 Utilizes a screen-film system within

RADIOLOGY a film cassette (x-ray detector)

DIAGNOSTIC IMAGING METHODS
Conventional Radiology
History
st
1985 – Wilhelm Roentgen produced the 1
x-ray image
– The light passed through his wife’s hand

How is an x-ray film produced in conventional radiography?

X-RAY
 Form of radiant energy similar to visible light
 Has very short wavelength
 Penetrates many substances that are opaque
to light
 Produced by bombarding a tungsten target
with an electron beam within an x-ray tube
X-rays pass through the body (a)
 x-rays are attenuated by interaction with body tissue (a)
 transmitted x-rays through the patient bombard a fluorescent particle-
coated screen (b) in the film cassette
 produces photochemical interaction
 light rays are emitted, which exposes the film (c) in the cassette
 film is developed

FILM RADIOGRAPHY COMPUTED RADIOGRAPHY (CR)

(1) Patient is positioned (2) X-ray is taken • Filmless system
• No processing
• Produces digital radiographic images
• Substitutes a phosphor imaging plate for the film screen cassette

How is an x-ray film produced in computed

radiography?
– X-rays pass through the body 
phosphor-coated imaging plate
interacts with x-rays transmitted
(4) X-ray film is read through (3) Film cassette is taken to through the patient  phosphor
a NEGATOSCOPE the dark room for developing plate is placed within a reading
device  data is captured and
processed into a digital image
Computed Radiography
(1) Patient is positioned
(4) Digital image is read
through a monitor
(2) X-ray is taken
(3) Film cassette is placed in a
computed radiography
processing machine
The x-ray tube is located beneath the patient
examination table and the fluorescing screen with
the image intensifier above the patient.
Amplification of
the faint
fluorescing
image by the
image
intensifier allows the radiation exposure to
be kept at low levels. Real-time fluoroscopic
images are viewed on a television monitor.
Radiographs are obtained by digital image
capture or through a film cassette.

NAMING RADIOGRAPHIC VIEWS

• Most x-ray views are named on the basis of the way that an x-ray beam
passes through the patient

DIGITAL RADIOGRAPHY
• Also a filmless system
• Substitutes a fixed electronic detector on charge-coupled device for the
film screen cassette or phosphor imaging plate
 NO CASSETTE NEEDED
• Immediate images are produced through direct readout

(1) Patient is positioned (2) X-ray is taken

Chest posteroanterior (PA) Chest anteroposterior (AP)

(3) Digital image is read through a monitor • Views are also named by the position of the patient

FLOUROSCOPY
• Real time radiographic visualization of moving anatomic structures
• Continuous x-ray beam passes through the patient and falls on a
fluorescing screen  produces a light pattern which is amplified
electronically  amplified real time images are displayed on a monitor
• Useful in evaluating motion such as gastrointestinal peristalsis, movement
of diaphragm during respiration, and cardiac action.
• Also used to monitor continuously radiographic procedures such as Barium
studies and catheter placements Abdomen left lateral decubitus Abdomen upright
 AIR DENSITY BONE AND METAL DENSITY
• Air attenuates very little • Bone, metal and contrast
FIVE BASIC RADIOGRAPHY DENSITIES of the x-ray beam – agents attenuate a large
most are transmitted  proportion of x-ray beam 
black on radiograph white on radiograph

FAT AND SOFT TISSUE DENSITY

• Fat and soft tissue attenuate
intermediate amounts of x-ray
beam  shades of gray on
radiograph

WHAT IS ATTENTUATION?
• process by which a beam of radiation is reduced in intensity when passing
through material
• If a tissue has low attenuation it would suggest that it is relatively
transparent and appears dark (air)
• high attenuation is a denser material and (bone) objects appear brighter
• In general, the denser the material, the better its ability to attenuate x-ray
beam, the brighter/whiter it would appear on x-ray images
SIHLOUETTE SIGN
Right Middle Lobe and Left Lower Lobe
Pneumonia.
Demonstrates pneumonia (P) in the right
middle lobe replacing air density in the lung
with soft tissue density and silhouetting the
right heart border. The dome of the right
hemidiaphragm (black arrow) is defined by air
in the normal right lower lobe and remains
visible through the right middle lobe infiltrate.
The left heart border (white arrow), defined
by air in the lingula, remains well defined despite infiltrate in the left lower lobe.
CROSS-SECTIONAL IMAGING TECHNIQUES
• CT, MR, and Ultrasound – techniques that produce cross-sectional images
of the body
• Produces slices of patient tissue to produce a two-dimensional image
• To analyze optimally all of the anatomic information of any particular slice,
the image is viewed at different window-width and window-level settings,
which are optimized for bone, air-filled lung, soft tissue, etc.
• allows for high-detail CT angiography and virtual CT colonoscopy and
bronchoscopy
• disadvantage: radiation dose, 3-5 times higher than with single-slice CT
ADVANTAGES OF CT COMPARED WITH MR:
– rapid scan acquisition
– superior bone detail, and demonstration of calcifications

COMPUTED TOMOGRAPHY (CT) PRINCIPLES OF INTERPRETATION

• uses a computer to mathematically reconstruct a cross-sectional image of • Like radiography, images are dependent on the degree of attenuation by
the body from measurements of x-ray transmission through thin slices of different materials
patient tissue • Hounsfield Units (HU) – Units of x-ray attenuation used in CT scanning
• displays each imaged slice separately – the brighter the tissue, the higher the HU
• no superimposed blurred structures seen in conventional tomography
Hounsfield unit (HU) scale
The patient is placed on an  Air: -1,000 H.
examination. An x-ray tube rotates  Lung tissue: -400 to -600 H
360° around the patient,  Fat: -60 to -100 H
producing pulses of radiation that  Water: value of 0 H
pass through the patient.  Soft tissue: +40 to +80 H
Transmitted x-rays are detected by  Bone: +400 to H
a circumferential bank of radiation
detectors.

TYPES OF CT SCAN • generally limited to the axial plane; but may be reformatted in sagittal,
1. Conventional CT (nonhelical) coronal, or oblique planes or as three-dimensional images.
• obtains image data one slice at a time – one slice per breath hold
• requires at least two to three times the total scanning time of helical CT PLANES

2. Helical CT (spiral CT) a to c: AXIAL /TRANSVERSE

• performed by moving the patient table through the gantry while scanning d: CORONAL
continuously with an x-ray tube rotating around the patient e: SAGGITAL
• continuous volume of image data is acquired during a single breath-hold
• improved speed of image acquisition
• improved visualization of small lesions

3. Multidetector helical CT (MDCT)

• latest technical advance in CT imaging
• like helical scanner but with multiple rows of detector rings
• obtains multiple slices per tube rotation  increases the area of the
patient that can be covered in a given time
• 5-8 times faster than single-slice helical CT
 CONTRAST ADMINISTRATION IN CT
Intravenous iodine-based contrast agents are administered in CT to:
 enhance density differences between lesions and surrounding parenchyma
 to demonstrate vascular anatomy and vessel patency
 to characterize lesions by their patterns of contrast enhancement

Oral or rectal contrast is generally required to opacify the bowel for CT scans of the
abdomen and pelvis. Bowel without intraluminal contrast may be difficult to
differentiate from tumors, lymph nodes, and hematomas.

PLAIN WITH CONTRAST

 gray scale: in the left edge

 centimeter scale: along the right side of the image
 R: patient's right side
 L: patient's left side
 Cross-sectional images in the transverse plane are routinely viewed from
“below,”as if standing at the patient's feet

Optimal bone detail is viewed at bone windows

 window width of 2,000 H, window level of 400 to 600 H
Lungs are viewed at lung windows
 window width of 1,000 to 2,000 H, window levels of about 500 to 600 H
Soft tissues
 window width of 400 to 500 H, window level 20 to 40 H
MAGNETIC RESONANCE IMAGING (MRI)
 produces tomographic images by means of magnetic fields
and radio waves
 MR is based on the ability of a small number of protons within
the body to absorb and emit radio wave energy when the
body is placed within a strong magnetic field

LUNG WINDOW

SOFT TISSUE WINDOW

MRI…
 Most tissues can be differentiated by differences in their T1 and T2
relaxation times
o T1 is a measure of a proton's ability to exchange energy with its
surrounding chemical matrix
 It is a measure of how quickly a tissue can become
magnetized
o T2 conveys how quickly a given tissue loses its magnetization
ADVANTAGES OF MR:
 outstanding soft tissue contrast resolution
 provides images in any anatomic plane
 absence of ionizing radiation
DISADVANTAGES OF MR:
 limited in its ability to demonstrate dense bone detail or calcifications
 involves long imaging times for many pulse sequences
 possesses limited spatial resolution compared with CT
 limited availability in some geographic areas
 expensive
CONTRAST ADMINISTRATION IN MR:
• Gadolinium chelates
• Given to:
– identify regions of disruption of the blood-brain barrier
– enhance organs to accentuate pathology
– document patterns of lesion enhancement
SAFETY CONSIDERATIONS IN MRI
 MR is contraindicated in patients who have electrically, magnetically, or
mechanically activated implants
– cardiac pacemakers, insulin pumps, cochlear implants,
neurostimulators, bone-growth stimulators, and implantable drug
infusion pumps
– intracardiac pacing wires or Swan-Ganz catheters
– Ferromagnetic implants, such as cerebral aneurysm clips, vascular
clips, and skin staples
– Bullets, shrapnel, and metallic fragments
 Safe for MR
– nonferromagnetic vascular clips and staples and orthopaedic
devices
– Prosthetic heart valves with metal components
 Pregnant patients can be scanned, provided the study is medically
indicated
PRINCIPLES OF INTERPRETATION:
 Soft tissue contrast is obtained through imaging sequences that accentuate
differences in T1 and T2 tissue relaxation times
 Water is the major source of the MR signal in tissues other than fat
 Mineral-rich structures, such as bone and calculi, and collagenous tissues,
such as ligaments, tendons, fibrocartilage, and tissue fibrosis, are low in
water content and lack mobile protons to produce an MR signal
o low in signal intensity on all MR sequence
FREE WATER IN MRI
• found mainly as extracellular fluid, also as intracellular free water
– Organs with abundant extracellular fluid
• kidneys (urine); ovaries and thyroid (fluid-filled follicles);
spleen and penis (stagnant blood); and prostate, testes,
and seminal vesicles (fluid in tubules)
• Edema (increase in extracellular fluid)
• Most neoplastic tissues have increase in extracellular fluid as well as an
increase in the proportion of intracellular free water  bright signal
intensity on T2WIs
PROTEINACEOUS FLUIDS IN MRI
• addition of protein to free water shortens T1 relaxation time – bright
• T2 relaxation is also shortened, but the T1 shortening effect is dominant
even on T2WIs -- remain bright on T2WIs
• synovial fluid, complicated cysts, abscesses, many pathologic fluid
collections, and necrotic areas within tumors
 A complicated rectal cyst showing hyperintensity on both T1 and T2 images

SOFT TISSUES ON MRI

 Soft tissues that have a predominance of intracellular bound water have
shorter T1 and T2 times than do tissues with large amounts of extracellular
water
o liver, pancreas, adrenal glands, and muscle -- intermediate signal FLOWING BLOOD ON MRI
intensities on both T1WIs and T2WIs  Higher-velocity blood flow alters the MR signal in complex ways,
depending on multiple factors.
T1W T2W o high-velocity signal loss predominates in spin-echo imaging,
resulting in signal void “black blood” in areas of flowing blood.

FAT ON MRI

 T1 relaxation time is short -- bright signal

 T2 of fat is shorter than T2 of water-- lower signal intensity for fat, relative
to water
 On images with lesser degrees of T2 weighting, T1 effect predominates and
fat appears isointense or slightly hyperintense compared with water.
 STIR sequences suppress signals from all tissues with short T1 times,
including fat
 ULTRASONOGRAPHY PLANES
AXIAL/TRANSVERSE
ULTRASOUND
 utilizes pulse-echo technique
 transducer converts electrical
energy to a brief pulse of high-
frequency sound energy

transducer becomes a receiver,

detecting echoes of sound energy

image is produced

 produces nearly real-time images of moving patient tissue

SAGITTAL/LONGITUDINAL
– enables assessment of respiratory and cardiac movement,
vascular pulsations, peristalsis, and moving fetus
 Images may be produced in any anatomic plane by adjusting the
orientation and angulation of the transducer and the position of the
patient.
– standard orthogonal planes: axial, sagittal, and coronal
 Visualization of structures by US is limited by bone and gas-containing
structures (e.g. bowel and lung)

Sound energy is nearly completely absorbed at interfaces between soft tissue and
bone, causing an acoustic shadow limiting visualization of structures deep to the
bone surface.

Soft tissue-gas interfaces cause nearly complete reflection of the sound beam,
LIMITATION OF ULTRASOUND (BONE)
preventing visualization of deeper structures
Sound energy is nearly completely
Looking at ultrasound images absorbed at interfaces between
soft tissue and bone (rib, R),
causing an acoustic shadow limiting
visualization of structures deep to
the bone surface
LIMITATION OF ULTRASOUND (BONE) ULTRASOUND ARTIFACTS

Soft tissue-gas interfaces (bowel Acoustic Shadowing

loop) cause nearly complete Gallbladder stone Bone (rib)
reflection of the sound beam,
preventing visualization of deeper
structures

Acoustic Enhancement
Cyst Gallbladder

DOPPLER ULTRASOUND

 adjunct to real-time gray-scale imaging

 detects reflection of the sound wave from a moving object – RBC in flowing
blood
 can detect presence of blood flow and its direction and velocity

Doppler ultrasound of the carotid artery

Comet-Tail Artifact

Comet-tail artifacts (>) adenomyomatosis of the gallbladder

arise from normal
pleura (*) reflecting
sound waves.
 PRINCIPLES OF ULTRASOUND INTERPRETATION
HYPOECHOIC

HYPERECHOIC
H

Fluid-containing Structures

Renal Cyst Dilated renal ANECHOIC

calyces and pelvis
Normal
Normal Bladder
gallbladder

Solid Tissue (Fatty Tissue)

Fatty liver Lipoma