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Imaging Modalities in IR

By: Jacob Fleming, Jared Sokol, Sanna Herwald

Introduction
The field of Interventional Radiology (IR) depends on medical imaging technology. With recent advances
in the imaging tools available to physicians, there are ever-expanding possibilities for interventional
radiologists to treat and cure diseases. By using minimally-invasive methods, IR physicians have turned
surgical tasks that once required large incisions and an overnight hospital stays into outpatient
procedures that cause minimal discomfort to the patient. Here we will review the most common
imaging modalities utilized by interventional radiologists and the advantages and disadvantages of each
method.

Radiograph
In 1895, Wilhelm Röntgen discovered the X-ray and took the first radiograph of his wife’s left hand. He
noticed that X-rays passed through human soft tissue, but not bone or metal. This was the birth of
radiology, and Röntgen was awarded the first Nobel Prize in Physics.

Radiography utilizes electromagnetic radiation, especially X-rays, to visualize the internal components of
the human body. When an X-ray beam is directed towards an area of interest, some radiation is
absorbed and some is transmitted according to the composition of the tissue. The transmitted radiation
is captured on a digital detector and processed into an image that represents the tissue. This method of
capturing the radiation “shadow” of a structure is also called projection radiography. Projection
radiography can quickly reveal abnormalities in soft and hard tissues at mid-level resolution.

For the patient, radiographs are a painless imaging modality that takes minutes to complete. X-rays are
a form of ionizing radiation, meaning that they contain sufficient energy to dislodge electrons from an
atom, thereby creating an ion. Ionizing radiation may cause DNA damage and increase future cancer risk
(International Commission on Radiological Protection, 2007). Fortunately, simple radiographs subject
the patient to extremely small levels of ionizing radiation, comparable to several days of background
radiation, and thus have a minimal associated risk. Projection radiography is an import tool for the
diagnostic radiology, but is less-frequently used for IR procedures.

Fluoroscopy
Fluoroscopy uses X-rays to create a real-time, live image of the human body, and is one of the most
important imaging modalities of interventional radiologists. Unlike a simple radiograph that takes a
static image, fluoroscopy allows for the visualization of both structure and movement. The beating of
the heart, the motion of swallowing, and the placement of a catheter can all be visualized using
fluoroscopy. In the modern IR suite, X-ray beams are projected towards the patient, and are either
absorbed by or transmitted through the patient. The transmitted beams then collide with a flat panel
detector that converts the radiation into electrical signals, which in turn are converted into a live
fluoroscopic image. Interventional radiologists usually operate the fluoroscopy machine with a foot
pedal, turning it on and off when necessary.

Interventional radiologists use iodinated contrast to visualize the vascular system to visualize the digestive system. 2007). Unfortunately. 2006). In some patients. the motorized table and the X-ray source both move continuously to produce a helical scan (Brenner & Hall. is equivalent to two years of natural background radiation exposure (Lin. CT does pose a risk to the patient. Like in fluoroscopy.. IVC filter placement. fluoroscopy subjects the patient to more ionizing radiation than a simple radiograph. the addition of contrast can lead to usually reversible acute kidney injury (Aspelin et al. fluoroscopy should be used in moderation to protect both the patient and the medical team. a computer compiles the scanned information into a three-dimensional image which can either be viewed in cross section or reconstructed into rotatable 3-D images. and are offered in different osmolarities. CT may use contrast to highlight certain regions of interest. Rudnick et al. CT offers excellent image quality and multiple views. Solomon et al. which is often used for body scans.. Therefore. such as catheter-directed thrombolysis. In Axial CT. MRI and CT differ in several ways. 2010). For either type of CT. delineate patient anatomy. MRI uses magnetic fields and low-energy radiofrequency . fluoroscopy also poses a risk for cutaneous radiation reactions (Balter. Magnetic Resonance Imaging (MRI) Magnetic Resonance Imaging (MRI) is a powerful diagnostic modality that generates serial slices of the patient’s anatomy. While useful. A normal chest CT scan delivers 70 times as much radiation as a chest radiograph. carbon dioxide may be neurotoxic if used near the cerebral circulation. and therefore does not pose an increased risk of cancers or radiation burns. After that slice is complete the table moves for the next slice. and endovascular aneurysm repair. Importantly. so its use as a contrast agent should be restricted to below the diaphragm (Schreie et al. 2006). 1996). 2007). Fluoroscopy is usually the imaging modality of choice for many IR procedures. such as the vasculature or the digestive system. CT scans are used both before and after IR procedures to identify pathologies. which is commonly used for head scans. similar to CT. and the ionizing radiation from CT scans is estimated to cause 1. which can be used alone or paired with iodinated contrast. are delivered intravenously. and evaluate the success of a procedure.. Computed Tomography (CT) Computed tomography (CT) uses multiple X-ray scans to create a three-dimensional image that can be viewed as cross sections. and is an extremely important tool for interventional radiologists. MRI does not utilize ionizing radiation.Contrast agents are frequently used to enhance the utility of fluoroscopy. Instead. Nonetheless.5- 2% of all cancers in the United States (Brenner & Hall. Furthermore. Diagnostically. Most importantly. 2003. 2010). An alternative contrast agent that has little nephrotoxicity is carbon dioxide (Shaw & Kessel. In helical CT. CT scans can be performed during IR procedures in order to confirm and plan instrument placement relative to patient anatomy. More recently.. Iodinated contrasts consist of iodine molecules bound to either an ionic or organic (non-ionic) compound. the table remains stationary while the X-ray source rotates to create a slice. 2006. The X-ray source rotates around the patient and produces many fan-shaped beams between 1 mm and 20 mm in width. Patients lie on a motorized table that moves through a circular X-ray source.

In addition. MRI has become one of the most important diagnostic modalities in radiology. PET imposes a large dose of radiation. Furthermore. it provides information primarily about the patient’s physiology. 2010). MRI images depend on a tissue’s magnetic properties (instead of its radiolucency. who considered the use of nuclear magnetic resonance (NMR). Nonetheless. . rather than from outside it. rather than anatomy. 1973). MRI is not commonly used during IR procedures. and subtle fractures difficult to detect on X-ray or CT. such as pregnant women. unlike other modalities. acute ischemic stroke. The molecules undergo a form of decay that emits a positron. MRI scans involves loud equipment that most patients find displeasing. producing gamma rays that are detected by a ring-shaped detector similar to that of a CT scanner. including brain tumors. and cannot be used in some patients. and CT). and therefore offers exquisite soft tissue resolution superior to that of CT. a common technique in organic chemistry labs. such as those with most types of cardiac pacemakers. as in plain X-ray. MRI does have some downsides. and thus MRI is subject to many imaging artifacts. Like CT. Because of time limitations. producing a map of the metabolically active-tumor. The positron quickly interacts with an electron (its antiparticle) and annihilates.bursts to obtain images based on the proton densities and magnetic properties of the tissue. but in patients with diagnosed malignancy. Positron Emission Tomography (PET) Positron Emission Tomography (PET) scans differ from almost every other imaging modality because PET images are generated from radiation emitted from inside the patient’s body. but is often used in pre-operative planning of interventions. One of the primary uses of PET is for assessment of cancer treatment. after several decades of research and development. and thus provide a map of where the radiopharmaceutical decayed (Moore. Thereafter. are relatively expensive. MRA can be used in certain patients who are contraindicated for contrast agents and patients with larger body habitus for whom CT would provide lower quality images (Mauro. An MRI scan takes much longer than a CT scan and requires the patient to remain still. Pharmaceuticals labeled with radioactive isotopes are given to the patient either orally or intravenously. 2008). pharmaceuticals such as 18-F fludeoxyglucose (FDG) are administered to the patient and preferentially taken up by tumor cells. and these molecules become localized to areas of high metabolic activity. Thus. Algorithms calculate the point of incidence of the gamma rays to determine where the positron was emitted. 1971). Also. In particular. magnetic resonance angiography (MRA) produces images of the vasculature that can guide interventions. to distinguish tumors from normal tissue (Damadian. Paul Lauterbur produced the first image based on NMR (Lauterbur. the diagnostic and therapeutic benefit of PET generally outweighs the radiation risk. MRI is a useful option in patients for whom radiation is a major concern. A disadvantage of PET is its poor visualization of normal tissue anatomy. et al. Now. This diagnostic technique was first proposed in 1971 by Raymond Damadian. and therefore PET is often coupled with CT. fluoroscopy. MRI is a more sensitive modality for many diagnoses. Using the above principles.

it does not use any ionizing radiation or magnetic fields. US can be used as the primary modality in bedside interventions. Also. Additionally. such as the lungs. Because these interventions may be required emergently. the portability of US is crucial. instead. . US produces a dynamic. moving image that must be adjusted by the operator in order to be useful. US uses highly portable equipment that allows for use in emergent and bedside procedures. US is also used in many common hospital procedures such as thoracentesis and paracentesis. First. In IR. Second. Third.Ultrasound (US) Ultrasound (US) is unique among imaging modalities for multiple reasons. US does not provide useful visualization in areas containing a large volume of gas. and the production of images that are not intuitive to an outside interpreter. Limitations of US include its operator-dependent nature. and it has high diagnostic yield (Screaton et al. for complex vascular interventions. an US transducer produces sound waves that echo off of patient tissues back to a detector to produce an image. and importantly. US can be used as an adjunct for gaining initial access into the jugular or femoral vein (Mauro. such as fine needle aspiration of thyroid masses. This is a safe and quick way to biopsy tissue in the outpatient setting. 2003). 2008).

locating disrupted by large volumes of gas vessels for access in vascular procedures . CT Uses high-dose ionizing radiation. poor of cancer treatment anatomical detail and may need to be paired with CT (additional radiation) Ultrasound Bedside procedures (FNA. Highly operator-dependent. paracentesis). image thoracentesis. useful in evaluation Uses high-dose ionizing radiation. loud. cannot be used in patients with certain implanted medical devices PET Limited use in IR. Pre-procedural planning Uses small levels of ionizing radiation ray) Fluoroscopy Intra-procedural visualization of Uses ionizing radiation (acivate via foot anatomy. expensive. some angiography (w/ or w/o contrast). esp. subject to imaging artifacts. vasculature pedal only when necessary) CT Pre-procedural planning. patients may have allergies or adverse intra-procedural 3-D evaluation of reactions to contrast agents anatomy and instrument placement MRI Pre-op planning (MRA) Slow. Summary Modality Uses in IR Limitations Simple Radiograph (X.

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