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BASIC CONCEPTS IN DIAGNOSTIC IMAGING

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BASIC CONCEPTS IN DIAGNOSTIC IMAGING J.J. Jimenez, M.D. A. Tamrazi PhD Carle Clinic Association University of Illinois College of Medicine ... – PowerPoint PPT presentation

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Title: BASIC CONCEPTS IN DIAGNOSTIC IMAGING


1
BASIC CONCEPTS IN DIAGNOSTIC IMAGING
  • J.J. Jimenez, M.D.
  • A. Tamrazi PhD
  • Carle Clinic Association
  • University of Illinois College of Medicine

2
Outline
  • Introduction
  • X-Rays
  • Fluoroscopy
  • GI
  • GU
  • CT
  • MR
  • Innovative Modalities

3
Modalities Available in Radiology
  • Plain Film / X-Ray/Mammography
  • Fluoroscopy
  • Ultrasound
  • CT
  • MRI
  • Nuclear Medicine/Molecular Imaging
  • Angiography/Interventional

4
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5
Relative Cost of Imaging Studies
6
Relative Availability of Diagnostic Imaging
Teaching Hospital xxxx xxxx xxxx xxxx xxxx xxxx xxxx
Urban Hospital xxxx xxxx xxxx xxxx xxxx xxxx xxx
Suburban Commun-ity Hosp xxxx xxxx xxxx xxxx xx xxx xx
Rural Hospital xxxx xxxx xxx xxx x xx x
Plain Film Fluoro U/S CT NM MRI Angio-interven-tional
7
X-Rays
  • Discovered in 1895 and still used today
  • Most widely performed imaging exam
  • X Rays are emitted and detected in cassette
  • Cassette can generate either a film or a digital
    image
  • Films are kept on file or in a digital archive

8
Most Useful Applications for Plain X-Rays
  • Chest
  • Musculoskeletal
  • Abdomen limited usefulness

9
Plain X-Rays Pros Cons
  • Widely available
  • Inexpensive
  • Doesnt require advanced technologist knowledge
  • Can be performed quickly
  • Portable
  • Ionizing Radiation
  • Relatively insensitive
  • Requires patient cooperation

10
Fluoroscopy
  • Utilizes X-Rays
  • Real-time imaging
  • Utilizes image intensifier
  • Involves use of contrast agents

11
Main Uses of Fluoroscopy
  • Gastrointestinal Imaging
  • Genitourinary Imaging
  • Angiography
  • Other
  • Intraoperative
  • Foreign body removal
  • Musculoskeletal

12
Fluoroscopy Pros Cons
  • Widely Available
  • Inexpensive
  • Functional and Anatomic
  • No sedation required
  • Requires ingestion/injection of contrast
  • Patient cooperation
  • Time consuming

13
Gastrointestional Fluoroscopy
  • Esophogram/Barium Swallow
  • Modified Barium Swallow/Dysphgiagram
  • Upper GI
  • Small Bowel Series
  • Enteroclysis
  • Contrast Enema
  • Defecography

14
Single Contrast vs Double Contrast
  • Single Contrast
  • Generally uses just thin Barium
  • Distends lumen with high density material
  • Easier for patient/less mucosal detail
  • Double Contrast/Air Contrast
  • Thick barium coats lumen
  • Effervescent tablets ingested to distend lumen
    with air
  • Produces see-through images with greater
    mucosal detail
  • Greater sensitivity for small lesions, polyps,
    ulcers

15
Single Contrast vs Double Contrast
Single Contrast Barium Enema
Double Contrast Barium Enema
16
Contrast Materials for GI Exams
  • Barium Sulfate
  • Thick used in double contrast studies
  • Thin used in single and double contrast exams
  • Paste mod Ba swallow and defogography
  • Gastrograffin
  • Full stregnth rarely used
  • Dilute

17
Barium vs Gastrograffin
Gastrograffin Swallow Study
Barrium Swallow Study
18
Barium Sulfate
  • Most widely used
  • Better images than gastrograffin
  • Chalky taste
  • Peritonitis may develop if perforation
  • If delayed transit, may form concretions in colon

19
Gastrograffin
  • Water soluble
  • Foul Taste
  • Poor mucosal coating
  • Basically used for R/O obstruction
  • Wont cause peritonitis if perforation
  • May cause severe chemical pneumonitis if
    aspirated
  • Osmotic pressure draws fluid into bowel lumen
  • Progressive distention in small bowel obstruction
  • Therapeutic enema in constipation

20
Patient Factors in GI Fluoroscopy
  • Ability to ingest contrast
  • In order to get high quality images, a relatively
    large volume of contrast needs to be ingested
    fairly quickly
  • Mobility
  • Multiple positions required for GI exams,
    particularly double contrast exams.
  • Limited mobility less diagnostic images
  • Weight
  • Tables have weight limits
  • Requires maximal radiographic technique and
    exposure is often suboptimal

21
Esophogram or Barium Swallow
  • Evaluates pharynx and esophagus
  • Limited evaluation of stomach
  • Double or Single Contrast
  • Mucosal contour and Motility

22
Modified Barium Swallow
  • AKA Dysphagiagram and at Carle cookie swallow
  • Performed with Speech Pathologist
  • Barium administered in various bolus
    consistencies ranging from liquid to solid
  • Evaluates swallowing mechanism
  • Evaluates for aspiration
  • Performed on videotape

23
Modified Barium Swallow
24
Upper GI Exam
  • Evaluates esophagus, stomach and duodenum
  • Double or Single Contrast
  • Can be combined with small bowel series
  • Largely replaced by endoscopy and cross-sectional
    imaging
  • Fairly insensitive

25
Small Bowel Series
  • Patient drinks 2 cups of thin Ba
  • Overhead films obtained at routine intervals
  • The Ba column is followed through until it
    reaches the colon
  • Transit time, mucosal contour, bowel loop
    distribution are evaluated.
  • Insensitive for small masses

26
Small Bowel Series
27
Small Bowel Enteroclysis
  • Double Contrast Small Bowel Series
  • NGT placed at duodenal-jejunal junction
  • Ba injected followed by methylcellulose
  • See-through appearance to small bowel
  • Greater sensitivity for small masses and mucosal
    lesions
  • Patient discomfort related to NGT and diarrhea

28
Contrast Enemas
  • Barium or Gastrograffin
  • Double contrast or single contrast
  • Generally less sensitive than endoscopy
  • Requires bowel prep to assess for mucosal lesions
  • Requires some element of patient cooperation

29
Contrast Enemas
Single Contrast Barium Enema
Double Contrast Barium Enema
30
Defecogram
  • Barium paste is inserted into rectum
  • Patient is asked to defecate under fluoroscopy
  • Ano-rectal and pelvic floor dynamics can be
    assessed
  • Rectocele, intussusception, pelvic floor
    relaxation, stress incontinence

31
Genitourinary Fluoroscopy
  • Cystogram
  • Voiding cystourethrogram
  • Retrograde urethrogram
  • Hysterosalpingogram

32
Cystogram
  • Usually in adult patients
  • Looking for tear or intraluminal mass
  • Catheter placed and bladder filled with contrast
    to capacity usually 300-500 ml.
  • Spot films obtained when full
  • Post void film usually overhead

33
Cystogram
Cystogram with Intraperitoneal Rupture
34
Voiding Cystourethrogram VCUG
  • Usually in children with history of UTI
  • Searching for vesicoureteral reflux
  • In males, evaluate for urethral abnormalities
    posterior urethral valves
  • Same as cystogram except when full patient voids
    under fluoro with spot films

35
Retrograde Urethrogram RUG
  • Male patients
  • Pelvic Trauma
  • Post-infectious STD- looking for stricture
  • Different techniques
  • Meatus occluded and contrast injected into
    urethra under fluoro

36
Retrograde Urethrogram RUG
37
Hysterosalpingogram
  • Used to evaluate endometrial canal and fallopian
    tubes
  • Infertility and uterine anomalies
  • Dye injected into cervical os under fluoro
  • Injection continued with goal to opacify the
    fallopian tubes and spill contrast into peritoneum

38
Musculoskeletal Fluoroscopy
  • Fracture/Dislocation reduction
  • Hardware placement in the OR
  • Flexion/Extension views of c-spine
  • Arthrography
  • May be performed in conjunction with MRI or CT

39
Techniques Relevant to MSK Radiology
  • Radiography (routine and specialized views)
  • CT
  • MRI
  • US
  • Densitometry
  • Interventional procedures (arthrography,
    percutaneous biopsy/vertebroplasty)

40
MSK Radiology
MRISagittal Knee T1 Weighted
Vertebroplasty
41
Computed Tomography (CT)
  • Cross Sectional imaging modality
  • Mobile X-ray tube that rotates around a pt
  • Slices of X-ray transmission data reconstructed
    to generate image
  • Data displayed in multiple window settings (lungs
    parenchyma, bone, etc.)
  • Density measurements/Hounsfield Units analyze
    chemical component of tissue
  • HU -150-0 fat, 0 water, 0-20 serous
    fluid, 45-75 blood,
  • 100-1000 bone/calcium

42
CT Contrast Agents
  • Intravenous contrast---iodinated
  • Differentiate blood vessels vs. vascular
    internal organs
  • Enteric contrast---barium
  • Differentiate bowel vs. intra-abdominal
    fluid/masses
  • Rectal contrast
  • Retrograde urinary bladder contrast

43
CT Applications
  • Neuro-imaging
  • -Acute head trauma, acute intracranial
    hemorrhage
  • -Low sensitivity for early ischemic stroke,
    intracranial metastatic disease, white matter
    degenerative disease
  • Head and Neck imaging
  • -Soft tissue of neck, paranasal sinuses, temporal
    bone imaging, orbital wall imaging

44
CT Applications
  • Body Imaging
  • -Chest, Abdomen, Pelvis (with enteric and IV
    contrast)
  • Pulmonary nodules, Renal Calculi (without
    contrast)
  • Acute appendicitis (with enteric and IV contrast)
  • Specialized protocols
  • -Liver masses, pancreatic tissue, renal masses,
    adrenal masses

45
CT Applications
  • Acute Abdomen
  • -decrease rate of false laparotomy procedures
  • Trauma Spine Imaging (cervical, thoracic, lumbar)
  • Other osseous structures (pelvis, extremities)
  • Vascular Imaging
  • -CT angiography--- i.e. coronary arteries

46
CT Axial, with oral contrast in stomach
47
CT
PET
PET/CT
48
The Power of CT
CTA (CT Angiography)
CT Cardiac Imaging
49
Magnetic Resonance Imaging (MRI)
  • Multi-planar scanning
  • Without ionizing radiation
  • Images generated using powerful magnets and
    pulsed radio waves passing through the body
  • Data from Pts body used to generate image
  • Field strength of magnets 0.3-3.0 Tesla

50
MR Contrast Agents
  • Intravenous contrast---Gadolinium chelate-based
    contrast agents
  • Gadolinium is a paramagnetic lanthanide that is
    toxic as a free metal
  • Contrast to evaluate BBB, intracranial edema and
    hemorrhage
  • Novel agents being developed as tagged Monoclonal
    antibodies for Molecular Imaging

51
MR Applications
  • Neuro-imaging
  • -Excellent tool due to high soft tissue contrast
    resolution
  • -Abundant water content of CNS allows for
    imaging soft intracranial tissue
  • Head and Neck imaging
  • -Multi-planar capability allows for monitoring
    extent of disease
  • -Differentiating subtle soft tissue boundaries of
    head and neck

52
MRI Axial, T2-Weighted
53
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54
MR Applications
  • Body Imaging
  • -Thorax mediastinal, hilar, chest wall
    abnormalities
  • Limited lung imaging due to artifacts
  • New advances in breast imaging
  • Potentials for cardiac MRI with coronary MR
    angiography

55
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56
MRI Breast Imaging
57
MR Applications
  • MSK Imaging
  • - High sensitivity for neoplastic, inflammatory,
    and traumatic conditions of bone and soft tissue
  • - T1-weighted---fluid collections and
    abnormalities in fatty marrow
  • - T2-weighted---lesions in both marrow and soft
    tissue

58
MRI Sagittal, T1-Weighted
59
Innovative Modalities
  • Constantly evolving face of radiology
  • New contrast agents for CT and MR
  • Molecular Imaging
  • - Imaging molecular events---enzymatic activity,
    receptor binding, cellular events
  • Interventional Radiology and Interventional
    Neuroradiology
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