Tuesday, 29 December 2015

xrayoftheweek 52: what causes this appearance at the lung bases?

This is the final #xrayoftheweek of 2015 - what has caused the dense opacities in the lung bases on this chest x-ray?

Monday, 21 December 2015

xrayoftheweek 51: a barium swallow spot diagnosis

The #xrayoftheweek is this single image from a barium swallow study in someone with long standing dysphagia - what is the name of this classic sign and what is the diagnosis?

Saturday, 19 December 2015

xrayoftheweek 50: a classic barium appearance

The #xrayoftheweek is this image from a barium study - this is a barium follow through to assess the small bowel. What can you see?

Saturday, 12 December 2015

xrayoftheweek 49: what does this MRI sequence tell you?

The #xrayoftheweek is this panel of two images from a liver MRI - this is a specific sequence which provides the answer to the odd appearance of the liver. 

Which sequence is this and what is going on in the liver?

Friday, 27 November 2015

xrayoftheweek 48: where is the gas?

The #xrayoftheweek is this chest x-ray is someone who presented with chest pain following a bout of vomiting. There is a lot of gas where it shouldn't be - where can you see it?

Tuesday, 24 November 2015

xrayoftheweek 47: complications of chronic liver disease on DWI

The #xrayoftheweek is this panel of MRI images, once again illustrating the use of diffusion weighted imaging in abdominopelvic MRI. These DWI, ADC and post-contrast T1-weighted images are from someone with a background of chronic liver disease. Which TWO major complications can you see?

a & d: diffusion weighted image (b=800)
b & e: ADC map
c & f: arterial phase post-contrast fat saturated T1

Monday, 16 November 2015

xrayoftheweek 46: another example of diffusion weighted imaging

The #xrayoftheweek is this panel of CT and MRI images in someone with a known past gynaecologic malignancy and now presenting with upper abdominal pain and vomiting. 

The images are as follows:
a & b: axial contrast-enhanced CT images from the upper abdomen
c & d: diffusion weight sequence (b=800) in same slice position as a & b
e & f: apparent diffusion coefficient (ADC) map of slices c & d

Which imaging signs can you see on these images and what do they mean? Why is this person vomiting?

Friday, 13 November 2015

xrayoftheweek 45: which fruit is this sign named after?

The #xrayoftheweek is this thick MIP image reconstructed from a CT of someone who has suffered a stab injury to the lower abdomen. What is the name given to this imaging sign?

Wednesday, 4 November 2015

xrayoftheweek 44: what's wrong with this heart?

The #xrayoftheweek is this chest x-ray in a young woman with shortness of breath - what do you see and what is the leading cause of this worldwide?

Wednesday, 28 October 2015

xrayoftheweek 43: that's not a USB stick...is it?

The #xrayoftheweek is this chest x-ray. What is that device projected over the left side of the chest? Is it a USB stick left in the shirt pocket? Or is it something else?

Thursday, 22 October 2015

xrayoftheweek 42: a classic spine x-ray

The #xrayoftheweek is this AP view of the lumbar spine in someone with a chronic disorder and acute pain. What is the underlying disorder and what is the new complication?

Thursday, 15 October 2015

xrayoftheweek 41: an "IFFI" diagnosis

The #xrayoftheweek is these two CT images, in the axial and coronal planes. These images are from a case report that we recently published in BJR case reports. This middle aged woman with a history of diverticular disease presented with left iliac fossa pain and vomiting, so a CT was requested for the assessment of diverticulitis. 

What alternative diagnosis do these CT images show?

Friday, 9 October 2015

xrayoftheweek 40: which long term condition is seen here?

The #xrayoftheweek is this chest x-ray of a young man with a long term condition. What are the signs on the x-ray and what is the differential for the underlying diagnosis?

Friday, 2 October 2015

xrayoftheweek 39: what's your diagnosis?

The #xrayoftheweek is this panel of 2 images - can you work out the diagnosis from these images?

Saturday, 26 September 2015

xrayoftheweek 38: a classic brain MRI finding

The #xrayoftheweek is this axial image from a brain MRI. 

(1) Which MRI sequence is this?
(2) What is the finding and the significance?
(3) Can you guess how this person presented?

Wednesday, 16 September 2015

xrayoftheweek 37: can you name this sign?

This week's #xrayoftheweek is this single axial slice from a spine MRI study. Two questions:
(1) Can you see an animal in this image? I can see a cat!
(2) What is the actual name of the sign seen here and what is it due to?

Sunday, 6 September 2015

xrayoftheweek 36: this is NOT a Boxer's fracture!

The #xrayoftheweek is the subject of a poster I have co-authored with a colleague (and superstar GI radiologist in the making, James Stephenson), and is being displayed at the Royal College of Radiologists' Annual Scientific Meeting from Monday 7th to Wednesday 9th September 2015

We conducted a survey using social media (SoMe; Instagram, Figure 1, Google+ and Twitter) to ask healthcare professionals what they called this fracture (other than a 5th metacarpal fracture), what their profession was, and where they were based.

Wednesday, 2 September 2015

xrayoftheweek 35: which procedure has been performed?

This week's #xrayoftheweek is this chest x-ray - which procedure has this person had in the past and why?

Friday, 28 August 2015

xrayoftheweek 34: what name is given to this classic sign?

This week's #xrayoftheweek is this reconstruction from a CT of the abdomen and pelvis. What does it show and what name is given to this classic sign?

Thursday, 20 August 2015

xrayoftheweek 33: previous gastric surgery and now chest pain - why?

The #xrayoftheweek is this chest x-ray in a man who had previously undergone gastric surgery (Roux-en-Y gastric bypass as a second procedure for reflux), and presented with chest pain with ST segment depression on his ECG. What do you see and what might this be the result of?

Friday, 14 August 2015

xrayoftheweek 32: a novel MRI technique to evaluate Crohn's disease

This week's #xrayoftheweek is another one exploring the use of diffusion weighted imaging in abdominopelvic radiology. The panel of images shown below is from a small bowel MRI:

All images in a coronal plane:
(a) diffusion weighted image (b=800)
(b) ADC map
(c) Balanced steady state gradient echo sequence
(d) Post contrast fat suppressed T1

In (c) and (d) you can see that there is mural thickening and hyperenhancement of the small bowel in the right iliac fossa - indicating active inflammation. This area is shown as having restricted diffusion on (a) and (b) - high signal on the high b value DW image and low signal on the ADC map (this is a recap of the basics of diffusion weighted imaging). 

This is an active area of research with multiple studies validating the use of DWI as an additional sequence in small bowel MRI, with interest in being able to replace post-contrast imaging. I have been using it routinely in all my small bowel MRI cases for almost a year, and have found it increases my confidence in identifying active inflammation, particularly when contrast has not been used. By adding this, and the peristalsis sequence I described in xrayoftheweek 17, I have moved away from an analysis based solely on static findings, and am using more dynamic and functional data in my reporting.

If you want to read more about this topic, these two articles by Hordonneau and Sinha are a good starting point.

#FOAMed #FOAMrad 

Wednesday, 5 August 2015

xrayoftheweek 31: identifying high risk rectal cancers

This week's #xrayoftheweek is another panel of MRI (and one CT) images (of the rectum and liver), illustrating the importance of accurate reporting and the emergence of data which allows us to stratify rectal cancer into low and high risk groups.

a = coronal MRI showing rectal cancer and tumour signal tissue extending into a large vessel

b = coronal CT showing rectal cancer and tumour density tissue extending into a large vessel

c & e = diffusion weighted image (b=1000) showing rounded high signal lesion in liver

d & f = ADC map showing low signal in lesions seen on c & e respectively, indicating restricted diffusion and liver metastases

Wednesday, 29 July 2015

xrayoftheweek 30: the start of a series on diffusion weighted imaging (DWI)

One of the most interesting and stimulating parts of being a doctor in general, and a radiologist in particular, is keeping up with new technology and techniques and being involved in their evolution and application. A technique that has risen to prominence in abdominal imaging in this early part of my career is diffusion weighted imaging (DWI) - an MRI sequence that essentially interrogates how freely water molecules can move in the extracellular space. This sequence is quick to acquire, doesn't require contrast, and provides valuable functional information. This video by Frank Gaillard of Radiopaedia does an amazing job of explaining what DWI is and how it works.

For the next few weeks, the #xrayoftheweek will feature DWI - and I'll describe how I have introduced it and adapted it for various abdominal applications in my Consultant post in Leicester. 

The first of these is this panel of selected images from a liver MRI:

a: diffusion weighted image, b=1000
c: apparent diffusion coefficient map
d: calculated ADC map (takes into account T2 shine through)

The lesion in the right lobe of the liver is seen on the STIR image as having central hyperintensity, with a rim of intermediate signal tissue. This rim is bright on the DWI image and darker on the ADC map, indicating restricted diffusion. Bear in mind that this is a subjective assessment, and that proper reading of these images necessitates using ROIs to measure the ADC value. The calculated ADC map shows the rim as bright - confirming restricted diffusion. 

Conversely, the centre of the lesion is mildly hyperintense on both the DWI and ADC, in keeping with T2 shine through - confirmed on the calculated ADC map.

This turned out to be a metastatic deposit with central necrosis. The active tumour (with restricted diffusion) is the rim of the lesion, with the tumour growing radially outwards and leaving necrosis in the centre. Abscesses usually have restricted diffusion throughout.

This chart is a very simplistic illustration of how signal change is classified on DWI images, and once again, this subjective assessment should be backed up by an objective assessment of the ADC values using ROI tools.

One of the applications of this technique under research is using the ADC value of lesions to monitor the response to therapy, as we move away from using simply 2 dimensional measurements to a multiparametric assessment of tumours. For detailed reading, the following references will provide a lot of relevant background information, and are useful for an overview of use of DWI in abdominal imaging:

Sinha et al in Radiographics and Sandrasegaran in Radiology Clinics of North America.


Wednesday, 22 July 2015

xrayoftheweek 29: can you find an abnormality on this chest x-ray?

Can you find an abnormality on this week's #xrayoftheweek?

Wednesday, 15 July 2015

xrayoftheweek 28: what's the story behind this cine clip?

This week's #xrayoftheweek is this cine clip of a fluoroscopy study - from this clip, can you work out:
1. what treatment the person has had before?
2. what is the current complication?

Wednesday, 8 July 2015

xrayoftheweek 27: where is the pathology?

This week's #xrayoftheweek is one for non-radiologists - there is airspace opacification on this chest x-ray (the shadowing in the right lung). 

The questions for you are:
1. which lobe is it in?
2. how can you tell?

Tuesday, 30 June 2015

xrayoftheweek 26: dynamic pelvic floor MRI (proctogram)

The latest #xrayoftheweek is a special one linked to a talk I'm giving this morning (or will have given if you are reading this after 1 pm on Wednesday 1st July!) about Pelvic Floor Imaging at the UKRC meeting in Liverpool. This is the UK's largest radiology conference and I am delighted to have been invited to talk about this.

This video is the dynamic evacuation sequence used to evaluate for the presence and degree of prolapse of the pelvic organs. Read on below to learn about what this video shows.

Tuesday, 23 June 2015

xrayoftheweek 25: why is this woman in pain?

This is a coronal CT reconstruction in someone who attends the emergency department with a short history of severe abdominal pain. On examination, they have diffuse tenderness across the mid and lower abdomen. From these images, can you:

  1. work out what type of surgery they have had in the past?
  2. what is the current problem?

You can scroll through these images on my Radiopaedia upload of this case.

Wednesday, 17 June 2015

xrayoftheweek 24: anything unusual about the anatomy here?

This man was having a CT to follow up a small lung nodule - what do you think about the vascular anatomy in this week's #xrayoftheweek - is it normal?

Tuesday, 9 June 2015

xrayoftheweek 23: what's the story behind this xray?

This week's #xrayoftheweek is the type that is loved in radiology exams - there are a number of findings which add up to a story, and it can be worked out all from careful analysis of the x-ray.

Can you work it out?

Wednesday, 3 June 2015

xrayoftheweek 22: abnormality and differential diagnosis?

It's a slightly tricky chest x-ray for this week's #xrayoftheweek. Can you see any abnormalities on this x-ray, and what is your differential diagnosis?
(hint: the background lung parenchyma looks a little "noisy" but is otherwise normal)

Wednesday, 27 May 2015

xrayoftheweek 21 - can you spot the variant anatomy here?

This week's #xrayoftheweek is this oblique image from a CT - there is no abnormality, but there is a common anatomic variant - can you spot it?

Friday, 22 May 2015

Need a 2nd opinion on your scan? I can help!

If you would like a second opinion on imaging that you have already had, I can now help. I will provide this service exclusively through a website called diagnose.me. This website provides a portal through which you may request your scans to be reviewed by any of a number of leading radiologists from around the world. 

Wednesday, 20 May 2015

xrayoftheweek 20: man with cough and back pain

This week's #xrayoftheweek is a chest x-ray, good for medical students, junior doctors, radiographers and allied health professionals to learn about. What three important signs are there on this CXR, and what would you do next?

Wednesday, 13 May 2015

xrayoftheweek 19: can you spot the problem?

This is the #xrayoftheweek, an abdominal x-ray. Two questions for you:
1. Which procedure(s) has this patient had in the past?
2. What complication can you see?

For bonus marks, which single imaging test would you like to see next?

Wednesday, 6 May 2015

xrayoftheweek 18: back to basics

A favourite of medical students and junior doctors this week for #xrayoftheweek: what can you see on this chest x-ray and what is the cause?

Wednesday, 29 April 2015

xrayoftheweek 17: physiology brought to life

This week's #xrayofthweek is a video clip showing peristalsis of the small bowel on MRI. I use this cine sequence routinely in my small bowel MRI studies to evaluate for normal and abnormal motion of the small bowel - segments which are narrowed and fixed due to stricture formation do not peristalse well and stand out. This particular clip shows peristalsis of normal small bowel.

I have detailed the methods used to acquire this sequence in this Radiopaedia case. In future #xrayoftheweek posts, I will describe other innovative MRI sequences I have developed and use in my day-to-day GI imaging practice. 


Tuesday, 21 April 2015

xrayoftheweek 16: cough in an immunosuppressed man

Why has this man with immunosuppression got shortness of breath and a cough?

Wednesday, 15 April 2015

xrayoftheweek 15: shortness of breath and cough - why?

The latest #xrayoftheweek is one for medical students/junior doctors/radiographers. What can you see on the chest xray of this person who presented with progressive shortness of breath and a cough over the previous 2 weeks?

Wednesday, 8 April 2015

xrayoftheweek 14: is this a real finding?

What is causing the appearance on this CT image?

Wednesday, 1 April 2015

xrayoftheweek 13: can you pinpoint the site of pathology?

It's back to plain films for this week's #xrayoftheweek case. This man presented with abdominal distension. Can you pinpoint the site of pathology and offer a differential?

Wednesday, 25 March 2015

xrayoftheweek 12: difficulty swallowing

Back to the screening (fluoroscopy) room for the latest #xrayoftheweek case. This is a single image from a barium swallow study in someone who had mild difficulty in swallowing. What can you see?

Wednesday, 18 March 2015

xrayoftheweek 11: is this ultrasound abnormality significant?

 This week's #xrayoftheweek case is an ultrasound image to start with. This was seen in the right iliac fossa/right adnexa of a woman with vague abdominal pains. What could this be and what is it's significance?

(hint: previous salpingo-oopherectomy)

Wednesday, 11 March 2015

xrayoftheweek 10: why has this man got right upper quadrant pain?

This week's #xrayoftheweek is a CT case. This man had an unremarkable ultrasound for right upper quadrant pain, so he went on to have a CT. This is an axial image - what is the abnormality?

Wednesday, 4 March 2015

xrayoftheweek 9: a classic radiology exam xray

This week's #xrayoftheweek is a radiology exam classic and favourite. This is a routine CXR of a young man. What can you see? What is the diagnosis?

Wednesday, 25 February 2015

xrayoftheweek 8: is this a normal chest xray?

Have a look at the latest #xrayoftheweek: is this chest xray normal? (hint: it's not going to be if its on this website!). 

Wednesday, 18 February 2015

xrayoftheweek 7: why is this person unwell?

Another abdominal #xrayoftheweek: what abnormality can you see here?

Wednesday, 11 February 2015

xrayoftheweek 6: what does this bone scan tell you?

This is the nuclear medicine bone scan image from a middle aged man. What are the salient findings and what is the diagnosis?

Wednesday, 4 February 2015

xrayoftheweek 5: why is this woman short of breath?

This is the chest xray of a young woman with chronic shortness of breath. 
1. What are the relevant xray signs?
2. What is the differential diagnosis?
3. What is the next test of choice and how would it help?

Wednesday, 28 January 2015

xrayoftheweek 4: why has this man got back pain?

This man has back pain and is generally unwell. 
1. What are the xray signs?
2. Which investigations would you do next?