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Dr Imran Lasker, FRCRMusculoskeletal Radiology Fellow,
Imperial College NHS Trust, London, UK
Modified with permission from Dr E Dick
Radiology for the Busy
Anaesthetist
Infomed Anaesthetic Update Course: London, June 2018
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• HDU/ITU
• Pre & post op
• Trauma
• Lines and tubes
• Knobology
• Spines
• How can the
Radiologist help you?
A
B
C
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30 yo male Cyclist
• Facial injuries
• Le Fort III
• Difficult airway
Airway1
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30 yo male Cyclist
• Facial injuries
• Le Fort III
• Difficult airway
Airway1
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www.headneckbrainspine.com
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ETT balloon over
inflated in vestibule
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Tracheal membrane
False lumen & ETT
True lumen
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Signs of TracheoBronchial rupture
• Surgical emphysema neck
• Pneumomediastinum
• Malposition of ETT
• ETT Balloon overinflation (N< 2.8cm)
• Transtracheal herniation of ETT (dumbbell
shape)
• Tracheal wall defect– directly seen in 71%
• Gold standard: fibreoptic bronchoscopy
Gunn: Current Concepts in Penetrating Transmediastinal Injury. Radiographics 2014
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70 yo man, tried to hang himself
• tied rope around
his neck
• attached it to post
• drove away
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Thanks to Dr John Curtis, Aintree Univiersity Hospitals
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ETT Balloon below cricoid
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20 year old female, playing sport,
blunt neck injury
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20 year old female, playing sport,
blunt neck injury
Dyspnea, Hoarse, Swelling R neck
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Aryepiglottic fold
laceration
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True vocal cords
Right arytenoid medially displaced
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Tracheostomy tube DISPLACED
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Narrow Airway - Amyloid
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Tube RMB (total left lobe collapse)
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Tube RMB (total left lobe collapse)
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Free intraperitoneal air - ETT in Oesophagus
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NGT Right Main Bronchus
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Post RIJV line insertion ? Ptx
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Where is the wire?
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Collapse vs.
Consolidation
Volume LossNo air bronchogramsRemainder of lung has to expand
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Predictable site of consolidation
or collapse
Left lobesRight lobes
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Dense
Consolidation
No volume lossAir bronchograms
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Right lower lobe consolidation
• No loss of volume
• air space shadowing
• right hemidiaphragm
obscured
• right heart border
clear
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Ampoule bronchus intermedius,
RML & RLL collapse
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Ampoule bronchus intermedius,
RML & RLL collapse
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Tooth LMB, post op, near complete
Left lobe collapse
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Radiologists! Think where teeth go
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Elderly frail man – TRAUMA CALL
fall 20 foot, haemodynamically
unstable• # T8 to L1
• # R 8/9 rib
• Shattered Sacrum
• Pubic rami #
• PM correlation
• Tooth – RMB
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Elderly lady, Fall, 2 floors,
Fractured mandible, missing teeth
NGT
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Teeth fragments in stomach
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? Coin in
trachea
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Coin in
Oesophagus
Coronal
plane
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Stabbing #1.Haemothorax, chest drain,
consolidation
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Ultrasound (effusion)
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Ultrasound Knobology
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• Dark room
• Machine
• Cost
• Probe
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Ultrasound (Consolidation)
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Ultrasound for Ptx
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PTx False +ve on US
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Abnormality: Pneumothorax
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Became increasingly difficult to ventilate during clavicle
fixation
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Tension
pneumothorax
ON CT!!
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Bullous lung disease
• RTA
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RTA, Bullae, Chest drain
outside pleural space
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1. upper lobe blood diversion (pulmonary veins)
2. Kerley B lines – tiny horizontal from pleural edge
3. Bats wings –type peri-hilar haziness
4. Alveolar shadowing (hazy shadowing throughout)
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Pulmonary Vasculature
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55 Yr-old with SOB,
increasing O2
Requirements.
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CTPA
Thanks to Dr Elika Kashef
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Sub-massive PELarge main PA PE
RV strain
HD stable
CD
T
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Trauma subsegmental PE
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Trauma subsegmental PE
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• Pulmonary
artery HT
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Don’t be fooled Xrays!
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Pericardial effusion before and after
drain
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Anatomy of Spine• Denis: 3 column
theory of stability
• Anterior
• Middle
• Posterior
• Generally:– If middle column
disrupted = unstable
– If OK = stable
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CSpine - Checklist
7mm
21mm
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Male - Trampoline InjuryC5/6
C6/7
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Trampoline Injury
67
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34 yo, fell off sofa (EtOH)
paraplegic
C4/5 bifacetal dislocation
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C4/5 bifacetal dislocation
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C4/5 bifacetal dislocation
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C4/5 bifacetal dislocation
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C4/5 bifacetal dislocation
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C4/5 bifacetal dislocation
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C4/5 bifacetal dislocation
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C4/5 bifacetal dislocation
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C4/5 bifacetal dislocation
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C4/5 bifacetal dislocation
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C4/5 bifacetal dislocation
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C4/5 bifacetal dislocation
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Bifacetal dislocation C 4/5
C4/5 bifacetal dislocation
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RA ?atlantoaxial subluxation
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Male Ank Spondylitis fall
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AS fall, epidural haematoma
has central cord syndrome
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Have a low threshold for MRI
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Elderly lady, Fall, complete
spinal level at C7
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Midline
5
6
↑ ? interlaminar space
↓ disc space
Disc osteophyte bar
C5-C6
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Right
5
C5 articular facet #
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3 column injury
5
Ant longitudinal ligament
torn
ALL intact
ALL intact
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3 column injury
5
C5/6 & C6/7 disc oedemaCord contusion
& oedema
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3 column injury
5
Interspinous oedema
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Paediatric Spine Imaging
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NICE Guidelines
• Updated 2014
• 3 view radiographs first
• CT only if strong suspicion of injury
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• Locally, ½ of CTs in kids did not follow
NICE guidelines
•
• In first year of MTC 175 paediatric major
trauma – 1/3rd had CT Cspine, only one
was abnormal!!!!
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Paediatric CSpine Checklist
Atlantoaxial distance 5mm
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Radiograph Evaluation
• Basion dens interval
– Basion to the tip of dens
– <12 mm
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Atlantooccipital and atlantoaxial
distraction
• Basion dens interval
– Basion to the tip of dens
– <12 mm
Keiper et al, Neuroradiology 1998
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Child – Fall 4 stories
normal growth plate C1/2
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Radiographics 2003
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Fall into recycling processor
Polytrauma head, abdo pelvis
L2
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Fall into recycling bin, post fixation
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Considerations for spinal
anaesthesia
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Normal epidural space
T2 fluid bright T1 fluid dark FS T2
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Congenital abnormalities
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Adult female with Known Spina
Bifida
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Spinal dysraphism:
Diastomatomyelia
Syringomyelia
Tethered cord
Fused vertebral bodies
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Spinal dysraphism
Diastomatomyelia
Syringomyelia
Tethered cord
Fused vertebral bodies
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Spinal dysraphism
Diastomatomyelia
Syringomyelia
Tethered cord
Fused vertebral bodies
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Spinal dysraphism
Diastomatomyelia
Syringomyelia
Tethered cord
Fused vertebral bodies
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T1 shows epidural fat
Spinal dysraphism
Diastomatomyelia
Syringomyelia
Tethered cord
Fused vertebral bodies
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Assessing the Epidural Space
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70 yo vasculopath, epidural in situ
5 days, now leg weakness
• recent angioplasty left SFA for acute
severe leg pain & worsening gangrene
• left SFA occlusion
• epidural for pain removed after few days
• Leg weakness
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Use T1 and T2 MRI to
Identify blood
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T2 T1
Blood – low signal T2, high T1
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Normal epidural space
T2 fluid bright T1 fluid dark
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T2 T1
Blood – low signal T2, high T1
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T2 T1
Blood – low signal T2, high T1
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Epidural and psoas abscess T2
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Epidural and psoas abscess T2
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Epidural and psoas abscess T2
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Epidural abscess Sag post gad
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Ax post gad, everything bright =
infection – psoas abscess epid
abscess, only IVC = normal
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Ax post gad, everything bright =
infection – psoas abscess epid
abscess, only IVC = normal
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• HDU/ITU
• Pre & post op
• Trauma
• Lines and tubes
• Knobology
• Spines
• How can the
Radiologist help you?
A
B
C
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Thanks to the team:
• Dr Elizabeth Dick• Dr Bob Dick • Dr John Dick • Dr Ian Renfrew • Dr Simon Morley• Prof Wady Gedroyc
• Dr Maria Nordlander
• Dr Shema Hameed
• Dr Afshin Alavi
• Mr Mo Akmal
• Mr Reza Mobasheri
• Miss Nicola Batrick
• Dr Raghu Kamanahalli
• Dr Joel Dunn
• Dr Elika Kashef
• Dr Olga Kirmi
• Dr Ali Alsafi