Introduction to Radiology - Michigan State University

Introduction to Radiology - Michigan State University

Introduction to Radiology Course Overview Four Required On-line modules 2 Case discussion sessions Four quizzes Two examinations Course Overview

Expectations Active participation and preparation Utilization of provided on-line materials Exciting Fun Course Introduction Lecture Historical overview X-rays Appropriateness Criteria

Application of the various technologies to be discussed in the course Ionizing Radiation Historical Overview Wilhelm Conrad Rentgen 1845 1923 November 8, 1895 discovery of the x-ray Discovered effect of passing this ray through materials First radiograph of his wifes hand 1901 Nobel Prize Physics Antoine Henri Becquerel 1852-1908

Radioactive nature of Uranium 1903 Nobel Prize Physics Ionizing Radiation Historical Overview Marie and Pierre Curie 1867-1934, 1859 1906 Marie coined term radioactivity Discovery of Polonium and Radium 1903 - 1910 Nobel Prize Physics - Chemistry Died July 4, 1934 Pernicious Anemia William D. Coolidge Patent holder for the original x-ray tube 1913

Robert S. Ledley Patent holder for original CT scanner 1975 US Historical Overview George D. Ludwig Late 1940s research for the Navy Classified work using US to evaluate tissues Report June 1949 first published work on US applications Douglass Howry, Joseph Holmes Pioneering work in B-Mode ultrasound Joseph Holmes, William Wright and Ralph Meyerdirk

First articulated arm scanner 1963 James Griffith, Walter Henry NIH Mechanical oscillating real-time apparatus 1973 Martin H. Wilcox Linear array real time scanner 1973 NM Historical Overview Benedict Cassen, Lawrence Curtis, Clifton Reed Automated scintillation detector 1951 Hal Anger

Scintillation Camera 1958 Picker Corporation 3 inch rectilinear scanner 1959 John Kuranz Nuclear Chicago First commercial Anger (Gamma Camera) MRI Historical Overview Felix Bloch, Edward Purcell NMR Spectroscopy Paul Laterbur, Peter Mansfield 2003 Nobel Prize Physiology / Medicine

Raymond Damadian First patent in field of MRI 1970 Imaging Modalities Ionizing Radiation: Diagnostic Radiology (X-rays) Interventional Radiology Computed Tomography (CT) Nuclear Medicine Positron Emission Tomography (PET) No Ionizing Radiation: Diagnostic Ultrasound (Ultrasonography)

Magnetic Resonance Imaging (MRI) X-Rays High energy electromagnetic radiation Behaves both like a particle (photon) and a wave Production of X-Rays Free electrons produced at filament of x-ray tube (cathode) High Speed movement of electrons Rapid deceleration of electrons at anode Emission of a x-ray photon X-ray Tube Schematic

Envelope Anode Tungsten Target Electron Beam X-rays Cathode Window Collimator

Production of Image X-ray pass through tissue to expose detector Passage depends on Tissue characteristics Density Atomic Number Number of electrons per gram

Thickness Production of Image Differential absorption of X-ray as the beam passes through the patient Unabsorbed X-rays expose the detector (i.e. film, CR Plate, solid state detector), creating the image (photographic effect) Differential absorption of X-ray by the tissues is the cardinal feature of image formation Special terms used on x-ray reports Radiopaque, Radiolucent, High attenuation, Low attenuation, Water density

Standard X-Ray Machine X-Ray Tube X-Ray Tube Detector Detector Fluoroscopic Imaging Unit X-Ray Tube Detector

Detector X-Ray Tube Natural Densities Natural densities in the body Bone Soft tissue and body fluid Fat Lung and air containing organs

Appearance on the radiographic image White Shades of Gray Black Image Density X-ray Radiopaque High attenuation Appears white on film black on fluoroscopy X-ray photons dont reach the detector

Radiolucent Low attenuation Appears black on film white on fluoroscopy X-ray photons unimpeded traveling to detector Water density Appears grey on film All soft tissues Natural Contrast Differential contrast between bone and soft tissues Differential contrast between soft tissues

and air Little difference between various tissue types i.e. fat, muscle, solid organs, blood. Natural Contrast Pathologic processes may cause differences in natural densities that can be visualized on the X-ray; high density tumor in air filled lung- white Low density cyst in radio-opaque bone- black Pathologic processes of almost the same density as adjoining structures are not

visible on X-ray. May need to use additional artificial contrast to visualize a density difference Contrast Agents Contrast material (radio-opaque or radiolucent) administered to see structures or pathologic processes that would not be seen otherwise Some useful contrast agents Barium sulfate in the GI tract Iodine compounds in the vessels Carbon dioxide in the vessels or GI tract Naturally occurring air in the GI tract

Fluoroscopic Room Video Camera Radiosensitive Screen Appropriateness Criteria Guidelines to assure proper imaging choices Based on attributes developed by the Agency for Healthcare Research and Quality (AHRQ) ACR Appropriateness Review Criteria Overview

Appropriateness Criteria Validity lead to better outcomes based on scientific evidence Reliable and reproducible other experts should develop same recommendations based on the same scientific evidence Clinical applicability guideline indicates target population ACR Appropriateness Review Criteria Overview Appropriateness Criteria

Clinical flexibility specify expectations Clarity unambiguous, clear definitions Multidisciplinary all affected groups should be represented Scheduled review fixed time to review and revise Documentation evidence used and approach taken is documented ACR Appropriateness Review Criteria Overview Appropriateness Criteria ACR Appropriateness Criteria search

engine: http://www.acr.org/SecondaryMainMenuCa tegories/quality_safety/app_criteria.aspx Allows searching by 10 diagnostic imaging expert panels Useful resource when evaluating what clinical exam may be useful Appropriateness Criteria Electronic Decision Support for Medical Imaging Future opportunities to improve health care

X-Ray Ionizing radiation Exposure concerns Somewhat limited discrimination between structures of similar density Tumor vs. normal organs Inexpensive Readily available First line imaging tool X-Ray Primary applications:

Chest Imaging Infiltrates Masses Cardiac silhouette Abdominal imaging Gas/ bowel distribution Free air Calcifications

Organomegaly/ masses X-Ray Primary Applications Bone and Joint imaging Trauma Neoplasm Soft Tissues Mass Foreign bodies Breast imaging

X-Ray Secondary applications: Contrast enhanced examination Urinary tract IVU Cystography, urethrography Angiography Pulmonary/ Cardiac Pulmonary Coronary Great vessels General

Neoplasm Vascular abnormalities X-Ray Secondary applications: Dual energy Lung lesions Soft tissue calcifications Bone density evaluation Tomography tomosynthesis Interventional Radiology Minimally invasive technology

Biopsy Cavity drainage Infections Neoplasm Revascularization TPA Angioplasty Stenting Interventional Radiology Lumen restoration / drainage Biliary tree Ureters

Others Vertebroplasty/ kyphoplasty Computed Tomography Ionizing radiation Requires concern and careful utilization Excellent discrimination between subtle tissue density differences Moderately expensive Readily available Growing spectrum of applications across a broad spectrum of diseases and body parts

Computed Tomography Primary applications: First line evaluation in suspected cerebral vascular events hemorrhagic vs. ischemic First line evaluation in soft-tissue and skeletal trauma First line evaluation in suspected pulmonary embolism First line evaluation in suspected urinary calculi Computed Tomography Primary applications:

Head & Neck CVA evaluation Carotid and intra-cerebral vascular evaluation Head-neck trauma evaluation for subdural and epidural hematoma evaluation for cervical fracture Neoplasm staging Thorax Lung- mediastinum nodule/ mass evaluation, Cardiac, coronary, pulmonary and great vessel vascular evaluation Airway evaluation Neoplasm staging

Computed Tomography Primary applications: Abdomen/ Pelvis Solid organ evaluation Urinary tract evaluation for calcification CT angiography CT colonography CT urography Lumbar spine evaluation (pacemakers, stimulators) Neoplasm Staging

Computed Tomography Primary applications: Bones & Joints 3-D joint reconstructed images Evaluation of fracture union Evaluation of neoplasm / extent Secondary applications: Evaluation of patients with a contraindication to MRI imaging

Bone mineral density analysis Nuclear Medicine / PET Ionizing radiation Radio-isotopes attached to molecules targeting specific organs or metabolic processes Spatial resolution limited Able to evaluate temporal resolution of uptake/ events Nuclear Medicine / PET Primary applications: First line evaluation of biliary function

evaluation First line evaluation of cardiac perfusion First line evaluation of solid pulmonary nodules First line evaluation for many neoplasms, staging treatment response Nuclear Medicine / PET Primary applications: Head & Neck Brain death evaluation cerebral blood flow CSF flow evaluation Bone abnormality evaluation

Thorax V-Q Scanning Ventilation Perfusion scanning for Pulmonary Embolism detection secondary exam Pulmonary nodule evaluation (PET) Cancer staging (PET) Nuclear Medicine / PET Primary applications: Abdomen & Pelvis

Liver spleen scanning Hepatobiliary scanning Renal scanning Bladder & Reflux evaluation GI bleed evaluation Cancer staging (PET) Soft tissues Bone & Joints Bone scanning Tumor scanning (Gallium, PET) Infection scanning (labeled white cells, Gallium)

Magnetic Resonance Imaging No ionizing radiation Utilize magnetic fields and radio waves Contraindication: implanted devices, ferromagnetic metals Relative contraindication: claustrophobia Differentiation of distribution of Hydrogen ions as impacted by adjoining molecules Ability to do spectral analysis (remember organic chemistry) Magnetic Resonance Imaging Primary applications: First line evaluation of suspected neurologic abnormality

First line evaluation of soft tissue mass/ neoplasm First line evaluation of joint disarrangements First line evaluation of bone neoplasm Magnetic Resonance Imaging Primary applications: Head

Neoplasm Infection CVA Developmental anomalies Trauma MR angiography Neck

Effect of arthritis and degenerative changes Neoplasm Trauma MR Angiography Magnetic Resonance Imaging Primary applications: Thorax Spine cord, roots, bodies Heart function, perfusion MR angiography Abdomen

Liver mass, iron content, biliary tree MR Cholangiography Kidneys MR Urography MR Colonography Retroperitoneum Magnetic Resonance Imaging

Primary applications: Pelvis Prostate Neoplasm Hypertrophy CAD Uterus & Ovaries Masses Leiomyoma Spine

Cord Roots Foramina Stenosis Arthritis Magnetic Resonance Imaging Primary applications: Bones & Joints

Tendons and ligaments injury Articular cartilage evaluation Muscle abnormality Trauma fracture, contusion Mass/ Neoplasm appearance and extent Soft tissues Mass/ Neoplasm MR angiography

Ultrasound No ionizing radiation Principles of fairly uniform speed of sound transmission in human tissues Ability to differentiate fairly subtle tissue differences based on echo reflection and interactions Application of Doppler principles for fluid motion Ultrasound Primary applications: First line evaluation of pregnancy and

developing fetus First line evaluation for differentiation of cystic from solid masses/ structures First line evaluation of liver and biliary tree First line evaluation of kidneys and bladder First line evaluation of thyroid gland Ultrasound Primary applications: Head & Neck

Thyroid Adenopathy Orbits & globe Salivary glands Fetal brain Soft tissue masses Thorax

Cardiac Pleural effusions Breast lesions Soft tissue masses Ultrasound Primary applications: Abdomen

Liver Pancreas Spleen Kidneys Aorta Splanchnic and renal vessels Ultrasound Primary applications: Pelvis

Pregnant uterus and fetus Uterus Fallopian tubes Ovaries Bladder Prostate Testes and scrotum

Ultrasound Primary applications: Soft tissues, bones & joints Tendons, Ligaments and supporting structures Fluid collections and masses Vascular malformations Artery and vein evaluation

Foreign bodies

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