RAJAT JAIN

MD(MAMC), DNB,FRCR(UK)

NEW DELHI

Rajat Jain

Energy associated with any radiation can be transferred to matter. This transfer of energy can remove electrons from the orbit of atoms

leading to the formation of ions

Rajat Jain

Type Mass& Charge Comment

Electromagnetic

1). X-ray

2). Gamma ray

Particulate

1). Electron (e)

2). Proton (p)

3). Neutron (n)

4). Alpha particle

0

0

variable mass

&

Charge

X-rays and gamma rays do not

differ except in the source. Gamma

rays are produced intranuclearly,

and x-rays are produced

extranuclearly (i.e., mechanically).

—

Exhibits a Bragg peak

Cannot be accelerated by an

electrical field

Helium nucleus

IONIZING RADIATION

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Major Sources of ionizing radiation include Most nuclear processes (e.g., nuclear

fission, nuclear fusion, radioactive decay),

X-ray equipment, high-energy physics experiments, and Background radiation.

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All human beings are constantly exposed to ionizing radiation.

Environmental sources include the cosmic radiation from space and radiation from the ground and from inhaled and ingested materials.

Airline travel and mining both increase exposure to the background radiation.

Radiation originating in the body comes mainly from radioactive potassium, which emits beta and gamma rays.

Cosmic exposure contributes 28 mrem per year. The ground and internal sources contribute 26 and 27 mrem

per year, respectively.

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X-ray tube

Patient

Cassette

collimator

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X-RAY TUBE

PARTS OF X RAY TUBE

1) Glass Envelope 2) Cathode Filament Supporting wires Focusing cup 3) Anode Stationary Rotating

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Tube Housing - Made of cast steel - Contained in a glass envelope (Pyrex) - Concept of target window

Cathode - Made up of the filament (s) (Tungsten) and a focusing cup. - Addition of Thorium to the filament Anode - Target (Tungsten – rhenium alloy) - Tungsten has: High atomic number (74), thermal conductivity level & melting point

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When kVp increases - X-ray penetration increases, exposure increases (darker film) and contrast goes down.

Maximum energy as well as number of x-rays increased.

Film contrast - primarily dependent on kV. Increasing mAs - increased film exposure

(more x-rays produced), which darkens the film.

Maximum energy of x-rays - NOT changed. Rajat Jain

S. No. Type of Radiation Quality

factor

1.

2.

3.

4.

X, gamma or beta radiation

Alpha particles and multiple charged particles

Neutrons

High energy protons

1

20

10

10

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TISSUE WEIGHTING FACTOR

Gonads 0.2

Active bone marrow, Colon, Lungs, Stomach. 0.12

Bladder, Breast, Esophagus, Liver, Thyroid 0.05

Bone surfaces, Skin 0.01

At diagnostic energy levels, the rad, rem and roentgen

may all be considered equal , because the energy

deposited in soft tissues by 1 R of exposure is only 5%

more than a rad. i.e. 1 R= 1 rad= 1 rem. Rajat Jain

Unit Quantity Measured

Roentgen (R) Exposure

Rad Dose

Gray (Gy)

(KERMA)

Dose

Sievert (Sv) Dose Equivalence

Rem Dose Equivalence

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Chest (single PA film) Skull Thoracic spine Lumbar spine Hip Pelvis Abdomen IVU Barium follow thrugh CT head CT chest CT abdomen or pelvis

0.02 0.07 0.7 1.3 0.3 0.7 1.0 2.5 3 2.3 8 10

Diagnostic procedure dose(msv)

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Occupational workers public

Limit Annual

equivalents

Limit

Annual

equivalents

ICRP 20mSv/yr over 5 years 20 mSv 1mSv/yr over 5

years 1 mSv

NCRP Cumulative dose= Age in yrs x

10mSv 50 mSv

5mSv for 5 yr

period 1 mSv

AERB 100mSv for 5 year period 30mSv 1mSv/yr for 5

years 1mSv

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Dose limit of 2mSv applied to the surface of her

lower abdomen equal to 1msev dose to fetus

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Conventional x-ray

Phosphor plate (PSP)

Latent image

Laser beam

Emission of light

Ultra-sensitive PMT

Electronic signal (digital)

CRT or Hard copy

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X-ray

Patient

Flat panel detector

Electrical energy

Digital image

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•Advantages – Better contrast resolution Less ‘repeat’ rates Compatible with PACS Teleradiology

•Limitations –

Cost

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Low energy X-ray spectrum (20-35 KV) Small focal spot size(0.2-0.5 mm) Beryllium Window Target-Filter combination Molybdenum(preferred);Rhodium;Tungsten

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Grade Interpretation Managemant

0 Incomplete evaluation Complete it

1 Normal None

2 Benign None

3 Probably benign (<2%) Short follow-up

4 Suspicious/ indeterminate Biopsy

5 Highly suspicious (>95%) Biopsy

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If a non-palpable mammographic lesion is noted and there is low index of suspicion (<2%), CORRECT further advise should be?

Mammographic follow-up annually

Mammographic follow-up in 3–6 months

Stereotactic core biopsy

Surgical biopsy

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If a non-palpable mammographic lesion is noted and there is low index of suspicion (>2%), CORRECT further advise should be?

Mammographic follow-up annually

Mammographic follow-up in 3–6 months

Stereotactic core biopsy

Surgical biopsy

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Acoustic shadow is produced by - Calculus - Air - Fluid - Fat

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Acoustic enhancement is produced by - Calculus - Air - Fluid - Bone

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Note : illuminated warning sign

sliding shielded doors

radiation warning sign

CT Room Entrance

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Thin beam from various directions

Detectors measure attenuation

Local attenuation at each point Translated to CT no Shades of gray

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Chest (single PA film) Skull Thoracic spine Lumbar spine Hip Pelvis Abdomen IVU Barium follow thrugh CT head Bone scan CT chest CT abdomen or pelvis

0.02 0.07 0.7 1.3 0.3 0.7 1.0 2.5 3 2.3 <5.0 8 10

Diagnostic procedure dose(msv)

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Substance HU value

Air -1000

Fat -50 to -100

Water 0

Muscle 10-40

Blood ~60

Contrast 130

Bone >400

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Quantitative scale for describing density Radio-density of distilled water at STP is

defined as 0 HU while the radio-density of air at STP is defined as -1000 HU.

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Thin slices (1-1.5 mm) are used with 10-mm spacing

Covers only 10% of the chest but provides improved detail while minimizing radiation dose

high spatial frequency algorithm -sharpens images, increases noise, not problematic in lungs

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True 3D image acquisition within a single breath hold.

Continuous acquisition of projection data

Continuous rotation of the x-ray tube and detectors and simultaneous translation of the patient through the gantry opening

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Multislice CT era started in 1992 with the introduction of Elscint CT Twin- dual slice

1998- Four-slice CT scanners

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Faster acquisition Coverage of larger area Less movement artifacts Isotropic multi-planar reformats Improved vascular and cardiac imaging Potential for faster throughput of patients

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T1 - measure of relaxation time in the Longitudinal plane

T2 - measure of relaxation time in the Transverse plane.

Fluid –hyperintense (white) to virtually everything else on T2W images. Low-to- intermediate signal on T1W.

Where to look - Urinary bladder & CSF.

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Things bright on T1W -

Fat Hemorrhage Proteinaceous

substances Melanin Paramagnetic agents

(gadolinium).

Dark on both T1W & T2W -

Air Flowing blood (on

SE/FSE images) cortical bone, and Ligaments, tendons,

and other dense fibrous tissues

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Contra-indications for RCM - Multiple myeloma - Renal failure - History of allergy/ asthma - Diabetic nephropathy - Severe dehydration - Previous reactions to contrast media

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Copyright © 2006 by the American Roentgen Ray Society

Gleeson, T. G. et al. Am. J. Roentgenol. 2004;183:1673-1689

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CT

Anatomical images

PET

Functional images Fusion

(software)

PET/CT

Fused anatomical + functional images

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Short-lived positron emitters - 11C, 13N, 15O, 18F, 82Rb, 68Ga

Principle – Annihilation coincident detection (511kev)

18F – metabolism, 13N – perfusion

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Type Mass& Charge Comment

Electromagnetic

1). X-ray

2). Gamma ray

Particulate

1). Electron (e)

2). Proton (p)

3). Neutron (n)

4). Alpha particle

0

0

variable mass

&

Charge

X-rays and gamma rays do not

differ except in the source.

Gamma rays are produced

intranuclearly, and x-rays are

produced extranuclearly (i.e.,

mechanically).

—

Exhibits a Bragg peak

Cannot be accelerated by an

electrical field

Helium nucleus

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Penetrating power

Ionization power

Damaging power

Maximum Gamma Alpha Alpha

Minimum Alpha Gamma Gamma

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Used in both tele and brachy Cs>Co> Ir

Radiotherapy

Teletherapy Brachytherpy Interstitial Intracavitatory Mould Temporary Permanant

•Co60 •Cs137 •Linear accelerator

•Ir 192 •Cs137 •Sr 90 •Co60 •Ra 226 •Radium 222 •Yetrium 169

•Au 198 •Pd103 •Cs 131 •I125

Systemic Radionuclide •I131 •P32

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Emission of Beta Rays by Both Beta+ gamma rays

Ytterium Gold

Phosphorus I- 131

Strontium Radium

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Most Least

Stage of cell cycle G2M S

Organ Ovary,testis Vagina>bone>cns

Tissue Gonads, bone marrow

Nervous tissue

Cellt ype undifferentiated, well nourished, divide quickly and are highly metabolically active

quiscent

Blood cell Lymphocyte platlet

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isotope Half life

Tc99 6 hours

I123 13 hours

I125 60 days

I131 8 days

I132 2.3 hours

P32 14 days

Co60 5.2 years

Ra 226 1622 years

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Highly sensitive Least Radiosensitive

Wilms Hepatoma

Ewings Osteosarcoma

Lymphoma Melanoma

myeloma Pancreatic Carcinoma

seminoma

WELMS HOMP

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Nuclear Scans

Radiopharmaceutical compound is used Most common radioactive compound is

Tc99m Pharmaceutical compound depends on the

imaging organ DTPA for GFR DMSA for cortical scarring

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•TC pyrophosphate - Acute Myocardial infarction •TC thallium subtraction scan - Parathryoid gland •TC 99 Macroaggregated albumin – Pulmonary perfusion •TC 99 Human serum albumin - Cardiac chamber •TC labeled RBC – Splenic diseases •Thallium scan - Myocardial Perfusion •Gallium scan - tumors/Abscess •Xenon gas - lung ventilation •Chromium -RBC labeling •DTPA –GFR •DMSA -Cortical Structure of kidney •Selenium 75 Methionine - Pancreas •Selenium and I131 -Thyroid •I 131 & I132 -Placental Function •I 131 Orthohippurate -Kidney

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imaging

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Swirl sign

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hematoma- imaging

Crescent shaped collection

Not limited by sutures – can spread along entire hemisphere.

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hematoma

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EDH SDH Assc with skull

fractures

Biconvex collection

Limited by sutures

Not limited by dural reflection – can cross the midline

Shear type injury

Crescent shaped collection

Not limited by sutures

Limited by dural reflection – does not cross the midline

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Diffuse Axonal Injury

White matter injury – unequal rotation or deceleration of adjacent tissues

Predilection for – lobar white matter, corpus callosum and dorsolateral brainstem.

80% of lesions are non hemorrhagic.

Staging system – Adams’

CT findings in DAI

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Cerebral contusion Most frequently encountered intra axial injury

Areas of hemorrhage ,necrosis and edema.

Coup/contracoup injuries

Gyral crests are frequently involved

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TUMORS

Herpes Simplex type 1

Temporal and frontal lobes, parahippocampal, uncus, cingulate gyri

Involvement of the insula and white matter lateral to the lentiform nucleus is characteristic

Sparing of basal ganglia

Patchy hemorrhage + contrast enhancement

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Herpes Encephalitis

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Japanese Encephalitis (JE)

Location - Thalamus, basal ganglia, brainstem,

cerebral hemispheres, cerebellum

MR – T2 hyperintensity, No gad enhancement

Hemorrhagic transformation described in

thalamus and cortex

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Japanese Encephalitis (JE)

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Japanese Encephalitis

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BARE ORBIT

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DIASTEMATOMYELIA

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OPTIC NERVE SHEATH MENINGIOMA

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SPINAL CORD EDEMA

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MENINGIOMA

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TB MENINGITIS

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NEUROFIBROMA

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LACUNAR INFARCT

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Unilateral lung hyperlucency Patient positioning

Rotation Scoliosis

Chest wall defect Mastectomy Poland syndrome (absent pectoralis muscle)

Pneumothorax

Airway obstruction Bronchial compression (hilar mass, cardiomegaly) Endobronchial obstruction with air trapping (foreign body, tumor) Obliterative bronchiolitis Swyer-James syndrome

Pulmonary vascular cause Pulmonary embolism Pulmonary artery hypoplasia

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Silhouette/Structure Contact with Lung

Upper right heart border/ascending aorta

Anterior segment of RUL

Right heart border RML (medial)

Upper left heart border Anterior segment of LUL

Left heart border Lingula (anterior)

Aortic knob Apical portion of LUL (posterior)

Anterior hemidiaphragms Lower lobes (anterior)

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Westermark Sign

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Hampton Hump

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Fleischner Sign

.

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Reverse S Sign

With mass adjacent to a fissure, the fissure takes the shape of an "S". The proximal convexity is due to a mass, and the distal concavity is due to atelectasis.

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Football Sign

Large oval radiolucency that represents a large amount of pneumoperitoneum in the shape of an American football. The ovoid appearance is the acknowledged hallmark of the football sign. Infants with GIT perforation

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Miliary Nodules What is a Miliary

Pattern?

Diffuse

Well defined

Randomly distributed

Round or oval lesions

1-5 mm diameter

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Differential Miliary Nodules Common Causes:

Tuberculosis / Fungi

Metastases Thyroid (Papillary)

Renal

Melanoma

Pneumoconiosis Silicosis

Talcosis

Sarcoidosis

Less Common Causes:

Amyloidosis

Alveolar microlithiasis

Hemosiderosis Mitral stenosis

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HYDATID CYST Meniscus/double arch/moon/crescent sign due to

thin radiolucent crescent in uppermost part of cyst.

Combo sign due to air fluid level inside endocyst and air between pericyst and endocyst.

Collapsed membranes inside the cyst outlined by air causing ‘serpent’ sign.

Completely collapsed crumpled cyst membrane floating on the cyst fluid produces “water Lilly” sign of Camalotte.

Cyst in cyst sign

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Bronchiectasis Irreversible bronchial dilatation Cylindrical, Varicose, Cystic Identification of an enlarged internal bronchial

diameter

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Bronchiectasis

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25 M

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Neuroenteric cysts Abnormal connection between the primitive

endoderm and ectoderm during the 3rd week of life.

Vertebral segmental abnormalities

Persistent connection between spinal canal and foregut

Harmatomas (displaced nests of endodermally derived tissue)

Other names - enterogenous cyst, enteric cyst, gastrocytoma, dorsal enteric fistula

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Neuroenteric cysts

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Quantifying Pleural Pathologies Pneumothorax –

Erect X-ray – 50 cc

Supine – 500 cc

Expiratory - <50 cc

Pleural effusion –

Lateral decubitus – 5 cc

Lateral – >75

Frontal – >200

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QUESTION A 16 yo with CoA has anomalous post-coarctation

origin of the right subclavian artery. The ribs most likely to demonstrate inferior rib notching would be: -

- Left third to ninth ribs

- Bilateral third to ninth ribs

- Right third to ninth ribs

- Bilateral first and second ribs

- Left first and second ribs

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Rib Notching – Superior 1) CTDs

RA SLE SS SjS

2) Metabolic HPT

3) Others

NF

RLD

Polio

Marfan’s

OI

Progeria

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Rib Notching - Inferior 1) Arterial

CoA Aortic

Thrombosis Subclavian

obstruction

2) Venous SVC obstruction

3) AV

Pulmonary AVM

Chest wall AVM

4) Neurogenic

NF

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QUESTION True among the following?

“Figure of 8” heart: Infracardiac TAPVC

“Sitting-duck” heart: Tricuspid atresia

“Box-shaped” heart: Infracardiac TAPVC

“Globular” heart with plethoric lung fields: TGV

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TGV

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TGV Normally, aorta is anterior to & at the right of PA In TGA, PA is to the right of its normal location

and obscured by aorta on chest X-ray This malposition+stress-induced thymic atrophy

+hyperinflated lungs = apparent narrowing of the superior mediastinum (most consistent sign of TGA)

CV silhouette enlarged and globular – “egg on a string”

Pulmonary flow - increases with closure of the ductus arteriosus.

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TAPVR

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Ebstein’s Anomaly

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PAPVC

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ToF

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Endocardial Cushion Defects

Sitting goose with an elongated neck on the AP projection in left ventricular angiography

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Explanation LA:

- Enlargement of the LA appendage

- “Splaying" of the carina

- Elevation of the LMB

- “Double density" projecting over the central portions of the heart

- Displacement of descending aorta to the left (Bedford sign)

- Always check left heart border for straightening.

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M mode cardiac US

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M mode cardiac US M-mode (Motion-mode) US shows the motion

of cardiac structures.

High sampling frequency (up to 1000 pulses per second)

Yields a one-D image, sometimes called an 'ice pick' view of the heart.

Detect valvulopathies (calcifications, etc.) & cardiomyopathies (dyskinesis, aneurysm, etc.).

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CORONARY ARTERIES

LCx

LM

Ao

LAD

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CT Coronary Angiography

Clinical Applications : Diagnosis of CAD

Evaluation of CABG graft patency

Evaluation of CA stent patency

Identification & characterization of plaques

Surgical planning prior to CABG

Anatomic abnormalities of coronaries

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MUGA Multiple gated acquisition scan is a method of

assessing EF. Also assesses LV wall motion & cardiac muscle

damage. Injecting RBCs, radiolabeled with Tc99, into the

patient's bloodstream & recording the emissions with a gamma camera.

Asses and follow cardiac function in patients on adriamycin.

Detects early changes in cardiac function that might easily be missed by other techniques, such as the echocardiogram.

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Explanation Thallium Stress Testing

What is this?

When is thallium stress testing the answer?

When is it the wrong answer?

What is the alternative choice?

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Thallium/Persantine Thallium Test Most accurate method of assessing myocardial

perfusion without an angiography.

Thallium-labeled RBCs are injected into the patient's blood-stream.

Provides a view of the blood flow into heart muscle.

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Thallium Test Indications

- when resting EKG changes make exercise EKG difficult to interpret

- to localize the region of ischemia

- to assess revascularization following bypass or angioplasty.

- History of chest pain - not certain if it is ischemic in nature (equivocal cases).

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CORONARY CALCIUM SCORING Agatston score

standardized EBCT protocol score < 11, minimum risk shows variable reproducibility*

SCORE > < 1 130 199

2 200 299

3 300 399

4 400

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Normal Peristaltic Activity Primary peristalsis

Major stripping wave

Initiated by deglutition

Starts from pharyngo-esophageal jn.

Secondary peristalsis

Arises due to local distention

Clears residual bolus

Appearance same as primary wave

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Tertiary contractions

Uncoordinated, non-peristaltic, non-propulsive segmental contractions

Function unknown

Asymptomatic persons

Increased incidence with age (presbyesophagus)

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Mass impression on the gastric antrum

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Intussusception

Barium enema

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Serous Cystadenoma Older age - 60 yrs

> 6 cysts, each cyst < 2 cm in diameter

Calcification - central stellate scar within fibrous stroma, may have a sunburst appearance

Multilocular cyst with a thin (< 2 mm) wall and lacks mural nodules or calcifications

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Mucinous Cystadenoma Body and tail

Female

Fewer cysts > 2 cm in diameter

Enhancement of tumor nodule

Peripheral calcification

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APPROACH TO A PATIENT WITH

ABDOMINAL TRAUMA

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CAB EVALUATION & INITIAL RESUSCITATION

HEMODYNAMIC STABILITY

UNSTABLE STABLE

SIGNS OF I/P

INJURY

FAST (+)

LAPAROTOMY

RELIABLE CLINCAL EXAM

NOT

POSSIBLE

CT/ OTHER

INVESTIGATIONS

POSSIBLE

EVIDENCE OF I/P INJ

YES NO

OBSERVE

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Obstructive jaundice

USG

Calculi

MRCP CT

Mass

DPCT

No obv mass

IHBRD No IHBRD

Liver biopsy +/- MRCP

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Achondroplasia Limbs Rhizomelic micromelia

Symmetric

Splayed and cupped metaphyses with bowing

Trident hand

‘V’ shaped notches in the

growth plates (chevron sign)

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Achondroplasia

Pelvis

- Ilium short and flat (tomb stone like)

- Acetabulum is horizontal with thick triradiate cartilage (champagne glass appearance)

- Small sciatic notch

Thorax

- Squared inferior angle of scapula

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DISH Wave like hyperostosis

Flowing ossification

>4 contiguous vertebras

Thoracic spine

Ossified ALL

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Ankylosing Spondylitis

B/L symmetric Lower two third Rosary bead appearance Reactive sclerosis Bony ankylosis osteoporosis

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Ankylosing Spondylitis Romanus lesion(erosion)

Squaring

Shiny corner sign

Marginal Syndesmophytes

Bamboo spine

Trolley-track sign

Dagger sign

SPINE

Osteomalacia Osteopenia

Looser’s zones or pseudofractures –

Linear areas Under mineralised psteoid

Bilateral and symmetric

Right angle to the cortex.

Axillary margins of scapula, sup and inf pubic rami, inner margin of prox femur, post margin of prox ulna , ribs

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Deformities

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Tri-radiate Pelvis

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Subperiosteal resorption Pathognomic

Sites

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Lamina

dura

resorption

Dental

sepsis

FD

Paget’s

Trabecular resorption

Throughout the skeleton

‘Salt and pepper’ skull

(classic)

Focal areas of skull thickening

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Brown tumor

Sites - Mandible, clavicle, ribs, pelvis, tubular bones

Heals after parathyroidectomy

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Renal lesions

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Primary HPT Secondary HPT

FEATURES HPT only HPT + ROD

Skeletal changes Less florid More florid

Sclerosis Rare Common

Brown tumor More common Less common

Chondrocalcinosis More common Less common

Soft tissue & vas

calcification

Less common More common

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Introsseous

membrane ossification

CALCIFICATION AT THE MUSCULAR AND LIGAMENTOUS ATTACHMENTS

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Rose thorn appearance in ribs

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Rickets - Imaging findings

Widening of growth plate- earliest

Irregular metaphyseal margins

Splaying and cupping of metaphyses- paintbrush appearance

Osteopenia

Epiphyses – irregular borders

Skeletal deformities

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Rickets

Scurvy - Imaging features

Osteoporosis

White line of Frenkel

Trummerfeld zone

Wimberger’s ring

Pelkan’s spur

Corner sign

Subperiosteal haemorrhage

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PROTRUSIO ACETABULI

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HEMANGIOMA

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Tuberculosis

Earliest –frequency, Later -Dysuria and hematuria

IVP- modality of choice

Early stages - only finding may be irregularity or destruction of one or more papillae

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Advance Changes

RAS/RVH

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