OF HEMATOMA INTRACRANIAL HEMORRHAGE

Transcription

1 SCOPE TUTORIAL RADIOLOGY CT BRIAN BREASTS US MRCP Natrada Rawdhetubhai, M.D. Radiology Department, Lerdsin General Hospital CT OF HEMATOMA INTRACRANIAL HEMORRHAGE Intra-axial Extra-axial Intraventricular hemorrhage Subdural hemorrhage Epidural hemorrhage Subarachnoid hemorrhage Time CT Hyperacute < 12 hours Isodense Acute 12 hours-7 days Hyperdense Subacute 1 week 1 month Isodense Chronic > 1month Hypodense INTRAPARENCHYMAL HEMORRHAGE INTRAVENTRICULAR HEMORRHAGE Trauma Non-trauma Hypertension Cerebral amyloid angiopathy Tumor Hemorrhaging transformation Vascular anomaly Coagulopathy Vascuitits Primary HTN Vascular anomaly Drug-indeced coagulopathy Venous sinus thrombosis Vasculitis Intraventricular tumor Premature infant Secondary IPH SAH 1

2 IPH AND IVH CEREBRAL HEMORRHAGIC CONTUSION Multiple hyperdense foci with surrounding edema at Anterior cranial fossa floor Temporal lobe Varying in size; petechial -> large SUBDURAL HEMORRHAGE SUBDURAL HEMORRHAGE Peripheral crescentshaped lesion lying between the inner table and the cerebral hemisphere Dose not cross suture Limited by flax and tentorium Majority from venous origin Less mass effect Acute Subacute Chronic P.M.Parizel, Intracranial hemorrhage: Principle of CT and MRI interpretation. Eur.Radiol. (2001) HYPERACUTE SUBDURAL HEMORRHAGE EPIDURAL HEMORRHAGE 2 hours after trauma An isodense, extracerebral, homogeneous SDH along the right convexity A focal biconvex configuration 90% associated skull fracture Cross dural fold Cross midline Infratentotial <--> Supratentorial Dose not cross suture Majority from arterial origin Acute isodense subdural hematoma on computed tomography scan diagnostic and therapeutic trap: a case report. J Med Case Rep. 2016; 10: 43. P.M.Parizel, Intracranial hemorrhage: Principle of CT and MRI interpretation. Eur.Radiol. (2001) 2

3 SUBARCHNOID HEMORRHAGE Serpentine or linear area of high attenuation in subarachnoid space Cause Trauma Rupture intracranial aneurysm AVM P.M.Parizel, Intracranial hemorrhage: Principle of CT and MRI interpretation. Eur.Radiol. (2001) Suprasellar cistern Sylvian fissure Serpentine hyperdense lesion filling the subarachnoid space around circle of Willis BREAST MAMMOGRAM and ULTRASOUND Breast Imaging Reporting and Data System 5 th Edition (2013) ACR: American College of Radiology Lexicon BREAST COMPOSITION Almost entirely fatty Scatter area of fibroglandular density Heterogeneously dense Extremely dense 3

4 MAMMOGRAM: LEXICON A. Masses B. Calcifications C. Architectural distortion D. Asymmetries E. Intramammary lymph node F. Skin lesion G. Solitary dilated duct H. Associated features I. Location of lesion 1.Shaped 2.Margin 3.Density MASSES SHAPED Round Oval Irregular MARGIN a) Circumscribed b) Obscured c) Microlobulated d) Indistinct e) Spiculated a) Circumscribed (obscured <25%) b) Obscured MARGIN MARGIN c) Microlobulated d) Indistinct e) Spiculated 4

5 a) High density b) Equal density c) Low density d) Fat containing DENSITY a) High density DENSITY เท ยบ Fibroglandular tissue b) Equal density c) Low density DENSITY CALCIFICATIONS 1. Typical benign 2. Suspicious morphology 3. Distribution (Simple cyst) d) Fat containing CALCIFICATIONS SKIN CALCIFICATION 1. Typical benign a) Skin b) Vascular c) Coarse or popcorn-like d) Large rod-like e) Round f) Rim g) Dystrophic h) Milk of calcium i) Suture Tightly group, <5 mm individual group Lucent center 5

6 VASCULAR CALCIFICATION COARSE OR POPCORN-LIKE CALCIFICATION Parallel tracks Linear tubular calcification Large (>2-3 mm in greater diameter) Involuted fibroadenoma LARGE-ROD CALCIFICATION ROUND CALCIFICATION Periductal Intraductal Discontinuous smooth linear rods 0.5 mm Usually bilateral, radiated to nipple <1 mm <0.5 mm Punctate calcification P RIM CALCIFICATION DYSTROPHIC CALCIFICATION Post trauma, surgery Irregular shaped Usually > 1 mm Lucent center Fat necrosis Calcified wall of cyst 6

7 MILK OF CALCIUM SUTURE CALCIFICATION Linear or tubular appearance Linear or crescent-shaped on ML view Smudgy on CC view CALCIFICATIONS AMORPHOUS CALCIFICATIONS PPV 20% (BI-RADS 4B) 2. Suspicious Morphology a) Amorphous b) Coarse heterogeneous BI-RADS 4B c) Fine pleomorphic d) Fine linear or find-linear branching BI-RADS 4C Hazy in appearance COARSE HETEROGENEOUS CALCIFICATION PPV 15% (BI-RADS 4B) FINE PLEOMORPHIC CALCIFICATION PPV 29% (BI-RADS 4B) Irregular, conspicuous mm Vary in size and shape, usually < 0.5 mm 7

8 Calcification in benign duct Ductal carcinoma in situ FINE LINEAR FINE-LINEAR BRANCHING PPV 70% (BI-RADS 4C) Thin, linear, irregular calcification, usually < 0.5 mm FINE PLEOMORPHIC CALCIFICATION (BI-RADS 4B) CALCIFICATIONS DISTRIBUTION 3. Distribution a) Diffuses b) Regional c) Grouped d) Linear e) Segmental DIFFUSE REGIONAL Distributed randomly throughout the breast Large portion of breast tissue > 2 cm One quadrant or more 8

9 GROUPS LINEAR 5 calcification in 1 cm 2 cm in area Array in line Not vascular and large rod-like calcification typical benign SEGMENTAL Deposit in duct or ducts and their branches ULTRASOUND: LEXICON US:MASSES A.Masses B.Calcifications C.Associated features D.Special case 1.Shaped 2.Orientation 3.Margin 4.Echo pattern 5.Posterior feature 9

10 a) Parallel b) Not parallel ORIENTATION a) Parallel ORIENTATION ORIENTATION b) Not parallel MARGIN a) Circumscribed b) Not circumscribed Taller-than-wide NOT CIRCUMSCRIBED ECHO PATTERN I. Indistinct II. Angular III. Microlobulated IV. Spiculated a) Anechoic b) Hyperechoic c) Complex cystic and solid d) Hypoechoic e) Isoechoic f) Heterogeneous 10

11 POSTERIOR FEATURE POSTERIOR FEATURE a) No posterior feature b) Enhancement c) Shadowing d) Combined pattern b) Enhancement c) Shadowing CALCIFICATION 1.Calcification in a mass 2.Calcification outside of at mass 3.Intraductal calcification Up to 2 cm in longest diameter. > 2 cm - Very thin cortex Hyperechoic fatty hilum NORMAL LYMPH NODE Length 1.8 cm Patho: Granulomous lymphadenitis with extensive necrosis Shaped: irregular Margin: Not circumscribe Size: 3.3x 1.7 cm Cortical thickening: - Hilar compression or displacement: No fat hilum An oval shaped circumscribed hypoechoic lesion with parallel orientation and posterior acoustic enhancement =BI-RADS 3 11

12 BI-RADS 3 >0% BUT 2% LIKELIHOOD OF MALIGNANCY woman, check up A solid mass with a circumscribed margin, oval shape, and parallel orientation (most commonly fibroadenoma) An isolated complicated cyst Clustered microcysts MLO: Mediolateral oblique CC: Cranio caudal An obscured oval shaped equal density mass at upper outer quadrant of right breast RT upper LT upper RT outer LT outer RT lower LT lower RT Inner LT Inner A circumscribed irregular shaped hypoechoic lesion with parallel orientation and posterior acoustic enhacement BI-RADS 4: SUSPICION FOR MALIGNANCY >2% BUT <95% LIKELIHOOD OF MALIGNANCY BI-RADS 4A Patho: Fibroadenoma 4A: Likelihood of malignancy >2 but 10% Partially circumcribed (<75%) solid mass with US features suggestive of a fibroadenoma Palpable solitary complicated cyst Probable abscess 12

13 BI-RADS 4: SUSPICION FOR MALIGNANCY >2% BUT <95% LIKELIHOOD OF MALIGNANCY BI-RADS 4: SUSPICION FOR MALIGNANCY >2% BUT <95% LIKELIHOOD OF MALIGNANCY 4B: Likelihood of malignancy >10% but 50% A group of amorphous or find pleomorphic calcifications Solid mass with indistinct margin 4C: Likelihood of malignancy >50% but <90% New indistinct, irregular solid mass A new group of fine linear calcification WOMAN, SCREENING Two irregular shaped equal density lesion with spiculated margin at lower inner quadrants of right breast Skin thickening An irregular shaped hypoechoic lesion with spiculated margin (sharp line radiated from mass), taller-than-wide and posterior acoustic shadowing at 6 o clock of right breast Architectural distortion An irregular shaped hypoechoic lesion with indistint and angular margin, tallerthan-wide and posterior acoustic shadowing at 3 o clock of right breast BI-RADS 4C Patho: Invasive ductal carcinoma 13

14 WOMAN, PALPABLE MASS - Segmental fine pleomorphic and coarse heterogeneous calcifications at upper outer quadrant of left breast - Skin thickening - Nipple retraction BI-RADS 5 95% LIKELIHOOD OF MALIGNANCY BI-RADS 5 Patho: IDC Irregular, spiculated, high-density mass with associated microcalcifications New find linear and branching calcifications in segmental distribution A 67-YEAR-OLD WOMAN, PALPABLE MASS Mass: Circumscribed oval shaped high dense mass at upper outer quadrant of left breast 14

15 Calcification: Regional fine pleomorphic calcifications Skin thickening Circumscribed heterogeneous echoic lesion with parallel orientation, posterior enhancement and calcifications in the mass and abnormal left axillary lymph node BI-RADS 5 Patho: Mucinous carcinoma ULTRASOUND CIRRHOSIS Liver Gallbladder Volume distribution Coarse echotexture Nodular surface Nodule Portal HTN: Ascites, splenomgaly, varices 15

16 HEPATIC HEMANGIOMA A well-demarcated homogeneous hyperechoic lesion with faint acoustic enhancement at posterior right lobe No significant flow is identified HCC Nodular surface, coarse echotexture of liver A well-defined heterogeneous hypoechoic lesion at right lobe Sized 1.6 x 1.3 cm. No vascularity No posterior feature HCC A well-defined homogeneous hyperechoic lesion at right lobe Sized xxxx No vascularity No posterior feature Ref: Carol M. Rumack, Diagnostic ultrasound FOCAL FAT INFILTRATION HCC Hemangioma Focal fat infiltration Lipoma Ref: Carol M. Rumack, Diagnostic ultrasound Anterior to portal vein at porta hepatis (Segment IV) No mass effect Geometric margin Rapid change with time as early as 6 days Ref: Carol M. Rumack, Diagnostic ultrasound 16

17 Large HCC Nodular surface, coarse echotexture of liver A well-defined hyperechoic lesion at segment III A well-defined hyperechoic lesion at right lobe with peripheral hypoechoic halo Liver cirrhosis with multiple HCC A well-defined heterogeneous lesion with central hypoechoic region at right lobe with thin peripheral hypoechoic halo. Minimal internal vascularity HEPATIC HEMANGIOMA LIVER ABSCESS A well-demarcated lobulated heterogeneous mixed echoic lesion without posterior feature at posterior right lobe No significant flow is identified Complex cystic lesion with mixed echogenicity Thick wall/septation Fluid-fluid level Posterior acoustic enhancement No internal vascularity Ref: William D. middleton. THE REQUISITES Ultrasound Ref: Carol M. Rumack, Diagnostic ultrasound ACUTE CALCULOUS CHOLECYSTITIS FINDINGS - Gallstones - A positive sonographic Murphy sign - Gallbladder distention (diameter > 4 cm) - Wall thickening (> 3 mm or > 5mm) - Pericholecystic fluid Most specific Gas producing organism: Echogenic foci with a posterior dirty shadow. Ref:Gore and Levine, Textbook of Gastrointestinal Radiology 17

18 Case 1 Case 1 An echoic foci with posterior acoustic shadowing at gallbladder neck Gallbladder distention Gallbladder wall thickening Ref:Gore and Levine, Textbook of Gastrointestinal Radiology An echoic foci with posterior acoustic shadowing at gallbladder neck Gallbladder distention Gallbladder wall thickening Pericholecystic fluid Dx: Acute calculous cholecystitis Ref:Gore and Levine, Textbook of Gastrointestinal Radiology Case 2 Case 3 Multiple dependent echoic foci with posterior acoustic shadowing Gallbladder distention Gallbladder wall thickening Dx: Acute calculous cholecystitis Ref: Carol M. Rumack, Diagnostic ultrasound A echoic foci with posterior acoustic shadowing at gallbladder neck Gallbladder distention Gallbladder wall thickening Intraluminal fluid debris level/sludge Dx: Acute calculous cholecystitis Ref: Carol M. Rumack, Diagnostic ultrasound ACUTE BACTERIAL CHOLANGITIS BILIARY TREE FINDINGS - Dilatation of biliary tree - Choledocholithiasis (CBD stone) - Bile duct wall thickening - Hepatic abscess Ref: Carol M. Rumack, Diagnostic ultrasound CBD, CHD, Right hepatic duct and left hepatic duct Lying anterior to the PVs Routinely seen on US Second-order branches may be visualized Intrahepatic duct: Not in a fix relation to the PV Ref: Carol M. Rumack, Diagnostic ultrasound 18

19 CBD dilatation (> 6 mm) Intraluminal echoic foci with posterior acoustic shadowing Ref:Gore and Levine, Textbook of Gastrointestinal Radiology Bile duct wall thickening Gallbladder wall thickening Ref: Carol M. Rumack, Diagnostic ultrasound GALLBLADDER POLYP MRCP Multiple polypoid isoechoic lesion attach/adhear to the gallbladder wall No mobility No posterior acoustic shadowing Thick-slap(T2WI): A wellcircumscribed low signal intensity filling defect in distal common bile duct 19