FRCR 2B Rapid Reporting : CXR cases

The rapid reporting cases when we sometimes miss the finding include:

• Subtle pneumothorax (especially Apical and Supine PT).
• Apical pulmonary nodule / mass.
• Lytic lesion rib.
• Mastectomy.

Other less subtle ones include : Rib fracture, distal clavicular fracture, Left Upper Lobe collapse, Right middle lobe pneumonia, RLL/LLL collapse.

Patterns of pulmonary edema, SPN, Hilar lymphadenopathy, lobar consolidation are usually the obvious 'abnormal's in the exam, which should not pose any problems.

Ill-defined air-space opacification in right mid-zone, with poor definition of right cardiac margin (loss of silhouette), consistent with a right middle lobe pneumonia.  Unless careful, can pass this as normal. 

Case courtesy of Dr Jan Frank Gerstenmaier, Radiopaedia.org. From the case rID: 25805

The above case is a case of D10 ivory vertebra due to sclerotic metastasis from breast Ca.
However for the RR purpose, see the left mastectomy, with increased transradiancy of left hemithorax.
In addition there are few surgical clips seen in the lateral chest wall on left side.

The above image shows how to follow a checklist in each CXR case. The importance to follow a checklist for each region cannot be discounted in any case. This image also shows how subtle rib lytic lesions can be.

Click here for the Chest Radiograph RR Checklist

Good web resources for RR:

1. Radiology Masterclass

2. Radiopaedia ( Now have 6 packets of RR free).

3. Norwich Image Interpretation Course.

4. FRCR Academy (Paid Membership, ~30 RR packets).

5. Dr. Sameer Shamshuddin's Website : This site has numerous other resources and links for FRCR.
6. Dr. Gaurav Shankar's FRCR 2B Tips.

Xanthogranulomatous Cholecystitis (Histology from Imaging)

Male patient, 65 years, presenting with vague right hypochondrial pain. On USG showing marked diffuse thickening of gall bladder wall, measuring up to 20mm maximum thickness. Increased vascularity is also noted within the thickened GB wall.

GB lumen showed a large 20.5mm x 18.6mm calculus, with associated luminal sludge.

Above image showing marked thickening of GB wall on left and ill-defined interface of thickened GB wall with hepatic parenchyma (segment V).

A radiologist in his / her report if can suggest the histopathological diagnosis, I believe that would be an ideal situation. Its never easy even with history, clinical diagnosis, lab tests. The ill-defined margins of thickened GB wall and hepatic parenchyma, was suspicious of infiltration. CA-19-9 value was not available at the time of scan. CECT Abdomen was also performed without much significant added information. There were no significant lymphadenopathy / other focal liver lesions / ascites. Close differentials of XGC and Ca.GB were given. Patient underwent surgery, in which GB wall seen adherent to liver and a partial resection of involved parenchyma was also done. HPR came as Xanthogranulomatous Cholecystitis.

'Hummingbird and Morning Glory' of Radiology

Progressive Supranuclear Palsy (PSP) (Syn : Steele-Richardson-Olszewski Syndrome)

• Adult onset neurodegenerative disorder. Taupathy.
• Characterized by early postural instability leading to backward falls within the first year, abnormal eye movements due to supranuclear vertical gaze palsy and abnormal cognition.
• Important to distinguish PSP from Parkinsons Disease and and others like MSA as levodopa is less or no efficacious in treatment in PSP.
• PSP shows marked dorsal midbrain atrophy, with reduction in AP diameter.
• MRI describes few signs in Progressive Supranuclear Palsy namely the Hummingbird sign (aka Penguin Sign), Morning Glory Sign. 
• Reduction in the ratio of areas of Midbrain and Pons is described in PSP.
• Other signs include widening of the Inter Peduncular Cistern and Reduced AP distance of the midbrain at the level of superior colliculus from the interpeduncular fossa to the intercollicular groove (<12mm).
• Increased T2 signal of midbrain and olives, atrophy  and increased signal intensity of superior cerebellar peduncles are also seen.
• Bilateral putamina can show hypointense signal intensity due to increased iron content.
• Associated frontal and parietal atrophy are also seen. Third ventricle is usually dilated.

Above image shows the method of assessing for Morning Glory sign.

Again a normal patient with convex lateral margin of tegmentum.

Above image showing the concave lateral margin of tegmentum, termed as the Morning Glory Sign, which has been stated as a more specific sign of Progressive Supranuclear palsy.

Above images shows the comparison with a normal midbrain showing the superior convex contour and that of an atrophic midbrain showing concave superior contour in a Progressive Supranuclear Palsy patient. The appearance is likened to that of a Humming Bird.

Note : In the original article, the Morning glory sign, is described as the authors saw a likeness of atrophied midbrain to the lateral view of morning glory flower.

References :
1. Magn Reson Med Sci. 2004 Dec 15;3(3):125-32. Morning glory sign: a particular MR finding in progressive supranuclear palsy. Adachi M(1), Kawanami T, Ohshima H, Sugai Y, Hosoya T.
2. CT and MRI of the Whole Body, 6th Edition, John.R.Haaga, Elsevier Publications.
3. Humming bird and Morning glory images from pixabay.com , under CC0.