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...]

Diagnosis Please : May 3rd, 2016

56yr old male with right eye proptosis of 10yr duration.

DIAGNOSIS ???

Diagnosis Please : May 2nd, 2016

What could be probable diagnosis in this elderly patient?

click here for ANSWER

Frontal lobe abscess : follow up MRI

Patient 2 months back, presented with headache and fever. CT and MRI done were consistent with the clinical diagnosis of Brain Abscess in the frontal lobe, which measures ~5.1cm x 4.6cm x 3.1cm (~37mL as per 0.52 x ABC). Abscess was aspirated at that time.

Present MRI showed T2 hyperintense lesion with hypointense rim / capsule. Perilesional vasogenic oedema was seen in frontal-parietal and temporal white matter.

Lesion is showing a T1 iso to mildly hyperintense rim. 

SWI images showed peripheral blooming artefacts of the lesion, which are seen tracking towards the calvarium - indicating the possibility of post aspiration haemorrhage.

Track is also seen showing susceptibility artefacts.

The entire contents of the abscess cavity is showing restricted diffusion.

Smooth rim enhancement of the lesion in post contrast images are noted. 

The track is also noted enhancing. Surrounding parenchyma also showed intense enhancement. No other lesions were seen. No CVT / Oto-mastoiditis seen. Lesion in the current study measured only about ~8mL.