Basic Radiology

PAFP Refresher Course

September 27, 2014

Marilyn Benedith Anastacio-Laceda, MD, DPAFP

I. Chest Radiography
II. Abdominal Radiography
III. Pediatric Sinus Radiography
IV. Mammography
V. Ultrasound
1. Breast
2. Kidneys, Ureter, and Bladder
3. Prostate
VI. 2D Echocardiography
VII. Cranial Computed Tomography Scan

Topic Outline
Radiography
DENSITIES Air < fat < liver < blood < muscle < bone <
barium < lead
• Air — least dense; most transparent or radiolucent; air-
filled densities appear black
 Lungs, gastric bubble, trachea, bifurcation of bronchi
• Fat — breasts
• Fluid — most of what you see; vessels, heart,
diaphragm, soft tissues, mediastinal structures
• Mineral — most dense (or radiopaque) of body
structures; appear white; bones (marrow is aerated),
aortic calcifications such as the aortic knob, calcification
of the coronary arteries, old granulomas; bullets, safety
pins, etc.
Chest Radiography
Cardiac Silhoutte

1. R Atrium 6. Tricuspid Valve

2. R Ventricle 7. Pulmonary Valve
3. Apex of L Ventricle 8. Pulmonary Trunk
4. Superior Vena Cava 9. R PA
5. Inferior Vena Cava 10. L PA
Pneumonia: Case 1

Findings: There is an ill-defined area of increased density in the

right upper lobe without volume loss. The right hilus is in normal
position. Air bronchogram is present (arrow).

Interpretation: Acute Lobar Pneumonia

Pneumonia: Case 2
Pneumonia: Case 3
 Atelectasis
• Result of loss of air in a lung or part of the lung with
subsequent volume loss due to airway obstruction or
compression.

• In many cases atelectasis is the first sign of a lung cancer.

The key-findings on the X-ray are:

• Sharply-defined opacity obscuring vessels without air-
bronchogram
• Volume loss resulting in displacement of diaphragm, fissures,
hili or mediastinum
• In a child, aspiration of a foreign body is a more likely cause of
obstruction of a bronchus.
Atelectasis: Case 1
Atelectasis: Case 2
Pulmonary Tuberculosis

Findings: Patchy
consolidation,
nodules and cavities
(arrows) on bilateral
upper lobes.
Pulmonary Tuberculosis: Cavitary Lesion
Pulmonary Tuberculosis: Miliary PTB

Findings: Granular alveolar pattern diffusely visible in both lung

fields. Little hilar adenopathy with no evidence of cavitation.
Blunting of both costophrenic angles indicates probable small
pleural effusion.
Pleural Effusion
Abdominal Radiography

Stomach
Liver

Left Psoas Margin

Descending Colon

Sacrum
Cecum

Left Iliac Bone

Left Femoral Head

Pneumoperitoneum

Double wall Sign

or Rigler’s Sign
Large Bowel Obstruction

Haustra

Fecal
Material
Small Bowel Obstruction

Valvulae
Conniventes
Large Bowel Obstruction with Multiple Air Fluid Levels
Pediatric Sinus Radiography
Water’s View
Caldwell’s View
Lateral View
Water’s View
 Mammography
• although sensitive, not specific

• 25% of nonpalpable lesions detected are found to

be malignant at biopsy

• sine qua non: spiculated density with ill-defined

margins

• features that are suggestive but not diagnostic of

cancer includes: fine stippled calcifications,
asymmetric density, ductal asymmetry, distortion of
skin, nipple and normal breast architecture
 Mammography: Uses
1. Examinations of an indeterminate mass that
presents as a solitary lesion suspicious of CA

2. Examination of an indeterminate mass that cannot

be considered a dominant nodule

3. Follow-up examination of breast cancer treated by

conservative surgery

4. Follow-up of examinations of contralateral breast

following mastectomy for CA

5. Evaluation of the large fatty breast in the

symptomatic patient
Mammography
 Mammography
BI-RADS Classification of Mammographic Abnormalities

Category Assessment Recommendation

1 Negative Routine screening

2 Benign finding Routine screening

3 Probably Benign Finding Short interval follow-up to

establish stability
4 Suspicious abnormality Not characteristic, but
definite probability of
malignancy, consider
biopsy
5 Highly suggestive of malignancy High probability of cancer;
appropriate action
should be taken
Ultrasound

Echogenicity
Anechoic or sonolucent
Hypoechoic
Hyperechooic or echogenic
Isoechoic
Posterior enhancement

Ultrasound Nomenclature
Breast Ultrasound
Used in assessing the following indications:

•Investigating a palpable lump on whether it is

cystic or solid

•Mammography abnormality

•Follow up of known lesion

•Mastalgia, Nipple discharge, Infection or

Mastitis

•Guidance for biopsy

Breast Cysts

A simple breast cyst: A complex breast cyst:

1. Anechoic Sedimentary movement may be
visible by scanning the patient
2. Well circumscribed
erect.
3. Have posterior Fine needle aspiration and
enhancement cytological assessment can
4. It's height should NOT confirm the diagnosis.
exceed it's width
Fibroadenoma

• Benign
• Well circumscribed
solid ovoid mass with
posterior
enhancement
Breast Carcinoma

Common ultrasound appearance:

Poorly circumbscribed, hypoechoic mass.
Height greater than width.
Posterior shadowing
You may also see: punctate, micro-calcifications, tethering of
adjacent tissues or the mass crossing tissue boundaries.
 KUB Ultrasound
Used to Identify the cause of:

• Flank pain
• Haematuria (frank or microscopic)
• Follow-up of previously identified pathology
• Classification of a mass (Solid V's cystic)
• Post surgical complications
• Guidance of aspiration, biopsy or intervention
• Post injury
• Assess the bladder wall for thickening,
trabeculation, masses and diverticulae. Pre and
post micturition volumes. Vesico-ureteric junctions
also can be visualised. Bladder calculi & foreign
bodies.
What to Check

o Kidney size (should not be >1cm difference

between sides)

o Cortical thickness(not <10mm)

o Cortico-medullary differentiation

o Cortex at least as hypoechoic as the liver

o Pyramids slightly hypoechoic relative to the

cortex

o No hydronephrosis

o Renal scarring
Renal Calculi

• A large renal calculus

in the renal pelvis.
A calculus will appear
as an echogenic focus
with shadowing.
Hydronephrosis

• A markedly
hydronephrotic
kidney.
• The medullary fat is
compressed and there
is clubbing of the
major calyces
(smooth convexity)
 Renal Cysts

Small simple cortical Complex, cortical renal cyst:

cyst: Hypoechoic; Well
Well circumscribed, circumscribed; Posterior
anechoic with posterior enhancement.
enhancement. No discernable internal
vascularity when interrogated
with low PRF colour doppler
• .
Bosniak Classification of Renal Cystic Disease

Category I. : Category I lesions are simple benign cysts showing

homogeneity, water content, and a sharp interface with adjacent renal
parenchyma, with no wall thickening, calcification, or enhancement.

Category II. : This category consists of cystic lesions with one or two
thin (≤ 1 mm thick) septations or thin, fine calcification in their walls or
septa (wall thickening > 1 mm advances the lesion into surgical
category III) and hyperdense benign cysts with all the features of
category I cysts except for homogeneously high attenuation. A benign
category II lesion must be 3 cm or less in diameter, have one quarter of
its wall extending outside the kidney so the wall can be assessed, and
be nonenhancing after contrast material is administered.
Category IIF : This category consists of minimally complicated
cysts that need follow-up. This is a group not well defined by
Bosniak but consists of lesions that do not neatly fall into category
II. These lesions have some suspicious features that deserve
follow-up up to detect any change in character.

Category III : Consists of true indeterminate cystic masses that

need surgical evaluation, although many prove to be benign. They
may show uniform wall thickening, nodularity, thick or irregular
peripheral calcification, or a multilocular nature with multiple
enhancing septa. Hyperdense lesions that do not fulfill category II
criteria are including in this group.

Category IV. : These are lesions with a non-uniform or enhancing

thick wall, enhancing or large nodules in the wall, or clearly solid
components in the cystic lesion.
 Prostate Ultrasound
Role of Ultrasound

Visualisation of the Prostate using the TRUS

(Transrectal Ultrasound) plays an important role in most
prostatic diseases.

It is necessary for all prostate biopsies.

If the PSA is elevated or increasing rapidly or there is an

abnormal prostate examination then a TRUS and prostate
biopsy may be indicated to obtain tissue to make the diagnosis
of prostate cancer.

Transabdominal Ultrasound can assess the volume of the

prostate but is not reliable to diagnose carcinoma.
Normal Prostate

• Transverse view of a
normal prostate gland
Prostate CA

• CA of the Prostate lesions

may appear hypoechoic,
hyperechoic, or isoechoic
on TRUS. Therefore,
TRUS is used primarily
to direct the physician to
suggestive areas in the
prostate or guide the
prostate biopsies.
 2D Echocardiography
Who should have an Echo?

• Assessment of valve function

• Assessment of Left ventricular function
• Suspected endocarditis
• Suspected myocarditis
• Cardiac tamponade
• Pericardial disease
• Complications of MI
• Suspicion of intracardiac masses
 2D Echocardiography
• Cardiac chamber size
• Assessment of artificial valve function
• Arrhythmias
• Assessment of RV and right heart
• Estimation of intracardiac and vascular
pressures
• Stroke and TIA
• Exclusion of LVH in hypertension
• Assessment of congenital heart disease
 Important Terms to Remember

Ejection Fraction
• Measures the ability of the heart to pump out
blood, and indicates the presence of heart
failure. The normal range of values are between
50 and 70.

Preserved ejection fraction – referred as diastolic

heart failure. The heart contracts normally but the
ventricles do not relax as they should during
ventricular filling.
Reduced ejection fraction – referred as
systolic heart failure. The heart does not
contract effectively and less oxygen-rich
blood is pumped out to the body.

Hypokinesia
• Indicates decreased motion of the heart
a) Regional wall motion abnormality
b) Global hypokinesia (LVH, Dilated
Cardiomyopathy)
c) Regional hypokinesia – occurs after an
heart attack
Cranial CT Scan

• Acute bacterial
meningitis.
• This axial
nonenhanced
computed
tomography scan
shows mild
ventriculomegaly
and sulcal
effacement
CT scan of the
brain showing early
signs of a left
middle cerebral
artery ischaemic
CVE. In this picture
only loss of
definition of the gyri
are seen clearly
• An established right
hemisphere
ischaemic CVE.
The damaged area
is clearly seen on
the left side of the
image. It is darker
(hypoperfused),
there are far fewer
gyri and the
swelling has
compromised the
ventricular space.
• This CT scan shows
a haemorrhagic
stroke - white area.
The slightly darker
area surrounding it
is oedema.