DIAGNOSTIC IMAGING

METHODS
CONVENTIONAL RADIOLOGY
HISTORY
1895 – Wilhelm Roentgen produced the 1st x-ray
image

Source: news.stanford.edu
Wilhelm C. Roentgen
 X-RAY
• Form of radiant energy similar
to visible light
• Has very short wavelength
• Penetrates many substances
that are opaque to light
• Produced by bombarding a
tungsten target with an
electron beam within an x-ray
tube

http://findmeacure.com
Source: Brant & Helms
 FILM RADIOGRAPHY
(1) PATIENT IS POSITIONED (2) X-RAY IS TAKEN

(4) X-RAY FILM IS READ (3) FILM CASETTE IS TAKEN TO

THROUGH A NEGATOSCOPE THE DARK ROOM FOR
DEVELOPING
 FILM RADIOGRAPHY:
• Utilizes a screen-
film system within a
film cassette (x-ray
detector)
 How is an x-ray film produced in
conventional radiography?
X-rays pass through the body (a)
 x-rays are attenuated by
interaction with body tissue
(a) transmitted x-rays through
the patient bombard a
fluorescent particle-coated
screen (b) in the film cassette a

 produces photochemical
interaction  light rays are b
emitted, which exposes the film c
(c) in the cassette  film is b
developed
 COMPUTED RADIOGRAPHY
(CR)
• Filmless system
• No processing
• Produces digital
radiographic images
• Substitutes a phosphor
imaging plate for the film
screen cassette
 How is an x-ray film produced in
computed radiography?
– X-rays pass through the
body  phosphor-coated
imaging plate interacts with
x-rays transmitted through
the patient  phosphor
plate is placed within a
reading device  data is
captured and processed
into a digital image
COMPUTED RADIOGRAPHY
(1) PATIENT IS POSITIONED (2) X-RAY IS TAKEN

(4) DIGITAL IMAGE DEVELOPED (3) FILM CASETTE IS PLACED IN A

IS READ THROUGH A MONITOR COMPUTED RADIOGRAPHY
PROCESSING MACHINE
 DIGITAL RADIOGRAPHY

• Also a filmless system

• Substitutes a fixed electronic detector on
charge-coupled device for the film screen
cassette or phosphor imaging plate  NO
CASSETTE NEEDED
• Immediate images are produced through
direct readout
 DIGITAL RADIOGRAPHY
(1) PATIENT IS POSITIONED (2) X-RAY IS TAKEN

(3) DIGITAL IMAGE IS READ

THROUGH A MONITOR
 FLUOROSCOPY
• Real time radiographic visualization of
moving anatomic structures
• Continuous x-ray beam passes through
the patient and falls on a fluorescing
screen  produces a light pattern which is
amplified electronically  amplified real
time images are displayed on a monitor
 FLUOROSCOPY
• Useful in evaluating
motion such as
gastrointestinal
peristalsis, movement of
diaphragm during
respiration, and cardiac
action.
• Also used to monitor
continuously radiographic
procedures such as
Barium studies and
catheter placements
 FLUOROSCOPY

Source: Brant & Helms

http://faxil.leeds.ac.uk
 NAMING RADIOGRAPHIC
VIEWS
• Most x-ray views are named on the basis
of the way that an x-ray beam passes
through the patient

• Views are also named by the position of

the patient
 NAMING RADIOGRAPHIC VIEWS
Naming on the basis of the way that an x-ray beam passes
through the patient:

Chest posteroanterior (PA) Chest anteroposterior (AP)

http://www.keywordpicture.com http://www.med-ed.virginia.edu
NAMING RADIOGRAPHIC VIEWS
Naming on the basis of the position of the patient:

Abdomen left lateral decubitus Abdomen upright

http://www.herryyudha.com
 5 basic radiography densities

– Air density
• lungs
– Fat density
• Subcutaneous tissue
– Soft tissue density
• Heart
– Bone density
• ribs
– Metal/contrast density
• pacemaker

http://www.keepingyouwell.com/
 5 basic radiography densities

– Air density
• Bowel gas
– Fat density
• Flank stripe
– Soft tissue density
• liver
– Bone density
• pelvis
– Metal/contrast density
• barium
 What is attenuation?
• process by which a beam of radiation is reduced
in intensity when passing through material
• If a tissue has low attenuation it would suggest
that it is relatively transparent and appears dark
(air)
• high attenuation is a denser material and (bone)
objects appear brighter
• In general, the denser the material, the better its
ability to attenuate x-ray beam, the
brighter/whiter it would appear on x-ray images
 Air density
• Air attenuates very TRACHEA

little of the x-ray beam

– most are LUNGS
transmitted  black
on radiograph

GASTRIC BUBBLE
 Bone and Metal Density
• Bone, metal and CLAVICLE
VERTEBRA
contrast agents
attenuate a large
proportion of x-ray RIBS

beam  white on METAL

IMPLANTS
radiograph
 Fat and Soft tissue density
• Fat and soft tissue
attenuate LIVER

intermediate amounts
of x-ray beam 
shades of gray on
radiograph PROPERITONEAL
FAT STRIPE
 Silhouette sign:
Right Middle Lobe and Left
Lower Lobe Pneumonia.
Demonstrates pneumonia (P) in
the right middle lobe replacing air
density in the lung with soft
tissue density and silhouetting
the right heart border. The dome
of the right hemidiaphragm (black
arrow) is defined by air in the
normal right lower lobe and
remains visible through the right
middle lobe infiltrate. The left
heart border (white arrow),
defined by air in the lingula,
remains well defined despite
infiltrate in the left lower lobe.

Source: Brant & Helms

 CROSS-SECTIONAL IMAGING
TECHNIQUES:
• CT, MR, and Ultrasound – techniques that
produce cross-sectional images of the body
• Produces slices of patient tissue to produce a
two-dimensional image
• To analyze optimally all of the anatomic
information of any particular slice, the image is
viewed at different window-width and window-
level settings, which are optimized for bone, air-
filled lung, soft tissue, etc.
 COMPUTED TOMOGRAPHY
(CT)
• uses a computer to mathematically
reconstruct a cross-sectional image of the
body from measurements of x-ray
transmission through thin slices of patient
tissue
• displays each imaged slice separately
• no superimposed blurred structures seen
in conventional tomography
 COMPUTED TOMOGRAPHY (CT)
The patient is placed on an
examination. An x-ray tube rotates
360° around the patient, producing
pulses of radiation that pass through
the patient. Transmitted x-rays are
detected by a circumferential bank of
radiation detectors.

Source: Brant & Helms

topnews.in
 Types of CT scan:
Conventional CT (nonhelical)
• obtains image data one slice at a time – one slice per
breath hold
• requires at least two to three times the total scanning
time of helical CT
Helical CT (spiral CT)
• performed by moving the patient table through the gantry
while scanning continuously with an x-ray tube rotating
around the patient
• continuous volume of image data is acquired during a
single breath-hold
• improved speed of image acquisition
• improved visualization of small lesions
 Types of CT scan:
Multidetector helical CT (MDCT)
• latest technical advance in CT imaging
• like helical scanner but with multiple rows of detector
rings
• obtains multiple slices per tube rotation  increases the
area of the patient that can be covered in a given time
• 5-8 times faster than single-slice helical CT
• allows for high-detail CT angiography and virtual CT
colonoscopy and bronchoscopy
• disadvantage: radiation dose, 3-5 times higher than with
single-slice CT
Advantages of CT compared
with MR:
– rapid scan acquisition
– superior bone detail, and demonstration of
calcifications
 PRINCIPLES OF
INTERPRETATION
• Like radiography, images are dependent
on the degree of attenuation by different
materials
• Hounsfield Units (HU) – Units of x-ray
attenuation used in CT scanning
– the brighter the tissue, the higher the HU
 Hounsfield unit (HU) scale
– Air: -1,000 H.
– Lung tissue: -400 to -600 H
– Fat: -60 to -100 H
– Water: value of 0 H
– Soft tissue: +40 to +80 H
– Bone: +400 to +1,000 H
Air: -1000 H

HEART: +40 to +80 H

LUNGS: -400 TO -600 H

VERTEBRA: 400 TO 600 H

 PRINCIPLES OF
INTERPRETATION
• generally limited to the
axial plane; but may be
reformatted in sagittal,
coronal, or oblique
planes or as three-
dimensional images.
 Planes
a to c: AXIAL/
TRANSVERSE
d: CORONAL
e: SAGGITAL

http://ars.els-cdn.com

healthpages.org
•gray scale: in the left edge
•centimeter scale: along the right side of the image
•R: patient's right side
•L: patient's left side
•Cross-sectional images in the transverse plane are routinely
viewed from “below,”as if standing at the patient's feet
• Optimal bone detail is viewed at bone
windows
– window width of 2,000 H, window level of 400
to 600 H
• Lungs are viewed at lung windows
– window width of 1,000 to 2,000 H, window
levels of about 500 to 600 H
• Soft tissues
– window width of 400 to 500 H, window level
20 to 40 H
 LUNG WINDOW

SOFT TISSUE WINDOW

 Contrast Administration in CT
• Intravenous iodine-based contrast agents are
administered in CT to:
– enhance density differences between lesions and
surrounding parenchyma
– to demonstrate vascular anatomy and vessel patency
– to characterize lesions by their patterns of contrast
enhancement
• Oral or rectal contrast is generally required to
opacify the bowel for CT scans of the abdomen
and pelvis. Bowel without intraluminal contrast
may be difficult to differentiate from tumors,
lymph nodes, and hematomas.
Contrast Administration in CT

PLAIN WITH CONTRAST

MAGNETIC RESONANCE
IMAGING (MRI)
 MRI
• produces tomographic images by means
of magnetic fields and radio waves
• MR is based on the ability of a small
number of protons within the body to
absorb and emit radio wave energy when
the body is placed within a strong
magnetic field
MRI
 MRI
• Most tissues can be differentiated by
differences in their T1 and T2 relaxation
times
– T1 is a measure of a proton's ability to
exchange energy with its surrounding
chemical matrix
• It is a measure of how quickly a tissue can become
magnetized
– T2 conveys how quickly a given tissue loses
its magnetization
ADVANTAGES OF MR:
• outstanding soft tissue contrast resolution
• provides images in any anatomic plane
• absence of ionizing radiation
DISADVANTAGES OF MR:
• limited in its ability to demonstrate dense bone
detail or calcifications
• involves long imaging times for many pulse
sequences
• possesses limited spatial resolution compared
with CT
• limited availability in some geographic areas
• expensive
CONTRAST ADMINISTRATION
IN MR:
• Gadolinium chelates
• Given to:
– identify regions of disruption of the blood-
brain barrier
– enhance organs to accentuate pathology
– document patterns of lesion enhancement
 SAFETY CONSIDERATIONS
IN MRI
• MR is contraindicated in patients who have electrically,
magnetically, or mechanically activated implants
– cardiac pacemakers, insulin pumps, cochlear implants,
neurostimulators, bone-growth stimulators, and implantable drug
infusion pumps
– intracardiac pacing wires or Swan-Ganz catheters
– Ferromagnetic implants, such as cerebral aneurysm clips, vascular
clips, and skin staples
– Bullets, shrapnel, and metallic fragments
• safe for MR
– nonferromagnetic vascular clips and staples and orthopaedic devices
– Prosthetic heart valves with metal components
• Pregnant patients can be scanned, provided the study is
medically indicated
 PRINCIPLES OF
INTERPRETATION:
• Soft tissue contrast is obtained through imaging
sequences that accentuate differences in T1 and
T2 tissue relaxation times
• Water is the major source of the MR signal in
tissues other than fat
• Mineral-rich structures, such as bone and
calculi, and collagenous tissues, such as
ligaments, tendons, fibrocartilage, and tissue
fibrosis, are low in water content and lack mobile
protons to produce an MR signal
– low in signal intensity on all MR sequence
 FREE WATER in MRI

Ventricles and sulci

contain CSF  black
on T1 , white on T2

T1W T2W
 FREE WATER in MRI
• found mainly as extracellular fluid, also as
intracellular free water
– Organs with abundant extracellular fluid
• kidneys (urine); ovaries and thyroid (fluid-filled
follicles); spleen and penis (stagnant blood); and
prostate, testes, and seminal vesicles (fluid in
tubules)
• Edema (increase in extracellular fluid)
• Most neoplastic tissues have increase in
extracellular fluid as well as an increase in the
proportion of intracellular free water  bright
signal intensity on T2WIs
 Proteinaceous Fluids
in MRI
• addition of protein to free water shortens
T1 relaxation time – bright
• T2 relaxation is also shortened, but the T1
shortening effect is dominant even on
T2WIs -- remain bright on T2WIs
• synovial fluid, complicated cysts,
abscesses, many pathologic fluid
collections, and necrotic areas within
tumors
 Proteinaceous Fluids
in MRI

T1W T2W

A complicated rectal cyst showing hyperintensity on both

T1 and T2 images
 Soft Tissues on MRI
• Soft tissues that have a predominance of intracellular
bound water have shorter T1 and T2 times than do
tissues with large amounts of extracellular water
• liver, pancreas, adrenal glands, and muscle --
intermediate signal intensities on both T1WIs and
T2WIs

T1W T2W
 Fat on MRI
– T1 relaxation time is short -- bright signal
– T2 of fat is shorter than T2 of water-- lower
signal intensity for fat, relative to water
– On images with lesser degrees of T2
weighting, T1 effect predominates and fat
appears isointense or slightly hyperintense
compared with water.
– STIR sequences suppress signals from all
tissues with short T1 times, including fat
 Fat on MRI

SUBCUTANEOUS
T1W
FATS ARE BRIGHT
ON BOTH T1 and T2

T2W
 Flowing Blood on MRI
– Higher-velocity blood flow alters the MR signal in
complex ways, depending on multiple factors.
• high-velocity signal loss predominates in spin-
echo imaging, resulting in signal void “black
blood” in areas of flowing blood.

PATENT BLOOD VESSELS

ULTRASONOGRAPHY
 ULTRASOUND
• utilizes pulse-echo technique
• transducer converts electrical energy to a
brief pulse of high-frequency sound energy
transmitted into patient  transducer
becomes a receiver, detecting echoes of
sound energy reflected from tissue 
composite image is produced
medicalexpo.com

ULTRASOUND
PROBE, a
transducer and
a receiver.

http://4.bp.blogspot.com
 ULTRASOUND
• produces nearly real-time images of moving
patient tissue
– enables assessment of respiratory and cardiac
movement, vascular pulsations, peristalsis, and
moving fetus
• Images may be produced in any anatomic plane
by adjusting the orientation and angulation of the
transducer and the position of the patient.
– standard orthogonal planes: axial, sagittal, and
coronal
• Visualization of structures by US is limited by
bone and gas-containing structures (e.g. bowel
and lung)
LOOKING AT
ULTRASOUND IMAGES

faculty.southwest.tn.edu
 PLANES
• Sagittal/longitudinal
• Transverse/axial
• Coronal
 AXIAL/TRANSVERSE

http://reference.medscape.com
 SAGGITAL/LONGITUDINAL

Aorta

http://sinaiem.us
 LIMITATION OF ULTRASOUND
(BONE)
Sound energy is nearly completely
absorbed at interfaces between soft
tissue and bone (rib, R), causing an
R acoustic shadow limiting
visualization of structures deep to
the bone surface

medscape.com
 LIMITATION OF ULTRASOUND
(AIR)
Soft tissue-gas interfaces (bowel
loop) cause nearly complete
reflection of the sound beam,
Bowel wall preventing visualization of deeper
structures

http://www.jultrasoundmed.org
 DOPPLER ULTRASOUND
DOPPLER ULTRASOUND
OF THE CAROTID ARTERY

Radiologyinfo.org
 Doppler US:

• adjunct to real-time gray-scale imaging

• detects reflection of the sound wave from
a moving object – RBC in flowing blood
• can detect presence of blood flow and its
direction and velocity
ULTRASOUND ARTIFACTS
 ACOUSTIC SHADOWING
Gallbladder stone Bone (rib)

S S

Medscape.com

med-ed.virginia.edu
ACOUSTIC ENHANCEMENT

Cyst Gallbladder

ultrasoundpaedia.com
 COMET-TAIL ARTIFACT

http://sinaiem.us http://radiopaedia.org
Comet-tail artifacts (>) arise from
normal pleura (*) reflecting sound adenomyomatosis of the gallbladder
waves.
PRINCIPLES OF ULTRASOUND
INTERPRETATION
onlinejets.org
FLUID-CONTAINING STRUCTURES

Dilated renal calyces and pelvis

ultrasoundcases.info
medison.ru

myhealth.alberta.ca ars.sciencedirect.com
 SOLID TISSUE
(FATTY TISSUE)

Lipoma
Fatty liver

cdn.fatty-liver.com
 SOLID ORGANS

(P) Pancreas Kidney

medison.ru med.cmu.ac.th ep.bmj.com

 HYPOECHOIC

Liver
Liver

Focal nodular hyperplasia

rsna.org
 HYPERECHOIC

Liver

Liver

Gallbladder stones
medison.ru
 ANECHOIC

Normal gallbladder

medison.ru
medison.ru
QUIZ
1. W_____ R_____ produced
st
the 1 x-ray image.

Source: news.stanford.edu
 2. Type of radiography?
(1) PATIENT IS POSITIONED (2) X-RAY IS TAKEN

(4) X-RAY FILM IS READ (3) FILM CASETTE IS TAKEN TO

THROUGH A NEGATOSCOPE THE DARK ROOM FOR
DEVELOPING
 3. What does radiography,
fluoroscopy and CT scan have
in common?
• Filmless
• Make use of x-rays
• Real time
• Produce 2-D images
4. What do you call this chest
radiograph view?
 4-6. Fill basic radiography densities

– _4_ density
• lungs
– Fat density
• Subcutaneous tissue
– _5_ density
• Heart
– Bone density
• __6__
– Metal/contrast density
• pacemaker

http://www.keepingyouwell.com/
7. Which of the following are cross-
sectional imaging techniques?
• CT
• MR
• Ultrasound
• Fluoroscopy
• Radiography
 8. What is the latest technical
advance in CT imaging
Conventional CT scan
Multidetector CT (MDCT)
Helical CT scan
 9. In what plane is this image
viewed?

• axial
• Sagittal
• coronal
10. Which of the 2 images has
contrast?