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Introduction to Radiological Modalities

Department of Radiology, p gy, Vancouver General Hospital

Dr. Savvas Nicolaou Director of ER/Trauma Radiology savvas.nicolaou@vch.ca

Objectives
• Understand the basic principles of the following modalities: • • • • • • Ultrasound Radiography Computed Tomography Magnetic Resonance Positron Emission Tomography Nuclear Medicine

• Understand the relative radiation risk of the different imaging modalities e able ecog e the e ajo densities ou d on an ay • Be ab e to recognize t e five major de s t es found o a x-ray

Objectives
• Be able to define the following terms: • Attenuation, radiodense, radiolucent, Hounsfield Unit • B able t d fi th f ll i views on x-ray plain fil Be bl to define the following i l i film • X-ray - Lateral - Anteroposterior (AP) - Posteroanterior (PA) • Be able to recognize and define the anatomical planes on cross sectional imaging: • Sagittal • Coronal • Transverse/Axial

What is Radiology?

What is Radiology?

• Area of clinical medicine involving anatomical imaging to help identify pathologies • Requires in-depth knowledge of anatomy, physiology and pathology

• Medical imaging began with the discovery of X-rays but continues to include additional modalities and improve on old ones as technology develops

Why is understanding radiographic imaging and anatomy important to me?
•As future physicians, most of you will h A f t h i i t f ill have t order and i t to d d interpret t radiographic images •Imaging is how you will be viewing anatomy in the future it is Imaging future, important you can correlate what you see on an image with basic anatomical structures

Why is understanding radiographic imaging and anatomy important to me?
• As future physicians, most of you will have to order and interpret physicians radiographic images • Most of you will be ordering images on real patients and need to understand the benefits and risks of what is being ordered

25 yr old female

VS

70 yr old male

with persistent diarrhea…… diarrhea Choice of imaging may be different!

Radiology in the curriculum
Provided throughout your four years of medical school

•PRIN – 10 workshops- f PRIN k h focus on understanding modalities and correlating d t di d liti d l ti anatomy with radiographic images •FMED (next semester and next year)– Clinical radiology emphasizing the FMED year) development of a system to interpret radiographs and specific pathologies •3rd year – survival skills for clerkship, opportunities for electives, and relevant imaging for emergency medicine •4th year – Refresher course for LMCC

Overview of imaging modalities
• X-ray systems • Radiography (plain films, fluoroscopy, angiography) • C Computed T t d Tomography (CT) h

• Magnetic Resonance Imaging (MRI)

• Ultrasound

• Nuclear Medicine (NM) / Positron Emission Tomography (PET)

Similar Theme of imaging (for all modalities)

Signal (xradiation or sound) is projected at or through tissue

Tissue changes signal (absorbs, (absorbs scatters, reflects, selectively takes up source etc)

Changed signal provides information which is used to construct an image

Keep th K these th themes in mind and the modalities i i d d th d liti will be easier to understand!

Radiography

X-rays are high energy electromagnetic radiation capable of penetrating human tissues

Discovered in the 17th century, their ability to help y y p visualize anatomical structures gave birth to diagnostic radiology in 1895

Early Xray Machine 1899

Radiography

Most common examination in gy radiology

X-rays are passed through patient X-rays detected on other side by film or digital detector Images often referred to as ‘x-rays’ or ‘plain film’

X-ray Unit

Radiography

As x-rays pass y p through the body, they are attenuated (absorbed and ) y scattered) by interaction with body tissues

Tissues with a higher density will attenuate more xrays and appear lighter (radiodense) on a plain film

Tissues with a lower density will attenuate less xrays and appear darker (radiolucent) on a plain film

Radiography
5 major densities are found on radiographs, and are demonstrated on this image g
Air - fat - water - bone - metal Soft tissue

Lower

Higher

fat

Note that THICK structures attenuate more radiation than THIN structures of the same composition
air metal

bone

Radiography

Liver L2 spinous process

Anatomic t t A t i structures are visible when they are outlined in whole or part by tissues of different x-ray density

Iliopsoas muscle

Bowel B l gas

Naming Radiographic Views
Most views are named by how x-rays pass through the patient

Posteroanterior

Anteroposterior

Naming Radiographic Views
Most views are named by how x-rays pass through the patient

Lateral

Oblique

Posteroanterior (PA) view

• Regularly used for chest x-rays • Decreases cardiac shadow compared to anteroposterior (AP) view • Reason for use in chest x-rays x rays

Posteroanterior (PA) vs Anteroposterior (AP)

PA

AP

Anteroposterior (AP) view

• Regularly used for non-chest xnon chest x rays along midline

Lateral view

The name is selfexplanatory, a view from th l t l side the lateral id

Oblique View

Not parallel to either AP or lateral views (may appear lateral but try comparing to previous slide)

Importance of using different views

Fluoroscopy Continuous low dose radiography used to monitor part of the body in real-time Often used in conjunction with contrast, can be helpful to evaluate motion such as gastrointestinal peristalsis Used less commonly in urban settings

NB: Contrast is an exogenous agent used to alter the attenuation of a structure

Barium Swallow

Contrast Agents
Intracavitary contrast eg barium for th f the GI tract (taken orally or t t (t k ll introduced per rectum)

GI is normally full of air or fecal matter, but with barium appears radiodense

Intravenous agents to visualize I t t t i li arterial system (angiography)

Catheter

Filling defect -embolus in L b l i pulmonary artery

Normally cannot visualize blood vessels without contrast

Computed Tomography (CT)

Computed Tomography

• Similar to radiography in that it uses ionizing radiation from a source to produce an image

Cross sectional • Cross-sectional image based on the same principles of attenuation as an x-ray

• 3D information based on tissue density

Computed Tomography (CT)

X ray Source • Source and detector rotates 360º around patient (modern scanners less than 0.5s)

• Less time averaging Object Detector

• Computer uses number of profiles to construct 3D information in 2D slices

CT (and MRI) views

Because the data is multi-planar multi planar, images can be reconstructed in different planes • Coronal view • Sagittal view • Transverse/Axial view

CT/MRI Axial views

Imagine feet are coming out of the screen

Anterior

Posterior

CT Views

CT A i l Axial CT Coronal CT Sagittal

Computed Tomography (CT)

A Hounsfield unit is assigned for every volume element (voxel)
•This unit is relative to the attenuation of water •The Hounsfield unit can help identify certain tissues - Eg Air 1000; fat -100; water 0; blood 30 ;b bone 500 HU 500+
NB the upper and lower values may change slightly depending on the scanner, but the values are always relative to water (0) l l l ti t t

Hounsfield Unit (HU)

Gall bladder 6 HU

Colon -1000 HU

Liver 50 HU

Fat -120

Air -1000; fat -100; water 0; blood 30 ; bone 500+ HU

CT windows

• We can differentiate only ~16 shades of grey

• CT data (Hounsfield units) cover a much larger range of values (( 1000 to +500)

• To interpret images, we limit the number of Hounsfield units displayed

• The computer is able to convert the ranges used to shades of grey we can see

CT windows
Window width: •The range of HU of all tissues of interest •Tissues i thi range will b di l Ti in this ill be displayed i various shades of grey d in i h d f •Tissues with HU outside the range are displayed as black or white

Window level: •The central HU of all the numbers in the window width

CT Windows

Wide Window

Hounsfield Units +400 +300 300 +200
Window Level

Narrow Window

+100 0 -100 -200 -300 -400

CT windows
Same patient – use of windowing allows inspection of areas with completely different density

Bone Window W:2500 L:480 – Frontal bone skull fracture

Soft Tissue Window W:80 L:40 – Epidural and parenchymal hemorrhage

Dynamic imaging, can follow anatomy

Transverse/Axial

Coronal

CT Strengths and weaknesses

Strengths • • Excellent bone detail Good soft tissue contrast • CT angiography (use of contrast in blood vessels) • 3D image rendering • • • • •

Weaknesses Availability Cost (though less expensive than MRI) Radiation Weight limitation 160 kg (350 lb) Contrast complications (allergies, nephrotoxicity) • Artefacts with metal

Magnetic Resonance Imaging (MRI)

Physics is complicated..…………. Simplified: • Protons in a strong magnetic field are bombarded with low energy (non ionizing) radiowaves

• In different tissues ( (environments) they absorb and ) y release the energy at different, detectable, and characteristic rates Looks like a CT but much different

Magnetic Resonance Imaging (MRI)
The released energy can be detected over time and images can be `weighted` to enhance different characteristics of the soft tissue

• T1 weighted – usually best anatomical detail, gadolinium can be used as contrast • T2 weighted – usually most sensitive for pathological lesions g y p g (Water is White in T2 - World War 2)

MRI Images
Which plane is this? p Sagittal

T1 weighted

T2 Weighted

MRI vs CT for Soft tissue
Which plane is this? Axial

CT

T2 Weighted MRI

showing same mass in R axilla

Magnetic Resonance Imaging (MRI)
Strengths • excellent soft tissue contrast • no radiation • MR angiography • gadolinium IV contrast is not nephrotoxic and may be used in setting of renal failure Weaknesses • availability/cost (very expensive) • procedure time (immobile, elderly, sick patients, children) • Movement can severely affect image quality • poor bone detail • metal and other artifacts • risk of complications related to magnetic metal implants (pacemakers, aneurysm clips etc,) etc ) • rare serious contrast reactions

Ultrasound (US)

• •

High frequency sound waves Sound reflected by body structures is converted to grey g y image

Doppler ultrasound uses the principal that flow changes the sound frequency, can detect blood flow bl d fl

First line imaging for heart

Ultrasound (US)

• Ultrasound imaging relies on sound echoes from tissue interfaces in the body • Strength of reflections depends upon the difference in acoustic properties of the interface tissues • Bone and air reflect virtually all the sound so US cannot be used near bone or the lungs very well.

ultrasound transducer sound pulse reflected pulses

Ultrasound Imaging
• Determination of cystic (fluid filled) vs. solid structures - cysts do not reflect sound and are anechoic • Evaluation of • bile ducts • gall bladder • Renal/ovarian/breast cysts • hydronephrosis Etc. • Evaluation of stones • gall stones • renal calculi l l li • Evaluation of abdominal and pelvic organs

Ultrasound Terminology
Terminology T i l Anechoic Description D i ti • black with no echoes or sound wave reflection • simple cysts, vessels, ascites

Hypo-echoic

dark on the film with some low grade echoes
• Organs, nodes, tumors, complex fluid

Isoechoic Echogenic

• the same echogenicity as another structure

bright on the film with significant sound wave reflection
• Fat, air, bone, complex fluid

Acoustic shadowing

reflection of sound waves with distal shadowing
• Stones, bone, gas

Ultrasound (US)

1

2
Anechoic

3

Echogenic Acoustic Shadow Hypo-echoic

Longitudinal cross section of the gall bladder. Fluid in bladder shows no reflections (1) whereas calcified stones (2) show strong reflections with decrease of signal beyond (3)

Ultrasound Imaging

Advantages

• Disadvantages

• No radiation • Relatively cheap • Modality of choice to examine the heart • Real-time • Can be performed at bedside • Most sensitive for fluid

• Difficult in obese patients • View often obscured by air – lung, bowel, bone • Operator dependent

Nuclear Medicine

•Branch of radiology that utilizes intravenous radio-pharmaceuticals for imaging •Radio-pharmaceuticals which may be deposited in certain tissues emit gamma rays •The rays are detected by a gamma camera

Nuclear Medicine
•Assessment of function •Most common radioisotope technetium-99m can b t t h ti 99 be tagged with d ith substances that are selectively taken up by different organs p y g •Examples: •bone scan •ventilation-perfusion scanning •cardiovascular scanning •thyroid scanning

Nuclear Medicine - Bone Scan

Multiple metastatic bone lesions show higher retention of radiolabelled bone seeking agent g g

Hot spot

Nuclear Medicine – Ventilation-perfusion scan

Ventilation-perfusion mismatch – will learn about next semester in pulmonary block – detectable by nuclear medicine

Nuclear Medicine – Positron Emission Topography (PET)

• Positron Emission Tomography g p y PET uses fluorine-18 which is a positron emitter. Positron emission produce photons that can be imaged. • Fluorine-18 can be incorporated into biologically active molecules such as fluoro-18-deoxyglucose – used for cancer staging

CT

PET/CT

PET

Nuclear Medicine / PET

Advantages

• Disadvantages

• Excellent specificity • Provides physiologic information

• Expensive • Availability of service (rarely available) • Radiation • Poor spatial resolution

Risks associated with radiation exposure

• It has long been known that radiation can cause a number of effects through genetic changes:

Cancer
Skin damage

Fetal abnormalities

• At the doses of radiation used in diagnostic Imaging the risk of these effects are normally very low • Nevertheless, it is prudent to minimize ANY risk by minimizing the number of procedures

Radiation Exposure
• The organ most radio-sensitive is the thyroid gland

• Tumors likely to occur after exposure to ionizing radiation include leukemia leukemia, thyroid, breast, lung and skin

• A rad is a measure of absorbed dose

• R di ti associated with h d CT i greater th associated with a chest xRadiation i t d ith head is t than i t d ith h t rays (4000 vs. 12 millirads)

Age and Mortality Risk
• Children are more radiosensitive than adults • Females are more radiosensitive than males • Older adults least sensitive ( average age at VGH 55y )

Lifetime mortality risk (%/Sv)

30 25 20 15 10 5 0 0 10 20 30 40 50 60 70

female
1996 Re-analysis Hiroshima data

male
Age at time of exposure

Scenario from earlier

25 yr old female

VS

70 yr old male

with persistent diarrhea Point from earlier- More consideration of dose reduction has to be made when imaging a female in reproductive age compared to an older male ( p (especially the abdomen) y )

Radiation Doses for common tests
Procedure Equivalent number of b f Chest x-rays Equivalent Period P i d Natural Background (~3mSv) <1 day <1 day <1 day 2 days 12 days 7 weeks 10 weeks 3 months 4 months 6 months 8 months 1 year 1.67 years 2 years 2 years 2 years 2.7 years 2.7 years 5 years 5.3 years

Very Low Dose Knee Bone density Scan Shoulder Low Dose Chest PA Skull series Mammography g p y Pelvis AP Abdomen AP Thoracic Spine AP Intermediate Dose Lumbar Spine AP CT Head IVP Small bowel series Higher doses Upper GI Series Spine CT Pelvis CT Abdomen CT Barium enema Chest CT (PE) Coronary angiography

0.25 0.5 0.5 1 5 20 30 35 50 75 100 150 250 300 300 300 400 400 750 800

Xray

CT Fluoroscopy (real-time Xray) CT Fluoroscopy CT

For more information on doses see Radiology 2008; 248(1):254-63.

Methods to reduce radiation exposure

• Reduction in unnecessary examinations (e.g. daily ICU films)

• Dose reduction (CT)

• Exposure time reduction (fluoroscopy)

• Use of US and MRI (non ionizing)

Imaging in pregnancy
• No proven risk to fetus of ultrasound • No proven risk to fetus of MRI, but avoid in first trimester if possible • I Importance of performing examinations if medically necessary t f f i i ti di ll • Importance of re-evaluating "set protocols" e.g. trauma protocols in a pregnant patient • Dose reduction • Shielding S ed g • Note shielding unhelpful in nuclear medicine - bladder emptying and hydration most helpful • Studies that should be performed only if absolutely necessary with shielding if possible

Relative Costs of Procedures

Study
CXR Abdominal series Barium enema Abdominal US UGI series with SBFT

Relative Cost
1 2 3 4 4 4 5 6 9 10 12 12 16 16 17

Xrays, fluoroscopy y , py and US are relatively cheap

Most nuclear medicine scans are moderately costly

IVP Bone scan Lung VQ scan CT abdomen CT chest

CT is more costly

MRI is fairly y expensive PET scans are very expensive

MRI abdomen MRI of lumbar spine Colonoscopy PET scan Chest + abdomen + pelvic CT

Not N t reasonable bl to order excess tests