Tugas Radiologi 2020

Oleh : Juki, Robert, Riky, Dede, Felita, Jeffrey

Pembimbing : dr. Luh Putu Endyah Santi M, Sp.Rad
1.
 Conventional Radiographs
• Most common imaging test for evaluating the
heart and great vessels
• Consists of an upright posterior-to-anterior (PA)
& left lateral (LAT) projections
• The disatance between the x-ray tube source &
the film is at least 6 feet → minimize
magnification & distortion
• Ideally performed with the patient at maximal
inspiration → to be able to count 9 to 10
posterior ribs / 5 to 6 anterior ribs from the lung
apices to the hemidiaphragms through the
aerated lungs

Chen, M., Ott, D. and Pope, T., 2011. Basic Radiology. New York, N.Y.: McGraw-Hill
Education LLC.
 Patients → supine position → redistribution of blood flow to the
upper lobe pulmonary veins (cephalization) → the heart may appear
enlarged relative to its appearance on the upright PA radiograph →
magnification

Expiratory phase of respiration → may

appear to have cardiomegaly, vascular
congestion, and even pulmonary edema Chen, M., Ott, D. and Pope, T., 2011. Basic Radiology. New York, N.Y.: McGraw-Hill
Education LLC.
 Cardiothoracic Ratio
• Obtained from PA view
• Calculated by dividing the transverse cardiac diameter (measured from
each side) by the widest diameter of the chest (measured from the inner
aspect of the right and left lungs near the diaphragm)
• Average normal value :
 Adults → 50%
 Over 50% → abnormal in an upright inspiratory-phase PA film
• Cannot be reliably used for the AP projection → the heart is magnified
• Small person with a petite frame & small thoracic cage → heart size
may be normal → CTR may measure over 50%
• If the patient has pulmonary disease (emphysema) → heart may be
enlarged → because of the overinflation of the lungs → CTR may still
be normal

Chen, M., Ott, D. and Pope, T., 2011. Basic Radiology. New York, N.Y.: McGraw-Hill
Education LLC.
 Recognizing An Enlarged Cardiac Silhouette

Pericardial effusion
• Which mimics the appearance of cardiomegaly on conventional
radiographs
Extracardiac
• Factors that produce apparent cardiac enlargement

Cardiomegaly
• True cardiac enlargement
Herring, W., 2015, Learning Radiology, Recognizing the Basics 3rd Edition, Elsevier,
Philadelpia.
 Recognizing Cardiomegaly On The
Lateral Chest Radiograph
• Lateral projection → look at
the space posterior to the
heart & anterior to the spine
at the level of the diaphragm
• Normal person → the cardiac
silhouette will usually not
extend posteriorly & project
over the spine
• As the heart enlarges → the
posterior border of the heart
may extend to, or overlap,
the anterior border of the
thoracic spine

Herring, W., 2015, Learning Radiology, Recognizing the Basics 3rd Edition, Elsevier,
Philadelpia.
 Recognizing Cardiomegaly in Infants

• In newborns & infants → heart will normally

appear larger
• CTR > 50% → abnormal in adults, CTR in
infants may reach up to 65% → still be normal
Newborns cannot take as deep an inspiration as
adults
Relative proportions in the size of their
abdomen to chest are not the same as for adults

Herring, W., 2015, Learning Radiology, Recognizing the Basics 3rd Edition, Elsevier, Philadelpia.
 Right Atrial Enlargement
• Subtle and moderate right atrial enlargement is not accurately
determined on plain films because there is normal variability in
the shape of the right atrium Enlarged, globular heart
• Features are non-specific but include 

Narrow vascular pedicle

Gross enlargement of the right atrial shadow, i.e. increased

convexity in the lower half of the right cardiac border
- Right atrial convexity is more than 50% of the
cardiovascular height
- Right atrial margin is more than 5.5 cm from the midline
 Left Atrial Enlargement
Direct visualization of the enlarged atrium includes:
1. Double Density Sign
• When the right side of the left atrium pushes into the
adjacent lung, and becomes visible superimposed or
even beyond the normal right heart border (known
as atrial escape) 
2. Oblique measurement of greater than 7 cm
• measured from midpoint of left main bronchus to the right border of the left
atrium (this requires a double density sign of course)
• thought to be the most reliable sign on chest radiography
 Left Atrial Enlargement
3. Convex left atrial appendage (third mogul sign): normally
the left heart border just below the pulmonary outflow track
should be flat or slightly concave
 Right Ventricle Enlargement

Frontal View Lateral View

Filling of the
Rounded left
retrosternal
heart border
space

Rotation of the
Uplifted Two view chest X-ray showing right ventricular
heart
cardiac apex hypertrophy (arrows, note filling of the retrosternal space
posteriorly
by an enlarged right ventricle in the lateral view) and
enlarged central pulmonary arteries (arrowhead).
 Left Ventricle Enlargement
• Left ventricular dilatation: left heart border is
displaced leftward, inferiorly and posteriorly
• Left ventricular hypertrophy : may show
rounding of the cardiac apex
• Hoffman-Rigler sign
• Shmoo sign
 Determining Which Ventricle is Enlarged

• Examine the corresponding outflow tract for each

ventricle
• If the heart is enlarged (CTR >50%) & the main
pulmonary artery is large (i.e., projects beyond
the tangent line) → cardiomegaly is made up of
at least the right ventricular enlargement
 Determining Which Ventricle is Enlarged

• If the heart is enlarged (CTR >50%) & the aorta is

prominent (ascending aorta, aortic knob, and
descending aorta) → cardiomegaly is made up of at
least the left ventricular enlargement
2. CT Scan pada EDH, SDH,
SAH, IVH, ICH, Infark
 EDH/ Epidural Hematoma
• Pengumpulan darah ekstra-aksial pada
ruang potensial antara lapisan luar dura
mater dan bagian dalam
tengkorak/endosteal layer. Gambaran klasiknya
adalah massa
• Ini terjadi pada sekitar 10% dari cedera
otak traumatis (TBI) yang membutuhkan bikonveks atau
rawat inap berbentuk lensa
pada CT scan otak
• Kebanyakan hematoma epidural terjadi
akibat perdarahan arteri dari cabang arteri
meningeal tengah
• >95% are supratentorial
• temporoparietal: 60%
• frontal: 20%
• parieto-occipital: 20%
• <5% are located infratentorially
 SDH/Subdural Hematoma
• Perkumpulan darah yang terakumulasi
di ruang subdural, ruang potensial Gambaran klasiknya
antara dura dan arachnoid dari adalah crescent-
meningen di sekitar otak. shaped pada CT scan
• Terjadi karena peregangan dan otak
robeknya vena kortikal jembatan yang
melintasi ruang subdural untuk
drainase ke sinus dural yang
berdekatan.
• Akut : Hiperdens (>50-60 HU) , < 72
jam
• Subakut : 3-7 hari, -35-40 HU
• Kronik : > 3 minggu, hipodense bisa
0 HU
 SAH/ Sub Arachnoid Hematoma
• Pengumpulan darah pada darah antara
membran arachnoid dan membran pia
Gambaran klasiknya
• Paling umum ini terlihat di sekitar adalah mengikuti
lingkaran Willis, karena sebagian besar sulcus pada CT scan
aneurisma berry terjadi di wilayah ini otak
(~ 65%), atau di celah Sylvian (~ 30%)
• Darah pada SAH dapat melewati
ruangan CSF : Sulcii, fisura, cysterna
basal, ventrikel
IVH/ Intra Ventrikular Hemorrhage
• Terdapatnya darah sistem ventrikel
otak dan dapat menyebabkan
hidrosefalus obstruksi pada beberapa Gambaran klasiknya
pasien. . adalah tampak
• Primer : darah di ventrikel dengan darah pada ventrikel
sedikit (jika ada) darah parenkim pada CT scan otak
• Sekunder : Terdapat komponen
ekstraventrikular besar (misalnya
parenkim atau subarachnoid) dengan
ekstensi sekunder ke ventrikel
ICH/ Intra Cerebral Haemorrhage
• perdarahan intraserebral terjadi ketika pembuluh darah di dalam otak pecah
sehingga darah bocor ke dalam otak.
• Lokasi :
• Basal Ganglia
• Pontine
• Thalamic
• Cerebellar
• Lobar
ICH
Infark Cerebral

• Infark serebral adalah nekrosis

otak fokal akibat iskemia
lengkap dan berkepanjangan
yang mempengaruhi semua
elemen jaringan, neuron, glia,
pembuluh darah.
3. IVP, Appendikogrfi
 IVP (Intravena Pyelography)
• IVP  pemeriksaan dengan menyuntikan bahan kontras secara
intravena untuk melihat anatomi dan fungsi dari traktus urinarius
(ginjal, ureter, vesica urinaria). Biasanya IVP didahului dengan
BNO/KUB (Kidney Ureter Bladder).
• Indikasi  untuk melihat anatomi dan fungsi dari traktus urinarius,
yang meliputi:
• Kelainan kongenital
• Radang atau infeksi
• Batu, massa, tumor
• Trauma
• Persiapan : malam sebelumnya
pasien minum obat pencahar,
puasa, kurangi bicara dan merokok.
• Dosis kontras media : 0,5 – 1
cc/kgBB
• Prosedur
• Foto BNO
• Injeksi kontras media (sebelumnya
dites alergi kontras)
• Setelah injeksi selesai, ambil foto
serial pada waktu :
• Menit ke 1-3 atau 5
• Menit ke 15
• Menit ke 30 atau 45
• Post miksi

Foto BNO
Foto 5 menit setelah injeksi kontras
• Fase nefrogram  dinilai fungsi
ekskresi ginjal, kontur ginjal dan system
pelvokalises (PCS).
• Normal  kontras akan nampak
mengisi PCS sehingga nampak
gambaran radioopaq dan tidak
didapatkan ekstravasasi kontras ke
jaringan sekitar yang menunjukan
adanya rupture ginjal.
Foto 15 menit setelah injeksi kontras
• Fase pyelogram  kontras akan
mengisi PCS dan ureter sehingga
ureter tampak radioopaq.
• Jika terdapat batu pada ureter
radioopaq ataupun
radioluscent, maka akan
nampak kontras yang tidak
mengalir dan kemudian papillae
renalis nampak cubbing (berbentuk
seperti mangkok). Hal ini
menunjukkan telah
terjadi hidronefrosis.
 Foto 30/45 menit setelah injeksi kontras
• Fase sistogram  kontras telah
mengisi vu sehingga vu nampak
putih.
• VU dinilai
• Dinding : rata (N) atau
bergelombang (sistisis/radang VU)
• Adakah filling defect yang nampak
radioluscent saat vu terisi kontras
• Indentasi
• Additional shadow (menunjukan
adanya batu/massa)
• Ekstravasasi kontras (rupture VU)
Foto post miksi
• Dilakukan setelah pasien
berkemih.
• Untuk menilai pengosongan VU
Appendikografi
• Appendikografi  pemeriksaan secara radiologi pada bagian
appendiks dengan menggunakan BaSO4 (barium sulfat) yang
diencerkan dengan air dan dimasukan secara oral.
• Indikasi  appendicitis akut atau kronis
Prosedur
• Persiapan bahan
• Larutan barium sulfat (+- 250gr) + 100 -200 cc air
• Persiapan pasien
• Sehari sebelum pemeriksaan pasien diberi BaSO4 dilarutkan dalam air dan diminum setelah
itu puasa
• Hari 1  dibuat foto pendahuluan AP supine abdomen. Kemudian pasien diberi BaSO4 dan
diminum pada malam hari
• Hari 2  foto setelah meminum barium, posisi supine, prone, obliq
 Gambaran normal apendiks pada apendikografi

• Apendik yang normal  memberikan

gambaran berupa pengisian penuh
barium sulfat pada lumen apendiks
dan memiliki mukosa apendiks yang
halus.
Gambaran apendisitis pada apendikografi
• Temuan:
• Non filling apendiks
• Iregularitas nodularitas dari
apendiks yang memberikan
gambaran edema mukosa yang
disebabkan oleh inflamasi akut.
• Efek massa pada sekum serta usus
halus yang berdekatan

Non filling apendiks

Appendicogram dengan non-filling
appendiks (negatif appendicogram)
barium sulfat tidak dapat mengisi
lumen apendiks. Ada beberapa
kemungkinan penyebab dari gambaran
negatif appendicogram yakni adanya
obstruksi pada pangkal apendiks
(dapat berupa inflamasi) yang
mengindikasikan apendisitis atau
suspensi barium sulfat belum
mencapai apendiks karena perhitungan
waktu yang tidak tepat
(false negative appendicogram).
4.
• Tulang vertebra terdiri dari 33 tulang: 7 vertebra
servikal (C), 12 vertebra torakal (Th), 5 vertebra
lumbalis (L), 5 vertebra sacrum (S) dan 4 vertebra
coccygeal. Selain vertebra C1 dan C2, corpus
vertebra terpisah satu sama lain oleh diskus
intervertebralis.
• Penilaian radiografi vertebra secara umum
(ABCS)
Alignment / kesegarisan
Bone : Bentuk, densitas, fraktur, destruksi, osteofit,
dll
Cartilage : sela sendi/ celah diskus intervertebralis
Soft tissue / jaringan lunak: massa, kalsifikasi, dll
Alignment/ kesegarisan vertebra
Penilaian alignment vertebra cervikal dilakukan pada posisi lateral
dengan melihat kesegarisan :
- Garis anterior vertebra
- Garis posterior vertebra
- Garis spinolaminar
- Garis posterior spinosus
- Garis clivus-odontoid

Sementara pada level vertebra lainnya, alignment dinilai dengan

melihat kesegarisan garis anterior vertebra, posterior vertebra dan
posterior spinosus. Vertebra dinyatakan mengalami listesis
(spondilolistesis) jika terdapat ketidaksegarisan / pergeseran garis-
garis tersebut.
Pelvic ring

Foramen obturator
Terdapat beberapa garis khayal di radiografi pelvis yang memiliki makna
khusus, terutama pada kasus trauma. Garis khayal tersebut adalah:
1. Garis iliopectineal/ iliopubic. Jika terjadi diskontinuitas pada garis ini
maka kemungkinan telah terjadi fraktur kolum anterior acetabulum.
2. Garis ilioischial. Jika terjadi diskontinuitas pada garis ini maka
kemungkinan telah terjadi fraktur kolum posterior acetabulum.
3. Tear drop. Jika tear drop bergeser maka kemungkinan terdapat occult
fracture acetabulum.
4. Garis arkuata sacrum. Jika tidak segaris maka kemungkinan terdapat
fraktur sacrum.
5. Garis Shenton’s. Jika tidak segaris maka kemungkinan terjadi fraktur
femur proksimal.
6. Garis pada tiga cincin yaitu pelvic ring dan foramen obturator. Jika
terdapat disrupsi cincin, maka kemungkinan terjadi fraktur.
Introduction
• Relating things to certain natural objects or events to remember is
human nature.
• Clinical and radiological signs are named after natural signs.
• In orthopaedics, many radiological findings are named for the natural
phenomena of which they mimic.
Butterfly vertebrae
• A butterfly vertebra is a rare congenital symmetric fusion defect.
• It is mostly an incidental finding and rarely causes back pain.
• There is a widening of the lateral parts of vertebrae, and a bony
bridge may or may not form between two lateral fragments
Scottie dog sign
• Scottie dog sign is present in normal lumbar spine vertebrae present
in an oblique view.
• The Scottie dog sign is very useful in the diagnosis of spondylosis
where a pars interarticularis defect manifests itself as a defect of the
neck.
Bamboo sign
• The bamboo spine is a term used for the x-ray image of a spine
affected by ankylosing spondylitis where the spine is affected by
bridging syndesmophyte and sacroiliitis.
• There is enthesis formation between individual adjoining vertebrae.
The outer fibres of the annulus fibrosis of the intervertebral discs
ossify to form syndesmophytes bridges between the vertebrae.
Fish vertebrae
• Fish vertebrae sign is the biconcave deformity of the vertebrae seen in
osteopenia.
• Clinically, fish vertebrae are seen in osteopenia or osteoporosis
Ivory vertebrae
• Ivory vertebrae is a sign denoting diffuse and uniform increases in
vertebral opacity. There is no effect on the vertebral size or its
adjacent intervertebral discs.
• Ivory vertebrae result from infectious or metastatic disorders.
• Ivory vertebrae is a radiographic sign associated with many conditions
including lymphomas, breast cancer, prostate cancer, Paget’s disease,
and osteomyelitis
Winking owl
• Winking owl is the name of the sign when a pedicle is not visible on
anteroposterior (AP) plane x-ray of the spine.
• The pathophysiology is from a tumour that has spread to the
vertebral body that then spreads to the surrounding structures. It is
also caused by spinal metastasis, tuberculosis, lymphoma or
infections
Scalloping vertebrae
• This sign is associated with intraspinal mass like:
• spinal astrocytoma,
• ependymoma,
• schwannoma,
• neurofibroma,
• Achondroplasia, etc
5. Gambaran radiologi pada
app dll
Appendicitis
• Modalitas: CT, USG, MRI
• CT
• Appendicolith (15%)
• Bermanifestasi khususnya pada CT sbg kalsifikasi lumen appendix
• Nyeri perut + gambaran appendicolith -> dx menjadi 90%
• Dilated appendix (>6 mm)
• Contrast enhancement dinding appendix
• Perforasi: udara di periappendicial extraluminal dlm jumlah sedikit/ abses
periappencial
P

Normal app
Axial computed tomographic image of an inflamed appendix with an
appendicolith (arrow) and associated periappendiceal and pericecal free
fluid.
• Xray
• Not specific
• Not recommended
• No cost effective -> can be misleading
• <5% pasien, tampak fecalith di RLQ

appendicolith
• USG
• Normal: tdk terlihat, d <6 mm
• Aperistaltic tube dgn d >6 mm, non compressible
• Fecalith bisa terlihat: hyperechoic dgn posterior acoustic shadow
Figure 1: High-frequency (7.5–10 MHz linear transducer) ultrasonographic appearance in right iliac fossa in a patient
diagnosed clinically as acute appendicitis showing a blind-ended, tubular, hypoechoic, aperistaltic, noncompressible structure
originating from cecum having gut signature with a diameter of 7.6 mm with surrounding fat stranding and no associated
lymphadenopathy
Appendicogram

normal
Intususepsi
• Penyebab tersering obstruksi intestinal anak <3 thn
• Paling sering: ileocaecal – ileoileocolic – ileoileal – colocolic – gastric
intussuseption

Sel target/ doughnut sign

`

Pseudokidney sign
Xray
CT scan
Hirschprung disease
• congenital aganglionosis
• Absence ganglion cell di sigmoid/rectosigmoid
• Type:
• Short segment (75%)
• Rectal & distal colon sigmoid
• Long segment (15%)
• Extends to colon transversal
• Total colon aganglionosis (7,5%)
• Known as Zuezler Wilson Synd.
• Hingga Small bowel
• Ultra short
• 3-4 cm internal sphincter anal
Atresia Esofagus
• Etiologi: ?
• Paling sering: dengan fistula antara trakea dan distal esophageal
remnant
• Gejala: choking, drooling, regurgitation, aspiration, respiratory
distress.
• Imaging findings
• No fistula: tdk ada udara yg msk -> abdomen is airless (N: ada udara dlm 15
menit setelah lahir)
• Distal fistula: gas di usus +, blind ending, dilatasi esofagus atas
• Dapat terjadi pneumonia aspirasi lobus kanan atas
 AP
Fluoroscopy
Achalasia
• Neuromuscular abnormality -> failure of relaxation at cardiac
sphincter
• Gx: disfagia, chest pain/discomfort, regurgitasi
• Gambaran:
• Barium examination: smooth, penyempitan yg meruncing pada lower end
esofagus
• Dilatasi esofagus (biasa mengandung food residue), absent peristaltis
• Gas di lambung (-) -> karna esofagus terisi yg berperan sbg water seal
 Normal

Widened mediastinum caused by

Dilated esophagus
Achalasia
Hypertrophic Pyloric Stenosis
• HPS: hipertrofi abnormal otot pilori -> gastric outlet obstruction
• Acquired condition, progressive
• Males, Riwayat keluarga +
• Gx: recurrent non bilious emesis, muntah proyektil
• 1st line: USG -> direct assessment morfologi pylorus
(length, thickness)
- abnormal: phylorus memanjang (>14 mm) & menebal (>3mm)
 Longitudinal USG
4 mm thick, length: 20 mm
Atresia Duodenum
• Gx: makanan tdk bisa turun ke usus -> distensi abdomen, muntah, BU
(-)
• Biasa disertai dengan kelianan down syndrome
Xray
- Double bubble sign with gas filled distended abdomen dan duodenum
with an absence of distal gas
fluoroscopy
Definition
• Anal atresia, or imperforate anus, refers to a spectrum of anorectal
abnormalities ranging from a membranous separation to complete
absence of the anus.
• Clinically there is no anal opening
• Subtypes can be classified into two broad categories: high
(supralevator) or low (infralevator), depending on the location of the
atretic portion.

https://radiopaedia.org/articles/anal-atresia
Abdominal Radiograph
• Can be variable depending on the :
Site of atresia (i.e. high or low),
Level of meconium impaction and
Physiological effects such as straining
• May show multiple dilated bowel loops with
an absence of rectal gas
• Air within urinary bladder suggests high type 
• Calcified meconium in the bowel loops would
suggest high type (meconium calcifies due to
urine exposure)

https://radiopaedia.org/articles/anal-atresia
Invertogram

• A coin/metal piece is placed over the

expected anus and the baby is turned
upside down (for a minimum 3 minutes).
• The distance of the gas bubble in the
rectum from the metal piece is noted:
>2 cm denotes high type
<2 cm denotes low type
• False-positive: if image is taken in the
1st 24 hours of life or impacted
meconium in distal rectum

https://radiopaedia.org/articles/anal-atresia
 Ultrasound

• The anus may be seen as an

echogenic spot at the level of the
perineum and in anal atresia, this
echogenic spot may be absent 
• May show bowel dilatation
• An infracoccygeal or
transperineal approach may
allow differentiation between
high and low subtypes  

https://radiopaedia.org/articles/anal-atresia
6. Gambaran radiologi pada
anak
 Hyaline Membrane Disease
• Temuan Radiologi
• Gambaran Ground Glass bilateral dan simetris
• Air bronchograms
• Hipoaerasi pada paru yang tidak mengembang
(nonventilated)

William Herring, Learning radiology 3 rd edition

Hyaline Membrane Disease

https://radiologykey.com/neonatal-chest-imaging/
 Transient Tachypnea of the Newborn
Gambaran radiologi
• Hiperinflasi paru
• Streaky, perihilar, linear density
• Cairan pada fissura / efusi pleura

William Herring, Learning radiology 3 rd edition

Transient Tachypnea of the Newborn

https://radiologykey.com/neonatal-chest-imaging/
 Meconium Aspiration Syndrome
Gambaran Radiologi
• Bilateral diffuse patchy opacities
• Hiperinflasi paru
• Dapat ditemukan efusi pleura
• Pneumotorax dan
pneumomediastinum pada 20-40%
kasus
Meconium Aspiration Syndrome

William Herring, Learning radiology 3 rd edition

 Pneumonia Neonatus
• Broad and wide spectrum of
abnormalities varying from a normal
chest, localized or diffuse alveolar
densities, reticular opacities and features
similar to respiratory distress syndrome
• Gambaran air bronchogram
 Pneumonia Neonatus

Extensive bilateral (right greater than left) streaky https://radiopaedia.org/cases/neonatal-pneumonia

interstitial pulmonary opacities with airspace
opacification at the right base.