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Radiology:

Turning things inside out

Susan Shamimi-Noori MD
Assistant Professor of Radiology
Thomas Jefferson University
August 7, 2016
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Welcome to Medical School!


You are about to learn a new language!
Understand the concepts first, then learn all
the little details.this will make learning much
much easier!

http://www.blatner.com/adam/cartoons/medsch1959-63/memorize.JPG

Welcome to Medical School!


You are about to learn a new language!
Understand the concepts first, then learn all
the little details.this will make learning much
much easier!

http://cdn1.porisrael.org/files/2015/04/CIGI_Thinker_Statue-450x330.png

First Concept

Cura Personalis

Cura Personalis

http://www.fred-nijhuis.nl/wp-content/uploads/2012/12/Leonardo-da-Vinci-Vitruvian-Man.jpg

Cura Personalis
Care for the whole person
Attention to a specific organ/pathology but
also to the specific
personal/psychological/social needs of the
patient
Care for the mind and body

http://www.fred-nijhuis.nl/wp-content/uploads/2012/12/Leonardo-da-Vinci-Vitruvian-Man.jpg

The Persistence of Time, 1931

The Essential Flow Diagram of Medicine

Differential Diagnosis
List of diseases with similar signs and symptoms
Most probable diseases are listed first
Zebras are listed last (or not at all)

Slang for an exotic medical condition being


listed when a more commonplace diagnosis
is more likely

http://www.wpclipart.com/cartoon/animals/horse/horse_cartoon_zebra.png

Differential Diagnosis: Cough

22 y/o M non-smoker
Allergies
Asthma
Infection
Cancer

78 y/o M smoker
Chronic Bronchitis
Cancer
Infection
Allergies

= Tracheobronchopathia osteochondroplastica???...Dont worry about the


Zebras right now

The Essential Flow Diagram of Medicine

The Essential Flow Diagram of Medicine

* Radiology

Radiology
The branch of medical science using x-rays,
radioactive substances and other forms of
radiant and non-radiant energy in diagnosis
and treatment of disease
Turning things inside out

Human Pathology Radiology


Correlation

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Human Pathology Radiology


Correlation

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The Elephants, 1948

Radiant Energy:
Electromagnetic Spectrum

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCKellpDm58YCFUx0PgodkwYNyA&url=http%3A%2F%2Fimagine.gsfc.nasa.gov%2
Fscience%2Ftoolbox%2Femspectrum1.html&ei=3uirVac-zOj5AZONtMAM&bvm=bv.98197061,d.cWw&psig=AFQjCNF6ouNZ5ULlLhUcC7NrFoD1O_H2YQ&ust=1437415888242141

Radiant Energy:
Electromagnetic Spectrum

* Radiology
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Fscience%2Ftoolbox%2Femspectrum1.html&ei=3uirVac-zOj5AZONtMAM&bvm=bv.98197061,d.cWw&psig=AFQjCNF6ouNZ5ULlLhUcC7NrFoD1O_H2YQ&ust=1437415888242141

How a Radiograph is Created

X-Ray = photon of light


Radiograph = resultant image after an object is exposed to x-rays
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Radiodensity
The relative inability of electromagnetic
energy to pass through a particular material
Air has LOW radiodensity

Metal has HIGH radiodensity

Attenuation

Radiodensity
X-Ray Source

Object

Detector

Image

Radiolucent
Air

Radiodense
Radiopaque
Metal

5 Basic Radiodensities
1. Air: Low density (black)
2. Fat: Low-Intermediate density
(gray-black)
3. Water/Soft Tissue: Intermediate
denisty (gray)
4. Bone: High density (white)
5. Metal/Contrast Agents: Very high
density (very white)
http://image.slidesharecdn.com/mycxrnet-120108095659-phpapp02/95/basics-of-chest-x-ray-interpretation-4-728.jpg?cb=1326873902

5 Basic Radiodensities
Fat

Air

Bone

Metal
Soft Tissue

Radiograph Edges
An edge, or silhouette, is seen when objects
of different densities are adjacent to one
another
An edge is seen because two objects of
different radiodensities attenuate X-rays
differently

Radiograph Edges

Silhouette Sign
The lack of an interface between two objects
with similar radiodensities
Two objects with similar radiodensities
attenuate X-rays similarly and therefore
appear inseparable on a radiograph

Silhouette Sign

Courtesy of Dr. James Smirniotopoulos

Silhouette Sign

Courtesy of Dr. James Smirniotopoulos

Silhouette Sign

Computed Tomography
Computed Tomography= CT = Computerized
Axial Tomography = CAT scan
X-Rays are projected in many angles onto an
object and then detected on multiple angles
therefore resulting in a cross-sectional or
tomographic image

Computed Tomography

http://www.medicalradiation.com/wp-content/uploads/CT_gross.jpg?a17713
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Computed Tomography

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Image Planes
Axial

Coronal

Sagittal

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Laterality Convention
R

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Geopoliticus Child Watching the Birth of the New Man, 1943

Radiologic Modalities
Radiography
Computed Tomography (CT or CAT scan)
Nuclear Scintigraphy (Nuclear Medicine)
Magnetic Resonance Imaging (MR or MRI)
Ultrasound Imaging (US or Sonography)

Radiologic Modalities

Radiography
Density

Computed Tomography (CT or CAT scan)


Density, Enhancement

Nuclear Scintigraphy (Nuclear Medicine)


Counts, Activity

Magnetic Resonance Imaging (MR or MRI)


Intensity, Enhancement

Ultrasound Imaging (US or Sonography)


Echogenicity

Nuclear Scintigraphy
Radiopharmaceuticals are taken internally
(PO or IV)

Radiopharmaceutical = substance attached to


a radioactive material
(ie: glucose attached to radioactive fluorine)

http://www.radiology-equipment.com/instrumentpics/FORTE_beauty.jpg
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Nuclear Scintigraphy
External detectors capture radiation photons
emitted by the radiopharmaceutical resulting
in an image
Imaging contrast depends on biologic activity
(vs. radiography imaging contrast depends on structure
attenuation)

http://www.radiology-equipment.com/instrumentpics/FORTE_beauty.jpg
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Magnetic Resonance Imaging


Magnetic field pulses cause different electron
changes in different structures
The electron changes result in emission of
radiofrequency waves which are detected
resulting in an image

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Magnetic Resonance Imaging


Imaging contrast depends on different effects
on electrons in different structure types
(simplified version of complex physics)

http://www.aboutkidshealth.ca//En/Assets/BT_Neuro_MRI2_MEDIMG-PHO_EN.jpg
http://www.news-medical.net/image.axd?picture=2013%2F8%2Fgallery-img_6.jpg

Ultrasound Imaging
High frequency sound waves are emitted into
the body and bounce back as echoes
Different structures bounce back echoes of
the sound waves at varying times and
frequencies
Sound wave echoes are detected
resulting in an image
http://www.providianmedical.com/wp-content/gallery/philips-iu22/philips-iu22-4.jpg?328974
http://www.commondreams.org/sites/default/files/imce-images/fetal-ultrasound-via-wikipedia-commons-615x345.jpg

Ultrasound Imaging
Image contrast depends on how a structure
echoes back a sound wave

http://www.providianmedical.com/wp-content/gallery/philips-iu22/philips-iu22-4.jpg?328974
http://www.commondreams.org/sites/default/files/imce-images/fetal-ultrasound-via-wikipedia-commons-615x345.jpg

Galatea of the Spheres, 1952

Radiologist
Physicians who diagnose and treat pathologic
processes using various imaging modalities

Radiologist Spectrum
Interpret images
Create and interpret images
Create images, interpret images and
perform image based procedures to aide
in diagnosis
Create images, interpret images and
perform image based procedures to
diagnose and treat

Interpretation
Differentiate normal and abnormal on an image
Combine the history/physical/other clinical
information with the Imaging findings and create
a differential diagnosis
Based on the differential diagnosis determine
what are the next tests to further narrow the
differential diagnosis
With small differential diagnoses, let the referrer
know what the treatment options are

Interpretation Requires a LOT of


Knowledge
Know the differential diagnoses of combinations of
histories and physicals
Know the differential diagnoses of imaging findings
Combine those differential diagnoses and know
which are more probable
Know how to further narrow the differential
diagnoses
Know what treatment to recommend based on the
diagnosis

Radiology Specialties
By Amount of Procedures
Performed
Diagnostic Radiology
Interventional Radiology
By Modality
MRI
Ultrasound
Nuclear Medicine
By Disease Groups
Womens Imaging
Oncologic Imaging

By Anatomy
Chest Radiology
Cardiovascular Radiology
Musculoskelatal Radiology
Neuroradiology
Mammography
Gastrointestinal Imaging
Genitourinary Imaging
Abdominal Imaging

Interventional Radiology
A specialty of radiology in
which minimally invasive
procedures are performed
using image guidance
A specialty that performs
diagnostic and
therapeutic interventions
for a variety of organ
systems/pathologic
entities

Interventional Radiology

Interventional Radiology
Consult service

Other specialties ask IR physicians about medical opinion/treatment


options for patients in the hospital of whom other specialties are the
primary care givers

Admitting service

IR physicians are the primary care givers of patients admitted to the


hospital

Inpatient procedures

Procedures performed on hospitalized patients

Outpatient procedures

Procedures performed on patients who go home after the procedure

Outpatient clinic

Patients come for opinions on disease and treatment options and


patients return for follow up visits after treatments

How to become a Radiologist


1 year internship (medicine or surgery)
4 years diagnostic radiology residency
1-2 years fellowship (optional)

How to become an Interventional Radiologist


1. Internship + DR residency + IR fellowship (1-2 years)
2. Internship + IR residency (5 years)
(combined IR and DR board eligible)

Interventional Radiology
Interest Group
Facebook group: Jefferson CVIR
JeffersonCVIR@gmail.com
Lindsay.Young@Jefferson.edu

(group president)

Sleep, 1937

Case
58 y/o male presents to his primary care
physician with 3 days of right leg swelling

Case
Vital Signs are Stable (VSS)
Temperature
Blood Pressure
Heart Rate
Respiratory Rate
Oxygen Saturation

http://il5.picdn.net/shutterstock/videos/1240198/thumb/1.jpg?i10c=img.resize(height:160)

Case
Physical Exam (PE)
Alert & Oriented
Heart/Lungs/Abdomen Normal
Lower extremities Right leg swollen from
ankle to just above the knee

Case

http://www.thrombosisadviser.com/html/images/library/vte/deep-vein-thrombosis-right-leg-PU.jpg

Case
Differential Diagnosis

VITAMIN C
(in no particular order)
Vascular
Infectious
Traumatic
Autoimmune
Metabolic
Idiopathic/Iatrogenic
Neoplastic/Neurologic
Congenital

Case
Differential Diagnosis
Trauma
Infection
Vascular
Arterial
Venous

Case
Differential Diagnosis
Trauma Ask more history
Infection Look for signs of infection
Vascular
Arterial Check pulses
Venous Radiology to the rescue!!!!

Ultrasound of Right Lower Extremity


Normal

Our Patient

Lower Extremity Deep Venous


Thrombosis

Treatment
Anticoagulation (blood thinners)

Patient goes home with a prescription for


anticoagulation

Case
5 days later, patient goes to the ER with acute
shortness of breath (SOB)

Case
Vital Signs
Elevated respiratory rate (Tachypnea)
Decreased oxygen saturation
Mild elevated heart rate (Tachycardia)
Physical Exam
Heart Tachycardic, but otherwise normal
Lungs Tachypnic, but otherwise normal
Remainder of exam, including lower
extremities, is normal

Case
Differential Diagnosis
Pulmonary Embolus (clot in lung artery)
Pneumonia
Asthma
Anxiety (panic attack)
Radiology to the rescue!!
Treat patient with oxygen in the meantime
(ABCs)

Chest Radiograph

Computed Tomography

Pulmonary Embolism
Treatment
Prevent more clot from going to the lungs
Radiology to the rescue!!

Inferior Vena Cava Filter

Case
Patients respiratory status normalizes and he
goes home

Case
9 days later, patient presents to primary care
physician with severe bilateral lower extremity
swelling and pain necessitating him to use a
wheel chair
Primary care physician sends patient to ER for
further evaluation

Case
Vital Signs
Stable
Physical Exam
Bilateral lower extremity swelling from the
ankles to the upper thighs
Bilateral medial thigh erythema (redness)
and tenderness
Remainder of the exam is normal

Case

http://int-prop.lf2.cuni.cz/foto/012/pic00016.jpg

Ultrasound
Right Lower Extremity

Left Lower Extremity

Computed Tomography

Case
Treatment
Pharmacomechanical Thombectomy
Radiology to the rescue!!

Phamacomechanical Thombectomy

Case
Patient walks out of the hospital two days
later feeling great

Final Thoughts
Radiology is an invaluable specialty for the
diagnosis and treatment of disease
No matter what specialty you decide to enter,
you will use radiology
The field of radiology is diverse, fascinating
and rewarding!

GOOD
LUCK!!

Salvidor Dali
1904-1989