Lucky Song

Carlos Antenna (32) has been fighting a middle ear infection for a couple of weeks. He suffers from pain and his hearing has decreased. He was a bit late to visit his ENT specialist because he has been traveling much lately for professional reasons. He has not really been taking his expensive antibiotics, either, because he left the package at home. Now another spike of fever has forced him to see his doctor again. The colleague immediately referred him to radiology for a radiograph. Hannah has...

Did You Know That

Wladimir von Bechterew was a neurologist and psychiatrist in St. Petersburg around 1900. His psychiatric ideas and models were highly speculative, but his neuroanatomical scientific work is relevant to this day. He was one of the first to comprehensively describe ankylosing spondylitis. One of his colleagues and major rivals in St. Petersburg was Ivan Pavlov, whose experiments we all know. In 1927 the leader of the Soviet Union, a certain Comrade Stalin, sought his medical advice. The...

Preexisting Spinal Problems That Increase Trauma Risk

Effect Spine Injury

Fig. 14.18a In ankylosing spondylitis, also called Bech-terew disease, slowly progressive ossification of the complete ligamentous apparatus of the spinal column occurs. You have already seen the prototypical appearance of the bamboo spine in Fig. 8.44b, p. 146. Note the fracture at the C6 7 level after a minor trauma in this patient. b In Forestier disease only the anterior longitudinal ligament of the spinal column ossifies, but the effect is the same the spine loses all its elasticity. Every...

One Truly International Colleague Who Made a Dent in Trauma Survival

Geoffrey Jefferson was a Manchester-born neurosurgeon who worked in St. Petersburg during World War I, where he served in the Anglo-Russian Hospital, a gift of the British Empire to the Russian ally. Obviously he gained a lot of experience with severe trauma during that time. He became a skeptic witness of the 1917 communist October revolution. He earlier practiced in Canada where his wife came from later in the war he worked in France. He described the typical fracture of the atlas in 1920....

CEslm AntGetingi Startedoinlinica Radiiologyci o2006oThiemehite blood cell All rights reserved Usage subject to terms

Table 9.1 Suggestions for diagnostic modalities in gastrointestinal imaging1 (Continued) Table 9.1 Suggestions for diagnostic modalities in gastrointestinal imaging1 (Continued) To further assess US-proven obstructive jaundice, especially below the hilar level. Crucial in staging malignant hilar level obstruction. May predict unresectability in pancreatic cancer. In hilar level obstruction MR cholangiopancreatography is the investigation of choice. Depicts pattern and extent of duct involvement...

Recurrent Carcinoma in a Breast Reconstructed with an Implant

And another group of suspicious lesions appears in the contralateral breast. The left-sided lesion is a recurrence until proven otherwise. The finding in the right breast must also be examined histologically. Fig. 12.25 a This T2-weighted and fat saturated MRI sequence shows the intact implant in the left breast three years after the resection of a carcinoma. b After contrast administration, an enhancing lesion is appreciated medially in the left breast and another group of suspicious lesions...

Protection of the Patient

F The best radiation protection is to adhere to a strict indica-i tion list, reducing the number of examinations to the absolute necessary minimum, and whenever feasible to choose other imaging modalities that do not require radiation. The technical execution of the examination by an experienced diagnostician comes next in line fluoroscopy times are kept short, the radiated volume is kept small by careful collimation, the distance of the patient to the detector is kept short, and the...

What is Your Diagnosis

Pics Degenerated Spondylo

Osteochondrosis Osteochondrosis is the degenerative loss of height of the intervertebral disk, which ends in the destruction of the central disk and the formation of a central gas pocket (also called vacuum phenomenon). In addition, osseous protuberances spondylo-phytes are formed at the rims of the vertebral end plates these may become very large and eventually bridge the intervertebral gap (Fig. 8.36). Degenerative osteophytes may also develop around the posterior facet joints. The Fig. 8.35...

What on Earth is Wrong with My Husband

Tortoise Mri

Joe-James Lee-Chong (47) is accompanied by his wife. They have consulted the neurologists together because Mr. Lee-Chong has had a chronic headache for quite a few weeks. Before that he was never really sick. His wife reports that he is normally a very active and humorous personality. Now he tends to sit in this armchair and does not seem to care about anything. A sudden tonic seizure last week scared the daylights out of them and made his wife get an urgent appointment with the neurologist....

Risks of Radiological Procedures

Risks of Projection Radiography and Computed Tomography The terrifying experiences of the early x-ray pioneers, some of their patients, and the victims of Hiroshima, Nagasaki, and Chernobyl demonstrate the risks of exposure to large doses of ionizing radiation with dire clarity. However, the number of human beings who have been helped by the use of radiation in diagnosis and therapy exceeds that of the victims by several orders of magnitude. The injuries that can be induced by the normal...

Eastman Getting Started in Clinical Radiology 2006 Thieme All rights reserved Usage subject to terms and conditions of

Suggestions for diagnostic modalities in gastrointestinal imaging Table 9.1 Suggestions for diagnostic modalities in gastrointestinal imaging1 (Continued) Table 9.1 Suggestions for diagnostic modalities in gastrointestinal imaging1 (Continued) Some centers use CT for the frail elderly patient. Increasing role of CT colonoscopy, also called virtual colonoscopy, in large centers. May suggest diagnosis and likely level. Single contrast (ideally water-soluble contrast medium) study can confirm...

The Case of Agostino Martinez

Fig. 13.1a This Tl-weighted sagittal MR image shows a lobulated tumor at the base of the nose. b After contrast administration, the periphery of the lesion enhances markedly. A communication to the subarach-noid space was not seen on this or on other images in this study. p. 9) or tissue may be left behind or misdirected on its path of migration. Congenital midline lesions of the face can extend deep into the cranium and ultimately even extend to the subarachnoid space or the brain....

Intradural spinal tumor

Intradural extramedullary spinal tumor The most frequent intradural extramedullary spinal solid tumor is the spinal meningioma. It is a slow-growing tumor that may also expand the spinal canal (Fig. 11.50a see also p. 241). Metas-tases often spread via the CSF also settle in the thecal sac (Fig. 11.50b). They are a feared complication, particularly in pediatric tumors of the posterior fossa. Intramedullary spinal tumor intramedullary spinal masses tend to be primary CNS-type tumors such as...

Problem of the Grottos

Sid Cavern (54) has been sent to the radiology department by his doctor to get some sinus radiographs done. The clinician has treated him for a sinusitis for a little while and is worried now because the clinical symptoms have not changed at all despite prolonged therapy. Paul and Hannah are covering the bone unit today. Having gathered a little experience with these patients, they know that two types of radiographs are needed for the proper evaluation of the paranasal sinus the Waters view...

Lateral Radiograph of the Cervical Spine

By now the lateral radiograph of the cervical spine is ready for inspection. The trauma surgeons and the anesthesiologist want to know how careful they have to be during repositioning of the patient and whether the stiff collar can be taken off. The radiograph of the cervical spine is always difficult to evaluate and any mistakes can be fatal. f Twenty percent of all polytraumatized patients have an i injury of the cervical spine, a dislocation injury (particularly in deceleration trauma), or a...

Schwannoma

Hidradenitis Breast

Fig. 11.56a The usual axial T1-weighted MR image displays a mass (arrow) in an intervertebral foramen on the right. It is reminiscent of a dumbbell. b After contrast administration, the typical dumbbell configuration of the schwannoma becomes much clearer. Fig. 11.56a The usual axial T1-weighted MR image displays a mass (arrow) in an intervertebral foramen on the right. It is reminiscent of a dumbbell. b After contrast administration, the typical dumbbell configuration of the schwannoma becomes...

M V f i

Fig. 13.7d The axial Tl-weighted MR image (left) obtained after contrast administration (the content of the eye bulb is dark) shows fluid retention in both sphenoid sinuses with marked mucosal enhancement particularly in the right sinus (long arrow). There is an additional fluid pocket in the temporal fossa (short arrows) that is surrounded by enhancing, swollen meninges. This is a potentially lethal epidural abscess associated with meningitis as a consequence of sinusitis Note another frontal...

Unlucky Fellows

While on his daily walk through the Royal Botanic Garden this morning, retired stockbroker Rob McClellan lost his balance on slippery ground and fell on his shoulder. He has not been able to move his shoulder since (Fig. 14.41). His girlfriend Nadine Rothman tried to help him up but also fell on the slippery concrete. Now her right hip is painful and she cannot move her leg anymore (Fig. 14.42a). McClellan's grandson Philipp who had joined them for the walk, tried to come to their help on his...

The Ill Prepared Study

Any examination can lead you astray or cause erroneous findings if it is poorly executed. Reasons may be the lack of experience of the examining physician, especially when dealing with less frequent clinical problems, or when performing a study that requires considerable technical skill but has not been performed by that particular physician in a while. When considering the choice of a radiographic modality, its particular operator dependence also needs to be taken into account. If your...

1

Vacuum phenomenon 139, 140, 265 valvulae conniventes 176 vascular access 110-111 vascular occlusive disease interventions 99-103 examination 8 vena cava, MR angiography 97 vena cava filter placement 109-110 angiography 97 venography 97,102-103 CT 79, 80 venous angioma 259, 260 venous hemorrhage, cranial 236 venous obstruction 102-103 venous sinus thrombosis 239, 240 venous thrombosis 79, 80 ventilation-perfusion mismatch 79, 81 ventricle, left (cardiac) aneurysm 89 failure 63-64, 65, 66...

Tell Me the Truth

Nastassja Rimzky (35) has been sent for mammogra-phy by her gynecologist. During a routine examination, this physician has palpated a lump in her right breast and sent her for a diagnostic mammogram to further work it up. Mrs. Rimzky had discontinued her breast self-examinations a long time ago. It made her too nervous, she says. She is quite tense now. There is no family history of breast cancer, but her family is rather small. She finds breast compression during mammography quite painful....

S Risks Risk Minimization and Prophylactic Measures

Radiographers Causing Harm Patients

Every diagnostic and interventional procedure harbors potential risks to the patient. Risks can be very real and immediate, that is, they can directly harm the patient's health, or they can be indirect, resulting in other risky studies to prove or disprove a preliminary suspicious finding. Counterbalancing the risk of a study is, of course, the potential benefit it brings to the patient an invasive procedure may yield a comprehensive diagnosis allowing for immediate therapy such as in...

Paget

Humerus Cancellous Bone

Fig. 8.21 a, b The radiograph of the humerus (a) shows an enlargement of the whole bone with thickening of the cortex and an extreme coarseness of the cancellous bone pattern so-called woven bone. This is a typical case of Paget. The view of a skull base specimen from above (b) illustrates the textile character of the bone in Paget disease and makes clear why the cranial nerves may eventually be compressed and why patients used to come to their physicians for advice because their hats would no...

Gregorys Test

Fig. 8.82 This coronal MR section with fat saturation and after intravenous contrast administration displays a significantly enhancing structure lateral to the femoral metaphysis. Location and structure are typical for a synovial hemangioma. Finally Joey considers lesions in typical locations Synovial hemangioma This is a vascular lesion in the direct vicinity of the knee joint (Fig. 8.82). Giufeng, Hannah, Paul, Ajay, and Joey sit in the skeletal imaging unit at the end of the day and are...

Can We Reach a Diagnosis that Approaches Histological Certainty

If a pathological finding has been detected, it must be classified and the differential diagnoses must be contemplated. Going through the following questions in your mind may help you come up with a more concise list of potential diagnoses. Scars in parenchymal organs and pulmonary atelectasis are associated with volume loss that is, neighboring elastic tissues move toward the pathological process. Abscesses, tumors, and metastases act quite differently they tend to increase in volume and...

Tissue Biopsies

Pneumothorax Pathway

Is the lesion to be biopsied a true abnormality, adequately documented (CT, ultrasound, MRI) Is the lesion large enough to reasonably expect success targeting it Is it accessible from the outside Are there crucial organs in the way of the trajectory that you cannot cross (discuss with interventionalist) Is the blood clotting function adequate Can the patient tolerate a pneumothorax (in chest lesions) Ann Hightower (62) has been sent to the oncology department by her general practitioner. She...

What Do You Have to Pay Attention to in Image Analysis

First compare the distribution of the glandular parenchyma of both breasts it should be distributed almost symmetrically (Fig. 12.1a). Breasts are not always of the same size, however When stellate lesions are seen (Fig. 12.1b, c), try to determine whether they are due to the superimposition of normal parenchymal structures or whether the architecture of the breast is truly disturbed, that is, distorted or scirrhous. Is the stellate figure visible on the second projection Sometimes a magnified...

Radiologys Role in Medicine

What Is So Different in Radiology as Opposed to Other Clinical Disciplines A radiologist primarily approaches the patients by looking at images, in a procedure quite similar to the one pathol-ogists normally follow but quite unlike what any other clinical specialist would do. The unbiased analysis of the image is the first, and undoubtedly an abstract, intellectual step. This certainly implies that radiologists must be pretty brainy, or else they can lay down their arms right there. Thus, there...

My Wife Doesnt Know Me Anymore

Charlotte Braggbag (62) was quite a well-known personality in her neighborhood, generously sharing her opinion about absolutely everything with all those who cared to listen and those who did not. Her husband could live with it. For a few months now she has not really had an opinion about anything. Her husband could have lived with that as well. But when she looked at him mistrustfully a week ago, and asked him who he was and what he was doing in her apartment, he decided to seek help....

Interventional Radiology

Angiography Lower Extremities

As this chapter is being written, the importance of purely diagnostic conventional angiography decreases by the day. Vascular anatomy and disease can be imaged with a multitude of noninvasive modalities ultrasound, Doppler ultrasound, spiral CT, and MR imaging (Fig. 7.1). These tests alone or in combination can sufficiently address most diagnostic issues. There are circumstances, however, where catheter-based angiography still has its place. It certainly is an integral component of all...

Suddenly the Tea Cup Fell

Noncontrast Hemorrhage Stroke

Anastasia Peabody-Smith (57) had her girlfriends over for that regular 5 o'clock tea at her Woolloomooloo mansion when she suddenly suffered a stroke. Her friends called the ambulance at once and so she reached the emergency unit only half an hour after the incident. The neurologist in the emergency room diagnosed a hemiparesis on the left and transferred her immediately for a cranial CT to verify and further specify the stroke. Giufeng happens to be on duty and is the first to see the CT...

The Case of Loretta Hotblood Endocrine Ophthalmopathy

Retrobulbar Muscles Enlarged

Fig. 13.17 This MRI sequence with enhancement of the orbital fat depicts a coronal image directly posterior to the eyeball. Fig. 13.17 This MRI sequence with enhancement of the orbital fat depicts a coronal image directly posterior to the eyeball. saved a ship and its rebellious crew by taking over command during a storm. The ship suffered a leak, the pumps broke down, and the crew attempted to abandon ship. Graves destroyed the only lifeboat with an axe and repaired the pumps with leather from...

The Case of Cathy Nuremberg

Pituitary Gland Mri Abnormal

Fig. 11.31 a Here you see a representative MR section of Cathy Nuremberg's head. Do you notice any abnormalities b Compare her image to this normal sagittal noncontrast MRI section of the pituitary gland. Typically the fine pituitary stalk (arrow) leads to the low-signal-intensity anterior adenohypophysis, Fig. 11.31 a Here you see a representative MR section of Cathy Nuremberg's head. Do you notice any abnormalities b Compare her image to this normal sagittal noncontrast MRI section of the...

Osteochondrosis Dissecans

Girdle Wearers

Fig. 8.69a The standard radiograph of the knee joint displays an extensive contour defect of the lateral femoral condyle. b The dislodged osteochondral fragment the mouse'' has moved into the suprapatellar joint recess just above the patella (arrow). c The MR image shows the osteochondral composition of the fragment (arrow) to its best advantage. Fig. 8.69a The standard radiograph of the knee joint displays an extensive contour defect of the lateral femoral condyle. b The dislodged...

Gastrointestinal Radiology

Virtual Colonoscopy

The evolution of fiberoptic endoscopy has brought about a profound change in the frequency and spectrum of examinations performed by abdominal radiologists today. No other subspecialty in radiology has undergone a comparable shift in recent decades. Direct visualization of the gastrointestinal tract has largely replaced classical radiology, especially in the evaluation of the stomach, duodenum, and colon. While our forefathers (look for some gray-haired survivors in the dark corners of the...

Osteopetrosis

Human Anatomy Helper Head Neck

Fig. 13.22 The bone windows of this cranial CT show an enormous increase in density and volume of the bone. It is obvious that the osseous foramina will eventually be so narrow that compression of the respective central nerves is inevitable and that the eyeball will be forced out of the orbit. Fig. 13.22 The bone windows of this cranial CT show an enormous increase in density and volume of the bone. It is obvious that the osseous foramina will eventually be so narrow that compression of the...

Interventions in Vascular Occlusive Disease

Quadrantanopia Mri

As all angiographies are dedicated tests undertaken exclusively by specialists, nobody will seriously expect you to interpret the results in your real clinical life as a nonradiol-ogist. You should , however, know the potential treatment options afforded by each modality and be familiar with the most important interventions, their preparation, and their complications. What is true everywhere remains valid here Technology and new procedures develop extremely rapidly. Problems that seem...

Pneumothorax

Depressed Left Hemidiaphragm

Fig. 14.4d Vascular markings are lacking in the periphery of the right hemithorax (compare to the left hemithorax). The visceral pleura and with it the collapsed lung are appreciated with ease. The right hemidiaphragm is severely depressed, while the mediastinum is displaced to the contralateral side (note the course of the nasogastric tube within the esophagus). Subcutaneous emphysema is present in the right cervical region. The parietal Fig. 14.4d Vascular markings are lacking in the...

Test Cases

Swollen Painful Right Pelvic

A This elderly man complained of cervical pain. b This patient had the same problem. a This elderly man complained of cervical pain. b This patient had the same problem. c This hand of a young woman was warm, swollen, and painful. d This joint was painful. c This hand of a young woman was warm, swollen, and painful. d This joint was painful. f A large swelling and pain in the right lower abdomen and pelvis was the problem here. Tell us the histology i This kid has a problem. j This elderly...

Ligamentary Injury of the Cervical Spine

Photo Cervical Mri After Whiplash

Fig. 14.17 a This patient suffered a whiplash trauma during a motor vehicle collision. The radiograph in flexion shows a subtle kink at the level C3 C4. b The MR image confirms the disk prolapse at this level. Fig. 14.17 a This patient suffered a whiplash trauma during a motor vehicle collision. The radiograph in flexion shows a subtle kink at the level C3 C4. b The MR image confirms the disk prolapse at this level. Ligamentous injuries Primary ligamentous injuries are of great relevance for...

Alone among Women

Clinical Gynnacomastia

Clark Winterbottom (55) was persuaded to go to the breast clinic by his wife. He had felt a lump behind his right nipple a few weeks ago. To top it off, the whole thing now started to be painful. He sits in the waiting room and leafs through a fashion magazine uneasily. During her clinical examination of his breasts, Hannah palpates a lump in the retromamillary region on both sides. The ultrasound examination confirms the presence of glandular tissue. Hannah knows that there are only two major...

Short Run through Radiological Basics

3 Tools in Radiology 6 3.1 Projection Radiography 6 Generation of X-Rays 6 Attenuation of X-Rays 6 Detection of X-Rays 6 Techniques of Exposure 8 Contrast Media Examinations 8 Image Processing 8 3.2 Computed Tomography 9 Working Principle 9 Contrast Media 10 10 Working Principle 10 3.4 Magnetic Resonance Tomography 10 Generation of the MR What Is So Special about the External and Internal Magnetic in a Spatial Allocation of the MR signal 14 Analysis of the MR 3.5 Our Perception 15 4 Phenomena...

Pulmonary Symptoms without Correlating Findings in the Chest Radiograph

Cxr Pulmonary Embolism

Pulmonary Symptoms without Correlating Findings in the CXR Was a myocardial infarction ruled out Has the possibility of a pulmonary embolus been considered Are the symptoms suggestive of an aortic dissection head He worries about a pulmonary embolism, which is the most serious cause of unexplained dyspnea. He wants a venogram or a Doppler ultrasound of the lower extremities and a ventilation perfusion scan, possibly a pulmonary angiography after that and he wants Giufeng and Ajay to organize...

Multiple Sclerosis

Dawson Fingers Multiple Sclerosis

Fig. 11.22 a This parasagittal MR image shows the typical centripetal orientation of the demyelination plaques along the long axis of medullary veins to their best advantage. This phenomenon is sometimes called Dawson's fingers. b The lesions have a high signal in T2-weighted sequences (arrow). c In an acute relapse, the lesions tend to accumulate contrast in their periphery (arrow). Fig. 11.22 a This parasagittal MR image shows the typical centripetal orientation of the demyelination plaques...

Where is the Tube

Apical Pneumothorax

Fig. 14.3 The tip of the tube is located in the right mainstem bronchus The left lung is increased in density owing to atelectasis and has lost volume the mediastinum is displaced to the left. The stomach is significantly overdistended as a consequence of a previous esophageal intubation, which has since been corrected. During the accident or during intubation, the patient has aspirated a dental filling. There is another extremely important finding visible on this radiograph. Do you see it...

Auxiliary Lines for the Evaluation of the Cervical Spine

Posterior Atlanto Dental

Fig. 14.12a The auxiliary lines for the evaluation of the configuration of the lateral cervical spine run (from anterior to posterior) along the anterior edges of the vertebral bodies, along the posterior edges of the vertebral bodies, and along the anterior contour of the posterior vertebral arches. Another auxiliary line the Chamberlain auxiliary line courses from the hard palate to the occiput. The apex of the dens should not traverse it. Another important point is the atlanto-dental...

Intervertebral Joint Osteoarthritis

Osteoarthritis Draw

Fig. 8.37a This misalignment at the L4 L5 level is caused by degenerative disk disease and degenerative changes in the posterior elements of the spine, the intervertebral joints. Because it is not due to a defect of the pars interarticularis of the vertebral body, it is also called pseudospondylolis-thesis or degenerative spondylolisthesis by some. The whole L4 vertebral body including the spinous process and the body itself has moved ventrally relative to L5. b If you draw one line along the...

Magnetic Resonance Tomography

Ultrasonography Bone And Air

Magnetic resonance tomography is the technically most complex imaging modality in radiology but it also holds the largest diagnostic potential. Many are terrified by the prospect of having to understand the basic principles of magnetic resonance (MR). All of this is completely unnecessary, of course the thing is in essence nothing but a bicycle dynamo. But let's start at the beginning. I Working Principle of Ultrasonography I Working Principle of Ultrasonography Fig.3.5a If an alternating...

Paraganglioma

Brachiocephalic Fistula

Fig. 13.28a A strongly contrast-enhancing mass in the left carotid bifurcation is visible in this axial MRI section of the tongue base. b Selective angiography with the catheter tip in the left common carotid artery documents several well-vascularized tumors at the bifurcation and the skull base. c After emboliza-tion with small particles via a branch of the external carotid artery, the vascular blush is gone and chances for a safer and effective curative surgical procedure are greatly...

What Pathology Do You Find Here

Radiology Pathology Pictures

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Medulloblastoma

Multiple Sclerosis Axial Brain Anatomy

Fig. 11.25 The postcontrast axial (a) and sagittal (b) MR images reveal a mass in or around the fourth ventricle with a small cyst inside. This is a medullo-blastema. Based on its imaging appearance, the differential diagnosis includes an ependymoma. Fig. 11.25 The postcontrast axial (a) and sagittal (b) MR images reveal a mass in or around the fourth ventricle with a small cyst inside. This is a medullo-blastema. Based on its imaging appearance, the differential diagnosis includes an...

Invasive Breast Carcinoma

Ultrasound Cyst Fibroadenoma Cancer

Fig. 12.8a This large lesion (left) has changed the architecture of the neighboring breast tissue. The magnified view in another projection (right) displays the scirrhous extensions of the tumor into the glandular parenchyma. b This tumor does not visibly invade the surrounding tissue. Mammographically it could also be a cyst or a fibroadenoma. An ultrasound examination should definitely be performed for further characterization. c The ultrasound examination yields crucial additional...

Osteoporosis

Radiology Osteoporosis

Fig. 8.25 This is a radiograph of the thoracolumbar spine. The first lumbar vertebra is recognized by the fact that no ribs originate from it. First analyze all the dorsal spinous processes on this film. Are all of them present Now go ahead and follow the upper and lower end plates as well as the lateral contours of all the bodies. Are they complete Finally check out the pedicles. The T11 pedicle on the right is gone, the pedicle of T12 is denser that the others. The T11 abnormality is most...

Radiograph of the Chest in Polytrauma

Pneumothorax Before Chest Tube Radiology

Is the endotracheal tube well positioned Is there a pneumothorax or even a tension pneumothorax Are central venous lines correctly placed Are there rib fractures, particularly in the region overlying the spleen Is there a pulmonary edema, a lung contusion Is the mediastinum widened Beware Patient positioning Is the endotracheal tube correctly positioned Your first concern must be the endotracheal ET tube. Its tip should ideally be 1.5 cm above the tracheal bifurcation. If it is placed lower,...

That Tiny Bit of Calcium

Vascular Calcification

Dorothy Lamour 45 has dropped by the breast clinic to get herself screened. After being told that the clinic is not part of a breast screening scheme, she pauses for a while, then complains about lumps she has felt in both breasts recently. On clinical examination, Hannah confirms the lumpy consistency of both breasts but cannot find any dominant lesion. Skywang repeats the examination and comes to the same conclusion. Mrs. Lamour does not know of any breast cancer in her family. Mammograms are...

A Sectional Study of the Head

Head Gland Calcified Images

Key Points of Thorough Image Analysis The basic steps of image evaluation are similar for CT and MRI of the brain. Let us run through the analysis of a head CT to familiarize you with a good standard approach. The first aspect to pay attention to is the gross morphologic appearance of the brain Fig. 11.1a, b How wide are the inner and outer cerebral fluid spaces For example, how well can you see the cerebellar gyri and sulci Is the temporal horn of the lateral ventricle of normal caliber Does...

Perfusion Disturbances of the Brain

Left Lateral Ventricle Hemmorhage

Does the patient suffer from chronic headache attacks or is this a new type of headache Is there a history of medication with headache as potential side effect or could the patient be intoxicated Did the headache occur under physical stress or exertion Does the patient suffer from arterial hypertension Is the headache accompanied by other neurological symptoms or loss of consciousness Will Klington 37 is brought to the emergency unit unconscious. It is late at night. His escorts report that...

Protection of the Examining Physician

Mri Cable Burns

Most factors that serve the radiation protection of the patient also diminish the radiation exposure of the radiologist. These include the adequate experience of the examining physician, short fluoroscopy times, strict collimation of the x-ray beam, dose-minimized x-ray equipment, and a strict adherence to the indication list. One very effective protective measure is to keep the greatest possible distance dose decreases by the square of the distance from the primary or secondary sources of...

Risk of Thrombolysis

Genue Right Internal Capsule

Fig. 11.8a Initial noncontrast head CT of this patient shows very subtle edema of the basal ganglia on the left, indicating infarction that has led to an acute right-sided hemiparesis. There was definitely no hemorrhage present at the time of diagnosis. b Regional thrombolysis initiated immediately after the head CT was complicated by massive hemorrhage extending into the ventricle and a subsequent CSF flow obstruction. See the blood in the right posterior horn of the lateral ventricle. There...

Chewing and Problem Solving

Isabella Nutcracker 41 is passing through a very exciting phase in her life as an engineer. During her nerve-wracking work in the Sydney cross-city tunnel project she has now developed an excruciating pain in her right facial half. She feels a click when opening her mouth. The head and neck surgeon has sent her for a dedicated functional MRI of the temporomandibular joint to establish the cause of her suffering. Giufeng covers the MRI unit today and is as usual very well prepared for the...

What Does Giufeng Know about the TMJ

Mastoid Fluid Mri

She knows that the joint consists of two distinct compartments that are divided by a disk with a dumbbell-like configuration. The disk is suspended by ventral and dorsal ligaments and translates the force from the mandibular condyle to the articular tubercle of the temporal bone. As the mouth is opened, the condyle slides out of the mandibular fossa underneath the articular tubercle. If the mouth is closed, the dorsal part of the disk stands in the 12-o'clock position Fig. 13.13a The axial...

The Ultimate Exam

Radiology Exams

Paul celebrates his last day in the chest unit and has brought along a large box of cookies. It is late in the afternoon and Giufeng eats one biscuit after the other while sipping her cappuccino and listening to Paul's bright future plans with great amusement. Suddenly Gregory comes around the corner holding a pack of films in his hands. He senses the very special occasion and whips some of his films on the viewbox. How about a tiny test, Paul he roars and pats him on his shoulder. Giufeng...

Bone Densitometry

Bone Age Radiology

L2-4 comparison to reference values 1-441-------- c L2-4 comparison to reference values 1.44 -i-------- Fig. 8.26a This young lady was referred by a colleague from endocrinology. Bone densitometry was performed with dual-energy x-ray-absorptiometry DXA equipment. With this modality the lumbar spine is scanned with a narrow x-ray beam twice, first with a higher and subsequently with a lower energy spectrum. The difference after subtraction of the collected attenuation values correlates with the...

Contrast Media for Extravascular

Definition Barium-containing as well as iodine-containing CMs are used preferentially for studies of the gastrointestinal tract. Frequently, barium-containing substances are administered together with air or methylcellu-lose to achieve a radiopaque coating of the luminal surfaces of hollow organs, which stand out nicely against adjacent air during so-called double contrast examinations. Dosage These CMs are administered orally or rectally. The exact dosage, viscosity, etc., depend on the...

Myositis Ossificans Heterotopic Bone Formation

Heterotopic Bone Formation

Fig. 8.81 There is overshooting calcification or ossification of the soft tissues after a severe shoulder injury, often transforming a hematoma myositis ossificans. The range of motion in this joint is naturally very limited. The patient also suffered a heavy brain injury and stayed in coma for three weeks. Comatose patients tend to develop particularly large areas of heterotopic bone formation. Fig. 8.81 There is overshooting calcification or ossification of the soft tissues after a severe...

Renal Calculi

Olivia Stone 45 has been referred by her general practitioner for investigation of recurrent left-sided renal colic. The colicky pain radiates into the left groin. The GP already suspected renal calculi, but they have not been treated successfully. Initially an intravenous urogram was requested, but after discussion with a friendly older colleague it was decided to perform a CT scan for diagnosis of calculi. Paul stares spellbound at the unenhanced thin CT sections appearing one after the other...

GoutI Neuropathic Arthropathy

Gout Neuropathy Big Toe

Fig. 8.74 Loss of joint space and sclerosis are present predominantly in the left base joint of the big toe. The large defects of the head of the metatarsal bone of the first toe are caused by gout tophi. Fig. 8.74 Loss of joint space and sclerosis are present predominantly in the left base joint of the big toe. The large defects of the head of the metatarsal bone of the first toe are caused by gout tophi. imitates an exostosis or a bunion. Pain and inflammation are frequent findings due to the...

Intracranial Hemorrhage

Intracerebral Hemorrhage

Fig.11.5a This precontrast head CT shows parenchymal hemorrhage in the frontal lobe caused by a ruptured medial cerebral artery aneurysm. The hemorrhage has broken into the ventricle. b In another patient, massive hemorrhage has occurred in the right hemisphere. There is a slight associated SAH on the right. The mass effect is considerable midline shift to the left of more than 2 cm has occurred. CSF flow is already impaired, as you can see by the dilatation of the anterior horn of the left...

Carotidocavernous Fistula

Crohns Fistulas

Fig. 13.19a This T1-weighted MR image of the skull base displays a large signalfree structure posterior to the right orbit. It is a large vessel segment that certainly does not belong there. b A subtraction angiography is performed by administering contrast via a catheter into the right common carotid artery you can see the catheter tip and subtracting the precontrast image from the postcontrast images. An enormous dilatation of an artery in the cavernous sinus with early venous drainage is...

Genitourinary Tract

Ivu Radiograph

Currently ultrasound US and computed tomography CT are the most important imaging techniques in uro-radiology. Renal US is a very important and frequently performed investigation, hence you should be familiar with the fundamentals of this modality. Renal and adrenal tumors are mainly diagnosed by US, CT, and magnetic resonance imaging MRI . Renal calculi can be demonstrated on US, renal and ureteric calculi on CT Table 10.1 . The intravenous urogram IVU or pyelogram IVP , once the mainstay of...

How Do You Evaluate the Image Quality

The optical density of the film is optimal if you can appreciate the skin contour well with the hot light. The glandular parenchyma should be penetrated to the extent that vessels are discernible even in the densest areas of the breast. Principally the breast images should be as symmetric as possible. Digital mammography systems allow adjustment of some image parameters by the radiologist, which can compensate to a certain degree for suboptimal exposure while interpreting the radiograph....

Chest

Radiography Image Reading Practice Chest

The examination of the chest is the most frequently performed radiological study overall. It is also one of the most important and demanding studies, particularly for the radiological novice, especially when alone at night on-call, and in emergency situations. The comprehensive analysis of a chest radiograph CXR is also a rather intellectual affair just like a good crime story and fortunately just about as much fun. The basic prerequisite for a correct image analysis is a sound knowledge of the...

Increase of Brain Volume

Generalized Swelling

Fig. 11.44 Generalized brain edema is present after an overdose of the drug ecstasy. The widths of inner and outer CSF spaces in this 23-year-old addict are significantly reduced. Fig. 11.44 Generalized brain edema is present after an overdose of the drug ecstasy. The widths of inner and outer CSF spaces in this 23-year-old addict are significantly reduced. also lead to atrophy Fig. 11.43a . But dehydration or therapy with high-dose steroids Fig. 11.43b also causes a loss of brain volume. You...

Central Nervous System

New imaging modalities have often been developed for and evaluated in the head region before their introduction to clinical body imaging. The reasons for this are straightforward the head is relatively small at least in most of us , and on a larger scale there is no significant biological motion that can give us so much trouble when imaging heart, lungs, and abdomen. Yet a lot can go wrong in the head and since without brains life just isn't the same, advances in head and brain imaging are of...

An Abdominal Radiograph

Abdominal Radiograph Normal

The abdominal radiograph is almost always evaluated in combination with a chest radiograph for two good reasons On the chest radiograph the directly subdiaphragmatic regions of the abdomen may be better appreciated because exposure parameters optimized for the lung are also well suited to imaging this area. Free intra-abdominal air rises to the nondependent portion of the abdomen and is therefore easily detected under the diaphragm on an upright radiograph. Other conditions that can present...

There Aint No Class without Gwilym Lodwick

Boris Packer 22 has bruised his knee joint severely during one of his international tennis tournaments. Looking at the radiographs, Paul is pretty sure that there is no fracture. He has, however, searched the image with great care and has found a circumscribed lesion in the distal femur Fig. 8.1 . Boris has never had any complaints in this area before the tournament. It is undoubtedly an incidental finding. Has Paul saved Boris's life by detecting a little malignant lesion so early that it can...

Increase in Renal Volume

Is the increase in renal volume unilateral or bilateral Are both kidneys visualized Is there any urinary obstruction Fig.10.16 Demonstrated is a representative image of Ms. Peacock's CT. Can you help Paul It is almost impossible to obtain a history from Lydia Peacock 34 because of her mental impairment secondary to meningitis at a young age. Her young caretaker has only known her for three days. The referral note does not provide any more useful information follow-up CT has been requested....

The Nonindicated Study

Hippocrates First Harm

A study is not indicated if in a given clinical setting no information can be expected from it that could in any way alter further management. That may sound trivial. The execution of any nonindicated procedure, however, may lead to the delay or prevention of necessary, indicated diagnostic or interventional measures. As a matter of fact, it may sometime prove fatal for the patient Patient Paelie Brazil Paell 56 fell out of the bus that carried him and his friends back home from an out-of-town...

Fractures of the Metacarpal Bones 4 and

Metacarpal Fracture

Fig. 14.35 If Dung does not get his temper under control he will get this typical fistfighter injury more often. His 4th and 5th metacarpal bones are fractured and deviated to the palmar side. The respective radiograph of Sylvester Stallone or Bud Spencer would certainly be of interest for comparison. Fig. 14.35 If Dung does not get his temper under control he will get this typical fistfighter injury more often. His 4th and 5th metacarpal bones are fractured and deviated to the palmar side. The...

Who is Gwilym Lodwick

Gwilym Lodwick was a famous American bone radiologist. After leaving his chair at the Uni_ versity of Missouri at Columbia, he and his gigantic collection of skeletal cases moved into a little office at the Massachusetts General Hospital of the Harvard Medical School. There he continued to teach for a long time. He was not easy to get along with but was a full-blooded, dyed-in-the-wool radiologist. Table 8.2 Classification of bone lesions according to Gwilym Lodwick1 Table 8.2 Classification of...

Studies with Contrast Media

Contrast-enhancing substances are commonly used in plain radiography, CT, MRI, and sometimes even in ultrasound. They serve to improve the visualization of hollow organs, vessels, and parenchymal organs, and to document the perfusion or metabolism of tissues. Contrast media can result in a higher or lower signal intensity of structures of interest relative to the immediate anatomical surround-ing in radiography and CT the radiation attenuation is increased or decreased. Contrast Media in...

Insertion of a Drain

Sclerosing Injections Esophagus

Is the material to be drained viscous, does it contain particulate matter, or is it very fluid How long is the drain intended to stay Procedure Mr. Strongarm brings along a strong pain reliever from the ward. Hannah injects the drug slowly as he is positioned on the CT table. Chaban chooses the CT image Fig. 7.11b that shows the access route best, injects a local anesthetic, and incises the skin with a pointed scalpel directly ventral of the target area. He advances a thin, long needle toward...

The Case of Isabella Nutcracker

Pneumatized Tuberosity

Fig. 13.14 The images of this study are aligned parasagittallyat a slight angle in order to optimally demonstrate the function of the temporomandibular joint. The ventral side is on the left of the image. Images a and b depict the right joint, c and d the left joint. First localize the mandibular condyle, then identify its slip track along the articular tubercle, and finally find the low-signal disk. The upper part of the images shows the temporal lobe, the lower posterior part the pneumatized...

Adrenal Tumors

Fatty Tumor Adrenal Gland

Gill Bates 45 is being worked up by his general practitioner for persistent decreased appetite and a slightly elevated erythrocyte sedimentation rate. Today he is booked for an abdominal CT. He is a little nervous, but Paul reassures him, while giving him a big cup of dilute oral contrast that will fill the lumen of the stomach and the small and large intestine. An intravenous cannula is inserted before the investigation. Contrast is injected after an initial unenhanced CT scan to better...

Astrocytoma

Multifocal Primary Lung Carcinoma

Fig. 11.16 a Noncontrast head CT left depicts a hypodense, well-demarcated lesion in the right temporal lobe. After contrast administration right , the tumor, a grade 2 astrocytoma, remains unchanged. A subacute stroke could have a similar appearance. b In the T2-weighted sequence left , edema is seen in the left occipital lobe. After contrast administration, the T1-weighted sequence right demonstrates small contrast-enhancing foci, compatible with but not specific for a malignant tumor. This...

The Case of Pamela Baywatch I

Fig. 12.23a This part of the story Mrs. Baywatch told the mammography technologists only in the intimacy of the mammography room She has had several breast augmentations in her life. The tissue between chest wall and the implant cannot be visualized, despite the efforts and tricks of the most experienced technologist. A cancer could easily hide there. b The MRI of the breast will hopefully clarify the situation. Fig. 12.23a This part of the story Mrs. Baywatch told the mammography technologists...

Surfing

Weber Type Fracture

The opportunities for avid surfers within the city are limited but there are ways for the desperate and the airheaded. Hank and his friend Dude are a little bit of both, and to a dangerous degree. After participating in the annual Mardi Gras parade, drunk as skunks, they surfed on the train coupling of the last suburban line to Bondi Junction and fell off at full speed. Fortunately, they were found quite quickly by some other nighthawks. Hank is lying apathetically on a vacuum mattress with his...

Congenital Malformations of the Brain

Radiographyof The Brain

Fig. 11.46 h In this patient with a Sturge-Weber angiomatosis, the cranial CT reveals extensive calcification of the gray-white matter junctional zone left , which can sometimes even be appreciated on plain radiography of the skull. The angiomatous Fig. 11.46 h In this patient with a Sturge-Weber angiomatosis, the cranial CT reveals extensive calcification of the gray-white matter junctional zone left , which can sometimes even be appreciated on plain radiography of the skull. The angiomatous...

Jefferson Fracture Traumatic Spondylolisthesis

Fracture From Car Wreck

Fig.14.14a This CT image shows a fracture of the anterior and posterior arches of the atlas ring. It is quite obvious that this fracture is frequently unstable. The dens axis has completely lost its osseous fixation. b The lateral migration of the joint facets is best documented by this CT image, which was reconstructed in a plane that shows the abnormality to better advantage. The transverse ligament that normally holds the dens in place must also be torn. Fig.14.14a This CT image shows a...

Implantation of a Transjugular Intrahepatic Portosystemic Stent Shunt TIPSS

Portal Vein Coverd Stent

Is the arterial perfusion of the liver sufficient Is the main portal vein open Is blood clotting sufficient despite the liver disease Procedure After the patient has been positioned on the interventional table and draped with sterile blankets, Segner carefully punctures the right internal jugular vein under ultrasound control. With a dedicated set he advances a needle into the right hepatic vein. He measures the pressure 6 mmHg. Under ultrasound guidance Gregory, I need to see that needle tip...

Giant Cell Tumor

Giant Cell Tumor Humerus Mri Humerus

Fig. 8.8a The margins of this bone lesion arrows are very irregular and ill defined. The cortex has clearly been destroyed. This is a typical giant cell tumor. b On MRI the same lesion shows a fluid-fluid interface. You can also appreciate a focal defect of the cortex. Fig. 8.8a The margins of this bone lesion arrows are very irregular and ill defined. The cortex has clearly been destroyed. This is a typical giant cell tumor. b On MRI the same lesion shows a fluid-fluid interface. You can also...

Ewing Sarcoma Osteomyelitis

Osteomyelitis Radiology

Fig. 8.15 This Ewing sarcoma has destroyed the bone almost entirely there is a pathological fracture arrow . The margin of the defect is extremely irregular moth-eaten, wide zone of transition . The periosteum tries to contain the tumor but in this frustrating process it has been displaced far laterally already. Fig. 8.15 This Ewing sarcoma has destroyed the bone almost entirely there is a pathological fracture arrow . The margin of the defect is extremely irregular moth-eaten, wide zone of...

Acoustic Schwannoma

Internal Acoustic Meatus

Fig. 11.38a High-resolution CTof the internal acoustic meatus reveals a funnel-shaped expansion of the right meatus arrow . b The axial Tl-weighted MRI after contrast administration documents a small but strongly enhancing tumor at the entry of the internal acoustic meatus arrow . c In another patient, the acoustic schwannoma is a lot larger and partially cystic arrow . Fig. 11.38a High-resolution CTof the internal acoustic meatus reveals a funnel-shaped expansion of the right meatus arrow . b...

Venous Sinus Thrombosis and Venous Infarction 113 Brain Tumors

Venous Sinus Infarct

Fig. 11.11 This T1-weighted coronary MRI sequence after contrast administration shows signal loss in the right paramedian region of the cortex next to the interhemispheric fissure caused by venous infarction. A typical filling defect seen in the superior sagittal sinus is the underlying occlusive venous thrombus arrow . Fig. 11.11 This T1-weighted coronary MRI sequence after contrast administration shows signal loss in the right paramedian region of the cortex next to the interhemispheric...

Greenstick Fracture

Forearm Fracture Children

Fig. 14.43 In children the bone can break without seriously injuring the periosteal cuff around it. This is called a greenstick fracture. Frequently the only sign is a little bulge of the cortex Fig. 14.43 In children the bone can break without seriously injuring the periosteal cuff around it. This is called a greenstick fracture. Frequently the only sign is a little bulge of the cortex arrow in a and b . Philipp has a greenstick fracture of the distal forearm, which will heal rapidly when...

Lymphoma of the Skull Base

Bizarre Radiography

Fig. 13.20a Review of this head CT in bone windows shows a bizarre calcification below the orbital roof. This is suggestive of a meningioma because these tumors tend to calcify in such a fashion. b Angiography reveals the typical spoke-wheel-type vascular pattern of a meningioma. Fig. 13.21 This patient complained of an acute decrease of visual acuity on the left. The axial CT section displays the tumor, which extends from the sphenoid sinus into the left orbit and on other slices into the...

Cruciate Ligament Injuries

Suprapatellar Bursal Effusion

Fig. 8.67a These menisci are normal. b The posterior horn of the medial meniscus is torn. The tear reaches the undersurface of the meniscus long arrow . There is an effusion in the suprapatellar bursa small arrows , most likely hemorrhagic in nature. Arising from the posterior joint space, a synovial outpouching can develop filled with joint fluid the rather frequent Baker cyst short arrow , which is characteristically located between the tendons of the medial head of the gastrocnemius and the...

Patient A Ultrasound

Kidney Stones Radiology

Fig. 14.1a View of the Morrison's pouch. The fine peritoneal recess between liver and right kidney arrows is Morrison's pouch. This is where free fluid collects early and where it cannot be mistaken for fluid in any hollow organ. b The US probe is located in the superior lateral abdominal wall sagittal section . Fig. 14.1a View of the Morrison's pouch. The fine peritoneal recess between liver and right kidney arrows is Morrison's pouch. This is where free fluid collects early and where it...

Occipitocervical junction injuries down to C2C3

Jefferson fracture The Jefferson fracture is a typical compression fracture due to axial loading for example, a head-first dive into shallow waters . The anterior and posterior arch of C1 is split Fig. 14.14a , which causes a I Fractures of the Upper Cervical Spine Fig. 14.13 Illustrated are the most important fractures of the upper cervical spine.

Normal Findings in a Cranial CT

Subdural Hematoma With Midline Shift

Fig. 14.21 a This is a normal CT of a 50-year-old. The inner and outer CSF spaces are well appreciated. Gray and white matter are easily differentiated from each other and are of normal density. b The basal and posterior fossa cisterns are also well seen. I Generalized Brain Edema Due to Head Trauma I Generalized Brain Edema Due to Head Trauma Fig. 14.22 This 40-year-old patient was hit by a wooden plank falling from a building. The pupils had already become unreac-tive to light in the...