Anatomy by Diagnostic g g Imaging

Introduction to Radiologic Anatomy

WE ARE HERE

Patricia Moser, MD Assistant Professor, Diagnostic Radiology University y of Florida College g of Medicine

Radiology gy
Diagnostic Imaging Angiography and Interventional Radiology Not to be confused with Radiation Oncology (Radiation ( ad at o Therapy) e apy) Different specialty

Diagnostic g Imaging g g
Electromagnetic Radiation
X-ray & Computed Tomography (CT) Magnetic Resonance Imaging (MRI) Nuclear Scintigraphy (Nuclear Medicine)

Sound Waves (not radiation)

Ultrasound

Wilhelm Conrad Roentgen 18451845 -1923

January 1896 - First x x-ray made in public

Routine xx-ray current technology

Xray
Plain Radiography X RAY PRODUCTION inherent contrast film digital Contrast Radiography barium iodine i di Fluoroscopy CT (Computed Tomography)

ELECTRONS

XRAYS

A diagnostic image is composed of differences in contrast between tissues which result from differences in radiation interaction in the tissues

1. Electrons generated at filament 2. Negatively charged electrons move toward anode and d strike t ik t target t at t high hi h speed d 3. 99% result in heat dissipated by the rotating target 4. 1% create x-rays which are directed through the window 5. X-rays pass through patient to a receptor (film, digital, fluorescent screen, etc.)

Tissue Thickness

LESS GET THROUGH>>MORE GET THROUGH WHITE GRAY BLACK

The thickness of the tissue affects the attenuation of the x-rays.

Xray
Plain Radiography X ray production INHERENT CONTRAST film digital / PACS Contrast Radiography barium iodine i di Fluoroscopy CT (Computed Tomography)

Tissue type

MORE GET THROUGH>>LESS GET THROUGH BLACK GRAY WHITE

The tissue type affects the attenuation of the x x-rays rays

Radiographs are summation shadows created by differences in contrast between tissues. Tissue thickness and tissue composition affect the attenuation and therefore, the shade(s) of gray in the final shadow image.

Inherent Contrast
Tissue
Air Fat Soft Tissues Bone, Calcium Metal

Appearance on XRAY
Bl k Black Dark Gray Gray White Really y White

BONE SOFT TISSUE FAT AIR

BONE SOFT TISSUE FAT AIR

METAL

Xray
Plain Radiography X ray production inherent contrast FILM digital / PACS Contrast Radiography barium iodine i di Fluoroscopy CT (Computed Tomography)

Film Radiography
NOTE THAT MOST OF THE DARKENING OF THE FILM IS NOT BY XRAYS BUT BY VISIBLE LIGHT PHOTONS PRODUCED BY XRAYS HITTING A SCREEN IN FRONT OF THE FILM INSIDE OF A CASSETTE

Film Radiography
FILM CASSETTE DEVELOPING TANKS

Film Radiography
XRAY VIEWERS

PASS BOX

SAFE LIGHT

Film Radiography
XRAY FILM STORAGE

Xray
Plain Radiography X ray production inherent contrast film DIGITAL / PACS Contrast Radiography barium iodine i di Fluoroscopy CT (Computed Tomography)

Digital g Radiography g p y
Two types
Computed radiography, called CR
Uses existing equipment to make exposures Film cassette is replaced with a charged metal plate After exposure, plate is read in a special device

Computed Radiography CR

Digital Di it l radiography, di h called ll d DR

Requires conversion of the entire xray room Film cassette is replaced by a CCD sensor (like in a digital camera or video camera)

HERE ARE THE PLATES

PACS=Picture Archiving and C Communication i ti S System t

Film --> Computer Viewing

21ST CENTURY Awareness bracelet Flat screens Windows XP

20TH CENTURY Bad haircuts Films View box Whats Wh with i h the h t-shirts dudes?

Contrast Agent g
Anything that enhances the differences between tissues of similar densities For XRAY there are TWO commonly used contrast agents:
Barium Iodine

PLAIN RADIOGRAPH OF THE CHEST

BARIUM SWALLOW

Various ways they are introduced

Swallowed: barium swallow, upper GI By enema: barium enema In vein: Intravenous urogram In artery: y Arteriogram g

PLAIN RADIOGRAPH OF THE ABDOMEN

BARIUM ENEMA

Barium: upper GI
STOMACH

Iodine: Intravenous urogram py g Intravenous pyelogram (IVU or IVP)

KIDNEYS URETERS BLADDER

Iodine: Arteriogram through ( ) a catheter (tube) in the leg

RENAL ARTERY AORTA ILIAC ARTERY

Xray
Plain Radiography X ray production inherent contrast film digital / PACS Contrast Radiography barium iodine i di FLUOROSCOPY CT (Computed Tomography)

Fluoroscopy relies on image intensifiers to make moving (real time) XRay pictures

Xray
Plain Radiography X ray production inherent contrast film digital / PACS Contrast Radiography barium iodine i di Fluoroscopy CT (COMPUTED TOMOGRAPHY)

Diagram of fluoroscopic unit

Photograph of a fluoroscopic unit

Computed p Tomography g p y( (CT) ) $$$$ EMI

Computed Tomography (CT)

Still uses XRAYS like radiography Tube spins around patient Detector spins around patient opposite the tube Detector output and angular position fed into a computer p Computer performs calculations to estimate density of tissues in each square of a slice

Computed Tomography (CT)

Contrast for CT
Iodine injected into an arm vein during the scan Iodine or Barium diluted in water given orally for abdomen scans There are some risks
Allergic reaction Kidney damage

Enhances the blood vessels and organs and makes them much easier to see Enhances cancerous tissue in many cases

CONTRAST IODINE

Evolution of CT
First used clinically in late 1970s and early 1980s Quite slow: 1 minute per slice Still was revolutionary Generations: 1st, 2nd, 3rd, 4th, spiral, p , multi slice Now have detectors up to 320 slices wide Can scan the whole body in <1 minutes p Incredible detail possible Essentially a whole new modality Another revolution in the making

CT Of The Entire Body In 2 Minutes

CT Images from modern machine

CT WINDOWS
Soft tissue

Bone

Lung

Some cool things we can do with CT these days

CT Angiography Scan rapidly during Iodine injection in vein Colonography Scan colon after filling with air Bronchoscopy B h Scan chest air is already in bronchi 3D Images Computer reconstruction

CT Angiograms

CT Colonography

CT Bronchoscopy

3D CT of the heart

3D CT of the knee and leg

Ultrasound
Uses high frequency sound to make g images The sound is produced and detected with the same device: TRANSDUCER Transducer
Speaker: sound into patient Microphone: sound coming back from patient

Ultrasound

Analogous to SONAR used in undersea warfare

TRANSDUCER

Ultrasound Machines Getting Much Smaller

TRANSDUCER

Ultrasound Pictures Used To Be Hard To See

Not Any More

Obstetric Ultrasound

Ultrasound Of Breast Benign

Ultrasound Of Breast Cancer

Magnetic g Resonance Imaging g g

Starts with a really strong magnet
Supercooled with Liquid Helium / Nitrogen

Magnetic Resonance Imaging (MRI)

Transmit radio wave pulses into patient Listen for return radio waves caused by interaction with protons (water) in the patients patient s body Process the frequency and phase of the e u ed s signals g a s by co computer pu e returned Different tissues give different intensities of returned radio waves > image

MRI Contrast
Gadolinium solution injected into vein Same idea as the Iodine contrast used for CT Gadolinium alters the interaction of protons in water so radio waves with the p that it gives MORE signal Shows up as white on images

Magnetic Resonance Angiography

Nuclear Scintigraphy
Often called NUCLEAR MEDICINE Uses radioactive tracers that emit radiation
Electromagnetic OR particulate

Nuclear Scintigraphy
Nuclear Medicine

Often these are injected j into the vein Different tracers go to different organs or parts of the body Images are made by detecting the radiation coming out of the patient

NORMAL BONE SCAN

ABNORMAL BONE SCAN

NORMAL LUNG SCAN BLOOD FLOW (TOP) & VENTILATION (BOTTOM)

ABNORMAL LUNG SCAN BLOOD FLOW (TOP) & VENTILATION (BOTTOM)

Angiography And Interventional Radiology

Interventional Radiology
Radiologists do invasive procedures guided by images for either diagnosis or treatment Basically anything that breaks the skin
Needles for biopsy or fluid removal Catheters to make angiograms Catheters with balloons to open p blood vessels Stents to hold blood vessels open Coils and material to block blood vessels Catheters to drain abscesses Tubes for feeding etc t etc t

Drawing of normal kidney

Frank Netter, MD you will love this guy by the time you are a e finished s ed

Angiogram of normal kidney

SPINE 11TH RIB

Angiogram of kidney cancer

THIS IS THE CANCER MASS THIS IS THE CATHETER COMING UP FROM THE LEG ARTERY

Angiogram after embolization

NO BLOOD FLOW TO THE MASS NOW IT CAN BE REMOVED WITHOUT EXCESSIVE BLEEDING

Non Surgical Biopsy

Non Surgical Shunting For Cirrhosis of Liver TIPS

Angioplasty Balloon Vascular Stent

Angioplasty & Stent

AFTER

Irregular renal artery reduced blood flow to kidney, produces hypertension

Post angioplasty, flow is restored and the patient becomes normotensive

BEFORE

Diagnostic Imaging
X-ray radiography, di h contrast t t studies, t di CT Ultrasound Magnetic Resonance Imaging MRA Nuclear Scintigraphy

WHY DO I NEED TO KNOW THIS?

Angiography And Interventional Radiology

ANATOMY

Knee - MRI Sagittal

PATHOLOGY

ANTERIOR CRUCIATE LIGAMENT

POSTERIOR CRUCIATE LIGAMENT

IMAGING IS ESSENTIAL TO MODERN HEALTH CARE DELIVERY

GROWTH OF IMAGING

Rothenberg, Korn. The Opportunities and Challenges Posed by the Rapid Growth of Diagnostic Imaging. J Am Coll Radiol 2005;2:407-410.

ONE REASON FOR GROWTH

Percentage g of internists saying y g that the loss of an innovation would have the most adverse effect on their patients.
Fuchs VR, Sox HC Jr. Physicians views of the relative importance of thirty medical innovations. Health Aff 2001;20:30-42.