RAD553 2010 Lecture 2 - MSU Radiology€¦ · 4/28/2010 1 Lecture 2 Chest X-Ray Technical Consideration • Entire chest should be included • Thoracic vertebrae should be barely

4/28/2010

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Lecture 2

Chest X-RayTechnical Consideration

• Entire chest should be included• Thoracic vertebrae should be barely seenThoracic vertebrae should be barely seen

through heart on PA film• Optimal inspiration – diaphragm at level of

10th rib posterior• Medial clavicles (anterior midline)

equidistant from spinous processes (posterior midline)

• Ribs slightly offset on lateral

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Chest Normal

Normal Chest Anatomy

• Right heart border– Upper portion - SVC and

ascending aortaascending aorta– Lower portion – right atrium

• Left heart border– Upper portion – aortic arch– Mid portion – main

pulmonary artery– Lower middle portion – left p

atrium– Lower portion – left

ventricle

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Normal Chest Lateral

• Anterior heart border– Upper portion –pp p

aortic arch– Mid portion –

pulmonary artery– Lower portion – right

ventricle• Posterior heart borderPosterior heart border

– Upper portion – left atrium

– Lower portion – left ventricle and IVC

Chest Normal

RULLUL

RML/

RUL

LUL/

RUL/LUL

RLL/LLL

RML/LUL

RLL LLLL UL

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Pulmonary Lobes

RML/RL

RUL LUL

LUL/L

RUL/LUL

RLL/LLL

RML/LUL

Frontal Lateral

L LL L

Normal Pulmonary Vascularity• Lung markings

branch and taper symmetricallysymmetrically

• Upper markings sparser and thinner than mid and lower on upright filmupright film, difference less prominent on recumbent studies

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Normal Pulmonary Vascularity

• Easily see vessels in inner thirdinner third

• Vessels identified but less prominent middle third

• Difficult to see discrete vessels outerdiscrete vessels outer third

Cardiac Radiography

• Frontal view– Left ventricular – Left atrial appendage– Pulmonary artery– Aorta– Superior vena cavaSuperior vena cava

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Cardiac Radiography

• Lateral view– Right ventricular size– Posterior border left atrium– Posterior border left ventricle– PA dimension of thorax

• Oblique views• Oblique views– Optimize evaluation of cardiac margins

Cardiac Radiography

RA

SVC

PA

RV

IVC

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Cardiac Radiography

AA

LA

LV

Cardiac Radiography

RA

SVC

AA

DA

RV

RPALPA

MPA

IVC

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Cardiac Radiography

LV

LA

MV

AV

LV

Cardiac Radiography

• Cardiac size– 50% or less of the trans thoracic diameter– UP to 60% in children– Cardiac thoracic ratio– Caution!! Poor inspiration false increase in

cardiac size– Evaluate both frontal and lateral views– Pericardial fluid also can cause apparent

cardiac enlargement

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Reading the Chest X-raya Systematic Approach

Diaphragm• Diaphragm• Pleura• Costophrenic angles• Lungs

H t d t l• Heart and great vessels• Trachea and mediastinum• Bones and soft tissues

Chest Normal

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What Is the

Finding?

What Is thethe

Finding?

Absent Left

Breast

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Where Are theAre the Shotgun Pellets?

3-D Imaging• Lateral view

reveals pellets in thepellets in the anterior aspect of the chest wall

• Need perpendicular p pview to ascertain exact location

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Where is the Straight Pin?

Where Is the Straight Pin?

• Straight pin in the b hbronchus

• Lateral view is needed for 3-dimensional orientation

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Acute Abdominal Series

• Supine abdomen (KUB, “flat plate”)• Upright abdomen –

– detects air-fluid levels and free intraperitoneal air, horizontal beam (parallel to the floor);

– Patient needs to maintain position for at least 10 minutes prior to obtaining x-rays10 minutes prior to obtaining x-rays

Acute Abdominal Series

• Chest x-ray – detects free intraperitoneal air and chest pathology

• Left lateral decubitus abdomen – substitutes for upright view in debilitated

patients, ti t d t i t i iti f t l t 10– patient needs to maintain position for at least 10

minutes

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Abdominal Imaging PositioningRadiographic Appearance

• SupineAir in body of stomach

• UprightAir in fundus– Air in body of stomach

– Air in transverse colon

• Prone– Air in fundus of

stomach

– Air in fundus

• Decubitus– Right side up air in

right colon andstomach– Air in rectum– Air in ascending and

descending colon

right colon and duodenum

– Left side up air in left colon and stomach

Reading the Abdominal X-ray(ABCD Approach)

A. -- Air (air pattern, free air)B. -- BoneC. -- CalcificationsD. -- Density (soft tissue)D. Density (soft tissue)

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Normal Mucosal Folds

A. Valvulae conniventes of small intestine

B. Haustra of colon

C G t iC. Gastric rugae of stomach

A B C

Normal Acute Abdomen

• Normal abdomen

• Upright abdomen• Air-fluid level

stomach fundus• Stool in colon

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Normal Chest, Acute Abdomen

Study

• No free air• No chest

disease

Normal Acute Abdomen

Series• Supine film• Normal gas

distribution• No masses• Normal organs

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Uroradiologic Studies• X-Ray:

– Plain film, KUB (Kidneys Ureter Bladder) and tomographyg p y

– Intravenous Urography (IVU)– Voiding CystoUrethroGraphy (VCUG)– Angiography and Digital Subtraction Angiography

(DSA)• Ultrasound (US)• Computed Tomography (CT) and Magnetic p g p y ( ) g

Resonance Imaging (MRI)• Radionuclide renal scan• Positron Emission Tomography (PET)

Normal Urinary Tract Anatomy

• Renal parenchyma:– Cortex, medulla

• Urinary collecting system:– Calyces, infundibula, pelvis, ureters

• Urinary bladderU th• Urethra

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Normal KUB Film

• Kidneys Ureter Bladder (KUB)Bladder (KUB)

• Supine• Left kidney visualized• Right kidney partially

obscured• Evaluate kidney size,Evaluate kidney size,

shape, position and presence/absence of calcifications

Normal KUB Film

• Evaluate kidney size9 13 cm– 9-13 cm

• Shape-– Reniform– Bean shaped

• PositionP ll l t th– Parallel to the psoas muscles

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Anatomic Correlation

• Normal Anatomy

PsoasMargin

PsoasMargin

IVU Tomogram• Immediately after contrast injection• Contrast in proximal tubules

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Intravenous Urogram (IVU)

• Indications– Hematuria– Trauma– Abdominal Pain (referred to urinary tract)– Palpable abdominal mass– Mass or calcification on KUB

MSU RADIOLOGY ©2002 All rights reserved, Gerald R. Aben, MD

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Mass or calcification on KUB

Iodine Contrast Physiology

• Intravenous contrast excreted by Glomerular FiltrationFiltration

• Concentration of filtrate = concentration in the plasma

• Proximal tubule water resorption increases contrast concentration 5 - 10 foldDi t l T b l /C ll ti t t ti


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• Distal Tubule/Collecting system water resorption increases contrast concentration to a total of 30 - 50 fold greater than plasma concentrations

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IVU

• Insignificant contrast secretion– <2% excretion by liver and small bowel– Primary route of clearance in renal failure


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IVU

• Risks– An incidence of allergic reaction

• Not dose related• May be related to Iodine or carrier molecule• Use of non-ionic agents

– Renal failure exacerbation


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• Low function to start• Multiple Myeloma

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Nephrotoxic Effects of Contrast

• Ionic Contrast– Hyperosmolar to plasma– Significant risk of inducing renal failure

• Especially if “at risk”– Relatively inexpensive

• Non-Ionic Contrast


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Non Ionic Contrast– Recent innovation ~1970– Reduces risk of inducing renal failure– Increase cost – initially 25x ionic contrast

Nephrotoxic Effects of Contrast

• Non-Ionic Contrast– Recent developments

• Even lower osmolality• May reduce risks even more


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IVU

• Nephrogram-– Contrast concentration in the renal

parenchyma– Short period immediately following injection– Rapidly disappears as contrast moves into the

calyces and renal pelvis


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Renal Size and Contours

• Size– Symmetric– 9-12 cm in adults– <1cm difference right to left

• ContoursSmooth or slightly undulating


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– Smooth or slightly undulating– Occasional lobulation especially on left

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Normal IVU

Normal Examination


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IVU Tomogram


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CT Indications

• Indications• Suspicion of ureteral calculi (Procedure of

choice)– Evaluation of all retroperitoneal structures– Renal mass by other modalities– Hematuria with suspicion for renal neoplasm


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– Hematuria with suspicion for renal neoplasm– Staging of neoplasm

• Prostate• Ovary

CT Normal Anatomy

Superior Mesenteric Vein

Superior Mesenteric ArteryAortaVena Cava

DuodenumRenal Pelvis


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Crus of Diaphragm

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CT Urogram

MSU RADIOLOGY ©2008 All rights reserved, Michigan State University Gerald R. Aben,

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CT Urogram

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CT Angiography


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US Principles

• High frequency sound– Relatively uniform speed of transmission inRelatively uniform speed of transmission in

tissues– Passes through fluid without interaction– Reflected by bone and air

• Acoustic windows


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– Liver for right kidney– Left more difficult no good window– Bladder for Pelvis

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Normal Renal US

Normal Right Kidney


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Normal Renal US

Normal Right Kidney


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Normal Bladder


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MRI NormalNormal kidneys

Liver


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MRI Normal 2


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MR Angiography


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Normal Flow


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Radionuclide Renal Scan• Normal

perfusion • IV injection j

followed by imaging every 3 seconds

• See uptake in aorta, arteries, kidneyskidneys

• Allows evaluation of blood flow

Documents

RAD553 2010 Lecture 2 - MSU Radiology€¦ · 4/28/2010 1 Lecture 2 Chest X-Ray Technical Consideration • Entire chest should be included • Thoracic vertebrae should be barely