General Radiology

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Chapter Outlines
 X-rays
 Computed Tomography
 Ultrasound Imaging
 MRI Basics
 Contrast Media in Radiology
 Multiple Choice Questions with Solution
 Starting a Radiology book with General Radiology (with lots of Read this section with a resolve…at a time when you are at
Physics in it) is not easy. your cognitive best…and you will realize it will create a very
But believe me it’s the right thing to do! STRONG foundation for your image interpretation part to
General radiology—is the essence of Systemic diagnostic follow. Also this one our weakest sections in Radiology, because
Radiology. we read a few systemic radiology bits in our clinical subjects
Fair warning though, it is full of: but we have never read about the imaging modalities and basics
ƒƒ Physics ever.
ƒƒ Chemistry—little bit I have tried to make it lucid and interesting by adding interactive
ƒƒ Mathematics—little bit images, flowcharts, anecdotes as and where possible.
ƒƒ Equations Get set…get ready…Let’s Rock!!
ƒƒ Numericals, and so forth

X-rays

ƒƒ Are a part of Electromagnetic spectrumQ ƒƒ On further experimentation, he also found that the new

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ƒƒ Electromagnetic spectrumQ: ray would pass through most substances casting shadows
•• Spectrum comprising of energy components/photonsQ

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of solid objects on pieces of film. He named the new ray
that are propagated in space by a combination of “X”-ray, because in mathematics “X” is used to indicate
electric and magnetic fields the unknown entity. Though today we know almost
•• In increasing order of frequencies/energies this everything about X-rays, this name is still being carried
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spectrum includes—Radio waves (Least frequency forward in his honor.
and energy),Q Microwaves, Infra-red, Visible light, ƒƒ He was awarded the 1st Nobel prize in physics in 1901.
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Ultraviolet, X-rays and Gamma rays (Maximum
frequency and Energy).Q
•• All components travel in space at same speedQ—Speed
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of light–3 × 108 m/sQ

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•• All components travel in space by the same type of

waveQ, though the individual wave properties (like
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amplitude, wavelength, frequency) may differ.

Discovery of X-rays
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ƒƒ X-rays were discovered by Sir Willhelm Conrad

RoentgenQ, on 8th Nov 1895Q
ƒƒ Hence he is designated as the Founding Father of
RadiologyQ and this day—8th November is celebrated as
International Radiology dayQ
ƒƒ He was working with cathode ray tubes, that had 2
electrodes (one positive- one negative), filled with a special
gas. When he passed a high electric voltage through it, the
tube would produce a fluorescent glow. This is the 1st X-ray image that he took—an image of his wife’s—
ƒƒ He shielded the tube with heavy black paper, and found Mrs Bertha Roentgen’s - hand, with their engagement ring on it!
that a green colored fluorescent light could be seen coming
from a screen setting a few feet away from the tube.
ƒƒ He realized that he had produced a previously unknown Atomic Structure—2 Basic Concepts
“invisible light,” or ray, that was being emitted from the ƒƒ In order to understand X-rays better we need to know
tube; a ray that was capable of passing through the heavy a few basic concepts about the structure of an atom.
paper covering the tube. Consider a Tungsten atom for example:
X-rays

28  •  Conceptual Review of Radiology


ƒƒ An atom consists of
•• Central nucleus—comprised of protonsQ and neutronsQ
•• Electrons orbiting around the nucleus in Shells—(K,
L, M, N)… and so forth. Each shell can contain a
fixed number of electrons—2, 8, 18, 32 and so forth
respectively. When all shells are filled with the entire
full set of electrons—the atom is considered a stable
atom.
ƒƒ Consider the K-shell electron in the image above (Yellow
circle). This electron—if you watch carefully—is a bound
electron, in the sense that it is bound by the positive charge
of the Nucleus, and hence must stay in the K-shell. In fact,
all electrons are bound by the positive charge of the nucleus
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in their respective shells, the inner-shell electrons are tightly
bound, the outer-shell electrons are loosely bound.
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ƒƒ Scientists decided to conduct an experiment and tried to
remove this innermost shell electron from a tungsten atom.
Because it was bound by the nucleus, when they tried to
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pull out this electron they had to spend some energy in
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pulling it out—precisely around 70 keVQ.
ƒƒ Thus when they spent an energy of 70 keV, they pulled out
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the K-shell electron. The following mathematical equation
just summarizes the above experiment
X (initial energy of electron) + 70 keV = Free electron
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in space (has energy level of Zero)
So
X + 70 = 0
Thus
X = –70
ƒƒ X = –70 thus represents the initial energy level of the K-shell
electron. It is also the energy level of the K shell itself.
ƒƒ Remember that each and every shell in an atom has its own
fixed energy level. All electrons in that shell are at exactly
that energy level, which is in K shell of tungsten atom the
energy levels of all electrons is—70.
ƒƒ If amount of energy required to remove K-shell electron
was 70 keV, the amount of energy required to remove an
L-shell electron would be less than that (as it is located away
from the nucleus) and it was found to be 12 keV. Similarly
for M shell it was further less at 2 keV.
Basic Concept 1
• Every shell in an atom has its own fixed Energy level associated
with it.Q
• All electrons in that shell lie at that fixed Energy level
• Energy levels for inner shells in a Tungsten atom are:
K - shell –70 keV
L - shell –12 keV
M - shell –2 keV
ƒƒ Now look what happens after the removal of the K-shell
electron. In the K-shell there is just one electron left.
Because of a deficient electron, an electron void/empty
space is created in innermost shell, thus making the atom
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unstable. The atom wants to become stable, but how?
Think….
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ƒƒ What happens is that an outer shell electron jumps to the
inner shell. L-shell to K-shell. Subsequently outer shell
electrons jump to the underlying inner shells and finally a
free electron in space fills the outermost shell—making the
atom stable again.
ƒƒ Look at the jumping L shell electron—
•• L-shell energy level is –12
•• K-shell energy level is –70
ƒƒ Thus if an electron has to jump from L-shell (–12) to K-shell
(–70) it will have to lose some energy so that it comes to
an energy level of -70. Thus the energy lost is equal to the
energy difference between the shells, here it is 58 keV.
Basic Concept 2
• Whenever an electron jumps from an outer shell to inner shell,
it has to lose some of its energyQ
• The amount of energy lost is equal to the difference between
the energy levels of the two shells
K-shell Energy level –70 keV
L-shell Energy level –12 keV
If electron jumps from L shell to K shell 58 keV of Energy
it will have to release
These 2 concepts will help us understand X-ray better!
X-rays
Conceptual Review of Radiology  •  29
 Tungsten ƒƒ These are Glass tubes with vacuum inside and 2 electrodes
Because Tungsten is a very important component of an X-ray ƒƒ Cathode:
tube, let us quickly review few important aspects: •• Made of Tungsten filament/coilQ—hence called as
ƒƒ Symbol—WQ Cathode filament
ƒƒ Atomic number—84Q •• Given very high negative potentialQ
ƒƒ Atomic mass—183.8Q ƒƒ Anode: Given a very high positive potentialQ
ƒƒ Atomic mass number—184Q •• Conventional X-ray tubes—TungstenQ
ƒƒ Classified as Transitional metalQ in the Periodic table •• Recent X-ray tubes
 Tungsten (90%) + Rhenium (10%)Q
X-ray Tube Structure  MolybdenumQ
•• Anode may be stationary or Rotating anode (better)
ƒƒ Large potential difference—is applied across the anode
and cathode—very important in production of X-rays
ƒƒ Exit window and Filter: Window is like a slit from which
the X-ray beam will come out of the tube. Various filters
are applied across the exit window. Aluminum filterQ is the
most commonly used.

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Production of X-rays
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It will be very easy to understand and remember using the following flow-chart
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X-rays

30  •  Conceptual Review of Radiology

Mechanism of Production of X-rays
1. Continuous spectrum radiation/BremsstrahlungQ: Based on Law of thermodynamics—Energy can never be created, nor can it be
destroyed. But it can be converted from one form into another.

Thus kinetic energy of the electron—is converted into energy of X-rays

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2. Characteristic spectrum radiation: Based on the 2 Basic concepts regarding structure of atom that we have discussed

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Thus the amount of energy lost when an outer shell electron jumps to an inner shell– is converted into energy of X-rays

Mechanisms of X-ray Production: Comparison

Continuous Spectrum Radiation/Bremsstrahlung Characteristic Spectrum Radiation

Also known as White radiation/Braking radiation
Contributes to 70–80% of X-rays used in diagnostic radiology
Consists of X-ray beam of variable energy—creates a Continuous
spectrum of energies on a graph—hence the name
No specific synonym
Q
Contributes to 20–30% of X-rays used in diagnostic radiologyQ
Consists of X-ray beams of characteristic energy content—that is
equal to difference between energy levels of 2 shells
X-rays

Used predominantly in most of diagnostic imaging Used predominantly in MammographyQ

Conceptual Review of Radiology  •  31

 Exposure Factors: Kilovolt Peak (kVp) and ƒƒ Milliampere second (mAs)Q
Milliampere Second (mAs) •• Combination of:
 mAmpQ—Current passed through the cathode
ƒƒ Kilovolt peak (kVp): filament
•• Voltage applied across the cathode and anode in the  TimeQ—Time of exposure
X-ray tube •• Determines the number of X-ray photonsQ in the in
•• Higher is the voltage, higher is the kinetic energy of the X-ray beam
electrons hitting the Anode, greater is the penetrating •• Affects the DensityQ/BlackeningQ of the Film
power of the emerging X-raysQ •• Directly affects the contrast—Increased mAs—Increased
•• Thus High kVp—results in higher penetrating power contrastQ
of X-raysQ
•• kVp also affects Radiographic Contrast – Interaction of X-rays with Matter—What
 Low kVp—High contrastQ—called as Short scale
contrastQ Happens in the Patient’s BodyQ
 High kVp—Low contrastQ—called as Long scale ƒƒ These are ways in which X-ray beams interact with
contrastQ the patient's body, when they enter inside. Various
interactions are known—
•• Compton effectQ—Most common interaction.Q
Discussed in detail below
•• Photoelectric effectQ—Discussed in detail below.

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Compton Effect and Photoelectric Effect can be Confusing, Hence Let us Study Them in a
Comparative Manner

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Compton effectQ Photoelectric effectQ
• Interaction of X-ray photon with OUTER shell electronQ • Interaction of X-ray photon with INNER shell electronQ
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X-rays

Contd…

32  •  Conceptual Review of Radiology

 Compton effectQ Photoelectric effectQ
• Most common interaction of X-rays with matterQ • Less common
• Is a Mid-energy phenomenonQ • Is a Low-energy phenomenonQ
• Most important outcome is Scatter radiationQ. It causes Image • There is no scatter radiationQ—hence image quality is better.
distortion, blurring and decreased diagnostic quality of the • Because there is no Scatter radiation, we try to MAXIMIZE
radiographic image Photo-electric effectQ
• Hence, to minimize scatter radiation, we try to MINIMIZE • Maximizing Photo-electric effect—
Compton effectQ ƒƒ Using Low energy X-raysQ
• Minimizing Compton effect— ƒƒ High atomic number targetQ
ƒƒ Using High energy X-raysQ

•• Coherent scatteringQ/Classical scatteringQ/ •• PhotodisintegrationQ –

Thompson’s scatteringQ/Rayleigh scatteringQ –  Part of the nucleus of an atom (Alpha particle/
 Low energy X-ray photon transfers its energy to neutron/combination) is ejected by a high energy
an electron in an atom incident photon
 The excited electron vibrates thus releasing  Occurs only if incident photon is > 7 MeV—not
the excess energy as a scatter X-ray beam. No in diagnostic RadiologyQ
ionization occurs, only direction of X-rays is •• Pair productionQ—
changed  High energy photon hits a nucleus and photon
 If a single electron of atom is involved— disappears

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Thompson’s scatteringQ  The photon (energy) is converted into 2 particles
 If all atomic electrons are involved together— (matter)—one electron, one positron

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Rayleigh scatteringQ  Occurs only if incident photon is > 1.02 MeV—
 Not important in Diagnostic radiology. y, not in diagnostic Radiology

Radiation Units
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It is a very factual topic and is very difficult to remember. Let us try to apply some “Mnemonic Secret” strategies to remember them.

Radiation ExposureQ—(Keyword is Exposure)

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• Conventional unit—RoentgenQ
ƒƒ Whenever you read the word exposure just remember the 1st
person exposed to X-rays was Roentgen—the unit.
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• SI unit—Coulomb/KgQ
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Absorbed DoseQ—Just look at this term, and pick up the 1st letter of each word
• Conventional unit—RadQ
ƒƒ Rad—stands for Radiation absorbed dose
ƒƒ Just looking at Absorbed Dose you get A and D, so the unit is Rad!
• SI unit—GrayQ
ƒƒ Red—is a color, that in a typical Indian accent of English may be
sometimes pronounced as Rad (No offence, I am a proud Indian
myself)
ƒƒ If Rad is a color-resembling term, the SI unit that goes along with it is
X-rays

another color-resembling word Gray (similar to Grey)

Conceptual Review of Radiology  •  33

 Equivalent DoseQ—The letter of highlight here is E
Other Radiation Units
ƒƒ Radio-activityQ:
•• CurieQ—Conventional unit
•• BecquerelQ—SI unit
ƒƒ KermaQ:
•• Kinetic energy released per unit mass of tissue
Effects of Radiation on Human body
Time Based Classification
ƒƒ Acute effectsQ:
•• Effects occurring in 1st 6 monthsQ of exposure
•• If exposure is high—organ death may occur
•• If dose is low—Parenchymal damage occurs, with
partially affected organ function
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ƒƒ Sub-acute effects:
•• Effects occurring 6–12 monthsQ following exposure
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•• Secondary parenchymal degeneration results in decreased
resistance to radiation is seen
ƒƒ Chronic effects:
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•• Effects occurring beyond 12 monthsQ of exposure
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•• Include carcinogenesis, genetic mutations and chro-
mosomal aberrations
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Acute Radiation SyndromesQ
Acute Radiation Syndrome (ARS) (also known as Radiation
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toxicityQ or Radiation sicknessQ) is an acute illness caused by
irradiation of the entire/most of the body by a high dose of
penetrating radiation in a very short period of time (usually
minutes). The major cause of this syndrome is depletion of
immature parenchymal stem cells in specific tissues. Examples
of people who suffered from such syndromes are the survivors
of the Hiroshima and Nagasaki atomic bombs, the firefighters
that first responded after the Chernobyl Nuclear Power Plant
event in 1986.
Three classical types exist -
ƒƒ Hematopoietic syndromeQ/Bone marrow syndromeQ:
•• 1st organ system to be affected in the bodyQ
•• Threshold dose: Around 1–2 GrayQ
•• LD 50/60 is 2.5–5 GrayQQ
•• Drop in all blood cell counts occurs for several weeks.
•• Primary cause of death is infection and hemorrhage.
X-rays
•• Survival decreases with increasing dose.
•• Most deaths occur within a few months after exposure.
34  •  Conceptual Review of Radiology
• Conventional unit—REMQ
ƒƒ Rem—stands for Radiation Equivalent in Man
ƒƒ E is letter of highlight—so both units contain E prominently!
• SI unit—SievertQ
ƒƒ E is letter of highlight—so both units contain E prominently!
ƒƒ Gastro-Intestinal syndrome:
•• 2nd organ system affected
•• Threshold dose is 6–10 GrayQ
•• Symptoms are malaise, severe diarrhea, electrolyte
imbalance
•• Survival is extremely unlikely, death occurs within 2
weeks
ƒƒ Cardio-vascularQ/CNS syndromeQ:
•• Threshold dose is around 20 GrayQ
•• Death likely due to collapse of the circulatory system
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as well as increased pressure in the confining cranial
vault as the result of increased fluid content caused by
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edema, vasculitis, and meningitis.
•• Death occurs within 3 days of exposure
Acute Radiation Syndromes (ARS)—Why
They Occur in a Particular Order?
• ARS—is a factual topic you are supposed to remember. If you
try to remember it by mugging it up, you will find it difficult. Let
us look at its Conceptual basis.
• Law of Bergonie and TribondeauQ:
ƒƒ Basic concept in Radio-biology
ƒƒ Whatever tissue/organ/region in the body has the maximum
proportion of undifferentiated cells/cells in active mitosis
will be more sensitive to radiation.
ƒƒ Thus can you guess which tissue/organ will be the most
sensitive?
ƒƒ Yes it is—Bone marrow. It contains undifferentiated stem cells
constantly involved in Hematopoiesis. Hence the Hematologi-
cal/Bone marrow syndrome—is the earliest syndrome to occur.
ƒƒ Next is GIT syndrome—as the mucosal layer is the cell
population undergoing active mitosis—the superficial layers
of cells is being replaced from basal layers
ƒƒ Last is CVS/CNS—minimal proliferation—hence relatively
high doses are required.
Deterministic and Stochastic Effects of
Radiation
Remembering the various properties of these effects can be
difficult. Hence let us study them in a comparative manner.
Also try to remember their examples first so that using those
examples we can remember the individual properties.
 Deterministic Effects Stochastic Effects
Examples • Acute radiation syndromes (discussed above)
Q
• Radiation induced carcinogenesisQ
• CataractQ • Genetic mutationsQ
• Skin changesQ—Erythema, ulceration • Chromosome aberrationsQ
• SterilityQ
• Radiation myelitis
• Fibrosis
• Teratogenesis/Fetal death
Onset • AcuteQ and Sub-acuteQ effects • Chronic effectsQ
Threshold dose • YesQ • No threshold doseQ
Severity of effect • Directly proportional to doseQ • Not related to doseQ
Risk of occurrence • Non-linear relationship with thresholdQ • Linear relationship with no threshold (LNT)Q

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Deterministic effects and dose relationship

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ALARA Principle •• DistanceQ
ƒƒ As Low As Reasonably Achievable Q
y, •• ShieldingQ
ƒƒ The ALARA radiation safety principle is based on the
minimization of radiation doses and limiting the release of 10–Day RuleQ
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radioactive materials into the environment by employing all ƒƒ A rule proposed by the International Commission on
“reasonable methods” Radiological Protection (ICRP)Q
ƒƒ ALARA is not only a sound radiation safety principle, but
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ƒƒ Applies to women of child bearing age

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it is a regulatory requirement for all “radiation protection

ƒƒ “Whenever possible, one should confine the radiological
programs”
examination of the lower abdomen and pelvis to the 10-
ƒƒ The ALARA concept is an integral part of all activities that
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days following onset of menstruation»Q

involve the use of radiation or radioactive materials and can
ƒƒ Linked to the teratogenic effect of radiation, despite low
help prevent unnecessary exposure as well as overexposure.
doses involved in diagnostic imaging.
ƒƒ The three major principles to assist with maintaining doses
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“As Low As Reasonably Achievable” are

•• TimeQ

Computed Tomography Computed Tomography

ƒƒ Computed tomography is basically a fusion of 2 technologies:
•• TomographyQ—X-ray based imaging technique devel-
oped to acquire sectional images of the body.
•• ComputersQ—Brought in to deal with the complex
mathematical algorithms and iterations in the image
reconstruction
X-rays were Discovered. CT scan was Invented!
ƒƒ X-rays were accidentally discovered by Sir Wilhelm
Röntgen—as discussed in the previous topic.
ƒƒ CT scans—however were invented—as a result of dedicated
and prolonged efforts to improvise the Conventional
tomographic technique over the years
ƒƒ Sir Godfrey Hounsfield—Inventor of CTQ. Known as
Founding father of CT technology, he was awarded the
Nobel prize in physics jointly with Allan Cormack in 1979
ƒƒ His machine was called as the EMI scannerQ (Electrical and
Musical Instruments Company) or the 1st generation scannerQ
ƒƒ There is also a unit scale named in his honor—Hounsfield
unit scaleQ

Conceptual Review of Radiology  •  35

 Basic Principle of CT Scan
“The internal structure of an object can be reconstructed from multiple projections of that object”Q

• An X-ray tube at Position A emits a beam that cuts through a slice of

the patient's brain
• An image is acquired on detectors located diametrically opposite to
Point A—this image is Projection 1 (P1)
• P1—is just like a spot radiograph/Routine X-ray image
• Now the tube is moved to point B along the circumference of the circle
around the patient. The detectors are also moved to a diametrically
opposite position
• Same process is repeated—Projection 2 (P2) is acquired
• Realize that P1 and P2 will appear different as they are acquired from
different angles around the patient
• This process is repeated such that P3, P4, P5……….Pn projection
images are acquired
• All these images are transmitted to a Computer. Computer will
process all these images and will reconstruct the actual slice image of
the brain from all the projection data.
• This image is showing us the “Internal Structure” of the head region.

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Read the CT principle again: “The internal structure of an object can be reconstructed from multiple projections of that object”
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CT Scan Generations
Ist Generation: Translate—RotateQ Scanner
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• Thin Pencil shaped X-ray beam

• Single detector
• Tube-Detector complex travels horizontally across
the patient's body to cover the entire cross section—
Translation
• 1 Translation = 1 Projection (P1)
• After every Translation the entire setup rotates
around the patient
• Again translation occurs resulting in P2
Computed Tomography

• Thus alternate translation and rotation occur

• Slow working machine

36  •  Conceptual Review of Radiology

2nd Generation: Translate—RotateQ Scanner
• Similar to 1st generation except –
ƒƒ Fan shaped X-ray beam
ƒƒ Row of detectors
• Lesser Translation and Rotation is required due to
fan shaped X-ray beam
• Faster machine than 1st generation

3rd Generation: Rotate—RotateQ Scanner

• Wide fan shaped X-ray beam covering the entire
patient cross section—hence translation is
eliminated
• There are 2 Rotation movements –

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ƒƒ Rotation of X-ray tube
ƒƒ Rotation of Detectors

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• Faster than 2nd generation
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4th Generation: Rotate—FixedQ Scanner

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• Entire 3600 detector ring is present around patient's

body, hence detector motion is eliminated
• There is only 1Rotation movement –
ƒƒ Rotation of X-ray tube around the patient
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• Faster than 3rd generation

• But requires a large number of detectors—added
cost for similar resolution to that of 3rd generation
machines

Computed Tomography

Conceptual Review of Radiology  •  37

 5th Generation: Electron BEAMQ Scanner
• No moving part in entire machine
• Electron beam is fired on a tungsten ring around the
patient's body—X-ray production occurs
• X-ray beam passing through patient's body is
detected by a complete 3600 detector ring around
patient's body
• Fastest developed machine till date
• Still in experimental stages

Helical/Spiral CTQ would then be brought back to its start point, the CT table
(on which patient is lying) is pushed further and the process
ƒƒ As seen above, the X-ray tube in the CT scan machine has

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repeated to acquire the next slice.
to move round-and-round around the patient to acquire
projections. A lot of wires are attached to any X-ray tube. ƒƒ If the tube could be rotated round-and-round around the

With so many wires attached, a few rotations would
entangle and pull all the wires—resulting in a short-circuit
explosion in the CT machine.
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ƒƒ Hence in older machines the rotation of the X-ray tube was
restricted to just one rotation around the patient. The tube
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patient continuously, non-stop data acquisition would be
possible thus saving precious time.
ƒƒ This was made possible by introduction of Slip Ring
TechnologyQ. In order to conceptually understand how it
works, let us compare it a daily example we come across—

Slip Ring Technology and Chennai Express!

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Chennai Express: The train not the movie!

• Travels from Mumbai to Chennai, covering a distance of around 1300 km in around 22 hours.
• How does the engine (of any electrically powered engine) receive its electrical supply?
• High voltage Overhead cables—are laid above the track from Mumbai to Chennai. There is a Pantograph on top of the train, with
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horizontal metal rod above it, that maintains constant physical contact with the overhead cable.
• Not even a single external fixed wire is attached to engine from outside, so it is free to go wherever there are overhead cables.
Computed Tomography

Contd…

38  •  Conceptual Review of Radiology

 CT Scan Slip Ring Technology: It is exactly similar to the above discussed mechanism:
• Overhead cables = Slip-Rings
• Railway engine = X-ray tube
ƒƒ Here instead of 1 ring around the patient there are 2 rings:
 Outer Ring: Stationary—like the overhead cables. All Electrical wires are attached to it.
 Inner Ring: Rotating with the X-ray tube mounted on it.
 Now like the Pantograph and metal rod on the top of the engine, there are brush contactors on the inner ring that maintain
constant electrical contact with the outer ring
ƒƒ Thus the X-ray tube is rotated freely round-and-round without the fear of any wires being stretched/pulled.

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• Now to cover the entire abdomen/thorax/brain the:

ƒƒ The tube is rotated continuously around the patient
ƒƒ The table is also continuously moved in one direction
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Computed Tomography

ƒƒ Thus if you imagine both these motions occurring simultaneously, it appears as if the tube is tracing the path of a Spiral/Helix
Computed Tomography

around the patient's body—hence the name Spiral/Helical CTQ

Multidetector CTQ
ƒƒ In all the above CT machines, we have seen that only one slice of image is obtained at a time. That is because the beam is a fan
shaped beam that cuts through only a single slice of the patient's body in one go.

39  •  Conceptual Review of Radiology Conceptual Review of Radiology  •  39


ƒƒ
ƒƒ
Multiple rows
of Detectors
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ƒƒ Cone BeamQ: It is a 3-D X-ray beam shaped like a cone, so
that in one rotation around the patient it can cover a large
thickness (multiple slices) of the patient's body, depending
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upon its third dimension.
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ƒƒ To detect all the X-ray data, multiple rows of detectors
are placed beyond the patient's body—hence the name
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Multidetector CT.
ƒƒ Depending upon how many slices of the body are obtained
in one cut, it may be called as:
•• 16 Slice CT scanner
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•• 64 Slice Ct scanner
•• 128 Slice CT scanner
CT Value ScaleQ/Hounsfield Unit (HU) ScaleQ
ƒƒ In CT scan the appearance of a tissue is predominantly
based on “Density”Q of that tissue.
ƒƒ Because computers are involved, a huge advancement of
this technology is that the appearance of each and every
Computed Tomography
tissue in the human body is allotted a specific numerical
value. This value allotted to a particular tissue is called as its
Hounsfield Unit (HU) value/CT value.Q
ƒƒ It is calculated based on the following formula:
40  •  Conceptual Review of Radiology
mx – mw
CT number = 1000 ×
mw
ƒƒ µx = Linear attenuation coefficient of a tissue “x”
ƒƒ µw = Linear attenuation coefficient of Water
ƒƒ Main determinant of Linear attenuation coefficient of a
tissue—is its DensityQ
H.U Value of Water:
•• Substitute µx as µw in the above equation and you
will get the HU value of water as 0—ZEROQ.
Look at the Hounsfield Unit scaleQ:
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Please note that each tissue has a range of corresponding HU
values. I have mentioned single values here so that it is easier
for you to remember. The range is usually a range of 50–100 on
either sides of the value mentioned above.
CT Physics—Practical Importance
Do we really need to know all this physics at your level???
Well, like it or not the answer is YES. For 2 reasons
1. Questions have been asked in your examinations regarding HU
values, CT generations and other related topics.
2. Practically it will help you in CT image interpretation in solving
MCQs.
ƒƒ Early scanners used to take around 25–30 minutes for a Brain
study. With recent Multidetector 4th generation scanners this
time has come down to a few seconds. This has made CT the
Imaging modality of choice in Emergency conditions like Acute
strokeQ, Head injuryQ etc. When time is not a constraint MRI is
better than CT for brain evaluation.
ƒƒ HU Values help us definitively arrive at a tissue level diagnosis.
Just by putting a measurement pointer at a site and looking at
the HU value there helps us know what tissue it may be, thus
making the assessment more accurate and objective.
CT: Descriptive Terminology
Right versus Left
ƒƒ Imagine that when the patient is lying in the CT machine,
you are standing at his foot end and looking at the imaging
slice from inferior aspect. Hence the Right—Left of the
patient is as shown here by convention
Densities
ƒƒ Hypo-denseQ—means Black/dark. Air (around the patient's
y,
skull), Water (CSF in ventricles) will appear hypodense
ƒƒ Iso-denseQ—means Gray. Generally all soft tissues (Brain)
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in the body will appear isodense
ƒƒ Hyper-denseQ—means White/bright. Acute hemorrhage
(Left basal ganglia hemorrhage here) and Bone (Skull)
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appear hyperdense.
Gray-White Matter Differentiation on CT
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ƒƒ Though we have mentioned that Brain appears isodense,
can you differentiate the appearance of Gray and White
matter on the image above?
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ƒƒ You see that the Cortical rim of gray matter is appearing
mildly hyperdense in comparison to mildly hypodense
central core of white matter. This distinction is also seen
in the central basal ganglia region, especially on right side.
ƒƒ So CT scan can differentiate between them, but it is not a
very good distinction—as their densities are very close to
each other!
Special CT Applications:
HRCTQ • High resolution computerized tomography.
• It is a technique in which, axial (cross sectional) images of lung are obtained using very thin slices.
• Lungs and Temporal bones are the two body structures which are imaged using HRCT.Q
• Evaluating a HRCT Thorax includes a pattern approach and is said to provide biopsy level diagnosis.
• A bone algorithmQ that uses high spatial resolutionQ to increase the contrast between 2 widely differing densities
is used, like air and vessels in thorax.
• Typically slice thickness of 0.625 to 1.25 mmQ are used.Q
• Good patient breath-hold is necessary for it.
CT Room Shielding
ƒƒ Computed tomography rooms typically have high
workloads and high kilovoltage technique settings.
ƒƒ Hence “Lead”Q is used the wall of CT scan room to prevent
leakage of radiation outside the CT room.
ƒƒ As a result, at least 1/16-inch lead shielding or equivalent is
required for the walls, doors, floors, ceilings, and operator’s
barrier.
ƒƒ The concrete equivalence of 1/16-inch thick lead would be
about 4 to 6 inches of standard-density concrete.
ƒƒ CT rooms with high workloads and with fully occupied
uncontrolled space directly adjacent to the scanner may
need shielding that is thicker than 1/16-inch lead or 4 to 6
inches of concrete to meet the recommended NCRP Report
CT Dose Index (CTDI)Q
ƒƒ Standardized measure of CT radiation output used so that
various CT machines can be compared with each other on
a common scale
•• CTDI100Q—Linear measure of dose distribution over
a 100 mm long ionization chamber and hence does
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not take into consideration the regional variation of a
1/
human body and is therefore not in clinical use
•• CTDIwQ—Weighted average of dose over a single slice
- is closer to the human dose profile as compared with
the CTDI100
•• CTDIvolQ—is obtained by dividing CTDIw by pitch
factor.
•• Dose Length Product (DLP)Q—Another commonly
used index, which factors in the length of the scan to
show overall dose output.
DLP: CTDIvol × scan length
Pitch
Table movement per rotation
ƒƒ Pitch =
Beam collimation or slice thickness
ƒƒ Pitch = 1—means that X-ray beams are contiguous for
adjacent rotations
ƒƒ Pitch > 1—X-ray beams are not contiguous, there are gaps
between X-ray beams and tissue is not irradiated. Scan
time and radiation exposure is decreased but scan quality
is decreased
ƒƒ Pitch < 1—X-ray beams overlap. Thus some part of body
tissue is irradiated more than once during a scan. Scan
duration and radiation exposure increases, scan quality also
increases.
Computed Tomography
Contd...
Conceptual Review of Radiology  •  41
 • Images are viewed on the lung window setting (window width of 1000 to 1500 HU and level of -600 to 700).
• Variations in technique include prone position scans to detect early ILD and dependent densities of asbestosis
(will persist in non dependent positions). Expiratory scans to identify subtle areas of air trapping (appear dark)
• Earlier there was difference between a HRCT Thorax and a CT Thorax. Presently with advent of multidetector CT
scans nearly each CT Thorax when viewed on lung window setting acts as an HRCT.
CT PerfusionQ
• Perfusion—means capillary level blood flow
• CT Perfusion imaging helps us determine the actual tissue level/capillary level blood flow in a particular tissue
• Iodinated contrast medium is injected rapidly and as it reaches the tissues, the rapid changes in tissue density are
detected by the machine and various parameters are plotted graphically.
• These include:
ƒƒ Mean transit time (MTT)Q or Time to peak (TTP)Q of the deconvolved tissue residue function (Tmax)
ƒƒ Cerebral blood flow (CBF)Q
ƒƒ Cerebral blood volume (CBV)Q
• Usually used in:
ƒƒ Ischemic stroke—to identify the penumbra
ƒƒ Brain/Head and neck Tumors
CT AngiographyQ • Before Multi-Detector Computed Tomography (MDCT), the main barriers to the clinical implementation of CT
angiography (CTA) were acquisition speed and both spatial and temporal resolution. Imaging of any vascular bed
requires rapid volume coverage coupled with the ability to resolve disease in small diameter contrast opacified
vessels.
• In many cases noninvasive imaging has become complimentary to catheter angiography, such as Doppler imaging
for the evaluation of patient's with recurrent symptoms after angioplasty.

e
• In many cases CT has been used in conjunction with catheter angiography, and in a few cases such as imaging the
aorta and the pulmonary arteries, CTA has supplanted catheter angiography as the gold standard.

1/
CT DensitometryQ/ • Quantitative CT is different from DEXA in that it provides separate estimates of trabecular and cortical bone BMD
Q-CTQ as a true volumetric mineral density in milligrams per cubic centimeter
(Quantitative CT)Q • It can be performed at axial sites (like lumbar vertebrae) as well as peripheral sites (like distal radius)
y,
• Quantitative CT is excellent for predicting vertebral fractures and serially measuring bone loss, generally with
better sensitivity than projectional methods (such as DEXA) because it selectively assesses the metabolically
active and structurally trabecular bone in the center of the vertebral body.
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• This selective assessment of trabecular bone also makes quantitative CT sensitive in measuring changes over a
short follow-up period.
Dual Source CTQ/ • Uses two separate energy sets to examine the different attenuation properties of matter.
l

Dual Energy CTQ • Independent attenuation values at two energy sets can create virtual non-contrast images from contrast
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enhanced imaging.
• It can also help determine the composition of renal calculi and arterial plaque
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• Dual source dual energy

ƒƒ Two X-ray tubes producing different voltages offset at 90 degreesQ
• Single source dual energy
ƒƒ a single X-ray tube with fast switching voltage otherwise known as kVp switchingQ
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• Single source dual layer

Applications:
• Virtual non-contrast image can be obtained. This only one set of CT images have to be acquired saving time and
energy
• Fatty liver quantification for liver donors
• Assessment of stent stenosis in coronary arteries
• Post CT Angiography bone subtraction
• Renal calculi composition assessment
Computed Tomography

• Bone densitometry
Cardiac CT/ • Assessment of Coronary arteries post stenting/Bypass procedure
CT Coronary • Evaluation of coronary artery anatomy variants
AngiographyQ • Being evaluated as a screening tool for Coronary artery imaging
• Calcium scoring of coronaries may be done
CT EnterographyQ: • Contrast medium is given per-orally, CT images acquired when the contrast reaches the small bowel. These
techniques however do not demonstrate mucosal abnormalities
CT Enteroclysis :
Q
• A contrast medium is introduced directly into small bowel through a nasojejunal tube and CT images are acquired
CT Colonoscopy :Q
• Following bowel preparation, the large bowel is distended with air/CO2 and Supine and Prone images are
obtained. 3D endoluminal projections are used to review the mucosal surface of colon.

42  •  Conceptual Review of Radiology