MAHSA University

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Faculty of Medicine

Introduction to Medical
Imaging
Part (1)
DR MUNA MOHAMMED HUSSEIN MOFREH
IMAGING =? RADIOLOGY
Name the modality
 IMAGING & RADIOLOGY

• Old radiology = “conventional”: X-ray images were the only means

of visualizing the interior of the human body.
• “Imaging” was then called radiography and the study of the normal
or diseased body was radiology.
• Rapid innovative creative science : started by Computerized
Tomography (CT) then (Ultrasound, MRI…), and non stop
development.
• The continuous development was mainly for less hazardous methods
– both for the patient and the investigator. On the other hand, our
main aim is a better understanding of normal anatomy and detection
of the pathological abnormality through the imaging.
IMAGING MODALITIES
1-Conventional radiographs (“x-rays”)
• Fluoroscopy
• Mammography

2-Computed Tomography (CT)

3-Nuclear Medicine (NM)
• Bone scan, PET scan –SPECT scan , then combines CT and NM

4-Ultrasound (US)
5-Magnetic resonance imaging (MRI)

6-Angiography and interventional radiology

IMAGING MODALITIES

The field of medical imaging has progressed rapidly:

X-Ray Photography discovered by Wilhelm Roentgen, 1895
Catheter Angiography (1950s)
Nuclear Medicine (1960s)
Ultrasound and Computed Tomography (CT) (1970s),
Magnetic Resonance Imaging (MR imaging), Positron Emission
Tomography (PET), and Interventional Radiology (1980s)
Multi-detector CT and Ultrafast MR Techniques (early to mid-1990s)
Functional and Molecular Imaging (late 1990s to the present)
THE BEGINNINGS OF RADIOLOGY
NOVEMBER 1895
ROENTGEN DISCOVERED X-RAYS
THE BEGINNINGS OF RADIOLOGY

X-Ray Photography discovered by Wilhelm Roentgen, 1895

•when experimenting with cathode ray tubes in a darkened

room, he noticed a faint fluorescent glow emanating from a
plate he had left on the bench
•when he moved to pick it up, he was amazed to see the image
of the bones from his hand cast onto the plates
•the prospects for x-ray diagnosis were immediately recognised
but Roentgen refused to patent his discovery

•He won first Nobel Prize in Physics for his discovery - 1901
 IMAGING EMPLOYS ELECTROMAGNETIC
RADIATION

•An x-ray is a discrete bundle of electromagnetic energy

called a photon.
•It is similar to other forms of electromagnetic energy
such as light, infrared, ultraviolet, radio waves, or
gamma rays.
 IMAGING EMPLOYS
ELECTROMAGNETIC RADIATION
• The various forms of electromagnetic energy differ only in frequency (or
wavelength).
• However, because the energy carried by each photon is proportional to the
frequency, the higher frequency x-ray or gamma ray photons are much more
energetic than, for example, light photons and can readily ionize the atoms in
materials on which they impinge.
• The energy of a light photon is of the order of 1 electron volt (eV), whereas the
average energy of an x-ray photon in a diagnostic x-ray beam is of the order of
30 kilo electron volts (keV).
X-RAY IMAGING
X RAY IMAGING

Early X-ray apparatus ~ 1920’s Modern direct capture Radiography

X RAY IMAGING

•X-rays, after having passed through the body, will strike a

photographic film, producing a black-and-white and different grey
scale shadows image.
 CONVENTIONAL X-RAY IMAGES

• Conventional X-ray
images are taken by
passing the rays through
the body and exposing a
photographic film, called
x-ray film.
 DIGITAL X-RAY IMAGES

• Nowadays: X-ray image can

also be stored in a digital form
on a computer.

This gives advantages of;

 immediate image preview and availability;
 elimination of costly film processing steps
a wider dynamic range, which makes it less affected by over- and under-
exposure
the ability to apply special image processing techniques that enhance
overall display of the image.
FLUOROSCOPY

• X-ray images can also be viewed with a fluorescent screen like that
of a monitor. In such an image exposed areas are bright, unexposed
areas dark.
• Such images are temporary.
• This method is called fluoroscopy. It exposes the patient to much
higher doses of X-radiation and is far more hazardous.
BLACK GREY AND
WHITE

• The loss of energy of x-ray beam when pass through the body is called
attenuation, depends on some tissue characteristics.
• Some tissues are “transparent” to X-rays, some are “translucent” (partially
transparent) and some are “opaque” to X-rays. A totally opaque material will
absorb all the X-rays, allowing none to pass through.
 IMAGE DENSITIES

• On the x-ray film or image

• Bone – calcium  greater attenuation  white shadows

• Soft tissues  less attenuation  gray shadows
• Air  least attenuation  black or dark shadows

However … tissue thickness will affect the density of the shadow color.
 5 BASIC RADIOGRAPHIC
1.
DENSITIES
• Air
4.
• Fat
• Soft tissue/fluid
• Bones or calcifications
• Metal
2. 5.

3.

Name these radiographic densities.

CHEST X-RAY - BONES
•Chest Xray PA view:
A
A
B
•Oval A (a part of the clavicle); B

•Oval B, the end of the clavicle is formed C

C D
by a thin solid plate with a large centre of
“spongy” bone. The overall picture is
therefore a bit darker.
• The appearance of the rib at C (“flat
across” the X-ray beam). Compare with
the arrowheads D where greater lengths of
the ribs are across the X-ray beam, as the
ribs curve around the thorax.
 CHEST X-RAY – AIR & SOFT TISSUES
• Make out the difference between the air
outside the body and air in the lungs – lungs
B
are soft tissue filled with air!
• The shape of the heart– notice how the
thick muscle wall and the blood that fills
the heart create a white image
A
•Structures in the hilum of the lung can be
seen with variable clarity as at A. Again, a
blood vessel “end-on” is more opaque than
one “across” the beam.
•The cervical and upper thoracic vertebrae
can be seen in the oval B.
 CHEST X-RAY & TISSUE THICKNESS

Observe and distinguish the following:

breast shadow,
liver shadow,
axillary folds.
CARTILAGE

• Elbow x ray.
• The articular surfaces of the
bones are covered by hyaline
cartilage.
•The clear bands (arrows)
between the bones are areas of
cartilage.
 Soft Tissues

•In this image of a part of the lumbar vertebral column, can you see the bands by
the sides of the vertebrae? (Shown by the double-headed arrow on the right
side). What do you think they are?
 TISSUE CONTRAST!

 First of all, notice the ribs.

 name the vertebral bodies.
 Observe the bodies of vertebrae. They are made
of a thin shell of solid bone and spongy bone
inside. The oval outlines (one shown by the
white arrow) are joints between the articular
processes. The red arrow shows a spine
 The lighter bands between the bodies of
vertebrae are the intervertebral discs.
 These are bubbles of gas in the colon (black
arrows). Ordinarily, the colon is invisible but
Gas inside the colon creates contrast.
 TISSUE CONTRAST?

Indicate the right diaphragmatic copula in both images?

The white arrows are indicating important radiological sign which indicate surgical
EMERGENCY, what is it?
 CONTRAST MEDIA

• Opaque material to X-ray can be introduced in hollow organs. Will create

‘contrast’ between the contents of the cavity and walls. The cavity shows up
as white in an X-ray image.
• In some organs we can also introduce air or
a gas so that it shows up as black.
• Contrast materials are either:
positive or negative contrast.
 CONTRAST MEDIA

• An IV or oral contrast media must satisfy certain criteria :

• It must be inert (non-reactive) non-toxic.
• It must not be absorbed or retained by the body.
• It must be easily excreted.
 BARIUM SWALLOW

Oblique view of a barium swallow.

See the ribs and the vertebrae.

At the upper end of the picture the barium

column is narrow and smooth, indicating that
the oesophageal muscle is contracting to push
the ‘bolus’ down.

some barium has entered the stomach where?

 BARIUM MEAL - STOMACH

F
 The outline of the stomach is obvious.
Observe the air bubble in the fundus (F).
 The white arrow shows the pylorus. The
pyloric sphincter is a small mass of muscle
and therefore not visible.
 Note the extensive spread of Barium in the
intestines.
 Is this a small bowels or large bowels?
 plicae circulares= vulvulae conneventis .
 UROGRAPHY
• These pictures show intravenous
urography (IVU).
• In intravenous urography, the medium is
injected through IV.
• It will be diluted in the bloodstream.
Then will be excreted and
‘concentrated’ in the urine by the
kidneys.
• Identify the following: Renal calyces
and the ureters, as also the course of the
ureter.
• In about an hour’s time identify the
urinary bladder.
• IVU study the kidneys function
 LIMITATIONS OF X-RAY
IMAGING
• ‘conventional’ images have limitations.  two dimensional
images. For a 3-D so sometimes need more than one projection.

• The resolution of the images is also limited. It is possible to

“focus” the X-ray beam on a specific plane in the body. This is
called tomography – meaning picture of a slice.

• Modern methods of imaging have sought to overcome some of

these limitations.
 CT, MRI AND ULTRASOUND PHYSICS

• (CT)

• the X-ray source rotates around a plane of the body, taking serial pictures with images
received on a detector (instead of a film) The resulting picture created by the computer is like a
section of the body and can be recorded on a film.

• (MRI) uses the property of protons aligning themselves in a magnetic field and their reaction to
radio frequency waves. Effectively it is the imaging of protons. The most commonly imaged
proton is of hydrogen nucleus. So no radiation so it is safe method of imaging.

• Ultrasound : uses mechanical waves of frequencies beyond the audible range. These waves are
reflected to various degrees from junctions of tissues of different nature. Ultrasound has a great
advantage – it does not cause cellular damage when used in quantities required for imaging.
COMPUTED TOMOGRAPHY
(CT SCAN)
THE CT SETUP
X

1
2
3

• The X-ray tube (X), housed in a ‘wall’ (1) rotates around a hole (2) in the wall.
The detector (D) also rotates diametrically opposite the tube. The patient, lying
on a sliding trolley (3) or a couch passes through the hole. The movement of the
patient can be controlled so that ‘slices’ of the body are scanned by the
apparatus.
COMPUTED TOMOGRAPHY (CT
SCAN)

• Terms used:
• Attenuation
• Density
• Enhancement
HOUNSFIELD SCALE OR CT
NUMBERS
• Hounsfield scale or CT numbers is a quantitative scale for
describing radiodensity.

• Hounsfield Units
• -1000 air ***
• -100 fat
• 0 water ***
• 20-80 soft tissues
• 1000 bone/Ca/contrast
• >1000’s metal
THE CT IMAGE
• A CT image can be taken as a plain image or with the introduction of a
contrast medium.
• Like conventional X-ray images, bone appears white, air black and soft tissues
have intermediate densities depending on their composition and thickness.
A

R Liver L

P
COMPUTED TOMOGRAPHY (CT
SCAN)

• Large radiation dose

END OF PART I