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The Basics
Rathachai Kaewlai, MD
www.RadiologyInThai.com
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Study Objectives
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Basics: Plain Film Radiography
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Basics: Plain Film Radiography
Density Appearance
Air least dark
Fat less dark, but still dark
Soft tissue medium
Bone bright
Metal most brightest
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Basics: Plain Film Radiograph
Projections (views) of radiograph
determined by
Location of the x-ray tube and the
x-ray film in relation to the patients
anatomy.
For example, Postero-anterior (PA)
view means the x-ray beam travels
from back to front of the patients
and hit the film in the front of the
patients.
Chest x-ray (PA)
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The difference between PA and AP, is
the organ (or part of the body) that is
closer to the film, will be better
visualized. For example, in PA skull
radiograph, the lesion in frontal bone
will be better visualized than in
occipital bone. In chest radiograph,
different magnification causes the
cardiac silhouette to be larger in AP
projection. The rule is put the film on
the side of interest.
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Basics: Plain Film Radiograph
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Basics: Plain Film Radiograph
Portable radiograph:
The only indication is when the patient is too sick to leave the
bed. Example - ICU patients, injured patients on the trauma
board or in the operating rooms.
Cons: Different magnification (distortion of the size of organs),
decreased quality of the images.
Usually it is done in AP projection, which is still different from AP
projection performed in the radiography room.
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Basics: Plain Film Radiograph
Stress radiograph:
Put a stress (either patients
own weight, force or extra
weights to carry) on specific
organs, usually joints. For
example, acromioclavicular
joints radiograph, standing
knee radiograph, flexion/
extension views of the
cervical spine.
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Basics: Computed Tomography
CT works by
Passing a thin x-ray beam through the body of the patient in the axial
plane, as the x-ray tube moves in a continuous arc around the patient.
The opposite side of the x-ray tube are electronic detectors. The detectors
converted the exit beam into electronic signals.
The signals are sent to the computer, which calculates the x-ray
absorption values and arrange the image.
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Basics: Computed Tomography
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Basics: Computed Tomography
CT window
Different windowing in CT allows optimal evaluation of
each organs; e.g. subdural window (for subdural blood), brain
window (for brain parenchyma), bone window (for bone), etc.
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Basics: Computed Tomography
CT protocol
Almost all CT scans were performed in axial plane. These axial
scans can be processed into sagittal, coronal reformations or
others.
What is useful to find out, as a clinician?
Scanner type (conventional, helical, multidetector),
Slice thickness (ranges from submillimeter to 10
mm),
Location of first and last slices (to see the extent of study; will it
include the organ of interest?),
Type of contrast usage (what kind of contrast will radiologists give to
the patients?)
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Basics: Computed Tomography
View the CT scan as though you
were looking up at it from the
patients feet.
CT protocol
Different radiology departments have
different CT protocols. It is best to
know your own hospitals radiology
department scanners and protocols,
in order to adjust it with your own Right
Left
practice.
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Basics: Computed Tomography
Reformatted CT images
The CT scanner computer or a separate
computer can stack a series of CT slices
on top of one another, so the stack can be
sliced in other planes such as coronal,
sagittal or oblique planes.
The techniques are especially useful to
see pathology of the spine, long bone,
joint. Coronal images are easier to
understand by clinicians.
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Basics: CT Angiography
Technical difference from CT
Need faster scanner (helical, multidetector).
Need faster IV contrast injection rate (means
larger size of the needle).
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Basics: CT Angiography
Head-to-toe applications
Head and neck: aneurysm, AVM,
carotid atherosclerosis, venous sinus
thrombosis, etc.
Body: aortic dissection, pulmonary
embolism, coronary artery, renal artery
stenosis, deep vein thrombosis, etc.
Extremity: brachial, femoral
arteriogram.
Preparation
No oral contrast or rectal contrast
used.
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Basics: MRI
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Basics: MRI
Various body tissues emit
characteristic MR signals, which
determine whether they will appear
white, gray or black on the images. T2-WI
In general: Water is black on T1-WI
(T1 weighted image), white on T2-
WI. Most tumors and inflammatory
masses appear white on T2-WI.
Compact bone appears black in all
sequences. T1-WI
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Basics: MRI
T1-WI
Advantages
Greater differentiation of soft tissue
structures.
Can be acquired in any planes.
Can provide vascular study without use of
IV contrast.
Disadvantages
Longer time of scanning.
Motion artifacts from respiration, cardiac
pulsation (for scanning of the chest and
abdomen).
T1-WI + IV contrast
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Basics: Ultrasound
Advantages
No ionizing radiation, no biological injury.
Can be acquired in any planes.
Less expensive machine and exam cost.
Can be performed at the bedside of the very sick patients.
Provide moving images of the heart, fetus, and other structures.
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Basics: Ultrasound
Disadvantages
Less sharp and clear images,
Take more time than CT,
Quality and accuracy
depending on operators skills.
Some structures such as bone
and lung cannot be examined.
Normal Doppler US of the
lower extremity veins
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Basics: PACS
Advantages:
Image manipulation: brightness, contrast, rotate, zoom, measurements, etc. Better
diagnostic accuracy, e.g. see through bone in chest x-ray.
Less storage space for hard-copy images, less risky for wrong patients identification.
Teleradiology.
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With PACS, radiologists can play
with the images in multiple way. For
example: we can look at lung, ribs and
spine in one chest radiograph without
difficulty.
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Prepare Your Patients for
Imaging
Rule #1: select the right imaging technique to answer the specific clinical
question.
Know the indications.
Know what to expect from each imaging modality (its limitation and
usefulness).
Know your hospital capability (scanners, radiologists preference and ability).
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Rule #1
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Rule #2
CT: contraindications
There is no absolute contraindication if benefits weigh risks.
X-ray related: in pregnant patients and children
Contrast related:
Hypersensitivity to iodinated contrast medium.
History of seafood allergy is NOT a contraindication to iodinated
contrast medium administration. Although, if other allergic disorders
coexist, this will increase the chance of having contrast
hypersensitivity.
Asthma, allergic disorders increase risk of hypersensitivity.
Renal failure, diabetes, current use of metformin contribute to
increased risk of contrast-related renal failure.
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Rule #2
CT: contraindications - What To Do?
Pregnancy, children Other modalities (MRI, US)
Risk of hypersensitivity
Premedication with oral/IV
Steroids (consult your radiologist)
Use non-ionic contrast medium reduces the risk of minor reaction.
High serum creatinine (usually defined as Cr > 1.5 in healthy
adults, lower in older individuals. Treatment protocol varies
(consult your nephrologist)
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Rule #2
MRI: contraindications
Generally, MRI is very safe and adverse reactions to contrast
agents are extremely rare.
Absolute contraindications
Cardiac pacemakers,implanted cardiac defibrillators, otic/inner ear/
cochlear implants, metal fragments in the eye.
Others
Heart valve, aneurysm clip (depending on the models), passive
implants (depending on its ferromagnetic status).
Pregnancy: No known risks, however, late effects on fetus may be
unrealized since MR has been widely available for only 15 years.
Gadolinium is not FDA-approved during pregnancy.
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Rule #3
Know your radiologist
Communication is the key. Two-way communication between
clinicians and radiologists is encouraged for a better patient
care.
Having radiologists in the emergency department will make a
difference.
There is a different nature of emergency radiology from other
radiology subspecialties.
Safe, fast, effective radiology protocols
Supervision of the technical performance of imaging.
Performing bedside procedures.
Timely interpretation of the images.
Better communication with the emergency physicians.
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Rule #4
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Rule #4
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What to Expect
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Current Trends in ED
Radiology
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Current Trends in ED
Radiology
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New Trends in Radiology
Coronary CT angiography
Functional MRI
Molecular imaging
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How Radiology Effects Patient
Care
Pros
Help in clinical decision making, surgical VS. medical issue.
Triage patients toward proper areas (discharge, observation unit, surgery or
admission).
Fast, accurate, noninvasive diagnosis.
This could lead to faster treatment, better outcome and an overall better patient
care.
Cons
Higher cost?
Non-important incidental findings from CT may lead to multiple unnecessary
follow ups.
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Suggested reading:
Basics in radiology
Novelline RA. Squires Fundamentals of Radiology, 6th edition
(2004).
American College of Radiology Appropriateness Criteria
http://www.acr.org/s_acr/sec.asp?CID=1845&DID=16050
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The information provided in this presentation
Is intended to be used as educational purposes only.
Is designed to assist emergency practitioners in providing
appropriate radiologic care for patients.
Is flexible and not intended, nor should they be used to
establish a legal standard of care.
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