History of Medical Imaging

Author(s): William G. Bradley

Source: Proceedings of the American Philosophical Society, Vol. 152, No. 3 (Sep., 2008), pp.
349-361
Published by: American Philosophical Society
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 HistoryofMedicalImaging1
WILLIAM G. BRADLEY
andChairman,
Professor Department ofRadiology
San Diego
ofCalifornia,
University

IMAGING beganin November1895 withWil-

helmConradRoentgen'sdiscovery of theX-ray.Working
withan earlycathoderaytubecalleda Crooke'stube,he
noticedthattheinvisible rayswereable to penetrate somesolids(like
humanflesh)better than others (likeboneor metal). confined
He himself
to hisbasement laboratory inWürzburg, Germany, forsixweekswhile
Frau Roentgenbroughthim meals.Duringthattimehe discovered
mostofwhattheworldwouldknowaboutX-raysforthenexttwenty
years.Forhisefforts he was awardedthefirst NobelPrizein 1901.
X-rayis thebasisforwhatwe radiologists call"planefilms"or sim-
ply"X-rays" used for
commonly evaluating thechest and bone frac-
tures.The originalX-rayfilmshad to go through a wetdeveloper pro-
cessina darkroom.Ifthestudywas crucial,theradiologist wouldread
itwhileitwas stilldripping wet.Theterm"wetreading"is stillusedfor
an emergency radiology reporteventhoughmanyX-raystodayareac-
quireddigitallywithout anyfilmat all.
As theX-raybeambecamemorepowerful, patientmotioncouldbe
visualizedand "fluoroscopy" becamepossible.In the 1920s,radiolo-
gistsbegangivingpatients radio-opaquebariumas a swallowor an en-
emaandtakingfilmsas thebariumtraversed tract.
thegastrointestinal
Thatis how cancersof theesophagus,stomach,and bowelas wellas
and appendicitis
ulcers,diverticulitis, wereinitiallydiagnosedbyradi-
ologists.Fluoroscopy is in
still common use today, ithas advanced
but
considerably.In theearlydaystheimageswereso dimthatradiologists
had to wearredgogglesall dayto minimize thetimeneededto accom-
modateto thedimlightwhentheywentbackintothefluoroscopy suite.
Today, with modern imageintensifies, that is no longernecessary.In
addition,manyof thediseasesinitially diagnosedby fluoroscopy are
nowdiagnosedbycomputed tomography (CT: see below).

1Read 26 April2007.

PROCEEDINGS OF THE AMERICAN PHILOSOPHICAL SOCIETY VOL. 152, NO. 3, SEPTEMBER 2008

[349]

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350 WILLIAM G. BRADLEY

X-rayis also thebasisofmammography, whichis a dedicatedsys-

temthattakeshigh-resolution images of thebreasts,lookingforbreast
cancer.Over theyears,theX-raydose of themammograms has de-
creased,makingtheexamination safer.In addition,thefilmoftheold
dayshas beenreplacedwithdigitalplatesofcharge-coupled detectors
thatfeedtheimagesdirectly to high-resolution workstations (so-called
"fullfielddigitalmammography").
X-raytomography was introduced in the1940s,allowing"tomo-
grams" or slices to be obtained throughtissueswithouttheover-or
under-lying tissue'sbeing seen. This was achievedbyrotating theX-ray
tubeso thatonlythedesiredsliceoftissuestayedin focusduringtube
rotation. Tomography perse is no longerperformed, havingbeenre-
placed with CAT axial
(computerized tomography) scanning or CT (see
below).BothCT and MRI are tomographic techniquesthatdisplay
theanatomyin slicesrather thanthrough andthrough projections (like
an X-ray).
X-rayis also thebasisof "angiography," or theimagingof blood
vessels.In theearlydaysa radiodense contrast agentlikeiodinewas in-
jecteddirectly intotheartery ofinterest. Whenimagingthebrainfora
suspectedstroke,braintumor,or vascularmalformation, thisusually
required a direct carotid puncture with a needlesomewhat largerthan
a soda straw.In thelate 1950s,theSeldinger technique,in whichthe
arterial puncture takes placein the femoral arteryin thegroin,was im-
ported from the Karolinska Institute in Stockholm. A flexible
guidewire
is inserted through thepuncture needleand a plasticcatheter is passed
overtheguidewireand runthrough thebloodvesselsto theorganof
interest.Iodinated contrastcanthenbe injected to makea diagnosis, e.g.,
vascularnarrowing ofthecarotidartery (whichcouldlead to a stroke)
or narrowing ofthecoronaryarteries(whichcouldlead to a heartat-
tack).Today,interventional radiologists and cardiologists
routinely ex-
pand narrowed vessels with a balloon ("balloonangioplasty"), often
followedbya coilofwire(calleda "stent")to keepthevesselopenafter
theprocedure.
In the1950snuclearmedicine entered ourarmamentarium ofdiag-
nosticimagingtests.In thesetests,thesourceof theX-raysis notan
X-raytube but ratherradioactivecompounds,whichtypically emit
gammaraysas theydecay.Theyare combinedwithothercompounds
thatare takenup as partof thediseaseprocessto studya particular
problem.Forexample,Technicium 99mcan be combinedwithméthy-
lène diphosphonate, whichis takenup by bone beinginvadedby a
tumor.So, forexample,cancerof thebreastor lung,whichtendsto
spread("metastasize") to thebones,can be easilydetectedby sucha
nuclearbonescan.

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HISTORY OF MEDICAL IMAGING 351

The mostexciting testin nuclearmedicinetodayis positronemis-

siontomography or "PET" scanning. Insteadof emitting gammarays,
theseisotopesemitpositrons whentheydecay.Positrons arepositively
chargedelectrons. Following emission, a positron combines witha local
electron and annihilates, emitting two 511 kev in
photons oppositedi-
rections.Bynoting the arrival timeof the two photonsat thedetectors
aroundthepatient("coincidencedetection"), the sourceof emission
can be localizedin space.
MostPET is basedon a positron-emitting isotopeoffluorine (F-18)
thatis incorporated intoa glucoseanalog calledfluorodeoxyglucose
(FDG). Sinceglucoseuptakeis increased inmostcancers, FDG PET has
becomea mainstream to
technique diagnose both the primary cancer
and cancerthathas metastasized to otherpartsof thebody.More re-
centlyPET has beencombinedwithCT as "PET-CT."This combines
themetabolic(albeitlow resolution) information ofPET withthehigh
spatialresolution of CT,facilitatinglocalization of thecancerforbiopsy,
radiationtherapy, or surgery.
Ultrasound was first usedclinically in the1970s.UnlikeX-rayand
nuclearmedicine, ultrasounduses no ionizingradiation - just sound
waves.As thesoundwavespass throughthetissueand are reflected
back,tomographic imagescan be createdand tissuescan be character-
ized.Forexample,a massfoundon a mammogram can be furtherchar-
acterized as solid(possibly cancer)or cystic(mostlikelybenign).Ultra-
soundis also usefulforthenoninvasive imagingof theabdomenand
pelvis,including imaging thefetusduring pregnancy. Earlyclinicalultra-
soundunitswerebulkymachineswitharticulated armsthatproduced
lowresolution images. Today ultrasound can be performed bya portable
unitno largerthana laptopcomputer.
Computersreallyenteredthe world of medicalimagingin the
early1970s withtheadventof computedtomography (CT scanning)
andthenmagnetic resonanceimaging(MRI). CT was a majoradvance
thatfirstallowedmultiple tomographic images(slices)of thebrainto
be acquired.Priorto theadventofCT in 1973,we had onlyplanefilms
of the head (whichbasicallyjust show the bones) or angiography
(whichonlysuggests masseswhenthevesselsofthebrainaredisplaced
fromtheirnormalposition).Basicallytherewas no wayto directly im-
age thebrain.In CT an X-raytuberotatesaroundthepatientandvari-
ous detectors pickup theX-raysthatarenotabsorbed,reflected, or re-
fracted as theypass through thebody.EarlyCT unitsproducedcrude
imageson a 64x64 matrix.Earlycomputers tookall nightto process
theseimages.Today'smultidetector rowCTs acquiremultiple submilli-
meterspatialresolution sliceswithprocessing speedsmeasured inmilli-
secondsratherthanhours.Iodinatedcontrast agents are used with CT

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352 WILLIAM G. BRADLEY

since theyblock X-raysbased on theirdensitycomparedwiththat of

normaltissue.

Magnetic Resonance Imaging

MRI also evolvedduringthe 1970s, initiallyon resistivemagnetswith

weak magneticfields,producingimages with low spatial resolution.
Even then,however,it was obvious thatthe softtissuediscrimination
of MRI was superiorto thatof CT, allowingearlierdiagnoses.MR also
had the advantagethatit did not requireionizingradiationlike X-ray-
based CT. Over the 1980s and 1990s, superconducting magnetsbecame
common,initiallyat 1.5 Tesla and now at 3 Tesla. (Tesla is a measure
of magneticfieldstrength.The earth'smagneticfield,for example, is
.00005 Tesla. Thus a 1.5 T magnethas a fieldstrength30,000 times
strongerthanthatof theearth.)
Most clinicalMRI today uses the hydrogennucleusbecause it is so
abundantin waterand becauseitsnucleushas a property knownas spin.
Hydrogen nuclei (singleprotons)resonateat frequenciesin the radio-
frequencyrange.The exact resonancefrequencydepends on the local
value of the magneticfield.When a protonresonates,it emitsa radio-
frequencysignalthatcan be detectedby a radio antenna(usuallyin the
formof an RF coil around the body partbeingimaged).
An MRI scannerconsistsof a large (usuallysolenoidal,supercon-
ducting)magnetwith a 100-centimeter room-temperature bore and a
very uniform magnetic field 1
(like part per million [ppm] variation
over a 30 cm volume). When imagingis performed,resistiveelectro-
magnetsjustinsidethisbore are temporarily activated,generatingmag-
netic fieldgradientsalong the x, y, or z axes in the magnet.These
weaker gradientfieldsadd or subtractfromthe main magneticfield,
creatinga linear variationin net magneticfieldalong the threeaxes.
Justinsidethe gradientcoils are radiofrequency (RF) transmitand re-
ceivecoils.
When exposed to radiowaves at a particularfrequency, only those
protons at the rightvalue of the magneticfield resonate. Since the
strength of thegradientfieldsand thefrequenciesbeingtransmitted are
known, the location of the hydrogen nucleican be determined.For ex-
ample,if one gradientcoil along, say,the x axis is activated,thereis a
linear variationin magneticfield,and thereforeresonancefrequency,
along the x axis. In practicethe body is exposed to an RF pulse con-
tainingmultiplefrequencies.By separatingthe complex radio signals
comingfromthe body intodifferent frequencies(usinga Fouriertrans-
form),each hydrogennucleus's position along a particulargradient
axis can be inferred. The greaterthe numberof protonsat a point,the

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HISTORY OF MEDICAL IMAGING 353

Figure 1. Seventy-four-year-old man who arrivedat the hospitalsevenhours

following a stroke(notin timefor A. T2WI on admissionis normal.B. Diffu-
tPA).
sion imageon admissionshows restricted motionof waterin the hyperintense
basal ganglia- whichis thecore of the stroke.C. Perfusionimage(meantransit
timemap) showsthelargerarea at riskforextensionof thestrokeifthereis no
treatment. The differencebetweenB and C is calledthe"ischemiepenumbra"and
is the brainat riskforthe extensionof the stroke.D. T2WI twelveweeks later
showsthatthe initialperfusion(MTT) map accuratelypredictedthe size of the
resultinginfarcì(stroke).

greater theamplitude ofthesignalat a particular frequency. Byknow-

and
ingposition amplitude, one can produce an MR image(fig.1).
Conventional MR imagingassumesthatall protonsresonateat ex-
actlythesamefrequency at a givenfieldstrength. In actuality,
protons
in different chemicalenvironments mayresonateat slightly different
frequencies evenifthefieldstrength is thesame.(Thisis thebasisfor
nuclearmagnetic resonance or "NMR" in chemistry.) By makingthe
magnetic field10 timesmoreuniform, e.g.,0.1 ppm,overa smallre-
gion of thebrain and bysuppressing water, different chemicalspecies
withslightly resonancefrequencies
different (or "chemical shifts")can
be detected.Thisis knownas "MR Speçtroscopy" (MRS). givesus the
It
abilityto perform chemicalanalysisofthebrainnoninvasively (fig.2).
Forexample, withMRS we can detectN-acetylaspartate(NAA),which
is a markerof normalneurons.Whennormalbrainis replacedbytu-
moror infection, theNAA in thatpartofthebrainis decreased.NAA
is also decreasedin dementia. We can also detectcholine,whicharises
frommembrane turnover.It is elevatedin tumorsbutnotin abscesses.
Thus two processesthatmightappearsimilaron conventional MRI,

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354 WILLIAM G. BRADLEY

e.g.,tumorandabscess,can be differentiated on thebasisofthecholine

levelby usingMRS. In fact,themoremalignant thebraintumor, the
higher thecholineandthelowertheNAA levels.
Byvarying thetimingoftheRF pulses,different typesofMR con-
trastcan be produced.Thesecan be basedon fundamental NMR pa-
rameters liketheTl and T2 relaxationtimes,or theycan be basedon
motionofwateror blood (justto namea few).Forexample,on an im-
age thatis sensitive to T2 differences (a "T2-weighted image"),we can
distinguish different forms of hemoglobin and tellwhen bleedingoc-
curred.Oxyhemoglobin (thecirculating for
formof blood), example,
has a longerT2 thandeoxyhemoglobin, whichis foundin hematomas
inthebrainaftertwenty-four hours.The shortT2 ofdeoxyhemoglobin
makesit darkon a T2-weighted imageand allows us to distinguish
ischemiestrokes(whichmightrespondto clot-busting drugsliketPA
[tissueplasminogen activase])fromhemorrhagic strokes(whichare a
contraindication to tPA).
Whena task(likefinger tapping)is performed, thepartofthebrain
thatcontrolsthefingers paradoxically getsmoreblood thanit needs,
leading to lessoxygen extraction. Since oxygenated bloodhas a longer
T2 thandeoxygenated blood, subtraction of images with fingertapping
vs. thoseperformed at restshowsthepartofthebraininvolvedin the
task.Thispermits us to perform a techniquecalled"functional MRI"
(fMRI), which allows us to see theparts of the brain involved in any
task.Thisrichness ofcontrast mechanisms is theprimary advantageof
MRI overCT.
FunctionalMRI is complementary to anotherimagingtechnique
called"magnetoencephalography" or "MEG." MEG is similarto the
morefamiliar EEG (electroencephalograpy) althoughit is betterthan
EEG forlocalizingsignalscomingout of thebrain.The electrical sig-
nalsofEEG aredistorted the
by scalp and other conducting tissues be-
tweenthebrainand theelectrodes on theskin.The electrical currents
pickedup by EEG also produceweak magneticfieldspickedup by
MEG- but withoutthe distortion caused by the scalp. Becausethe
magnetic fieldscoming out of the brain aremanyordersofmagnitude
lessthantheearth'smagnetic field,MEG needsto be performed in a
specialmagnetically shielded room. MEG can be usedto localizeseizure
activityforpossiblesurgery. LikefMRI,it can be usedto showbrain
activation witha certaintask.WhilefMRIis basedon blood flow,its
temporal resolution is on theorderofseconds.MEG,on theotherhand,
has temporal resolution on theorderofmilliseconds. The magnetic sig-
nals detectedby MEG are usuallydisplayedon a three-dimensional
MRI thathas beenblownup likea balloon(seeavi#1inthelinkinthe
Suggested Readingsbelow).

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HISTORY OF MEDICAL IMAGING 355

The sensitivity of MRI to motionallowsus to imagemicroscopic

watermotion("diffusion imaging")andmacroscopic bloodflow("MR
angiography"). In diffusion imaging, stronggradient pulsescause wa-
terdiffusing randomly in theextracellular space of the brainto getout
of phaseand to lose signal.In acutestroke,waterin theextracellular
spaceofthebrainmovesintothecellsas cytotoxic edemawhereitsmo-
tionis limited. Sincethewaterno longerdiffuses normally in thisarea
ofstroke, of
itno longergetsout phase and shows up on a diffusion im-
age as an area ofbrightness (fig.1). Byperforming a relatedtechnique
knownas "diffusion tensorimaging," boththemagnitude and thedi-
rectionof diffusion can be shown.Major whitemattertracts(axons)
in thebraincan be demonstrated, sincewatertendsto diffuse parallel
(ratherthanperpendicular) to axons.Diffusion tensorimaging(DTI)
can be usedto showthewhitematter connections betweenthepartsof
thebrainthatlightup on fMRIduringa task.DTI (fig.3) can also show
whether whitemattertractsare intactnextto a braintumor, or have
already been invaded. This allows the neurosurgeon to avoid cutting
intactwhitematter tractsduringsurgery (fig.3).
Liketheuse ofiodinatedcontrast agentsin CT,MR also has an in-
travenous contrast agentbasedon paramagnetic gadolinium (Gd).Brain
tumorsthatturnbright, i.e.,"enhance,"usingiodineon CT also en-
hanceusinggadolinium on MRI. Gadolinium(Gd) can also be usedto
perform "perfusion" imaging ofthebrain,whichprovidesa measureof
cerebralbloodflow,meantransit time,and cerebralbloodvolume.By
comparing the diffusion and perfusion scansin strokepatients, thera-
peutic decisions the
(likegiving thrombolytic agenttPA) can be made
(fig.1).Therelative cerebral bloodvolume(rCBV)isdecreased instrokes,
but is increasedin braintumors.The rCBV represents the capillary
density, whichis increased bynewbloodvesselformation ("angiogene-
in
sis") braintumors. Thus theareaofthetumorwiththehighest rCBV
reflects themostmalignant partof thetumorand becomesthetarget
fortheneurosurgeon's biopsy(fig.4).
MR angiography can be performed withor withoutGd. We typi-
callyperform itwithoutGd in thebrainand withGd whenevaluating
thecarotidarteries or otherarteries throughout thebody(fig.5). In the
of for
setting stroke, example, may we be able to see a narrowedca-
rotidartery, whichcan be treated eitherbysurgery or byan angioplasty
and stent.A majordifference betweencontrast-enhanced MR angiog-
raphy and the catheter angiography described above is that theformer
involvesa low-riskvenousinjection, whilethelatterinvolvesa more
invasivearterialinjection.Bothcatheterangiography and contrast-
enhancedMR angiography can showtheflowof bloodovertime(see
avi #2inthelinkbelow).

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 Figure 2 (above). Forty-five-year-old
manwithlefttemporallobe seizures.
A. Fluidattenuatedinversionrecovery
(FLAIR) MR imageshowstumorin
lefttemporallobe.B. MRS shows
elevatedcholineand decreasedNAA.
C. Cholinemap guidesneurosurgeon
to highestgradeportionof tumorfor
biopsy(redarea).
Figure 3 (left). Fifty-three-year-old
manwithlefttemporallobe tumor.
Diffusiontensorimaging(DTI) shows
thatthewhitematterdeepto the
tumoris displaced,notinvaded.

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HISTORY OF MEDICAL IMAGING 357

MR is usefulfortheevalu-
ationof the heart.Withmod-
ern systems, the beatingheart
can be visualizedwithmultiple
slicesin variousplanesof an-
gulation(see avi #3in thelink
below). This is important be-
cause myocardialwall motion
maybe locallyabnormalduring
andfollowing a heartattack, de-
pending on which coronary ar-
teryhas become blocked. Twenty
minutesfollowinginjectionof
gadolinium,it accumulatesin
infarctedmyocardium, showing
theexactextentof damagefol-
lowinga heartattack(fig.6). CT
can also show a beatingheart
in threedimensions (see avi #4
inlinkbelow).Coronary CT an-
giography (fig.7) can shownar-
ofthe arteries Figure 5. Seventy-three-year-old man
rowing supplying with stroke.Contrast-
theheart,whichmaybe treated enhancedMR right hemispheric
angiogramshows narrow-
by coronaryangioplastyand ing ("stenosis")of proximalrightinternal
stent(performed bycardiology) carotidartery(arrow).
or by coronaryarterybypass
graft(CABG;performed bya cardiothoracic surgeon).
MR can be usedto diagnoseand to stageprostateand breastcan-
cer.Theprimary useforMRI intheevaluationofprostate carcinomais
to stagethedisease,i.e.,to determine whether it is extending beyond
theprostatic capsule(indicating nonsurgical treatment) or is withinthe
capsule(inwhichcase surgicaltreatment is possible)(fig.8). The evalu-
ationof breastcancerhas beensignificantly improved at 3 Teslacom-
pared with 1.5 T, since higher resolution is now possible,showingthe
spiculated borderstypical of cancer (fig.9).
MR canalso be usedto monitor certaintreatments inrealtime.MR
is nowgoingintooperating rooms,allowingneurosurgeons to be sure
thatall thebraintumorthatcan be safelyremovedhas beenremoved.
(In 80 percent ofcasesinwhichneurosurgeons thinktheyhaveremoved

manwithleftposteriorfrontal
Figure 4 (facingpage,bottom). Fifty-six-year-old
lobe tumor.A. FLAIR imageshows tumor.B. MRS shows elevatedcholineand
decreasedNAA consistent withtumor.C. Relativecerebralblood volume(rCBV)
map showsincreasedcapillarydensitydue to angiogenesis
(redarea).

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358 WILLIAM G. BRADLEY

all of a tumor, morecan be foundby

intraoperative MRI.) As a resultofits
sensitivityto temperature change,MR
can be usedto monitorthermalabla-
tion techniqueslike focusedultra-
sound.Take thetreatment of uterine
fibroids as an example.Untiltenyears
ago, the onlytreatment was a hyster-
Ten
ectomy. yearsago, uterine artery
embolizationbecame possible,sub-
jectingthepatientto a groinpuncture
insteadofa lowerabdominalincision.
Figure 6. Forty-nine-year-oldNow,usingMR-guided focusedultra-
man withacutemyocardialinfarc- sound,certainfibroids can be ablated
tion(a.k.a. heartattack)."Delayed without
MR imageac-
everbreaking skin.It can
the
hyperenhancement" also be used inthebrainfortumor, neu-
quiredtwentyminutesafterinjec-
tion of Gd shows hyperintensityrogenic pain,andpossibly acutestroke.
(arrow) in inferiorwall, corre-
spondingto siteof infarction. Computed Tomography
Withmodernmultidetector CT scanners,CT angiography (CTA) can
also be performedfollowing a venous An
injection. exciting
application
of CTA is in thesettingof acutechestpain.In thepast,cardiologists
wouldhave to takethepatientto thecardiaccatheterization labora-
tory,perform an arterial(usuallyfemoral) andthreada cath-
puncture,
eterintothecoronary arteries,which supplytheheart.
Today,coronary

Figure 7. Fifty-two-year-old womanwithacuteheartattack.A. Coronarycath-

eterization(arterialinjection)shows a narrowingof the midportionof the left
anteriordescending(LAD) coronaryartery. B. CoronaryCT angiogramsuperim-
posed on CT of heartshowsthesame thing(but followingan intravenous injec-
tion).C. CoronaryCTA removedfromtherestoftheheartshowsnarrowedLAD
following venousinjection.

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HISTORY OF MEDICAL IMAGING 359

Figure 8. Prostatecarcinomain
man.MRI
forty-nine-year-old
performedusing an endorectalcoil
arrow)
(short shows low on
intensity a
T2-weightedimagecorresponding to
thecancer(longarrow).Sinceitis
confinedbytheprostaticcapsule,it is
amenableto surgicalremoval.

CTA (fig.7) allowsus to screenchestpainpatientsso thatonlytheones

witha coronary occlusiongo to thecathlab forangioplasty and stent.
The patientsthathavechestpain foranotherreason,e.g.,pulmonary
embolismor aorticdissection, If noneof these
are treateddifferently.
threecausesofchestpainis found,thepatientcan safelygo homewith-
outhavingan invasive, expensive procedure.
Multidetector CT is frequently thefirsttestorderedin theemer-
gencyroom.A CT scancovering theentirebodycan be performed in
twenty seconds.The samedata setcan be viewedwithbonewindows

Figure 9. Improveddiagnosisof breastcancerat 3 Tesla vs. 1.5 T. A. Typical

256X256 matrixat 1.5T appearssmoothly marginatedlikebenignfibroadenoma.
B. Magnifiedimage. C. Subtractedimage, i.e., unenhancedsubtractedfrom
enhancedimage.D. A 512X400 matrixover same fieldof view providesmuch
greaterspatialresolutionat 3T, showingspeculationtypicalof cancerinsteadof
benigndisease.E. Magnified.F. Subtracted.

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360 WILLIAM G. BRADLEY

forfractures and softtissuewindowsforlacerationsof the liveror

spleen(see #5in thelinkbelow).
avi
MultidetectorCT can also be usedforevaluationofpatientswith
an acutestroke.CT is excellent fordetecting hemorrhage in thebrain,
whichis a contraindication fortPA(currently, theonlytreatment for
acutestroke).In addition,CT can producean isotropiedata setwith
0.6 mmspatialresolution. Followingadministration ofiodinatedcon-
trast,thesamedatasetcan be usedforperfusion imaging and CT angi-
ography to showwheretheembolushas lodgedintheintracranial vas-
culature.Withthisinformation, the neurointerventionalistcan go in
and literally
grabtheclot,limiting thedamagefromthestroke.
MultidetectorCT can also detectaneurysms inthebrain(seeavi#6
inlinkbelow)and elsewhere inthebody.Sincetheseweakenings ofthe
arterialwallcan lead to ruptureand death,itis important to makethe
diagnosisnoninvasively so the neurointerventionalistcan administer
coilsintotheaneurysm, causing itto clotoffand notrupture. Similarly
CT can be usedto demonstrate tumorsandto showtherelationship to
adjacentbonesand bloodvesselsto helpthesurgeonin thepreopera-
tiveplanning(seeavi #7inthelinkbelow).

Conclusion
In conclusion,medicalimaginghas comea longwayin the110 years
sinceRoentgenfirstdiscovered theX-ray.The exploratory surgery of
just 10 or 20 yearsago has beenreplacedwithnoninvasive CT and
MRI anatomicimaging. It is nowpossibleto getinformation at thecel-
lularlevelwithMR diffusion and perfusion imagingto assistin the
management of stroke and brain tumors. We can evengetinformation
at themolecular levelnow,withPET andMRS.
And thisis justthebeginning. In thefuture, new contrastagents
targeting,forexample, angiogenesis willbe used to determinewhether
a particularchemotherapeutic is
drug working withinhours,rather
thanwaitingweeksto see whether thetumoris shrinking or growing
on MRI or CT. Suchmolecularimagingagentsmaybe visualizedusing
different"reporters," e.g.,Tc 99m fortraditional nuclearmedicine, a
positronemitter forPET,or gadolinium forMRI. In thefuture we will
be ableto detectcancerthathas notyetproducedanatomicchange,on
thebasisof alterations in metabolicfluxesat thecellularlevel.Using
hyperpolarized MRI, we willbe able to detectdifferences
C-13 in gly-
to
colysis(pyruvate lactate) and citric
acid formation- which differsin
prostatecarcinomaand in normalprostatetissue.Throughthesead-
vancesin medicalimaging, diseasewillbe detectedlessinvasively and
earlier,
allowing for treatment before the diseasehas progressed the
to
of
point being incurable.

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history of medical imaging 361

Suggested Reading
Stark,D. D., andW. G. Bradley, eds.MagneticResonanceImaging, 3rded. St.Louis:
Mosby,1999.
Movie(avi)filesat http://radiology.ucsd.edu/Resident_Review/aps%20avis.ppt
1. Magnetoencephalography (MEG) of a patientbeingshowntheword"apple"
and beingaskedto visualizean apple.The MEG data is referenced to a brain
thathas beenexpandedlikea balloon,eliminating theinfoldings of thegyri
and sulcion thesurfaceof thebrain.Thismovieclipshowstheactivation of
thebraininrealtime.
2. SúbelavianStealSyndrome. Time-resolvedcontrast-enhanced MR angiography
ofpatient witha stenosis oftheproximalleftsubclavian artery, whichsupplies
theleftarm.Sincetheleftvertebral artery
(supplying thecerebellum andbrain-
stem)arisesbeyondthisstenosis, thearm"steals"bloodfromthebrainduring
exercisebyreversing flowintheleftvertebral leadingto dizziness,
artery, brain-
stemischemia, andpotentially stroke.
3. 4D MRI ofa beatingheart
4. 4D CT ofa beatingheart
5. Multidetector CT ofa traumapatient witha fracturedleftiliaccrest.Themovie
showstheskinand musclebeing"virtually dissected"away,showingonlythe
boneandthecontrast-enhanced bloodvessels.
6. CT angiogram showing a leftmiddlecerebral aneurysm.
artery Themoviestrips
awaytheboneoftheskull,eventually onlyshowingtheaneurysm frommulti-
pleprojections intreating
to assisttheneurointerventionalist it.
7. CT angiogram of a rightcarotidbodytumor, whichsplaystheinternal and
external carotidarteries outward.The movieshowsthelocationofthetumor
relativeto theoverlying mandible(jaw bone)andrelative to thecarotidartery.

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