Why Another Textbook of Radiology

Can You Imagine Radiology to be Fun?

Radiology can be a lot of fun! It is this very personal experience of the authors that will accompany you throughout this book and hopefully throughout the rest of your medical life. It is also the main reason why we considered this book to be necessary. Can diagnostic imaging and the therapy of patients in need be a pleasant task? The answer is a resounding "yes." Successful management in medicine relies on keeping a certain distance from the events. Empathy and respect are essential for a trustful relationship with the patient. The optimal path to the right diagnosis and subsequent adequate therapy, however, requires primarily clear thinking. Clear thinking, in turn, greatly profits from motivation, optimism, and enjoyment of what one is doing. The enthusiasm for a "great case," which temporarily seems to ignore the often tragic personal fate of the patient, must not be taken away from the radiologist. The same is true for learning about radiology—as a student, as a young doctor: One has to enthuse the neophytes for the fascinating field of radiology!

What Is So Special about Learning (and Teaching) Radiology?

Radiology is a gigantic, continually growing specialty that gets ever more complex by the month. It is, for several reasons, not to be learned by heart. The tools of image acquisition and image analysis have to be mastered, i.e., their principles have to be understood. Understanding the principles of imaging—just like the understanding of any individual image—is primarily an intellectual challenge. It is on this foundation that specific knowledge can be accumulated, of course through reading the literature but most of all through very personal transfer of experience: "There is no substitute for a seasoned radiology teacher." In few medical fields can the exchange of knowledge between the teacher and the trainee be as intense, interactive, and multifaceted as in radiology. Radiology for that reason is a didactic specialty "par excellence." Using exemplary image material, most relevant diagnostic techniques can be taught and learned. That is the great opportunity of academic radiology—we just have to seize it.

What Makes This Textbook Different to Others?

Well... a lot of things. But one of the main ideas we try to convey in this book is the overriding importance of a sound indication for every radiological examination or therapy. The number of nonindicated examinations is unfortunately high; the driving forces are manifold: litigation, examinations that are "en vogue," overworked referring doctors who would rather get the scan and then examine the patient, and the practice of self-referral by non-radiologists who have a financial interest in imaging the patient in their own private practice or institution. All lead to many unnecessary diagnostic examinations with unintended consequences for our patients. Overutilization also poses a threat for the future—i.e., your professional life and our healthcare systems—as it is not economically sustainable in any of today's societies. We would like to infuse you with the right attitude and give a proper orientation of what is indicated when. The indication guidelines of the British Royal College of Radiologists under the title "Making the best use of a Department of Clinical Radiology" have thus been inserted into and adapted to this book.

How Is This Book Structured?

The first part of this book, entitled "A Short Run Through Radiological Basics," will describe and hopefully allow you to understand the essentials of imaging. For starters, you are going to be fed the technical principles of image acquisition. To keep this part digestible, "normal life" analogies have been recruited wherever complex technologies made this necessary and where it was felt to be didactically appropriate. Subsequently we'll take you through the phenomena and procedures that help you tackle image analysis in diagnostic imaging. We take special care to alert you to the importance of psychophysical perception: in a world filled with fantastically expensive imaging equipment it is still your visual and central nervous system that detects and categorizes disease. This fundamental truth is frequently underrepresented in other texts. Last but not least, you are going to learn about the obvious and not so obvious risks of imaging and image-guided therapy.

The second, the clinical, part of this book is entitled "From Detection to Diagnosis and Beyond." You will get to know not only the specific examination modalities for each organ system but also the most efficient diagnostic work-up in emergency radiology—under circumstances you will encounter in your not too distant future professional medical life when you are most likely to make crucial decisions yourself. You will be confronted with cases to solve just as if you were already engulfed in clinical routine. Every individual problem is approached by a combination of image analyses, taking into account relevant available history, and whatever clinical symptoms you might be able to verify yourself. The path to the right diagnosis is then laid out— you just have to stay on it. The differential diagnoses are described in the approximate order of likelihood, if that does not interfere with the didactic point to be made. The traditional pathologically oriented approach thus takes a step back to leave center stage to radiological morphology: it is just you and the image you have to evaluate.

Who Will Accompany You through This Book?

Five medical students will see you through this book: Giu-feng, Hannah, Joey, Paul, and Ajay. All of them are bright, highly motivated kids, well prepared by their teachers and eager to solve cases on their own. It goes without saying that they eventually present their findings to "their" radiologist in charge—to get the final blessing and to learn even more. Their first few weeks in radiology have made them inspired diagnosticians, running down interesting cases and not giving up before they find a convincing diagnosis. They are also a truly international bunch, having been attracted to this academic hospital in "down under" Sydney for a variety of reasons. (Hannah, Giufeng, Joey, Paul, and Ajay are, of course, fictitious persons. All stories relating to them are also pure fiction. We would like to thank our young colleagues and collaborators Juliane Stoll, Il-Kang Na, Ralph Patrick Chukwuedo, Ansgar Leidinger and Tino Bejach for the permission to use their pictures. Working together with them was a lot of fun. A great thanks goes to our pleasant young colleague Gero Wieners who posed as Gregory. The patients' names are also fictitious. Similarities to real persons are not intended and are pure coincidence. The cases are didactically optimized and compressed to fit the objective of this book.)

Ralph Patrick ChukwuedoRalph Patrick Chukwuedo

Giufeng (Chinese for "the gentle one") (Fig. 1.1) is a native of Sydney, to where her parents moved in the eighties straight from Singapore. As you can undoubtedly tell from the picture, she has developed a special interest in neuroradiology. She knows everything about the cranial nerves, their tracts and nuclei. The sensory organs are another one of her specialties. For that and other reasons, Gregory, the senior resident assigned to neuro-radiology, frequently visits with her.

Hannah (Fig. 1.2) has come from Berlin for her final year in medical school. Her love of the sun, the beach, and classical music got her to the "emerald city." If she had to pick a favorite field in radiology, she would probably choose musculoskeletal radiology. She has already made up her mind to try her luck in radiology, but if that doesn't work out she will try to become an orthopod. She never loses control, however mixed-up things may be. Wiseguys get finished off by her with just a few carefully chosen words. Her private passion is—you guessed it already—surfing on Sydney's Bondi beach.

Paul (Fig. 1.3) says he sucked radiology in with his mother's milk. His father is a medical physicist, his mother a successful painter of abstract art, his brother a Melbourne investment broker almost unscathed by any bear attacks. Paul loves to dive into complex cases much like others get submerged in the latest thriller by Michael Crichton. In any case: He finds radiology a very attractive field—almost as attractive as . . . well, as far as Paul is concerned, he is getting sick and tired of this neuro guy and his interventions.

What Is There to Say about the Style of the Book?

Radiology is a thriving field with fashions, moods, fascinating personalities, and a lot of history to go around. Radiologists love to assign names to phenomena, signs, and techniques. Most of these are globally understood—radiol-ogy was a truly global thing from the very beginning. So there are a lot of Latin, German, and French terms—add a Greek cracker now and then. If they help us understand, we should use them. Some remind us of great physicians who were inventors, researchers, teachers. It does not hurt to acknowledge their accomplishments, and we support that by giving a little worthwhile or possibly useless information about them now and then in this book.

Radiology Then And NowGero Wieners

Ajay (Fig. 1.4) is originally from Johannesburg, South Africa, where his grandfather used to work with a certain Mahatma Ghandi. The family is rumored to be obscenely rich—car manufacturing, real estate, you name it. He is already married at the age of 25, much to the sorrow of the women around him. His wife is dashingly beautiful and three handsome kids are coming right after their father. Ajay has an untamable urge to tell delicate jokes to everyone, in one of four languages. He is interested in radiology because he loves to handle expensive hardware.

Joey (Fig. 1.5) has just managed to make the right histological diagnosis off just one radio-graph—and seems to enjoy the experience. He will hopefully make this a habit. Joey just loves intervention. Every time he watches a difficult angiographic or drainage procedure, his fingers grab for imaginary catheters, guide wires, and needles. The interventional folks have recognized his passion for their trade and let him work with them whenever it is possible. As for his social life, he comes across as the "big loner." Apart from that he is a cheerful guy from New York who has left that city for the first time in his life to do his radiology "down under."

And then there is Gregory (Fig. 1.6), of course. As already mentioned, he is the young and enterprising senior resident with a special interest in neuroradiol-ogy. He has made it a habit to take care of the medical students—with very definite preferences and in more than one way. He is hoping for an academic career. His hormonal status is acknowledged with benevolent interest by many in the department. A nice guy at heart, he can turn into a son of a ... at times. When you come right down to it, he is just one of us normal guys in academia.

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