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Radiology Np Students2

Staging of testicular cancer MRI: Scrotal masses that are indeterminate on US Scintigraphy: Acute scrotal pain MUSCULOSKELETAL SYSTEM Plain films: Initial study for trauma, suspected fracture, joint disease US: Soft tissue masses, joint effusions, tendon/ligament injuries CT: Complex fractures, bone tumors, postoperative evaluation MRI: Soft tissue and bone marrow lesions, postoperative evaluation, suspected ligament/tendon injury Bone scan: Suspected metastasis, stress fractures Arthrography: Internal derangements of joints MUSCULOSKELETAL SYSTEM Plain

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Joshua Daniel Hanelin, MD
OVERVIEW I. Why Radiology II. Cost III. Radiation Dose IV. Imaging Modalities, Physics, and Contrast Reactions V. Organ Based Approach to Imaging VI. How to Order an Exam
WHY RADIOLOGY?
WHY RADIOLOGY? Specific Question vs Fishing Expedition: Tailor your study to answer the question.  Does my patient have gallstones?  Does my patient have a kidney stone?  Does my patient have a small bowel obstruction?  Does my patient have fibroids? Vs  Why does my patient have this vague abdominal pain?  Why does my patient have a fever?  Why does my patient have knee pain?
COST  Radiographs: $30 - $80  Ultrasound: $120 - $160  CT: $300 - $2000  Nuclear scans: $120 - $240  MRI: $670 - $1,250  PET-CT: > $3,000  Current expenditures on all medical imaging: $100 billion per year  Growth rate: doubling every decade
RADIATION DOSE
RADIATION DOSE  Chest X-ray: 0.05 mSv  Extremity X-ray: 0.1 mSv  Abdomen X-ray: 1.0 mSv  Head CT: 1 mSv  Bone scan: 5 mSv  Abd. Fluoro (e.g. barium enema): 5-15 mSv  Abdomen CT: 10-20 mSv
RADIATION DOSE  100 mSv to each of 100 adults yields about 1 extra malignancy  Dose from a single abdomen CT minimally – but definitely – increases cancer risk  Age at exposure is crucial
RADIATION DOSE  Chest X-ray: 0.05 mSv  Extremity X-ray: 0.1 mSv  Abdomen X-ray: 1.0 mSv  Head CT: 1 mSv  Bone scan: 5 mSv  Abd. Fluoro (e.g. barium enema): 5-15 mSv  Abdomen CT: 10-20 mSv
RADIATION DOSE Brenner D, Elliston C, Hall E, Berdon W. Estimated Risks of Radiation- Induced Fatal Cancer from Pediatric CT. AJR 2001;176:289–296.
RADIATION DOSE  Belly exams are the big-dose ones  If you can avoid a few hundred per career, you’ll probably avoid causing a cancer  Still - for any serious disease, failure to diagnose is still more dangerous than the radiation.
WHY RADIOLOGY? Always ask yourself: Will the results of this test change my management of the patient? Is this cost effective? Are the risks worth the benefit?
Conventional Radiography Image Generation:  X ray – Electromagnetic radiation
Conventional Radiography EQUIPMENT
Conventional Radiography FILM RADIOGRAPHY
Conventional Radiography FILM RADIOGRAPHY
Conventional Radiography FILM RADIOGRAPHY
Conventional Radiography COMPUTED RADIOGRAPHY
Conventional Radiography DIGITAL RADIOGRAPHY
Conventional Radiography CONVENTIONAL TOMOGRAPHY
Conventional Radiography CONVENTIONAL TOMOGRAPHY
Conventional Radiography FLUOROSCOPY
Conventional Radiography FLUOROSCOPY
CONVENTIONAL RADIOGRAPHY FLUOROSCOPY Contrast Agents: Barium Sulfate – Well tolerated. Aspiration rarely causes a clinical problem. Major risk is barium peritonitis due to spill into peritoneal cavity through bowel perforations. Water-soluble iodinated contrast media – No risk of peritonitis. Aspiration causes chemical pneumonitis. Large volumes in the GI tract draw water into the gut and may lead to hypovolemia, shock, and death.
Conventional Radiography CONVENTIONAL ANGIOGRAPHY
Conventional Radiography RADIOGRAPHIC VIEWS  Beam Direction:  Posteroanterior (PA)  Anteroposterior (AP)  Craniocaudad(CC)  Patient Position:  Erect  Supine  Prone  Lateral Decubitus  Obliques
Conventional Radiography PRINCIPLES OF INTERPRETATION  5 basic radiographic densities:  Air – little attenuation  Fat – intermediate attenuation  Soft tissue – intermediate attenuation  Bone – high attenuation  Metal/Contrast agents – high attenuation
Conventional Radiography PRINCIPLES OF IMAGE INTERPRETATION  Structures are seen when outlined by tissues of different xray attenuation
CROSS-SECTIONAL IMAGING IMAGING PLANES
CROSS-SECTIONAL IMAGING COMPUTED TOMOGRAPHY  Computer reconstruction of cross section of body from measurements of x-ray transmission through thin slices of the patient
CROSS-SECTIONAL IMAGING COMPUTED TOMOGRAPHY  Conventional CT  Images obtained one slice at a time  Helical/Spiral CT  Patient table moves while xray tube rotates around patient  Multidetector helical CT  Multiple detectors allowing multiple slices per rotation of the xray tube
CROSS-SECTIONAL IMAGING COMPUTED TOMOGRAPHY Contrast:  Intravenous – Enhance density differences between lesions and surrounding parenchyma, demonstrate vascular anatomy, and characterize lesions by patterns of contrast enhancement  Oral – Required to opacify the bowel to help differentiate between from tumors, lymph nodes, and hematomas
CROSS-SECTIONAL IMAGING COMPUTED TOMOGRAPHY
CROSS-SECTIONAL IMAGING COMPUTED TOMOGRAPHY Contrast Reactions:  Mild – nausea, vomiting, urticaria, injection site warmth, injection site pain Tx: Observation 20 – 30 minutes  Moderate – hives, vasovagal reactions, bronchospasm, mild laryngeal edema Tx: Diphenhydramine, beta-agonists, epinephrine, leg elevation  Severe – severe bronchospasm, severe laryngeal edema, loss of consciousness, seizures, cardiac arrest Tx: Life support equipment and CPR
CROSS-SECTIONAL IMAGING COMPUTED TOMOGRAPHY Local adverse contrast effects: venous thrombosis, extravasation of contrast with associated pain, edema, skin slough, or deeper tissue necrosis Tx: elevate limb, warm compresses, consider plastic surgery consult
CROSS-SECTIONAL IMAGING COMPUTED TOMOGRAPHY Contrast-induced Nephropathy  Acute renal failure within 48 hours of contrast administration  Possibility of permanent renal damage  Risk factors: diabetes and chronic renal insufficiency  Prevention: Adequate hydration, administration of N- acetylcysteine, use of Visipaque  Chronic dialysis patients at risk for adverse effect of osmotic load and direct toxicity on heart; recommend dialysis on day of contrast administration
CROSS-SECTIONAL IMAGING COMPUTED TOMOGRAPHY Metformin  Oral antihyperglycemic used for type 2 DM  May precipitate fatal lactic acidosis in presence of renal impairment  FDA recommends withholding metformin for 48 hrs following administration of IV contrast and reinstated only after renal function has been reevaluated and found to be normal
CROSS-SECTIONAL IMAGING COMPUTED TOMOGRAPHY Patients at risk for adverse reactions:  Reassess need for IV contrast and consider diagnostic alternatives  Previous history of adverse reaction  History of asthma or allergies: Iodine? Shellfish?  Cardiac dysfunction: CHF, arrhythmias, unstable angina, recent MI, pulmonary HTN  Renal insufficiency  Diabetes  Sickle cell disease  Multiple Myeloma  Age over 55 yrs
CROSS SECTIONAL IMAGING COMPUTED TOMOGRAPHY Premedication regimens:  Prednisone 50 mg orally taken at 13, 7, and 1 hour prior to contrast administration. Diphenhydramine 50 mg orally, IV, or intramuscularly at 1 hour prior to contrast. Use nonionic low-osmolality agent.  Methylprednisolone 32 mg orally at 12 and 2 hours prior to contrast administration. Use of diphenhydramine is optional. Nonionic low-osmolality agent should be used.
CROSS-SECTIONAL IMAGING MAGNETIC RESONANCE IMAGING  Based on the ability of protons in the body to absorb and emit radio wave energy when the body is placed in a strong magnetic field  Multiple different pulse sequences used to emphasize different tissue characteristics  Advantages: excellent soft tissue contrast resolution, provides images in any plane, absence of ionizing radiation  Limitations: Inability to demonstrate dense bone detail or calcifications, long imaging times, limited spatial resolution compared with CT, expensive
CROSS-SECTIONAL IMAGING MAGNETIC RESONANCE IMAGING
CROSS-SECTIONAL IMAGING MAGNETIC RESONANCE IMAGING
CROSS-SECTIONAL IMAGING MAGNETIC RESONANCE IMAGING Intravenous contrast: Enhance differences between lesions and surrounding parenchyma, demonstrate vascular anatomy, and characterize lesions by patterns of contrast enhancement  Adverse reactions (rare): nausea, vomiting, headache, injection site warmth, paresthesias, dizziness, itching  No nephrotoxicity Oral contrast: Not used
CROSS-SECTIONAL IMAGING MAGNETIC RESONANCE IMAGING Nephrogenic Systemic Fibrosis (NSF)  Rare disorder affecting patients with renal impairment after receiving intravenous MRI contrast agents  Fibrosis of skin, joints, eyes, and internal organs  Constant pain, muscle restlessness, and loss of skin flexibility  No consistently effective therapy  Avoid MRI contrast agents if GFR < 30
CROSS-SECTIONAL IMAGING MAGNETIC RESONANCE IMAGING Nephrogenic Systemic Fibrosis (NSF)
CROSS-SECTIONAL IMAGING ULTRASONOGRAPHY  Ultrasound transducer converts electrical energy to a pulse of high frequency sound energy, which reflects off of tissues, producing echoes which are used to generate images.  Real time imaging of moving patient tissue  Doppler ultrasound permits detection of blood velocity and direction  Highly operator dependent
CROSS-SECTIONAL IMAGING ULTRASONOGRAPHY
CROSS-SECTIONAL IMAGING NUCLEAR MEDICINE External detection and mapping of the biodistribution of radiotracers that have been administered to a patient. Poor spatial resolution, but high functional resolution. Examples: Ventilation perfusion scan, bone scan, biliary scan, white blood cell scan, renal scan, thyroid scan, brain scan, PET, liver spleen scan
CROSS-SECTIONAL IMAGING NUCLEAR MEDICINE
NEUROLOGIC IMAGING: BRAIN General rule: CT for acute neurologic illness (< 48 hrs); MRI for chronic neurologic illness (> 3 days), never use plain films If the CT or MRI suggests:  Vascular lesion MR or CT angiogram  Tumor Contrast  No infarct, but Sx of infarct Carotid doppler US or MRA or CTA Acute Trauma CT with no contrast MR I inappropriate: multisystem trauma, assisted ventilation Sedation for agitated adults and children
NEUROLOGIC IMAGING: BRAIN SPECIFIC SITUATIONS Acute Trauma: Noncontrast CT Stroke: Noncontrast CT followed by MRI Seizure: 1st Seizure, contrast-enhanced MR or CT Postictal state or residual neurologic deficit, Noncontrast CT Chronic seizure disorder, detailed MRI Infection and Cancer: contrast-enhanced MRI Headache: Acute headache, noncontrast CT Chronic headache with no neurologic Sx, noncontrast MRI Chronic headache with neurologic Sx, contrast-enhanced MRI Dementia: noncontrast MRI
NEUROLOGIC IMAGING: BRAIN XX, best study; X acceptable study (depending on situation)
NEUROLOGIC IMAGING: SPINE Acute Trauma: Plain film, CT if plain film findings equivocal Everything else: MRI
HEAD AND NECK IMAGING CT vs MRI CT: Patient cannot hold still, obstructed salivary ducts, fractures MRI: Discrimination of soft tissue pathology
THORACIC IMAGING Mainstay: Posteroanterior (PA) and lateral chest radiographs Special views:  Lateral decubitus: Small effusions or small pneumothorax  Expiratory radiograph: Focal or diffuse air trapping  Apical lordotic view: Visualization of lung apices  Chest fluoroscopy: Diaphragmatic paralysis
THORACIC IMAGING
THORACIC IMAGING
THORACIC IMAGING
THORACIC IMAGING PET: Oncologic diagnosis and staging Ventilation/Perfusion Lung Scan: Diagnosis of PE `
LIVER  Contrast-enhanced multidetector CT (MDCT): Primary imaging method  MRI with contrast: Inability to give iodinated contrast or need for multiple repeat examinations  US: Screening method for patients with abdominal symptoms and suspected diffuse or focal liver disease, assessment of hepatic vessels
BILIARY TREE  US: Screening for biliary obstruction  MRCP: High resolution imaging of biliary tree
GALLBLADDER US: Method of choice Cholescintigraphy: Equivocal ultrasound for detection of acute cholecystitis
PANCREAS AND SPLEEN PANCREAS: Contrast enhanced multidetector CT vs contrast enhanced MRI US poor visualization of pancreas SPLEEN: Contrast enhanced CT and US
PHARYNX AND ESOPHAGUS Barium Swallow/Esophagram: Swallowing disorders and mucosal lesions CT: Cancer staging, extent of disease MR: Cancer staging, extent of disease, preferred for evaluation of nasopharynx
STOMACH AND DUODENUM Upper GI Series (UGI): Evaluation of mucosal surface, largely being replaced by endoscopy CT: Extraluminal component of disease
SMALL BOWEL Small Bowel Follow Through (SBFT): Insensitive, bowel lumen and mucosa details Enteroclysis: Improved anatomic detail, shorter imaging time CT: Extraluminal disease
ADRENAL GLANDS AND KIDNEYS ADRENAL GLANDS CT: Modality of choice MRI: High quality images with ability to differentiate benign adrenal adenomas
ADRENAL GLANDS AND KIDNEYS KIDNEYS Contrast enhanced MDCT: Modality of choice MRI: Patients who cannot tolerate iodinated IV contrast US: Screening study to detect hydronephrosis and demonstrate kidney size
PELVICALYCEAL SYSTEM AND URETERS Contrast enhanced MDCT: Modality of choice MRI with or without contrast: Patients who cannot tolerate iodinated IV contrast or with poor renal function
BLADDER Cystogram: Detailed examination of bladder mucosa CT or MRI: Cancer staging
URETHRA Retrograde urethrogram: Anterior male urethra Voiding cystourethrogram: Anterior and posterior urethra
GENITAL TRACT FEMALE GENITAL TRACT US: Primary imaging modality; Transvaginal vs Transabdominal CT/MRI: Staging and follow up of pelvic malignancies Hysterosalpingography (HSG): Congenital anomalies and causes of infertility
GENITAL TRACT TESTES AND SCROTUM Color US: Primary imaging method CT/MRI: Tumor staging and locating undescended testes
GENITAL TRACT PROSTATE AND SEMINAL VESICLES MR with endorectal coil: Local disease staging CT/MRI: Nodal disease and distant spread
MUSCULOSKELETAL Plain Radiograph: Minimum of two films at 90 degrees to each other CT: Examination of fine bony details or high suspicion of fracture not seen on plain radiograph MRI: Extent of tumor, characterization of soft tissues, radiographically occult fractures
ORDERING AN EXAM  Ask for exams sequentially rather than all at once  Use your radiologists  Train your radiologists  Help your radiologists
ORDERING AN EXAM
WHEN IN DOUBT ASK YOUR LOCAL RADIOLOGIST
THAT’S IT AND THAT’S ALL G’BYE Y’ALL!
Questions, Comments, Concerns… Joshua D Hanelin, MD jdhnyc14@yahoo.com
Radiology Np Students2
Radiology Np Students2
Radiology Np Students2
Radiology Np Students2
Radiology Np Students2
Radiology Np Students2
Radiology Np Students2
Radiology Np Students2
Radiology Np Students2
Radiology Np Students2
Radiology Np Students2
Radiology Np Students2
Radiology Np Students2
Radiology Np Students2
Radiology Np Students2
Radiology Np Students2
Radiology Np Students2
Radiology Np Students2
Radiology Np Students2
Radiology Np Students2