Contrast Radiography

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Contents:
Contrast media
History
principle
Classification and types
Properties
Adverse effects
Sialography
Arthrography
Barium studies
Contrast media in pulp chamber

2
Angiography
Lymphangiography
Contrast enhanced ultrasonography
Contrast enhanced MRI
Contrast enhanced CT
Radionuclide imaging

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Contrast media : Radiopaque substances that
have been developed to alter artificially,
the density of different parts of the patient
so altering the subject contrast

A radiopaque substance used in

radiography to permit visualization of body
structures
Dorland’s Medical Dictionary

4
HISTORY:
Strain et al – 1895 – used Plaster of Paris and lead
subacetate as contrast medium
Marcel Guerbet – 1901- Lipidol
Moses Swick – 1928 – intravenous organic iodinated
contrast media
Metrizamide first commercially available non ionic
contrast medium
THOROTRAST:
Thorium Dioxide
High atomic number – 90
Good image quality
Carcinogenic
5
IODINE:
Early 1920s, Treatment of Syphilis with
Sodium Iodide –
However, sodium iodide was very toxic for i.v.
use
UROSELECTAN:
Moses - Swick (Berlin) – 1928
First radiological contrast medium that could
produce safe and reliable Urograms

BENZOIC ACID MOLECULE: Since mid 1950’s

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Classification

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 According to Carr D H

Depending on the nature of material

Iodine based
Non-iodine bases- barium sulphate

Depending on the solvent

Conventional ionic water soluble
Oil soluble

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9
 Positive And Negative Contrast Agents
Positive contrast agents have a higher
atomic number than tissue, eg:
Barium = 56.
Iodine = 53.
Lead= 82
Negative contrast agents are relatively
radiolucent due to low specific gravity.
Oxygen, Air, CO2, Nitrous Oxide

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 Depending on the ionic nature

Mono- acidic monomer- Diatrizoate,

Iothalamate
Non-ionic monomer- Iopamidol, Iohexol,
Ioversol
Mono-acidic dimer- Hexabrix
Non-ionic dimer- Iodixanol, Iorrol

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According to WHAITES E
Barium sulphate suspensions - Gastrointestinal
tract
Iodine-based aqueous solutions
Ionic monomers: Iothalmate e.g. Conray
 Metrizoate e.g. Isopaque
 Diatrizoate e.g. Urografin
Ionic dimers: Ioxaglate e.g. Hexabrix

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 Non-ionic monomers:
Iopamidol e.g. Niopam
iohexol e.g. Omnipaque
Iopromide e.g. Ultravist

Iodine-based oil solutions Lipiodol, Ethidol,

Pantopaque
(Iodized poppy seed oil) used for lymphography
and sialography

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Chemistry:
Barium sulphate (BARITE, common ore of
barium)
A white crystalline salt
Insoluble in water
Extremely low solubility protects the patient
from absorbing harmful amounts of metal
Readily removed from the body
Specific gravity- 4.5, melting point- 15800c,
density- 4.5 gm/cm3, solubility in water-
0.00115 gm/L at 180c
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 Advantages:
Insoluble.
Inert.
Gives good mucosal detail.
No osmotic effect therefore radiodensity persists.
Inexpensive.
Relatively palatable.

Disadvantages:
Aspiration pneumonia if aspirated.
If leaks into body cavities or organs may persist
indefinitely and can cause granulomatous reactions.

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Available in several forms:
Colloidal suspension
Paste
Powder
Enema kits

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 Iodine:
Atomic weight- 127
Iodine provides radiopacity, others – carrier,
increase solubility and reduce toxicity
Coo-
I I

Hydrophilic, low lipid solubility, reduced

toxicity, low binding affinities
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Quantity of iodine required????
Low sensitivity of film screen radiography

Very large amounts of iodine

Photodetectors in CT scanning- sensitive
Average daily turnover of iodine- 0.0001 g
Total iodine content in the body- 0.01 g
Dose given – 70 g

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 Facts to
remember
!!!

Osmolality: Dependent on the number and not the

size of the particles of the solute in the solution.
Low osmolality- reduces pain on intra-vascular
injections
<500 mOsmol/kg of water- PAINLESS

Radio-opacity: Iodine concentration of the solution

Number of iodine atoms per molecule,
concentration of molecules in the solution
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Iodine particle ratio:
Number of iodine atoms/molecule
Number of osmotically active particles/
molecule of solute in solution
3:2 to 6:1

Non-Ionicity: Reduces the frequency of

minor and severe reactions to intravenous
contrast agents.

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Ideal properties of contrast agents:
1. Safe to use and handle
2. Non-toxic and no adverse reactions
3. Not cross the blood brain barrier
4. Miscible with body fluids
5. Have pharmacologic inertness
6. Produce satisfactory opacification
7. Low surface tension and low viscosity
8. Easy to inject
9. Easy elimination
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10.Provide satisfactory time for radiography
11.Not have any residual side effect
12.Cost- effective

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GENERAL PROPERTIES OF CONTRAST MEDIA
1. Viscosity:
Assessed by measuring its rate of flow through
a standard thin capillary tube under standard
conditions of temperature and pressure
To determine the force required to inject it
through a needle or catheter
2. Maintenance:
Lowering the concentration
Warming the contrast medium

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3. Osmolality:
Process in which solutions of higher
concentration draws water from the
solutions of lower concentration
Concentration of particles (osmoles)/
weight of the solvent
Closer to that of body fluids- better
tolerance

Sensation of heat and α Osmolality of the

discomfort contrast medium
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4. Chemotoxicity:
Mechanism responsible for causing toxic
effects of the contrast media which cannot
be explained by other means
Hydrophilicity
Lipophilicity
Protein binding
Histamine release: responsible for allergy-
like reactions

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 Adverse reactions:
Smallest concentration and smallest total
dose
American college of radiology

Idiosyncratic

Non-
combined Idiosyncratic

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 Idiosyncratic anaphylactoid reactions:

Most dreaded, most frequent, serious

and fatal
Occur without warning, cannot be
predicted
85%- within 5 minutes of injection
Same manifestation as anaphylactic
reaction, not true hypersensitivity reactions

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 Possible mechanisms!!!
Inhibition of enzymes: cholinesterase
Contrast medium
enzyme deactivation
Increased concentration of acetylcholine
vagal overstimulation
Cardiovascular collapse, bradycardia,
bronchospasm

Release of vasoactive substances- Histamine,

serotonin, bradykinin- vasomotor collapse

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 Activation of physiological cascade systems:

Complement
system

Coagulation Cascade Kinin

system system
systems

Fibrinolytic
system

Anxiety, apprehension, fear

Activate the hypothalamic reaction resulting in
cardiovascular and respiratory collapse 29
Mild symptoms:
Scattered urticaria, pruritus, rhinorrhoea, nausea/
vomiting, diaphoresis, coughing, dizziness
Moderate symptoms:
Persistent vomiting, diffuse urticaria, headache,
facial edema, laryngeal edema, mild
bronchospasm, palpitations, tachycardia,
bradycardia, hypertension and abdominal cramps
Severe symptoms:
Life threatening arrhythmias, hypotension,
bronchospasm, laryngeal and pulmonary edema,
seizures, syncope and death
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 Non-idiosyncratic reactions

Chemotoxic

Vagal Osmotoxic

Direct organ
Vasomotor
toxicity
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 Factors predisposing to adverse reactions:

1. Previous adverse reaction: severe reaction in

2nd time by 6-10 times
2. History of asthma or bronchospasm- 5-10
times
3. History of allergy or atopy
4. Cardiac disease: 2-5 times
5. Dehydration
6. Hematological and metabolic conditions
7. Renal disease

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8. Other conditions: neonates, aged, infirm
patients
9. Anxiety and apprehension
10.Delayed adverse reactions: common in females

Delayed arm pain, delayed rash, flu like

symptoms (headache, skin lesions, salivary
gland swelling, iodine mumps)
Delayed vasculitis, DLE, SJ syndrome have been
reported

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How to prevent adverse reactions?????
A. Patient should be monitored for a
minimum of 20 minutes after an ICM
injection
B. Rooms to be stocked with appropriate
basic and advanced life supporting
systems, monitoring equipments and drugs
C. Brief history: medical conditions,
medications
D. Assess vital signs

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 Minimize contrast agent reactions
1. Recommended prophylactic regimens
Methylpredinosone- 32 mg orally , 12 and 2 hours before
study
Prednisone 50 mg orally 13,7 and I hour before study

2. Previous reaction- alternative study (MRI)

3. Antihistamines

Diphenhydramine- 50 mg orally 1 hour before study

H2 blocker- 300 mg orally 1 hour before study and/or
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ranitidine- 50 mg orally 1 hour before study
4. To minimize nephrotoxicity- recent test of serum
creatinine (>/= 2 mg/dl – further consultation)
5. Patients should be encouraged to drink plenty of
clear fluids before and after the procedure
6. N-acetyl-cysteine
Reduce the chances of nephrotoxicity

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 Investigating patients at increased risk

a) Always weigh the possible advantages of the

diagnostic procedure against the small risk of
adverse reaction to the contrast medium
b) Other imaging modalities- MRI, CT, Ultrasound
c) Referring clinician should be consulted
d) Perform a 1 ml or smaller test dose- IV or
mucosal testing
e) Smallest dose, lowest concentration, smallest
number of injections- reliable, comprehensive
results
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f) Do not leave the patient unattended for
the first 20 minutes
g) Premedication- asthmatics and allergic
patients (24 hours of oral
corticosteroids and antihistamines)
h) LOCM should be preferred over HOCM
i) Before administering the emergency
trolley should be checked, alarm
system, ECG, suction apparatus,
defibrillator

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 Contrast agents available in Indian
market
Angiografin: 0.65 gm meglumine diatrizoate
in aqueous solution ( 20 ml amp and 50 ml vial)
Barium sulphate: 400 mg
Magnevist: 469 mg gadopentate acid
dimeglumine (10ml and 20 ml vial)
Radioaque ( IOHEXOL) : 10, 20, 50 ml
Sunray 280: meglumine iothalamate (20 ml
amp)
Sunray 420: (20 ml amp)
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 Ultravist 300: 0.623 gm iopromide
(inj 20, 50,100,200 ml)
Urografin: Sodium Diatrizoate, Meglumine
Diatrizoate
Urovision: Sodium Diatrizoate 0.4 mg,
Meglumine Diatrizoate 0.18 gm (50 ml)

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Sialography

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“Sialography is the retrograde injection of an
iodinated contrast medium into the ductal
system of a salivary gland”
Delbalso, Maxillofacial Imaging

CARPY, 1904 – first sialogram, isolated

parotid gland, using mercury
Arcelin, first in vivo sialogram, bismuth
solution
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The first account of a sialogram carried out
as a diagnostic measure appeared in 1925
when Barsony described a method of
outlining the parotid duct, using 20 per
cent. potassium iodide.
Medium- irritant
Abandoned the technique
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 I931, R. T. Payne published the first of his
classical series of papers on the subject.
Using a glass pipette, he injected 1/2 to 1
ml. of lipiodol very slowly into the appropriate
duct orifice until discomfort was complained
of.
Radiograph was taken immediately with the
instrument in situ.

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 Indications:
Detection or confirmation of small parotid and
submandibular gland sialoliths or foreign bodies.
Evaluation of the extent of irreversible ductal
damage present as a result of infection.
Differentiation of diseases such as chronic
sialadentitis, sjogren’s syndrome, sialosis
Evaluation of fistulae, strictures, diverticula,
communicating cysts and ductal trauma
As a dilating procedure of mild ductal stenosis.

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 Demonstration of tumor and
determination of its size, location and
origin.
Selection of a site for biopsy
Detection of residual tumors , fistula or
stenosis or retention cysts following
simple lithotomy or other surgical
procedures.

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 Contraindications:
Clinically active infection- drives the
infection back into the gland
Pain present- intolerable
Recent acute sialadenitis, gland has
returned to normal clinical state- can
reactivate a clinically quiescent infection.
(oral antibiotic coverage immediately after
the study)
Allergic sensitivity to iodine compounds
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Contrast media:
An ideal sialographic contrast media should have
following characteristics:
1. Physiological properties similar to that of saliva
2. Miscibility with saliva
3. Absence of local or systemic toxicity
4. Pharmacological inertness
5. Satisfactory opacification
6. Low surface tension and low viscosity to allow
filling of fine components of the ductal system.

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7. Easy elimination but should be durable
for sufficient time so as to permit time
for satisfactory radiographs.
8. Residual contrast medium should be
absorbed by the salivary gland and
detoxified by the liver or excreted by the
kidney.

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 Equipment to
perform sialogram

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a) Sialographic cannulas-
Rabinov type cannulas with tips
0.012 to 0.033
Variations: Manashil modification of the
Rabinov cannula
Lowman and Bezella cannula
Larger diameter- Parotid gland
Smaller diameter- Submandibular gland
Cannulas with polyethylene connecting
tube- greater mobility during the procedure.
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Rabinov 16, 32 – versatile, easiest to use
No. 16- non tapered, end hole catheter,
0.016 inch
Small and stenotic ducts

No.32- tapered, blunt ended, 0.032 inch

Acts as its own dilator, used in large
ducts

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Radiology 141:245-246, October 1981 53
 54
Radiology 141:245-246, October 1981
b) A set of lacrimal dilators ranging from
0000through 0 caliber
c) A 5-10 ml syringe
d) 4X4 inch gauze sponge pads
e) Sinografin ( equivalent contrast agent)
f) Secretogogue such as fresh lemon, lemon
extract or lemon concentrate
g) Adequately focused light
h) High powered magnifying glasses
I) Cotton rolls
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Cotton rolls- Dry field to work
Stabilize the catheter

Lemon drops:
Used to induce salivation
Facilitate the placement of cannula
Evaluate glandular washout following
contrast injection

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Preliminary films:
Preliminary plain film views of the gland
and surrounding structures

Presence of radiodensities
Background against which sialogram can be
compared

Evidence of bone destruction- neoplastic

process
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 Preliminary films for parotid:
1. AP View
2. AP Puffed cheek view
3. Lateral view
4. Lateral oblique view

Preliminary films for submandibular gland:

5. AP View
6. Lateral oblique
7. SMV View

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Water soluble media Fat soluble media (Oil Based)

These are principally iodinated There are two types of fat soluble
benzene or pyridone derivatives. contrast media. 1. Iodized Oil. 2. Water
  Insoluble Organic Iodine Compounds.

These compounds have a low viscosity, These compounds are more viscous
less surface tension and are more have more surface tension and are less
miscible with the salivary secretions miscible with the salivary secretions.

These physical characteristics permit It requires a higher injection pressure

filling of the finer ductal system under than that of the water soluble media,
lower pressure and facilitate prompt to visualize finer ducts. Oil based
drainage media is poorly eliminated and causes
ductal obstruction.

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Water soluble media Fat soluble media (Oil Based)
Causes less pain or discomfort, with no Extravasation of the fat soluble media
granulomatous reaction, in the glands. can produce severe foreign body
reaction with focal necrosis of the
parenchyma and stroma.

Opacification of the water based
media is not as good as that of oil
media.
The fat soluble contrast media on the
whole produces a satisfactory degree
of opacification. This is an excellent
media if the ductal systems under
examination are Intact.

The excretion of the contrast media is
very rapid
Hydropaque and Renografin are the
available water soluble contrast media
The excretion of the contrast media is
slow and gives adequate time to carry
out the various radio­graphic
procedures
Ethidol is the available fat soluble
contrast media

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 Procedure:
Collect all data:
Patient’s name, age

Chief complaint, clinical

impression

Previous history of allergy

Radiologic study and reports

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 Patient is instructed to raise his hand if he
feels any discomfort during the procedure.
Amount of contrast media- production of
pain

Parotid gland study:

A preliminary flat film is taken to rule out
calculi or other abnormal soft tissue or
osseous shadows

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 Cannulation:

Intraoral opening of the

stenson’s duct

Apply pressure to the cheek and

evert the papilla

Dilators- widen the opening

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Slight abduction of the cheek with thumb and
index finger- better exposure and angle for
cannulation

Insertion of the cannula, pushed gently

posteriorly

Cannula held in place by taping the tube to the

face or patient biting on the tube wrapped in
sponge

0.5-1.5 ml of contrast medium is injected

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 Submandibular gland:
Elevation of the floor of the mouth- patient to lift the
tongue

Application of external pressure to the floor of the mouth

Gentle passage of lacrimal probe

Cannula inserted and directed posteriorly and infero-laterally

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 Distension

Hydrostati Hand
c injection

Injection
techniques

66
 Hydrostatic injection:
Use of reservoir containing contrast solution
placed 70 cm above the patient’s head
Permits constant perfusion of the ductal
system
Provides uniform pressure without examiner
being present in the room

Distension:
Hand injection of the contrast until gland
“bulges”
Requires 2.5-3 ml of contrast
67
 Hand injection:
Preferred technique
Gentle hand injection using a steady,
constant pressure
Stopped when patient feels
uncomfortable

Normal parotid: 0.5-0.75 ml

Normal submandibular: 0.5 ml

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Continuous-infusion Pressure-monitored
Sialography
An infusion pump delivering 0.2-0.4 ml /
min of contrast media
Contrast agent is injected through a 1-m
coil of polythene tubing
Connected through a pressure transducer
via a short close fitting nylon cannula
Monitoring of pressure
Rises initially- 50 mm of Hg
Falls down- 30 mm of Hg
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 Ductal
Acinar

Evacuation

Phases of sialography

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 Ductal phase:
Starts with the injection of contrast
Ends- parenchyma of gland becomes hazy
Parotid gland:
Main duct of uniform caliber, progressive
arborization of secondary and tertiary ducts

Leafless tree appearance

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Normal
intraglandular
patterns of a
parotid gland

Delbalso, maxillofacial
imaging

72
Ductal phase of submandibular gland:
1st subphase:
Filling of the deep portion of the
duct
2nd subphase:
Filling of superficial segment
perpendicular to the mylohyoid muscle

73
Normal
intraglandular
patterns of a
submandibular
gland

74
 Acinar phase:
Commences with completion of ductal
opacification and ends with generalized
increased density

Evacuation and post-evacuation phase:

Provides an estimate of the secretory function
of the gland
1st subphase:
Non- stimulated evacuation of the gland and
ductal system.
75
 Performed over a minute- checking for the
spontaneous clearing of the contrast agent.
2nd subphase: glandular response to
stimulation
Performed if a significant amount of contrast
agent is present in the gland

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Abnormal findings
77
Extrinsic masses:
Cause indentation or rotation and
displacement of the entire gland. Lesions of
this type are due to enlarged lymph nodes
adjacent to the gland, to tumors of the face
and neck or to abnormal bone structures

78
Abnormalities of the ductal system :
Inflammatory
Neoplastic infiltrating processes

79
 Variations in the caliber of the entire duct
system, with irregular interruption of the
continuity of the ducts, strictures and
sacculations, the latter occurring especially
at the terminal ends of the ducts.
Larger defects may form due to
coalescence of smaller cavities
Sjogren’s syndrome: “SNOW STORM”
appearance
80
 Recurrent Pyogenic Parotitis
Payne (I933)
Demonstrated the ' BRONCHIECTATIC' type of
terminal dilatation of the parotid duct.
Streptococcus Viridans, Streptococcus
Pyogenes, B. Proteus, Pneumococcus, organisms
of Vincent’s angina and even atypical coliform
bacilli.
Sialogram:
In the early case, the terminal dilatation may
be confined to one area alone or there may be
scattered isolated dilatations
81
The duct itself shows no abnormality.
The gland parenchyma is usually well
outlined and no anatomical abnormalities
are revealed.

82
Late case of S. viridans infection :
SIALANGIECTASIS is seen
There is a saccular dilatation of the
terminal ducts and acini.
Main ducts become ' BEADED.'
This appearance results from alternate
dilatation and narrowing of the duct, and is
an indication of the duration of the
infection.

83
Pneumococcal recurrent parotitis (payne,
1940)
Sialogram
The gross degree of dilatation with no
evidence of a gland outline.
The main duct is much wider than normal
with periodic constrictions along its length.
'SAUSAGE-STRING' appearance has been
noted.
the reaction of the duct to infection is one
of alternate stricture and dilatation
84
85
 Salivary duct obstruction
Dependent on an abnormality of
mastication following or accompanying a
dental derangement

Buccal

Portion of
duct involved

86
 The main duct is dilated, narrowing down to a
fine point at its oral end. The gland itself is not
involved and there is no evidence of
sialangiectasis
87
The stricture extends up the duct to the point where it
perforates the buccinator muscle. Beyond the obstruction
the duct is dilated in a somewhat irregular manner,
indicating a degree of secondary infection
88
 Salivary calculi

Is it necessary?????

89
 Reasons for doing
sialography!!!!!
Feuz (1932) - That up to 20 per cent of salivary
calculi are radiotranslucent .
Secondly, a knowledge of the exact
whereabouts of the stone may be essential before
treatment is decided upon

90
The calculus lies in the deep part of the duct after it
turns down into the gland. Dilatation of the main
duct behind this, but no sialangiectasis.
91
 Salivary gland tumors:

Swelling

Salivary gland is involved????

92
The filling defect
Common finding with tumours and
depends for its presence on a space
occupying lesion unfilled by the radiopaque
medium.
Comparative translucency corresponding
with the soft tissue swelling

93
Distortion of the duct anatomy
Main duct may be pushed out of position,
seen running over an obvious
intraglandular tumour
Two adjacent subsidiary branches may be
widely separated by an interposed
neoplasm.

“Ball in hand appearance” ducts adjacent

to the tumor stretched

94
95
 Arthrography Of
Temporomandibular Joint

96
A study where contrast material is injected
into lower or lower and upper joint
compartments to visualise soft tissues such
as articular disc and joint capsule
(Maxillofacial Imaging, Larheim TA,
2006, 1ST ed )

Injection of a radiopaque contrast media

into a synovial space followed by radiograph
of the joint.
(History and examination of TMDs, Okeson
JP, 4th edition) 97
First reported attempt- Zimmer, 1941
Extremely difficult
Plain lateral and anteroposterior projections-
Beneficial
Nogaard- arthrogaphy
Detect articular disk changes
1947- normal and pathological appearances
Wilkes, 1978
Arthrographic manifestations of internal
derangements
98
Nogaard and frenkel
Use of visible and palpable landmarks for
injections into the synovial spaces of TMJ
Inferior synovial cavity- lateral approach
Puncture point-
Halfway between the tragus and condyle
with the patient’s mouth half open.
As the needle hits the articular fibrocartilage-
soft tap
Palpate the condyle by the sensation
transmitted through the needle to the finger
tips.
99
0.5-1.0 ml of the contrast solution is injected.

Superior synovial cavity

Opened patient’s mouth as wide as possible
Puncture point- same site
Directed the needle tip superiorly with some
anteromedial angulation
Bony resistance at the depth of the
mandibular fossa
Retract – 1-2 mm
Inject 1.3- 2.0 ml of contrast medium
100
 Frenkel’s technique:

Injected contrast medium using lateral

approach
Patient’s mouth open to improve access
Injected into either ISC or SSC
Needle’s position is confirmed by tactile
discrimination, failure to aspirate fluid
Light piston pressure for injection

101
 Non- fluoroscopic technique
1. Patient seated- upright position
2. All foreign objects- glasses, hearing aids,
wigs, jewelry
3. Drape to cover patient’s hair and
shoulders
4. Skin over lateral surface of joint and over
2 cm of EAC – disinfected
5. Local anesthesia- 25 gauge needle- two
0.5 ml infiltrations

102
 Side of the face to the lateral aspect of
the joint

Posterior aspect of the condyle,

anterior wall of external auditory canal

Entry in the acoustic canal- TRAGOHELICINE

INCISURE
8-12 mm medial to the tragus of the ear
Shaft parallels the transverse axis and 45
degrees to the mid-sagittal plane

103
 Tip- directed to the posterior slope of
condylar head
Confirmation made-
Lateral transcranial and anteroposterior
skull radiographs
Injection of contrast medium
Patient extrudes jaw- 2-3 mm to enlarge
the posterior recess of ISC
Needle tip is withdrawn 1-2 mm and
repositioned slightly medially against the
condyle
104
 With one hand holding the needle in
position opposite hand – Aspiration
Actual aspiration rarely occurs
Blood aspirated- vascular bed of the
posterior ligament
0.5 ml contrast medium- injected
Patient feels pressure and ipsilateral
disarticulation of the posterior occlusion
Lateral transcranial projection
( A WHITE CAP ON THE CONDYLE)

105
Opacified lower joint space
Inferior limit of the posterior recess to the crest
of the condyle, anteriorly and inferiorly into the
antrior recess
Injection is incorrect
Wait! And reinject

Additional radiographs:
Lateral, transcranial, plain film radiography in
open, closed, intermediate positions of the
mandible
106
 Contrast agent:
75% solution of sodium diatrizoate, diluted
with LA of 4:1
Epinephrine (1:1000), dilution (1:45,000)

25 gauge syringe is attached to needle with

plastic extension tubing

107
 Fluoroscopic technique:
Katzberg, Anderson, Helms
Patient placed on fluoroscopic table in lateral
recumbent position
TMJ- Transcranial projection

108
 Local anesthesia and fluoroscopic observation
23 gauge ¾ to ¼ inch scalp needle

Perpendicular to skin surface over the lateral

pole of the condyle and advanced until bone is
encountered
Jaw opened slightly
Needle guided into the posterior recess of
LJS
Injection of 0.5 cc of contrast medium

109
 Needle withdrawn and images are
videotaped.
Spot radiographs are taken- open and
closed positions

Meglumine diatrizoate- 3 cc ( 282 mg

iodine, 0.03 cc of 1:1000 epinephrine)

110
Synovial space selection for
opacification

Frenkel-
Opacification of either the upper and
lower joint space, but not both.
Preference for injecting only the lower joint
space, opacification of this space is more
diagnostic than opacification of superior
surface
111
 Westesson and others- opacification of
both spaces
Opacified upper joint space blocks out
portions of the lower joint space,
decreasing diagnostic information available
Opacification of both joints-
More operative time
Increased post-operative discomfort

112
 Anatomic approach
Norgaard and frenkel

Preauricular injection site by means of digital palpation of

the lateral pole of the condyle during mandibular
movement
Common in current use

113
 Lynch and chase
Through the anterior wall of the external auditory
canal, approaching the synovial space from the
posterior direction

Lynch, Chase, Irby

Posterior approach is technically easier and
more certain
Lateral approach- needle tip is directed to
more narrow lateral aspect of the posterior
recess of the IJS.
114
 Zetz and coworkers
Posterior technique- sufficient predicatibility to
be safely performed without fluoroscopic
guidance necessary with lateral technique
University of Texas and health science center
at san antonio
Patients- posterior technique, more comfortable
Lateral technique-
Probability of iatrogenic perforation of the
articular disk

Increased post-operative discomfort

115
Westesson technique:
Prior to arthrography radiographs:
Submentovertex
Lateral oblique
Transcranial
Transmaxillary
For evaluation of the structural changes
and changes of the demineralised parts of
the joint and establishing the position of
the condyle relative to mandibular fossa
116
 Equipment:
Image intensifier, spot filming capacity
Tomography- 2 compartment

Patient position: Supine, head on the

table as in transcranial projection
Preauricular region- cleansed with soap
and antiseptic, anesthetized and draped
Lower compartment cannulated
(posterior recess)- 1.1X32mm cannula

117
 Upper compartment- anterior recess (0.8X25
mm)
Inner needles of cannulas are withdrawn and
teflon catheters are advanced medially into the
compartments
Tips of catheters in joint space, outer parts
fixed to the skin
Water soluble iodine contrast medium- lower
compartment
Joint movements, functional abnormalities
recorded
118
 Contrast medium- upper compartment
0.3-1ml contrast medium is injected
Double contrast arthrography-
tomographic unit
Excess iodine contrast medium is
aspirated, 0.5-1 ml of air is injected.

119
Lateral with fluoroscopy
Safe and efficacious
Greater control of procedure
Dynamic study possible
Less operator/ patient time
5. Concurrent injections of both joint
spaces facilitated
Posterior without fluoroscopy
Safe and efficacious
Smaller radiation dose
Less possibility of vascular/nerve
injury
Greater availability and less
expensive equipment
Can be performed iwith dental
equipment in dental office or other
non- hospital setting
120
 Complications:
Lydiatt and associates
1. Minor pain
2. Alteration in occlusion
3. Limited opening
4. Extravasation of contrast material
5. Intravasation of epinephrine containing
contrast solution
6. Hematoma
7. Infection
8. hypersensitivity
121
 Epinephrine- transient tachycardia if
absorbed too quickly or intravasated
Metrizamide- less neurotoxicity, longer
duration

122
123
124
125
126
127
128
129
 Barium studies of the
esophagus
A procedure used to examine the upper GI
tract, which includes the esophagus and, to a
lesser extent, the stomach.

130
 Evaluate the condition and
functionality of the GIT.
Upright double contrast radiographs
and prone single contrast radiographs
Technique currently used in
UNIVERSITY OF PENNSYLVANIA

131
 Intravenous injection of 0.1 mg of glucagon
Patient then swallows the contents of one
packet of effervescent granules or FIZZIES
followed by 10 ml of water.

CO2 released in the stomach

Gas refluxes in the stomach

Double contrast effect

132
 Patient gulps a cup of high density barium (4
oz) as quickly as possible. E-Z-HD and HD 85
Rapid swallowing- peristaltic sequence is
interrupted, esophagus becomes hypotonic
Patient swallows air along with high density
barium

Double contrast effect

2-4 spot films are exposed in rapid sequence
and demonstrate the entire length of
esophagus
133
 Water soluble contrast examination:
When perforation of the pharynx or
esophagus is suspected
Iodinated water-soluble contrast media,
such as meglumine and sodium diatrizoate
If an esophageal perforation is suspected
but not shown by water-soluble contrast
examination
Immediate reexamination with barium
sometimes demonstrates the abnormality

134
Contrast medium
in pulp
chamber????

135
 Contrast medium in the pulp chamber
Adjunctive contrast medium, hypaque in
conjunction with NaOCl 5%, 17% EDTA- The Ruddle
Solution
In a study:
Low osmolality iodinated, water-soluble,
radiopaque contrast medium. Ultravist 370
(iopromide) introduced into the root canal using the
same style irrigating needles and a 10 mL syringe
under hand pressure, until a jet of contrast medium
was seen to emerge from the apical foramina.

136
 Some benefit could be achieved using contrast
medium in retreatment cases, contrast medium
can be perfused in order to identify any anatomical
variations in order to know the reason for failure
Contrast medium- used to verify the canal
morphology pre-operatively
Problems:
Expensive, short half life
Multiple attempts
Ultravist tends to accumulate in the cracks and
fissures – radiographic artefacts

137
Another study: in vitro
Iohexol is a tri-iodated, nonionic, water-
soluble contrast medium
To aid visual reference of contrast medium in
the root canal, one drop of 0.1% methylene
blue dye was mixed with 1mL of iohexol
radiopaque contrast medium
Increments of the mixture were injected
passively into the canals with a 31-gauge
needle placed to the most apical level possible.
A blunt size 8 K-file was introduced1mm short
of the apical foramen
International after36,the
Endodontic Journal, first
12-19, 2003increment

138
 Teeth were then immersed in iohexol and
subjected to vacuum (24 in. mm/Hg) for 2min.
The vacuum was reapplied for further 2 min
until air bubbles ceased escaping from the
access cavity
Contrast injection Contrast injection
with passive with vacuum
injection

139
 When contrast medium was introduced
with the aid of vacuum, it significantly
improved detecting the number of canals,
canal visibility, canal terminus and canal
configuration
Passive injection of iohexol improved
detection with the number of canals, canal
visibility and canal configuration being
significantly better than the non contrasted
radiographs

International Endodontic Journal, 36, 12-19, 2003 140

Angiography

141
 Angiography or arteriography is a medical
imaging technique used to visualize the
inside, or lumen , of blood vessels and
organs of the body, with particular interest in
the arteries, veins and the heart chambers
Angeion, "vessel", and Graphein, "to write
or record“
Film or image of the blood vessels is called
an angiograph/ angiogram

142
First developed in 1927 by – Egas Moniz,
University Of Lisbon
Moniz performed the first cerebral
angiogram in lisbon in 1927
Introduction of seldinger technique in
1953

Markedly safer

143
144
 Procedure:
The typical procedure can be divided into four
phases:
Phase 1 – Patient preparation – the technologist
assists with preparing the patient for the procedure:
Obtaining patient consent
Setting up tray
Set up injector & filming equipment
Establish patient monitoring
Shave & prepare the puncture site
Establish vascular access

145
The Seldinger technique
Administer local

146
Access vessel

147
Thread guidewire & remove needle

148
Insert catheter

149
Remove guide

150
 Phase 2 – catheter placement
Phase 3 – filming
Phase 4 –patient dismissal
• Dress puncture site(s)
• Assure that patient &/or nurse
understand post-procedure order

151
 Uses:
Coronary angiography- To visualize the blood
in the coronary arteries.
Microangiography: Is commonly used to
visualize tiny blood vessels.
Neuro-vascular angiography:
An angiographic procedure is neuro-vascular
digital substraction angiography in order to
visualise the arterial and venous supply to the
brain.
Peripheral angiography
152
 Indications for angiography in the head and
neck
To show the vascular anatomy and feeder
vessels associated with haemangiomas.
To show the vascular anatomy of
arteriovenous malformations.
Investigation of suspected subarachnoid
haemorrhage resulting from an aneurysm in
the Circle of Willis.
Investigation of transient ischaemic attacks
possibly caused by emboli from
atheromatous plaques in the carotid arteries
153
Used in diagnosis of temporal arteritis

154
Procedure
Local anesthesia administered
Horizontal incision about 1.5 cm. In length - just
above the malar bone in front of the ear.
The superficial temporal artery exposed, tied off
proximally
Cannulated distally, using a tapered length of
polyethylene Catheter PE 160
The cannula is not introduced by more than 1 cm.
Head turned into the supine position, 2 .5 ml. Of
45% hypaque is injected slowly by hand, single
lateral radiograph is taken at the termination of the
injection
Ann. rheum. Dis. (1969), 28, 267
155
 Satisfactorily visualized
The catheter is removed and a small
portion of the temporal artery is excised for
histological examination

Giant cell arteritis Normal arteriogram

156
 It is a useful adjunct before any surgical
identification and repair, ligation, or ablation
of indicated vasculature
When combined with endovascular
embolization, angiography can successfully
manage vascular injury, spontaneous
vascular pathology, and congenital vascular
anomalies

Atlas Oral Maxillofacial Surg Clin N Am 11 (2003) 73–86 157

 Aneurysm of the basilar artery
An aneurysm appears as a projection or out- pouching
from the parent vessel and may extend with dissection
through soft tissue
158
Lymphangiography

159
 Lymphangiography, or lymph node angiogram, is a
test which utilizes x-ray technology, along with the
injection of a contrast agent, to view lymphatic
circulation and lymph nodes for diagnostic purposes.
-Medical dictionary
X-ray film or image of the vessels and nodes is called
a lymphogram or a lymphangiogram

160
 Uses:
Diagnose the presence or spread of
tumors, lymphatic cancer (lymphoma), and
other cancers
Distinguish primary lymphedema from
secondary lymphedema
Localize tumors for surgical removal
Assess the effectiveness of chemotherapy
and radiation therapy in treating problems
associated with metastatic cancer
161
 Procedure:
No special preparation needed before
lymphangiography
Patients may be asked to empty their bladder
before testing
Sign a consent form before the test is
administered.

A sedative may be given to help the patient relax.

After the skin of each foot is cleaned with an
antiseptic, a blue indicator dye is injected between
the first, second, and third toes of each foot

162
 The dye spreads into the lymphatic system
in about 15 to 30 minutes.
The thin, bluish lines that appear on the top
of each foot delineate the lymphatic vessels.
A local anesthetic is injected and a small
incision is made into one of the larger blue
lines in each foot.
A needle or catheter is inserted into a vessel
in each foot, and an oil-based contrast
medium is injected at a slow, steady rate.

163
 A fluoroscope is used to monitor the
progress of the contrast medium as it
spreads slowly (about 60 to 90 minutes)
The catheter is removed and the
incisions are stitched and bandaged
Appropriate radiographs are taken
After testing, the patient's blood pressure,
pulse, breathing status, and temperature
are monitored at regular intervals until
they are stable.
164
 Bed rest for at least 24 hours following the
test is recommended, with feet elevated to
help reduce swelling at the incision sites
Patient should also inspect the incision
sites for infection
After the test, the patient's skin, feces,
and urine may have a bluish tint for two to
three days and there may be some
discomfort behind the knees and in the
groin area.

165
 Complications of lymphangiography
Oil embolism to other organs, i.e., kidney, brain,
liver.
Cellulitis at site of cut-down.
Allergy to iodine containing dye (Ethiodol) or
Alphazurine 2G (patent blue dye) used for labeling
lymphatic vessels.
Occasional fever lasting 12-30 hr after injection of
the contrast material. This may be associated with
excessive pulmonary oil embolism.
Transient pain usually at the site of involved nodal
masses within the abdomen or pelvis.

166
Contrast enhanced
ultrasonography
167
Contrast-enhanced ultrasound (CEUS)
Is the application of ultrasound contrast
medium to traditional medical sonography.
Commercially available contrast media are
gas-filled microbubbles that are administered
intravenously to the systemic circulation
Microbubbles have a high degree of
echogenicity

168
 The echogenicity difference between the gas
in the microbubbles and the soft tissue
surroundings of the body is immense.
Ultrasound imaging using microbubble
contrast agents

Enhances the ultrasound backscatter or

reflection of the ultrasound waves

Produce a unique sonogram with increased

contrast due to the high echogenicity difference.

169
 Microbubble contrast agents
Microbubble shell:
A more hydrophillic material tends to be taken up
more easily, which reduces the microbubble
residence time in the circulation.
This reduces the time available for contrast
imaging.
The more elastic the material, the more acoustic
energy it can withstand before bursting
Microbubble shells are composed of albumin,
galactose, lipid, or polymers.

170
 Microbubble gas core
Determines the echogenicity.
Gas bubbles are caught in an ultrasonic frequency
field

Compress and oscillate

Reflect characteristic echo

Strong and unique sonogram in CEUS

Gas cores can be composed of air, heavy gases like
perfluorocarbon, nitrogen
171
Optison, a (FDA)-approved microbubble made
byGE Healthcare , has an albumin shell and
octafluoropropane gas core
Levovist, made by Schering has a
lipid/galactose shell and an air core
Microbubble size is uniform- 1-4
micrometres
Smaller than red blood cells, which allows
them to flow easily through the circulation as
well as the microcirculation

172
Targeted microbubbles
Retain the same general features as untargeted
microbubbles
Outfitted with ligands that bind specific
receptors expressed by cell types of interest, such
as inflamed cells or cancer cells
The shell is modified with molecules that allow
for the attachment of ligands that bind certain
receptors.
These ligands are attached to the microbubbles
using carbodiimide, maleimide or biotin-
streptavidin coupling

173
Two forms of contrast-enhanced ultrasound

Untargeted

targeted

174
 Untargeted CEUS

Untargeted microbubbles are injected

intravenously into the systemic circulation in a
small bolus.

The microbubbles will remain in the systemic

circulation for a certain period of time.

Ultrasound waves are directed on the area of

interest
175
 Microbubbles in the blood flow past the imaging
window

Compressible gas cores oscillate in response to the

high frequency sonic energy field

Microbubbles reflect a unique echo

Ultrasound system converts the strong echogenicity

into a contrast-enhanced image of the area of
interest

176
 Targeted CEUS
Microbubbles targeted with ligands that bind
certain molecular markers that are
expressed by the area of imaging interest are
still injected systemically in a small bolus

Travel through the circulatory system

Finding
Detection theirmicrobubbles
of bound respective maytargets
then showand binding
that the area of
interest is expressing that particular molecular, which can be indicative
specifically
of a certain disease state, or identify particular cells in the area of
interest
177
 Applications:
Untargeted CEUS- echocardiography
Organ Edge Delineation: Microbubbles can
enhance the contrast at the interface between the
tissue and blood.
A clearer picture of this interface gives the clinician
a better picture of the structure of an organ.
Blood Volume and Perfusion:
Evaluating the degree of blood perfusion in an
organ or area of interest
Evaluating the blood volume in an organ or area of
interest
178
 Targeted CEUS
Inflammation :In inflammatory diseases such as
crohn’s disease, atherosclerosis and even heart
attacks, the inflamed blood vessels specifically
express certain receptors likeICAM-1, VCAM-1, E-
Selectin
Cancer: If microbubbles are targeted with ligands
that bind receptors like VEGF, they can non-
invasively and specifically identify areas of cancers
Gene delivery: When the targeted microbubble
accumulates at the cell surface with its DNA payload,
ultrasound can be used to burst the microbubble.
179
 Drug Delivery:
Drugs can be incorporated into the
microbubble’s lipid shell.
The microbubble’s large size relative to
other drug delivery vehicles like liposomes
may allow a greater amount of drug to be
delivered per vehicle.

180
Advantages:
Ultrasound imaging allows real-time evaluation of
blood flow.
Ultrasonic molecular imaging is safer than molecular
imaging modalities such as radionuclide imagingbecause
it does not involve radiation.
Ultrasound, on the other hand, is very cost-efficient
and widely available.
Micrograms of microbubbles are needed compared to
milligrams for other molecular imaging modalities.
Targeting strategies for microbubbles are versatile and
modular. Targeting a new area only entails conjugating a
new ligand.

181
Disadvantages:
Microbubbles don’t last very long in circulation.
Ultrasound produces more heat as the
frequency increases, so the ultrasonic frequency
must be carefully monitored.
Microbubbles burst at low ultrasound
frequencies.
Targeting ligands can be immunogenic
Low targeted microbubble adhesion efficiency,
which means a small fraction of injected
microbubbles bind to the area of interest..

182
Precontrast US angiogram
in right common carotid
artery

Postcontrast US angiogram
obtained after injection of 0.5
mL of FS069 shows complete
luminal enhancement.

183
Contrast enhanced MRI

184
 Group of contrast media used to
improve the visibility of internal body
structures in magnetic resonance imaging
Work through shortening the relaxation
time of protons located nearby
Administered:
Orally
Blood stream

185
 Gadolinium:
Used for enhancement of the vessels in
MR angiography
Enhancing lesions and tumors where Gd
leaks out Initially remains in the circulation
Distributes into the interstitial space or is
eliminated by the kidneys.

186
 Gadodiamide(omniscan)
Gadobenic acid(multihance)
Gadopentetic acid(magnevist)
Gadoteridol(prohance]
Gadofosveset(ablavar)
Gadoversetamide(optimark)
Gadoxetic acid(eovist)

187
 Iron oxide: Superparamagnetic
Two types :
Superparamagnetic Iron Oxide (SPIO)
Ultra small Superparamagnetic Iron Oxide (USPIO)

Suspended colloids of iron oxide nanoparticles

and when injected

Reduce the T2 signals of absorbing tissues

Cliavist, Combidex, Resovist, Sinerem

188
 Manganese (Paramagnetic)
Enhance the T1 signal
Oral
 Gadolinium and manganese chelates
 Iron salts
 Barium sulphate
 Clay
Natural products: green tea, blueberry
Perflubron-
Gastrointestinal imaging in pediatric patients
189
Contrast enhanced computed tomography
CT contrast is used to make specific organs,
blood vessels and/or tissue types "stand
out" with more image contrast
Contrast medium is given:
Intravenous injection
Given orally
Given rectally
Inhaled as a gas

190
 Intravenous contrast is used in CT
Highlight blood vessels
Enhance the tissue structure of various
organs such as the brain, spine, liver and
kidneys.
75 cc to 150 cc (about 2.5 oz. to 5 oz) of
contrast
Oral CT contrast
Barium sulphate, Gastrografin
000 to 1500 cc (about three to four 12 oz.
drinks)
191
Radionuclide
imaging
192
 Radioisotopes :
Isotopes with unstable nuclei, which undergo
radioactive disintegration. This disintegration
is often accompanied by the emission of
radioactive particles or radiation
Emissions include;
Alpha particles
Beta (electron) and Beta+ (position)
particles.
Gamma radiation

193
 Radionuclides used:
Technetium (99mTc) – salivary glands,
thyroid, bone, blood, liver, lung and heart.
Gallium (67Ga) – tumors and inflammation
Iodine (123I) – thyroid
Krypton (81K) – lung
Thallium-201
Gallium-67
Fluorine-18 Fluorodeoxyglucose
Indium-111 Labeled Leukocytes
194
Indications for Conventional Isotope imaging in
Head and Neck:
Tumour staging – the assessment of the sites and
extent of bone metastasis.
Investigation of salivary gland function,
particularly in Sjogren’s syndrome
Evaluation of bone grafts
Assessment of continued growth in condylar
hyperplasia
Investigation of thyroid
Brain scans and assessment of a breakdown of
the blood-brain barrier
195
 Administration of a radionuclide by:
Intravenous injection in liquid or aggregate form
Ingestion while combined with food
Inhalation as a gas or aerosol
Rarely, injection of a radionuclide that has
undergone micro-encapsulation
Advantages over conventional radiography:
Target tissue function is investigated.
All similar target tissues can be examined during
one investigation. Eg. The whole skeleton can be
imaged during one bone scan.
Computer analysis and enhancement of results
are available.
196
Disadvantages:
Poor image resolution – often only
minimal information is obtained on target
tissue anatomy.
The radiation dose to the whole body can
be relatively high.
Images are not usually disease – specific.
Difficult to localize exact anatomical site
of source of emissions.
Some investigations take several hours.
Facilities are not widely available.
197
Radionuclide imaging of salivary glands:
Sodium pertechnetate (technetium 99m)
is the commonly used
Concentrated and excreted by salivary
glands
Warthin’s tumors readily take up
pertechnetate resulting in formation of
“Hot spots”. 
Gallium 67 citrate is useful for studying
inflammatory / neoplastic disease of
salivary glands and adjacent areas
198
 67Ga citrate planar image shows the PANDA SIGN in a
patient with sarcoidosis
Bilateral radionuclide uptake is seen in the lacrimal and
parotid glands.

199
 RADIONUCLIDE IMAGING- BONE
Performed with technetium-99m–labeled
Diphosphonates.
These compounds accumulate rapidly in bone,
and by 2–6 hours after injection, about 50% of the
injected dose is in the skeletal system
Adsorbed to the mineral phase of bone, with
relatively little binding to the organic phase
Degree of radiotracer uptake:
Blood flow
The rate of new bone formation
200
 Plays an integral part in tumor staging and
management
The presence of multiple, randomly distributed
areas of increased uptake of varying size, shape,
and intensity is highly suggestive of bone
metastases
Osteoarthritis and degenerative changes may
manifest as areas of intense activity on
radionuclide bone images
Detecting fractures in patients with a history of
trauma
Procedure of choice for diagnosing osteomyelitis

201
 Paget’s disease:
Changes manifest as intensely increased
activity throughout the involved bones

202
 References:
1. Whaites E.Essentials of dental radiography and radiology.2 nd edition.Churchill
Livingstone,1996.p-181.
2. Swanson DP. Radiographic Contrast Agents In: Sander MP, Patton JA, Shaff MI, Powers
TA, Partain CL, editors. Correlative Imaging.1st edition, Williams and Wilkinson, USA,
1989. p105
3. Benson BW, Robert PL,Abramovitch K. Temporomandibular joint arthrography: A
comparison between a fluoroscopic and a non fluoroscopic technique. Oral Surg Oral
Med Oral Pathol 1989;67:600-5.
4. Verhoeven JW. Choice of contrast medium in sialography. Oral Surg Oral Med Oral
Pathol 1984;57:323-336.
5. Luky NH et al. Recent trends in imaging the salivary glands.Dento Maxillofac Radiol
1991;20:3-10.
6. Arshiya S, Rao BB, Mamtha GP. Contrast Media – A Review.JIAOMR 2003;15(3):89-92.
7. Grainger RG. Intravascular Contrast MediaIn: Grainger RG, Allison D,
editors.Diagnostic Radiology.3rd edition,Hong Kong,p.35
8. Abramovitch K, Dolwick MF, Langlais RP. Temporomandibular joint arthrography
without Fluoroscopy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1988;65:387-
95 203