Amar Udare, MD

An adolescent male presented with complaint of pain in the left hip, which is relieved by analgesics.


Plain radiograph (Figure 1) shows a tiny lucency in the region of the left femoral neck with adjacent periosteal reaction. The finding is confirmed on CT (Figure 2), which shows a small lucent lesion in the left femoral neck with adjacent periosteal reaction. The lesion is PET avid (Figure 3). MRI STIR images confirm the small lesion in the left femoral neck with significant adjacent marrow edema.

Present with complaint of nocturnal pain, which is relieved by analgesics

Small lucent nidus with adjacent solid periosteal reaction affecting long tubular limb bones, proximal femur being the most common site
 

Solid periosteal reaction with thickened cortex

â Nidus may be seen as small lucency

â Lucent lesion <2 cm with adjacent solid periosteal

â A central sclerotic dot may be seen within the lucency

â Double density sign: intense central uptake surrounded by lesser degree of uptake in the adjacent bone

â Shows adjacent marrow edema, however the nidus may not be seen well

Management includes surgical resection or radiofrequency ablation.

1. Gaillard F. Osteoid osteoma. Radiopaedia.org [Internet]. Radiopaedia.org. 2016 [cited 21 September 2016]. Available from: 

https://radiopaedia.org/articles/osteoid-osteom.

2. Berry M. Diagnostic Radiology: Musculoskeletal and Breast Imaging Hardcover – 2005. New Delhi: Jaypee Bros. Medical Publishers; 2005.

3. Yochum T Rowe L. Yochum and Rowe's essentials of skeletal radiology. Philadelphia, Pa.: Lippincott Williams & Wilkins; 2005.

Poll

Adolescent male presented with complaint of pain in the left hip, which is relieved by analgesics.

Image IQ: Adolescent Male with Hip Pain

A 56-year-old construction worker presents with dry cough.

Ill-defined curvilinear opacities are seen projecting over both lung fields predominantly in the mid and lower zone with sparing of the apices.

Answer: 2. Asbestos-related pleural plaques. 

Chronic exposure to asbestos (in the form of inhalation of fibers) can cause a number of neoplastic and non-neoplastic manifestations in the chest and pleural cavity 

. The constellation of these manifestations is termed as asbestos-related diseases.

Occupational exposure to asbestosis is seen in

Manufacture and repair of gaskets and brake linings.

Manifestations of long-term asbestos exposure include:					

. These can be hemorrhagic and tend to recur 

: Areas of pleural fibrosis commonly involving the parietal pleura, especially the posterolateral and lateral chest wall with sparing of the costophrenic angles

. Calcification is seen only 10-15% percent of the cases but bilateral calcified pleural plaques are very specific for asbestos exposure 

: This is a non-specific finding and is a result of fusion of the visceral and parietal pleura following multiple benign pleural effusions 

. Unlike plaques, thickening involves both parietal and visceral pleura 

Secondary to inflammatory, fibrosis and subsequent in folding of the pleural fold into the lung as it matures and contracts

It is seen as a rounded pleural based peripheral opacity with a typical comet tail/crow feet appearance of the adjacent Broncho vascular structures going into the mass

Pulmonary fibrosis secondary to long-term asbestos exposure (usually more than 20 years)

Imaging features are non-specific and include areas of ground-glass opacification with small nodular opacities and ill-defined diaphragmatic contours. HRCT shows subpleural fibrotic strands in early phase along with the above features

Commonly affects the pleura, however can also affect the peritoneum and pericardium.

This has a long latency period of more than 30 years and a poor prognosis

Imaging features include generalized lobulated thickening of the pleura with decreased volume of the hemithorax. It often extends along the fissures and invades into adjacent mediastinal structures 

Norbet C, Joseph A, Rossi SS, Bhalla S, Gutierrez FR. Asbestos-Related Lung Disease: A Pictorial Review. Curr Probl Diagn Radiol. 2015;44:371–82. [PubMed]

Roach HD, Davies GJ, Attanoos R, Crane M, Adams H, Phillips S. Asbestos: when the dust settles-an imaging review of asbestosârelated disease. Radiographics 2002; 22: S167–84.

A construction worker presents with a dry cough, can you diagnose this patient?

Image IQ: 56-year-old construction worker presents with dry cough

35-year-old female with prior history of breast carcinoma presented with frontal headaches.


MRI images reveal a well-defined extra-axial lesion located in the left frontal region. The lesion appears hypointense on T1W images and iso to hypointense on T2W images and shows intense homogenous post contrast enhancement (Figures 1-3). There is no perilesional edema. On T2W images a CSF cleft is seen, which confirms the extra-axial nature of the lesion (Figure 2). On post contrast images, another lesion was seen in the parafalcine location which was inconspicous on the plain scans (Figure 4). It showed homogenous enhancement and a dural tail.


Meningiomas are the most common primary non-glial intracranial tumor. Meningiomas mostly affect people in the middle and late decades of life with a strong female predilection (M:F ratio 1:2).

 Multiple meningiomas are also associated with neurofibromatosis and are found in the younger age group of this population.

• Parasagittal or attached to the sagittal sinus (most common location).

• Dura adjacent to the anterior sylvian fissure region.

• Other locations: clivus, the tentorial leaf, and the tentorial free margin.

Usually meningiomas are asymptomatic. Symptoms are most commonly due to mass effect on adjacent structures and they depend on the tumor location.

• Convexity/parasagittal: seizures & hemiparesis.

• Cavernous sinus: cranial nerve deficit(s).


On plain CT meningiomas appear as a hyperdense to isodense mass lesion with areas of calcification (20-25 percent).

 There may be hyperostosis in the adjacent bones. On post contrast scans, they show intense homogenous enhancement. On T1W MR images, the mass appears hypointense while on T2WI the appearance is variable.

 T2W images are ideal for imaging CSF clefts and the vascular flow voids.

 Post contrast scans show homogeneous enhancement with presence of dural tail, which is a non-specific finding.

 On MR spectroscopy there is presence of alanine peak at 1.3-1.5 ppm at short TE.

 On conventional angiography, there is radial appearance with prolonged vascular stain (termed as the mother-in-law sign).


1. Meningioma.  In: Osborne A. Diagnostic Imaging: Brain. 1

 edition. Salt lake City, Utah: Amirsys. 2004.

2. Jayaraman M, Boxerman J. Adult Brain Tumors. In: Atlas S. Magnetic Resonance Imaging of the Brain and Spine. 4

Edition. Lippincott Williams and Wilkins. 2008.

Image IQ: 35-year-old Female with Headaches

A male child of normal intelligence, belonging to a nonconsanguineous marriage was sent to the radiology department for skeletal survey to assess coarse facial features,  short stature and spinal deformity. Radiographs of the hands , skull and spine are provided.

Morquio syndrome is a genetic disorder caused by lack of the enzyme responsible for the breakdown of the mucopolysaccharide keratin sulphate.

 Patients with Morquio syndrome do not develop mental retardation, as the metabolism of heparan and dermatan sulphate is normal.

· Marked dwarfism in early childhood
· Kyphoscoliosis
· Muscular hypotonia
· Pectus carinatum
· Coarse facies
· Corneal clouding
· Enlarged wrists and deformed hands are noted.
· Atlantoaxial dislocations occur owing to odontoid hypoplasia

· Central beaking of vertebral bodies (Hurlers: anteroinferior beaking)
· Universal platyspondyly
· Hypoplastic or absent odontoid
· Dysplastic acetabula and capitalfemoral epiphyses
· Short metacarpals with proximal tapering of bases of the metacarpals
· Inclination of the distal growth plate of the radius and ulna
· J-shaped sella

1. Parashari U, Khanduri S, Bhadury S, Rawat S. Roentgenographic diagnosis of mucopolysaccharidosis with particular reference to Morquio syndrome.

2. Seron M, Yochum T, Barry M, Rowe L. Skeletal Dysplasias. In: Yochum T, Rowe L Essentials of Skeletal Radiology, 3

 edition. London: Lippincott Williams & Wilkins; 2005.

Male child of normal intelligence sent for skeletal survey for coarse facial features, short stature and spinal deformity.

Amar Udare, MD

Articles

Image IQ: Adolescent Male with Hip Pain

Image IQ: 56-year-old construction worker presents with dry cough

Image IQ: 35-year-old Female with Headaches

Image IQ: Coarse Facial Features, Short Stature, Spinal Deformity