11/15/2012

Residents Review Session

Department of Radiology, Vancouver General Hospital

Dr. Savvas Nicolaou Director of ER/Trauma Radiology savvas.nicolaou@vch.ca

Note: NO NEW SLIDES! All Review

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Lecture 1- Introduction to Imaging Modalities

Overview of imaging modalities

X-ray systems Radiography (plain films, fluoroscopy, angiography) Computed Tomography (CT)

Magnetic Resonance Imaging (MRI)

Ultrasound

Nuclear Medicine (NM) / Positron Emission Tomography (PET)

Radiography
5 major densities are found on radiographs, and are demonstrated on this image
Air - fat - water - bone - metal Soft tissue

Lower

Higher

fat

Note that THICK structures attenuate more radiation than THIN structures of the same composition
air metal

bone

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Fluoroscopy Continuous low dose radiography used to monitor part of the body in real-time Often used in conjunction with contrast, can be helpful to evaluate motion such as gastrointestinal peristalsis Used less commonly in urban settings

NB: Contrast is an exogenous agent used to alter the attenuation of a structure

Barium Swallow

CT Views

CT Axial CT Coronal CT Sagittal

Hounsfield Unit (HU)

Gall bladder 6 HU

Colon -1000 HU

Liver 50 HU

Fat -120

Air -1000; fat -100; water 0; blood 30 ; bone 500+ HU

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Magnetic Resonance Imaging (MRI)

The released energy can be detected over time and images can be `weighted` to enhance different characteristics of the soft tissue

T1 weighted usually best anatomical detail, gadolinium can be used as contrast T2 weighted usually most sensitive for pathological lesions (Water is White in T2 - World War 2)

MRI Images

T1 weighted

T2 Weighted

Ultrasound (US)

2
Anechoic

g Echogenic Acoustic Shadow Hypo-echoic

Longitudinal cross section of the gall bladder. Fluid in bladder shows no reflections (1) whereas calcified stones (2) show strong reflections with decrease of signal beyond (3)

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Nuclear Medicine - Bone Scan

Multiple metastatic bone lesions show higher retention of radiolabelled bone seeking agent

Hot spot

Nuclear Medicine Positron Emission Topography (PET)

Positron Emission Tomography PET uses fluorine-18 which is a positron emitter. Positron emission produce photons that can be imaged. Fluorine-18 can be incorporated into biologically ti i t bi l i ll active molecules l l such as fluoro-18-deoxyglucose used for cancer staging

CT

PET/CT

PET

Lecture 2- Imaging of the Spine

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Radiograph Views of the Spine

Anterior-Posterior (AP)

Lateral

Lateral View of Cervical Spine

Anterior arch of CI Dens

Posterior arch of CI Pedicle (best seen on oblique image)

CII Vertebral Body

Inferior Articular Process

CIII
CIII-IV Vertebral Disc

Superior Articular Process

CIV

Transverse Process Spinous Processes

CVI
Intervertebral Foramen
(best seen on oblique image)

CVII TI

AP View
From the AP view, thoracic and lumbar vertebrae create an owl appearance:

Eyes are pedicles Beak is spinous process Face is vertebral body Ears are transverse processes

CVII Vertebral Body

Right Pedicles of CVII & TI

Spinous Processes

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Right Intervertebral Foramen (CIII nerve)

Pedicle

CIV Vertebral Body

Spinous Processes

Inferior Articular Process

Superior Articular Process

Oblique

Radiographical Views: X-ray

Odontoid

Dens and body of CII centre Lateral masses of CI right and left

CT Images

Anterior arch

Dens Anterior arch Dens

Foramen transversarium

Right lateral mass

Left lateral mass

Right lateral mass Posterior arch

Left lateral mass

Posterior arch

This is CI (Atlas)

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CT Images - Coronal

Dens

CI lateral mass

CII vertebral body

CI lateral mass

Inferior articular facet CI

Superior articular facet CII CII vertebral t b l body

Intervertebral disc

CV

Anterior arch CI

Dens CII vertebral body

Spinal canal

Spinous Processes

Intervertebral disc space

Spinous Process Spinal Cord (dark on MR) CSF surrounding the cord (light on MR) Vertebral Body V t b lB d

Intervertebral Disc (cannot differentiate annulus from nucleus due to age related desiccation of disc)

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X-ray Thorax AP

Numbering vertebra is easiest from top or bottom (most superior or inferior vertebra articulating with a rib)

Transverse Process Spinous Process

Note: The owl appearance is consistent between thoracic and lumbar vertebrae

Pedicle T12 12th rib

Thoracic Lateral

? Vertebral Bodies Intervertebral disc spaces

Intervertebral foramen Inferior Articular Process Superior Articular Process

CT Sagittal

Vertebral bodies

Intervertebral foramen Inferior articular process Superior articular process

Intervertebral disc spaces Pedicles

Pars interarticularis

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X-ray Lumbar AP

12th rib Pedicles Spinous Processes Intervertebral disc space Transverse Processes

Sacrum

X-ray Lumbar Lateral

LI LII Intervertebral Foramen Inferior articular process Superior articular process Pars interarticularis

LIII Intervertebral disc space

LIV

LV

Lecture 3- Imaging of the Shoulder

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AP View

1. 2. 3. 4.

Clavicle acromial end Clavicle- sternal end Acromion Coracoid process

1 3 4 2

AP View

5. Glenoid cavity 6. Humerus greater tuberosity 7. Humerus lesser tuberosity 8. Head of humerus

8 7 6

AP View

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9. Surgical neck of humerus 10. Anatomical neck of humerus 11. Supraglenoid tubercle 12. Infraglenoid tubercle

10 9 12

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1 2 3 3

A) What are the borders of the scapula indicated by the yellow arrows? 1. Lateral border 2. Superior border 3. Medial border B) What are the angles of the scapula indicated by the green arrows?

1. Superior angle 2. Inferior angle 3. Lateral angle

Lateral View

1 7 3 2 4 5

1. Clavicle acromial end 2. Acromion 3. Coracoid process 4. Spine of scapula 5. Head of humerus 6. Humerus 7. Superior angle of scapula 8. Inferior angle of scapula

Axillary View
1. 2. 3. 4. Humerus Coracoid Process Clavicle Glenoid cavity 5. 6. 7. 8. Greater tuberosity Lesser tuberosity Intertubercular sulcus Head of humerus 9. Anatomical neck 10. Surgical neck 11. Acromion

2 5 7 6 1 10 8 9 11 4 3

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Lecture 4- Imaging of Elbow and Forearm

Radiograph Views of the Elbow

AP View Lateral View

AP View of Elbow
Medial Supracondylar Ridge Lateral Supracondylar Ridge Medial Epicondyle

3 1

2 6

Lateral Epicondyle Radial Neck 1. 2. 3. 4. 5. 6. 7. Trochlea Capitulum Olecranon (behind trochlea) Ulna Radius Radial Head Radial Tuberosity

Coronoid Process of Ulna

4 7 5

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Lateral View of Elbow

1. 2. 3. 4. 5. 6. 7.

Shaft of Humerus Trochlea Olecranon Coronoid Process Head of Radius Radial Tuberosity Tuberosity of Ulna

4 2
Trochlear Notch

5 7

Lecture 5- Cross Sectional Imaging of the Chest

Full size axial CT with contrast

8 7 6 3 2 1 5 4 9

1. Esophagus 2. Trachea 3. Brachiocephalic Artery (Bifurcation into Right Common Carotid Artery and Right Subclavian Artery) 4. Left Common Carotid Artery

5. Left Subclavian Artery 6. Right Subclavian Vein 7. Right Internal Jugular Vein 8. Left Internal Jugular Vein 9. Left Subclavian Vein

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Full size axial CT with contrast

6 4 2 1

1. Esophagus 2. Trachea 3. Brachiocephalic Artery 4. Left Common Carotid Artery

5. Left Subclavian Artery 6. Right Brachiocephalic Vein 7. Left Brachiocephalic Vein

Full size axial CT with contrast

2 1

1. Esophagus 2. Trachea 3. Superior Vena Cava

4. Aortic Arch

Full size axial CT with contrast

5 4 7

2 1

1. Esophagus 2. Bifurcation into Right Main Bronchus 3. Bifurcation into Left Main Bronchus 4. Pulmonary Trunk

5. Ascending Aorta 6. Descending Thoracic Aorta 7. Superior Vena Cava

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Full size axial CT with contrast

4 8

7 6

1 5 2 3 9

1. Right Main Bronchus 2. Left Main Bronchus 3. Esophagus 4. Pulmonary Trunk 5. Right Pulmonary Artery

6. Left Pulmonary Artery 7. Superior Vena Cava 8. Ascending Aorta 9. Descending Thoracic Aorta

Full size axial CT with contrast

1. Esophagus 2. Descending Thoracic Aorta 3. Sinus of Valsalva (Aortic Sinus) -directly distal to aortic valve outlined-

Full size axial CT with contrast

1 2

(4)

1. Esophagus 2. Descending Thoracic Aorta

3. Inferior Vena Cava (4. Liver)

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Full size coronal CT with contrast

1 5

7 6 3 4 (9) 2

(10)

1. Trachea 2. Pulmonary Trunk 3. Ascending Aorta 4. Aortic Sinus 5. Brachiocephalic Artery

6. Superior Vena Cava 7. Right Brachiocephalic Vein 8. Left Brachiocephalic Vein (9. Right Atrium) (10. Left Ventricle)

Full size coronal CT with contrast

1 5 4 6 3 8 2 7

1. Trachea 2. Pulmonary Trunk 3. Aortic Arch 4. Brachiocephalic Artery 5. Left Common Carotid Artery

6. Right Brachiocephalic Vein 7. Left Brachiocephalic Vein 8. Superior Vena Cava 9. Inferior Vena Cava

Full size coronal CT with contrast

4 3

6 5

1. Esophagus 2. Trachea 3. Aortic Arch 4. Left Subclavian Artery

5. Right Pulmonary Artery 6. Left Pulmonary Artery

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Full size coronal CT with contrast

1 2 5 3 7

1. Esophagus 2. Trachea 3. Right Main Bronchus 4. Left Main Bronchus

5. Descending Thoracic Aorta 6. Right Pulmonary Artery 7. Left Pulmonary Artery

Full size coronal CT with contrast

1. Esophagus

2. Descending Thoracic Aorta

Coronal CT Imaging of Lungs

4 7 3 5 8 2 1 6 8

3 5 1 6

1. 2. 3. 4.

Right Major (oblique) fissure Left major (oblique) fissure Right minor (horizontal) fissure Right Upper Lobe

5. 6. 7. 8.

Right Middle lobe Right Lower lobe Left Upper lobe Left lower lobe

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Full size sagittal CT with contrast

1. Left Main Bronchus 2. Aortic Arch 3. Descending Thoracic Aorta

4. Left Subclavian Artery 5. Left Brachiocephalic Vein

Full size sagittal CT with contrast

(5)

4 1

3 2

(6)

1. Trachea 2. Right Pulmonary Artery 3. Ascending Aorta

4. Left Brachiocephalic Vein (5. Brachiocephalic Artery) (6. Left Atrium)

Lecture 6- Imaging of The Cardiac Anatomy

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Heart borders (anterior)

Aortic root Superior vena cava Right atrium

Pulmonary artery

Left ventricle Right ventricle

Heart borders (right lateral)

Aortic root

Right atrium Right atrial appendage

Right ventricle

Radiology Anatomy of the Thorax Axial View

Aortic Valve

Left atrium

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Radiology Anatomy of the Thorax Axial View

Right Atrium

Left inferior pulmonary vein Descending Aorta

Radiology Anatomy of the Thorax Axial View

Right ventricle

Tricuspid Valve

Left Ventricle

coronary sinus

Radiology Anatomy of the Thorax Axial View

Moderator Band

Left Ventricle

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Valvular Anatomy: Pulmonary Valve

Tricuspid + Mitral valves

Radiology Anatomy of the Thorax Coronal View

Aorta Pulmonary Artery

Ascending Aorta

Left Ventricle

Right Ventricle

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Radiology Anatomy of the Thorax Coronal View

Trachea

Right Pulmonary Ri ht P l Artery

Left Pulmonary Artery Left Ventricle

Volume rendered heart (anterior)

Aortic root

Right coronary artery

Left anterior descending coronary artery

Volume rendered lateral

Aortic root

Right coronary artery Left anterior descending coronary artery

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Volume rendered - Left lateral

Left Circumflex

LAD coronary artery

Volume rendered - posterior

Posterior descending artery

Origins of coronary arteries

Right coronary artery

Ascending aorta Left main coronary artery

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Left coronary artery branches

Left main coronary artery

Left anterior descending artery

Circumflex artery

Left coronary artery branches

Circumflex artery

Left coronary artery branches

Left anterior descending artery

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Lecture 7- Imaging of CXR

BASIC ANATOMY

Trachea Transverse thoracic aortic arch Left hilum Left atrial appendage Left ventricle

SVC / Azygos confluence Right hilum

Right atrium

Right hemidiaphragm

Costophrenic angle

Sternum

Thoracic Vertebral bodies

RT Ventricle abutting retrosternal space

Left Atrium

Posterior margin of LT ventricle

Normal Lateral Chest

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MAJOR AIR WAYS

Pneumothorax - Air in Pleural Space

Parietal pleura Visceral pleura

HILUM

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Right Upper, Middle and Lower Lobes

RUL RUL

RML RML RLL

RLL

Left Lower and Upper Lobes

LUL

LUL

LLL LLL

Lecture 8 Imaging of Abdominal X-Ray

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GASTROINTESTINAL SYSTEM Interpreting the Abdominal Radiograph How the radiograph is taken
Routine 3 Views: Supine AP abdomen Erect AP abdomen Erect chest x-ray

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Liver

Spleen Stomach

pedicle
Hepatic flexure

Left kidney

Spinous process

Left psoas margin g

Left sacroiliac joint

Left hip joint

Symphisis pubis

Soft Tissue
Liver Spleen Stomach Left kidney Hepatic flexure

Left psoas margin

Rectum

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Bone

Spinous process

Pedicle g Right iliac crest

Right acetabulum

Left sacroiliac joint

Right femoral head

Bowel Gas

Bowel Gas

Lecture 9 Cross Sectional Imaging of the Abdomen

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Upper abdomen axial view level of the pancreas and L1

12 2 3 8 7 11 5 4 6 1 10

12 2 4 5 9 3 8 11
8. Abdominal aorta 9. Inferior vena cava 10. Right crus 11. Left adrenal gland 12. Rectus abdominus

1 10

6 7

1. 2. 3. 4. 5. 6. 7.

Liver Stomach Pancreas Small intestine Large intestine Intra-abdominal fat Spleen

Mid-abdomen axial view level of kidneys and L3

10 3 2 1 8 7 9 5 6 2

10 3

8 7 9

5 4 6

1. 2. 3. 4. 5. 6.

Liver Ascending colon Transverse colon Descending colon Small intestine Left kidney

7. Abdominal aorta 8. Inferior vena cava 9. Psoas muscle 10. Rectus Abdominus

Lower abdomen - axial view level of L5

4 8 10 9 7 5 6 3 12 8 7 10

4 23 9 1 5 6

1. Transversus abdominus muscle 2. Internal oblique muscle 3. External oblique muscle 4. Rectus abdominus 5. Psoas muscle

6. Quadratus lumborum muscle 7. Lumbar vertebral body 8. Ascending Colon 9. Descending Colon 10. Small Intestine

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Mid-Sagittal view

2 2 1 1 3 3
1. Abdominal aorta 2. Liver 3. Small intestine

Right Para-Sagittal view

6 6 5 5 4 4

4. R Kidney 5. Quadratus lumborum muscle 6. Liver

Left Para-Sagittal view

7 4 5

7 4 5

4. L Kidney 5. Quadratus lumborum muscle 6. Stomach 7. Spleen

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Vascular Review
1. Aorta 2. Left Common Iliac Artery 3. Right Common Iliac Artery 4. Left External Iliac Artery 5. Left Internal Iliac Artery 6. 6 Inferior Vena Cava

1 6 2 3 5 4

Coronal view

1 2

3 4 2 7 6 5

3 4

7 5 6
5. Descending colon 6. Rectum 7. Ascending colon

1. 2. 3. 4.

Liver Gallbladder Stomach Small intestine

Coronal view

4 3 2

1 2

5 6 6 5

1. Fundus of stomach 4. Cardial notch 2. Body of stomach 5. Psoas muscles 3. Pyloric antrum of stomach 6. Iliacus muscle

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Coronal view

1 3 4

1 3 4

5 6 6

1. 2. 3. 4.

Liver Spleen Left kidney Psoas muscle

5. Gluteal muscles 6. Rectum

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