Radiology Lecture

By Dr Kebede(MD,Radiologist)
 Learning objectives:
• Understand sources of radiation exposure
• Discuss Ethical, professional and legal issues of
radiation exposure
• Understand mechanisms of protecting patients and
the public from inappropriate radiation exposure
• Discuss medical application of radiation and common
diagnostic imaging modalities
• Discuss radiological approach to common diagnostic
imaging modalities
 Mode of Assessment
• Progressive assessment (attendace,active
participation)….25%
• Written exam : 75%
 Responsibility of the students
• Attendance : 100%
• Attentiveness
• Active participation
 Sources of radiation
Natural (70-85%,2.4 Man-made(15-
milisielvert/year) 30%,0.6milisilviert/year)
• Inhalational(Radon gas) • Diagnostic medical
• Radionuclide from rock exposure
• Ingestion • Atmospheric nuclear testing
• Cosmic radiation • Occupational exposure
 Radiation exposure of the public
• 70-85% (2.4msV)natural background radiation
• 15-30% (0.6msv)medical radiation exposure
• Overall exposure : 3msV /Year
• CT scan contributes for 4% of all diagnostic
imaging modality but shares 40% of all
medical radiation exposures
 Hazards of radiation exposure
• Carcinogenesis
• Teratogenesis
• Abortion
• Burn
NB: Stochastic vs. Deterministic effects
 Life time risk of fatal cancer after
diagnostic medical radiation exposure
 Guideline while imaging a patient
• A useful investigation is one in which the
result - positive or negative – will alter clinical
management and/or add confidence to the
clinician's diagnosis.
• Significant number of radiological
investigations do not fulfill these aims hence
causing inappropriate patient radiation
exposure.
Major causes of inappropriate patient
exposure
1. Repeating investigations
2. Investigation when results are unlikely to affect
patient management
3. Investigating too often
4. Doing the wrong investigation
5. Failing to provide appropriate clinical
information and questions that the imaging
investigation should answer.
6. Over-investigating
 Mechanism to protect patients and
the public
• Justification of the procedure
• Optimization of a procedure
• Dose reduction techniques
The field of Radiology and Imaging
• Young dynamic field on continuous changes
and improvement
• Importance of radiology and its value for
modern medicine
• Futures and Advances in Imaging
• Risks ,medico-legal issues and public concerns
 What did radiology Add to medicine?
• Imaging difficult organs(organs like
Brain,mediastinum,retroperitoneum,.)
• Better surgical planning
• Staging cancers
• Interventional radiology
• radiotherapy
 Imaging Modalities
• Radiation emitting • Non-Radiation emitting
modalities modalities
– Radiographs (analogue, • Ultrasound
computed Radiograph • Magnetic Resonance
and digital) Imaging(MRI)
– Fluoroscopy
– Mammography
– Computed Tomographic
(CT) Scan
– Nuclear medicine
Imaging
 Mode of imaging
• Anatomical imaging • Functional Imaging
– Radiographs – Nuclear medicine
– Mammography (PET,SPECT)
– Ultrasound – Functional MRI
– CT scan • Combined
– MRI – PET-CT
– PET-MRI
Conventional radiographs
• .
Fluoroscopy
 CT scan
• . • .
 Radiographic densities
• Air : blackest on a radiograph
• Fat, which is shown in a lighter shade of gray
than air
• Soft tissue or fluid (because both soft tissue and
fluid appear the same on conventional
radiographs, it’s impossible to differentiate the
heart muscle from the blood inside of the heart
on a chest radiograph)
• Calcium (usually contained within bones)
• Metal : appears the whitest on a radiograph
MRI
Systematic approach to common
radiographs
By Kebede(MD,Radiologist)
 LECTURE -2

Systematic Approach to CXR

 Technique :
• Standard : PA and lateral
• Critically ill patients, pediatrics: AP/Supine
Indications :
– Persitenent cough > 2weeks
– In working up Complications of pneumonia
– Congestive Heart failure, pulmonary edema
– Pulmonary Thromboembolism
– Lung cancer and ,metastatic work up
– Preoperative work up
– Follow up of treatment
 1. Assessing Technical adequacy
• Labeling : Identification ,Technique, right/left, Date
• Inspiratory /Expiratory : anteriorly 6 ribs, posteriorly 10
ribs has to be seen
• Rotation : medial ends of the clavicle should be at
equidistance from the spinous process/ 1/3rd of the
cardiac shadow should be in the right hemi chest and
2/3rd should be in the left hemi chest
• Penetration : above 4 thoracic vertebrae should be
visualized…..underpenetrated  if not visualized and
over penetrated if lower vertebrae are visualized.
AP film : apparent magnification of the cardiac and mediastinal
outline is seen
ANTERIOR RIBS

POSTERIOR RIBS
Expiratory Inspiratory
 Drawbacks of expiratory film
• cardiomegaly
• Abnormal contour of the aorta and
• patchy opacification in both lower zones.
 Drawbacks of Underpenetrated film
• apparent cardiomegaly
• apparent hilar abnormalities
• apparent mediastinal contour abnormalities
• the lung parenchyma tends to appear of
increased density, i.e. ‘white lung’.
 ….technical adequacy
• Field of view: should include the lung apices and
the costophrenic angles
• Others: breast shadow should be outside of the
lung field, foreign bodies like necklace should be
removed
• Hence , before reading Chest film its technical
adequacy has to be assessed whether it is
adequate to read or not since technically
inadequate film may mask or overcall findings
and mislead to patient mismanagement.
 INSIDE –OUT-APPROACH
• Air ways
– Trachea :
• Location : Central/slight shift to the right
• Size : 13mm-23mm in females,15mm-27mm in males
• Lumen: air field
• Carinal angle : acute angle,72 degrees
• Para tracheal strip < 4mm
Right partracheal strip
• Hilum
– Location : left is always higher than the right
– Density : symmetric and concave outward; Contributed by
: pulmonary artery and veins,lymphatics not the air ways
• Pulmonary vasculatures:
– Are the only white branching linear opacities in lung field
which fade in peripheral 1/3rd of the lung field/first
intercostal space
– In PA film lower lung zones are more vascularized than the
upper lung zones
– If there is at least equalization of vascular diameter in
upper and lower zone there is vascular redistribution or
cephalization
 ….continued
• Lung Fields:
– Compare both lungs zone by zone
– Upper lung zone is more ventilated than the lower
lung zone
– Upper lung zone : up to 2nd intercostal space
– Mid lung zone : between 2nd and 4th intercostal
space
– Lower lung zone : below 4th intercostal space
 Cont…..
• Cardiac and mediastinal silhouette
• Location : Central
• Shape
• Size : <50% in adult on PA ,<60% in pediatrics and
supine films
• Outlines: Its borders should be well outlined
• Diaphragm
• Well outlined
• Dome shaped
• Acute costophrenic angles
 ….cont
• Rib cage and soft tissue
– Bones : osteolytic or sclerotic changes, missing
ribs, deformity
– Soft tissue : swelling,gas,calcifications ,nodules,..
• Hidden Areas
– Sub diaphragmatic areas,retrocardiac
areas,paratracheal areas and peripheral lung fields
 Common terminologies
• Opacification : increased density in the lung field
• Luncency : increased blackness/transradiancy
• Consolidation : ill-defined opacity with internal
branching tubular radiolucent areas representing
patent terminal bronchioles……air bronchogramme .
• Collapse : well defined increased opacity due to
blocked air ways; could be segemental,lobar,total…..no
air bronchogramme.
• Reticulations : linear radio-opaque shadows
• Nodules : discrete ,round radio-opaque shadows < 3cm
• Mass: well defined radio-opacity >3cm
 ..cont
• Blebs : subpleura air containing lesions < 1cm in
diameter having thin wall
• Pneumatocele: air containing lesions < 1cm in
diameter having thin wall measuring <1mm
• Bullae : air containing lesions >1cm in diameter
having thin wall <1mm
• Cavity : air containing lesions >1cm in diameter
having thick wall <1mm(active infection >3mm,air
fluid level in the cavity and adjacent
consolidation)
 …cont
• Silhouette sign : Loss of the normal radiologic
definition/contrast between two adjacent
structures
Consolidation with air-bronchogramme
 REVERSED BATWING
• When the periphery of the lung is affected
and the central areas are spared
Atelectasis

Atelectasis with well defined increased opacity

mass

Nodule
 Reading assignment
• How to approach and differentiate air space
VS. Interstitial lung Parenchymal diseases on
chest X RAY (Learning radiology recognizing
the basics chapter 5 and Radiology Assistant
Chest X-Ray - Lung disease Four-Pattern
ApproachInternet)
 Lecture -3

Approach to spine X ray

 Approach to cervical spine x ray
• Technique : AP and lateral
• Supplementary views: Open mouth view
,flexion and extension views
Technical adequacy: Skull base and C7/T-1
Junction should be included
Systematic Approach : ABCS
NORMAL : LATERAL
NORMAL : AP
NORMAL OPEN MOUTH VIEW
 A-Alignment(assed on lateral film)
• Line 1 is in the prevertebral soft tissue……..10mm
anterior to C-1 ,5-7mm between C-2-C-4, and
22mm between C-5-C-7. It should have smooth
contour.
• Line 2 follows the anterior vertebral bodies and
should be smooth and uninterrupted.
• Line 3 is similar to the anterior vertebral body line
(line 2) except that it connects the posterior
vertebral bodies.
• Interruption of the anterior and posterior
vertebral body line is a sign of a serious injury
 Cont…..
• Line 4, called the spino-laminal line, connects the
posterior junction of the lamina with the spinous
processes.
• The spinal cord lies between lines 3 and 4;
therefore any offset of either of these lines could
mean that a bony structure is impinging on the
cord.
• Severe neurologic deficits can result from very
little force against the cord, and any bony
structure lying on
 …cont
• Line 5 is not really a line so much as a
collection of points—the tips of the spinous
processes
• After visually inspecting these five lines on the
lateral C-spine, inspect the C1–2 area a little
more closely. Make certain that the anterior
arch of C1 is no greater than 2.5 mm from the
dens in adults and 5mm in children.
 B-bones
• Height : Anterior and posterior vertebral body
height should be equal
• Size : progressively increase downwards
• Cortical outline should be smooth
• End plates : smooth
• Density (normal trabecullar pattern ,accentuated
trabecullar pattern….osteoporosis)
• Look for any osteolytic or sclerotic changes
• Look for osteophytes
 C-Cartillage/Disc spaces
• The disc spaces are examined next to check
for any inordinate widening or narrowing,
either of which could indicate an acute
traumatic injury.
• If a disc space is narrowed, it will usually be
secondary to degenerative disease. Make
certain that associated osteophytosis and
sclerosis are present.
• Look also for facet joints and neural foramina
Vertebral columns
 Stable Vs Unstable Fracture
• Stable : Fracture involving only one column
• Unstable fracture : Fracture involving more
than one column
 Terminologies
• Spondylosis : bony Overgrowth over the vertebral
bodies(osteophytosis)
• Spondylolisthesis : sliding of vertebral bodies over
one another(Grade -1 < 25% of the vertebrae has
slided over, Grade 2 25-50%,Grade 3 50-75% and
Grade 4 mores than 75% of the vertebral body is
sliding over the inferior)
• It could be posterior or anterior
• Spondylolisis : Fracture of the vertebrae
Common Indications for cervical spine
x ray
• Trauma
• Radiating neck pain
• Infection(vertebral and soft tissue)
• Metastasis
• Degenerative changes
• Neoplastic conditions
• Upper air way obstruction
• Foreign body,..
 Thoracic and Lumbar spine
Technique : AP and lateral
Normal vertebral curvature in adults
• Cervical and lumbar : lordosis
• Thoracic and sacral spine : Kyphotic
• 5-lines are used in cervical spine only
• The size of vertebral body and the height of
disc spaces will gradually increase downwards
• Otherwise systematic approach is the same
Lumbar spine : AP
 NB:
• For systematic approach of thoracic and lumbar
spine X ray please refer emergency radiology
page 328-329
• Spine Tuberculosis is the most common
musculoskeletal tuberculosis
• Thoraco-lumbar junction is the most common
site
• Paravertebral collection/abcesses with
calcification is pathognomonic for Tuberculoses
spondylodiscitis
 Role of MRI in spine
• MRI is superior for evaluation of degenerative
vertebral and disc diseases, disc prolapse ,for
assessing central canal and neural foraminal
stenosis, for diagnosis of spondylodiscitis
• MRI has also superior efficacy for spinal cord
neoplasms,infection and inflammatory
condition of the spine, and for assessing spinal
cord injury and compression.
 Role of CT in spine
• Gold standard for bony lesion
• For assessing trauma
• For assessing Bone
neolasms(Primary/secondary)
• Assessing Osteoporosis
 Lecture -4

Systematic approach to extremity

radiographs
 Indication
• Infection
• Inflammatory conditions like rheumatoid
arthritis
• Bone neoplasm's
 Systematic approach: ABCS
• A-Adequacy and alignment
– View : Atleast two views
– Areas of interest should be included
– Adequately penetrated film
– Normal alignment in specific region
 B-Bone
• Cortex : have smooth cortical outline ,fracture
lines
• Normal medullary cavity
• osteolytic or sclerotic changes
• Density : normal or osteoporotic
 C-Cartillage /joint
• Articulating surface : smooth outline with no
irregularity
• Joint space : look for asymmetric widening or
narrowing
• Look for any intra-articular foreign
bodies/loose bodies
 S-Soft tissue
• Look for swelling
• Fat planes….obliteration/displacement
• Gas in soft tissue(indicates gas forming
infections/abcesses), foreign bodies
 Imaging modalities of choice
• MRI and Nuclear medicine scan : detect
osteomyelits at earlier stage(in the first 3 days)
• Conventional Radiographs: There is radiological
lag of 10days -2weeks for osteomyelits
• MRI : Is helpful to know the extent of bone and
soft tissue involvement in sarcomas of the bone
and soft tissue
• CT : Better for assessing and grading fracture
• Ultrasound : cellulites ,soft tissue abscess,
Pyomyositis, joint effusion
Plain Abdominal X ray ,normal and abnormal bowel gas distribution,
signs of extra luminal gas…well discussed in class

LECTURE -5
 Plain Abdominal X ray
• Standard : Erect plain abdominal X ray
• Other views: Supine and cross table lateral
decubitus
 Systematic approach to plain
abdominal x ray
• Look for normal bowel gas distribution
• Look for abnormal bowel gas distribution
• Look for abnormal soft tissue density
• Look for abnormal calcifications
 Normal bowel gas distribution
• Stomach : air is always seen except in NG tube
decompression or excessive vomiting
• Small bowel : 2-3 non-dilated bowel loops
• Large bowel: Normally seen in rectum and
sigmoid
 Abnormal bowel gas distribution
• The presence of > 3 air fluid levels in small
bowel
• The presence of one air-fluid level in large
bowel is abnormal
• Absence of gas in the rectum
• Dilated bowel loops(>3cm in small
bowel,>6cm in large bowel and > 9cm in
cecum==rule of 3)
• Signs of extralumnal gas.
 References
• Learning radiology recognizing the basics 3rd
edd
• Emergency radiology 1st edd
• Fundamentals of skeletal radiology 4th edd
• Internet : Radiology Assistant