Diagnostic Medical Imaging

DIAGNOSTIC MEDICAL
IMAGING
D r. G . O lscam p , D r. D . R ap p ap o rt, an d D r. D . S alo n e n
D e b ra C h an g, C h ri s G rah am , an d R o n jo n R ah a, e d i to rs
D e b o rah C h e n g, asso ci ate e d i to r
IMAGING MODALITIES . . . . . . . . . . . . . . . . . . . . . 2
CHEST IMAGING. . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
G e n e ral
Ap p ro ach to th e C h e st X-R ay ( C XR )
C o m m o n C XR Ab n o rm ali ti e s
C T S can
MUSCULOSKELETAL SYSTEM . . . . . . . . . . . . . . .10
M o d ali ti e s
G e n e ral Ap p ro ach to I n te rp re tati o n o f B o n e X-R ays
Trau m a
Arth ri ti s
Tu m o u r
I n fe cti o n
M e tab o li c
GASTROINTESTINAL TRACT. . . . . . . . . . . . . . . . .15
Ab d o m i n al P lai n F i lm s
C o n trast S tu d i e s
S o li d Vi sce ral O rgan I m agi n g
I T I S I m agi n g
GENITOURINARY SYSTEM . . . . . . . . . . . . . . . . . 19
I n tro d u cti o n
M o d ali ti e s
S e le cte d P ath o lo gy
M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s D i agn o sti c M e d i cal I m agi n g 1
NEURORADIOLOGY. . . . . . . . . . . . . . . . . . . . . . 22
I n tro d u cti o n
M o d ali ti e s
S e le cte d P ath o lo gy
NUCLEAR MEDICINE . . . . . . . . . . . . . . . . . . . . 24
T h yro i d
C h e st
B o n e
Ab d o m e n
I n flam m ati o n an d I n fe cti o n
B rai n
VASCULAR-INTERVENTIONAL . . . . . . . . . . . 26
RADIOLOGY
APPROACH TO COMMON . . . . . . . . . . . . . . 29
PRESENTATIONS
M u scu lo ske le tal P ath o lo gy
Ab d o m i n al P ath o lo gy
U ri n ary Tract P ath o lo gy
R e p ro d u cti ve P ath o lo gy
N e u ro p ath o lo gy
D i agn o sti c M e d i cal I m agi n g 2 1 999 M C C Q E R e vi e w N o te s
N o te s
IMAGING MODALITIES
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1 999 M C C Q E R e vi e w N o te s D i agn o sti c M e d i cal I m agi n g 3
N o te s
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N o te s
CHEST IMAGING
GENERAL
J d e n sity: d e fin e d b y th e ab ility o f a stru ctu re to atte n u ate th e
x-ray b e am ( air < wate r < fat < calciu m )
J co n trast: d iffe re n ce b e twe e n d e n sitie s
J stan d ard vie ws: e re ct PA an d le ft late ral ( se e F igu re 1 )
J su p p le m e n tal film s m ay in clu d e o b liq u e , lo rd o tic, an d d e cu b itu s ( le ft o r righ t) vie ws
J stru ctu re s fu rth e r away fro m film are e n large d d u e to scatte rin g o f rays
J d iffe re n tiate AP fro m PA, an d su p in e fro m e re ct
Figure 1. Norma1 PA and Late ral of Che s t
APPROACH TO THE CHEST X-RAY (CXR)
J M n e m o n ic: It May Pro ve Qu ite Righ t b u t Sto p An d Be Ce rtain
Ho w Lu n gs Ap p e ar
Extrins ics
J Id e n tificatio n : d ate o f e xam , p atie n t n am e , se x, age
J Marke rs: R an d L
J Po sitio n : m e d ial e n d s o f clavicle s sh o u ld b e e q u id istan t fro m
sp in o u s p ro ce ss at m id lin e
J Qu ality: d e gre e o f p e n e tratio n ( e .g. d isc sp ace s ju st visib le th ro u gh
h e art b u t n o t ab le to se e d e taile d b o n y an ato m y)
J Re sp iratio n : righ t h e m id iap h ragm at 6th an te rio r in te rsp ace o r 1 0th
rib p o ste rio rly o n go o d in sp iratio n
p o o r in sp iratio n re su lts in p o o r ae ratio n , vascu lar cro wd in g, co m p re ssio n
an d wid e n in g o f ce n tral sh ad o w
Intrins ics
J So ft tissu e s: n e ck, axillae , p e cto ral m u scle s, b re asts/n ip p le s, ch e st wall
n ip p le m arke rs can h e lp id e n tify n ip p le s
lo o k fo r m asse s an d am o u n t o f so ft tissu e p re se n t
so ft tissu e s m ay cast sh ad o ws in to th e lu n g fie ld s
J Ab d o m e n : live r, sto m ach an d gastric b u b b le , sp le e n , gas-fille d
b o we l lo o p s, ve rte b rae , fre e air
J Bo n e s: C -sp in e , T-sp in e , sh o u ld e r gird le , rib s ( tu rn film o n its sid e
to h e lp fo cu s o n rib s) , ste rn u m ( b e st o n late ral film )
J Ce n tral sh ad o w: trach e a, h e art b o rd e rs, gre at ve sse ls, m e d iastin u m , sp in e
J Hila: p u lm o n ary ve sse ls, m ain ste m an d se gm e n tal b ro n ch i, n o d e s
J Lu n gs: p le u ra, d iap h ragm , lu n g p are n ch ym a
J Ab se n t stru ctu re s: re vie w th e ab o ve , n o tin g rib s, b re asts, lu n g lo b e s
COMMON CXR ABNORMALITIES
J ab n o rm al fin d in gs are n o t p ath o gn o m o n ic o f a p articu lar d iagn o sis
an d o n ly su gge st ce rtain typ e s o f d ise ase
J always co n sid e r th e clin ical h isto ry
J ALWAYS H AVE P R E VIO U S F IL M F O R C O M PAR IS O N ( if availab le )
Bone s and Soft Tis s ue s
J o b lite ratio n o f clavicu lar co m p an io n sh ad o w m ay re p re se n t e xce ss
fat o r su p raclavicu lar ad e n o p ath y ( th e latte r m o st like ly if u n ilate ral)
J lytic o r scle ro tic le sio n s m ay b e p rim ary o r m e ts ( se e M u scu lo ske le tal S yste m b e lo w)
J fractu re s in rib s ( d isco n tin u ity in b o n y co rte x o r sh arp lin e )
J fe atu re s o f o ste o p o ro sis ( o ste o p e n ia, co m p re ssio n , we d ge d
ve rte b ral b o d ie s) m ay b e se e n in th e T-sp in e ( se e M u scu lo ske le tal
S yste m b e lo w)
h o rizo n tal fissu re
ao rtic arch
h ilar arte rie s
b re ast sh ad o w
righ t an d le ft
m ain ste m b ro n ch i
co sto p h re n ic
an gle s ( sh arp )
trach e a
ao rta
re tro ste rn al tran srad ian cy
righ t p u lm o n ary arte ry
h o rizo n tal fissu re p o sitio n
o b liq u e fissu re p o sitio n
re tro card iac tran sp are n cy
le ft p u lo m ary arte ry
N o te s
CHEST IMAGING . . . CONT.
Ple ura, Diaphragm, and Vis ce ra
J p le u ral an d e xtrap le u ral m asse s: fo rm o b tu se an gle s
at th e ir e d ge s
J p u lm o n ary m asse s: fo rm acu te an gle s with th e p le u ra
J p le u ral th icke n in g an d e ffu sio n s
J h igh d iap h ragm : ab d o m in al d iste n tio n , lu n g co llap se ,
p n e u m o n e cto m y, p re gn an cy, p le u ral e ffu sio n
J lo w d iap h ragm : asth m a, e m p h yse m a, large p le u ral
e ffu sio n , tu m o u r
J fre e air u n d e rn e ath d iap h ragm ( p n e u m o p e rito n e u m )
J calcificatio n s in d iap h ragm : asb e sto sis
Blunting of Cos tophre nic Angle s
J in d icate s p le u ral e ffu sio n o r th icke n in g
J fe atu re s o f e ffu sio n
flu id is h igh e r late rally th an m e d ially
flu id fo rm s m e n iscu s with p le u ra, b e st se e n o n late ral
n o air b ro n ch o gram
wh e re e ffu sio n ru n s in to a fissu re , b o th sid e s o f th e fissu re
are visib le
trach e a an d m e d iastin u m ce n tral o r p u sh e d to o p p o site sid e
late ral d e cu b itu s film with e ffu sio n in d e p e n d e n t p o sitio n
will sh o w laye rin g
m ay se e p artial co llap se ( ate le ctasis)
J p o o lin g o f flu id o ccu rs first in p o ste rio r re ce ss, th e n sp re ad s
late rally an d an te rio rly
J first sign m ay b e a sh ift o f m axim al co n ve xity o f th e h e m id iap h ragm
fro m th e m id d le 1 /3 to th e ju n ctio n o f th e m id d le 1 /3 an d late ral 1 /3
J n e e d at le ast 200 cc o f flu id in su b p u lm o n ic p le u ral sp ace fo r
b lu n tin g to o ccu r
J n e ve r se e h o rizo n tal flu id le ve l u n le ss asso ciate d with p n e u m o th o rax
( always a m e n iscu s)
J e ffu sio n s m o re like ly to b e m align an t wh e n m assive ( a so ft sign )
J b lu n tin g m ay also re p re se n t scarrin g o f p arie tal p le u ra fro m o ld
in fe ctio n s, trau m a, su rge ry
J U /S su p e rio r o ve r p lain film fo r d e te ctio n o f sm all e ffu sio n s
( can also aid in th o raco ce n te sis)
Pne umothorax (s e e Colour Atlas K8)
J th in , ve il-like p le u ral m argin o ve r th e lu n g e d ge with n o lu n g
m arkin gs e xte n d in g b e yo n d
J air co lle cts su p e rio rly
J m o re o b vio u s o n e xp irato ry o r late ral d e cu b itu s film
J ate le ctasis ( p artial, co m p le te ) m ay b e se e n
J m e d iastin al sh ift if air u n d e r te n sio n
Enlarge me nt/Dis tortion of Cardiovas cular Shadow
J card io th o racic ratio
in ad u lts, th e ratio o f th e gre ate st tran sve rse d im e n sio n o f th e
ce n tral sh ad o w to th e gre ate st tran sve rse d im e n sio n o f th e
th o racic cavity
o n ly valid o n go o d q u ality e re ct PA ch e st film
> 0.5 ab n o rm al
card io m e galy, p o o r in sp iratio n , su p in e p o sitio n , o b e sity, p e ctu s
e xcavatu m
D D x o f ratio > 0.5: card io m e galy su gge sts e ith e r m yo card ial
h yp e rtro p h y o r d ilatatio n o r p e ricard ial e ffu sio n ( p u re
h yp e rtro p h y ve ry h ard to se e )
m ay b e < 0.5 an d still b e e n large d if m u ltip le p ro b le m s
( e .g. card io m e galy +e m p h yse m a)
J p e ricard ial e ffu sio n
glo b u lar h e art
lo ss o f in d e n tatio n s o n le ft m e d iastin al b o rd e r
p e ri- an d e p icard ial fat p ad se p aratio n o n late ral film
J tran sve rse d iam e te r o f h e art ch an ge s b y 1 cm b e twe e n systo le an d d iasto le
N o te s
Is olate d Cardiac Chambe r Enlarge me nts ( se e F i gu re 2)
LV R V L A
Figure 2. Cardiac Enlarge me nt Patte rns
J R A e n large m e n t
in cre ase in cu rvatu re o f righ t h e art b o rd e r
e n large m e n t o f S VC
J L A e n large m e n t
straigh te n in g o f le ft h e art b o rd e r
in cre ase d rad io -o p acity o f lo we r righ t sid e o f card io vascu lar
sh ad o w ( d o u b le h e art b o rd e r
e le vatio n o f le ft m ain b ro n ch u s, sp laye d carin a ( late )
co m p re ssio n o f e so p h agu s o n G I b ariu m stu d ie s
J R V e n large m e n t
e le vatio n o f card iac ap e x o ff d iap h ragm
an te rio r e n large m e n t o n late ral le ad in g to lo ss o f
re tro ste rn al air sp ace
in cre ase d co n tact o f R V again st ste rn u m
J LV e n large m e n t
d isp lace m e n t o f card iac ap e x in fe rio rly an d p o ste rio rly
in cre ase d o u tward lo we r b u lgin g
o n late ral film , fro m ju n ctio n o f IVC an d h e art at le ve l o f
d iap h ragm , m e asu re 1 .8 cm p o ste rio rly th e n 1 .8 cm su p e rio rly >
if card iac sh ad o w e xte n d s b e yo n d th is, th e n LV e n large m e n t ( R igle rs S ign )
Calcifications
J valve s, co ro n ary arte rie s, p e ricard iu m , ao rta, walls o f LV ( p o ste rio r
in farct/an e u rysm ) , co sto ch o n d ral ju n ctio n
J to id e n tify calcifie d /artificial valve s, co n sid e r d ire ctio n
o f b lo o d flo w an d lo catio n
J o n late ral film , d raw lin e fro m carin a to xip h o id > d ivid e h e art
in to th ird s > valve s sh o u ld fall at ju n ctio n s o f lin e s sh o wn in F igu re 3
Figure 3. Late ral Che s t Showing Valve s
Hype rinflation (s e e Colour Atlas K11 and K12)
J in cre ase d rad io lu ce n cy ( in cre ase d ae ratio n )
J vascu latu re sp re ad fu rth e r ap art ( atte n u atio n )
J lo w, flatte n e d d iap h ragm s, o fte n se rrate d ( fib ro sis) , se e n b e st o n
late ral
T
Ao
M
P
P = p u lm o n ic valve
Ao = ao rtic valve
M = m itral valve
T = tricu sp id valve
N o te s
J lo o k fo r sp o n tan e o u s p n e u m o th o rax se co n d ary to ru p tu re o f air
b u llae
J in cre ase d AP ch e st d iam e te r an d re tro ste rn al airsp ace o n late ral
J H R C T is b e st m o d ality
Silhoue tte Signs (s e e Colour Atlas K10)
J in C XR , can se e d iap h ragm an d m e d iastin u m b e cau se o f
ab ru p t ch an ge o f rad io d e n sitie s b e twe e n lu n g an d th e se stru ctu re s
J silh o u e tte sign re fe rs to lo ss o f n o rm ally ap p e arin g p ro file s
o r in te rface s im p lyin g so lid ch an ge in ad jace n t lu n g
e .g. lo ss o f R h e art b o rd e r = R M L co n so lid atio n
L h e art b o rd e r = lin gu la
R h e m id iap h ragm = R L L o r p le u ra
L h e m id iap h ragm = L L L o r p le u ra
ao rtic arch = an t se g L U L
su p e rio r ve n a cava = R U L
J sign s m o stly d u e to co n so lid atio n , b u t o th e r p ro ce sse s m ay also
p ro d u ce silh o u e tte sign ( ate le ctasis, m asse s)
Air Space Dis e as e vs Inte rs titial Dis e as e (s e e Colour Atlas K1 and K2)
J air sp ace d ise ase : p ath o lo gical p ro ce ss p rim arily in alve o li
acin ar sh ad o ws ( sm all, flu ffy, ill-d e fin e d d e n sitie s wh ich te n d to co ale sce )
air b ro n ch o gram ( air-co n tain in g b ro n ch i su rro u n d e d b y
d e n se , airle ss lu n g)
th e silh o u e tte sign
J D D x: flu id ( p u lm o n ary e d e m a) , p u s ( p n e u m o n ia) , b lo o d ( h e m o rrh age ) ,
ce lls ( lu n g C A/lym p h o m a) , p ro te in ( alve o lar p ro te in o sis)
J in te rstitial d ise ase : p ath o lo gical p ro ce ss p rim arily in lu n g
in te rstitiu m ( i.e . scaffo ld in g o f lu n g)
re ticu lar p atte rn : th in , we ll d e fin e d lin e ar d e n sitie s, o fte n in
n e t-like arran ge m e n t; K e rle y B lin e s m ay b e p re se n t ( se e b e lo w)
n o d u lar p atte rn : m u ltip le , d iscre te , n o d u lar d e n sitie s,
< 5 m m d iam e te r
re ticu lo n o d u lar: m ay se e b o th p atte rn s
J D D x: p u lm o n ary e d e m a, m iliary T B
(s e e Colour Atlas K6), id io p ath ic p u lm o n ary fib ro sis,
sarco id o sis, p n e u m o co n io se s
J b o th air sp ace an d in te rstitial d ise ase m ay b e o ccu rrin g
sim u ltan e o u sly ( e .g. p u lm o n ary e d e m a)
Cons olidation (s e e Colour Atlas K2)
J p ro ce ss wh e re b y air in lu n g acin i is re p lace d b y flu id ( o r tissu e )
( i.e . air sp ace d ise ase )
J are as vary fro m 5 m m to e n tire lu n g fie ld s
J in itially m ay h ave m u ltip le fo ci, ill-d e fin e d an d irre gu larly-sh ap e d
J fo ci m ay late r co ale sce in to are as o f h o m o ge n e o u s rad io p acity
( i.e . lo b ar co n so lid atio n )
J fe atu re s
sh ap e co n fo rm s to th at o f lo b e s o r se gm e n ts ( se e F igu re 4)
n o h o m o ge n e o u s sh ad o w o u tsid e th e lu n g e d ge
air b ro n ch o gram m ay b e p re se n t
wh e re th e co n so lid atio n ab u ts again st a fissu re , o n ly o n e
sid e o f th e fissu re is visib le
trach e a an d m e d iastin u m are p u lle d to ward sid e o f
sh ad o w ( se co n d ary to vo lu m e lo ss)
silh o u e tte sign
J D D x: in fe ctio n ( e sp e cially b acte rial p n e u m o n ia) , in farctio n , p u lm o n ary
co n tu sio n , alle rgy, tu m o u r
N o te s
R U L R M L R L L
L L L L U L L IN G U L AR
Figure 4. Common Cons olidation Patte rns
Pulmonary Ede ma
J e ith e r card io ge n ic ( C H F, re n al failu re , vo lu m e o ve rlo ad ) o r
n o n -card io ge n ic ( AR D S , asp iratio n , n o xio u s gas in h alatio n ) , n e u ro ge n ic
J e d e m a flu id in itially co lle cts in in te rstitiu m > se e re ticu lo n o d u lar
p atte rn first > K e rle y B lin e s
J se e n first in h ilu m , th e n sp re ad o u tward s to p e rip h e ry - " b at win g's ap p e aran ce "
J in se ve re p u lm o n ary e d e m a, flu id b e gin s to co lle ct in alve o li
Se ptal (Ke rle y) Line s
J th icke n e d co n n e ctive tissu e p lan e s
J o ccu r m o st co m m o n ly in p u lm o n ary e d e m a an d lym p h an gitis
carcin o m ato sa
J K e rle y A lin e s: rad iate to ward s h ila in m id - an d u p p e r-lu n g zo n e s,
lin e s 3-4 cm lo n g, sm alle r th an vascu lar m arkin gs ( n o t u se fu l)
J K e rle y B lin e s: h o rizo n tal, < 2 cm lo n g an d 1 m m th ick, at p e rip h e ry o f
lu n g, re ach lu n g e d ge ( ve ry u se fu l)
J D D x o f K e rle y B L in e s
1 . p u lm o n ary e d e m a
2. lym p h an gitic carcin o m ato sis
3. sarco id
4. lym p h o m a
Se que ntial Patte rn of Findings in CHF Re lative to LVEDP
(s e e Colour Atlas K3 and K4)
J LVE D P o f 1 5 - p u lm o n ary vascu lar re d istrib u tio n to u p p e r lu n g zo n e s
J LVE D P o f 20 - in te rstitial e d e m a with K e rle y B lin e s an d
p e rib ro n ch ial cu ffin g ( e d e m a)
J LVE D P o f 25 - alve o lar e d e m a, sign ifican t air sp ace p atte rn
Ate le ctas is
J lo ss o f vo lu m e p atte rn ( su b se gm e n tal p u lm o n ary co llap se )
J m ay b e se co n d ary to b ro n ch ial o b stru ctio n , fib ro sis, p le u ral
d ise ase , P E , b ro n ch ie ctasis
J e xam p le s o f b ro n ch ial o b stru ctio n in clu d e b ro n ch o ge n ic
C A an d p o st-o p m u cu s p lu ggin g
J re so rp tio n : co llap se o f alve o li d e ve lo p s with in a fe w h o u rs o f
airway o b stru ctio n b e cau se air d istal to le sio n is re so rb e d
J p assive : d e cre ase d lu n g vo lu m e se co n d ary to a sp ace -o ccu p yin g le sio n
J cicatrizatio n : in cre ase d re co il se co n d ary to fib ro sis
J sign s o f co llap se
sh ift o f a fissu re ( m o st im p o rtan t)
m e d iastin al sh ift to th e sid e o f co llap se
sh ift o f h ilu m
d iap h ragm e le vatio n ( le ss vo lu m e in th e h e m ith o rax)
in cre ase d d e n sity ( sh ad o w o f co llap se d lo b e )
co m p e n sato ry h yp e rin flatio n ( ve n tilate d are as are b lacke r
silh o u e tte sign m ay b e se e n
b ro n ch o ge n ic C A u n til p ro ve n o th e rwise
N o te s
Pulmonary Nodule s ( se e Tab le 2)
(s e e Colour Atlas K7)
J D D x
p rim ary C A ( 35%)
n o n -sp e cific gran u lo m a ( 35%)
T B gran u lo m a ( 20%)
h am arto m a ( 5%)
m e tastatic C A ( 5%)
Table 2. Pulmonary Nodule s
Malignant Be nign
margin ill-d e fin e d /sp icu late d we ll-d e fin e d
( co ro n a rad iata)
contour m u lti-lo b u lar sm o o th
calcification e cce n tric o r stip p le d d iffu se , ce n tral, p o p co rn , co n ce n tric
doubling time 20-460 d ays < 20 d ays, > 460 d ays
othe r fe ature s cavitatio n , co llap se ,
ad e n o p ath y, p le u ral
e ffu sio n , lytic b o n y
le sio n s, sm o kin g h isto ry
J d o u b lin g tim e : tim e to in cre ase d iam e te r b y 1 .26x - co m p are o ld film s
J if n o ch an ge in size o ve r 2 ye ars, 99% ch an ce b e n ign
J C T scan e xce lle n t fo r d e te rm in in g th e p atte rn o f calcificatio n an d
p re se n ce o f fat ( as in h am arto m a)
J clin ical in fo rm atio n an d C T ap p e aran ce d e te rm in e le ve l o f su sp icio n o f C A
if h igh p ro b ab ility, th e n d o an in vasive te st
if lo w th e n re p e at C XR in o n e m o n th an d re p e at e ve ry 6 m o n th s fo r 2 ye ars
J n e e d le asp iratio n - C T o r flu o ro sco p ic gu id an ce
m o re se n sitive th an T B B b u t in cre ase d m o rb id ity
d iagn o stic yie ld > 90% fo r m align an cy
se n sitivity fo r b e n ign le sio n s le ss th an with T B B
iatro ge n ic p n e u m o th o rax in 25%, 1 /3 o f wh ich n e e d ch e st tu b e d rain age
Me dias tinal Mas s e s
J an te rio r ( an te rio r to h e art an d trach e a)
th e 5 Ts : te rato m a, th yro id , th ym u s, th o racic ao rtic an e u rysm , te rrib le lym p h o m a
p e ricard ial cyst, fat p ad , M o rgagn i h e rn ia if at le ve l o f d iap h ragm
J m id d le ( m e d iastin al stru ctu re s; h e art an d gre at ve sse ls)
b ro n ch ial C A, b ro n ch o ge n ic cyst, ao rtic an e u rysm , e so p h agu s/h iatu s h e rn ia
J p o ste rio r ( p o ste rio r to h e art)
G I o r sp in e
ao rtic an e u rysm , n e u ro ge n ic tu m o u rs, so ft tissu e m ass o f
ve rte b ral in fe ctio n o r n e o p lasm
J lym p h o m a m ay b e se e n in an y are a
Pulmonary Embolus (PE)
J C XR m ay b e n o rm al ( ap p ro xim ate ly 50%)
J m ay se e d e cre ase d lu n g vo lu m e with e le vate d h e m id iap h ragm , ate le ctasis
J u n d e rp e rfu se d lu n g d istally, d ilate d h ilar arte ry p ro xim ally
J +/ p le u ral e ffu sio n
J We ste rm ark's sign : ab ru p t cu to ff o f vascu latu re d istal to e m b o lu s
J H am p to n 's h u m p : p le u ral-b ase d we d ge re p re se n tin g lu n g in farct
with p le u ral e ffu sio n
J in farct always in vo lve s p le u ral-b ase d lu n g ( again st ch e st wall,
d iap h ragm , m e d iastin u m , o r fissu re s)
J e valu ate with V/Q scan an gio grap h y, o r sp iral C T
CT SCAN
J fo r in ve stigatio n o f m asse s, m e tastase s, stagin g o f C A,
so m e o th e r lu n g p ath o lo gie s ( e .g. b ro n ch ie ctasis) wh e n n o t ce rtain
u sin g C XR alo n e
J b e st way to im age m e d iastin u m an d asse ss ad e n o p ath y
J H R C T is go o d fo r asse ssin g d iffu se in filtrative lu n g d ise ase
( in te rstitial lu n g d ise ase )
D i agn o sti c M e d i cal I m agi n g 1 0 1 999 M C C Q E R e vi e w N o te s
N o te s
MUSCULOSKELETAL SYSTEM
MODALITIES
J plain films : m ain stay o f M S K rad io lo gy
in itial stu d y u se d in m o st e valu atio n s o f b o n e
n o t ve ry e ffe ctive in e valu atin g so ft tissu e in ju ry
J MR: e xce lle n t fo r visu alizatio n o f m arro w an d su rro u n d in g so ft tissu e s
n o t as go o d as C T fo r visu alizatio n o f b o n e co rte x
m u ltip lan ar vie win g an d re co n stru ctio n with n o
rad iatio n e xp o su re to th e p atie n t
J CT: fo r e valu atio n o f b o n e co rte x an d typ e o f co rtical e xp an sio n
IV co n trast m ay b e u se d to d e te rm in e le sio n vascu larity
sp e cific p ro to co ls an d win d o ws o p tim ize its ab ility to d e lin e ate
b o n e
J U/S: fo r e valu atio n o f su rro u n d in g so ft tissu e ( n e rve s, jo in ts, e ffu sio n s,
im p in ge m e n t)
n o t u se d fo r im agin g b o n e
u se d in m u scle fo r d e te rm in atio n o f cystic stru ctu re s
u se d to d iagn o se te n d o n an d ligam e n t in ju ry
J nucle ar me dicine : d e te rm in e th e d e gre e o f activity ( u p take ) with in th e b o n e
lo calize s are as o f in cre ase d b o n e tu rn o ve r
Te chne tium-99 (Tc99): a trip h asic b o n e scan can
e stab lish ske le tal vs. so ft tissu e in fe ctio n an d d istin gu ish
se p tic arth ritis vs.o ste o m ye litis vs p e rip h e ral ce llu litis
b ase d o n u p take
Indium-111 WBC: tracks th e active m igratio n o f th e WB C ;
n o t a go o d te st fo r d isce rn in g th e d iffe re n t typ e s o f in fe ctio n s
Gallium-67 Citrate : sp e cific to in fe ctio n b u t n o t go o d at
d isce rn in g th e d iffe re n t typ e s; u se fu l fo r so m e tu m o u rs ( e .g. lym p h o m a)
J ap p ro ach to se le cte d co m m o n p ath o lo gie s ( se e Tab le 1 0)
GENERAL APPROACH TO INTERPRETATION
OF BONE X-RAYS
J id e n tificatio n - n am e , age o f p atie n t, typ e o f stu d y, re gio n o f in ve stigatio n
J so ft tissu e s
J jo in ts - align m e n t, jo in t sp ace , syn o vial stru ctu re s
J b o n e - p e rio ste u m , co rte x, m e d u lla, trab e cu lae , d e n sity
TRAUMA
Fracture /Dis location
J ap p ro ach
m in im u m 2 film s at righ t an gle s to e ach o th e r
C T fo r cu rve d b o n e s: sku ll, sp in e , ace tab u lu m , calcan e o u s
if in d o u b t, co n sid e r o th e r te ch n iq u e s
J ch aracte ristics o f fractu re s ( se e O rth o p e d ics N o te s)
b re aks in co n tin u ity o f co rte x
rad io lu ce n t o r rad io p aq u e fractu re lin e s
o ve rlap o f co rtical b o n e an d sp o n gy b o n e
u n e xp lain e d fragm e n ts o f b o n e
are as o r lin e s o f d e n sity re p re se n tin g im p actio n o f b o n e
d isco n tin u ity in trab e cu lar p atte rn s o r ch an ge s in trab e cu lar d e n sity
so ft e valu atio n o f
p e rio ste al are as fo r b o n e b ru ise s o r callu s fo rm atio n
su rro u n d in g are a fo r swe llin g, fo re ign b o d ie s,
air ( n o t all fo re ign b o d ie s are rad io p aq u e )
in cre ase d lu ce n cy o f th e fat p ad m ay su gge st swe llin g an d
e d e m a n e ar th e b o n e ( e .g. p ate llar fat p ad , an te rio r
sail sign , p o ste rio r sail sign )
C-Spine Injury
J cle arin g th e C -sp in e an d in te rp re tatio n o f film s
( se e E m e rge n cy M e d icin e N o te s)
1 999 M C C Q E R e vi e w N o te s D i agn o sti c M e d i cal I m agi n g 1 1
N o te s
MUSCULOSKELETAL SYSTEM . . . CONT.
ARTHRITIS
Approach
J co n sid e r
clin ical h isto ry
p h ysical e xam
lab re su lts
d istrib u tio n o f arth ro p ath y
Chondropathic/Os te oarthritis
J classic sign s
n arro we d jo in t sp ace
asym m e trical jo in t in vo lve m e n t
su b ch o n d ral scle ro sis ap p e ars as in cre ase d d e n sity su rro u n d in g th e jo in t
m argin al o ste o p h yte with o r with o u t sp o n d ylo listh e sis/sp o n d ylo lysis
vacu u m p h e n o m e n o n : tran slu ce n t d isc sp ace are a th at is p o cke t o f gas
su b ch o n d ral cysts with scle ro tic b o rd e rs in large r jo in ts
Inflammatory
Patte rns of Pe rios te al Patte rns of Margination
Cortical Ne w Bone Me dullary of Le s ions
Dis turbance Formation De s truction
Figure 5. Radiographic Appe arance of Inflammatory Bone Proce s s e s
Drawingsby Myra Rudakewich
J Infe ctious Arthritis
p e riarticu lar so ft tissu e swe llin g an d d iste n tio n o f affe cte d jo in t with flu id
+/ jo in t sp ace n arro win g d u e to p ro te o lytic e n zym e s
d e stro yin g th e cartilage
lo calize d o ste o p e n ia
b o n y d e stru ctio n ch aracte rize d b y irre gu larity o f th e
su b ch o n d ral b o n e an d o p p o sin g m argin s u su ally p re se n ts
8-1 0 d ays afte r o n se t
ch ro n ic an kylo sis an d fu sio n o f th e jo in t m ay re su lt if
in fe ctio n b e co m e s ch ro n ic
J Rhe umatoid Arthritis (RA)
b e gin s in d istal jo in ts, sym m e trical fash io n
so ft tissu e swe llin g with ch aracte ristic fu sifo rm p atte rn
p e riarticu lar o ste o p e n ia in su b ch o n d ral b o n e
m alalign m e n t first m an ife ste d as u ln ar d e viatio n
jo in t d e stru ctio n b e gin n in g with d istal clavicle e ro sio n
sym m e trical n arro win g o f jo in ts, p an n u s, in flam m ato ry
p ro ce ss aro u n d articu lar su rface
p an n u s fo rm in g in itially o n th e rad ial sid e s o f th e M C , M T,
p h alan ge s, rad io u ln ar jo in ts
sp in al in vo lve m e n t in se ve re case s m ay le ad to atlan to axial
su b lu xatio n , re stricte d ce rvical sp in e s with o d o n to id e ro sio n
p u n ch e d o u t
th i n ri m
o f scle ro si s
th i ck ri m
o f scle ro si s
n o rm al
m o th e ate n
p e rm e ati ve
C o d m an s
Tri an gle
o n i o n -
ski n laye re d
h ai r-o n -e n d
sp i cu late d
su n b u rst
d i ve rge n t
e xp an si le /
b allo o n e d
e n d o ste al
scallo p i n g
i n vi si b le
m argi n /
co rti cal
d e stru cti o n
sau ce ri zati o n
so li d
u n d u lati n g
N o te s
J Se rone gative Spondyloarthropathie s
Ankylos ing Spondylitis (AS)
sacro iliitis rad io grap h ically ch aracte rize d b y b lu rrin g an d
irre gu larity o f S I jo in t m argin s with scle ro sis an d o b lite ratio n o f jo in t
in te rm in al stage s, b o n e b rid ge s fu se th ro u gh o u t sp in e ,
b e gin n in g in th e lu m b ars > classic b am b o o sp in e
Ps orias is
typ ically re stricte d to sm all jo in ts o f h an d s an d fe e t
n o o ste o p o ro sis
D IP an d P IP : classic p e n cil in cu p d e fo rm ity
d e cre ase in th e to tal le n gth o f th e p h alan x
Re ite rs
asym m e trical jo in t d istrib u tio n ( m o stly in fe e t)
ap p e ars sim ilar to p so riasis
wh iske r-like flu ffy p e rio ste al in flam m atio n ( th icke n in g o f
p e rio ste u m ) u su ally in p lan tar fascia
m ay p re se n t with sacro iliitis
Inflammatory Bowe l Dis e as e (IBD)
sym m e trical sacro iliitis b u t n o t as e xte n sive as an kylo sin g sp o n d ylitis
u su ally an in cid e n tal fin d in g o n AXR
rad io grap h ically wo rse n s with IB D e xace rb atio n
J Se ropos itive Spondyloarthropathie s
De rmatomyos itis
lack o f b o n e an d jo in t p ath o lo gy
so ft tissu e calcificatio n s ( ch o n d ro calcin o sis)
Sys te mic Lupus Erythe matos us (SLE)
a n u m b e r o f n o n sp e cific in flam m ato ry p ro ce sse s
so ft tissu e atro p h y, o ste o p o ro sis, p o o r jo in t align m e n t d e sp ite
lack o f articu lar e ro sive p ro ce ss
swan n e ck d e fo rm itie s an d AVN co m m o n
Scle rode rma
rad io lo gical fin d in gs re stricte d to th e h an d s with tap e re d p h alan x
( atro p h y o f so ft tissu e s an d b o n e re so rp tio n )
m ay also p re se n t with calcificatio n o f so ft tissu e
J Gout
rad io grap h ic fin d in gs d o n o t ap p e ar u n til 8-1 0 ye ars afte r th e d iagn o sis
b e gin as p e riarticu lar e ro sio n
so ft tissu e m asse s with n o sign s o f calcificatio n
jo in t sp ace p re se rve d
u su ally n o sign s o f o ste o p o ro sis
le sio n s are we ll d e m arcate d an d sh arp ly d e fin e d , o fte n
with sp u r b o n e fo rm atio n o f th e p e rip h e ry
J Ps e udogout (CPPD)
ch o n d ro calcin o sis
calcificatio n o f th e fib ro cartilage
swe llin g o f th e jo in t cap su le d u e to syn o vitis with p ro gre ssio n to o ste o arth ritis
( u su ally ap p e ars as b ro ad b ase d o ste o p h yte s o f th e M C P jo in ts)
TUMOUR
Approach
J m e tastatic tu m o u rs m u ch m o re co m m o n th an p rim ary b o n e tu m o u rs
d iagn o sis will u su ally re q u ire a b io p sy if p rim ary n o t lo cate d
fe w b e n ign tu m o u rs/le sio n s h ave p o te n tial fo r m align an t tran sfo rm atio n
p lain film s: o n e o f th e le ast se n sitive to o ls fo r e valu atio n o f b o n e tu m o u rs
C T: b e st way to id e n tify th e e xte n t o f b o n e le sio n in th e co rte x, m e d u lla,
so ft tissu e
M R : go o d fo r tissu e d e lin e atio n an d p re o p e rative asse ssm e n t
o f su rro u n d in g so ft tissu e s
Cons ide rations
J age
J sin gle o r m u ltip le le sio n s: m u ltip le le sio n s m o re su gge stive o f m align an t
p ro ce ss o r m e tab o lic d ise ase
J ch aracte ristics o f le sio n ( se e Tab le 3)
m argin s: sh arp ly d e fin e d with n o scle ro sis su gge stive o f m u ltip le m ye lo m a
zo n e o f tran sitio n : tran sitio n are a fro m n o rm al b o n e to are a o f le sio n , re fle ctive
o f th e aggre ssive n e ss o f th e le sio n
scle ro se d b o rd e rs, grad u ate d zo n e s: m o re su gge stive o f a
slo w p ro ce ss; it d o e s n o t id e n tify m align an t o r b e n ign
N o te s
e xp e n sile
in tact, b allo o n e d co rte x: m o re like ly b e n ign
d e stru ctio n o f co rte x: m o re like ly m align an t
J p e rio ste al re actio n
lam e llar: fain t an d so lid , fin e p e rio ste al d e n sity
p aralle lin g co rte x, m o st like ly b e n ign p ro ce ss
wavy: u n d u latin g th ickn e ss o f th e p e rio ste u m , m o st like ly
P VD o r b o n e in farct
su n b u rst: E win g s sarco m a ( h igh ly su gge stive )
h air o n e n d : th alasse m ia o r o ste o sarco m a ( h igh ly su gge stive )
J co rtical th icke n in g: n e w b o n e fo rm atio n , su gge stive o f
o ste o m ye litis o r m align an cy
Table 3. Characte ris tics of Be nign and Malignant Bone Le s ions
Be nign Malignant
sin gle le sio n m u ltip le le sio n s
n o b o n e p ain b o n e p ain
sh arp are a o f d e lin e atio n p o o r d e lin e atio n o f le sio n
o ve rlyin g co rte x in tact lo ss o f o ve rlyin g co rte x/b o n y d e stru ctio n
n o o r we ll o rgan ize d p e rio ste al re actio n p e rio ste al re actio n
th ick an d sh arp zo n e o f tran sitio n th in an d wid e zo n e o f tran sitio n
m in im al d isto rtio n o f n o rm al an ato m y scatte re d are as o f sp o tty d e n sity
le sio n co n tin u o u s with co rte x d iagn o sis o f p rim ary can ce r
ce n tralize d calcificatio n
N o te : sp e cifc b o n e tu m o u rs ( se e O rth o p e d ic N o te s)
Me tas tatic Bone Tumours
J all m align an cie s h ave p o te n tial to m e tastasize to b o n e , with
so m e m u ch m o re like ly th an o th e rs
J m e tastase s are 20-30x m o re co m m o n th an p rim ary b o n e tu m o u rs
J wh e n a p rim ary m align an cy is first d e te cte d , a b o n e scan is p art o f
th e in itial wo rk-u p
J m ay p re se n t with p ath o lo gical fractu re s o r p ain
J b io p sy o r d e te rm in atio n o f p rim ary is th e o n ly way to co n firm th e d iagn o sis
J m e tastasis can cau se a lytic o r a scle ro tic re actio n wh e n se e d in g to b o n e
Table 4. Characte ris tic Bone Me tas tas e s
of Common Cance rs
lytic s cle rotic
lu n g p ro state
th yro id b re ast
kid n e y
b re ast
m u ltip le m ye lo m a
INFECTION
Os te omye litis
J P lain F ilm
visib le o n p lain x-ray 8-1 0 d ays afte r o ste o m ye litis h as b e gu n
Tc99 rad io iso to p e scan is th e b e st m o d ality to e stab lish
th e p re se n ce o f b o n e in fe ctio n
o ste o m ye litic ch an ge s o n p lain film
so ft tissu e swe llin g th at is d e e p an d e xte n d s fro m th e b o n e
with lo ss o f tissu e p lan e s ( m u scle , fat, skin )
lo cal p e rio ste al re actio n o ve r th e are a o f b o n e
b o n e d e stru ctio n d ire ctly o ve r th e are a o f b o n e in fe ctio n
p o cke ts o f air ( fro m an ae ro b e s o r Clostridium m ay b e se e n
in th e tissu e p lan e s
m e tap h ysis o ve r th e are a o f in fe ctio n m ay ap p e ar m o ttle d
an d in h o m o ge n e o u s with a classic m o th -e ate n ap p e aran ce
Bone Abs ce s s
J classical ap p e aran ce kn o wn as B ro d ie s Ab sce ss
o ve rlyin g co rte x h as p e rio ste al n e w b o n e fo rm atio n ( o n io n skin p atte rn )
sh arp o u tlin e d rad io lu ce n t are a with variab le th ickn e ss in zo n e o f tran sitio n
variab le th ickn e ss p e rio ste al scle ro sis
N o te s
METABOLIC
Approach
J h o rm o n al ch an ge s re su lt in d im in u tio n o f b o n e m ain te n an ce
m e ch an ism s
th in n in g o f co rte x
sp o n gy b o n e b e co m in g m o re lu ce n t
p ath o lo gical fractu re s
o ve rall d iffu se p ro ce ss, affe ctin g all b o n e s
Os te oporos is
J D E XA se n sitive to > 1 2-1 5% b o n e lo ss
d iagn o stic se n sitivity h igh e st wh e n B M D m e asu re d at lu m b ar
sp in e an d p ro xim al fe m u r
T-S co re : d iffe re n ce o f B M D fro m yo u n g ad u lt m e an
m e asu re o f cu rre n t fractu re risk
Z -sco re : d iffe re n ce o f B M D fro m age -m atch e d m e an
J rad io grap h ic m an ife statio n
in cre ase in b o n e lu ce n cy
co m p re ssio n o f ve rte b ral b o d ie s
b ico n cave ve rte b ral b o d ie s ( co d fish in g ve rte b rae )
lo n g b o n e s h ave ap p e aran ce o f in cre ase d co rte x size
wid e n in g o f b o n e sp icu le s
isch e m ic n e cro sis o f h ip s le ad in g to sn o wcap p in g
Os te omalacia
J L o o se rs Z o n e s ( ch aracte ristic rad io lo gical fe atu re )
fissu re s o r cle fts e xte n d in g th ro u gh co rte x o f lo n g b o n e s
( re p re se n t failu re o f o ssificatio n o f th e fib ro u s tissu e o f th e b o n e )
J irre gu lar re so rp tio n o f b o n e > so fte n in g an d arch in g o f lo n g b o n e s
J in itial rad io lo gical ap p e aran ce o f b o th o ste o p o ro sis an d
o ste o m alacia is o ste o p e n ia
Re nal Os te odys trophy
J m an ife statio n s are a h yb rid o f h yp e rp arath yro id ism an d o ste o m alacia
J slip p e d e p ip h ysis ( b ilate ral)
J sp o n tan e o u s se p aratio n s
J ch o n d ro calcin o sis: in tra-articu lar d e p o sits o f calciu m
J calcificatio n s o f th e so ft tissu e s ( in clu d in g arte rie s
an d aro u n d th e jo in ts)
J AVN o f fe m o ral h e ad m u st b e co n sid e re d in all case s
J su b p e rio ste al e ro sio n o f fe m o ral n e ck
J o ste o p e n ia
J p o o r d e fin itio n o f trab e cu lae an d co rte x
J in cre ase d b o n y d e n sity
Page ts Dis e as e
J m ay in vo lve sin gle o r m u ltip le b o n e s
J d e stru ctio n o f b o n e fo llo we d b y re p air o f b o n e alth o u gh lysis m ay
o ccu r faste r in so m e are as
th icke n in g o f co rte x o r sh arp ju n ctio n s
co arse n in g o f th e trab e cu lae
e n large m e n t o f b o n e
p atch y sp ace s o f d e n se b o n e ( co tto n wo o l)
b o n e so fte n in g/b o win g
b o n e scan will re ve al h igh activity, e sp e cially o n b o n e e n d s
N o te s
GASTROINTESTINAL TRACT
J ap p ro ach e s to se le cte d co m m o n p ath o lo gie s ( se e Tab le 1 1 )
ABDOMINAL PLAIN FILMS
J ab d o m in al se rie s
u su ally in clu d e s su p in e ( flat p late /K U B ) , u p righ t, L L D B e re ct C XR
Pathologie s As s e s s e d
J b o we l o b stru ctio n /ile u s
J b o we l isch e m ia
J vo lvu lu s
J calcificatio n s ( e .g. gallsto n e s, re n al sto n e s)
J ab n o rm al gas co lle ctio n s ( fre e air, in tram u ral air, b iliary air
J ascite s ( u se d le ss o fte n )
J b o n y ab n o rm alitie s ( e .g. m e tastase s)
J fo re ign b o d ie s ( e .g. iatro ge n ic ite m s fro m su rge ry)
Approach to Inte rpre tation
J id e n tifyin g d ata
n am e , age o f p atie n t, typ e o f stu d y ( su p in e , u p righ t, d e cu b itu s)
J su p rap h re n ic stru ctu re s
h e art, lu n g b ase , co sto p h re n ic an gle s
J ske le tal stru ctu re s
th o racic ve rte b rae : rib s attach e d
lu m b ar ve rte b rae : rib s, p e lvis, h ip s
J so ft tissu e s
flan ks - o fte n trilam in ar in ap p e aran ce
su p e rficial - su b cu tan e o u s fat
in te rm e d iate - ab d o m in al wall m u scu latu re
d e e p - flan k strip e o f e xtrap e rito n e al/p re p e rito n e al fat
p so as sh ad o w
re p re se n ts fatty fascia e n ve lo p in g th e m u scle
righ t p so as sh ad o w o fte n n o t se e n ; n o rm al varian t
J so lid visce ral o rgan s: b e st se e n with o th e r m o d alitie s
live r: m ay se e d e p re ssio n o f h e p atic fle xu re ( co lo n ) with
h e p ato m e galy
sp le e n : m ay se e m e d ial d isp lace m e n t o f gastric air b u b b le with
sp le n o m e galy
kid n e ys: o u tlin e d b y p e rire n al fat, 8-1 5 cm in ad u lts, le ft h igh e r
th an righ t ( re n al h ila lo cate d at L 2 an d L 1 re sp e ctive ly) , lo n g axis
p aralle l to p so as sh ad o w
gallb lad d e r an d p an cre as: n o t u su ally visu alize d
ao rta
b lad d e r an d u te ru s
J h o llo w viscu s: sto m ach , sm all b o we l, large b o we l, re ctu m
gas p atte rn ( am o u n t an d d istrib u tio n )
n o rm ally so m e air in sto m ach an d th ro u gh o u t co lo n
b u t little in sm all b o we l
asse ss fo r o b stru ctio n , in trap e rito n e al air ( fre e air , in tram u ral air
d iffe re n tiate sm all an d large b o we l ( se e Tab le 5)
J calcificatio n s
R U Q - re n al sto n e , ad re n al calcificatio n , gallsto n e
R L Q - sto n e in u re te r, ap p e n d ico lith , gallsto n e ile u s ( rare )
L U Q - sp le n ic ve sse l, re n al sto n e , ad re n al calcificatio n , tail o f p an cre as
ce n tral - ao rta, p an cre as, lym p h n o d e s
p e lvis - p h le b o lith s, fib ro id s, b lad d e r, p ro state
Table 5. Diffe re ntiating Small and Large Bowe l
Small Bowe l Large Bowe l
mucos al folds u n in te rru p te d p licae circu lare s/valvu lae co n n ive n te s in te rru p te d h au stra
location ce n tral p e rip h e ral
maximum diame te r 2.5 - 3 cm 5 cm
othe r rare ly co n tain s so lid fe cal m ate rial co m m o n ly co n tain s so lid fe cal m ate rial
N o te s
GASTROINTESTINAL TRACT . . . CONT.
Abnormal Findings
J p aralytic ile u s vs m e ch an ical o b stru ctio n ( se e Tab le 6)
Table 6. Paralytic Ile us vs . Me chanical Obs truction
Paralytic Ile us Me chanical Obs truction (s e e Colour Atlas C1)
Calibre of bowe l n o rm al o r d ilate d in sm all an d /o r u su ally d ilate d in sm all an d /o r large b o we l
loops large b o we l
Air-Fluid le ve ls sam e le ve l in a sin gle lo o p ste p lad d e r ap p e aran ce
( o n ly o n u p righ t lo n ge r o n e s in th e co lo n strin g o f p e arls ( ro w o f sm all gas accu m u latio n s
an d late rald e cu b itu s co lle cte d in th e d ilate d valvu lae co n n ive n te s)
film s)
Othe r air th ro u gh o u t th e G I tract d ilate d b o we l u p to th e o b stru cte d se gm e n t
m ay b e ge n e ralize d o r lo calize d n o air d istal to o b stru cte d se gm e n t
in a lo calize d ile u s, a d ilate d lo o p ( u n le ss ve ry e arly o b stru ctio n )
( se n tin e l lo o p ) re m ain s in th e sam e
lo catio n o n se rial film s an d is u su ally
ad jace n t to are as o f in flam m atio n
( e .g. p an cre atitis, ap p e n d icitis)
in large b o we l o b stru ctio n , im p o rtan t to asse ss th e fu n ctio n ality o f th e ile o ce cal valve
if co m p e te n t an d fu n ctio n al
se e large b o we l d iste n tio n fro m site o f o b stru ctio n to valve
m arke d ce cal d iste n tio n with risk o f p e rfo ratio n ( if > 9 cm )
if in co m p e te n t
p re ssu re re le ase d in to sm all in te stin e , cau sin g
d iste n tio n o f b o th large an d sm all b o we l
ce cu m is re lative ly p ro te cte d fro m p e rfo ratio n in th is case
m ay b e d ifficu lt to d iffe re n tiate large b o we l o b stru ctio n
with in co m p e te n t valve an d p aralytic ile u s
J fre e in trap e rito n e al air ( p n e u m o p e rito n e u m )
L L D B : lo o k fo r fre e air b e twe e n live r an d
righ t an te ro late ral ab d o m in al wall
e re ct PA C XR : air u n d e r d iap h ragm (s e e Colour Atlas C2)
su p in e film p o o r fo r sh o win g fre e ab d o m in al air u n le ss
large am o u n t, b u t m ay se e
R igle rs sign - b o th th e in n e r an d o u te r wall o f
th e b o we l se e n ( o u tlin e d b y fre e air
falcifo rm ligam e n t sign - fre e air co lle cts o n b o th
sid e s o f falcifo rm ligam e n t, o u tlin in g it
fo o tb all sign with a large am o u n t o f air
D D x: h o llo w viscu s p e rfo ratio n ( m o st co m m o n ) , iatro ge n ic,
in tro d u ctio n p e r vagin a, p n e u m o th o rax ( d u e to p le u ro p e rito n e al
fistu la) , p e rito n e al d ialysis cath e te r
J in tram u ral air ( p n e u m ato sis)
lu ce n t air stre aks in wall o f b o we l
lin e ar typ e - isch e m ia
cysto id e s typ e - se e n in large b o we l d u e to C O P D
J b iliary air
lo cate d ce n trally o ve r live r
cau se s: sp h in cte ro to m y, gallsto n e ile u s
J p o rtal ve n o u s air
p e rip h e rally lo cate d b ran ch in g air u n d e rn e ath th e
d iap h ragm d u e to b o we l isch e m ia
J vo lvu lu s
in d e sce n d in g o rd e r o f rad io grap h ic re co gn itio n
sigm o id - co ffe e b e an sign
ce cal - sin gle /large b o we l lo o p in L U Q
gastric
sm all b o we l ( m o st d ifficu lt to d iagn o se )
p lain film : u se fu l in all e xce p t sm all b o we l wh e re C T n e e d e d
fo r d e fin itive d iagn o sis
co n trast stu d ie s: b ird b e ak sign typ ical o f vo lvu lu s
J isch e m ia
im p o rtan t acu te cau se s: h yp o te n sio n , e m b o lic, th ro m b o tic, vo lvu lu s
p lain film : n o t u se fu l e xce p t wh e n th icke n e d fo ld s,
p n e u m ato sis, o r p o rtal ve n o u s air se e n
N o te s
C T: b e tte r yie ld , e sp e cially C T an gio ( th icke n e d fo ld s,
m e se n te ric ch an ge s, e m b o lu s)
U /S : go o d scre e n in g, e sp e cially with p lain film fin d in g o f
gasle ss ab d o m e n as cau se o f isch e m ia
an gio grap h y u se d le ss o fte n
J to xic m e gaco lo n
se e n with U C , C ro h n s, in fe ctio u s/p se u d o m e m b ran o u s co litis
rad io grap h ic fin d in gs - th u m b p rin tin g o f co lo n ic m u co sa +/ d ilatatio n
clin ical p ictu re o f to xicity
d ilatatio n ( > 6 cm ) an d p ro gre ssive d iste n tio n with clin ical
d e te rio ratio n > im p e n d in g p e rfo ratio n
J in tu ssu sce p tio n
d iagn o se d b y b ariu m e n e m a o r U /S
p o ssib le to re d u ce with d iagn o stic b ariu m e n e m a, air e n e m a
CONTRAST STUDIES ( se e Tab le 7)
(s e e Colour Atlas C3-C6)
J b ariu m su lp h ate se rve s as co n trast m e d iu m with in lu m e n o f G I tract
J p ro vid e s flu id cast im age s, m u co sal re lie f im age s ( b ariu m
sp re ad o ve r m u co sal su rface ) , o r d o u b le -co n trast im age s ( air
in je cte d in to lu m e n with b ariu m p re se n t)
J e so p h agu s to re ctu m e xam in e d in d o u b le co n trast ( air +b ariu m )
J m u co sal d e tail an d m u ral ch an ge s se e n as we ll as
in tralu m in al ab n o rm alitie s
Contraindications to Barium Study
J u n ab le to with stan d o r p e rfo rm th e p o sitio n s re q u ire d
J can n o t u n d e rgo b o we l p re p aratio n
J P O b ariu m co n train d icate d in su sp e cte d co lo n ic o b stru ctio n b e cau se o f
risk o f d e h yd ratio n o f b ariu m an d se co n d ary co lo n ic im p actio n
in ste ad co n sid e r co lo n o sco p y o r h yp aq u e e n e m a
in sm all b o we l o b stru ctio n , lu m in al co n te n ts re tain e d are
liq u id , th e re fo re b ariu m P O is n o t co n train d icate d
J su sp e cte d o r kn o wn p e rfo ratio n o r if p re d isp o se d ( e .g. isch e m ic co litis)
J to xic m e gaco lo n
Table 7. Type s of Contras t Studie s
Study De s cription Are a As s e s s e d Dis e as e s
Cine Es ophagogram co n trast age n t swallo we d ce rvical e so p h agu s asp iratio n , we b s, Z e n ke rs,
re co rd e d fo r late r p layb ack an d crico p h aryn ge al b ar, laryn ge al
an alysis tu m o u rs
Barium Swallow co n trast age n t swallo we d u n d e r th o racic e so p h agu s ach alasia, h iatu s h e rn ia,
flu o ro sco p y e so p h agitis, can ce r
se le ctive im age s cap tu re d
Uppe r GI Se rie s b ariu m +e ffe rve sce n t age n t th o racic e so p h agu s, u lce rs, n e o p lasm s, fillin g d e fe cts
swallo we d fo r d o u b le co n trast sto m ach , d u o d e n u m
p atie n t N P O afte r m id n igh t b e fo re
stu d y
Small Bowe l Follow im age s o f sm all b o we l o b tain e d sin gle co n trast b ariu m o f n e o p lasm s, IB D , p ain ,
Through fo llo win g U G I se rie s e n tire sm all b o we l m alab so rp tio n , in fe ctio n
Small Bowe l Ene ma in tu b atio n with b ariu m /m e th yl ce llu lo se sm all b o we l IB D , an e m ia, p o lyp o sis syn d ro m e s,
(e nte roclys is ) in fu sio n an d flu o ro sco p ic e valu atio n M e cke l s, n e o p lasm
Barium Ene ma co lo n fille d re tro grad e with b ariu m large b o we l d ive rticu lo sis, n e o p lasm s, IB D
an d air/C O 2 in su fflatio n re ctu m m ay b e o b scu re d
b o we l p re p th e n igh t b e fo re p ro ce d u re b y tu b e - th e re fo re
m u st d o sigm o id o sco p y
( co m p le m e n tary te st
to e xclu d e re ctal le sio n s)
Hypaque Ene ma wate r so lu b le co n trast with o r with o u t large b o we l p e rfo ratio n , o b stru ctio n
b o we l p re p
N o te s
SOLID VISCERAL ORGAN IMAGING
Live r
J m o d e rate h e p ato m e galy d ifficu lt to d e te rm in e o n p lain film s
J U /S go o d fo r asse ssm e n t o f cysts, ab sce sse s, tu m o u rs, b iliary tre e
J C T with IV co n trast b e st fo r im agin g live r p are n ch ym a
J primary tumours
e ch o ge n ic o n U /S ( co m p are d to e ch o -fre e cysts) ,
b u t h yp o e ch o ic co m p are d to n o rm al live r p are n ch ym a
co ld sp o ts o n rad io iso to p e live r scan s ( m o st)
m o st are le ss d e n se th an th e p are n ch ym a o n C T b u t
vascu lar tu m o u rs m ay b e m o re d e n se ( in cre ase d co n trast
u p take )
m ay h ave ill-d e fin e d m argin s, n e cro tic ce n tre s, calcificatio n
J me tas tas e s - more common
co m m o n p rim arie s are lu n g, b re ast, G I ( e sp e cially co lo n )
o fte n m u ltip le
m e tastase s are ge n e rally le ss d e n se th an p are n ch ym a o n C T
U /S m ay sh o w large ( > 2 cm ) ill-d e fin e d , h yp o e ch o ic m asse s
J cys ts and abs ce s s e s
b o th : ap p e ar le ss d e n se th an p are n ch ym a o n C T ( m o d ality
o f ch o ice )
cysts: sh arp ly-d e fin e d ro u n d m asse s; e ch o lu ce n t ce n tre s
o n U /S
ab sce sse s: le ss sh arp ly-d e fin e d , te n d to h ave flu id
ce n tre s, th ick walls, m ay b e co m e n e cro tic
vary in ap p e aran ce o n U /S , d e p e n d in g o n
am o u n t o f flu id with in ab sce ss cavity
J cirrhos is and portal hype rte ns ion
C T: alte re d live r size , co n to u r, d e n sity
if fatty in filtratio n , live r ap p e ars le ss d e n se th an
sp le e n ( re ve rse is tru e if h e alth y)
if ad van ce d cirrh o sis, live r is sm alle r an d irre gu lar;
sp le n o m e galy an d ascite s m ay b e p re se n t d u e to p o rtal
H T N
n u cle ar m e d icin e stu d y: sm all sh ru n ke n live r with
in cre ase d b ackgro u n d m arro w activity
Sple e n
J sp le n o m e galy m ay b e su gge ste d b y U /S , C T, an d /o r rad io n u clid e
scan
J lym p h o m a m o re co m m o n ly se e n th an m e tastase s
Biliary Tre e
J U /S im agin g m o d ality o f ch o ice
J b ile d u cts n o rm ally n o t se e n
J if e n large d , se e " d o u b le tract" sign an d th ro u gh tran sm issio n
J o b stru ctio n : in tra- an d e xtrah e p atic d ilatatio n o f b ile d u cts +
so u rce o f o b stru ctio n ( sto n e , p an cre atic m ass)
J ch o le cystitis ( se e " itis im agin g" b e lo w)
J C T, E R C P, M R C P, P T C fo r fu rth e r wo rk-u p
J o n C T, d ilate d in trah e p atic d u ctu le s are b ran ch in g an d tu b u lar
fo llo win g p ath way o f p o rtal ve n o u s syste m
Pancre as
J p lain film : n o t se e n u n le ss calcificatio n s are p re se n t (s e e Colour Atlas C7)
J U /S : se e n in m o st p atie n ts
J C T: give s b e tte r d e tail with IV +/ P O co n trast m ate rial
J lo o k fo r m asse s, p se u d o cysts, b iliary o b stru ctio n , e vid e n ce o f
p an cre atitis
J E R C P : u se d wh e n U /S an d C T in co n clu sive
J p an cre atitis ( se e " itis Im agin g b e lo w)
J tu m o u rs
U /S : u se fu l, th e m ass b e in g m o re e ch o ge n ic th an n o rm al
p an cre atic tissu e
C T: p re fe rre d wh e n tu m o u r su sp e cte d ; d e n sity o fte n n o rm al
N o te s
ITIS IMAGING
J acu te ch o le cystitis, ap p e n d icitis, d ive rticu litis, p an cre atitis re q u ire
sp e cial im agin g
Acute Chole cys titis
J U /S ve ry accu rate - th ick wall, p e rich o le cystic flu id , gallsto n e s,
d ilate d gallb lad d e r, p o sitive so n o grap h ic M u rp h y s sign
J n u cle ar m e d icin e ( H ID A scan ) m ay b e h e lp fu l in e q u ivo cal case s
Acute Appe ndicitis
J U /S ve ry u se fu l - th ick wall ap p e n d ix, ap p e n d ico lith , d ilate d flu id -fille d
ap p e n d ix
J m ay fin d o th e r cau se s o f R L Q p ain ( e .g. o varian ab sce ss, IB D ,
e cto p ic p re gn an cy)
J C T d o n e wh e n ab sce ss p re se n t an d to facilitate p e rcu tan e o u s d rain age
Acute Dive rticulitis
J co m m o n site is re cto sigm o id
J C T: im agin g m o d ality o f ch o ice , th o u gh U /S is so m e tim e s u se d as scre e n in g
o ral an d re ctal co n trast give n b e fo re C T to o p acify b o we l
card in al sign s: th icke n e d wall, m e se n te ric in filtratio n ,
gas-fille d d ive rticu la, ab sce ss
so m e tim e s d ifficu lt to d istin gu ish fro m p e rfo rate d C A
( th e re fo re , se n d ab sce ss flu id fo r cyto lo gy)
C T: u se d fo r p e rcu tan e o u s ab sce ss d rain age b e fo re d e fin itive
su rgical in te rve n tio n
Acute Pancre atitis
J clin ical sym p to m s an d lab re su lts ( se ru m am ylase an d lip ase ) im p o rtan t
J U /S : go o d scre e n in g ( th o u gh u se le ss if ile u s p re se n t b e cau se gas
o b scu re s p an cre as)
se e h yp o e ch o ic e n large d p an cre as
J C T: u se fu l in ad van ce d stage s o f p an cre atitis an d asse ssin g fo r
co m p licatio n s ( e .g. p se u d o cyst, ab sce ss, p h le gm o n , n e cro sis)
e n large d p an cre as, m e se n te ric an d G e ro ta s fascial
th icke n in g, p se u d o cyst in le sse r sac, ab sce ss ( gas o r th ick walle d
flu id co lle ctio n ) , p an cre atic n e cro sis ( lo w atte n u atio n gas-
co n tain in g n o n -e n h an cin g p an cre atic tissu e )
C T-gu id e d n e e d le asp iratio n an d /o r d rain age d o n e fo r ab sce ss
d rain age wh e re clin ically in d icate d
p se u d o cyst m ay b e fo llo we d b y C T an d d rain e d if sym p to m atic
GENITOURINARY SYSTEM
INTRODUCTION
J stu d ie s co m m o n ly u se d to e valu ate th e u rin ary tract
IVP /IVU
re tro grad e p ye lo gram /u ro gram
cysto gram ( o fte n co m b in e d with stu d y o f u re th ra as a VC U G )
U /S
C T scan
M R I
re n al arte rio grap h y
iso to p e stu d ie s
MODALITIES
IVP/IVU (s e e Colour Atlas M1 and M2)
J a m o rp h o lo gic e xam in atio n , an d also a ro u gh p h ysio lo gical stu d y o f re n al
fu n ctio n
J asse ssm e n t m ad e b y vie win g th e film s te m p o rally
J co n sists o f K U B an d se rie s o f p o st-co n trast in je ctio n film s
J th e p atie n t sh o u ld h ave cle ar flu id s o n e d ay p rio r to th e
stu d y, cath artics th e e ve n in g b e fo re , an d N P O afte r
m id n igh t b e fo re th e stu d y ( liq u id s are allo we d in th e
m o rn in g if th e stu d y is b o o ke d fo r th e afte rn o o n )
J co n train d icatio n s to co n trast ( se e Tab le 1 )
N o te s
GENITOURINARY SYSTEM . . . CONT.
J p re -co n trast sco u t fi lm
K U B p lain film d o n e su p in e
lo o k fo r ab n o rm al calcificatio n s in th e kid n e ys, calyce s,
u re te rs ( ru n n in g o ve r th e tran sve rse p ro ce sse s - lo o k fo r
late r film s to id e n tify th e ir p ath )
b e ware o f p h le b o lith s ( calcifie d ve n o u s th ro m b i in p e lvic
ve in s)
o fte n sm o o th , ro u n d , m ay h ave a ce n tral lu ce n cy o f re can alizatio n
like ly if th e calcificatio n e xists in fe rio r to a lin e d rawn
b e twe e n th e isch ial sp in e s
n e p h ro to m o gram s can also b e d o n e to lo cate sto n e s fu rth e r
J n e p h ro gram p h ase
1 m in u te p o st-co n trast in je ctio n
co n trast m ate rial e n te rs th e m icro vascu latu re an d tu b u le s
with in o n e m in u te , o p acifyin g th e kid n e y
asse ss kid n e y p o sitio n ( T 1 2-L 3) , size ( 1 0-1 5 cm , d iffe re n ce
< 1 .5 cm ) , sh ap e , o u tlin e , p are n ch ym a o u tlin e
D D x o f b u lge s: m ass, tu m o u r, cyst
D D x o f in d e n tatio n s: in farctio n , scarrin g
D D x o f d e cre ase d /ab se n t o p acificatio n
d e cre ase d b lo o d flo w to th e kid n e y
( e .g. re n al arte ry co m p ro m ise d )
d e cre ase d b lo o d flo w fro m th e kid n e y
( e .g. re n al ve in th ro m b o sis)
b lo cke d d rain age ( i.e . u re te ral sto n e )
n e p h ro n d ysfu n ctio n
J su b se q u e n t p o st-co n trast i n je cti o n fi lm s
u su ally o b tain 2 o r m o re film s at 5 m in u te in te rvals
asse ss ( in o rd e r calyce s ( cu p p e d = n o rm al; clu b b e d o r e n large d
= d ilate d ) , p e lvice s, u re te rs ( n o rm al d iam e te r < 7 m m ) ,
b lad d e r
afte r 20-30 m in u te s, th e co lle ctin g syste m is to o fain t an d
b lad d e r is o p acifie d
p re -vo id : irre gu lar o u tlin e o f b lad d e r ( su p e rio r-fib ro id s,
sigm o id ; in fe rio r-p ro state )
p o st-vo id : to asse ss cle aran ce o f b lad d e r
Re trograde pye logram/urogram
J co n trast m e d iu m in je cte d in to u re te rs at cysto sco p y via
u re te ral cath e te rizatio n
Cys togram
J co n trast in je cte d re tro grad e in to b lad d e r to visu alize b lad d e r
J VC U G e n ab le s visu alizatio n o f u re th ra
U/S
J u se fu l in e valu atin g re n al size an d re n al sh ap e
J can d iffe re n tiate so lid vs. cystic m asse s
J T R U S also u se fu l to e valu ate p ro state glan d an d gu id e b io p sie s
CT
J u se fu l in e valu atin g re n al m ass le sio n s, e xtrare n al m asse s th at are
d isto rtin g o r d isp lacin g n o rm al u rin ary tract
J b e st m e th o d to d e te rm in e e xtrare n al in vo lve m e n t o f tu m o u rs
( e .g. vascu lar in vo lve m e n t, n o d e s) , re n al trau m a, sto n e d ise ase
J go o d fo r asse ssin g re n al co lic
J u se u n e n h an ce d im agin g fo r sto n e s
sp iral C T go ld stan d ard fo r d e te ctin g sto n e s
J co n trast e n h an ce m e n t m ay sh o w h yp e rvascu larity o f m ass le sio n s,
are as o f n e cro sis with in m ass
J C T an gio grap h y m ay also b e u se d to e valu ate re n al arte ry ste n o sis
MRI
J u se d to e valu ate re n al m asse s o r e ffe cts o f p e lvic n e o p lasm s
o n b lad d e r
J u se fu l in e valu atin g p ro state tu m o u rs b o th d iagn o stically an d in
p lan n in g tre atm e n t ( i.e . su rgical vs. rad iatio n tre atm e n t)
ve ry u se fu l in asse ssin g gyn e co lo gical p ath o lo gy, e sp e cially tu m o u rs
N o te s
GENITOURINARY SYSTEM . . . CONT.
Re nal Scan
J 2 rad io n u clid e te sts fo r kid n e y: re n o gram an d m o rp h o lo gical scan
J in re n o gram , p assage o f rad io n u clid e ( Tc99m D T PA o r io d in e -
lab e le d h ip p u rate ) q u an titate d to asse ss fu n ctio n
J u se fu l in e valu ato n o f re n al failu re , wo rku p o f u rin ary tract
o b stru ctio n an d H T N , in ve stigatio n o f re n al
tran sp lan t
J m o rp h o lo gical stu d y d o n e with Tc99m D M S A an d Tc99m
glu co h e p to n ate to lo o k at re n al an ato m y
J u se fu l in in ve stigatio n o f re n al m ass an d co rtical scars
SELECTED PATHOLOGY
Obs truction
J se e U ro lo gy N o te s
J IVP fin d in gs
m ay se e rad io p aq u e sto n e o n p lain film ( ~ 90% are calcifie d )
(s e e Colour Atlas M1)
d e laye d visu alizatio n o n th e ab n o rm al sid e - th e late wh ite
kid n e y o f acu te re n al o b stru ctio n
ap p e aran ce o f calyce s: b lu n tin g o f e n d s o f m in o r calyce s
d e gre e o f d ilatatio n o f co lle ctin g syste m ( h yd ro n e p h ro sis vs
p e lvicalyu re te ctasis) d e p e n d s o n wh e th e r o b stru ctio n is
p artial o r co m p le te an d also d u ratio n o f o b stru ctio n
(s e e Colour Atlas M2)
u su ally e n tire le n gth o f u re te rs n o t se e n d u e to cle arin g b y
p e ristalsis ( if se e n co n sid e r U P J o b stru ctio n )
J U /S will b e p o sitive if sign ifican t h yd ro n e p h ro sis
Mas s Le s ions
J D D x o f m ass le sio n s in kid n e ys: cysts, tu m o u rs, o r in flam m ato ry
le sio n s
J le sio n s e lse wh e re in u rin ary tract: m o st like ly tu m o u rs
J in itial in ve stigatio n sh o u ld b e U /S
cysts: u n ifo rm ly h yp o e ch o ic, go o d th ro u gh tran sm issio n ,
im p e rce p tib le wall
tu m o u rs: so lid , co n to u r d e fo rm in g
J to fu rth e r d e te rm in e n atu re o f m ass, C T with co n trast e valu ate s
vascu larity, n e cro sis, lo cal in vasio n
J arte rio grap h y ( rare ly d o n e ) will sh o w vascu larity an d re n al
ve in /IVC in vasio n
Othe r
J o th e r G U p ath o lo gy ( se e N e p h ro lo gy an d U ro lo gy N o te s)
J ap p ro ach e s to se le cte d co m m o n G U an d R e p ro d u ctive
p ath o lo gy ( se e Tab le s 1 2 an d 1 3)
N o te s
NEURORADIOLOGY
INTRODUCTION
J p rim ary m o d alitie s to rad io lo gically in ve stigate b rain an d sp in al co rd
p lain film
C T
M R I
m ye lo grap h y
J d iagn o stic ap p ro ach e s to se le cte d N e u ro p ath o lo gy ( se e Tab le 1 4)
MODALITIES
Ve rte bral Films
J m ain stay fo r d iagn o sis o f d ise ase s in ve rte b ral co lu m n
J sh o u ld b e th e in itial stu d y
J C -sp in e vie ws ( se e E m e rge n cy M e d icin e N o te s)
late ral
AP o f lo we r co lu m n an d cran io atlan to axial re gio n
o b liq u e
+/ fle xio n /e xte n sio n vie ws
J th o racic an d lu m b ar vie ws
fro n tal an d late ral
o b liq u e lu m b ar vie ws in n o n -trau m atic case s
Skull Films
J a h igh ly o ve ru se d , lo w-yie ld e xam in atio n
J ge n e rally, n o t in d icate d fo r h e ad trau m a!
J in d icatio n s
p e n e tratin g trau m a
d e stru ctive le sio n s
m e tab o lic d ise ase
sku ll an o m alie s
p o st-o p ch an ge s
J stan d ard vie ws ( e ach d e sign e d to d e m o n strate a p articu lar are a o f th e sku ll)
PA - fro n tal b o n e s, fro n tal an d e th m o id sin u se s, n asal
cavity, su p e rio r o rb ital rim s, m an d ib le
late ral - fro n tal, p arie tal, te m p o ral, an d o ccip ital b o n e s,
m asto id re gio n , se lla tu rcica, ro o fs o f th e o rb its,
late ral asp e cts o f facial b o n e s
To wn e s vie w ( o ccip ital) - o ccip ital b o n e , m asto id an d m id d le e ar
re gio n s, fo ram e n m agn u m , zygo m atic arch e s
b ase vie w - b asal stru ctu re s o f sku ll, in clu d in g m ajo r fo ram in a
Wate rs vie w ( o ccip ito m e n tal) - facial b o n e s an d sin u se s
J ap p ro ach to in te rp re tatio n : b o n y vau lt, se lla tu rcica, facial b o n e s,
b asal fo ram in a, sin u se s, calcificatio n s, so ft tissu e s
Mye lography
J in tro d u ce wate r-so lu b le , lo w o sm o tic co n trast m e d ia in to su b arach n o id
sp ace u sin g lu m b ar p u n ctu re > co n ve n tio n al film s o r C T scan ( C T
m ye lo grap h y)
J e xce lle n t stu d y fo r d isc h e rn iatio n s, trau m atic n e rve ro o t avu lsio n s
J u se h as d e cre ase d d u e to M R I
CT Scans (s e e Colour Atlas G1-G6)
J m o d ality o f ch o ice fo r p atie n ts with su sp e cte d in tracran ial ab n o rm alitie s
J e xce lle n t stu d y fo r e valu atio n o f d isc h e rn iatio n s
J u su ally d o n e with o u t, an d th e n with in trave n o u s co n trast, to sh o w
vascu lar stru ctu re s o r an o m alie s
J atte n u atio n : b o n e > gre y m atte r > wh ite m atte r ( fatty m ye lin ) > C S F > air
J vascu lar stru ctu re s an d are as o f b lo o d -b rain b arrie r im p airm e n t:
rad io p aq u e ( wh ite ) with co n trast in je ctio n
wh e n in d o u b t, lo o k fo r circle o f Willis o r co n flu e n ce o f sin u se s to
d e te rm in e p re se n ce o f co n trast e n h an ce m e n t
J h e ad C T: in sp e ct so ft tissu e s, b o n e , co rtical p are n ch ym a,
ve n tricu lar syste m , m ass le sio n , sym m e try, sh ift o f falx, p o ste rio r
fo ssae o b scu re d b y b o n e an d H o u n sfie ld p h e n o m e n o n
J targe t le sio n s ( asso ciate d with co n trast rin g e n h an ce m e n t) : m e tastase s, in fe ctio n s
N o te s
NEURORADIOLOGY . . . CONT.
MRI
J rap id ly b e co m in g th e p rim ary in ve stigative to o l fo r su sp e cte d
in tracran ial ab n o rm alitie s
J sh o ws b rain an ato m y in e xtre m e ly fin e d e tail
J cle arly d istin gu ish e s wh ite fro m gre y m atte r
J m o d ality o f ch o ice fo r sp in al co rd p ath o lo gy ( e .g. d isc h e rn iatio n ,
in fe ctio n s, tu m o u rs, trau m a) , b rain tu m o u rs, p itu itary tu m o u rs, M S
J m u ltip lan ar re co n stru ctio n h e lp fu l in p re -o p asse ssm e n t
Ce re bral Angiography
J to e valu ate vascu lar le sio n s su ch as arte rio scle ro tic o cclu sive
d ise ase , an e u rysm s, vascu lar m alfo rm atio n s
J also h e lp fu l in su p p le m e n tin g C T an d M R I in p atie n ts with tu m o u rs
J d igital su b tractio n an gio grap h y co m m o n ly u se d
Nucle ar Me dicine
J S P E C T H M PAO im agin g asse sse s ce re b ral b lo o d flo w
J P E T im agin g asse sse s m e tab o lic activity
SELECTED PATHOLOGY ( se e N e u ro su rge ry N o te s)
J d iagn o stic ap p ro ach e s to se le cte d n e u ro p ath o lo gy ( se e Tab le 1 4)
He ad Trauma
J C T: im agin g m o d ality o f ch o ice fo llo win g h e ad trau m a if an y e vid e n ce o f
in tracran ial d am age ( e .g. L O C , n e u ro lo gical ab n o rm alitie s)
J tre atm e n t d ire cte d at th e n e u ro lo gic ab n o rm ality
th e p re se n ce o r ab se n ce o f a sku ll m ay n o t m ake an y d iffe re n ce
in M x o f p atie n t, E XC E P T
1 ) d e p re sse d
2) p e n e tratin g fo re ign o b je ct ( e .g. b u lle t)
J facial fractu re s: n e e d C T fo r co m p le te e valu atio n
J se e N e u ro su rge ry an d P lastic S u rge ry N o te s
Ve rte bral Trauma ( se e E m e rge n cy M e d icin e N o te s)
Intracranial Mas s Le s ions ( se e N e u ro su rge ry N o te s)
J in ve stigate with C T scan , M R I with co n trast, an gio grap h y
(s e e Colour Atlas G2)
Vas cular Dis e as e
J in clu d in g in farctio n , in trace re b ral h e m o rrh age ,
AVM , e xtrace re b ral h e m ato m as
J caro tid D o p p le r U /S u se d in e valu atin g fo r caro tid
arte ry d ise ase
J arte rio grap h y if caro tid an gio p lasty co n sid e re d
J fin d in gs in isch e m ic in farctio n
b asal gan glia m o st co m m o n site
first fe w h o u rs: n o rm al
1 2-24 h o u rs: re d u ce d d e n sity ( e d e m a/m ass e ffe ct) with n o
co n trast e n h an ce m e n t
1 -4 we e ks: p atch y e n h an ce m e n t
1 m o n th : d e n sity ap p ro ach e s th at o f C S F
J T IAs - n o fin d in gs
Multiple Scle ros is (MS)
J M R I sh o ws p laq u e s th at fo rm with in th e wh ite m atte r o f th e b rain
De ge ne rative Spinal Abnormalitie s
J sp o n d ylo sis
m ild : sligh t d isc sp ace n arro win g an d sp u r fo rm atio n
se ve re : m arke d d isc sp ace n arro win g, face t jo in t n arro win g,
sp u r fo rm atio n
sp u rs m ay im p in ge o n sp in al co rd > e valu ate
with C T, M R I, m ye lo grap h y
J h e rn iate d d isc
if sym p to m atic, e valu ate with C T, M R I, an d /o r m ye lo grap h y
N o te s
NEURORADIOLOGY . . . CONT.
Ve rte bral Column Me tas tas e s
J co m m o n are a fo r m e tastase s
J e valu ate with p lain film s, b o n e scan s, M R I, C T
J M R I: m o st se n sitive , can d e lin e ate are as o f sp in al co rd co m p re ssio n
J p lain film : n o t se n sitive ( n e e d ~ 50% o f can ce llo u s b o n e
d e stru ctio n b e fo re visib le o n p lain film s)
NUCLEAR MEDICINE
THYROID
Radioactive Iodine Uptake
J rad io active I-1 31 o r I-1 23 P O in fastin g p atie n t
J p ro vid e s in d e x o f th yro id fu n ctio n ( trap p in g an d o rgan ificatio n o f io d in e )
m e asu re d as a p e rce n tage o f ad m in iste re d io d id e take n u p b y th yro id
J e le vate d in h yp e rth yro id state s ( e .g. G rave s, to xic m u ltin o d u lar
go ite r, to xic ad e n o m a)
J d e cre ase d in h yp o th yro id state s ( e .g. su b acu te th yro id itis, late
H ash im o to s d ise ase )
J false ly d e cre ase d in p atie n t with re ce n t rad io grap h ic co n trast stu d ie s
Thyroid Imaging (Scintis can)
J te ch n e tiu m p e rte ch n e tate IV, rad io active io d in e to d e te rm in e
if n o d u le fu n ctio n in g
J p ro vid e s fu n ctio n al an ato m ic d e tail
J h o t ( h yp e rfu n ctio n in g) le sio n s
ad e n o m a, to xic m u ltin o d u lar go ite r
C A ve ry u n like ly
J co ld ( h yp o fu n ctio n in g) le sio n s
C A m u st b e co n sid e re d u n til b io p sy n e gative
J co o l le sio n s
C A m u st b e co n sid e re d as th e y m ay re p re se n t co ld
n o d u le s su p e rim p o se d o n n o rm al tissu e
if cyst su sp e cte d , co rre late with U /S
CHEST
V/Q Scan
J fo r su sp e cte d P E an d q u alitative o r q u an titative
e valu atio n o f p u lm o n ary ve n tilatio n an d p e rfu sio n
J lo o k fo r are as o f lu n g wh ich are ve n tilate d b u t n o t p e rfu se d o r vice ve rsa
J in P E , se e are as o f lu n g th at are we ll ve n tilate d b u t n o t p e rfu se d
J n o rm al p e rfu sio n scan m ake s P E u n like ly
J ve n tilatio n scan
p atie n t b re ath e s rad io active gas ( ae ro so lize d te ch n e tiu m -D T PA
o r xe n o n -1 33) th ro u gh a clo se d syste m , th u s fillin g alve o li
p ro p o rtio n al to ve n tilatio n
d e fe cts se e n if airway o b stru ctio n , ch ro n ic lu n g d ise ase ,
b ro n ch o sp asm , tu m o u r m ass o b stru ctio n , o xyge n atio n o f lu n g fie ld s
J p e rfu sio n scan
rad io trace r ( alb u m in m acro aggre gate s) in je cte d IV >
trap p e d in p u lm o n ary cap illarie s acco rd in g to b lo o d flo w
p e rfu sio n scan re lative ly co n train d icate d in se ve re
p u lm o n ary H T N , righ t-to -le ft sh u n t
d e fe cts in d icate re d u ce d b lo o d flo w d u e to P E , p are n ch ym al
lu n g d ise ase
Myocardial Pe rfus ion Scanning
J th alliu m -201 is a rad io active an alo gu e o f p o tassiu m
J active u p take b y m yo card iu m p ro p o rtio n al to re gio n al b lo o d flo w
J th alliu m in je cte d at p e ak e xe rcise o r afte r p e rsan tin e ch alle n ge an d
again at re st to d e te ct isch e m ia
J p e rsiste n t d e fe ct su gge sts in farctio n ; re ve rsib le d e fe ct su gge sts
isch e m ia o r fixe d ste n o sis
J fo r in ve stigatio n o f an gin a, atyp ical ch e st p ain , co ro n ary arte ry
d ise ase , re ve rsib le vs. irre ve rsib le ch an ge s wh e n o th e r
in ve stigatio n s are e q u ivo cal
N o te s
NUCLEAR MEDICINE . . . CONT.
Radionuclide Ve ntriculography
J te ch n e tiu m -99m attach e d to re d b lo o d ce lls
J first p ass th ro u gh R V > p u lm o n ary circu latio n > LV
J p ro vid e s in fo rm atio n ab o u t R V fu n ctio n
J card iac M U G A scan ( M U ltip le G Ate d acq u isitio n scan ) su m s
m u ltip le card iac cycle s
e valu atio n o f LV fu n ctio n
im age s are o b tain e d b y gatin g th e co u n t acq u isitio n s to th e
E C G sign al
p ro vid e s in fo rm atio n o n e je ctio n fractio n , e stim ate s o f
ve n tricu lar vo lu m e , wall m o tio n
Pyrophos phate Scintigraphy
J te ch n e tiu m p yro p h o sp h ate co n ce n trate s in b o n e an d in d yin g
an d n e cro tic tissu e
J u se d to d e te ct in farcte d tissu e 1 -5 d ays p o st-M I wh e n E C G an d
e n zym e re su lts are e q u ivo cal o r u n re liab le
J se n sitivity an d sp e cificity ab o u t 90% in tran sm u ral in farct
BONE
Bone Scan
J te ch n e tiu m with a p h o sp h ate o r flu o rid e carrie r b in d s to
h yd ro xyap atite o f b o n e m atrix
J in cre ase d wh e n in cre ase d b lo o d su p p ly to b o n e an d /o r h igh b o n e
tu rn o ve r
J in d icatio n s: b o n e p ain o f u n kn o wn o rigin ; scre e n in g o f
p atie n ts with su sp e cte d m align an cy; stagin g o f C A o f
b re ast, p ro state , o r b ro n ch u s; fo llo w u p afte r tre atm e n t; d e te ctio n
an d fo llo w u p o f p rim ary b o n e d ise ase ; asse ssm e n t o f ske le tal
trau m a; d e te ctio n o f so ft tissu e calcificatio n ; re n al failu re
J p o sitive b o n e scan
b o n e m e tastase s fro m b re ast, p ro state , lu n g, th yro id
p rim ary b o n e tu m o u rs
arth ritis
fractu re s
in fe ctio n s
J m u ltip le m ye lo m a: typ ically n o rm al o r co ld
J kid n e ys an d b o n e s: n o rm ally e q u al in in te n sity
J lo w re n al u p take : re n al failu re , m e tab o lic b o n e d ise ase ,
d iffu se b o n y m e tastasis ( su p e rscan )
ABDOMEN
Live r/Sple e n Scans
J IV in je ctio n o f rad io iso to p e -lab e le d su lfu r co llo id ( u su ally
te ch n e tiu m ) wh ich is p h ago cyto se d b y re ticu lo e n d o th e lial ce lls o f
live r an d sp le e n
J co ld sp o ts : le sio n s d isp lacin g th e n o rm al
re ticu lo e n d o th e lial syste m ( tu m o u r, ab sce ss, cyst)
J d iffu se p atch y re d u ctio n in u p take : d iffu se p are n ch ym al
d ise ase ( e .g. cirrh o sis)
HIDA (He patobiliary Iminodiace tic Acid) Scan
J IV in je ctio n o f rad io trace r ( H ID A) wh ich is b o u n d to p ro te in , take n
u p , an d e xcre te d b y h e p ato cyte s in to b iliary syste m
J can b e p e rfo rm e d in n o n -fastin g state b u t p re fe r N P O afte r m id n igh t th e
d ay b e fo re
J gallb lad d e r visu alize d wh e n th e cystic d u ct is p ate n t
J if gallb lad d e r is n o t visu alize d , su sp e ct o b stru cte d cystic d u ct
J D D x o f o b stru cte d cystic d u ct: acu te ch o le cystitis, d e cre ase d
h e p ato b iliary fu n ctio n ( co m m o n ly d u e to alco h o lism ) ,
b ile d u ct o b stru ctio n , p are n te ral n u tritio n
J if gallb lad d e r fills, ru le o u t ch o le cystitis ( < 1 % p ro b ab ility)
RBC Scan
J IV in je ctio n o f rad io trace r with se q u e n tial im age s o f th e ab d o m e n
N o te s
NUCLEAR MEDICINE . . . CONT.
J fo r G I b le e d
if b le e d in g acu te ly at > 0.5 m L /m in , th e fo cu s o f activity in
th e im age s ge n e rally in d icate s th e site o f th e acu te b le e d
m o re se n sitive fo r lo we r G I b le e d
J fo r e valu atio n o f live r le sio n
h e m an gio m a h as ch aracte ristic ap p e aran ce
Re nal Scan
J se e G e n ito u rin ary S yste m ab o ve
INFLAMMATION AND INFECTION
J u se galliu m citrate - an d in d iu m -lab e le d WB C s
J galliu m accu m u late s in n o rm al live r, sp le e n , b o n e m arro w, site s o f
in flam m atio n , so m e n e o p lasm s ( lym p h o m as)
J in d iu m -lab e le d WB C s accu m u late in n o rm al sp le e n , live r, b o n e
m arro w, site s o f in flam m atio n an d in fe ctio n
BRAIN
J S P E C T H M PAO im agin g asse sse s ce re b ral b lo o d flo w
J P E T im agin g asse sse s m e tab o lic activity
VASCULAR-INTERVENTIONAL
RADIOLOGY
Contraindications to Intravas cular Contras t Me dia ( se e Tab le 1 )
Vas cular Proce dure s , Indications , Cons ide rations , Complications ( se e Tab le 8)
Nonvas cular Proce dure s , Indications , Cons ide rations , Complications ( se e Tab le 9)
N o te s
VASCULAR-INTERVENTIONAL RADIOLOGY...CONT.
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N o te s
APPROACH TO COMMON PRESENTATIONS
J Tab le s 1 0-1 4
M o d ality o f C h o ice
id e n tifie s th e b e st availab le d iagn o stic to o l( s) re gard le ss o f co st
su b je ctive co n se n su s fro m re fe re n ce s an d facu lty e d ito rs b ase d
u p o n se n sitivity an d sp e cificity ( p articu larly sp e cificity)
in so m e case s ( e .g. an gio grap h y fo r m assive lo we r G I b le e d )
th e rap e u tics we re also co n sid e re d
Ap p ro ach to Im agin g
p ro vid e s a fram e wo rk fo r th e wo rk-u p o f a su sp e cte d d iagn o sis
in ge n e ral, in o rd e r o f se n sitive scre e n in g m o d alitie s to m o re sp e cific stu d ie s
co m p ile d fro m E ise n b e rg, R L an d M argu lis, AR , Radiology Pocket Reference: What toOrder When, 1 996
Table 10. Mus kulos ke le tal Pathology *NOTE: Plain Films (PF) are ALWAYS us e ful
Pathology Modality of Choice Approach to Imaging
Avascu lar N e cro sis M R I 1 . P F : n o t se n sitive b u t id e al fo r fo llo win g p ro gre ssio n o f d iso rd e r
1 a. R ad io n u clid e b o n e scan : m ay d e te ct ab n o rm ality b e fo re P F
2. M R I: m o st se n sitive fo r d e te ctin g e arly ch an ge s wh ile P F an d scan are n o rm al
2a. +/ S P E C T if M R I u n availab le
H e m ato ge n o u s M R I 1 . R ad io n u clid e b o n e scan : in cre ase d activity in e arly d ise ase ; n o t sp e cific, b u t se n sitive
2. M R I: e q u ally o r m o re se n sitive th an scin tigrap h y, n o t sp e cific
In flam m ato ry arth ro p ath y P F 1 . P F o f affe cte d jo in ts, p lu s S I jo in ts if se ro n e gative su sp e cte d
M e n iscal Te ar ( K n e e ) M R I 1 . U S : b e co m in g m o re co m m o n , b u t o p e rato r-d e p e n d e n t
arth ro sco p y 2. M R I: d e te cts m e n iscal te ars an d asso ciate d ab n o rm alitie s o f co llate ral ligam e n ts an d cru ciate s
* N O T E : n e e d fo r M R I is co n tro ve rsial an d so m e stu d ie s in d icate th at arth ro sco p y alo n e is su fficie n t
M u ltip le M ye lo m a P F ( ske le tal su rve y) 1 . P F : ske le tal su rve y is sp e cific b u t n o t se n sitive
2. M R I: p re fe rre d scre e n in g stu d y
O ste o arth ritis P F 1 . P F
O ste o m ye litis C T 1 . P F : n o ch an ge se e n u n til 8-1 0 d ays
D ire ct se e d in g o r M R I 2. G alliu m S can : se n sitive b e fo re 8-1 0 d ays
C o n tigu o u s sp re ad 3. C T: to d e te ct se q u e stra
4. M R I: se n sitive b u t n o t sp e cific
O ste o p o ro sis m e asu re m e n ts o f b o n e 1 . B o n e m in e ral co n te n t: m an y d iffe re n t m e th o d s
m in e ral co n te n t 1 a. U su ally D E XA-scan with X-ray so u rce = = = > lu m b ar sp in e an d R h ip
* N O T E : P F m ay d e te ct co m p re ssio n fractu re ; o th e rwise n o t in d icate d sin ce rad io lu ce n cy n o t se e n
u n til 50-70% b o n e lo ss
P rim ary M align an t M R I 1 a. P F : in itial scre e n in g, b u t p o o r se n sitivity; h o we ve r, yie ld s u se fu l in fo wh e n p o sitive
Tu m o u rs o f B o n e 1 b : B o n e scan : if su sp e ct m e tastase s th e n e sse n tial to scan ( n o t a P F ske le tal su rve y)
2. M R I: b e st fo r d e te rm in in g b o n y an d so ft tissu e e xte n t, ab ility to d istin gu ish b e n ign fro m
m align an t is co n tro ve rsial
R o tato r C u ff Te ar M R I 1 . U /S : o p e rato r-d e p e n d e n t
2. M R I: d e te cts p artial an d co m p le te te ars
3. Arth ro gap h y: if M R I u n availab le ; o n ly d e te cts co m p le te te ars
S e p tic Arth ritis asp irate an d cu ltu re 1 . R ad io n u clid e b o n e scan : n o t sp e cific b u t m ay p e rm it e arly d iagn o sis
* N O T E : m u st asp irate an d cu ltu re ; p lain film s n o t sp e cific/se n sitive
S ke le tal m e tastase s rad io n u clid e b o n e scan 1 . R ad io n u clid e b o n e scan : false n e gative m ay o ccu r if th e re is u n ifo rm u p take b y d iffu se m e tastase s
2. P F : ge n e rally n o t in d icate d u n le ss scan is e q u ivo cal, in se n sitive ( 40-80% o f b o n e m u st b e
d e stro ye d to b e ap p are n t) th u s N E VE R o rd e r a ske le tal su rve y to scre e n fo r m e tastase s
3. C T o r M R I: to e valu ate n o n sp e cific fo cal ab n o rm alitie s fro m scan o r P F, sh o u ld n o t b e
u se d as in itial scre e n in g
S tre ss F ractu re rad io n u clid e b o n e scan 1 . R ad io n u clid e b o n e scan : se n sitive fo r e arly d e te ctio n
2. P F : fractu re m ay n o t b e d e te ctab le fo r se ve ral we e ks
Ve rte b ral rad io n u clid e b o n e scan 1 . R ad io n u clid e b o n e scan : d e te ct e arly activity
2. M R I: se n sitive fo r d e te ctin g ab n o rm ality b u t d o e s n o t accu rate ly d istin gu ish in fe ctio n fro m tu m o u r
D i agn o sti c M e d i cal I m agi n g 30 M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s
N o te s
APPROACH TO COMMON PRESENTATIONS . . . CONT.
Table 11. Abdominal Pathology
AAA M R I 1 . U /S : m o st co st-e ffe ctive , se rial e xam s to m o n ito r
2. C T: if su sp e ct le ak o r acu te ru p tu re , m o re accu rate th an U /S , e sp e cially with M D C T
= = = > allo ws d igital re co n stru ctio n o f re n al/visce ral vascu latu re
3. M R I: o n ly if U /S an d C T fail to p ro vid e in fo ab o u t re n al, iliac arte ry, an d visce ral in vo lve m e n t
C h o le cystitis ( acu te ) ch o le scin tigrap h y 1 . ch o le scin tigrap h y: 95% sp e cific, 98% se n sitive ( p o st-p ran d ial H ID A scan )
U /S 2. U /S
C h o le cystitis ( ch ro n ic) U /S 1 . U /S
C o lo n C A ( d iagn o sis) d o u b le -co n trast B E 1 . B E
2. co lo n o sco p y/fle x sig: sligh tly m o re se n sitive an d sp e cific th an B E b u t co st & co m p licatio n s
C o lo n C A ( stagin g) C T 1 . C T: m o st e ffe ctive fo r d e m o n stratin g p re se n ce an d e xte n t o f co lo n ic sp re ad
tran sre ctal U /S 2. tran sre ctal: m o st accu rate fo r stagin g lo cal re ctal C A ( d e p th o f in vasio n , p re se n ce in lym p h n o d e s)
C ro h n s B E 1 . sm all b o we l fo llo w-th ro u gh : if le ve l o f su sp icio n fo r d ise ase is lo w
C T 1 a. e n te ro clysis ( sm all b o we l e n e m a) : if clin ical su sp icio n n o t lo w
2. sm all b o we l e xam in atio n re q u ire d if te rm in al ile u m n o t visu alize d in B E
3. C T: b e st fo r d e m o n stratin g m e se n te ric an d e xtrain te stin al e xte n t o f d ise ase an d ab sce ss fo rm atio n
D ive rticu litis C T 1 . C T
B E 2. B E ( H E m ay b e in d icate d d u e to th re at o f sigm o id p e rfo ratio n )
D ive rticu lo sis B E 1 . B E
F atty L ive r C T 1 . C T
H e p ato ce llu lar C A C T 1 . C T: p re fe rre d scre e n in g te ch n iq u e
M R I 2. U /S : scre e n ch ro n ic H e p B carrie rs
3. M R I: m ay p e rm it sp e cific d iagn o sis o f h e p ato ce llu lar C A
Irritab le B o we l S yn d ro m e n o th in g o r B E 1 . B E : p rim arily p e rfo rm e d to e xclu d e IB D o r C A ( d iagn o sis o f e xclu sio n )
L arge B o we l O b stru ctio n AXR 1 . AXR : can d iffe re n tiate b e twe e n ile u s an d m e ch an ical o b stru ctio n
C T 2. B E ( H E if th re at o f p e rfo ratio n )
3. C T with d ilu te co n trast
M assive L o we r G I B le e d co lo n o sco p y 1 . C o lo n o sco p y: first ch o ice if b le e d n o t o b scu rin g visio n
an gio grap h y 2. R B C scan : as a sco u t to d ire ct fu rth e r in ve stigatio n
3. An gio gram : to lo calize b le e d , can b e th e rap e u tic; su p e rio r to R B C scan
P an cre atitis ( acu te ) C T 1 . C T: su p e rio r to U /S fo r in flam m atio n , e d e m a, gas d e te ctio n
2. U /S : u se d fo r fo llo w-u p o f sp e cific ab n o rm alitie s
P an cre atitis ( ch ro n ic) C T 1 . AXR : o fte n d o n e in p ractice , b u t lo w yie ld
2. C T: m o st accu rate in d e m o n stratin g m align an cy
3. E R C P /M R C P
P e rito n itis C T 1 . AXR : u p righ t o r late ral d e cu b itu s fo r fre e air; su p in e lo o k fo r d o u b le wall sign
2. C T: p ro ce d u re o f ch o ice to d e te ct flu id , ab sce ss, stran gu latio n
P U D e n d o sco p y 1 . u p p e r G I se rie s ( d o u b le co n trast)
u p p e r G I se rie s 1 a. u re ase b re ath te st: n u cle ar m e d icin e can b e u se d u n d e r ce rtain circu m stan ce s
2. e n d o sco p y: m ay b e p re fe rab le fo r su sp e cte d G U b /c can b io p sy, fails to d e te ct 5-1 0% o f p e p tic u lce rs
* N O T E - O n ce th e d iagn o sis o f b e n ign P U D is m ad e th e re is n o n e e d to re p e at im agin g
S m all B o we l O b stru ctio n AXR 1 . AXR
C T 2. C T: o n ly re q u ire d if AXR are e q u ivo cal o r n e ce ssary to sh o w p re cise site an d e lu cid ate e tio lo gy
S p le n ic Ab sce ss C T 1 . C T: p re fe rre d scre e n in g te ch n iq u e
2. rad io n u clid e scan : sp e cifically id e n tify m ass as an ab sce ss
U lce rative C o litis B E o r co lo n o sco p y 1 . sigm o id o sco p y: d ire ct visu alizatio n
2. B E o r co lo n o sco p y: to d e te rm in e fu ll e xte n t o f d ise ase an d d e te ct C A
N o te s
Table 12. Urinary Tract Pathology
C an ce r o f th e K id n e y C T 1 . U /S o r C T: U /S go o d fo r scre e n in g; co n trast-e n h an ce d C T is m o st se n sitive
( d iagn o sis)
C an ce r o f th e K id n e y C T o r M R I 1 . C T o r M R I: M R I fo r lym p h ad e n o p ath y; ch e st C T fo r m e tastase s
( stagin g) 1 a. +/ U /S with D o p p le r to e lu cid ate vascu larity
2. rad io n u clid e b o n e scan : fo r m e tastase s
3. arte rio grap h y ( o fte n u se d p re -o p e rative ly to in farct kid n e y)
H e m atu ria
P ain le ss cysto sco p y 1 . U /S : e fficie n t fo r d e te ctin g n e o p lastic re n al m asse s an d vascu lar an o m alie s; d o e s n o t e xclu d e
C T b lad d e r tu m o u r o r cystitis
2. IVP : e xce lle n t fo r sto n e s an d p ap illary n e cro sis; can n o t e xclu d e b lad d e r o r u re th ral p ath o lo gy
3. cysto sco p y: re q u ire d in an y ad u lt with u n e xp lain e d h e m atu ria
4. C T: m o re se n sitive th an U /S fo r re n al m asse s
P ain fu l C T 1 . IVP : p re fe rre d fo r scre e n in g, can d e fin e site an d d e gre e o f o b stru ctio n
2. U /S : d e te ct u re te ral d ilatatio n , sto n e
3. C T: d e te ct sto n e s
P o lycystic K id n e y D ise ase C T 1 . U /S o r C T
( Ad u lt)
P ye lo n e p h ritis
Acu te im agin g o n ly re q u ire d if 1 . C T
p atie n ts fail to re sp o n d to 2. U /S : le ss se n sitive th an C T fo r su b tle ch an ge s; e fficie n t fo r h yd ro n e p h ro sis
tre atm e n t o r se ve re ly ill * N O T E : co n trast is co n train d icate d if p atie n t is fe b rile /to xic
C h ro n ic IVP 1 . IVP : ch aracte ristic fo cal co rtical scar
2. U /S
R e n al F ailu re U /S 1 . U /S
2. D T PA R ad io n u clid e scan at tim e d in te rvals ( n o n -n e p h ro to xic)
* N O T E : b io p sy o fte n re q u ire d if AR F an d large ( > 1 2 cm ) o r n o rm al-size d kid n e ys fo r d e fin itive d x
R e n o vascu lar D ise ase arte rio grap h y 1 . U /S with D o p p le r
2. Arte rio grap h y
U T I
In fan t & ch ild rad io n u clid e o r vo id in g 1 . rad io n u clid e o r vo id in g cysto grap h y: m o st se n sitive fo r ve sico u re te ral re flu x
cysto grap h y 2. U /S : p re fe rre d scre e n in g
* N O T E : co m p le te in ve stigatio n im p o rtan t b e cau se o f h igh p ro b ab ility o f an ato m ic ab n o rm ality
3. IVP
4. C T if in d icate d
O ld e r ch ild /Te e n age r U /S 1 . U /S : o n ly stu d y n e e d e d if ch ild h as o n ly lo we r u rin ary tract sign s an d sym p to m s an d n o rm al U /S
Ad u lt U /S 1 . IVP : stru ctu re an d fu n ctio n o f u rin ary tract
2. U /S : p re fe rre d im agin g m o d ality fo r critically ill p atie n t with su sp e cte d U T I
3. C T: in d icate d if U /S an d u ro grap h y n o rm al b u t stro n g clin ical su sp icio n
* N O T E : u n co m p licate d U T I in a fe m ale re q u ire s N O im agin g
D i agn o sti c M e d i cal I m agi n g 32 M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s
N o te s
Table 13. Re productive Pathology
Ab n o rm al u te rin e b le e d in g h yste ro sco p y/co lp o sco p y 1 . U /S : u su ally in itial scre e n in g
2. so n o h ysto gram : m o re d e tail
Acu te Te sticu lar P ain U /S with D o p p le r 1 . U /S with co lo u r D o p p le r
2. rad io n u clid e flo w stu d y: can d e m o n strate to rsio n
D ysm e n o rrh e a U /S 1 . U /S
2. lap aro sco p y
E m e rge n t/acu te situ atio n s U /S 1 . U /S
( e .g. to rsio n , e cto p ic, ab sce ss)
E n d o m e trial C an ce r so n o h ysto gram 1 . U /S
( d iagn o sis) C T 2. so n o h ysto gram
3. C T
E n d o m e trial C an ce r M R I 1 . C T
( stagin g) 2. M R I
In fe rtility h yste ro salp in go grap h y o r 1 . h yste ro salp in go grap h y
lap aro sco p y with d ye 1 a. U /S with co n trast ( i.e . S o n o vist) in je ctio n
in je ctio n 2. U /S o r M R I: if ab o ve is n o rm al, to d e te ct co n ge n ital an o m alie s o f fe m ale tract ( 1 0%)
3. lap aro sco p y with d ye in je ctio n : if h isto ry o f e n d o m e trio sis/P ID
P e lvic M ass M R I 1 . U /S
2. C T
3. M R I
Te sticu lar M ass M R I 1 . U /S
2. M R I
N o te s
Table 14. Ne uropathology
Acu te h e ad trau m a C T 1 . C T: p re fe rre d fo r b o n e an d b lo o d
2. M R I: in d icate d o n ly wh e n C T h as faile d to d e te ct an ab n o rm ality in p re se n ce o f stro n g clin ical su sp icio n ;
valu ab le in su b acu te an d ch ro n ic p h ase s
* N O T E : n o in d icatio n fo r p lain sku ll rad io grap h y
Acu te su b d u ral h e m ato m a C T 1 . C T
2. M R I: n o t se n sitive fo r d e te ctin g acu te b le e d b u t co ro n al im age s m ay b e o f valu e if C T fails
B e ll s P alsy M R I 1 . M R I: to e xclu d e a m ass o r d e m ye lin atin g le sio n
B rain Tu m o u r M R I 1 . C T: n e arly always d o n e at first p re se n tatio n
2. M R I
C VA M R I 1 . C T: n o n -co n trast scan p re fe rre d in itial p ro ce d u re in su sp e cte d acu te stro ke
2. M R I: u n e n h an ce d M R I with an gio grap h y is m o re se n sitive th an C T
D e m e n tia M R I 1 . M R I: m o st se n sitive fo r le sio n s
2. S P E C T
2a. P E T: u se d as ad ju n ct in su sp e cte d Alzh e im e rs
H e ad ach e M R I 1 . C T: in p ractice , o fte n first lin e if le ve l o f u rge n cy h igh ( i.e . h e m o rrh age /m ass le sio n su sp e cte d )
2. M R I: m o st se n sitive fo r ce re b ral le sio n s
L acu n ar In farctio n M R I 1 . C T: u su ally d o n e first to e xclu d e acu te /tre atab le p ath o lo gy; lack o f fin d in gs se rve s as in d icatio n fo r M R I
2. M R I: o n ly m o d ality th at can co n siste n tly d e m o n strate th e le sio n s
M e n in gitis ( Acu te ) C T 1 . C T: m o st im p o rtan t ro le is to e xclu d e a m ass ( ab sce ss) p rio r to L P ( m ain d iagn o stic te st)
M e n in gitis ( S u b acu te /ch ro n ic) M R I 1 . M R I: co n trast re q u ire d , d e m o n strate e d e m a, ab sce ss, n e o p lasm , an d in flam m atio n
2. p lain ch e st film : se arch fo r u n d e rlyin g T B o r sarco id o sis
M S M R I 1 . M R I: m o st se n sitive fo r d e te ctio n o f d e m ye lin atio n
O rb ital B lo w-o u t fractu re C T 1 . p lain film ( Wate rs vie w) : p re fe rre d scre e n in g fo r b o n y ab n o rm alitie s an d so ft-tissu e m ass, air-flu id le ve ls
2. C T: d e fin itive stu d y
S e izu re D iso rd e r M R I 1 . C T: n o n -co n trast re co m m e n d e d as in itial stu d y if p o stictal o r if re sid u al n e u ro lo gic d e ficit
2. M R I: m o st se n sitive fo r d e te ctin g ce re b ral le sio n s, F /U in 3-6 m o n th s if fail to d e te ct a so u rce
3. P E T: im p ro ve s lo calizatio n o f se izu re fo cu s
T IA M R I 1 . d u p le x, co lo u r-flo w D o p p le r U /S
2. e ch o card io grap h y
3. M R I
4. in tra-arte rial d igital su b tractio n an gio grap h y
4a. M R An gio grap h y
Tin n itu s C T 1 . C T: p re fe rre d fo r e ar b o n e ab n o rm alitie s
M R I 2. M R I: p re fe rre d fo r sm all tu m o u rs o f C N VIII
Ve rtigo M R I 1 . M R I: d e te ctin g p o ste rio r fo ssa an d ce re b e llo p o n tin e an gle ab n o rm alitie s
2. C T: in d icate d fo r m id d le e ar p ath o lo gy
MODALITIES OF CHOICE . . . CONT.
MODALITIES OF CHOICE . . . CONT.
Drawing by Teddy Cameron

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