Vlahos intensive FRCR 2b courses on Mar 5-6 (Weekend) or Mar 21-22 (Mon-Tue).
1 place left on Mar 21-22 course
2 places left on Mar 5-6 course
Registrants are already receiving pre-course interactive teaching by email. Currently we are doing Rapid Reporting packs! The earlier you register, the more you get!

Radiology Level: Junior +
FRCR, MRCP, EDiR

Radiology Level: Senior +++
FRCR, ABR, EDiR
No other sites bone isotope abnormality

Classic Case: Radiology Level - Challenge ++++, FRCR, EDiR, ABR, MRCP

A chest radiograph and an AP lumbar spine radiograph are provided. The chest radiograph demonstrates unfolding of the thoracic aorta which may be aneurysmal although this can be difficult to determine on a plain radiograph alone. There is fine linear calcification running along the right lateral margin of the mediastinum (large arrow), identifying the lateral aspect of the aortic arch. This extends in a continuous fashion to the coarsely calcified ligamentum arteriosum in the AP window (small arrow). There is no coarse calcification of the aorta. The heart size is normal. The lungs are clear.

The AP radiograph of the lumbar spine demonstrate a right total hip replacement and a short segment scoliosis of the mid lumbar spine associated with sclerosis and some fragmentation of the concave aspect as well as new bone formation and loss of normal orientation. There are no congenital variations in this region.

There are several ways in which we can approach the interpretation of these images. A short segment scoliosis has a relatively limited differential. This includes congenital variations such as hemivertebrae related to failures of segmentation such as occurring patients with neurofibromatosis or VACTERL. None of these are present here. Post traumatic appearances can result in short segment scoliosis, however, again not demonstrated here. Tuberculous destruction can result in discitis with partial collapse, however, the endplates, typically destroyed in tuberculous discitis, are well preserved in this instance and the abnormality extends over several levels. Finally one can consider the possibility of a neuropathic (Charcot)spine which is the best fit for the current appearance. Much like other joints a neuropathic spine is associated with the 4 Ds (density, destruction, debris, deformity/dislocation). Causes of a neuropathic spine include spinal cord injury, diabetes and tabes dorsalis (syphilitic).

The most common current cause of a Charcot spine is diabetes, however, in this instance the chest radiograph provides an additional clue. The ascending aortic dilatation and fine ascending aortic peripheral calcification, in contradistinction to the coarse thick calcifications of atherosclerotic aortas arising near the aortic isthmus are typical of syphilitic aortitis. This is the unifying diagnosis in this case–tertiary syphilis with syphilitic aortitis and tabes dorsalis.

Syphilitic aortitis (previously termed luetic aneurysm/aortitis) is a tertiary manifestation of syphilis infection. This is an adventitial disease process resulting in obliterative endarteritis of the vasa vasora resulting in ischaemic injury of the adventitial/media which may progress to aneurysm formation or fine peripheral calcification. Dissection is unusual due to the fibrosis of the medial layer. Coronary calcification, or involvement of the aortic root may also occur. At CT asymmetrical aortic sinus involvement or "tree bark" intimal calcifications can be demonstrated. The disease process is now rare in the Western World due to the reduction of syphilitic infections following introduction of penicillin.

Tabes dorsalis is a form of tertiary neurosyphilis. These presents with dorsal column/nerve root symptomatology relating to weakness and abnormal gait related to lack of proprioception with sensory ataxia (tabetic gait) that as in this case may predispose to falls. Lightening-like paraesthesia pains can occur with altered sensation from joints result in degeneration, as in this case with a right hip replacement. The lower limbs demonstrate hypotonia and diminished reflexes. The differential diagnosis includes other demyelinating pathologies of the cord including multiple sclerosis, transverse myelitis, HIV, Vitamin B12 deficiency resulting in subacute combined degeneration, and focal neoplasms.

This is a classic radiological interpretation to enjoy. A bonus features seen in some cases is calcification of injections in the buttocks due to Bimuth injections predating penicillin treatment.

Classic Case:
Radiology Level - Challenge ++++, FRCR, EDiR, ABR, MRCP

Courtesy Dr A. Brooks

This case is a complimentary case to the prior case.

Both cases relate to congenital airways abnormalities. This is the far more common (0.5%-1%) right upper lobe bronchus arising from the trachea. This is usually an incidental finding although there are reports of associated recurrent right upper lobe infection also in the literature. In part this may be coincidental detection of the airway abnormality in people being scanned for recurrent infection but it would make sense that the narrowed airway, often arising at an acute angle as in this case, may predispose to mucoid impaction and recurrent infection. However, it should be reinforced that this is usually just an incidental finding.

There is actually a wide variety of abnormalities that can occur in this region. Most typically in my experience and the published literature a bronchus to the apical segment of the right upper lobe arises from just beyond the origin of the right main bronchus. A separate right upper lobe bronchus supplies the anterior and posterior segments arising more distally from the right main bronchus. The next most common appearance in my experience is the one demonstrated here, an apical segmental bronchus arising from the trachea itself. Finally, origin of the entire right upper lobe bronchus from the trachea can occur although this is more uncommon. This historically has been referred to as a “pig bronchus” or “bronchus suis” although the nomenclature has been used more widely for variations in this region as above. The axial imaging clue here is that there is an additional airway above the axial plane demonstrating the tracheal bifurcation. Coronal oblique ,minimum intensity or 3D volume projections can demonstrate the anatomy beautifully for the benefit of bronchoscopists as this is a finding they should be aware of if endoscopically evaluating the patient for other reasons.

If you can work out what is unusual about this case's airways maybe you can also solve Case 56!

Difficulty Level: Radiology - Mid ++ (FRCR, EDiR, ABR, MRCP)

Difficulty Level: Radiology - Mid ++ (FRCR, EDiR, ABR)

The axial images provided demonstrate that there is dilatation of the oesophagus with extensive food residue. Inferiorly new the diaphragm there is a focal dilatation of the oesophagus. This appearance can raise several considerations. In the first instance one may consider whether there has been a gastric pull up following lower oesophagectomy (Ivor Lewis procedure), however, there are no surgical sutures present and the stomach is below the diaphragm in its entirety. One may also consider whether there is a dysmotility of the oesophagus, such as achalasia or scleroderma. The latter is not associated with food residue but rather a patulous oesophagus, prone to reflux. The former is a consideration, however, there is insufficient dilatation just above the level of the gastro-oesophageal junction and does not account for the focal dilatation of the oesophagus. One can also consider whether the focal dilatation of the oesophagus relates to a sliding or paraesophageal hernia, however, in either of these hernias this should be two entrances/connections to the hernia from the oesophagus. One connection reflecting the inferior oesophageal continuation to the stomach, the more superior connection demonstrating the connection from the hernia to the more proximal oesophagus. In this instance, however, axial images demonstrate only a single focal connection to this dilatation of the oesophagus. Therefore, this finding reflects a diverticulum. In this typical location the findings are due to an epiphrenic diverticulum. The findings become very much more apparent on the curved planar reconstuction below.

Large diverticula of the intrathoracic oesophagus can be due to traction effects, occurring historically due tuberculous nodes resulting in traction of the oesophagus in the mid oesophagus. Epiphrenic diverticula are, however, pulsion diverticula, usually arising along the right posterolateral margin of the distal oesophagus just above the gastro-oesophageal junction. These diverticula are associated with raised intraluminal pressure and therefore may be associated with distal oesophageal webs/strictures or generalised motility disorders such as achalasia. They are false diverticula in that they are focal herniations of the submucosa and mucosa through the muscularis propria. These may predispose to severe reflux, food regurgitation and aspiration. They are frequently, as in this case originally, misinterpreted as hiatus hernias. Resection is advised and may be performed by VATS/Laparoscopy.