Radiology Syllabus Notes

Contents
Diagnostic imaging .................................................................................................................................. 3

1. Nature and properties of the radiologic image .............................................................................. 3
2. Digital imaging. PACS ...................................................................................................................... 3
3. Computed tomography- principles. Current developments........................................................... 4
4. Ultrasound- principles. Main applications ...................................................................................... 5
5. Magnetic resonance imaging (MRI). Principles. Notion of sequences. .......................................... 6
6. Contrast media- classification. Advantages and limitations ........................................................... 8
7. Invasive and interventional radiology ............................................................................................. 9
8. Imaging methods of the lungs ...................................................................................................... 10
9. Imaging of airway diseases: .......................................................................................................... 12
10. Imaging of inflammatory lung diseases .................................................................................... 14
11. Pulmonary embolism- current status of imaging ..................................................................... 15
12. Pleural diseases ......................................................................................................................... 18
13. Pulmonary tuberculosis. Classification, radiological appearance of primary and secondary tbc
20
14. Pulmonary carcinoma. Imaging and staging ............................................................................. 21
15. Benign lung tumours. Echinoccocus ......................................................................................... 22
16. Occupational lung diseases- Silicosis ........................................................................................ 23
17. Imaging in diaphragmatic lesions ............................................................................................. 25
18. Imaging of the mediastinum. Mediastinal tumours ................................................................. 25
Heart: .................................................................................................................................................... 27
19. Imaging of the heart, coronary arteries great vessels and peripheral vessels. 20.Imaging of
the normal heart ................................................................................................................................... 27
21.Imaging of the acquired valve diseases ........................................................................................... 28
22. Myocardial diseases: ....................................................................................................................... 30
23. Pericardial affections ...................................................................................................................... 31
24. Aortic diseases. Peripheral vessel diseases..................................................................................... 32
Digestive system: .................................................................................................................................. 33
25. Imaging anatomy of esophagus and stomach ................................................................................ 33
26. Esophageal lesions- diverticula, stricture, tumours, varices........................................................... 35
27. Imaging of the ulcer ........................................................................................................................ 36
28. carcinoma of the stomach. Staging. Postoperation imaging .......................................................... 37
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29. imaging of bowels. Colon carcinoma. ............................................................................................. 37
30. Imaging of the liver. Focal liver lesions. .......................................................................................... 38
31. Imaging of the biliary tract. Biliary calculosis.................................................................................. 39
32. Radiology of the ‘acute’ abdomen: ................................................................................................. 42
33. Imaging of the urinary system. 34. Radiological anatomy of the urinary system. Varieties and
anomalies .............................................................................................................................................. 43
35. Renal calculosis. Hydronephrosis.................................................................................................... 47
36. Renal cell carcinoma. Transition cell carcinoma. Staging ............................................................... 49
37. Imaging in obstetrics and gynaecology: .......................................................................................... 50
38. Musculo-skeletal imaging ............................................................................................................... 50
39. Radiology of main bone pathology processi ................................................................................... 50
40. Traumatic bone and joint lesions- fractures, fissures, luxations. ................................................... 51
41. Osteomyelitis- acute, chronic, atypical forms. Osteo-articular tbc. ............................................... 51
42. Benign bone producing tumours: osteoma, osteoid-osteoma, osteoblastoma ............................. 52
43. Benign bone producing tumours: chondromas, osteochondromas, hemangiomas, ostoclastomas
.............................................................................................................................................................. 52
44. Malignant bone producing tumours- Osteosarcoma ..................................................................... 52
45. Malignant bone producing tumours- Ewing sarcoma, myeloma, chondrosarcoma. ..................... 52
46. Degenerative and inflammatory diseases of joint and spine ......................................................... 53
47. Avascular necrosis- Morbus perthes............................................................................................... 54
48. Imaging methods of the CNS .......................................................................................................... 54
49. Brain tumours ................................................................................................................................. 55
50. Imaging of ischemic stroke: ............................................................................................................ 57
51. Imaging of subarachnoid hemorrhage (SAH) .................................................................................. 58
52. Imaging of the spinal cord............................................................................................................... 58
53. imaging of the breast. Carcinoma of the breast. Mastopathia....................................................... 60
54. Ofaciall-maxillary imaging ............................................................................................................... 61
55. Radiation protection of staff and patient: ...................................................................................... 61
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Diagnostic imaging
1. Nature and properties of the radiologic image

Roentgen discovered X-rays in 1895.
What are X-rays?
a) Nature:
 Particles and electromagnetic waves
 Wavelength of 0.5-0.001 nm
 X-rays are radiation emitted by electrons
 They are a form of electromagnetic radiation that can pass the human body and produce an
image of internal structures. Resulting image X-ray or ‘plain film’
 X-rays range in energy from 100eV to 100 keV (kiloelectronvolt)
 We use an X-ray tube (vacuum tube) that uses a high voltage to accelerate electrons
released by a cathode. The high velocity electrons collide with a metal target (anode)
creating the X-rays. In medicine, X-rays are produced in an X-ray tube by focusing a beam of
high-energy electrons onto a tungsten target.
 As the beam of X-rays passes the human body, some of the X-rays are absorbed or scattered
producing a reduction (attenuation) of the beam
 Depending on the density we have more or less X-ray beam attenuation.
 In order of increasing density:
- Air/gas= lungs, bowel, stomach
- Fat= dark grey e.g. SC tissue layer, retroperitoneal fat
- Soft tissues/water= light grey e.g. solid organs, heart, blood vessels, muscle and fluid
filled organs e.g. bladder
- Bone= off-white
- Contrast material/metal= bright white
X-rays are structure reflecting and give a 2D image
b) Properties:
 X-rays are types of ionizing radiation i.e. they can add or remove electrons from molecules,
producing electrically charged ions
 X-ray photons carry enough energy to ionize atoms and disrupt molecular bonds
 High radiation dose over short time period radiation sickness, lower doses increased
risk of radiation induced cancer.
 Ionizing capability of X-rays can be used in cancer treatment to kill malignant cells using
radiation therapy
 In lecture, properties were ionization, luminescence, heat, electrical conductivity,
photochemical effects and
In modern practice, radiographic images are produced digitally using CR (computed radiography)
and DR (digital radiography) next question
2. Digital imaging. PACS

Nowadays, radiographs are produced digitally:
a) CR- computed radiography
- Use of cassettes that are inserted into a laser reader to convert X-ray data into a digital
image
b) DR- digital radiography
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- Uses a detector screen containing silicon detectors that produce an electrical signal
when exposed to X-rays signal analysed to produce a digital image
- Better than CR because you can magnify areas of interest, alter density, measure
distance and angles
PACS:
Picture Archiving and Communication Systems- a computer network for digitalized radiologic images
and reports. It is a medical imaging technology which allows instant recall and display of a patient’s
imaging studies (X-ray, CT, MRI, US). Images can be displayed on monitors throughout the hospital
wards, meeting rooms and operating theatres as required. PACS replaces film with electronically
stored and displayed digital images.
Advantages/uses of PACs:
- Replaces need for hard-copy films
- Allows remote access enables clinicians in different physical locations to review the
same data simultaneously
- Electronic platform for images
3. Computed tomography- principles. Current developments

 CT (computed tomography) is an imaging technique whereby cross-sectional images are
obtained with the use of X-rays.
 The patient is passed through a rotating gantry where the X-ray tube and detector spin
rapidly around the patient.
 The information is transferred to a computer and multiple images are reconstructed and
displayed as a gray-scale image.
 CT images give the impression of looking at cross-sectional slices of the patient
 Remember that in plain X-rays high density objects cause more attenuation of the X-ray
beam and therefore displayed as lighter grey than objects of lower density. White or grey
objects= high attenuation and dark and black objects= low attenuation.
 In CT the density measurement is given as an attenuation value, expressed as Hounsfield
units (HU). In CT, water has attenuation value of 0 HU. Substances that are less dense than
water (fat and air) have negative values.
Multidetector row CT:
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 Helical (spiral scanners) differs from conventional
scanners in that the tube and detectors rotate as the
patient passes through the scanning table
 Multidetector row CT aka Multislice CT is based on
the concept of helical CT, however, multiple detector
rows are used instead of a single row of detectors.
 Multislice CT allows for reconsruction of highly
accurate 3D images as well as sections in any desired
plane.
Terminology: hyper-,iso-,hypo-,hetero- Dense
4. Ultrasound- principles. Main applications

Ultrasound (US imagining) uses ultra-high-frequency sound waves (greater than 20kHz) to produce
cross-sectional images of the body.
 Transducer is used to emit and to receive sound waves from various tissues in the body. The
transducer is placed against the patient’s skin with a thin layer of gel (the gel displaces the
air so it doesn’t reflect)
NOTE: the basic component of the transducer is the piezoelectric crystal; excitation of the crystal
causes it to emit ultra-high-frequency sound waves sound waves reflected back to the crystal by
various tissues of the body
 As sound travels into the patient, waves spread out. At tissues, the beam is partially
reflected and transmitted. (different reflex at the interface of tissue with different acoustic
impedance)
 The reflected sound waves (echoes) travel back to the transducer converted into
electrical signals amplified and analysed by a computer producing a cross sectional image
Main applications:
Different probes/transducers are available for imaging and biopsy guidance of various body cavities
and organs:
 Transvaginal US- gynaecological problems and assess early pregnancy up to 12 week
gestation
 Transrectal US- guidance for prostate biopsy; staging of rectal cancer
 Endoscopic US- assess tumours in upper GIT and pancreas
 Transesophageal echocardiography
Advantages of US:
 No ionizing radiation
 Low cost
 Portable equipment
Disadvantages:
 Operator dependent- US relies on operator to produce and interpret images
 Cannot penetrate gas or bone
Doppler US:
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Doppler Effect= the influence of a moving object on sound waves (think of a police or ambulance
siren speed past you)
 Object travelling towards the listener gives higher frequency and away from the listener give
lower frequency.
 Doppler effect to US imaging: flowing blood alters the frequency of sound returning to the
transducer this frequency shift is calculated to quantify blood flow
 Colour Doppler blood flowing towards the transducer= red, away from transducer= blue
presented on the cross-sectional image allowing instant assessment of presence and
direction of flow e.g. assess vascularity of tumours
Terminology in reporting: an-,hypo-,iso-,hetero-,hyper- echogenic
5. Magnetic resonance imaging (MRI). Principles. Notion of sequences.

MRI generates cross-sectional images (coronal, axial, saggital i.e. slices in all planes) using a large
magnetic field. No X-rays are used.
It is based on the fact that some nuclei (those with unpaired electrons)- behave like tiny magnets
Hydrogen nuclei (protons) are suitable since they are normally present in vast numbers in body
tissues
 First, you need the application of a strong, external magnetic field i.e. the patient is placed
within a large powerful magnet of 1.5 or 3.0 telsa (T)
 This strong external magnet field will force a proportion of these nuclei to align in a new
magnetic axis from their previous random orientation
 In addition to the magnet, the MRI machine also uses pulses of radiowaves (RF pulse-
radiofrequency pulse) to excite and detect the magnetised protons. The pulse of radiowaves
displaces nuclei from their new alignment and is detected by the RF receiver coils and used
to produce an MR image.
 When the RF pulse is turned off, the spins return to their equilibrium state by dissipating
energy to the surrounding molecules.
 The rate of energy loss is mediated by the intrinsic relaxation properties of the tissue,
designated as the longitudinal (T1 ) and transverse (T2) relaxation times.
1) T1: represents the restoration of longitudinal magnetization along the axis of the main
magnetic field- it is the time constant which determines the rate at which excited protons
return to equilibrium. It is a measure of the time taken for spinning protons to realign with
the external magnetic field.
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2) T2 : represents the decay time of magnetization in the transverse plane- it is the time
constant which determines the rate at which excited protons reach equilibrium or go out of
phase with each other
 TR= repetition time is the amount of time between successive pulse sequences applied to
the same slice
 TE= time of echo is the amount of time between delivery of the RF pulse and the receipt of
the echo signal
Notion of sequences:
 T1-weighted images  using short TE and TR times. Can also be performed infusing
gadolinium contrast (causes T1 shortening and thus increased signal on T1-weighted images)
 T2-weighted images using longer TE and TR times
Fluid
- T1= hypointense (dark)
- T2=hyperintense (greyish)
Fat
- T1= hyperintense
- T2= hypointense
Bone (Ca)
- T1= hypointense
- T2= hypointense
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Advantages and applications of MRI:
 Imaging modality for most brain and spine disorders
 Musculoskeletal disorders
 MR of abdomen for staging of tumours
Terminology: hyper-,iso-,hypo-,hetero- intense (signal)
6. Contrast media- classification. Advantages and limitations

Conventional radiography and fluoroscopy is used to display a range of organs. These structures can
be enhanced using various contrast materials, also known as contrast media.
Fluoroscopy= radiographic exam of the anatomy and motion of internal structures by a constant
stream of X-rays.
 The most common contrast materials are based on barium or iodine.

 Barium or iodine have a high atomic number that strongly absorb X-rays and thus seen
dense white on radiography
 To view the GIT with fluoroscopy, contrast materials are swallowed or injected via a
nasogastric tube to outline the esophagus, stomach and small bowel.
 They can also be introduced via an enema tube to delineate the large bowel.
 GI contrast materials are usually barium (non-water soluble)
 Iodine containing contrast material are water-soluble can be injected into veins, arteries and
various body cavities.
Contrast materials in CT:
 IV iodine containing contrast materials are used in CT to:
- Differentiate normal blood vessels from abnormal masses
- Make abnormalities more apparent e.g. liver metastasis
 oral contrast can also be used for abdomen CT to differentiate normal bowel loops from
abnormal masses or fluid collections, diagnose perforations in GIT etc.
 For detailed exam of the pelvis and distal bowel, administration of rectal contrast media is
occasionally used
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Contrast-enhanced US:
 Use of IV injected microbubble contrast agents
 Microbubbles consist of spheres of gas that rapidly oscillate by the US beam thus increasing
the echogenicity of blood
 In echocardiography it is used to better visualise blood and calculate ventricular function
 Assess liver masses
Contrast material used in MRI:
 Gadolinium (Gd) is a paramagnetic substance that causes T1 shortening and thus increased
signal on T1-weighted images.
 Unbound Gd is highly toxic so a binding agent is needed for in-vivo use
 Brain= for inflammation (meningitis), tumours
 Spine= infection e.g. epidural abscess, tumours
 Musculoskeletal system= soft tissue tumours
 Abdomen= characterization of tumours of liver, kidney and pancreas
Limitations of contrast media:

 Anaphylactoid contrast media reactions: (usually with injected IV iodinated contrast media)
- Mild anaphylactoid reactions= mild urticaria and pruritis
- Intermediate reactions= more severe urticaria, hypotension and mild bronchospasm
- Severe reactions= more severe bronchospasm, laryngeal edema, pulmonary edema,
cardiac arrest
 Contrast induced nephropathy: reduction of renal function within 3 days of contrast medium
injection.
7. Invasive and interventional radiology

Interventional radiology:
 The use of medical imaging techniques to guide doctors as they diagnose and treat problems
in nearly every organ system.
 IR is also called image-guided therapy
 Interventional radiologists guide small catheters and guidewires through blood vessels or
other organ pathways to treat many diseases
 It is a minimally invasive procedure
a) Angiography: real time X-rays of arteries or veins following injection of contrast material
locate blockages in vessels. Used to guide many IR procedures in the circulatory system e.g.
angioplasty, embolization, targeted delivery of chemotherapy
b) CT angiogram- cross sections obtained during CT are used to create a 3D picture of blood
vessels used to see if a patient may benefit from angioplasty or stent placement for artery
or vein occlusion
c) Fluoroscopy: used for guidance in IR procedures including angiography and image-guided
biopsy
d) MRA (magnetic resonance angiography)- patient is placed in a magnetic field and
radiowaves are used to create images of arteries and veins. MR guidance is used to provide
real-time monitoring and temperature mapping
e) US: used in IR procedures such as biopsies, abscess drainage or tumour ablation
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8. Imaging methods of the lungs
Imaging modalities used for the lungs include:
 Fluoroscopy- Radiograms
 Contrast enhanced imaging
 Cross sectional images i.e CT
 Angio
 Conventional radiograph i.e. Chest X-ray
Common symptoms due to respiratory disease include: cough, sputum production, hemoptysis,
dyspnoea, chest pain. Sometimes they can be accompanied by systemic symptoms e.g. fever,
weightloss, night sweats
- The physician needs to take an accurate history and PE (chest auscultation), spirometry
etc.
- CXR is requested in virtually all patients with respiratory symptoms
So, lets begin with how to read a CXR:
a) Projections performed:
1) Posteroanterior (PA) erect
- The patient is positioned standing with their chest wall against the X-ray film with the X-
ray tube behind the patient X-ray passes through in a post. To ant. Direction. Note the
patient must
inspire maximally
during PA CXR
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2) Lateral: i.e. side view the patient has their arms above their head. It is used to further view
the lungs to show areas obscured on the PA film, for further assessment of the heart,
lesions, view of the thoracic spine
3) Other projections: Anteroposterior (AP)/ supine X-ray= for ill or traumatized patients in ICU.
Expiratory film for pneumothorax (in expiration the lung is smaller while pneumothorax does
not change the volume), air trapping (accentuated on exhalation)
Refer to other document for a systematic review of CXR

CT scan:
Air Jet black
Fat Moderately black
Water Grey
Muscles Slight white
Bones White
Calcification Dense white
Indications: CXR abnormality, pleural and medistinal abnormalities, lung cancer staging, empyema vs
abscess , staging of bronchogenic carcinoma, detect pulmonary metastases, chest trauma, CT
angiogram to assess aorta, diseases of thoracic aorta (aortic dissection)
3 windows:
1. Medistinal window/ soft tissue window
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2. Lung windows
3. Bone windows
NOTE: HRCT= high resolution CT is a modified chest CT whereby thin 1-2mm sections provide
detailed views of the lung parenchyma for
- diffuse lung diseases e.g. bronchiectasis (shows dilated thick bronchi)
- intersitital lung diseases e.g. sarcoidosis
- haemoptysis
9. Imaging of airway diseases:

The airway diseases we will discuss are:
- Pneumonia
- Edema
- Haemorrhage
- Aspiration
In the CXR we look out for:
- Soft shadowing
- Unsharp borders
- Repeating lung structure
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- May contain ‘air bronchogram’
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10. Imaging of inflammatory lung diseases
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11. Pulmonary embolism- current status of imaging
Pulmonary embolism (PE) is a common cause of morbidity and mortality in postoperative patients,
as well as in patients with other risk factors such as prolonged bed rest, malignancy and cardiac
failure.
Pulmonary embolism is a blockage in the pulmonary arteries, which delivers blood to the lungs to
pick up oxygen
 Typically it is a thromboembolism, which happens when a blood clot from DVT lodges itself
in the pulmonary arteries.
 Depending on the what artery in the lungs are blocked, it can seriously decrease the
oxygenated blood to the body
Symptoms: pleuritic chest pain, shortness of breath, cough and hemoptysis. Most PEs are clinically
silent
 Small embolism no symptoms
 Large sudden and severe chest pain, shortness of breath, fatigue
 If embolism occurs at pulmonary saddle blocks both lungs sudden death
 Multiple emboli occur over time pulmonary hypertension or R. Ventricular failure
Clinical diagnosis usually requires confirmation with imaging studies including CXR and CT pulmonary
angiography (CTPA)
CXR: this is done on initial imaging investigation in all patients with suspected PE. Signs of PE on CXR
include pleural effusion, localized area of consolidation contacting a pleural surface or a localized
area of collapse. The main role of CXR is to diagnose other causes of the patients symptoms e.g.
pneumonia.
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radiographic signs:
 Decreased vascularity in the peripheral lung (westermark sign)- due to obstruction of
pulmonary artery or distal vasoconstriction of hypoxic lung
 Pleural based areas of increased opacity (hamptom hump)- dome shaped opacity due to
lung infarction
 Enlarged central pulmonary artery (fleischner sign)

 Enlarged R. Descending pulmonary artery (palla’s sign)- seen below
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 Hemidiaphragm elevation
CT pulmonary angiography:
Usually the method of choice to confirm
diagnosis of PE. IV injection of iodine
containing contrast
- Seen as filling defects within
contrast-filled blood vessels
V/Q scan: indicated in

patient with history of allergic
reaction to IV contrast. Patient
breathes a radioactive tracer
(ventilation phase), images obtained
after IV injection of microalbumen
aggregates (perfusion phase). V/Q
compared. In PE there is V/Q
mismatch i.e. perfusion reduced but
ventilation preserved.
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12. Pleural diseases
Pleural disorders include:
- Accumulation of fluid in pleural spaces (pleural
effusion)
- Air leaks= pneumothorax and
pneumomediastinum
- Pleural thickening
1) Pleural effusion:
-Accumulation of fluid in pleural space (between visceral and
parietal layers).
- Radiographic image is generally the same regardless of the

nature of fluid (transudate, exudate, blood, pus [empyema],
or lymph [chylothorax])
Causes: Cardiac failure, malignancy, infection e.g. TB,

bacterial pneumonia, trauma (rib fractures)
On CXR we see:
 dense homogenous opacity at base of lung
 Concave upper surface producing meniscus
 Small pleural effusion causes blunting of
costophrenic angle
 Large pleural effusion displace mediastinum towards the controlateral side
2) Pneumothorax:
Accumulation of air in pleural space
Causes: spontaneous (smokers), iatrogenic (lung biopsy), trauma (rib fracture), emphysema,
malignancy etc.
On CXR- usually seen well on inspiratory PA film

however, small pneumothorax can be seen easier on
expiratory film due to reduced volume of lung in
expiration, which makes the pneumothorax look
relatively larger.
The sign to look out for is the lung edge outline by air
in the pleural space
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Tension pneumothorax= continued air leak from lung into pleural space increased pressure in
pleural space with expansion of hemithorax and further lung compression
3) Pneumomediastinum:
Air leak into soft tissue of the mediastinum due to severe
coughing, asthma, chest trauma, osphageal perforation.
4) pleural thickening:
can occur secondary due to trauma, following empyema, TB,
asbestos exposure, pleural metastasis
on CXR we can identify:

- blunting of costophrenic angle (mimic pleural
effusion)
- soft tissue thickening over lungs and apices
- calcification of pleural surface (due to pleural hemorage or infection)
- pleural plaques (calcified if history of exposure to asbestos)
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13. Pulmonary tuberculosis. Classification, radiological appearance of primary
and secondary tbc
Pulmonary TB is caused by an aerobic acid-fast bacteria called mycobacterium tuberculosis. M.
Tuberculosis is an intracellular pathogen that enters the respiratory airways and penetrates the
alveoli, where the bacteria are phagocytosed by alveolar macrophages. Macrophages secrete
cytokines that in turn recruits T cells that activate the macrophages and stimulate cell killing. The
subsequent mass of necrotic cells (granuloma) will contain the infection.
Symptoms include- weightloss, malaise, cough, night sweats with sputum production (bloody or
purulent)
Classification:
1) Primary TB: usually asymptomatic and seen in patients not previously exposed to M. Tb.
Most common in children under 5years.
Radiologic appearance
- Can be anywhere in the lung in children whereas there is a predilection for upper or
lower zone in adults
- Initial focus of infection can be located
anywhere within the lungs
- Parenchymal infection is seen in most cases
- In most cases the infection becomes
localised and the caseating granuloma forms
(tuberculoma) which eventually calcifies and
is then known as Ghon lesion
- Lymphadenopathy is common in ipsilateral
hilar and paratracheal lesions on the right
side
- Pleural effusion more frequent in adults
- Ipsilateral calcified hilar node + Ghon lesion=
ranke complex
Post primary: is known as ‘reactivation TB’ or secondary TB- it

occurs years later due to decreased immunity.
Radiologic appearance: has strong predilection for apical and
posterior segments of upper lobes, plus apical(superior)
segments of lower lobes
- Typical appearance is variable and can include ill-
defined areas of alveolar consolidation and thick-
walled irregular cavities (patchy consolidations or
poorly defined nodular or linear opacities)
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2) Miliary TB: due to hematogenous dissemination of uncontrolled TB infection.
Radiologic appearance: evenly distributed throughout both lungs. CXR shows tiny densities
(nodules) of 2mm which are uniform in size and uniformly distributed.
14. Pulmonary carcinoma. Imaging and staging

Pulmonary carcinoma (AKA lung cancer AKA bronchogenic carcinoma) is classified into:
- small cell lung cancer (SCLC)= more aggressive.
- non-small cell lung cancer (NSCLC)= most cancers e.g. adenocarcinoma, SCC, large cell
carcinoma
It is most common cause of cancer in men
Risk factors: smoking, asbestos, COPD
Symptoms: cough, chest pain, hemoptysis, dyspnoea.
TNM system is used for staging:

 ‘T’= tumour size and evidence of chest wall or mediastinal invasion
 ‘N’= regional hilar or medistinal
lymph node involvement
 ‘M’= distant metastasis
NOTE: CT is the most commonly used
modality for tumour staging. CT is more
accurate than CXR to diagnose
lymphadenopathy or invasion of
medistinal and chest wall. It can also be
used for primary diagnosis if the CXR is
negative but there are suspected
symptoms of pulmonary carcinoma
Imaging:
 The majority of pulmonary
cancers are initially diagnosed in CXR.
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 The usual appearance of the cancer is pulmonary mass
 complications of the cancer will produce
more complex appearance in CXR:
- Segmental/lobar collapse
- Persistent areas of consolidation
- Hilar lyphadenopathy
- Mediastinal lymphadenopathy
- Pleural effusion
- Invasion to mediastinum, chest
wall
- Metastases
15. Benign lung tumours. Echinoccocus

Benign lung tumours: heterogenous group of neoplastic lesions originating from pulmonary
structures.
- Adenomas
- Hamartomas
- Uncommon (chondromas, fibromas, lipomas, hemangiomas etc.)
If growth is <3cm= nodule, in lungs= pulmonary nodule
Hamartomas are the most common benign lung tumours;
 They are composed of cartilage, CT, muscle, fat and bone
 Usually asymptomatic found accidentally on CXR, can be hemoptysis, bronchial obstruction
and cough.
 Usually composed of tissues that normally constitute lung and bronchi
 Located peripherally within lungs
 Well-circumscribed solitary nodules with smooth or lobulated margins, calcification may be
seen (popcorn calcification)
 CT- detects intralesional fat and calcification
Pulmonary nodules: are much more commonly found than lung cancers. Causes include:
- Healed over ‘wounds’ on lung due to TB, scar from surgery
- Infection from HPV
- Smokers
Echinococcus
 Human Echinococcus (hydatid disease) is caused by the larval stages of the genus Echinococcus
 Pulmonary hydatid infection is a common manifestation of hydatid disease
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 Definitive hosts (dogs,cats,foxes), and intermediate hosts are sheep. Humans are accidental
hosts and infection occurs by ingestion of contaminated Echinococcus eggs
 The lung is the second most common site of involvement with Echinococcus granulosus in adults
after the liver and the most common site in children
 When pulmonary hydatid cysts rupture and communicate with the bronchioles, patients cough
up ‘grape skin’ like material
 CT scan shows: multiple or solitary cystic lesions, can be unilateral or bilateral, predominantly
found in lower lobes.
- Uncomplicated cysts have round or oval masses with well-defined borders, hypodense
content relative to capsule
- Complicated cysts may show meniscus sign (air crescent sign), onion peel sign (combo
sign/ double arch sign), or consolidation adjacent to cyst (ruptured cyst), water-lily sign
(detached endocyst membrane resulting in floating
membranes within pericyst
that mimic waterlily- CT lung
window below )
Multiple well defined

opaque cysts seen within right
hemithorax.
16. Occupational lung diseases- Silicosis

Occupational lung diseases are a broad group of diagnoses caused by inhalation of dusts, chemicals,
or proteins. ‘Pneumoconiosis’ is the term used for diseases associated with inhaling mineral dusts.
Severity of the disease is related to the material inhaled, intensity and duration of exposure.
Asbestosis:
 Development of diffuse interstitial fibrosis secondary to asbestos inhalation

 Heavy asbestos exposure is most common in men in construction, mining or
ship/automotives industry
 Clinic- nonspecific with shortness of breath
 CXR shows irregular opacities with fine reticular pattern. Pleural plaques may be evident
PA CXR shows
reticulnodular
opacities at
lung bases
Page | 23
pleural plaques secondary to previous asbestos
exposure. Plaques are calcified. Plaques also in
diaphragmatic pleura
 CT- early manifestations confined to periphery and

lower zones;
- Centrilobular dot-like opacities (peribronchial
fibrosis)
- Intralobular linear opacities (reticulation)
- Subpleural lines
As the fibrosis progresses:
- parenchymal bands
- traction bronchiectasis (yellow arrows)- causes fibrotic lung pulling on bronchi thus
causing irreversible dilation
- honeycomb fibrosis (orange arrows)
Silicosis:
A fibrotic pneumoconiosis caused by inhalation of silica. Mining, quarrying and tunnelling is
associated with silicosis. Silica particles ingested by alveolar macrophages and breakdown of
macrophage releases enzymes which produce fibrogenic response.
a) Acute silicosis- manifests as alveolar silicoproteinosis
CXR- bilateral consolidation and/or ground glass opacities* (perihilar regions)
*Due to increased attenutation of lung
CT- bilateral centrilobular nodular ground-glass opacities, consolidation
Bilateral perihilar large focal opacities

with calcifications, along with
reticulonodular interstitial pattern
(predominantly in upperlobes).
Numerous lymph node eggshell
calcifications present
Page | 24
b) Classic silicosis- chronic interstitial reticulonodular disease. More common. Radiographic
findings classifies it as:
- Simple silicosis= small and round or irregular nodular opacities on CXR, CT shows
multiple small nodules usually in upper lobe, calcifications, hilar and mediastinal
lymphadeopathy, eggshell calcification
- Complicated silicosis= large opacities that equate to progressive massive fibrosis (CXR
below- large upper lobe masses (black arrow), ‘egg-shell’ calcification (white arrow),
scarring in both lobes (green
arrows).
17. Imaging in diaphragmatic lesions

Primary tumours of the diaphragm are very rare. Benign tumours are more common (lipomas, cystic
masses- bronchogenic and mesothelial cysts). Other benign tumours include (hemangioma,
angiofibroma etc.)
Malignant tumours are sarcomas of fibrous or muscular origin.
Radiologically, most diaphragmatic tumours are smooth or lobulated soft-tissue masses protruding
into the inferior portion of the lung or can resemble a diaphragmatic hernia.
CT or MRI can confirm the presence of the mass. When the tumour is large, it may not be possible to
determine whether it arises from the diaphragm, pleura or lungs,
or abdominal viscera.
Bronchogenic carcinoma, mesothelioma nad other primary or

secondary pleural or chest wall malignancies may secondarily
involve the diaphragm by direct extension.
18. Imaging of the mediastinum. Mediastinal

tumours
The mediastinum is the median portion of the thoracic cavity
(interpleural). It is limited by:
- Thoracic inlet superiorly
Page | 25
- Diaphragm inferiorly
- Sternum anteriorly
- Th12 posteriorly
It is divided into:
1) Superior mediastinum: lies between the first rib and
the sternal angle
Contains:
 Blood vessels (SVC, brachiocephalic veins, pulmonary
trunk, arch of aorta)
 Thoracic duct
 Trachea
 Oesophagus
 Thymus
 Nerves (vagus, left recurrent laryngeal nerve, phrenic
nerve)
2) Inferior mediastinum: lies between the sternal angle
and diaphragm
The inferior mediastinum is subdivided into:
a) Anterior mediastinum- thymus gland, lymph nodes
and fat
b) Middle mediastinum- heart, pericardium, phrenic
nerve, main bronchi
c) Posterior mediastinum – esophagus, thoracic aorta,
azygus vein, thoracic duct, vagus nerve)
Mediastinal tumours: i.e. mediastinal masses

Signs on CXR that a central opacity or mass lies within the
mediastinum rather than the lung include:
 Continuity with the mediastinal outline
 Sharp margin
 Convex margin
 Absence of air bronchograms
Anterior mediastinal masses can be:
- Retrosternal goitre
- Thymic tumour
- Lymphadeonpathy (Hodgkin’s disease)
- Aneurysm of ascending arota
Signs on CXR= merge with cardiac border,
cervicothoracic sign (masses passing upwards to neck
merge radiolocially with soft tissues of the neck and so
aren’t seen above the clavicles), displaced trachea
Middle mediastinal mass:

- Lymphadenopathy, mediastinal or hilar= bronchogenic carcinoma, lymphoma
- Aortic aneurysm
Signs on CXR shows opacity that merges with hilar structures and cardiac borders
Page | 26
Posterior mediastinal mass DDx:
- Hiatus hernia (opacity round behind heart, can
contain fluid level)
- Neurogenic tumours= well-defined mass in
paravertebral region, can be associated with
destruction of vertebral bodies or posterior ribs
CXR signs= doesn’t obscure heart or middle mediastinal
borders, cardiac borders and hila clearly seen, posterior
descending aorta obscured
Heart:
19. Imaging of the heart, coronary arteries great vessels and peripheral
vessels. 20.Imaging of the normal heart
1) CXR:
- Used to assess cardiac failure and its treatment
a) Position: apex directed towards left chest wall and 2/3 of the heart lies to the left of midline.
Malposition to one side due to collapse of ipsilateral lung, tension pneumothorax, large
pleural effusion.
- Dextrocardia= reversal of normal heart orientation with apex at patient’s right. Can be
isolated (other organs normally positioned) or situs transverses (all organs reversed and
gastric bubble at right diaphgragm)
b) Cardiac size: cardiacthoracic ratio (CTR)- explained in other document of imaging.
c) Pulmonary vascular patterns:
- Arteries branch vertically to upper and lower lobes
- Veins run horizontally towards lower hila
- Upper lobe vessels smaller than lower lobe vessels on erect CXR
- Vessels hard to see in peripheral thirds of the lungs
2) Echocardiography:
- For direct visualisation of cardiac anatomy, Doppler analysis of flow rates through valves
and septal defects and colour Doppler (to identify septal defects and stenotic valves)
- For; Systolic function- measure ejection fraction,Stroke volume and cardiac output
,Measure chamber volumes and wall thickness,Diastolic function- measure left
ventricular ‘relaxation’,Congenital heart disease ,Valvular dysfunc, Cardiac masses,
pericardial effusion, aortic dissection
We can further enhance echocardiography by injecting microbubble contrast agent- visualise cardiac
chambers
3) Coronary angiography:
- We place catheters via femoral artery into origins of coronary arteries and inject
contrast material.
- For coronary artery stenosis
- Can combine with coronary artery angioplasty to place a stent
Page | 27
4) CT:
- Anatomy
- Coronary arteries
- Kinetics of LV
- Valve assessment
- Aorta assessment
5) MRI:
- Cardiac MRI (CMR) used for: cardiac function (ejection fraction, thickness), congenital
heart disease, cardiac anatomy, infarct scan, aortic dissection, pericardial diseases
Great vessels= ascending aorta, aortic arch, azygous vein, main pulmonary a, SVC, IVC
21.Imaging of the acquired valve diseases

Aortic stenosis:
Aortic valve narrowing between the aorta and left ventricle less than 1-2cm^2. Causes less blood to
body:
- Brain= syncope
- Coronary arteries= angina pectoris
- CHF can occur: congestion in lungs pulmonary edema= dyspnoea
CXR:
- Dilation of ascending aorta with normal heart size (DDx with hypertension- entire
descending aorta enlarged)
- Late in the disease- can get cardiomegaly with HF features
Ascending aorta(yellow) leading to arch is dilated.(prominent right mediastinal border occupied by

ascending aorta) Descending aorta (red) normal. Left heart border (blue) traces up along
mediastinum and blends in with aortic arch.
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Coronal non contrast CT shows calcified aortic valve
(green arrows). Saggital contrast CT shows dilated aorta with normal descending aorta
US: determine severity of stenosis by evaluating outflow of blood from aortic valve
CT & MRI: better detail
Aortic valve regurgitation: aka aortic valve insufficiency= blood flows back into left ventricle during
diastole (ventricular filling). Symptoms of left heart failure with dyspnoea and angina.
Plain radiograph= apex displaced to left with signs of CHF.
US: echocardiography
MRI
Mitral stenosis: mitral valve separates the left atrium and ventricle. @ diastole the valve opens, if
doesn’t open enough= impaired filling of left ventricle mitral stenosis <CO, and stroke volume
CXR: dilation of left atria- convexity (left picture) or straightening (right picture) of left atrial
appendage just below the main pulmonary artery (along left heart border)
- Double density sign: enlarged L atrium pushes the adjacent lung and creates a contour
superimposed over the right heart (double right heart border)
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Mitral regurgitation: aka mitral valve insufficiency- @ systole the mitral valve should close but in
regurgitation it doesn’t close properly blood leaks back to LA
CXR: same as above but in acute cases left atrial enlargement is often absent, left ventricular
enlargement (DDx with mitral stenosis)eventually present due to volume overload, CHF may be
present, pulmonary edema often seen.
Note the cardiomegaly with dilated LA and LV in this picture and upper lung zone vasculature is
prominent suggesting pulmonary venous hypertension
22. Myocardial diseases:

Myocardial diseases show enlarged left ventricle usually.
Hypertrophic cardiomyopathy: hypertrophied (>15mm thickness) left ventricle due to any cause.
Signs of left-predominant CHF
-CXR: normal to enlarged heart, more useful to identify complication e.g. pulmonary edema.
- echocardiogram shows gradient of blood flow and obstructions
-MRI and CT more useful for accuracy
Dilated cardiomyopathy: left ventricular chamber dilation with decreased systolic function.
Ventricles dilated, thin and poorly contract. Etiology: CAD, infection, toxic, idiopathic, familial
- CXR: enlarged left ventricle and atria with pulmonary edema. Pleural effusion may be
seen (DDx= large pericardial effusion)
- US (echography), CT
- Cardiac MRI
Restrictive cardiomyopathy: least common cardiomyopathy, decrease in ventricular compliance.
Signs and symptoms of left ventricular failure and/or right ventricular failure. Mostly a disease of
diastolic dysfunction where the systolic (contractile) is usually unaffected. Etiology: many e.g.
amyloidosis= amyloid deposits on myocardium thickened LV
- CXR: heart size can be normal but sometimes theres biatrial dilation
- Echo: diastolic dysfunction
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- CMR: useful to differentiate between contrictive pericarditis
Infiltrative cardiomyopathy: amyloidosis of myocardium. Left ventricular wall thickened.
23. Pericardial affections

Pericardial effusion: excess fluid collects in the pericardial cavity (normal pericardial sac contains 30-
50mL of fluid).
- Etiology= due to inflammation or infection, neoplasms, cardiac surgery, trauma.
- Compression of the heart chambers causing the atrial walls to thin out and affects filling of the
heart. Systemic hypotension can result due to decreased ejection fraction <CO and increased jug.
Venous pressure
- symptoms occur when there are large effusions (>100ml)- shortness of breath, light headed,
decreased BP. Death in severe cases (cardiac tamponade)
CXR: very small effusion isn’t shown, needs to be greater than 200mL
- Water bottle configuration (globular enlargement of cardiac shadow)
- Lateral CXR- oreo cookie sign
- Different density sign at cardiac borders
Echo: method of choice to confirm diagnosis and estimate volume of fluid and heamodynamic
impact of the effusion
CT: thickened pericardium (>3-4mm), fluid density material surrounds heart.
Pericardial fluid (yellow) outlined by epicardial fat (blue

arrows) and pericardial fat (orange arrows), gives three
layered appearance aka ‘oreo cookie sign’
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Pericardial calcification: usually occurs in patients with history of pericarditis. Symptoms of L sided
HF. CXR- shows calcification mostly on right heart border (right ventricle), DDx with myocardial
calficiations= seen on LV.
24. Aortic diseases. Peripheral vessel diseases

1) Aortic diseases:
a) Aortic dissection: tear in the surface of intima allowing flow of blood into the aortic wall, this
creates a false lumen, with re-entry of blood into the true lumen.
Symptoms- acute chest pain (‘tearing’ sensation’)- can be anterior or posterior between the scapula,
and can radiate distally as the dissection progresses.
Classification according to Stanford system:
- Type A= all dissections involving the ascending aorta, with re-entry anywhere distally
down to and sometimes beyond aortic bifurcation. Worse prognosis due to risk of CA
occlusion, rupture of pericardium and aortic valve regurgitation
- Type B= doesn’t involve ascending aorta; confined to descending aorta
CXR: used to exclude other causes of chest pain. Non-specific signs usually.
- Can be alterations of the contour of aortic arch (double aortic contour)- shows true and
false lumen, and intimal calcification may be more specific but not seen that much.
Contrast enhanced CT: investigation of choice: intimal flap, double lumen, dilation of the aorta.
NOTE: true lumen is often compressed by false lumen so it is smaller. False lumen is larger due to
higher luminal pressures
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b)Aortic aneurysm:
- thoracic aortic aneurysm
-Abdominal aortic aneurysm- AAA (more common so will discuss this)
 AAA= dilations of the abdominal aorta greater than 3cm.
 Caused by weakening of the aortic wall due to atherosclerosis dilation of aorta which
progresses
Abdominal or lumbar spine radiographs: soft tissue mass with curviliniear calcification
US: optimal for screening and surveillance. 100% sensitivity and specificity
CT angiography: gold standard for evaluation, but patient exposed to high doses of radiation.
Accurately delineates the size and shape of AAA
2)peripheral vessel disease: clinical presentation= claudication

muscle pain and weakness at exercise and relieved by rest.
- physiological tests= Ankle-brachial index (ABI) at rest and after
exercise. This is combined with Doppler US to define patients that
need angiography. On Doppler US signs of arterial stenosis include
visible narrowing of the artery seen on 2D and colour images.
Aneurysm are also seen.
CTA and MRA are used for planning therapy in peripheral vessel
diseases.
Digestive system:
25. Imaging anatomy of esophagus and stomach

Esophagus: fibromuscular tube (25cm length) connecting
laryngopharynx to stomach. It is found anterior to the vertebral
colum and extends from approx C6 down and passes through the
esophageal hiatus of diaphragm at approx T10
Page | 33
- 3 parts: cervical, thoracic, abdominal
- Anatomical constrictions of esophagus:
1) Upper esophageal constriction= at the inlet of the esophagus
(strong circular muscular fibres which act physiologically with
cricophyrngeus muscle as one unite) narrowest part of
alimentary canal
2) Mid esophageal constriction= where the aortic arch crosses and
compressing the esophagus
Lower constriction= where the esophagus pierces the diaphragm
Barium swallow: used to evaluate pharyngeal motility during swallowing.

Barium is given orally with video recording of swallowing. It is the main
radiological method to assess the esophagus.
Double contrast- coating the esophagus with dense barium and
subsequently distending it with gas- for simultaneous examination of the
distended esophagus and its mucosal surface
There are several structures in close proximity to the esophagus that leave
an impression on the esophagus: double contrast below
1. Aortic arch
2. Left main bronchus
3. Left atrium
4. Hiatus diaphragm
We are looking for:

a) Structrural pathologies: diverticula, varices, perforation
b) Functional pathologies: achalasia (paralysis causing dilation)
c) Esophagitis
d) Rupture, fistulas,
e) Tumours
Endoscopic US: esophageal tumour

CT: cancer staging
Stomach: Cardia, fundus, body, antrum, pylorus. We can see mucosal folds on plain
radiograph but not on CT or MRI. Gastric bubble is visible in erect PA CXR or
abdominal X-ray.
Picture shows barium exam of the stomach.
Page | 34
Double contrast of the stomach:
26. Esophageal lesions- diverticula, stricture,

tumours, varices
Diverticula: sac/pouch projections arising from
esophagus
- True diverticula: include all esophageal
layers (traction)
- False diverticula: only mucosa and
submucosa ( pulsion) e.g. Zenker
diverticulum-pharyngeal pouch (posterior
outpouching of hypopharynx)
- Can be upper es. Diverticula e.g. zenker,
middle diverticula or lower diverticula e.g.
epiphrenic diverticula (pulsion type that
arises above LES)
Stricture: any persistent intrinsic narrowing of the esophagus.

Etiology:
Most common causes are fibrosis induced by inflammatory (esophagitis) or neoplastic processes
Upper and middle strictures- barrett esophagus, caustic ingestion (corrosive esophagitis)
Distal strictures- GERD
Treated with balloon dilation
Tumours: can be benign or malignant. Benign= leiomyoma (50% of benign tumours). Malignant are
more common than benign.
a) Benign:
- Mostly distal 1/3 of esophagus
- Symptoms= dysphagia, vomiting, weightloss
CXR- soft tissue mass in posterior mediastinum
- Contrast= round/ovoid filling defects, soft tissue mass
b) Malignant:
- Mostly SCC
Page | 35
- Etiology- smoking, alcohol, radiation,
achalasia.
- Symptoms appear late
- CXR= air-fluid level . Barium (picture)-
irregular stricture, pre-stricture dilation,
filling defect in middle portion of
esophagus.
- CT, transesophageal US and PET/CT used
to stage disease. CT best for distant
metastasis.
Varices:
Uphill varices- due to portal HT, dilated esophageal collateral vessels to SVC, longitudinal filling
defects in distal half of thoracic portion of esophagus
Downhill varices- due to SVC obstruction with

downward flow via dilated esophageal collateral
vessels to portal venous system and IVC.
Longitudinal filling defects in upper and middle part
of esophagus.
27. Imaging of the ulcer

Ulcer= open sore on an internal/external surface
Ulcers can appear anywhere in GIT most commmony in stomach or duodenum
Stomach ulcer etiology= overproduction of HCl
Duodenal ulcer etiology= H.pylori, NSAIDs, stress
Imaging- best detected with contrast barium
round/ovoid mucosal defect (‘crater’=
collection of barium), thin gastric folds radiate
toward crater. Hampton line= thin
radioluscent line seen at the neck of gastric
ulcer. Majority of gastric ulcers are on lesser
curvature and posterior stomach in body and
antrum.
Double contrast shows radiating folds (green

arrow) coursing the base of a persistent
Page | 36
collection of barium (crater- white) on the posterior wall of the stomach
28. carcinoma of the stomach. Staging. Postoperation imaging

‘Ca ventriculi’= stomach/gastric cancer= primary malignancy arising from gastric epithelium
- 3rd most common malignancy after colorectal and pancreatic cancer
- Mostly in antrum/pylorus
- 95% of cases it is adenocarinoma
- Etiology is associated with H.pylori
- RF= atrophic gastritis, pernicious anemia
staging:
0= abnormal cells in stomach lining- ‘early stage’
1a= grown no further than stomach lining, 1b= still in stomach lining
2= grows into muscle layer
3= muscle wall and muscle layer
4= metastasis
Alternatively we use the TNM staging (refer to lung cancer)
Post operative
Imaging
Imaging: endoscopy is the most sensitive and specific diagnostic method- direct visualization of
tumour location, extent of mucosal involvement and biopsy taken.
Barium contrast= can be an elevated or superficial lesion i.e. polypoid or ulceration. Filling defect,
disrubption of mucosal lines, local rigidity
CT= staging modality of choice- assess primary tumour, local spread, distant metastasis. Look for
focal wall thickening, ulceration, polycyclic tumour.
REFER TO OTHER DOCUMENT FOR PICTURES
29. imaging of bowels. Colon carcinoma.

Barium of small bowel- barium follow through is used to demonstrate gross small bowel pathology
e.g. mechanical obstruction or malrotation. The patient drinks barium or gastrografin and images are
obtained until the contrast material reaches an obstruction or enters the large bowel
Small bowel enema (enterocolysis)= passing a nasogastric tube into the stomach which is then
guided into the duodenum. A mixture of barium and water or methyl cellulose is injected into the
small bowel double contrast effect
Barium enema for large bowel= indications suspected large bowel pathology or when colonoscopy
or CT colonography is unavailable. Single contrast with Gastrografin is useful for bowel obstruction.
Page | 37
Colon carcinoma: 2nd leading cause of cancer.
TNM staging. Symptoms= large bowel
obstruction, GIT bleeding, weightloss, anemia.
Mostly develops from polyps. Barium enema:
lesions as filling defects, apple core sign. CT is
used for staging and assess nodes and
metastases. CT colonography used too.
Note in this picture of double contrast= focal

narrowing of sigmoid colon. Severe stenosis
showing apple core sign. Apple core sign is also
associated with Chron disease, ulcerative colitis
30. Imaging of the liver. Focal liver

lesions.
The liver is the largest abdominal organ. Made
up of lobules.
CT of abdomen: coronal,no contrast (left), coronal withcontrast (middle), saggital vew
Contrast enhancement phases of liver:

The liver receives dual blood supply. The hepatic
artery supplies 20% of hepatic blood flow while the
portal vein supplies the remaining. 3 phases of
contrast enhancement occur following IV injection
of contrast
1) Arterial phase= 25s after injection
2) Portal venous phase= after 70s, after blood
has circulated the mesentery,intestine and spleen
Page | 38
3) Equilibrium phase= minutes after injection and redistribution of contrast to extracellular
space
Other methods of investigation of liver- CEUS (contrast enhance US), CT, MRI
Focal liver lesions:

Types= typical lesion large mass, well circumscribed, poor encapsulation
Atypical lacks central scar and central artery
Imaging modalities used= US, CT with/wo contrast, MRI, angiography
Hepatic hemangiomas- benign neoplastic vascular liver lesions DDx with hepatocellular carcinoma
Most liver tumours receive blood from hepatic artery and most
tumours are also hypovascular i.e. they receive less blood supply
than surrounding liver therefore, most liver tumours including
metastasis will occur in portal venous phase due to liver
enhancement. If the liver tumour recerives more blood supply
than the surrounding liver(hypervascular) we will see it at the
arterial phase e.g. small Hepatocellular carcinoma
31. Imaging of the biliary tract. Biliary calculosis

Biliary tract (biliary tree/biliary system) organs and ducts that make and store bile. Used to digest
fat. Gall bladder (stores bile) & bile ducts & liver. When food is eaten, gall bladder contracts and
releases stored bile into the duodenum
Page | 39
Path which bile is secreted by the liver than transported into the duodenum: liver cells secrete bile,
bile flows from liver to left and right hepatic duct merge to form common hepatic duct exits liver
and joins with cystic duct from gall bladder together the hepatic duct and bile duct which form the
common bile duct, which joins with the pancreatic duct and passes the sphincter of oddi/ampulla of
vater into the duodenum
Imaging
of the
biliary
tract:
 Radiographs= shows pathologies in gall bladder- Gall stone (if well calcified), porcelain
gallbladder, cholecystitis
 Ultrasonography- bile stones/gall stones (echogenic foci- bright), cholecystitis, biliary
dilation, tumours
 Cholecystography (picture below)- overnight absorption of oral contrast agent. Contrast
agent can be given IV. Concentration of gall bladder depends on ingetion and absorption in
the stomach, uptake by liver, excretion in bile. Non-opacification of gallbladder signifies
either absence or pathology of gallbladder provided that the common bile duct is opacified
 CT cholangiography- IV infusion of agent with CT performed
Page | 40
 MRCP- magnetic resonance cholangiopnacreatograpy- T2 weighted sequences. Suitable for
jaundice because it is not reliant on contrast excretion, gall stones on gall bladder and bile
duct
 ERCP- endoscopic retrograde cholangiopancreatography- both biliary and pancreatic ducts
are studied. Visual assessment of duodenum and ampulla of vater. Endoscopic injection of
contrast medium into biliary ducts.
Cholangiogram (ERCP image)
 PTC: direct puncture of intrapheatic ducts using a fine needle to demonstrate biliary tree.
Biliary Calculosis: Gall stones aka cholelithiasis- concentrations occurring anywhere within the
biliary system, most commonly the gall bladder. Can be in bile ducts. Most common complaint is
right upper quadrant or epigastric pain. Can be cholesterol stones due to supersaturation of bile,
mixed, pigmented stones (supersaturation of unconjugated bilirubin)
Spine radiograph: shows 2 well-defined calcified opacities in RUQ
note on CXR- some gallstones (15-20% are radioopaque)- can be

laminated, Mercedes-Benz sign (radioopaque outline with lucent
centre)
Oral cholecystography of calculi below: stones= filling defect
Page | 41
US: gold standard to detect gallstones.
CT: pure cholesterol stones are hypoattenuting to bile, calcified stones are hyperattenuating. Some
are isodense to bile and not seen clearly
Hypoattenuating (black): hyperattenuating (white)-
numerous round densities within gallbladder on portal venous phase
of CT
32. Radiology of the ‘acute’ abdomen:

Acute abdomen is a condition of severe abdominal pain- usually needs surgery. Key diagnostic
points:
- Location of pain
- Fever
- History of surgery
- Signs that indicate intestinal obstruction e.g. abdominal distension, vomiting, altered
bowel habit
AXR (abdominal XR)- suspected bowel obstruction or perforation in GIT.
Ct, Us, contrast studies also used. US good for gallstones.
 Perforation of GIT: peptic ulcer, diverticulitis, appendicitis, injury. Perforation in stomach,
small intestine and colon produce free gas in peritoneal cavity. Erect CXR shows gas beneath
diaphragm.
 Small bowel obstruction (SBO)AXR: multiple short fluid levels, string of beads sign, little air
in large bowel. In CT: dilated loops of small bowel containing fluid levels and non dilated
large bowel.
- Strangulated Hernia: protrusion of intra-abdominal contents (peritoneal fat, bowel
loops). Mostly inguinal hernias.
- Gall stone ileus: small bowel obstruction secondary to gallstone impaction. Chronic
cholecystitis- large gallstone erodes inflamed gallbladder wall to enter duodenum and so
the gallstone is impacted in small bowel causing obstruction.
Page | 42
 Large bowel obstruction: colorectal carcinoma- apple core sign. AXR: supine shows dilated
loops of large bowel, haustra (thick white lines that are widely separated), erect shows fluid
levels
- Cecal volvulus: twisting and obstruction of cecum: dilation of cecum, haustra
- Sigmoid volvulus: twisting of sigmoid colon with obstruction and dilation. Shows
inverted ‘U’ appearance.
 Right upper quadrant pain: acute cholecystitis. US gallstones. CT.
 Right lower quadrant pain: appendicitis- US and CT
 Acute lower quadrant pain: diverticulitis
 Renal colic and acute flank pain: ureter obstruction due to renal stones.
 Acute pancreatitis severe acute epigastric pain. Ct imaging of choice- diffuse or focal
pancreatic swelling with indistinct margins .
33. Imaging of the urinary system. 34. Radiological anatomy of the urinary
system. Varieties and anomalies
The urinary system consists of kidney, ureter, bladder and urethra. It spans the abdomen and the
pelvis. Prime purpose is filtration of blood producing, transit, storage and disposal or urine.
 US: no radiation, quick and inexpensive, repeatable. Disadvantages- no physiological info,

operator dependent. Solid masses can be distinguished. CT also principal imaging
investigations for assessing urinary tract.
 AXR
 Intravenous urography (IVU) (below)- consists of a series of radiographs performed after IV
injection of iodinated contrast material to show kidneys, renal collecting systems, ureters
and bladder.
 CT-contrast enhanced and no contrast

 CT urography
 MR urography
Page | 43
 Excretory MR urography- use gadolinium and diuretics
 Renal angiography- for renal artery stenosis
Kidneys: bean shaped, bilateral, retroperitoneal. Located in posterior abdomen wall @T12-L3. Right
kidney lower than left due to displacement by right liver lobe. The long axis of the kidney is parallel
to the lateral border of the psoas muscle. The kidneys
lie at an oblique angle (superior renal pole is more
medial and anterior than inferior pole)
 Fibrous capsule. 2 layers:
a) Renal cortex- under capsule
b) Renal medulla- consists of pyramids
 Major and minor calyx form to unite the renal
pelvis
 Arterial supply- renal arteries (from abdominal
aorta)
 Venous drainage- renal veins (to IVC)
Radiographic features: AXR- refer to other document;
kidney should not be less than 3 vertebral body in
lengths and no more than 4 vertebral body in lengths. CT- on unenhanced the renal pyramids appear
hyperdense. US- cortex is less echogenic than liver, medulla is more echogenic than cortex, pyramids
not usually seen, normal ureters not
well seen.
Anomalies:
 horseshoe kidney- renal fusion
anomaly, congenital, patients
kidney fuse together to form a
horse-shoe shape during
development in the womb
On the right is an IVU- both kidneys
are rotated, both lower poles are
directed medially towards spine
 Aberrant papilla (link

hydronephrosis): shows a filling defect (arrow)
Page | 44
 Compression of the renal hila: shows a
filling defect
 Fetal lobulation: variant seen occasionally in adult kidneys incomplete fusion of the
developing renal lobules (embryologcially- kidneys originate as distinct lobules that fuse
together as they develop and grow)- picture shows coronal CT in soft tissue phase
 Column of Bertin: extension of renal cortical tissue (hypertrophy) which separates the
pyramids. Normal structures. When they are unusually enlarged they can be mistaken for a
renal mass. Picture of C+ arterial phase
Page | 45
Ureter: paired fibromuscular tube transports urine from kidneys to bladder in pelvis. Has 3 parts:
1) Abdominal ureter (from renal pelvis)
2) Pelvic ureter (to bladder)
3) Intravesical ureter (in bladder)
 The ureter runs along the medial aspect of the psoas muscle
 Constrictions- most common sites of renal calculus obstruction;
- At the pelviureteric junction (PUJ) of renal pelvis and ureter
- As ureter enters pelvis and crosses over the common iliac artery bifurcation
- Vesicoureteric junction (VUJ) as the ureter enters bladder wall
Anomalies:
 Stenosis of pyelourethral junction (pelviuriteric junction)- causes dilation of renal pelvis and
is mainly congenital
Page | 46
Urinary bladder: extraperitoneal located in true pelvis. Reservoir for urine. As the bladder fills with
urine it extends superiorly into the abdominal cavity
Urethra: terminal segment of urinary system. Females= shorter- 4cm. Males have longer more
complicated course- 18-20cm length
35. Renal calculosis. Hydronephrosis

Renal calculosis: AKA kidney stones/renal stones/ urolithiasis /nephrolithiasis. From when solutes in
urine priciptates out and crystallise.
Etiology= metabolic, gout, UTI, hereditary, idiopathic
Most commonly calcium oxalate stones which are radiopaque on XR (white spot). Struvite stones
and calcium phosphate stones are also radiopaque. Uric acid stones and cystine stones are
radiolucent (transparent on XR)
Symptoms: flank pain, renal colic. Pain subsides when stone gets into bladder. Stones <5mm passed
within hours.
‘Transparent’ calculus: note the filling defect on the
right kidney in IVU. Sometimes there can be
pelvicalyceal dilation caused by renal stone.
Radiopaque Calculi in right kidney on plain film :
Page | 47
Staghorn calculus- stone form a cast of the renal pelvis and calyces, resembling the horn of a stag
Axial non contrast CT- showing bilateral nonobstructing

kidney sontes
Hydronephrosis: swelling of the kidney due to a build up of urine. Urine cannot drain out of kidney
to bladder due to blockage or obstruction (nephrolithiasis, UPJ obstruction) . We get dilation of the
calyces, pelvis and/or ureters. (hydronephrosis of newborn on the right). All the following are IVU.
Page | 48
notice the large, round white
area to the right of the lumbar
vertebrae= pelvis (large medial
collection of contrast). Calyces
are the smaller lateral white to
light grey circles. They’re dilated
due to obstruction of PUJ. The
ureter is never seen.
36. Renal cell carcinoma. Transition cell carcinoma. Staging

RCC- primary malignant adenocarcinoma derived from the renal tubular epithelium. Most common malignant
renal tumour/solid lesion in kidney. Symptoms are a triad of: macroscopic hematuria, flank pain and palpable
flank mass. CT is used frequently to diagnose and stage the cancer.
Stages:
I- Within the capsule
II- In perirenal fat
III- A- in renal vein B- lymph nodes
IIIC- A & B
IVA- neighbouring organs
IVB- distant metastasis
Most metastasis is in the lungs, lymph nodes, liver and bone. Rarely it metastasises to the brain heart and
spleen.
CT:
- Non enhanced CT- soft tissue mass deforms the contour of the kidney. Can be iso,hypo or
hyperdense. Calcification may be present.
Page | 49
- Contrast enhanced CT in corticomedullary phase shows a hypoattenuating mass (more dark)- solid
and evidence of necrosis
In general, small lesions enhance homogenously, and larger lesions have irregular enhancement due to areas of
necrosis.
MRI: after administration of gadolinium, MRI will enhance the mass indicative of malignancy
- T1= often heterogenous due to necrosis, hemorrhage
- T2= appearance depends on histology. If clear cell RCC= hyperintense, if papillary RCC= hypointense
Transitional cell carcinoma: also known as urothelial carcinoma. Occurs in urinary system (pelvis, ureter,
bladder, urethra). TNM staging (refer to lung TNM staging). Hypo or heterodense. Central infiltration. Usually
avascular. IVU – filling defect if in urethra, and dilated ureter above and below site of obstruction (goblet sign)
The next questions i’ve skimmed. Imaging is in other main document!!
37. Imaging in obstetrics and gynaecology:

US- most common imaging technique, examine stages in pregnancy, assess pacental position and
fetal morphology. Can be transabdominal or transvaginal US (TVUS). TVUS – vaginal probe, better
anatomical detail of uterus and ovaries.
MRI- for suspected endometriosis, giagnose uterine pathology and malignancies.
38. Musculo-skeletal imaging

Radiographs- for fractures and dislocations. Paget’s disease. Bone tumours and focal bone lesions
and CT or MRI used to stage and assess compications. Insensitive to early bony changes in conditions
e.g. osteomyelitis, stress fractures.
CT- multidetector CT for further delineation of complex fractures, and diagnose complication of
fractures such as non-union. Assist staging in bone tumours e.g. cortical destruction
MSUS (musculoskeletal US)- assess soft tissues of musculoskeletal systems i.e. tendons,ligaments,
muscle- muscle and tendon tears, soft tissue masses, soft tissue foreign bodies (thorns, wood
splinters, glass). Cannot visualise bone pathology however and most internal joint derangements.
MRI- visualise all different tissues of the musculoskeletal system including cortical and medullary
bone, hyaline, fibrocartilage, tendon, ligament and muscle. Lots of applications- internal
derangements of joints, staging of bone and soft tissue tumours,diagnose early or subtle bone
changes e.g. osteomyelitis, stress fracture and trauma
39. Radiology of main bone pathology processi

Osteoporosis- bone mineral density decreased. Senile or post menopausal (primary), thyroid
dysfunction, nutritional deficiencies (secondary). On imaging we see demineralization. XR- shows
luscent areas (‘glass like bone’)
Osteosclerosis- abnormal hardening of bone and increased bone density. XR- regions of increased
opacity, look for narrowing.
Page | 50
Osteonecrosis- aka avascular necrosis: due to reduced blood flow to bones in joints causing bones to
break down faster than body can make anough bone. XR- microfractures, decreased mineral density,
crescent sign seen in proximal femoral head. MRI most sensitive- double line sign: outer=dark,
inner= bright. Rim sign: osteochondral fragmentation
Osteolysis- pathological destruction of bone, XR will show areas abnormal lucency
40. Traumatic bone and joint lesions- fractures, fissures, luxations.

Fractures: continuity of bone is broken. Due to trauma (direct violence, torsion, compression) or
intrinsic (pathological fractures)
Types=
 Complete fractures= transverse full thickness of bone – transverse, oblique or spiral
 Incomplete fractures- fissures = usually children (have softer, more malleable bones);
- Buckle fracture= bend in bony cortex without actual cortical break
- Greenstick fracture
- Bowling fracture
Luxations: joint dislocation.
41. Osteomyelitis- acute, chronic, atypical forms. Osteo-articular tbc.

Osteomyelitis: inflammation of bone. Mostly
due to bacterial infection by hematogenous
spread. S.aureus, E.coli, H.influenzae.
Locations: lower limb most common, vertebrae
(L>thoracic>cervical)
Usually acute in children and either acute or
chronic in adults.
Hallmark characteristics= destruction of bone
and periosteal new bone formation
Osteoarticular TBC- chronic inflammatory joint

disease due to M.tb. Most common location is
spine followed by hip joint. Mode of spread is
hematogenous or by direct extension of a
neighbouring focus in the lungs or lymph nodes.
Radiographs show soft-tissue swelling with
progressive osteopenia, periosteal thickening
and periarticular bony and cartilaginous
destruction. CT same as radiograph but more
sensitive to ID soft-tissue abscess.
Page | 51
42. Benign bone producing tumours: osteoma, osteoid-osteoma, osteoblastoma
Osteoma- benign mature bony growth, seen almost exclusively in bones formed in the membrane
e.g. skull . types:
- Ivory
- Mature
- Mixed
Osteoid-ostemoa- benign bone forming tumours typically in adolescence. Mostly occur in long
tubular bones of limbs (especially neck of femur). Nidus= meshwork of dilated vessels, osteoblasts
and ostoid, may have a central region of mineralizatoin. Surrounding reactive sclerosis. CT is
modality of choice and shows a focally lucent nidus within surrounding reactive bone.
Osteoblastoma- very rare. Similar to osteoma. Usually occurs in spinal column. Lytic lesions seen
with a rim of reactive sclerosis.
43. Benign bone producing tumours: chondromas, osteochondromas,

hemangiomas, ostoclastomas
Chondromas= medullary cartilaginous neoplasm (benign cartilaginous tumour) Seen in any bone
formed from cartilage- Tubular bones of hands and feet, large tubular bone e.g. femur, tibia,
humerus. Lesions are translucent, nodular and gross. Enchondroma- tumour grows withing the bone
and expands it, ecchondroma- grows outward from the bone
Osteochondroma: overgrowth of cartilage and bone that happens at the end of the bone near the
growth plate. Most often in long bones in the leg, the pelvis or shoulder blade. XR will show the bony
outward growth. CT or MRI further defines the tumour.
Hemangioma of bone: vascular lesion occurring in vertebral column and skull. Plain XR; hallmark=
prominent trabecular pattern
Ostoclastomas: bone tumour characterized by massive destruction of epiphysis of long bone. Knee,
distal radius, sacrum and vertebral bodies affected.
44. Malignant bone producing tumours- Osteosarcoma

Osteosarcoma is the most common primary bone tumour. Most common found in bones of leg and
sometimes the arms (but it can start in any bone). Plain radiography shows medullary and cortical
bone destruction. CT for staging and biopsy. MRI for direct assessment of tumour.
45. Malignant bone producing tumours- Ewing sarcoma, myeloma,

chondrosarcoma.
Ewing sarcoma- second most common highly malignant primary bone tumour after osteocarcoma.
Typically arises from medullary cavity with invasion of haversian system. Usually presents as moth-
eaten destructive lucent lesion in the shaft of long bones (femur most common) with large soft
tissue component without osteoid and typical onion skin periostitis, sclerosis may be found.
Page | 52
Myeloma: (multiple myeloma)- common malignancy of plasma cells characterized by diffuse bone
marrow infiltration or multiple nodules in bone. Occurs in elderly. Radiography is method of choice
in detection and staging. Alternatively whole body MRI may be sued. Common site of involvement
are spine, ribs, skull, pelvis and long bones. Several radiographic features may be seen:
- Generalized severe osteoporosis
- Multiple lytic, punched-out defects
- Multiple destructive and expansile lesions
Chondrosarcoma- tumours grows as multiple hyaline cartilage nodules and peripheral endochondral
ossification. Rings and arcs calcification and popcorn calcification on CT and plain film. Long bones
mainly affected (femur) followed by pelvis. Skull is uncommon.
46. Degenerative and inflammatory diseases of joint and spine

Degenerative- osteoarthritis:
 Primary osteoarthritis (OA)= degenerative arthropathy with no apparent
underlying/predisposing cause
-Asymmetric process involving the large weight-bearing joints, hips and kness, lumbar and
cervical spine, distal interpharangeal, first carpometacarpal and lateral carpal joints.
 Secondary OA=due to RA (below), trauma, or paget’s disease
OA causes loss of articular cartilage joint space narrowing and abnormal stresses on joint
margins formation of bony spurs (osteophytes) at joint margins
Radiographic changes:
- Joint space narrowing
- Osteophytes
- Sclerosis of joint surfaces
- Periarticular cyst formation
- Loose bodies in joints due to detached osteophytes and ossified cartilage debris
Inflammatory= RA- present with painful joints and asosicated soft tissue welling.
RA (rheumatoid arthritis)= inflammation of the synovium joint swelling and formation of a
synovial inflammatory mass (pannus). Pannus may cause bone erosions and lead to joint deformity.
 Usually symmetrical
 Affects small joints metacarpophalangeal, metatarsophalangeal, carpal, and proximal
interphalangeal joints. Rare spinal involvement.
Radiographic signs:
- Soft tissue swelling overlying joints
- Bone erosions occur in feet and hands
- Reduced bone density adjacent to joints (periarticular osteoporosis)
- Abnormal joint alignment with subluxation of metacarpophalangeal joints causing ulnar
deviation of fingers, and subluxation of metatarsophalangeal joints causing lateral
deviation of toes.
Seronegative spondyloarthropathy: (SpA)- asymmetrical arthropaties. Usually in spine and sacroiliac
joints. Ankylosing sponylitis is an example of SpA- XR=
 Vertically orientated bony spurs arising from vertebral bodies
 Fusion (ankylosing) of spine giving ‘bamboo spine’ appearance
Page | 53
 Erosions and irregular joint margins of sacroiliac joints
 Sclerosis and fusion of sacroiliac joints
47. Avascular necrosis- Morbus perthes

Morbus perthes (AKA Perthes disease)- idiopathic osteonecrosis of the femoral epiphysis seen in
children. (other causes of osteonecrosis= sickle cell disease, leukemia, Gaucher disease)
Traumatic hip pain or limp occurs. Abnormal or damaged blood supply to the femoral epiphysis
leads to fragmentation, bone loss and eventual structural collapse of the femoral head.
Diagnose with pelvic radiograph-

 early signs= joint effusion (widening of medial joint space), smaller epiphyseal femoral size
on affected side, increased density of femoral head epiphysis, radiolucency of proximal
metaphysic.
 Late= fragmentation and destruction of femoral head. The width of femoral neck increases
(coxa magna) in order to increase weight-bearing support.
MRI for early diagnosis and prognosis.
48. Imaging methods of the CNS

CT and MRI most common imaging modalities for brain. MRI preferred except for acute trauma and suspected
acute subarachnoid hemorrhage. Skull XR occasionally performed. Cranial US for diagnosis of cerebral
hemorrhage in
premature infants.
Page | 54
MRA: magnetic resonance angiograph
49. Brain tumours

Symptoms caused by brain tumours are variable:
 Increased intracranial pressure caused by tumour itself or hydrocephalus- headache, nausea,
vomiting
 Hemorrage into the tumour- sudden severe headache, stroke, seizure
 Focal neurological disturbance
 Cranial nerve palsy
WHO classificaiotn of tumours (I-IV= increasing malignancy and aggressiveness.
In adults, metastases from non CNS primary tumours account for 50% of brain tumours. Primary
brain tumours in adults gliomas, meningioma, pituitary adenoma. Most common brain tumour in
children is astrocytoma
Page | 55
2 most common imaging modalities are MRI and CT. MRI, including gadolinium enhancement=
investigation of choice. MRI= more detailed anatomical info and soft tissue characterization. CT used
when MRI is unavailable.
Page | 56
50. Imaging of ischemic stroke:
‘stroke’= acute event leading to focal neurological deficit that lasts for more than 24h. Ischemic
stroke= decreased blood flow to brain (due to cerebral ischemic and infarction). Most acute ischemic
strokes are due to acute thromboembolic occlusion of cerebral arteries causes central region of
infracted brain tissue with a surrounding zone of
hypoxic tissue.
CT- investigation of choice. CT of acute ischemic stroke

in picture- mild cerebral swelling and mass effect,
decreased attenuation of affected brain tissue,
increased density of cerebral arteries due to
thrombosis. From 12-24h and within 3 days=
increased edema and more obvious flattening of
cerebral gyri and mass effect.
JUST REMEMBER- any infarction of brain on CT will
show low attenuation (appear darker)
NOTE: another type of stroke is

hemorrhagic stroke- can be
subarachnoid hemorrhage,
hemorrhagic (on the right) or
parenchymal ( on the left-AKA
primary intracerebral- due to
hypertension, common site= basal
ganglia, brain stem, cerebellum and
deep white matter of cerebral
hemispheres). CT is sensitive to this
too.
MRI- with diffusion weighted image (DWI) and perfusion weighted

image (PWI) is an alternative.DWI is sensitive to diffusion of water
molecules within tissue. Areas of reduced water molecule diffusion
show on DWI as high signal: ischemia and cell death in brain causes
increased intracellular water with restricted diffusion infarction
on DWI shows an area of high signal (all white looking)
PWI= brain is rapidly scanned after following injection of a bolus of
contrast (gadolinium).
Page | 57
51. Imaging of subarachnoid hemorrhage (SAH)
Blood in the subarachnoid space. Sudden onset of severe headache accompanied by neck pain and
stiffness, diminished consciousness. Sponteanous SAH due to ruptured cerebral artery aneurysm
(can also be due to tumour). CT is modality of choice if (+) for SAH CTA (CT angiography) to
diagnose and define cause. Hydrocephalus is a common complication of SAH (due to obstruction of
CSF pathways with blood)
Non contrast CT- confirm diagnosis, suggest possible site of bleeding/cause, diagnose complications.
SAH is seen as high-attenuation material (fresh blood)

on contrast CT.
CT angiography- catheterization of carotid and vertebral arteries= gold standard to diagnose

cerebral aneurysm in the setting of SAH. CT angiography and MRA can be sued to image cerebral
vessels.
52. Imaging of the spinal cord

 Spinal cord is found within the spinal canal of the vertebral column.
 It is contained by the thecal sac, a continuation of the intracranial dura matter and extends
via the foramen magnum of the skull down to the tip of the conus medullaris.
 42-45cm in length.
 It is composed of grey and white matter like the brain, however, opposite to the brain, the
internal aspect is grey mater and white matter is external.
 Divided into cervical, thoracic and lumbar parts and terminates at conus medullaris at
approx L1 in adults.
 31 nerve roots emerge from it
 Transverse section shows peripheral mass of white matter surrounding the grey matter (H
shaped)
Page | 58
 https://radiopaedia.org/articles/spinal-cord#image_list_item_19313461- for images
 Normal saggital T1 and T2 MRI of spinal cord:
MRI is investigation of choice for spinal

cord injury- cord transection, cord edema,
hemorrhage, arachnoid cyst,
pseudomeningocele, disc herniation,
ligament tear, spinal canal hematoma. MRI
has better soft tissue contrast resolution
than CT, nerve roots and distal cord and
conus can be imaged without any contrast,
outline of anatomy of spinal canal and
intervertebral discs. It is also higly sensitive
for detection of spinal canal stenosis, disc
herniation and narrowing of intervertebral
foramina.
Page | 59
53. imaging of the breast. Carcinoma of the breast. Mastopathia
Imaging of the breasts:
Mammography=
 radiographic examination of the breast.
 Old mammography used XR film developed in a processor or dark room. 7Newer
technique= digital mammography (DM)- digital radiographic image and can use CAD.
 Indications= breast lump, nipple discharge, or search for a primary breast tumour if
metastasis found elsewhere.
 Standard mammography exam- carnicaudad view (top to bottom) and mediolateral oblique.
 Abnormalities seen= soft tissue masses, asymmetric densities,calcification, distorted breat
architecture and skin thickening
US=
 First investigation of choice for palpable breast lump
 Can be complementary to mammography to differentiate cysts from solid masses.
 Differentiate benign and malignant lesions
MRI=
 Staging of breast cancer using breast coils and IV gadolinium- malignant neovascularity with
‘leaky’ capillaries allows intense rapid enhancement with gadolinium.
Note: breast biopsy usually performed by imaging guidance with mammography or US.
Carcinoma of the breast:

Most common malignancy in women. Women at higher risk are 1st degree relative diagnosed with
breast or ovarian cancer, mutation of BRCA1/BRCA2 genes.
Classification:
Page | 60
 Ductal- ductal carcinoma in situ (DCIS), invasive ductal carcinoma (most common),
medullary
 Lobular- lobular carcinoma in situ (LCIS), invasive lobular carcinoma
 Inflammatory carcinoma- inflamed appearance of skin
Clinically- palpable breast mass
Mastopathia: fibrocystic change of the breast. Benign alteration in terminal ductal lobular
unit of the breast. Breast pain, tender nodular swelling, multifocal and bilateral. Mammography
shows heterogenous and dense parenchyma with circumscribed masses. Low density round
calcification in multiple lobes.
54. Ofaciall-maxillary imaging

Ie. Maxillofacial imaging(- aka dental and maxillofacial radiology- speciality in dentistry). Cone beam
CT, multislice CT, MRI, PET, US- diagnose and treat diseases and conditions of the mouth, jaws, face
and neck.
55. Radiation protection of staff and patient:

 Radiography, scintigraphy and Ct use ionizing radiation.
 In large doses ionizing radiation is harmful increased risk of developing cancer
 Radiation effects occur as a result of damage to cells, including cell death and genetic
damage
 Actively dividing cells (bone marrow, lymph glands gonads) are sensitive to radiation effects
 Deterministic effectscell death radiation burn, cataracts and decreased fertility. Varies
with dose
 Stochastic effects
Page | 61
 Effective dose is expressed as sievert and provides us to calculate the overall risk of radiation
effects
 ALARA principle= the basic rule of radiation protection is that all justifiable radiation
exposure is kept as low as reasonably achievable (ALARA principle). Achieved by doing the
following:
- Minimum number of radiographs is taken and minimum fluoroscopic screening time is
used
- Mobile equipment is only used when the pt. Cannot come to radiology dept.
- US or MRI avoided where possible
- Children are more sensitive to radiation than adults and greater risk of developing
radiation-induced cancers many decades after initial exposure
- In paediatric radiology, extra measures are taken to minimize radiation dose e.g. gonad
shields and adjust CT scanning parameters
- In pregnancy- radiation exposure of abdomen and pelvis minimized, all females of
reproductive age asked if they could be preggers prior to radiation exposure. During
organogenesis (happens soon after 1st missed period), the fetus is maximally
radiosensitive,therefore, radiographic or CT should be dilated post 24 weeks gestation or
ideally until baby is born.
Patient needs to be as far away as possible from source of radiation, staff wear lead aprons to
distribute weight, thyroid protection, lead glass eyewear, lateral shields and table curtains.
Page | 62

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Contents

Diagnostic imaging .................................................................................................................................. 3

1. Nature and properties of the radiologic image

2. Digital imaging. PACS

3. Computed tomography- principles. Current developments

Multidetector row CT:

4. Ultrasound- principles. Main applications

5. Magnetic resonance imaging (MRI). Principles. Notion of sequences.

6. Contrast media- classification. Advantages and limitations

 The most common contrast materials are based on barium or iodine.

Limitations of contrast media:

7. Invasive and interventional radiology

Refer to other document for a systematic review of CXR

9. Imaging of airway diseases:

 Enlarged central pulmonary artery (fleischner sign)

V/Q scan: indicated in

- Radiographic image is generally the same regardless of the

Causes: Cardiac failure, malignancy, infection e.g. TB,

On CXR- usually seen well on inspiratory PA film

on CXR we can identify:

Post primary: is known as ‘reactivation TB’ or secondary TB- it

14. Pulmonary carcinoma. Imaging and staging

TNM system is used for staging:

15. Benign lung tumours. Echinoccocus

Multiple well defined

16. Occupational lung diseases- Silicosis

 Development of diffuse interstitial fibrosis secondary to asbestos inhalation

 CT- early manifestations confined to periphery and

Bilateral perihilar large focal opacities

17. Imaging in diaphragmatic lesions

Malignant tumours are sarcomas of fibrous or muscular origin.

Bronchogenic carcinoma, mesothelioma nad other primary or

18. Imaging of the mediastinum. Mediastinal

Mediastinal tumours: i.e. mediastinal masses

Middle mediastinal mass:

21.Imaging of the acquired valve diseases

Ascending aorta(yellow) leading to arch is dilated.(prominent right mediastinal border occupied by

22. Myocardial diseases:

23. Pericardial affections

Pericardial fluid (yellow) outlined by epicardial fat (blue

24. Aortic diseases. Peripheral vessel diseases

2)peripheral vessel disease: clinical presentation= claudication

25. Imaging anatomy of esophagus and stomach

Barium swallow: used to evaluate pharyngeal motility during swallowing.

We are looking for:

Endoscopic US: esophageal tumour

26. Esophageal lesions- diverticula, stricture,

Stricture: any persistent intrinsic narrowing of the esophagus.

Downhill varices- due to SVC obstruction with

27. Imaging of the ulcer

Double contrast shows radiating folds (green

28. carcinoma of the stomach. Staging. Postoperation imaging

29. imaging of bowels. Colon carcinoma.

Note in this picture of double contrast= focal

30. Imaging of the liver. Focal liver

Contrast enhancement phases of liver:

Focal liver lesions:

31. Imaging of the biliary tract. Biliary calculosis

 CT cholangiography- IV infusion of agent with CT performed

Spine radiograph: shows 2 well-defined calcified opacities in RUQ

note on CXR- some gallstones (15-20% are radioopaque)- can be

Oral cholecystography of calculi below: stones= filling defect