‘The application of anthropomorphic similies supplies us with diagnostic clues and triggers that simplify the complicated and clarify the opaque’— easy for Victor Frankel
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(then, University of ...Washington) to say, in his 1977 letter, explaining the Terry-Thomas sign.
In a 1951 review of the causes of pulmonary hypertension, William Evans
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described the pathologic and radiologic features of emphysema in a series of patients. Postmortem pulmonary arteriograms ...showed ‘pruning of the terminal branches of the pulmonary tree giving it an appearance of a denuded shrub in winter contrasting with the leafy bush in spring which typifies the healthy pulmonary circulation’
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(Figure 1). Microscopically these abrupt pulmonary vascular terminations were said to be due to ‘endarteritis fibrosa.’ These findings in the living patient meant impending heart failure and an ‘unfavorable outlook.’ Evans used the word ‘pruning’ in the accompanying figure legend. The pruned tree terminology is more commonly used now than the phrase ‘denuded shrub.’
Figure 1
‘Emphysema. Pulmonary arteriogram showing pruning effect of terminal branches in patient with pulmonary hypertension and heart failure left, and compared with normal control right.’ Reprinted from Evans’. Congenital pulmonary hypertension. Proc R. Soc Med., 1951, 44, 600–8, with permission of the Royal Society of Medicine
Napoleon Hat (Bow) Sign Mulligan, Michael E.
Classic Radiologic Signs,
1997, 1996
Book Chapter
Sir James Brailsford
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(The Queen’s Hospital, London) discussed many deformities of the lumbosacral spine in a lengthy 1929 article. One of the conditions he elaborated on was spondylolisthesis. ...Regarding the antero-posterior radiographs he said, ‘These may be absolutely typical … It will be seen that the anterior border of the transverse process is continuous with the anterior border of the body. With a definite case of spondylolisthesis, the superior surface of the body of the 5th lumbar vertebra is facing forwards, and an anteroposterior radiograph of the patient will show the 5th lumbar body and transverse processes in this plane, and this characteristic outline Figure 1 of the anterior border of the body and transverse processes will be projected against the shadow of the sacrum.’ He later used the term ‘bow sign’ to describe this appearance
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. Other terms, more commonly used today, include the Napoleon hat sign or gendarme’s hat sign (the latter from Anne Brower, personal communication).
Figure 1
Anteroposterior radiograph showing Napoleon-hat sign of spondylolisthesis. Case courtesy of Dr C. Resnik, University of Maryland
Leo Davidoff
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, in 1936, studied the skull roentgenograms of nearly 2500 normal individuals in an attempt to understand the significance of the appearance of the convolutional markings upon the ...inner table of the skull. This work was done at the Neurological Institute in New York. The patients had an age range from 3 months to 18 years. The ‘appearance of patchy areas of diminished density in the roentgenograms of the skull in certain cases is a matter of frequent experience. These areas are assumed to be the result of impressions of the cerebral convolutions upon the inner table of the skull, and when accompanied by pressure atrophy of the sella turcica or separation of the cranial sutures, or both, are indications of increased intracranial pressure. When the intracranial pressure is great, these markings may resemble beaten silver.’
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(Figure 1). He emphasized that this appearance could be normal in growing children who did not have any other evidence of increased intracranial pressure. The presence of other signs of increased intracranial pressure was most important.
Figure 1
‘Skull X-ray of 7-year-old child’
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showing beaten silver or brass pattern. Reprinted from Davidoff. Convolutional digitations seen in the roentgenograms of immature human skulls. Bull. Neurol. Inst NY, 5, 61–71
Bamboo Spine Mulligan, Michael E.
Classic Radiologic Signs,
1997, 1996
Book Chapter
Ankylosing spondylitis has been recognized in skeletons found throughout the centuries. Bernard Connor (1666–1698), an Irishman, ‘while demonstrating anatomy in France … came across a most unusual ...skeleton found in a graveyard in which the ilium and sacrum and the 15 lowest vertebrae and adjoining ribs formed one continuous bone … Connor fully realised the importance of his discovery and reported it in three languages, in French … in Latin … and in English … By the late 1800s sufficient interest allowed Strumpell in 1884 to venture a tentative textbook mention, citing two patients with complete ankylosis of the spine and hip joints … this was followed by … papers by Strumpell (1897), von Bechterew (1893 and 1899) and Pierre Marie (1898).’
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Thumbprinting Sign Mulligan, Michael E.
Classic Radiologic Signs,
1997, 1996
Book Chapter
Thumbprinting as a sign of submucosal hemorrhage or edema in colonic vascular occlusion was reported in two articles by Scott Boley and colleagues
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and Solomon Schwartz and co-workers
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, in 1963. ...The first article described the barium enema findings in five patients seen at the Jewish Hospital of Brooklyn and Downstate Medical Center (Figure 1). ‘The roentgenologic finding of importance is pseudotumor formation or ‘thumbprinting’. This appears to be caused by submucosal hemorrhage or by pericolic fat inflammation or both.’
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The second article detailed the course of the radiographic changes in one of the original five patients. They confirmed their impressions of the radiographic findings by conducting animal experiments. ‘Pathologic examination, when marginal indentation or ‘thumbprinting’ was present, revealed two possible explanations: (1) submucosal hemorrhage and (2) inflammatory areas in pericolic fat.’
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Recognizing these ‘pseudotumors’ as a sign of vascular disease is important. The vascular occlusion may only be temporary and the patient’s symptoms may resolve without surgical intervention.
Figure 1
‘Pseudotumors (‘thumbprinting’) are present along the superior aspect of the transverse colon.’ Reprinted from Boley et al. Reversible vascular occlusion of the colon. Surg. Gynecol Obstet, 1963, 116, 53–60, with permission of Surgery, Gynecology & Obstetrics, now known as the Journal of the American College of Surgeons
Scimitar Sign Mulligan, Michael E.
Classic Radiologic Signs,
1997, 1996
Book Chapter
The first detailed description of this pulmonary venous anomaly is said to be Edwards Albert Park’s autopsy report’ concerning a 2-month-old boy, published in 1912. This child was seen at the New ...York Foundling Hospital where he died about 2 weeks after admission. The scimitar term was not used in this report and there was no mention of an unusual vascular shadow in the description of the chest ‘X-ray picture’. The vascular shadow was probably not evident on the X-ray due to severe hypoplasia of the right lung and shift of the heart into the right side of the chest. Park’s clinical diagnosis was lobular pneumonia with the right lung ‘consolidated in all but its upper part.’ The autopsy showed a very small right pulmonary artery. No right pulmonary veins drained into the left auricle (atrium). Further examination revealed a large vein (the ‘scimitar’) receiving branches from both the right upper and lower lobes ‘emptying into the inferior vena cava immediately at its point of emergence from the diaphragm.’
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Examination of the peripheral soft tissues often yields valuable clues to the radiologist who does not forget to inspect this part of the radiographic image. The appearance of a sausage digit ...(cocktail sausage digit) (Figure 1) is classically associated with the single-ray pattern of involvement seen in some patients with psoriatic arthritis. It may be the initial manifestation of the disease. This term is attributed, by Verna Wright and John Michael H. Moll
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, to Charles Bourdillon
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who wrote his doctoral thesis on Psoriasis et arthropathies in 1888 with detailed accounts of 36 patients including descriptions of their swollen digits. Deborah Forrester, in a more recent article from UCLA-USC Medical Center, listed the differential diagnosis as trauma, cellulitis, osteomyelitis, the rheumatoid variant disorders and gout
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.
Figure 1
Radiograph showing diffuse soft tissue swelling around finger of patient with psoriatic arthritis. Case courtesy of Dr C. Resnik, University of Maryland
Searching for pelvic masses with an ultrasound probe can be a difficult task; shadowing from bowel gas may obscure masses and some masses may obscure themselves. This fact is borne out in Paul ...Guttman’s 1977 description
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of benign cystic ovarian teratomas that showed only the ‘tip of the iceberg’
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! He reported 23 surgically proven cases from Stanford University. ‘The consistent, diagnostic feature was the presence of a complex mass with hyperechoic zones that produced acoustic shadowing of the far wall of the mass. In six cases … only the near wall of the mass was recognized, hence the term ‘tip of the iceberg’ sign … The presence of highly reflective and attenuating hair within the sebaceous material … produces the characteristic acoustic shadowing’
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(Figure 1). He stressed the importance of not confusing this appearance with shadowing due to bowel gas and he discussed steps that could be taken to make the distinction. Today transvaginal ultrasound scanning, computerized tomography and magnetic resonance imaging make the diagnosis of pelvic masses a less hazardous task and pelvic ‘icebergs’ less of a danger.
Figure 1
‘Midline sagittal sonogram demonstrating the near wall of the dermoid only due to acoustical shadowing (AS) from the hairball (HB), the so-called ‘tip of the iceberg’sign.’ Reprinted from Guttman
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. In search of the elusive benign cystic ovarian teratoma. J. Clin. Ultrasound, 1977, 5, 403–6. Copyright 1977 John Wiley & Sons. Reprinted by permission of John Wiley & Sons Inc.
Porcelain Gallbladder Mulligan, Michael E.
Classic Radiologic Signs,
1997, 1996
Book Chapter
The term ‘porzellangallenblase’ (porcelain gallbladder) was proposed by Heinrich Florcken
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(Frankfurt), in 1929, to denote the changes seen in an inflammatory condition that caused calcification of ...the gallbladder wall. It was presumably meant to emphasize ‘the brittle consistency and bluish discoloration of the wall’
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. Although Florcken considered it to be the result of a previous inflammatory process and of no consequence, other cases were soon reported that disputed its supposed innocuous nature
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. These gallbladders may function poorly and often contain gallstones. Gallbladder carcinoma, a relatively uncommon gastrointestinal tract malignancy, has an increased incidence in cases of porcelain gallbladder. The pattern of calcification in the gallbladder wall is important when one is considering the possibility of carcinoma (Figure 1). ‘Incomplete calcification of the wall is much more likely to be associated with gallbladder carcinoma than the complete type.’
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This is likely to be due to the fact that with complete calcification the mucosal epithelium is totally replaced by dense connective tissue that is not prone to undergo a cancerous change. Ultrasound and computerized tomography can also be used to detect and evaluate porcelain gallbladders. A giant gallstone is one plain film mimic that also has been reported to have an association with the development of a gallbladder carcinoma.
Figure 1
Abdominal radiograph showing calcified gallbladder. Case courtesy of Dr D. Fleming, Bethesda Naval Hospital
