Question 3 : Diagnosis?

Click on this image for answer !!!

Subclavius Posticus ! - An accessory muscle of the Shoulder

SUBCLAVIUS POSTICUS

Subclavius posticus is an accessory muscle of the shoulder, originating from the superior surface of sternal end of 1st rib, coursing posterolaterally to attach along the superior surface of scapula, usually lateral to the inferior belly of omohyoid muscle. This muscle is usually supplied by the suprascapular nerve.

This accessory muscle courses superior to the Subclavian vessels and brachial plexus and is sited as a potential cause of effort thrombosis of Axillo-Subclavian veins (Paget Schrotter syndrome) and also Thoracic Outlet Syndrome (especially venous compression).

The muscle measured ~10.3cm in length in this patient. Appearance of subclavius posticus in our case was more or less supero-inferiorly flattened, measuring 16.3mm in width and 7.2mm in cranio-caudal thickness.

The coronal T2 images is shown below, which shows the relationship of the Subclavius posticus muscles with the supraspinatus, subscapularis muscles. The suprascapular nerve is seen coursing along the superolateral surface of the muscle, just before the suprascapular notch, with high likelihood of nerve compression.

Below image shows comparison of Sagittal T2 images of two different patients, on the left with Subclavius Posticus muscle and on the right without this accessory muscle.

Interestingly the normal Subclavius muscle was found absent in the present case. Below image, on the right shows the normal Subclavius muscle in another patient.

I couldn't find any reference on association of 'absence of normal Subclavius' in cases of Subclavius posticus.

I am ending this long post, with this T2 Axial image, which shows the relationship of Subclavian vessels and brachial plexus coursing inferior to the S.Posticus muscle.



REFERENCES:
1. SINGHAL, S.; RAO, V. V. & MANJUNATH, K. Y. Subclavius posticus muscle - A case report. Int. J. Morphol., 26(4):813-815, 2008.

Diagnosis Please Series : December 2016 : Q2

Young female with headache..whats the likely diagnosis ?

How strong is your 'Shoulder Anatomy' ?

Click on this image for answer !!!

Which arterial occlusion to suspect?

Diagnosis Please Series : December 2016 : Q1

4 year old child with upper abdominal pain. Serum Amylase >2000.

Idiopathic Intracranial Hypertension ( Pseudotumor Cerebri)

MR Imaging signs suggesting Idiopathic Intracranial Hypertension(IIH) :

1. Posterior scleral flattening.
2. Vertical tortuosity of the optic nerve in sagittal images.
3. Protrusion of the optic nerve at the optic disc.
4. Optic nerve sheath dilatation (>5mm), increased peri-optic nerve CSF.
5. Empty Sella.
6. Transverse Sinus narrowing.


Optic nerve sheath dilatation can be seen in both acute and chronic elevation of intracranial pressure(ICP). Its a more sensitive sign of increased ICP.

Posterior scleral flattening and optic nerve head protrusion has lesser sensitivity, but more specificity.

The vertical tortuosity of the optic nerve is seldom seen in cases of acute intracranial hypertension, and is believed may be evidence of chronically elevated ICP.

References :
1. Clinical Radiology, July 2016. Morphometric MRI changes in intracranial hypertension due to cerebral venous thrombosis: a retrospective imaging study. 

Diagnosis Please : 15.07.2016

Middle aged male presented with repeated falls, altered behavior. No seizures.

 

Diagnosis Please : 14.07.2016

 Clinical History : Middle aged female with chronic headache and recurrent visual blurring. 

What's your diagnosis based on these MR images?

ANSWER

 

Chest radiograph checklist for FRCR 2B Rapid Reporting

CHEST RADIOGRAPH CHECKLIST

1. Situs
2. Air: Pneumothorax, pneumomediastinum, pneumoperitoneum, surgical emphysema.
• Always look for any abnormal gas first. Beware of soft tissue shadows like skin folds mimicking pneumothorax.
3. Trachea, carina, bifurcation.
• After the first two steps follow the trachea from above down, to the carina and look into the proximal bronchi. Don't miss any metallic foreign bodies (coins, safety pins), or obvious bronchial occlusions.
4. Hilum : Can say enlarged hilum.
• After the bronchi, look both hila, look for enlargement, nodularity, calcifications.
• We will get marks even if we dont distinguish between mass or nodes, can say enlarged hilum - will be sufficient to fetch you the 1 mark.
5. Mediastinum : 
• Look for pneumomediastinum, mediastinal masses, silhouette sign. 
• Mediastinal lucencies / air fluid level could represent achalasia cardia and absent fundic gas favors hiatus hernia.
6. Heart - usually not much cases.
7. Lung parenchyma : Compare both sides (Upper zone - Upper zone, MZ-MZ so on). 
8. Pleura : Pleural plaques (calcified). 
9. Bones: 
• Follow the clavicles from medial to lateral. Distal clavicular erosions with shoulder joint arthritis can point to RA.
• Look for AC joint subluxation or dislocation.
• Shoulder dislocation can be seen occasionally in CXRs. 
• Watch out for Proximal humeral lytic areas in cases of mastectomy, which will get you the other 1/2 marks.
• When you are looking for rib pathologies, look in pairs, comparing both sides at the same time.
10. Soft tissue – Never miss mastectomy. Look for axillary surgical clips. Look for neck/axillary soft tissue lesions. Don't mistake hair braids in female patients for neck /lung apical lesions.
11. Review Areas : Lung Apices (small pneumothorax, nodule, even obvious Pancoast may be missed if you dont look), Retroardiac lung, retro-diaphragmatic lung, gas under diaphragm, upper abdomen (calcifications). 

Large external iliac artery pseudoaneurysm : vascular complication of renal transplantation

 

contd...

Prominent Lateral Tentorial Venous Sinuses

TENTORIAL SINUSES

Numerous tentorial sinuses drain near the confluence / torcula herophili. These venous channels may provide significant drainage for adjacent cerebellum. They can be enlarged significantly if the straight sinus or superior sagittal sinus is occluded.

Diagnosis Please : 28.06.2016

Q. Do you know the prominent vascular structure seen on right in this SWI image?

Click on this image for answer !!!

MRI assessment of Suprapinatus atrophy and fatty replacement

THOMAZEAU's OCCUPATION RATIO (SUPRASPINATUS)
 Muscle atrophy of the supraspintatus is assessed by method suggested by Thomazeau et al, by which the 'occupation ratio' is calculated. Occupation ratio has been defined as the ratio between the cross section of the muscle belly and that of its fossa on the Y-view. The Y-view is the oblique sagittal (T1 WI) plane that crosses the scapula through the medial border of the coracoid process.

Ist trimester ultrasound

Ideal time for gestational age assessment in first trimester appears to be somewhere between 8wks and 13 + 6 weeks.


Ref : ISUOG 2013.

FRCR PART 1 : ANATOMY : 18

Name the structure marked by an arrow - 

STRUCTURE -A

STRUCTURE -B

STRUCTURE-C

STRUCTURE - D

Glomangioma ( Glomus Tumor)

40 year old female patient presented with gradually increasing pain and tenderness at the region of dorsum of distal phalanx of middle finger, which has become excruciating to touch recently. Non-contrast MR T2 and T1 sagittal images as shown above showed a small lesion at the proximal aspect of dorsum of the distal phalanx of middle finger, which is hyperintese on T2 and intermediate on T1.

Post contrast images showed intense enhancement of the lesion, consistent with that of a Glomangioma or a Glomus Tumor.

Sagittal T1 post contrast FS image showing the lesion.

In Coronal image, the lesion is visible in one section.

Synovitis with Bone Infarcts in distal femur

Bone infarcts are seen in distal femur. Thickened synovium with thickening of plica is also noted.

Post contrast Axial, Sagittal and Coronal images of the knee joint showing intense enhancement and thickening of the Synovium, consistent with synovitis.

Diagnosis Please : 14.05.2016

40year old female patient, with pain at tip of middle finger.

Click on the image for the answer !!

FRCR PART 1 : ANATOMY : 17

4 structures have been labelled in this T1 3D Sagittal images. Identify each one of them.

STRUCTURE A : 

STRUCTURE B :

STRUCTURE C:

STRUCTURE D :

FRCR 2B Rapid Reporting : The Beginning

Rapid reporting at present consist of viewing 30 radiographs in 35 minutes, writing which is normal OR abnormal and if 'abnormal', what is the abnormality you saw. Usually there is only one clear abnormality in the 'abnormal' x-rays.

And it requires to follow a diagnostic checklist FOR EACH RADIOGRAPH, so as not to miss any subtle abnormality. Every body part radiograph has its own checklist.

Deviating from the checklist can bring disastrous consequences to your overall result. 

Exam consists of Rapid Reporting (8 marks), Viva ( 8 + 8 marks) and Long cases reporting (8 marks). Out of which we need to get 24 out of 32 to pass the exam. And should not get less than 6 marks in more than two components. If we get less than 6 in more than two components (for example 5.5 + 5.5 + 5 + 8) and even if we make it up to 24, it's a fail.

TOTAL MARKS IN RR	OVERALL MARKS IN RR
0 to 24	4
24 ½	4 ½
25 to 25 ½	5
26 to 26 ½	5 ½
27	6
27 ½  to 28	6 ½
28 ½ to 29	7
29 ½	7 ½
30	8

 As we can see beyond the pass mark (6), it becomes increasingly difficult or in other words each mistake costs you more, going down from the 30 correct. (For example you got 29 correct, you will get 7 marks out of 8, loosing one mark for a single mistake).

Two things to remember is that however bad you do the RR, you will get 4 marks, and if you make 20 marks for the Viva and Long Cases, you can still pass, which is rather very difficult (7 + 7 + 6, 6.5 + 6.5 +7) and you will have to be exceptional to get that !. 2nd thing (common myth) its not like if you fail in one component ( get less than 6 marks), you will fail in the exam, and exemplified in the aforesaid example. (Similarly in Long cases, for a question which you don't know the answer, if you write anything, even if irrelevant, you will get '3' marks, giving you a fighting chance for getting the passing '6' marks average. On the other hand you just left the answer blank, you will get '0' marks)

You can get free great RR materials and instructions from frcrtutorials.com. Or you can purchase 30 RR packets from FRCR Academy. Other option is you make your own, with the help of few friends, whose interest and goals align with you.

We might not get 27/30 from the start itself. But with 'practice - practice - practice' we can reach the goal. Making an Individual RR Checklist and Reporting Templates will help.

 Sample RR template, which I used.

In the next few posts we will look into individual RR-Checklists, likely siting examples for each finding, which is going to be an arduous task ! .

D.V.

Meningioma / hemangiopericytoma presenting as proptosis

This 60yr old male patient presented with gradual, but progressively increasing proptosis, over the past 10 years. There was no history of diplopia. He had developed pain in right orbit, for which he took medical help.

Hemorrhagic dural and parenchymal metastases : BRAIN

The patient is an elderly female, suspected case of Lung Cancer, presented with altered sensorium.

T1 and T2 images, showed T1 hyperintense and T2 heterogeneously hyperintense dural bases lesion. Left front-parietal vasogenic oedema is noted.

The causes of hemorrhagic brain metastases include : 
Melanoma, Breast Ca, Choriocarcinoma, Bronchogenic Carcinoma, Thyroid Ca and Renal Cell Carcinoma.


The following are are post contrast images, which showed numerous lesions in addition to the larger lesions, which are not discernible in the pre contrast images.

[contd...]