This document contains 22 radiology case spots describing various pathologies. For each spot, the document provides a brief description of the imaging findings and diagnosis. The cases cover a wide range of topics including musculoskeletal, chest, neurologic, breast and vascular pathologies. Differential diagnoses are also provided for some cases to aid in arriving at the correct diagnosis.

1. BY : DR.CHANDNI WADHWANI
RESIDENT DOCTOR
DEPARTMENT OF RADIOLOGY
MEDICAL COLLEGE BARODA,
SSG HOSPITAL VADODARA,GUJARAT,INDIA.
SPOTTERS-III

2. SPOT 1: Name the deformity:

3. Opera glass hands
 Psoriatric arthritis
 Proximal as well as distal arthropathy with
ankylosis and subluxation.Telescoping of the
fingers is shown.
 Both psoriatric and rheumatoid arthritis can
produce arthritis mutilans, with characteristic
deformities of telescoping.
 Rheumatoid arthritis
 there is a MCP joint predominance in rheumatoid
arthritis (RA) vs interphalangeal predominant
distribution in PsA
 bone proliferation not a feature in RA
 osteoporosis not a feature in PsA

5. SPOT 2:61 year female, Painful, swollen fingers of several months
duration. Both hands are involved, and the pain became worse with
activity and was relieved by NSAIDs.

6. Gull-wing appearance:
Erosive osteoarthritis
 There is central erosions with marginal
proliferation at both of the DIP and PIP joints.
 Diffuse loss of cartilage space is noted at inter-
phalangeal and first carpometacarpal joints.
 Erosive osteoarthritis has a predilection for the
hands.
 subchondral erosions (at least two central
erosions affecting separate IP joints); typical
central location of the erosions produces the
classic "gull wing" appearance

8. SPOT 3:66 year female with Joint pain under
investigation.

9. Systemic sclerosis
 Extensive soft tissue calcification in a predominantly
periarticular distribution.
 Acro-osteolysis of the soft tissues of the terminal
tufts.
 Extensive demineralisation of bones.
 There are no erosions.
 Periarticular calcification of the hands and feet is
characteristic of systemic sclerosis involving the
musculoskeletal system.
 Other conditions where multiple sites of soft tissue
periarticular calcification is seen include:
1. Gout
2. End stage renal failure with changes
of hyperparathyroidism

10. SPOT 4:

11. Lhermitte-Duclos disease
 Dysplastic cerebellar gangliocytoma
 Rare tumour of the cerebellum
 The mass is striated and hyperintense onT2
and grey matter isointense onT1, with no
restricted diffusion and no contrast
enhancement.
 Differential diagnosis
 In the setting of sepsis or acute deterioration,
1. cerebellitis
2. subacute cerebellar infarction

12.  Treatment :
 The dysplastic mass grows very slowly, and initial
treatment revolves around treating
hydrocephalus.
 Surgical resection is often curative.
 Importantly it is crucial to remember association
with Cowden syndrome, hence, increase in risk of
other neoplasms such breast, endometrial and
thyroid cancers. So, recommendation for further
imaging or clinical assessment of possible
tumours in these locations should be included in
the radiologist's report.

13. SPOT 5: 3 year female, Delayed
developmental milestones.

14. Van der Knaap disease
 Megalencephalic leukoencephalopathy with
subcortical cysts
 Rare inherited AR disease characterised by diffuse
subcortical leukoencephalopathy associated with
white matter cystic degeneration.
 Subcortical white matter involved early in course of
disease with involvement of the subcortical U-fibers.
 Subcortical cysts especially temporal poles and
frontoparietal lobes.
 The main differential diagnosis is metachromatic
leukodystrophy (MLD).
 If U-fibers or cysts involved, MLC is considered.

15.  The lesions are seen sparing the basal ganglia
as well as both thalami.
 No pathological enhancement.
 Mild to moderate dilatation of the ventricular
system as well as prominent cortical sulci and
basal cisterns.
 No significant infra-tentorial abnormality.

16. SPOT 6:40 year old male patient complaining of confusion
after being in the parking area for hours.

17. Carbon monoxide poisoning
 Anoxic-ischaemic encephalopathy

18.  Radiographic features
 Tends to bilaterally affect the brain.The globus
pallidus is the most commonly affected area .
 CT brain
 Classically seen as low attenuation in the globus
pallidus region. Other features include diffuse hypo-
attenuation in cerebral white matter .
 MRI brain
 T1: affected areas are usually low signal,
haemorrhagic areas can be high signal
 T2/FLAIR: affected areas are high signal
 T1 C+ (Gd): can show patchy peripheral
enhancement in affected areas in the acute phase
 DWI: affected areas show restricted diffusion in the
acute phase

19. DIFFERENTIALS:
1. Mitochondrial encephalopathies: tends to
affect other basal ganglial regions
1. Leigh disease
2. Kearns-Sayre syndrome
2. Other toxic encephalopathies
1. cyanide neurotoxicity
2. methanol neurotoxicity: tends to affect the
putamen
3. Metabolic disorders
1. Wilson disease

20. 7. Afebrile female infant
presents with bilateral cheek
swelling and discoloration

22. Parotidhemangioma
 Contrast enhanced axial CT images
demonstrate bilateral, lobulated,
enhancing masses in the expected region of
the parotid glands.
 No cystic areas are seen within the masses.
 No normal parotid tissue is seen.
 Prominent enhancing vessels can be seen
adjacent to these masses

23. SPOT 8:

24. Caroticocavernous fistula
 Abnormal communication between the
carotid circulation and the cavernous sinus.

25.  CT
 proptosis
 enlarged superior ophthalmic veins
 extraocular muscles may be enlarged
 orbital oedema
 may show SAH/ICH from a ruptured cortical vein
 Angiography (DSA)
 rapid shunting from ICA to CS
 enlarged draining veins
 retrograde flow from CS, most commonly into the ophthalmic
veins
 Ultrasound
 arterialised ophthalmic veins may be seen on Doppler study

26. Caroticocavernous fistulas
 Classification
 It can be broadly classified into two main types:
1. Direct: direct communication between intracavernous ICA
and cavernous sinus
2. Indirect: communication exists via branches of the carotid
circulation (ICA or ECA)
 Another method is to classify according to four main types:
 Type A: direct connection between the intracavernous ICA and
CS
 Type B: dural shunt between intracavernous branches of the ICA
and CS
 Type C: dural shunts between meningeal branches of the ECA
and CS
 Type D: B + C

27. CASE 9:name the sign??

28. “Lyre sign”- Carotid body
tumour
 Refers to the splaying of
the internal and external carotid by a carotid
body tumour.
 Classically described on angiography
 Chemodectoma or carotid body
paraganglioma, is a highly vascular glomus
tumour that arises from the paraganglion
cells of the carotid body.
 It is located at the carotid bifurcation with
characteristic splaying of the ICA and ECA.

31. Differential diagnosis
 vagal schwannoma: tends to displace both
vessels together rather than splaying them
 vagal neurofibroma: tends to displace both
vessels together rather than splaying them
 lymph node mass: may look similar if
hypervascular
 glomus vagale tumour: same pathology but
located more rostrally
 carotid bulb ectasia

32. SPOT 10 : C/o halitosis, regurgitation while swallowing.

33. Zenker's diverticulum
 Zenker's diverticulum (posterior hypopharyngeal
diverticulum)
 is an acquired mucosal herniation
 through an area of anatomic weakness in the region of
the cricopharyngeus muscle (Killian's dehiscence).

34. 13.

35. SCHIMITAR SYNDROME
 Congenital pulmonary venolobar syndrome.
 Characterised by a hypoplastic lung that is drained
by an anomalous vein into the systemic venous
system.
 The anomalous vein drains most commonly into
IVC.
 The anomalous draining vein seen as a tubular
structure paralleling the right heart border in the
shape of aTurkish sword (“scimitar”).
 Occurs exclusively on right side.

36. 11. Preterm baby, Usg Head.

37. Peri Ventricular
Leukomalacia (PVL)
 It is a white matter disease that affects the
periventricular zones.
 In prematures -is a watershed zone between
deep and superficial vessels.
 PVL occurs most commonly in premature infants
born at less than 33 weeks gestation (38% PVL)
and less than 1500 g birth weight (45% PVL).
 Detection of PVL is important because a
significant percentage of surviving premature
infants with PVL develop cerebral palsy,
intellectual impairment or visual disturbances.

39. PVL grade 3
 PVL is diagnosed as grade 3 if there are areas
of increased periventricular echogenicity,
that develop into extensive periventricular
cysts in the occipital and fronto-parietal
region.

40. SPOT 13:

41. Germinal matrix hemorrhage:
 periventricular hemorrhage or preterm
caudothalamic hemorrhage.
 highly vascular & stress sensitive germinal
matrix,.
 The germinal matrix is only transiently present as
a region of thin-walled vessels.
 It has matured by 34 weeks gestation, such that
hemorrhage becomes very unlikely after this age.
 Most GMHs occur in the first week of life

43. Grade 4 Intracranial
hemorrhage
 grade 4 hemorrhages to be venous
hemorrhagic infarctions, which are the result
of compression of the outflow of the veins by
the subependymal hemorrhage.
 There is a large subependymal bleeding but
also a large area with increased echogenicity
in the brain parenchyma lateral to the
ventricle.
This is probably the result of a venous infarct.

44. 2.

45. SINUS PERICRANII
 Cranial venous anomaly in which there is an abnormal
communication between intracranial dural sinuses and
extracranial venous structures, usually via an emissary
transosseous vein.
 Low flow vascular malformation.
 Most frequently involves the superior sagittal sinus.
 Cranial vault defect can be seen.
 Association with blue rubber bleb nevus syndrome.

46. SPOT 15:50 year male, chronic dyspnoea

48. Pulmonary alveolar microlithiasis
 Widespread intra-alveolar deposition of spherical calcium
phosphate microliths (calcospherites).
 Often discovered incidentally on a chest radiograph.
 The radiographic features are frequently out of proportion to
clinical symptoms .
 Due to a mutation that causes inactivation of a sodium-
dependent phosphate cotransporter, which itself is found mainly
in alveolar type ii cells.
 This cotransporter normally clears phosphate from degraded
surfactant, and when inactivated there is accumulation of
phosphate in the alveolus, and calcium phosphate microliths are
then thought to form .
 Usually, there is no abnormal calciummetabolism.
 Associations
 Testicular microlithiasis

49. FINDINGS:
 Sandstorm" of diffuse pulmonary
microcalcification in a peripheral distribution
 "Lucent mediastinum" sign
 "Black pleura" sign

50. SPOT 16:

51. Multiple Angiomyolipomas
 Multiple Angiomyolipomas in a patient with
tuberous sclerosis.
 Sporadic AML is typically small, unilateral and
asymptomatic, usually seen as an incidental
finding.

52. SPOT 17:74 year male with knee pain.

53. Degenerative cyst
 Patient with arthrosis of the knee and a large
well-defined osteolytic lesion in the epiphysis
of the tibia.
 In young patients the differential diagnosis:
1. Chondroblastoma
2. intraosseous ganglion
3. giant cell tumor.
In this elderly patient with arthrosis this
lesion is a degenerative cyst.

54. SPOT 18: 30 year male.

55. Intraosseus ganglion
 A well-defined lucent lesion in the epiphysis of
the proximal tibia in young patient.
 On the sagittalT2WI with FS, the lesion has
high SI, but there is no extensive edema, which
makes the diagnosis chondroblastoma less
likely.
In an older patient with arthrosis the most
likely diagnosis would be a degenerative cyst.

56. SPOT 19:Mammography,male patient.

57. NORMAL MAMMOGRAM (MALE)
There is more fatty tissue and there are a
number of blood vessels.
There is a small amount of fibrous connective
tissue, but basically most of this breast is just
fat.

58. SPOT 20: Male patient, lump palpable in breast.

59. Leiomyoma
 Looks like a fibroadenoma, but men do not
get fibroadenomas.
It is a solid encapsulated mass and at biopsy it
happened to be a leiomyoma.
 If there are more than 2 mitoses per high
power field the pathologist calls it a
leiomyosarcoma.

60. SPOT 21: Female breast mammo

61. Extracapsular silicone
implant rupture.
 The capsule is the layer of fibrous tissue
generated by the breast in response to the
implant, which acts as a foreign body.
 The outer layer of the implant which contains
its contents is referred to as the "envelope."
When the silicone extends beyond the
capsule as in this case, this is extracapsular
rupture.

62. SPOT 22: Name the sign??

63. Linguine sign:
 Intracapsular implant rupture.
 After implantation of a silicone or
saline breast implant, a fibrous capsule (scar)
forms around the implant shell.
 In an intracapsular rupture, the contents of
the implant are contained by the fibrous scar,
while the shell appears as a group of wavy
lines.