines, feeding tubes, chest tubes, IAB pumps and other devices but are overall lower quality why can CT help distinguish between lung abscess and empyema? - Correct Answer both can have air-fluid levels on chest radiographs Window vs. Reconstruction on CT? - Correct Answer Reconstructions - processing of the raw CT data allows for better resolution of the structures [higher resolution and higher contrast] Reconstruction can be done in 3D (ortho) or in a linear way too (vascular) What is the total range of hounsfield units availabe? - Correct Answer -1000 (air) to +1000 (metal) [so range is 2000] What does a typical computer display show for greyscale range? What can the human eye actually distinguish? - Correct Answer 256shades (that means each shade of grey covers ~8HU) The can only distinguish 17 shades of grey What is a good way to check diaphragm flattening? - Correct Answer Look at the lateral film Diaphragm will be flat like you can set a ruler down on the edge What can a poor inspiration/hypoinflation appear like? - Correct Answer consolidation or PNA How to look at the lung fields? - Correct Answer Sweep or a zig zag down the lung field (both in PA and lateral views) look for focal, diffuse, BL asymmetrical, interstital/vasc markings, lucencies (cavity/bullae/PTX), compare upper and lower and L/R zones Middle lower zones Which hilum should always appear higher on the radiograph? - Correct Answer The LEFT sided hilum should be higher - if its not its pathological What to look for with the heart? - Correct Answer Size of the heart - the cadiac:thoracic cavity ratio LA

LV

What mediastinal lines should be observed on PA film? - Correct Answer R paratracheal line Azygous area Azygoesophageal line Paraaortic line (all the way down) If you can see these you need to figure out the reason why How to look at the bones on Xray? - Correct Answer Quadrant method [above and below the ribs] (the middle lung section you just also go down the spine looking for abnormalities, mets, or collapse When should you START looking at OLD films? - Correct Answer AFTER you have COMPLETELY evaluated the new scan What are the ACR appropriateness criteria? - Correct Answer The aim is to provide continuously updated evidence-based algorithms that ensure the safest, most cost- effective, and most efficient path to radiological diagnosis or intervention matched to specific variants of clinical presentations. Federal LAW requires referring physicians to consult Appropriate Use Criteria (AUC), such as ACR Appropriateness Criteria, prior to ordering advanced imaging services (ADIS), including CT, MR, nuclear medicine, and PET, for Medicare patients. How are appropriateness criteria divided/staged? - Correct Answer Older appropriateness rating tables used a numerical rating scale: • Usually Appropriate = 9, 8, or 7 • May be Appropriate = 6, 5, or 4 • Usually Not Appropriate = 3, 2, or 1 Newer appropriateness rating tables simply use the three categories: • Usually Appropriate (Green cells in the table) • May be Appropriate (Yellow cells in the table) • Usually Not Appropriate (Red cells in the table) What lobe of lung is seen at the apicies? - Correct Answer The R and L upper lobes What is the silhouette sign? - Correct Answer The visual interface between structures of different density. Its actually when a silhouette is LOST that we say its a "silhouette sign" What is spine sign? - Correct Answer When the combined density of the vertebrae and some source of fluid/consolidation make the vertebrae look MORE dense [just like ice over water accentuates the ice appearing like they have increased density even though they still the same ice]

What are cases in which spine sign occur? - Correct Answer Spine sign - vertebral bodies should be relative lucent (black) above the diaphragm on lateral projection. -Lateral x-ray goes through spine + pneumonia and vertebra will appear whiter (fewer x- rays reach detector since some are absorbed in the pneumonia)

• Helpful sign for detection of lower lobe pneumonia. - - Very useful for detecting LLL pneumonia behind the heart.
• If vertebral bodies appear more dense (whiter) above the level of diaphragm, and part of one of the diaphragms is obscured → spine sign → sign of lower lobe pneumonia
• There are other causes for the spine to appear whiter (such as a blastic bone metastasis). What is the lingula aligned with? - Correct Answer The left heart border (this is more visible in the lateral view xray) What are air bronchograms? - Correct Answer Air-filled bronchi within an area of consolidation. These are frequently seen in pneumonia, but can also be seen in some tumors and other lung abnormalities More common in alveolar disease Air bronchogram ≠ pneumonia Can be seen in lung cancer (adenocarcinoma with bronchioloalveolar pattern) Can be seen in lymphoma of the lung Seen in: A. Pneumonia C. Pulmonary edema D. Pulmonary hemorrhage E. ARDS Which patients w/ PNA should have a follow up xray? - Correct Answer All patients > 40 years History of recurrent pneumonia Current/former smokers Patients whose symptoms do not resolve What is the MC cause of solitary pulmonary nodules on CT scan? - Correct Answer Well-differentiated adenocarcinoma (formerly known as bronchioalveolar carcinoma (BAC)) Common in smokers AND non-smokers (esp females) True/False - mycoplasma PNA can cause Kerley B lines as seen in CHF?

What are Kerley B lines? - Correct Answer TRUE Kerley B lines (septal lines) represent thickening of interlobular SEPTA Note that sometimes Kerley B lines can be distinguished because they extend and touch the pleura What are ground glass opacities? - Correct Answer "Ground glass" is a radiology descriptive term (used in both chest radiographs and CT imaging) to indicate that blood vessels are not obscured, as would be the case in alveolar lung opacities. Compare ground glass opacities vs. consolidation opacities - Correct Answer Ground Glass: Blood vessels are not obscured on CT. "Smoke-like" opacity on CT that does not obscure blood vessels Descriptive term (usually primarily used on CT imaging). May represent either interstitial or alveolar disease. Some diseases (like PJP infection in HIV infection, early edema, etc.), often have "ground glass" opacities early in the disease process. Consolidation: BLOOD VESSELS are obscured on CT and air bronchograms are more common. What dosage of radiation in x-rays is 1 CT scan worth? - Correct Answer 150 x-rays worth of radiation per CT scan (ON AVERAGE) Some scans use more or less however depending on the application - for example PE scan = 400CXRs Abdominal Scan = 750CXRs V/Q scan = 800CXRs What is a hydropneumothorax? How much fluid is needed to be able to distinguish this?

• Correct Answer AN AIR-FLUID LEVEL (a horizontal edge between air and fluid) You will only see air-fluid levels on upright or decubitus studies It takes at least 150 cc of fluid to see it on a PA CXR; 50 cc on a lateral; and about 5 to 10 cc on a CT scan. What is a pleural pseudotumor? - Correct Answer A pleural "pseudotumor" is a loculated or localized collection of fluid in a major (oblique) fissure or right minor (horizontal) fissure and it can be mistaken for mass in the lung (hence the name "pseudotumor"). They are more common in pleural effusions associated with CHF for reasons that are not well explained. The abnormality is in the pleural space and NOT in the lung.

What is deep sulcus sign? - Correct Answer Deep sulcus sign is the sign of a pneumothorax on a supine chest radiograph (look for costophrenic angle thats pushing DOWN with a very sharp looking sulcus) What is continuous hemidiaphragm sign? - Correct Answer Continuous hemidiaphragm sign is a sign of a pneumomediastinum on a chest radiograph there appears to be a lucent line connecting both hemidiaphragms due to air between the pericardial sac and the diaphragm What is the overall utility of preoperative chest xrays? - Correct Answer No trial has shown the utility of preoperative CXRs (0% to 2% change in management). They remain common practice however Who qualifies for a preoperative CXR? - Correct Answer Two main indications for preoperative CXR:

1. Acute cardiopulmonary findings by H&P
2. Chronic cardiopulmonary disease in older adults, with no previous CXR within 6 months available How much overlap do you look at of the L upper/L lower lobe on the CXR? - Correct Answer A huge amount of overlap - you need to check the LATERAL film to get a sense of the depth Left Lower lobe drops BELOW the costophrenic angle and the Left UPPER lobe nearly ends AT the level of the diaphragm In which lobe is the lingula found? - Correct Answer Left UPPER lobe (its thought to be the REMNANT of a Left middle lobe that no longer exists) Means "tongue" What is a dual energy X-ray? - Correct Answer - Dedicated digital chest unit

• Two exposures are obtained milliseconds apart
• The imaging parameters are chosen to display bone and calcium on one image, and soft tissues on another image
• The two images are then combined (you can look at all 3 images separately too) If you find an nodule on CT or CXR what is your next move? - Correct Answer FIND THE OLD CT and CXR imaging - you need a comparison - this is the key This will help you figure out if its malignant/risky/ect....

At what diameter does a pulmonary "nodule" become a "mass"? - Correct Answer >3cm is called a "mass" What lung nodule characteristics should be assessed to guide management? What about patient factors that influence risk for cancer? - Correct Answer Nodule factors: Size of the nodule (malignancy increases over 1 cm) Edge (smooth, lobulated, spiculated, ill-defined) Presence and pattern of calcification (some patterns are benign) Growth (any change from prior images?) - fast growth is concerning Patient factors: History of lung fibrosis, asbestosis, etc. Age (over 40 the risk of malignancy increases) Smoking history (greatly increases risk a nodule is malignant) Travel history and history of living in areas where granulomatous disease is endemic (over 40% of people have nodules in some endemic histoplasmosis regions) History of other malignant diseases (could it be a metastasis?) What is the management strategy for <4mm nodules with no risk factors? What if there are risk factors (smoking)? - Correct Answer f <4mm and no risk factors - no followup needed If <4mm and risk factors - followup at 12 months (no imaging rec yet however) How is the management of a nodule >8mm handled? - Correct Answer RISK stratify first Low risk (<5%) of malignancy - serial low dose CT 3,6,9,12 months Intermediate risk (5-60% chance) - FDG PET/CT - if neg then serial CTs to track it, but if positive then get biopsy High risk (>60% risk) - straight to biopsy or surgical resection What is a ground glass NODULE? - Correct Answer Opacity that does not obscure the underlying lung parenchyma or blood vessels How much does low dose lung CA screening lower mortality in the smoking population?

• Correct Answer Mortality decreased by 20% Medicare requires that: (for CT cost coverage) Ages 55- Smoked at least 30 years (and if they quit it was w/in the last 15yr but no longer) What fraction of a normal CT scan is a "low dose" scan? - Correct Answer 1/5 - 1/ of the normal radiation dosage

What kinds of cancer does low dose CT typically detect? - Correct Answer Adenocarcinomas - usually as solitary nodules Screening is not as good for squamous cell tumors of the central airways. It is not at all useful for screening for small cell lung cancers, which grow very quickly. What is the next step when a SPN (solitary pulmonary nodule) is found on CXR? Should you go straight to biopsy? - Correct Answer You CANT characterize it from this low resolution GET A CT - then characterize the nodule to guide further management steps DONT go straight to biopsy b/c it might be an AVM or vascular and you would cause an emergency Should CT ordered for a SPN (nodule) on CXR be with contrast or without? - Correct Answer This scan can be done without contrast, which helps us assess if the nodule is calcified. IV contrast MAY be necessary in larger tumor masses, particularly if there is concern for hilar or mediastinal nodal involvement. Cost of a non-contrast CT of the chest? - Correct Answer ~$ Give a quick description of the reimbursement practices for imaging studies? - Correct Answer Reimbursement: How much an insurance company will reimburse for a particular study also varies between companies and geographical area. The reimbursement by Medicare and Medicaid is significantly less than most insurance companies (about 30 cents per $1 charged). Most institutions have contractual agreements with individual insurance companies and reimbursement is modified accordingly. Charges are usually split into technical fees (from the hospital) and interpretative (professional) fees (from the radiologist). Patients often get two bills and this may be confusing for them. Technical fees vary most and are generally higher except for some procedures. What conditions can make a PET scan unreliable? - Correct Answer nfections - body is in a state of increased metabolic activity Diabetes - the cells dont take up insulin and/or the body isnt making insulin (need to time this right and there are special methods)

Some adenocarcinomas dont take up the FDG Some hamartomas dont take up the FDG What are the surgical options for an investigating or treating lung cancers? - Correct Answer Lung biopsy/surgery options: Surgical lumpectomy (wedge resection) - either open or video-assisted through a mini- thoracotomy or VATS procedure Needle biopsy performed using fluoroscopy interventional radiology Needle biopsy performed using CT for guidance Lobectomy Pneumonectomy Bronchoscopy List the surgical procedures for lung removal on the basis of size (smallest to largest) - Correct Answer Wedge resection (bite) < Segmentectomy (smallest true anatomical division that can be removed) < Lobectomy (can be multiple lobes - bi / tri lobectomy) < Pneumonectomy (entire lung L or R removed) Have to assess how much lung function they have to start w/ to decide which is even possible. What are the contraindications to CT guided (percutaneous) lung biopsy? - Correct Answer Relative contraindications: Bleeding diathesis Pulmonary hypertension Severe emphysema Ventilated patient Central lesions What imaging studies are appropriate to order for a suspected (non-tension) pneumothorax? - Correct Answer 1. An erect expiratory CXR plus

2. A lateral decubitus laying on the OPPOSITE side of the suspected PTX (make the lung fall away and show the gap) What determines the treatment for a small PTX? - Correct Answer Depends on the patient's clinical status (symptoms, pulse oximeter, etc.) If they are not symptomatic or have minimal symptoms:

• Watch and wait
• Repeat imaging in about four hours prior to discharge from the same day procedure unit
• If the PTX is unchanged or smaller, discharge with instructions to return immediately if symptoms worsen and repeat imaging a day or two after discharge.

What is the treatment for a Tension PTX? - Correct Answer large-bore needle into the second left interspace in the mid-clavicular line Most common post-op findings on CXR for pts who underwent thoracic and abdominal surgeries? - Correct Answer Etiology Lower lobe atelectasis (most commonly) Lower lobe pneumonia Pleural effusion. Differential diagnosis for complete opacification of a HEMIthorax? - Correct Answer Must consider the mechanisms that could cause this including: Loss of lung volume Shift of heart and mediastinum to side of complete opacity Mechanism causing mass/fluid in hemithoriax Shift of heart and mediastinum away from side of complete opacity Etiology often difficult to determine by chest radiograph

1. Pneumonectomy (lung was removed sugically)
2. Huge pleural effusion
3. Total Lung PNA
4. Large Mass (not ARDS because that would be bilateral?) Compare hydropneumothorax vs. simple pleural effusion - Correct Answer Air-fluid level in hydropneumothorax appears as a horizontal line, rather than the usual meniscus seen with an isolated simple pleural effusion [meniscus occurs with pleural effusion because there is negative pressure in the pleural space and the fluid tracks up the side] CXR signs of atelectasis - Correct Answer Volume loss in the affected hemithorax (smaller overall) Tracheal deviation to the affected side Hemidiaphragm elevation (but can still be seen) Hazy opacity over the affected hemithorax ('ground glass' - still can see the vascular markings of the lobe through it) Loss of heart border Large white mass pushing everything AWAY from it on CXR? - Correct Answer Huge pleural effusion (missing space pulls trachea and heart TOWARD it) What does an initial "trauma series" group of x-rays include? - Correct Answer nitial radiographic trauma series:

1. AP (supine) CHEST on a trauma board (remember your patient would need to stand for an erect PA)
2. AP supine PELVIS radiograph
3. ± a cross-table LATERAL C-SPINE radiograph None of these studies requires the patient to be moved from the trauma board. MOST CENTERS JUST USE CT NOW Whats the big risk w. a pelvic fracture? - Correct Answer MASSIVE bleeding CXR findings for aortic injuries? - Correct Answer Findings on chest radiographs which may reflect aortic injury include: Widening of mediastinum, indistinctness of mediastinal contours (don't see normal aortic knob, pulmonary artery, etc.) Inferior displacement of left main bronchus Apical pleural cap (related to dissection of blood over left apex ) CT findings for aortic injuries? - Correct Answer Focal abnormality of aortic lumen Focal bulge Pseudoaneurysm Small dissection flap in aortic lumen Mediastinal hematoma - Usually at level near ligamentum arteriosum What do type A and type B aortic dissections describe? - Correct Answer Type A involves ascending aorta Type B involves descending aorta Intramural hematoma will have blood in the wall of the aorta What is TEVAR? - Correct Answer Thoracic endovascular aortic repair (TEVAR) Treatment of descending thoracic aortic aneurysms (TAAs) in patients who were believed to be at excessive risk with conventional open surgery What is a Dobhoff tube? - Correct Answer Feeding tube (NG) What is deep sulcus sign? - Correct Answer • SBA: When supine, air in large PTX collects anteriorly/inferiorly in thorax, manifests by displacing costophrenic sulcus inferiorly, while producing increased lucency of that sulcus (deep sulcus sign)

• Sign of PTX on supine CXR
• SWA: right sulcus - not as low as L costophrenic sulcus

Can you see a small PTX on a SUPINE CXR? - Correct Answer Golden rule: If you can see a pneumothorax at all on a supine chest radiograph, it is at least moderate. How can you tell if the white line of a PTX is in fact a PTX and not a skin fold? - Correct Answer The visceral pleura line of a PTX will have dark ON EITHER SIDE of the line (where skin will just be light on one side and dark on the other). Signs that at PTX is a tension PTX? - Correct Answer Marked mediastinal shift away from the side of the pneumothorax Marked diaphragmatic depression on side of pneumothorax The lung is often completely collapsed Although going down too low may push an ETT tube into one of the R or L main bronchi

• what is the risk of not going far enough? - Correct Answer f an ETT is too high (e.g. tip above the clavicles), the balloon inflation may cause damage to the vocal cords or leak air. Where is the proper place for the tip of a FEEDING tube to reside? Why? What about regular NG or OG tube? - Correct Answer 3rd portion of the duodenum or duodenal-jejunal junction. This is to prevent reflux and aspiration of the NG feed. Tips of regular nasogastric (NG) or orogastric (OG) tubes should be in the stomach In what conditions should you order "rib films"? - Correct Answer Children with suspected child abuse (nonaccidental trauma) and possible posterior rib fractures on the screening CXR Patients with cancer and abnormalities on bone scans suspected to be benign fractures versus metastases When are rib fractures MOST visible on xray? - Correct Answer AFTER they have begun to heal and become more opaque How does pneumomediastinum appear? - Correct Answer A pneumomediastinum appears as streaky black lucencies in the mediastinum, and will usually appear as a black line along the heart border and aorta. You may see air in the subcutaneous tissues. Causes of pneumoediastinum? - Correct Answer Common causes of pneumomediastinum
• Spontaneous - usually young, fit, skinny men
• Related to high inspiratory or expiratory pressures - asthma, intubated patients (often with high PEEP settings such as acute respiratory distress syndrome)

• Secondary to a pneumothorax or pneumoperitoneum (e.g. laparoscopy)
• Secondary to esophageal perforation (vomiting, instrumentation, tumor)
• Traumatic from a tracheal or bronchial rupture
• Tuba playing
• Freebasing cocaine Radiographic signs of COPD? - Correct Answer Other radiographic signs of COPD:
• Hyperlucency of the lungs due to destruction of the capillary bed and lung parenchyma, especially in emphysema
• Narrowing of the cardiomediastinal silhouette secondary to hyperinflated lungs, especially in emphysema
• Bullae which are often apical chest radiograph corresponding CT
• Coarse and distorted bronchovascular and interstitial markings, more common in chronic bronchitis than emphysema
• Peribronchial cuffing, more common in chronic bronchitis as the walls of the bronchi are thickened (related to hypertrophy of mucus glands and inflammation)
• "Saber sheath" trachea due to compression of the mediastinum and trachea; Complications of COPD that can be seen on CXR? - Correct Answer Signs of complications of COPD: Cardiomegaly - especially right-sided chambers (can result in cor pulmonale) Enlarged central pulmonary arteries due to pulmonary hypertension Pneumomediastinum Pneumonia Pneumothorax What are pulmonary bullae? - Correct Answer Bullae represent thin-walled gas collections in the lung periphery (we typically call them "blebs" if they are smaller than 1.0 cm in diameter). Bullae (singular is bulla - it means bubble in Latin) are common in emphysema, but may also occur in people with no emphysema. They are most common at the lung apices. They are a common cause for PTX in young patients (particularly tall males). In which type of COPD is the DLCO DECREASED? - Correct Answer Emphysema Diffusion is limited by surface area, and in emphysema the amount of surface is drastically reduced as many aveoli break down and combine into large solitary units. Radiographic signs of COPD? - Correct Answer Radiographic signs of COPD include:

1. Hyperinflation: "Barrel shaped" thorax, increased AP diameter of chest and increased size of retrosternal clear space
2. Flattening of hemidiaphragms
3. Increased lucency (blackness) of lungs, resulting from destruction of lung parenchyma and lung vessels
4. Narrowing of cardio-mediastinal silhouette
5. Bullae - often apical
6. "saber sheath" deformity of trachea (Better seen on CT scan) Why is it so important to specify that you specify that you want a "CT angiogram evaluation of the aorta for aortic dissection" when you order this type of CT? - Correct Answer CT angiograms require precise timing of contrast administration so there is adequate opacification of the pulmonary arteries, aorta, or both. Your radiologist needs to know that you are concerned about aortic dissection so that the correct protocol is used. A non-contrast CT will NOT reveal an intimal flap!!! What is the next step to look for an aortic dissection if your patient has contraindication to receiving contrast.? - Correct Answer 1. Order an MRI with gadolinium
7. If they have GFR <30 do the MRI w/out gadolinium
8. If they ALSO have contraindication to MRI then do TEE (only useful for ascending aorta) What are the contraindications to MRI scanning? - Correct Answer - Intraorbital metallic foreign bodies. (Do an orbital x-ray if history is suggestive or patient is occupationally at risk.)

• Cardiac pacemakers and ICD devices.
• Temporary breast tissue expanders. (Prior to reconstructive breast surgery.)
• Epidural devices such as spinal stimulators.
• Severe claustrophobia. (Requires sedation, usually with p.o. Valium. Sedated patients cannot drive after the exam and will need a ride home.)
• Ferromagnetic aneurysm clips. (Most clips placed in the last 15 years are non-ferrous, but need an operative report to confirm non-ferrous nature.)
• Morbid obesity > about 300 lbs, depending on scanner. (Some newer scanners will allow up to 400 lbs.)
• Tattoos with ferromagnetic ink. How many Hounsfield units is water? - Correct Answer Water = 0 HU Metal: >1, Bone: 500 to 1, Soft tissues (e.g., Liver, spleen, bowel wall, muscle, brain parenchyma): 30 to 60 without contrast Fluid (e.g., cysts, gallbladder and bladder contents, CSF): 10 to 20 Water: 0

Fat: -50 to - Air: -1, What is the technical explanation for using contrast? - Correct Answer ntravenous contrast will increase the density (thus increasing the HU) of many soft tissues, as well as that of blood, depending on the blood flow to the tissue and the time that the scan was acquired relative to the contrast injection. Complex fluid collections (infection, hemorrhage, etc.) can measure higher than water density Why isnt D-dimer good for hospitalized and post procedural patients? - Correct Answer They already have fibrinogen products active in their body so theres a high likelihood for a meaningless positive test (just go to CT or US in these cases) Explain a V/Q scan - Correct Answer The perfusion is performed by injecting technetium-labeled macroaggregated albumin particles intravenously. These "stick" in the smaller pulmonary capillaries as they are larger than the capillaries, and remain there for several hours until phagocytosed. The particles only occlude a small percentage of precapillary arterioles and capillaries (we certainly don't want to occlude them all!), but the distribution of the particles provides us with a perfusion map of the lungs. The ventilation study can be performed in various ways, most commonly by the patient inhaling another Tc-99m labeled tracer (DPTA), which is aerosolized with a nebulizer or radioactive xenon gas. When is a V/Q scan indicated? - Correct Answer When looking for a pulmonary embolism but the patients kidney's cant handle the contrast needed for a CTA (CT angiography / helical CT) What is the "weakness" of a V/Q scan? - Correct Answer F the lungs are already abnormal - eg. BAD emphysema or COPD -then the scan is going to look very confusing Intermediate probability scans basically tell you NOTHING (probability of a PE is 20- 79%) these ARE good for a rule out though - if totally normal then you nearly are CERTAIN theres no PE What features you looking for on a V/Q scan? - Correct Answer "Matched Defects" - where there is a matched decrease in both ventilation and perfusion (as in PNA or emphysema) or

"Mismatched Defects" - only 1 flow is decreased as in PE where the blood isnt flowing despite good ventilation What is Visipaque™? - Correct Answer Visipaque™ is a non-ionic iso-osmolar iodinated contrast that may have less renal toxicity (although this is controversial and this contrast agent still has nephrotoxic potential in high-risk patients). What strategies can be used to decrease the toxicity and negative effects of contrast? - Correct Answer A. Pre scan hydration (best method) B. Post scan hydration (best method) C. N-Acetylcysteine (Mucomyst®) D. Reducing the dose of contrast G. Urine alkalinization What is considered a "high" dose of contrast? - Correct Answer ≥100 mL How are large saddle emboli handled? - Correct Answer They can be broken up with a catheter (these now have an ultrasound tip to help) What are other sources of embolized material besides just thromboembolisms? - Correct Answer - fat (associated with long bone fractures and embolized marrow fat),

• amniotic fluid embolism,
• air embolism (often from central catheters),
• foreign material embolism (e.g., talc from IV drug injection)
• septic emboli (from tricuspid endocarditis). TRUE / FALSE - there are new removal IVC filters that are being more commonly used
• Correct Answer True: These filters are often being used in younger patients, trauma patients, neurosurgery patients, etc., where you might not want or need to leave a filter in forever Note IVC thrombosis DOES occur - so there needs to be a very serious indication to use these CXR findings of pulmonary edema? - Correct Answer Peribronchial cuffing (related to edema around airways) Blurring of vascularity Upper lobe venous distention Perihilar fuzziness (also called perihilar haze) Kerley B (and A and C lines.) Fluid in the fissures Alveolar consolidation (see next page) Pleural effusions Cardiomegaly

Kerley A lines are longer and directed towards the lung hilar. Kerley C lines are randomly directed lines. All represent fluid or thickening of the interlobular septa between secondary pulmonary lobules. THese lines can also be due to fibrosis - not just edema Besides CHF, what other conditions cause Kerley B lines? - Correct Answer Lymphangitic carcinomatosis Viral pneumonia, occasionally Mycoplasma pneumonia Asbestosis Mitral stenosis Fibrosing mediastinitis Pulmonary vein stenosis What other causes can lead to increased cardiothoracic ratio when the heart is normal sized? - Correct Answer Causes of an increased cardiothoracic ratio where the heart is normal: AP films Pericardial effusion Obesity Pregnancy Pectus excavatum Large breasts (increasing distance from receptor) Lordotic or rotated study What is a trauma series include? - Correct Answer AP chest AP pelvis ± lateral C-spine What is a FAST scan? - Correct Answer FAST (focused assessment with sonography for trauma) scan is a limited ultrasound examination to look for free intraperitoneal and pericardial fluid. In the context of trauma, fluid is likely to represent hemorrhage. FAST scans focus on looking in four main areas in the abdomen and pelvis using portable ultrasound equipment. FAST scans look in 4 main areas:

1. Perihepatic
2. Perisplenic
3. Pelvic
4. Pericardiac When these are POSITIVE patient may then be sent for CT scan or straight to the OR

Clues to a bladder/urethral injury? - Correct Answer Blood at urethral meatus, Widened pubic symphysis Major structures to check when reading a pelvic trauma x-ray? - Correct Answer A. Check that all three pelvic rings (main pelvic ring and the obturator rings) are intact:

1. Superior ramus extends laterally from the body, forming part of the acetabulum
2. Inferior ramus joins the ischium
3. These two rami enclose part of the obturator foramen B. Make sure pubic symphysis is not widened (< 1cm) C. Look at sacroiliac joints: Symmetrical? Widened? D. Look at proximal femora: Femoral heads dislocated? Fracture of proximal femur? Why do you NOT place an ETT in the setting of a PTX that has no chest tube in? - Correct Answer t can end up creating a TENSION PTX situation Put the Chest tube in FIRST - then intubate When you see rib fractures - what else should you be looking for? - Correct Answer SECONDARY INJURIES: Ribs 1 to 3: pulmonary, tracheobronchial, and vascular injury. Ribs 4 to 9: cardiopulmonary insult. Ribs 9 to 12: splenic, hepatic, and diaphragmatic injury. Check that there is no radiological flail chest (three or more contiguous comminuted rib fractures, which are fractured in two or more places within the same rib, associated with paradoxical breathing). Is oral contrast used for trauma CT scans? What about IV contrast? - Correct Answer Oral contrast is NOT used for trauma CT scans. It takes one hour to opacify the small bowel and an obtunded patient may aspirate the contrast, even if it is injected through the NG tube. IV contrast is ESSENTIAL to trauma CT as it can reveal active bleeding and extravasation How is uncontrolled bleeding from solid organs managed? - Correct Answer Arterial embolization An initial angiogram is performed to identify the actively bleeding vessel, then the bleeding vessel is selectively catheterized and the embolization material injected. (like gelfoam, or steel coils or glues)

How do lacerations appear on CT? - Correct Answer Lacerations appear as irregular hypodense regions that do not enhance and are linear and branching in configuration. Often associated free fluid in the abdomen, retroperitoneum, or subcapsular collections around the injured solid organ Can tell when its a subcapsular collection because it flattens the underlying organ face What can be seen on CT in the setting of a bowel injury? - Correct Answer A. Free intraperitoneal gas B. Bowel wall thickening C. Free fluid D. Retroperitoneal gas (duodenal injury) E. Sometimes, nothing What happens if barium is spilled in the peritoneum? - Correct Answer t stays there FOREVER as it is never absorbed It will show up on ALL X-ray scanning from thereforeward What is the most effective way to assess for a bladder injury? - Correct Answer CT cystogram Before the patient gets a CT of the abdomen and pelvis, the bladder is distended with contrast through a Foley catheter hooked to a bag of contrast. CT cystogram can be performed as part of the regular trauma CT or immediately after. What are the 2 main types of bladder ruptures? - Correct Answer 1). Intraperitoneal (this requires immediate surgery) - see contrast starting to surround loops of bowel

2. Extraperitoneal Both of which are reliably diagnosed by the presence of contrast outside the confines of the bladder. (on CT cystogram studies) From which hemisphere is diaphragmatic herniation more common? - Correct Answer From the LEFT side b/c the liver is on the right and protects / blocks contents from herniating TRUE/FALSE - a small amount of intraperitoneal fluid on CT can be a normal finding - Correct Answer TRUE - this is especially true if the patient is getting a lot of IV fluids to protect the kidney after a trauma However - if the HU (hounsfield units) of the fluid are HIGH - be suspicious for a bleed

Best initial study for head trauma? - Correct Answer Head CT without contrast (especially good for bony lesions) [MRI is slower but has better resolution for brain parenchymal studies] What are the characteristics of epidural hematoma? - Correct Answer Occur in the potential space between the dura and the inner surface of the skull. Some of their characteristics include that they: Are biconvex or lenticular in shape Occur at the site of impact Are often associated with an overlying fracture. Do not cross the sutures Are usually arterial in origin, commonly from the middle meningeal artery Patients often have lucid interval and then decompensate Where is a good place to look for SAH on a CT scan (esp to differentiate it from a subdural hematoma) - Correct Answer Look for hyperdense areas on the CT WITHIN the sulci and the cisterns. (subdural doesnt communicate into these areas) What is the cause of an "interventricular hemorrhage" where does it occur? Where to find it on a CT? - Correct Answer Occurs due to tearing of subependymal veins. They can also occur when intraparenchymal hemorrhages extend into the ventricles. The best place to look for intraventricular hemorrhage is in the occipital horns of the lateral ventricles. What is a clay shoveler's fracture? Mechanism? Treatment? - Correct Answer Avulsion of the spinous process MC @C6 or C7 (or upper few thoracic vertebrae) Mechanism: Forced neck flexion to point where muscle pulls of a piece of the spinous process (usually occurs with sudden forceful deceleration w/ MVA) These are usually STABLE Tx: Non-operative - NSAID, rest, immobilize in hard collar for comfort. Surgery for non- union over time. What are the Canadian C-Spine Rules? - Correct Answer No imaging is necessary if the following criteria are met: Absence of the following high-risk factors:

• Age > 65 years

• "Dangerous mechanism"‡
• Paresthesias in extremities
• When low-risk factors allow safe assessment of range of motion
• Simple rear-end motor vehicle collision**
• Sitting position in ED
• Ambulatory at any time
• Delayed onset of neck pain
• Absence of midline cervical tenderness
• Able to actively rotate neck 45 degrees left and right ‡"Dangerous mechanism" defined as: Fall from an elevation of 3 feet or five stairs Axial load to the head (e.g., diving) Motor vehicle collision at high speed (> 62 mph, or 100 km/hr) or with rollover or ejection Collision involving a motorized recreational vehicle, or Bicycle collision What is the most sensitive imaging modality to look for small fractures: CT or MRI? - Correct Answer CT!! What are the NEXUS criteria? How are they used? - Correct Answer According to the NEXUS criteria, a patient undergoing trauma who meets all of the following criteria can have their c-spine cleared clinically WITHOUT imaging: No midline tenderness No pain with neck movement No distracting injury No neuro deficit No alcohol or drugs No altered mental status Interpreted as: Absence of posterior midline cervical-spine tenderness No evidence of intoxication Normal level of alertness Absence of focal neurological deficit No clinically apparent painful injuries that might distract from pain of a cervical spine injury What is a Hangman's fracture? - Correct Answer Traumatic bilateral fractures (spondylolysis) of the pedicles or pars interarticularis of the C2 [Axis] vertebra

Unstable fracture. Can lead to spondylolisthesis between C2 and C3 below it. C2 may slip forward too. Usually caused by extreme hyperextension of the skull, axis, and atlas followed by secondary flexion (with tearing of the posterior longitudinal ligament - this is why it becomes unstable) Usually no neural injury because the cervical canal is widest at the C2 level. Tx: <3mm displacement - hard collar 4-6wk (type I) 3-5mm dispalcement - closed reduction + halo 8-12wk

5mm displacement - surgical reduction What is a "ghost sign" on a AP x-ray - Correct Answer There appears to be 2 spinous processes on a single vertebrae (superior-inferior plane) due to fx of the spinous process and the fractured piece sliding down out of place What should you do for patient who has head injury and later has a CHANGE in their neuro exam? - Correct Answer GET ANOTHER CT!! They may be having evolution of a bleed or a new bleed or herniation ect.... What are the general measures taken for brain herniations? - Correct Answer General measures:

• Most patients require mechanical ventilation and need to be paralyzed to avoid straining or agitation.
• Sedatives should be used to calm the patient.
• Hyperventilation is known to cause vasoconstriction and helps lower the intracranial pressure.
• Fluids should be RESTRICTED, but the patient must not be dehydrated.
• Diuretics like mannitol can be administered to lower the ICP.
• Blood pressure control is vital but needs to be adequate to perfuse the brain.
• For malignancies and abscesses, corticosteroids may reduce vasogenic edema.
• Hypothermia is widely used today as it slows down brain metabolism, but it also makes the patient prone to infections and arrhythmias.
• Pentobarbital coma can lower cerebral blood flow, but it can also cause hypotension. What are the MC causes of increased intracerebral pressure? - Correct Answer Generalized cerebral edema Mass effect from tumors or hemorrhage Impaired CSF absorption or flow Increased CSF production What is the Monroe-Kellie hypothesis? - Correct Answer The Monroe-Kellie hypothesis describes the relationship between the volume of the brain, CSF, and blood.

if the volume of one of the components increases, then the volumes of the other two components have to decrease to maintain a normal intracranial pressure. As intracranial pressure (ICP) increases, cerebral perfusion pressure (CPP) decreases. (w/ loss of OXYGEN AVAILABILITY) CPP = MAP - ICP As the CPP decreases, the body responds by increasing blood pressure and dilating blood vessels which increases the CPP back to normal level What is Diffuse Axonal Injury (DAI)? - Correct Answer Caused by acceleration- deceleration causing disruption of axons (white matter damage):

• Usually results in coma
• Gray matter and white matter of the brain have different densities, so they decelerate at different speeds
• Shearing and disruption of the axons CT is not sensitive for DAI, and MRI should be done if there is clinical concern Where should you look if investigating diffuse axonal injury on MRI? - Correct Answer Most common sites of injury in DAI: Gray-white matter junction Basal ganglia and internal capsule Body and splenium of corpus collosum Brainstem What are the MRI findings for diffuse axonal injury? Best type of MRI to use for this study? - Correct Answer MR—Gradient Echo and Susceptibility-Weighted Imaging (SWI) are techniques useful in brain MR imaging to identify small amounts of hemorrhage and blood breakdown products. T2/FLAIR—oval shaped high intensity areas—edema What is the difference between an Acute, Subacute, and Chronic subdural hematoma? - Correct Answer Acute: (< 3 days) are generally hyperdense (bright) on CT. Subacute: (3 days to 3 weeks) are similar to acute, but usually isodense with gray matter. Harder to spot on a CT scan. look for inward displacement of the gray-white matter junction—the gray matter looks too thick. Chronic: (> 3 weeks) are typically hypodense. May show a "hematocrit level" where there are different blood densities of blood next to each other.

There can also be acute on chronic! [look for a "hematocrit level" on the image What is the falx cerebri? Do subdural hematomas cross the falx? - Correct Answer The falx cerebri is a crescent-shaped fold of meningeal layer of dura mater that descends vertically in the longitudinal fissure between the cerebral hemispheres. Subdural hematoma blood will be STOPPED at this interface. What limits the flow of blood in the case of epidural hematomas? - Correct Answer The crainial sutures of the skull Important place to check on CT scan for SAH? (not on the typical subarachnoid perimeter) - Correct Answer A key place to look for subarachnoid blood is in the suprasellar and interpeduncular cisterns, which can show very small amounts of blood. What radiographic findings are associated with Rheumatoid arthritis? - Correct Answer Marginal erosions seen on the sides of the joint Periarticular soft tissue swelling Subchondral erosions which involve the bone plate Swan neck and boutonniere deformities Uniform loss of joint space What is "eburnation"? - Correct Answer Subchondral sclerosis and osteophyte formation at the areas of cartilage loss, such as in osteoarthritis (not in RA so much) Side effects of chronic corticosteroid treatment - Correct Answer mmunosuppression Hyperglycemia Increased skin fragility Reduced bone density Weight gain Adrenal insufficiency Muscle breakdown Irregular menstrual periods Growth failure Diabetes What are the indications for bone density screening by imaging? - Correct Answer Common indications for bone density scans include: Female over age 65 (A) Male over age 75 Younger individuals with major risk factors: Other less common indications: History of prior fracture with minimal trauma Low body weight (BMI < 23)

Premature menopause Testosterone deficiency in men Chronic glucocorticoid therapy MC cause of osteopenia? - Correct Answer Osteoporosis Site where DEXA scan is done? - Correct Answer Hip - @ greater trochanter (calculate the T score at various locations in the hip) Measuring BOTH hip and spine better predicts the risk for both vertebral and hip fractures. Use/add wrist as well What is the alternative to DEXA and when is it used? - Correct Answer Quantitative computed tomography (QCT) is an alternative examination for measuring bone mineral density It requires increased exposure to ionizing radiation Reserved for patients w/ severe scoliosis or osteoarthritis that have difficult-to-interpret DEXA scans How is a Z-score different from the T-score? - Correct Answer Z-score is the number of standard deviations above or below what is normally expected for someone of the patient's age, sex, weight, and ethnic or racial origin. A Z-score less than -1.5 might indicate that there is an underlying secondary form of osteoporosis being caused by something other than aging. Because most 85-year-old women have osteopenia or osteoporosis, the Z-score can be used to indicate whether or not this is AGE-APPROPRIATE. When should you be concerned for osteomyelitis associated with a wound? - Correct Answer Osteomyelitis should be considered if:

• Deep or extensive ulcer, especially if chronic or over bony prominence
• Unhealed ulcer after six weeks or more of medical care and off-loading
• Visible bone
• Bone palpable with a probe
• Foot or toe swelling with history of ulceration
• Unexplained elevated WBC count or other markers of inflammation INITIAL imaging to order for suspected osteomyelitis? - Correct Answer Plain film X- rays (not a CT)