Rational Imaging Investigation For Common...
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M I T R A K H AL I L I M D
Rational Imaging Investigation For Common Diseases
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BASIC CONCEPTS IN DIAGNOSTIC IMAGING
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Modalities Available in Radiology
Plain Film / X-Ray/Mammography
Fluoroscopy
Ultrasound
CT
MRI
Nuclear Medicine/Molecular Imaging
Angiography/Interventional
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X-Rays
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
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Most Useful Applications for Plain X-Rays
Chest
Musculoskeletal
Abdomen: limited usefulness
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Fluoroscopy
Utilizes X-Rays
Real-time imaging
Utilizes image intensifier
Involves use of contrast agents
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Main Uses of Fluoroscopy
Gastrointestinal Imaging
Genitourinary Imaging
Angiography
Other
Intraoperative
Foreign body removal
Musculoskeletal
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Gastrointestional Fluoroscopy
Barium Swallow
Upper GI
Small Bowel Series
Enteroclysis
Contrast Enema
Defecography
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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
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Genitourinary Fluoroscopy
Cystogram
Voiding cystourethrogram
Retrograde urethrogram
Hysterosalpingogram
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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
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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
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Retrograde Urethrogram RUG
Male patients
Pelvic Trauma
Post-infectious: STD- looking for stricture
Different techniques
Meatus occluded and contrast injected into urethra under fluoro
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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
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Computed Tomography (CT
• Cross Sectional imaging modality
• Mobile X-ray tube that rotates around a patient 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
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CT Contrast Agents
• Intravenous contrast: Differentiate blood vessels vs. vascular internal organs
• Enteric contrast: Differentiate bowel vs. intra-abdomina fluid/masses
• Rectal contrast
• Retrograde urinary bladder contrast
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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
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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
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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
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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 Pt’s body used to generate image
• Field strength of magnets 0.3-3.0 Tesla
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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
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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
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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
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Respiratory system
Routine admission and preoperative CXR: - Admission chest radiographs were recommended only on patients with
clinical findings of cardiopulmonary disease or elderly patients unable to provide an accurate history or undergo a reliable physical examination.
- preoperative chest radiograph : advanced patient age (especially >70 years) and certain other patient- and procedure-related risk factors (eg, history of cardiopulmonary disease, unreliable history and physical examination, high-risk surgery) .
- Decision should derive to investigate a clinical suspicion for acute or unstable chronic cardiopulmonary disease that could influence patient care.
Portable CXR in ICU - Daily in acute cardiopulmonary problems - CXR after specific procedure - CXR for presence or course of disease
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Respiratory system
Acute respiratory illness in immunocompetent patient:
- >40 y/o
- Dementia
- Hemoptysis
- Positive physical exam
- Associated abnormality ( WBC, hypoxemia)
- CHF, coronary artery disease, drug induced acute respiratory disease
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Respiratory system
CXR in COPD:
- Complications such as pneumonia or pneumothorax, CHF, coronary artery disease ,chest pain, leukocytosis,edema
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Respiratory system
CT in ARI:
- severe pneumonia
-Febrile neutropenic patient with normal CXR
- Clinical suspicious for SARS or H1N1 and normal CXR
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Respiratory system
ARI in immunocompromised patient:
- CXR
- CT
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Respiratory system
Dyspnea:
-CXR : Chronic, severe,>40 y/o,cardiovascular or pulmonary or neoplastic disease
- HRCT: When CXR is non revealing or it reveal abnormality but no definitive diagnosis
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Respiratory system
Hemoptysis : Common causes include chronic bronchitis, bronchiectasis, pneumonia, fungal infections, tuberculosis, and malignancy and rarely vasculitis.
- CXR
- CT : suspicious chest radiograph findings or risk factors (>40 years of age, >30 pack-year smoking history).
- MDCT angiography : If hemoptysis recurs
Massive hemoptysis : Contrast-enhanced MDCT prior to embolization or surgery can define the source of hemoptysis as bronchial systemic, nonbronchial systemic, and/or pulmonary arterial.
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Respiratory system
Screening for pulmonary metastasis:
- CXR: baseline
- CT: Bone and soft tissue sarcoma, melanoma and head and neck carcinoma, RCC and testicular carcinoma with elsewhere metastatic disease
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Respiratory system
Rib fracture:
- CXR (PA view):indicated
- X-Ray rib view: usually not appropriate
- CT: usually not appropriate
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GI system
Acute abdominal pain and fever Abdominal abscess in postoperative or nonoperative state:
- CT with contrast
Acute abdomial pain:
1. Perforation/Obstruction
- AXR and CXR
- CT: High clinical suspicious with negative X-Ray
- Ba study should not be used as a primary modality in diagnosis of small bowel obstruction.
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GI system
2. Appendicitis :
-CT with oral and IV contrast : most accurate imaging
- US : in children
- MRI : in pregnancy with equivocal US exam
3. Pancreatitis :
- US : gallstone evaluation
- CT with iv contrast : choice
- MRI with iv contrast and MRCP
4. cholecystitis:
- US
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GI system
Dysphagia:
- Barium swallow : Motility disorders and subtle stricture in comparison with endoscopy
Esophageal perforation :
- CXR
- Contrast swallow
- CT : sensitive for detection of perforation
Dyspepsia :
- Endoscopy : If negative or symptoms persist or alarm signs are present Barium meal
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GI system
Jaundice :
1. Obstruction/ non obstruction
2. Benign/ malignant
3. Operative/ non operative
Stone : US / MRCP
Malignancy : Cross-sectional imaging ( CT / MRI )
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GI system
Palpable abdominal mass :
- US and CT : First line procedure
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GU system
Acute onset flank pain (stone?) : most complain
- CT without contrast : choice method
- IVP
- US and AXR : Children, pregnancy
Acute scrotal pain :
- Strong clinical suspicious to torsion : Explore
- Suspicious : Doppler ultrasound
- RNSI : Long examination time and less availability
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GU system
Hematuria : - Gross hematuria clearly conveys a much higher risk of
malignancy than microscopic disease and should be thoroughly evaluated.
- Young women with a clinical picture of simple cystitis and whose hematuria completely and permanently resolves after successful therapy will probably not require any imaging as well as glomerulopathy.
- Risk factors such as cigarette smoking, occupational exposure to chemicals, irritative voiding symptoms, a full urologic evaluation for urothelial carcinoma is recommended if even one urinalysis documents microhematuria.
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GU system
CTU : CTU is the first study in patients with hematuria .
Cystoscopy : The imaging evaluation will almost always be accompanied by cystoscopy to evaluate the urinary bladder
US : In patients who have contraindications to CTU or are sensitive to radiation (children and pregnant or child-bearing age women), or who have a very low risk of having a malignant cause of hematuria, US is the first-line imaging modality as well as patients with glomerular disease .
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GU system
Most adults with gross or persistent microhematuria require urinary tract imaging, with CTU replacing the traditional IVU for this indication.
Although MRI is an excellent technique to evaluate the renal parenchyma for masses and other abnormalities, it is inferior to CTU and IVU in detection of small stones and urothelial lesions.
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In the CT urogram, all patients receive water, primarily to hydrate the kidneys and distend the collecting system and ureter. Next, a noncontrast helical CT of the kidneys is obtained to evaluate renal calculi. This is followed by the injection of iodinated contrast media with the acquisition of a high-resolution (1- to 2-mm sections) nephrographic phase and a high-resolution delayed (five to 10 minutes) phase to evaluate for tumors and filling defects.
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GU system
Acute pyelonephritis : - CT without and with contrast : No response to AB
therapy in 72h/ complicated adult (history of stone ,prvious urological surgery, repeated pyelonephritis) / DM or Immunocompromised without response
Pyonephrosis : - US exam VCUG : demonstrate vesicoureteral reflux and only
performed routinely in children. DMSA scan : pediatric population - US and DMSA scanning is recommended in children
after their first febrile UTI
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GU system
Renal failure :
- US : First imaging modality : Separate chronic ESRD from reversible ARF with size/echo/hydronephrosis/cystic disease
- CT : Equivocal US for obstruction like stone or cystic disease
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GU system
Renal trauma : 1. Blunt abdominal trauma and gross hematuria 2. Blunt abdominal trauma, shock (systolic pressure <90
mm Hg in the field or during resuscitation), or other associated injuries and microscopic hematuria
3. Blunt trauma with injuries known to be associated with renal injury such as rapid deceleration, direct contusion to the flank, flank ecchymoses, or fractures of the lower ribs or thoracolumbar spine, regardless of the presence or absence of hematuria
4. Penetrating trauma to the upper abdomen or lower thorax regardless of the presence or absence of hematuria.
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GU system
Renal trauma :
- Hemodynamically stable patient (blunt and penetrating trauma): CT with contrast : modality of choice
- Only microscopic hematuria do not need radiological evaluation.
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GU system
Bladder injury ( Penetrating or blunt ) :
- CT of the pelvis with bladder contrast (CT cystography) : first line
- X-ray retrograde cystography : filled view, and postdrainage radiograph
- X-ray RUG is the examination of choice for a suspected blunt perineal trauma in the male (straddle injury) and should be performed for suspected urethral injury from a penetrating trauma.
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GU system
AUB :
- TVUS : Endometrial thickness is a well-established predicator of endometrial disease in post menopausal woman
Adnexal mass :
- US : Primary modality
- MRI : A problem solving tool
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GU system
Acute pelvic pain in reproductive age:
- TVUS/TAUS : modality of choice in obstetric or gynecologic etiology
- CT : In gastrointestinal or genitourinary pathology
- MRI : In pregnant patients for nongynecologic etiologies
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GU system
IUD :
- US
- AXR : only when IUD is not in uterine cavity
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Breast imaging
Mammography is the only method of screening for breast cancer shown to decrease mortality.
Annual screening mammography is recommended starting at:
1) age 40 for general population; 2) age 25-30 for BRCA (BReast CAncer 1) carriers and untested relatives of BRCA carriers; 3) age 25-30 or 10 years earlier than the age of the affected relative at diagnosis (whichever is later) for women with a first-degree relative with premenopausal breast cancer or for women with a lifetime risk of breast cancer ≥20% on the basis of family history; 4) 8 years after radiation therapy but not before age 25 for women who received mantle radiation between the ages of 10-30; 5) any age for women with biopsy-proven lobular neoplasia, atypical ductal hyperplasia (ADH), ductal carcinoma in situ (DCIS), or invasive breast cancer.
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Breast imaging
US :
1. Identification and characterization of palpable and nonpalpable abnormalities and further evaluation of clinical and mammographic findings.
2. Guidance of interventional procedures.
3. Evaluation of problems associated with breast implants.
Breast sonography is the initial imaging technique to evaluate palpable masses in women under 30 and in lactating and pregnant women.
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Breast imaging
MRI :
1. Screening
2. Extent of disease
3. Additional evaluation of clinical or imaging findings
MRI should not replace ultrasound or diagnostic mammography to evaluate clinical focal signs or symptoms in the breast or to evaluate lesions identified on screening mammography.
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Breast imaging
For high-risk women, annual screening mammography and contrast-enhanced MRI are both indicated. US can be used for patients with contraindications to MRI.
For intermediate-risk women, annual screening
mammography is indicated. Contrast-enhanced MRI may be indicated in some patients.
For average-risk women, annual screening
mammography is indicated.
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Breast imaging
Any highly suspicious breast mass detected by palpation or imaging should be biopsied.
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Trauma
Blunt abdominal trauma_ Unstable patient :
1. CXR (portable)
2. US (FAST)
3. pelvic X-Ray
4. Lat. Cervical X-Ray
5. CT : Chest, abdomen and pelvic
Blunt abdominal trauma_ Stable :
- CT with IV contrast : First line
- CXR
- US (FAST)
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Trauma
Blunt chest trauma : - CXR and chest CT/CTA are complementary first-line
imaging modalities in the workup of patients with high-mechanism blunt trauma.
- When initial trauma survey and mechanism of injury
suggest a low probability of significant thoracic trauma (normal mental status, normal clinical examination, and normal chest radiograph), further assessment with chest CT/CTA may not be necessary.
- suspected aortic injury CTA : First choice - TEE and MRA : alternative
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Trauma
Head trauma :
- Minor or mild closed head injury (GCS≥ 13)without risk
factor or neurological deficit : No imaging
- Minor or mild closed head injury ,focal neurologic deficit, moderate or severe acute closed head injury in adults or children : CT without contrast
- Penetrating head injury , stable : CT without contrast
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Trauma
Cervical spine trauma :
- Adult with low risk cervical spine trauma : No imaging
- Adult not low risk : CT ( Thin section with sagital and coronal reconstruction )
- Pediatrics : 3 view X-Ray
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Trauma
Thoracolumbar spine trauma :
- CT : Choice
- MRI : Cord injury
- Imaging of entire spine when there is fracture of any segments
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Trauma
MSK trauma :
- X-Ray : First imaging modality
- Reaeated radiograph/CT/MRI : High clinical suspicion
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62
Thank You
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