Professional Documents
Culture Documents
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in
any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by
law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/
go/permissions.
The right of Clifford R. Berry, Nathan C. Nelson, and Matthew D. Winter to be identified as the author of the edito-
rial material in this work has been asserted in accordance with law.
Registered Office
John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA
For details of our global editorial offices, customer services, and more information about Wiley products visit
us at www.wiley.com.
Wiley also publishes its books in a variety of electronic formats and by print-on-demand. Some content that
appears in standard print versions of this book may not be available in other formats.
Trademarks: Wiley and the Wiley logo are trademarks or registered trademarks of John Wiley & Sons, Inc. and/
or its affiliates in the United States and other countries and may not be used without written permission. All
other trademarks are the property of their respective owners. John Wiley & Sons, Inc. is not associated with any
product or vendor mentioned in this book.
This book is dedicated to my wife and love of my life, Brigitt, who has put up with this veterinary radiology
stuff all our adult lives. There will be a special place in heaven for her with her patience. To God be
the Glory (John 3:16)!
– Nate
To my wife, Brandy. Without her love, support, and twinkling spirit, none of this would be possible.
To my children, Mia and Damian, who make me the proudest person on the planet.
To my entire family, who have supported me always.
To all veterinarians and veterinary paraprofessionals that give of themselves day
in and day out – you are Superheroes.
Contents
CONTRIBUTORS IX
8 Imaging of Joint and Tendon Diseases 104
ACKNOWLEDGMENTS X
Nathan C. Nelson
PREFACE XI
ABOUT THE COMPANION WEBSITE XII
9 Fractures and Fracture Healing 131
Nathan C. Nelson
SECTION I INTRODUCTION AND PHYSICS
10 Aggressive Bone Disease 149
Erin Porter and Nathan C. Nelson
1 The Science, Art, and Philosophy of
Radiographic Interpretation 3
11 Imaging of the Head 166
Matthew D. Winter
Nathan C. Nelson
vii
viii Contents
R O BS O N G I G L I O , D V M , M S , P H D , D A C V R N AT H A N C . N E LS O N , D V M , M S , D A C V R ( D I , E D I )
Assistant Professor, Radiology Clinical Professor, Diagnostic Imaging
College of Veterinary Medicine Department of Molecular Biomedical Sciences
University of Georgia College of Veterinary Medicine
Athens, GA, USA North Carolina State University
Raleigh, NC, USA
F E D E RI CO R . VI LAPLAN A GRO SSO , LV,
DE CV D I , DACV R CINTIA R. OLIVEIRA, DVM, DACVR
Clinical Associate Professor, Diagnostic Imaging VetsChoice Radiology
Department of Small Animal Clinical Sciences Madison, WI, USA
College of Veterinary Medicine
University of Florida E R I N P O RT E R , D V M , D A C V R ( D I , E D I )
Gainesville, FL, USA Clinical Associate Professor, Diagnostic Imaging
Department of Small Animal Clinical Sciences
S I L K E H E C H T, D V M , M S , D E C V D I , D A C V R College of Veterinary Medicine
Professor, Diagnostic Imaging University of Florida
Department of Small Animal Clinical Sciences Gainesville, FL, USA
College of Veterinary Medicine
University of Tennessee S A N D R A TO U, D V M , D A C V I M ( I N T E R N A L
Knoxville, TN, USA M E D I C I N E A N D C A R D I O LO G Y )
Veterinary Cardiologist
S E A M US H O E Y, M V B , D E CV D I , DACV R ( D I A N D E D I ) Department of Clinical Sciences
Lecturer/Assistant Professor College of Veterinary Medicine
School of Veterinary Medicine North Carolina State University
University College Dublin Raleigh, NC, USA
Veterinary Science Centre
Dublin, Ireland M AT T H E W D . W I N T E R , D V M , D A C V R
Chief Medical Officer
E LO D I E E . H U G U E T, D V M , D A C V R Vet-CT
Clinical Assistant Professor, Diagnostic Imaging Orlando, FL, USA
Department of Small Animal Clinical Sciences Clinical Associate Professor, Diagnostic Imaging
College of Veterinary Medicine Department of Small Animal Clinical Sciences
University of Florida College of Veterinary Medicine
Gainesville, FL, USA University of Florida
Gainesville, FL, USA
E L I Z A B E T H H UY N H , D V M , M S , D A C V R
Veterinary Radiologist
VCA West Coast Specialty and Emergency Animal Hospital
Fountain Valley, CA, USA
ix
Acknowledgments
We would like to acknowledge our colleagues, residents, Bobbie Davis, Mary Wilson, and Theresa Critcher. The residents
interns, and students who have asked the right questions and over the years have always pushed us to be better and we
helped us to shape our interpretation paradigms for diagnostic greatly appreciate that.
imaging. A special shout out to the radiologists at the Univer- We want to acknowledge the incredible patience of the
sity of Florida, Michigan State University, and North Carolina editors and staff at Wiley Blackwell, especially Merryl Le Roux
State University for their insights and help in our formulation of and Erica Judisch, who have not relented in their efforts to help
Roentgen abnormalities, tying things together, and prioritizing us and have believed in this project from the beginning.
differentials. Of course, our programs would not be complete We want to acknowledge Elodie Huguet, DVM, DACVR,
without the veterinary imaging technicians who go above and for doing the textbook cover and the section pages for us.
beyond the call of duty daily to ensure quality studies without She is incredibly gifted in art and gave us great images to work
compromising patient care. A special shout out to the techni- with for these areas. We greatly appreciate you and your
cians at the University of Florida, Michigan State University, and talents, Elodie.
North Carolina State University, especially Danielle Maruagis, Thank you.
x
Preface
Why another diagnostic imaging textbook? There are many It would be impossible to present all the potential images
excellent textbooks on veterinary imaging that have been pub- that a patient will present with any given disease process,
lished previously and are still moving forward, with historical whether dealing with multicentric lymphoma or elbow dys-
editions being replaced with new ones. We felt that this text plasia. Again, this atlas will form a foundational pillar upon
should be first and foremost an introduction to diagnostic which other pillars can be built. We recognize that “pattern
imaging, although most of the text deals primarily with radiol- recognition” is a lower-order learning technique, but it is criti-
ogy. But more importantly, this textbook was meant to be an cal for building the foundation of interpretation of diagnostic
atlas so that we could show not necessarily the “classic” cases images that occurs each time a new set of images is made.
but some average cases and how the same disease can look dif- As with all published works, there will be mistakes in this
ferently depending on the stage of the disease at the time when book. We have tried our best to minimize those mistakes, but
the images are made. Being an atlas, this textbook is not a com- take the ultimate responsibility for errors.
prehensive overview of all the different diseases that one may We wish you the best in your future endeavors and hope
find in the literature, but should serve as an approach for “com- that this textbook can play some role in the diagnostic imaging
mon things occurring commonly.” And when there is overlap part of your veterinary medicine career.
between different disease presentations on the radiographs,
formulating a prioritized differential diagnosis list is given CLIFFORD R. BERRY (KIP)
precedence. It is hoped that the book will serve as a foundation
upon which the reader can add layers of information (science) NATHAN C. NELSON (NATE)
and clinical experience (art) over the course of their career in
veterinary medicine. MATTHEW D. WINTER (MATT)
xi
About the Companion Website
This book is accompanied by a companion website.
www.wiley.com/go/berry/atlas
The website includes figures from the book as downloadable PowerPoint slides and Radiology templates (Appendices I, II, III).
xii
SECTION I
The Science,
Art, and
Philosophy of
Radiographic
Interpretation
Matthew D. Winter
Department of Small Animal Clinical Sciences, College
of Veterinary Medicine, University of Florida, Gainesville,
FL, USA
Atlas of Small Animal Diagnostic Imaging, First Edition. Edited by Clifford R. Berry, Nathan C. Nelson, and Matthew D. Winter.
© 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/berry/atlas
3
4 S ECT IO N I Introduction and Physics
Shape The external shape or contour of an organ or object. Most organs Round or rounded
have a narrow range of normal shapes. Intestines are tubular, Oval
kidneys are, well, kidney shaped, etc.
Rectangular
Triangular
Fusiform
Broad-based
Amorphous
Number A value representing quantity or amount. In its simplest form, we Value (i.e., 3 pulmonary nodules)
might identify that there are 2 kidneys, 7 lumbar vertebrae, or Increased in number (compared to
10 pulmonary nodules. But we also might use this to characterize normal or a prior study)
the specific quantity of cardiac chambers or liver lobes enlarged or
affected by disease Decreased in number
Numerous
Location Place or position. Most organs have a normal, expected position that Normal
can be altered by disease. In many cases, the position of an organ Displaced (dorsally, ventrally, laterally, to
may be altered by an adjacent abnormality. Recognizing this is key the left, etc.)
to understanding the lesion. Knowledge of radiographic anatomy is
of the utmost importance. Remember that “Anatomy is Power!”
Opacity The relative ability to attenuate x-rays. There are five radiographic Gas, fat, soft tissue/fluid, mineral/
opacities. Relative differences in the soft tissue opacity of organs are bone, metal
often related to physical density or thickness
the x-ray beam as it passes through a patient. Gas has a small mineral, including but not limited to dystrophic mineralization,
physical density and does not attenuate x-rays. Therefore, things metastatic mineralization, uroliths, nephroliths, etc. At the end of
that contain gas are black, or less opaque on a radiograph. We see the continuum is metal. Metal attenuates, or stops, all x-rays, and
this in the lungs and the gastrointestinal tract. We should note the therefore appears white (radiopaque) on a radiograph. Examples
presence of gas where it is unexpected. Fat is more dense than gas are barium, microchips, surgical plates, and some foreign bodies.
and attenuates more x-rays. Therefore, it appears gray on radio- In addition to describing abnormal opacities, one may also
graphs. Soft tissue attenuates even more x-rays than fat, and has identify the relative uniformity of an organ or structure by using
the same density as fluid. It is important to realize that soft tissue terms such as homogeneous or heterogeneous. The presence of
structures (e.g. aortic walls) and fluid (e.g. the blood within the variable opacities in a structure that is normally uniform can be
aorta) cannot be distinguished radiographically. As with gas, it is described in terms of heterogeneity. Recognizing heterogeneity in
always important to document the presence of fluid in a space in a normally homogeneous structure can be an important finding.
which it does not belong or is excessive (pleural space, peritoneal While the above process is described in the context of radio-
space, retroperitoneal space, subcutaneous tissues). graphic interpretation, this tool set is similar for all imaging
Next on the opacity continuum is mineral. Bone is prob- modalities. The Roentgen approach is still the method by which
ably the most recognizable mineral opacity on a radiograph, but abnormalities should be characterized, though we modify
recall that many processes result in accumulation of abnormal the terminology around the Roentgen sign of opacity, which
6 S ECT IO N I Introduction and Physics
A B
FIGURE 1.3 Radiographs of a plastic container and two surgical gloves filled with water (A) and of two surgical gloves in which the fingers have
various degrees of superimposition (B). In both gloves, there are small gas bubbles (black arrowheads). In (A), note that the thumb in the lower right
of the image and the palm of the glove in the upper left are more opaque than the water in the container due to summation (S). The index finger
of the glove in the lower right (-) is less opaque than the thumb and the palm of the same glove. Some of this can be explained by summation, but
some is also a result of differences in the physical thickness of these structures. The margins of the fingers of the glove in the upper left are almost
completely lost in the container. These margins are border effaced as they are immersed in the water. Both the fingers and the water in the container
have the same opacity. The thumb of the glove in the upper left (+) is also very opaque. This thumb is viewed “end-on”, as if pointing down at the
container, creating even greater summation in this orientation. The margins of this thumb remain visible, as it is not immersed in the water. In
(B), note that in the regions in which the fingers of the two gloves overlap, the overall opacity is increased compared to the individual fingers
alone (S). This is another example of summation. Note that the margins of these digits are all well defined. While there is summation, there is gas
surrounding each digit, highlighting the margins. There is no border effacement here. Also, the palms of each glove (+) appear slightly more opaque
than the digits. This is due to the greater physical thickness of the palms compared to the digits. There is more water for the x-rays to penetrate,
therefore more x-rays are attenuated, creating a more opaque region despite the fact that this is the same material (water).
Also note that the fingers that are immersed in the water- statement, the differential diagnosis list, and next steps. The
filled container are not visible. This is because the fingers are first step, the description, is the process of using Roentgen
surrounded by the same opacity, and the margins of the fingers signs to evaluate anatomic abnormalities noted in the image.
have become border effaced. This means that the margins of The second step, the conclusion, consists of interpreting the
two structures of the same opacity, when in contact with one findings individually and in the context of other abnormalities
another, cannot be differentiated as separate structures (called and recognizing patterns. In the third step, we construct a list
border effacement). This is why you will not see hepatic veins of probable diseases that have pathophysiologic mechanisms
or portal veins in the liver, why you will not differentiate fluid in that could explain the imaging abnormalities or that fit the
the urinary bladder or intestines from the wall of those struc- pattern observed.
tures, or why you cannot see the individual chambers of the There are a large number of possible radiographic pre-
heart on a plain radiograph. These changes are seen commonly sentations for a disease process. Although this text is an atlas,
on radiographs, so make sure that you have an understanding it cannot present all possibilities, just common examples of
of these radiographic concepts. them. Part of the reason for this is the timeline of the disease
process. The image created during radiography represents a
snapshot in the timeline of a disease process. When are we tak-
ing the image relative to the severity of disease? Other factors
Organizing Information/ such as individual variations in response to disease (dealing
with a biological system) as well as the severity of disease are
Abnormalities important factors.
In the final part, one must strategically select next steps
It is important to organize data to assist in pattern recognition. that might help to arrive at a definitive or final diagnosis,
The process of organization can be divided into four parts: or list possible treatment options for the disease process
the description of abnormalities, the conclusion or summary that is the primary consideration based on the signalment,
8 S ECT IO N I Introduction and Physics
References
1. Scrivani, P.V. (2002). Assessing diagnostic accuracy in veterinary 2. Gunderman, R.B. (2009). Biases in radiologic reasoning. Am.
imaging. Vet. Radiol. Ultrasound 43: 442–448. J. Roentgenol. 192: 561–564.
CHAPTER 2
Physics of
Diagnostic
Imaging
Elizabeth Huyhn1, Elodie E. Huguet2, and
Clifford R. Berry3
1
VCA West Coast Specialty and Emergency Animal Hospital,
Fountain Valley, CA, USA
2
Department of Small Animal Clinical Sciences, College of
Veterinary Medicine, University of Florida, Gainesville, FL, USA
3
Department of Molecular Biomedical Sciences, College
of Veterinary Medicine, North Carolina State University,
Raleigh, NC, USA
and Advantages the patient based on the various physical densities compared
with the normal attenuation of water (called a Hounsfield
unit or HU).
Radiography is an imaging technique that uses x-ray attenu- Fluoroscopy also utilizes ionizing radiation to obtain
ation within veterinary patients to obtain two-dimensional dynamic, real-time images (usually limited by a frame rate of
images of internal organs and to assess for the presence or 30 frames/second) that are viewed over time. This modality is
absence of disease. Radiography in veterinary medicine can be used to observe the movement of contrast through the esoph-
subdivided into projectional radiography, computed tomogra- agus, cardiac structures, or different vessels, as well as diag-
phy (CT), and fluoroscopy. nosing dynamic diseases such as a collapsing trachea.
Projectional radiography utilizes electromagnetic or ion- Contrast radiography can be used in projectional radiog-
izing radiation to obtain static two-dimensional images of a raphy, computed tomography, and fluoroscopy to supplement
three-dimensional patient (body part), which in and of itself information gained from these modalities. Types of contrast
presents projection artifacts that have to be properly inter- radiography include positive contrast and negative contrast.
preted as normal or abnormal. Common uses for projection Common positive contrast agents used include barium sul-
radiography in veterinary medicine include thoracic, abdom- fate paste or liquid or iodine (i.e., nonionic, iodinated positive
inal, musculoskeletal, and contrast imaging (Figure 2.1). contrast medium). In radiography, positive contrast is metallic,
Atlas of Small Animal Diagnostic Imaging, First Edition. Edited by Clifford R. Berry, Nathan C. Nelson, and Matthew D. Winter.
© 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/berry/atlas
10
A
D E
FIGURE 2.1 (A) Left lateral thoracic radiograph in a normal dog. (B) Right lateral abdominal radiograph in a normal dog. (C) Ventrodorsal
pelvis radiograph in a normal dog. (D) Right lateral abdominal radiograph after barium positive contrast administration in a normal dog.
(E) Ventrodorsal abdominal radiograph after barium positive contrast administration in the same patient. Note the positive barium contrast in
the stomach (black arrow), duodenum (black arrowheads), and some segments of the jejunum.
12 S ECT IO N I Introduction and Physics
so it increases the visibility of the organ or vessel within which the contrast of the image will change; when the window width
it is introduced (Figure 2.1). Negative contrast agents typically narrows, there is increase in the displayed contrast. If changes
used are room air or carbon dioxide which is gas opaque (radio- to the window length are made, the brightness of the image
lucent) on the image (Figure 2.2). Double-contrast studies can will change.
be done using a combination of positive and negative contrast
media to give optimal detail of a mucosal surface such as the
urinary bladder (Figure 2.3) [1].
Digital projectional radiography is used as a common Basics of X-Ray
first-step modality in diagnostic imaging as it is relatively
affordable and can be obtained quickly. Digital radiography has Interaction in Matter
an increased dynamic range which implies that the anatomy
has varying density values that can be visualized. Using a To understand how radiographs are made, it is important to
broad scale contrast display, all the anatomy can be seen in recognize how photons interact with matter. Photons can
the radiographic image within the displayed range of optical interact with matter via (i) coherent scattering, (ii) photoelec-
densities. The displayed densities can be adjusted according tric effect, (iii) Compton scattering, (iv) pair production, and
to the contrast and brightness of the image. The contrast and (v) photodisintegration [2]. Pair production and photodisinte-
brightness of the image are attained through window width gration have no relevance to diagnostic radiology so they will
and window level. If changes to the window width are made, not be reviewed further.
A B
FIGURE 2.2 (A) Survey ventrodorsal abdominal radiograph. (B) Ventrodorsal abdominal radiograph after a pneumocolon. Note the
distinguishing margins of the colon (black arrows) in relation to the fluid-and gas-dilated segments of the small intestine (black arrowheads).
CHAPTER 2 Physics of Diagnostic Imaging 13
γ
e–
Digital Radiography
FIGURE 2.6 Compton scatter. Note the incoming photon (γ) is Digital imaging is the current standard of care for diagnos-
partially absorbed in an outer shell electron, which absorbs enough tic radiography, replacing analog film-screen combinations
energy to break the binding energy, and then becomes ejected (e−). that have been used for decades in human and veterinary
The ejected electron is a Compton electron. The incoming photon (γ) medicine [5, 6].
continues on a different path with less energy as scattered radiation. Digital detectors fall into two broad categories: computed
The scattered photon can interact with other atoms via photoelectric
radiography (CR) and digital radiography (DR). The DR cat-
effect or Compton scattering.
egory is really a misnomer as CR is a form of DR. In CR, an
imaging plate (also called the PSP or photostimulable plate)
and cassette are placed on the tabletop or in the table tray
for radiographic exposures. After an exposure is made, the CR
Principles of radiation safety for cassette is processed through a reader and the reader then
TA BLE 2 .1 produces an image based on the digital information stored
veterinary medicine.
in the imaging plate. This information is then erased and
1. The use of “hands free” exposures (all personnel out of the reloaded into the cassette for the next exposure. In DR (direct
x-ray room at the time of x-ray exposure of the patient) should
be the goal of every practice. or indirect), photon- sensitive hardware within the digital
2. Sandbags, sponges, tape, and positioning devices should plate directly interacts with the photons that are not attenu-
be used to accomplish “hands free” exposures. Adequate ated by the patient.
sedation or general anesthesia should be used when The digital systems (DR) available currently include hard-
appropriate. wired and wireless indirect, direct or CCD (charge coupled
3. Collimate the primary beam to the area of interest, recognizing device) types of detectors. A full explanation of these is beyond
that the smaller the collimated field, the greater the reduction
in x-ray scatter.
the scope of this text, but needless to say, digital radiography is
here to stay and has replaced the older analog systems.
4. All personnel operating the equipment should be properly
trained in usage of the equipment, proper anatomic posi-
tioning, technique, and transfer of images to different worksta-
tions and work environments (i.e., telemedicine).
5. If personnel are in the room at the time of the exposure, then: Limitations
• always wear lead apron, gloves, and thyroid shields
• always wear radiation detection badges to monitor exposure The primary limitation of projectional radiography is the
and adhere to strict guidelines for rotating personnel in radi- superimposition of organs causing summation or border
ology to minimize exposure to any one individual
effacement (flattening of a three-dimensional object into a
• never have any part of the personnel in the primary x-ray
beam even if wearing lead (lead only protects against scatter two-dimensional image). Orthogonal projections are made
radiation, not the primary beam) to help create a three-dimensional image in the interpreter’s
• personnel must be over 18 years of age brain. Radiography is a great first step to diagnosing and treat-
• pregnant personnel should never be used for holding ing diseases in veterinary patients. When referring to digital
patients for x-ray studies. radiography, the main disadvantage in relation to film-screen
radiography is decreased spatial resolution, but enhancement
Note: all states will have different regulations related to radiation safety and
it is incumbent upon the end user to determine these rules and laws for the techniques are used to improve the perceived spatial resolution
individual practice. of an image.
CHAPTER 2 Physics of Diagnostic Imaging 15
References
1. Wallack, S. (2003). Handbook of Veterinary Contrast Radiography. Diagnostic Radiology, 7e (ed. D.E. (e.) Thrall). St Louis, MO:
San Diego, CA: Veterinary Learning Systems. Elsevier.
2. Bushberg, J.T. (2012). The Essential Physics of Medical Imaging. 5. Robertson, I.D. and Thrall, D.E. (2018). Digital radiographic imag-
Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins. ing. In: Textbook of Veterinary Diagnostic Radiology, 7e (ed. D.E.
3. Centers for Disease Control and Prevention (2015). ALARA – As Low (e.) Thrall). St Louis, MO: Elsevier.
As Reasonably Achievable. www.cdc.gov/nceh/radiation/alara.html. 6. Widmer, W.R. (2008). Acquisition hardware for digital imaging.
4. Thrall, D.E. and Widmer, W.R. (2018). Radiation protection Veterinary Radiology and Ultrasound, 49: s2–s8.
and physics of diagnostic radiology. In: Textbook of Veterinary
Another random document with
no related content on Scribd:
Cross-head Designed by Mr. Porter.
Contract with Ormerod, Grierson & Co. Engine for Evan Leigh, Son & Co. Engine
for the Oporto Exhibition. Getting Home from Portugal.
Trouble with the Evan Leigh Engine. Gear Patterns from the Whitworth Works.
First Order for a Governor. Introduction of the Governor into Cotton Mills.
Invention of my Condenser. Failure of Ormerod, Grierson & Co.
Diagrams from Engine of Evan Leigh, Son & Co. Sixteen Pounds to the Inch.
And, after all, the fault was largely mine. I did not think of it till long
afterwards, and it did not occur to anybody else, not even to those
most deeply interested in the boiler. My surface condenser was the
cause of all the trouble, and that was why I have to this day deeply
regretted having put it in. The oil used in the cylinder was all sent