Sameer Raniga

Radiologist. Trauma and Emergency Radiology. One view is NO view. #radtwitter | #FOAMrad | #radres | #radEd| #radiology | #EmergencyRad

[Sameer Raniga @samrad77]

Quiz: Linear radiopaque material tracking along both sides of the skull on CT. What is it?

Answer: Post-procedural changes from middle meningeal artery embolization for chronic subdural hematoma.

Why we do it
•Chronic subdural hematoma is not just “old blood.”
•It is a biologically active membrane disease.
•Outer neomembrane develops along the dura.
•It is vascular, fragile, and fed largely by branches of the middle meningeal artery.
•Recurrent microbleeds and exudation maintain or enlarge the collection.
•Embolization shuts this supply → less rebleeding → lower recurrence.

Where it fits clinically
•Adjunct to burr-hole evacuation to reduce recurrence
•Standalone in selected patients (mild symptoms, high surgical risk)
•Recurrent or bilateral chronic SDH
•Increasing use with growing evidence, but still evolving practice patterns

—Pearls, pitfalls and wisdom from my reporting list

[Sameer Raniga @samrad77]

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[Sameer Raniga @samrad77]

In thalassemia major, SWI can show prominent susceptibility within the choroid plexus, reflecting iron deposition.

Seen at:
• Lateral ventricles
• Roof of 3rd ventricle
• Roof of 4th ventricle and foramen of Luschka

Also note:
• Diploic space widening
• Diffuse low T1 marrow signal (marrow hyperplasia)

Correlation with systemic iron overload is essential.

—Pearls, pitfalls and wisdom from my reporting list

[Sameer Raniga @samrad77]

“Hair-on-end” skull: X-ray and CT correlation

X-ray
•Widened diploic space
•Vertical radiating trabeculae
•“Hair-on-end” appearance

CT sagittal:
•Expanded diploic space
•Coarse, thickened trabeculae
•Perpendicular orientation
•Intervening low-density marrow

CT axial: expanded marrow spaces with intervening thickened trabeculae looks like a sponge 🧽

Think
•Marrow hyperplasia from chronic anemia
•Most often thalassemia major
•Less likely due to sickle cell and other chronic hemolytic states

—Classic signs from my reporting list

[Sameer Raniga @samrad77]

Papilledema on CT.

Look for subtle posterior globe flattening.

In the right context, think raised intracranial pressure.

And don’t stop there.
Ask why.

One important cause you don’t want to miss is cerebral venous sinus thrombosis (CVST). Especially when the brain parenchyma still looks deceptively normal.

—Pearls, pitfalls and wisdom from my reporting list

[Sameer Raniga @samrad77]

@aditya_gan3500 Evolving batwing.
Interstitial + early consolidation

[Sameer Raniga @samrad77]

All three Kerley lines in one image!

B lines at the bases. Millimeteters in length.

A lines from the hilum. Centimeters in length.

C lines as a fine reticular pattern.

This is interstitial edema in full display.

Plain radiographs still teach you how disease evolves.

What a treat to interpret plain radiographs!

—my reporting list

[Sameer Raniga @samrad77]

AP chest:

Right heart border absent.
No part of the heart lies to the right of the spine.

Middle lobe disease or chest wall deformity?

Lateral view:
Depressed sternum.

Diagnosis: Pectus excavatum.

Wisdom: Absent right heart border with leftward shift, think chest wall before lung.

—Nothing fancy today

[Sameer Raniga @samrad77]

@Cookie169Monste I agree! But today we did this FLAIR 3D sagittal for a patient with suspected demyelination and one of my trainees pointed out this! He flagged it as abnormal.

I just thought of putting it as a reminder!

[Sameer Raniga @samrad77]

Posterior pituitary bright spot.

It is a T1 finding.
Often not seen on FLAIR.

So absence on FLAIR does not mean true absence.

Pearl: Judge it on T1.
Pitfall: Calling it absent on FLAIR.

—Today’s reporting list

[Sameer Raniga @samrad77]

79/M. Left otitis media with left facial palsy and hearing loss.

In suspected malignant otitis externa (skull base osteomyelitis), the earliest clue is often not bone. It is loss of normal fat.

Subtle asymmetry.
Blurring of intermuscular planes.
Fat disappearing where it should be crisp.

Around the stylomastoid foramen.Within the masticator space. Along the skull base.

Easy to overlook.
Easy to dismiss.

By the time bone is destroyed, you are already late.

Reporting pearl:
Loss of deep skull base fat planes should be considered skull base osteomyelitis until proven otherwise, even if the bone looks intact.

—Pearls, pitfalls and wisdom from today’s reporting list

[Sameer Raniga @samrad77]

As William Shakespeare said,
“beauty is in the eye of the beholder”.

Love, just like beauty, is also in the eye of the beholder. 🙃

—From my heartful ❤️reporting list.

[Sameer Raniga @samrad77]

A child with neck pain, swelling and fever

Prevertebral soft tissue widening on lateral view: Think retropharyngeal infection.

Head tilt with rotation on AP view: Think fixed torticollis.

Put them together.
Consider Grisel syndrome: Retropharyngeal inflammation + fixed torticollis.

What next: urgent CT neck with contrast to look for retropharyngeal injection and atlantoaxial rotatory fixation.

Wisdom:
If you see fixed torticollis, check the retropharyngeal soft tissues.
If you see retropharyngeal soft tissue widening, assess atlantoaxial alignment.

—Pearls, Pitfalls, and Wisdom from my reporting list

[Sameer Raniga @samrad77]

@lorenzo_masci CPPD can absolutely be symptomatic, but in this case the focal amorphous FCU calcification with surrounding edema fits active HADD better than incidental TFCC chondrocalcinosis.

[Sameer Raniga @samrad77]

65-year-old man with acute ulnar-sided wrist pain. Referred from the ER to rule out fracture.

X-ray shows an amorphous (cloud-like) calcification just proximal to the pisiform, with adjacent soft tissue swelling.

This is typical of calcific tendinosis of the flexor carpi ulnaris tendon insertion, due to Hydroxyapatite Deposition Disease (HADD).

Often presents with acute, severe pain when the deposits becomes inflamed (resorptive phase).

No cortical break, no true fracture fragment

In the same patient, there is a separate, sharp linear subtle calcification in the triangular fibrocartilage complex (chondrocalcinosis) , consistent with Calcium Pyrophosphate Deposition Disease-(CPPD).

Do not mix the two:
•HADD (FCU) → amorphous, cloud-like, peri-tendinous.
•CPPD (TFCC) → thin, linear, cartilage-based.

Both can coexist. The painful one is usually HADD. CPPD is often incidental.

— Pearls, pitfalls and wisdom from today’s reporting list

[Sameer Raniga @samrad77]

One view is NO view

—Today’s list

[Sameer Raniga @samrad77]

@Cookie169Monste Yes 👍

[Sameer Raniga @samrad77]

MRI–CT correlation: when “atypical” is actually typical

A focal vertebral body lesion on MRI. Low on T1. Bright on T2.

This pattern raises concern on MRI. Metastasis, myeloma, chordoma. All reasonable.

What is next?
CT as a problem-solving tool.

Axial CT images showed the polka-dot appearance.
Coronal CT images showed the corduroy sign.

Classic for vertebral hemangioma.

Reporting tip:

If CT shows classic trabecular thickening (polka-dot/corduroy), confidently diagnose hemangioma despite atypical MRI signal.

Wisdom:
Not every T1 dark, T2 bright vertebral lesion is malignant.

Sometimes the answer is already there. Just in another modality.

— Pearls, pitfalls and wisdom from my reporting list