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  • 1. CV Radiology I New Zealander Education. Doctor of Chiropractic (D.C.), Palmer College of Chiropractic, Davenport, Iowa, 1979. Residency in Radiology, Cleveland College of Chiropractic, Kansas City, Missouri, 1981 - 1983. Certified as Diplomate American Chiropractic Board of Radiology, (D.A.C.B.R.) 1984. 12 years MRI education and experience Professional Experience. Professor, Department of Radiology, Palmer College of Chiropractic, May 1983 to present. Director Clinical Radiology, Palmer College of Chiropractic Public Clinics. Private Practice of Radiology (1983-) Ian D. McLean DC DACBR Mississippi Regional Imaging 1989 Radiologist – NYDIC Open MRI of America Director Clinical Radiology Continuing Education faculty, PCC. Lecture nation wide 6- 8 times per year to state chiropractic associations. Palmer College of Chiropractic Professional Memberships. Member, Iowa Chiropractic Society Past President, East Central District, Iowa Chiropractic Society. American Chiropractic Association. American Chiropractic College of Radiology Council on Diagnostic Imaging of the A.C.A. Presidents Club, Palmer College of Chiropractic Publications. Clinical Imaging with Skeletal, Chest and Abdomen Differentials. Dennis M. Marchiori. Elsevier 2004 lots of journal articlesReview of syllabus M, T, Th P202 Additionally, approximately three opportunities for Attendance is not required, but you would be insane an extra credit point is available through class not to be here participation exercises. Three unit examination Each examination has 40 questions and is This will be applied to reading and response equally weighted to calculate the final course exercises in class grade for 120 points Make-up examinations are scheduled (see BE HERE! syllabus), should be requested prior to regular examination, and reserved for emergenciesCompetencies Reference Text Affective Clinical Imaging - With attitude Skeletal, Chest and Abdomen Pattern Differentials Cognitive knowledge Dennis Marchiori DC, MS, DACBR Tawnia Adams DC Psychomotor Robert Percuoco DC skills Ian McLean DC Tracey Littrell Ray Conley 0 1
  • 2. What do I need to know (for the test). Palmer’s Radiology Curriculum This is a clinically based series of presentations that is Radiology I (intro, variants, arthritis, miscellaneous) designed to enhance your knowledge for clinical practice. Radiology II (tumors and trauma) I am not in the habit of teaching for tests. This information Radiology III (plain film physics) will be literature based, emphasized with 20 years of Radiology IV (radiographic positioning) practice and professional experiences. Radiology “V” (chest and abdomen) You will be expected to read the text emphasizing the Clinic film review sessions (image interpretation and information the items in class. clinical correlation) The notes are given as a study guide. DO NOT RELY ON THEM AS THE SOLE SOURCE OF INFORMATIONRadiology I Course Plan Imaging Experiences Unit One: Film review Imaging modalities (chapter 2) Normal anatomy (chapter 6) 9:30 am, 12:00 pm, 3:00 pm Image interpretation (chapter 5) Roentgenometrics (chapter 4) Normal variants (chapter 7) Radiology grand rounds Unit Two: Arthritides (chapter 9) last Wed each month 2:00 pm Unit Three: Congenital diseases (chapter 8) Infection (chapter 12) McLean Radiology website Hematologic bone disease (chapter 11) mcleanradiology.com Endocrine, Metabolic, and Nutritional diseases (chapter 14)http://www.mcleanradiology.com http://www.mcleanradiology.com 2
  • 3. Questions & Comments: Introduction to Imaging IMcLeanDC@aol.comQuestion Palmer Tenets Radiology is a DIAGNOSTIC PROCEDURE so The Palmer Chiropractic University System maintains that a What is the value of diagnosis? chiropractic examination incorporates the use of diagnostic procedures when indicated, including some or all of the following: Relates an understanding of patient anatomy and Patient history physiology. Examination for subluxation complex Biomechanical functional assessment Communicates data Spinal examination Dictates management Physical examination Laboratory and imaging studies Chiropractic Medical "As a gatekeeper for direct access to the health delivery system, the Both doctor of chiropractics responsibilities as a primary care clinician include wellness promotion, health assessment, diagnosis and the Other chiropractic management of the patients health care needs. When indicated, the doctor of chiropractic consults with, co-manages or refers to other health care providers."Imaging and Chiropractic practice Criteria for ordering radiographs (p.(p. 205) 207) Plain film (dominant imaging study) Remains Relatively inexpensive, readily controversial available (> 80% of chiropractors) Medical criteria Substantial tract of the curriculum, vs. chiropractic NBCE exams technique Intrinsic part of many chiropractic Lack of techniques empirical data MRI “gold standard” for musculoskeletal imaging 3
  • 4. Question Patient Selection Parameters Which chiropractic patients should be x-rayed? History and physical exam findings All absolutely critical! Some never x-ray without this! None Confirmation of clinical findings Purpose of Imaging Studies Questionable Histories Assist clinical impression (diagnosis) and “rule out pathology” management Lacks specificity Contribute to clinical picture Evaluation of : Hasn’t been x-rayed suspected pathology No RDA for x-ray biomechanics scoliosis Find subluxations components of subluxation Lacks anatomical and physiological specificity So what is the secret of image Does defensive radiography work? interpretation clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history Actually no because…… clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history The image needs interpreting (requires knowledge) clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history ? clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history Relatively insensitive to early disease (there are no clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history “rule out pathology” diagnostic imaging studies) clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history Correlation with clinical symptoms is poor clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history clinical history (that osteophyte doesn’t cause pain)4 4 1 4
  • 5. Conventional Plain Film Radiography. An x-ray examination without the use of contrast media. Shows osseous pathology Shows mal-alignment Poor sensitivity to early disease Inexpensive Wilhelm Roentgen 1895 Mrs. Roentgens handHigh energy electron beam striking high-Z material produces heat and x-rays. Basic X-ray Principles High-energy short-wave electromagnetic radiation Ability to penetrate various materials Electron Beam Variable attenuation of the x-ray beam X Rays Ionizes atoms - removes Less than 1% of electrons electron beam energy! High-Z Material p. 24-25X-ray Imaging An image is produced by the attenuation of the x-ray beam. Attenuation is influenced by the atomic number of the structure.X-Ray Source The denser the structure, the Patient greater the attenuation and Detector the less blackening of the film 5
  • 6. Terminology X-ray images represent a summation of densities Dense (“white”) opaque radiopaque radiodense Lucent (“black/dark”) radiolucent Radiographic imaging is a two dimensionalAppearance of the radiograph (fig. 5-11) representation of a three dimensional structure. Examinations require at least two views at 90 degrees each other. Air Bone Fat (oil) Metal WaterMagnification. Radiographic Distortion. A phenomenon related to the divergence of the x- Unequal Magnification secondary to: ray beam from the x-ray tube Position from the central ray Position from the image receptor I0 IX-Ray Source Patient Detector 6
  • 7. Anatomical Distortion. Recording Media Radiographic X-ray film and radiographic Unequal Magnification screens with light and x-ray Anatomic sensitive emulsion Example Fluoroscopic screens Lateral lumbar spine Sodium iodide crystals in radiography. radionuclide imaging L5 foraminal stenosis? Electronic sensors – CTPositioning Terminology Image Presentation A-P (Anterior-Posterior) PA (Posterior-Anterior) Lateral Oblique Upright vs. recumbent Chiropractic/surgical anatomicStress Radiography Stress view of ankle Spine - cervical and lumbar Acromioclavicular joint Gamekeepers thumb Ankle Knee 20 7
  • 8. Digital imaging (p. 61) Fluoroscopy Direct capture radiography (DR) evaluation of motion Computed radiography (CR) gastrointestinal musculoskeletal image intensified reduces radiation dose time dependent loss of resolution Early Fluoroscopy Experience Linear Tomography Blurs anatomy above and below the object plane (fulcrum) to give the appearance of an image slice. Replaced by CT Renal exams (intravenous pyelograms) Linear Tomography1 1 8
  • 9. Linear Tomography Computerized Tomography (p. 50) CT combines x-rays and computers to create cross sectional axial images of the human body.Godfrey Hounsfield Computerized Tomography 1919–, British electrical engineer. A radar expert A gantry houses the x-ray tube and detector system. In order for the Royal Air Force during World War II, in the 1950s Hounsfield began developing to obtain certain angles, the gantry itself can be tilted. computer and X-ray technology for EMI, Ltd., an A table moves the patient international electronics and entertainment corporation. He built the prototype for the first in and out of the gantry in CT machine, which produced detailed images of order to position the area cross-sections of the human body, in 1972. For being imaged. The table this innovation he shared the 1979 Nobel Prize in Physiology or Medicine with Allan Cormack, and the gantry are specially who had independently derived and published synchronized in order to the mathematical basis of CAT scanning in obtain accurate thin slices. 1963–64. Hounsfield was knighted in 1981. Back Projectionhttp://www.colorado.edu/physics/2000/tomography/auto_rib_cage.html 1 9
  • 10. Advantages CT vs X-ray Computer enhances soft tissue contrast “Removes” overlaying anatomy May require contrast enhancement CT myelography abdomen evaluation of aneurysmHounsfield Unit (box 2-2) Scout Image/Plan Scan unit of attenuation A digital radiograph CT # of the area of examination Water = 0 allows correlation Bone +1000 -50 with the subsequent Fat -50 axial images 100 each slice is collimated to 3-10 1000 mmsAxial Lumbar CT with Contrast Axial Cervical CT with Contrast psoas body body ce subarachnoid cord ce subarachnoid with nerve roots 10
  • 11. Image Recontruction Image Recording Initially, the images appear on a computer screen The technologist then transfers the information on the monitor to a laser imager The laser imager produces a hard copy x-ray sheet that can be viewed by the radiologist 1Contrast Media in Radiography (p.54) Iodine Contrast Examinations Used to enhance tissue contrast High Atomic Weight compounds Vascular Barium and iodine Renal Myelography Iodine reactions very rare esp. with low osmolar agents Administered by intravenous injection or orally hives (urticarial rash) vascular contrasts may be allergic reactions evaluate for renal function if over 50 or renal history patients with known allergies should be examined cautiously BUN, creatinine myelographic contrast injected through relatively skinny butterfly GI contrasts needles or catheters Barium GI examinations usually mild to no reactionsMyelography (p.59) Arthrography contrast media in the injection of iodinated contrast media into a joint subarachnoid space largely replaced by MR and CT p. 59 Conventional arthrography CT arthrography 11
  • 12. Discography (p. 60) Intravenous pyelogram Contrast examination of the disc contents more accurately called "IVU," or intravenous urogram A diagnostic “challenge” (patients says “ouch) contrast examination of the urinary tract contrast material injected into the antecubital vein. contrast excreted through the kidneys resulting in excellent pictures of the various components of the kidneys, ureters, and bladderBarium Contrast Examinations Indications a fluoroscopic test used to Barium enema study the large bowel, or colon cancer colon. diverticulitis polyps, especially with the air contrast technique two basic types: intussuseption Barium enema Upper GI Upper GI esophogram The regular, or single hiatus hernia contrast, barium enema ulcers air contrast barium enema. tumorsBarium (sulphate) Contrast Radionuclide Imaging (p. 55) Oral or rectal administration…not A small amount of radioactive material vascular (radionuclide), commonly technetium (Tc) is upper GI series, barium enemas, administered to the body. This substance can be sometimes CT scans injected, taken orally, or inhaled. is as inert as a substance can be except for its slightly chalky taste Usually “tagged” to other substances to accentuate If perforation is suspected a water- end-organ uptake soluble iodine-based agent is used 12
  • 13. Radioisotope decays - emitting gamma radiation During the exam, images are created by a gamma technetium most commonly utilized camera which detects the radiation emitted from the low radiation dose body. nontoxic very short biological half-lifeBone Scans Bone Metastasis Technetium (Tc 99) bound to a phosphate compound (MDP) hot spots evaluates bone pathophysiology and blood supply metastatic disease infection Paget’s disease sensitive but not specificLung Scans SPECT perfusion scans (shows blood Single Photon Emission Computed Tomography flow) As in x-ray CT, SPECT imaging involves the ventilation scans (movement of air) rotation of a photon detector array around the body to acquire data from multiple angles. injected for a perfusion scan and inhaled for the ventilation scan. Brain Cardiac Bone ventilation perfusion 13
  • 14. SPECT Imaging DEXA (p. 58) Spondylolisthesis Dual Energy X-ray Absorptimetry Qualitative method to assess bone density DEXA uses beams of x-rays at two engery levels to determine bone density normal osteopenic osteoporoticDEXA DEXA Scores (box 2-3) Number of standard deviations from young adult normals. Evaluates osteopororsis Low energy x-rays are passed The T-score decreases by -1 for ABOUT every 10% of bone lost (ie, a through the bones to measure the person with 90% of young adult normal bone density will tend to have a mineral (calcium) content of the T -score of about -1.) bones A bone density measurement will World Heath Organization defines osteoporosis on the basis of T-scores determine the bone mineral density T -1 or higher = NORMAL (BMD) for the area measured and T -2.5 to -l = OSTEOPENIA compares that result with the T below -2.5 = OSTEOPOROSIS average BMD of young adult normals T below -2.5 + fragility fracture = SEVERE OSTEOPOROSIS of similar sex and race at their peak BMD.Fracture Risk (box 2-4) DEXA Report The T score predicts fracture risk: For every - 1 SD T Score the fracture risk doubles. T- score = 0 has average risk for a normal 40 year old. T-score = -1 has twice the risk. T-score = -2 has 4 times the risk T -score = -3 has 8 times the risk. 1 14
  • 15. PET (p. 62) Positron Emission Tomography Positron Emission Tomography The fluor undergoes radioactive decay, emitting a Begins with an injection of FDG positron (fluorodeoxyglucose) a molecule of the positron collides with an electron, a matter-anti- glucose, attached to an atom of matter annihilation occurs, liberating a burst of radioactive fluor, produced in a cyclotron energy, in the form of two beams of gamma rays, in opposite directions detected by the PET scanner fig. 2-31 Fused Images CT PETUltrasound Physics uses high frequency sound waves to image soft Sonic energy 1-10 MHz tissue structures Piezoelectric effect from transducer common examinations: Nonionizing gallbladder Reflection of the ultrasound beam from interfaces aneurysm between tissues produces image kidney, liver etc. Operator dependent especially in orientation of obstetrics slices Does not image gas or bone 15
  • 16. Ultrasonography Advantages Not employ ionizing radiation Used in any chosen plane Less expensive than CT or MRI Portable Carotid ultrasound Fetal face – 3D ultrasound Abdomen ultrasound Baby (Alex)Ultrasound Examinations McLean a transverse slice showing obvious gender Aortic aneurysm Cholelithiasis 16
  • 17. Magnetic Resonance Imaging (p43) History A non-ionizing imaging system that uses magnetic 1946 Felix Bloch proposed that nuclei could behave fields and radio frequencies to spatially analyzes as small magnets in the presence of a strong the magnetic spin properties of tissue nuclei, magnetic field. principally hydrogen. 1974 Raymond Damadien - a crude image of a rat tumor. 1977 Damadien produced a body image with the “Indomitable” p. 43 Raymond Damadien July 1977 Magnetic Resonance Imaging Advantages: Does not employ ionizing radiation “true” three dimensional imaging Excellent soft tissue contrast Disadvantages: Relative high cost (>$1000 per region) Contraindications w/ some implants, artifactsHow Large are the Magnetic Fields MRI – equipment The MR magnets are commonly superconductive Primary magnet The magnets range from .2 – 1.5 Tesla (T) Superconducting, permanent, or resistive The magnetic field of the earth is .5 Gauss (G) Gradient magnets 10,000 G = 1T Slice selection High field Open MRI 17
  • 18. Magnetic Field Strength Magnetic Field Strength 1 In the MR exam, it is helpful to think of the Hydrogen Proton patient as a group of randomly oriented hydrogen protons Has Charge Has spin + Therefore has a magnetic field - Behaves as a dipole magnet1 1 Placing the patient in the magnet creates a net In the presence of a large magnetic field magnetic moment of hydrogen within tissues hydrogen protons rotate or precess Bo1 1 fig. 2-6 1 18
  • 19. What is the appropriate RF In the presence of a magnetic field and appropriate radiofrequency environment the protons resonateenvironment? (spin together)…… For protons in tissue, the relationship between the magnetic field strength Bo and the precessional frequency w is given by the Larmor equation w = yBo Bo where gamma is a physical constant (42.58 MHz/T) for the proton the precessional frequency in a 1 Tesla field is 42.58 MHz/T fig. 2-7Actually it’s all about resonance! (fig 2-8) The pulse is manipulated to tilt the H2 magnetic field a set amount. A 90o and 180o are common.The RF pulse is removed MRI – phases (fig. 2-9) The H2 magnetic fields realign with the magnetic field. Resting A weak RF signal is produced Magnetism The signal is detected by the scanner. Excitation Relaxation 19
  • 20. Manipulation of the RF pulse, and the time of signal detection and then a miracle occurs….. computers….algorithms etc…. result in images of differing contrast (table 2-1) T1-weighted, black CSF T2-weighted, white CSF Manipulation of the RF pulse, and the time of signal detection result in images of differing contrast. T1 Black CSF T1 White CSF T2TR = 800 msec TR T2TE = 30 msec Short Long Short SD T1 TE T2 --- Long fig. 210 20
  • 21. Spin Density T1 T2Axials Contraindications (p. 49 Table 2-1) both T1 and T2 are thorough history must be obtained from the patient commonly obtained with particular attention to surgical intervention and R industrial exposure to metals. images are in anatomical presentation!Contrast Agents (p.49) T1 Images with Gd Gadolinium is almost completely inert Delivered intravenously Increased signal intensity within pathological tissue on T1 images Doesn’t cross the intact Blood Brain Barrier Shows breakdown of BBB Enhances tumors Enhances scar tissue w/oGd Gd 21
  • 22. T1 Sagittal T2 SagittalAxials 22