Week 1 - History of Radiology

(1) Know when and who invented radiology

Wilhelm Conrad Roentgen is recognized as the Father of Radiology/Roentgenology. In
1895, Roentgen began experiments using electric current flow in a partially-evacuated
glass tube, known as a cathode-ray tube. He noticed that, whenever the tube was in
operation, a piece of barium platinocyanide in line with it gave off light.
Roentgen theorized that the interaction of electrons striking the tube's glass wall formed
an unknown radiation that caused the fluorescence. He called the mysterious
phenomenon X-radiation, or X-rays. Today, the cathode-ray tube is composed of
tungsten, except in mammography, where it is composed of molybdenum.
(2) Understand the concept of projection and how it affects image quality
The quality of a medical image is determined by the imaging method, the characteristics
of the equipment and the imaging variables selected by the operator. Image quality is
not a single factor but is a composite of at least 5 factors: contrast, blur, noise,
artifacts and distortion.
(3) Understand the concept of how an image is formed
In projection imaging (radiography and fluoroscopy), images are formed by projecting
an x-ray beam through the patient's body and casting shadows onto an
appropriate receptor that converts the invisible x-ray image into a visible light
image. The gamma camera records a projection image that represents the distribution
of radioactive material in the body. The primary advantage of this image type: a
large volume of the patient's body can be viewed with one image. A
disadvantage: structures and objects are often superimposed so that the
image of one might interfere with the visibility of another. Projection imaging
produces spatial distortion that is generally not a major problem in most clinical
applications.
Tomographic imaging, i.e., conventional tomography, computed tomography (CT),
sonography, single photon emission tomography (SPECT), positron emission tomography
(PET), and MRI, produces images of selected planes or slices of tissue in the
patient's body. The general advantage of a tomographic image is the increased
visibility of objects within the imaged plane. One factor that contributes to this is
the absence of overlying objects. The major disadvantage is that only a small slice
of a patient's body can be visualized with one image. Therefore, most
tomographic procedures usually require many images to survey an entire organ system
or body cavity.
(4) Understand the amount of radiation exposure with different radiologic
modalities
X-ray: most common imaging technique used today; the most common x-ray ordered
is a chest x-ray, and the musculoskeletal x-ray exam comes in second. An x-ray provides
a 2-D image of the 3-D interior of the body. A single x-ray passes through the body and
exposes the film on a radiograph (or fluorescent screen) placed on the opposite side.
CT: x-rays move as laser-like beam in an arch around the part of the body being
observed. The beam of x-rays passed through the region of the body imaged are
collected by a detector that converts the x-rays into electronic pulses, which produce
readings of the tissue density into a 1cm slice of the body. From these readings, a
computer can assemble a picture of the body, called a CT scan, which can be viewed on
a fluorescent screen, then photographed for later examination. It obtains parts of the

body that can't be seen on a standard x-ray with the help of computer algorithms in
conjunction with the enhanced x-ray technology.
MRI: uses the magnetic properties of the hydrogen nucleus, which is excited by
radiofrequency radiation transmitted by a coil, which surrounds the body part being
imaged. When placed in strong magnetic fields, the nuclei of certain atoms absorb
radiofrequencies beamed at them, and then emit their own radio frequency waves. This
process allows readers to see very clear pictures of the inside of the body, including
tissues, organs and blood vessels. MRI is a noninvasive technique that does not use
ionizing radiation. MRI has become one of the primary tools used to image the brain,
spinal cord, MSK (musculoskeletal) system, major blood vessels and several key organs
and extremities. The images can be produced in 3-D, which significantly enhances the
physician's ability to diagnose problems. MRI is also used to help view the process of
surgery in real time in 3-D, which assists with a whole host of surgical procedures.
Differences between CT scans and X-Ray's: CT scans are an advanced form of x-ray
technology used in detecting diseases in soft body tissues, and can actually provide
images of internal organs that are impossible to detect with standard x-ray techniques.
X-rays are good at finding bone fractures, and for being used as a contrasting agent
for several types of exams; however, CT provides greater detail and clarity. CT scans
have additional advantages of being able to produce imaging in virtually any orientation.
It is a more technologically developed version of an x-ray, which is used on specific parts
of the body. It also provides better images for bone structures, such as the inner
ear as it can easily detect tumors in the auditory canal and cochlea. CT scans help
diagnose bone fractures, bone tumors, internal injuries and bleeding and
blood clots, and to monitor heart diseases and cancer.
Differences between CT scans & MRI's: MRI uses magnetic waves to produce images
while CT images are produced using x-rays. CT provides more details of bony
structures compared to MRI. CT scans cannot help much in seeing clearly, very fine,
soft tissue details (ligaments or tendons) as in the shoulder or knee compared to MRI.
MRI scans are best for imaging soft tissue.
CT faster than MRI (CT takes seconds, MRI takes minutes).
MRI is bad for metal objects in the body. MRI is more expensive and takes
longer.
Table: American College of Radiology appropriateness criteria, relative radiation level
information
Relative radiation
level

Effective dose estimate

range

Example examinations

None

Ultrasound, MRI

Minimal

<1 mSv

Chest radiographs (CXR), hand

radiographs

Low

15 mSv

Head CT, lumbar spine radiographs

Medium

510 mSv

Abdomen CT, barium enema,

nuclear medicine bone scan

High

>10 mSv

Abdomen CT w/o and w/ contrast,

whole body PET (glucose uptake &
metabolism)

Week 2 Musculoskeletal
(1) Understand fracture terminology
Displaced: loss of contact between fracture fragments
Dislocated: loss of contact between joint surfaces
Comminuted: bone fractures into 2+ fragments
Angulation: bone fragments are at angles to one another
Intra-articular: break crosses into joint surface; always result in some degree of
cartilage damage.
Pathologic: abnormal bone; fracture through bone made weak by disease, such as a
tumor.
Insufficiency: weak bone; fracture through weak bone, such as due to osteoporosis.
Occult: does not appear in x-rays, but bone shows new formation (whiter) within 3-4
weeks of fracture.
Open vs. closed fractures:
o Closed/simple fracture: skin is still intact.
o Open/compound fracture: involves wounds that communicate with the fracture.
Stress fracture: fracture through bone due to abnormal force; NOT an insufficiency
fracture.
Greenstick / torus / buckle: typically occurs in a young, soft bone in which the
bone bends and partially breaks. It is due to mechanical failure on the tension side; that is,
since the bone is not as brittle as it would be in an adult, it does not completely fracture,
but rather exhibits bowing without complete disruption of the bone's cortex in the surface
opposite the applied force.
What do fractures look like?
- Loss of cortical integrtity
- Soft tissue swelling
- Deformity
- Bony lucency
- Effusion
- Invisible (occult)
- Periosteal reaction (subacute): formation of new bone in response to injury or other stimuli of
the periosteum surrounding the bone.
(2) Be familiar with the cervical spine bone anatomy
Lateral view
P-A view

Contour lines/margins:

(3) Be able to identify the following plain films:

- SALTER-HARRIS FRACTURE: involves epiphyseal/growth plate of a bone; common injury in
children.
Salter-Harris fracture

Normal epiphysis/growth plate

- Distal radius fracture
a) COLLE'S FRACTURE: fracture of the distal radius with dorsal/posterior
displacement of the wrist and hand; aka "dinner fork" deformity. It is a dorsallyangulated fracture b/c the fracture faces the dorsal/posterior surface.

b) SMITH'S FRACTURE (opposite of Colle's): fx

distal radius w/ volar/anterior/palmar
displacement of the wrist and hand. (pic at right)
Smiths fracture vs. Colles fracture:

of

c) BARTON'S FRACTURE: comminuted (2+ fragments), intra-articular fracture of the

distal radius with dislocation of the radiocarpal joint; palmar/volar is more common than
dorsal/posterior.

-BOXERS: transverse fracture through the neck of a

bone; more likely to occur from a straight punch, hence the
this image at right, distal 5th metacarpal fracture.
- Simple vs. comminuted fracture: see above (Colles vs.

Dislocation vs.
Dislocation fracture (aka
luxation): occurs when bones in a joint
become displaced or misaligned. It is often
caused by a sudden impact to the joint. The ligaments
become damaged as a result of a dislocation. A
subluxation is a partial dislocation.
Displaced fracture: fracture in which the 2
ends of the bone are separated from one
another, no longer in anatomical alignment.

metacarpal
name. In

Bartons)

displacement

always

- Hip Fracture (major kinds of femoral neck fractures)

-GREENSTICK FRACTURE

- Cervical spine fractures

CT: better for bone detail, MRI: better for soft tissue and joint detail
1. AA (ATLANTO-AXIAL) DISLOCATION: Hyperextension injury, kids > adults, head
slips forward on C1, usually fatal

2. JEFFERSON FRACTURE OF C1:

Fracture of the anterior and posterior arches of C1 (atlas
vertebra), often appearing as a 2-part or 3-part fracture. Burst
fracture; caused by compressive force. Bilateral breaks in
anterior and posterior arches
Open mouth view shows bilateral offset of C1 on C2. Not
associated with neurologic deficit

3. HANGMANS FRACTURE (traumatic spondylolisthesis) of C2:

Fracture of either both pedicles or pars interarticularis of C2 (axis vertebra).
Hyperextension/compression fracture. Most common fracture of C2. Most common
cervical spine fracture

Fractures through pedicles of C2, with anterior slip of

C2 on C3
Teardrop fracture of inferior aspect of C2 or C3 is
clue to dx of Hangmans fracture
Not associated with neurologic deficit

4. ODONTOID (DENS) FRACTURE:

Fracture through the odontoid process (dens). Hyperextension injury; generally
associated with anterior of C1 subluxation on C2. There are 3 types:

Type I (tip of dens): extends through the tip of the dens; usually stable.

Type II (base of dens): extends through the base of the dens; most commonly
encountered fracture for this region of the axis, never stable.

Type III (sub-dentate / below dens): extends through vertebral body of the
axis; can be stable or unstable.

5. FLEXION-TEARDROP FRACTURE
Fracture of the antero-inferior aspect of a cervical
body due to flexion of the spine, along
compression. It is usually associated with spinal
a result of displacement of the posterior portion of the
into the central spinal canal. Its a combination of flexion and
MVA (motor vehicle accident). Teardrop fragment comes from
aspect of vertebral body. Remainder of body displaced
spinal canal. Facet joint and interspinous distances usually
space may be narrowed. 70% have associated neurologic
- Pathologic fracture: fracture through bone, made weak by disease, such
by a tumor

vertebral
with vertical axial
cord injury, often
vertebral body
compression, e.g.
antero-inferior
backward into
widened. Disk
deficit.
as

- Radial head (proximal radius) fracture: sails sign present = anterior

and posterior fat pad displacement/elevation/swelling surrounding the
elbow joint

Week 3 - Abdomen Plain Films and Ultrasound

(1) Understand the diagnostic role of plain abdominal film
A. Abdominal X-ray has as much radiation as 30 chest xrays.
B. Good Reasons to order
a. Cheap, Fast, available, can be highly specific
C. Bad reasons to order
a. Cheap (get what you pay for), available (order because they can), can be limited.
D. What it shows
a. Free fluid
b. Air outside the bowel lumen
i. Intraperitoneal, retroperitoneal, abscess, pneumatosis
ii. Cant see pneumoperitoneum in supine position (erect or lateral decubitus is
used)
c. Air inside the bowel lumen
i. Ileus (no movement), Bowel obstruction, Volvulus
ii. Small bowel vs colon air
1. Small bowel: Centrally located (of the abdomen), plicae circularis
2. Colon: Peripherally located (of the abdomen), haustral markings.
iii. Too Much Gas Intestinal Dilation (3 cm in small bowel, 6-8 in colon)
1. Think Obstruction or Ileus
a. Ileus think absent bowel sounds and think post-op or possible
meds that suppress bowel activity (opioids/anti-cholinergics)
2. Next test for obstruction CT
3. After that UGI/SBFT/BE
iv. Air fluid levels Look for associated signs of obstruction.
d. Bowel wall thickening
e. Densities
i. Bones, appendicolith, stones, pancreatic calcification (lipase breaks down and
Ca binds), AAA (pooled blood)
f. Organs.
Plain abdominal film:
- Normal plain abdominal film does not exclude ileus or other pathology, and may
falsely reassure the clinician
- Plain abdominal film has a limited value in the evaluation of abdominal pain
- Plain abdominal films are useful for detection of:
o Kidney stones (urate stoneTLS, gout)
o Pneumoperitoneum
- All other indications: use CT or sonography/US
(2) Understand the best test to order for gallbladder disease, appendicitis, kidney
stones, testicular pain, and ovarian/gyn issues
a. Gallbladder disease: US (Single best for cholecystitis). Ultrasound is only 85%
sensitive in detection of bile duct stones (Still test of choice).
b. Pancreas: CT
c. Appendicitis:
i. CT: Single Best test
ii. US: for peds, poor in adults.
iii. MRI for Pregnant
d. Kidney Stones
iv. Non-Contrast CT is more Sensitive (contrast: fluid will show up as bright as
bone so the whole ureter will show up white)
v. US for Kidney masses (Cystic vs solid)
e. Testicular pain: US (small parts imaging: testes, breast, thyroid)
f. OBGYN Issues: US

(3) Be able to identify the following on a plain x-ray

of the abdomen:
Small bowel obstruction
a. Dilation over 3cm. Look for valvulae
conniventes (thin circular folds of mucosa
that span the entire width)
b. Causes: Adhesions, Ileus

Large bowel obstruction

a. Over 6-8 cm in diameter. Look for haustra.
b. Peripherally located.
c. Common cause: Colorectal carcinoma and
diverticular strictures, Hernias, Volvulus.

Constipation
Stool is Opaque white
surrounded by black bowel
gas

Free intraperitoneal air

i.
Emergency (Bowel Perforation)
ii.
Erect Position: Look for a crescent beneath the diaphragm.
iii.
(Below is same pt with free air highlighted in red)

Large kidney stones

This is seen post-op or pts on MEDS, gas dilates Small and large bowel all the way to rectum

Info/Pics from other sources:

-Small Bowel Obstruction
Key features: mechanical SBO
- Dilated small bowel
- Fighting loops
- Little gas in colon,
especially rectum
- Disproportionate
dilatation of SB
- Large Bowel

Obstruction

Key features of mechanical LBO:

Dilated colon until point of obstruction
Little or no air in sigmoid/rectum
Little or no gas in small bowel, if ileocecal valve remains
competent

Pneumoperitoneum (free intraperitoneal air)

Signs: air beneath diaphragm, both sides of bowel wall, falciform ligament sign
Single best test: abdominal & pelvic CT. (Dont give barium enema! Will cause peritonitis.)
Theres a pic of it somewhere in the next lecture set.
Not official objectives, but these were greatly talked about in lecture

US is very useful for biliary obstruction and choledocholithiasis (stone is common bile duct, but is
only 85% sensitive in the best of hands).

PANCREAS NEEDS TO BE DONE W/ CT or MRI. Not good w/ US

increased blood flow

webby

peripheral and

Week 4 - Chest: Part 1

(1) Understand X-ray densities and transmission of x-rays
Tissues having different densities show up as differing densities on the radiograph. There are 5
fundamental radiographic densities. This is how they may appear on the fluorescent screen:
air and gases appear black or radiolucent
fat appears gray to black
muscles and water appear grey
bones and calcium appear white, or radiopaque
metal appears extremely white
A tissue that is denser absorbs more x-rays than tissues that are less dense.
Radiopaque (bone/calcium and metal) is a very dense tissue, and a less dense tissue (fat) is said
to be radiolucent.

(2) How does an x-ray create a visible image on a radiograph?

Beam from cathode tube fans out and increases in size the further away it is from the source
(cathode tube). Want the area being imaged closest to film (not x-ray source/tube) in
order to properly capture the area. The further away the film is to the area being imaged,
the larger and more fuzzy (i.e., less clear and focused) the organ/image will be.
X-ray radiation for medical imaging is typically produced by x-ray tubes, which operate
through bombarding the anode with high energy electrons emitted from a hot cathode. Image
sharpness, contrast, and patient dosage are important considerations in medical
radiography and these requirements determined the desired energies of the tube, the type of
material used on the anode, and the method in which the power is generated to drive the tube.
The photons emitted come in discrete bands of energy corresponding to the material of the
anode, and the undesired bands are removed. Choice of the anode and its emitted radiation
energies depends on the application and the tissues being imaged, for instance molybdenum is
often used in mammography. Too high radiation energies will result in poor pictures since
the radiation cannot be readily attenuated, however too low energies will increase the radiation
dosage of the patient without improvements in image quality.
Sharpness of a radiographic image is strongly determined by the size of the x-ray
source. This is determined by the area of the electron beam hitting the anode. A large photon
source results in more blurring in the final image and is worsened by an increase in image
formation distance. This blurring can be measured as a contribution to the modulation transfer
function of the imaging system.
Use ionizing radiation (xrays) to create image (shadow)
Principles

Xrayphotonfates:
Completelyabsorbedinpt=showsupaswhite(e.g.,bone)
Transmittedthroughpt;strikedetector=showsupasblack
Scatteredwithinpt;strikedetector
Xrayabsorptiondependson:
Beamenergy(constant)
Tissuedensity

Allcardiothoracicpathologyandnormalanatomyisvisualized(ornot)byinteractionof7differentdensities
Howisthisaccomplished?Differentialxrayabsorption
Astructureisrenderedvisibleonaradiographbyjuxtapositionoftwodifferentdensities

(3) Describe the term that indicates when different densities may appear the same on
a radiograph, as well as being familiar with the major sources of artifact on chest xrays.

Silhouette sign: produced when two fluid densities are contiguous and the individual outline of
each is lost. Commonly used in the evaluation of chest problems. Loss of different densities
when a film is too dark OVER exposure, while a film that is too white UNDER exposed.
The silhouette sign refers to loss of normal border between structures, or an intrathoracic radio-opacity obscuring the border of the heart or aorta due to a contiguous structure. In
other words it is difficult to make out the borders of a particular structure - normal or
otherwise - because it is next to another dense structure, both of which will come up as white on
a standard X-ray. It may occur, for example, in middle lobe disease, where the right heart margin
is lost, and in right lower lobe pneumonia, where the border of the diaphragm on the right side is
obscured, while the right heart margin remains distinct.

CXRlocalization:silhouettesign
o Lossofexpectedinterfacenormallycreatedbyjuxtapositionoftwostructuresofdifferentdensity
o Noboundarycanbeseenbetweentwostructuresofsimilardensity

Most imaging methods can create image features that do not represent a body structure or
object. These are image artifacts. In many situations an artifact does not significantly affect
object visibility and diagnostic accuracy. But artifacts can obscure a part of an image or may be
interpreted as an anatomical feature. A variety of factors associated with each imaging method
can cause image artifacts.

DifferentialXrayAbsorption
Absenceofanormalinterfacemayindicatedisease
Presenceofanunexpectedinterfacemayalsoindicatedisease
Presenceofinterfacescanbeusedtolocalizeabnormalities
Cardiacradiography:Limitations
Muscle,blood,pericardium,valves,arteriesallsamedensity(water)
Detectionofcardiacabnormalitieslimitedtochangesinheartsize,shape,axis,orpresenceofdensermatter(valvereplacement,
calcification)
Requiresgoodknowledgeofanatomy
ApproachtotheCXR:technicalaspects
Inspiratoryeffort910posteriorribs;
Penetrationthoracicintervertebraldiscspacejustvisible
Positioning/rotationmedialclavicleheadsequidistanttospinousprocess

(4) Understand the technical approach to reading a chest x-ray

Check the image for - Inclusion, Projection, Rotation, Inspiration, Penetration and
Artifact
Inclusion: A chest X-ray should include the entire thoracic cage. Look for First ribs,
costophrenic angles and the lateral edges of ribs.
Projection: PA projection is typical. X-rays pass from the posterior to the anterior of the
patient - hence Posterior-Anterior (PA) projection. The image is viewed as if looking at the
patient face-to-face.
Rotation: The spinous processes of the thoracic vertebrae are in the midline at the back
of the chest. They should form a vertical line that lies equidistant from the medial ends of
the clavicles, which are at the front of the chest. Rotation of the patient will lead to offsetting of the spinous processes so they lie nearer one clavicle than the other. Find the
medial ends of the clavicles, Find the vertebral spinous processes, The spinous processes
should lie half way between the medial ends of the clavicles.
Inspiration: To assess the degree of inspiration it is conventional to count ribs down to
the diaphragm. The diaphragm should be intersected by the 5th to 7th anterior
ribs in the mid-clavicular line. Less is a sign of incomplete inspiration.
Penetration: A well penetrated chest X-ray is one where the vertebrae are just
visible behind the heart. Although X-rays are still occasionally over or under exposed, a
discussion of penetration now best serves as a reminder to check behind the heart. The
left hemidiaphragm should be visible to the edge of the spine. Loss of the hemidiaphragm
contour or of the paravertebral tissue lines may be due to lung or mediastinal pathology.

Artifact: examples include rotation, incomplete inspiration and incorrect penetration.

Other radiographic artifact includes clothing or jewelry not removed. Other common
artifact to find is medical or surgical equipment like NG tubes.

Mnemonic for reading a [normal] chest x-ray: ABCDEFGHI

A = Airway
B = Bone
C = Cardiac silhouette
D = Diaphragm
E = Edge of the heart
F = Field of lung
G = Gastric bubble
H = Hilum of lung
I = Impression (diagnosis)
14 steps (total):
1. Check the patient's name. Above all else, make sure you are looking at the correct
chest x-ray first.
2. Read the date of the chest radiograph. Make special note of the date when comparing
older radiographs (always look at older radiographs if available). The date the radiograph
is taken provides important context for interpreting any findings. For example, a mass that
has become bigger over 3 months is more significant than one that has become bigger
over 3 years.
3. Note the type of film (while this article assumes you are looking at a chest x-ray,
practice noting if it is a plain film, CT, angiogram, MRI, etc.) For chest x-ray, there are
several views as follows:
o The standard view of the chest is the posteroanterior radiograph, or "PA chest."
Posteroanterior refers to the direction of the x-ray traversing the patient from
posterior to anterior. This film is taken with the patient upright, in full inspiration
(breathed in all the way), and the x-ray beam radiating horizontally 6 feet away
from the film.
o The anteroposterior (AP) chest radiograph is obtained with the x-ray traversing
the patient from anterior to posterior, usually obtained with a portable x-ray
machine from very sick patients, those unable to stand, and infants. Because
portable x-ray units tend to be less powerful than regular units, AP radiographs are
generally taken at shorter distance from the film compared to PA radiographs. The
farther away the x-ray source is from the film, the sharper and less magnified the
image. (You can confirm this by placing your hand about 3 inches from a desk,
shining a lamp above it from various distances, and observing the shadow cast. The
shadow will appear sharper and less magnified if the lamp is farther away.) Since AP
radigraphs are taken from shorter distances, they appear more magnified and less
sharp compared to standard PA films.
o Lateral chest x-ray. The lateral chest radiograph is taken with the
patient's left side of chest held against the x-ray cassette (left
instead of right to make the heart appear sharper and less
magnified, since the heart is closer to the left side). It is taken with
the beam at 6 feet away, as in the PA view. (example pic at right)
o An oblique view is a rotated view in between the standard front
view and the lateral view. It is useful in localizing lesions and
eliminating superimposed structures.
o A lateral decubitus view is one taken with the patient lying down on the side. It
helps to determine whether suspected fluid (pleural effusion) will layer out to the
bottom, or suspected air (pneumothorax) will rise to the top. For example, if pleural
fluid is suspected in the left lung, check a left lateral decubitus view (to allow the
fluid to layer to the left sideyou want the fluid to go the bottom and not be

obstructed by the dropping mediastinum structures). If air is suspected in left lung,

check a right lateral decubitus view (to allow the air to rise to the left side).
Figure: Right lateral decubitus chest x-ray showing pleural
effusion. The A arrow indicates "fluid layering" in the right
chest. The B arrow indicates the width of the right lung. The
volume of useful lung is reduced because of the collection of
fluid around the lung.
4. Look for markers: 'L' for Left, 'R' for Right, 'PA' for posteroanterior,
'AP' for anteroposterior, etc. Note the position of the patient: supine
(lying flat), upright, lateral, decubitus.
5. Note the technical quality of film.
o Exposure: Overexposed films look darker than normal, making fine details
harder to see; underexposed films look whiter than normal, and cause
appearance of areas of opacification. Look for intervertebral bodies in a properly
penetrated chest x-ray. An under-penetrated chest x-ray cannot differentiate the
vertebral bodies from the intervertebral spaces, while an over-penetrated film
shows the intervertebral spaces very distinctly.
To assess exposure, look at the vertebral column behind the heart on the
frontal view. If detailed spine and pulmonary vessels are seen behind
the heart, the exposure is correct. If only the spine is visible, but not the
pulmonary vessels, the film is too dark (overexposed). If the spine is not
visible, the film is too white (underexposed).
o Motion: Motion blurred areas. Finding a subtle pneumothorax is hard if theres
significant motion.
o Rotation: Rotation means that the patient was not positioned flat on the x-ray film,
with one plane of the chest rotated compared to the plane of the film. It causes
distortion because it can make the lungs look asymmetrical and the cardiac
silhouette disoriented. Look for the right and left lung fields having nearly the same
diameter, and the heads of the ribs (end of the calcified section of each rib) at the
same location to the chest wall, which indicate absence of significant rotation. If
there is significant rotation, the side that has been lifted appears narrower and
denser (whiter) and the cardiac silhouette appears more in the opposite lung field.
6. Airway: Check to see if the airway is patent and midline. For
example, in a tension pneumothorax, the airway is deviated away
from the affected side. Look for the carina, where the trachea
bifurcates into the R and L main stem bronchi.
Figure: Left tension pneumothorax. Note the large, welldemarcated area devoid of lung markings, and deviation of the
trachea (airway) and the heart away from the affected side. The
bright metallic spots are snaps for EKG readings.
7. Bones: Check the bones for any fractures, lesions, or defects. Note the overall size,
shape, and contour of each bone, density or mineralization
(osteopenic bones look thin and less opaque), cortical thickness in
comparison to medullary cavity, trabecular pattern, presence of
any erosions, fractures, lytic or blastic areas. Look for lucent and
sclerotic lesions. A lucent bone lesion is an area of bone with a
decreased density (appearing darker); it may appear punched out
compared to surrounding bone. A sclerotic bone lesion is an area of
bone with an increased density (appearing whiter). At joints, look
for joint spaces narrowing, widening, calcification in the cartilages,
air in the joint space, abnormal fat pads, etc.
Figure: Fracture of the left clavicle.

8. Cardiac silhouette: Look at the size of the cardiac silhouette

(white space representing the heart, situated b/t the lungs).
Normal: less than the chest width.
o Look for water-bottle-shaped heart on PA plain film,
suggestive of pericardial effusion. Get an ultrasound or
chest CT to confirm.
Figure: Enlarged cardiac silhouette in a case of aortic dissection
(blood fills the mediastinum). Note that the cardiac silhouette
takes up more than half of the chest width. Characteristic of aortic dissection here is the
enlarged mediastinum (labeled 1) and aortic arched (labeled 2)
9. Diaphragms: Look for a flat or raised diaphragm. A flattened diaphragm may indicate
emphysema (COPD). A raised diaphragm may indicate area of airspace consolidation (as
in pneumonia) making the lower lung field indistinguishable in
tissue density compared to the abdomen. The right diaphragm is
normally higher than the left, due to the presence of the liver
below the right diaphragm. Also look at the costophrenic angle
(which should be sharp) for any blunting, which may indicate
effusion (as fluid settles down). It takes about 300-500 ml of fluid
to blunt the costophrenic angle.
Figure: Left pleural effusion associated with left lower lobe
pneumonia; note that the costophrenic angle is blunted, and the L diaphragm is raised
compared to R.
10.Edges of heart; External soft tissues:
Check the edges of the heart for the
silhouette sign: a radioopacity obscuring
the heart's border, in right middle lobe
and left lingula pneumonia, for example.
Also, look at the external soft tissues for
any abnormalities. Note the lymph nodes,
look for subcutaneous emphysema (air
density below the skin), and other lesions.
Figure: A) Normal chest radiograph; B) Q fever pneumonia affecting the lower and middle
lobes of the right lung. Note the loss of the normal radiographic silhouette (contour) b/t
the affected lung and its R heart border as well as between the affected lung and its R
diaphragm borderthis is called the silhouette sign.
11.Fields of the lungs: Look for symmetry, vascularity, presence
of any mass, nodules, infiltration, fluid, bronchial cuffing, etc. If
fluid, blood, mucous, or tumor, etc. fills the air sacs, the lungs will
appear radiodense (bright), with less visible interstitial markings.
Figure: R lower lobe pneumonia. Note prominent air-bronchogram
sign: air visualized in the peripheral intrapulmonary bronchi, due
to an infiltrate or consolidation surrounding the bronchi
12.Gastric bubble: Look for the presence of a gastric bubble, just below the heart;
note whether it is obscured or absent. Assess the amount of gas and location of the gastric
bubble. Normal gas bubbles may also be seen in the hepatic and splenic flexures of the
colon.

13.Hila: Look for nodes and masses in the hila of both lungs.
On the frontal view, most of the hilar shadows represent the left
and right pulmonary arteries. The left pulmonary artery is always
more superior than the right, making the left hilum higher. Look for
calcified lymph nodes in the hilar, which may be caused by an old
tuberculosis infection.
Figure: Enlarged lymph node in left hilum, in a case of carcinoid
tumor.
14.

Breast implants

(5) When looking at a chest x-ray, be able to identify normal anatomic landmarks and
major disease patterns, such as: Right Atrium, Right Ventricle, Left Ventricle, Diaphragms,
Ribs, Trachea, Aortic Arch, Pulmonary Fissures, Costophrenic Angle (see below at chest x-ray
anatomic structures to check)

CXR: Anatomy You Can See

CXR: Anatomy You Can See

Lateral CXR

Frontal CXR

Pneumonia

Aortic arch ()
Central pulmonary art ()
LV ( ), RA ( )
Diaphragms ( )
Trachea ( )
Bones

CHF note enlarged heart

Aortic arch ()
Central pulmonary arteries ()
RV ( ), LV ( )
Diaphragms
Right & left upper lobe bronchi
Trachea ( )
Bones- sternum, spine

Cardiomegaly

Air Bronchogram

Right Atrium, Right Ventricle,

Left Ventricle, Diaphragms,
Ribs, Trachea,
Aortic Arch, Pulmonary Fissures,
Costophrenic Angle

Pneumothorax

Consolidated lung dense

and white. Larger airways
spared low density
(blacker). This phenomenon
= air bronchogram
(characteristic sign of
consolidation)
- Free Intraperitoneal Air

- Pneumonia: The x-ray findings of pneumonia are airspace opacity, lobar consolidation, or
interstitial opacities. There is usually considerable overlap. Again, pneumonias are a spaceoccupying lesion without volume loss. What differentiates it from a mass? Masses are generally
more well-defined. Pneumonia may have an associated parapneumonic effusion.

- Congestive Heart Failure: The earliest CXR finding of CHF is cardiomegaly, detected as an
cardiothoracic ratio (>50%). In the pulmonary vasculature of the normal chest, the lower zone
pulmonary veins are larger than the upper zone veins d/t gravity. In a patient with CHF, the
pulmonary capillary wedge pressure rises to the 12-18 mmHg range and the upper zone veins
dilate and are equal in size or larger, termed cephalization. With increasing PCWP (pulmonary

capillary wedge pressure, 18-24 mmHg.), interstitial edema

occurs with the appearance of Kerley lines. Increased PCWP
above this level is alveolar edema, often in a classic peri-hilar
bat wing pattern of density. Pleural effusions often occur, too.

- Cardiomegaly: refers to excessive heart size in proportion to

the diameter of the rib cage. Heart size is usually estimated based
on the cardiothoracic ratio, which compares the maximum width
of the cardiac silhouette on a frontal CXR, with the maximum
internal diameter of the rib cage. Cardiomegaly is usually present if the maximum width of the
cardiac silhouette is >50% of the maximum internal diameter of the rib cage.

- Air Bronchogram: sign in which branching radiolucent columns of air corresponding to bronchi
is seen, usually indicates air-space (alveolar) disease, as from blood, pus, mucus, cells,
protein surrounding the air bronchograms; this is often seen in RDS (respiratory distress
syndrome), specifically occurring due to infiltrates outlining larger air passageways. Air
bronchograms occur when there is pulmonary infiltration or edema in the tissues immediately
adjacent to the bronchi. Darker tubular densities can be seen when the inflammatory process
involves the alveoli but has not filled the bronchi with fluid, and therefore distinguishes
this disease from cases of atelectasis or pulmonary edema.

- Pneumothorax: The sx of pneumothorax can be vague and

inconclusive, esp. in those with a small PSP, and confirmation with
medical imaging is usually required. In contrast, tension
pneumothorax is a medical emergency and may be treated before
imaging - especially if there is severe hypoxia, very low blood
pressure, or impaired consciousness. In tension pneumothorax, Xrays are sometimes required if there is doubt about the
anatomical location of the pneumothorax.
The lung is held close to chest wall because of the negative
pressure in the pleural space. Once the negative pressure is lost
the lung tends to recoil due to elastic properties and becomes
atelectatic. This occurs in patients with pneumothorax and pleural effusion.

- Pneumoperitoneum (free intraperitoneal air)

of

Signs: air beneath diaphragm, both sides

bowel wall, falciform ligament sign
White arrow: evidence of free air between the
abdominal wall and the liver. Black arrow:
evidence of free fluid in the peritoneum.

Chest x-ray anatomic structures to check

1. Trachea/bronchi
2. Hilar structures
3. Lung zones
4. Pleura
5. Lung lobes/fissures
6. Costophrenic angles
7. Diaphragm
8. Heart
9. Mediastinum
10. Soft tissues
11. Bones

Week 5 - Chest: Part 2

(1) Understand X-ray transmission and how that is related to CT scans
X-ray source and detectors rotate around patient
Amount of radiation transmitted though body at various angles is recorded
Creates density map of human tissue
Table carries patient past continuously rotating x ray tube = volumetric data
acquisition

X-ray tube & generator can make 360 revolution in 0.28 sec
Wide beam (up to 16 cm) with narrow detectors = high spatial resolution
Table carries patient past continuously rotating x ray tube = volumetric data acquisition
CT scans are an advanced form of x-ray technology used in detecting diseases in soft body
tissues, and can actually provide images of internal organs that are impossible to detect with
standard x-ray techniques. X-rays are good at finding bone fractures, and for being used as a
contrasting agent for several types of exams; however, CT provides greater detail and clarity. CT
scans have additional advantages of being able to produce imaging in virtually any orientation. It
is a more technologically developed version of an x-ray, which is used on specific parts of the
body. It also provides better images for bone structures, such as the inner ear as it can easily
detect tumors in the auditory canal and cochlea. CT scans help diagnose bone fractures,
bone tumors, internal injuries/bleeding and blood clots, and monitor heart diseases
and CA.
MRI

Superconducting magnet wire coils in liquid helium with electric current

High strength magnetic field 0.2 9T
o Stable magnetic field
Gradient magnets
o Create variable magnetic field
Radiofrequency pulse deposition of energy in pts tissues

(2) Understand the resolution differences between chest x-ray and CT scans
An Xray produces a single image in which structures are overlaid on each other. In contract a CT
produces many slices of an image, essentially using many xrays at different angles to create
images of layers throughout the body.
There are several advantages that CT has over traditional 2D medical radiography (i.e. plain xray films). First, CT completely eliminates the superimposition of images of structures
outside the area of interest. Second, because of the inherent high-contrast resolution of CT,
differences between tissues that differ in physical density by less than 1% can be
distinguished. Finally, data from a single CT imaging procedure consisting of either
multiple contiguous or one helical scan can be viewed as images in the axial, coronal,
or sagittal planes, depending on the diagnostic task. This is referred to as multi-planar
reformatted imaging. CT scans use a high level of ionizing radiation. Ionizing radiation has the
capacity to break molecular bonds, and thus alter the molecular structure of the irradiated
molecules.
(3) Understand how IV contrast administration effects contrast
IV contrast is used to highlight blood vessels and to enhance the structure of organs like the
brain, spine, liver, and kidney. Typically the contrast is contained in a special injector, which
injects the contrast through a small needle taped in place (usually on the back of the hand)
during a specific period in the CT exam. Once the contrast is injected into the bloodstream, it
circulates throughout the body. The CT's x-ray beam is weakened as it passes through the
blood vessels and organs that have "taken up" the contrast. These structures are
enhanced by this process and show up as white areas on the CT images. When the
test is finished, the kidneys and liver quickly eliminate the contrast from the body.
IV contrast is opaque to x-rays. When given, it brightens and allows greater visualization of
internal organs, arteries, veins and tissues as it courses through them. For some exams it is
essential and cannot be done properly without it, while with other exams it is contraindicated, as
it may cause anaphylaxis, nephropathy or negative drug-drug interactions.

4) When looking at CT scans, be able to identify normal landmarks:

- Heart (Here are 4 images: superior to inferior)
Aorta rises in front of
trachea then moves
behind esophagus
ATE=>TEA

- Pulmonary Arteries

- Pulmonary Fissures
Right side:
o major (oblique: yellow): separates upper from lower lobe
o minor (horizontal: white): separates upper from middle lobe
Left side:
o major (oblique: blue): separates upper from lower lobe

The coronal CT image on the left shows the right minor (horizontal) fissure (white arrow), right
major fissure (yellow arrow), and left major (oblique) fissure. These structures are also seen on
the right lateral sagittal CT image on the right. The minor fissure separates the right superior
lobe from the right middle lobe. The right major fissure separates the right upper and middle
lobes from the inferior lobe. The left major fissure (middle CT image) separates the left upper and
lower lobes. These fissures are easy to see because this patient suffers significant pleural
effusions that fill the pleural space and partially separates the lobes.

Week 6 - Abdomen: CT & Sectional Anatomy

Hounsfield Units: Relates attenuation coefficients of tissue to that of water. Low

attenuation (negative) blocks only a few x-rays
-Air = -1000
-Tissue = 40
-Fat = -50
-Calcium = 100
-Water = 0
-Bone = 1000
Metals can cause artifacts
Use CT Judiciously especially in the youth

1. Know when to order a CT scan of the abdomen

a. CT is very useful in the imaging of Cancer, Trauma, Vascular pathology, and
Abdominal Sx
b. Intraabdominal fluid is a marker of pathology.
2. Be able to determine when to use contrast and when to order a non-contrast
Abdominal CT
a. Oral and IV Contrast (IV is Iodine based)
i. Water soluble Oral contrast if you suspect Perforation.
1. Dont give them barium peritonitis!
ii. IV Contrast helps with vasculature, viscera, and distinguishes cystic
from solid.
b. Risk for IV Contrast
i. Allergy (Pretreat with steroids)
ii. Renal insufficiency (Creatinine >2.0; nl: 0.6-1.2)
c. No Contrast for Head Trauma and Renal Stones
3. Know how to diagnose the following conditions with an Abdominal CT
a. Kidney stones
i. History of Flank Pain
ii. (Left Ureteral Stone on image on the right)

b. Appendicitis
i. Worm like structure inferior to the cecum
ii. To find it, Find the ascending colon @ iliac crests and scroll
down until you reach the inferior cecum and find the
worm.

c. Diverticulitis: Wall thickening and edema in the fat adjacent to the sigmoid colon
(LLQ)

d. Abdominal aortic Aneurysm

i. Pt typically has hypotension and distended abdomen.

Week 7 - Neuroradiology: CT scan

(1) How are skull fractures characterized on a head CT (linear vs. depressed)
Linear: transverse full thickness of bone w/o being displaced downward. This is the most
common type of skull fracture. In a linear fracture, there is a break in the bone, but it does not
move the bone. These patients may be observed in the hospital for a brief amount of time,
and can usually resume normal activities in a few days. Usually, no interventions are
necessary.

Depressed: comminuted fracture where bone is depressed inward,

inc. pressure on brain. May be seen with or without a cut in the
scalp. In this fracture, part of the skull is actually sunken in from the
trauma. This type of skull fracture may require surgical intervention,
depending on the severity, to help correct the deformity. A skull
fracture is most clinically significant if the paranasal sinus or skull
base is involved.
- Distinguished from sutures
- Sutures have undulating margins both sutures

Diastatic skull fractures: These are fractures that occur along the suture lines in the
skull. The sutures are the areas between the bones in the head that
fuse when
we are children. In this type of fracture, the normal suture lines are
widened. These fractures are more often seen in newborns and
older infants.

Basilar skull fracture

This is the most serious type of skull fracture, and
involves a break in the bone at the base of the skull.
Patients with this type of fracture frequently have
bruises around their eyes and a bruise behind
their ear. They may also have clear fluid (CSF)
draining from their nose or ears due to a tear in part
of the covering of the brain. These patients usually
require close observation in the hospital.

Intracranial hematoma (ICH)

There are several types of ICH, or blood clots, in or around the brain. The different types are
classified by their location in the brain. These can range from mild head injuries to quite
serious and potentially life-threatening injuries.

(2) Understand the most common clinical scenarios: Subdural, Subarachnoid,

Intracerebral and Epidural Bleeds
- Subdural: rupture of bridging veins, usu. d/t deceleration and acceleration, or rotational
forces (atrophy predisposes, so common in elderly who fall)
- blood collects between arachnoid and dura matter, cant cross falx, tentorium
CT- Crescent shaped that crosses suture lines.
May contain hypodense foci due to serum, CSF or active bleeding (pic on right)

Subarachnoid:
- injury of small arteries or veins on the surface of the brain
- bleeds into space between pia and arachnoid mater
- trauma is most common cause
- also due to ruptured aneurysm
- worst H/A of life
- CT: Focal high density in sulci and fissures or linear hyperdensity in the
cerebral sulci
Epidural Bleeds

-Usually associated with a skull fracture

-Lacerates a dural artery or a venous
sinus (middle meningeal artery)
-The blood collects between the skull and
dura
-On CT, a hyperdense biconvex mass
-Can cross the dural reflections unlike a
subdural hematoma
-Usually does not cross suture lines where
the dura tightly adheres to the adjacent
skull
Intracerebral
The most common cause of non-traumatic intracerebral hematoma: hypertensive
hemorrhage. Other causes: Amyloid angiopathy, Ruptured vascular malformation,
Coagulopathy, Hemorrhage into a tumor, Venous infarction, Drug abuse
Contusion (intracerebral hematoma):
a bruise to the brain itself. A contusion
causes bleeding and swelling inside of the
brain around the area where the head was
struck. Contusions may occur with skull
fractures or other blood clots such as a
subdural or epidural hematoma.
When bleeding occurs inside the brain
itself (also called "intraparenchymal
hemmorage"), this can sometimes occur
spontaneously. When trauma is not the
cause, the most common causes are longstanding high blood pressure in older
adults, bleeding disorders in either children or adults, or the use of medications that cause
blood thinning or certain drugs of abuse (cocaine).
Diffuse axonal injury (DAI)
These injuries are fairly common and are usually caused by shaking of the brain back
and forth, which can happen in car accidents, from falls, or shaken baby syndrome.
Diffuse injuries can be mild, such as with a concussion, or may be very severe, as in
diffuse axonal injury (DAI). In DAI, the patient is usually in a coma for a prolonged period
of time, with injury to many different parts of the brain.
(3) Understand the most common cause of non-traumatic intracerebral bleeds
Hemorrhagic stroke, due to hypertensive hemorrhage
- 70-90% of non-traumatic primary intracerebral hemorrhages.
- Vasculopathy involving deep penetrating arteries of the brain (lacunar)
- Thalamus, pons, cerebellum, and basal ganglia
Blood may extend into the ventricular system. Associated with a poor prognosis
(4) Be familiar with the appearance of the following on a CT scan of the Head:
Epidural Bleed, Subdural Bleed, Subarachnoid Bleed, Intracerebral Bleed, Hydrocephalus, Skull
Fracture
(well, all except hydrocephalus were taken care of before, so lets git-r-done now)
Hydrocephalus
- A problem with the ratio of production of CSF to its reabsorption
- Communicating hydrocephalus is the most common and is due to arachnoid villi and
subarachnoid space obstruction. Meningitis is assoc w communicating hydrocephalus.

Obstructive hydrocephalus is less common but may occur as a result of the following:
aqueductal stenosis or occlusion; trapped 4th ventricle; ependymitis

Hydr
ocephalus

Normal