Introduction to Radiology
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Transcript of Introduction to Radiology
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Introduction to Radiology
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Course Overview
• Four Required On-line modules• 2 Case discussion sessions• Four quizzes• Two examinations
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Course Overview
• Expectations– Active participation and preparation– Utilization of provided on-line materials– Exciting Fun Course
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Introduction Lecture
• Historical overview• X-rays• Appropriateness Criteria• Application of the various technologies to
be discussed in the course
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Ionizing Radiation Historical Overview
• Wilhelm Conrad Röentgen– 1845 – 1923– November 8, 1895 – discovery of the x-ray
• Discovered effect of passing this ray through materials• First radiograph of his wife’s hand
– 1901 – Nobel Prize Physics• Antoine Henri Becquerel
– 1852-1908– Radioactive nature of Uranium– 1903 – Nobel Prize Physics
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Ionizing Radiation Historical Overview
• Marie and Pierre Curie – 1867-1934, 1859 – 1906– Marie coined term “radioactivity”– Discovery of Polonium and Radium– 1903 - 1910 – Nobel Prize Physics - Chemistry– Died July 4, 1934 – Pernicious Anemia
• William D. Coolidge– Patent holder for the original x-ray tube 1913
• Robert S. Ledley– Patent holder for original CT scanner 1975
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US Historical Overview• George D. Ludwig
– Late 1940’s research for the Navy– Classified work using US to evaluate tissues– Report June 1949 first published work on US applications
• Douglass Howry, Joseph Holmes– Pioneering work in B-Mode ultrasound
• Joseph Holmes, William Wright and Ralph Meyerdirk– First articulated arm scanner 1963
• James Griffith, Walter Henry NIH– Mechanical oscillating real-time apparatus 1973
• Martin H. Wilcox– Linear array real time scanner 1973
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NM Historical Overview
• Benedict Cassen, Lawrence Curtis, Clifton Reed– Automated scintillation detector 1951
• Hal Anger – Scintillation Camera 1958
• Picker Corporation– 3 inch rectilinear scanner 1959
• John Kuranz – Nuclear Chicago– First commercial Anger (Gamma Camera)
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MRI Historical Overview
• Felix Bloch, Edward Purcell– NMR Spectroscopy
• Paul Laterbur, Peter Mansfield– 2003 Nobel Prize Physiology / Medicine
• Raymond Damadian– First patent in field of MRI 1970
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Imaging Modalities
• Ionizing Radiation:– Diagnostic Radiology (X-rays)– Interventional Radiology– Computed Tomography (CT)– Nuclear Medicine– Positron Emission Tomography (PET)
• No Ionizing Radiation:– Diagnostic Ultrasound (Ultrasonography)– Magnetic Resonance Imaging (MRI)
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X-Rays• High energy electromagnetic radiation• Behaves both like a particle (photon) and
a wave• Production of X-Rays
– Free electrons produced at filament of x-ray tube (cathode)
– High Speed movement of electrons– Rapid deceleration of electrons at anode– Emission of a x-ray photon
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X-ray Tube Schematic
CathodeAnode – Tungsten Target
ElectronBeam
Window
X-rays
Envelope
Collimator
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Production of Image
• X-ray pass through tissue to expose detector
• Passage depends on– Tissue characteristics
• Density• Atomic Number• Number of electrons per gram • Thickness
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Production of Image• Differential absorption of X-ray as the beam
passes through the patient• Unabsorbed X-rays expose the detector (i.e.
film, CR Plate, solid state detector), creating the image (photographic effect)
• Differential absorption of X-ray by the tissues is the cardinal feature of image formation
• Special terms used on x-ray reports– Radiopaque, Radiolucent, High attenuation, Low
attenuation, Water density
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Standard X-Ray Machine
X-Ray Tube
X-Ray Tube
Detector
Detector
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Fluoroscopic Imaging Unit
Detector
X-Ray Tube
X-Ray Tube
Detector
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Natural Densities
• Natural densities in the body– Bone– Soft tissue and body
fluid– Fat– Lung and air
containing organs
• Appearance on the radiographic image– White
– Black
Shades of Gray
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Image Density X-ray• Radiopaque – High attenuation
– Appears white on film – black on fluoroscopy
– X-ray photons don’t reach the detector
• Radiolucent – Low attenuation– Appears black on film – white on
fluoroscopy– X-ray photons unimpeded
traveling to detector• Water density
– Appears grey on film– All soft tissues
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Natural Contrast• Differential contrast between bone and
soft tissues• Differential contrast between soft tissues
and air• Little difference between various tissue
types i.e. fat, muscle, solid organs, blood….
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Natural Contrast• Pathologic processes may cause
differences in natural densities that can be visualized on the X-ray; – high density tumor in air filled lung- white– Low density cyst in radio-opaque bone- black
• Pathologic processes of almost the same density as adjoining structures are not visible on X-ray.
• May need to use additional artificial contrast to visualize a density difference
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Contrast Agents
• Contrast material (radio-opaque or radio-lucent) administered to see structures or pathologic processes that would not be seen otherwise
• Some useful contrast agents– Barium sulfate in the GI tract– Iodine compounds in the vessels– Carbon dioxide in the vessels or GI tract– Naturally occurring air in the GI tract
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Fluoroscopic Room
RadiosensitiveScreen
Video Camera
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Appropriateness Criteria
• Guidelines to assure proper imaging choices
• Based on attributes developed by the Agency for Healthcare Research and Quality (AHRQ)
ACR Appropriateness Review Criteria Overview
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Appropriateness Criteria
– Validity – lead to better outcomes based on scientific evidence
– Reliable and reproducible – other experts should develop same recommendations based on the same scientific evidence
– Clinical applicability – guideline indicates target population
ACR Appropriateness Review Criteria Overview
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Appropriateness Criteria
– Clinical flexibility – specify expectations– Clarity – unambiguous, clear definitions– Multidisciplinary – all affected groups should
be represented– Scheduled review – fixed time to review and
revise– Documentation – evidence used and
approach taken is documented
ACR Appropriateness Review Criteria Overview
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Appropriateness Criteria
• ACR Appropriateness Criteria search engine:
• http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria.aspx
• Allows searching by 10 diagnostic imaging expert panels
• Useful resource when evaluating what clinical exam may be useful
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Appropriateness Criteria
• Electronic Decision Support for Medical Imaging
• Future opportunities to improve health care
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X-Ray
• Ionizing radiation– Exposure concerns
• Somewhat limited discrimination between structures of similar density– Tumor vs. normal organs
• Inexpensive• Readily available• First line imaging tool
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X-Ray
• Primary applications:– Chest Imaging
• Infiltrates• Masses• Cardiac silhouette
– Abdominal imaging• Gas/ bowel distribution• Free air• Calcifications• Organomegaly/ masses
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X-Ray
• Primary Applications– Bone and Joint imaging
• Trauma• Neoplasm
– Soft Tissues• Mass• Foreign bodies
– Breast imaging
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X-Ray
• Secondary applications:– Contrast enhanced examination
• Urinary tract– IVU– Cystography, urethrography– Angiography
• Pulmonary/ Cardiac– Pulmonary – Coronary– Great vessels
• General– Neoplasm– Vascular abnormalities
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X-Ray
• Secondary applications:– Dual energy
• Lung lesions• Soft tissue calcifications
– Bone density evaluation– Tomography – tomosynthesis
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Interventional Radiology
• Minimally invasive technology– Biopsy– Cavity drainage
• Infections• Neoplasm
– Revascularization• TPA• Angioplasty• Stenting
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Interventional Radiology
– Lumen restoration / drainage• Biliary tree• Ureters• Others
– Vertebroplasty/ kyphoplasty
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Computed Tomography
• Ionizing radiation– Requires concern and careful utilization
• Excellent discrimination between subtle tissue density differences
• Moderately expensive• Readily available• Growing spectrum of applications across a
broad spectrum of diseases and body parts
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Computed Tomography
• Primary applications:– First line evaluation in suspected cerebral
vascular events – hemorrhagic vs. ischemic– First line evaluation in soft-tissue and skeletal
trauma– First line evaluation in suspected pulmonary
embolism– First line evaluation in suspected urinary
calculi
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Computed Tomography
• Primary applications:– Head & Neck
• CVA evaluation• Carotid and intra-cerebral vascular evaluation• Head-neck trauma – evaluation for subdural and epidural
hematoma – evaluation for cervical fracture• Neoplasm staging
– Thorax• Lung- mediastinum nodule/ mass evaluation, • Cardiac, coronary, pulmonary and great vessel vascular
evaluation• Airway evaluation• Neoplasm staging
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Computed Tomography
• Primary applications:– Abdomen/ Pelvis
• Solid organ evaluation• Urinary tract evaluation for calcification• CT angiography• CT colonography• CT urography• Lumbar spine evaluation (pacemakers,
stimulators)• Neoplasm Staging
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Computed Tomography
• Primary applications:– Bones & Joints
• 3-D joint reconstructed images• Evaluation of fracture union• Evaluation of neoplasm / extent
• Secondary applications:– Evaluation of patients with a contraindication
to MRI imaging– Bone mineral density analysis
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Nuclear Medicine / PET
• Ionizing radiation• Radio-isotopes attached to molecules
targeting specific organs or metabolic processes
• Spatial resolution limited• Able to evaluate temporal resolution of
uptake/ events
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Nuclear Medicine / PET
• Primary applications:– First line evaluation of biliary function
evaluation– First line evaluation of cardiac perfusion– First line evaluation of solid pulmonary
nodules– First line evaluation for many neoplasms,
staging – treatment response
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Nuclear Medicine / PET
• Primary applications:– Head & Neck
• Brain death evaluation – cerebral blood flow• CSF flow evaluation• Bone abnormality evaluation
– Thorax• V-Q Scanning – Ventilation Perfusion scanning for
Pulmonary Embolism detection – secondary exam• Pulmonary nodule evaluation (PET)• Cancer staging (PET)
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Nuclear Medicine / PET
• Primary applications:– Abdomen & Pelvis
• Liver – spleen scanning• Hepatobiliary scanning• Renal scanning• Bladder & Reflux evaluation• GI bleed evaluation• Cancer staging (PET)
– Soft tissues – Bone & Joints• Bone scanning• Tumor scanning (Gallium, PET)• Infection scanning (labeled white cells, Gallium)
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Magnetic Resonance Imaging
• No ionizing radiation• Utilize magnetic fields and radio waves• Contraindication: implanted devices, ferro-
magnetic metals• Relative contraindication: claustrophobia• Differentiation of distribution of Hydrogen
ions as impacted by adjoining molecules• Ability to do spectral analysis (remember
organic chemistry)
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Magnetic Resonance Imaging
• Primary applications:– First line evaluation of suspected neurologic
abnormality– First line evaluation of soft tissue mass/
neoplasm– First line evaluation of joint disarrangements– First line evaluation of bone neoplasm
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Magnetic Resonance Imaging
• Primary applications:– Head
• Neoplasm• Infection• CVA• Developmental anomalies• Trauma• MR angiography
– Neck• Effect of arthritis and degenerative changes• Neoplasm• Trauma• MR Angiography
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Magnetic Resonance Imaging
• Primary applications:– Thorax
• Spine – cord, roots, bodies• Heart – function, perfusion• MR angiography
– Abdomen• Liver – mass, iron content, biliary tree• MR Cholangiography• Kidneys• MR Urography• MR Colonography• Retroperitoneum
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Magnetic Resonance Imaging
• Primary applications:– Pelvis
• Prostate– Neoplasm– Hypertrophy– CAD
• Uterus & Ovaries– Masses– Leiomyoma
• Spine– Cord– Roots– Foramina– Stenosis– Arthritis
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Magnetic Resonance Imaging
• Primary applications:– Bones & Joints
• Tendons and ligaments injury• Articular cartilage evaluation• Muscle abnormality• Trauma – fracture, contusion• Mass/ Neoplasm – appearance and extent
– Soft tissues• Mass/ Neoplasm• MR angiography
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Ultrasound
• No ionizing radiation• Principles of fairly uniform speed of sound
transmission in human tissues• Ability to differentiate fairly subtle tissue
differences based on echo reflection and interactions
• Application of Doppler principles for fluid motion
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Ultrasound
• Primary applications: – First line evaluation of pregnancy and
developing fetus– First line evaluation for differentiation of cystic
from solid masses/ structures– First line evaluation of liver and biliary tree– First line evaluation of kidneys and bladder– First line evaluation of thyroid gland
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Ultrasound
• Primary applications: – Head & Neck
• Thyroid• Adenopathy• Orbits & globe• Salivary glands• Fetal brain• Soft tissue masses
– Thorax• Cardiac• Pleural effusions• Breast lesions• Soft tissue masses
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Ultrasound
• Primary applications: – Abdomen
• Liver• Pancreas• Spleen• Kidneys• Aorta• Splanchnic and renal vessels
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Ultrasound
• Primary applications: – Pelvis
• Pregnant uterus and fetus• Uterus• Fallopian tubes• Ovaries• Bladder• Prostate• Testes and scrotum
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Ultrasound
• Primary applications: – Soft tissues, bones & joints
• Tendons, Ligaments and supporting structures• Fluid collections and masses• Vascular malformations• Artery and vein evaluation• Foreign bodies