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Co-authors
• S Koening, MD
• C Restrepo, MD
• V Ojili, MD
• A Sunnapwar, MD
• K Chintapalli, MD
• D Rajderkar, MD
Presenting author
Ameya Jagdish Baxi, MD
Disclaimer: We do not have any conflict of interest or financial gain to disclose
Solving the Mystery of Triads: The
Beautiful Threesomes of Radiology
Acknowledgements: P Nepal, MD
G Gunabushanam, MD
Purpose
• Several disease processes can present as constellations of
clinical, laboratory, & radiological findings - known as
triads
• The clinical significance of each triad varies
• Many times, initial imaging findings may incite further
investigation, such as advising CT abdomen contrast
study in a patient with pulmonary chondroma to look for
gastrointestinal stromal tumors and extra-adrenal
paraganglioma
Our goal is to present cases in quiz format of several classic triads to assist in review of
conditions & to sharpen the acuity of the radiologist’s eye to suggest further imaging
when needed to aid in diagnosis
• 26 year-old male who presents with shortness of breath and chest pain
• History of sickle cell disease
Case
Bilateral lower lobe infiltrates, pleural effusions, cardiomegaly, and auto-splenectomy
What is the name of triad?
Lonergan GJ, Cline DB, Abbondanzo SL. Sickle cell anemia. Radiographics. 21 (4): 971-94.
Acute Chest Syndrome
Case: What is the name of triad?
• 44 year old man with right upper quadrant pain with acute onset after
eating a fatty meal, vomiting, and fever
• Also seen with possible leukocytosis, fever, elevated transaminases
Sonographic and CT Findings
(Triad):
• Pericholecystic fluid
• Gallbladder wall thickening
• Positive USG murphy’s sign
Answer: Acute Cholecystitis Triad
Ralls PW , Colletti PM, Lapin SA, Chadrasoma P, Boswell WD, at al. “Real-time sonography in suspected acute cholecystitis.
Prospective evaluation of primary and secondary signs.” June 1985: 155(3).
Case: What is the name of triad?
Cardiomegaly with pericardial tamponade. Patients also had distended neck veins
Patient 1 Patient 2
Answer: Beck’s Triad (1935)
• It's components are:
– Distended neck veins
– Distant heart sounds
– Hypotension
• Seen with rising venous pressure, falling arterial pressure, and decreased heart
sounds
Fowler NO. “Cardiac tamponade. A clinical or an echocardiographic diagnosis?” Circulation 1993; 87(5): 1738-41.
Case What is the name of triad?
61 year old male with shortness of breath & altered mental status
Bergman’s Triad (1873)
Rodriguez—Gutierrez R et al. “Bergman’s Triad: Fat Embolism Syndrome.” American J of the Medical Sciences 2015; 349(2): 186.
Left-sided Hampton’s hump and pulmonary
arterial filling defects.Left proximal femoral fracture.
Bergman’s triad is seen with fat emboli syndrome and consists of
• Mental status changes
• Petichiae
• Dyspnea
Capp Triad
Capp triad refers to the constellation of clinical and imaging findings in patients with
retropharyngeal haematomas, and consists of:
1.Tracheal and esophageal compression
2.Anterior displacement of the trachea
3.Subcutaneous bruising over the neck and anterior chest
Case
Muñoz A, Fischbein NJ, de Vergas J et-al. Spontaneous retropharyngeal hematoma: diagnosis by mr imaging. AJNR Am J Neuroradiol. 22 (6): 1209-11.
• 48-year-old man presenting with acute
onset of retropharyngeal pain,
dysphonia, dyspnea , and dysphagia
• Status post MVC
• Clinical examination: Neck bruise
Large retropharyngeal hematoma (red
arrows) compressing and pushing
oropharyngeal airway (yellow arrows)
What is the name of triad?
Case: What is the name of triad?
• 31-year-old male who presented with diarrhea, lower extremity edema, and “hot flashes”
Small bowel mass in the right lower quadrant and multiple
hypodense hepatic lesions
Answer: Carcinoid Triad
Gedam BS et al . “Gastrointestinal carcinoids: International J of Biomed and Advanced Research.” 2015 6(11): 801-806
• Classic "carcinoid triad" includes flushing, diarrhea, and cardiac involvement
• The hormone largely responsible for most of these symptoms is serotonin
Case: What is the name of triad ?34 year old female presented with abdominal pain
Further imaging was done which showed multiple gastric masses (GISTs) (blue
arrows), pulmonary chondroma (green arrow), and left adrenal tumor (yellow arrow)
Answer: Carney’s Triad (1977)
Triad: Multifocal gastrointestinal stromal tumors (GISTs) (97%), Pulmonary chondromas (83%), & Extra-adrenal paragangliomas (53%)• 33% have all three findings• 10x more common in females• Paraganglioma usually nonfunctional• Screening of family members not recommended
Mayo Clin. Proc. 1999;74 (6): 543-52
Case
56-year-old male presented with
triad of with RUQ pain, fever
and jaundice
Imaging findings
• Biliary Obstruction
• Enhancing Duct Walls
• Cholangitic abscesses
• Managed with PTBD
What is the name of triad?
Answer: Charcot’s Cholangitis Triad
Frossard, J.L. & Bonvin, F. Int J Emerg Med (2011) 4: 18. doi:10.1186/1865-1380-4-18
28-year-old female with weakness and tremor
Also had staccato speech, nystagmus, & Intention tremor (triad)
• Multiple T2 hyperintense demyelinating plaques
within the callosal, pericallosal, & subcortical
white matter, & in the cervicothoracic spinal cord.
Case: What is the name of triad?
Answer: Charcot’s Neurologic Triad
• Associated with multiple sclerosis
• Named after Jean-Martin Charcot
Frossard, J.L. & Bonvin, F. Int J Emerg Med (2011) 4: 18. doi:10.1186/1865-1380-4-18
Case: What is the name of triad ?• 65-year-old male presented to the emergency center with severe mid
thoracic pain, hematemesis, and hemodynamic instability
Non-contrast, arterial, and venous axial CT images of the chest demonstrate a large
aorto-enteric fistula and thoracic aortic aneurysm
Answer: Chiari’s Triad (1914)
Aortoesophageal fistula and hematoma
Aortic diseases associated with esophageal fistula and consequent hematoma includes
• Thoracic aortic aneurysm
• Penetrating aortic ulcer and aortic dissection
• Prosthetic graft
Heckstall RL et al. “Aortoesophageal fistula: recognition & diagnosis in emergency department.” Ann Emerg Med. 1998 Oct; 32(4): 502-5
Case: Child with deformity
Currarino triad
What is the name of triad?
• Anorectal malformation (yellow arrow)
• Sacrococcygeal osseous defect (red arrow)
• Presacral mass (blue arrow)
Currarino G, Coln D, Votteler T. Triad of anorectal, sacral, and presacral anomalies. AJR Am J Roentgenol. 1981;137 (2): 395-8
Currarino syndrome is an autosomal dominant disorder, characterized by triad of partial
agenesis of the sacrum with additional pelvic malformation – anal atresia and presacral
teratoma. Presentation may be delayed to childhood, and even young adulthood. There is also a
risk for malignant degeneration of the presacral teratoma.
.
Case: What is the name of triad?
Red arrows- Hemorrhagic contusions
Yellow arrows- Vasogenic edema
Green arrow- Tonsillar herniation
• Triad: altered mental status, bradycardia, irregular breathing (impaired brainstem
function), and systolic hypertension (widening pulse pressure)
• Clinical triad with variable physiological nervous system response to increased
intracranial pressure
Hint: This triad suggests a cerebral hemorrhage in the setting of trauma or an space occupying
lesion (e.g. brain tumor) that is growing and a possible impending fatal herniation of the brain
Answer: Cushing’s Triad
Patient 1Patient 2
Fodstad H, Kelly PJ, Buchfelder M. “History of the Cushing Reflex.” Neurosurgery 2006; 59(5): 1132-37.
Case: What is the name of triad ?
• A 3 week old infant with vomiting, jaundice, pale stools, & dark urine
• A right upper quadrant USG & nuclear HIDA scan was performed
Non visualized gallbladder with
no tracer in duodenumUSG findings (Triad)
• Atretic gallbladder, length less than 19 mm
• Lack of smooth/complete echogenic mucosal
lining with an indistinct GB wall
• Irregular or lobular liver contour
Answer: Gall Bladder Ghost Triad
Biliary Atresia
Tan Kendrick AP et al . “Biliary atresia: making diagnosis by gallbladder ghost triad.” Pedatr Radiol 2003 May;33(5):311-5.
Case• 35 year old female presented with fatigue, cough, intermittent
shortness of breath, and swollen lymph nodes
CXR and axial CT images of the chest demonstrate the
“1-2-3 sign” also known as “Pawnbreaker’s sign,”
characterized by bulky right hilar lymphadenopathy (blue
arrow), left hilar lymphadnopathy (green arrow), and
right para-tracheal lymphadenopathy (yellow arrow)
What is the name of triad ?
Answer: Garland Triad
Akbar JJ et al. “Cardiopulmonary Imaging in Sarcoidosis.” Clinics in Chest Medicine. 2009 Sept; 29(3): 429-43.
Case: What is the name of triad?
Answer: Kartanager syndrome
47-year-old male presented with concern for pneumonia
Initially described in 1904 by Siewert. Also known as immotile cilia syndrome.
Triad: situs-inversus, chronic sinusitis, and bronchiectasis
Other findings: Male infertility and lack of smell
Patients present with repeated chest infections and can be clinically confused with
immunodeficient conditions
Bronchiectasis Situs inversusSinusitis
Case Reports176 Journal of Natural Science, Biology and Medicine | January 2014 | Vol 5 | Issue 1
• 58-year-old female presents with sepsis and a right-sided neck mass and pain
• Extensive soft tissue infection of the neck (yellow arrow)
• Thrombosis of the right internal jugular vein (blue arrows)
• Septic pulmonary emboli and parenchymal infection (red
arrows)
Answer: Lemierre’s Syndrome
Diagnosis rests on a high index of suspicion and is confirmed by
culture of Fusobacterium spp. from blood or infected sites
O'brien WT, Lattin GE, Thompson AK. Lemierre syndrome: an all-but-forgotten disease. AJR Am J Roentgenol. 2006;187 (3): W324.
Case: What is the name of triad ?
Reconstructed MDCT
coronal, sagittal, and
SSD images showing
aortic occlusion (blue
arrows) and multiple
collaterals (yellow
arrows)
Case : What is the diagnosis?• 69-year-old man presenting with triad of intermittent claudication,
impotence & diminished peripheral pulses
Diagnosis: Leriche Syndrome
• Aortoiliac occlusive disease: Atheromatous occlusion of the infrarenal aorta, common iliac
arteries, or both
• First described by French Surgeon Rene Leriche as a thrombotic occlusion of the end of
the aorta with a unique triad of claudication, impotence, and decreased peripheral pulses
Wooten et al. Clin. Anat. 27:1264–1274, 2014
Case: What is the name of triad?• 47 year old male who presents with severe chest pain after
vomiting secondary to excessive alcohol use
Pneumomediastinum, pneumothorax, (yellow arrows) left pleural effusion with mild
esophageal wall thickening and irregularity with contrast extravasation into the left
hemi-thorax (blue arrows)
Answer: Mackler’s Triad (1724)
• Mackler's triad: Vomiting, chest pain, & subcutaneous emphysema
• Indicates Boerhaave’s syndrome, also known as esophageal rupture
secondary to forceful vomiting and retching
Yagnik VD. “Boerhaave's syndrome: Spontaneous full thickness esophageal perforation.” Lung India 2012 Apr-Jun; 29(2): 197.
Case: What is the name of triad?
• A 35 year old female, G2P2, presented with weight loss,
increasing abdominal circumference, and palpable pelvic mass
Right hydrothorax Ascites Large right adnexal mass
Answer: Meigs’ Syndrome (1937)
Meigs syndrome is defined as the presence of ascites and pleural effusion/hydrothorax in
association with a benign, usually solid, ovarian tumor usually an ovarian fibroma (80-90%)
Sarria HP et al. “Meigs’ Syndrome: a case presentation and revision of the literature.
” Laparoscopy and Hysterectomy, Pregnancy and Birth, and Weight Management: June 2011.
Case: What is the name of triad?
• Results from valgus stress with rotation of the
knee
– ACL, MCL, MEDIAL MENISCUS TEAR
Shelbourne KD, Nitz PA. The O'Donoghue triad revisited. Am J Sports Med. 1992;19 (5): 474-7.
O'Donoghue's unhappy triad
Case: What is the name of triad?
• Newborn baby boy with
abdominal distention and
undescended testes
• Prune belly syndrome, also known as Eagle Barrett syndrome or triad
syndrome, is a rare anomaly comprising a specific constellation of features
• Three major findings:
– gross ureteric dilatation
– anterior abdominal wall maldevelopment (giving "prune belly" appearance)
– bilateral undescended testes
• Other associations include respiratory, gastrointestinal, musculoskeletal, and
cardiovascular anomalies
Prune Belly Syndrome Triad
Das narla L et-al. Pediatric case of the day. Prune-belly syndrome (Eagle-Barrett syndrome, triad syndrome). Radiographics. 18 (5): 1318-22.
Overdistended urinary bladder Undescended right testis-green
Bilateral hydroureteronephrosis
and thinned out anterior abdominal wall
Dilated posterior urethra and
right hydroureter
Case
• 38-years-old female presenting with the sustained
hypertension, hematuria and postmicturition syncope
Bladder pheochromocytoma presenting as hypertensive emergency
What is the diagnosis?
• Arise in the paraganglia of the visceral (autonomic) nervous system
• Location: submucosal either dome or posterior wall, close to the trigone
• Imaging is useful in localization and for determining multiple sites or metastases
Sweetser PM, Ohl DA, Thompson NW. Pheochromocytoma of the urinary bladder. Surgery. 1991;109:677–681.
triad of
Case
What is the name of triad?
Saint’s Triad
Saint's triad is a medical condition of concurrence of the following:
- Cholelithiasis
- Hiatal Hernia
- Colonic Diverticulosis Diverticular disease
Hauer-Jensen M, Bursac Z, Read RC. “Is herniosis the single etiology of Saint’s triad?” Hernia (2009) 13: 29.
Case: What is the name of triad?
• 10 year old male with elbow injury
Radiographic findings:
Posterior elbow dislocation
Coronoid process fracture
Radial head fracture
Terrible Triad of the Elbow
• The terrible triad of the elbow is a severe elbow fracture-
dislocation pattern and is so-called because it has poor
medium-to-long term outcome
Matthew PK, Athwal GS, Graham JW. “Terrible triad injury of the elbow.” J of the Am Academy of Ortho Surg 2009; 17(3): 137-151.
Case: Identify findings and triad
• 3-year-old female with history of congenital heart disease
• Pulmonary valve stenosis
• Right ventricular hypertrophy
• Atrial Septal Defect
Trilogy of Fallot
Bowie EA. “Longevity in tetralogy and triology of Fallot: Am Heart J 1961; 62(1): 125-132.
45-year-old woman with pain in abdomen
Case: What is the name of triad?
Arrows
• Pneumobilia (yellow)
• Small bowel obstruction (red)
• Gallstone (blue)
Rigler’s triad in gallstone ileus
Lassandro Francesco et al. “Role of Helical CT in Diagnosis of Gallstone Ileus and Related Conditions.” Am. J. Roentgenol. 185, no. 5 (November 1, 2005): 1159-1165
Case: What is the name of triad?
• 38 year old female on oral contraceptive pills presents with left
lower extremity pain and edema after an overseas flight
Answer: Virchow Triad
• Virchow's triad describes 3 broad categories of factors that contribute
thrombosis:
– Hypercoagulability
– Hemodynamic changes to flow (stasis, turbulence)
– Endothelial injury/dysfunction
Makin A, Silverman SH, Lip GY. “Peripheral vascular disease and Virchow’s triad for thrombogenesis.” QJ Med 2002; 95: 199-210.
Case
15 yo male, MV vs. pedestrian
What is the name of the triad?
Waddell’s Triad
Atabaki SM. “Updates in the general approach to pediatric head trauma and concussion.” Ped Clin of N Amer. 2013; 60(5): 1107-1122.
• Femur fracture
• Intra-abdominal or intra-thoracic injury
• Head injury
Case33-year-old obese female with right upper quadrant pain
What is the name of triad?
“WES” – Wall Echo Shadow Triad
Rybicki FJ. The WES sign. Radiology. 2000;214 (3): 881-2.
Single thin curvilinear hyperechoic line representing gallbladder wall & near
surface of gallstone with posterior acoustic shadowing distal to the gallstone
The "WES" triad is the demonstration of the gallbladder Wall, Echo of the stone, and the
acoustic shadow. It permits the specific diagnosis of stones in a contracted gallbladder & helps
to differentiate the contracted gallbladder with stones from a gas filled bowel loop
Two different patients with severe hypoglycemia & immediate response
to IV glucose
Case : What is the name of triad?
Patient 1
Patient 2Whipple’s Triad
Whipple triad is the clinical presentation of pancreatic insulinoma
– Fasting hypoglycemia (<50 mg/dl)
– Symptoms of hypoglycemia
– Immediate relief of symptoms after the administration of IV glucose
AJR Am J Roentgenol. 2003;181 (4): 987-92.
41 year old female with left flank pain
Case 25: What is the name of triad?
Answer: Xanthogranulomatous Pyeleonephritis
• Classic radiology triad of
– Unilateral large kidney
– Renal pelvis stone
– Nonfunctioning or poorly functioning kidney
Craig WD, Wagner BJ, Travis MD. Pyelonephritis: radiologic-pathologic review. Radiographics. 28 (1): 255-77.
Case: What is the name of triad ?37-year-old male presented with perineal pain, recurrent prostatitis,
painful ejaculation, and infertility
Right renal agenesis Seminal vesicle cyst and dilated tubular fluid filled structure in the right pelvis
Answer: Zinner Triad (1914)Maldevelopment of the distal part of the mesonephric duct results in atresia of the
ejaculatory duct (leading to obstruction and dilatation of the seminal vesicle) while abnormal
ureteral budding (leads to renal agenesis/dysplasia)
Ghonge Npet al; Indian J Urol. 2010;26 (3): 444-7.
Thank you