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Revision Notes for the

FRCR Part 1
Dr Hans-Ulrich Laasch
With contributions by:

Dr Rhidian Bramley
Dr Peter Bungay

Distributed By The Society Of Radiologists In Training
Revision Notes for the FRCR part 1

The Society of Radiologists in Training

© Dr Hans-Ulrich Laasch 1999

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or
by any means, electronic, mechanical, photocopying, recording or otherwise without the prior consent of the author.

This manuscript is intended as a guide to the level of knowledge required for FRCR part 1. It is neither complete nor
free of mistakes. The author and publisher do not accept any legal responsibility for any errors or omissions that may
be made.

Please use the on-line feedback form to report any errors or omissions.


a atomic number of element

= number of protons (= number of electrons)
λ wavelength
ρ density of matter [g/cm3]
= number of neutrons + protons

~ proportional to

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Revision Notes for the FRCR part 1



c = λ ·f c: speed of light (299,800 km/s)

E = h·c/λλ = h·f λ : wavelength, f: frequency
Within diagnostic range λ = 0.1 - 0.001 nm E: energy, h: constant


1. Elastic (coherent) scatter

complete energy transfer from photon to outer shell electron = Thomson-scatter
all electron shells = Rayleigh-scatter
which vibrate in resonance => excited state
on return to neutral state an identical amount of energy is re-emitted from the shell as “scattered” photon
=> change in direction without change in energy
number of interactions ~ to z² and
~ to density ρ of the matter irradiated
contribution to total scatter is negligible within the diagnostic range

2. Photoelectric effect:
interaction with tightly bound electrons, mainly k-shell, ideally when electron energy just greater then binding
complete energy transfer from photon to photoelectron =>
1. photoelectron
2. positive ion
3. subsequent characteristic radiation, absorbed within patient
4. no more x-ray photon => does not produce scatter reaching the film !!!
number of interactions ~ to z³
~ 1/keV³
~ density ρ
characteristic radiation rarely reaches film, except from Barium and Iodine
=> minimal contribution to scatter, large contribution to absorbtion (for low kVp)

3. Compton scatter (inelastic scatter):

partial energy transfer from photon to loosely bound outer shell electron, no energy required to liberate recoil
electron, photon continues in different direction and with increased wavelength (& lower frequency) => change
in direction and in energy
wavelength change dependent on angle of scatter
∆λ = 0.0024 ⋅ (1 − cos Φ )
maximum wavelength change = 0.48%

recoil electron accelerated in forward direction

energy transfer > 60%, even if φ = 180°
more forward scatter with increasing kVp
number of interactions ~ 1/keV
~ density ρ

- Within the diagnostic range Compton interactions predominate at all energies in soft tissues
- The photoelectric effect predominates at low energies in bone, but diminishes quickly with increasing beam energy
- within diagnostic range only small increase of Compton interactions with increasing kVp
- energy of photoelectrons is higher than of recoil electrons
- total scatter decreases with increasing energy, but proportionally more forward scatter reaching film => denser grid required
- scatter increases approx. linear with field size to maximum at 30 x 30 cm
- scatter may exceed intensity of primary beam (behind patient) i.e. abdominal film
- scatter increases with absorber thickness to a saturation level

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Revision Notes for the FRCR part 1

Attenuation: = Absorption + Scatter

bone : muscle = 6:1 for 20 keV monochromatic beam
= 2:1 for 100 keV
è lower contrast at higher energy (high kV chest x-ray!)
Intensity beam intensity is proportional to
~ tube current
~ kVp²
~ z (atomic number of target material)
− µ⋅d
Transmitted intensity (number of transmitted photons) N = N0 ⋅ e
N0 = incident intensity, µ = linear attenuation coefficient, d = thickness of absorber

Linear attenuation coefficient (LAC), µ:

attenuation per distance travelled in medium, sum of all interaction effects [ /mm]
µtotal = Σ [µelastic + µCompton + µphotoelectric]
varies not only for medium but also for its physical state and density
µiodine > µbone > µmuscle > µfat, insignificant for high kV

Mass attenuation coefficient (MAC):

LAC corrected for density, MAC = LAC/ρ
attenuation per unit mass of attenuator [cm²/g]
fat > muscle > bone > iodine
~ to number of electrons/gram tissue

Inverse square law

intensity of beam decreases with the square of the distance from a point source
=> best radiation protection is distance
does not directly apply to large sources, i.e. patient during radioisotope scan


Cathode ray tube working in the temperature limited/saturated part of its characteristic curve
1. stationary anodes
angled W target mounted in Cu-block
2. rotating anode
mushroom shaped Mo anode rotating at high speed to increase heat dissipation

Anode rotates at 3000 rpm standard, 9000 rpm high speed => increased thermal capacity
made of Molybdenum or Carbon (light)
Mo stem - poor heat conduction to insulate bearings
bearing lubricants must be solid (Pb, Ag) as within vacuum of tube

Target area of tungsten-rhenium (10%) alloy => improved thermal capacity and resistance to roughening
Tungsten: 184W highest melting point of all metals (3380° C)
low vapour pressure
good thermal capacity
k-edges at 59 and 69 keV => minimum of 75 kVp required

tube current = approx. 1/10 filament current

for fixed filament current the tube current reaches a maximum with increase of the tube voltage as the space
charge cloud is sucked off to the anode (= saturation)
x-ray tube works on the plateau = saturated region and the tube current is regulated by increase in cathode

kVp peak potential between cathode and anode in kilovolt

should be maintained to within ± 5kV max.
mA tube current in milli-Ampere
mAs tube current multiplied with exposure time
= total charge (number of electrons) that were accelerated from the cathode onto the anode
1 mAs = 1 Coulomb = 6.24 x 10 electrons
charge of one electron = 1.602 x 10 C
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Revision Notes for the FRCR part 1

Bremsstrahlung (German: deceleration radiation)

when electrons hit the anode most (> 99%) give up their energy as heat through interaction with the electron
shell of the target atoms
a minority of electrons (< 1%) interact with nuclei of target material and give off their energy as high energy
electromagnetic radiation, called “x-rays” by W. C. Roentgen 1896

efficiency of x-ray production increases with atomic number, z of target

Heat transfer Radiation: transfer through infra-red electromagnetic waves, traverses vacuum,
i.e. anode to envelope (also used in standard kitchen grill and toaster)
Convection: transfer from solids to gas or liquids causing motion of the molecules
i.e. envelope to oil (= fan assisted oven)
Conduction: transfer through opaque solids
i.e. anode to stem to bearings (attempt to keep this low by using Mo stems)
(= hot lid handle)

Stefan’s law of radiation:

heat transfer is proportional to temperature in Kelvin

Fourier's law of heat conduction:

heat conduction through an opaque body is proportional to the negative of the temperature gradient in the
body. The proportionality factor is called the thermal conductivity of the material.
(Jean Baptiste Joseph FOURIER 1882)
Tube rating increased by
- small anode angle (for same effective focal spot size) à larger target area
- fast anode rotation
- three phase tubes at short exposures, but single phase rectified voltage at long exposures

k-edge binding energy of electrons on the k-shell of an atom (= shell closest to nucleus),
to expel electrons from that shell by photoelectric or Compton-effect the energy required is slightly above the
binding energy
high absorption of x-rays at that energy and below => important for filters

after a k-electron had been expelled the deficit in the k-shell is filled by electrons ‘dropping down’ from outer
electron shells (i.e. l,m,n). During this they emit characteristic radiation of discrete energy peaks.
for kVp > 75 kV the characteristic radiation of a tungsten target contributes 10-15% to the intensity of the
primary beam
Pb 88 keV 207 Pb
W 58.5 and 69.5 keV 184W
Ba 37.4 keV
I 33.2 keV
Sn 29 keV
Mo 17.5 and 19.6 mammography target and filter
Se 13 keV xeroradiography
Cu 8 keV
Ca 4 keV
Al 1.6 keV
rare earths 17 - 50 keV

Components of filament circuit: mains autotransformer, electronic stabiliser,

space charge compensator, voltage stepdown
Autotransformer one coil only, low resistance, combines self and mutual induction
Pre-reading voltmeter: indicates acceleration voltage across tube
Exposure timers - synchronous. timers, integrating screening timers synchronous motors
- electronic timers capacitors, thyristors, mAs-timers
- phototimers light from fluoroscopy screen

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Distributed by the Society of Radiologists in Training 05/05/2001
Revision Notes for the FRCR part 1

X-ray generators
Quality of X-rays dependent on kVp and waveform
Quantity dependent on anode current, waveform and proportional to kV² and z of anode
efficiency of x-ray tubes around 1%
Wave-forms maintaining of tube voltage (kV) over time
in older generators negative half-wave of mains AC was either cut off or converted to a positive half-wave
= rectified
1. single phase half-wave rectification
2. full wave rectification (single phase without smoothing) => pulsed voltage 1/10 ms (100Hz)
3. three phase full-wave rectification => near-constant potential

3-phase generators maintain tube voltage pulses within 3.5% of kVp = approx. constant potential
modern generators are all constant potential generators and work independent of the mains 50 Hz alternating current

Falling load generator

aimed at high output work with long exposures
tube current maintained at maximum until critical heating of anode requires step-wise reduction via
useful for ortho-clinic (l-spine etc.), not useful in chest work due to short exposures and small loads
usually in same room as tube

Mobile units
a. single wave generators
rectified half-wave, uses 30 Amp. ring main => requires special points throughout hospital
b. constant potential generators
continuous rather than pulsed tube current => kVp = kVeff => shorter exposure times
1. battery (NiCd) powered
containing charge of 10 Coulomb (10.000 mAs) DC
inverter produces AC at 500 Hz with fixed current of 100 mA
=> easy calculation of exposure time
2. capacitor powered
charged from standard 13 A main
inverter produces AC at 4.5 kHz (!)
c. capacitor discharge units
1 µF (1 Farad = 1 Coulomb/Volt) capacitor discharges directly into a special grid-controlled x-ray tube
(= triode)
grid at 2 kV negative potential to cathode, when switched off discharges burst of electrons rather than
pulsed wave form
very precise control of tube current and short exposure times compared to “mechanical” relays

Anode Heel Effect: intensity of beam is lower on anode side of field, as radiation has to traverse the longer edge of the
bevelled anode target area.

Focal spot size: a. actual focal spot size 0.6 - 1.3 mm for general purpose
0.1 - 0.3 mm in mammography and high detail units
measured by pinhole camera, slit tool (two slits at 90°), star test tool
measurements are accurate to ± 25-50 % only, but minimal effect of variation in FSS on image
quality only
b. effective focal spot size
measured centrally in primary beam
dependent on filament size, anode angle, tube current and voltage
decreases with increase in kVp
increases in direct proportion to anode current = focal spot blooming

extremely small focal spot sizes (< 0.1 mm) can be achieved with electrostatic focusing

Anode angle 9-17° for general purpose, the smaller the angle, the more pronounced the anode-heel effect

Line pair resolution test tool = high contrast resolution test tool
(i.e.. star test pattern) measures resolving capacity, which is function of spot size as well as radiation
intensity distribution.
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Revision Notes for the FRCR part 1

Focal spot size estimated too large if edge band distribution of intensity, too small if centrally peaked

Penetrameter cassettes, i.e. Wisconsin cassette, Adrian Crooks cassette, Sussex cassette
Electronic penetrameter
measure kVp by comparing the penetration through a copper step wedge against standardised lead
variation ± 5 kVp acceptable
standard double sided emulsion + intensifying screen, screen covered by optical attenuators
film blackening under copper disks decreases, constant under lead mask, cross over of film blackening is
a measure of the energy of the beam

Reciprocity law as the intensity of the beam is product of tube current and exposure time,
high exposure for short time and low exposure for long time should result in the same film blackening
(for constant kVp)
in practice long exposure times result in lower film blackening than expected, supposedly a problem of
the x-ray/light conversion in the intensifying screens
noticeable in mammography

= removal of unwanted low energy radiation that would contribute to surface dose, but not to formation of the image
good filtration can reduce the skin dose by 50-75% for plain films

Half value layer d½ reduces beam to half the incident intensity

for thickness = n times the HVL, the beam intensity reduces to 1/2
i.e. n=10, intensity = 1/1024

for polychromatic (-energetic) beam the HVL increases with attenuation, as the beam is hardened
after 4x d½beam practically monochromatic

for 60 kVp HVL for soft tissue ~ 3 cm

Aluminium ~ 1 mm

Inherent tube filtration approx. 0.5-1 mm Al-equivalent, absolute minimum for W-targets = 0.5 mm Al-equivalent
target itself > casing > cooling oil > exit window
Minimal added filtration (to 0.5 mm Al-equivalent of inherent filtration)
< 70 kVp 1.5 mm Al
70 - 100 kVp 2.0 mm Al
> 100 kVp 2.5 mm Al
undercouch fluoroscopy 2.5 - 4 mm Al as short FOD
CT up to 7 mm Al equiv. as 3mm brass filter / bow tie filters

Aluminium useful as 1. K-edge 1.6 keV

2. characteristic radiation absorbed in air
3. readily available and easy to apply
Copper requires a backing filter of Al to absorb characteristic radiation of 8 keV
Molybdenum and Palladium filters used in mammography, usually with Mo and W target respectively

The Grid
Physical “sieve” to reduce the amount of scatter (that is produced in the patient) reaching the film. It consists of thin lead
strips which are interspersed with layers of Aluminium or carbon fibre. Radiation that is not parallel to the
lamellae is filtered out depending on the angle.

grid ratio height of strips : distance between them, usually 4:1 - 16:1

grid density number of lamellae per cm, commonly spaced at 30-50/cm

individual lead strips appr. 0.05 mm thick
=> gap between strips much larger than strip thickness

© Hans-Ulrich Laasch 1999. All rights reserved. Page 7

Distributed by the Society of Radiologists in Training 05/05/2001
Revision Notes for the FRCR part 1

contrast improvement factor = contrast with grid : contrast without grid, this is also dependent on
- kVp }
- field size } amount of scatter
- object thickness }
bucky factor correction of exposure factors required, when grid is introduced

Types of grids
parallel grid simplest form, parallel strips arranged perpendicular to film plane, no geometrical limitations
focused grid the outer lamellae are increasingly angled in order to follow the line of the diverging x-ray beam.
Can only be used at a specific FFD (or focus-grid distance), otherwise grid cut-off occurs.
Needs to centred other wise lateral decentering occurs.
crossed grid two sets of lamellae at right angles, rarely used, high bucky factor

Grid artefacts
grid cut-off if a focused grid is used at the wrong FFD the angled lateral lamellae will filter out part of the primary
beam => the lateral edges of the film become symmetrically underexposed.
Also occurs if the grid is upside down or tilted.
lateral decentering
if the grid is not centred to the primary beam asymmetrical underexposure of the film will occur.


electron-shell model for atoms modified to band-model in solids

3 main types of bands conduction band: high energy level, electrons can move freely to conduct electricity
forbidden band: does not contain free electrons but electron traps near conduction band and
hole traps near valence band
valence band: low energy level, contains valence electrons

Fluorescence electron-traps filled

x-ray effects elevate many electrons from valence to conduction band
the created holes in valence band move to hole traps in forbidden band
electrons from e-trap fall spontaneously (no extra energy required) into hole trap emitting visible light
excited electrons from conduction band fill electron traps
fast process, light emission within 10 µs

Phosphorescence electron traps empty

transition of excited electrons from conduction band to valence band
fall into e-traps
transition back into valence band only possible by being elevated into conduction band again
=> small amount of energy required, usually enough fluctuations within molecule, but can be
facilitated by heating
=> delayed process, > 10 µs
=> light emitted of higher energy than with fluorescence

Thermoluminescence transition into high energy state from e-trap requires so much energy that this does not occur
activated state very stable, light emitted on heating

Intensifying screens (of film-screen combinations)

layers: 1. base ± reflecting layer
2. phosphor, 100 µm thick (film emulsion 10-20 µm)
3. protecting layer => can be cleaned with soap and water

multiply one x-ray photon into several thousand* light photons

- increase contrast
- reduce patient dose
- reduce exposure times
- increase photographic unsharpness

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Revision Notes for the FRCR part 1

1. Calcium-tungstate (*1:1000) blue light up to 430 nm

2. 2. Rare earth screens (*1:4000)
1. gadoliniumoxysulphide green light up to 570 nm Kodak-system (green for Godak)
2. lanthanum blue light up to 430 nm Dupont-system
impurities within screen improve fluorescent properties = “Terbium activated”
NB: green sensitive film is also sensitive to shorter wavelengths of blue screens, but not vice versa
screens increase speed and reduce latitude
two screens as opposed two one double the radiographic contrast

Absorption fraction of incident x-ray photons interacting with screen

Ca-tungstate 30%
rare earths 60% due to lower k-edges
Conversion efficiency ratio emitted light photons / absorbed x-ray photons
Ca-tungstate 5%
rare earths 20% due to lower k-edges
Screen efficiency proportion of emitted light photons that reach the film, ~50%
Intensification Factor ratio required exposure without screen / exposure with screen
increased with higher kV, thicker screen, larger phosphor crystals

Radiographic film
Emulsion 90% AgBr, 10% AgI
sensitised with sulphur molecules = sensitivity specks, reduce interstitial Ag-atoms to latent image
Double-sided, commonest => seven layers
1. base polyester, 180 µm thick, contains blue dye for easier viewing, pigment to reduce cross-over
from screens to opposite emulsion, washed out during processing
2. substratum (x2) adhesive, bonds base to emulsion (“subbing layer”)
3. emulsion (x2) silverhalides, mostly AgBr, ~ 20 µm thick
contains dye to prevent light diffusion and cross-over, washed out in fixer
4. supercoat (x2) gelatine, protects
Single sided (with or without a single screen)
1. coating with anti-halation backing
2. base
3. substratum
4. emulsion
5. supercoat
emulsion and screen on the side of the base facing away from tube (x-rays penetrate film before reaching screen)
the side of the film facing the tube (i.e. not containing the emulsion) is coated with an anti-halation backing to prevent light
from screen that has penetrated film being reflected back onto emulsion
used in - mammography
- copy film
- high detail systems
- dental radiography

Density D optical density, measure for film blackening,

D = log 10
I trans
expressed as logarithm of ratio of incident and transmitted intensities as
1. logarithmic response of human eye to light
2. easy expression of a wide range of ratios
3. sum of densities of several films is the sum of their individual densities
Dtotal = D1 + D2 + Dn
useful density range for viewing: 0.2 - 2.5
film blackening is a function of kV for screen-film combinations

Characteristic Curve of a film is the density as a function of the decimal logarithm of the exposure
four parts of the curve
besides the emulsion it is also dependent on the screens and the processor conditions
1. toe initial curved part with finite minimum density for unexposed areas = base fog
2. linear part steepness γ represents latitude of film
3. saturation plateau of maximal film blackening
4. solarization further increase in exposure decreases film blackening due to recombination of
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Revision Notes for the FRCR part 1

copy films are solarized, exposure through the “light” parts of the original film lead to reduction in the density
in that area in the copy film, => the longer the exposure in the copying process, the lighter is the produced film

Contrast = difference between two densities
C = D2 − D1 = log10 2
human eye can differentiate differences in optical densities of up to 0.04% = 10% difference in intensity of
transmitted light

Subject contrast dependent on relative difference in absorption coefficients between structures, i.e.
- subject thickness
- subject density
- atomic number z
- kV
Film contrast / film gamma, γ
if = 1 reproduces subject contrast, if >1 amplifies subject contrast
Radiographic / film contrast)
dependent on subject contrast, scatter
Subjective contrast
dependent on radiographic contrast, viewing conditions

Unsharpness (blurring)
Failure to reproduce a distinct edge as a line
total unsharpness equals the square root of the sum of the individually squared components
hence the total unsharpness approximates the largest single contributor
U t = U g 2 + U p2 + U m2 + U a 2
1. geometric unsharpness
a. penumbra focal spot not infinitely small => lines become bands
b. magnification reduced with small OFD and large FOD
2. photographic unsharpness
a. screen unsharpness
light diffusion within screen phosphor layer, worse with faster screens as phosphor thicker
b. parallax-effect of double emulsion films
emulsions separated by film base (~ 180µm)
as beam diverges images on either side not completely congruent, effect minimal
c. light cross-over
light from screen 1 exposes grains in emulsion 2 and vice versa
3. motion unsharpness
patient movement, respiration, heart-beat etc., reduced by short exposures and immobilisation
4. absorption unsharpness
if object imaged has a curved edge the tangential beam fails to define a distinct margin

Magnification ratio of focus-film to focus-object distance

Mag .=
NB: magnification = 2 => object 100% magnified, i.e. twice original size
magnification = 1 => object reproduced in original size
magnification radiography requires very fine focal spots to reduce geometric unsharpness

Speed reciprocal of the exposure required to produce a density of 1 above base + fog (usually about 1.2)
increasing the speed of a film-screen combination
- reduces patient dose
- reduces exposure time
- reduces sharpness
- reduces contrast
- has no direct effect on quantum noise (unless dose reduced)
- increases fog

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Revision Notes for the FRCR part 1

Gamma (γγ) steepness of curve, represents latitude of film

dependent on grain-size in film emulsion and range of grain-size, as well as processing factors
for subtraction film = +1 => gives a negative of the image
for copy film = -1 => gives a positive of the image

Latitude film latitude: range of different densities the film can produce
wide latitude = lots of shades of gray, low contrast
narrow latitude = high contrast film, i.e. lithographic film
latitude is a function of the range of the grain size of the emulsion
exposure latitude: range of exposures covered by the linear part of the characteristic curve
wide exposure latitude => wide range of exposure settings tolerated

Density Contrast Latitude Speed Unsharpness

Grain size large ⇑
small ⇓
Range wide ⇑ ⇑ ⇑
narrow ⇓ ⇓ ⇓
Processor- increased ⇑ ⇑ ⇑
activity decreased ⇓ ⇓ ⇓
Fog & scatter ⇑ ⇓ ⇑

Ability to reproduce fine detail, measured in linepairs/mm
human eye can resolve 10-15 lp / mm

Line spread function

ability to reproduce a thin (10 µm) slit in a platinum plate as a thin line of the same width
images obtained usually order of magnitude wider than object
intensity distribution of obtained image ideally hat-shaped, in practice more or less bell-shaped
measure for accuracy of reproduction = width of intensity peak at 50% of peak intensity
=> full width half maximum, FWHM

Modulation -transfer function, MTF

efficiency at reproducing spatial frequencies (SF)
resolving power measured in linepairs/mm for MTF 10%
MTF values are acquired by 2 dimensional Fourier transformation of the line spread function of a very thin
wire or slit in a platinum plate
MTF of 1 = 100% reproduction of spatial frequencies

for a radiographic chain with n components: MTFout = SFin · MTF1 · MTF2 · MTFn

MTF of non-screen film > screen-film-combination > image intensifier > TV-camera
(20 lp/mm) (5-8 lp/mm) (2-4 lp/mm)

fluoroscopy chain: focal spot > image intensifier > movement unsharpness > camera
xeroradiography: poor for low spatial frequencies (< 5 lp/mm)
optimal between 10-50 lp/mm, then tails off again
tomography 2 lp/mm
mammography 20-22 lp/mm
CT 0.5-1 lp/mm 80% for 0.2 lp/mm
50% for 0.4 lp/mm
10% for 0.6 lp/mm
MTF is not affected by quantum noise
improves with magnification and reduced FOD, as spatial frequencies reduced

Limits of resolution low contrast quantum noise

high contrast unsharpness

Radiographic mottle inhomogeneity in density not caused by contrast of image
1. Film graininess worse for high speed film
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Revision Notes for the FRCR part 1

2. Screen mottle inhomogeneities of intensifier screen

3. Quantum mottle (- noise), QM
fluctuation of radiographic density around average due to statistical variation of recorded counts per unit area of
detectors (film or scintillation crystals, ionisation chambers etc.)
distribution of incident photons across detector array/film crystals is a random process
=> Gaussian distribution of recorded counts per detector around average
for average detected counts = N, the absolute fluctuation around the mean = N
proportional fluctuation for N counts per detector/pixel = N /N => much more important at small numbers of
recorded counts
i.e. for N=10 counts, variation = ±3 or 30%
N=10 counts, variation = ±100 or 1%
6 3
N=10 counts, variation = ±10 or 0.1%

quantum noise does not affect the MTF (but important for low contrast resolution)
does not increase with magnification of image, as photon flux unchanged
Noise in CT, DSA and γ -detectors is dominated by quantum mottle

Film Processing
1. Inherent fog ideal storage factors: temperature < 21°C, low humidity (but too dry: increased static!)
sealed from light and x-rays
2. Light light spread (= bad sandwich)
poor screen / film contact; foreign bodies
3. X-rays scatter
4. Chemical poor quality processing: contamination of chemicals, increased processing activity, temperature or time
dichromate fog: silver not washed out fully during fixing => delayed sepia-discoloration

Base + fog density of unexposed film, dependent on 1. + 4. + density of polyester base, should be less than 0.2
Speed exposure required to produce a density of 1 over base + fog
Dark-room 9m rectangular floor area, 3m high ceiling
air turned over 8-10 times/h
central location

Developer temperature within ± 0.2° C

Fixer silver content between 4-6 g/l

Quality assurance, QA and quality control, QC

Frequencies of testing:
Sensitometry daily reserved box of films
step-exposure with sensitometer
readings with densitometer
- unexposed area = base + fog
- density step of 1 over base = speed
- density step of 1 over speed = contrast
AEC at least annually copper step wedge/penetrameter at different
settings => output within 10 % of target settings
focal spot size if deterioration suspected line pair/star test tool, pinhole if FSS > 0.6 mm
filtration after tube service
film-screen contact as required grid image gets distorted in areas of poor contact

Tomography 6/12
slice thickness, height and arc
uniformity of exposure over arc
reject analysis of throw outs
periodically aiming at < 10% repeat rates

Digital subtraction radiography

wide range of film γ -equivalents can be simulated
logarithmic conversion of raw data post-acquisition
narrowing of window does not increase noise (original photon flux unchanged) but makes it more noticeable

© Hans-Ulrich Laasch 1999. All rights reserved. Page 12

Distributed by the Society of Radiologists in Training 05/05/2001
Revision Notes for the FRCR part 1


CsI input phosphor converts g-photons into light photons which are emitted onto a photocathode long
crystals in direction of photons, reflect light laterally, reduce scatter highly
hygroscopic, air-tight enclosure required => needs to be transparent at post. surface
Photocathode converts light from input phosphor into electrons which are accelerated through 30-40
kV on a curved path towards the (smaller) output phosphor
Zn-Cd-sulphide output phosphor converts electron beam back into (green) light,
inverted image,
Al-backing on cathode-side to prevent back scatter of light to photocathode

intensification through 1. minification

2. acceleration of electrons
= flux gain x 50
Minification gain (d = diameter of phosphor) x 100-200
 d input 
α  
 d output 
Conversion efficiency measure of quality of input phosphor
 light out   cd / m2 
= ;  
 x − raysin   µGy / s 
dose rate image intensifier requires 0.5µG/s
best detectable contrast difference = 5%
Automatic gain control
varies gain = amplification within monitor without change in exposure factors
Automatic brightness control
varies kVp and mAs
Distortion S-shaped: gravity effect
pincushion: electronic problem
Veiling glare mainly scattering of light in output phosphor, corresponds to screen scatter in cassettes
occurs in image intensifier or TV camera
worse in thick tissues
Vignetting reduction of brightness towards edge of screen due to
longer, curved path of electrons from periphery of input phosphor => inverse square law applies
curved input phosphor, straight output phosphor => autocorrection possible
Resolution similarly poorer at screen edge due to difficulties with electronic focusing
Magnification improves resolution
increases noise, if dose remains unchanged

Output phosphor of intensifier tube emits light photons towards the light-sensitive target plate of the camera. The target
plate liberates electrons where hit by light (photo-electric effect). Electrons produced by this process are accelerated through
250 V onto signal plate and charge areas corresponding to the original light exposure from the intensifier tube.
Signal plate has a positive potential against cathode at other end of tube and is scanned by electron beam from the cathode

Target plate photosensitive material, emits electrons where hit by light, these charge corresponding areas of the
signal plate
antimony trisulphate in mica matrix in Vidicon system
lead monoxide in Plumbicon system
Signal plate graphite plate electrode with + 25V potential against cathode
gets charged by excited areas of target plate
Electron beam current from camera cathode to signal plate
focused and moved by 2 sets of coils to scan signal plate in 625 horizontal lines
localised charge on signal plate is released by beam and the current across tube registers small pulses
corresponding to areas that were exposed to light
a specific signal demarcates the beginning of each new line
the pulses in the tube current allow temporal and spatial resolution

Bandpass maximal pulse frequency the processor can handle without distortion

Vidicon target has more lag as picture decays slower

© Hans-Ulrich Laasch 1999. All rights reserved. Page 13
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Revision Notes for the FRCR part 1

=> image blurring on movement of image intensifier

=> reduced quantum mottle as statistical variations are averaged out
Plumbicon camera faster than Vidicon, but more noise


Anode voltage 120 - 150 kVp, constant potential ± 0.01 % (!)

heavily filtered (≤ 0.5 mm Cu, equivalent to 7-8 mm Al) => approx. momoenergetic beam of 70 keV
focal spot 0.6 mm
pre- and post-patient collimation, slice thickness within ± 0.5mm
high dose examination, CT contributes to 2.5% of medical examinations, but to 25% of medical irradiation
effective dose, E head 1.8 mSv
abdomen 7.2 mSv
chest 8.3 mSv
CT-scanners 1. generation
pencil beam, single detector, both rotate
scan every 1° of 180° semi-circle at different lateral translations
=> translate-rotate scanning
2. generation
fan beam with multiple detectors covering appr. 15°, beam width narrower than slice width
=> translate-rotate scanning
3. generation
fan beam with detector array wide enough to scan full slice width, therefore translation obsolete
tube and detectors rotate, fast acquisition < 5sec/slice
=> rotate-rotate scanning, helical scanning
4. generation
rotating tube, fixed 360° ring of solid-state detectors
=> rotate-fixed scanning, helical scanning, possible due to slip-ring technology electric supply

cup-shaped vacuum tube which surrounds patient 270° containing Wo-target areas as well as multiple
electron beam electronically focused onto target areas in walls of cup which generate x-ray beam
through patient towards detectors on the other side
extremely fast, no moving parts, freezes cardiac cycle
one scanner in the UK in 1996

Helical CT (helix = spiral with constant radius)

continuous image acquisition during continuous table feeding = volume acquisition of the whole block of
tissue, slices can be reconstructed to the desired thickness after acquisition, down to a minimal slice
thickness = beam collimation
allows faster scan time (i.e. vascular), reduced patient dose and three-dimensional reconstruction
Three important parameters:
a. collimation: width (thickness) of x-ray beam during acquisition (e.g. 8-10mm in abdomen)
b. Pitch: ratio of table movement:collimation
i.e. table moves 12 mm during one revolution with 8mm collimation
= pitch of 1.5
increased pitch allows faster scanning and reduces dose, but leads to some loss in resolution, however
this is minimal up to a pitch of 1.5
c. index: thickness of the reconstructed slice, these are often reconstructed overlapping each other, e.g.
8mm slices at 7mm intervals overlap 0.5 mm either side

Multi-slice (multi-detector CT)

Several (i.e. 4) interlaced spirals are acquired at the same time, allowing faster table feed, shorter scan
times and high-definition three dimensional reconstructions (i.e. aorta, biliary tree)

Detectors 1. scintillation crystals (NaI/CsI)

hygroscopic and sensitive to mechanical and thermal insult
suffer from afterglow
2. gas ionisation chambers
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Revision Notes for the FRCR part 1

very stable but insensitive

3° scanners
3. modern solid state
CdW-crystals coupled with silicon photodiodes (semiconductors)
fast, reliable but expensive
104x more sensitive than gas detectors, > 99% absorption of x-rays
3° and 4° scanners
Hounsfield scale
Relative measure of attenuation in computed tomography.
Water = 0, cortical Bone = +1000, Air = - 1000
Most parenchymal organs between 0 and + 100
Fresh clotted blood + 90 (= white on narrow brain windows)

+ 1000 -¦------------------------------ Cortical Bone ----------------

¦ bone marrow

+ 100 -¦- - - - - - - - - - - - - - - - - - - - - - - - - - - -
¦ fresh haemorrhage
¦ Liver
¦ Brain (grey matter) Spleen > Kidney, Pancreas, Bowel
¦ Brain (white matter) Adrenal
± 0 -¦---------------------------------- Water -------------------
¦ |
¦ | |
¦ |Fat |Breast
¦ | |
- 100 -¦- -|- - - - - - - - - - - - - - - - - - - - - - - - - -
-¦ |
¦ |Lung
- 1000 -¦------------|---------------------- Air ---------------------

windowing window is selected to cover the attenuation of the “region of interest”

attenuation values above the upper limit will appear in white, below the lower limit in black
window width = range of units that will be represented as a shade of grey
window centre = Hounsfield value defining the middle of the represented range
i.e. WW: 500, WC: -400
structures of a higher attenuation than -150 will be depicted in white, everything below -650 in black.
Structures between -150 and -650 will appear in shades of grey.
example would be useful to investigate areas of fat or lung tissue, but will not be able to differentiate
between bowel, liver or bone.

CT monitor can represent 256 greyscales

human eye can differentiate 10-15 greyscales

narrowing WW reduces quantum noise

Linearity ability to represent a linear increase in attenuation as a linear increase in Hounsfield units
Spatial uniformity ability to represent every voxel of a uniform object by the same Hounsfield-unit throughout the image,
checked with water phantom monthly
Spatial resolution ability to distinguish two small high-contrast objects located close together under noise-free conditions

Slice sensitivity profile

ideally hat-shaped = no sensitivity outside the slice, but maximum sensitivity from edge to edge
in practice sensitivity tails beyond slice edges and slope from edge to sensitivity plateau
described in terms of full width (of sensitivity curve) at half maximum (sensitivity), FWHM
profile improved by post-patient collimation, but significant increase in patient dose

Magnification enlarges a part of the image including the pixels and the noise => resolution unchanged

Zoom recalculates a part of the raw data of the image over the whole matrix => resolution improved

CT-Artefacts 1. streak artefacts misalignment and motion

2. ring artefacts detector non-uniformity (damage), particularly severe in SPECT
3. beam hardening as beam gets filtered by superficial tissues
4. aliasing high frequency noise at sharp, high contrast interfaces
=> low frequency detail
© Hans-Ulrich Laasch 1999. All rights reserved. Page 15
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Revision Notes for the FRCR part 1

Extremities usually 8 mm slices at 16 mm intervals (i.e. non-contiguous with 8 mm gaps)

for joints 2-4 mm contiguous slices


Frequencies above 20 kHz, no natural background, medical: 1-20 MegaHz

cair 340 m/s
cfat 1450 m/s
cwater 1540 m/s
csoft tissue 1400 - 1600 m/s
cskull 4080 m/s

Piezoelectric effect
Appearance of an electric potential at the surfaces of a crystal when it is subjected to mechanical pressure. Conversely, when
an electric field is applied to the crystal, it undergoes mechanical distortion.
Jacques and Pierre Curie discovered the phenomenon in quartz and Rochelle salt in 1880 and named the effect
piezoelectricity (Greek piezein, “to press”).
1. Quartz
2. lead zirconate titanate
3. complex composites => modern transducers

applied voltage 150-300 V

resonance frequency of crystal dependent on thickness, not diameter

d = λ/2, 4 MHz for 0.5mm
Transducer Ultrasound Beam

1 2 3

Near (Fresnel) zone Far (Fraunhofer) zone
1 - Damping layer
2 - Crystal of radius r
3 - Matching layer of thickness d

Damping layer minimises oscillating time, shortens US-pulses

z of matching layer is equal to geometric mean impedance of crystal and tissues to be scanned
Maximum transition if thickness of matching layer d=¼ λ
Thickness of crystal = λ /2

Length of near zone l = r²/λ
sin α = 122
Diverging angle of far zone 2r

Increasing the scan frequency increases the near zone

increases the diverging angle
increases absorption
© Hans-Ulrich Laasch 1999. All rights reserved. Page 16
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Revision Notes for the FRCR part 1

Types of transducers
Mechanical small footprint
Sector array diverging beam, standard scan head
Linear array crystals arranged along short axis of probe
number of crystals determines number of lines in image
increase in lines reduces Fresnel zone => compensated for by triggering crystals in groups of four or
groups of crystals fired in one by one in quick succession, all receive echo of their own signal
vertical lines of image represent acoustic corridor of each individual group
parallel beam unless “curvi-linear array”
slice thickness determined by crystal length and correction via acoustic lens
Phased array delay in triggering individual crystal allows electronic focusing and beam steering
all crystals fire during acquisition of each line, beam direction and focus varies with each pulse
=> sector array
gated for reception = single crystals receive “their” line
small footprint

Acoustic impedance, z
z = p/v p - instantaneous excess pressure
v - instantaneous particle velocity
z = ρ·c ρ - density of material
c - speed of sound in material

Ultrasound and tissue

1. Reflection change of impedance z1 => z2
interface large » wavelength
roughness « wavelength
reflection coefficient for normal incidence (90°):
 z − z2 
R =  1 
 z1 + z 2 
90% at soft tissue / air interface
50% at soft tissue / bone interface
< 1% at soft tissue / soft tissue interface
2. Scatter scattering object « wavelength
roughness » wavelength
3. Refraction change of speed of sound, direction and wavelength at interface, not of frequency
Snell’s law:
sin(i) c
= 1
sin(r ) c2
i = angle of incidence, r = angle of refraction, c = speed in medium 1+2
c1 ≠ c2, λ1 ≠ λ2, f 1 = f 2
4. Absorption mechanical energy converted to heat through relaxation processes
energy falls exponentially with depth
for soft tissues the absorption is proportional to the USS frequency

Attenuation overall loss of intensity through a single medium

 I1 
decibels( db) = 10 log 10  
 I 2
tissue attenuation approx. 1 dB / cm x MHz
The intensity of the reflected echoes is reduced by factor 10.000 as compared with the original signal =
40 dB

Line spread function measured with nylon wires in a phantom


Lateral resolution improved with high frequency, small crystal and good focusing r
approx. 3 mm at 3 MHz

Axial resolution ~ 10x better than lateral, approx. ½length of pulse

© Hans-Ulrich Laasch 1999. All rights reserved. Page 17
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Revision Notes for the FRCR part 1

Length of sonic pulse = wavelength x number of waves

λ approx. 0.5 mm for 3MHz, 0.3 for 5 MHz (assuming c=1500 m/s)

Q-factor range of resonance frequencies of transducer

high Q-factor: narrow band-width => ideal transmitter
low Q-factor: wide band-width => ideal receiver

Intensity output energy of transducer (< 100mW/cm²)

proportional to square of wave amplitude

Coarse gain overall amplification of all received echoes

Near gain reduces intensity of echoes near the transducer

Far gain amplifies distant echoes

Enhancement amplification of echoes from a selected depth

Time gain control although displayed as a line is an exponential correction of the expected attenuation and calculated
according to the time required for the echo to return to the probe
basis for enhancement after fluid filled spaces, i.e. in cysts less attenuating than calculated, deeper
tissue “unnecessarily” enhanced

Delay tissue depth from which TGC becomes effective

Reject filter for low amplitude echoes, reduces noise similar to pulse height analyser in γ -camera

Frame rate, FR number of new images acquired per second


Doppler-shift (F0 = incident frequency, v = velocity of reflector, c = speed of sound in medium,

α = incident angle between beam and moving object)
2 ⋅ F 0 ⋅ cosα ⋅ v
∆F =

Continuous wave doppler, CWD

one transmitter, one receiver crystal, axes intersect in focus
no depth resolution
Pulsed doppler depth resolution via “range-gating” = transducer receives only for a short period of time
delay to reception determines depth of sampling
time span of sampling determines gate width
Colour doppler multigated throughout slice => real-time two dimensional imaging
Power doppler

Pulse repetition frequency, PRF

limited by time required for most distant echoes to return = time of flight, TOF
max. achievable depth = ½TOF
maximum frame rate = PRF/lines of frame
aliasing occurs if PRF < x2 doppler-shift = Nyquist-limit

Artefacts in ultrasound
Multiple reflections returning signal is partially reflected from surface of probe acting as a further primary pulse of
weaker intensity. This gives “ghost” echoes at multiples of the original transducer-interface distance
Acoustic shadows at interfaces with high degree of reflection
Acoustic enhancement artefact of time-gain-control after areas of low attenuation

© Hans-Ulrich Laasch 1999. All rights reserved. Page 18

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Revision Notes for the FRCR part 1

Reverberation echoes reflected echo is reflected back against original object by scatterer from where it is again reflected
back to the probe. This creates an apparent more distant echo from a non-existing structure
Doppler artefacts
Compound artefact CWD has no depth resolution => if more than one vessel within line of beam, detected doppler shift
is averaged

Mirror image doppler unable to determine direction of flow if angle between beam and reflector » 90°

Aliasing pulsed doppler artefact

if the detected doppler shift frequency becomes large (cos α large, incident angle shallow) compared
with the pulse repetition frequency, the machine has increasing difficulties determining the direction
of flow => colour spectrum is wrapped around giving mixed blue and red signals
remedial action: increase repetition frequency, decrease angle of probe
Fpulse rep. should be at least twice the detected doppler shift·(∆F)

Biological effects of US
1. tissue heating: not noticeable in diagnostic range
2. streaming: creation of flow along beam and back in perimeter, affects cell membrane permeability, proportional to
3. cavitation: interaction with microbubbles within tissue
1. stable cavitation, oscillating of bubbles
2. unstable cavitation, bubbles increase in size until they implode with temperature rise to
hundreds/thousand degrees
happens with high intensities (> 100 mW/cm²) at low frequencies
4. vibration, pressure changes, etc.


Protons precess at Larmor frequency ω in magnetic field of strength B; γ = gyromagnetic ratio

ω L = γ ·B0
~ 43 MHz for 1 Tesla, ~ 64 MHz for 1.5 Tesla
spin-up protons precess in opposite direction as spin-down protons
Tesla = strength of a magnetic field = 10,000 Gauss
Tesla, Nikola (1856-1943) Croatian-American inventor of the high-frequency generator (1890), a radio
transformer called the Tesla coil (1891), and father of the electromotor (1893).

Ratio of protons in low-energy (spin up) to high-energy state (spin down) is described by the Boltzman
distribution (approx. 10.000.001 : 10.000.000 for diagnostic field strength))

B-field produced by superconducting electro-magnet cooled to 4° K by liquid helium and nitrogen.

strong field, homogenous, but expensive and sensitive to Eddy-currents
quench = warming of the coil usually due to escaping coolant and destabilisation of field
RF-pulses generated and received by coils
- volume coil surrounds patient, major transmitter, receiver for large parts
- gradient coils slice selection, frequency and phase encoding; vibrate with sequence repetition
- surface coils anatomically shaped receiver coils for smaller anatomy: head, shoulder, breast
head coil = transmit / receive coil
- shim coils adjust field inhomogeneities

Nuclear angular momentum

dependent on whether number of nucleons even or odd
=0 for even numbers => protons do not precess
Slice selection gradient
modifies the strength of the longitudinal field B0 by ± 8-10% during the application of the RF- / rephasing
pulse. Thus different planes of the body are given different resonance frequencies ωL.
Slice thickness is determined by
a. bandwidth of RF-pulses and therefore the bandwidth of Larmor-frequencies covered.
b. steepness of gradient field and therefore distribution of resonance frequencies through the body

© Hans-Ulrich Laasch 1999. All rights reserved. Page 19

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Revision Notes for the FRCR part 1

Phase encoding gradient

Prior to acquisition a vertical gradient is applied for a short period of time until protons at different height in
the slice have lost phase coherence. When gradient is removed, the protons precess at the same frequency
again, but are out of phase.
=> spatial resolution along the y-axis
Frequency encoding gradient = “read-out gradient”
after all protons in the same slice have all been excited to precess at the same frequency a transverse gradient is
applied during acquisition which alters ωL and therefore the emitted signal frequency of the individual protons
across the slice
=> spatial resolution along the x-axis
Frequency- and phase encoding can be performed in any of the three axes, the long axis of the image is usually frequency
All signals throughout the slice vary in frequency, phase or both. After Fourier transformation they can be assigned to a
specific location in the slice

Signal-to noise ratio

improved by lengthening TR and shortening TE => reduction in contrast

Resolution improved by reduction in voxel size:

1. reduction in slice thickness (reduced partial voluming)
2. reduced field of view
3. increased matrix
Field of view, FOV
large FOV results in larger voxels (larger blocks of tissue per pixel)
=> reduced noise, but also reduced spatial resolution
Matrix fine matrix = smaller pixels
=> more noise, but increased spatial resolution as spatial frequencies reduced

T1 spin-lattice-relaxation
time required to regain 63% of the original longitudinal magnetisation after 90° RF-pulse, measured by tilting
recovering vector into horizontal plane by second 90° pulse
T2 spin-spin-relaxation
loss of phase-coherence of transversal magnetisation after spins have been put in phase by 90° pulse, time
required for transverse signal to decay to 37%
in T2 weighted sequence external effects on decay are neutralised by repeated 180° pulses which revert spin; T2
curve connects points of maximum transverse signal when phase coherence has reoccurred
T2* loss of phase coherence through internal and external effects, far shorter than T2
TR time to repetition, interval between pulse sequences
TE time to echo, interval between initial phasing pulse and signal acquisition in T2-sequence, rephasing 180° pulse
at TE/2
TI inversion time, in inversion recovery (as for T1 sequence, only initial pulse flips longitudinal vector 180°, before
recovery starts) interval between 180° inversion pulse and 90° pulse for measurement

values [ms] short medium long

TR <500 1000 >2000
TE 20 60 >80

Spin echo 90° pulse - decay of phase coherence / lateral magnetisation - 180°
rephasing pulse
- acquisition of echo after TE for T2
signal intensity = retained transverse magnetisation when spins in phase again at TE
(= TE/2 after rephasing pulse)
if T2 of tissue long => high signal (slow decay)
- T1 measurement after TR with repetition of sequence
signal intensity = recovered longitudinal magnetisation
if T1 of tissue short => high signal (quick recovery)
TR and TE short for T1-weighting
TR and TE long for T2-weighting

Proton-density/ long TR, short TE => T1 and T2 effects eliminated

© Hans-Ulrich Laasch 1999. All rights reserved. Page 20
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Revision Notes for the FRCR part 1

saturation recovery => signal only dependent on proton density

Partial saturation 90° pulse - after short TR repeat 90° pulse for acquisition
recovery T1 weighted

Inversion recovery 180° pulse inverts longitudinal magnetisation - recovery - spin echo sequence
heavily T1 weighted
if acquisition takes place when one particular tissue has got no longitudinal magnetisation, this
gives no signal
STIR short T1 inversion recovery, fat suppression
acquired when transverse magnetisation of fat has recovered to 0°
FLARE fluid attenuation recovery, fluid suppression

Gradient echo fast sequence

1. initial transverse pulse at small flip angle (<45°, short duration of pulse), thus leaving fair
amount of residual longitudinal magnetisation for early 90° acquisition pulse =>
2. TR very short (rate-limiting step in T1-weighting),
the longer TR, the more T1 weighted is the scan
3. external effects reinforced by applying gradient B-field into B0 at TE/2 => strong T2*-
effects (fast spin dephasing), rephasing by inversion of gradient and acquisition at TE when
spins in phase again

For total duration of sequence TR of major importance. Short scan times achieved by
- Gadolinium => shortens T1
- multi-slice-imaging => RF-pulses for subsequent slices are triggered during TR of first slice (which is
set slightly longer)
- gradient echo =>
a. smaller flip angle
b. acquisition with magnetic gradient is faster than 180° rephasing pulse in spin-echo
c. T2* effects work quicker than T2 effects

Contrast media
ferromagnetic unsuitable, as particles acquire and retain large magnetic moments once introduced into B-field
paramagnetic positive CM, increase local field strength, shorten T1
Gadolinium 157 Gd rare earth lanthanide, used in chelated form as dimeglumine-gadopentate, Gd-

DTPA (diethylene-triamino-penta-acetate) = soluble for iv use

dose: 0.2 ml/kg, max. dose 20 ml, 80% excreted renally within 3 h
side-effects much rarer than with non-ionic CM
CI: haemolytic anaemias, pregnancy

fatty oils for oral use

superparamagnetic negative CM
transient large magnetic moments, disrupt local magnetic field, enhance spin-spin effects and shorten T2
ferrite colloids

chemical shift due to different binding of protons in fat (C-H) and water (O-H) the Larmor frequency of these tissues differs
by approx. 100-250 Hz, which simulates a different spatial resolution in the direction of the frequency
encoding gradient
=> dark band at the fat / water interface
insignificant for B0=0.5 T
avoided by reduced field strength B0
reduced filed of view (FOV) = increased pixel size
increased receive band width to include difference in frequencies

susceptibility changes in local field strength through paramagnetic effects

© Hans-Ulrich Laasch 1999. All rights reserved. Page 21

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Revision Notes for the FRCR part 1


Decay constant Residual radioactivity

½ A = A0 ⋅ e − λ ⋅ t

COSH-regulations for occupational medicine apply for handling of isotopes

The Gamma Camera

for good images the total number of counts required is 300-500 kilocounts (kcts) for small images, up to 1 Mct for large
spatial resolution ~ 1cm

Collimator similar to secondary radiation grid, but main function is to allow spatial resolution as gamma rays emitted in
all directions, not only perpendicular to the crystal
as photons are emitted in all directions as well as scattered, collimators required for spatial resolution by
absorbing scatter
trade-off between sensitivity and resolution, sensitivity usually < 1%
- parallel hole collimator commonest
- pinhole collimator for thyroid and other small objects, produces inverted and enlarged image
(camera obscura)
problems with distortion of structures from different planes
- diverging collimator diverges towards patient, for large areas, reduces field of view
- converging collimator diverges towards camera, enlarges image, significant distortion
with modern large field g-eras diverging (and converging) collimators only rarely used (distortion!)

examples of parallel hole collimators (40 cm crystal) No. of holes hole diameter septal thickness
low energy, high resolution, LEHR 30.000 1.8 mm 0.3 mm
low energy, general purpose, LEGP 18.000 2.5 mm 0.3 mm
low energy, high sensitivity, LEHS 9.000 3.4 mm 0.3 mm
medium energy, high sensitivity, MEHS 6.000 3.4 mm 1.4 mm
LEGP for standard bone scan, LEHR for smaller FOV like pelvis/THR

Crystal NaI (high density, z=32) with Tl impurities (1 ppm) to increase sensitivity, 1-2 cm thick, sensitive to
mechanical and thermal shock
impurities influence wavelength of emitted light
80-90% of incident photons are absorbed
10% are converted to light at a ratio of 1:1.000 - 1:4000
(reduced absorption for energies > 200 keV)
emitted γ -radiation is monoenergetic and specific for isotope
spatial localisation along x- and y-axis
dead time ~ 0.2 µs => max. temporal resolution = 500 kcts/sec, but temporal resolution of electronics much
smaller => limiting factor

Sensitivity proportion of incident gamma photons that produce a scintillation event

PM-tubes photocathode (borosilicate) converts light photons into electrons, accelerated towards anode in a zig-zag
fashion hitting several dynodes in the process and liberating further electrons
=> amplified electrical impulse
height of impulse (= z-vector) proportional to energy deposited in crystal
hexagonal shape allows denser packing of tubes

Pulse height analyser

electronic filter, determines whether recorded pulse produced by isotope, background, scatter or other artefact,
used to differentiate between different isotopes
Energy window
range of energies that are included in image acquisition

© Hans-Ulrich Laasch 1999. All rights reserved. Page 22

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Revision Notes for the FRCR part 1

Resolution a. spatial ≥ 1 cm
b. temporal ≤ 50 - 60 kcts/s
c. energy via pulse height analyser, approx. 12% at 140 keV

Uniformity integral uniformity = variation from the mean number of counts over a defined area

Linearity degree of correct spatial resolution, i.e. how well the correct origin of the signals are being recognised

collimator, computer

Single photon emission tomography, SPECT

better sensitivity, resolution and speed than γ -camera
attenuation correction
photons emitted from centre of slice more attenuated than from superficial voxels
this is corrected for before backprojecting (pre-processing) by multiplication factors
this is not required for lung-scans

Isotopes z X

elements are described by their mass number a and their atomic number z
a denotes the (average) molecular weight, i.e. the number of nucleons (neutrons and protons)
z equals the amount of protons within the nucleus and therefore the number of electrons in the shell

The physical weight is dependent on a, the chemical properties on z

Isotopes are elements with the same z, (i.e. the same chemical properties) but different molecular weight =>
they differ in the number of neutrons

Technetium 43 Tc m most frequently used isotope with ideal properties
- pure γ -emitter
- ideal emitted energy (140 keV) => low patient dose, within range of scintillation crystals
- half-life (6 hrs) roughly as long as examination time
- easy production => generator
- good biochemical and pharmaceutical properties
- -
ion form as sodium-pertechnetate (TcO4 ) behaves similar to Cl ions
99 99m
Tc-generator: Mo (t½68 hrs) on Al column, ß-decay to metastable Tc which is eluated with NaCl
weekly replacement, maximum yield 22 hrs after previous elution
liquid Tc can be disposed of into drains, less than 30% of administered dose become waste
Hospitals may dispose up to 1 MBq/day without notification

Half-life, t½ time required for activity to reduce by 50%

1. Physical half-life = actual radioactive decay
2. Biological half-life = pharmacokinetics, excretion
1 1 1
= +
Effective Half-life t½eff t½phys t½bio

Chemical purity proportion of desired isotope of all contained substances, i.e. Tc : NaCl
99m 99
Radiochemical purity proportion of the isotope in its desired form, i.e. Tc : Tc
99m 99
Radionuclide purity proportion of the desired isotope of all radioactive isotopes in the preparation, i.e. Tc : Mo

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Revision Notes for the FRCR part 1

production t½ emission / keV stable product use

γ 92, 182, 300

Ga cyclotron 72 h WCC-scan
γ 171, 245
In cyclotron 67 h WCC-scan
γ 159
I cyclotron 13 h kidney / thyroid
ß, γ 80
Tl cyclotron 73 h cardiac scan
γ 392
113m 113
In generator 100 h Sn
γ 190
81m 81
Kr Rb-generator 13 sec ventilation scan
γ 140
99m 99 99
Tc Mo-generator 6h Tc
γ 172, 203, 375
Xe 36 days ventilation scan
ß, γ 81
Xe nuclear reactor 5 days ventilation scan
ß, γ 360
I nuclear reactor 8 days thyroid ablation
free pertechnetate behaves like Cl => accumulation in gastric mucosa and salivary glands

Tests & Radiopharmaceuticals

a. dynamic Tc-MAG-3 (mercapto acetyl triglycerine) 75-100 MBq
tubular secretion
quick, sensitive, not cheap
Tc-DTPA (diethylene triamino pentaacetic acid) 150-300 MBq
glomerular filtration
cheap, not as sensitive as MAG-3
I-hippuran (glomerular filtration and) tubular secretion 20 MBq
expensive, cyclotron-produced
b. static Tc-DMSA (2,3-dimercapto succinic acid) 80 MBq
tubular absorption, retained in renal cortex
Tc-glucoheptonate 300 MBq
glomerular filtration and tubular secretion, cortical retention
worse resolution, but smaller dose than DMSA
Bone Tc-MDP (methylene-diphosphonate), EDE 3-4 mSv 500-600 MBq
phosphate analogue, binds to bone, rapid (renal) clearance from other tissues => renal imaging possible
image acquisition 3-4 hrs post-injection when diphosphonates integrated into bone and soft tissue activity has
NB: increased speed of uptake in abnormal bone
uptake into muscular damage/calcification (trauma, surgery, im-injections)
shin-splint uptake in periosteal reaction (stress in the growing tibia)
superscan: diffuse metastatic disease, all activity immediately taken up by bone, no background or renal
activity, virtually pathognomonic for Ca-prostate (other malignancies don not get that far)
3-phase-scan for hyperaemia (infection, tumour)
1. arterial blood flow, immediate dynamic scan
2. blood pool / equilibrium after several minutes, soft tissue hyperaemia
3. delayed static scan > 4hours
Heart myocardial perfusion, TlCl
3-5 % deposited within myocardium, dependent on blood flow and Na/K-pump
distribution heart : lung > 2.5:1
patient fasted (exercise!), post-exercise images can be obtained without further injection
Liver Tc-labelled colloids iv 70-80 MBq
=> phagocytosed in reticulo-endothelial cells (15% of liver cells = Kupffer-cells)
demonstration of liver (75% of activity), spleen (15%) and bone marrow (10%)
Ind.: tumours, chr. liver disease
Tc-IDA ( imino-diacetic acid) derivates 75 (-150) MBq
behaves like bilirubin, selective uptake by hepatocytes, secreted into bile, concentrated in gallbladder
Ind.: biliary atresia and obstruction, biliary leaks/anastomoses post-surgery, cholecystitis

© Hans-Ulrich Laasch 1999. All rights reserved. Page 24

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Revision Notes for the FRCR part 1

Lung EDE 1-2 mSv, dose to foetus ~ 0.2 mSv

Kr gas: room air pumped through generator 2000 MBq
t½= 13 s => tidal breathing
performed simultaneously with perfusion scan as higher energy (192 keV) than Tc, but
for each position the perfusion image is acquired first to avoid cross-talk from down-
scatter, activity decays in between repositioning
lateral views useless due to high energy and penetration
Tc-DTPA aerosol, cheap and easy 80 MBq
separate* from perfusion-scan as same isotope, CI: COAD
“Technegas” 20 MBq
carbon electrode boiled off in Ar / Tc filled chamber
=> Tc-labelled C-particles, deposited in alveoli, => alveolar ventilation
separate* from perfusion-scan
* if Tc used for ventilation scan, perfusion scan possible directly afterwards, if MAA dose increased x5
Xe gas needs high energy collimator, exhaled gas must be collected
Xe gas ß-emitter => high dose, low energy => must precede perfusion scan
exhaled gas must be collected
Perfusion: 80-100 MBq
Tc-labelled albumin-macroaggregates (10-90 µm) or -microspheres (20-30 µm)
occlude < 1% of pulmonary capillary bed with 95% deposition in lungs

Parathyroid Tc - Tl subtraction scan

uptake of TlCl thyroid and parathyroid = mask < 80 MBq = ~ 10 mSv
selective thyroid scan with Tc subtracted < 80 MBq = ~ 1 mSv
Thyroid Pertechnetate, EDE 2.5 mSv 60-80 MBq
behaves similar to iodine => trapped in thyroid, but not organified
target : background = 10 : 1 (4:1 in salivary glands)
pinhole collimator !
I, given as a drink orally (NaI) 20 MBq
concentrated in thyroid > 3-4 hrs, better images, but higher dose than Tc

Ga-citrate, iv 150 MBq
high dose, no preparation required, three different energies can be imaged
highly protein-bound (esp. transferrin), normal uptake in RES and salivary/lacrimal glands
excreted mainly into bowel => high activity up to 72 h

radio-labelled white cell scans

leucocytes harvested from patient, separated, labelled and reinjected
minimum WCC 2.000/µl, donor cells can be used
In 20 MBq
Tc - HMPAO (hexamethyl-propylene-amine-oxime) 200 MBq

Tumours phaeochromocytoma, carcinoid, medullary Ca. thyroid and other APUD tumours, neuroblastoma
I - MIBG (meta-iodo-benzyl-guanidine) 250 (-400) MBq
I - MIBG, cheaper and better available, but higher dose and inferior images 20 MBq
acts as noradrenalin-equivalent, antidepressants and sympathomimetics (nose drops!) must be stopped
thyroid blockade with NaI or Lugol’s solution
slow iv-administration
Brain a. Tc - glucoheptonate } 500 MBq static
b. Tc - DTPA } 800 MBq dynamic
similar properties, cross damaged blood-brain-barrier only, lower noise due to faster clearance than
static images after 1-2 hrs => in normal brain remaining activity in non-neural tissue and vessels
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Revision Notes for the FRCR part 1
c. Pertechnetate 1000 MBq
accumulates in choroid plexus, salivary glands and thyroid

Anatomical markers
wands with radio-active tip
Co-point sources


Primary effects of x-rays

- ionisation 35 eV required to produce one ion pair => one 70 keV photon produces 2000 ion pairs
- heating (negligible)

Secondary effects
- physical: fluorescence (immediate, < 10 µs), phosphorescence (delayed), thermoluminescence (on
- chemical: redox-reaction, i.e. x-ray film
- biochemical: destruction of enzymes through free electrons
- biological: inactivation of bacteria

slow moving electrons ionise more

Bragg-curve: relative ionisation as a function of the distance travelled in air

Minimal focus-skin distance 30 cm, recommended 45 cm

60 cm for thorax (lungs)

Measurement of radiation
Measurements in air, as 1. cheap and ubiquitous
2. constant composition
3. atomic number of air (7.6) very similar to soft tissue (7.4)
but lower density requires relation to unit mass and the use of mass attenuation coefficient rather than linear attenuation

Radiation exposure, X total charge (amount of ion pairs) produced per unit mass [C/kg]
1 Roentgen = 2.58·10 C/kg
X =
Exposure rate exposure per unit time [C/kg·s]
• ∆X
X =
Absorbed dose, D energy deposited per unit mass [J/kg = Gray, Gy]

Dose rate dose per unit time [Gy/s]

Equivalent dose, H absorbed dose corrected for relative biological effect by specific weighting factor
H= WR x D [J/kg = Sievert, Sv]
exam dose equivalent
Ba-enema 8
CT-chest 8
Ba-meal 5
lat. lumbar spine 2-3
VQ-scan 1-2
Tc-thyroid scan 0.5
chest pa 0.04
extremity 0.01

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Revision Notes for the FRCR part 1

Relative biological effect, RBE

correcting factor WR for different types of radiation, compared with biological effect of 200 kV x-
x- and γ -rays 1
ß-particles 1
protons > 20 MeV 5
neutrons 5-20
α-particles 20

Effective dose, E total sum of the fractional doses each organ has received during the exposure to radiation
E = Σ (H x WT)n [Sv]
the organ doses are individually weighted according to the relative sensitivity of the organ (tissue
weighting factor WT)
organ WT
skin, bone 0.01

bladder, breast, thyroid 0.05

liver, oesophagus, other

stomach, colon 0.12

lung, red bone marrow

female breast 0.15

gonads 0.2

Dose and dose rate effectiveness factor, DDREF

biological effects of radiation at lower doses uncertain, assumed to be higher => correction factor
for extrapolation
x2 for doses < 0.2 Gy
? >2 for doses < 0.05 Gy

Collective dose dose to a population [man Sv]

= average effective dose to individual x number of individuals

Dose-area-product, DAP absorbed dose in air (averaged over beam area) x area of beam [cGy/cm²]
independent of distance to tube, measures tube output, does not take geometry and nature of
exposed parts into account
guideline for exposure during examination
used as dose measurement by NRPB

DAP-meter air ionisation chamber mounted onto exit window of x-ray tube

Linear energy transfer, LET

measure of energy deposited per distance travelled in tissue [keV/µm]
radiation energy LET
x-/γγ-rays 1 MeV 0.5
x-/γγ-rays 100 keV 6
ß-particles 20 keV 10
neutrons 5 MeV 20
α-particles 5 MeV 50
if LET high, likelihood of multiple DNA-breaks is high
for low LET-radiation this is increased by a high partial pressure of O2 and reduced by
sulfhydryl- and ethanol-groups (antioxidants garlic and alcohol)

Air Kerma Kinetic Energy (of electrons) Released per unit Mass of Air, [Gy]
if Kerma high => production of secondary Bremsstrahlung, not accounted for in calculation of
absorbed dose

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Several phases for conduction of electricity through a gas:

1. with increasing voltage ions move to electrodes, current proportional to field strength
2. 1st plateau, all prevalent ions are being collected
3. further increase of current with field strength as secondary ionisation occurs, current still
proportional to field
4. Geiger-Müller plateau, increase in discharge no longer proportional to increase in voltage
5. continuous discharge

Ionisation chambers “air-equivalent walls”, contains Xenon (inert, high atomic number => many interactions) at high
pressure, secondary electrons produced in wall ionise gas
can measure rate, as current proportional to number of ionizations

Geiger-Müller-counter glass tube filled with nobel gas (Argon) at low pressure with added alcohol for quenching
fine central wire acting as anode, potential 300-400 V
long dead-time between detections, ~300µs
detects x-rays as well as ß-particles
simple, cheap, compact, sensitive, unspecific
good detector of radiation activity but unsuitable for monitoring rate or dose

Film-badge dosemeter double sided emulsion of different speed (back = slower)

fast emulsion used for doses < 100 mSv, slow emulsion < 10 Sv (!)
for high doses the (completely blackened) fast emulsion is stripped off for evaluation
different filters allow energy resolution
sensitive range: x-rays 10 keV-2Mev, β-particles 500 keV-3.5 MeV, sensitive to neutrons
filter attenuation
air-window α-particles (in film wrapping)
thin plastic (50g/cm²) low energy β-particles
thick plastic (300g/cm²) low energy x-rays, most β-particles
Dural (Al-alloy, 1mm) x-rays < 65 keV, all β-particles
Sn (0.7mm)-Pb (0.3mm) x-rays < 75 keV
Cd (0.7mm)-Pb (0.3mm) converts thermal neutrons to x-rays => film blackening
developed at specialist centres together with films from the same batch exposed to a standard γ -

Scintillation counter NaI-crystal up to 2.5 cm thick

requires light-proof envelope
sensitive to thermal and mechanical injury
photomultiplier tube required (series of dynodes along 1200 V)

Thermo-luminescent dosemeters, TLD

usually LiF, CaSO4 for low energies
electrons captured in electron traps (impurities) in forbidden band after irradiation are only
released when heated to 300-400° C except for some low temperature peaks which are released
spontaneously within 24-48 hrs
=> TLD’s left for 2 days prior to processing (= fading)
+ small and easy to use
+ emitted light practically proportional to absorbed dose
+ high sensitivity
+ sensitivity independent of radiation dose and energy
+ stored information stable for a long time
+ re-useable after “annealing”
- require careful calibration
- careful annealing required to maintain constant properties

classified person occupational exposure > 0.3 of limit, i.e. 15 mSv/a

supervised area dose rate 2.5 - 7.5 µSv/h
controlled area dose rate > 7.5 µSv/h (> 300 µSv/wk)
clearly marked, physically demarcated, access restricted to patients and qualified personnel,
volatile as only exist when mains switched on - access for unqualified personnel out of hours

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Revision Notes for the FRCR part 1

Background radiation 2.5 mSv/year, (3-5 cGy in 30 years)

responsible for 10% natural mutations and neoplasms
Natural sources 87% (=> 50% radon)
Medical 12%
“civilisation” < 1%
(air travel, watches etc.) > military fallout > occupational > nuclear industry

main contributors to medical background:

examination contribution to total examinations contribution to background
CT 2% 20 %
L-spine 3.3 % 15 %
Ba-enema 0.9 % 14 %
Ba-meal 1.6 % 12 %
IVU 1.3 % 11 %
CXR 25% 2%

increased risk of dying from a cancer caused by exposure to ionising radiation = 70 per mSv
majority of genetic mutations are not related to radiation effects

Stochastic effects Non-stochastic effects

not dose-dependent dose-dependent
linear increase of incidence with dose non-linear increase of severity with dose
(= probability of developing effect) accepted threshold 150 mSv

1. somatic effects
leucaemia erythema, necrosis, infertility
neoplasms bone marrow suppression

2. Genetic injuries -------

affect future generations
chromosomal abnormalities

Dose Limits (ICRP, IRR 85)

=> non-stochastic effects should never occur
Occupational trainee < 18 years Gen. public [mSv / year ]
Whole body 50 15 5
extremities & individual organs 500 150 50
lens of eye 150 45 15
pregnant abdomen (total dose during pregnancy) 2

women of child-bearing age -- 13 mSv / 3 months

occupational dose limit 50 mSv / year => 1mSv / week (2 weeks holiday) => 25 µSv / hr (40 hrs/wk)
expected to be dropped to 20 mSv/a, ICRP 60 from IRR 1990 awaited
NB: currently no total dose limits for patients => ALARP, NRPB has published lists of British averages and recommended
max. doses
Absorbed dose rate at the skin for fluoroscopy < 0.01 mGy/min

Average additional effective dose from occupational exposure [ mSv / year ]

nuclear industry, air crews 2 mSv
miners, industrial radiology 1 mSv
medical/dental/veterinary staff 0.25 mSv

additional background in Cornwall 5 mSv

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Revision Notes for the FRCR part 1

Threshold doses for non-stochastic effects on individual organs (single dose) [mSv]
temporary blood film changes 200 hair loss 500
bone marrow suppression 500 skin erythema 2,000
bone marrow ablation 2,500 dermatitis, ulcerations 5,000
conditioning for BMT 10,000

temporary infertility (men) 150 lens opacities 500 - 2,000

sterility (testes/ovaries) 3,000 - 6,000 cataract 5,000

LD 50 3,000 - 5000 mSv

National radiation protection board, NRPB

National level, basis for UK ionisation radiation legislation
- national protocol for patient dose measurements in diagnostic radiology July 1992
- patient dose reduction in diagnostic radiology
- guidelines on MRI and USS as alternatives to radiographs
- radiation protection of pregnant women
report R 200 table of average British radiation doses for individual examinations
75th percentile of nation wide DAP-measurements aimed as maximum dose for particular exam
Ba-enema 6,000 cGy/cm²
IVU 4,000 cGy/cm²
Ba-meal 2,500 cGy/cm²
L-spine 1,200 cGy/cm²
abdomen 800 cGy/cm²
pelvis 500 cGy/cm²

20 % of requested investigations do not contribute to clinical management

Radioactive substances act 1993 , RSA (Her Majesty’s Inspectorate of Pollution, HMIP)
a. certificate of registration
identify site, type, amount and purpose of substances, person responsible
b. certificate of authorisation for accumulation / disposal of radioactive waste

The medicines (administration of radioactive substances) regulations 1978, MARS (Dpt. of Health)
prohibit administration of radioactive substances except by doctor/dentist holding ARSAC-certificate or by a person under
directions of such a doctor
ARSAC = administration of radioactive substances advisory committee
certificate specifies substances and site on which administered
copy of certificate to radiation protection advisor
enforced by Medicines Control Agency

International Commission on Radiation Protection and ionising radiations regulation (Dpt. of Health)
Basic philosophy 1. Justification
2. Optimisation = ALARA
3. Limitation
ICRP 26 (IRR 1976)
basic guidelines for staff protection
under current legislation ICRP can recommend only, legislation founded on “Health and Safety at Work” act 1974

IRR 85
legally binding guidelines for the protection of workers against ionising radiation resulting from work activities
=> approved code of practice
employers are responsible for - restriction of occupational exposure,
- appointing radiation protection advisors, RPA
- safe equipment / protective equipment
- ensure dose limits are not exceeded
- definition and demarcation of controlled areas, access restriction
- inform Health and Safety Executive, HSE of accidental over-exposure
- keep documentation over 50 years

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employees obliged to - follow guidelines, not expose themselves or others unnecessarily

- use protection
- report faults in diagnostic and protective equipment
- notify employer of over-exposures

The approved code of practice, ACOP (IRR 1985)

• employer has the overall responsibility
• radiation protection advisor, RPA
physicist with minimum 6 years experience, to ensure work is in accordance with the regulations
needs to be informed in the event of accidental over-exposure
• radiation protection supervisors, RPS in individual x-ray departments
responsible to superintendent radiographer, should ensure that everybody is in possession and familiar with the
relevant part of the local rules, as well as obeying them
needs to be informed about pregnant workers
• demarcation of controlled areas
• guidelines for mobile units
controlled area: 2 m around unit, 3 m in theatre
in direction of primary beam
fluoroscopy: 2m
chest and extremity work 5 m
other and theatre to attenuating wall or backstop
• elective radiography (incl. abdomen) of women of child-bearing age within 28 days of last period
• equipment checks, providing of protective equipment
• procedures for accidental over-exposure
• framework for local rules

IRR 1988: Protection of persons undergoing medical examination or treatment, POPUMET

regulation 2: - guidelines for physical and clinical (ARSAC-holder) direction of medical exposures
- local guidelines
regulation 3: - regulations do not apply to scientific research
regulation 4: - dose limitation, ALARP
- responsibility with the physically and clinically directing individual => criminal prosecution
regulations 5-8: - adequate training, core of knowledge
regulation 9: - detailed records of equipment
regulation 10: - employer needs to provide services of adequately qualified (min. six years) physicist
regulation 11: - local rules (apply for x-ray dept. only, nuclear medicine dealt with by MARS and RSA)
regulation 33: - criteria for notification of accidental overexposure
fluoroscopy x3 }
mammography/abdo/pelvis/lumbar spine x10 }intended dose
chest/skull/extremities/dental x20 }

enforcement by POPUMET inspectors

The ionising radiations (outside workers) regulations 1993

protection of classified personnel employed temporarily on other sites

UK investigation limit: 15 mSv/a, 75 mSv/5aa

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The Skeleton
Synovial joints costo-transverse joints
sacro-iliac joints (upper 2/3)
median atlanto-occipital joint
incu-stapedial joint

Spine all cervical vertebrae have transverse foramina, but vertebral a. usually enters C6 or higher
C2/3-6 usually bifid spinous processes
ant. spinous ligament stronger than post., both adhere to discs, the ant. to a degree to the vertebral bodies,
not the post. as it has to pass over basivertebral veins
T3 smallest thoracic vertebra
spina bifida occulta ~ 10%
sacralisation of L5 ~ 5%

Calcification in membrane Calcification in cartilage

clavicle, first bone to calcify, from 6/40 scapula
flat bones of the skull, skull vault sphenoid, ethmoid

Appearance of primary ossification centres

wrist 1. capitate 2-3 months
2. hamate 3 months
radial epiphysis 1 year
3. triquetral 2-3 years
4. lunate 3 years
5. trapezium 3-4 years
6. trapezioid 4 years
7. scaphoid 4-5 years
ulnar epiphysis 6-7 years
8. pisiform 8-9 years
Bone age scores a. Greulich & Pyle, comparison with standardised hand x-rays
b. Tanner & Whitehouse, 20 bone score, carpal score, etc., point score for individual bones

elbow C capitulum humeri 6 months Come left elbow (years)

R radial head 5 years Rub I (6) E (11)
I internal (ulnar) epicondyle 6-7 years My T (9) C (0.5)
T trochlea 9 years Tree O (10) R (5)
O olecranon 9-10 years Of
E external (radial) epicondyle 10-11 years Love

shoulder med. humeral head 3 months

coracoid 6-12 months, fuses at 15, calcification begins in utero from 8/40
lat. humeral head 1-2 years
greater tuberosity 3 years
lesser tuberosity 5 years

sternum fusion of sternebrae by 25 years

fusion of xiphoid by 40 years

knee femoral epiphysis in utero, 36/40

tibial epiphysis in utero, 38/40
fibular head 4 years
patella 4 years
ankle calcaneus in utero, 26/40
talus in utero, 28/40
tibial epiphysis 6-8 months
fibular epiphysis 10-12 months
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Revision Notes for the FRCR part 1

foot cuboid at birth

lateral cuneiform 3-6 months
medial cuneiform }
interm. cuneiform } 2.5 years
navicular }

Arterial System
Aorta abdominal aorta
1. four unpaired branches
coeliac axis, sup. & inf. mesenteric aa., medial sacral a.
2. three paired visceral branches
middle suprarenal aa. T12, renal aa. L1, gonadal aa. L2
3. parietal branches
inferior phrenic aa. T12, subcostal aa., lumbar aa. x4

diameter: root 4.5 cm

ascending aorta 4 cm
descending aorta 3 cm
abdominal aorta 2 cm

bifurcation: body L4 60%

below 30%

Coeliac trunk arises upper body of L1 in 50%, higher in 45%

in abnormal configurations the coeliac trunk is defined as the trunk out of which two out of the
following four vessels arise:
1. left gastric a. }
2. splenic a. } usual configuration
3. common hepatic a. }
4. superior mesenteric a., SMA
normal variants: - replaced right hepatic artery from SMA 20%
(if only one segment supplied from SMA it is usually segment 6)
- replaced common hepatic artery from SMA 5%
- left hepatic artery or branches from left gastric 10% (all variants)

- splenic a. from aorta 0.5%

common hepatic a. 0.5%
left gastric a. 1%

common coeliac and SMA 0.5%

Superior mesenteric artery, SMA

arises lower border L1, 6mm below coeliac axis
Inferior mesenteric artery, IMA

Venous system
few valves in ascending veins
one valve proximal to junction of long saphenous and femoral in 70%
no valves proximal to inguinal ligament in 25%

The sphenoid ridge with the ant. clinoid processes forms the anterior border of the middle cranial fossa, the petrous ridges
with dorsum sellae and post. clinoid processes form the posterior border. The anterior and posterior cranial fossae lie
anteriorly/posteriorly to these boundaries.

Anatomical lines:
Chamberlain’s hard palate - sup. edge of occipital bone at foramen magnum
McGregors hard palate - inf. edge of occipital bone at foramen magnum, more reliable

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basal invagination if odontoid peg extends > 2 mm / 5mm above it

(?name) sphenoid tuberculum - int. occipital protuberance, crosses fourth ventricle

Basal angle angle between lines from tuberculum sellae to nasion and basion (= plane of clivus)
platybasia if > 145° (normal 125°-142°)

Foramina optic II, ophthalmic a. and v.

rotundum Vb }anterior to posterior

ovale V c, access. meningeal a. (maxillary a.) }in major wing
spinosum a. meningea media (maxillary a.) }of sphenoid bone

lacerum cartilage between sphenoid and occiput

jugulare ant.: IX, inf. petrosal sinus between petrous bone and occiput
post.: X + XI, bulbus v. jugularis inferior to int. audit. meatus

mastoid emissary vv.

hypoglossal canal XII occipital bone

Fissures sup. orbital III, IV + VI, V1

sup. ophthalmic vv. ⇔ angular vein
inf. orbital zygomatic nerve => infraorbital n.
infraorbital a. from maxillary a.

Sutures normal width 10-15 mm at birth

3 mm at 12 months
1 mm at 2 years

mendosal horizontal between limbs of lambda usually gone after 1 year

separates intraparietal from supraoccipital portion of occipital bone
metopic ant. extension of sagittal suture usually gone at 2 years
persists in 10 - 20%
spheno-occipital synchondrosis closes at puberty

bregma junction of coronal and sagittal suture

lambda junction of sagittal and lambdoid suture
asterion junction of squamosal and lambdoid sutures
pterion junction of coronal, sphenofrontal, sphenosquamosal and squamosal sutures
Parietal Bone

Sphenoid Squamous
Bone Temporal

odontoid peg fuses with axis from 7 years

Fontanelles lateral closes at 6 months

posterior closes at 9 months
anterior closes at 18 months

Craniostenosis = cranial deformation due to premature closure of sutures

growth perpendicular to suture stops and compensatory growth in direction of synostosis takes place
Scaphocephaly sagittal suture, reduced lateral / excessive ap growth => narrow, long skull
commonest form, boys > girls
Brachycephaly coronal suture, reduced ap / excessive lateral growth => tall, wide skull
if unilateral mainly orbital asymmetry = pyrgocephaly

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Turricephaly lambdoid and coronal suture => peaked, tower-like skull

also acrocephaly, oxycephaly
Microcephaly all sutures affected, mental defects

Paranasal sinuses
Maxillary sinus form after few weeks, into adulthood
4 recesses, maxillary, palatine, zygomatic and alveolar, roots of 1st and 2nd molar can extend into floor
drain into ostiomeatal complex in the middle meatus with frontal and ant. ethmoidal air cells
(nasolacrimal duct drains into inferior meatus)
Frontal sinus form between 2 and 14 years
within frontal bone, can extend into orbital plate, very variable in size
middle meatus
Ethmoid air cells as frontal sinus
between orbits and nasal cavity, below crista galli
ant. cells drain into middle meatus
post. cells drain into superior meatus
Sphenoid sinus forms > 3years, can extend into sphenoid or ant. clinoids
often incomplete separation of both sides, can be continuous with the (anterior) ethmoid cells,
above nasopharynx, medial to cavernous sinus, inferior to pituitary fossa and chiasma opticum,
drain into sphenoethmoidal recess
Mastoid air cells pneumatised at 14

Inner ear int. carotid a. antero-inferiorly

jugular bulb inferiorly
epitympanic recess above scutum, contains head of malleus and body of incus
footplate of stapes in oval window
facial nerve posterior wall (after knee)
promontory = basal turn of cochlea

Intracranial calcification (normal variants)

pineal gland 5% < 10 years, 70% > 70 years, up to 10 mm in size “normal”
5cm post-sup. on a line intersecting the plane of the to clivus at right angles 1 cm below post. clinoids
choroid plexus post-sup. to pineal gland
habenular calc. choroid plexus in 3rd ventricle ant. to habenular commissure
just ant-sup. to pineal, reverse c-shaped
petro-clinoid and interclinoid ligaments, dura, falx and sagittal sinuses

Teeth enamel, dentine, pulp & root canal, periodontal membrane, lamina dura

Brain does not have lymphatic drainage

Cavum septum pellucidum obliterates 2-3 months post partum

Frontal lobe three horizontal gyri, association centres and inhibition

middle: voluntary conjugate eye movements
inferior (ant => post): zona orbitalis, tringularis and opercularis, the two latter contain Broca’s area

Basal ganglia Internal capsule

ant. limb transmits cranial nerve fibres from motor cortex
post. limb transmits fibres from motor cortex from ant. to post. upper limb, trunk, lower limb
separates head of caudate nucleus (ant. limb) and thalamus (post. limb)from lentiform nucleus
Lentiform nucleus
globus pallidum (medial) and putamen, separated laterally from claustrum by external capsule
separated medially from claustrum by extreme capsule, just deep to Sylvian fissure

Corpus callosum rostrum, genu, body, splenium from ant. to post.

below falx, above septum pellucidum and IIIrd ventricle
commissural fibres connecting corresponding parts of the hemispheres

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ant. commissure = frontal fibres form ant. forceps

post. commissure = interoccipital fibres form post. forceps

The cranial nerves

motor: III, IV, VI and XII
autonomic fibres: III, V (secondary), VII, IX, X
I. Olfactory tract olfactory bulb above cribriform plate -
II. Optic optic canal with ophthalmic artery .-. chiasma - optic tract - lat. geniculate bodies
III. Oculomotor between cerebral peduncles - lat. to sella - superolat. wall of cavernous sinus - splits into superior ramus
(mm. levator palpebrae sup. and rectus sup.) and inferior ramus (parasympathetic and other fibres) before
entering sup. orbital fissure
at risk of compression by post. communicating aneurysm in interpeduncular fossa between post. cerebral
a. and sup. cerebellar a.
motor: all extraocular muscles except sup. oblique and lat. rectus
parasympathetic: m. sphincter pupillae, m. ciliaris
Edinger-Westphal, to ciliary ganglion via radix brevis of inf. ramus
IV. Trochlear dorsal surface of midbrain - ambient cistern - tentorium - sella - wall of cavernous sinus - sup. orbital
motor: sup. oblique m., reading muscle, int. rotates, adducts and depresses gaze
V. Trigeminal ant.-lat. part of pons - cerebello pontine angle -
major part of trigeminal root (sensory) runs as pars compacta to petrosal ridge, becomes looser pars
plexiformis before becoming trigeminal (semilunar) ganglion Gasseri (in Meckel’s cave) over tip of
pyramid and dividing into three branches.
minor part (motor) follows sensory root anteriorly and inferiorly, passes under trigeminal ganglion to join
mandibular branch
a. ophthalmic branch supplies orbit, cornea, nose, dura, straight and cavernous sinus
lat. wall of cavernous sinus - splits into frontal, lacrimal and nasociliary branches -
sup. orbital fissure
b. maxillary branch supplies face between mouth and ext. canthus, nasopharynx, gums and
teeth of maxilla, palate, dura mater of middle cranial fossa
lat. wall of cavernous sinus - foramen rotundum - pterygopalatine fossa - inf. orbital
fissure - infraorbital foramen
c. mandibular branch supplies skin, mucus membranes and teeth of mandible, muscles as below
joined by motor root - foramen ovale - infratemporal fossa -
- n. alveolaris inf. - for. mentale - n. mentalis
- n. lingualis, receives fibres from n. intermedius/chorda tympani via CN VII
- n. auriculotemporalis, receives secretory fibres to parotid from CN IX
sensory: face, cornea and conjunctiva, mouth and nose, meninges
ant. 2/3 of tongue
motor: (mandibular branch only) mm. masseter, temporalis, medial and lat. pterygoids,
mylohyoid, ant. belly of digastric, tensor tympani and tensor veli palatini
VI. Abducens ant. junction of pons and medulla - prepontine cistern - clivus - tip of petrous bone - through cavernous
sinus - sup. orbital fissure
motor: lat. rectus
VII. Facialis lat. junction of pons and medulla - cerebello-pontine angle - int. acoustic meatus - facial canal - ganglion
geniculi - chorda tympani - ramus to m. stapedius - foramen stylomastoideum -
- rr. temporofrontales two
- rr. zygomatici zulus
- rr. buccales buggered
- r. marginalis mandibulae my
- r. colli (platysma cat
n. intermedius (= lies between VII and VIII):
afferent sensory fibres, efferent autonomic fibres, splits in facial canal into
1. n. petrosus major to lacrimal gland and nose
2. chorda tympani to tongue via lingual n. (V.c.) and submandibular ganglion

autonomic: submandibular and sublingual glands, lacrimal glands } chorda

sensory: ant. 2/3 of tongue } tympani
motor: facial muscles, m. stapedius

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VIII. vestibulo-cochlearis
post.-lat. junction of pons and medulla - int. acoustic meatus
cochlear part more sensitive to damage

IX. Glossopharyngeal
medulla oblongata, post. to olive - anterior part of jugular for. (-branches to carotid plexus) - mm.
stylopharyngeus + styloglossus - tongue
autonomic: minor petrosal nerve to parotid, fibres to carotid plexus
sensory: posterior third of tongue and pharynx
middle ear and Eustachian tube
motor: m. stylopharyngeus, upper pharyngeal constrictors

X. vagus medulla oblongata, post. to olive - posterior part of jugular foramen - post. to int. jugular v. in carotid
sheath - behind main bronchi and pulmonary aa. - post. pulmonary plexus - ant. and post. vagal trunks
along oesophagus
autonomic: secretory fibres to respiratory and GI-tract
inhibitory fibres to heart
sensory: ear, respiratory and GI-tract
motor: somatomotor: palate, pharynx,
larynx (superior [cricothyoroideus m.] and recurrent laryngeal n.)
visceromotor: GI-tract, bronchioles

XI. accessory rootlets from medulla oblongata and cervical cord - ascends through foramen magnum - descends through
posterior part of jugular foramen
motor: mm trapezius and sternomastoideus
fibres via vagus to striated visceral muscles in larynx, pharynx and oesophagus

XII. hypoglossus medulla oblongata, rootlets post. to olive- ascends through foramen magnum - descends through
hypoglossal canal - follows internal carotid to hyoid bone - tongue
motor only: tongue, strap muscles (with fibres from C1-3 via ansa cervicalis profunda)

Optic tract lateral geniculate bodies (=> reflexes) and superior colliculi
Acoustic tract medial geniculate bodies and inferior colliculi

Inferior surface of the brain

Telencephalon ant. perforating substance behind origin of optic tract, lat. to chiasma
Diencephalon tuber cinereum (pituitary infundibulum) and corpora mamillaria behind chiasma
Mesencephalon post. perforating substance between cerebral peduncles with origin of CN III
Metencephalon pons, separated from middle cerebellar peduncles by origin of CN V (CN IV wraps around sup.
part of pons from dorsally), CN VI from inf. surface
Medulla oblong. origin of CN VII and VIII at junction with pons, CN IX, X XI lat. surface, CN XII rostral surface
ant. to olives, decussatio of pyramidal tract

behind 4th ventricle, below tentorium, between sigmoid sinuses
grey cortex, deep white matter
three pairs of peduncles to 1. midbrain }
2. pons } brainstem
3. medulla oblongata }

Limbic system cingulate gyrus, splenial gyrus, dentate gyrus, hippocampus, fornix, mamillary bodies

Midbrain - cerebral peduncles, crura cerebri connecting int. capsule with pons
ant. part = efferent fibres } separated by
post. part = tegmentum, afferent fibres } substantia nigra
- post. surface = quadrigeminal plate sup. colliculi => lat. geniculate bodies of optic tract
inf. colliculi => med. geniculate bodies of auditory tract
- sup. cerebellar peduncles, roof of IV ventricle

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Medulla oblongata
- ant. part: pyramidal tract with (ventral) median fissure which is obliterated by the decussation
- inf. cerebellar peduncles
- forms floor of IV ventricle
- olives at upper edge

Circle of Willis
complete with all branches in only 40%
Internal carotid
petrosal part branches to eardrum, pterygoid plate, wall of cavernous sinus, pituitary and dura of ant. cranial fossa

intracranial part
1. O phthalmic a. orbital canal, crosses nerve from lat. to medial
2. P ost. communicating a.
3. A nt. choroidal a. choroid plexus, ⇔ post. choroidal a.
4. S triate a. lentiform nucleus
5. A nt. cerebral
r ecurrent a. of Heubner
a nt. communicating a.
f rontopolar a.
ca llosomarginal a.
per icallosal a.
c entral a.
6. M iddle cerebral a., largest branch
lenticulostriate aa. basal ganglia and int. capsule
cortical rr. frontal/parietal/sup. temporal/angular

Vertebral a. 1. meningeal branch post. fossa

2. ant. spinal a.
3. medullar branches
4. PICA inferior cerebellum

Basilar a. 1. pontine branches

2. labyrinthine branches
3. AICA anterolat. cerebellum
4. sup. cerebellar a. superior cerebellum
5. post. cerebral a
branches to cerebral peduncles, post. thalamus, med. geniculate bodies and quadrigeminal plate
thalamostriate a. thalamus and lentiform nucleus
post. choroidal a. choroid plexus
cortical branches inf. temporal lobe, occipital lobe

hypoplastic ant. communicating a. 3%
unilateral supply to ant. comm. a. 2%
hypoplastic post. communicating a. 22%
fetal post. comm. a. (from middle cerebral) 15%

Cerebral venous system

Superior sagittal sinus runs a-p over convexity of brain (which it drains) to sinus confluence
= Torcular Herophili
turns to the right to become right transverse sinus => right int. jugular vein usually larger
Inferior sagittal sinus runs a-p in lower edge of falx, joins great cerebral vein of Galen to become straight sinus
which usually turns left to become left transverse sinus
Sigmoid sinus extension of transverse sinus after taking up sup. petrosal sinus
joins with inf. petrosal sinus in jugular foramen to become the internal jugular vein
Cavernous sinus lies lateral to pituitary and sphenoid bone, inferior to optic tract, extends from sup. orbital
fissure to foramen lacerum
receives ophthalmic and superf. middle cerebral veins and sphenoid sinus
drains via sup. and inf. petrosal sinus into transverse and sigmoid sinus respectively

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both sides connected via intercavernous sinuses around pituitary

contains: internal carotid a., CN III, IV, Va+b, VI
Internal cerebral veins formed by 1. septal vein from septum pellucidum
2. choroidal vein from lat. ventricle
3. thalamostriate vein
unite to form the great vein of Galen
Basal vein of Rosenthal formed by 1. anterior cerebral vein
2. deep middle cerebral veins from insula
3. striate veins from basal ganglia
drain into the great vein of Galen
Superficial cerebral veins 1. superficial (middle) cerebral v.
drains lat. surface of brain - Sylvian fissure - lat. sulcus - sphenoid sinus - sinus cavernosus
2. Vein of Labbe
anastomoses superficial cerebral v. with transverse sinus in 60%
3. Sup. anastomotic vein of Trollard
anastomoses superficial cerebral v. with sup. sagittal sinus in 30 %

Ventricular system
150 ml CSF, 125 ml within cranial cisterns and ventricles, 25 ml in spinal canal, produced in choroid plexus at 25 ml/hr,
absorbed by arachnoid villi penetrating into sinuses, esp. sup. sagittal sinus
Choroid plexus - of lateral and third ventricle: continuous from temporal horn through body into third ventricle
ant. choroidal artery from int. carotid a. through temporal horn
post. choroidal arteries from post. cerebral a. through body and temporal horn
- of fourth ventricle invaginates its roof
branch from inf. cerebellar artery
Lateral ventricles open into 3rd ventricles through interventricular foramen of Monroe
frontal (anterior) horn floor and lat. wall: caudate nucleus, thalamus
medial wall: septum pellucidum
roof: corpus callosum
no choroid plexus
temporal (inferior) horn floor: hippocampus
lat. wall: tapetum
roof: caudate and amygdaloid nucleus
occipital horn very variable in extension, no choroid plexus
lies mainly within grey matter of occipital lobe
lat. wall: tapetum and optic radiation
Third ventricle flat structure between thalami, contains interthalamic adhesion in 60% (massa intermedia) = non-
neuronal connection
ant. wall (lamina terminalis): above optic chiasma with supraoptic recess
floor: hypothalamus and subthalamic groove
infundibular recess into pituitary stalk
pineal recess into pineal stalk, suprapineal recess above
roof: column (anterior 1/3) and body of fornix
Aqueduct 1.5 cm long, 1.5mm wide
anterior to quadrigeminal plate (tectum), behind cerebral peduncles
nuclei of CN III, IV and V form periaqueductal grey matter
Fourth ventricle floor (rhomboid fossa): pons / medulla oblongata
roof: cerebellar peduncles with sup. and inf. velum
Foramen Magendie: post. mid-line opening into cisterna magna
Foramina of Luschka: lat. openings into pontine cistern (at apices of lateral recesses under
inf. cerebellar peduncles)
Cisterna magna between cerebellum and medulla
=> 4th ventricle (for. Magendie)
=> cervical spine (for. magnum)
contains vertebral artery and PICA
(Pre-) pontine cistern
between pons and clivus
=> 4th ventricle (foramina of Luschka)
=> to cisterna magna laterally
=> interpeduncular cistern above
contains basilar artery with pontine and labyrinthine branches

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Interpeduncular cistern
between cerebral peduncles and dorsum sellae
=> suprasellar cistern ant.
=> ambient cistern post.
=> pontine cistern below
contains post. choroidal a.
Ambient cistern joins interpeduncular with quadrigeminal cistern around midbrain
contains post. cerebral and great vein, CN III
Suprasellar cistern above and lat. to pituitary fossa, ant-inf. to III ventricle
=> interpeduncular cistern post.
=> Sylvian cistern lat.
contains chiasma and ant. part of circle of Willis
Quadrigeminal plate cistern
between quadrigeminal plate and tentorium a.p.
between splenium of corpus callosum and vermis
contains venous confluence (basal and great vein and inf. sagittal sinus)

Pineal gland post. to 3rd ventricle and habenular commissure

calcifies commonly from early 20’s, up to 10 mm on
midline “shift” < 2-3 mm normal

TMJ’s condylar process/head of mandible articulates with mandibular fossa of temporal bone, slips anteriorly
over articular tubercle on opening, covered by fibrocartilage
cartilaginous disk divides joint into sup. and inf. part, fixed to condylar process, moves forward with
opening of mouth
lat. pterygoid m. attaches to disk
plain film taken with 30° caudal angulation

Salivary glands
Parotid gland lies superficial to masseter m. with isthmus around mandible
ant. relations: mandible, masseter
post. relations: mastoid process and sternomastoid m.
med. relations: styloid process, pharyngeal mm.
5 cm duct running superf. to masseter m. to pierce buccinator m., os opposite upper 2nd molar
ext. carotid a. divides into two terminal branches within post. part at level of isthmus
facial nerve runs through deep part superficial to facial a. & v.

Submandibular gl. wrapped around mylohyoid m. from behind, medial to angle and post. body of mandible
5 cm duct comes off deep part, goes over (cranial) to lingual n., opens onto sublingual papilla

Sublingual gland multiple ductless opening directly into floor of mouth


Branchial arches
each segment usually supplied by one cranial nerve and one aortic arch
1st branch mandible and face, malleus and incus, muscles of mastication and ant. belly digastricus,
mylohyoid, tensor tympani & veli palatini
CN V (motor: mandibular branch), maxillary artery
ant. 2/3 of tongue
2nd branch styloid process and stylohyoid ligament, stapes, lesser horn and sup. body of hyoid
CN VII, connection to V via chorda tympani, arteries to stapes and hyoid
3rd branch stylopharyngeus muscle
CN IX, internal carotid artery
post. 1/3 of tongue
4th branch superior laryngeal cartilages incl. epiglottis
CN X, superior laryngeal nerves
5th branch obliterates
6th branch inferior laryngeal cartilages
CN X, recurrent laryngeal nerves
Thyroglossal tract ant to body of hyoid
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Revision Notes for the FRCR part 1

External carotid
Bifurcation at C4, initially medial to int. carotid, enters parotid
1. sup. thyroid a. (inf. thyroid from thyrocervical trunk / subclavian a.)
2. lingual a. =>
3. ascending pharyngeal a. => larynx, meningeal vessels through foramen lacerum
4. facial a. --- ophthalmic a. => face, submandibular gland, soft palate, tonsils
5. sternomastoid branches
6. occipital a. => meningeal vessels through jugular foramen
7. post. auricular a. => pinna, parotid, scalp
================================================== parotid
8. superf. temporal a. --- ophthalmic a. => pinna, parotid, scalp, TMJ
9. maxillary a. --- middle meningeal a.

common origin of lingual and facial a. in 20%

Internal carotid
lies initially posterior and lateral to external carotid
medial to int. jugular vein with vagus nerve post. between them
sympathetic trunk post., outside carotid sheath

Vertebral a. through transverse ffor. of upper 6 cervical vertebrae with vertebral vv. (C5 and above in 5%)
cervical branches and ant. spinal a. to cord

right brachiocephalic vein receives inf. thyroid vein and right lymphatic trunk
SVC formed at T3

Cervical fascia
Investing fascia from mandible/zygoma/mastoid to manubrium/clavicle/acromion, includes hyoid and spinous processes
Pre-tracheal fasc. below larynx
around thyroid, trachea and oesophagus, fuses with carotid sheath
Prevertebral fasc. from sphenoid to T3
encloses spine and pre-vertebral muscles, phrenic nn., sympathetic trunk and brachial plexus

Larynx suspended from hyoid by thyrohyoid membrane and ligaments

3 unpaired cartilages
cricoid, thyroid and epiglottis
3 paired cartilages
arytenoids, corniculates (above), cuneiformes (lat. in aryepiglottic folds)
cricoid, thyroid and arytenoids are hyaline cartilages

3 levels vestibule
=========================== false (vestibular) cords
laryngeal ventricle (± saccule anteriorly)
=========================== vocal cords, glottis
infraglottic larynx

cross-section triangular at level of false cords, elliptical at level of glottis,

D-shaped below
Recurrent laryngeal nerves
come off vagus nerve, hook around right subclavian a. at T2/3 and aortic arch at T4/5
run in groove between trachea and oesophagus => local branches, medial to thyroid

Thyroid thyroid cartilage to 6th tracheal ring (C5-T1, ~ 4cm), isthmus at C6

pyramidal lobe in 40%, arteria thyroidea ima from aortic arch in 10%
thoracic duct behind left lobe
lateral to superior and recurrent laryngeal nn.
Aa. sup. thyroid artery --- ext. carotid (1st branch) }
inf. thyroid artery --- thyrocervical trunk } -- arterial plexus
a. thyroidea ima (10%) --- brachiocephalic / aortic arch }

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Revision Notes for the FRCR part 1

Vv. sup. and middle thyroid vv --- int. jugular

inf. thyroid v. --- left brachiocephalic v.

Parathyroid glands
within pretracheal fascia behind . thyroid
superior glands constant at C6, inferior glands can lie deep within thorax
supplied by inf. thyroid a.

Stellate ganglion
fusion of inferior cervical and 1st thoracic ganglion
above first rib, ant. to transverse processes of C7, behind vertebral a.

Ribs 7 true, 3 false (do not reach sternum), 2 floating
1 ½facets for their own rib and the one below (except T11 + 12)
cervical ribs occur < 1%, 50% bilateral, twice as common in women

Variants of the aortic arch
- both common carotids of innominate a. 27%
- left vertebral a. from arch 4%
- right vertebral a. from right subclavian a. 90%
- anomalous right subclavian (a. lusoria) 1-2%, off descending aorta, pre-/postoesophageal, pretracheal

aortic diameter root 4.5cm

(angio) ascending 4cm
arch 3.5 cm
descending 3cm
abdominal 2cm
bifurcation 1.5 cm

Aortic nipple left sup. intercostal vein viewed tangentially in front of aortic knuckle

Left SVC connection between left sup. intercostal vein and oblique cardiac vein

Azygos system
azygos vein L2, from right ascending lumbar and right subcostal vein or as branch of IVC
ascends to right of aorta and thoracic duct through aortic hiatus (median arcuate lig.), medial to right
lung and pleura, arches forward over right hilum at T4 and feeds into SVC
receives all but 1st intercostal vein, right bronchial, oesophageal, mediastinal and pericardial veins
hemiazygos v. L2, from local veins as azygos ± renal vein, passes behind aorta at T7 (variable) to feed into azygos
access. azygos v. 4th-8th post. intercostal veins, runs caudally to pass behind aorta above hemiazygos
1st right and 1st-3rd left intercostal veins drain directly into brachiocephalic veins

Thoracic duct contains valves, ascends to the left of azygos v., crosses to the left at T5 to lie posterior to oesophagus and
aortic arch
feeds into left brachiocephalic vein at C7

The Heart
Eustachian valve directs venous blood returning into right atrium to foramen ovale

Projection of heart valves within cardiac shadow

p.a. film aortic midline at junction of 3rd costal cartilage with sternum
mitral (patient’s) left of midline at junction of 4th costal cartilage with sternum
(below and to the left of aortic valve)
pulmonary above and to the (patient’s) left of aortic valve, highest and most anterior valve
tricuspid anywhere on a line from the junction of the right 6th costal cartilage with sternum to the
mitral valve (i.e. low and to the right)
lateral on a line from the carina to the anterior cardiophrenic angle
aortic above, projecting under aortic root
mitral below, posterior to aortic valve

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coronary arteries
LCA dominant in 15-20%, balanced 20-30%, RCA dominant in 50-60%

left c. a. 1. left anterior descending a. to septum and apex

septal and two diagonal branches, occ. branch to right ventricle
2. left circumflex artery to posterior wall, anastomoses with post. descending a.
obtuse marginal a. to lateral wall, atrial branches
right c. a. branches to pulmonary outflow tract,
branch to SA-node
marginal branches to right ventricle
branch to AV-node
posterior descending a.
cardiac veins
draining into the coronary sinus are
from the left great cardiac vein (LAD)
left posterior ventricular v. (obtuse marginal a.)
left oblique atrial v., oblique vein of Marshall

from the right small cardiac v. (anterolateral wall)

middle cardiac vein (posterior descending a.)
anterior cardiac vv. from the anterosuperior wall and pulmonary outflow tract directly into the right atrium

Trachea starts at C6, carinal angle 50-65°
left main bronchus = hyp(o)arterial bronchus (under artery) 5 cm long
right main bronchus = ep(i)arterial bronchus (behind artery) 2.5 cm long

segmental bronchi divide into 6-20 respiratory bronchioles => terminal bronchioles (no cartilage within wall)
=> alveoli
acinus resp. bronchiole + alveolar duct + alveoli
lobule 3-5 acini separated by septa
Pores of Kohn air flow between alveoli
Channels of Lambert air flow between alveoli and term. bronchioles
interstitial lines interlobular septa Kerley B
deep septa Kerley A

Hila project over 7-8th post. rib

Hilar point intersection of upper lobe vein with descending inferior lobe artery
Hilar angle 120°

Oblique fissure from T2 to 6th rib parasternally, left runs steeper course (60°) than right (50°)
Horizontal fissure intersects interlobar a. 1 cm below right hilar point
Accessory fissures inferior acc. fissure 8 %, commonest, separates mediobasal segment of right lower lobe
superior acc. fissure 5%, separates apical segment of right lower lobe
azygos fissure < 1%, azygos vein pushed into upper lobe => contains four layers of pleura
Paratracheal stripe right < 3mm, left not present due to aortic arch
Parasternal stripe < 7.5 mm, wavy
Retrosternal stripe < 3 mm, ant. edge of lungs, straight
Pleural reflections 6th - 8th - 10th - 12th rib parasternal - MCL - MAxL - paravertebral
Lung border 6th - 8th - 10th MCL - MAxL - MScL
[mid-clavicular / -axillary / -scapular line]

pulmonary veins run antero-inferior to arteries

diameter of pulmonary arteries < 1.5 x the corresponding bronchi
pulmonary vessels should be < 3mm in diameter in 1st ICS
lower lobe a. should be less than 16 mm in diameter (14 mm in women)

on a rotated CXR the lung away from the film appears more radiolucent

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The Breast
acini => lobules => lobular duct => 15-20 lobes => lactiferous ducts => nipple
parenchyma enclosed in superf. fascia anteriorly and deep fascia posteriorly
separated from pectoralis major m. by pectoralis fascia
acini increase in number during pregnancy and breast feeding involute after lactation resulting in reduced glandularity than
glandular breast more difficult to assess on mammography as increased radiodensity
Cooper’s ligaments
septa running through breast from pectoralis fascia to skin

blood supply 1. int. thoracic a. (subclavian a.)

2. lat. thoracic a. (axillary a.)
3. branches of intercostal aa.
venous drainage analogous
lymph drainage 1. axillary nodes
2. internal thoracic nodes
3. cross-over to contralateral side (!)
Oesophagus C6 - diaphragm at T10
four narrow segments 1. behind cricoid
2. behind aortic knuckle
3. behind left main bronchus
4. piercing the diaphragm
striated muscle in upper 2/3
maximal diameter smaller than that of pylorus

Diaphragm trigonum sternocostale, Larrey internal thoracic vessels => superior epigastric vessels
Foramen venae cavae Right central tendon, T8: IVC, Right phrenic nerve
oesoph. hiatus fibres of median arcuate ligament, ant. to aortic hiatus, T10
oesophagus, vagal trunks, arterial and venous anastomoses
median arcuate ligament aortic hiatus, T12: aorta, thoracic duct, azygos vein
medial arcuate ligaments psoas arcade, L2: psoas muscles, sympathetic trunk
lateral arcuate ligaments L1: quadratus lumborum
= trigonum lumbocostale Bochdalek
Phrenic nerve C3/4/5 (keep the diaphragm alive)
right: ant. to scalenus ant. m./behind right subclavian vein - lat. to SVC/right atrium/IVC
left: ant. to scalenus ant. m./behind thoracic duct and origin of right brachiocephalic vein - lateral
to aortic arch/left atrium/left ventricle

Fundus enhances with iv-contrast

Small bowel
Circumferential folds contain mucous membrane only, do not disappear on dilatation
Mesentery extends from L2-vertebra to right SI-joint

Duodenum independent peristaltic pacemaker

D1 intraperitoneal
D2 longitudinal ridge, begin of circumferential folds
accessory papilla in 10% on anterior wall of D2, proximal to major papilla

Jejunum larger diameter }

thicker wall } than ileum
more prominent valvulae conniventes }
complex arterial arcades with extensive anastomoses

Ileum arterial arcades reduced to max. 3

cobblestoning due to hyperplastic lymph follicles normal between 3-16 years

Peyer’s plaques = lymph follicles in ileum

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Meckel’s diverticulum
1 - 1.2 m proximal to ileocaecal valve, contains gastric mucosa or pancreatic tissue
=> accumulate pertechnetate

Large bowel
Ascending and descending colon usually retroperitoneal
= neither have a mesocolon in 50 %
= both have a mesocolon in 15 %
supplying arteries = endarteries
Marginal artery of Drummond
artery running along watershed area of splenic flexure, anastomoses SMA and IMA
Anal canal
|| || ====== sup. rectal a. + v.
int. iliac lymph nodes <= || HINDGUT ||
|| ||
-------------------------- || ~~~~~~~ linea dentata ~~~~~~~ || ====== middle rectal a.
|| === external (voluntary) sphincter === ||
inguinal lymph nodes <= || ||
|| ANAL PIT || ====== inf. rectal a. + v.
Skin line _____|| ||_____

Pre-sacral space max. 1.5 cm at S4 on lat. Ba-enema

Rectal ears herniation of recto-sigmoid into inguinal hernia

Liver largest solid organ

hepatic vv. join IVC at T12
Falciform ligament
anatomical division of the upper surface of the liver, separates lateral segments of left lobe from caudate
and quadrate lobe. Ligamentum teres and venosum follow the same course on the under surface of the liver.
Ligamentum teres
obliterated umbilical vein which transports blood from the placenta to the fetus
runs in free lower edge of falciform ligament from the anterior inferior edge of the liver to the porta
Ligamentum venosum
continues the course of the lig. teres from the porta posteriorly to the IVC, remainder of the ductus venosus
Arantii which shunts blood from the portal vein to the left hepatic vein or IVC (bypassing the liver) in
early and middle pregnancy
Liver segments 1 caudate lobe }
2 lateral superior segment } left
3 lateral inferior segment } lobe
4 quadrate lobe }
======================= middle hepatic vein
5 anterior inferior segment }
6 posterior inferior segment } right
7 posterior superior segment } lobe
8 anterior superior segment }
Caudate lobe between IVC and ligamentum venosum
possesses own venous drainage direct to SVC => hypertrophies in Budd-Chiari syndrome as all others
blocked. Portal venous and arterial supply from both sides
Riedel’s lobe caudal extension of segment 5, not a true lobe
(B. Riedel, 1846-1916, Professor of surgery in Jena, Germany)

Omentum minus, lesser net

ant. to post.: CBD - hepatic a. - portal vein
right hepatic a. post. to common duct in > 90%
Bursa omentalis, lesser sac
separated from peritoneal cavity (greater sac)
ant: omentum minus
inf.: mesocolon transversum
left: gastrolienal ligament
right: continuous through foramen epiploicum Winslowi

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Portal system and umbilical vessels

portal vein formed behind neck of pancreas by joining of splenic vein (which has already received IMV) and SMV
umbilical vein one vein, umbilicus to portal vein in free lower edge of falciform lig., obliterates to lig. teres
ductus venosus portal vein to left hepatic vein or IVC (bypassing the liver), obliterates to lig. venosum
umbilical arteries two arteries, from the two internal iliac arteries to the placenta

rotation of duodenal ectoderm leaves ventral bud to the right, dorsal bud to the left
ventral bud migrates dorsally to lie inferior to dorsal bud and become uncinate process and lower part of head with distal part
of major duct

splenic aa. + vv. divide into 4-5 branches before entering the hilum
Lienorenal lig. “mesosplenium”
Gastrolienal lig.

Splenunculi occur in 10%, usually < 1cm

Kidneys tilted 45° backwards

arteries divide into lobar branches before entering kidney, accessory arteries enter kidney direct
(extrahilar), no anastomoses at segmental level
renal aa. post. to pelvis, vv. ant to pelvis, double veins in 10%

Adrenal glands
at birth 1/3 size of kidneys, involute to 50% within 3/12
Blood supply: 1. inferior phrenic a.
2. middle adrenal a., origin at T12/L1
3. renal a.
Suprarenal vein drains to IVC (right) and renal vein (left)

CT: up to 4cm long, limbs < 10 mm thick

right V-shaped, left Y-shaped

Lymphatic drainage
Stomach upper abdominal nodes
Small bowel mesenteric nodes
Bladder external iliac nodes
Prostate int./ext. iliac and sacral nodes
Ovaries lateral- and preaortic

Coeliac ganglion, plexus solaris

lat. to aorta, between coeliac axis and renal aa.

Pectineal line pubic tubercle - ilio-pubic eminence
Spaces of the perineum:
===================== levator ani
===================== uro-genital diaphragm
superficial perineal space
---------------------------------- superficial perineal fascia
Ischio-rectal fossa inf. to levator ani, lat. to rectum, medial to int. obturator m.

Internal iliac a. forms at L5/S1 in front of SI-joint
Anterior division Obturator a. through obturator foramen to thigh
Umbilical a
Superior vesical a. bladder
Inferior vesical a. bladder, seminal vesicles, prostate / vaginal a.
Middle rectal a.

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Uterine a. lig. latum to cervix, uterus, Fallopian tubes and ovaries <=> ovarian aa.
Inferior glutaeal a. through greater sciatic foramen to buttock and thigh
Internal pudendal a. greater sciatic foramen - hooks around ischial spine - lesser sciatic foramen
=> external genitals
=> inferior rectal a.
Posterior division Iliolumbar a. iliopsoas m., cauda equina
Lateral sacral a. through ant. and post. sacral ffor., sacral canal and lower back
Superior glutaeal a. through greater sciatic foramen to pelvic wall and thigh

External iliac a, inferior epigastric a. anastomoses with sup. epigastric a. from int. thoracic a.
abdominal wall, scrotum/vulva
deep circumfl iliac a. abdominal wall

Bladder blood from sup. and inf. vesical (sive vaginal) a.

lymph drainage: mainly external iliac nodes
Prostate underneath bladder, on top of uro-genital diaphragm, post. to lower edge of symphysis
prostatic vv. drain to internal iliac v. and int. and ext. prevertebral plexus => metastases
lymph drainage: mainly int. iliac nodes ± ext. iliac nodes
Penis root in superficial peroneal space
bulb beneath UG-diaphragm, crura from ischio-pubic rami
suspensory ligament from anterior edge of symphysis
fundiform ligament loops around penis with two origins from linea alba
supplied by int. pudendal a.

pre-vesical space of Retzius

Donovillier’s fascia separates prostate from rectum, relative barrier for local spread of malignancies

Upper limb
Vasculature nutrient vessels to the bone “go to the elbow and flee the knee”

Subclavian a middle part runs behind scalenus ant. together with brachial plexus
(s-cl. v. ant. to scalenus ant. m. and behind sternomastoid)
aberrant right s-cl.a. usually passes behind oesophagus (dysphagia lusoria)
1. vertebral a.
2. thyrocervical trunk => suprascapular a. and cervical branches, inf. thyroid a.
3. internal thoracic a.

Axillary a. from lat. border 1st rib to inf. border of teres major m.
through brachial plexus to lie between
radial nerve post., median n. supero med., ulnar nerve inf.
1. sup. thoracic a.
2. acromiothoracic trunk
3. subscapularis a
4. ant. & post. circumflex humeri aa.
5. lat. thoracic a.
Brachial a. from inf. border of teres major to below elbow => bifurcation ant to radial head
1. pofunda brachii => in radial groove
2. nutrient a. of humerus
3. muscular branches
4. branches to elbow

Ulnar a. larger, deeper branch, gives off common interosseus a.

becomes superficial at wrist, over flexor retinaculum => superficial palmar arch
Radial a. becomes lat. at wrist joint, branch to superf. palmar arch, runs at bottom of anatomical snuffbox to the back
of the hand => deep palmar arch

Veins median v. from palmar surface

cephalic and basilic vv. from dorsum of hand, cephalic v. runs laterally, has to pierce clavipectoral fascia at
the shoulder => contrast stasis

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Shoulder glenoid covers 1/3 of humeral head

capsule inserts behind labrum and at anatomical neck
long biceps tendon runs intra-articular to insert into labrum glenoidale
acromio-humeral distance > 7mm
lymph drainage: axillary and deep cervical nodes
Rotator cuff supraspinatus, infraspinatus, subscapularis and teres minor stabilise the joint from all sides
supraspinatus tendon runs under acromion and separates sub-acromial bursa from joint space

sub-acromial bursa - subdeltoid bursa = largest bursa in the body, does not communicate with joint
space unless supraspinatus tendon is gone
ubscapular bursa communicates with joint space

Elbow 3 joints, one synovial space

carrying angle: male 160°
forearm flexors originate from medial epicondyle

Wrist two separate joint spaces, radio-carpal and intercarpal joint

disc in ulno-triquetral articulation

Flexor retinaculum
superficial palmaris longus m.
ulnar n. & a.
flexor carpi ulnaris via pisiform (= sesamoid) to hook of hamate and base MTC V
lateral radial a. & n.
flexor carpi radialis in carpal canal to base of MTC II + III
deep deep and superf. finger flexors, long thumb flexor

Carpal angle angle between the two tangents of the lower carpal row, 125° - 140°

Accessory carpal bones

os centrale overlying junction of capitate, trapezoid and scaphoid
os radiale ext. distal to radial styloid
Metacarpal index
mean ratio of metacarpal length to width (of MC II-V, width at mid-shaft)
normal <8, if >8.4 => arachnodactyly

Lower limb
Common femoral a.
continuation of ext. iliac a. after passing through lacuna vasorum of inguinal ligament
1. superficial circumflex iliac a.
2. superficial epigastric a.
3. external pudendal a.
4. profunda femoris a.
med. + lat. circumflex aa., collaterals to knee and glutaeal region
perforating aa. to muscles
Superf. femoral a.
deep to sartorius m. between adductor and extensor group => adductor canal
descending genicular branch to genicular anastomosis
adductor hiatus between femur and femoral v., deep to tibial nerve

Polpiteal a. four genicular branches

crosses politeal fossa from medial to lateral deep to vein (deep to tibial n.)
tri-furcation behind prox. tibio-peroneal joint
1. ant. tibial a.
pierces interosseus membrane med => lat to lie on ant. surface of it and lat. to tibia,
becomes dorsalis pedis a. between malleoli
most lateral of the three vessels in ap-projection

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2. post. tibial a. / tibioperoneal trunk

continues caudally on post. surface of interosseus membrane
becomes tibialis post. a. passing behind lateral malleolus
main supply of the foot as the medial and lat. plantar aa.
most medial of the three vessels in ap-projection
3. peroneal a.
projects between tibial vessels on ap-view, ends at calcaneus

Veins 1. paired deep veins system follow arteries

2. long saphenous v., ant. to medial malleolus
3. short saphenous v., post. to lat. malleolus

Hip Y-line over sup. borders of femoral head epiphyses

acetabular angle 28° ±15 < 3 months between Y-line and acetabulum
22° ±10 < 12 months
angle of NOF 160° in infants
125° in adults
anteversion of NOF 30-50° < 1 year
10° in adults => int. rotation educes foreshortening of neck

Shenton’s line: lower edge of n.o.f. should be in continuity with lower edge of upper pubic ramus (> 1 year)

3 geographical muscle groups
1. anterolateral, supplied by femoral nerve
quadriceps femoris
2. posteromedial, supplied by obturator nerve
adductor longus, brevis and magnus
3. posterior, “hamstrings”, supplied by sciatic nerve
semitendinosus (superficial to semimembranosus)
biceps femoris

Sartorius m. from ant. sup. iliac spine to medial tibial plateau

passes post. to knee joint => flexor of knee and hip, ext. rotator of thigh, int. rotator of leg
= tailor’s muscle

Femoral A. & V. deep to sartorius

Long saphenous v. between gracilis and sartorius

physiological valgus of 80° in males, 76° in females
=> medial condyle larger to allow horizontal tibial plateau
=> patella dislocates laterally
7 bursae gastrocnemius, popliteus, semimembranosus and suprapatellar bursa communicate with the synovial cavity,
3 further bursae around patella these do not communicate

Cruciate ligaments
ant. cruciate lies anterolateral to the post. ligament
runs from above and lateral to down and medial (= parallel to fibres of external oblique m.)
intraarticular but extrasynovial
post. tightens on flexion
Menisci fibro-cartilagenous discs, attached to femoral condyles via coronary ligaments
ant. edges joined by transverse ligament
larger, open “C” with ant. and post. attachments to tibial plateau anterior to respective cruciate
smaller, near-complete circle with attachments between cruciates

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Pes anserinus (lat. goosefoot) insertion of sartorius, gracilis and semitendinosus into medial tibial plateau
Calcaneus Boehler’s angle (intersection of tangentials along cranial surface and subtalar surface) 30-35°
if < 28° => fracture

Sesamoid bones
os peroneum 20% lat. to proximal cuboid, peroneus longus tendon
os vesalianum lat. to base of Vth metatarsal
os trigonum 8% behind talo-calcanear joint
os tibiale externum medial to navicular tuberosity, tibialis post. tendon?
Heel pad thickness males: < 23 mm
females: < 21 mm

Anatomical levels (body of vertebra)

C4 carotid bifurcation
C6 cricoid cartilage, begin of oesophagus and trachea, thyroid isthmus


T2 sternal notch
T3 formation of SVC manubrium
T4 aortic arch, azygos => SVC manubrium, angle of Louis
T5 carina (+/- 1 on deep in-/exspiration), angle of Louis
T6 xiphoid process
T8 IVC pierces diaphragm
T10 oesophagus pierces diaphragm, g/o-junction
T11 gallbladder
T12 aorta pierces diaphragm, tail of pancreas

L1 coelic axis, SMA originates <6mm inferiorly, pylorus
L2 lower end of Left diaphragmatic crus, renal hilum (vein sup. to artery),
begin of hemi-/ azygos vv.
L3 lower end of Right diaphragmatic crus, origin of IMA, gonadal aa.
L4 aortic bifurcation
L5 begin of IVC

S3 begin of rectum
femoral heads ischio-rectal fossa, cervix
symphysis bladder neck, prostate

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Revision Notes for the FRCR part 1


blurring - proportional to swing angle
- due to the geometry more pronounced on the tube side of the fulcrum plane than on the film side
- independent of exposure factors (these need to be increased by appr. 10 kV and 5 mAs
no effect on radiographic sharpness

linear lower dose than cyclical / helical

10° angle 6.9 mm slice thickness
20° angle 3.4 mm
wide-angle: reduced contrast, hence more suitable for high inherent contrast areas i.e. bone, middle ear
objects parallel to tube motion give streak/parasite artefacts
cyclical phantom images, particularly for small arcs

Orbits and paranasal sinuses pa position markedly lower dose to eyes than ap

Surface Landmarks

ant. chest sternal notch T2

angle of Louis T4
xiphoid process T6

Positioning always relative to film

LAO - left shoulder to film, patient facing film, pa beam
left decubitus - right side elevated

Plain Films

Head and neck

- Skull O.F. 20 (pa) prone, baseline 90° to film, 20° caudal angulation centred through nasion
70 kV, 30 mAs, focused grid

Towne’s view supine, baseline 90° to film, 30° caudal angulation

(O.F. 30) centred frontal bone => foramen magnum
reversed Towne’s = same projection with O.F. beam (cranial angulation)

SMV extended neck, film on vertex parallel to baseline; centred through midpoint between
angles of mandible with 5° angulation towards forehead

O.M. prone, mouth on film, baseline 45° to film

beam 90° to film through lower orbital margin (= p.a. with patient looking up)
O.M. 30 prone, mouth on film, baseline 45° to film (patient looks up)
30° caudal angulation through vertex to lower orbital margin

IAM seen on not on

Towne’s view OF 20
Upper Limb
- Hand pa 3rd MCPJ,
lat (= obl) 5th MTPJ, then tube angled with central beam through 3rd MCPJ
45 kV

- Thumb pa MCPJ; retroverted arm, abducted thumb

lat MCPJ; abducted thumb, extended wrist, flexed MCPJ’s

- Wrist pa midline distal radio-ulnar joint,

lat radio-ulnar plane perpendicular to film (= hand slightly supinated)
50 kV
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- Scaphoid 1. dv 2. dv; tube angled 25° proximally

3. oblique in 45° pronation 4. lat in 0°

- Elbow ap 1inch distal from midline between humeral epicondyles; full extension
lat lat. epicondyle; right angles shoulder and elbow, 0° pronation
55 kV

- Humerus ap midshaft; abducted shoulder 45°, extended elbow

lat midshaft; elbow 90°, hand on hip (= 90° int. rotation)

- Shoulder ap proc. coracoideus (possibly slightly medially and caudally to fill picture) incl. upper part of
thorax and lower c-spine
ap (trauma) slight dorsal rotation to get glenoid tangentially; collimated on joint
mod. axial 1. curved cassette in axilla with cranio-caudal beam or
2. caudo-cranial beam
tang chest wall
60-65 kV

Lower Limb
- Hip
von Rosen’s view int. rotation and 45° abduction
axes of femora should cross in front of promontory in midline
frog view flexion and ext. rotation with soles together
? epiphysiolysis

- Knee ap full extension; 2.5 cm below lower pole patella

lat. superimpose condyles
tunnel kneeling on film or curved cassette
skyline flexed 90°, patient holds cassette
60 kV
- Lower leg ap midline knee-ankle
lat 1, as for lat. ankle, i.e. int. rotated
2, as for lat. knee
- Ankle ap midline between malleoli; plantar flexion ankle/15° cephalad to open up ankle joint
lat mild int. rotation to superimpose (post.) fibula with tibia
- Calcaneus pa full dorsal extension of ankles, shoot through soles
- Foot dv cuboid/navicular area
lat (oblique) lat. border elevated 15°
50 kV

- c. spine ap centre sternal notch, angle up through cricothyroid to compensate for lordosis
lat. increased FFD, “air-gap” technique
centre 2.5 cm behind mandible

Chest 70 kV, 6mAs

pa ap
film should be marked
scapulae rotated out of lung fields
vertebral laminae visualised with diverging beam vertebral endplates seen

LAO aortic arch, tracheal bifurcation

RAO left atrium and ventricle
apical lordotic view apices, interlobar areas, pulmonary segments

High kV technique 110-150 kV

- shorter exposure => reduced motion unsharpness
- more efficient patient penetration => reduced patient dose

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- more forward scatter reaching the film => higher grid ratio required
- reduced radiographic contrast => bones less prominent
- increased exposure latitude
Automated multi-beam exposure radiography, AMBER
horizontal fan beam scans patient
exposure factors fixed: 130 kVp, 20-60 mAs (dependent on patient size)
array of twenty detectors behind patient and 20 corresponding step-wedge filters between tube and patient
dose for each segment of the beam is modulated via feedback from the detector to the attenuator
=> much more homogenous exposure with reduced contrast and better penetration of thick structures

Abdomen on arrested inspiration, should include hemidiaphragms and pubic symphysis

centred at L4
65-70 kVp, grid!
decubitus named after the side touching the film => left decubitus = right side up
detects up to 1 ml of free air
dependent diaphragm lies higher within chest and moves less

spine }
scapula pa }ribs, breathing
oblique sternum }

upper c-spine jaw movement

at present most sensitive method for detection of microcalcification, MTF 20-22 lp/mm, supplemented by7.5 MHz USS
skin dose 6-8 mGy, effective dose 0.5 - 1 mSv
breast tissue most sensitive to irradiation in late pregnancy and lactation
induction of neoplasm by mammography 2 per Mio
• Mo-anode and -filter (0.3 mm) for 25 kVp or W-anode and Pd-filter for 30 kVp
• fine focal spot (0.1-0.3 mm) => long exposure (>0.5 s)
• single sided film/screen, low kVp (25-30 kV) for high contrast
• processed at lower temperature with longer cycle
• compression vital => immobilisation and dose reduction
• cranio-caudal and oblique views at the level of the nipple, including axillary tail

Magnification factor F O D (magnification approx. = 1, if object in contact with film)
- usually 1.5 - 2 times
- ultrafine focus required (penumbra directly related), i.e. 0.1-0.3 mm
=> low tube rating => long exposure times => immobilisation required
- screen unsharpness improved as spatial frequencies reduced by magnification
- geometric and movement unsharpness worsened
- quantum mottle unchanged

exposure of semi-conducting Se-plate pre-charged at 1600 kV
wide image altitude
strong edge enhancement due to increase of electric field around edges
non-linear MTF, ideal reproduction of spatial frequencies between 15-50 lp/cm
Indications: cephalo-pelvic disproportion persistent breech
small stature (of mother), < size 4 shoes post emergency Caesarean
non-engaging head prev. difficult labour
Contraindication: labour

1. AP pelvis & erect lateral plain films with air-gap technique

2. CT-scanogram
AP-inlet upper edge of symphysis - promontory 11 cm
AP-outlet lower edge of symphysis - lowest fixed part of sacrum 11.5 cm
Transverse inlet (maximal lateral diameter) 12.5 cm
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Interspinous distance (ischial spines) 10 cm

Contrast media, CM
1. Intravascular
balance of number of molecules : number of iodine atoms
toxicity is a function of osmolality and whether agent is ionic or not
anaphylactic reactions 6-10 times more common with ionic agents
Ionic agents (3:2)
Benzene ring with iodine in 2, 4 and 6-position
- toxic until amide groups substituted at position 3 and 5
- if benzene-ring substituted with organic group at 5C => renal excretion,
if not => high protein binding and hepatic uptake
differences between agents:
- differences in side chains
- concentration
- methyl-glucamine (meglumine) versus sodium salts:
Sodium salts Meglumine salts
irritant to vessel wall +++ +
cardiotoxic* ++ ++
neurotoxic +++ +
anaphylactic reactions x4 more common
*for cardiac work mixture with physiological concentration of sodium ideal

osmolality typically 5-7 times osmolality of plasma (1200-200 mosm/kg)

=> vasodilatation, release of histamine, vascular and blood cell injury
osmolality is a function of particles in solution (and as ionics dissociate, there are two per molecule), but
indirectly related to the molecular weight

meglumine diatrizoate (Urografin®)

Side-effects 1. activation of complement

2. release of histamine => anaphylaxis
3. osmotic effect => fluid-shift, alteration of erythrocytes (haemolysis, educed flexibility) sickle cell!
4. toxic effects

- vascular vasodilatation, hypotension, tachycardia

- cardiac drop in systolic and increase in diastolic pressure, bradycardia, arrhythmias
- renal hypotension, hyperosmolar, chemotoxic, precipitation of proteins (myeloma,
Waldenström, Tamm-Horsfall = normal protein produced by tubulo-epithelial cells)

Non-ionic agents (3:1)

do not dissociate, approx. half the osmolality of ionic agents, in fact less as larger molecules tend to aggregate leading to
relative increase in molecular weight, majority of agents for intravascular administration
metrizamide first compound, expensive and inconvenient to use as available as a freeze-dried powder only
iohexol (Omnipaque®)
Dimeric agents
ionic (6:2) Na-/meglumine ioxaglate (Hexabrix®)
non-ionic (6:1), extremely low toxicity, hypo-osmolar => saline added
iotrolan (Isovist®), first compound, licensed for myelography 1990
iodixanol (Visipaque®)

heterotopic excretion
renal in oral cholecystograms, if biliary obstruction
biliary in iv media, if renal failure

arm pain following injection indicates stasis => basilic vein preferable, more common with sodium salts of high
time to left ventricle 10-15 sec.

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2. Oral
Barium sulphate
inert within GI-tract, can cause obstruction above tight stricture
harmless within lungs, high mortality if intraperitoneal or intravascular

powdered suspensions, particle size 0.1 - 3 µm

better coating with higher concentrations => higher viscosity
less flocculation with smaller particle size => more expensive
concentration: 30 - 250 % weight/volume (g/dl)

HOCM, mixture of meglumine and sodium diatrizoate with 370 mg Iodine/ml
hyperosmolar effect within GI-tract => therapeutic for meconium ileus
intrapulmonary => pulmonary oedema
intraperitoneal => paralytic ileus

CT 1.4% w/v Barium or 2% Gastrografin

bowel artefacts if scan time > 5 sec

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access: right side easier for right-handed, always scrub both femorals in case of difficulties
Right axilla => ascending aorta
Left axilla => descending aorta
Sones-technique: coronary angiogram / left ventricle; cut-down onto brachial artery, single catheter, no sheath

Guide wires 2 wires within coil of third, only one forms tip => flexible
can have stiff and floppy end
J-tip with 3mm, 7.5mm or 15mm curve
coating: polyethylene standard
Teflon reduced friction but increased thrombogenicity
hydrophilic slippery when wet, good torque
Size catheter: 1 French = 0.3 mm circumference, length in cm
guidewire: 1/1000 inch (milli-inch) in diameter, i.e. size 38 = 0.038 in = 0.97 mm
size 35 = 0.035 in = 0.89 mm

Angiographic catheters
Headhunter standard for selective cerebral angiography, single end-hole
Sidewinder / for visceral or difficult selective cerebral angiography
Simmons reformable loop, advances on traction, single end-hole
Cobra standard visceral catheter, single end-hole
Pigtail for large volumes fast, i.e. flush aortography
end-hole and multiple side-holes
Judkin’s coronaries from femoral approach, different shape for left/right coronary
Sone’s coronaries from brachial approach, one shape, femoral use possible
Sheldon sideholes, direct vertebral puncture

clot formation at catheter tip is directly related to catheter size and length and indirectly to the size of the artery

Coronary arteriogram
2-9 ml
hand injected, very fast frame rate (60 fps), CM should disperse immediately, otherwise catheter might be
occluding the artery => immediate withdrawal
Selective cerebral angiography
5F Headhunter ± Sidewinder, sheath makes catheter exchange easier
hand injection 8 ml for carotids, 5-6 ml for vertebral arteries
carotid O.F. 20 ± cross compression vertebral: reversed Towne’s view
lateral lateral
lateral obliques
Aortic arch angiogram
5F pigtail
40 ml LOCM 350 pump injected 20-25 ml/s
LAO: origin and bifurcation of RIGHT common carotid
RAO: origin and bifurcation of LEFT common carotid
Flush aortogram (abdominal)
50 ml LOCM 350 pump injected 12 ml/s
Aorto-femoral arteriogram
5F pigtail or straight catheter with multiple sideholes
120 ml of diluted contrast, LOCM 350 : NaCl = 1:1
pump injection 24ml/3 sec 8ml/s
images at 1fps proximally, 2 fps distally
Translumbar aortogram
40 ml of LOCM 320 14 ml/s
10 ml test injection of contrast obligatory
a. high puncture, aimed at T12/L1, above / below 12th rib angling medially and cranially for anterior edge
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of vertebral body
shows renal arteries, obligatory if aneurysm suspected
b. low puncture, aimed at L3, above iliac crest
Mesenteric arteriogram
Cobra catheters, iv Buscopan to avoid bowel artefacts
for combined procedures IMA should be examined first => bladder filling (!)
a. coeliac axis
36 ml LOCM 350 6 ml/s
b. SMA
50 ml LOCM 350 8 ml/s
c. IMA
origin anterolaterally to the left at L3 => LPO best projection
25 ml LOCM 350 3 ml/s
or hand injection of 10 ml
Pulmonary angiogram
Grollman pulmonary pigtail catheter half-way between pulmonary valve and bifurcation
filling enhanced by balloon-occlusion
40 ml LOCM 350 25 ml/s
a.p. film most important, ± ant. oblique of the side of interest
Renal arteriogram
Cobra / renal double curve catheter
10-15 ml of LOCM 300 via hand injection, alternatively flush aortogram

Digitised intravenous arteriography, DIVA

50 ml LOCM 240 - 270 pump injected via large (16G) needle in antecubital fossa over 2 sec

Adrenal venography
if possible simultaneous hormone sampling
Right side more difficult as vein feeds into vena cava 2 ml of CM
Left side drains into renal vein 8 ml of CM
slow injection to avoid rupture

Percutaneous splenoportography
posterior axillary line puncture angling anterior and cephalad
pulp pressure < 11mm Hg
gelfoam for haemostasis

Interosseus venography

Vessels visualised by injection of methylene-blue s.c., taken up within 30 min, cannulation with 30G needle
a. Lipiodol has the advantage of showing lymph nodes as well as vessels, lymphangiogram persists up to 3 days, lymph
nodes are demonstrated up to one year => control for cytotoxic therapy
7 ml per leg, 4 ml per arm,
if patient with respiratory compromise only right leg injected with 10 ml as more cross over from right to left
side, if other side needs demonstrating as well > 7 days
injected over 45 min or until L3 level reached
b. LOCM 240, 10 ml
demonstration of vessels only (not nodes)

films: a. immediate series

10’ ankles
15’ knees
20’ thighs
30’ pelvis
45,60, 90’ abdomen
120’ chest, usually shows thoracic duct, ± supraclavicular nodes
b. 24 hr series
c. delayed series 2, 4, 8 weeks

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chronic lung disease => consider unilateral injection
right-to-left shunt / pulmonary AVM
less than 3/52 after radio- or chemotherapy
complications: allergy, infection and emboli
multiple small pulmonary emboli lead to transient reduction in KCO
right to left shunt/radio-Rx to lungs < 3/52 => systemic emboli
lymphatic obstruction => hepatic emboli
intravenous injection => globulation (caviar sign)
more and more replaced by Tc-micro-colloid scan

Indications: absence / CI to MRI
root avulsion disc prolapse
acute cord trauma pre-surgery
acute cord compression intraxial SOL
Suboccipital puncture only indicated for spinal block, otherwise CM is run up from lumbar approach
Ionic CM cause arachnoiditis and fits, in particular under anti-epileptic medication
Maximum intrathecal dose of iodine = 3g (=> 10 ml LOCM 300)


Ba-meal 200-250% w/v, inhomogenous particle size as flocculation not a problem due to short examination time
small particle sizes required to demonstrate areae gastricae
high kVp => reduce movement artefact + improve contrast

Ba-follow through
40-60% w/v
Small bowel enema
20-40% w/v
tube inserted in right elevated decubitus as rising air distends pylorus / right side down if weighted tip
1200 ml of at 75 ml/min
transit can be accelerated with cold saline
100% w/v
delay after colonic biopsy 3 days for superficial Bx
10 days after deep Bx

a. oral cholecystography
CM not substituted at 5C-atom => high protein binding => hepatic uptake; uricosuric, displaces other drugs
(i.e. digoxin)
supine oblique shows neck and body, prone oblique shows fundus
GB contracts 10-20 min. after fatty meal
ipodate (Biloptin®): after 1-5 hrs in bile ducts, after 14-19 hrs in gall bladder
=> 2 doses given at -3 and -15 hrs
b. intravenous cholangiogram
dimeric CM, active uptake reaches saturation => 1h infusion
glucagon increases transport into bile, practical value dubious
reflux into duodenum post-cholecystectomy can simulate gallbladder filling
stratification in gallbladder represents layering of old and new bile => late erect film
contraindications: pseudocysts, thoracic aortic aneurysm, not duodenal diverticula
2-5 ml CM for pancreatic duct, up to 3 mm
acute pancreatitis in 1%
d. intraoperative
stationary grid/gridded cassette
intrahepatic biliary tree should be demonstrated
e. T-tube

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Revision Notes for the FRCR part 1

at 7.-10. days post-op., antibiotic cover not required

right hepatic duct easier to demonstrate than left, distal bile duct should be seen
f. percutaneous transhepatic, PTCA
mid-axillary line, undilated biliary systems can be demonstrated in > 60%
gallbladder is often not seen

Urinary tract
Intravenous Urogram, IVU
Dynamic study for assessment of anatomy as well as function
Indications: haematuria, obstruction, colic
Contraindications: allergy, myeloma
mortality rate: 1:40.000
Technique: 6-8 hour fast unless renal impairment, dehydration does not improve nephrogram as CM freely filtrated
300 mg Iodine / kg as quick bolus (the faster the injection the more likely are side-effects)
50ml of Iohexol 350 deliver 17.5g total iodine = 230 mg/kg for 70 kg
50ml of Diatrizoate 370 deliver 18.5g total iodine = 265 mg/kg for 70 kg
1. control film, full length
± oblique views for calculi
2. +7 min. film, can be renal area only => renal outline, position, size, parenchyma, early
3. +15 min. compression film (renal area only) => filled calyceal system
if renal contours not demonstrated, consider tomogram 8-10 cm / USS
4. immediate release film (full length) => filled ureters ± prone film
5. if indicated post-mictuition film of bladder (incl. ureters if obstruction / reflux)

Children: gas-filled stomach as window for visualising kidneys

High dose IVU
in renal failure, double dose contrast (600mg/kg), immediate tomograms
Transplant kidney
for haemorrhage, urinary leak, lymphocele, obstruction
same dose (300mg/kg), control tomograms often required

Antenatal USS

Estimation of gestational age

up to 12 weeks crown-rump length, afterwards unreliable as spine flexed
after 12/40: BPD or femur length
Visualisation limb buds 5/40
yolk sac 5/40 - 12/40
foetal heart 6/40
skull 8/40
head / BPD > 10/40
lateral ventricles 12/40
localisation of placenta > 12/40
(filled) bladder 16/40
Ossification centres
calcaneus 24-26/40
talus 28/40
distal femur 36/40
prox. tibia 38/40

Normal measurements
BPD 44 ±2 mm 18/40
femur length 28 ±2 mm 18/40
ventricular atrium < 10 mm 15-40/40
cisterna magna a.p. 3-10 mm 15-40/40
cerebellum width in mm equals age in weeks up to 3rd trimester

Genito-urinary tract
mesonephros foetal excretory system => metanephric systems = permanent kidneys

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Revision Notes for the FRCR part 1

mesonephric duct Wolffian duct => ureters and trigone vesicae

=> ductus deferens/epidydimis, seminal vesicles
post. outgrowth = ureteric bud => collecting system
required to stimulate evolution of metanephric system (no ureter => no kidney)
paramesonephric duct Müllerian duct => uterus and upper vagina
=> appendix testis, prostatic utricle

Horse-shoe kidney 1: 400 - 1: 600

Pituitary anterior lobe => Rathke’s pouch (ectoderm)
post. lobe => diencephalon

Abnormality scan 18-20/40

high sensitivity (75-85%), excellent specificity ( 99%)

Heart four chambers, septum and valve motion should be visualised, right ventricle thicker than left

Abdomen section including stomach, portal vein and chord insertion

small bowel prolapses into amniotic fluid through paraumbilical abdominal wall defect
physiological < 11/40, delayed return to abdominal cavity is associated with malrotation
prolapse of bowel ± liver into umbilical chord
associated with neural tube defects, bad prognosis
Single umbilical artery
- diabetes mellitus
- twins
- cardiac and other abnormalities

Choroid plexus cysts
associated with chromosomal abnormalities i.e. 18³
Neural tube defects
failure of fusion of the invaginated mid-line ectoderm to form the neural tube and its protecting structures
wide spectrum: spina bifida - meningocele - myelomeningocele - anencephaly
intracranial signs are
banana-sign of cisterna magna as cerebellum oval rather than dumbbell shaped
lemon-sign of skull = not uniformly oval in cross-section, but frontal peak
hydrocephalus if associated Chiari-malformation (= herniation of cerebellar tonsils) compresses IVth
Anencephaly 1:1000, f:m = 4:1, raised AFP
no development of Tel- and Dienecephalon
absence of cranial vault with developed facial bones => “frog eyes”
Dandy-Walker syndrome
defect of development of midline structures
vermis-agenesis => IV ventricle communicates with cisterna magna between the unconnected cerebellar
hemispheres, associated with other midline defects
rare defect of midline structure development, absence of diencephalon, failure of cleavage of telencephalon
familial, associated with chromosomal abnormalities (15³, 18³)
- single, large mid-line ventricle
- absence of falx and lat. ventricles <=> DD: Dandy-Walker, subarachnoid cyst
- facial anomalies

Signs of foetal death

absence of heart beat
spalding-sign: overlapping of sutures
air within cerebral ventricles
air within bowel

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