Principles of Radiology

INTRODUCTION
The spectrum composing electromagnetic radiation includes gamma rays, UV rays, infra
red and electric waves. X-rays are a part of this gamma ray spectrum emitted by the cosmic
system.
Medical X-rays, which are used routinely for diagnostic purposes, are not emitted
from any radioactive material. Instead, they are produced by heating a tungsten or
molybdenum cathode in a vaccumized tube at high temperatures, such that electrons
having short wave emit radiation from the surface of these materials.
This radiation is then raced towards a tungsten anode by a strong electrical
current, which results in abrupt stopping of the X-ray beam and a change in its direction,
thereby focusing the rays on to the part of the body under examination. There after upon
penetrating the body, they cast an impression on the X-ray plate kept under the area of
study. This plate is subsequently processed and an image is generated for medical
evaluation.
Since the X-rays have a short wave length, they are invisible to human eyes. Hence
the need to be conscious about the dangerous side effects of X-rays.
The X-rays are composed of particles of energy called photons, which have no
mass, no charge and travel at the speed of light. These photons are called X-ray photons.
 HISTORY OF X-RAYS
X-rays were discovered accidentally on the 8th of November 1895, by Wilhelm Conrad
Roentgen. Roentgen was a German physicist from the University of Wurzburg. He was engaged
in studying the behaviour of an electron beam as it passed through a vacuumized tube to strike
a tungsten plate. To his surprise, he observed that, in addition to electrons, certain unknown
rays were also produced, which could penetrate the glass envelope of his apparatus and
produce a glow on a distant fluorescent screen. He was able to photograph the bones of the
hand of his wife by placing it over a photographic plate and then shining the rays on it. Since no
name had been given to this kind of radiation, the name
X-ray was given by him.
For his unique discovery, Roentgen was awarded the Nobel Prize in Physics in the year,
1901
The discovery of X-rays provided a new dimension to the advancement of medical and other
sciences.
The medical use of X-rays are for both diagnostic and therapeutic purposes. The technique of
using X-rays for imaging body parts is called radiography, for diagnosing disease, radio-diagnosis
and for treatment of disease, radiotherapy.
As a diagnostic tool radiography has proved of immense value in detection of the
diseases, fractures and many other problems in the human body.
Therapeutically, X-rays are used in the treatment of many types of cancers because, the
rays can destroy cancer cell, though the adjacent normal cells also get affected.
PROPERTIES OF X-RAYS
The relevant properties of X-ray are as follows.
1. Penetrating Power
X-rays closely resemble visible light rays in having a similar photographic effect. But they differ from
the light rays in being invisible and in having a shorter wavelength. The wavelength of X-rays is 0.01
to 10 nanometers. It is this property of short wave length which gives them the power of
penetration through difterent materialIs.
When X-rays pass through matter, they are absorbed to varying extent. The degree of
absorption depend on the density (atomic weight) of the matter. Radiography is based on the
differential absorption of of the X-rays. Dense tissues such as bones, metals and materials having
high atomic numbers absorb X-rays far more readily than do the soft tissues of the body. These cast
a white shadow on the image plate as no X-rays can reach the imaging plate. Structures which are
easily penetrated by X-rays such as air and fat allow the X-rays to reach the image plate, thereby
casting a black to grey impression, identical to the physical appearance of intervening structure.
These are described as radiolucent shadows and the structures which are penetrated with difficulty
or are not penetrated at all are described as radiopaque.
Different density structures, therefore, can be arranged in a scale of increasing radiopacity.
a. Air, in the respiratory passages, stomach and intestines is black.
b. Fat is greyish black and relatively less dark than air.
c. Soft tissue, eg. muscles, vessels, nerves, and viscera cast an impression by virtue of the adjoining
fat or air outlining them or else they would not be visible on X-rays.
d. Bones, due to their calcium content appear grayish white.
e. Enamel of teeth, and metallic foreign bodies, e.g. metallic filling of the teeth, and radiopaque
contrast media also appear white, the brightness being much more than the bone.
 2. Photographic Effect
When X-ray photons strike a photosensitive film, the image of the object under examination gets imprinted
on the film. When such a film is developed and fixed chemically, a radiography image becomes visible.
The X-ray film has a base made up of cellulose acetate, which is Coated on either side with silver
bromide (photosensitive) emulsion 0.001 inch thick. The film is blue tinted and transparent.
An X-ray image (picture) is called skiagram (skia= shadow), radiograph, or roentgenogram
Computed and Digital Radiography
The conventional X-ray cassette containing the X-ray film is now replaced by a novel imaging system. The
imprint of the body part made by exposing it to X-rays, can either be directly read off by a
digital radiographic system and displayed straight on the monitor screen or visualized through an indirect
computed radiographic system. These technologies are called direct digital radiographic
system--DR system or, if indirect, they are called CR system. An image of the exposed part can be obtained
in these systems on an imaging film by processing it through an image printer. Alternatively, the image can
simply be stored on the computer, e-mailed or burnt on a CD and given to the patient. These systems have
several advantages over the conventional film screen method.
The images can be manipulated and improved so that unnecessary repetitions of radiographs due to
quality concerns can be avoided. The films can be stored in the computer, retrieved, mailed or even printed
on paper. This saves money, time, storage
space and even reduce the cost of silver which is needed to make the conventional X-ray films. Hence as of
today, most institutions have switched over to either CR or DR system.
 3. Fluorescent Effect

When X-rays strike certain metallic salts (phosphorous, zinc, cadmium,

sulphide), the rays cause them to light up, that is, light rays are
produced and the image of the object becomes visible to the naked eye
during the period of the exposure. This property of X-rays is utilized in
live screening of objects such as bowel loops, bones, blood vessels,
heart and spinal cord to name a few structures.
 4. Biological Effect
X-rays can destroy both normal and abnormal cells. This effect is utilized in the treatment
of various cancers but at the costs of destroying adjacent normal cells as well.
Hence, X-rays are potentially dangerous. On repeated exposures, they cause burns, hair
loss, brittle nails, development of cancers and even genetic mutations. Therefore,
adequate protectilve measures must be taken against repeated exposures to X-rays.
wnerever and whenever possible they should be avoided particularly in children, young
people and pregnant. However, should the need arise, they must be used with adequate
precautions to reduce morbidity and mortality.
Radiography
Method of obtaining X-rays of different body parts is called Radiography. Radiographs are
generally obtained from a single direction if it is the chest or abdomen or from two
directions at right angle to each, if it is the extremities and spine. This gives complete
information about the area in question. The term used by
radiologist for this is "views"
The 'view expresses the direction of flow of the X-ray beam. In AP
(anteroposterior) view, the rays pass from the front to back, the latter resting against the X-
ray plate. In PA (posteroanterior) view the X-rays pass from the back to front, the front
surface resting against the X-rays plate. The part of the body touching the X-ray plate (i.e.
near the X-ray plate) casts a sharper shadow than the part facing the X-ray tube.
The views can be anteroposterior (AP), lateral or oblique depending on the
relationship of the body part with the X-ray beam. Chest X-rays are usually posteroanterior
(PA) views. For visualizing the thoracic spine, AP view is preferred.
RADIOGRAPHIC PROCEDURES
1. Fluoroscopy
Fluoroscopy is visualizing the body part in real time using X-rays. lt is of special advantage in
observing the movements of the organs (lungs, gastrointestinal tract, diaphragm), flow of
administered Contrast through blood vessels and bowel and in positioning the
subject during the examination.
Fluoroscopy in earlier days was done in a dark room. But now image intensifiers and
television monitors are used which have eliminated the need for darkening the room.
The fluoroscopic image is visualized directly on the fluorescent screen which is covered
with a sheet of lead glass to absorb unwanted X-rays and to protect the fluoroscopist. Now-a-days
the conventional fluoroscopic screen has been replaced by an image intensifier system with the
image being projected on an accompanying television monitor.
The sharpness of the fluoroscopic image is inferior to that of a radiograph but it provides
information about motion and flow which a static X-ray cannot do.
2. Plain Radiography
An X-ray image, obtained directly without using any contrast medium, is called a plain X-ray. It is
useful in the study of normal bones, lungs, normal joints, paranasal air sinuses and gaseous
shadows in the abdomen.
Strength: Covers a large area quickly, relatively low X-ray exposure and low cost. Easy accessibility
(Figs 10.1 to 10.3).
Weakness: Relatively low resolution and low soft tissue contrast as Compared to CT scans.
 .
3. Contrast Radiography
The hollow viscera and solid organs cannot be visualized in plain radiography
due to their having similar soft tissue densities. However, their differences or
contrast can be accentuated by filling such organs or cavities with either a
radiopaque or a radiolucent substance.
Radiography done after artificial accentuation of the contrast density is called
contrast radiography.
The radiopaque compounds used in contrast radiography are:
1. Barium sulphate suspension (emulsion) in water for gastro- intestinal tract
(Figs 10.4 to 10.6).
2. Aqueous solution of appropriate iodine compounds, for urinary and biliary
passages and vascular system.
SPECIAL PROCEDURES
These include several newer technologies.
CT scans, ultrasound and MRI are primarily anatomic studies. PET scan is study of metabolism. PET
CT or PET MRI is a combination of metabolic and anatomic study. Nuclear medicine is a metabolic
study with capability of concentrating into specific body parts depending upon the composition of
the radioisotope and the tissue specific atom used.
1. Computed tomography (CT scanning): Computed tomography is a major technological
breakthrough in radiology. Using X-rays and a series of detectors, it provides images of the body
comparable to gross anatomical slices ranging from 0.25 to 10 mm and even
more, by which one can distinguish tissues with even slight differences in their density.
Differentiation between vascular and avascular areas can be enhanced by simultaneous
scanning and injection of a radiopaque medium in the vessels.
Thus CT scanning helps in the diagnosis of the exact location and size of tumours,
haemorrhage, infarction and malformation. including hydrocephalus, cerebral atrophy, abdominal
lesions, chest lesions, and in the study of bones and joints lesions. This technique must be used
sparingly, if at all, in pregnant women and children. The radiation must be regulated to bare
minimum, needed for diagnostic quality images (Fig. 10.7).
Strength: Excellent resolution.
Weakness: Relatively high radiation exposure.
2. Ultrasonography: Ultrasonography is a process using high frequency sound waves to
create images of soft tissue structures of the body. It is a safe procedure because
instead of X-rays, sounds waves are used. These sound waves are sent into the body
by an electrically stimulated piezo electric crystal, housed in an ultrasound probe. They
are then reflected back to the crystal from the interfaces formed by tissues having
different densities. In this process, their character undergoes a change. Using a
computer, the data is reconstructed into an image which one can see on the
accompanying display system of the machine (Fig. 10.8).
The sound waves used are above the range of human hearing,i.e. above 20,000 cycles
per second, or 20 kilohertz (hertz = cycles per second). As the technique is quite safe, it
is especially valuable in obstetric and gynecological problem.
Strength: Non-invasive. Safe, as it does not involve electromagnetic radiation Soft tissue
contrast enables study of the soft tissues of the body. High accessibility and low cost.
Extremely versatile, can be used in studying blood flow, heart, brain, abdomen,
musculoskeletal system, pregnancy and many more areas. No radiation.
Weakness: Operator dependent. Air and bones cannot be penetrated.
MAGNETIC RESONANCE IMAGING (MRI)
MRI is an imaging technique, which, unlike CT, does not use X-rays to produce images.
Instead, using a strong magnet which creates an external magnetic field and
radiofrequency pulses, it first disturbs hydrogen atoms in the body from their resting
position and then allows them to revert to their original state. The resultant energy
deposited in the atoms, is released in the form of radiofrequency signals which are picked
up by antennas. These signals are then evaluated by a computer, which through a series
of complex mathematics, locates the position and number of hydrogen atoms which had
send them the signals, thereby accurately identifying their location and quantity in the
part under investigation. Thereafter, the computer converts this data into an anatomical
image which is displayed on the computer screen.
There are various pulse sequences used in MRI for creating images. These are T1,
T2 and proton density sequences. These sequences produce different appearances of the
images which help in identifying the nature of the disease process.
Additionally, by using signal characteristics of various structures, such as water,
fat, calcium, bones, minerals, it can give an exquisite detail of the composition of
the part under examination. Since several atoms besides hydrogen, produce MR
signals, this capability can be used in studying blood flow, vascularity of various
diseases and organs. These agents-called contrast agents, enhance the diagnostic
capability of MRI. Further, MRI can produce images in axial, coronal and sagittal
planes. This helps in examining diseases from different angles and planning
treatment (Figs 10.9 and 10.10).
Strength: It is the investigation of choice to study brain and spinal cord, It is also
used for abdominal, musculoskeletal and cardiac Imaging and in studying blood
flow (Fig. 10.11).
No radiation is used. Multiplanar images can be obtained for
further evaluation of organs.
High soft tissue contrast is seen in the images obtained on MRI.
Weakness: Claustrophobia
Long examination times
High cost.
POSITRON EMISSION TOMOGRAPHY (PET)
A PET scan uses radioisotopes which are combined with a carrier such as
FDG and injected into the body. The FDG is flourodeoxygluconate compound
which is taken up in large quantities by areas having increased metabolic
activity. The isotope accumulates in these areas and give a bright signal
which is picked up by a receiver and displayed as an image.
When combined with CT or MRI, it is called PET CT or PET MRI (Fig.
10.12).
The CT and MRI give the anatomical location and the PET
demonstrates foci of increased metabolic activity in these anatomic areas.
Thus the lesion showing high signal on PET is accurately located anatomically
as well.
Strength: PET detects metabolic uptake whereas CT scan or MRI
demonstrates structural changes. Metabolic uptake tells us the state of the
disease in terms of disease activity. This helps identifying sites for biopsy,
response to treatment, deciding if the disease is slowly progressive or
otherwise, benign or malignant nature of the disease.
Weakness: Costly procedure. Uses radiation.
INTERVENTIONAL RADIOLOGY
Fluoroscopy with image intensifiers, ultrasound and CT scans have enabled accurate
localization of disease processes inside the body. This has opened up a whole new field
called interventional
radiology.
Interventional radiology involves a wide variety of procedures.
These include:
Percutaneous catheterization and embolization in the treatment of tumours to
reduce tumor size and vascularity prior to operation in difficult cases.
Percutaneous transluminal dilatation and arterial stenosis for the treatment of
localized stenosis in the arteries.
Needle biopsy under imaging control for lung tumours and abdominal masses.

Transhepatic catheterization of the bile ducts for draining in obstructive jaundice.

Needle puncture and drainage of cysts in the kidneys or abscesses

using ultrasound or CT.
Pleural taps.
Catheter drainage of pleural fluid.
Performance of vascular studies.
The procedures are safe, quick and cheaper than surgery, do not need general anaesthesia,
can be performed as outpatient procedures, but are dependant on experts to do them.
• POINTS TO REMEMBER
X-rays have shorter wavelength which gives them the power of penetration
into different materials.
• X-rays are potentially dangerous. Adequate protective measures must be
taken against repeated exposures to X-rays especially during early
pregnancy.

• For viewing the lungs posteroanterior view (PA view) is taken Viscera are
visualised by contrast radiography or by ultrasound.
• Ultrasound is a relatively safe imaging procedure during pregnancy.
• Magnetic resonance imaging is best used to visualize brain and spinal cord.
• Positron emission tomography detects functional changes at an early stage.