Diagnostic Med. Image
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Lucian MuflicDiagnostic Med. Image
Uploaded by
Lucian MuflicDIAGNOSTIC
MEDICAL
IMAGING
Dr. T. Chung, Dr. N. Jaffer, Dr. G. Olscamp, and Dr. D. Salonen
Gus Chan, Rob Hawkes, and Tyler Rouse, chapter editors
Sharon J. Kular, associate editor
IMAGING MODALITIES . . . . . . . . . . . . . . . . . . . . . 2
CHEST IMAGING . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
General
Approach to the Chest X-Ray (CXR)
Common CXR Abnormalities
Computerized Tomography (CT) Scan
MUSCULOSKELETAL SYSTEM. . . . . . . . . . . . . . . 9
Modalities
General Approach to Interpretation of Bone X-Rays
Trauma
Arthritis
Tumour
Infection
Metabolic
GASTROINTESTINAL (GI) TRACT. . . . . . . . . . . 13
Abdominal Plain Films (AXR)
Contrast Studies
Solid Visceral Organ Imaging
ITIS Imaging
GENITOURINARY SYSTEM. . . . . . . . . . . . . . . . . 17
Modalities
Selected Pathology
MCCQE 2002 Review Notes Diagnostic Medical Imaging DM1
NEURORADIOLOGY . . . . . . . . . . . . . . . . . . . . . . . 19
Modalities
Selected Pathology
NUCLEAR MEDICINE . . . . . . . . . . . . . . . . . . . . . . 21
Thyroid
Chest
Bone
Abdomen
Inflammation and Infection
Brain
VASCULAR-INTERVENTIONAL . . . . . . . . . . . . . 23
RADIOLOGY
APPROACH TO COMMON. . . . . . . . . . . . . . . . . . 26
PRESENTATIONS
Musculoskeletal Pathology
Abdominal Pathology
Urinary Tract Pathology
Reproductive Pathology
Neuropathology
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
DM2 Diagnostic Medical Imaging MCCQE 2002 Review Notes
IMAGING MODALITIES
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DM4 Diagnostic Medical Imaging MCCQE 2002 Review Notes
CHEST IMAGING
GENERAL
Attenuation: reduction of the intensity of an x-ray beam as it traverses matter
Density: defined by the ability of a structure to attenuate (absorb) the x-ray beam
(air < fat < water < soft tissue < bone/metal/calcium)
absorption is inversely proportional to penetration
structures further away from film are enlarged due to scattering of rays
contrast: difference between densities
standard views: erect PA and left lateral (see Colour Atlas DM1-DM3)
differentiate AP from PA, and supine from erect
supplemental films may include oblique, lordotic, and decubitus (left or right) views
APPROACH TO THE CHEST X-RAY (CXR)
Mnemonic: It May Prove Quite Right but Stop And Be Certain How Lungs Appear
Extrinsics
Identification: date of exam, patient name, sex, age
Markers: R and L
Position: medial ends of clavicles should be equidistant from spinous process at midline
Quality: degree of penetration (e.g. disc spaces just visible through
heart but not able to see detailed bony anatomy)
Respiration: right hemidiaphragm at 6th anterior interspace or 10th
rib posteriorly on good inspiration
poor inspiration results in poor aeration, vascular crowding, compression
and widening of central shadow
Intrinsics
Soft tissues: neck, axillae, pectoral muscles, breasts/nipples, chest wall
nipple markers can help identify nipples
look for masses and amount of soft tissue present
soft tissues may cast shadows into the lung fields
Abdomen: liver, stomach and gastric bubble, spleen, gas-filled bowel loops,
vertebrae, free air
Bones: C-spine, T-spine, shoulder girdle, ribs (turn film on its side to help focus on ribs),
sternum (best on lateral film)
Central shadow: trachea, heart borders, great vessels, mediastinum, spine
Hila: pulmonary vessels, mainstem and segmental bronchi, nodes
Lungs: pleura, diaphragm, lung parenchyma
Absent structures: review the above, noting ribs, breasts, lung lobes
COMMON CXR ABNORMALITIES
abnormal findings are not pathognomonic of a particular diagnosis and only suggest certain types of disease
always consider the clinical history
ALWAYS HAVE PREVIOUS FILM FOR COMPARISON (if available)
Bones and Soft Tissues
obliteration of clavicular companion shadow may represent excess fat or
supraclavicular adenopathy (the latter most likely if unilateral)
lytic or sclerotic lesions may be primary or mets (see Musculoskeletal System section)
fractures in ribs (discontinuity in bony cortex or sharp line)
features of osteoporosis (osteopenia, compression #, wedged vertebral bodies)
may be seen in the T-spine (see Musculoskeletal System section)
Pleura, Diaphragm, and Viscera
pleural and extrapleural masses: form obtuse angles at their edges
(see Colour Atlas DM4 and DM5)
pulmonary/parenchymal masses: form acute angles with the pleura
pleural thickening and effusions (see Colour Atlas DM4)
high diaphragm: abdominal distention, lung collapse, diaphragmatic paralysis,
pneumonectomy, pregnancy, pleural effusion
low diaphragm: asthma, emphysema, large pleural effusion, tumour
free air underneath diaphragm (pneumoperitoneum) (see Colour Atlas G2)
calcifications in diaphragm: asbestosis
gastric air bubble located under the left hemidiaphragm
Blunting of Costophrenic Angles (see Colour Atlas DM4)
indicates pleural effusion or thickening
features of effusion
fluid is higher laterally than medially
fluid forms meniscus with pleura, best seen on lateral
MCCQE 2002 Review Notes Diagnostic Medical Imaging DM5
CHEST IMAGING . . . CONT.
where effusion runs into a fissure, both sides of the fissure are visible
trachea and mediastinum central or pushed to opposite side
lateral decubitus film with effusion in dependent position will show layering
may see partial collapse (atelectasis)
pooling of fluid occurs first in posterior recess, then spreads laterally and anteriorly
for subpulmonic effusion first sign may be a shift of maximal convexity of the hemidiaphragm
from the middle 1/3 to the junction of the middle 1/3 and lateral 1/3
need at least 200 cc of fluid in subpulmonic pleural space for blunting to occur
never see horizontal fluid level unless associated with pneumothorax
(always a meniscus), i.e. a hydropneumothorax
effusions more likely to be malignant when massive (a soft sign)
blunting may also represent scarring of parietal pleura from old infections, trauma, surgery
U/S superior over plain film for detection of small effusions (can also aid in thoracocentesis)
Pneumothorax (see Colour Atlas R8)
thin, veil-like pleural margin over the lung edge with no lung markings extending beyond
air collects superiorly
more obvious on expiratory or lateral decubitus film
atelectasis (partial, complete) may be seen
mediastinal shift if air under tension
Enlargement/Distortion of Cardiovascular Shadow (see Colour Atlas DM7)
cardiothoracic ratio
in adults, the ratio of the greatest transverse dimension of the central shadow
to the greatest transverse dimension of the thoracic cavity
only valid on good quality erect PA chest film
> 0.5 abnormal
cardiomegaly, poor inspiration, supine position, obesity, pectus excavatum
DDx of ratio > 0.5: cardiomegaly suggests either myocardial hypertrophy,
myocardial dilatation or pericardial effusion
(pure hypertrophy very hard to see)
may be < 0.5 and still be enlarged if multiple problems (e.g. cardiomegaly + emphysema)
pericardial effusion
globular heart
loss of indentations on left mediastinal border
peri- and epicardial fat pad separation on lateral film
transverse diameter of heart changes by 1 cm between systole and diastole
Isolated Cardiac Chamber Enlargements (see Figure 1)
Figure 1. Cardiac Enlargement Patterns
right atrial (RA) enlargement
increase in curvature of right heart border
enlargement of superior vena cava (SVC)
left atrial (LA) enlargement
straightening of left heart border
increased radio-opacity of lower right side of cardiovascular shadow (double heart border)
elevation of left main bronchus (specifically, the upper lobe bronchus on the lateral film),
distance between left main bronchus and heart border > 7 cm, splayed carina (late)
compression of esophagus on GI barium studies
right ventricular (RV) enlargement
elevation of cardiac apex off diaphragm
anterior enlargement on lateral leading to loss of retrosternal air space
increased contact of RV against sternum
left ventricular (LV) enlargement
displacement of cardiac apex inferiorly and posteriorly
increased outward lower bulging
on lateral film, from junction of inferior vena cava (IVC) and heart at level of diaphragm,
measure 1.8 cm posteriorly then 1.8 cm superiorly > if cardiac shadow extends beyond this,
then LV enlargement (Riglers Sign)
DM6 Diagnostic Medical Imaging MCCQE 2002 Review Notes
CHEST IMAGING . . . CONT.
Calcifications
valves, coronary arteries, pericardium, aorta, walls of LV (posterior infarct/aneurysm), costochondral junction
to identify calcified/artificial valves, consider direction of blood flow and location
on lateral film, draw line from carina to xiphoid > divide heart into thirds
> valves should fall at junctions of lines (see Figure 2)
Figure 2. Lateral Chest Showing Valves
Hyperinflation (see Colour Atlas R11 and R12)
increased radiolucency (increased aeration)
vasculature spread further apart (attenuation)
low, flattened diaphragms, often serrated (fibrosis), seen best on lateral
look for spontaneous pneumothorax secondary to rupture of air bullae
increased AP chest diameter and retrosternal airspace on lateral
HRCT is best modality
Silhouette Sign (see Colour Atlas R10)
in CXR, can see diaphragm and mediastinum because of abrupt change of radiodensities
between lung and these structures
silhouette sign refers to loss of normally appearing profiles or interfaces implying solid change
in adjacent lung
e.g. loss of R heart border = right middle lobe (RML) consolidation
L heart border = lingula
R hemidiaphragm = right lower lobe (RLL) or pleura
L hemidiaphragm = left lower lobe (LLL) or pleura
aortic arch = anterior segment left upper lobe (LUL)
superior vena cava = right upper lobe (RUL)
signs mostly due to consolidation, but other processes may also produce silhouette sign (atelectasis, masses)
Air Space Disease vs Interstitial Disease (see Colour Atlas R1 and R2)
air space disease: pathological process primarily in alveoli
acinar shadows (small, fluffy, ill-defined densities which tend to coalesce)
air bronchogram (see above)
the silhouette sign (see above)
DDx: fluid (pulmonary edema), pus (pneumonia), blood (hemorrhage), cells (lung cancer/lymphoma),
protein (alveolar proteinosis)
interstitial disease: pathological process primarily in lung interstitium (i.e. scaffolding of lung)
reticular pattern: thin, well defined linear densities, often in net-like arrangement;
Kerley B lines may be present (see below)
nodular pattern: multiple, discrete, nodular densities, < 5 mm diameter
reticulonodular: may see both patterns
DDx: pulmonary edema, miliary TB (see Colour Atlas R6), idiopathic pulmonary fibrosis,
sarcoidosis, pneumoconioses
both air space and interstitial disease may be occurring simultaneously (e.g. pulmonary edema)
Consolidation
process whereby air in lung acini is replaced by fluid (or tissue) (i.e. air space disease)
areas vary from 5 mm to entire lung fields
initially may have multiple foci, ill-defined and irregularly-shaped
foci may later coalesce into areas of homogeneous radiopacity (i.e. lobar consolidation)
T
Ao
M
P
P = pulmonic valve
Ao = aortic valve
M = mitral valve
T = tricuspid valve
MCCQE 2002 Review Notes Diagnostic Medical Imaging DM7
CHEST IMAGING . . . CONT.
features
shape conforms to that of lobes or segments (see Figure 3)
no homogeneous shadow outside the lung edge
air bronchogram may be present
where the consolidation abuts against a fissure, only one side of the fissure is visible
trachea and mediastinum are pulled toward side of shadow (secondary to volume loss)
silhouette sign
DDx: infection (especially bacterial pneumonia), infarction, pulmonary contusion, allergy, tumour
Figure 3. Common Consolidation Patterns
Pulmonary Edema
either cardiogenic (congestive heart failure (CHF), renal failure, volume overload) or non-cardiogenic
(acute respiratory distress syndrome (ARDS), aspiration, noxious gas inhalation), neurogenic
edema fluid initially collects in interstitium > see reticulonodular pattern first > Kerley B lines
seen first in hilum, then spread outwards to periphery
in severe pulmonary edema, fluid begins to collect in alveoli
("bat wing's appearance" is seen with alveolar edema)
Septal (Kerley) Lines (see Colour Atlas DM7)
thickened connective tissue planes
occur most commonly in pulmonary edema and lymphangitis carcinomatosis
Kerley A lines: radiate towards hila in mid- and upper-lung zones, lines 3-4 cm long,
smaller than vascular markings (not useful)
Kerley B lines: horizontal, < 2 cm long and 1 mm thick, at periphery of lung, reach lung edge (very useful)
differential diagnosis of Kerley B Lines: pulmonary edema, lymphangitic carcinomatosis, sarcoid, lymphoma
Sequential Pattern of Findings in CHF Relative to
Left Ventricular and Diastolic Pressure (LVEDP) (see Colour Atlas R3 and R4)
LVEDP of 15 - pulmonary vascular redistribution to upper lung zones
LVEDP of 20 - interstitial edema with Kerley B lines and peribronchial cuffing (edema)
LVEDP of 25 - alveolar edema, significant air space pattern
Atelectasis
loss of volume pattern (subsegmental pulmonary collapse)
may be secondary to bronchial obstruction, fibrosis, pleural disease, pulmonary embolus (PE), bronchiectasis
examples of bronchial obstruction include bronchogenic cancer and post-op mucus plugging
there are three causes of atelectasis:
1) resorption: collapse of alveoli develops within a few hours of
airway obstruction because air distal to lesion is resorbed
2) passive: decreased lung volume secondary to a space-occupying lesion
3) cicatrization: increased recoil secondary to fibrosis
signs of collapse
shift of a fissure (most important)
mediastinal shift to the side of collapse (except in a tension pneumothorax)
shift of hilum
diaphragm elevation (less volume in the hemithorax)
increased density (shadow of collapsed lobe)
compensatory hyperinflation (ventilated areas are blacker)
silhouette sign may be seen
bronchogenic cancer until proven otherwise
Pulmonary Nodules (see Table 2) (see Colour Atlas R7)
differential diagnosis: primary cancer (35%), non-specific granuloma (35%), TB granuloma (20%),
hamartoma (5%), metastatic cancer (5%)
DM8 Diagnostic Medical Imaging MCCQE 2002 Review Notes
CHEST IMAGING . . . CONT.
Table 2. Pulmonary Nodules
Malignant Benign
Margin ill-defined/spiculated well-defined
(corona radiata)
Contour multi-lobular smooth
Calcification eccentric or stippled diffuse, central, popcorn, concentric
Doubling Time 20-460 days < 20 days, > 460 days
Other Features cavitation, collapse,
adenopathy, pleural
effusion, lytic bony
lesions, smoking history
doubling time: time to increase diameter by 1.26x - compare old films
if no change in size over 2 years, 99% chance benign
CT scan excellent for determining the pattern of calcification and presence of fat (as in hamartoma)
clinical information and CT appearance determine level of suspicion of cancer
if high probability, then do an invasive test
if low then repeat CXR in one month and repeat every 6 months for 2 years
fine needle aspiration - CT or fluoroscopic guidance
more sensitive than TBB but increased morbidity (causes bronchial obstructions)
TBB better for central lesions; TTB better for peripheral lesions
diagnostic yield > 90% for malignancy
sensitivity for benign lesions less than with TBB
iatrogenic pneumothorax in 25%, 1/3 of which need chest tube drainage
Mediastinal Masses
anterior (anterior to heart and trachea)
the 5 Ts: teratoma, thyroid, thymus, thoracic aortic aneurysm, terrible lymphoma
pericardial cyst, fat pad, Morgagni hernia if at level of diaphragm
middle (mediastinal structures; heart and great vessels)
bronchial cancer, bronchogenic cyst, aortic aneurysm, esophagus/hiatus hernia
posterior (posterior to heart)
gastrointestinal (GI) or spine
aortic aneurysm, neurogenic tumours, soft tissue mass of vertebral infection or neoplasm
lymphoma may be seen in any area
Pulmonary Embolus (PE) (see Colour Atlas DM6 and DM8)
CXR may be normal (approximately 50%)
may see decreased lung volume with elevated hemidiaphragm, atelectasis
underperfused lung distally, dilated hilar artery proximally
+/ pleural effusion
Westermark's sign: abrupt cutoff of vasculature distal to embolus
Hampton's hump: pleural-based wedge representing lung infarct with pleural effusion
infarct always involves pleural-based lung (against chest wall, diaphragm, mediastinum, or fissures)
evaluate with ventilation/perfusion (V/Q) scan angiography, or spiral CT
CT SCAN
for investigation of masses, metastases, staging of cancer, some other lung pathologies
(e.g. bronchiectasis) when not certain using CXR alone
best way to image mediastinum and assess adenopathy
HRCT is good for assessing diffuse infiltrative lung disease (interstitial lung disease)
MCCQE 2002 Review Notes Diagnostic Medical Imaging DM9
MUSCULOSKELETAL SYSTEM (MSK)
MODALITIES
plain films: mainstay of MSK radiology
initial study used in most evaluations of bone
not very effective in evaluating soft tissue injury
MRI: excellent for visualization of marrow and surrounding soft tissues
not as good as CT for visualization of bone cortex
multiplanar viewing and reconstruction with no radiation exposure to the patient
CT: for evaluation of bone cortex and type of cortical expansion
IV contrast may be used to determine lesion vascularity
specific protocols and windows optimize its ability to delineate bone
U/S: for evaluation of surrounding soft tissue (nerves, joints, effusions, impingement)
not used for imaging bone
used in muscle for determination of cystic structures
used to diagnose tendon and ligament injury
nuclear medicine: determine the degree of activity (uptake) within the bone
localizes areas of increased bone turnover
Technetium-99 (Tc99): a triphasic bone scan can establish skeletal vs. soft tissue infection
and distinguish septic arthritis vs.osteomyelitis vs peripheral cellulitis based on uptake
Indium-111 WBC: tracks the active migration of the WBC;
not a good test for discerning the different types of infections
Gallium-67 Citrate: may see uptake in some tumours
approach to selected common pathologies (see Table 10)
GENERAL APPROACH TO INTERPRETATION OF BONE X-RAYS
identification - name, age of patient, type of study, region of investigation
soft tissues
joints - alignment, joint space, synovial structures
bone - periosteum, cortex, medulla, trabeculae, density
TRAUMA
Fracture/Dislocation
approach
minimum 2 films at right angles to each other
CT for curved bones: skull, spine, acetabulum, calcaneus
image proximal and distal joints
if in doubt, consider other techniques
characteristics of fractures (see Orthopedics Chapter)
breaks in continuity of cortex
radiolucent or radiopaque fracture lines
overlap of cortical bone and spongy bone
unexplained fragments of bone
areas or lines of density representing impaction of bone
discontinuity in trabecular patterns or changes in trabecular density
soft evaluation of
periosteal areas for bone bruises or callus formation
surrounding area for swelling, foreign bodies, air (not all foreign bodies are radiopaque)
increased lucency of the fat pad may suggest swelling and edema near the bone (e.g. patellar fat pad,
anterior sail sign, or prescence of posterior fat pad in the elbow)
C-Spine Injury
clearing the C-spine and interpretation of films (see Emergency Medicine Chapter)
ARTHRITIS
Approach
consider
clinical history
physical exam
lab results
distribution of arthropathy
Chondropathic/Osteoarthritis
classic signs
narrowed joint space
asymmetrical joint involvement
subchondral sclerosis appears as increased density surrounding the joint
marginal osteophyte with or without spondylolisthesis/spondylolysis
vacuum phenomenon: translucent disc space area that is pocket of gas
subchondral cysts with sclerotic borders in larger joints
DM10 Diagnostic Medical Imaging MCCQE 2002 Review Notes
MUSCULOSKELETAL SYSTEM . . . CONT.
Infectious Arthritis
periarticular soft tissue swelling and distention of affected joint with fluid
+/ joint space narrowing due to proteolytic enzymes destroying the cartilage
localized osteopenia
bony destruction characterized by irregularity of the subchondral bone and
opposing margins usually presents 8-10 days after onset
chronic ankylosis and fusion of the joint may result if infection becomes chronic
Inflammatory
Patterns of Periosteal Patterns of Margination
Cortical New Bone Medullary of Lesions
Disturbance Formation Destruction
Figure 4. Radiographic Appearance of Inflammatory Bone Processes
Illustrations by Myra Rudakewich
Rheumatoid Arthritis (RA)
begins in distal joints, symmetrical fashion
soft tissue swelling with characteristic fusiform pattern
periarticular osteopenia in subchondral bone
malalignment first manifested as ulnar deviation
joint destruction beginning with distal clavicle erosion
symmetrical narrowing of joints, pannus, inflammatory process around articular surface
pannus forming initially on the radial sides of the metacarpal (MC), metatarsal (MT),
phalangeal, radioulnar joints
spinal involvement in severe cases may lead to atlantoaxial subluxation,
restricted cervical spines with odontoid erosion
Seronegative Spondyloarthropathies
Ankylosing Spondylitis (AS)
sacroiliitis radiographically characterized by blurring and irregularity of
sacroiliac (SI) joint margins with sclerosis and obliteration of joint
in terminal stages, bone bridges fuse throughout spine,
beginning in the lumbar spines> classic bamboo spine
Psoriasis
typically restricted to small joints of hands and feet
no osteoporosis
distal interphalangeal (DIP) and proximal interphalangeal (PIP) joint:
classic pencil in cup deformity
decrease in the total length of the phalanx
Reiters
asymmetrical joint distribution (mostly in feet)
appears similar to psoriasis
whisker-like fluffy periosteal inflammation (thickening of periosteum) usually in plantar fascia
may present with sacroiliitis
Inflammatory Bowel Disease (IBD)
symmetrical sacroiliitis but not as extensive as ankylosing spondylitis
usually an incidental finding on AXR
radiographically worsens with IBD exacerbation
punched
out
thin rim
of sclerosis
thick rim
of sclerosis
normal
motheaten
permeative
Codmans
Triangle
onion -
skin layered
hair-on-end
spiculated
sunburst
divergent
expansile/
ballooned
endosteal
scalloping
invisible
margin/
cortical
destruction
saucerization
solid
undulating
MCCQE 2002 Review Notes Diagnostic Medical Imaging DM11
MUSCULOSKELETAL SYSTEM . . . CONT.
Seropositive Spondyloarthropathies
Dermatomyositis (DMY)
lack of bone and joint pathology
soft tissue calcifications (chondrocalcinosis)
Systemic Lupus Erythematosus (SLE)
a number of nonspecific inflammatory processes
soft tissue atrophy, osteoporosis, poor joint alignment despite lack of articular erosive process
swan neck deformities and AVN common
Scleroderma
radiological findings restricted to the hands with tapered phalanx
(atrophy of soft tissues and bone resorption)
may also present with calcification of soft tissue
Crystal-Induced Arthropathies
Gout
radiographic findings do not appear until 8-10 years after the diagnosis
begin as periarticular erosion
soft tissue masses with no signs of calcification
joint space preserved
usually no signs of osteoporosis
lesions are well demarcated and sharply defined, often with spur bone formation
of the periphery
Pseudogout
chondrocalcinosis
calcification of the fibrocartilage
swelling of the joint capsule due to synovitis with progression to osteoarthritis
(usually appears as broad based osteophytes of the MCP joints)
TUMOUR
Approach
metastatic tumours much more common than primary bone tumours
diagnosis will usually require a biopsy if primary not located
few benign tumours/lesions have potential for malignant transformation
CT: best way to identify the extent of bone lesion in the cortex, medulla, soft tissue
MR: good for tissue delineation and preoperative assessment of surrounding soft tissues
plain films: one of the least sensitive tools for evaluation of bone tumours
Considerations
age
single or multiple lesions: multiple lesions more suggestive of malignant process or metabolic disease
characteristics of lesion (see Table 3)
margins: sharply defined with no sclerosis suggestive of multiple myeloma
zone of transition: transition area from normal bone to area of
lesion, reflective of the aggressiveness of the lesion
sclerosed borders, graduated zones: more suggestive of a slow process;
it does not identify malignant or benign
expansile
intact, ballooned cortex: more likely benign
destruction of cortex: more likely malignant
periosteal reaction
lamellar: faint and solid, fine periosteal density paralleling cortex, most likely benign process
wavy: undulating thickness of the periosteum, most likely peripheral vascular disease (PVD)
or bone infarct
sunburst: Ewings sarcoma (highly suggestive)
hair on end: thalassemia or osteosarcoma (highly suggestive)
cortical thickening: new bone formation, suggestive of osteomyelitis or malignancy
Table 3. Characteristics of Benign and Malignant Bone Lesions
Benign Malignant
single lesion multiple lesions (metastatic)
no bone pain bone pain
sharp area of delineation poor delineation of lesion
overlying cortex intact loss of overlying cortex/bony destruction
no or well organized periosteal reaction periosteal reaction
thick and sharp zone of transition thin and wide zone of transition
minimal distortion of normal anatomy scattered areas of spotty density
lesion continuous with cortex diagnosis of primary cancer
centralized calcification
Note: for specific bone tumours see Orthopedics Chapter
DM12 Diagnostic Medical Imaging MCCQE 2002 Review Notes
MUSCULOSKELETAL SYSTEM . . . CONT.
Metastatic Bone Tumours
all malignancies have potential to metastasize to bone, with some much more likely than others
metastases are 20-30x more common than primary bone tumours
when a primary malignancy is first detected, a bone scan is part of the initial work-up
may present with pathological fractures or pain
biopsy or determination of primary is the only way to confirm the diagnosis
metastasis can cause a lytic (decreased density) or a sclerotic reaction (increased density)
when seeding to bone
Table 4. Characteristic Bone Metastases of Common Cancers
Lytic Sclerotic
lung prostate
thyroid breast
kidney
breast
multiple myeloma
INFECTION
Osteomyelitis
Plain Film
visible on plain x-ray 8-10 days after osteomyelitis has begun
Tc99 radioisotope scan is the best modality to establish the presence of bone infection
osteomyelitic changes on plain film
soft tissue swelling that is deep and extends from the bone with loss of tissue planes
(muscle, fat, skin)
local periosteal reaction over the area of bone
bone destruction directly over the area of bone infection
pockets of air (from anaerobes or Clostridium) may be seen in the tissue planes
metaphysis over the area of infection may appear mottled and non-homogeneous with a classic
moth-eaten appearance
Bone Abscess
classical appearance known as Brodies Abscess
overlying cortex has periosteal new bone formation (onion skin pattern)
sharp outlined radiolucent area with variable thickness in zone of transition
variable thickness periosteal sclerosis
METABOLIC
Approach
hormonal changes result in diminution of bone maintenance (mechanisms)
thinning of cortex
spongy bone becomes more lucent
pathological fractures
overall diffuse process, affecting all bones
Osteoporosis
Dual X-ray Absorptiometry (DEXA) sensitive to > 12-15% bone loss
diagnostic sensitivity highest when bone mineral density (BMD) measured at lumbar spine
and proximal femur
T-Score: difference of BMD from young adult mean
measure of current fracture risk
Z-score: difference of BMD from age-matched mean
radiographic manifestation
increase in bone lucency
compression of vertebral bodies
biconcave vertebral bodies (codfishing vertebrae)
long bones have appearance of increased cortex size
widening of bone spicules
ischemic necrosis of hips leading to snowcapping
Osteomalacia
Loosers Zones (characteristic radiological feature)
fissures or clefts extending through cortex of long bones
(represent failure of ossification of the fibrous tissue of the bone)
irregular resorption of bone > softening and arching of long bones
initial radiological appearance of both osteoporosis and osteomalacia is osteopenia
MCCQE 2002 Review Notes Diagnostic Medical Imaging DM13
MUSCULOSKELETAL SYSTEM . . . CONT.
Renal Osteodystrophy
manifestations are a hybrid of hyperparathyroidism and osteomalacia
slipped epiphysis (bilateral)
spontaneous separations
chondrocalcinosis: intra-articular deposits of calcium
calcifications of the soft tissues (including arteries and around the joints)
avascular necrosis (AVN) of femoral head must be considered in all cases
subperiosteal erosion of femoral neck
osteopenia
poor definition of trabeculae and cortex
increased bony density
Pagets Disease
may involve single or multiple bones
destruction of bone followed by repair of bone although lysis may occur faster in some areas
thickening of cortex or sharp junctions
coarsening of the trabeculae
enlargement of bone
patchy spaces of dense bone (cotton wool)
bone softening/bowing
bone scan will reveal high activity, especially at bone ends
GASTROINTESTINAL (GI) TRACT
approaches to selected common pathologies (see Table 11)
ABDOMINAL PLAIN FILMS
abdominal series
usually includes supine (flat plate/KUB), upright, left lateral decubitus (LLD) erect CXR
3 views abdomen: upright, supine, LLD
+/ erect CXR
Pathologies Assessed
bowel obstruction/ileus
bowel ischemia
volvulus
calcifications (e.g. gallstones, renal stones)
abnormal gas collections (free air, intramural air, biliary air)
bony abnormalities (e.g. metastases)
foreign bodies (e.g. iatrogenic items from surgery)
caution should be exercised if pregnancy is a possibility
Approach to Interpretation
identifying data
name, age of patient, type of study (supine, upright, decubitus)
supraphrenic structures
heart, lung base, costophrenic angles
skeletal structures
thoracic vertebrae: ribs attached
lumbar vertebrae: pelvis, hips
soft tissues
flanks - often trilaminar in appearance
superficial - subcutaneous fat
intermediate - abdominal wall musculature
deep-flank stripe of extraperitoneal/preperitoneal fat
psoas shadow
represents fatty fascia enveloping the muscle
right psoas shadow often not seen; normal variant
solid visceral organs: best seen with other modalities
liver: may see depression of hepatic flexure (colon) with hepatomegaly
spleen: may see medial displacement of gastric air bubble with splenomegaly
kidneys: outlined by perirenal fat, 8-15 cm in adults, left higher than right (renal hila located at L2
and L1 respectively), long axis parallel to psoas shadow
gallbladder and pancreas: not usually visualized
aorta
bladder and uterus
hollow viscus: stomach, small bowel, large bowel, rectum
gas pattern (amount and distribution)
normally some air in stomach and throughout colon but little in small bowel
assess for obstruction, intraperitoneal air (free air), intramural air
differentiate between small and large bowel (see Table 5)
DM14 Diagnostic Medical Imaging MCCQE 2002 Review Notes
GASTROINTESTINAL TRACT . . . CONT.
calcifications
right upper quadrant (RUQ) - renal stone, adrenal calcification, gallstone
right lower quadrant (RLQ) - stone in ureter, appendicolith, gallstone ileus (rare)
left upper quadrant (LUQ) - splenic vessel, renal stone, adrenal calcification, tail of pancreas
central - aorta, pancreas, lymph nodes
pelvis - phleboliths, fibroids, bladder, prostate
Table 5. Differentiating Small and Large Bowel
Small Bowel Large Bowel
Mucosal Folds uninterrupted plicae circulares/valvulae conniventes interrupted haustra
Location central peripheral
Maximum diameter 2.5 - 3 cm 5 cm
Other rarely contains solid fecal material commonly contains solid fecal material
Abnormal Findings
paralytic ileus vs mechanical obstruction (see Table 6)
Table 6. Paralytic Ileus vs. Mechanical Obstruction
Paralytic Ileus Mechanical Obstruction (see Colour Atlas G1)
Calibre of bowel normal or dilated in small and/or usually dilated in small and/or large bowel
loops large bowel
Air-Fluid levels same level in a single loop step ladder appearance
(only on upright longer ones in the colon string of pearls (row of small gas accumulations
and lateraldecubitus collected in the dilated valvulae conniventes)
films)
Other air throughout the GI tract dilated bowel up to the obstructed segment
may be generalized or localized no air distal to obstructed segment
in a localized ileus, a dilated loop (unless very early obstruction)
(sentinel loop) remains in the same
location on serial films and is usually
adjacent to areas of inflammation
(e.g. pancreatitis, appendicitis)
in large bowel obstruction, important to assess the functionality of the ileocecal valve
if competent and functional
see large bowel distention from site of obstruction to valve
marked cecal distention with risk of perforation (if > 9 cm)
if incompetent
pressure released into small intestine, causing
distention of both large and small bowel
cecum is relatively protected from perforation in this case
may be difficult to differentiate large bowel obstruction with incompetent valve
and paralytic ileus
free intraperitoneal air (pneumoperitoneum)
LLB: look for free air between liver and right anterolateral abdominal wall
erect PA CXR: air under diaphragm (see Colour Atlas G2)
supine film poor for showing free abdominal air unless large amount, but may see
Riglers sign - both the inner and outer wall of the bowel seen (outlined by free air)
falciform ligament sign - free air collects on both sides of falciform ligament, outlining it
football sign with a large amount of air
DDx: hollow viscus perforation (most common), iatrogenic, introduction per vagina, pneumothorax
(due to pleuroperitoneal fistula), peritoneal dialysis catheter
intramural air (pneumatosis)
lucent air streaks in wall of bowel
linear type - ischemia
cystoides type - seen in large bowel due to chronic obstructive pulmonary disease (COPD)
biliary air
located centrally over liver
causes: sphincterotomy, gallstone ileus
portal venous air
peripherally located branching air underneath the diaphragm due to bowel ischemia
MCCQE 2002 Review Notes Diagnostic Medical Imaging DM15
GASTROINTESTINAL TRACT . . . CONT.
volvulus
in descending order of radiographic recognition
sigmoid - coffee bean sign
cecal - single/large bowel loop in LUQ
gastric
small bowel (most difficult to diagnose)
plain film: useful in all except small bowel where CT needed for definitive diagnosis
contrast studies: bird beak sign typical of volvulus
ischemia
important acute causes: hypotension, embolic, thrombotic, volvulus
plain film: not useful except when thickened folds, pneumatosis, or portal venous air seen
CT: better yield, especially CT angio (thickened folds, mesenteric changes, embolus)
U/S: good screening, especially with plain film finding of gasless abdomen as cause of ischemia
angiography used less often
toxic megacolon
seen with ulcerative colitis (UC), Crohns, infectious/pseudomembranous colitis
radiographic findings - thumb printing of colonic mucosa +/ dilatation
clinical picture of toxicity
dilatation (> 6 cm) and progressive distention with clinical deterioration > impending perforation
intussusception
diagnosed by barium enema or U/S
possible to reduce with diagnostic barium enema, air enema
CONTRAST STUDIES(see Table 7) (see Colour Atlas G3-G6)
barium sulphate serves as contrast medium within lumen of GI tract
provides fluid cast images, mucosal relief images (barium spread over mucosal surface),
or double-contrast images (air injected into lumen with barium present)
esophagus to rectum examined in double contrast (air + barium)
mucosal detail and mural changes seen as well as intraluminal abnormalities
Contraindications to Barium Study
unable to withstand or perform the positions required
cannot undergo bowel preparation
PO barium contraindicated in suspected colonic obstruction because of
risk of dehydration of barium and secondary colonic impaction
instead consider colonoscopy or hypaque enema
in small bowel obstruction, luminal contents retained are
liquid, therefore barium PO is not contraindicated
suspected or known perforation or if predisposed (e.g. ischemic colitis)
toxic megacolon
Table 7. Types of Contrast Studies
Study Description Assessment Diseases
Cine Esophagogram contrast agent swallowed cervical esophagus aspiration, webs, Zenkers,
recorded for later playback and cricopharyngeal bar, laryngeal
analysis tumours
Barium Swallow contrast agent swallowed under thoracic esophagus achalasia, hiatus hernia,
fluoroscopy esophagitis, cancer
selective images captured
Upper GI Series barium + effervescent agent thoracic esophagus, ulcers, neoplasms, filling defects
swallowed for double contrast stomach, duodenum
patient NPO after midnight before
study
Small Bowel Follow images of small bowel obtained single contrast barium of neoplasms, IBD, pain,
Through following UGI series entire small bowel malabsorption, infection
Small Bowel Enema intubation with barium/methyl cellulose small bowel IBD, anemia, polyposis
(enteroclysis) infusion and fluoroscopic evaluation syndromes, Meckels, neoplasm
Barium Enema colon filled retrograde with barium large bowel diverticulosis, neoplasms, IBD
and air/CO2 insufflation rectum may be obscured
bowel prep the night before procedure by tube - therefore
must do sigmoidoscopy
(complementary test
to exclude rectal lesions)
Hypaque Enema water soluble contrast with or without large bowel perforation, obstruction
bowel prep
DM16 Diagnostic Medical Imaging MCCQE 2002 Review Notes
GASTROINTESTINAL TRACT . . . CONT.
SOLID VISCERAL ORGAN IMAGING
Liver
moderate hepatomegaly difficult to determine on plain films
U/S good for assessment of cysts, abscesses, tumours, biliary tree
CT with IV contrast best for imaging liver parenchyma
primary tumours
echogenic on U/S (compared to echo-free cysts), but hypoechoic compared to normal liver parenchyma
cold spots on radioisotope liver scans (most)
most are less dense than the parenchyma on CT but vascular tumours may be more dense
(increased contrast uptake)
may have ill-defined margins, necrotic centres, calcification
metastases - more common
common primaries are lung, breast, GI (especially colon)
often multiple
metastases are generally less dense than parenchyma on CT
U/S may show large (> 2 cm) ill-defined, hypoechoic masses
cysts and abscesses
both: appear less dense than parenchyma on CT (modality of choice)
cysts: sharply-defined round masses; echolucent centres on U/S
abscesses: less sharply-defined, tend to have fluid centres, thick walls, may become necrotic
vary in appearance on U/S, depending on amount of fluid within abscess cavity
cirrhosis and portal hypertension
CT: altered liver size, contour, density
if fatty infiltration, liver appears less dense than spleen (reverse is true if healthy)
if advanced cirrhosis, liver is smaller and irregular;
splenomegaly and ascites may be present due to portal HTN
nuclear medicine study: small shrunken liver with increased background marrow activity
Spleen
splenomegaly may be suggested by U/S, CT, and/or radionucleotide scan
lymphoma more commonly seen than metastases
Biliary Tree
U/S imaging modality of choice
bile ducts normally not seen
if enlarged, see "double tract" sign and through transmission
obstruction: intra- and extrahepatic dilatation of bile ducts + source of obstruction (stone, pancreatic mass)
cholecystitis (see "Itis Imaging" below)
CT, ERCP, MRCP, PTC for further work-up
on CT, dilated intrahepatic ductules are branching and tubular following pathway of portal venous system
Pancreas
plain film: not seen unless calcifications are present (see Colour Atlas G7)
U/S: seen in most patients
CT: gives better detail with IV +/ PO contrast material
look for masses, pseudocysts, biliary obstruction, evidence of pancreatitis
ERCP: used when U/S and CT inconclusive
pancreatitis (see "Itis Imaging below)
tumours
U/S: useful, the mass being more echogenic than normal pancreatic tissue
CT: preferred when tumour suspected; density often normal
ITIS IMAGING
acute cholecystitis, appendicitis, diverticulitis, pancreatitis require special imaging
Acute Cholecystitis
U/S very accurate - thick wall, pericholecystic fluid, gallstones,
dilated gallbladder, positive sonographic Murphys sign
nuclear medicine (HIDA scan) may be helpful in equivocal cases
Acute Appendicitis
U/S very useful - thick wall appendix, appendicolith, dilated fluid-filled appendix
may find other causes of RLQ pain (e.g. ovarian abscess, IBD, ectopic pregnancy)
CT done when abscess present and to facilitate percutaneous drainage
Acute Diverticulitis
common site is rectosigmoid
CT: imaging modality of choice, though U/S is sometimes used as screening
oral and rectal contrast given before CT to opacify bowel
cardinal signs: thickened wall, mesenteric infiltration, gas-filled diverticula, abscess
sometimes difficult to distinguish from perforated cancer
(therefore, send abscess fluid for cytology)
CT: used for percutaneous abscess drainage before definitive surgical intervention
MCCQE 2002 Review Notes Diagnostic Medical Imaging DM17
GASTROINTESTINAL TRACT . . . CONT.
Acute Pancreatitis
clinical symptoms and lab results (serum amylase and lipase) important
U/S: good screening (though useless if ileus present because gas
obscures pancreas)
see hypoechoic enlarged pancreas
CT: useful in advanced stages of pancreatitis and assessing for complications
(e.g. pseudocyst, abscess, phlegmon, necrosis)
enlarged pancreas, mesenteric and Gerotas fascial
thickening, pseudocyst in lesser sac, abscess (gas or thick walled
fluid collection), pancreatic necrosis (low attenuation gas-containing
non-enhancing pancreatic tissue)
CT-guided needle aspiration and/or drainage done for abscess
drainage where clinically indicated
pseudocyst may be followed by CT and drained if symptomatic
GENITOURINARY (GU) SYSTEM
studies commonly used to evaluate the urinary tract
IVP/IVU
retrograde pyelogram/urogram
cystogram (often combined with study of urethra as a VCUG)
U/S
CT scan
MRI
renal arteriography
isotope studies
MODALITIES
IVP/IVU (see Colour Atlas U2)
a morphologic examination, and also a rough physiological study of renal function
assessment made by viewing the films temporally
consists of KUB and series of post-contrast injection films
the patient should have clear fluids one day prior to the study, cathartics the evening before, and NPO after
midnight before the study (liquids are allowed in the morning if the study is booked for the afternoon)
contraindications to contrast (see Table 1)
pre-contrast scout film
KUB plain film done supine
look for abnormal calcifications in the kidneys, calyces, ureters (running over the transverse
processes - look for later films to identify their path)
beware of phleboliths (calcified venous thrombi in pelvic veins)
often smooth, round, may have a central lucency of recanalization
likely if the calcification exists inferior to a line drawn between the ischial spines
nephrotomograms can also be done to locate stones further
nephrogram phase
1 minute post-contrast injection
depends on renal blood flow (i.e., renal artery patency)
contrast material enters the microvasculature and tubules within one minute,
opacifying the kidney
assess kidney position (T12-L3), size (10-15 cm, difference < 1.5 cm),
shape, outline, parenchyma outline
DDx of bulges: mass, tumour, cyst
DDx of indentations: infarction, scarring
DDx of decreased/absent opacification
decreased blood flow to the kidney (e.g. renal artery compromised)
decreased blood flow from the kidney (e.g. renal vein thrombosis)
blocked drainage (i.e. ureteral stone)
nephron dysfunction
subsequent post-contrast injection films
usually obtain 2 or more films at 5 minute intervals
assess (in order) calyces (cupped = normal; clubbed or enlarged=dilated), pelvices, ureters
(normal diameter < 7 mm), bladder
after 20-30 minutes, the collecting system is too faint and bladder is opacified
pre-void: irregular outline of bladder (superior-fibroids, sigmoid; inferior-prostate)
post-void: to assess clearance of bladder
Retrograde Pyelogram/Urogram (see Colour Atlas DM9)
contrast medium injected into ureters at cystoscopy via ureteral catheterization
Cystogram
contrast injected retrograde into bladder to visualize bladder
VCUG enables visualization of urethra
DM18 Diagnostic Medical Imaging MCCQE 2002 Review Notes
GENITOURINARY SYSTEM . . . CONT.
U/S
useful in evaluating renal size and renal shape
can differentiate solid vs. cystic masses
TRUS also useful to evaluate prostate gland and guide biopsies
CT
useful in evaluating renal mass lesions, extrarenal masses that are distorting or displacing normal urinary tract
best method to determine extrarenal involvement of tumours (e.g. vascular involvement, nodes),
renal trauma, stone disease
good for assessing renal colic
use unenhanced imaging for stones
spiral CT gold standard for detecting stones
contrast enhancement may show hypervascularity of mass lesions, areas of necrosis within mass
CT angiography may also be used to evaluate renal artery stenosis
MRI
used to evaluate renal masses or effects of pelvic neoplasms on bladder
useful in evaluating prostate tumours both diagnostically and in planning treatment
(i.e. surgical vs. radiation treatment)
very useful in assessing gynecological pathology, especially tumours
Renal Scan
2 radionuclide tests for kidney: renogram and morphological scan
in renogram, passage of radionuclide (Tc99m DTPA or iodine-labeled hippurate)
quantitated to assess function
useful in evaluaton of renal failure, workup of urinary tract obstruction and hypertension, investigation of renal
transplant
morphological study done with Tc99m DMSA and Tc99m glucoheptonate to look at renal anatomy
useful in investigation of renal mass and cortical scars
SELECTED PATHOLOGY
Obstruction (see Urology Chapter)
IVP findings
may see radiopaque stone on plain film (~90% are calcified) (see Colour Atlas U1)
delayed visualization on the abnormal side - the late white kidney of acute renal obstruction
appearance of calyces: blunting of ends of minor calyces
degree of dilatation of collecting system (hydronephrosis vs pelvicalyuretectasis) depends on whether
obstruction is partial or complete and also duration of obstruction(see Colour Atlas U2)
usually entire length of ureters not seen due to clearing by peristalsis (if seen consider UPJ obstruction)
U/S will be positive if significant hydronephrosis
Mass Lesions
DDx of mass lesions in kidneys: cysts, tumours, or inflammatory lesions
lesions elsewhere in urinary tract: most likely tumours
initial investigation should be U/S
cysts: uniformly hypoechoic, good through transmission, imperceptible wall
tumours: solid, contour deforming
further determines nature of mass, CT with contrast evaluates vascularity, necrosis, local invasion
arteriography (rarely done) will show vascularity and renal vein/IVC invasion
Others
other GU pathology (see Nephrology and Urology Chapter)
approaches to selected common GU and Reproductive pathology (see Tables 12 and 13)
MCCQE 2002 Review Notes Diagnostic Medical Imaging DM19
NEURORADIOLOGY
primary modalities to radiologically investigate brain and spinal cord
plain film
CT
MRI
myelography
diagnostic approaches to selected Neuropathology (see Table 14)
MODALITIES
Vertebral Films
mainstay for diagnosis of diseases in vertebral column
should be the initial study
C-spine views (see Emergency Medicine and Orthopedics Chapter)
lateral
AP of lower column and cranioatlantoaxial region
oblique
+/ flexion/extension views
thoracic and lumbar views
frontal (AP) and lateral
oblique lumbar views in non-traumatic cases
Skull Films
a highly overused, low-yield examination
generally, not indicated for head trauma!
indications
penetrating trauma
destructive lesions
metabolic disease
skull anomalies
post-op changes
standard views (each designed to demonstrate a particular area of the skull)
PA - frontal bones, frontal and ethmoid sinuses, nasal cavity,
superior orbital rims, mandible
lateral - frontal, parietal, temporal, and occipital bones, mastoid region, sella turcica,
roofs of the orbits, lateral aspects of facial bones
Townes view (occipital) - occipital bone, mastoid and middle ear regions,
foramen magnum, zygomatic arches
base view - basal structures of skull, including major foramina
Waters view (occipitomental) - facial bones and sinuses
approach to interpretation: bony vault, sella turcica, facial bones, basal foramina,
sinuses, calcifications, soft tissues
Myelography
introduce water-soluble, low osmotic contrast media into subarachnoid
space using lumbar puncture > conventional films or CT scan (CT myelography)
excellent study for disc herniations, traumatic nerve root avulsions
use has decreased due to MRI
CT Scans (see Colour Atlas NS1-NS6)
modality of choice for patients with suspected intracranial abnormalities
excellent study for evaluation of disc herniations
usually done without, and then with intravenous contrast, to show
vascular structures or anomalies
attenuation: bone > grey matter > white matter (fatty myelin) > CSF > air
vascular structures and areas of blood-brain barrier impairment:
radiopaque (white) with contrast injection
when in doubt, look for circle of Willis or confluence of sinuses to
determine presence of contrast enhancement
head CT: inspect soft tissues, bone, cortical parenchyma, ventricular system, mass lesion,
symmetry, shift of falx, posterior fossa obscured by bone and Hounsfield phenomenon
target lesions (associated with contrast ring enhancement): metastases, infections
DM20 Diagnostic Medical Imaging MCCQE 2002 Review Notes
NEURORADIOLOGY . . . CONT.
MRI
rapidly becoming the primary investigative tool for suspected intracranial abnormalities
shows brain anatomy in extremely fine detail
clearly distinguishes white from grey matter
T1 best to differentiate between grey and white matter
T2 greatly enhances CSF
modality of choice for spinal cord pathology (e.g. disc herniation, infections, tumours, trauma),
brain tumours, pituitary tumours, MS
multiplanar reconstruction helpful in pre-op assessment
Cerebral Angiography
to evaluate vascular lesions such as arteriosclerotic occlusive disease,
aneurysms, vascular malformations
also helpful in supplementing CT and MRI in patients with tumours
digital subtraction angiography (DSA) commonly used
Nuclear Medicine
SPECT using HMPAO (technetium-99m labeled derivative of propylamine oxane)
imaging assesses cerebral blood flow because it diffuses rapidly across the blood brain barrier (BBB),
becomes trapped within the cells, and remains long enough to allow time for scanning
PET imaging assesses metabolic activity
SELECTED PATHOLOGY(see Neurosurgery Chapter)
diagnostic approaches to selected neuropathology (see Tables 14 and 15)
Head Trauma(see Neurosurgery and Plastic Surgery Chapters)
CT: imaging modality of choice following head trauma if any evidence of intracranial damage
(e.g. LOC, neurological abnormalities)
able to visualize intracranial hemorrhage (see Colour Atlas H3-H6)
treatment directed at the neurologic abnormality
the presence or absence of a skull # may not make any difference
in management of patient, EXCEPT
1) depressed #
2) penetrating foreign object (e.g. bullet)
facial fractures: need CT for complete evaluation
Vertebral Trauma (see Emergency Medicine Chapter)
Intracranial Mass Lesions (see Neurosurgery Chapter)
investigate with CT scan, MRI with contrast, angiography (see Colour Atlas NS15, NS16 and NS17)
Vascular Disease
including infarction, intracerebral hemorrhage, arteriovenous malformation (AVM), extracerebral hematomas
carotid Doppler U/S used in evaluating for carotid artery disease
arteriography if carotid angioplasty considered
findings in ischemic infarction (see Colour Atlas DM10)
basal ganglia most common site
first few hours: normal
12-24 hours: reduced density (edema/mass effect) with no contrast enhancement
1-4 weeks: patchy enhancement
1 month: density approaches that of CSF
TIAs - no findings
Multiple Sclerosis (MS)
MRI shows plaques (hyperintense lesions) that form within the white matter
with a periventricular distribution (T2 weighted image) of the brain
Degenerative Spinal Abnormalities
spondylosis (see Colour Atlas NS21)
mild: slight disc space narrowing and spur formation
severe: marked disc space narrowing, facet joint narrowing, spur formation
spurs may impinge on spinal cord > evaluate with CT, MRI, myelography
herniated disc
if symptomatic, evaluate with CT, MRI, and/or myelography
MCCQE 2002 Review Notes Diagnostic Medical Imaging DM21
NEURORADIOLOGY . . . CONT.
Vertebral Column Metastases
common area for metastases
evaluate with plain films, bone scans, MRI, CT
MRI: most sensitive, can delineate areas of spinal cord compression
plain film: not sensitive (need ~50% of cancellous bone destruction before visible on plain films)
NUCLEAR MEDICINE
THYROID
Radioactive Iodine Uptake
radioactive I-131 or I-123 PO in fasting patient
provides index of thyroid function (trapping and organification of iodine)
measured as a percentage of administered iodide taken up by thyroid
elevated in hyperthyroid states (e.g. Graves, toxic multinodular goiter, toxic adenoma)
decreased in hypothyroid states (e.g. subacute thyroiditis, late Hashimotos disease)
falsely decreased in patient with recent radiographic contrast studies
Thyroid Imaging (Scintiscan)
technetium pertechnetate IV, radioactive iodine only to determine if nodule functioning
(done after technetium pertechnetate scan)
provides functional anatomic detail
hot (hyperfunctioning) lesions
adenoma, toxic multinodular goiter
cancer very unlikely
cold (hypofunctioning) lesions
cancer must be considered until biopsy negative
cool lesions
cancer must be considered as they may represent cold nodules superimposed on normal tissue
if cyst suspected, correlate with U/S
CHEST
V/Q Scan
for suspected pulmonary embolism (PE) and qualitative or quantitative evaluation
of pulmonary ventilation and perfusion
look for areas of lung which are ventilated but not perfused or vice versa
in PE, see areas of lung that are well ventilated but not perfused
normal perfusion scan makes PE unlikely
ventilation scan
patient breathes radioactive gas (aerosolized technetium-DTPA or xenon-133)
through a closed system, thus filling alveoli proportional to ventilation
defects seen if airway obstruction, chronic lung disease, bronchospasm,
tumour mass obstruction, oxygenation of lung fields
perfusion scan
radiotracer (albumin macroaggregates) injected IV >
trapped in pulmonary capillaries according to blood flow
perfusion scan relatively contraindicated in severe pulmonary HTN, right-to-left shunt
defects indicate reduced blood flow due to PE, parenchymal lung disease
Myocardial Perfusion Scanning
thallium-201 is a radioactive analogue of potassium
active uptake by myocardium proportional to regional blood flow
thallium injected at peak exercise or after persantine challenge and
again at rest to detect ischemia
persistent defect suggests infarction; reversible defect suggests ischemia or fixed stenosis
for investigation of angina, atypical chest pain, coronary artery disease (CAD),
reversible vs. irreversible changes when other investigations are equivocal
DM22 Diagnostic Medical Imaging MCCQE 2002 Review Notes
NUCLEAR MEDICINE . . . CONT.
Radionuclide Ventriculography
technetium-99m attached to red blood cells
first pass through right ventricular (RV) > pulmonary circulation > left ventricle (LV)
provides information about RV function
cardiac MUGA scan (MUltiple GAted acquisition scan) sums multiple cardiac cycles
evaluation of LV function
images are obtained by gating the count acquisitions to the ECG signal
provides information on ejection fraction, estimates of
ventricular volume, wall motion
Pyrophosphate Scintigraphy
technetium pyrophosphate concentrates in bone and in dying and necrotic tissue
used to detect infarcted tissue 1-5 days post-MI when ECG and
enzyme results are equivocal or unreliable
sensitivity and specificity about 90% in transmural infarct
BONE
Bone Scan
technetium with a phosphate or fluoride carrier binds to hydroxyapatite of bone matrix
increased when increased blood supply to bone and/or high bone turnover
indications: bone pain of unknown origin; screening of patients with suspected malignancy;
staging of cancer of breast, prostate, or bronchus; follow up after treatment;
detection and follow up of primary bone disease; assessment of skeletal trauma;
detection of soft tissue calcification; renal failure
positive bone scan
bone metastases from breast, prostate, lung, thyroid
primary bone tumours
arthritis
fractures
infections
multiple myeloma: typically normal or cold
kidneys and bones: normally equal in intensity
low renal uptake: renal failure, metabolic bone disease, diffuse bony metastasis (superscan)
ABDOMEN
Liver/Spleen Scans
IV injection of radioisotope-labeled sulfur colloid (usually technetium)
which is phagocytosed by reticuloendothelial cells of liver and spleen
cold spots: lesions displacing the normal reticuloendothelial system (RES)
(tumour, abscess, cyst)
diffuse patchy reduction in uptake: diffuse parenchymal disease (e.g. cirrhosis)
HIDA (Hepatobiliary Iminodiacetic Acid) Scan
IV injection of radiotracer (HIDA) which is bound to protein, taken up,
and excreted by hepatocytes into biliary system
can be performed in non-fasting state but prefer NPO after midnight the day before
gallbladder visualized when the cystic duct is patent
if gallbladder is not visualized, suspect obstructed cystic duct
DDx of obstructed cystic duct: acute cholecystitis, decreased hepatobiliary function
(commonly due to alcoholism), bile duct obstruction, parenteral nutrition
if gallbladder fills, rule out cholecystitis (< 1% probability)
RBC Scan
IV injection of radiotracer with sequential images of the abdomen
for GI bleed
if bleeding acutely at < 0.5 mL/min, the focus of activity in the
images generally indicates the site of the acute bleed
if bleeding acutely at > 0.5 mL/min, use angiography
more sensitive for lower GI bleed
for evaluation of liver lesion
hemangioma has characteristic appearance
MCCQE 2002 Review Notes Diagnostic Medical Imaging DM23
NUCLEAR MEDICINE . . . CONT.
Renal Scan
see Genitourinary System above
INFLAMMATION AND INFECTION
use gallium citrate- and indium-labeled WBCs
gallium accumulates in normal liver, spleen, bone marrow, sites of inflammation,
some neoplasms (lymphomas)
indium-labeled WBCs accumulate in normal spleen, liver, bone marrow,
sites of inflammation and infection
BRAIN
SPECT HMPAO imaging assesses cerebral blood flow
PET imaging assesses metabolic activity
VASCULAR-INTERVENTIONAL RADIOLOGY
Contraindications to Intravascular Contrast Media (see Table 1)
Vascular Procedures, Indications, Considerations, Complications (see Table 8)
Nonvascular Procedures, Indications, Considerations, Complications (see Table 9)
DM24 Diagnostic Medical Imaging MCCQE 2002 Review Notes
VASCULAR-INTERVENTIONAL RADIOLOGY . . . CONT.
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DM26 Diagnostic Medical Imaging MCCQE 2002 Review Notes
APPROACH TO COMMON PRESENTATIONS
Tables 10-15
Modality of Choice
identifies the best available diagnostic tool(s) regardless of cost
subjective consensus from references and faculty editors based
in some cases (e.g. angiography for massive lower GI bleed)
therapeutics were also considered
Approach to Imaging
provides a framework for the work-up of a suspected diagnosis
in general, in order of sensitive screening modalities to more specific studies
compiled from Eisenberg, RL and Margulis, AR, Radiology Pocket Reference: What to Order When, 1996
Table 10. Muskuloskeletal Pathology *NOTE: Plain Films (PF) are ALWAYS useful
Pathology Modality of Choice Approach to Imaging
Avascular Necrosis MRI 1. PF: not sensitive but ideal for following progression of disorder
(AVN) 1a. Radionuclide bone scan: may detect abnormality before PF
2. MRI: most sensitive for detecting early changes while PF and scan are normal
2a. +/ SPECT if MRI unavailable
Hematogenous MRI 1. Radionuclide bone scan: increased activity in early disease; not specific, but sensitive
2. MRI: equally or more sensitive than scintigraphy, not specific
Inflammatory arthropathy PF 1. PF of affected joints, plus sacroiliac (SI) joints if seronegative suspected
Meniscal Tear (Knee) MRI 1. U/S: becoming more common, but operator-dependent
arthroscopy 2. MRI: detects meniscal tears and associated abnormalities of collateral ligaments and cruciates
*NOTE: need for MRI is controversial and some studies indicate that arthroscopy alone is sufficient
Multiple Myeloma PF (skeletal survey) 1. PF: skeletal survey is specific but not sensitive
(MM) 2. MRI: preferred screening study
Osteoarthritis PF 1. PF
Osteomyelitis CT 1. PF: no change seen until 8-10 days
Direct seeding or MRI 2. Gallium Scan: sensitive before 8-10 days
Contiguous spread 3. CT: to detect sequestra
4. MRI: sensitive but not specific
Osteoporosis measurements of bone 1. Bone mineral content: many different methods
mineral content 1a. Usually DEXA-scan with X-ray source ===> lumbar spine and R hip
*NOTE: PF may detect compression fracture; otherwise not indicated since radiolucency not seen
until 50-70% bone loss
Primary Malignant MRI 1a. PF: initial screening, but poor sensitivity; however, yields useful info when positive
Tumours of Bone lb. Bone scan: if suspect metastases then essential to scan (not a PF skeletal survey)
2. MRI: best for determining bony and soft tissue extent, ability to distinguish benign from
malignant is controversial
Rotator Cuff Tear MRI 1. U/S: operator-dependent
2. MRI: detects partial and complete tears
3. Arthrography: if MRI unavailable; only detects complete tears
Septic Arthritis aspirate and culture 1. Radionuclide bone scan: not specific but may permit early diagnosis
*NOTE: must aspirate and culture; plain films not specific/sensitive
Skeletal metastases radionuclide bone scan 1. Radionuclide bone scan: false negative may occur if there is uniform uptake by diffuse metastases
2. PF: generally not indicated unless scan is equivocal, insensitive (40-80% of bone must be
destroyed to be apparent) thus NEVER order a skeletal survey to screen for metastases
3. CT or MRI: to evaluate nonspecific focal abnormalities from scan or PF, should not be
used as initial screening
Stress Fracture radionuclide bone scan 1. Radionuclide bone scan: sensitive for early detection
2. PF: fracture may not be detectable for several weeks
Vertebral radionuclide bone scan 1. Radionuclide bone scan: detect early activity
2. MRI: sensitive for detecting abnormality but does not accurately distinguish infection from tumour
MCCQE 2002 Review Notes Diagnostic Medical Imaging DM27
APPROACH TO COMMON PRESENTATIONS . . . CONT.
Table 11. Abdominal Pathology
Pathology Modality of Choice Approach to Imaging
Abdominal Aortic MRI 1. U/S: most cost-effective, serial exams to monitor
Aneurysm (AAA) 2. CT: if suspect leak or acute rupture, more accurate than U/S, especially with MDCT
===> allows digital reconstruction of renal/visceral vasculature
3. MRI: only if U/S and CT fail to provide info about renal, iliac artery, and visceral involvement
Cholecystitis (acute) cholescintigraphy 1. cholescintigraphy: 95% specific, 98% sensitive (post-prandial HIDA scan)
U/S 2. U/S
Cholecystitis (chronic) U/S 1. U/S
Colon Cancer (diagnosis) double-contrast 1. BE
barium enema (BE) 2. colonoscopy/flex sig: slightly more sensitive and specific than BE but cost & complications
Colon Cancer (staging) CT 1. CT: most effective for demonstrating presence and extent of colonic spread
transrectal U/S 2. transrectal: most accurate for staging local rectal cancer (depth of invasion, presence in lymph nodes)
Crohns BE 1. small bowel follow-through: if level of suspicion for disease is low
CT 1a. enteroclysis (small bowel enema): if clinical suspicion not low
2. small bowel examination required if terminal ileum not visualized in BE
3. CT: best for demonstrating mesenteric and extraintestinal extent of disease and abscess formation
Diverticulitis CT 1. CT
BE 2. BE (HE may be indicated due to threat of sigmoid perforation)
Diverticulosis BE 1. BE
Fatty Liver CT 1. CT
Hepatocellular Cancer CT 1. CT: preferred screening technique
MRI 2. U/S: screen chronic Hep B carriers
3. MRI: may permit specific diagnosis of hepatocellular cancer
Irritable Bowel Syndrome nothing or BE 1. BE: primarily performed to exclude IBD or cancer (diagnosis of exclusion)
(IBS)
Large Bowel Obstruction AXR 1. AXR: can differentiate between ileus and mechanical obstruction
(LBO) CT 2. BE (HE if threat of perforation)
3. CT with dilute contrast
Massive Lower GI Bleed colonoscopy 1. Colonoscopy: first choice if bleed not obscuring vision
angiography 2. RBC scan: as a scout to direct further investigation
3. Angiogram: to localize bleed, can be therapeutic; superior to RBC scan
Pancreatitis (acute) CT 1. CT: superior to U/S for inflammation, edema, gas detection
2. U/S: used for follow-up of specific abnormalities
Pancreatitis (chronic) CT 1. AXR: often done in practice, but low yield
2. CT: most accurate in demonstrating malignancy
3. ERCP/MRCP
Peritonitis CT 1. AXR: upright or lateral decubitus for free air; supine look for double wall sign
2. CT: procedure of choice to detect fluid, abscess, strangulation
Peptic Ulcer Disease endoscopy 1. upper GI series (double contrast)
(PUD) upper GI series 1a. urease breath test: nuclear medicine can be used under certain circumstances
2. endoscopy: may be preferable for suspected GU b/c can biopsy, fails to detect 5-10% of peptic ulcers
*NOTE - Once the diagnosis of benign PUD is made there is no need to repeat imaging
Small Bowel Obstruction AXR 1. AXR
(SBO) CT 2. CT: only required if AXR are equivocal or necessary to show precise site and elucidate etiology
Splenic Abscess CT 1. CT: preferred screening technique
2. radionuclide scan: specifically identify mass as an abscess
Ulcerative Colitis (UC) BE or colonoscopy 1. sigmoidoscopy: direct visualization
2. BE or colonoscopy: to determine full extent of disease and detect cancer
DM28 Diagnostic Medical Imaging MCCQE 2002 Review Notes
APPROACH TO COMMON PRESENTATIONS . . . CONT.
Table 12. Urinary Tract Pathology
Pathology Modality of Choice Approach to Imaging
Cancer of the Kidney CT 1. U/S or CT: U/S good for screening; contrast-enhanced CT is most sensitive
(diagnosis)
Cancer of the Kidney CT or MRI 1. CT or MRI: MRI for lymphadenopathy; chest CT for metastases
(staging) 1a. +/ U/S with Doppler to elucidate vascularity
2. radionuclide bone scan: for metastases
3. arteriography (often used pre-operatively to infarct kidney)
Hematuria
Painless cystoscopy 1. U/S: efficient for detecting neoplastic renal masses and vascular anomalies;
CT does not exclude bladder tumour or cystitis
2. IVP: excellent for stones and papillary necrosis; cannot exclude bladder or urethral pathology
3. cystoscopy: required in any adult with unexplained hematuria
4. CT: more sensitive than U/S for renal masses
Painful CT 1. IVP: preferred for screening, can define site and degree of obstruction
2. U/S: detect ureteral dilatation, stone
3. CT: detect stones
Polycystic Kidney Disease CT 1. U/S or CT
(PCKD) (Adult)
Pyelonephritis
Acute imaging only required if 1. CT
patients fail to respond to 2. U/S: less sensitive than CT for subtle changes; efficient for hydronephrosis
treatment or severely ill *NOTE: contrast is contraindicated if patient is febrile/toxic
Chronic IVP 1. IVP: characteristic focal cortical scar
2. U/S
Renal Failure U/S 1. U/S
2. DTPA Radionuclide scan at timed intervals (non-nephrotoxic)
*NOTE: biopsy often required if ARF and large (> 12 cm) or normal-sized kidneys for definitive dx
Renovascular Disease arteriography 1. U/S with Doppler
2. Arteriography
Urinary Tract Infection (UTI)
Infant & child radionuclide or voiding 1. radionuclide or voiding cystography: most sensitive for vesicoureteral reflux
cystography 2. U/S: preferred screening
*NOTE: complete investigation important because of high probability of anatomic abnormality
3. IVP
4. CT if indicated
Older child/Teenager U/S 1. U/S: only study needed if child has only lower urinary tract signs and symptoms and normal U/S
Adult U/S 1. IVP: structure and function of urinary tract
2. U/S: preferred imaging modality for critically ill patient with suspected UTI
3. CT: indicated if U/S and urography normal but strong clinical suspicion
*NOTE: uncomplicated UTI in a female requires NO imaging
MCCQE 2002 Review Notes Diagnostic Medical Imaging DM29
APPROACH TO COMMON PRESENTATIONS . . . CONT.
Table 13. Reproductive Pathology
Pathology Modality of Choice Approach to Imaging
Abnormal uterine bleeding hysteroscopy/colposcopy 1. U/S: usually initial screening
2. sonohystogram: more detail
Acute Testicular Pain U/S with Doppler 1. U/S with colour Doppler
2. radionuclide flow study: can demonstrate torsion
Dysmenorrhea U/S 1. U/S
2. laparoscopy
Emergent/acute situations U/S 1. U/S
(e.g. torsion, ectopic, abscess)
Endometrial Cancer sonohystogram 1. U/S
(diagnosis) CT 2. sonohystogram
3. CT
Endometrial Cancer MRI 1. CT
(staging) 2. MRI
Infertility hysterosalpingography or 1. hysterosalpingography
laparoscopy with dye 1a. U/S with contrast (i.e. Sonovist) injection
injection 2. U/S or MRI: if above is normal, to detect congenital anomalies of female tract (10%)
3. laparoscopy with dye injection: if history of endometriosis/pelvic inflammatory disease (PID)
Pelvic Mass MRI 1. U/S
2. CT
3. MRI
Testicular Mass MRI 1. U/S
2. MRI
Table 14. Neuropathology in MRI
Tissue/lesion T1 weighted T2 Weigthed
CSF, cyst, hygroma, cerebromalacia 99 Intensity 8 Intensity
Ischemia, edema, demyelination, most 9 Intensity 8 Intensity
malignant tumours
Subacute/chronic hemorrhage 8 Intensity slight 8 Intensity
Fat, e.g., dermoid tumour, lipoma, 8 Intensity 8 Intensity
some metastasis, atheroma
Acute hemorrhage Isointense 9 Intensity
Meningioma (usually identified from Isointense Isointense
structural change or surrounding edema)
DM30 Diagnostic Medical Imaging MCCQE 2002 Review Notes
APPROACH TO COMMON PRESENTATIONS . . . CONT.
Table 15. Neuropathology
Pathology Modality of Choice Approach to Imaging
Acute head trauma CT 1. CT: preferred for bone and blood
2. MRI: indicated only when CT has failed to detect an abnormality in presence of strong clinical
suspicion; valuable in subacute and chronic phases
*NOTE: no indication for plain skull radiography
Acute subdural hematoma CT 1. CT
2. MRI: not sensitive for detecting acute bleed but coronal images may be of value if CT fails
Bells Palsy MRI 1. MRI: to exclude a mass or demyelinating lesion
Brain Tumour MRI 1. CT: nearly always done at first presentation
2. MRI
Cerebrovascular Accident MRI 1. CT: non-contrast scan preferred initial procedure in suspected acute stroke
(CVA) 2. MRI: unenhanced MRI with angiography is more sensitive than CT
Dementia MRI 1. MRI: most sensitive for lesions
2. SPECT
2a. PET: used as adjunct in suspected Alzheimers
Headache MRI 1. CT: in practice, often first line if level of urgency high (i.e. hemorrhage/mass lesion suspected)
2. MRI: most sensitive for cerebral lesions
Lacunar Infarction MRI 1. CT: usually done first to exclude acute/treatable pathology; lack of findings serves as indication for MRI
2. MRI: only modality that can consistently demonstrate the lesions
Meningitis (Acute) CT 1. CT: most important role is to exclude a mass (abscess) prior to LP (main diagnostic test)
Meningitis (Subacute/chronic) MRI 1. MRI: contrast required, demonstrate edema, abscess, neoplasm, and inflammation
2. plain chest film: search for underlying TB or sarcoidosis
Multiple Sclerosis (MS) MRI 1. MRI: most sensitive for detection of demyelination
Orbital Blow-out Fracture CT 1. plain film (Waters view): preferred screening for bony abnormalities and soft-tissue mass, air-fluid levels
2. CT: definitive study
Seizure Disorder MRI 1. CT: non-contrast recommended as initial study if postictal or if residual neurologic deficit
2. MRI: most sensitive for detecting cerebral lesions, F/U in 3-6 months if fail to detect a source
3. PET: improves localization of seizure focus
Transient Ischemic Attack MRI 1. duplex, colour-flow Doppler U/S
(TIA) 2. echocardiography
3. MRI
4. intra-arterial digital subtraction angiography
4a. MR Angiography (MRA)
Tinnitus CT 1. CT: preferred for ear bone abnormalities
MRI 2. MRI: preferred for small tumours of CN VIII
Vertigo MRI 1. MRI: detecting posterior fossa and cerebellopontine angle abnormalities
2. CT: indicated for middle ear pathology
REFERENCES
Brant WE, Helms CA. Fundamentals of diagnostic radiology. 1999. Philadelphia. Lippincot Williams and Wilkins.
Katz DS, Math KR, Groskin SA. Radiology secrets. 1998. Philadephia. Hanley and Belfus.
Sam PM, Curtin HD. Head and neck imaging. 3rd ed. 1996. St. Louis. Mosby.
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