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Imaging & Diagnostics

Back Clinic Imaging & Diagnostics Team. Dr. Alex Jimenez works with top-rated diagnosticians and imaging specialists. In our association, imaging specialists provide fast, courteous, and top-quality results. In collaboration with our offices, we provide the quality of service our patients’ mandate and deserve. Diagnostic Outpatient Imaging (DOI) is a state-of-the-art Radiology center in El Paso, TX. It is the only center of its kind in El Paso, owned and operated by a Radiologist.

This means when you come to DOI for a radiologic exam, every detail, from the design of the rooms, the choice of the equipment, the hand-picked technologists, and the software which runs the office, is carefully chosen or designed by the Radiologist and not by an accountant. Our market niche is one center of excellence. Our values related to patient care are: We believe in treating patients the way we would treat our family and we will do our best to ensure that you have a good experience at our clinic.


Ensuring Patient Safety: A Clinical Approach in a Chiropractic Clinic

Ensuring Patient Safety: A Clinical Approach in a Chiropractic Clinic

How do healthcare professionals in a chiropractic clinic provide a clinical approach to preventing medical errors for individuals in pain?

Introduction

Medical errors resulted in 44,000–98,000 hospitalized American deaths annually, and many more caused catastrophic injuries. (Kohn et al., 2000) This was more than the number of people who died annually from AIDS, breast cancer, and auto accidents at the time. According to later research, the actual number of deaths may be closer to 400,000, placing medical errors as the third most common cause of death in the US. Frequently, these mistakes are not the product of medical professionals who are inherently bad; rather, they are the outcome of systemic issues with the health care system, such as inconsistent provider practice patterns, disjointed insurance networks, underutilization or absence of safety protocols, and uncoordinated care. Today’s article looks at the clinical approach to preventing a medical error in a clinical setting. We discuss associated medical providers specializing in various pretreatments to aid individuals suffering from chronic issues. We also guide our patients by allowing them to ask their associated medical providers very important and intricate questions. Dr. Alex Jimenez, DC, only utilizes this information as an educational service. Disclaimer

Defining Medical Errors

Determining what medical error is the most crucial step in any conversation about preventing medical errors. You might assume this is a very easy chore, but that is only until you delve into the vast array of terminology utilized. Many terms are used synonymously (sometimes mistakenly) since some terminology is interchangeable, and occasionally, the meaning of a term depends on the specialty being discussed.

 

 

Even though the healthcare sector stated that patient safety and eliminating or reducing medical errors were priorities, Grober and Bohnen noted as recently as 2005 that they had fallen short in one crucial area: determining the definition of “perhaps the most fundamental question… What is a medical error? A medical error is a failure to complete a planned action in a medical setting. (Grober & Bohnen, 2005) However, none of the terms that one would often identify expressly with a medical error—patients, healthcare, or any other element—are mentioned in this description. Despite this, the definition offers a solid framework for further development. As you can see, that specific definition consists of two parts:

  • An execution error: A failure to complete a planned action as intended.
  • A planning error: is a technique that, even with perfect execution, does not produce the desired results.

The concepts of faults of execution and planning errors are insufficient if we are to define a medical error adequately. These may occur anywhere, not only at a medical establishment. The component of medical management must be added. This brings up the idea of unfavorable occurrences, known as adverse events. The most common definition of an adverse event is unintentional harm to patients brought about by medical therapy rather than their underlying disease. This definition has gained international acceptance in one way or another. For example, in Australia, the term incidents are defined as in which harm resulted in a person receiving health care. These consist of infections, injury-causing falls, and issues with prescription drugs and medical equipment. Certain unfavorable occurrences might be avoidable.

 

Common Types of Medical Errors

The only issue with this notion is that not all negative things happen accidentally or intentionally. Because the patient may ultimately benefit, an expected but tolerated adverse event may occur. During chemotherapy, nausea and hair loss are two examples. In this instance, refusing the recommended treatment would be the only sensible approach to prevent the unpleasant consequence. We thus arrive at the concept of preventable and non-preventable adverse occurrences as we further refine our definition. It isn’t easy to categorize a choice to tolerate one impact when it is determined that a favorable effect will occur simultaneously. But purpose alone isn’t necessarily an excuse. (Patient Safety Network, 2016, para.3) Another example of a planned mistake would be a right foot amputation due to a tumor on the left hand, which would be accepting a known and predicted unfavorable event in the hopes of a beneficial consequence where none has ever arisen before. There is no evidence to support the anticipation of a positive outcome.

 

Medical errors that cause harm to the patient are typically the focus of our research. Nonetheless, medical mistakes can and do occur when a patient is not harmed. The occurrence of near misses could provide invaluable data when planning how to reduce medical errors in a healthcare facility. Still, the frequency of these events compared to the frequency clinicians report them needs to be investigated. Near misses are medical errors that could have caused harm but did not to the patient, even if the patient is doing well. (Martinez et al., 2017) Why would you acknowledge something that could potentially result in legal action? Consider the scenario where a nurse, for whatever reason, had just been looking at photographs of different medications and was about to provide a medication. Maybe something lingers in her memory, and she decides that’s not how a specific medication looks. Upon checking, she found that the incorrect medicines had been administered. After checking all the paperwork, she fixes the mistake and gives the patient the right prescription. Would it be possible to avoid an error in the future if the administration record included photographs of the proper medication? It is easy to forget that there was a mistake and a chance for harm. That fact remains true regardless of whether we were fortunate enough to find it in time or suffer any negative consequences.

 

Errors of Outcomes & Process

We need complete data to develop solutions that improve patient safety and decrease medical errors. At the very least, when the patient is in a medical facility, everything that can be done to prevent harm and put them in danger should be reported. Many doctors have determined that using the phrases errors and adverse events was more comprehensive and suitable after reviewing mistakes and adverse events in health care and discussing their strengths and weaknesses in 2003. This combined definition would increase data gathering, including mistakes, close calls, near misses, and active and latent errors. Additionally, the term adverse events includes terms that usually imply patient harm, such as medical injury and iatrogenic injury. The only thing that remains is determining whether a review board is a suitable body to handle the separation of preventable and non-preventable adverse events.

 

A sentinel event is an occurrence where reporting to the Joint Commission is required. The Joint Commission states that a sentinel event is an unexpected occurrence involving a serious physical or psychological injury. (“Sentinel Events,” 2004, p.35) There isn’t a choice, as it needs to be documented. Most healthcare facilities, however, do keep their records outlining sentinel incidents and what to do in the event of one to guarantee that the Joint Commission standards are met. This is one of those situations when it’s better to be safe than sorry. Since “serious” is a relative concept, there may be some wriggle room when defending a coworker or an employer. On the other hand, reporting a sentinel event incorrectly is better than failing to report a sentinel event. Failing to disclose can have serious consequences, including career termination.

 

When considering medical errors, people frequently make the mistake of focusing just on prescription errors. Medication errors are undoubtedly frequent and involve many of the same procedural flaws as other medical errors. Breakdowns in communication, mistakes made during prescription or dispensing, and many other things are possible. But we would be gravely misjudging the issue if we assumed that drug errors are the only cause of harm to a patient. One major challenge in classifying the different medical errors is determining whether to classify the error based on the procedure involved or the consequence. It is acceptable to examine those classifications here, given numerous attempts have been made to develop working definitions that incorporate both the process and the outcome, many of which are based on Lucian Leape’s work from the 1990s. 

 


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Analyzing & Preventing Medical Errors

Operative and nonoperative were the two main categories of adverse events that Leape and his colleagues distinguished in this study. (Leape et al., 1991) Operative problems included wound infections, surgical failures, non-technical issues, late complications, and technical difficulties. Nonoperative: headings such as medication-related, misdiagnosed, mistreated, procedure-related, fall, fracture, postpartum, anesthesia-related, neonatal, and a catch-all heading of the system were included under this category of adverse occurrences. Leape also classified errors by pointing out the point of process breakdown. He also categorized these into five headings, which include: 

  • System
  • Performance
  • Drug Treatment
  • Diagnostic
  • Preventative

Many process faults fall under more than one topic, yet they all help to pinpoint the exact cause of the issue. If more than one physician was engaged in determining the precise areas that need improvement, then additional questioning might be required.

 

 

Technically, a medical error can be made by any staff member at a hospital. It is not limited to medical professionals like physicians and nurses. An administrator may unlatch a door, or a cleaning crew member could leave a chemical within a child’s grasp. What matters more than the identity of the perpetrator of the mistake is the reason behind it. What before it? And how can we make sure that doesn’t occur again? After gathering all the above data and much more, it’s time to figure out how to prevent similar errors. As for sentinel events, the Joint Commission has mandated since 1997 that all of these incidents undergo a procedure called Root Cause Analysis (RCA). However, using this procedure for incidents that need to be reported to outside parties would need to be corrected.

 

What Is A Root Cause Analysis?

RCAs “captured the details as well as the big picture perspective.” They make evaluating systems easier, analyzing whether remedial action is necessary, and tracking trends. (Williams, 2001) What precisely is an RCA, though? By examining the events that led to the error, an RCA can focus on events and processes rather than reviewing or placing blame on specific people. (AHRQ,2017) This is why it is so crucial. An RCA frequently makes use of a tool called the Five Whys. This is the process of continuously asking yourself “why” after you believe you have determined the cause of an issue.

 

The reason it’s called the “five whys” is because, while five is an excellent starting point, you should always question why until you identify the underlying cause of the problem. Asking why repeatedly could reveal many process faults at different stages, but you should keep asking why about every aspect of the issue until you run out of other things that could be adjusted to provide a desirable result. However, different tools besides this one can be utilized in a root cause investigation. Numerous others exist. RCAs must be multidisciplinary and consistent and involve all parties involved in the error to avoid misunderstandings or inaccurate reporting of occurrences.

 

Conclusion

Medical errors in healthcare institutions are frequent and mostly unreported events that seriously threaten patients’ health. Up to a quarter of a million individuals are thought to pass away each year as a result of medical blunders. These statistics are unacceptable in a time when patient safety is supposedly the top priority, but not much is being done to alter practices. If medical errors are accurately defined and the root cause of the problem is found without assigning blame to specific staff members, this is unnecessary. Essential changes can be made when fundamental causes of system or process faults are correctly identified. A consistent, multidisciplinary approach to root cause analysis that uses frameworks like the five whys to delve down until all issues and defects are revealed is a helpful tool. Although it is now necessary for the wake of sentinel events, the Root Cause Analysis may and should be applied to all mistake causes, including near misses.

 


References

Agency for Healthcare Research and Quality. (2016). Root Cause Analysis. Retrieved March 20, 2017, from psnet.ahrq.gov/primer/root-cause-analysis

Grober, E. D., & Bohnen, J. M. (2005). Defining medical error. Can J Surg, 48(1), 39-44. www.ncbi.nlm.nih.gov/pubmed/15757035

Kohn, L. T., Corrigan, J., Donaldson, M. S., & Institute of Medicine (U.S.). Committee on Quality of Health Care in America. (2000). To err is human : building a safer health system. National Academy Press. books.nap.edu/books/0309068371/html/index.html

Leape, L. L., Brennan, T. A., Laird, N., Lawthers, A. G., Localio, A. R., Barnes, B. A., Hebert, L., Newhouse, J. P., Weiler, P. C., & Hiatt, H. (1991). The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med, 324(6), 377-384. doi.org/10.1056/NEJM199102073240605

Lippincott ® NursingCenter ®. NursingCenter. (2004). www.nursingcenter.com/pdfjournal?AID=531210&an=00152193-200411000-00038&Journal_ID=54016&Issue_ID=531132

Martinez, W., Lehmann, L. S., Hu, Y. Y., Desai, S. P., & Shapiro, J. (2017). Processes for Identifying and Reviewing Adverse Events and Near Misses at an Academic Medical Center. Jt Comm J Qual Patient Saf, 43(1), 5-15. doi.org/10.1016/j.jcjq.2016.11.001

Patient Safety Network. (2016). Adverse events, near misses, and errors. Retrieved March 20, 2017, from psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors

Williams, P. M. (2001). Techniques for root cause analysis. Proc (Bayl Univ Med Cent), 14(2), 154-157. doi.org/10.1080/08998280.2001.11927753

Disclaimer

Spinal Stenosis MRI: Back Clinic Chiropractor

Spinal Stenosis MRI: Back Clinic Chiropractor

Spinal stenosis is when space somewhere along or within the spine begins to narrow, closing off the ability of normal/comfortable movement and nerve circulation. It can affect different areas, including the cervical/neck, lumbar/low back, and, less commonly, the thoracic/upper or mid-back regions causing tingling, numbness, cramping, pain, muscle weakness, or a combination in the back, leg/s, thighs, and buttocks. There can be various factors causing the stenosis; correct diagnosing is the first step, and where a spinal stenosis MRI comes in.

Spinal Stenosis MRI: Injury Medical Chiropractor

Spinal Stenosis MRI

Stenosis can be challenging to diagnose as it is more of a symptom/complication than a condition, often caused by herniated discs, bone spurs, a congenital condition, post-surgery, or after an infection. Magnetic resonance imaging/MRI is a common test used in diagnosis.

Diagnosis

  • A healthcare professional, like a chiropractor, physical therapist, spine specialist, or physician, will begin with understanding symptoms and medical history.
  • A physical exam will be conducted to learn more about the location, duration, positions, or activities that decrease or worsen the symptoms.
  • Additional tests include muscle strength, gain analysis, and balance testing to help better understand where the pain is coming from.
  • To confirm a diagnosis, imaging will be required to see what is going on.
  • An MRI uses computer-generated imaging to produce images that show bone and soft tissues, like muscles, nerves, and tendons, and if they are compressed or irritated.
  • A healthcare professional and MRI technician will go over the safety requirements before the imaging.
  • Because the machine uses powerful magnets, there can be no metal on or in the body, like implanted prostheses or devices that include:
  • Pacemakers
  • Cochlear implants
  • Medication infusion pumps
  • Intrauterine contraceptives
  • Neurostimulators
  • Intracranial aneurysm clips
  • Bone-growth stimulators
  • A different imaging test may be used if an individual cannot have an MRI like a CT scan.

An MRI can range from several minutes to an hour or longer, depending on how many positions are necessary to isolate the injured area and get a clear image. The test is painless, but sometimes individuals are asked to maintain a specific position that could be uncomfortable. The technician/s will ask if there is discomfort and offer any help to make the experience as easy as possible.

Treatment

Not all cases of stenosis cause symptoms, but there are treatment options that a healthcare professional can recommend.

  • Conservative care is the first recommendation that includes chiropractic, decompression, traction, and physical therapy.
  • Treatment increases muscle strength, improves range of motion, improves posture and balance, decreases discomfort symptoms, and incorporates strategies to prevent and manage symptoms.
  • Prescription medications could be part of a larger treatment plan.
  • Surgery could become an option in more severe cases where conservative care is not working.

Spinal Stenosis


References

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-. Diagnosis of lumbar spinal stenosis: an updated systematic review of the accuracy of diagnostic tests. 2013. Available from: www.ncbi.nlm.nih.gov/books/NBK142906/

Ghadimi M, Sapra A. Magnetic Resonance Imaging Contraindications. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: www.ncbi.nlm.nih.gov/books/NBK551669/

Gofur EM, Singh P. Anatomy, Back, Vertebral Canal Blood Supply. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: www.ncbi.nlm.nih.gov/books/NBK541083/

Lurie, Jon, and Christy Tomkins-Lane. “Management of lumbar spinal stenosis.” BMJ (Clinical research ed.) vol. 352 h6234. 4 Jan. 2016, doi:10.1136/bmj.h6234

Stuber, Kent, et al. “Chiropractic treatment of lumbar spinal stenosis: a review of the literature.” Journal of chiropractic medicine vol. 8,2 (2009): 77-85. doi:10.1016/j.jcm.2009.02.001

Spinal Imaging Back Pain Clinic Expectations

Spinal Imaging Back Pain Clinic Expectations

Chiropractors and spine specialists utilize spinal imaging through X-rays, MRIs, or CT scans to figure out what is causing back problems and pain. Imaging is common. Whether chiropractic or spinal surgery, they help immensely discover back issues and allow the individual to see what is happening. Types of cases include back pain that:

  • Comes from trauma
  • Has lingered for four to six weeks
  • It is accompanied by a history of:
  • Cancer
  • Fever
  • Night sweats

Doctors use these images when diagnosing a spinal condition. Here is some insight into spinal imaging.

 

Spinal Imaging Back Pain Clinic Expectations

X-rays

X-rays for back pain can be quite helpful. An X-ray is radiation-based and is used to examine the conditions of the bone structures. X-rays are optimal for bone tissue or tissues that are ossified or calcified. They work the best with hard tissues, specifically bones. Soft tissues like muscles, ligaments, or intravertebral discs do not present as well.

Individuals undergoing a back X-ray will be scanned by a machine that generates a beam. A receiver picks registers the beam after it passes through the body and generates an image. It takes around five minutes to complete but could be longer depending on the doctor’s number of images. X-rays are helpful for insurance purposes and rule out bone conditions like compression fractures and/or bone spurs. X-rays are ordered for specific reasons and are often part of a whole-body diagnostic study. This includes MRI and/or CT scan.

CT Scan

CT stands for computed tomography. It is a series of X-rays that are digitized into images using a computer. The advantage of a CT scan to standard X-rays is that it offers different views/angles of the body and can be in 3D. CT scans are most often used in trauma cases or individuals who have had surgery. They take around five minutes. For X-rays, individuals stand up or lay under the X-ray machine as it scans the body. A CT scan has the individual lie down in a circular donut-looking machine that scans while rotating during the imaging. Individuals are recommended to wear casual loose, comfortable clothing. Sometimes a dye, or intravenous contrast, is used to get the vascular tissues to stand out, generating clearer images.

MRI

MRI is short for magnetic resonance imaging. MRIs use magnets to generate images. MRI imaging is often used in individuals that have undergone surgery. They take longer, usually around 30 to 45 minutes. No metallic objects are allowed in the MRI. Patients are asked to remove items like belts, jewelry, etc. Contrast dye can be a part of an MRI. The machine is like a tunnel. This can become challenging for individuals that have claustrophobia. Consult with a doctor and find out how to get comfortable during the process.

Other Forms of Spinal Imaging

Other forms of imaging include:

CT navigation

  • CT navigation shows real-time CT scans during the procedure.

Fluoroscopy

  • Fluoroscopy involves an X-ray beam that passes directly through the body that shows live, moving images.

Both of these types of spinal imaging are utilized during surgeries. For some cases, intraoperative imaging is used. This type of imaging uses high-tech robotics to help surgeons navigate through tight spaces during the procedure. This increases the surgeon’s accuracy and reduces the size of the incision.

Ultrasound

Ultrasound can be used for spinal conditions. This is an imaging test that uses sound waves to generate images. However, the imaging tests which are used in spinal imaging are primarily X-rays and MRIs.

Imaging Appointment

Talk with your doctor or chiropractor ahead of time to understand what to expect during the imaging process. They will let you know how to prepare and any special instructions before the appointment. Along with medical history and a physical examination, spinal imaging is an important part of the diagnostic process to find what is causing the pain and to develop the best treatment plan.


Body Composition


Short-term Effects of Coffee and Blood Pressure

The caffeine in coffee is a stimulant or substance that excites the body’s systems. When caffeine is ingested, individuals experience an increase in excitement, specifically in the cardiovascular system. This excitement causes the heart rate and blood pressure to rise and then lower back to a baseline level for healthy individuals. Coffee slightly increases short-term blood pressure. Moderate coffee consumption is safe for individuals that do not have pre-existing cardiovascular conditions.

References

United States Nuclear Regulatory Commission. (May 2021) “Doses in Our Daily Lives” www.nrc.gov/about-nrc/radiation/around-us/doses-daily-lives.html

X-Ray for Back Pain: Current Reviews in Musculoskeletal Medicine. (April 2009) “What is the role of imaging in acute low back pain?” www.ncbi.nlm.nih.gov/pmc/articles/PMC2697333/

Pediatric Complaints Diagnostic Imaging Approaches | El Paso, TX.

Pediatric Complaints Diagnostic Imaging Approaches | El Paso, TX.

  • This is a brief review of some of the essential pediatric complaints encountered in clinical practice.
  • Acute Trauma including acute head trauma
  • Non-accidental Trauma in children (battered child)
  • Musculoskeletal Complaints (Juvenile Idiopathic Arthritis, scoliosis,
  • Common pediatric neoplasms (CNS & others)
  • Infection
  • Metabolic disease

Acute Pediatric trauma:

pediatric diagnostic imaging el paso, tx.
  • FOOSH injuries (e.g., fell off the monkey-bar)
  • Supracondylar Fx, elbow. Always d/t accidental trauma. <10-y.o.
  • Extra-articular Fx
  • Gartland classification grades minimally displaced subtle injuries treated with simple immobilization vs. posterior elbow dislocation treated operatively
  • A potential risk of ischemic compromise if care is delayed (Volkmann contracture)
  • The Radiological exam is crucial: sail sign & posterior fat pad sign with anterior humeral line failed to intersect mid/2/3 of Capitellum.

Incomplete pediatric Fx:

pediatric diagnostic imaging el paso, tx.
  • Most in <10 y.o. Greenstick, Torus, Plastic aka Bowing deformity
  • Typically heal well, treated conservatively with immobilization
  • Plastic deformity if >20-degrees requires closed reduction
  • Ping pong skull fracture may develop following trauma, forceps delivery and complications of birth trauma. May need to be assessed by the pediatric neurosurgeo.n
pediatric diagnostic imaging el paso, tx.
  • Salter-Harris types of physeal growth plate injuries
  • Type 1-slip. e.g., Slipped Capital Femoral Epiphysis. Typically no bone fracture noted
  • Type 2-M/C with good prognosis
  • Type 3- intra-articular, thus carries the risk of premature osteoarthritis and may require operative care d/t being unstable
  • Type 4- Fx through all regions about the physis. Unfavorable prognosis and limb shortening
  • Type 5- often no evidence of actual bone fracture. Poor prognosis d/t crush injury and vascular damage with limb shortening
  • Imaging evaluation is crucial

Non-Accidental Injury (NAI)in Children

pediatric diagnostic imaging el paso, tx.
  • There different forms of child abuse. Physical abuse may range from skin injuries to different MSK/systemic injuries affecting bones and soft tissues. Imaging is crucial and may identify definite signs alerting medical providers and informing child protection services and law enforcement agencies about physical abuse.
  • In an infant: �shaken baby syndrome� may present with CNS signs d/t tearing of immature bridging vein and subdural hematoma which can be fatal. Retinal hemorrhaging often a clue. Head CT is crucial.
  • MSK Radiological Red Flags:
  • 1) major bone Fx in an un-ambulatory very young child (0-12 m.o.)
  • 2) Posterior ribs Fx: naturally never occur d/t accidents. Most likely mechanisms: grabbing and squeezing a child or direct hit.
  • 3) Multiple Fractures with different chronological healing rates, i.e., bone calluses indicating repeated physical trauma
  • 4) Metaphyseal corner Fx aka Bucket handle Fx, often pathognomonic for NAI in children. Occurs when the affected extremity is held and violently twisted.
  • 5) Spiral fracture of long bones in a young child is another example of NAI.
  • Other important clues of NAI. Inconsistent history provided by guardians/caregivers. No evidence of congenital/metabolic bone abnormalities like Osteogenesis Imperfecta or Rickets/osteomalacia etc.
  • N.B. When child�s guardians state a history that reports fall and accidents in the house, It is important to know that apparently most accidents/falls in the house are very rarely or unlikely result in major bone fractures.
  • Reporting child abuse in Illinois:
  • www2.illinois.gov/dcfs/safekids/reporting/pages/index.aspx

MSK Imaging Approach in Pediatrics

pediatric diagnostic imaging el paso, tx.
  • Juvenile Idiopathic Arthritis (JIA)-considered M/C chronic disease of childhood. Clinical Dx: joint pain/swelling for 6-weeks or longer in a child <16-y.o. Different forms exist: Early Dx is crucial to prevent delayed complications
  • Most familiar forms of JIA:
  • 1) Pauciarticular disease (40%)- m/c form of JIA. Girls are at greater risk. Presents as arthritis in <4 joints: knees, ankles, wrist. Elbow. This type shows high association with ocular involvement as iridocyclitis (25%) that may potentially lead to blindness. Labs: RF-ve, ANA positive.
  • 2) Polyarticular disease (25%): RF-ve. Girls are at greater risk. Affects small and large joints often affect Cervical spine
  • 3) Systemic form of JIA (20%): often presents with acute systemic manifestation as spiking fevers, arthralgias, myalgias, lymphadeno[pathy, hepatosplenomegaly, polyserositis (pericardial/pleural effusion). Important Dx features characteristic evanescent salmon pink rash on the extremities and trunk. The Systemic form has a distinct lack of ocular involvement. Joints typically shoe no erosions compared to other types. Thus joint destruction is not typically seen

Imaging in JIA

pediatric diagnostic imaging el paso, tx.
  • Joint effusion bone overgrowth squaring of patella cartilage/bone erosion superimposed DJD
  • Fingers and long bones early physeal closure/limb shortening
  • Rad DDx knee/ankle: Hemophilic arthropathy Rx: DMARD.
  • Complications may occur joint destruction, growth retardation/limb shortening, blindness, systemic complications, disability.

Most Common Pediatric Malignant Bone Neoplasms

pediatric diagnostic imaging el paso, tx.
  • Osteosarcoma (OSA) & Ewing�s sarcoma (ES) are 1 st and 2nd M/C primary malignant bone neoplasms of childhood (peak at 10-20 y.o.) Clinically: bone pain, change in activity, early metastasis especially pulmonary mets may occur. Poor prognosis
  • Ewing�s may present with bone pain, fever and elevated ESR/CRP mimicking infection. Early Dx with imaging and staging are crucial.
  • Imaging of OSA & ES: x-ray, followed by MRI, chest CT, PET/CT. On x-rays: OSA may affect any bone but most present as aggressive bone forming neoplasms about the knee (50% cases) especially as osteoid forming an aggressive lesion in the metaphysis with speculated/sunburst periostitis & Codman triangle. Marked soft tissue invasion.
  • ES may present in the shaft and show very early soft tissue spread. MRI is crucial to reveal the extent of bone and ST invasion, MRI required for surgical planning
  • OSA & ES Rx: A combination of surgery, radiation, chemo. Limb salvage techniques are performed in some cases. Poor prognosis if detected late.
pediatric diagnostic imaging el paso, tx.
  • Imaging of Ewing�s sarcoma
  • Permeating bone distraction
  • Early and extensive soft tissue invasion
  • Aggressive periosteal reaction with laminated (onion skin) response
  • Saucerisation of cortical bone (orange arrow)
  • A Lesion is typically diaphyseal with some metaphyseal extension
  • Known as Round cell tumor along with Multiple Myeloma and Lymphoma

Common Childhood Malignancies

pediatric diagnostic imaging el paso, tx.
  • Neuroblastoma (NBL) M/C malignancy of infancy. Derives from neural crest cells aka PNET tumors (e.g., sympathetic ganglia). Most occur in children <24-months. Some show good prognosis but >50% cases present with advanced disease. 70-80% at age 18-months or older present with advanced metastasis. NBL may develop in the adrenal medulla, sympathetic ganglia and other location. Presents as an abdominal mass, vomiting. >50% presents with bone pain d/t metastasis. Clinically: physical exam, labs, imaging: chest and abd x-rays, CT abdomen and chest is crucial to Dx. MRI may help. NBL may metastasize to the skull and infiltrate sutures with a characteristic presentation as pathological sutural diastasis.
  • Acute Lymphoblastic Leukemia is the m/c malignancy of childhood. Pathology: leukemic cell infiltration of bone marrow leading to bone pain and replacement of other normal marrow cells with anemia, thrombocytopenia, neutropenia and associated complications. Leukemic cells may infiltrate other sites including CNS, spleen, bone and other regions. Dx: CBC, serum lactate dehydrogenase levels, Bone marrow aspiration biopsy is the key. Imaging may help but not essential to diagnosis. On radiography, leukemic infiltration of the bone may typically appear as radiolucent bands along the physeal growth plate. Rx: chemotherapy and treating complications
pediatric diagnostic imaging el paso, tx.
  • Medulloblastoma: M/C malignant CNS neoplasm in children
  • Majority develop before 10-y.o.
  • M/C location: cerebellum and posterior fossa
  • Histologically represents a PNET type tumor not a glioma as was originally thought
  • MBL, as well as Ependymoma and CNS lymphoma, may lead to drop metastasis via CSF and additionally represent a unique that unlike other CNS tumors demonstrate metastatic spread outside CNS, m/c to the bone
  • 50% of MBL may be fully resectable
  • If Dx and treatment begin before metastasis, 5- year survival is 80%
  • Imaging is crucial: CT scanning may be used but the imaging modality of choice is MRI that will additionally provide a more superior evaluation of the entire neuraxis for metastasis.
  • MBL typically appears as heterogenous hypo, iso and hyperintense lesion on T1, T2 and FLAIR scans (top images) if compare to surrounding brain tissue. Often compressing 4th ventricle with obstructive hydrocephalus. The tumor typically shows contrast enhancement on T1+C gad (bottom left image). Drop metastasis from MBL with T1+C enhancing lesion in the cord

Important Pediatric Infections

pediatric diagnostic imaging el paso, tx.
  • In the neonate/infant <1month: fever >100.4 (38C) may indicate bacterial and some viral infection. Strep B, Listeria, E. Coli may lead to sepsis, meningitis. Approach: chest x-ray, lumbar puncture with culture, blood culture, CBC, urinalysis.
  • In young children, Hemophilus influenza type B (HIB) may lead to Epiglottitis a rare but serious complication. The current vaccine helps to reduce the number of cases of Epiglottitis and other HIB related illnesses.
  • Parainfluenza or RSV virus may lead to Croup or acute Laryngotracheobronchitis.
  • Epiglottitis and Croup are Dx clinically but AP and lateral soft tissue neck x-rays are very helpful
  • Epiglottitis presents with a characteristic �thumb sign� that is consistent with thickened epiglottis d/t epiglottic edema. This can be a life-threatening emergency compromising airways (top left)
  • Croup may show a �steeple sign� or �wine bottle sign� with distended hypopharynx as acute narrowing of subglottic airway on AP and lateral neck soft tissue x-ray (top right)
  • Respiratory Syncytia Virus (RSV) and influenza may lead to viral pneumonia potentially with life-threatening complications in the immunocompromised, very young and children with comorbidities. CXR is crucial (middle left)
  • Streptococcal pharyngitis with GABHS infection may lead to some acute or delayed complications (e.g., Rheumatic fever)
  • Peritonsillar abscess (above middle right) may develop in some cases and be complicated by spreading along soft tissue planes in the neck potentially leading to spread into sublingual/submandibular spaces (Ludwig Angina) when airways need to be controlled d/t base of tongue edema
  • Development of a retropharyngeal abscess may potentially lead to spread of the infection through freely communicating neck fascia resulting in necrotizing mediastinitis, Lemmier syndrome and invasion of carotid spaces (all are potentially life-threatening complications)
  • Griesel syndrome- (above bottom left) rare complication of regional tonsillar/pharyngeal oral infections that can spread to prevertebral space leading to C1-2 ligaments laxity and instability
  • Other important infections in children are typical bacterial (Pneumococcal) pneumonia, Urinary tract infection and Acute Pyelonephritis (especially in girls) and Meningococcal Meningitis
pediatric diagnostic imaging el paso, tx.
  • Pediatric Metabolic Disease
  • Rickets: considered osteomalacia in skeletally immature. Zone of provisional calcification of the epiphyseal growth plate is particularly affected
  • Clinically presents with growth retardation, extremity bowing, rachitic rosary, pigeon chest, depressed ribs, enlarged and swollen wrists, and ankles, skull deformity
  • Pathology: Vit D and calcium abnormality is the m/c cause. Lack of sun exposure esp. dark-skinned individual, restrictive clothing to light exposure, prolonged exclusive breastfeeding, veganism, malabsorption syndromes of the gut, renal damage and others
  • Imaging: frayed metaphysis aka paint brush metaphysis with flaring, widening of the growth plate, bulbous costochondral junction as a rachitic rosary, extremity bowing
  • Rx: treat underlying causes, correct nutritional deficit, etc.

References

The Abdomen: Diagnostic Imaging Approach | El Paso, TX.

The Abdomen: Diagnostic Imaging Approach | El Paso, TX.

 

  • Diagnosis of the diseases of the abdomen can be classified into:
  • Abnormalities of the gastrointestinal tract (esophagus, stomach, small & large bowel, and the appendix)
  • Abnormalities of the accessory digestive organs (Hepatobiliary & pancreatic disorders)
  • Abnormalities of the genitourinary & reproductive organs
  • Abnormalities of the abdominal wall and major vessels
  • This presentation aims to provide the most basic understanding of general diagnostic imaging approach and appropriate clinical management of patients with the most common diseases of the abdomen
  • Imaging modalities used during an investigation of the abdominal complaints:
  • AP abdomen (KUB) and upright CXR
  • Abdominal CT scanning (with oral and I.V. contrast and w/o contrast)
  • Upper and Lower GI Barium studies
  • Ultrasonography
  • MRI (most used as Liver MRI)
  • MRI enterography & enteroclysis
  • MRI rectum
  • Endoscopic Retrograde Cholangiopancreatography (ERCP)- mostly hepatobiliary and pancreatic ductal pathology
  • Nuclear imaging

Why Order An Abdominal X-ray?

abdomen diagnostic imaging el paso tx.

 

  • Include a preliminary evaluation of bowel gas in an emergent setting. For example, a negative study in a low probability patient may obviate the need for a CT or other invasive procedures
  • Evaluation of radiopaque tubes, lines, and radiopaque foreign bodies
  • Post-procedural evaluation intraperitoneal/retroperitoneal free gas
  • Monitoring the amount of bowel gas and resolution of postoperative (adynamic) ileus
  • Monitoring the passage of contrast through the bowel
  • Colonic transit studies
  • Monitoring renal calculi

 

abdomen diagnostic imaging el paso tx.

 

What to Note on AP Abdomen: Supine vs. Upright vs. Decubitus

  • Free Air (pneumoperitoneum)
  • Bowel obstruction: Dilated loops: SBO vs LBO (3-6-9 rule) SB-upper limit-3-cm, LB-upper limit-6-cm, Caecum-upper limit-9-cm. Note loss of haustra, note dilation (presence) of valvule conivente (plica semilunaris) in SBO
  • SBO: note different heights air-fluid levels on upright film step ladder� appearance, typical of SBO
  • Note paucity of rectal/colonic gas (evacuated) in SBO

 

abdomen diagnostic imaging el paso tx.

 

  • Abdominal CT scanning -modality of choice during the investigation of acute and chronic abdominal complaints especially in adults. For example, abdominal malignancy can be successfully diagnosed and staged providing clinical information for care planning
  • Abdominal, renal and pelvic ultrasound can be performed to help the diagnosis of appendicitis (esp. in children), acute & chronic vascular pathology, hepatobiliary abnormalities, obstetric and gynecological pathology
  • Use of ionizing radiation (x-rays & CT) should be minimized in children and other vulnerable groups.

 

abdomen diagnostic imaging el paso tx.

 

Diagnostic Imaging of Major Diseases of the Gastrointestinal System

  • 1) Esophageal disorders
  • 2) Gastric carcinoma
  • 3) Gluten Sensitive Enteropathy
  • 4) Inflammatory Bowel Disease
  • 5) Pancreatic ductal adenocarcinoma
  • 6) Colorectal carcinoma
  • 7) Acute Appendicitis
  • 8) Small bowel obstruction
  • 9) Volvulus

Esophageal disorders

  • Achalasia (primary achalasia): failure of organized esophageal peristalsis d/t impaired relaxation of the lower esophageal sphincter (LOS) with marked dilatation of the esophagus and food stasis. Obstruction of the distal esophagus (often due to tumor) has been termed “secondary achalasia” or “pseudoachalasia.� Peristalsis in the distal smooth muscle segment of the esophagus may be lost due to an abnormality of Auerbach plexus (responsible for smooth muscle relaxation). Vagus neurons can also be affected
  • Primary: 30 -70s, M: F equal
  • Chagas disease (Trypanosoma Cruzi infection) with the destruction of the Myenteric plexus neurons of the GI system (megacolon & esophagus)
  • However, the heart is the M/C affected organ
  • Clinically: Dysphagia for both solids and liquids, in comparison to dysphagia for solids only in cases of esophageal carcinoma. Chest pain and regurgitation. M/C mid esophageal squamous cell carcinoma in approximately 5% due to chronic irritation of the mucosa by stasis of food and secretions. Aspiration pneumonia may develop. Candida esophagitis
  • Imaging: �Bird -beak� on upper GI barium swallow, dilated esophagus, loss of peristalsis. An endoscopic exam is crucial.
  • Rx: difficult. Calcium channel blockers (short -term).Pneumatic dilatation, effective in 85% of patients with 3 -5% risk of bleeding/perforation. Botulinum toxin injection lasts only approx. 12 months per treatment. May scar the submucosa leading to increased risk of perforation during subsequent myotomy. Surgical myotomy (Heller myotomy)
  • 10 -30% of patients develop gastroesophageal reflux (GERD)

 

abdomen diagnostic imaging el paso tx.

 

  • Presbyesophagus: used to describe the manifestations of degenerating motor function in the aging esophagus >80-y.o. Due to interruption of the reflex arc with decreased sensitivity to distension and alteration in peristalsis.
  • Patients may complain of dysphagia or chest pain, but most are asymptomatic
  • Diffuse/distal esophageal spasm (DES) is a motility disorder of the esophagus that may appear as a corkscrew or rosary bead esophagus on barium swallow.
  • 2% of non-cardiac chest pain
  • Manometry is the gold-standard diagnostic test.
abdomen diagnostic imaging el paso tx.

 

  • Zenker diverticulum (ZD) aka pharyngeal pouch
  • An outpouching at the level of the hypopharynx, just proximal to the upper esophageal sphincter, known as the Killian dehiscence or Killian triangle
  • Patients are 60-80 y.o and present with dysphagia, regurgitation, halitosis, globus sensation
  • May complicate with aspiration and pulmonary abnormalities
  • Patients may accumulate medications
  • ZD- is a pseudodiverticulum or pulsion diverticulum resulting from herniation of the submucosa through the Killian dehiscence, forming a sac where food and other contents may accumulate.
abdomen diagnostic imaging el paso tx.

 

  • Mallory-Weiss syndrome refers to mucosal and submucosal tears of the distal oesophageal venous plexus associated with violent retching/vomiting and projection of gastric contents against the lower esophagus. Alcoholics are at particular risk. Cases present with painless hematemesis. Treatment is typically supportive.
  • Dx: imaging plays little role, but contrast esophagram may demonstrate some mucosal tears filled by contrast (bottom right image). CT scanning may help to exclude other causes of upper GI bleeding
abdomen diagnostic imaging el paso tx.

 

  • Boerhaave syndrome: esophageal rupture secondary to forceful vomiting
  • Presentation: M>F, vomiting, chest pain, mediastinitis, septic mediastinum, pneumomediastinum, pneumothorax pleural effusion
  • In the past, was invariably fatal
  • Mechanisms involve forceful expulsion of gastric contents especially with large undigested foods when esophagus forcefully contracts against closed glottis with 90% occurring along left posterolateral wall
abdomen diagnostic imaging el paso tx.

 

  • Hiatus hernias (HH): herniation of abdominal contents through the esophageal hiatus of the diaphragm into the thoracic cavity.
  • Many patients with HH are asymptomatic, and it is an incidental finding. However, symptoms may include epigastric/chest pain, postprandial fullness, nausea and vomiting
  • Sometimes HH is considered synonymous with gastro-oesophageal reflux disease (GORD), but there is a poor correlation between the two conditions!
  • 2-types: sliding hiatus hernia 90% & rolling (paraoesophageal) hernia 10%. The latter may strangulate leading to ischemia and complications.
abdomen diagnostic imaging el paso tx.

 

  • Esophageal Leiomyoma is the M/C benign esophageal neoplasm. It is often large but yet non-obstructive. Gastrointestinal stromal tumors (GIST) are the least common in the esophagus. Should be differentiated from Esophageal carcinomas.
  • Imaging: contrast esophagram, upper GI barium swallow, CT scanning. Gastroesophagoscopy is the Dx method of choice.

abdomen diagnostic imaging el paso tx.

  • Esophageal carcinoma: presented with increasing dysphagia, initially to solids and progressing to liquids with obstruction in more advanced cases
  • <1% of all cancers and 4-10% of all GI malignancies. There is recognized male preponderance with the squamous cell subtype due to smoking and alcohol. Barrett esophagus and adenocarcinoma
  • M: F 4:1. Black individuals are more susceptible than White individuals 2:1. Poor prognosis!
  • A barium swallow can be sensitive in identifying esophageal mass. Gastroesophagoscopy (endoscopy) confirms the diagnosis with tissue biopsy
  • Overall the most common malignancy is 2ndary gastric fundal carcinoma invading distal esophagus
  • Squamous cell is typically found in the mid esophagus, Adenocarcinoma in the distal region
abdomen diagnostic imaging el paso tx.
  • Gastric carcinoma: primary malignancy of gastric epithelium. Rare before the age of 40. The median age at diagnosis in the United States is 70 years for males and 74 years for females. Japan, South Korea, Chile, and Eastern European countries have one of the highest rates of stomach cancer in the world. Stomach cancer rates are declining worldwide. Gastric cancer is the 5th causes of cancer-related death. Association with Helicobacter pylori infection 60- 80%, but only 2% population with H. Pyloris develop Stomach cancer. 8-10% have an inherited familial component.
  • Gastric Lymphoma is also linked to H. Pyloris infection. Gastrointestinal Stromal Cell Tumour or GIST is another neoplasm affecting the stomach
  • Clinically: No symptoms when it is superficial and potentially curable. Up to 50% of patients may have non-specific GI complaints. Patients may present with anorexia and weight loss (95%) as well as vague abdominal pain. Nausea, vomiting, and early satiety d/t obstruction may occur with bulky tumors or infiltrative lesions that impair stomach distension.
  • Prognosis: Most gastric cancers diagnosed late and may reveal local invasion with regional adenopathy, liver, and mesenteric spread. A 5-year survival rate of 20% or less. In Japan and S. Korea, early screening programmes increased survival to 60%
  • Imaging: Barium upper GI study, CT scanning. Endoscopic examination is the method of choice for the diagnosis. On imaging, Gastric cancer may appear as an exophytic (polypoid) mass or Fungative type, Ulcerative or Infiltrative/diffuse type (Linitis Plastica). CT scanning is important to evaluate local invasion (nodes, mesentery, liver, etc.)
abdomen diagnostic imaging el paso tx.
  • Celiac disease aka non-tropical sprue aka Gluten-sensitive enteropathy: A T-cell mediated autoimmune chronic gluten-induced mucosal damage resulting in loss of villi in the proximal small bowel and gastrointestinal malabsorption (i.e., sprue). Considered in some cases of iron deficiency anemia of undetermined cause. Common in Caucasians (1 in 200) but rare in Asian and black individuals. Two peaks: a small cluster in early childhood. Typically in 3rd and 4th decades of life.
  • Clinically: Abdominal pain is the m/c symptom, malabsorption of nutrients/vitamins: IDA and guaiac-positive stools, diarrhea, constipation, steatorrhea, weight loss, osteoporosis/osteomalacia, dermatitis herpetiformis. Increased association with T-cell lymphoma, Increased association with esophageal squamous cell carcinoma, SBO
  • Dx: Upper GI endoscopy with multiple duodenal biopsies is considered a diagnostic standard for celiac disease. Histology reveals T-cell infiltration and lymphoplasmacytosis, Villi atrophy, Crypts hyperplasia, Submucosa, and Serosa are spared. Rx: elimination of gluten-containing products
  • Imaging: Not required for Dx but on Barium swallow fluoroscopy: mucosal atrophy and obliteration of mucosal folds (advanced cases only). SB dilation is the most typical finding. Nodularity of the duodenum (bubbly duodenum). Reversal of jejunal and ileal mucosal folds:
  • �The jejunum looks like ileum, the ileum looks like the jejunum, and the duodenum looks like hell.�
abdomen diagnostic imaging el paso tx.

Inflammatory Bowel Disease: Crohn Disease (CD) & Ulcerative Colitis (UC)

  • CD: chronic relapsing-remitting autoimmune inflammation that affects any part of the GI tract from the mouth to the anus but at onset most typically involves the terminal ileum. M/C presentation: abdominal pain/cramping and diarrhea. Path: granulomata formation that unlike UC is transmural, potentially leading to strictures. Areas affected by the inflammation are typically patchy
  • Complications are numerous: malabsorption of nutrients/vitamins (anemia, osteoporosis, developmental delay in children, susceptibility to GI malignancy, bowel obstruction, fistula formation, extra-abdominal manifestations: uveitis, arthritis, AS, erythema nodosum and others. 10- 20% may require abdominal surgery after 10-years of CD usually for strictures, fistiluzation, BO.
  • Dx: clinical, CBC, CMP, CRP, ESR, serological tests: DDx of IBD: anti-Saccharomyces cerevisiae antibodies (ASCA), perinuclear antineutrophil cytoplasmic antibody (p-ANCA) histologically or in serum. Fecal Calprotectin test helps to DDx IBS and evaluate response to treatment, disease activity/relapses.
  • Dx of choice: endoscopy, ileoscopy, and multiple biopsies may reveal endoscopic and histological changes. Video capsule endoscopy (VCE), Imaging may help with Dx of complications. Rx: immunomodulatory drugs, complementary medicine, diet, probiotics, operative. No cure but the aim is to induce remission, control symptoms and prevent/treat complications
  • Imaging Dx: KUB to DDx SBO, Barium enema (single and double contrast), small bowel follow through. Findings: skip lesions, aphthous/deep ulcerations, fistula/sinus tracts, String sign, creeping fat pushed loops of LB, cobblestone appearance d/t fissures/ulcers pushing mucosa, CT scanning with oral and IV contrast.
abdomen diagnostic imaging el paso tx.
  • Imaging from a Crohn’s patient who had a small bowel resection for obstruction.
  • (A) CT scan shows non-specific inflammation whereas
  • (B) MRE of the same area shows a fibrostenotic stricture
abdomen diagnostic imaging el paso tx.
  • UC: characteristically involves only the colon but backwash ileitis may develop. Onset is typically at 15-40s and is more prevalent in males, but the onset after the age of 50 is also common. More common in North America and Europe (hygiene hypothesis). Etiology: A combination of environmental, genetic and gut microbiome changes are involved. Smoking and early appendectomy tend to show a negative association with UC, unlike in CD considered some of the risk factors.
  • Clinical Features: Rectal bleeding (common), diarrhea, rectal mucous discharge, tenesmus (occasionally), lower abdominal pain and severe dehydration from purulent rectal discharge (in severe cases, especially in the elderly), fulminant colitis and toxic megacolon can be fetal but are rare complications. Pathology: No granulomata. Ulcerations affect mucosa and submucosa. Pseudopolyps present as elevated spared mucosa.
  • An initial process always affects the rectum and remain a local disease (proctitis) in (25%). 30% Proximal disease extension may occur. UC may present as left-sided (55%) and pancolitis (10%). Majority of cases are mild to moderate
  • Dx: colonoscopy with ileoscopy with multiple biopsies confirm Dx. Labs: CBC, CRP, ESR, Fecal calprotectin, Complications: anemia, toxic megacolon, colon cancer, extra-colonic disease: arthritis, uveitis, AS, Pyoderma gangrenosum, Primary sclerosing cholangitis. Rx: 5-aminosalicylic acid oral or rectal topical therapy, corticosteroids, immunomodulatory drugs, colectomy is curative.
  • Imaging: not required for Dx but barium enema may reveal ulcerations, thumbprinting, in advanced cases loss of haustra and narrowing of the colon producing �lead-pipe colon.� CT scanning may help with Dx seen as mucosal thickening detected only in moderate and severe cases. CT may help with of Dx of complications. Plain film image reveals �lead-pipe colon� and sacroiliitis as Enteropathic arthritis (AS)
abdomen diagnostic imaging el paso tx.
  • Colorectal carcinoma (CRC) m/c cancer of the GI tract and the 2nd most frequent malignancy in adults. Dx: endoscopy and biopsy. CT is the modalities most frequently used for staging. Surgical resection may be curative although the five-year survival rate is 40- 50% depending on staging. Risk factors: low fiber and high fat and animal protein diet, obesity (especially in men), chronic ulcerative colitis. Colonic adenomas (polyps). Familial adenomatous polyposis syndromes (Gardener syndrome) and Lynch syndrome as non-familial polyposis.
  • Clinically: insidious onset with altered bowel habits, fresh blood or melena, iron deficiency anemia from chronic occult blood loss especially in the right-sided tumors. Bowel obstruction, intussusception, heavy bleeding and metastatic disease especially to the Liver may be initial presentation. Path: 98% are adenocarcinomas, arise from pre-existing colonic adenomas (neoplastic polyps) with malignant transformation. The five-year survival rate is 40-50%, with stage at operation the single most important factor affecting prognosis. M/C rectosigmoid tumors (55%),
  • N.B. Some adenocarcinomas esp. mucinous types typically presented late and usually carry poor prognosis due to late presentation and mucin secretion and local/distant spread
  • Imaging: Barium enema is sensitivities for polyps >1 cm, single contrast: 77-94%, double contrast: 82-98%. Colonoscopy is a modality of choice for prevention, detection, and identification of colorectal carcinoma. Contrast-enhanced CT scanning is used for staging and prognosis evaluation of mets.
  • Screening: colonoscopy: men 50 y.o.-10-years if normal, 5-years if polypectomy, FOB, 1st degree relative with CA begin surveillance at 40 y.o
abdomen diagnostic imaging el paso tx.

 

abdomen diagnostic imaging el paso tx.
  • Pancreatic Cancer: ductal epithelial adenocarcinoma (90%), very poor prognosis with high mortality. 3rd M/C abdominal cancer. Colon is #1, stomach #2. Pancreatic cancer accounts for 22% of all deaths due to gastrointestinal malignancy, and 5% of all cancer deaths. 80% of cases in 60+. Cigarette smoking is the strongest environmental risk factor, a diet rich in animal fats and protein. Obesity. Family history. M/C detected in the head and uncinate process.
  • Dx: CT scanning is crucial. Invasion of Superior Mesenteric Artery (SMA) indicates unresectable disease. 90% of pancreatic adenocarcinomas are unresectable at Dx. Most patients die within 1-year of Dx. Clinically: painless jaundice, abd. Pain, Courvoisier�s gallbladder: painless jaundice and enlarged gallbladder, Trousseau�s syndrome: migratory thrombophlebitis, new onset diabetes mellitus, regional and distant metastasis.
  • CT Dx: pancreatic mass with strong desmoplastic reaction, poor enhancement, and slightly lower attenuation compared to the adjacent normal gland, SMA invasion.
abdomen diagnostic imaging el paso tx.
  • Appendicitis: very common condition in general radiology practice and is a major cause of abdominal surgery in young patients
  • CT is the most sensitive modality to detect appendicitis
  • Ultrasound should be employed in younger patients and children
  • KUB Radiographs should play no role in the diagnosis of appendicitis
  • On imaging, appendicitis reveals inflamed appendix with wall thickening, enlargement, and periappendiceal fat stranding. Similar findings of wall thickening and enlargement are noted on US. Typical �target sign� is noted on short axis US probe position.
  • If the appendix is retro-caecal than US may fail to provide accurate Dx and CT scanning may be required
  • Rx: operative to avoid complications
abdomen diagnostic imaging el paso tx.
  • Small bowel obstruction (SBO)-80% of all mechanical intestinal obstruction; the remaining 20% result from large bowel obstruction. It has a mortality rate of 5.5%
  • M/C cause: any Hx of previous abdominal surgery and adhesions
  • Classical presentation is constipation, increasing abdominal distension with nausea and vomiting
  • Radiographs are only 50% sensitive for SBO
  • CT will demonstrate the cause of SBO in 80% of cases
  • There are variable criteria for maximal small bowel obstruction, but 3.5 cm is a conservative estimate of dilated bowel
  • On Abd x-ray: supine vs. upright. Dilated bowel, stretched valvulae conivente (mucosal folds), alternative air-fluid levels �step ladder.� Absent gas in the rectum/colon
  • Rx: operative as �acute abdomen.�
abdomen diagnostic imaging el paso tx.
  • Volvulus-m/c in the Sigmoid colon esp. in elderly. The main reason: chronic constipation with redundant sigmoid twisting on sigmoid mesocolon. Leads to Large bowel obstruction (LBO). Other common causes: a colon tumor. Sigmoid vs. Caecum volvulus
  • Clinically: signs of LBO with constipation, abdominal bloating, pain, nausea, and vomiting. Onset may be acute or chronic
  • Radiographically: loss of haustra in the LB, LB distension (>6-cm), �coffee bean sign� next slide, the lower end of volvulus points to the pelvis
  • N.B: Rule of thumb for dilated bowel should be 3-6-9 where 3-cm SB, 6-cm LB & 9-cm Coecum
  • Rx: operative as �acute abdomen.�
abdomen diagnostic imaging el paso tx.

References

 

Diseases Of The Chest Approach To Diagnostic Imaging

Diseases Of The Chest Approach To Diagnostic Imaging

Core Anatomy

  • Note generations of the tracheal-bronchial tree, lobes, segments, and fissures. Note secondary pulmonary lobule (1.5-2-cm)-the basic functional unit of lungs observed on HRCT. Note important structural organization of the alveolar spaces with communications in between (pores of Kohn & canals of Lambert) that permit air drift and by the same mechanism allow exudative or transudative fluid to spread through the lung and stopped at the fissure. Note the anatomy of the pleura: parietal that is a part of the endothoracic fascia and the visceral that forms a lung edge � pleural space in between.

 

chest diagnostic imaging el paso tx.

 

  • Mediastinum: surrounded by the pleura and the lung. Accommodates major structures contains numerous lymph nodes (see diagramme showing mediastinal nodes and their involvement in Lymphoma

 

chest diagnostic imaging el paso tx.

 

General Approach to Investigating Chest Complaints

  • Radiographic examination (Chest X-ray CXR); excellent 1st step. Low cost, low radiation exposure, multiple clinical complaints evaluation
  • CT scanning: chest CT, High-Resolution CT (HRCT)
  • Chest pathology approach:
  • Trauma
  • Infection
  • Neoplasms
  • Pulmonary edema
  • Pulmonary emphysema
  • Atelectasis
  • Pleural pathology
  • Mediastinum

PA & Lateral CXR

chest diagnostic imaging el paso tx.

 

  • Additional views may be used:
  • Lordotic view: helps to evaluate apical regions
  • Decubitus views right and left: help to evaluate subtle pleural effusion, pneumothorax and other pathology

 

chest diagnostic imaging el paso tx.

 

chest diagnostic imaging el paso tx.

 

  • Normal CXR PA & Lateral views. Ensure good exposure: T-spine discs and vessels through the heart are visualized on PA view. Count 9-10 right posterior ribs to confirm adequate inspiratory effort. Begin a thorough survey using the following approach: Are There Many Lung Lesions A-abdomen/diaphragm, T-thorax wall, M-mediastinum, L-lungs individually, Lungs-both. Develop a good search pattern

 

chest diagnostic imaging el paso tx.

 

  • 1) Airspace disease aka alveolar lung disease? Filling of the lung’s alveoli, acini and subsequently the entire lobe with fluid or substance of any composition (blood, pus, water, proteinaceous material or even cells) Radiographically: lobar or segmental distribution, airspace nodules may be noted, tendency to coalesce, air bronchograms and silhouette sign present. Batwing (butterfly) distribution noted as in (CHF). Rapidly changing over time, i.e., increase or decrease (days)
  • 2) Interstitial disease: infiltration of pulmonary interstitium (alveoli septum, lung parenchyma, vessel walls, etc.) by for example by viruses, small bacteria, protozoans. Also infiltration by cells such as inflammatory/malignant cells (e.g., lymphocytes) Presented as an accentuation of lung interstitium with a reticular, nodular, mixed reticulonodular pattern. Different etiologies: inflammatory autoimmune diseases, fibrosing lung disease, occupational lung disease, viral/mycoplasma infection, TB, sarcoidosis lymphoma/leukemia and many other.

 

chest diagnostic imaging el paso tx.

 

  • Recognizing different patterns of pulmonary disease can help with DDx. Mass vs. Consolidation (left). Note different patterns of pulmonary disease: airspace disease as lobar consolidation indicative of pneumonia, diffuse consolidation indicative of pulmonary edema. Atelectasis (collapse and volume loss). Interstitial patterns of pulmonary disease: reticular, nodular or mixed. SPN vs. Multiple focal consolidations (nodules) likely representing mets infiltrates vs. septic infiltrates

 

chest diagnostic imaging el paso tx.

 

  • A = intraparenchymal
  • B = pleural
  • C = extrapleura
  • Recognize important location of chest lesions

 

chest diagnostic imaging el paso tx.

 

  • Important signs: Silhouette sign: help with localization and DDx. Example: Bottom left image: radiopacity in the right lung, where is it located? Right MM because the right heart border that is adjacent to right middle lobe is not seen (silhouetted) Air bronchograms: air containing bronchi/bronchioles surrounded by fluid

 

chest diagnostic imaging el paso tx.

 

Chest Trauma

  • Pneumothorax (PTX): air (gas) in the pleural space. Many causes. Complications:
  • Tension PTX: continuous increase of air in the pleural space that rapidly compresses mediastinum and lung rapidly reducing venous return to the heart. It can be fatal if not treated rapidly
  • Spontaneous PTX: primary (young adults (30 -40) especially tall, thin men. Additional causes: Marfan�s syndrome, EDS, Homocystinuria, a – 1 -antitrypsin deficiency. Secondary: older pts with parenchymal disease: neoplasms, abscess, emphysema, lung fibrosis and honeycombing, catamenial PTX d/t endometriosis and others.
  • Traumatic pneumothorax: lung laceration, blunt trauma, iatrogenic (chest tubes, etc.) acupuncture, etc.
  • CXR: note visceral pleural line aka lung edge. An Absence of pulmonary tissue/vessels beyond the visceral pleural line. Subtle pneumothorax can be missed. On erect position, air rises and PTX should be sought at the top.
  • Rib fractures: v.common. Traumatic or pathological (e.g., mets, MM) Rib series x – rays are not very useful because CXR and/or CT scanning are more important to evaluate posttraumatic PTX (bottom left) lung laceration and another major path

 

chest diagnostic imaging el paso tx.

 

Infection

  • Pneumonia: bacterial vs. viral or fungal or in the immunocompromised host (e.g., Cryptococcus in HIV/AIDS) Pulmonary TB

 

chest diagnostic imaging el paso tx.

 

  • Pneumonia: community-acquired vs. hospital-acquired. Typical bacterial pneumonia or Lobar (non-segmental) pneumonia with purulent material filling the alveoli and spreading to the entire lobe. M/C organismStreptococcus Pneumonia or the Pneumococcus
  • Others: (Staph, Pseudomonas, Klebsiella esp. in alcoholics potentially leading to necroSIS/lung gangrene) Mycoplasma (20-30s) aka walking pneumonia, etc.
  • Clinically: a productive cough, fever, pleuritic chest pain sometimes hemoptysis.
  • CXR: confluent airspace opacity confined to the entire lobe. Air bronchograms. Silhouette sign help with location.
  • Viral: Influenza, VZV, HSV, EBV, RSV, etc. presents as interstitial lung disease that can be bilateral. May lead to respiratory compromise
  • Atypical pneumonia and Fungal Pneumonia: Mycoplasma, Legionnaire’s disease, and some fungal/Cryptococcus pneumonia may present with interstitial lung disease.
  • Pulmonary abscess: an infectious collection of purulent material in the lungs that often necrotizes. May lead to significant pulmonary and system complications/life-threatening.
  • On CXR or CT: round collection with thick borders and central necrosis containing air-fluid level. DDx from empyema that distorts the lung and pleural-based
  • Rx: antibiotics, antifungal, antiviral agents.
  • Pneumonia needs to be followed up with repeat CXR to ensure complete resolution
  • Lack of radiographic improvement of pneumonia may represent declined immunity, antibiotic resistance, underlying lung carcinoma or other complicating factors

Pulmonary TB

chest diagnostic imaging el paso tx.

 

  • Common infection worldwide (3rd world countries). 1 in 3 persons worldwide is affected by TB. TB is caused by Mycobacterium TB or Mycobacterium Bovis. Intracellular bacillus. Macrophage plays a key role.
  • Primary Pulmonary TB & Post-primary TB. Requires repeated exposure through inhalation. In most immunocompetent hosts, the active infection does not develop
  • TB presents as 1) cleared by the host, 2) suppressed into Latent Tuberculosis Infection (LTBI) 3) cause active disease TB. Patients with LTBI are not spreading TB.
  • Imaging: CXR, HRCT. Primary TB: pulmonary airspace consolidation (60%) lower lobes, lymphadenopathy (95%- hilar & paratracheal), pleural effusion (10%). The Spread of primary TB most likely in immunocompromised and children.
  • Milliary TB: pulmonary and system complication dissemination that can be fatal
  • Post-primary (secondary) or reactivation infection: Mostly in the Apices and posterior segments of the upper lobes )high PO2), 40%-cavitating lesions, patchy or confluent airspace disease, fibrocalcific. Latent features: nodal calcifications.
  • Dx: Acid-fast bacilli (AFB) smear and culture (sputum). HIV serology in all patients with TB and unknown HIV status
  • Rx: 4-drug regimen: isoniazid, rifampin, pyrazinamide, and either ethambutol or streptomycin.

Pulmonary Neoplasms (primary lung cancer vs. pulmonary metastasis)

  • Lung cancer: m/c cancer in men and 6th most frequent cancer in women. Strong association with carcinogens inhalation. Clinically: late discovery, depending on the location of the tumor. Pathology (types): Small cell (SCC) vs. Non-small cell carcinoma
  • Small cell: (20%) develops from neuroendocrine aka Kultchitsky cell, thus may secrete biologically active substances presenting with paraneoplastic syndrome. Typically located centrally (95%) at or near the mainstem/lobar bronchus. Most show poor prognosis and unresectable.
  • Non-small cell: Lung adenocarcinoma (40%) (M/C lung cancer), M/C in women and non-smokers. Others: Squamous cell (may present with cavitating lesion), Large cell and some others
  • Plain film (CXR): new or enlarged focal lesion, widened mediastinum suggestive of lymph node involvement, pleural effusion, atelectasis, and consolidation. SPN-may represents potential lung cancer especially if it contains irregular borders, feeding vessels, thick wall, in the upper lungs. Multiple lung nodules are likely to represent metastasis.
  • Best Modality: HRCT with contrast.
  • Other chest neoplasms: Lymphoma is v. common in the chest especially in mediastinal and internal mammary notes.
  • Overall M/C pulmonary neoplasms are a metastasis. Some tumors show a higher predilection for lung mets, e.g., Melanoma, but any cancer can metastasize to the lungs. Some mets referred as �Cannonball� metastasis
  • Rx: radiation, chemotherapy, resection

 

chest diagnostic imaging el paso tx.

 

  • Pulmonary edema: a general term defines abnormal fluid accumulation outside vascular structures. Broadly divided into Cardiogenic (e.g., CHF, mitral regurgitation) and Non-cardiogenic with a multitude of causes (e.g., fluid overload, post-transfusion, neurological causes, ARDS, near drowning/asphyxiation, heroin overdose, and others)
  • Causes: increased in Hydrostatic pressure vs. decreased in oncotic pressure.
  • Imaging: CXR and CT: 2-types Interstitial and Alveolar flooding. Imaging presentation depends on stages
  • In CHF: Stage 1: redistribution of vascular flow (10- 18-mm Hg) noted as �cephalization� of the pulmonary vasculature. Stage 2: Interstitial edema (18-25-mm Hg) Interstitial edema: peribronchial cuffing, Kerley lines (lymphatics filled with fluid) A, B, C lines. Stage 3: Alveolar edema: airspace disease: patchy consolidations developing into diffuse airspace disease: Batwing edema, air bronchograms
  • Rx: 3 main goals: Initial O2 to keep O2 at 90% saturation
  • Next: (1) reduction of pulmonary venous return (preload reduction), (2) reduction of systemic vascular resistance (afterload reduction), and (3) inotropic support. Treat underlying causes (e.g., CHF)

 

chest diagnostic imaging el paso tx.

 

  • Lung atelectasis: incomplete expansion of pulmonary parenchyma. The term “collapsed lung” is typically reserved for when the entire lung is collapsed
  • 1) Resorptive (obstructive) atelectasis occurs as a result of complete obstruction of an airway (e.g. tumor, inhaled objects, etc.)
  • 2) Passive (relaxation) atelectasis occurs when contact between the parietal and visceral pleura is disrupted (pleural effusion & pneumothorax)
  • 3) Compressive atelectasis occurs as a result of any thoracic space-occupying lesion compressing the lung and forcing air out of the alveoli
  • 4) Cicatricial atelectasis: occur as a result of scarring or fibrosis that reduces lung expansion as in granulomatous disease, necrotizing pneumonia, and radiation fibrosis
  • 5) Adhesive lung atelectasis occurs from surfactant deficiency and alveolar collapse
  • 6) Plate-like or discoid often developed after following general anesthesia
  • 7) Imaging features: lung collapse, migration of lung fissures, deviation of the mediastinum, rising of the diaphragm, hyperinflation of adjacent unaffected lung

 

chest diagnostic imaging el paso tx.

 

  • Mediastinum: pathology can be divided into those that result in a focal mass or those that result in diffuse disease involving the mediastinum. Additionally, air may track into the mediastinum in pneumomediastinum. Knowledge of mediastinal anatomy helps the Dx.
  • Anterior mediastinal masses: thyroid, thymus, teratoma/germ cell tumors, lymphoma, lymphadenopathy, ascending aortic aneurysms
  • Middle mediastinal masses: lymphadenopathy, vascular, bronchial lesions etc.
  • Posterior mediastinal masses: neurogenic tumours, aortic aneurysms, esophageal masses, spinal masses, aortic chain adenopathy

 

chest diagnostic imaging el paso tx.

 

  • Pulmonary emphysema: loss of normal elastic tissue/elastic recoil of the lung with the destruction of capillaries and alveolar septum/interstitium.
  • Destruction of lung parenchyma due to chronic inflammation. Protease-mediated destruction of elastin. Air trapping/airspace enlargement, hyperinflation, pulmonary hypertension, and other changes. Clinical: progressive dyspnea, irreversible. By the time the forced expiratory volume in 1 second (FEV1 ) has fallen to 50% the patient is breathless upon minimal exertion and adapts to lifestyles.
  • COPD is the third leading cause of global death. Affects 1.4% of adults in the US. M:F = 1 : 0.9. Pts 45 years and older
  • Causes: Smoking and a-1-Antitrypsin deficiency (divided into centrilobular (smoking) and panacinar.
  • Imaging; signs of hyperinflation, air trapping, bullae, pulmonary hypertension.

 

chest diagnostic imaging el paso tx.

 

Head Trauma And Other Intra-Cranial Pathology Imaging Approaches

Head Trauma And Other Intra-Cranial Pathology Imaging Approaches

Head Trauma: Skull Fractures

head trauma imaging el paso tx.
  • SKULL FX: COMMON IN THE SETTINGS OF HEAD INJURIES. SKULL FX OFTEN POINT TO OTHER COMPLICATING FACTORS: INTRA-CRANIALHEMORRHAGING, CLOSED TRAUMATIC BRAIN INJURY AND OTHER SERIOUS COMPLICATIONS
  • SKULL X-RAYS ARE VIRTUALLY OBSOLETE IN EVALUATING HEAD INJURY. CT SCANNING W/O CONTRAST IS THE MOST IMPORTANT INITIAL STEP IN EVALUATION OF ACUTE HEAD TRAUMA. MRI HASA POOR ABILITY TO REVEAL SKULL FRACTURES, AND NOT TYPICALLY USED FOR AN INITIAL DX OF ACUTE HEAD TRAUMA.
  • SKULL FX ARE IDENTIFIED AS FXS OF SKULL VAULT, SKULL BASE AND FACIAL SKELETON EACH ASSOCIATED WITH SPECIFIC FEATURES AND HELP TO PREDICT COMPLICATIONS.
  • LINEAR SKULL FX: SKULL VAULT. M/C FX. CT SCANNING IS THE KEY TO EVALUATE ARTERIALEXTRADURAL HEMORRHAGING
  • X-RAY DDX: SUTURES VS. LINEAR SKULL FX. FX IS THINNER, �BLACKER� I.E. MORE LUCENT, CROSSESSUTURES,�AND VASCULAR GROOVES, LACKSSERRATIONS
  • RX: IF NO INTRACRANIAL BLEEDS THAT NO TREATMENT. NEUROSURGICAL CARE IF BLEEDSDETECTED BY CT SCANNING
head trauma imaging el paso tx.
  • DEPRESSED SKULL FX: 75% IN THE VAULT. CAN BE DEADLY. CONSIDERED AN OPEN FX. MOST CASES NEED NEUROSURGICALEXPLORATION ESPECIALLY IFFRAGMENTS DEPRESSED >1-CM.COMPLICATIONS: VASCULAR INJURY/HEMATOMAS, PNEUMOCEPHALUS, MENINGITIS, TBI, CSF LEAK, BRAIN HERNIATION ETC.
  • IMAGING: CT SCANNING W/O CONTRAST
head trauma imaging el paso tx.
  • BASILAR SKULL FX: CAN BE DEADLY. OFTEN ALONG OTHER MAJOR HEAD TRAUMA OF THE VAULT AND FACIALSKELETON, OFTEN WITH TBI AND MAJORINTRACRANIAL HEMORRHAGING. OFTEN OCCUR AS �HEADBAND� EFFECT OF IMPACT AND MECHANICAL TENSION THROUGH THE OCCIPUT AND TEMPORAL BONES THROUGH SPHENOID AND OTHER BASE OF SKULL BONES. CLINICALLY: RACCOON EYES, BATTEL SIGN, CSFRHINO/OTORRHEA.

Facial Fractures

head trauma imaging el paso tx.
  • NASAL BONES FX: 45% OF ALLFACEFXM/C IMPACT IS LATERAL(FIST BLOW ETC.) IF UNDISPLACEDNO TREATMENT, IF DISPLACED MAY COMPLICATE AIR FLOW AND RESPIRATORY PASSAGE, MAY BE ASSOCIATED WITH OTHER FACIAL/SKULL INJURY. X-RAYS 80%SENSITIVE, FOLLOWED BY CT INCOMPLEX INJURIES.
  • ORBITAL BLOW OUT FX: COMMONORBITAL INJURY D/T IMPACT ON THE GLOBE AND/OR ORBITAL BONE. FX OF ORBITAL FLOOR INTOMAXILLARY SINUS VS. MEDIAL WALL INTO ETHMOID SINUS. COMPLICATIONS: ENTRAPPEDINFERIOR RECTUS M, PROLAPSEORBITAL FAT,�AND SOFT TISSUES, HEMORRHAGING AND OPTIC NERVE DAMAGE. RX: CONCERNS OF GLOBE INJURY ARE IMPORTANT, GENERALLY TREATEDCONSERVATIVELY IF NO COMPLICATIONS PRESENT
head trauma imaging el paso tx.
  • TRIPOD FX: 2ND M/C FACIAL FX#AFTER NASAL (40% OF MIDFACEFX) 3-POINT FX-ZYGOMATICARCH, ORBITAL PROCESS OF ZYGOMATIC BONE & SIDE OF MAXILLARY SINUS WALL, MAXILLARY PROCESS OF ZYGOMATIC BONE.COMPLICATED BY NERVE INJURY, TEMPORALIS M DAMAGE ETC. CT SCANNING IS MORE INFORMATIVE THAT X-RAYS (WATER�S VIEW).
  • LEFORT FX: SERIOUS FX ALWAYS INVOLVES PTERYGOID PLATES, POTENTIALLY SEPARATINGMIDFACE AND ALVEOLAR PROCESS WITH TEETH FROM THE SKULL. CONCERNS: AIRWAYS, HEMOSTASIS, NERVE INJURIES. CT SCANNING IS REQUIRED. POTENTIAL RISK OF BASILAR SKULL FX
head trauma imaging el paso tx.
  • PING-PONG FX:�EXCLUSIVELY IN INFANTS. AN INCOMPLETE FX D/T FOCALDEPRESSION: FORCEPS DELIVERY, DIFFICULT LABOUR ETC. FOCALTRABECULAR MICROFRACTURIINGLEAVING DEPRESSION RESEMBLING APING-PONG. DX IS MAINLY CLINICALSEEN AS FOCAL DEFECT �DEPRESSION� IN THE SKULL. TYPICALLYNEUROLOGICALLY INTACT. CT MAY HELP IF BRAIN INJURY IS SUSPECTED. RX: OBSERVATIONAL VS. SURGICAL IN COMPLICATED INJURIES. SPONTANEOUSREMODELING HAS BEEN REPORTED
head trauma imaging el paso tx.
  • LEPTOMENINGEAL CYST (GROWING SKULL FX)- ARE AN ENLARGING SKULL FRACTURE THAT DEVELOPS ADJACENT TO POSTTRAUMATIC ENCEPHALOMALACIA
  • IT IS NOT A CYST, BUT AN EXTENSION OF THEENCEPHALOMALACIA THAT SEEN A FEW MONTHS POST-TRAUMA WITH PREVIOUS SKULL FX FOLLOWEDBY HERNIATION OF THE MENINGES AND ADJACENTBRAIN WITH PULSATIONS OF THE CSF. CT IS BEST ATDX THIS PATHOLOGY. INDICATES: GROWING FX AND ADJACENT ENCEPHALOMALACIA AS FOCALHYPOATTENUATING LESION.
  • CLINICALLY: PALPABLE CALVARIAL ENLARGEMENT, PAIN, NEUROLOGICAL SIGNS/SEIZURES. RX: NEUROSURGICAL CONSULT IS REQUIRED
  • DDX: INFILTRATING CELLS/METS/OTHER NEOPLASMSINTO SUTURES, EG, INFECTION ETC.
head trauma imaging el paso tx.
  • MANDIBULAR FXS: COMMON. POTENTIALLYCONSIDERED AN OPEN FX D/T INTRA-ORALEXTENSION. 40% FOCAL BREAK DESPITEMANDIBLE BEING A RING. DIRECT IMPACT(ASSAULT) M/C MECHANISM
  • PATHOLOGICAL FX D/T BONE NEOPLASMS, INFECTION ETC. IATROGENIC DURING ORAL SURGERY (TOOTH EXTRACTION)
  • IMAGING: MANDIBLE X-RAYS, PANOREX, CT SCANNING ESP. IN CASES OF ASSOCIATEDFACE/HEAD TRAUMA
  • COMPLICATIONS: AIRWAY OBSTRUCTION, HEMOSTASIS IS A MAJOR CONSIDERATION, DAMAGE TO MANDIBULAR N, OSTEOMYELITIS/CELLULITIS AND POTENTIAL SPREAD THROUGH FLOOR OF THE MOUTH (LUDWIGANGINA) AND NECK FASCIAL SOFT TISSUES INTOMEDIASTINUM. CANNOT BE NEGLECTED D/T HIGH MORTALITY RATES.
  • RX: CONSERVATIVE VS. OPERATIVE

Acute Intracranial Hemorrhage

head trauma imaging el paso tx.
  • EPI AKA EXTRADURAL: (EDH) TRAUMATIC RAPTURE OF MENINGEAL ARTERIES (MMA CLASSIC) WITH RAPIDLY FORMING HEMATOMA BETWEEN THE INNER SKULL AND OUTER DURA. CT SCANNING IS THE KEY TO DX: PRESENTS AS �LENTIFORM� I.E. BICONVEX COLLECTION OF ACUTE (HYPERDENSE) BLOOD THAT DOES NOT CROSSSUTURES AND HELPS WITH DDX OF A SUBDURAL HEMATOMA. CLINICALLY: HA, LUCID EPISODE INITIALLY AND DETERIORATING IN A FEW HOURS.COMPLICATIONS: BRAIN HERNIATION, CN PALSY. O/A GOOD PROGNOSIS IF QUICKLY EVACUATED.
  • SUBDURAL HEMATOMA (SDH): RAPTURE OF BRIDGINGVEINS BETWEEN INNER DURA AND THE ARACHNOID.SLOW BUT PROGRESSIVE BLEED. MAY PARTICULARLYAFFECT THE VERY YOUNG AND ELDERLY AND IN ALL AGES (MVA, FALLS ETC.) MAY DEVELOP IN �SHAKEN BABY SYNDROME�. DX MAY BE DELAYED AND WORSEN THE PROGNOSIS WITH HIGH FATALITIES. IN ELDERLY HEAD TRAUMA MAY BE MINOR OR NOT RECALLED. EARLYIMAGING WITH CT IS CRUCIAL. PRESENTS AS CRESCENTSHAPEDCOLLECTION THAT CAN CROSS SUTURES BUT STOPPED AT DURAL REFLECTIONS. DIFFERENTATTENUATION ON CT D/T DIFFERENT STAGES OF BLOODDECOMPOSITION: ACUTE, SUBACUTE,�AND CHRONIC.MAY FORM A CHRONIC COLLECTION-CYSTICHYGROMA. CLINICALLY: VARIABLE PRESENTATION, 45-60% PRESENT WITH SEVERELY DEPRESSED CNS STATUS, PUPILLARY INEQUALITY. OFTEN WITH INITIAL BRAIN CONTUSION, THEN A LUCID EPISODE BEFORE SEVERELYDETERIORATING. IN 30% CASES OF FATAL BRAIN INJURY PATIENTS HAD SDH. RX: URGENT NEUROSURGICAL.
head trauma imaging el paso tx.
  • SUBARACHNOID HEMORRHAGE (SAH): BLOOD IN THE SUB-ARACHNOID SPACE AS THE RESULT OF TRAUMATIC OR NON-TRAUMATIC ETIOLOGY: BERRY ANEURYSMS AROUND CIRCLE OF WILLIS.SAH 3% OF STROKES, 5% OF FETAL STROKES.CLINICALLY: PRESENTS AS A �THUNDERCLAP HEADACHE� DESCRIBED AS A �WORST HA INLIFE�. PT COLLAPSES MAY OR MAY NOT REGAIN CONSCIOUSNESS. PATHOGY: DIFFUSE BLOOD INSA SPACE 1)SUPRASELLAR CISTERN WITH DIFFUSE PERIPHERAL EXTENSION, 2)�PERIMESENCEPHALIC, 3) BASAL CISTERNS. BLOOD LEAKED INTO SA SPACE UNDERARTERIAL PRESSURE INDUCES GLOBAL INCREASE IN INTRACRANIAL PRESSURE, ACUTE GLOBAL ISCHEMIA WORSENED BY VASOSPASM AND OTHER CHANGES.
  • DX: IMAGING: URGENT CT SCANNING W/O CONTRAST, CT ANGIOGRAPHY MAY HELP TO RULE OUT 99% OF SAH. LUMBAR PUNCTUREMAY HELP IN DELAYED PRESENTATION. AFTER INITIAL DX: MR ANGIOGRAPHY HELPS TO FIND THE CAUSE AND OTHER IMPORTANT FEATURES
  • IMAGING FEATURES: ACUTE BLOOD IS HYPERDENSE ON CT. FOUND IN DIFFERENTCYSTERNS: PERIMESENCEPHALIC, SUPRASELLA, BASAL, VENTRICLES,
  • RX: INTRAVENOUS ANTIHYPERTENSIVE MEDS, OSMOTIC AGENTS (MANNITOL) TO DECREASEICP. NEUROSURGICAL CLIPPING AND OTHER APPROACHES.

CNS Neoplasms: Benign vs. Malignant

head trauma imaging el paso tx.
  • BRAIN TUMORS REPRESENT 2% OF ALL CANCERS. ONE THIRD ARE MALIGNANT, OF WHICH METASTATIC BRAIN LESIONS ARE THE MOST COMMON
  • CLINICALLY PRESENT WITH LOCAL CNS ABNORMALITIES, INCREASED ICP, INTRACEREBRAL BLEEDING ETC. FAMILIALSYNDROMES: VON-HIPPEL-LANDAU, TUBEROUS SCLEROSIS, TURCOT SYNDROME, NF1 & NF2 INCREASE THE RISK. IN CHILDREN: M/C ASTROCYTOMAS, EPENDYMOMAS, PNETNEOPLASMS (E.G. MEDULLOBLASTOMA) ETC. DX: BASED ON WHO CLASSIFICATION.
  • ADULTS: M/C BENIGN NEOPLASM: MENINGIOMA. M/C PRIMARY: GLIOBLASTOMA MULTIFORME (GBM)METSESPECIALLY FROM LUNG, MELANOMA,�AND BREAST.OTHERS: CNS LYMPHOMA
  • IMAGING IS CRUCIAL: INITIAL SYMPTOMS MAY PRESENT AS SEIZURE, ICP SIGNS HA. EVALUATED BY CT AND MRI WITH IV GADOLINIUM.
  • IMAGING DETERMINES: INTRA-AXIAL VS. EXTRA-AXIALNEOPLASMS. METS FROM PRIMARY BRAIN NEOPLASMS MAYO CCUR VIA CSF AND LOCAL VESSELS INVASION
  • NOTE AXIAL CT SLICE OF MENINGIOMA WITH AVIDCONTRAST ENHANCEMENT.
  • AXIAL MRI ON FLAIR PULSE SEQUENCE REVEALED EXTENSIVE NEOPLASM AND MARKED CYTOTOXIC EDEMA OF THE BRAIN PARENCHYMA CHARACTERISTIC OF GRADE IV GLIOMA (GBM) WITH VERY POOR PROGNOSIS. ABOVE FAR RIGHT IMAGE: AXIAL MRI FLAIR: BRAIN METASTASIS FROM BREAST CANCER. MELANOMA IS COMMONLY METASTASIZESTO THE BRAIN (SEE PATH SPECIMEN) MRI CAN BE DIAGNOSTIC D/T HIGH SIGNAL ON T1 AND CONTRAST ENHANCEMENT.
  • RX: NEUROSURGICAL, RADIATION, CHEMOTHERAPY,�IMMUNOTHERAPY TECHNIQUES ARE EMERGING

Inflammatory CNS Pathology

head trauma imaging el paso tx.

CNS Infections

  • BACTERIAL
  • MYCOBACTERIAL
  • FUNGAL
  • VIRAL
  • PARASITIC