Professional Documents
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Electromagnetic spectrum:
Photons that propagate in vacuum in straight lines at the speed of light;
(Gamma ray X-ray Ultraviolet Visible light Infrared Microwaves Radio-waves)
Wave length
Photon energy (Kev) & Frequency
X-rays:
Uses:
1. X-ray crystallography.
3. CT scan.
2. Mammography.
4. Airport security.
1.
2.
ii.
Calcification; different particle shape & density & the cluster shape is
irregular or triangular pointing toward the nipple).
iii.
iv.
Architectural distortion.
v.
vi.
Skin thickening.
vii.
Pathological lymph nodes; benign are rounded, well defined with fatty centre
(lucent center) while pathological lymph node are dense & opaque (no fatty
center).
2. Calcifications:
Most are benign and can be dismissed.
The goal is to identify new or increasing calcifications or those with suspicious
morphology (Cluster of linear & branching micro-calcifications).
Benign calcifications:
1. Skin or dermal calcifications.
2. Vascular calcifications.
3. Lucent-centered calcifications (Fat necrosis).
4. Egg-shell or rim calcifications (Fat necrosis or calcification in cyst wall).
5. Coarse or popcorn calcification (Fibro adenoma).
6. Secretory calcifications, large rod like calcifications.
7. Punctuate calcification (less than 0.5mm).
8. Milk of calcium (in dependant part of the cyst).
9. Suture calcification.
10.
2.
Annual clinical breast exam age 40 and older (Q 3 years age 20-40).
3.
4.
5.
Barium administration
through the anal canal.
CT:
A painless, noninvasive diagnostic x-ray procedure using ionizing radiation that produces a
cross-sectional image of the body.
Hounsfield
unit
No radiation.
Contraindications:
1. Pacemaker.
2. Cochlear implant.
3. Aneurysmal clip.
4. Claustrophobia.
In breast screening; MRI is useful when you can't see lesions by mammogram and you highly
suspect that there is a lesion.
Angiography:
Introduction of contrast media into the blood vessels (arteries or veins) and obtain proper
images for them using fluoroscopy, CT and MRI.
Under fluoroscopic guidance it can be done as diagnostic and therapeutic procedure (stenting
of lower limb arteries).
Ultrasound:
Uses: Abdomen, pelvis, breast, thyroid, scrotum, blood vessels (DVT, carotid arteries).
of:
1. Bones.
2. Fractures.
vessels.
Radio-opaque dye is injected and vessels
3. Calcification.
are visualized
Gold standard for studying cerebral
vessels.
Not an X-ray, electromagnetic (similar to microwave).
Electromagnetic field aligns all the protons in the
brain.
Radiofrequency pulses cause the protons to spin.
Amount of energy emitted from the spin is
proportional to number of protons in the tissue.
No ferromagnetic objects.
Neuro-imaging:
Cytotoxic cerebral edema:
Brain Herniation:
1. Subfalcine midline herniation;
Most common; can cause ipsilateral anterior cerebral artery occlusion.
2. Central herniation;
Diffuse supratentorial swelling causing vertical displacement of the midbrain through
the tentorial hiatus.
3. Tentorial (uncal) herniation;
Can cause Compression of the oculomotor nerve and brain stem.
4.
Tonsiliar herniation;
Sub-tentorial expanding mass or greater supratentorial pressure causes herniation
of the cerebellar tonsils through the foramen magnum.
Cerebral Hemorrhage:
Look at the causes if you want.
Causes of SAH:
1. Cerebral aneurysm (saccular aneurysm) is the most common cause of non-traumatic
SAH.
2. Non-aneurysmal (venous) peri-mesencephalic hemorrhage.
3. Cerebral AVM (5%-10%).
4. Anticoagulants.
5. Amyloid Angiopathy.
6. Abuse of Sympathomimetics such as cocaine and methamphetamine
Subdural Hematoma:
1. Cross sutures of skull; Rounds the bend to follow falx or tentorium.
2. Tendency for crescent shapes.
3. More mass effect than expected for their size.
4.
Epidural hematoma:
1. Crosses falx or tentorium (Limited by sutures of skull typically).
2. Tendency for lentiform shape.
3. Typical source: skull fracture with arterial or sinus laceration.
4. Epidural bleeds may also occur in the spinal column.
CNS Infection:
1. Meningitis:
Most common imaging findings in meningitis: NONE.
Diffuse Meningial enhancement is a common finding.
Leptomeningitis = pia-arachnoid while Pachymeningitis: dura.
Sub-Dural effusion:
Common in children especially with H. influenza meningitis.
Can be treated conservatively.
Brain abscess.
2. Viral infections:
MRI is very sensitive for diagnosis of viral encephalitis.
Herpatic encephalitis has a characteristic bilateral temporal lobe involvement.
Brain tumors:
2. Extra-axial:
Arising from the brain coverings or nerve sheaths.
Meningiomas are the most common pathological type, Nerve sheath tumors are
less common, e.g. schwannoma, neurofibroma.
Trauma:
1. Axial injury:
Concussion:
Brain damage at the microscopic level.
Usually associated with normal imaging.
Contusion:
Focal area of edema associated with hemorrhage (Salt & pepper).
Usually involves the fronto-temporal lobes.
Dementia:
1. Primary role of imaging is to exclude treatable causes, e.g.:
Hydrocephalus.
Subdural hematoma.
Neoplasm.
Ms:
1. MRI is the imaging study of choice
2. Identify acute (inflammatory) vs. chronic lesions (enhancement = active inflammation).
3.
Epilepsy:
1. MRI is the imaging study of choice.
2. Polymicrogyria, Schizencephaly.
3. Mesial Temporal Sclerosis:
Most common pathology found in medically refractory epilepsy patients.
Rare under age 10 or with new seizures.
Pathology: Hippocampal atrophy / gliosis.
The basic imaging modalities used are X-ray1, CT2, MRI3, Ultrasound4 &Nuclear Medicine5.
Types;
1. Helical/spiral; conventional.
2. High resolution, used without contrast to investigate
interstitial lung diseases.
3. CTA, the initial test of choice to diagnose PE.
4. Axial CT, not used any more.
2. Allergy.
Role of CT
Common Indications:
1. Pancoast tumor;
Ask for MRI if you noticed an apical
mass in the lung in CXR.
2. Brachial plexus tumors/injury.
3. Cardiac (dynamic and anatomic study).
4. MRA.
Usually targeted examination (unlike CT).
Chest x-ray:
A. Routine:
PA vs. AP / AP is used in pediatric age group and unstable patients.
lateral CXR.
pathology
When we say right lateral decubitus film, the right side is the dependent side of the
patient.
Used to assess pleural effusion;
If you suspect pleural effusion on the right side, then you have to take right lateral
decubitus film (size & possible loculation).
Air trapping.
Used to assess pneumothorax;
If you suspect pneumothorax on the right side, then you have to take left lateral
decubitus film.
C. Lordotic view;
Used to assess Pancoast tumors and right middle lung lobe collapse.
Notes:
1. Regarding Penetration:
a. In PA image, a good penetration means that you can count three visible thoracic vertebrae
in the retro-cardiac region.
b. In lateral x-ray;
The spine darkens (increased radiolucency) as we go caudally.
Sternum should be seen edge on.
Two sets of ribs posteriorly (the wider and more dorsal set represents the right ribs).
2. Expiration film;
2. Pleura:
Mediastinum is wider.
Potential Space that contains about 10 cc of serous fluid Dont see unless abnormal
(effusion, chylothorax, empyema, hemothorax).
Specific Entities:
1. Pulmonary edema.
2. TB.
3. Airway disease.
4. Pneumothorax.
Chest pathology:
1. Lung Parenchymal pathology:
Air space disease (alveolar lung disease).
Ground glass appearance (partial) & Consolidation (complete).
Features:
1) Air bronchogram.
Criteria to determine the area
of consolidation
1. Cardiothoracic ratio.
2. silhouette sign:
Right middle lobe =
1. Acute:
Obliteration of Left
2.
Chronic:
Pulmonary edema.
Broncho-alveolar carcinoma.
Pneumonias.
Lymphoma.
Pulmonary hemorrhage.
Alveolar proteinosis.
diaphragm.
3. Air bronchogram.
Patterns:
1) Linear pattern:
Short (1-2cm).
Peripheral sub-pleural location.
More common in lower lung
d. Lymphangitis carcinomatosis.
fields
2) Reticular pattern:
Result from summation of irregular linear opacities.
Usually associated with low lung volumes.
Classic example:
a. Idiopathic pulmonary fibrosis.
b. Asbestosis.
c. Scleroderma.
3) Nodular pattern:
Numerous small nodules (1mm-10mm in diameter).
Miliary pattern: small nodules 1-2mm in diameter.
Classic examples:
a. Miliary TB.
b. Sarcoidosis.
c. Silicosis.
d. Metastasis from thyroid, kidney, etc.
Focal lung masses/ Nodules:
Bronchogenic carcinoma:
1. Adeno-carcinoma:
Most common.
Peripherally located.
Broncho-alveolar carcinoma is a subtype.
2. Squamous cell carcinoma:
Second most common type.
Strong smoking association.
Centrally located, most likely to cavitate.
2. Mediastinal pathology:
1) Superior mediastinum:
Lesion extending from the neck e.g. thyroid mass, cystic hygroma.
Lymphadenopathy.
Vascular abnormalities e.g. aneurysm.
2) Anterior mediastinum:
Thymoma.
Teratoma.
Thyroid.
Terrible lymphoma.
3) Middle mediastinum:
Vascular/ aneurysm.
Lymphadenopathy.
Congenital lesions.
4) Posterior mediastinum:
Neurogenic tumors.
Others e.g. lymphoma, descending aortic aneurysm, esophageal varices, hiatal
hernia.
Pleural pathology:
Pleural effusion:
Accumulation of transudate or exudate fluid in the pleural cavity.
Signs of pleural effusion:
1) Blunted costo-phrenic angle.
2) Meniscus sign.
3) Opacification of hemithorax:
a) Total lung collapse/ atelectasis;
There is no shift.
d) Post pneumonectomy.
Loculated effusion:
Usually seen in empyema or malignant effusion.
Failure of layering on decubitus film.
CT may show split pleural sign.
Pneumothorax
Special conditions!
Pulmonary edema
2. Peribronchial cuffing.
3. Thickening of the fissures.
4. Pleural effusions.
2. Tension:
Progressive loss of air into pleural space
Bullous Emphysema
Increase in the volume of the lung, Sign on CXRY :
1. Increase air in the lung, more hyperlucency .
2. Flat diaphragm.
3. On lateral Xray ; retrosternal space >4.5cm
Bronchiectesis
1. Heart small.
Abdomen CT:
Allergic patient; prepare him by giving pridnesolone tablets 1 day before the scan.
Gastrografin when used orally may lead to aspiration (chemical pneumonitis) & pulmonary edema.
Three phases:
Delayed:
1. Ureter injury.
2. CT urography.
3. Liver lesion.
Stone protocol:
Liver protocol
Without (without IV contrast, to see if there is calcification and base line for enhancement).
Triple phases.
Adrenal protocol
Without.
PV & delayed (we need more delay,15 min due to less perfusion).
pancreatic protocol
Contrast:
Single contrast (anatomy).
Double (for mucosa and pathology).
A constriction could be normal (if moving due to peristalsis) or abnormal (if constant).
Barium meal:
Jujenum:
Indentration (plicae circulares).
Ilium:
Has no feathery appearance (plicae circulares).
Barium enema:
Contraindications :
Absolute:
1. Toxic mega colon.
2. Pseudo- Toxic mega colon.
3. Pseudomembraneous colitis.
4. Rectal biopsy via:
Relative:
1. Incomplete bowel preparation.
2. Recent barium meal wait for 7-10 days.
3. Uncooperative patient .
Notes:
1. Achalasia bird beak sign or rat tail appearance.
2. Carcinoma of the esophagus long irregular stenosis with filling defect (almost looks
like an apple core lesion in the esophagus).
3. Zinger's diverticulum Pouch in cervical esophagus (criopharayngeal muscle).
4. Crohn's disease: the presence of skip lesions and presence of discrete ulcers, Rose thorn
ulcer, Cubblestone appearance.
5. Multiple polyposis; multiple small & round filing defect.
6. UC: Loss of haustraion, Wide terminal ileum, Lead pipe sign, Backwash Ileitis.