A Global TextBook of Radiology I

The NICER C e n ten n ia l
B ook 1995
A Global
TextBook of
Radiology
T he N ICER C entennial
B ook 1995
A Global
TextBook of
Radiology
Edited by
H olger Pettersson, M D
Professor o f R adiology
University H ospital
Lund, Sw eden
E ducational and Scientific D irector
The NICER Institute
I
Techniques
CNS
Musculoskeletal system
Pediatrics
Breast
S e r i e s on D i a g n o s t i c I m a g i n g
From
T he NICER Institute
The NICER program and the NICER books
The NICER program is a activities to all former course participants and
unique approach to continu all other subscribers to the Bulletin.
ing education in diagnostic The NICER Books embrace a wide spec
imaging, and consists of a trum o f radiological knowledge ranging from
global program provided by the basic to state-of-the-art. The first book se
NICER some o f the world’s leading
authorities. Its goal is the
ries, published in 1991- 1992 comprised five
volumes, o f 300 - 600 pages per volume. Each
provision of high-quality education, dissoci multi-author volume covered one or two organ
ated from any commercial interests or influ areas, different aspects of the subject matter
ences, to radiologists throughout the world. being written by leading radiologists and
The teaching program is run by: edited by world authorities.
the N ICER Institute Since 1994 NICER publishes a new series
which is an educational foundation based on a on diagnostic imaging called The NICER
collaboration between Yearbook Series. Each year we will publish
the Departm ent of Radiology, University of one volume devoted to a particular radiologi
Lund, Sweden cal topic, but presented in a manner that will
and be informative and interesting to both the gen
the Nycomed Imaging A/S, Oslo, Norway eral radiologist and the specialist.
Till now (1995) more than 5000 course par
The NICER program consists of three parts:
ticipants have attended the courses around the
The NICER Courses
world, and more than 50 000 NICER books
The NICER Case Bulletin
have been distributed.
The NICER Book Series
To celebrate the first century o f diagnostic
The NICER Courses comprise a series of 2-4 imaging, the NICER Yearbook 1995 is called
courses, given in different regions o f the world, “centennial”.It embraces radiology as a whole,
each series running over a period o f 2 - 4 years. and will be published in English, with transla
The courses in a complete series cover the tions to Chinese, Russian and Spanish: A
whole field of diagnostic imaging, each course Global Textbook of Radiology.
dealing with one or two organ systems. The NICER Institute welcomes you, the
The NICER Case Bulletin is published readers. We hope you will enjoy the reading
twice a year, presenting one or two interesting and we look forward to see you at future
cases and providing information about NICER courses.
University of Lund Sab NYCOMED

Sweden IMAGING
The NICER Institute

All rights reserved. No part of this publication may be reporduced, stored
in a retrieval system or transmitted in any form or by any means,
electronic, mechanical, photocopying, recording or otherwise,
whitout the prior permission of the copyright owner.
ISBN 82-990882-3-2
Published by: The NICER Institute, Oslo • Graphic design: Mons R0nning
Printed by: Casper Evensens Trykkeri A/S, Norway
Reprinted papers are available from The NICER Institute

Po.Box 4462, Torshov, N-0401 Oslo, Norway
Editorial Board
Sudarshan K. Aggarwal, India

David J. Allison, United Kingdom
Jose Luis Ramirez Arias, Mexico
Albert L. Baert, Belgium
Xing-Rong Chen, China
Mahmoud R. Elmeligi, Egypt
Philippe Grenier, France
Derek Harwood-Nash, Canada
Charles B. Higgins, USA
Takahiro Kozuka, Japan
Javier Lafuente Martinez, Spain
Peter Peters, Germany
Howard Pollack, USA
Donald Resnick, USA
Leonid S. Rosenstrauch, Russia
Michael Sage, Australia
This book is partly based on a Scandinavian Textbook of Radiology

(Nordisk Larobok i Radiologi, Studentlitteratur, Lund, Sweden, 1993),
and the publisher’s permission to use material from this book is highly
appreciated.
Editors of the Scandinavian Textbook:

Holger Pettersson, Sweden
Niels Egund, Denmark
Baldur Sigfusson, Iceland
Amulf Skjennald, Norway
Carl-Gustaf Standertskjold-Nordenstam, Finland
Contents
VOLUME I
Chapter 1 W.C. Roentgen and the discovery of X-rays.............. 1

Peter Peters, Germany
Chapter 2 Radiology in an international perspective................ 13
Carl-Gustaf Standertskjold- Nordenstam, Finland
Chapter 3 Radiophysics................................................................ 17
Aaro Kiuru, Finland
Chapter 4 Modalities and methods................................................ 47
Hans-Jorgen Smith, Norway
Chapter 5 Radiology worldwide - the WHO approach.............. 85
Philip E.S. Palmer, USA
Thure Holm, Sweden
Gerald P. Hanson, Switzerland
Chapter 6 Digital imaging............................................................. 101
Tatsuo Kumazaki, Japan
Hans Ringertz, Sweden
Chapter 7 Contrast media in diagnostic radiology.................... 115
Torsten Almen, Sweden
Peter Aspelin, Sweden
Chapter 8 Interventional radiology.............................................. 143
Christoph Zollikofer, Switzerland
Chapter 9 The brain....................................................................... 167
Kjell Bergstrom, Sweden
Giuseppe Scotti, Italy
VII
Chapter 10 The head and neck...................................................... 229
Sven-Goran Larsson, Saudi Arabia
Anthony Mancuso, USA
Chapter 11 Dental radiology......................................................... 263
Lars Hollender, USA
Karl-Ake Omnell, USA
Chapter 12 The spine..................................................................... 297

Stig Holtas, Sweden
Maximilian F. Reiser, Germany
Axel Stabler, Germany
Chapter 13 Musculoskeletal radiology....................................... 371
Niels Egund, Denmark
Kjell Jonsson, Sweden
Holger Pettersson, Sweden
Donald Resnick, USA
Chapter 14 Pediatric musculoskeletal radiology...................... 459
Andrew K. Poznanski, USA
Chapter 15 Pediatric radiology.................................................. 533
Donald R. Kirks, USA
Sven Laurin, Sweden
Chapter 16 Pediatric neuroradiology.......................................... 611
O lof Flodmark, Sweden
Derek Harwood-Nash, Canada
Chapter 17 Breast imaging........................................................... 627
Ingvar Andersson, Sweden
Baldur F. Sigfusson, Iceland
Index .....................................................................................XVII
VOLUME II
Chapter 18 The lungs and mediastinum...................................... 669

A lf Kolbenstvedt, Norway
Arnulf Skjennald, Norway
Chapter 19 The heart.................................................................... 773
Arnulf Skjennald, Norway
VIII
Chapter 20 The peripheral vessels............................................... 809
Christoph Zollikofer, Switzerland
Frode Laerum, Norway
Chapter 21 The lymphatic system.............................................. 871
Elias Zerhouni, USA
Chapter 22 The gastrointestinal tract......................................... 891
Richard M. Mendelson, Australia
Chapter 23 The liver, biliary tract, pancreas and spleen........... 1027
Carl-Gustaf Standertskjold-Nordenstam, Finland
Chapter 24 The acute abdomen................................................... 1079
Olle Ekberg, Sweden
Frans-Thomas Fork, Sweden
Chapter 25 The genitourinary system......................................... 1111
Henrik Thomsen, Denmark
Howard Pollack, USA
Chapter 26 Obstetric imaging...................................................... 1217
Con Metreweli, Hong Kong
Chapter 27 Tropical diseases....................................................... 1237
Philip E.S. Palmer, USA
Stanley P. Bohrer, USA
Carlos Bruguera, Argentina
Xing-Rong Chen, China
Mahmoud R. Elmeligi, Egypt
Hassen A. Gharbi, Tunisia
S.B. Lagundoye, Nigeria
M. W. Wachira, Kenya
Chapter 28 Radiology in AIDS.................................................... 1309
Marie-France Beilin, France
Philippe Grenier, France
Nadine Martin-Duverneuil, France
Index ..................................................................................... XV
IX
List of Authors
David J. Allison, BSc, MD, Marie-France Beilin, MD

MRCP, FRCR Department of Radiology
Department of Diagnostic Groups Hospitalier,
Radiology Pitie-Salpetriere,
Royal Postgraduate Medical Paris, France
School,
Hammersmith Hospital, Kjell Bergstrom, MD
London, UK Department of Radiology
Academic Hospital,
Torsten Almen, MD University of Uppsala,
Department of Radiology Uppsala, Sweden
Malmo General Hospital,
University of Lund, Stanley P. Bohrer, MD
Malmo, Sweden Department of Radiology
Bowman Gray School of
Ingvar Andersson, MD Medicine of Wake Forest
Department of Radiology University,
Malmo General Hospital, Winston-Salem, NC, USA
University of Lund,
Malmo, Sweden Carlos Bruguera, MD
Marina del Sol,
Peter Aspelin, MD Victoria S. Fernando, Argentina
Department of Radiology
Huddinge Hospital, Xing-Rong Chen, MD
Karolinska Institute, Department of Radiology
Stockholm, Sweden Hua Shan Hospital,
Shanghai Medical University,
Shanghai,China
X
Niels Egund, MD Gerald Hanson, PhD.
Department of Radiology Radiation Medicine
Odense University Hospital, World Health Organization,
Odense, Denmark Geneva, Switzerland
Olle Ekberg, MD Derek Harwood-Nash, MB,

Department of Radiology ChB, FRCP(C)
Malmo General Hospital, Department of Radiology
University of Lund, The Hospital for Sick Children,
Malmo, Sweden University of Toronto,
Toronto, Ontario, Canada
Mahmoud R. Elmeligi, MD
Department of Radiology Charles B. Higgins, MD
University of Cairo, Department of Radiology
Cairo, Egypt UCSF Medical Center,
San Francisco, CA, USA
Olof Flodmark, MD
Department of Radiology Lars Hollender, Odont dr
Karolinska Hospital, Department of Oral Medicine
Stockholm, Sweden University of Washington,
Seattle, WA, USA
Frans-Thomas Fork, MD
Department of Radiology Thure Holm, MD
Malmo General Hospital, Department of Radiology
University of Lund, University Hospital,
Malmo, Sweden Lund, Sweden
Hassen A. Gharbi, MD Stig Holtas, MD

Department of Radiology, Department of Radiology
Clinique Saint Augustin, University of Hospital,
Tunis, Tunisia Lund, Sweden
Philippe Grenier, MD Kjell Jonsson, MD

Department of Radiology Department of Radiology
Groups Hospitalier, University Hospital,
Pitie-Salpetriere, Paris, France Lund, Sweden
XI
Donald R. Kirks, MD Sven Laurin, MD
Children’s Hospital, University Hospital,
Harvard Medical School, Lund, Sweden
Boston, MA, USA
Anthony Mancuso, MD
Aaro Kiuru, PhD Department of Radiology
Department of Oncology and University of Florida,
Radiotherapy College of Medicine,
Turku University, Gainesville, FL, USA
Central Hospital,
Turku, Finland Nadine Martin-Duverneuil, MD
Alf Kolbenstvedt, MD Groups Hospitalier,
Department of Radiology Pitie-Salpetriere, Paris, France
Rikshospitalet,
University of Oslo, Norway Richard Mendelson, MB, ChB,
MRCP, FRCA, FRACA
Tatsuo Kumazaki, MD Department of Diagnostic
Department of Radiology Radiology
Nippon Medical School, Royal Perth Hospital,
Tokyo,Japan Perth, Australia
Frode Laerum, MD Con Metreweii, MB, BChir,

Department of Radiology FRCR, FRCP
Rikshospitalet, Department of Radiodiagnosis
University of Oslo, Norway Prince of Wales Hospital,
Chinese University
S.B. Lagundoye, MD of Hong Kong,
Department of Radiology Hong Kong
University College Hospital,
Ibadan, Nigeria Karl-Ake Omnell, Odont dr
Department of Oral Medicine
Sven-Goran Larsson, MD University of Washington,
Department of Radiology Seattle, WA, USA
King Faisal Specialist Hospital
& Research Center, Philip E.S. Palmer, MD
Riyadh, Saudi Arabia Professor Emeritus,
Davis, С A, USA
XII
Peter Peters, MD Donald Resnick, MD
Westfalische Wilhelms- Veterans Administration
Universitat, Medical Center,
Munster, Germany San Diego, CA, USA
Holger Pettersson, MD Giuseppe Scotti, MD

University Hospital, Istitutio Scientifico,
Lund, Sweden Ospedale S.Raffaele,
Milan, Italy
Howard Pollack, MD
Department of Diagnostic Baldur F. Sigfusson, MD
Radiology Mammographic Department,
The Hospital of the University Icelandic Cancer Society,
of Pennsylvania, Reykjavik, Iceland
Philadelphia, PA, USA
Arnulf Skjennald, MD
Andrew Poznanski, MD Department of Radiology
Department of Radiology Ulleval Hospital,
The Children’s Memorial University of Oslo, Norway
Hospital,
Chicago, IL, USA
Hans-Jergen Smith, MD
Maximilian F. Reiser, MD
Rikshospitalet,
University of Oslo, Norway
Klinikum Grosshadem,
University of Munich,
Carl-Gustaf Standertskjold-
Munich, Germany
Nordenstam, MD
Department of Diagnostic
Hans Ringertz, MD
Radiology
Helsinki University,
Karolinska Hopsital,
Central Hospital,
Stockholm, Sweden
Helsinki, Finland
XIII
Axel Stabler, MD Elias A. Zerhouni, MD
Klinikum Grosshadem, The Johns Hopkins Hospital,
University of Munich, Baltimore, MD, USA
Munich, Germany
Christoph Zollikofer, MD
Henrik Thomsen, MD Department of Radiology
Department of Radiology Kantonspital Winterthur,
Herlev Hospital, Winterthur, Switzerland
University of Copenhagen,
Copenhagen, Denmark
M.W. Wachira, MD
Kenyatta National Hospital,
Nairobi, Kenya
XIV
Preface
It is a great pleasure and privilege for the NICER Institute to present “The
NICER Centennial Book 1995 - A Global Textbook of Radiology” to
the radiological community. The title may seem somewhat pretentious
but we hope that its meaning will be taken as we intended, i.e. to imply
that this is a book that may be of assistance to radiologists working in
many different situations throughout the world.
Radiology is a vital discipline for modem medicine as a whole and it
has undergone an almost explosive development in recent decades.
Radiologic investigation of an appropriate nature should be available to
any patient who needs it but given the economic and political realities
of the world we live in, this state of affairs is, unfortunately, far from be
ing the case. Wherever radiology is available, however, it is essential that
those working in the discpline should at least be in the possession of up-
to-date basic knowledge and this requirement is the raison d’etre for this
book. It is written by highly distinguished, internationally renowned ra
diologists from all over the world. Together, these authors possess a spec
trum of knowledge which embraces, at one extreme, very advanced -
even futuristic - imaging, and at the other basic radiology which is not
only extremely important but encompasses an ever-increasing amount
of information and varies in its emphasis and aspect from community to
community and continent to continent.
The book is intended to be a broad and thorough update of what every
general radiologist needs to know in his or her daily work whether that
be in technically advanced surroundings or in a situation in which only
basic equipment is available. It is aimed both at radiologists in training
and as a brush-up for general radiologists, as well as for those physicians
XV
who refer their patients for radiological investigation. It is also hoped
that the book will be used in medical schools throughout the world. The
chapters that comprise this work cover most of the vast and fascinating
fields in our discpline, - both diagnostic and interventional. The book
also represents NICER’s contribution to the centennial celebration o f ra
diology which is why it includes an introductory chapter on the discov
ery of x-rays.
To make the book as broadly available as possible, editions in four
world languages will be published during 1995: Chinese, English,
Russian and Spanish.lt is our sincere hope that the purpose of this en
deavour will be fulfilled: that you, the readers around the world, will find
this book both instructive and enjoyable to read. It may then make some
modest contribution to the improved use of radiological resources which
in turn will serve our common goal: good health care, for the benefit of
patients everywhere.
Lund, January 1995

Holger Pettersson
Chapter 1
W.C. Roentgen and the discovery

of X-rays
Peter Peters
In today's competitive academic climate, W.C. Roentgen would proba

bly not even attain a place at university, let alone one at medical school.
He certainly would not be accepted onto one of the more prestigious ra
diological programmes, and his pioneering paper "On a New Kind of
Rays" published in an undistinguished German journal - a journal with
out peer-review and devoid of any academic impact - would probably
remain unnoticed in the world of science. Fortunately, however, one hun
dred years ago things were different...
On the occasion of both the 150th anniversary of W.C. Roentgen's
birth and the centennial celebrations of his momentous discovery, you
are cordially invited to join me on a short historical journey.
Wilhelm Conrad Roentgen was bom on Thursday, March 27th, 1845
in Lennep (today a suburb of Remscheid, Germany) to Friedrich Conrad
Roentgen, a distinguished cloth manufacturer and merchant, and his wife
Charlotte Constanze, nee Frowein. The house in which Roentgen was
bom still stands today and now forms part of the Roentgen Museum,
where it houses a large library (Fig. 1). Visitors are able to study there
in the peace and quiet afforded by a secluded district town.
In 1848, many European countries, including Germany, were shattered
by revolution. W.C. Roentgen's parents sold their house in Lennep and
emigrated to Apeldoom (The Netherlands), because Mrs. Roentgen was
of Dutch origin. Wilhelm attended primary school there, and then a pri
vate boarding school, until 1861, when he left home to continue his stud
ies in Utrecht. A somewhat curious event took place there, which was to
have a considerable impact on his future life. What would be a harmless
student prank by today's standards caused a "consilium abeundi" - in
1
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 1.
Wilhelm Conrad Roentgen's birthplace at
Remscheid-Lennep, Germany.
other words, he was expelled from school. What actually happened has
never been made completely clear. According to Glasser's biography,
one of Roentgen's classmates had drawn a caricature of the teacher on
the firescreen when the teacher arrived unexpectedly early and discov
ered the picture. He became very angry and asked Roentgen to name the
culprit, which Roentgen refused to do. The teacher threatened him with
suspension and eventually succeeded in having him expelled.
On advice from friends of his father, Roentgen revised at home in
preparation for the entrance examinations to university. Unfortunately,
in the decisive examination one of the examiners was a teacher who had
been involved in the suspension proceedings at his former school, with
the result that Roentgen failed to secure a place. It seemed that the road
to university was permanently blocked (Fig. 2).
In 1862 W.C. Roentgen enrolled at the Utrecht Technical School, a
private institution which prepared students for entrance into technical
high school by way of a two-year course. Then, in 1865, he was enrolled
for a short time as a visiting student in the Department of Philosophy at
the University of Utrecht. In November 1865 he moved to Ztirich
(Switzerland) and the Polytechnic of Zurich (today Eidgenossische
Hochschule, ETH) which accepted students such as Roentgen who did
not have a normal school leaving certificate, after a demanding admis
sion test.
2
W.C. ROENTGEN AND THE DISCOVERY OF X-RAYS
Figure 2.
Wilhelm Conrad Roentgen during his
schooldays in Holland.
While in Zurich, Roentgen studied mechanical engineering, seriously

and successfully, and in 1868 he received his diploma in that subject. He
then continued his studies, in close cooperation with August Kundt, who,
at the age of just 29 years, was Professor of Physics at the ETH. On June
12, 1869, Roentgen obtained his Ph.D. degree from the University of
Zurich following submission of his thesis entitled "Studies on Gases".
At the age of 24, W.C. Roentgen became Professor Kundt's assistant
in the Department of Experimental Physics. Two years later, in 1870,
Kundt accepted the Chair of Physics at the University of Wiirzburg, and
Roentgen followed him there.
Wurzburg University, however, considerably hindered the furtherance
of Roentgen's academic career. Acting under Bavarian law, it barred his
academic promotion because of both his lack of a school leaving certifi
cate and his lack of the requisite training in classical languages, despite
Kundt's efforts on his behalf.
Roentgen's situation improved in 1872, nevertheless, when Kundt was
invited to the newly founded German University of Strassbourg (now in
France) and took his assistant with him once again. This new university
was less dogmatic and assisted Roentgen in his scientific career: in 1874,
Roentgen was promoted to "Privat-Dozent" and was appointed as a lec
turer at Strassbourg University.
3
Only one year later, in 1875, at the age of 30, Roentgen was called to
the Agricultural Academy of Hohenheim (near Stuttgart, Germany) as
Professor of Physics and Mathematics.
He was not happy there, however, because the institute was poorly
equipped and this prevented him from carrying out his scientific work.
As a result he readily accepted an offer of the position of Associate
Professor with his former teacher Kundt at the University of Strassbourg,
and returned there in 1876.
Three years later he was offered the Chair of Physics at the University
of Giessen (Germany). A new institute was built for him there, allowing
him to carry out a series of important experimental studies which further
strengthened his position as one of the leading physicists in Germany at
that time. In 1886 he received an offer from the University of Jena
(Germany) and, in 1888, another from the University of Utrecht (The
Netherlands), both of which he declined.
In 1888, however, Roentgen received an offer which he could not
refuse: the same University of Wurzburg, which had previously ob
structed his academic career now offered him the position of full pro
fessor and director of its highly esteemed and well equipped Physics
Institute. He accepted the appointment and moved back to Wurzburg
where, in 1894, he received the ultimate academic accolade in his elec
tion as Rector. On November 8, 1895 he discovered a new kind of rays,
a discovery which laid the foundations for the development of our med
ical speciality and which led to a phenomenal expansion in research in
the fields of physics, technology and astronomy (Fig. 3).
Figure 3.
Wilhelm Conrad Roentgen during his time in
Wurzburg.
4
A new kind of rays

The story of the discovery of "X-rays", as Roentgen called them, has
been told in countless variations. This is due mainly to the fact that in
his will Roentgen requested that on his death all his papers, including his
laboratory books, be burned, unread. There is thus much room for spec
ulation and relatively little safe historical ground.
Unfortunately, the limited scope of a short historical note such as this
prevents us from detailing the various traditions in any depth. Suffice it
to say that even during Roentgen's lifetime the story was already current
that the discovery was made more or less accidentally, despite the fact
that it was Roentgen who had not only observed the fluorescent light on
a barium platinocyanide screen but who also demonstrated its nature with
such flawless experimental technique that, following the publication of
his three papers entitled "On a New Kind of Rays", no publication of
equivalent importance was made by any other scientist until 1905 when
Charles C. Barkla from Liverpool discovered the so called "characteris
tic" X-ray.
The prevailing tenor of contemporary discussion regarding the cir
cumstances of Roentgen's discovery is best encapsulated in a comment
made by the contemporary philosopher Munsterberg of Harvard
University who on January 15th, 1896 wrote in a report to Science:
"Suppose chance helped. There were many galvanic effects in the world
before Galvani saw by chance the contraction of a frog's leg on an iron
gate. The world is full of such chances and the Galvanis and Roentgens
are few."
In his original communication Roentgen reported the experimental set

up and his observations (Roentgen 1895):
"If one passes the discharges of a fairly large Ruhmkorff induction coil
through a Hittorf vacuum tube, a sufficiently evacuated Lenard or
Crookes tube, or a similar apparatus, and if one covers the tube with a
rather closely fitting envelope of thin black cardboard, one observes in
the completely darkened room that a piece of paper painted with barium
platinocyanide lying near the apparatus glows brightly or becomes flu
orescent with each discharge, regardless of whether the coated surface
or the other side faces the discharge apparatus. The fluorescence is still
5
visible at a distance o f 2 m from the apparatus ...”

(Roentgen's original communication, translated by Otto Glasser.)
In the communication Roentgen acknowledges the achievements of sev

eral renowned scientists of his time: H.D. Ruhmkorff (1803-1877) orig
inally built musical instruments. In later life he moved to Paris and be
came famous for the invention of electromagnetic devices such as the in
duction coil alluded to in the above quotation. J.W. Hittorf (1824-1914),
Professor of Physics and Chemistry at the University of Mtinster,
Germany, studied cathode rays and developed a tube with a vacuum more
complete than had hitherto been available. Sir William Crookes
(1832-1919) built a wide variety of vacuum tubes designed for research
into "radiant matter”. He was of such renown that even in his lifetime
the term "Crookes tube” was used to refer to any kind of vacuum tube.
Lastly, Roentgen refers to P. Lenard (1862-1947), who was awarded the
Nobel Prize in Physics in 1905 for his ingenious work on cathode rays.
In 1892 he built a tube with the rays directed toward a thin aluminium
window, enabling for the first time the study of cathode rays outside the
tube in which they were produced. It is not known which of these vari
ous tubes W.C.Roentgen actually used; in his original comunication he
merely mentioned the three different types in a general way. Lenard,
however, considered himself to be "the mother of X-rays" while
Roentgen was "the midwife who happened to deliver the child".
Certainly, both scientists were nominated for the first Nobel Prize in
Physics in 1901; and the committee recommended that the prize should
be divided equally between Roentgen (Mtinchen), and Lenard (Kiel). In
the event, the Royal Academy of Science did not follow this recom
mendation but decided to award the prize to Roentgen alone. In 1896,
however, the two scientists were jointly awarded the Rumford Medal of
the Royal Society of London. Neither man actually travelled to London
to receive his prize, though, and as a result, the two men did not meet on
this occasion, nor, indeed, on any other.
The moment of discovery

Owing to the fact that W.C. Roentgen ordered that all his laboratory notes
be destroyed, we must attempt to reconstruct the precise sequence of
events from his own first communication and from the accounts of his
friends and biographers.
6
W.C. ROENTGEN A ND THE DISCOVERY OF X-RAYS
Figure 4.
The old Department o f
Physics, University o f
Wurzburg, where W.C.
Roentgen discovered
the rays.
It was late afternoon on Friday, November 8th, 1895, W.C. Roentgen

preferred to work alone in his laboratory, and on a Friday he could be
fairly certain that nobody would disturb him. He had been conducting a
series of experiments on cathode rays using a Lenard’s tube - the one
with the thin aluminium window - but, apparently, that night he decided
to use a Hittorf or Crookes tube instead, without such a window (Fig. 4).
After energizing the cathode ray tube he noted the well known phe
nomenon of fluorescence of the tube's glass walls. He had darkened the
room and was investigating the fluorescence of barium platinocyanide
pasted onto a piece of cardboard. In order to avoid interference with flu
orescence originating from the glass walls of the tube he wrapped the en
tire tube in black cardboard. After energizing the tube again he made sure
that the cardboard shielding was adequate. Despite efficient shielding,
however, a faint glimmer was visible from the barium platinocyanide
screen, which was more than one meter away from the tube. He repeated
the experiment several times and established beyond doubt that this phe
nomenon could not be due to ordinary light reflections, nor due to the
cathode rays, because they did not travel so far through air.
Over the following seven weeks Roentgen worked very hard in his
laboratory investigating this phenomenon. It is said that he even ate his
meals in the laboratory and had his bed moved there so that he could
work without interruption.
Roentgen had already proved his capability as an experimental physi
cist, and the experimental set-up for the study of the ’’new light" was
carefully planned.To document his observations he used photographic
plates. On the evening of December 22, 1895, he asked his wife Bertha
to let him photograph her hand using the new rays. After a fifteen minute
7
Figure 5.
Radiograph o f the hand o f Bertha
Roentgen, taken December 22nd, 1895.
exposure the first radiograph of a human being was obtained showing

clearly the bones of the hand and the two rings she was wearing. This
date is the true birthday of radiology as a medical speciality (Fig. 5).
In retrospect it is apparent that many scientists unknowingly encoun
tered X-rays in the course of their experiments. For example, Crookes
complained to Ilford, his supplier of photographic plates, about fogged
and blackened plates in unopened boxes. The company replaced the
plates but observed that the damage must have occurred in the physicist's
institute, since no other complaints had been received.
Another well-known case of unintentional experimentation with X-
ray is that which was reported by Professor A.W. Goodspeed of the
University of Pennsylvania as occurring on February 22,1890, when car
rying out studies with Crookes tubes. It was only after the publication of
Roentgen's paper that those involved were able to explain the cause of
the strange shadowy pictures they had taken six years earlier (Fig. 6).
Spreading the news

We tend to assume that rapid communication is an achievement made
possible only in this electronic age of statellites, fax machines and global
computer networks; yet news of Roentgen's discovery spread all over the
Figure 6.
First 8-ray shadow pic
ture, taken accidentally
by Arthur W. Goodspeed
at the University o f
Pennsylvania on
February 22nd, 1890.
Figure 7. щ —3- -----------------------

Roentgen's first communication. First ^CU Off.
eUuL, M
i v
page o f the handwritten manuscript. - 4/

' <■***>
7, KOm X « u l o
world with astonishing speed. After seven weeks of hard work W.C.
Roentgen wrote a short manuscript entitled "On a New Kind of Rays.
First Communication" and handed it to the secretary of the Wurzburg
Physical Medical Society. Because the society did not meet during the
Christmas holiday, Roentgen asked that the manuscript be published
prior to its oral presentation, which was scheduled for January 23rd, 1896.
The secretary agreed and the manuscript was published in the
"Sitzungsberichte der Physikalisch-Medizinischen Gesellschaft in
Wurzburg" (S. 132-141, Band 137, 1895) (Fig. 7).
9
Three days later, on January 1st, 1896, Roentgen had already obtained
the offprints of the manuscript and had sent them, together with a few il
lustrative pictures, to his scientific colleagues and friends as a New Year
Greeting. One of these offprints went to his old friend Prof. Exner, whom
he had known since college days in Zurich. Prof. Exner showed the man
uscript and pictures to a group of physicists who were attending an in
formal scientific get-together at his home. One member of the group was
Prof. Lecher from Prague who asked Exner if he might borrow the man
uscript for a single day. Lecher's father was the editor of the Vienna news
paper "Die Presse", and it was he who wrote the first article on the dis
covery, which appeared in the Sunday, January 5th, 1896, edition of that
newspaper. Owing to haste in the preparation of the article the name of
the Wtirzburg Professor was misspelled as "Routgen". By the following
evening, that of Monday, January 6th, 1896, the news had been an
nounced to the whole world by cable from London. The press notice read:
"The noise of war's alarm should not distract attention from the marvel
lous triumph of Science which is reported from Vienna. It is announced
that Professor Routgen (sic) of Wurzburg has discovered a light which,
for the purpose of photography, will penetrate wood, flesh and most other
organic substances. The Professor has succeeded in photographing metal
weights which were in a closed wooden case, also a man's hand, which
shows only the bones, the flesh being invisible".
The London Standard printed the report on January 7th, 1896, adding the
following remarks:
"The Presse assures its readers that there is no joke or humbug in the
matter. It is a serious discovery by a serious German Professor".
While the first reports in New York were published on January 8th, 1896,
the first report by the local newspaper, "Wtirzburger Generalzeiger", did
not appear until January 9th, 1896!
Thus, within ten days of the submission of the manuscript to a pub
lisher the news had spread to the entire world - before, even, Roentgen
had presented his findings to the scientific society. On January 23rd,
1896, an English translation appeared in Nature (London), and, two
weeks later, in Science (USA).
10
W.C. ROENTGEN A N D THE DISCOVERY OF X-RAYS
On January 13th, 1896, Roentgen presented his work to Emperor

Wilhelm II in Berlin and, on January 23rd, 1896, he eventually gave his
oral presentation to the Wtirzburg Physical Medical Society.
The period following the discovery

W.C. Roentgen did not relish the sudden publicity he gained after the
discovery of "a new kind of rays" which were named "Roentgen rays"
following his oral presentation at Wurzburg. He was awarded numerous
honorary memberships, medals and other decorations but virtually never
accepted these accolades in person. He did travel to Stockholm, how
ever, to accept the first Nobel Prize in Physics in 1901, but did not give
an official speech even on that occasion. He was honoured by the Prince
Regent of Bavaria with the Royal Order of Merit of the Bavarian Crown
which carried with it personal nobility. Roentgen accepted the decora
tion but refused the status of nobility, a gesture which was most uncom
mon in those days in Germany. He turned down several chances to make
financial profit from his discovery. Mr. Levy, a representative of a well
known German company, was sent to Roentgen to negotiate a contract
for the industrial exploitation of his current and future discoveries. Mr.
Levy recalled Roentgen's answer:
"He declared, however, that according to the good tradition of German
University professors he was of the opinion that his discovery and in
ventions belonged to humanity and that they should not in any way be
hampered by patents, licences, contracts or be controlled by one group."
In 1900, W.C. Roentgen became Professor of Physics at the University
of Munich and Director of the new Physics Institute. He retired in 1920
and died, at the age of 78, on February 10th, 1923, in Munich. His mor
tal remains were put to rest beside those of his wife and his parents in a
cemetery at Giessen.
11
Chapter 2
Radiology in an international
perspective
Carl-Gustaf Standertskjdld-Nordenstam
The ready availability of radiographical services is accepted as a normal

part of life by those living in industrialized countries where the average
member of the population undergoes 0.3-1.0 radiological studies per an
num.
In such countries the most sophisticated imaging systems are avail
able and there is one piece of radiological equipment per 1,500-10,000
of the population, one radiologist per 10,000-30,000 and one radiogra
pher per 2,000-5,000.
Globally, however, radiology is a luxury. More than three-quarters of
the world's population lives in circumstances in which the possibility of
receiving even the most elementary radiological services is exceedingly
remote. In developing countries this may mean that there is only one item
of x-ray apparatus per 50,000-1,000,000 of the population, one radiol
ogist per 100,000-2,000,000 and one radiographer per 50,000-200,000;
the number of radiological studies under these circumstances may be less
than 0.01-0.1 annually per inhabitant. These statistics underline the prob
lem of health care in these countries and mean that the scope of deliver
ing satisfactory radiological services is severely limited, particularly as
standards of both equipment and radiology often leave much to be de
sired.
In industrialized countries specialized studies, including fluoroscopic
and contrast medium studies, account for 20-30 % o f all examinations
(and this proportion is increasing), whereas they represent only 5-10 %
of the total number of studies in developing countries. The distribution
of radiological equipment in the latter is also different: in industrialized
countries basic services are widespread and readily accessible, but in de-
13
veloping countries the available radiological equipment and knowledge

is often confined to a few large centres.
Radiological performance in the developing countries is often ham
pered by the poor condition of equipment. Even basic radiological
equipment is usually designed on the assumption that it will be used in
a well organized system where technical maintenance is of a high stan
dard and readily available. When such equipment is installed in a tech
nically less advanced milieu a protracted break-down of activities usu
ally ensues. The lack of maintenance personnel may result in the nonu
tilization of equipment that has been purchased at high cost with precious
"hard" currency. These problems are exacerbated by other adverse fac
tors such as extremes of climate, lack of clean water and interruptions in
electricity supplies. In these conditions radiological services which, in
theory, may have been well planned and structured, never practice in
function, and the anticipated benefits of newly acquired technology re
main unrealized.
Analysis of cost and benefit is an important process in industrial coun
tries, and may show cost savings in health care by stimulating the ac
quisition and rational utilization of high technology modalities such as
computed tomography and magnetic resonance imaging. For 75 % of
the world's population, however, the problems are on a completely dif
ferent plane - for instance, how to get a plain radiograph of the lungs or
bones. In order to remedy this problem the World Health Organization
(WHO) created the so-called Basic Radiological System (BRS), which
has now evolved into the WHO Imaging Systems (WHIS). This is de
scribed in chapter 5.
A similar basic ultrasound unit is now also part of the WHIS. The use
of ultrasonography seems certain to increase, because of the intrinsic ad
vantages of the modality and the price and durability of the equipment.
Radiological activity is based on radiological education which con
cerns both radiologists and radiographers and is unfortunately also be
set with problems despite its importance. The models for teaching have
usually evolved in industrialized countries which means that their orga
nization and balance may be unsuitable for non-industrialized countries
and imported experts and visiting teachers may have problems in ad
justing to local circumstances and requirements. In expert groups, e.g.
in the WHO, the prevailing opinion has been that teaching systems would
be developed in their own surroundings giving due consideration to the
14
RADIOLOGY IN AN INTERNATIONAL PERSPECTIVE
prevailing realities in order to respond to the local needs. The level of

radiology undertaken is to a large extent determined by its customers,
i.e. the referring doctors and it is to these, as well as radiologists, that
teaching programmes should be directed - a philosophy incidentally, that
could be applied with benefit in every country.
The organization of teaching and education in radiology is a matter of
concern to several international organizations. The European
Association of Radiology, EAR, strives to coordinate education in
Europe and similar efforts are made by the Radiological Society of North
America (RSNA), The Interamerican College o f Radiology, and the
Asian Oceanian Society o f Radiology (AOSR) in their respective areas
of the world. The International Society of Radiology, ISR, being a global,
non-governmental organization, aims at the global promotion of radio
logical education. This is done by arranging and accrediting courses and
teaching programmes and by arranging the International Congress of
Radiology. The ISR also sponsors teaching centres. There are several
other first-class teaching programmes in various parts of the world.
Radiology is an expensive and capital-intensive modality and the ra
diological activity of any country is determined by that nation's economic
resources. Significant differences in the availability of radiological ser
vices across the globe seem likely therefore, unfortunately, to remain for
the foreseeable future.
15
Chapter 3
Radiophysics
Aaro Kiuru
Medical imaging plays a central part in the diagnostic examination of

patients, as well as in invasive radiological procedures, which are in
creasingly dependent on accurate diagnostic information. Such infor
mation can be gained by applying transmitted, emitted or reflected elec
tromagnetic radiation or mechanical vibration (ultrasound). The follow
ing physical phenomena are the basis of modem imaging:
- X-rays are absorbed in tissue (X-ray examination),
- radio frequency radiation is yielded by the excitation of odd atomic
nuclei in a magnetic field (magnetic imaging based on nuclear mag
netic resonance, NMR),
- radioactive isotopes concentrated in certain tissues emit gamma radi
ation (nuclear medicine imaging or isotope imaging),
- high frequency beams of compression and rarefaction are reflected
back towards a transmitter sensor (ultrasound examination),
- infrared radiation is emitted spontaneously by tissues (infrared imag
ing, thermography).
All of these methods except ultrasound are based on electromagnetic

(em-) radiation in different energy domains. Ultrasound imaging is based
on the detection of vibration, which is generated in a piezoelectric crys
tal. Isotope, ultrasound, and magnetic examinations were developed into
useful imaging methods in the seventies and eighties, whereas X-radia-
tion was discovered one hundred years ago in 1895.
Those types of radiation (X, gamma, beta and alpha radiation) which
can impart more energy than light ( 2 - 4 eV), have the capacity to ion
ize atoms and dissociate molecules and therefore cause biological dam
age. The use of non-ionizing methods like ultrasound and magnetic res
onance should generally be preferred, because of their inherent safety
17
without taking account of their other advantages.
X-ray imaging methods can be grouped in the following way:

- radiography with a screen and film or a cassette (about one hundred
years old), and today with a digital cassette
- fluoroscopy or transillumination (from the beginning of the century)
with an image intensifier and a television camera tube which began
in the sixties, and
- computerized axial imaging methods (which began in the seventies).
Imaging methods can also be grouped according to whether a volume of

tissue or a thin slice of tissue is imaged. In a conventional X-ray exam
ination a 3-dimensional object is projected into a 2-dimensional image.
Shadows of different organs are summated on film. The entire tissue vol
ume is exposed, which means that much scattered radiation is generated
which degrades image quality, particularly by reducing contrast.
In axial imaging (e.g. computed tomography, CT) radiation is directed
only into a thin disc or slice of tissues. Conventional tomography is an
older method, whereby shadows of objects outside the focal plane are
blurred by synchronous movement of the X-ray tube and screen-film
combination.
Computed Tomography (CT) was invented in 1973. A computer was
used for the first time to measure, analyze and display an axial image in
digital units. The greatest advantage of this method is good contrast res
olution. Axial imaging is also used in magnetic resonance imaging and
in nuclear medicine to a lesser extent. Ultrasound imaging is also re
stricted to one plane, but an image is not formed with reconstruction tech
niques like in the other axial modalities. Different imaging methods
based on different physical principles therefore project different views
of the anatomy and physiology of organs.
Digital computers play a pivotal role in all modem imaging methods.
They will assume even more importance in the nineties both in digital
bone and thorax imaging as well as in converting all image information
(measurement, display, archiving, transmission and communication)
into digital form.
The interactions of different energy forms with matter are scrutinized
in this chapter, as well as the physical principles underlying imaging
methods. The construction, function, and use of X-ray generating de-
18
RADIOPHYSICS
vices, the biological consequences of radiation, and radiation protection,

and factors affecting image quality are also discussed.
INTERACTIONS OF RADIATION WITH MATTER

AND RADIOACTIVITY
Matter and radiation

The smallest unit of radiation, a photon or a quantum, arises in matter,
when a nucleus, an atom or electrons of an atom, is affected by a distur
bance coming from outside. In order to understand the physical princi
ples of imaging methods and the technical aspect of devices, one must
have knowledge of the atomic structure of matter and of those changes
which occur when an atomic microsystem is disturbed (e.g. a tungsten
nucleus in an X-ray tube).
Figure 1. Binding energy (keV)
Energy level-diagram o f the electrons o f a
tungsten atom. The binding energy o f each 0,02 P -д-
0,07 О -ЯГЖ
shell is shown. This is the minimum energy,
which an incoming electron or gamma quan 0,6 N
tum must have to be able to ionize the atom.
Excitation with a smaller amount o f energy
2,8 M
only raises an electron to one o f the higher
levels provided that a vacancy exists. Two
characteristic X-ray quanta are also shown. 11,0 L
K a„ K pa
-59 67 keV
69,5 К A A
Tungsten
Fig. 1 shows the orbits or shells K, L, M etc. of tungsten. These shells

are saturated with electrons up to the N-shell and even O- and P-shells
are partly filled. It is normal for electrons to be situated in the lowest
available orbits, in other words that their energy be as small as possible.
The situation is different at higher temperatures, in radioactive sub
stances and generally, when an atomic microsystem is disturbed. This
happens for instance when an incoming electron crashes into the anode
of an X-ray tube or light is produced from the heated filament of a light
bulb. Microsystems become ionized or excited in these ways
Once excited, an electron is raised from a low energy shell (e.g. the
К-shell) to a higher energy shell. An excitation state is discharged by the
19
emission of characteristic X-radiation, when simultaneously an electron

from the L-shell, or less likely the M-shell, falls down to the К-shell. The
energy difference between these shells in question (59 keV Ka or 67 keV
Kp) is liberated as a monochromatic quantum. This filling up of an elec
tron hole in a shell is followed by a series o f similar events in higher or
bits with smaller and smaller energy transfers until the system is returned
to its stable state. All this happens very quickly, in a considerably shorter
time period than a milliardth of a second.
Radiation is divided into two principal components:

1. particle radiation, of which only the electron (and positron, the posi
tive electron) has importance in imaging methods, and
2. electromagnetic (em-) radiation. Its basic quantity, a quantum or a
photon moves with the speed of light and lacks mass.
It is accepted in modem physics that a photon can behave as a particle

or as a wave. The properties of radiation can therefore be characterized
with three concepts; energy (unit being an electron volt eV, keV etc.),
frequency (Hz, MHz etc.) and wavelength (cm etc.). Frequency is di
rectly proportional and wavelength inversely proportional to energy.
When an X-ray spectrum is generated in an X-ray tube the penetrat
ing properties and to a lesser extent the intensity of radiation are deter
mined by the high voltage (kilovolt kV or kVp). Em-radiation varies from
very low-energies (low frequency or high wavelength) to high energies.
Due to historical reasons different names for separate domains of the em-
spectrum are in use, but in fact they refer to the same phenomenon, i.e.
electromagnetic radiation:
- X-ray, ultraviolet- and visible light arise from changes in electron
shells,
- infrared radiation is a consequence of heat liberated by the motion of
atoms and molecules,
- radio waves arise from the motion of electrons in a conductor and also
from changes in nuclear orbit and spin, etc.,
- gamma radiation originates as a consequence of changes in the exci
tation of a nucleus
The different ways with which a photon interacts with matter are greatly
dependent on energy. Different photon energies are utilized in imaging
20
RADIOPHYSICS
Figure 2. X-ray quanta are absorbed heterogeneously in different tissues, most occurs
in bone and contrast media and least occurs in air-containing spaces like lungs (Fig. 9).
The transmitted primary quanta and a significant part o f the scattered, through lead
grid penetrated quanta, expose the film. Details o f the object are seen in the image i f
large enough intensity differences (contrast, Fig. 10) have been produced by the
distribution o f X-rays.
methods to get information from tissues, but the direct in vivo utiliza
tion of particle radiation (electrons) in medicine happens only in radio
therapy. On the other hand, ultrasound means vibration in matter. It is
transmitted through tissues at the speed of sound (compared with the
much higher velocity of light). Ultrasound is not radiation.
Interactions of X-rays and gamma rays with matter

X-ray imaging is the imaging of shadows (see Fig. 2). Different tissues
allow the transmission of different amounts of quanta, which are pro
jected onto the image plane. This is either a screen-film-combination, an
image intensifier or a sensor, for instance in a CT unit. Radiation must
therefore possess two properties for the formation of a radiograph or an
X-ray image:
1. Photons must penetrate tissues to a sufficient degree (resulting in a
radiation dose).
2. Quanta should be attenuated differently in different tissues (resulting
in image contrast).
When X-rays are used, external radiation penetrates tissues and the
quanta are detected on the other side of the patient. In nuclear medicine
imaging, photons from activity distributions within body tissues are emit-
21
Figure 3. The interactions ofphotons and electrons with matter. Pair production is
possible only at higher energies than 1.022 MeV. It has no importance in X-ray and
nuclear medicine imaging, but plays an important role in radiotherapy.
ted. In the latter case, there is a prerequisite that the target object has col
lected more (or less) activity than organs in the background.
The interactions of X-rays and gamma rays with tissues are the same.
Their mode of production is, however, different. A gamma quantum
comes from de-excitation of a nucleus and its energy therefore has a spe
cific value. In other words, gamma radiation is monochromatic (differ
ent nuclei decay of course with quanta of different energies). On the other
hand, an X-ray spectrum consists of quanta with energies between a max
imum and minimum value (polychromatic radiation). These limits are
determined by the high voltage and filtration of the tube (see X-ray
Generator and X-ray tube and Fig. 5).
In the other types of em-radiation quanta have similar interaction prop
erties. Light and infrared radiation for instance penetrate tissues only in
small amounts. Infrared radiation, as well as high frequency radiation,
penetrates matter to a certain degree, but high spatial resolution is not
possible. With infrared radiation it is possible to detect heat producing
phenomena only in the vicinity of the skin surface. The situation is some
what different in magnetic resonance imaging, where tissues are stimu
lated with radio waves in a strong external magnetic field.
Fig. 3 shows the interactions of photons with matter in the energy do
mains utilized in X-ray and nuclear medicine imaging, as well as in ra
diotherapy. The figure also shows the interactions of electrons. All phe-
22
RADIOPHYSICS
Figure 4. Probabilities fo r photoelectric absorption and Compton scattering, (these

phenomena are schematically inserted in the figure with the diameters o f an average
atom and a nucleus) in various elements and at various energies. On the line in the
picture the probabilities are equal. Scattering occurs therefore very frequently in soft
tissues (atomic number approximately 7,5). Egamma, EbimJ and Еш mean the energy o f
the incoming quantum, the binding energy o f the shell and the kinetic energy o f the
electron.
nomena described in the figure are simultaneously possible with differ

ent probabilities, except pair production (which occurs in radiotherapy)
which requires a minimum energy. Each interaction of a photon gives
energy to one or more electrons. High-energy electrons are then able to
ionize and excite atoms and dissociate tissue molecules. Radiation dose,
so characteristic of ionizing radiation is closely connected to these so-
called secondary electrons.
Photoelectric absorption and Compton scattering are the important
photon interaction phenomena in the diagnostic energy domain of
15-500 keV (Fig. 4). In X-ray and isotope examinations, so-called co
herence scattering is of little importance and does not need to be con
sidered. The former phenomenon is an absorption event, at which a pho
ton gives all its energy to an electron, frequently in one of the inner atom
shells. This photoelectron is slung from the atom with kinetic energy
equal to the original energy of quantum reduced with the binding energy
of the shell.
23
In Compton scattering a photon scatters (changes its direction) with a

reduction in energy caused by giving part of its energy to an electron.
The relationship between photoelectric and Compton phenomena varies
so that in low atomic weight substances, such as soft tissues (and in all
matter at high energies), scattering happens much more often than pho
toelectric absorption (Fig. 4). The frequency of occurrence of these two
phenomena is the reverse at low energies and particularly in heavy sub
stances (i.e. in protective layers like lead apron), where quanta are al
most entirely absorbed.
Depending on the thickness of the object, a fraction of the number of
primary photons is able to penetrate through tissue in the original direc
tion. The remainder is stopped in tissue. Effects of radiation in tissues
are later described incorporating such concepts as absorbed dose and
dose equivalent (Radiation protection and patient dose).
Fig. 3 shows one photon and its path through matter. But in an X-ray
examination nearly parallel quanta are coming in very great quantities
from the focus of the X-ray tube. The number of quanta, i.e. the intensity
of radiation (quanta/cm2 s) diminishes as the radiation penetrates more
deeply through matter. In addition to the previous description of absorp
tion and scattering phenomena, the effects of radiation can also be de
scribed statistically as a great number of quanta (the magnitude of 1012
quanta hit the patient’s skin during the creation of an X-ray image). It is
therefore postulated that radiation is attenuated which implies two things;
1. photons are absorbed in electron shells, and
2. photons are deviated from their original direction i.e. they are scat
tered.
Attenuation follows the exponential function 1 = 1 exp"^ x , where

Io is the incoming and I the transmitted intensity of radiation, x is the
thickness of the tissue and ju is a coefficient of attenuation, jn is a con
stant and characteristic of every element and every combination of ele
ments, in other words characteristic of substances and tissues. It depends
strongly on radiation energy and other factors.
Interactions of electron; X-ray spectrum from X-ray tube

Fig. 3 shows that an electron with kinetic energy excites and ionizes
atoms and dissociates molecules in matter. When kinetic energy in
creases, this also increases the probability of a braking radiation inter-
24
RADIOPHYSICS
Figure 5. Braking radiation is generated in the anode o f an x-ray tube. In medical

imaging the energy?o f the incoming electron may vary between 15-200 keV (see also
text o f Fig. 8).
action. This phenomenon means that when a negatively charged electron

passes a positively charged nucleus, the former changes direction and
loses part of its energy as an em-radiation quantum (Fig. 5). The nearer
the electron comes to the nucleus, the greater the change in direction and
hence the greater the amount of energy loss. The quantum can gain any
amount of energy from the maximal energy of electron (a straight hit) to
the energy of a light photon or infrared photon (that is in the range of a
few eV). The latter events are the most common. Therefore, the number
of low-energy photons inside the anode is greater than the number of
high-energy photons (the upper curve in Fig. 5). This makes the anode
surface glow, and there is a risk that the anode can even melt under ex
cessively long exposures.
The lower curve in Fig. 5 depicts the quantum radiation spectrum used
in patient examinations. It is worth remembering that the secondary elec
tron set in motion by a quantum is particularly important when consid
ering radiation biology and patient dose.
Interactions in a magnetic field

In a magnetic examination a patient on the examination table is exposed
to a strong and very homogeneous magnetic field. The field strength can
be between 0.04-2 T, (400-20 000 gauss), which is much bigger than
the magnetic field of the earth. In the Nordic Countries this is approxi
25
mately 0.6 gauss. This static magnetic field changes the direction of all
of the spinning hydrogen nuclei, (i.e. protons), so that they are aligned
parallel to the direction of the field. Radio frequency (rf-) radiation is
then applied to tissues where energy quanta are absorbed by some of the
protons. These become excited as a result and while decaying send quanta
of em-radiation to the environment. These photons are detectable and
slice images are reconstructed from the resultant interference pattern
(magnetic imaging). During this procedure, magnetic field gradients are
utilized to extract three-dimensional information.
The photons which make up the radio-frequency interference pattern
have such a low energy that they are not able to ionize matter. Magnetic
resonance imaging, however, combines strong static and quickly vary
ing magnetic fields, as well as quickly varying rf-pulses which can cause
eddy currents. These eddy currents can generate heat in metallic foreign
bodies, if such exist in tissue. The theory and practice of magnetic reso
nance imaging are described more closely in the chapter on Modalities,
with possible biological effects and contraindications.
Interactions of ultrasound
A vibrating ultrasound crystal in contact with skin (using a gel coupling
medium for good transmission of vibration energy) forces tissues to
move synchronously with the crystal's characteristic frequency, which
may vary between 2 and 20 MHz in medical ultrasound examinations.
This phenomenon can not be used in a vacuum like em-radiation, it al
ways needs matter. In soft tissues vibrations occur back and forth in the
examined cone of tissues the dimensions of which are fixed by the char
acteristics of the crystal. Motion amplitudes are small, but even so dy
namic (changing in time) areas of compression and rarefaction are gen
erated in matter. The resolution of ultrasound imaging (something be
tween 0.8-0.08 mm) is determined by the wave characteristics of the
transmitted beam.
Matter is composed of molecules bound to one another with varying
degrees of elasticity. Matter is somewhat slow to set in motion, and it
opposes the genesis and propagation of motion. Translation speed in soft
tissues varies between 1460-1580 m/s (approximately five times faster
than in air) and in bone between 2500-4700 m/s. Ultrasound advances
straight in homogeneous matter and it behaves very much like light; it is
reflected, refracted, absorbed and scattered. This means that energy di-
26
RADIOPHYSICS
Attenuation occurs everywhere

(absorption, scattering, reflection, refraction)
Figure 6. Ultrasound is reflected at all boundary surfaces according to the coefficient

o f reflexion R. Calculated values o f vibration intensity in the figure are given in per
centages o f the incoming intensity. Boundary/ surfaces are seldom perpendicular to the
ultrasound ray, therefore according to the reflexion law a considerable share o f vibra
tion energy is lost from the main direction (this also causes artifacts). Vibration en
ergy is scattered and absorbed everywhere in matter, in other words energy is attenu
ated on its way into tissues and on its way back to the crystal.
minishes continuously in the cone of tissues in the direction of the mo

tion (and also after reflection while returning back towards the crystal),
in other words vibration is attenuated.
The ultrasound image is constructed with that part of the vibration en
ergy which is reflected back towards to the crystal at each boundary sur
face or tissue interface. The amount of reflected energy depends on the
characteristics of the tissue, its acoustic impedance (= ultrasound's trans
lation speed multiplied by the density of tissue), the frequency of the
beam, the orientation of the reflecting surface in relation to the direction
of the applied ultrasound cone, as well as the interface structure and
"roughness” compared with the wavelength of the applied beam (Fig. 6).
From an even surface ultrasound is reflected in the same way as light
from an even metal surface; the angle of reflection equals the angle of
incidence. Reflected energy is determined by the coefficient of reflexion
R. At the boundary surface between soft tissue and air almost all energy
is reflected (it is almost impossible to examine lung) and very little at the
boundary surface between two tissues with approximately the same value
of acoustic impedance. Vibration energy is scattered in all directions par
ticularly at surfaces with rough structure compared with the wavelength.
This is the reason that inclined tissue surfaces can not well be imaged.
Ultrasound imaging method and applications are described in the chap
ter on Modalities.
27
Radioisotopes and radiopharmaceuticals

An organ can be visualised by measuring the emission of gamma radia
tion from a radioisotope with which a physiological or metabolic agent
is labelled. Such an agent (a "radiopharmaceutical”), is introduced into
the body by intravenous injection or oral ingestion. The imaging or mea
surement of a patient is performed with a gamma camera or a PET-cam-
era (see chapter on Modalities)
In contrast to X-ray imaging, radioisotopes emit radiation from their
nuclei. In nature almost one hundred elements can be found, whereas the
number of known elements is greater than this. Every element (with a
fixed number of protons) has several isotopes, which differ from each
other by the number of neutrons. An isotope is stable if the ratio between
the number of protons and neutrons is in "balance”; in light elements the
number of neutrons is approximately the same as the number of protons,
in heavy elements there are more neutrons. Most of known isotopes are
radioactive, which means that they are in an excited state. Radioisotopes
for medical purposes are produced artificially in a nuclear reactor or a
particle accelerator.
The energy of a radioactive isotope is released by the emission of em-
radiation (a monochromatic gamma quantum) and also by the emission
of particle radiation (an electron = beta-minus particle, a positron = pos
itively charged electron = beta-plus particle, an alpha particle, etc.). In
these latter cases an element is simultaneously transformed to another
substance. Radionuclides which emit only gamma radiation are most
commonly utilized in diagnostic nuclear medicine, because only em-ra-
diation with suitable energy (60-600 keV) has the capacity to travel from
tissues to a gamma camera. Fast electrons with kinetic energy lose this
energy in tissues and contribute only to the radiation dose.
28
RADIOPHYSICS
Table 1. Clinically important radionuclides (with type o f emission and

half-life) and with them labelled examination substances, so-called ra
diopharmaceuticals, which are often produced in hospitals by the injec
tion ofTc solution into a so-called ”kitn-bottle. The notation 2x511 keV
implies that two photons o f 511 keV are simultaneously emitted by the
nuclide concerned.
Nuclide Emission Half-life Application

Domain keV
Carbon-11 2x511 20 min Glucose metabolism
Nitrogen-13 2x511 10 min Amino acid metabolism
Oxygen-15 2x511 2 min 0 2 , СО, C02
Fluorine-18 2x511 110 min Receptor imaging
Gallium-67 92, 182 72 h Malignancy, infection
Technetium-99m 140 6h Majority of examinations
Indium-111 173,247 2,8 d Components of blood
Iodine-123 160 13 h Kidney
Iodine-131 360 8d Thyroid
Xenon-133 81 5.3 d Lung embolus
Thallium-201 80 73 h Heart infarct, ischemia
An excellent example of a pure gamma radiation emitter is 99mT с which

has a gamma quantum of 140 keV and a half-life of 6 hours (that time,
after which half of the original nuclides are in existence). 99mTc is used
in most nuclear medicine examinations. Table 1 shows clinically im
portant radionuclides and some of their areas of application.
The parent substance of technetium is molybdenum "M o with a half-
life of 66 hours. This so-called Mo-Tc-generator is transported to hos
pital once or two times in a week. It is "milked”, that is rinsed with saline,
to produce sterile sodiumpertechnetate solution which is used to label
different examination agents. The labelling happens by injecting some
of the solution into a sterilized vial, containing freeze dried physiologi
cally or metabolically active agent. The product is then normally ready
to be injected to patient. Typically, the amount of effective radioactive
labelled substance is extremely small (the agent can even be poisonous)
and it is always dissolved in some millilitres of saline.
The number of decaying radioisotope nuclei per unit time is described
as activity A. Its unit is one decay event/s = one Becquerel, Bq. The older
unit is the curie, Ci, = 3,7 x Ю10 decay events/s. Thus, a typical in vivo
29
patient dose of 99mTc is 370 MBq = 10 mCi. If the mass and volume of
radiopharmaceutical agents are also taken into account, the concepts of
mass and volume specific activity (Bq/kg and correspondingly Bq/m3)
can be used.
Radioactive decay follows the exponential function A = Ao exp'lambda x1
where lambda is the constant of disintegration or decay (characteristic to
each radioactive nuclide) and t is time. The decay constant and half-life
have the following relationship: half-life = 0.693/decay constant. In addi
tion to the physical half-life, the concept of the biological half-life is also
used. The combination of these terms is called the effective half-life.
RADIATION PROTECTION AND PATIENT DOSE

Both ionizing and non-ionizing radiation as well as ultrasound are used
in medical imaging methods. Somatic (occurs in own tissues) or genetic
(in descendants) damage in patients or personnel are always a risk of ex
aminations which employ ionizing radiation. Photons of non-ionization
radiation (radio wave radiation in a strong magnetic field), as well as ul
trasound, carry insufficient energy to cause injuries at diagnostic energy
levels. Consequently, radiation protection is needed in practice only in
X-ray and isotope examinations and in radiotherapy.
There are many factors which influence image quality. By increasing
the amount of radiation (and patient dose) image quality can be increased
to a certain level, but simultaneously several factors in the imaging chain
can diminish quality. The quality control of imaging methods should be
arranged such that high image quality with a dose as low as reasonably
achievable (ALARA) is maintained.
The purpose of radiation protection is to eliminate the acute toxicity
of radiation exposure and diminish the somatic and genetic risks to pa
tients and personnel. It is useful to remember that the natural background
radiation in the Nordic Countries varies between 3-6 mSv (300-600
mrem) per year. There is radiation coming from space, soil (radon gas is
a very considerable source of radiation) and construction materials, as
well as from our own tissues. Background radiation can vary depending
on residential area, life style, etc. This value of 3-6 mSv is the same or
der as the skin dose from an X-ray image of the body.
30
RADIOPHYSICS
Quantities and units of radiation dose

Interactions of X-ray and gamma photons always set electrons in motion
with sufficient energy to ionize and excite atoms and molecules (see
Interactions of radiation with matter). An electron therefore deposits en
ergy in its wake. Around 10-100 ionizations/|nm caused by an electron
are generated at diagnostic X-ray energies (approximately 33 eV/ion
pair). The concept of linear energy transfer, LET (unit keV/|am) can be
used to describe this phenomenon together with the concept quality fac
tor Q, explained later. In addition, part of the energy of the electron is
absorbed by secondary electrons, so-called delta particles; they in turn
have sufficient energy to cause new ionizations.
Exposure
Exposure implies that ions are generated in air as a consequence of the
passage of radiation. Ions can be measured with an ionization chamber,
which is an air space between two conducting plates coupled to the pos
itive and negative poles of a voltage source. The exposure = the number
of ions with negative (or positive) charges divided by the mass of air in
the ionization chamber. The Sl-unit is C/kg (C = coulomb). The older
unit is roentgen R = 2,58 10"4 C/kg.
Absorbed dose
This quantity is the energy per unit mass, which matter has absorbed
from radiation. The Sl-unit is the gray Gy = J/kg (the old unit was rad =
0.01 Gy). At X-ray and isotope imaging energies (15-500 keV) one R
exposure causes approximately 10 mGy (one rad) absorbed dose in all
other tissues except in bone, where the absorbed dose at low energies
(around 20 keV) reaches up to around 40 mGy.
Kerma
The concept kerma comes from the words Kinetic Energy Released in
Matter. It takes into account the dose generated by the aforementioned
delta electrons. It is approximately equal to the absorbed dose in air at
diagnostic X-ray energies.
Dose equivalent
When energy has been absorbed in tissue the biological effect varies de
pending on the organ in question, the type of radiation and energy, dose
31
rate, exposure time etc. These are incorporated in the concept quality fac
tor Q, by which the absorbed dose must be multiplied to get the equiva
lent dose. Its unit is sievert Sv = J/kg (= 100 rem, the old unit).
In X-ray and isotope imaging, Q is approximately 1, because X and
gamma radiation deposit relatively small amounts of energy in tissue.
Another concept, effective dose, describes the probability of damage to
different organs with a weighting coefficient, which is high for radiation
sensitive organs such as gonads, bone marrow, lungs, colon, breast etc.
and small for other tissues, e.g. muscle. The sum of the weighting fac
tors equals to 1.
From the foregoing it is clear that in diagnostic imaging, the units Gy
and Sv, as well as R, rad and rem, have about the same numeric values,
although the concepts have different meanings.
Dose rate
One useful concept in dosimetry is the rate, with which a given amount
of radiation strikes tissues, for instance kerma rate and exposure rate
mR/min, R/h etc. Activity (see the chapter Radioisotopes and radio
pharmaceuticals) is also a concept which incorporates the function of
time. Whether X-rays from an X-ray device or gamma radiation from ra
dionuclides are discussed, the same concepts can be used to describe ra
diation phenomena and the biological effects of radiation.
Radiation biology
Ionization and excitation result in fragmentation of molecular bonds with
potentially harmful consequences to cell structure, metabolism and organ
function. Injuries are divided into genetic and somatic ones. The former
can appear in descendants after a long time has elapsed, and the latter may
occur quickly (acute consequences) or after a considerable delay. In the
peaceful usage of ionizing radiation acute toxicity does not occur.
A distinction is also made between stochastic and non-stochastic ef
fects of radiation. Stochastic implies that even a single ’’hit” of radiation
to one cell or to a small cell group can cause a biological consequence.
Damage may be either hereditary (in gonads) or carcinogenic (in tissue).
There is no threshold, i.e. the extent of the damage does not depend on
absorbed dose (cancer is contracted or not), although the probability of
an adverse event increases with dose. This stochastic nature of radiation
is therefore the basis of conservative radiation protection.
32
RADIOPHYSICS
The non-stochastic effect of radiation has a definite threshold (nor

mally different for every tissue and organ). These have been found from
past experience, e.g. in cancer treatment with radiotherapy during this
century. Diagnostic radiation examinations (where skin dose varies be
tween 0.1 mSv and 0.1 Sv / examination) expose the patient to very small
doses so the consequences of non-stochastic effects do not evolve. One
clear exception is the dose to a fetus, particularly during the sensitive pe
riod of organogenesis. Therefore, the indications for pediatric examina
tions involving ionizing radiation must be examined particularly closely.
It is estimated that if 200 000-2 000 000 people get a dose of 1 mSv
(the same as the background dose per year without radon) it is probable
that one person will develop cancer. It is, however, impossible to sepa
rate so few cases from cancers caused by other factors, such as environ
mental toxins and unknown reasons etc.
Many other factors such as the type of radiation and energy, LET-
value, dose rate, time between exposures or fractionation of dose, dif
ferent sensitivity of tissues for radiation, biological variations etc. have
a significant effect on the likelihood of injury.
Radiation protection
Because injuries from small doses can partly be stochastic the starting
point of radiation protection is to avoid and reduce somatic and genetic
doses to as low a level as possible (ALARA, As Low As Reasonably
Achievable). The consequences of small doses given over long periods
of time are partly unknown, and as the time for a carcinoma to appear
can be decades, damages caused by low level radiation are often impos
sible to separate from diseases caused by other factors. On the other hand
it is important to use sufficient radiation to achieve good quality images.
These examinations, which are clinically indicated, must be performed
with sufficient radiation to achieve an image of diagnostic value.
Patient
The dose can be measured or estimated at different depths in the patient,
or in different parts of the environment. Terms like skin dose (or surface
or entrance dose), depth dose, dose in patient’s centre, exit dose (approx
imately the same as dose to the screen without a grid) and organ dose are
fairly self-evident. Dose diminishes as the depth at which it is measured
increases. In the diagnostic examination of the body only a 1/100-1/1000
33
Figure 7.
Patient thickness very
strongly influences the
entrance dose needed fo r an
image. Measurement condi
tions are also shown.
о J_____ i 1 i_____L
5 10) 15 J20 25
Patient thickness (cm)
part of the initial dose penetrates through. Dose decreases also without
matter, even in air. Radiation intensity (as well as light intensity) decreases
in inverse proportion to the square of the distance from the focus.
Fig. 7 shows how skin dose and exit dose are changed with patient
thickness when the exposure of film to a constant blackness (optical den
sity) is made with an automatic exposure meter. In this case exit dose
does not depend on thickness, because a screen-film combination always
requires a certain amount of radiation.
Many features of X-ray devices and properties of patient tissues in
fluence the dose needed for good image quality. In Table 2 the most im
portant factors are mentioned.
Table 2. Factors influencing patient dose
- radiography (mAs value x number of images) or fluoroscopy (mA

value x examination time)
- high voltage (kVp) and its stability
- filtration
- distance from focus
- field size
- thickness of object and absorption in tissues
- lead grid
34
RADIOPHYSICS
- sensitivity of screen, image intensifier and detectors

- usage of image memory (for instance in surgical operations)
There are big differences in the properties of different imaging methods

and in radiation detectors. Screen-film-combinations are always used in
practise instead of film alone. Screen sensitivities vary from speed value
20 to 1600 (that of the reference screen-film-combination being 100),
when the speed of the film alone has a value of about 1. Consequently
corresponding alterations can be found in patient doses.
Personnel
The first rule in the radiation protection of personnel is to go outside the
X-ray laboratory when a patient exposure is made. In fluoroscopic ex
aminations one must work 1) quickly, 2) with sufficient protective cloth
ing, and 3) at an appropriate distance from radiation sources. These three
measures are of primary importance in both X-ray and isotope work. The
staff who are most likely to be exposed to radiation are those who work
Figure 8. Diagnostic x-ray device: generator, X-ray tube and console (control board).
Exposure is ended when the ionization chamber(s) in the automatic exposure system
has (have) collected enough radiation (ionization) to blacken the film adequately (after
development). The positions o f the three chambers are shown in the radiation field, as
well as spectra (number ofphotons as a function o f energy) in different phases o f the
X-ray chain.
35
with fluoroscopic devices (radiologists, surgeons etc.), nurses who hold

small children or non-cooperative patients, as well as staff working with
the nuclear medicine imaging of patients.
National and international radiation legislation and recommendations
are universally in use. According to these regulations, for instance, ex
amination rooms, devices and working conditions must be adapted so
that doses are diminished to as low a level as possible and that the qual
ity of images and examinations attains the highest possible level. The
most recent ICRP recommendation (publication 60, 1991) puts the max
imum dose level of 20 mSv per one year to the whole body of person
nel. This value is 40% of the earlier maximum limit, which shows the
increasingly conservative attitude in radiation protection.
One should remember that the dose to personnel from scattered radi
ation is 100-1000 times smaller than the dose in the entrance field on the
patient's skin. Therefore it is essential for the radiation worker to avoid
putting his hands in the primary radiation field (use lead gloves). The pa
tient's body can also serve as good protection, if one can place oneself
in such a position that one does not directly see the entrance field of ra
diation.
X-RAY GENERATOR AND X-RAY TUBE

X-rays are obtained from an X-ray tube, to which an X-ray generator
feeds energy in the form of kinetic energy of electrons (Fig. 8). The pri
mary function of a generator is to accelerate electrons to a constant en
ergy value during the whole period of exposure by generating constant
high voltage (kVp) between the glow cathode and rotary anode of the
tube. There are also other requirements:
1. The system should tolerate continuous lasting use.
2. The intensity of radiation should be sufficiently high to enable short
exposure times (diminishes motion artifacts) at a focus-film distance
of approximately 1 m (diminishes distortions and dose as well as im
proves resolution).
3. The size of the focus should be as small as possible (between 0.1x0.1
and 2x2 mm2, improves resolution), and the radiation field must be
limited to the immediate vicinity of the organ in question (radiation
protection, reduces scattered radiation).
36
RADIOPHYSICS
The generator is an electric transformer which converts 220 V (1-phase)

or 380 V (3-phase) alternating voltage to high voltage somewhere be
tween 20-150 kV. High voltage is rectified with a diode bridge.
Depending on the electric coupling in the transformer, 6 or 12-pulse (dur
ing the period of 20 ms) high voltage is generated, with corresponding
pulsatile variations in the radiation yield (both in intensity and in the abil
ity to penetrate tissues). However, so-called medium or high frequency
generators have progressively come into use; they use modem small-
scale electronics to generate constant (as opposed to pulsed) high volt
age. In the past, 2-pulse generators were used especially in dental radi
ography which meant that voltage (and X-ray output also) went down to
zero between peaks of pulses.
Filtration of X-ray spectrum

There is often both a small and a big focus in the cathode (dual-focus).
Electrons emitted from the cathode wire hit the anode in an oblong area,
the surface of which in the direction of the patient is a square of normally
0.3x0.3, 0.6x0.6 or 1.2x1.2 mm2. Both braking radiation and character
istic radiation (see Interactions of electron; X-ray spectrum from X-ray
tube) are generated in the anode. X-rays leave the focal point in all di
rections from the focus, but they are utilized for imaging purposes only
in the direction of the patient by using a multileaf collimator.
In an X-ray tube there is also an aluminium (1-5 mm) and/or a cop
per (0.1-0.5 mm) filter and a light source with a mirror to simulate the
radiation field on the skin. The filtration of the X-ray spectrum dimin
ishes particularly the number of low energy quanta and therefore raises
the average energy of the beam.The patient's body diminishes further the
total intensity (area) of the spectrum and simultaneously hardens the av
erage energy. Spectra at different phases in the imaging chain are shown
in Fig. 8.
The lower curve of Fig. 5 (and the curve labelled "leaves tube" in Fig.
8) shows that the glass or metal envelope and filter have removed all very
low energy photons, which have only a small probability of penetrating
the patient. In the braking radiation spectrum in Fig. 8 one can see the
peaks of characteristic radiation (59 and 67 keV from tungsten anode),
if the energy of incoming electrons is sufficient to excite electrons in the
К-shell (Fig. 1). The area underneath these peaks is only a small per
centage of the total area of the spectrum.
37
Attenuation coefficient f j (1/cm)
10
0,5
0,2
0,1
0,05 Contrast on film

20 30 40 50 60 80 100 150
Energy (keV)
Figure 9. The attenuation coefficient |i fo r Figure 10. Properties o f an object, such

iodine contrast media, bone, muscle and fa t as its thickness and tissue composition,
depends on radiation energy; jli-vales are as well as radiation energy are impor-
biggest at low energies in heavy materials tant factors when adjacent tissues are to
(photoelectric effect). Differences between be seen separately in an image,
bone-muscle and muscle-fat coefficients are
shown with dotted lines. The К-edges o f
medium and heavy elements are situated in
the energy range o f diagnostic X-ray imag
ing. Therefore, an incoming electron or
photon must have more energy than 33.2
keV to excite or ionize an electron from the
К-shell o f iodine.
THE OBJECT AND ITS INFLUENCE ON IMAGE
CHARACTERISTICS
Tissue contrast and total contrast

After X-rays have gone through the object and lead grid the quality of
radiation (X-ray distribution in Fig. 2) cannot be further influenced. Local
variations in the intensity of radiation, in other words tissue contrast must
be conferred as effectively as possible to the image.
Tissue contrast is visualised in a radiograph when two (nearby) areas
can be separated from each other due to their different optical densities
or darkness of film. Reasons for this can be 1) that tissues with equal
thickness have different coefficients of attenuation, or, 2) that their thick
ness is not the same (Figs. 9 and 10).
38
RADIOPHYSICS
Tissue contrast is therefore a property of an object, and it depends on

the inner structure and tissue or elemental composition of the object. The
visualisation of tissue contrast depends in addition on kVp and radiation
spectrum as well as on the amount of scattered radiation. Fig. 9 shows
how attenuation of tissues, based on attenuation of elements, changes as
a function of energy.
Tissue contrast is caused mainly by differences in the coefficients of
tissue attenuation, which depend on energy. An X-ray image is produced
by an X-ray spectrum, in other words by a huge number of polychro
matic quanta with different energies (Fig. 5). The probability of each
photon ending up in a photoelectric absorption or Compton scattering
depends on its energy. Photons with medium energy are most abundant
in a spectrum, but a radiograph is the result of all interactions of photons
in tissues. The low-energy photons cause the biggest contrast, but their
ability to penetrate an object is the lowest.
With radiation detectors such as a screen-film combination (radiogra
phy) or image intensifier (fluoroscopy) or with a digital subtraction de
vice (DSA) it is possible to increase total contrast (which is tissue con
trast amplified by detector contrast). The amplification factor for film
(gamma value) is usually between 2 and 3. An image intensifier does not
generally reinforce contrast, but with DSA one can very substantially
emphasize contrast between soft tissues and blood when a contrast me
dia bolus is used (e.g. in angiography).
When the current (mA) of an X-ray tube, exposure time (s) or their
product (mAs) is increased, the spectrum also changes, its total area or
intensity increases in the same proportion. The image becomes darker,
as blackness or optical density on the film increases. On the other hand,
when voltage (kVp) is increased, this also increases photon energy and
the radiation beam becomes more penetrating (resulting in a smaller
dose), but contrast is reduced.
In an X-ray image or radiograph the shadows of bones are demonstrated
white or light, because bone efficiently stops radiation quanta, especially
at low X-ray energies. Soft tissues are seen in grey tones and organs con
taining gas in dark tones. In digital image manipulation this grey shade
scale is easy to turn upside down. In DSA strongly absorbing objects, like
veins filled with contrast media are normally displayed black, etc.
Photographically speaking, an X-ray film is a negative. Normal X-ray
imaging without contrast media (plain radiography) is suitable for the
39
examination of bones and organs containing gas (like the lungs), but soft
tissues cannot be separated from one another. Liver and kidney for in
stance, as well as brain and cerebrospinal fluid are equally grey in a ra
diograph. For the visualization of soft tissues contrast media and/or dig
ital methods with a computer must be used.
Influence of scattering
After Compton scattering the photon continues with reduced energy in
a new direction (see Interactions of X-ray and gamma quantum with mat
ter). All scattering angles have nearly the same probability, but at higher
energies scattering in small, forward directed angles is more probable.
This is regrettable, because film is positioned in the direction of the pri
mary photons and these small angle scattered photons. Primary photons
make the image, but scattered photons only reduce contrast.
Scattered radiation is present in all X-ray and nuclear medicine imag
ing. Its influence is smallest in thin objects imaged with small field size
and at low energy. When examining large and thick objects (body) the
number of scattered photons in the exit field, in other words at the film,
can be 5 or even 10 times bigger than the number of primary photons.
The following ways are efficient in diminishing the adverse influence
of scattered radiation in X-ray examinations:
1. Keep the field size as small as possible. In other words, collimation
of radiation, e.g. with a blade-type diaphragm must be used.
2. Use a grid against scattered radiation.
3. The space between an object and the film can be used to reduce scat
ter (so-called air gap technique).
4. The object can be compressed
5. Low voltages reduce scattering (but this is against the main principle
of radiation protection as it increases the patient dose).
A lead grid allows primary photons from the focus to go through to the
film like a Venetian blind allows light to go through. The grid consists
of thin non transparent lead lamellae placed side by side with transpar
ent aluminium or carbon fibre lamellae. It lets only merely parallel or al
most parallel photons pass through (Fig. 2). The relation between the
height of a lamella (a few mm) and the distance from a non-transparent
lamella to the next one (0.1-0.5 mm) is called the grid ratio. It is gener
ally between 5 and 15. Both parallel and focused grids are in use. The
40
RADIOPHYSICS
Figure 11.
X -ra y focus
Distortions arise in an
image due to imaging
geometry and the charac
teristics o f an object.
grid can also be set in motion during the exposure so that the lamellae
can not be seen in the image.
Imaging geometry
In conventional X-ray examinations tissues can be divided into four main
groups: skeletal structures (seen as white or in light tones in the image),
soft tissues (grey), fat (somewhat darker than soft tissues) and gas (dark).
The basic X-ray examination is well suited to skeleton and thorax ex
aminations, because the boundaries between tissues (with the exception
of soft tissues and fat) can clearly be seen. To separate muscles, inner
soft tissue organs etc. from one another, contrast media or newer exam
ination methods like CT or magnetic resonance imaging must be used.
Electromagnetic radiation travels in straight lines. Without scattering,
the understanding of the formation of an X-ray image would demand
only appreciation of laws of geometry, in the same manner as articles
between a light source and a screen cause shadows. Fig. 11 shows the
geometrical enlargement in exaggeration, as well as different distorted
shadows of object details on a film surface.
There is always enlargement in a radiograph. It is biggest on the edges
of an image and from those objects which are most distant from the film
surface. Enlargement is smallest in the middle of the image field and
from objects nearest to the film surface. A shadow on an image is caused
by a real object, i.e. a lesion in tissue with different absorption proper
ties to its surroundings, or it can be a sum of shadows of two or more ob
jects on each other in the direction of the radiation beam. It can happen
that a small or rather poorly absorbing object lying behind a bigger, more
strongly absorbing object, can not be distinguished at all (for instance a
small tumour lesion behind a rib).
41
Figure 12.
Patient Image receptor Film Factors in having a
Anatomy Screen - film Development greater or lesser influ
Physiology combination time, temperature
Physical properties Image intensifier Chemicals ence on image quality
Detector in the imaging chain.
Abbreviations C, R, N,
Geometry Image reading and D stand fo r
Distance Illumination Contrast, Resolution
focus-patient-film Inspection
Distortions
(sharpness), Noise
Object properties (proportional to the
square root o f the
Motion Imaging technique Interpretation number o f quanta) and
Patient as whole kVp, mA, s exposure Dose.
Internal motion Filtration
X-ray tube Exposure
Image receptor Focus
The understanding of geometrical facts is of primary importance for

an image interpreter and user of an X-ray device. Long exposure time
when an object moves causes, for instance, unsharp images of sharp bone
edges. Short exposure times are always recommended; they require large
amounts of current and demand a big load from the X-ray tube.
An important factor is the shape of an object. Many organs are cylin
ders or they have curved surfaces. More radiation is absorbed in the mid
dle of spherical objects and therefore a radiograph tends to be darker at
its edges. This absorption unsharpness (for instance in a lung tumour)
can be seen in an image.
IMAGE QUALITY
In all imaging methods there are many factors which influence image
properties and quality. X-radiography is mainly described in this chap
ter, but the following concepts are usable in all medical imaging meth
ods. Fig. 12 shows factors and parameters divided into eight groups
which have significant effects on image quality.
What is image quality? An image is always a two-dimensional pre
sentation of a three-dimensional organ (possibly 3D, if slices are taken
side by side or if changes in time are taken into account). The chain from
target tissue via transmitted or emitted radiation to the interpreter’s brain
(with a more or less definitive understanding of the normal and patho
logical findings) is long and complicated. There are factors which influ
ence the interpretation in different directions. The first part of the chain
42
RADIOPHYSICS
is rather well known; physically measurable quantities: contrast, resolu

tion, and noise do exist. The terminal parts of the chain, i.e. the tasks and
functions of the eye and brain for the detection and recognition of find
ings are not so well known.
Connection between the physical quality parameters and diagnostic
applicability is difficult and laborious to determine objectively. To com
pare two imaging methods objectively it is possible to measure sensi
tivity and specificity for studied objects and diagnosis, and express re
sults in the form of a so called ROC-analysis (Receiver Operating Curve).
Randomized groups of images are compared by several interpreters. The
functioning point of each interpreter is situated (he uses a threshold be
tween pathological and normal findings) somewhere in the ROC-curve.
Physical parameters of the image

Contrast, resolution, noise, and signal to noise ratio as well as the posi
tion of the image and image portions on a grey scale are important pa
rameters in all imaging. By changing the latter in a digital image (win
dowing) the usability of the image can be greatly improved (see chapter
on Digital image processing).
Contrast (the difference of blackness or optical density of film between

nearby areas in an image, Figs. 2 and 10) is caused by properties of tis
sues and properties of the film or other radiation detector. The difference
of transmitted X-ray intensities in Fig. 10 can be normalized with the
sum of intensities resulting in contrast scale from 0 to 1. The human eye
can detect differences in contrast of 0.02 under good light conditions.
With digital methods it is possible to go down to the 0.001 level (Fig.
13). While viewing images on a lightbox it is important to mask light
from any side of the image reaching the eye. A magnifying glass or a
bright light should be used when necessary. These measures improve
greatly the detection of low contrast areas.
Many factors which strongly affect contrast have already earlier been
described. Noise in an image also frequently plays an important role par
ticularly at low contrast levels. Noise can be seen as a locally variant,
fine or rough change in optical density which occurs even in an image
of an evenly exposed water or Plexiglass phantom. There are two prin
cipal causes of noise in an X-ray image:
43
1. The number o f X-ray quanta varies both as a function of time and site
(quantum noise, statistical nature of radiation).
2. The construction of the film, screen and image amplifier, as well as
the electric circuits in the imaging devices causes noise.
Relatively few X-ray quanta per exposure are collected while working
with fast screen-film combinations and a very grainy image may result,
like spots of rain on an asphalt surface. With normal or slow screen-film
combinations (as well as with mere film) much more quanta, "raindrops"
(dose increases) are detected, and an image looks as if it is "calming"
out, and not so noisy. The signal-to-noise ratio is a fundamental concept,
with which image characteristics can quantitatively be compared, par
ticularly in digital imaging methods.
In the image of a sharp edge the film blackness changes to another
level of blackness on a short distance serving as a measure of image
sharpness. Unsharpness is caused by many factors in imaging chain; fo
cus size, motion of the object, thickness of the screen, geometrical fac
tors etc. Sharpness is in practice defined by spatial resolution, which tells
how many details or lines (line pair, lp) can be distinguished for instance
in one mm (unit lp/mm). The following values are in general use:
- 20 lp/mm (film alone)
- 10 lp/mm (normal screen-film-combination)
- 5 lp/mm (fast screen-film-combination)
- 1-2 lp/mm (image intensifier-television chain, magnetic camera)
- 1 lp/mm (CT device and ultrasound device)
- 0.1 lp/mm (gamma camera)
Resolution can also be defined as the smallest distance (mm) between

two objects, which can be separated from each other in an image. The
concept of modulation transfer function, MTF is also useful when com
paring the contrast and resolution properties of imaging methods.
Comparison of imaging methods

In Fig. 13 general imaging methods are compared in terms of resolution
and contrast. Both, i.e. low contrast level and small details, can not be
achieved simultaneously. For instance contrast must be high when small
details are to be separated, (e.g. in the inner ear or fine structure of bone).
On a thorax image "shadows" in lung parenchyma are usually looked for;
44
RADIOPHYSICS
Figure 13. Mean values o f contrast and resolution in various imaging methods. The
CR-curve o f digital cassette radiography lies in the neighbourhood o f that o f the CT
curve, but shifted to the left fo r smaller detail.
the areas of such lesions must therefore be relatively large especially if their
density does not differ much from the surroundings. Low contrast at an
edge, large focus size and geometrical magnification make it more diffi
cult to see small objects in thorax imaging. Different imaging methods can
consequently be used depending on the information which one is seeking.
Digital imaging methods improve the ability to register small contrast
differences (Fig. 13). The aforementioned windowing method can play
a central role in the image interpretation performed in modem image
work stations, where digital images from different devices (CT, DSA,
magnetic resonance imaging, nuclear medicine, PET, ultrasound) are
compared and analyzed. Fig. 13 contains no information regarding the
dynamic characteristics of imaging methods or of noise.
45
Chapter 4
Modalities and methods
Hans-Jergen Smith
PROJECTION X-RAY IMAGES: RADIOGRAPHY,

FLUOROSCOPY AND FLUOROGRAPHY
The evolution of radiology during the past two decades has been tremen
dous, not least due to the introduction of computed tomography (CT) and
ultrasonography (US) in the seventies, and magnetic resonance imaging
(MRI) in the eighties. These new modalities all provide sectional im
ages, i.e., two-dimensional displays of tissue slices. However, the ma
jority of examinations performed at most radiology departments still pro
duce traditional projection images.
The techniques used in projection X-ray imaging may be divided into
three main groups: 1) direct analogue techniques, 2) indirect analogue
techniques, and 3) digital techniques.
Direct, analogue techniques

With these techniques, the final X-ray image is created directly on a de
tector medium, i.e., without any complicating intermediate steps. The
medium may be a radiographic film or a fluorescent screen. The film and
the screen are both analogue detectors of X-rays, which means that their
response to a steady and continuous increase in radiation dose, is also
steady and continuous, as opposed to stepwise. The radiographic film re
sponds with blackening, the fluorescent screen by emitting visible light
(fluorescence).
The two main direct, analogue techniques are: a) direct radiography,
and b) direct fluoroscopy.
47
Direct radiography
This is the original, traditional means o f radiography where the X-rays,
after having passed through the patient, create an image directly on a
photographic film (Fig. 1).
The film is covered,
usually on both sides, by
a photographic emulsion.
The emulsion consists of
a layer of gelatine con
taining tiny silver bro
mide crystals. (Average
linear dimension is ap
prox. 1 |nm.) The emul
sion is sensitive to pho
tons having a wide range
of energies; X-rays, ultra
violet radiation, and visi
ble light may all blacken
Figure 1. X-ray instrument fo r direct radiography. the film. The silver bro
In the box between the X-ray tube (arrow) and the
patient are adjustable lead diaphragms reducing the
mide crystals are ionised
primary beam to the maximum size needed fo r the by the photon energy. The
region to be imaged. Prior to exposure, the size and number of silver ions
position o f the X-ray field on the patient surface may
(Ag+) thus created, varies
be seen by means o f a light source above the
diaphragms. The radiographic cassette is placed in with the number of pho
a tray (open arrow) below the patient table, and lo tons transmitted to the
cated between the table and the cassette is a mov film; the higher the radia
able secondary-radiation grid to remove scattered
radiation from the patient (see Figure 2 in the
tion dose, the higher the
Radiation physics chapter). (Phototechnical number of silver ions. The
Department, Rikshospitalet, Oslo.) varying density of the sil
ver ions creates a latent
image within the emulsion, the images only become visible after treat
ment with a liquid developer. When the film is developed, black metal
lic silver is precipitated from those crystals containing silver ions. The
non-ionised silver bromide crystals remain unchanged and invisible.
After being developed, the film is washed, fixed, and dried. The fixative
removes the silver bromide crystals, leaving the metallic silver behind,
thus making the film insensitive to light.
48
MODALITIES AND METHODS
In this way, the visible image on the radiographic film is related to

varying degrees of blackening, caused by the varying density of the mi
croscopic black silver granules. The darkest areas in the images have
been subjected to the highest radiation intensity or dose, and the image
is thus a so-called negative.
One might believe that the blackening of the radiographic film is
caused solely by irradiation with X-rays, and indeed this was the case in
the earliest days of radiography. Today however, the film is nearly al
ways placed within a cassette between two fluorescent screens, so-called
intensifying screens. The screens are effective absorbers of X-ray pho
tons (photo-electric absorption). In the process, light photons are emit
ted, and these photons are the main cause of blackening of the film. The
response of the screens to X-rays is linear; a certain increase in radiation
dose is followed by a corresponding increase in emitted light intensity.
The radiographic cassette is 10-1,000 times as effective as film alone,
and the use of cassettes therefore allows a considerable reduction in ra
diation dose. The cassette protects the film from external light and makes
it possible to undertake the radiographic exposure in daylight and then
bring the film to the darkroom for development. The cassette may also
contain a grid to reduce secondary or scattered radiation to the film, and
the back of the cassette may have a layer of lead to stop the X-ray pho
tons.
There are different kinds of intensifying screens and radiographic
films. Some screens emit blue light (calcium tungstate and some lan
thanides), and others emit green light (various lanthanides).
Correspondingly, there are films that are especially sensitive to blue light
or green light, respectively. The newer lanthanide screens may be 3-5
times as sensitive to radiation as the older calcium tungstate screens,
which means less dose to the patient in otherwise comparable circum
stances.
A film-screen combination has a characteristic curve, showing the
variation of the blackening {density) of the photographic emulsion with
exposure (Fig. 2). In radiography, the structures of interest should lie
within the middle, linear part of the curve. Here, the contrast amplifying
effect of the film has its maximum. The slope of the linear part of the
curve is called the gamma, and film-screen combinations having a large
gamma will yield high-contrast images. Parameters such as sensitivity,
spatial resolution, and noise are to a large extent determined by the in-
49
D
Figure 2. Characteristic curves o f two dif
ferent film-screen combinations, A and B,
showing the variation o f film density D with
exposure E. Both ordinate and abscissa are
logarithmic. The density is defined as
log(Li/Lt), where Li is the light intensity in
cident on the film, and Lt is the light inten
sity transmitted by the film. I f the intensity o f
the transmitted light is 1/10 the intensity o f
the incident light, D = log 10 = 1, which is
a moderate density. A common density
range o f radiographic films is approx.
0.2-3.0. The (nearly) linear part o f curve A
has a steeper slope (higher gamma value)
than that o f curve B, and A therefore pro
vides higher contrast than B.
tensifying screens. A thick screen containing large fluorescent crystals

is fa st (i.e., has a short exposure time) due to its high sensitivity. The ad
vantage to the patient is low radiation dose; the disadvantages are low
spatial resolution and high noise. Slow screens are thinner with smaller
fluorescent crystals that give higher spatial resolution and less noise, the
radiation dose needed is higher, however. When low patient dose is im
portant, as in imaging pregnant women, fast intensifying screens should
be used.
Direct radiography using radiographic cassettes is still quantitatively
the most important radiological modality. The technique is also called
full-size radiography because the anatomy is shown in its original size,
with some added geometric enlargement. The technique provides static
images with the highest spatial resolution of all radiological modalities.
Full-size radiography is too slow for movie-like (cine) displays; to give
the impression of smooth motion, at least 25 images per second are
needed. With the use of so-called serial changers it is possible, however,
to perform full-size radiography with an exposure frequency of e.g. 2
images per second. Serial changers may be compared to the automatic
film advance of modem cameras. The film is drawn into the primary ra
diation beam for exposure, and then transported into a receiving cassette
for later development. Full-size serial radiography is used in angiogra
phy (contrast-enhanced X-ray imaging of blood vessels) to follow the
flow of contrast medium in the vascular tree.
50
Figure 3.
Tube
Traditional tomography. X-ray tube and
radiographic cassette move together in
such a way that the projections o f all
points in the plane o f interest remain
stationary on the film. Point I is located
in the plane o f interest and is imaged
sharply; point 2 is located outside the
desired plane, and its image on the film
is blurred due to gross movement un
sharpness.
The projection image provided by direct analogue radiography contains

all radiopaque structures of the three-dimensional object being imaged.
Obtaining several projection views of the object (e.g. frontal, lateral,
oblique), shows the spatial relationships of the various structures to bet
ter advantage, and improves visualisation of the anatomy. Traditional ra
diography may, however, also provide "sectional" images. The technique
is called (traditional) tomography and involves movement of the X-ray
tube and film in such a way that only a thin plane through the patient,
parallel to the film, is imaged sharply. Structures located in planes other
than that being examined (closer or more distant to the film) are sub
jected to blurring due to gross movement unsharpness (Fig. 3).
Traditional tomography is fundamentally different from the more mod
em tomographic and cross-sectional imaging modalities, such as US, CT,
MRI, SPECT, and PET (see later). The sectional images provided by
these new modalities contain information from thin slices of tissue only.
The traditional tomographic image, on the other hand, also contains
blurred information from all tissues above and below the sharply imaged
plane. The importance and use of traditional tomography has greatly di
minished with the introduction of the new imaging modalities.
Direct fluoroscopy
Traditional fluoroscopy or screening, common in clinical practice until
the mid-1960s is now obsolete. The transmitted X-ray beam fell on a flu
orescent screen, resulting in a dynamic projection light image. The im
age could be observed directly by the radiologist, who was protected
51
from transmitted X-rays by a sheet of lead glass. The technique was es
pecially used to study physiological movements such as swallowing, res
piration and cardiac contractions. To keep the exposure rate to the pa
tient at tolerable levels (levels today considered too high), the screen lu
minance was extremely low, in fact so low that approximately 15 minutes
of dark-adaptation was needed by the radiologist prior to fluoroscopy.
Traditional direct fluoroscopy has long since been replaced by indirect
fluroscopy employing X-ray image intensifiers and TV-technique.
Indirect, analogue techniques

In modem fluoroscopy, the primary projection image is created on a flu
orescent screen, quite similar to the direct techniques. The screen image,
however, is not observed directly. The screen is part of an X-ray image
intensifier that enhances the brightness (luminance) of the primary im
age by a factor of about 5,000 (Fig. 4).
The minified and intensified image that emerges from the intensifier,
may be recorded via lenses by a TV camera and shown on a monitor.
The image may also be reflected by a mirror to a small-film still camera
(70 mm, 100 mm or 105 mm film format), or cine camera (16 mm or 35
mm film format) (Fig. 4). Filming with a still camera, so-called spotfilm
ing, is also calledfluorography, and the spot film itself afluorogram. The
patient dose in fluorography is about 1/10 the dose in full-size
Input fluorescent
Figure 4. X-ray image-intensifier-television system. The transmitted X-rays emerging

from the patient, fa ll on the input fluorescent screen o f the image intensifier tube. The
screen is in intimate contact with a photocathode. The X-rays release light from the
screen, and the light produces electrons (photoelectrons) from the photocathode. The
electrons are accelerated through the image intensifier tube, and are focused on an
output fluorescent screen, much smaller than the input screen. The intensified and
minified image on the output screen is transmitted via lenses to a TV camera, and
reaches a TV monitor (or videotape recorder) as an electric video signal. The output
image may also be mirrored to a small-film still or cine camera.
52
phy; the image quality, however, (especially spatial resolution) is

markedly inferior. Cine-fluorography provides movie-like images with
a time resolution of e.g. 50 images per second. Cine-fluorography using
35 mm film is still commonly used in angiographic studies of the heart
and coronary arteries (although digital techniques are gradually replac
ing the analogue ones). The cine-film is usually shown projected on a
screen by a movie projector.
Digital techniques
All radiological techniques and modalities are analogue at the starting
point of imaging. The light intensity in a fluorescent screen, the electric
current induced by X-rays in the CT detector, by the echo in the ultra
sound transducer, or by the magnetism in the MR receiver coil, are all
analogue, continuous responses. The last three modalities, computed to
mography (CT), ultrasonography (US) and magnetic resonance (MR)
imaging, are still considered digital techniques because the analogue re
sponse (the electric current) is digitised (given certain numerical values).
Digital techniques may be applied in projection X-ray imaging as well,
and the term digital radiography is commonly used in this restricted
sense only.
A "true" digital image is composed of a digital matrix, i.e., rows and
columns of numbers. The numbers may represent echo strength in an ul
trasound image, X-ray attenuation in a CT image, tissue magnetism in
an MR image or light intensity from a fluorescent screen in digital pro
jection X-ray imaging. To visualise the image, the digital matrix is trans
formed into a matrix of visible picture elements, pixels, where each pixel
is given a shade of grey according to the corresponding number in the
digital matrix. (See the Digital radiography chapter.)
There are several ways to produce digital projection X-ray images.
Following exposure to X-rays, special imaging plates retain a latent im
age of stored energy. By scanning the imaging plate with a laser beam,
the energy is released as light or luminescence, where the light intensity
is proportional to the absorbed dose of X-ray photons. The emitted light
is recorded by a photo detector as analogue signals; the signals are digi
tised, and the image may be presented in a grey scale format on a mon
itor or hardcopied by a laser printer.
An alternative digital technique is to digitise the analogue video sig
nal coming from the TV camera in a X-ray image-intensifier-television
53
system (Fig. 4). The digitised image may be displayed on a TV monitor

(digitalfluoroscopy), or it may be photographed by a small-film camera
(digital fluorography). A variant of this technique is used in angiogra
phy for subtraction of images. In addition to displaying digital an
giograms, the technique may also be used to subtract the data contained
in an image having no radiographic contrast medium in the blood ves
sels from an image of the exact same area containing contrast medium
within the blood vessels. The result is a selective and improved visuali
sation of the vessels; all other structures, e.g. bone, are more or less sub
tracted. This technique is called digital subtraction angiography (DSA).
The spatial resolution of digital images is inferior to full-size radio
graphs due to the relatively large pixel size. The digital format still has
many advantages. Key words are digital archiving (on magnetic and op
tical disks), communication (via network, phone and satellite), and post
processing and manipulation (e.g. change of contrast, grey scale, and
size; calculation of distance, area, and volume; measurement of pixel in
tensities).
COMPUTED TOMOGRAPHY
The invention of computed tomography (CT) by Sir Godfrey Hounsfield
in the early 1970s, was considered by many to represent the greatest step
forward in radiology since the discovery of the X-rays. Together with
Allen Cormack, Hounsfield was awarded the Nobel Prize in 1979 for his
achievement. The first CT scanners were designed for head studies only,
but soon whole body scanners became available as well. Today, CT scan
ning can be used for imaging of any part of the body.
The technological advances in both hardware and software have been
tremendous and have greately enhanced the applications and image qual
ity of CT scanning since the introduction of the first CT scanner (EMI-
Scanner) in 1972. Even though CT has met competition, first from ul
trasonography, and then from magnetic resonance imaging, there are still
many indications where CT is the imaging method of choice. The diag
nostic role of CT will be further discussed in the clinical chapters.
Physical principles
On their way through tissues, X-rays are attenuated, partly due to ab
sorption of energy, partly due to scattering. The attenuation may be ex
pressed by the equation:
54
I = I0e -^ (l)
where I is the intensity of the transmitted radiation (i.e., the radiation ex
iting from the tissue), I0 is the intensity of the incident radiation (enter
ing the tissue), ц is the so-called total linear attenuation coefficient of
the tissue, and d is the travelled distance of the radiation through the tis
sue (tissue thickness). The attenuation coefficient, ц, is determined by
the atomic number and electron density of the tissue; the higher the
atomic number and electron density, the higher the attenuation coeffi
cient. Atomic number and electron density are thus the two parameters
determining the X-ray attenuating properties of a tissue. Note that the at
tenuation coefficient is also dependent upon the X-ray energy (see Fig.
9 in the Radiation physics chapter).
All imaging techniques and modalities using X-rays, are based upon
the fact that different tissues provide different degrees of X-ray attenu
ation. The radiographic film used in full-size radiography has a very high
spatial resolution, provided there are sufficiently large differences in at
tenuation between the structures being imaged. In this respect, full-size
radiography is superior to all other radiological modalities. One of the
major disadvantages of the film, is that its sensitivity to small differences
in attenuation is low, i.e., its contrast resolution is poor. A radiographic
film may roughly differentiate between only four different "substances"
in the body: bone/calcification, soft tissue/fluid, fat, and gas (in decreas
ing order of attenuation). It is impossible to differentiate between dif
ferent soft tissues, or between soft tissue and fluid. The ability of the ra
diographic film to show structural detail is further diminished by the pro-
jectional nature of the technique, resulting in considerable overlap of
structures. Traditional tomography may improve the display of structural
details, but even tomographic images contain (blurred) information from
overlapping structures contributing to a reduction in contrast resolution.
With CT, only thin tissue slices are exposed to X-rays. There is no dis
turbing superimposition or blurring of structures located outside the se
lected tissue planes. The result is a contrast resolution far superior to pro
jection X-ray techniques. The technical developments that have occurred
in CT vary between manufacturers, and several generations of CT scan
ners have evolved. The generation number (first, second, third, fourth
generation scanner, etc.) refers to the fundamental tube-detector struc
ture of the scanner. Most scanners today have a basic tube-detector sys-
55
Figure 5.
Schematic drawing o f tube-detector
system o f 3rd generation CT scan
ner. The X-ray tube emits a sharply
collimated fan beam ofX -rays which
passes the patient and reaches an ar
ray o f detectors. Tube and detector
array rotate together around the p a
tient; one exposure often comprises
360° rotation.
tem as illustrated in Fig. 5 (3rd generation). A thin, collimated, fan

shaped beam of X-rays, perpendicular to the long axis of the body, is
emitted from the tube. The fan may be wide enough to encompass the
entire body diameter. By altering the collimation, the fan thickness may
be varied from e.g. 1-10 mm. The thickness of the tissue slice exposed
varies accordingly. The fan beam of X-rays transmitted through the pa
tient is detected not by a film, but by an array of special detectors. The
detector number may be approximately 700, and their location and dis
tribution are adjusted to the fan beam width (Fig. 5). Detectors in cur
rent use are either solid-state crystals of various compositions (e.g.
sodium iodine) or hollow chambers filled with pressurised xenon. In the
detectors, X-ray photons generate electrical signals. The higher the in
tensity of the primary beam reaching the detector, the stronger the elec
trical signal. By recording the intensity of the transmitted radiation (I in
Eq. 1), the attenuation of the primary beam may be calculated. CT de
tectors are approximately 100 times more sensitive than radiographic
film in detecting differences in radiation intensity, and are therefore
equally more sensitive in detecting differences in attenuation.
A CT examination starts with a digital projection radiograph
("scanogram", ’’scout view") of the anatomical region to be slice imaged.
The projection image is obtained by moving the examination table with
the patient through the fan beam without rotating the tube or detectors
(Fig. 6). The projection image is used for selection of slice locations,
which are shown as superimposed lines ("slice level annotation").
56
An exposed tissue
slice may be consid
ered divided into a
number of equally
large volume ele
ments, so-called vox
els (Fig. 7). To calcu
late the X-ray attenua
tion in each voxel, the
attenuation recorded
by each detector needs
to be measured at sev
eral projections. This
is done by simultane Figure 6. CT scanner. The X-ray tube and detectors are
ous rotation of the X- located inside the frame-work or gantry, surrounding the
patient. The gantry may be angled around a horizontal
ray tube and detector axis to a maximum o f approx. 20 °. The examination
array in the slice plane starts with a projection image (scanogram): the patient
during exposure (Fig. table is fe d through the gantry opening (aperture) during
exposure without movement o f the tube-detector system.
5). In the two-dimen-
A vertical tube-detector orientation (tube at 6 or 12 o'
sional image of the tis clock) yields frontal projections, and a horizontal tube-
sue slice (the CT detector orientation (tube at 3 or 9 o'clock) provides lat
scan), each voxel is eral projections. (Phototechnical Department,
Rikshospitalet, Oslo.)
represented by a pic
ture element, or pixel,
the size and location
of the pixel being de
termined by the size
and location of the
voxel in the scan
plane. The scan is pre
sented on a monitor,
where each pixel is
given a shade of grey
or brightness, accord
ing to the attenuation
Figure 7. The imaged slice o f tissue divided into volume
in the corresponding elements, voxels. The attenuation in each voxel deter
voxel. Pixels repre mines the brightness (shade o f grey) o f the correspond
senting high attenuating pixel in the final two-dimensional image.
57
Figure 8.
Fat Scale o f Hounsfield units
Water (HU). The approximate scale
Tissue Dense locations o f different sub-
Air Icalcium Bone bone stances are indicated. (By "tis
sue" is meant most fat-defi-
11 ч i «n 111 Ч 1 1 1 lu jl !------- j________ L. d en t soft tissues and
-1000 0 1000 2000 3000 parenchymal organs.)
Hounsfield units Reference points: -1,000 H U
fo r air, 0 HU fo r water.
ing voxels (e.g. bone) are bright, and pixels representing low attenuat
ing voxels (e.g. adipose tissue) are relatively dark.
CT scanning allows measurement o f tissue attenuation in a simple
manner, and these measurements may have some diagnostic value. For
example, fatty infiltration of the liver may be diagnosed by measuring
abnormally low attenuation in the liver parenchyma. The attenuation is
usually given a numerical value, an attenuation number or CT number.
The numbers are set on an arbitrary linear scale which in modem CT
scanners ranges from approximately -1,000 to +3,000 (Fig. 8). The unit
for CT attenuation is named the Hounsfield unit (HU). The CT scanner
is calibrated to give water an attenuation number equal to 0, and air an
attenuation number equal to -1,000. Due to the computer technology used
in CT scanning, the attenuation scale is based upon the binary system
(see the Digital radiography chapter). The scale comprises 4,096 atten
uation numbers (12 bits, 212), and the exact values range from -1,024 to
+3,071. (Older scanners will show only 2,048 numbers, ranging from
-1,024 to +1,023. The numbers for water and air are the same, however.)
Bone tissue has attenuation numbers ranging from approximately 800
HU in normal cortical bone to approximately 3,000 HU in the temporal
bone pyramids. Most parenchymal tissues have values in the range o f
40-80 HU, and pure fatty tissue has attenuation numbers in the order of
-100 HU. Theoretically, these arbitrary numbers are directly proportional
to the linear attenuation coefficients of the tissues; it should be noted,
however, that the measurements of these numbers suffer from inaccura
cies and inconsistencies caused by artifacts. For diagnostic purposes, at
tenuation numbers should therefore be used with caution.
Although CT scans have a contrast resolution far superior to traditional
radiography, the spatial resolution is inferior. The spatial resolution is
determined by the voxel size, i.e., by the pixel size and slice thickness.
58
The smaller the voxels, the higher the spatial resolution. An ordinary
number of voxels (and pixels) in a square field-of-view (FOV, the area
being imaged) is 256 x 256 or 512 x 512 (the matrix size). If an area dis
played in a 512 x 512 matrix measures 250 x 250 mm, each pixel will
have a size of approximately 0.5 x 0.5 mm (250 mm : 512). The slice
thickness is often 5-10 mm, but may be as thin as 1 mm. Thin slices are
good for spatial resolution, but require a higher radiation dose to retain
image quality (signal-to-noise ratio). Thin slices are also impractical
when a large anatomical coverage is needed. The number of slices could
become very high, further increasing the total radiation dose to the pa
tient. The examination time will also increase with the number of slices.
The choice of slice thickness is therefore a compromise between the de
mands for high spatial resolution, low radiation dose, and short exami
nation time.
A recently introduced, entirely new scanning concept, named spiral
CT, has dramatically increased the efficiency of CT scanning with re
spect to anatomic coverage per unit time. During exposure, there is a
continuous linear movement of the table through the primary fan beam,
and simultaneously a continuous rotation of the tube and detector array.
The result is a spiral shaped trajectory of the fan beam through the pa
tient. A large anatomical area may thus be covered during one breath-
hold. By providing thin and contiguous ’’slices” (i.e., densely packed,
thin windings in the spiral), spiral CT may yield very high quality three-
dimensional reconstructions. Combined with intravenous bolus injec
tions of contrast medium and subtraction techniques, CT angiograms
may be reconstructed, providing projection images of the three-dimen
sional vascular tree.
Contrast media in CT scanning

Contrast in CT scanning is determined by differences in attenuation, but
despite the superior sensitivity of CT in detecting attenuation differences,
these differences are often too small for diagnostic purposes. In the vast
niajority of CT examinations, various contrast media are therefore added
to enhance attenuation differences. The various contrast media are re
viewed in the chapter Contrast media, and their diagnostic usefulness is
discussed in the clinical chapters. The reader is therefore referred to these
sections.
59
Cine CT
Even spiral CT scanners are too slow to give a detailed depiction of the
cardiac structures. There is, however, a very special CT instrument hav
ing exposure times of 50 ms and a maximum exposure rate of 17 images
per second. This speed is sufficiently high to "freeze” cardiac motions;
sharply delineated images of the heart at different phases of contraction,
may be acquired without the use of ECG trigging or gating. The scanner
has been named cine CT, ultra fast CT, and millisecond CT. The X-ray
source is a large electron gun with several massive parallel anode tar
gets, oriented in semicircular rings around the patient. The intense elec
tron beam is electronically steered along the tungsten anode rings. The
X-ray beam thus created, sweeps through the patient in a fan shape, and
is detected by a fixed array of detectors. There is thus no movement of
”tube" or detectors.
Cine CT instruments are more expensive than conventional CT scan
ners, and they are so far not widely used. Competition from spiral CT
and MR imaging will also probably contribute to a restricted use in the
future. In addition to cardiac studies, cine CT has played a role in scan
ning of small children. The short exposure time "freezes" patient move
ments, and the use of sedation, which otherwise is necessary at most pae
diatric CT examinations, may be avoided.
RADIONUCLIDE IMAGING
X-ray examinations and nuclear medicine have in common the use of
ionising radiation. All X-ray examinations (including CT) are based upon
the detection of radiation having passed through the patient, i.e., trans
mitted radiation. Radionuclide imaging, on the other hand, involves de
tection of radiation emitted from a radioactive tracer inside the patient.
Radioactive tracers, termed radiopharmaceuticals, may be used for
either diagnostic or therapeutic purposes. They all contain radionuclides,
which are unstable atoms that decay spontaneously with the emission of
energy. This radioactive part of the radiopharmaceutical is often coupled
to a carrier molecule which determines the distribution in the body. The
ideal radiopharmaceutical is distributed only to the organs or structures
to be imaged. The distribution may be determined by e.g. metabolic
processes (the carrier molecule may be part of the metabolic process), or
by local perfusion or blood flow. Recording of radioactivity may then
give important functional information. The ability to show physiologi
es
calfunction, is the major advantage of radionuclide imaging as compared

to alternative radiological modalities. A relative disadvantage is the low
spatial resolution of the technique.
The radionuclide itself should ideally have a half-life in the order of
one to few times the examination time, which may range from ten min
utes to several hours. This would ensure sufficient radioactivity through
out the examination, without undue radiation to the patient after com
pletion of the study. The radioactive decay process may yield emission
of alpha, beta or gamma rays. For imaging purposes, radionuclides emit
ting gamma photons (high-energy electromagnetic radiation) are pre
ferred. Alpha particles (helium nuclei) and beta particles (electrons) are
unsuited for imaging due to poor tissue penetration. Similar to X-rays,
the penetration of gamma rays increases with increasing photon energy.
The energy should not be too high, however, or the photons may pene
trate the detector without being absorbed. In radionuclide imaging,
gamma photon energies in the range of 50 to 300 keV are preferred; the
ideal energy is about 150 keV. (The most commonly used radionuclide,
99mTc, emits photons with an energy of 140 keV.)
The gamma camera

The detector used in the majority of radionuclide imaging procedures is
the gamma camera (scintillation camera) (Fig. 9). The main component
is a large, disk-shaped scintillation crystal (often made from sodium io
dine, maximum diameter about 60 cm) (Fig. 10). Placed in front of the
crystal, facing the patient, is a special lead shielding device, a so-called
Figure 9.
Patient preparation prior to
radioisotope scanning. The
gamma camera is placed in
close proximity to the region
(here brain) to be imaged.
(Phototechnical Department,
61
Figure 10.
Analogue Schematic sectional drawing o f
electric signals gamma camera with parallel hole
Photo multiplier collimator (see text).
tube
Crystal
collimator. The collimator may have various designs, and it determines

the projection of the emitted radiation onto the crystal. The parallel hole
collimator shown in Figure 10, is a thick lead plate pierced with multi
ple parallel holes. Due to the parallel arrangement of the holes, the two-
dimensional distribution of the radiopharmaceutical in the body is pro
jected on the crystal surface in a 1:1 ratio.
Gamma photons absorbed by the scintillation crystal, result in the re
lease of light. The light is distributed through an optically coupled light
pipe to numerous photomultiplier tubes, where electrical signals are gen
erated. The amplitudes of the electrical signals are proportional to the
amounts of light received. The light from each scintillation is shared by
all the photomultiplier tubes, but the light intensity is maximum in the
photomultiplier tube located directly above the position of the scintilla
tion. By simultaneous analysis of all the photomultiplier signals, the in
tensity and location of each scintillation are determined. From these data,
a two-dimensional projection image of the radiopharmaceutical distrib
ution is reconstructed. The final image may be displayed in an analogue
format directly on a cathode ray tube (CRT) or on a photographic film.
However, most gamma cameras also provide digital images by digitis
ing the analogue electrical output signals from the photomultiplier tubes.
Digital technology is a prerequisite for several radionuclide imaging pro
cedures, e.g. various dynamic studies, ECG-gated cardiac studies, and
tomographic studies.
62
The practical procedure

In radionuclide imaging (also referred to as radioisotope scanning), the
vast majority of procedures are performed with intravenous administra
tion of the radiopharmaceutical (one exception is inhalation of radioac
tive aerosols or gases, e.g. xenon, in pulmonary ventilation studies). As
a radiation protection measure, a lead-shielded syringe is used for injec
tion. The time lapse from injection to gamma camera detection of the
emitted radiation, varies greatly with the type of study.
Pulmonary perfusion studies are examples of immediate post-injec-
tion imaging. The indication for this study is suspected pulmonary em
bolism. The most commonly used radiopharmaceuticals are 99mTc la
belled serum albumin macroaggregates or microspheres with a particle
size of 20-100 |am. The particles are trapped in the smallest pulmonary
arterioles, but only 0.2% of the arterioles are blocked at the same time.
Immediate imaging of the lungs is performed in several projections by
placing the gamma camera next to the part of the lungs to be imaged. A
frontal view of the anterior parts of both lungs is obtained by placing the
gamma camera in front of the lungs, and a posterior view is obtained
with the gamma camera behind the lungs. Lateral and oblique views may
be acquired as well. During exposure, the scintillations are counted, and
the exposure is terminated when a predetermined number of counts have
been acquired (e.g. 500,000). In pulmonary perfusion studies, this may
take 2-3 minutes.
An example of moderately delayed post-injection imaging is bone
scanning (skeletal imaging), where the detection with the gamma cam
era is performed 2-4 hours after injection of 99mTc labelled diphospho-
nates (distributed to metabolically active bone tissue). In the search for
occult tumours or inflammation with gallium scanning, the post-injec
tion delay is very long; scanning is not performed until at least 2 days
after the injection of 67Ga citrate.
Emission computed tomography

Similar to X-ray computed tomography (CT), radionuclide imaging also
has its tomographic techniques. Two major tomographic methods have
evolved: 1) single photon emission computed tomography (SPECT), and
2) positron emission tomography (PET).
63
1) SPECT
The least sophisticated versions of SPECT are simply based on an ordinary
gamma camera made to rotate around the patient. By recording the ra
dioactivity at numerous angles, sectional images may be reconstructed.
SPECT is a widely used technique, especially in cardiac and brain studies.
2) PET
This tomographic technique involves the use of positron emitting ra
dionuclides. The mass of positrons and electrons are identical, but
positrons are positively charged. The emitted positron reacts quickly with
a nearby electron; the reaction is termed annihilation and involves the
formation of two 511 keV gamma photons that radiate in diametrical op
posite directions. Collinearly opposed special detectors are used to de
tect the coincident annihilation photons; the photon energy (511 keV) is
too high to employ ordinary gamma cameras.
PET allows quantitative estimations of radionuclide concentrations
and has a great potential in the study of metabolic processes at various
disease states. Several elements that take part in important biochemical
processes have positron emitting isotopes, e.g. n C, 13N, 150 . Other im
portant metabolites may be labelled with positron emitting isotopes; as
an example, 18F labelled deoxyglucose may be used to study cerebral
glucose metabolism. The major disadvantages of positron emitting ra
dionuclides are their need for production by expensive cyclotrons, and
their short half-lives (the half-lives of 150 and 18F are 2 minutes, and 110
minutes, respectively). The rapid decay in radioactivity requires a cy
clotron very close to the laboratory, a requirement that has contributed
to a slow distribution of PET units.
DIAGNOSTIC ULTRASOUND
In radiology, ultrasound is used for two major purposes: to make sec
tional images and to measure blood flow velocities. The ultrasound imag
ing technique is named ultrasonography (US). The most commonly used
ultrasonic flow measurement technique is called Doppler ultrasound,
Doppler sonography, or Doppler flow measurement. Ultrasonography
(US) is by far the most widespread ultrasound modality in radiology. The
use of Doppler ultrasound is steadily increasing, however. The basic prin
ciples of ultrasonography are first reviewed.
64
Ultrasonography
Ultrasound refers to sound waves with a frequency above 20,000 Hz,
i.e., above the human hearing range. Frequencies in the 2-10 MHz range
are most commonly used (1 MHz = 1 million Hz).
Ultrasonography is performed by transmitting a narrow beam of ul
trasound into the body from a transducer. The ultrasound is reflected from
the various tissues back to the transducer as echoes. The echoes form the
basis of the sectional ultrasound image, quite similar to the sonar of fish
ing boats. The major steps from transmission of the ultrasound until for
mation of the final image will briefly be explained.
Transmission and reception of ultrasound

The ultrasound is generated in a hand-held transducer, usually placed on
the skin of the patient adjacent to the anatomical region to be examined
(Fig. 11). The most essential part of a transducer is one or several piezo-
electrical crystals. These crystals have a dual property; application of an
electrical potential across the crystal causes mechanical deformation of
the crystal, and mechanical compression of the crystal generates an elec
trical potential. Mechanical vibration of the crystal is induced by a short
electrical pulse, and the frequency of the ultrasound thus generated, is
determined by the resonance frequency of the crystal, which in turn is
determined by the thickness of the crystal. The thinner the crystal, the
higher the frequency. The echoes reflected back to the transducer, set up
mechanical vibrations in the crystal creating electrical signals of the same
frequencies as those of the echoes. In this way the echoes are recorded.
Figure 11.
Ultrasound scanner. The hand
held transducer is placed on the
skin o f the patient after applica
tion o f a gel. The real-time dy
namic image is displayed on the
monitor. The image may be
"frozen " and hardcopied, or a
dynamic scanning sequence may
be recorded on videotape.
(Phototechnical Department,
65
The ultrasound being transmitted from the transducer is pulsed. An ul

trasound pulse of 1 |is duration is transmitted 1,000 times per second.
The remaining 999/1,000 (or 99.9%) of the time, the transducer acts as
a receiver, listening for echoes. The creation of echoes is explained in
the next section.
Attenuation and reflection

The intensity o f the ultrasound transmitted, is gradually reduced by pas
sage through the tissues of the body. The total loss of intensity (or power)
is named attenuation. The major reason for the attenuation is absorption
of the ultrasound as heat. This part of the attenuation is proportional to
the ultrasound frequency; the higher the frequency, the higher the loss
of energy as heat.
The part of the ultrasound not being absorbed, may be scattered or re
flected from the tissues back to the transducer as echoes. A fraction of
the ultrasound will be reflected whenever there is a change in the "resis
tance" to the propagation of the ultrasound. How easily ultrasound prop
agates through a tissue is dependent partly upon the particle mass (which
determines the density o f the tissue), and partly upon the elastic forces
binding the particles together. The elasticity of a tissue largely deter
mines the propagation velocity of ultrasound through that tissue. The
density and elasticity of a tissue together determines its so-called acoustic
impedance (or "resistance"). (Z = p • c, where Z is the acoustic imped
ance, p is the density, and с is the propagation velocity of the ultrasound
in the tissue.)
The larger the change in acoustic impedance, the larger the reflection
of ultrasound. Between soft tissue and gas there is an extremely large
difference in acoustic impedance, and nearly all of the ultrasound is re
flected at the border. This is why a gel is applied between a patient's skin
and the transducer to expel the air that otherwise would have stopped the
ultrasound beam, and it is also the reason why ultrasonography is unable
to display regions covered by bowel gas or airfilled lung tissue. There is
a relatively large difference in acoustic impedance between soft tissue
and cortical bone as well, and most bones therefore restrict the applica
tion of diagnostic ultrasound.
66
From echo to image: А-mode, M-mode, and B-mode

Every echo returning to the transducer generates an electrical signal
whose strength (amplitude) is determined by the strength of the echo.
The transformation of electrical signals into an image on a monitor is
based on the relatively constant propagation velocity of ultrasound
through tissues. By measuring the time from transmission of the ultra
sound pulse to reception of the echoes, the depths from which the echoes
originated can be estimated. During the "listening" period after each
pulse transmission, numerous echoes are recorded from ever increasing
depths. Due to the attenuation of the ultrasound in the tissues, echoes
from the deepest structures will be the weakest. This is compensated for
by increasing the amplification of the electrical signals generated by late
arriving echoes. The later the arrival of the echo (i.e., the deeper its ori
gin), the more amplification applied by the so-called time gain compen
sation or time gain control (TGC).
Figure 12. А-mode and M-mode.

a) Schematic drawing o f transducer transmitting a narrow beam o f ultrasound into the
body. The beam passes a pulsating blood vessel (hatched circle). Four reflecting struc
tures along the beam are indicated: the skin surface (1), the anterior wall o f the vessel
(2), the posterior wall o f the vessel (3), and the posterior body wall (4).
b) А-mode display o f the four reflecting structures.
c) M-mode display o f the same four structures. The vessel pulsations may be seen as
periodic changes in the distance between the anterior and posterior wall echoes.
67
The simplest visual display of the recorded echoes is the so-called A-

mode (amplitude mode) display. In this format, the echoes from the var
ious depths are shown as vertical spikes on a horizontal line indicating
depth (or actually time) (Fig. 12 b). The first recorded echo after a pulse
transmission is shown to the far left, and the latest recorded echo is shown
to the far right on the depth line. The strength o f the echo determines the
height or amplitude of each spike shown, hence the term amplitude mode
or А-mode. The А-mode format gives only a one-dimensional display
of changes in acoustic impedance along the ultrasound beam, and is very
seldom used in radiology.
Dynamics may be added to the А-mode format by an alternative
method named M-mode (M = motion) or TM (time motion) mode (Fig.
12 c). In this display, the depth axis has a vertical orientation on the mon
itor. The various echoes are not shown as deflections along a line, but
rather as dots having a brightness determined by the echo strength. These
bright dots are made to scroll across the screen from left to right, thus
creating bright curves indicating the change in position of the reflecting
structures with time. The monitor curves are updated each time the bright
dots reach the right hand side of the screen (similar to the display shown
Figure 13.
B-mode
a) Same schematic "anatomy" as in
Figure 12. A linear transducer, having
an array o f multiple crystal elements,
is used. A narrow beam o f transmitted
ultrasound sweeps linearly along the
crystal elements, and echoes along
scan lines corresponding to each ele
ment are recorded.
b) The real-time dynamic В-mode image
displayed on a monitor. The image is
made from numerous bright dots, the
b) B-mode vertical position o f each dot being de
termined by the time delay o f the echo,
and the horizontal position being de
termined by the position o f the receiv
ing transducer element. The echo am
plitudes determine the brightness o f
the dots.
68
by ECG monitors). The M-mode curves provide very detailed informa

tion on the motional behaviour of reflecting structures along the ultra
sound beam, and the method has been especially popular in cardiology
to show the motion patterns of the various cardiac valve leaflets.
In radiology, the В-mode (B = brightness) format is used almost ex
clusively. The term indicates that the echoes are shown as bright dots on
the screen, the brightness being determined by the echo strength. A B-
mode image gives a two-dimensional, sectional display of the anatomy
(Fig. 13).
In the early days of ultrasonography, compound scanners providing
static images dominated the market. Today, these have been replaced by
real-time scanners. The transducers used in real-time scanning often
have numerous small crystal elements arranged side-by-side. By differ
ent techniques, a narrow beam of transmitted ultrasound is made to scan
or sweep through the patient in a linear (Fig. 13 a) or sector-shaped fash
ion, and echoes are recorded from each position (scan line) of the beam.
One scan line position may correspond to the position o f one single crys
tal element. The echoes from all the scan lines create a rectangular or
sector-shaped image on the screen (Fig. 13 b). The image is dynamic and
may show phenomena such as respiratory motion, vessel pulsations, car
diac contractions, and foetal movements. The transducer is connected to
the ultrasound instrument with a pliable cable to enable any position and
angulation of the transducer.
Modem ultrasound scanners employ digital techniques. The analogue
electrical signals generated in the transducer crystal by the echoes, are
digitised, and a digital image matrix based upon signal strength is cre
ated. In the final image shown by the monitor, the pixels are given shades
of grey determined by the corresponding numbers in the digital matrix.
Doppler sonography
Measurement of blood flow velocity using ultrasound, is usually based
upon the general phenomenon that the frequency of a wave form is de
pendent upon the relative velocity between the emitter and receptor of
the wave. This is the Doppler effect, which is applicable to any kind of
wave, both electromagnetic (e.g. light) and mechanical (e.g. ultrasound).
In Doppler sonography of blood vessels, a narrow beam of ultrasound
is transmitted into the body from a Doppler transducer. If the ultrasound
beam intersects a blood vessel or a cardiac chamber, a small fraction of
69
the ultrasound will be reflected from the red blood cells. If the red blood
cells are flowing towards the Doppler transducer, the echoes reflected
will have a higher frequency than the one emitted from the transducer.
When blood flows away from the transducer, the echoes will have a lower
frequency than the emitted one. The difference between the frequency
of the echoes received by the transducer and the frequency of the ultra
sound emitted from the transducer, is called the Dopplerfrequency shift,
or sometimes just the Doppler shift or Doppler frequency. This shift in
frequency is directly proportional to the blood flow velocity. During flow
measurement, the Doppler frequency shift is continuously estimated by
the Doppler instrument, and most instruments will also automatically
convert the change in ultrasound frequency into relative blood flow ve
locity (e.g. m/s). Relative velocity means the component of the velocity
pointing straight towards the transducer. If the angle between the Doppler
beam and the direction of blood flow (the so-called Doppler angle) is
known, then the true flow velocity may be calculated.
When measuring blood flow velocity, the Doppler frequency shift is
usually within the frequency range of human hearing. All Doppler in
struments are therefore equipped with loudspeakers making it possible
to listen to the Doppler frequency shifts of the blood flow. This "sound
of blood flow" is very helpful to the examiner, both in localising vessels
and in semi-quantitative assessment of flow patterns and velocity. O f
course, this audio display is far too inaccurate for the exact quantifica
tion of flow velocity. A visual display of the flow velocity is therefore
also provided by the Doppler instrument, usually as a graph or wave form
showing velocity along the ordinate and time along the abscissa. In most
blood vessels, flow velocity is not uniform across the vessel lumen; most
often the velocities are highest in the centre of the vessel and decreasing
towards the vessel walls. A so-calledfu ll spectral display shows the vari
ation with time of all the flow velocities present in the vessel (Fig. 14,
bottom). Single line tracings showing how for example the maximum or
mean velocity changes with time, may also be presented.
Principally, there are two ways of transmitting and receiving ultra
sound in Doppler applications: continuous wave mode (CW) and pulsed
Doppler mode (PD). In the continuous wave mode, the Doppler trans
ducer contains two separate crystals. One crystal continuously transmits
and the other crystal continuously receives the echoes. This concept al
lows measurement of very high velocities. Velocities are measured from
70
a large range of depths si

multaneously, and it is not
possible to selectively
measure velocities at a par
ticular predetermined
depth. In pulsed Doppler
mode, the same crystal
both transmits and receives
the ultrasound. The ultra
sound is transmitted as Figure 14. Duplex scanning. Real-time B-mode
brief pulses, and the echoes imaging o f upper abdominal aorta (top) combined
with pulsed Doppler sonography (bottom). The
are registered in the waiting
dotted line superimposed on the top image shows
time between pulse trans the direction o f the Doppler beam; the Doppler
missions. The time from sample volume encompassing the aortic lumen, is
pulse transmission to echo indicated by two horizontal lines along the beam.
The electronic calliper (broken line) oriented
reception determines the along the long axis o f the aorta, gives the angle be
depth at which velocities tween Doppler beam and flow direction (here 63 °),
are being measured. Pulsed and the true flow velocities are presented in the fu ll
Doppler ultrasound makes spectral display (bottom)
it possible to measure flow velocities from very small volumes (so-called
sample volumes) along the ultrasound beam, but the maximum measur
able velocities are considerably lower than those measurable with con
tinuous wave Doppler.
The most commonly used Doppler instruments in radiology are so-
called duplex scanners, combining real-time ultrasonography and pulsed
Doppler sonography. In duplex scanning, the direction of the Doppler
beam is superimposed on the B-mode image, and the size and location
of the sample volume along the beam can be selected by means of elec
tronic markers (Fig. 14). When an electronic cursor is manually placed
parallel to the direction of blood flow, the Doppler angle is measured au
tomatically, and the true flow velocity is displayed (Fig. 14). If the cross-
sectional area of the vessel is measured, volume blood flow may also be
calculated (as e.g. ml/s).
Colourflow imaging is a further extension of duplex scanning. Colours
are superimposed on the real-time B-mode image to indicate the pre
sence of flowing blood. Stationary tissues are shown in shades of grey,
and vessels are given a colour (shades of blue, red, yellow, green) de
termined by relative mean velocity and direction of flow. The colour-
71
coded image gives a good overview of the various vessels and flow di
rections present, but the quantitative information provided by this
method is less accurate than that provided by continuous wave or pulsed
Doppler. Colour flow imaging is therefore always combined with pulsed
Doppler sonography, and the colour flow image serves as a good guid
ance for placement of the pulsed Doppler sample volume.
MAGNETIC RESONANCE
Magnetic resonance imaging

Magnetic resonance imaging, MRI, is the latest newcomer o f the radio
logical modalities. MR units can provide sectional images in any plane
of any part of the body. No ionising radiation is involved, and air or bone
represent no obstacle to imaging. Compared to ultrasonography and com
puted tomography, the modality is more expensive, technically more ad
vanced, and theoretically more difficult to comprehend. Nevertheless,
MRI has completely revolutionised some areas of diagnostic radiology.
The usefulness of MRI will be reviewed in the organ-related clinical
chapters; the present chapter will concentrate on giving a simplified ex
planation of the most basic principles of this new imaging technique.
The MR unit and its magnetic field

The most basic components of a MR unit are a very strong magnet, a ra
dio transmitter, a radio frequency receiver coil, and, of course, a com
puter. The interior of the magnet is often tunnel-shaped and big enough
to contain a human adult (Fig. 15). Most magnets have a magnetic field
orientated parallel to the long axis of the patient (Fig. 16).
Figure 15.
Patient preparation prior to MR imaging.
Before start o f scanning, the patient table
is elevated and fe d into the tunnel-shaped
interior o f the magnet. The anatomic re
gion o f interest must be located in the cen
tre o f the magnet. The entire procedure
may last fo r approx. 1/2-1 hour, and dur
ing this period, the patient must remain
nearly motionless (sedation is needed fo r
small children). (Phototechnical
Department, Rikshospitalet, Oslo.)
72
Figure 16.
The MR magnet. Most magnets
are electromagnets with a hor
izontal magnetic field (BJ.
During imaging, the patient
lies in the tunnel-shaped inte
rior o f the magnet. The z, x,
and у co-ordinates are shown.
Permanent magnets with verti
cal magnetic fields are avail
able as well.
The magnetic field of the strong magnet is designated BQ, and is illus
trated as a vector, i.e., an arrow whose orientation shows the direction
of the magnetic field from south to north, and whose length indicates the
strength of the magnetic field. The orientations within the magnet are
shown by means of an imaginary frame of reference with three co-ordi-
nates, z, x, and у (Fig. 16). The z-direction is always the direction of the
magnetic field, B0, and when this field is parallel to the long axis of the
patient, the horizontal axis perpendicular to z is named x, and the verti
cal axis is named y. The plane through x and у (the x-y plane) is thus ori
entated perpendicular to the magnetic field, B(|. The strength of the mag
netic field is measured in tesla (T) or gauss, where 1 tesla = 104 gauss.
For clinical MR imaging, field strengths from 0.02 tesla to 2.0 tesla have
been used (experimentally 4.0 tesla has also been used). Most MR units
have field strengths from 0.1-1.5 tesla. For comparison, the earth has a
magnetic field strength of 0.7 gauss at the poles and 0.3 gauss at the equa
tor.
Hydrogen nuclei (protons) in a magnetic field

Magnetic resonance imaging exploits the fact that hydrogen nuclei - in
this context often named protons - are tiny magnetic dipoles with a north
pole and a south pole. The magnetic moment of one proton is often termed
ц (Fig. 17). When a patient is placed within the strong magnetic field of
an MR magnet, all the tiny proton magnets of the body line up in the di
rection of the external field (BQ) (similar to compass needles adjusting to
the magnetic field of the earth). In addition, the magnetic axis of each
proton starts to rotate around the direction of the external magnetic field
(Fig. 17). This particular rotational motion is called precession, and its
frequency is named the resonance frequency or Larmor frequency (after
73
Figure 17.
Precession. The magnetic moment o f one proton is
illustrated as a vector (\x). The vector indicates the
direction o f the proton magnetic field from south to
north (the magnetic axis). In a strong, external mag
netic field (BJ, the magnetic axis o f the proton will
rotate (precess) around the B() (z) direction, the
north pole (and south pole, not shown) describing a
cone-shaped figure. (The circle in the origo o f the
frame o f reference indicates the proton.) co0: the
Larmor frequency.
the French physicist Larmor). The Larmor frequency (coo) is proportional

to the external magnetic field strength (B0):
G)0 = y B 0
The equation is called the Larmor equation, and у is a constant named

the gyromagnetic ratio. This ratio (coo/B0) is specific to each type of mag
netic atomic nucleus, and for the hydrogen nucleus, the ratio is equal to
42.58 MHz/tesla. This means that at the magnetic field strengths used in
MRI, the Larmor frequency of the hydrogen nucleus is in the radio fre
quency range (42.58 MHz at 1.0 tesla).
Unlike ordinary compass needles, the magnetic moments of the pre-
cessing protons do not all point towards the north pole. A small major
ity of protons precess with their magnetic moments aiming towards
"north", i.e., in a direction closely parallel to the external magnetic field.
These are consequently called "parallel protons ". The remainder of the
protons precess with their magnetic moments aiming towards "south",
i.e., close to antiparallel to the external magnetic field. These are the "an
tiparallel protons”. The result is the creation of a net magnetic moment
in the tissues of the patient; the tissues become magnetic, and the mag
netism (M) is oriented exactly parallel to the external magnetic field, BQ.
At first, the tissue magnetism has no precessional motion. Although the
individual protons all precess, they are evenly distributed around the BQ
direction, leaving no magnetic component in the x-y plane (Fig. 18 a).
The size of M is determined by the surplus of parallel protons. The sur
plus is proportional to the external magnetic field strength, but is always
very small, only in the order of 1-10 protons per 1 million protons. M is
74
Figure 18.
a) The tissue magnetism (M) is created by a
surplus number o f "parallel"protons (see
text). The magnetic vectors o f the individ
ual protons (thin arrows) are evenly dis
tributed around the z-axis, and M is there
fore oriented exactly in the z-direction.
b) A 30° radio frequency pulse has rotated all
protons and M 30° away from z, in the
clockwise direction. Due to never ending
proton precession around the z-axis, M is
also precessing around z.
Ь) 2
c) The result o f a 90° pulse: M is precessing
around z in the x-y-plane.
also proportional to the number of pro

tons per volume unit of tissue, i.e., the
proton density. The enormous amount
of protons (i.e., hydrogen nuclei) pre
sent in most tissues (approximately
C)
1022 per ml water), accounts for the
fact that the net magnetic moment, M,
is strong enough to induce an electric
current in a receiver coil located out
side the patient. These induced MMR
signals”, as will be explained below,
are used for the reconstruction of MR
images.
The MR signal
Any magnetism may induce an electric current in a coil, but a prerequi
site for this to happen, is a change in the magnetic field strength running
through the bore of the coil. To make the tissue magnetism, M, induce a
current in a coil, radio waves are needed. Radio waves are electromag
netic waves, containing both an electric and a magnetic field. When a
short electromagnetic radio frequency pulse is transmitted into the pa
tient along the у-axis, the magnetic field of the radio waves will force
the magnetic moments of all the protons to rotate in a clock-wise direc
tion around the у-axis. For this to happen, the frequency o f the radio
waves must be exactly equal to the Larmorfrequency o f the protons. This
75
is the phenomenon
Induced
electric current termed magnetic res
onance. Resonance
means synchronous
vibration, and in this
context it implies that
the magnetic fields of
b) Coil the protons and the ra
dio waves must res
Ш onate, i.e., have the
T
same frequency, in
Figure 19. order to change the
a) After the transmission o f a 90° pulse, the tissue mag orientation of the pro
netism (M) is inducing an electric current (MR signal)
ton magnetic mo
in the receiver coil. The signal strength determines the
shade o f grey o f the corresponding area in the final ments.
image. When the surplus
b) The situation in a) may be compared to a rotating bar parallel protons are
magnet (= the tissue magnetism M) inducing an elec
rotated away from the
tric current in a coil being connected to a light bulb.
The amplitude o f the current determines the light in BQdirection, M must
tensity o f the bulb (= shade o f grey in the MR image). follow (Fig. 18 b). The
protons will continue
to precess around the z-axis (they are forced to do so by the BQmagnetic
field), and M will consequently also start to precess around the z-axis
(Fig. 18 b). The strength and duration of the radio frequency pulse de
termine how many degrees M is rotated away from the B0 direction, and
the pulse is named accordingly. The result of a 90° pulse is thus that M
(for a short period of time) will rotate in the x-y plane, perpendicular to
the BQdirection (Fig. 18 c).
A receiver coil is placed on the outside of the anatomical region with
its bore oriented towards the patient, perpendicular to the BQdirection.
When M rotates in the x-y plane, it will induce an electric current in the
coil, and this electric current is called the MR signal (Fig. 19 a). These
(or similar) signals are used for reconstruction of sectional MR images.
The situation after a 90° pulse is analogous to a bar magnet rotating past
the opening of a coil (Fig. 19 b). The varying magnetic field through the
coil will induce an electric current, and if the coil is connected to a light
bulb, the bulb will shine. The stronger the magnet, the brighter the light.
The same principle applies to MR imaging; tissues exhibiting a strong
76
magnetism (M) will induce strong signals and appear bright in the im
age, and tissues exhibiting a weak magnetism will induce weak signals
and appear dark.
Image contrast: Proton density, T1-, and T2-weighting

As explained above, contrast in MR images is determined by differences
in tissue magnetisms, or more precisely, by the different strengths of
magnetism that rotate in the x-y plane and induce currents in the receiver
coil. Tissue magnetism is first of all determined by the proton density
(see above). Anatomic areas containing very few protons, like air, will
always induce very weak MR signals and therefore always appear dark
in images. Water and other fluids, on the other hand, having a very high
proton density, presumably should always appear bright in MR images.
This is not the case, however. Depending upon to the method used for
image acquisition, fluids (like CSF) may appear either bright or dark.
The reason for this perhaps confusing fact is that proton density is not
the sole determinant of image contrast. Several other parameters play a
role as well, and the two most important of these are named T1 and T2.
To reconstruct an image, several MR signals are needed, and several
radio frequency pulses must therefore be transmitted. Between the pulse
transmissions, the protons undergo two different relaxation processes,
T l- and T2-relaxation. The rapid decay of the induced signal seen in
Figure 19 a, is partly the result of T2-relaxation. The decay is a conse
quence of the gradual disappearance of the magnetism in the x-y plane,
Mxy, caused by small differences in the local magnetic field strength
(partly due to magnetic molecules in the tissues). Protons exposed to
slightly different magnetic field strengths will have slightly different
Larmor frequencies, and the surplus "parallel" protons that were closely
packed around Mxy immediately after the 90° pulse (Fig. 18 c), will de
phase, i.e., spread out around the z-axis. When the individual protons are
evenly distributed around the z-axis, Mxy is gone. This loss of net mag
netism in the x-y plane is called 72 relaxation, and T2 is defined as the
time until M has lost 63 % o f its original, maximum value. A common
T2 value in parenchymal tissue is approximately 50 ms. After a time
equal to 4-5 times the T2 value, Mxy will have disappeared completely.
The T2 value varies considerably, however, with the physical and chem
ical properties of the tissues. Fluid and fluid-like tissues typically have
77
a long T2 (Mxy and the MR signal disappear slowly), and solid tissues
and substances have a short T2 (M x y and the MR signal disappear
rapidly).
77 relaxation is a slower process than T2 relaxation, and involves the
gradual alignment of the individual protons with the BQdirection, thus
restoring the situation prior to the 90° pulse (Fig. 18 a). During this
process, the net magnetic moment along the z-axis, Mz, will increase
from zero with ever decreasing speed until its maximum value, deter
mined by the proton density in the tissue, is reached. 77 is defined as the
time until M_ has regained 63% o f its original, maximum value. The
shorter the T l, the faster the restoration o f Mz. After a time equal to 4-5
times the Tl value, Mz is completely regained. A common Tl value in
parenchymal tissue is approximately 500 ms. There is, however, a large
variation in Tl in the different tissues. The T l value is largely deter
mined by molecular size and mobility. Generally, Tl is shortest in tis
sues having molecules of medium size and mobility, e.g. adipose tissue.
Smaller, more mobile
molecules (as in fluids)
and larger, less mobile
molecules (as in solids)
have longer Tl values.
By adjusting the time
period between the ra
K -T R -H Time dio frequency pulses
transmitted, the opera
Figure 20. Tl-weighting. T l relaxation curves showing
tor of a MR unit may
how the magnetism in the z-direction (MJ in two differ
ent tissues (A and B) increase from zero after repetitive decide whether image
90° pulses. The shaded parts o f the first two relaxation contrast should be de
curves indicate how Mz would have increased until termined mainly by
maximum i f the next 90° pulse had not been transmitted.
The Mzs o f tissue A and В would have levelled out at
proton density, Tl or
the same maximum value, indicating similar proton T2. A certain time in
densities in the two tissues. The repetition time (TR) is terval between the
so short, however, that Tl relaxation is not completed pulses is needed to al
when the next pulse is transmitted. At pulse transmis
sion, tissue A, having the shortest Tl, will have re low regaining of Mz.
gained a larger Mz than tissue B, and tissue A will The longer the time in
therefore induce a stronger signal in the receiver coil terval (up to a certain
after each 90° pulse. The difference in signal strength is
point), the larger the Mz
caused by differences in Tl, hence the term Tl-weighted
to be rotated into the x-
78
у plane by the next 90° 90°

pulse, and the stronger
the MR signal induced.
If the next 90° pulse is
transmitted before com
pletion of T1 relaxation
in the tissues, the size of
Mzin the tissues will de
pend upon their T1 val
ues. Provided fairly Figure 21. Proton density and T2-weighting. The re
gain o f M_ and loss o f Mxy are shown fo r two tissues (A
similar proton densi and B), having short Tl and T2 (A), and long T1 and
ties, tissues having the T2 (B), respectively. After having recorded the MR sig
shortest T1 will have nals, the waiting time until the next 90°pulse is suffi
regained the largest Mz, ciently long to complete Tl relaxation in both tissues.
The possible effect on contrast by differences in Tl, is
and will consequently thereby eliminated. Early signal registration provides
induce the strongest proton density weighting (PD); late registration gives
MR signals after the T2-weighting (T2).
following 90° pulse
(Fig. 20). These tissues will therefore appear bright in the final image.
Tissues with the longest T1 will similarly induce the weakest signals.
MR images where contrast is largely determined by differences in T 1,
are called Tl-weighted images. The time interval between the radio fre
quency pulses is named repetition time (TR), and Tl-weighted images
are acquired with relatively short TRs (approximately 500 ms).
By increasing the TR, it is possible to achieve alternative image con
trast; either proton density weighted images, or T2-weighted images. In
proton density (PD) weighted images, the tissues with the highest pro
ton density induce the strongest MR signals and appear bright, and in
T2-weighted images, the brightest tissues are those having the longest
T2. For both types of contrast long TRs are needed to eliminate the ef
fect of differences in T1 on image contrast. Using TR values more than
5 times the longest T 1 of the tissues, ensures that all tissues have com
pletely regained their maximum Mz before transmission of the next 90°
pulse (Fig. 21). The maximum magnetism along the z-axis is determined
by the proton density, and the relative strengths of the MR signals de
rived from the various tissues immediately after the 90° pulses, will there
fore reflect the relative proton densities of the tissues. The contrast be
comes PD-weighted. T2-weighted contrast is achieved by introducing a
79
THE NICER GLOBAL TEXTBOOK. OF RADIOLOGY
time interval (called echo time, ТЕ) between the 90° pulse and the sig
nal measurement. During this time interval, the size of Mxy is gradually
reduced due to T2 relaxation; slowly in tissues having a long T2, more
rapidly in tissues having a short T2. The amplitudes of the induced MR
signals recorded at the end of the echo time, will therefore reflect the dif
ferences in T2 in the tissues (Fig. 21). (A detailed explanation of how
the MR signal - in this context termed echo - is actually measured at the
end of the echo time, is beyond the scope of this chapter. The interested
reader should consult more in-depth literature.)
It should be clear from the above that image contrast in MR imaging
can be made much more variable than image contrast in alternative
modalities such as computed tomography and ultrasonography. Image
contrast is determined by operator-dependent parameters such as repe
tition time and echo time, and by tissue-dependent parameters such as
proton density, T l, and T2. A basic knowledge of these parameters is
necessary for proper evaluation of MR images.
Slice selection. Magnetic field gradients

Radio frequency pulses will cause induction of MR signals only when
the pulse frequency is exactly equal to the proton Larmor frequency. This
fact makes it possible to collect MR signals from a predetermined thin
slice of tissue. The first step towards slice selection is to create a mag
neticfield gradient through the anatomical region to be imaged (Fig. 22).
Special coils (gradient coils) create small additional magnetic fields with
the result that the strength of the B0 magnetic field increases linearly in
one direction. The Larmor frequency o f the protons is proportional to the
magnetic field strength (see the Larmor equation), and the Larmor fre
quency will therefore increase linearly in the gradient direction. By trans-
Figure 22. Slice selection (axial slice). By means
o f gradient coils, the external magnetic field in
creases linearly in the z-direction. Planes perpen
dicular to this magnetic field gradient have uni-
(o>(Oq form magnetic field strength. In the axial plane at
^"YBq the field strength B(y the Larmor frequency o f the
°)<t°0 protons is (o0; cranial to this plane, field strengths
and Larmor frequencies are higher, caudal to this
plane they are lower. I f a 90° pulse having the fr e
quency oo0 is transmitted, only the protons in the
plane having the exact same Larmor frequency
will be rotated 90 ° and induce a signal.
80
mitting radio frequency pulses having a predetermined narrow frequency

range, MR signals will be recorded from only the thin slice of tissue that
has a Larmor frequency range corresponding to the pulse frequency
range. The orientation of the magnetic field gradients and therefore also
the slice directions, are freely selectable.
Reconstruction o f the MR image

The tissue slice to be imaged, may be considered as consisting of sev
eral equally large volume elements, voxels (see Fig. 7 in the section on
CT). After each 90° pulse, every voxel has its own tissue magnetism
(Mxy) which induces a signal in the receiver coil. The amplitude of the
individual voxel signal is determined by the size of the voxel tissue mag
netism, which again is determined by voxel dependent factors such as
proton density, T l, and T2, and choice of repetition time and echo time.
Each voxel corresponds to a picture element, pixel, in the final two-di-
mensional image. The brightness (shade of grey) of the pixel is deter
mined by the signal amplitude induced by the magnetism in the corre
sponding voxel.
The MR signal recorded from a slice of tissue, is a composite signal
induced by all the individual voxel magnetisms simultaneously. The MR
computer needs to dif
ferentiate between the
various voxel signals to
assign the correct
brightness to each
pixel. To enable the
computer to do so, each
voxel signal must be
given a unique and
recognisable code. The
code being used, is the Figure 23. Phase and frequency encoding. Part o f a tis
frequency and phase of sue slice in the x-y plane (axial slice) is shown with vox
els. A brief magnetic field gradient in the y-direction
the voxel signal, which applied between pulse transmission and signal registra
is determined by the tion, provides the voxel signals with phases determined
frequency and phase of by the voxel locations in the у -direction. A magnetic
field gradient in the x-direction applied during mea
the rotating voxel mag surement o f the MR signal, provides the voxel signals
netism (Mvi).
xy
The en- with frequencies determined by the voxel locations in
coding is done by two the x-direction.
81
magnetic field gradients, applied in the y- and x-direction, respectively

(for axial slices). The gradients affect the rotation of the voxel mag
netisms in such a way that the resulting voxel signals are given a phase
determined by the voxel location along the у-axis, and a frequency de
termined by the voxel location along the x-axis (Fig. 23). As a result,
each voxel is given a unique code of phase and frequency. (A detailed
explanation is beyond the scope of this chapter.)
To extract the various frequencies and phases contained in the com
posite MR signal, a complicated mathematical analysis termed two-di
mensional Fourier transform is used. This method is dependent upon the
information contained in numerous repetitive signals derived from the
same slice, and this is the reason why ’'conventional" MR imaging is rel
atively time-consuming.
Circulating blood: a natural ncontrast medium "

In MR imaging, stagnant blood has a signal intensity (brightness) deter
mined by the proton density, T l, and T2 of blood, and by the contrast
"weighting" chosen. (In practice, stagnant blood appears bright at most
"weightings".) Circulating blood, on the other hand, will - due to its flow
velocity - in most instances induce no MR signal, and thus behave as an
effective "negative" contrast medium. Vessel lumina and heart chambers
will appear dark and clearly delineated by the brighter surrounding sta
tionary tissue.
There are, however, special MR techniques that make circulating blood
appear bright and stationary tissue appear dark. These techniques are be
ing used in MR angiography (MRA) to create two-dimensional projec
tion images of three-dimensional vascular structures. After a single im
age acquisition, the vascular anatomy may be viewed from any angle.
MR contrast media
Five to ten years ago, contrast media for MR imaging were considered
completely unnecessary. In many clinical situations this is still true.
Experience has shown, however, that contrast media may increase the
diagnostic information in several disease states. During recent years, a
growing number of contrast media have been developed. They all have
magnetic properties, and they change the signal intensity of the tissues
where they are located, by shortening the relaxation processes (Tl and/or
T2) of the surrounding protons. The most commonly used contrast me
82
dia contain the paramagnetic metal ion gadolinium (Gd3+), chelated to a

carrier molecule. These contrast media are administered by intravenous
injection, and they have a distribution in the body similar to water solu
ble X-ray contrast media.
Contraindications and potential dangers

No harmful effects of the static or fluctuating magnetic fields used in MR
imaging, have been shown. Ferromagnetic objects are subjected to very
strong mechanical forces, however, and any ferromagnetic object hav
ing a location where motion of the object may be harmful to the patient,
represents an absolute contraindication to MR imaging. The most im
portant and dangerous objects are ferromagnetic intracranial aneurys
mal clips and intraocular ferromagnetic foreign objects. The main po
tential danger involved with these objects is serious haemorrhage. The
presence of a pacemaker represents an absolute contraindication to MR
imaging. The function of the pacemaker may be affected by the mag
netic field, and furthermore, electric currents may be induced in the pace
maker electrode with possible heating of the endocardium.
The transmitted radio frequency waves will always have a heating ef
fect on the tissues. To avoid harmful heating, the maximum allowable
energy transmitted to the patient is regulated by international recom
mendations. First trimester pregnancy is by some considered an absolute
contraindication to MR imaging due to possible heating of the foetus. In
the first trimester, the foetus is surrounded by a relatively large amount
of amniotic fluid, and has little capability to remove the extra heat.
Magnetic resonance spectroscopy

MR units having a magnetic field strength of at least 1.5 tesla, may also
provide the possibility of undertaking in vivo magnetic resonance spec
troscopy (MRS). In vitro MRS has been known since the 1940s, and is
a much older technique than MRI. MRS is based upon the fact that mag
netic atomic nuclei and molecules located in a magnetic field will cause
local changes in the field strength depending upon the molecular struc
ture and composition. Magnetic atomic nuclei of the same type (e.g. hy
drogen) will therefore have Larmor frequencies that vary slightly with
the molecular locations of the nuclei. The MR signal induced after a ra
dio frequency pulse will contain these frequencies. A frequency analy
sis of the composite MR signal generates a frequency spectrum, which
83
is an amplitude versus frequency display showing the different frequen

cies present and their respective amplitudes. Such a frequency spectrum
can tell the presence and relative concentration of numerous molecules
or metabolites.
Several magnetic atomic nuclei may be used in MRS, but the two most
commonly used nuclei in in vivo MRS are hydrogen (!H) and phospho
rous (31P). There are large differences in Larmor frequency between dif
ferent types of nuclei, and the receiver coil may receive signals from only
one type of nucleus at a time. MR imaging and MR spectroscopy may
be combined, e.g. by first performing (proton) MR imaging for localis
ing purposes. An area of interest may be selected from the MR images
before switching to a phosphorous receiver coil for phosphorous spec
troscopy. The result may be displayed as a frequency spectrum, or may
also be shown as colour coding of areas in the grey scale MR image, the
colours indicating the location and concentration of various phosphorous
compounds such as ATP, ADP, or inorganic phosphate. Hydrogen (pro
ton) spectroscopy may also be done, and local concentrations of e.g. lac
tate indicative of ischemia may be shown. In vivo MRS thus makes it
possible to acquire information on important metabolic processes in both
normal and pathological tissue, and to follow functional effects of treat
ment. The great potential of in vivo MRS has been realised for many
years, but the method still awaits its breakthrough in everyday clinical
practice. The technical difficulties have been more profound than ex
pected, and we probably have to wait still some years until in vivo MRS
becomes a natural part of the diagnostic armamentarium of radiology.
84
Chapter 5
Radiology worldwide - the WHO

approach
Philip E.S. Palmer, Thure Holm and Gerald P. Hanson
INTRODUCTION
This is a Global Textbook of Radiology; but is diagnostic imaging truly
"Global", and is it available, as it should be, to everyone?
Unfortunately, the answer to both questions is "NO", because only
about one third of humanity has easy access to diagnostic imaging, even
at its most simple and therefore most important level. Yet, and here is
the contradiction that all radiologists must face, every student and trainee
physician in any medical school quickly learns that most fractures, real
or suspected, need to be radiographed. Many patients with a cough will
need a chest x-ray and it is of benefit to many pregnant women to have
at least one ultrasound examination. The list of patient complaints that
leads to some form of imaging would be very long and impressive, if it
were not taken for granted that imaging is part of good, standard, health
care. Diagnostic imaging should not be a rare privilege, but should be
the right of any patient when his or her doctor believes that it will assist
in accurate diagnosis and result in better treatment (Figs. 1 and 2).
The World Health Organization (WHO) is a specialized agency of the
United Nations, with its headquarters in Geneva, Switzerland, and six
Regional Offices serving different areas of the world. Almost every one
of the 189 member states has a WHO representative readily available to
help the health authorities when requested. WHO is particularly con
cerned with providing "Health for All". Its programmes include public
health and prevention (e.g. water supplies, environmental sanitation and
vaccines), as well as the treatment, and if possible, control of the vast
numbers of communicable diseases and the increasing morbidity and
85
Figure 1. Diagnostic imaging should Figure 2. Diagnostic imaging should

be available to everyone who needs be available wherever it is needed. A
it. Radiography o f the hand o f a patient in Yemen looking at his own
Maasai girl in Kenya. (Photo: Diane radiograph. (Photo: WHO)
Gibson)
mortality from accidents and injuries. Any physician can provide a list
of health problems in which diagnostic imaging will play an important
role, often providing the only way to make the correct diagnosis. Several
important publications, including "The hospital in rural and urban dis
tricts” (WHO Technical Report Series 819, Geneva, 1992) make it clear
that diagnostic imaging for the most common illnesses is an essential
part of the resources in any hospital to which patients will go for diag
nosis and treatment.
So what has WHO done about this serious deficiency, apart from pub
lishing various books and papers, holding conferences or lecturing at ra
diological meetings? Since the 1960's, WHO has, through expert com
mittees and advisors, worked with the x-ray industry on the design of
imaging equipment for developing countries, and of equal importance,
on the improvement of image quality, safety and the availability of imag
ing services. Training programmes for radiologists have been set up in
cooperation with the International Society of Radiology (ISR), and the
training and work of radiographers/x-ray technicians and sonographers
have been studied with their international organizations. Radiation ther
apy has not been neglected but is not part of this textbook.
86
RADIOLOGY WORLDWIDE - THE WHO APPROACH
This lengthy and often frustrating process has resulted in universally

applicable guidelines which are of importance to all radiologists. There
are minimum specifications for equipment, together with technical man
uals which, if followed, will prevent the waste of money caused by the
wrong choice of equipment and technique. Image quality will be im
proved compared with much that is available today, because it has been
shown that the radiographs produced by a WHO specified radiographic
system are comparable to or even of better quality than images at pres
tigious university departments. Equipment does not have to be complex
and expensive to produce good images.
Why is diagnostic imaging so important?
Table 1. Worldwide estimated percentage distribution o f Disability-

Adjusted Life Years (DALY) lost, by major categories for 1990. Source:
World Development Report 1993, Investing in Health. Publishedfo r the
World Bank by Oxford University Press, Inc.
Area of Populations DALY loss (in percent)

world in millions
Communi Non-com- Mechanical
cable unicable injuries
diseases diseases
Sub-Saharan Africa 510 71.3 19.4 9.3
Middle East Crescent 503 51.0 36.0 13.0
India 850 50.5 40.4 9.1
China 1,134 25.3 58.0 16.7
Other Asia & Islands 683 48.5 40.1 11.3
Latin America and the
Caribbean 444 42.2 42.8 15.0
Formerly socialist
European economies 346 8.6 74.8 16.6
Established market
economies 798 9.7 78.4 11.9
World total 5,267 45.8% 42.2% 11.9%
Table 1 shows the worldwide estimated percentage distribution of dis

ability-adjusted life years (DALY) lost, by major categories for 1990.
DALY loss, the number of disability-adjusted life years lost, is a way of
describing the difference between the actual age at death and the expec
87
tation of life at that age in a low-mortality population in combination

with an adjustment for the severity of disabilities in the same population.
DALY loss thus can be used as a measure of the burden of disease.
The importance of diagnostic imaging is that it makes possible the ac
curate diagnosis of much of the disease and trauma responsible for these
deaths and disabilities. Whenever adequate therapeutic services are
available, the years of disability and life lost can be reduced.
Yet, nearly 100 years after the discovery of x-rays about two thirds of
the world s population does not have access to the most essential diag
nostic imaging service. The fundamental principle of "Health for All" is
equity, which demands that this universally recognized diagnostic
modality be made available to all who need it. There can then be quick
and accurate diagnosis, less hospitalization, prompt return of the patient
to home or workplace, and additionally and most importantly, less pain
and suffering.
CHOICES - INDICATIONS
When choosing either x-ray, ultrasound, or any other imaging equip
ment, there are three basic questions which must be fully answered.
1. Who and how many need diagnostic imaging?
2. What types of diagnostic imaging are needed?
3. Where will the imaging be made?
1. Who and how many need diagnostic imaging?

When equipment must be chosen for imaging departments, the task can
be either to plan for a large area, such as a city, district, region or coun
try, or to choose for a particular clinic or hospital. It is easier to plan for
a region, large or small, because 90% or more of the imaging does not
require complex equipment. Most of the inhabitants of the region will
need diagnostic imaging because they suffer a fracture, develop a cough,
or have an abdominal or pelvic pain. The women will become pregnant.
Only a small percentage (probably less than 10%) will need gastroin
testinal, cardiovascular, or other advanced studies.
Where money is short, the majority should be properly served first and
the few, who will need by far the most expensive equipment, must be
given a lower priority.
When the task is to plan imaging services for a particular hospital, at
tention must be paid to the catchment area, the size of the population,
88
the size of the hospital or clinic, the pattern of referrals, the local disease
profile (e.g. heavy industry or rural occupations), the current hospital sta
tistics and future plans, including the special skills of newly appointed
specialists who will request specific imaging techniques.
2. What types of diagnostic imaging are needed?

The full list of possible indications for diagnostic imaging is too long to
include here, but reference to the chapters or index of this textbook will
show the range. It is possible to make a summary, however, because
WHO has studied the problem all over the world. The summary is very
simple, because everywhere in the world the most common indications
for diagnostic imaging are:
Indications Use x-rays for Use ultrasound for

Trauma skeleton and chest soft tissue
(liver,spleen, etc)
Chest infections (pneumo pleural effusions

disease nia, tuberculosis,
mycoses) and heart
problems
Abdominal calculi, obstruc calculi, jaundice,

disease tion, perforation obstruction, perfo
ration, pelvic in
flammation
Pregnancy - obstetric examinations
Table 2 shows the percentage distribution of examinations at small hos

pitals and primary care x-ray departments in different parts of the world.
About 15% of the examinations are of children. There is considerable
seasonal variation but the overall pattern is consistent everywhere. Over
90% of required examinations are for chest and skeleton. Ultrasound,
where available, lowers the number of x-ray examinations of the ab
domen.
89
Table 2. The distribution o f radiographic examinations in small x-ray

departments, obtained from the records o f small hospitals in Sweden,
Latin America and Africa
Swedish Columbian African mission hospitals

primary care ruralhospital using BRS units in:
centre with BRS Kenya Tanzania
(1977) (1982) (1987) (1988)
The number of
exams/year 4,900 2,200 2,800 2,600
Gl barium
examinations 770 - - 60
General radiogra
phic exams 4,130 2,200 2,800 2,540
Percentage
distribution
- chest 38% 58% 46% 35%
- skeleton 54% 34% 50% 54%
- abdomen 8% 8% 4% 11%
In practice, chest and skeletal examinations are the most important in
dications for diagnostic imaging in any country and at any clinic or hos
pital, regardless of size. The majority o f these examinations require only
"plain radiography" (without fluoroscoy) or general purpose ultrasound.
Thus, in small rural or suburban hospitals, plain radiography will account
for over 90% of all necessary examinations and ultrasound will satisfy
a large part of the other 10%. Indeed, plain radiography or "plain" ul
trasound will be all that is necessary for 70-80% of all diagnostic imag
ing even in a sophisticated university hospital in a big city.
3. Where will the imaging be made?

Imaging should be provided only at those clinics or hospitals where a
competent person is available to interpret the results. The request for
imaging and the interpretation of the images are the responsibility of
physicians. The only exception is that qualified and well trained mid
wives can do routine antenatal ultrasound examinations, provided they
have a physician to whom they can refer when there is a difficult image
to interpret.
90
This means, and WHO recommends, that small hospitals and clinics
with at least one doctor (the first referral level) or any large hospital or
clinic (the second and third referral levels) all need imaging equipment.
The type of equipment increases in complexity and cost as the level of
available treatment is raised, but all hospitals will always require good
facilities for plain radiography, whatever else may be available.
Patients should be imaged as close to their home as possible, where
they can be treated for all their common ailments by the doctors and
nurses whom they know best. Ideally, all images should be taken by a
trained radiographer or ultrasonographer and interpreted by a radiolo
gist. Unfortunatly, in much of the world this does not happen. If profes
sionals are not available, imaging should be restricted to plain radiogra
phy and general ultrasound.
Fluoroscopy or any complex imaging should not be installed, unless
there are both radiologists and fully trained technologists to use it. This
requirement is equally important for CT, MRI, angiography, nuclear
medicine and advanced ultrasound.
SOLUTIONS
Radiography
When WHO had ascertained that the vast majority of x-ray examinations
were going to be "plain", non-fluoroscopic radiography, the following
design requirements were established for the radiographic system.
1. High quality images, as good as or better than most radiographs avail

able in major centres.
2. Standard radiographic projections, which will easily be recognized by
any doctor.
3. Safety for staff and patients.
4. Easy installation and maintenance. Easy operation.
5. Ability to operate with poor main electrical supply.
Fulfilling these requirements is not difficult, but WHO chose technical

solutions which are unconventional. The explanation which follows does
not indicate any order of priority, because all requirements are interde
pendent.
91
Technical solutions
Power supply
Developing countries, and indeed almost any country, may have a highly
variable and often intermittent main electric supply. Batteries become
the logical method of power storage, because power from batteries is
available at any time. Batteries are rechargeable from many different
power sources and are insensitive to voltage or frequency fluctuations.
The power from a simple grounded "kitchen" or similar outlet or from a
small 230 V, 10 A alternating current (AC) generator is all that is re
quired. Sealed and maintenance-free lead-acid batteries are recom
mended.
The design of high tension generators using stored direct current (DC)
energy must include inverter technology: the use of a medium or high
frequency converter x-ray generator is essential.
X-ray generator
The x-ray unit must be able to produce good radiographs of a finger (low
power), a child's chest (medium power, very short exposure time), a large
adult chest (high power, short exposure time), and a lateral view of the
lumbo-sacral junction of a heavy patient (very high power, long expo
sure time).
To accomplish this the x-ray tube voltage must range from about 50
kV to 120 kV and these voltage values should be reached in 2-3 ms (mil
liseconds). The current-time product (milliampere-second value) must
be variable between 0.8 and 200 mAs in 26% increments. The instanta
neous output of the generator must be more than 12 kW and the total en
ergy output must be no less than 25 kWs (kilowatt-seconds). If a "green"
screen-film system is used, a total energy output of 12-15 kWs may be
satisfactory.
Given the almost constant output from a converter generator, the im
age quality will depend on focus-film distance, object-film distance, the
collimation and the use of an antiscatter grid.
Focal spot an d im aging geom etry

WHO recommends the use of a focal spot of 1 mm or less. The focus-
film distance is 140 cm for ALL examinations. The patient-film distance
is 2-3 cm. Thus, a chest film exposed at 140 cm will have the same mag-
92
Figure 3. Patients can be examined standing, sitting or lying down; the beam can be
angled as required. Cross-table decubitus projections o f the skull, chest or abdomen
are easily obtained. (From WHO-BRS: Manual o f Radiographic Technique)
nification of the heart as one made at the more usual 180-200 cm and a
patient-film distance of 6-8 cm.
Grid
Because the focus-film distance is fixed, an accurately focused anti-scat
ter grid with a ratio of 10:1 can be used. The line density should be 40-
60 lines/cm. A correctly focused high-quality grid with more than 40
lines/cm is almost invisible on the radiograph when the film is viewed
at a distance of 30 cm or longer. A bucky mechanism is not necessary,
which saves space in the cassette holder, reduces the complexity of the
unit and saves maintenance and money.
93
Figure 4. The two pages o f the WHO Technique Manual which show how to take an
"erect" PA chest radiograph. The operator follow s the instructions given in the dia
grams and, at the bottom o f the second page, can see the result which should be ob
tained.
The specified range o f movements

This permits a WHO-designed x-ray unit to function equally well as a
chest unit, a vertical bucky, or a floating-top table. Although there is a
fixed tube-film relationship, it is possible to use a vertical or horizontal
beam +/- 30°. The range of movements is best shown by illustrations (see
Fig. 3). As part of the imaging system, WHO has produced a "Manual
of Radiographic Technique", designed for this type of unit and demon
strating over 100 standard projections (see Fig. 4).
Exposure values
Based on the use of a 200 speed screen-film combination, exposures can
be obtained from the technique manual, using measurements of the pa
tient's thickness. If necessary, it is easy to recalculate the mAs-values
for other screen-film combinations which have different speeds. All ex
posure values in the WHO manual are valid for 3-phase or multipulse
converter generators. If an outdated single-phase generator is used, the
mAs-values will probably have to be doubled.
94
Safety
The WHO-specified frequency converter generator produces a high qual
ity x-ray beam at almost constant potential. The x-ray tube should have
a total filtration equivalent to about 4 mm aluminium (Al). Thus, the
amount of soft radiation likely to be absorbed in the patient is very low.
The collimator cannot be removed and in the simplest WHO specifi
cation the collimated x-ray fields are matched to the film sizes. Even
when the collimator is wide open, the x-ray beam cannot bypass the cas
sette holder, which has a radiation-absorbing back.
The focus-film distance is fixed at a longer distance than is conven
tional for most general radiography and the grid is accurately focused to
this non-variable focus-film distance.
These factors added together result in an average patient surface dose
of about 50% when compared with conventional equipment using sin
gle phase generators, poorly filtered x-ray tubes, primitive collimators
and variable focus-film distance. It is possible to reduce doses further by
replacing the common "blue" screen-film system with a "green" screen-
film system, doubling the sensitivity in the 90-120 kV range. Because
correct alignment is assured and the scattered radiation is low, this WHO
design is one of the safest x-ray units ever produced.
Design and installation

The examination stand of the WHO-designed x-ray unit consists of a
long arm, shaped as a question mark, carrying an x-ray tube and a cas
sette holder at opposite ends (see Figure 3). This arm is mounted on a
fixed vertical column in such a way that the assembly can be moved up
and down and rotated to provide different beam directions in a single
plane. The entire stand weighs 200-300 kg. The column has a rectangu
lar base (about 20x30 cm) and may be installed standing on a flat, strong
floor, held steady by a 40-50 cm long support to the nearest wall. Instead
of using a wall support, the unit can be mounted on a large (about 1 m2)
base plate of steel.
The patient may be examined standing, sitting, or lying down on a trol
ley with large wheels and x-ray translucent top. Cross-table decubitus
projections of any part of the patient are easy to obtain (Fig. 3). Any
WHO-specified x-ray unit can be installed by two people in a single day.
There is no need to discuss the details of installation, room size or lay
out any further. One possible layout for a very small x-ray department
95
Figure 5. Layout o f a 42 m2x-ray department fo r 2000-3000 examinations p er year.

(Scale 1:100). There are many alternative designs.
(2000-3000 exams/year) is shown in Fig. 5. Many variatations are pos

sible. The specifications of equipment, room sizes, films, darkroom
equipment, protection requirements and everything else required can be
obtained from the Chief of Radiation Medicine, WHO/OMS, 1211
Geneva 27, Switzerland.
How does the WHO-designed equipment work in practice?

The WHO Basic Radiological System, originally abbreviated to WHO-
BRS, was recently (1993) renamed to include ultrasound. It is now known
as the WHO Imaging System - WHIS - with components of Radiography
(RAD), Ultrasound (US), Darkroom (DR), and Manuals (MAN). All the
sub-systems have been well tested, particularly the WHIS-RAD and the
radiographic manuals. Extensive experience in the use of the WHIS-
RAD has been documented by several primary care centers in Sweden,
at a mass-chest centre in Moscow, and in nine rural hospitals in Africa.
In and around Lund, Sweden, there are four installations supervised
by the University Radiology Department and two private installations.
More than 250,000 examinations have been made with an average of
four films per examination. The results completely meet the needs of pa
tients and staff, the radiographers and radiologists from the University
Hospital in Lund, and the referring physicians.
96
In 1990, in Moscow, the International Organization for Migration

(IOM) needed to have chest x-rays of about 200,000 emigrants within 3
years. A single WHO installation examined 300-400 chests every day,
completing 50,000 examinations in the first nine months with a one-day
breakdown - and this was due to an overload of the automatic proces
sor, not the x-ray unit. The film quality was consistently high. After three
years, with the addition of a second WHO-unit, more than 300,000 ex
aminations have been made. The only repair has been the replacement
of the x-ray tube in the oldest unit.
In different countries in Africa, nine WHO-units were installed as gifts
from the Netherlands Charity "SIMAVI", all in small rural hospitals.
After they had been working for two years, an independent team com
posed of a radiologist, a radiographer and a radiation physicist was sent
to inspect each unit, check radiation output, film quality, clinical results
and "customer satisfaction". While the teams found they could further
improve image quality, most of the faults had occured in the darkroom.
The overall conclusion was that the WHO design was the best, and ide
ally suited for general purpose radiography, especially in a rural setting.
Image quality with WHO-specified radiographic units

It is difficult to define the "quality" of an image. The subjective impres
sion of many observers is that the images produced with the WHO-spec-
ified units are equal or better than those produced in many unversity-
level hospitals. Generally, the image quality is superior to the image qual
ity of most conventional x-ray installations.
Attempts have been made to quantify these impressions. In an assess
ment by the National Health Service of the United Kingdom, equipment
following the WHO design was compared with conventional x-ray equip
ment at an 800 bed hospital. The images of the chest, abdomen, skull,
spine, pelvis and extremities produced by the WHO unit were consid
ered to be excellent by the radiologists in 20% of the examinations ver
sus only 6% for conventional equipment. About 1% of the radiographs
were considered to be unsatisfactory for both types of equipment.
Radiation protection and patient dose with the WHO-BRS

The International Commission on Radiological Protection (ICRP)
Publication 34, Protection o f the Patient in Diagnostic Radiology, states
that "The aim of the radiation protection of the patient has gradually
97
shifted from a concern about population exposures and hereditary ef

fects, to the ambition of limiting the risk to the individual patient".
Consequently, during the past decade, authorities responsible for radia
tion protection have become increasingly involved with measuring the
dose received by patients during x-ray examinations.
Surveys, each using essentially the same techniques, have been con
ducted in England, France, Italy and Sweden, and these results have been
compared. Among the data reported was the mean entrance surface dose,
which was obtained by placing thermoluminescent dosimeters on the
skin according to a method developed by the National Radiological
Protection Board (NRPB) of the United Kingdom.
For the majority of the examinations the entrance surface radiation
dose from the WHO-unit tested in Sweden is several times lower than
the mean values obtained in England, France and Italy, where conven
tional equipment was used.
WHO manuals fo r diagnostic imaging

The manuals which are part of the World Health Imaging System
(WHIS), Radiographic Technique, Darb'oom Technique, and
Radiographic Interpretation fo r General Practitioners, have been ac
cepted all over the world. The Manual of Radiographic Interpretation for
General Practitioners had, in 1994, been published in nine languages,
with a total estimated sale of more than 100,000 copies. The fourth
WHIS-Manual, the WHO Manual of Diagnostic Ultrasound, will be pub
lished in 1995. The fifth manual, describing the design, layout and equip
ment of x-ray department buildings, the choice of equipment, and train
ing, should also be published in 1995.
Ultrasound
There is an increasing need for ultrasound examinations, especially for
the abdomen and in obstetrics and neonatal care: it has become a very
popular way of imaging. Because there is no harmful radiation (so far as
is known in 1994), many physicians and others have purchased ultra
sound equipment. Some small ultrasound units seem attractive and
cheap, but most do not give a good quality image. Too many ultrasound
units are used by untrained and unqualified people, often to learn the sex
of the fetus. In some societies this has led to abortions because the fetus
is of the "wrong" gender.
98
WHO has reacted to this demand for ultrasonography in two ways.

First, by providing specifications which include all necessary features
for a general purpose ultrasound unit (WHIS-US or GPUS). Units meet
ing these minimum specifications will give high quality images and sat
isfy all the general diagnostic needs of a busy general or obstetric clini
cal practice. In many places the Doppler techniques will be unnecessary:
there are neither the vascular diseases nor the vascular surgeons to war
rant extra expenditure. These specifications were originally drawn up by
an expert international group and have since been updated. Secondly, by
emphasizing the need for training and by the publication (1995) of a
Manual of Diagnostic Ultrasound, which is designed for those who work
alone, especially those who have no experience with the clinical use of
ultrasound.
General purpose ultrasound specifications are available, either in the
Manual of Diagnostic Ultrasound or from the Radiation Medicine Unit
at WHO, Geneva. These provide all the necessary information required
to choose a unit and will be kept up-to-date. The quality of the image re
mains the major guiding principle behind the specifications.
Ultrasound equipment is probably physically safe to use, but there is
potential danger because many diagnostic errors will occur if the oper
ator is not properly trained. WHO has recommended minimum training
requirements. Radiologists must assume the responsibility for insisting
that these minimum standards (both professional and ethical) are met.
Currently (1994), very few governments have laid down regulations gov
erning the use of ultrasound, but there is hope that these will soon be
forthcoming.
GLOBAL IMAGING
In 1994 - and perhaps for a few years to come - true "global imaging
available to all who need it, is a goal towards which WHO and organiz<
radiology must strive. Quality, safety and availability for the majorit
must be the criteria: all are met by the WHO Imaging System. Too many
governments, hospitals and clinics buy their equipment because a per
suasive salesman has convinced them of their need. Radiology is ex
pensive, and the selection and purchase of imaging equipment should,
and indeed can, only be properly made knowing the answers to these
questions: who needs to be imaged, why is the imaging necessary, how
many will need each type of imaging, who will produce the image, and
99
who will interpret the image?

These decisions will be based not only on patient need, but also on the
treatment which is available. An MRI scan of a brain tumour serves lit
tle purpose if there is no neurosurgeon or oncologist to whom the patient
may be easily referred. Fortunately, for both ourselves and our health
service budget, few of us will develop brain tumours! But we are all, at
all ages, at considerable risk of trauma and chest disease.
WHO efforts to provide "Health for All" should be used to guide the
choice and distribution of imaging facilities in every health care system.
For the majority of imaging examinations, the WHIS (WHO Imaging
System) will more than satisfy the needs of the majority of patients. It is
the responsibility of radiologists to ensure that these essential patient
needs are met everywhere.
100
Chapter 6
Digital imaging
Tatsuo Kumazaki and Hans Ringertz
ANALOGUE AND DIGITAL IMAGES

Historically, radiological images were recorded on glass plates covered
with a light-sensitive emulsion. This emulsion, sensitive to a wide range
of photon energies, consisted of microscopic particles of silver com
pounds which following exposure, developing and fixation built up an
image, consisting of small black dots, of the radiographed object.
Different types of intensifying screens and filmbased materials have not
changed the basic principle that the information content of the image
consists of microscopic dark dots, the density of which determines the
darkness in a given image area. The darkness thus varies continuously
and the image produced is called an analogue image.
If the darkness along a line across an analogue image is measured with
a densitometer as in Fig. 1 a, the result will be an irregular curve where
the finest irregularities represent the individual silver particles. If the reg
istered curve is divided into equal parts the density in each part can be
calculated as an average that can be given a numerical value. The aver
ages are seen in Fig. 1 b and the corresponding numerical values in Fig.
1 c. When the whole surface of a radiological film is measured with a
densitometer line by line in this way the analogue image can be trans
formed into a so called digital image (Fig. 2).
The distances between the lines and the size of the equal parts divid
ing each line defines the resolution of the digital image. A quadrilateral,
as high as the distance between two lines and with the width of one di
vision along a line, is called a picture element or a pixel.
The digital image is naturally adapted to computer techniques. Thus,
the images are normally divided into a number of pixels equal to pow
ers of 2, e.g. 512 x 512, 1024 x 1024 or 2048 x 2048 pixels. The num-
101
С 2 5 7 6 6 4 1 2 4 6 8 10 11 10 12 14 7 3 1 3
D 0010 0101 0111 0110 0110 0100 0001 0010 0100 0110 1000 1010 1011 1010 1100 1110 0111 0011 0001 0011
Figure 1. Analogue to digital conversion o f a photometry recording along a line into a

sequence o f binary signals.
A) Schematic photometry curve o f a line, e.g. across a radiographic film
B) The same curve divided into equal distances. For each segment the average pho
tometer recordings have been assessed on a scale from 0 to 15 (24steps)
C) Digital printout o f the photometer averages in 1 В
D) Binary representation o f the digital series o f numbers in 1 C.
Figure 2.
The influence o f spatial and den
sity resolution on image quality
in an analogue to digital image
transformation.
a) Analogue image with moder
ate spatial and density resolu
tion. A low spatial resolution
matrix is superimposed upon
the image.
b) The same analogue image
A n a lo g u e to d ig ita l with a 10 by 10 pixel spatial
tra n s fo r m a tio n matrix and 2 bits contrast res
10 times 10 pixels olution, i.e. 4 density levels.
with 2 bits (2 x 2) shades c) The final digital representa
tion o f the low spatial and
density resolution image.
102
DIGITAL IMAGING
ber of possible shades between black and white are also often referred
to by a binary value, for example 8 bits = 28 or 256 shades, 10 bits = 1024
shades, or 12 bits = 4096 shades. In Fig. 1 d the darkness is given as 4
bits or 16 shades or levels and in Fig. 2 as 2 bits or only 4 levels.
IMAGE ACQUISITION
Radiological images today are acquired utilizing a wide spectrum of dif
ferent techniques, ranging from analogue via various acquisition modal
ities to direct digital registration. The technique is usually dependent on
the radiological modality in question.
Conventional radiology techniques usually acquire an analogue im
age on photographic film where the density varies continuously without
any discrete steps. The image is normally formed through direct or in
direct radiation on the emulsion layer of the film by X-rays emanataing
from an X-ray tube and by light emitted by the intensifying screens (see
Chapter 4). This category also contains techniques such as scanograms
and ultrasonography where analogue image information is amplified
electronically and transmitted as a video signal to image screens and pho
tographic film. The video signal is the means by which analogue infor
mation is transmitted electronically.
The images created on image plates, during digital fluoroscopy, digi
tal subtraction angiography, in certain ultrasonographic equipment, and
in gamma cameras are initially registered in digital form. These data can
subsequently be transformed and presented either in analogue or digital
form on image screen or photographic film.
Finally, we have the group of modalities which comprised the break
through for digital techniques in radiology, namely computed tomogra
phy (CT), and later Single Photon Emission Computerised Tomography
(SPECT), Positron Emission Tomography (PET), and Magnetic
Resonance Imaging (MRI). In these modalities transmitted or emitted
electromagnetic photons not primarily depicting anatomy are registered
and the image is calculated by computer from the photon information.
They are thus producing calculated digital images and the density of each
pixel has been obtained as the solution of a series of equations.
Analogue/digital transformation
Image content, transmitted by electronic or optical means within radio
logical equipment, a radiological department, or between different de
103
partments is sent in analogue form via an electric current or by an opti

cal signal varying in intensity in a similar manner to that shown in the
curve in Fig. 1 a. The image can also be transmitted as binary digital sig
nals demonstrated in Fig. 1 d.
Acquisition of radiological information as well as presentation of im
ages on a monitor are thus sometimes digital and sometimes analogue.
This means that there is a need for units that convert electronic image
information from analogue to digital and vice versa. Such units are called
A/D and D/A converters.
Digital image plates

The radiological image on a photographic film is produced through illu
mination with light from intensifying screens and to a lesser degree as a
direct effect of X-ray quanta. On digital image plates the information is
stored as excited electrons in phosphorous plates containing complex in
organic substances.
Thus, the radiological information, after passage of the radiation
through the object/body, is temporarily stored on the image plate in in
verse proportion to the absorbed radiation dose. In order to read this in
formation a laser beam is used to release the trapped energy stored in the
image plate as emitted light. The laser beam sweeps over the image plate
line by line until the whole surface has been read. After the laser stimu
lation the stored information is transformed from emitted light to elec
tronic signals using a photo multiplier. The image plate can be reused
many thousands of times.
The electronic signal is amplified, digitized, and transferred to an im
age processor. This unit has a twofold function. Firstly, it calculates the
mean darkness of the image and the total range between the light and the
dark parts of the image. Secondly, it uses this information to calculate
an optimal image that is transmitted to a laser printer which produces the
image on transparent film.
The digital information can also be transmitted to a Picture Archiving
and Communications System (PACS), which used in combination with
high resolution monitors for diagnostic work and conferences can elim
inate the use of photographic film.
The use of digital images from image plates has a number of advan
tages:
104
DIGITAL IMAGING
1. There is increased sensitivity to X-ray quanta which can be utilised

to increase the image quality and/or reduce the radiation dose.
2. Erroneous exposures are greatly reduced as nearly all exposures can
be salvaged by the image processing.
3. The digital image can be transmitted, manipulated, and presented in
many different ways.
Calculation of a tomographic image

CT and other modalities where the image is calculated from emitted or
transmitted electromagnetic information, use tomographic sections. This
means that the calculated images represent parallel planes through the
anatomy in question. Such a section is defined as the plane in which the
detectors of the CT, SPECT, or PET units are located. In MRI, the im
age reconstruction can be made in any selected plane (2D) or volume
(3D).
The calculations involved are complex and time-consuming even for
powerful computers. As a simplified description in the case of CT each
detector reading can be said to represent the absorption along the line of
volume elements through which the X-ray beam has passed.
This will give an equation where the absorption in each single volume
element is the unknown parameter that represents the darkness of the
corresponding pixel. As a large number of detector readings is made, a
huge equation system is obtained, for example in a 512 x 512 matrix
there are 262,144 unknown parameters.
These equations are solved with different, more or less approximate
mathematical techniques. The result will be a density value for each pixel
of the tomographic image.
Spatial and density resolution

The most important aspect of image quality is resolution. The number
of line pairs per mm that can be resolved by the eye under defined cir
cumstances is often used. However, this definition is only valid for ana
logue images. Digital images cannot of course resolve details that are
smaller than one pixel. This type of resolution is called spatial resolu
tion, compare Figs. 2 a, b.
If the spatial resolution of a conventional radiological film is deter
mined it is comparable to a digital image with a resoution as high as 4096
x 4096 pixels. Under certain circumstances even higher spatial resolu-
105
tion is used, e.g. in

Digital greyscale mammography.
-1000 -500
I . . . i 1, i. In order to assess the
-I- Window width 800 HU spatial resolution the
Darkness level -600 HU
contrast resolution has
to be maximal. This
Figure 3. The settings o f a typical grey scale in com means that the line pairs
puted tomography. The digital image in the computer and the background
memory has a contrast resolution from about -1000
(air) to +1000 (bone). An example o f the setting o f the have to be black and
window width and level is indicated. The level is -600 white. If the contrast
HU and the width 800 HU. The resulting image with resolution is less the
these settings will show -1000 and below, as black, and
spatial resolution will
-200 and above, as white.
be reduced. The con
trast resolution in a digital image depends upon the number of possible
shades of darkness and is often better than that of an analogue image.
IMAGE MANIPULATION
The digital image is thus inferior to a conventional analogue radiographic
image when it comes to spatial resolution. This is compensated for by
the nature and potential of digital technology. The contrast resolution is
superior which is an advantage when the potential for the eye to observe
the different shades of darkness is enhanced by the ability to shift the
contrast scale, for example on a monitor (Figs. 3, 4).
It is possible to carry out a number of manipulations of the digital im
age in order to enhance the information content of the image. Most of
these manipulations can also be carried out with analogue images but
this is more cumbersome and time-consuming. As digital images should
be assessed on a monitor simple measures such as changing black and
white (Fig. 4 C) or magnification of a detail can be routinely performed.
The goal for image manipulation in radiology is to increase diagnos
tic accuracy (Fig. 5). In the process of object-image production and fi
nal diagnostic image assessment, the image manipulation is included as
a quality enhancement. In addition, the potential for different image in
terpretation techniques is increased compared with conventional film
reading. Techniques for both interactive interpretation and automatic im
age analysis are being evaluated presently.
106
DIGITAL IMAGING
Figure 4. Examples o f differ

ent simple manipulations o f
one digital image o f a com
puted tomography section
through the chest.
A) A limited density range im
age with a window level o f 0
HU corresponding to water
attenuation, and a window
width o f 1000 HU. Pixels
with a value equal to or less
than -500 are black, and
pixels with a value equal to
or above +500 are white.
B) The same image with a pu l
monary setting. Window
level is -600 H U and the
window width is between -
1000 and-200 H U as in
Fig. 3. It can be seen that the soft tissue details disappear in the chest wall while the
structure o f the lung is visualised compared with a).
C)Fig. A) with reversal o f the scale so that pixels o f +500 H U and above are black,
while pixels o f -500 or below, are white.
D) The full density range from -1000 to +1000 HU. Observe the diminished contrast
resolution between muscle, fat, and glandular structures in the chest wall and
breasts.
E) The same image as Fig. D) with single application o f an edge enhancement algo
rithm. Some new structures are seen in the lung.
F) The same image as Fig. D) with double application o f an edge enhancement algo
rithm. Most o f the lung structures seen in Fig. B) are seen but a disturbing back
ground noise has been added to other tissues.
Figure 5. Schematic repre Object Image

sentation o f the diagnostic
imaging process and image
Linage egqujsition
manipulation. Image acqui Ultrasound
Conventional X-rays
sition from the object, in this Computed
case the liver, may give pos tomography
MR-imaging etc.
sibly important but vague di
agnostic information. Image Diagnostic Imaging
manipulation will give a
processed image that en
hances the diagnostic find Image gngiyse?
Visual
The liver has normal size and
ings - or discards them. shape. Two rounded defects
Interactive
Automatic
are seen within the liver.
Image analysis, normally vi /Signed I.M.Radiologist < — - -
sual, leads to diagnostic as
sessment in the form o f a re
port.
107
Darkness level and window width

The simplest form o f digital image manipulation is the normal use of
darkness (contrast) level and windowing when evaluating CT or MRI
images on the monitor. A digital image with 2048 darkness shades will
lack contrast if all 2048 levels are visualized with 0 as black and 2047
as white (Fig. 4 d). A darkness level o f 1024 and a window o f 2048 steps
has then been chosen. On a CT the scale normally runs from -1024 to
+1024 Hounsfield units, HU, as seen in Fig. 3.
In order to assess the lungs optimally on a CT chest slice, a darkness
level close to the average CT density of the lungs (between -600 and -
900 HU) ought to be chosen (Fig. 4 b). The window width 800 and the
level -600 means that -1000 HU is seen as black and -200 HU and above
is white (Fig. 3). If the same digital image is used to assess the skeletal
details of the chest a window width of 1000 and the level +500 HU will
result in a complete grey-scale between 0 and +1000 HU (Fig. 4).
Image subtraction
The subtraction of a pre-contrast film from a radiographic film after con
trast medium injection into the arteries - angiography - has been prac
tised for many decades. This technique was especially used when the
background to the vascular tree was very irregular or dense as for ex
ample in the base of the skull or the upper part of the chest. The pre-con
trast film was inverted photographically so that black became white and
vice versa and then matched to the post-contrast film so that only the vas
cular structures were seen.
This procedure is o f course both faster and simpler to perform elec
tronically with a computer. Whole sequences of cine background images
can be subtracted from moving contrast-filled vascular structures such
as the coronary arteries of the beating heart. The technique is called
Digital Subtraction Angiography (DSA). The subtraction is often made
in real time while the contrast injection is being recorded. A computer
ized advantage is to be able to find automatically the optimal subtraction
orientation of the two images, if a slight movement has occurred between
the pre- and post-contrast image.
To manipulate an image
The possibilities of performing mathematical manipulations on digital
images are more or less unlimited. In practice, only relatively few ma-
108
DIGITAL IMAGING
nipulations are used, primarily edge enhancement and contrast equal

ization. They are used to even out the contrast span over the whole im
age, to enhance contours that can be difficult to see, and to even out ir
regularities in homogenous structures. The reason for evening out the
contrast span is to be able to assess equally structures that are located in
very dark or very light areas on the original image.
The methods for image manipulation are mathematically based on a
recalculation of each pixel based on the values in surrounding pixels.
Squares of pixels, e.g. 3 times 3 or 5 times 5, are used to influence the
Figure 6. rtNTEPIOP 16 .3 DI
2"*7 .5 AN
Examples o f simple radiological DIST 2
16 .7 DI
264 .6 ЙЫ
measurements performed on digital DIST 3
23 .2 DI
images by the modality computer. 359 .6 ftN
A) Distances 1, 2, and 3 within the

chest are given in centimetres (DI)
together with the angle in degrees
between the line (indicating the
distance) and the vertical direc
tion (AN).
B) Angles in degrees between the in
dicated lines are given on the im
age.
C) The circular Region o f Interest
(ROI) in the lung indicates an av
erage attenuation o f -815 HU
(ME) with an average pixel devia
tion from the mean o f 70.76 (SD).
The surface o f the circle is also
calculated (AR) and is 30.73 cm2.
109
value of the middle pixel. Edge enhancement gives an image that mim-
icks the manipulation made by the eye sending visual information to the
cerebral cortex. This means that the second derivative of the densito-
metric curve is used around an edge resulting in an extra bright zone on
the light side of the edge and an extra dark zone on the dark side (Figs.
4 e, f).
Radiological measurements
The ruler and the protractor have always been radiological tools.
Measurement in radiology was then advanced when the development of
ultrasound introduced the ability to make simple measurements such as
distances and angles between identified points on the image. This capa
bility was especially important when no relative size estimate was avail
able on the screen. Subsequently, area and examination- specific mea
surements were developed.
The same options are nowadays accessible for most screen oriented
modalities independent of whether the images are analogue or digital.
Simultaneous measurements of multiple distances (Fig. 6 a) and angles
(Fig. 6 b) can be obtained. Both regularly and irregularly shaped surfaces
can also be analysed with respect to area, mean density (e.g. HU atten
uation), and the standard deviation of the density (Fig. 6 c).
In the future the ability to make measurements on the image will be
combined with normal values for the measurement related to measures
such as patient age, height, or weight. It ought, for example to be possi
ble to measure the projected area or volume of a kidney and relate the
result to an appropriate parameter of body size. This should also be true
for cardio-thoracic ratio or cardiac volume per square meter body sur
face area, etc.
PACS
As mentioned above this abbreviation means "Picture Archiving and
Communications System". A first step in the development of PACS in a
hospital or health care organization, is a HIS or "Hospital Information
System". The corresponding system in a radiological department is called
RIS or "Radiological Information System". Such computer systems con
tain data about the patient, e.g. name, address, previous examinations,
modalities, and diagnoses, scheduled visits, referring physician, ward,
etc. When linked to a PACS and the units that produce digital radiolog
110
DIGITAL IMAGING
ical images they form the basis of a digital radiological unit.
A PACS technically contains five parts:

1. The communication network with the image sources (Modalities)
2. A registry of examinations and patients and the archive for storage of
such demographic data
3. Programs for implementing the demonstration and manipulation of
images
4. An archive of all images
5. A unit for communication via a telephone connection or computer net
to other digital systems
It is important that the patient administration system also keeps track of

the digital images in order to maintain professional secrecy and order in
the system. The access time for an examination in a PACS depends on
many factors. This time is longer if multiple image sources are connected,
if complex manipulations are made, or if frequent requests for previous
examinations are made.
In a completely developed PACS, radiological conferences are per
formed on image screens rather than photographic films. During a tran
sition period analogue films and image sceens often coexist and both may
be used during conferences.
Archival of digital images

Developments in the computer field have made it possible to store large
numbers of digital images even if a very large memory capacity is nec
essary. A binary figure is called a bit. In most instances eight bits form
one character (a decimal figure, a letter or comparable entity) and is called
a byte. One kilobyte is 1024 bytes and a megabyte is about one million
bytes in a computer. The hard disc of an ordinary personal computer con
tains of the order of 100 megabyte.
One image with a spatial resolution of 1000 x 1000 pixels uses one
megabyte of memory with the possibility of 8 bite or 256 levels of con
trast resolution. As larger radiological departments produce millions of
images per year the required computer archive is enormous if all images
are digital.
In order to reduce storage requirements the digital image information
is normally compressed in one of two ways. In the first type of com-
111
pression an image identical to the original can be obtained from re-

versibly compressed data. The gain in computer storage is about 50 to
70% and the compression is in the order of two or three times. The re
duction can be described in a simplified way as putting together all neigh
bouring pixels with the same value and storing them as one piece of in
formation, indicating the start and the end of these pixels.
In the second type of compression the compression factor can be up
to 40, or even more. This means, however, that the recalculated image
differs somewhat from the original. In the case of higher compression
ratios the differences between the original and final images may be
marked and could influence their diagnostic usefulness. There is thus a
balance between image quality on the one hand and computer memory
on the other.
A second such balance exists between retrieval time and cost. If the
image has to be retrieved immediately from the memory the cost is high,
especially if the archive is large. Using tape, laser- or CD disks that might
be searched for and mounted prior to image retrieval will increase the
time cost but reduce the economic cost.
Image communication
Digital images in a PACS are transmited between image producing
modalities, image workstations, image screens for conferences, and com
puter archives. The large volumes of data makes great demands on the
communication network. The network of special computer lines can be
separate for PACS but sometimes when there are large distances between
image producing units and computers and work-stations, the general
computer network of the hospital is used. In such a case the demands for
professional secrecy is high and the large amount of image data tend to
block even medium capacity networks. In such cases optical cables can
be used for transmission of images since such cables have large capac
ity and better security.
The first system for data communication in a hospital often deals with
administrative data and comprises a computer in contact with a computer
terminal. The components of PACS are so complex and take up so much
computer memory that image communication is between computers. The
main reason for this is the time needed to produce an image on screen.
If each image were transmitted to the viewing station when it was re
quested, the time required would be unacceptably long. For this reason
112
DIGITAL IMAGING
whole image packages are transmitted to the work station at the same
time as the first image is made ready for viewing and manipulation.
Teleradiology
One extreme of image communication within PACS is teleradiology or
transmission of digital radiological images between radiology depart
ments or to a referring unit over the telephone network. It is not yet very
common but can be used for consultations between radiologists or when
radiological examinations are performed without a radiologist on site.
The radiological evaluation is made after image transmission over a
telephone line. It is, however, important that the clinical data and other
information is given verbally or in written form. One line of develop
ment is to use teleradiology to enable for the radiologist on call to per
form most of his consultations at home. Another is to have subspecial
ized radiological service available for large areas via teleradiology.
Radiological conferences with smaller referring units or practices with
no radiologist can be performed without travel if the consultation is made
over the telecommunication network.
Most current teleradiological systems are either connected to digital
archives or to a video camera or laser digitiser that digitises an analogue
film and records the data in a separate teleradiological memory. In the
video camera case it is important for the quality of the diagnostic image
that possible magnifications of parts of the original image are made
through zooming with the video camera and not on the transmitted im
age. If the magnification is made on the teleradiologically transmitted
image the spatial resolution is much lower.
The equipment on the receiving side depends upon the application.
Normal and high resolution screens as well as laser printers for films can
be used.
The digital radiological department

A digital radiology department only using digital images and screens
would have a branched or circular network connecting all involved func
tions. These are 1) image producing units (modalities), 2) image work
stations, 3) the archive, and 4) a central or divided computer system.
The image producing units include MRI and CT machines, gamma
cameras, digital ultrasound, and image plate systems. In addition, there
are digitizing units where analogue images on film will be digitised into
113
the PACS of the department. There is probably also a need for laser print
ers to produce analogue films to be sent outside the institution.
The image workstations are also of different types. The simplest re
quiring a minimum of computer power is directly connected to the ex
amination room. It is used as a check to ensure that the image contains
the appropriate part of the anatomy, correct projection, etc. The next type
is used for demonstration during conferences and may consist of multi
ple screens placed to resemble a conventional film alternator. Con
ventional viewing boxes should also be available in the conference area
to allow hard copy analogue film.
The third type of workstation is intended for the diagnostic work. The
monitor screen has to be of high quality with good resolution and suffi
cient brightness and frame rate. The advantages of high spatial resolu
tion is lost if the brightness is inadequate and will necessitate a higher
monitor frame rate. The computer capacity must be sufficient to perform
all types of image manipulations fast. The conferences can be prepared
at this diagnostic workstation, with appropriate image manipulation,
such as selecting relevant recording o f magnified areas of importance,
reduced number of, informative images of magnified areas, etc.
The PACS archive requirements differ for the patient/examination de
mographic database and for the digital image data. The most recent ex
aminations ought to be immediately available and thereafter there is a
progressively diminishing retrieval frequency of older images with time.
It might be acceptable to wait for a couple of minutes for older films and
even longer for educational cases, research material, etc.
114
Chapter 7
Contrast media in diagnostic

radiology
Torsten Almen and Peter Aspelin
In modem imaging department today images of patients are produced

using either electromagnetic radiation (visible light, X-rays, radio waves
in magnetic resonance imaging) or ultrasound (pressure waves). X-rays
have a frequency and photon energy that are several order of magnitude
higher than those of visible light and they can penetrate the patient’s body.
Their photon energy is so large that they can break chemical bonds and
induce ionization. X-rays can be detected on radiographic film and by
different fluorescent materials.
The radio waves used in magnetic resonance imaging have a frequency
and photon energy that are many order of magnitude lower than those of
visible light. Like X-rays they can penetrate the human body. They have
not sufficient energy to induce any ionization, but they can make mole
cules vibrate, which means that they produce heat. These radio waves
are detected by antennas.
Ultrasound consists of pressure waves of a much higher frequency than
those of audible sound. Ultrasound energy is both produced and detected
by piezoelectric crystals. Ultrasound propagates through the body and
causes vibrations of molecules which again produces heat in the tissues.
All contrast media in diagnostic imaging have one task, to increase the
differences between the different "voxels" in the body regarding their
ability to absorb and/or reflect energy from electro-magnetic radiation
or ultrasound. A "voxel" in this context may mean any structure, such as
a piece or slice of normal tissue, or a complete organ, or a pathologic
process or any other morphologic detail. Different contrast media influ
ence electro-magnetic radiation or ultrasound by different mechanisms.
115
To perform their task the contrast media should reach different con
centrations in different structures or "voxels”. The larger the difference
in contrast medium concentration between those structures, the smaller
those structures (representing morphological details) can be while re
maining detectable in the images.
A good contrast medium must influence electro-magnetic radiation or
ultrasound energy inside the body, but should, ideally, not have any other
effects on living tissue. Unfortunately, this is impossible and all contrast
media have adverse effects.
CONTRAST MEDIA FOR ROENTGEN RAYS

(X-RAYS)
In conventional radiology and computerized tomography, contrast me
dia may be classified as positive or negative media.
Negative contrast media (air, carbon dioxide and other gases) attenu
ate X-rays less than the soft tissues of the body, because a gas (the neg
ative contrast medium) contains per unit volume a much lower number
of radiation attenuating atoms than the patient's soft tissues.
Positive contrast media and the body's soft tissues contain a similar
number of atoms per unit volume. Some atoms in the contrast medium
(e.g. iodine or barium) have a much higher atomic number than those of
the soft tissues (hydrogen, carbon, nitrogen, oxygen). A higher atomic
number is generally associated with an increased ability to attenuate X-
rays. At the photon energies which are used in diagnostic radiology, the
radiation is attenuated by photoelectric absorption and Compton scatter.
Such attenuation is proportional to the third or fourth power of the atomic
number. In positive contrast media, iodine or barium atoms attenuate ra
diation 50-1000 times more than an atom of the human soft tissue (such
as carbon-, nitrogen- and oxygen).
The positive contrast media can either be water soluble, which in clin
ical practice today means water solutions of organic compounds with io
dine covalently bound to an aromatic structure, or water insoluble con
trast media, which in daily practise means an aqueous suspension of in
soluble crystals of barium sulphate.
116
CONTRAST MEDIA IN DIAGNOSTIC RADIOLOGY
POSITIVE CONTRAST MEDIA
Water soluble iodine contrast media for the extracellu

lar space
These contrast media are used for intravenous urography, angiography
and for contrast enhancement in computerized tomography.
History - mechanisms o f toxicity

In 1895 Wilhelm Conrad Rontgen discovered X-rays. As early as 1986
the first arteriography was performed in an amputated hand. A contrast
medium consisting of a suspension of chalk in water was injected into
the arteries. The first water soluble iodine contrast medium was used in
1920 and was discovered because patients with syphilis in those days
were treated with sodium iodide. The sodium iodide was observed in an
image of the abdomen as an ’’increased density" of the kidneys. Sodium
iodide, however, had a high toxicity when used as contrast medium.
Table 1. Different contrast media - their structure, ratio, viscosity, os

molality and name
Structure Ratio Viscosity Osmolality Generic name Trade name
20° 37°
Figure 2 ionic monomer 3:2 = 1.5 5+ 3+ 1500-1600 iothalamate Conray

9++ 5++ Vasoray
metrizoate Isopaque
amidotrizoate Urografin
Angiografin
Gastrografin
ioxithalamate Telebrix
Figure 3 ionic dimer 6:2 = 3 12 6 600 ioxaglate Hexabrix
Figure 4 non-ionic
monomer 3:1 = 3 11 6 500-700 iohexol Omnipaque
iopamidol lopamiro
iopromide Ultravist
ioversol Optiray
Figure 5 non-ionic dimer 6:1 = 6 25 10 300 iodixanol Visipaque
iotrolan Isovist
Values of viscosity (cP) and osmolality (mOsm/kg H20 ) have been approximated to an iodine concentration of
300 mg I/ml.
f are viscosity values for sodium salts.
++ are viscosity values for meglumine salts.
117
Figure 1.
ф Eliminating carboxyl Transformation o f an ionic
w decreases neurotoxicity
monomer (above) to a non-ionic
(2 ) Eliminating ions
^ decreases osm otoxicity monomer (below).
(g ) Adding hydroxyl groups
^ decreases chem otoxicity
Figure 2.
Cation Ionic monomer (ratio 1.5).
sodium or
methylglucamine 2 ions in solution per 3 iodine
atoms
3 iodine atoms per molecule
1 carboxyl group (-COO) p er
molecule
No hydroxyl group (-OH) except
Compound R ioxithalamate with one OH/mole-
Diatrizoate - NHCOCH3 cule
lothalamate - CONHCH3 Intravenous LD50 fo r mouse
loxithalamate - CONHCH2CH2OH
lodamide - c h 2n h c o c h 3
5-10 g I/kg mouse
Metrizoate - N(CH3)COCH3
The efforts to design less toxic contrast media were started in the 1920s
and are still continuing. A major development occurred in the beginning
of the 1950s when it was found that contrast media with three iodine
atoms bound to a benzene ring had low toxicity (amidotrizoate Table 1,
Fig. 2). A benzene ring with three iodine atoms is in contrast medium
research defined as a "mer". A monomer, for example, contains one such
three-iodinated benzene ring, while a dimer contains two such structures.
In the 1960s a radiologist, T. Almen, proposed the synthesis of monomers
and oligomers of non-ionic, tri-iodinated contrast media (Fig. 1). The
first non-ioinic monomer was produced by the Norwegian contrast
medium company, Nyegaard & Co (Today Nycomed Imaging AS).
Further factors that influence toxicity and water solubility are de
scribed below. Table 1 and Figures 2-5 show the most commonly used
contrast media, their names, chemical structures, osmolality, viscosity
and ratio between number of iodine atoms and number of contrast
medium particles in an ideal solution.
118
Water solubility and toxicology

Water is the most common molecule in the human body, both inside and
outside the cells. In order to enable a high contrast medium concentra
tion in extracellular water, high water solubility is necessary for contrast
media in urography, angiography, etc. This water solubility is achieved
in different ways by ionic and by non-ionic contrast media. Water is a
polar solvent; the water molecules are electrically neutral (equal num
bers of positive and negative unit charges within the water molecule),
but the positive and negative charges are distributed so that there is a sur
plus of positive charges (lack of electrons) at the site of the hydrogen
atoms (which form positive poles) and a surplus of negative charges (ex
cess of electrons) around the oxygen atom (which forms a negative pole).
Ionic contrast media dissociate in water into electrically charged par
ticles named ions. The positively charged ion may be a sodium ion or a
meglumine ion. The negatively charged ion is the benzene derivative
with three iodine atoms and a negatively charged carboxyl group. The
ionic contrast media are water soluble because the positive and negative
ions are attracted to the negative and positive poles of the water mole
cules.
Non-ionic contrast media are electrically neutral like the water mole
cules. The nonionic contrast media are water soluble because they con
tain polar groups (OH-groups, hydroxyl groups) which have an uneven
distribution of electrical charges with excess electrons around the oxy
gen atoms (forming negative poles) and a deficit of electrons around the
hydrogen atoms (forming positive poles). The electrical poles in the OH-
groups of the contrast media are attracted to the electrical poles in the
water molecules - thus achieving water solubility.
The only desirable effect of a contrast medium is to attenuate radia
tion. All other effects of the contrast medium in the body, regardless
whether they cause clinical symptoms or not, are not desired. When these
effects cause changes observable in laboratory tests or clinical symptoms
they are deemed to be adverse effects. Different chemical structures have
been designed to achieve high water solubility and this has resulted in
contrast media with different toxicity.
The total toxicity of a contrast medium solution is the sum of the
chemotoxicity of the contrast medium molecules, the osmotoxicity of
the contrast medium solution and the ion toxicity - a surplus or deficit
of various ions in the solution:
119
1. The chemotoxicity of a contrast medium molecule may depend on its

effects on proteins in the extracellular space and/or in the cell mem
brane, and effects on cell organelles and enzymes by the small num
bers of contrast medium molecules which go intracellularly. (The car
boxyl ion in ionic contrast media is an example of a chemical struc
ture with high neurotoxicity in the subarachnoid space. Therefore,
ionic contrast media must not be used in myelography.)
2. Osmotoxicity. Ionic contrast media have a high osmolality per amount
of iodine, because the iodinated and negatively charged ions (diatri-
zote, iothalamate, metrizoate) are accompanied by the non-iodinated
positively charged ions (sodium ions, meglumine ions) (see also the
section: "Osmolality ratio, below). The hypertonicity of the contrast
medium solution causes fluid shifts from erythrocytes, endothelial
cells and other structures. This induces pain in arteriography, dilata
tion of blood vessels with a fall in blood pressure and viscosity
changes of the blood.
3. Ion-imbalance. When contrast medium instead of blood flows through
blood vessels, a too high or too low concentration of different ions
produce side-effects (ventricular fibrillation at coronary arteriogra
phy, influence on plasma proteins).
Osmolality and the ratio concept

The ionic monomeric contrast media are highly hypertonic compared to
blood. Blood has an osmolality of 300 mosmol/kg water and the ionic
contrast media used in angiography have an osmolality of 1500-2000
mosmol/kg. The osmolality is proportional to the number of particles in
a solution. The "ratio" of a contrast medium describes the proportions
between its ability of being a "good" contrast medium (by attenuating
X-rays) and its tendency to induce side-effects (by its osmotoxicity). You
can calculate a theoretical ratio of a contrast medium as "the number of
iodine atoms per volume contrast medium" divided by "the number of
particles (contrast medium ions or contrast medium molecules) per vol
ume contrast medium solution".
The ionic monomeric contrast media have a ratio of 1.5 (3/2 = 1 .5 )
(three iodine atoms per two water soluble particles [ions]). When there
was a need to decrease the osmotic effects per amount of iodine, it was
done by increasing the ratio, e.g. the number of iodine atoms/number of
particles (Figs. 1 and 2).
120
Figure 3. Ionic dimer (ratio 3).

2 ions in solution per 6 iodine
atoms
1 carboxyl group (-COO) per
molecule
1 hydroxyl group (-OH) per
molecule
Intravenous LD50mouse 10-15 g
I/kg mouse
Figure 4.
Non-ionic monomer (ratio 3).
1 molecule in solution per 3 io
dine atoms
No carboxyl group (-СОСУ)
4 -6 hydroxyl groups (-OH) per
molecule
Intravenous LD5Qmouse 15-20
g I/kg mouse
A non-ionic monomeric contrast medium that does not dissociate in

water, has three iodine atoms per water soluble molecule and therefore
ratio 3 (3/1 = 3) (Fig. 4).
The evolution of contrast media has continued and one of its goals has
been to further reduce the osmolality of both the ionic and non-ionic me
dia by making dimers of them. First the synthesis of a dimeric, ionic con
trast medium, which has the ratio 3 (6/2 = 3) was made (Fig. 3). Later,
in the 1980s and 1990s, dimeric non-ionic contrast media have been ex
plored and these contrast media have such low osmolalities that elec
trolytes have to be added in order to make them iso-osmotic with blood
(Fig. 5). They have a ratio of 6 (6/1 = 6).
121
lotrolan
Figure 5.
ratio 6.0 Non-ionic dimer (ratio 6).
H O c h 2- c h O H H O c h 2- c h O H I molecule in solution per 6 iodine atoms
/ \
c o n h c h - c HjjU
CONHCH-CH OH c oo nn hh cchh--c h 2O
2u h
H 6 iodine atoms per molecule
H O ch2
')&'
H O c h -c h n hH
ccCT O
'I T 4 nN-COCH 2C
w v 1T «O
'A' ^0H
. , h T ,'Y N CONHCH
--------j - chO H
No carboxyl group (-COO)
More than 8 hydroxyl groups (-OH) per
^O H 1 ch3 ch3I c h 2O H
molecule
lodixanol Intravenous LDwmouse 20 g I/kg mouse
ratio 6.0
OH OH OH OH
conhch^chch2 c o n h c h 2c h c h 2
'й :1
с „2снсн2м н с о ' У ' N C H CHCH, N
''ijV'
- V
OH OH t° OH t° ^ I
ch 3 ch. OH OH
Different types o f contrast media

The strategies above about handling water solubility, chemo- and osmo
toxicity have led to four different types of iodine contrast media for urog
raphy, angiography and computerized tomography (Figures 2-5).
1. Ionic monomeric contrast media
2. Ionic dimeric contrast media
3. Non-ionic monomeric contrast media
4. Non-ionic dimeric contrast media
As the ability of the iodine atom to attenuate X-rays is independent of

the organic molecule in which it is chemically bound, a comparison be
tween side-effects, toxicity, osmolality, viscosity or price of different
contrast media must always be made in iodine equivalent amounts and
concentrations. (It is thus important to relate adverse effects, price, etc.,
to the desired effect o f a contrast medium, i.e. its attenuation of X-rays,
which is proportional to the amount of iodine.
Contrast media kinetics

The four contrast medium groups above have all high water solubility,
low plasma protein binding, almost exclusive distribution to the extra
cellular space and minor intracellular distribution. The size of the mol
ecules enables them to pass through the glomerular basement membrane.
They are to a very small extent reabsorbed or excreted by the tubular
cells and are quantitatively handled by the kidneys like Inulin. The me
dia can therefore be used to determine glomerular filtration rate (GFR).
Their half-life in plasma is dependent on the GFR. At normal GFR they
122
have a half-life of 1.5-2 h. If GFR is decreased by a factor 2 or 4, their

plasma half-life incresaes by a factor 2 or 4, etc.
A small amount (at normal GFR less than 2%) of these contrast me
dia is excreted via the biliary system. The high-osmolar media (ratio 1.5)
give in iodine equivalent doses a larger osmotic diuresis than the ratio 3
and ratio 6 media. Therefore, the ratio 1.5 media have a lower urinary
concentration than the ratio 3 and 6 media.
After a rapid intravenous bolus injection of contrast medium an almost
undiluted volume of contrast medium reaches the heart where it is mixed
with blood and this "blood-contrast medium bolus" passes through the
pulmonary vascular bed and reaches the left side of the heart and the
aorta and its branches. There is rapid contrast medium diffusion through
most capillary membranes from the blood mainly into the extracellular
space as the media have very low binding to plasma proteins and a very
small intracellular distribution. For only a few minutes after a bolus in
jection, the media may be regarded as representing the distribution of the
blood and blood vessels in the body. This fact makes it possible to de
tect necrotic tumors and cysts which are not vascularized and therefore
contain less contrast medium-filled blood than the surrounding normal
tissue. Likewise, it is possible during the same period to detect tumors
or inflammatory processes that are hypervascularized because they con
tain more contrast medium filled blood than the surrounding normal, less
vascularized tissues.
In the brain, the normal blood-brain-barrier prevents the contrast me
dia from escaping from the blood out into the brain parenchyma. In ar
eas where the blood-brain barrier is damaged due to a tumor or an in
flammatory process, contrast media may leak from the blood into the
brain parenchyma. Regions with an injured blood-brain-barrier may thus
be detected at contrast medium enhanced computerized tomography due
to the higher contrast medium concentration in those regions than in the
surrounding normal brain parenchyma.
Hematological effects
When contrast medium is injected into the blood stream, it comes in con
tact with blood cells, endothelium and various proteins of the coagula
tion cascades.
The red blood cells are influenced by the osmotic effects of a large
contrast medium bolus. This occurs particularly with the high osmotic
123
ratio 1.5 media, which draw water out of the cells and deform them. Red
blood cells thereby become rigid and lose their normal deformability,
which tends to decrease their flow through small vessels, such as capil
laries.
It is known that vascular endothelium may be injured by hyperosmo
lar solutions, such as solutions of ratio 1.5 contrast media. Damaged en
dothelium may elicit thrombus formation on it, particularly when a high-
osmotic contrast medium is used in those phlebographic techniques
which cause prolonged contact between the medium and the endothe
lium. The new ratio 3 and ratio 6 contrast media have lower osmolality
than the ratio 1.5 media and therefore cause less damage to the en
dothelium and are thereby less prone to promote thrombus formation on
it. They are in this context less procoagulant than the ratio 1.5 media.
All contrast media when mixed with blood in a test tube or in an an
giography cathter are anticoagulants. The old, more toxic ratio 1.5 con
trast media are in this context stronger anticoagulants than the new, more
biocompatible, less toxic ratio 3 and ratio 6 media. Inside an arteriogra
phy catheter with end- and side-holes, the anticoagulant effect of he-
parinized saline or solutions of ratio 1.5, ratio 3 or ratio 6 contrast me
dia, becomes very small, because even a few seconds after the injection
of contrast medium or heparinized saline into the catheter, the injected
solution is already contaminated by blood. Therefore, catheters must be
flushed at least every second minute so that blood does not stay within
the catheter lumen or in the holes of the catheter and coagulate there, in
dependent of what contrast medium or flushing fluid that has been used.
Lungs
When large intravenous bolus injections (urography, pulmonary an
giography, intravenous contrast enhancement in computerized tomogra
phy, etc.) are performed, the lung is the first organ, after the heart, to be
reached by the contrast medium bolus. When high-osmotic contrast
medium is injected, there is a steep rise in pulmonary arterial pressure,
and the higher the osmolality, the higher the increase in pressure due to
the induced rigidity of the red cells. The increase in pressure has been
shown to be particularly dangerous to patients with pulmonary hyper
tension and these patients should not have intravenous bolus injections
of ionic ratio 1.5 media of high osmolality. Also patients with decreased
lung function should have contrast media with low osmolality in order
124
to reduce the adverse effects on the pulmonary circulation. Furthermore,

the release of histamine and other vaso-active substances, when contrast
media activate the large number of mast-cells in the lungs, is considered
to be one of the explanations for the higher frequency of some adverse
reactions (vomiting, urticaria) following intravenous injection of con
trast media than following intraarterial injections of the media. This is
another reason to use low-osmotic contrast media when large intravenous
doses of the media are considered.
Heart
In selective coronary arteriography high-osmolarity contrast media (ra
tio 1.5) induce a larger reduction of the contractile force of the heart than
less hypertonic (ratio 3) or plasma-isotonic contrast media (ratio 6). If,
in spite of this, ionic contrast media are chosen for coronary arteriogra
phy, those containing sodium ions in the same concentration as plasma
should be used due to their lower risk of inducing ventricular fibrillation
compared to the pure meglumine salts of the ionic media. It is also pos
sible that adverse effects on the heart from the non-ionic media can be
further reduced by using media with optimized electrolyte content and
with oxygen saturation of the contrast medium solution.
Peripheral vascular bed

In femoral arteriography with a contrast medium concentration around
300 mg I/ml, the ratio 6 media are isotonic with plasma, while the ratio
1.5 media have 5 times the plasma osmolality (1500 mOsm/kg water)
and the ratio 3 media have osmolalities in between. Some adverse ef
fects of the media in femoral arteriography parallel their osmotoxicity
so that ratio 1.5 media produce most pain, most feeling of warmth and
most vasodilatation while the ratio 6 media produce least pain and va
sodilatation and the ratio 3 media produce something in-between.
Chemotoxicity is also involved in vasodilation, because sodium chloride
solutions made isotonic with ratio 1.5, ratio 3 or ration 6 contrast media
produce less vasodilation than these media.
Subarachnoid space
In the subarachnoid space only those contrast media should be used
which do not contain carboxyl groups and furthermore have hydroxyl
groups evenly distributed throughout the contrast medium molecule.
125
Animal experiments have shown that those media have the lowest risk
of inducing seizures. You may find the media intended for subarachnoid
use among the nonionic monomers and dimers. Please, look at the label
of your contrast medium vial and DO NOT INJECT into the subarach
noid space those media which are NOT intended for subarachnoid use.
By exchanging ionic monomers for non-ionic monomers the osmolality
of the contrast medium solution was reduced by a factor of 2 while the
total toxicity in the subarachnoid space of animals was reduced by a fac
tor of 30. This decreased toxicity cannot be due to reduction in osmo-
toxicity alone; it must also be due to reduced chemotoxicity achieved by
the elimination of carboxyl groups and by the introduction of hydroxyl
groups. You may regard the non-ionic contrast media as surrounded by
a cloud of water molecules which by electrostatic forces are attracted to
the contrast medium molecules so that the body might recognize the lat
ter as a cloud of water molecules with a low toxicity.
Kidneys
In urography there is a need for a high iodine concentration in the cor
tex (cortical nephrogram) in order to analyze cortical pathology and the
size and margins of a kidney. A high iodine concentration in the renal
pelvis and ureter (pyelogram) is desired to detect processes in the ca
lyces, renal pelvis and ureters. Different mechanisms regulate the con
trast medium concentration obtained during urography in the cortex and
in the renal pelvis. The quality of the cortical nephrogram depends on
the contrast medium concentration in the cortical blood vessels and in
the primary urine in Bowman's space and proximal tubules. The pyelo
gram depends only on the contrast medium concentration in the final
urine and is independent of the contrast medium concentration in the
blood vessels and primary urine.
In selective renal arteriography the ratio 3 contrast media give 10 to
100 times less proteinuria than the ionic ratio 1.5 contrast media. In cell
cultures the tubular cells have a greater tolerance towards non-ionic ra
tio 3 contrast media than towards ratio 1.5 media. This beneficial prop
erty of the ratio 3 media is counteracted by their higher concentration in
the tubular urine than ratio 1.5 media.
There are many reports on contrast medium induced renal insuffi
ciency. The larger the contrast medium dose and the lower the pre-in
jection glomerular filtration rate (GFR), the larger the risk of this con
126
trast medium nephropathy. Patients with a markedly decreased GFR due

to a long lasting diabetic nephropathy are at particular risk of develop
ing contrast medium nephrotoxicity. The clinical manifestations of this
may vary. There may be a transient rise and later normalization of serum
creatinine as the only sign of toxicity; there may be a transient oliguria
or anuria which may require dialysis a few times before complete or par
tial return of function; there may, in the worst cases, be a need for chronic
dialysis or renal transplantation. There are many reports on patients with
reduced GFR showing that the lower the contrast medium dose and the
better the water balance before and after the contrast medium injection,
the smaller the risk of inducing further renal insufficiency. There are also
data indicating that the use of calcium blockers might reduce the risk of
contrast medium induced renal insufficiency. Large clinical trials have
shown a smaller risk of contrast medium nephrotoxicity when non-ionic
ratio 3 media are used instead of ionic ratio 1.5 contrast media, while
some smaller clincial trials have failed to show this advantage of non
ionic ratio 3 media.
Unpredictable, acute reactions

Unpredictable reactions to contrast media and other pharmaceuticals
may occur on one occasion, but not on another occasion, despite injec
tion of the same substance in the same dose in the same patient. The
symptoms may be those of an allergic type 1 reaction. The majority of
the contrast medium reactions is not caused by an antigen-antibody re
action and they often occur without previous exposure to the contrast
medium. In fact, there are only three reports of antibodies to contrast me
dia. The majority of contrast medium reactions are called "pseudoaller-
gic" because they cause exactly the same clinical symptoms and require
the same symptomatic treatment as true allergic reactions, but they are
not initiated by an antigen-antibody reaction. Instead they occur by ac
tivation of immunologic effectors through other mechanisms. Reactions
with minor symptoms are named pseudo-allergic or allergoid and those
with more serious symptoms pseudo-anaphylactic or anaphylactoid.
Contrast media (and other pharmaceuticals) may by chemotoxicity,
hypertonicity or ion toxicity trigger immunologic effects by at least two
mechanisms:
127
1. Interaction with cell membranes releases vasoactive substances such

as histamine and platelet activating factor (mast cells), serotonin
(platelets), leucotrienes (mast cells, leukocytes), thromboxane A2
(platelets, leukocytes) and prostaglandins (endothelium).
2. Interactions with biomolecules of the complement, kinin, coagulative
or fibrinolytic systems may activate these systems creating
bradykinin, other vasoactive substances and anaphylatoxins and
macroproteins which form channels through cell membranes causing
cell lysis. Erythrocytes, leukocytes, lymphocytes and mast cells all
contain complement receptors so that products of the activated com
plement system can cause cell membranes to release substances ac
cording to mechanism 1.
The release or creation of vaso-active substances according to mecha

nisms 1. and 2. may cause the same acute symptoms as those seen after
a true allergic type-I-reaction when the release of vaso-active substances
is caused by an antigen-antibody reaction. Whether the patient's reaction
is of pseudo-allergic (common) type or true allergic (uncommon) type
does not matter because in the acute situation the treatment o f the two
types of reaction is the same.
Contrast medium reactions can be divided into

- mild (no treatment necessary)
- moderate (treatment necessary, but no intensive care)
- severe (life-threatening, intensive care necessary)
The ratio 1.5 contrast media cause mild adverse reactions in up to 10%
of the patients and severe reactions in a frequency of 1:900-1:3000 and
a mortality rate of approximate magnitude 1:50 000-1: 100 000. The new
low-osmolar contrast media, especially the non-ionics, have a lower risk
of pseudo-allergic reaction. In conclusion, we do not know the mecha
nisms behind these contrast medium reactions. The present opinions are
that they are, in the majority of cases, not caused by an antigen-antibody
reaction, not caused by the presence of iodine atoms in the contrast
medium molecules and not caused by shell fish allergy.
128
Risk factors
The statistical chance of a pseudoallergic reaction to a planned contrast
medium injection increases in the presence of the following risk factors:
an earlier pseudo-allergic reaction to contrast media or other pharma
ceuticals, bronchial asthma, cardiac disease, the presence of any type of
allergy (including shell fish allergy). The larger the dose of contrast
medium, the larger the risk of an acute reaction. The larger the number
of risk factors, the greater the readiness for immediate treatment of an
acute reaction should be.
Treatment o f adverse reactions

Vasovagal reactions (falling blood pressure and bradycardia) are treated
with the Trendelenburg position and intravenous fluids (normal saline or
Ringers lactate). If hypertension persists, atropine 0.5-1.0 mg intra
venously should be administered. If fluids and atropine are ineffective,
dopamine 5-10 microgram/kg/min. intravenously may be considered.
Below is a scheme of treatment of contrast medium reactions. It in
cludes symptomatic treatment of the effects of various vasoactive sub
stances produced by the mechanisms of a pseudoallergic or a genuinely
allergic reaction as earlier described. The symptoms are treated in the
same way irrespective of whether they have true allergic or pseudo-al
lergic etiology.
Treatment of radiographic contrast medium induced reactions

SC=subcutaneously, IM=intramuscularly, IV=intravenously
1. Acute allergoid (allergic) reaction:

General urticaria and/or Quincke edema (sometimes in combination with
headache, vomiting, abdominal pain -(diarrhoea), asthma-rhino-con-
junctivitis)
Treatment
a/ Epinephrine 0.5 mg (1 mg/ml) SC
b/ Oxygen 2-6 1/min
с/ Diphenhydramine 50 mg IM
2. Anaphylactoid (anaphylactic) reaction:

Symptoms like acute allergic reaction and: tachycardia, fall in blood pres
sure, paleness
129
Treatment
а/ Epinephrine 0.3-0.5 mg (O.lmg/ml) IV
Ы Oxygen 2-6 1/min intravenous line should be arranged
3. Anaphylactoid (anaphylactic) shock:

Symptoms resembling anaphylactic reaction, but more dramatic with:
unconsiousness - status asthmaticus - respiratory arrest - circulatory col
lapse - cardiac arrest
Treatment
a/ Epinephrine 0.3-1.0 mg (0.1 mg/ml) IV
b/ Oxygen 2-6 1/min
с/ Hydrocortisone 250 mg IV
d/ Intubation + ventilation
In patients with a high risk of an acute reaction to contrast medium:

1. Re-evaluate the indication for the investigation and discuss alterna
tive investigations with the referring physician
2. Choose a non-ionic monomer as the contrast medium. Do not choose
the same as before if the patient earlier had a moderate to severe re
action on that non-ionic medium
3. If the previous reaction was:
a/ Mild - consider performing the investigation without premedica
tion
b/ Moderate - premedication according to below
с/ Severe - premedication according to below and have an anes
thesiologist standing by or perform the investigation under gen
eral anesthesia
Premedication
Elective investigation
1. Prednisolone 50 mg (10 tabl) orally 12 and 2 hours before the inves
tigation
2. Clemastin 1 mg/ml, 2 ml IM 1 hour before the investigation
Emergency investigation
1. Water soluble hydrocortisone, 200 mg IV immediately and thereafter
every fourth hour until the investigation is terminated
2. Clemastin 1 mg/ml, 2 ml IM 1 hour before the investigation
130
Barium contrast media

Preparations of barium sulphate contain a suspension of practically in
soluble barium sulphate particles with a size of 0.1-0.3 mm. The indi
vidual particles in this suspension are irregular aggregates of crystals of
barium sulphate. In addition, the suspension contains additives (pectin,
sorbitol, agaragar, carboxy-methyl-cellulose) which are partly bound to
the surface of the particles and determine their electrical charge, and also
determine the pH of the suspension and its stability and viscosity. All
these factors determine the tendency of the suspension to sediment and
to foam and to adhere to the mucosa during double contrast examina
tions. The barium sulphate particles remain in the intestinal lumen, are
not absorbed from the intestine and are therefore non-toxic. Barium ions
are toxic, but the extremely small amounts of barium ions in solution in
the suspension, available for intestinal absorption, are regarded as hav
ing no practical importance.
Barium sulphate is available in two forms. One is a powder which is
mixed with water before use (BarytgenR, BarisperseR). The other is a
ready-to-use suspension for specific diagnostic purposes (MixobarR -
esophagus, colon).
Two levels of barium concentrations are clinically used - one for sin
gle contrast and one for double contrast.
For single contrast the intestinal lumen is filled with a low density bar
ium suspension (0.5-1 g barium sulphate/ml suspension).
For double contrast studies (when barium sulphate covers the mucosa
with a thin layer and the intestinal lumen is distended with air) a suspen
sion with high density is used (2.0-2.5 g barium sulphate/ml suspension.
Adverse effects
Oral barium sulphate may accidentally be aspirated into a bronchus or
may, in the presence of gastrointestinal perforation, penetrate into the me
diastinum or flow into the peritoneal cavity. Barium in the bronchial tree
is less harmful than aspiration of food. It often disappears quickly and sel
dom causes any problems. In the mediastinum and peritoneal cavity bar
ium sulphate may produce adhesions and/or granuloma. The passage of
barium sulphate and of food, intestinal and pancreatic enzymes and fae
cal matter through a perforation is considered more damaging than the
passage of barium sulphate alone. This is supported by animal experi
ments, which also suggest that pure barium sulphate induces less damage
131
than barium sulphate containing additives which stabilize the suspension.

Constipation may follow oral barium sulphate and can be treated with
fluid and laxatives. If the equipment used during a barium sulphate en
ema damages the anorectal mucosa, the barium sulphate may leak into
the retroperitoneum. If the enema equipment perforates a blood vessel
intravascular embolization of barium sulphate may ocur. This can em-
bolize the liver via the portal vein, or the barium sulphate may reach the
pulmonary circulation. Most patients who have experienced an in
travascular infusion of barium sulphate have died.
If perforation of the gastrointestinal tract is suspected, you must con
sider performing the gastrointestinal investigation with a water soluble
iodine contrast medium. If there is a perforation and contrast medium
leaks into the mediastinum or peritoneal cavity, the water soluble con
trast will be resorbed into the blood stream and excreted through the kid
neys and there is no risk of granuloma formation. If a water soluble gas
trointestinal contrast medium is used, it should preferably be a ratio 3 or
6 contrast medium in order to avoid undesired osmotic dehydration by
the hypertonic ratio 1.5 media; this is particularly important in children.
Similarly, when an orally ingested contrast medium has entered the lungs
via a tracheo-esophageal fistula, the ratio 3 and 6 media will draw less
fluid into the lung than the ratio 1.5 media.
Organ specific contrast media - lymphography

Lymphography is an investigation that has decreased in use in recent
years. For lymphography we use an oily contrast medium, Lipiodol
Ultrafluid, consisting of iodinated ethylesters of fatty acids from poppy
seed oil. The contrast medium is injected directly into a dissected lym
phatic vessel, normally simultaneously in both lower extremities. The
water insoluble oil is retained only in those lymph nodes which receive
lymph from the injected lymphatic vessels. On the radiographic images
the contrast medium can be detected within the lymph nodes from a cou
ple of months to several years after the injection. During this time re
peated radiological examinations can give information about the status
of the nodes without further injection of contrast medium.
Adverse effects
The contrast medium may give an inflammatory foreign body reaction
within the lymph node. During lymphography the injection rate should
132
be controlled and the dose of the contrast medium adjusted to the small
est possible amount in order to minimize oil embolization to the lungs
via the thoracic duct or other anastomoses between lymphatic vessels
and veins. Oil embolization to the pulmonary capillaries can cause a 60%
reduction of the diffusion capacity of the lungs after lymphography and
decreased lung function is a relative contraindication to lymphography.
Sometimes, a chemical pneumonitis occurs 1-7 days after lymphogra
phy. The mechanism is thought to be enzymatic breakdown of contrast
medium in the lungs. The split products may then damage the vessel en
dothelium and the membranes of the alveoli with hemorrhages and ex
udation as a result. The mortality of lymphography is approximately
1:2000.
Organ specific contrast media - biliary media
Oral contrast media

Iocetamic acid, iopanoic acid, salts of ipodate or tyropanoate are exam
ples of cholecystographic contrast media, which are given orally. The
contrast medium is absorbed in the intestines and is carried to the liver
where it enters the hepatocytes. Here it is conjugated with glucuronic
acid, which increases its water solubility and decreases its fat solubility.
The conjugated contrast medium is excreted into the bile canaliculi.
When the hepatic and cystic ducts are patent the contrast medium flows
into the gallbladder in which it is concentrated by the resorption of wa
ter through the gallbladder wall. The high binding affinity of the media
for albumin decreases their renal excretion and increases their hepatic
excretion. In optimal pharmacokinetic circumstances the gallbladder is
filled with contrast medium about 10-19 hours after its oral ingestion.
Within that period different media produce their maximal gallbladder
opacification at different intervals, for instance, ipodate at 10 hours and
iopanoic acid at 14-19 hours.
Different mechanisms may lead to a low contrast medium concentra
tion in the gallbladder, which on the radiographic examination results in
a non-visualized gallbladder.
1. Diarrhoea caused by the intake of the contrast medium, with exces
sively fast passage through the intestines preventing sufficient ab
sorption for visualization of the gallbladder.
133
2. Hepatic dysfunction with decreased hepatocyte uptake and biliary ex

cretion of the medium.
3. Mechanical obstruction of bile drainage into the gallbladder (biliary
calculus, tumor).
4. Decreased ability of the gallbladder wall to concentrate bile (chole
cystitis).
5. The water soluble glucuronic acid conjugated contrast medium may
diffuse back into the blood through an injured gallbladder wall (chole
cystitis).
6. Glucuronidase activity of bacteria in the gallbladder in cholecystitis
may deconjugate the contrast media and the (now) fat soluble con
trast medium is resorbed through the gallbladder wall.
Unpredictable pseudo-allergic reactions may occur at cholecystogrpahy.

A serious complication after cholecystography is renal failure with olig-
uria-anuria. The mechanism of the latter is not clear. The frequency of
severe complications after cholecystography is 1:20 000 and the mor
tality rate is 1:40 000.
Intravenous contrast media

For intravenous cholangiography the meglumine salts of iodipamide or
iotroxic acids are used. The intravenous biliary contrast media are trans
ported in blood bound to albumin. This protein bound contrast medium
is not excreted in urine by glomerular filtration, but competes with biliru
bin for binding sites on albumin. Intravenous cholangiographic media,
that have a high water solubility, are not conjugated in the liver but are
excreted unchanged in the bile canaliculi in such a high concentration
that the intrahepatic bile ducts and common bile duct are visualized on
the roentgenograms; the cholegraphic media do not require concentra
tion by the gallbladder. After intravenous injection of the medium the
biliary tract is visualized 1/2-2 hours later. No reabsorption of the cholan-
giograhic media occurs in the intestines.
Large series have shown a mortality rate of cholegraphy of
1:5000-1:8000 and severe complications in a frequency of
1:300—1:600. The latter are most often circulatory collapse and acute re
nal insufficiency. Presently, the use of intravenous cholegraphy is de
creasing. A total dose of 5-6 g iodine and an infusion time of 30 min
utes are most commonly used. Sometimes, in cases of decreased liver
134
function an infusion time of 5-8 hours is utilized.
Colloid intravascular contrast media

Blood pool contrast media are presently being investigated by different
research groups. Blood pool contrast media are defined as media which
after intravenous injection leave the blood slower than the presently used
monomers and dimers of ionic and non-ionic iodinated media. These
blood pool media would have the advantage that after an intravenous bo
lus injection in, for example, computed tomography, they would remain
inside the large arteries and veins and show their morphology for a longer
period than the presently utilized media. To achieve these effects iodi
nated macromolecules and iodinated suspensions have been tried. Such
colloidal contrast media are often removed from the blood by the phago-
cytosing cells of the reticulo-endothelial system. Depending on the par
ticle size of the contrast medium its major site of deposition will be in
the bone marrow, spleen and/or liver. Some of these contrast media have
successfully been used in early clinical investigations to detect liver
metastases as these contrast media may reach a higher concentration in
the normal hepatocytes and/or Kupffer-cells than in the cells of primary
liver tumors or liver metastases.
Atoms with a higher atomic mass than iodine as

contrast media
Atoms with a higher atomic mass than iodine atoms attenuate more X-
rays per atom than the iodine atom. Gadolinium, tungsten and lead are
examples of such atoms. Attempts have been made to covalently bind
these atoms in organic molecules or to include cations of these heavy
atoms in water soluble chelates. So far, there has been no success in syn
thesizing molecules with toxicity as low as that of the iodine atom in
modem contrast media. Therefore, such contrast media have not yet been
introduced into clinical use.
NEGATIVE CONTRAST MEDIA

The negative radiological contrast media are the gases air, oxygen, ni
tric oxide (N20 ) or carbon dioxide (C 02) and they may be combined with
water suspensions of barium sulphate for double contrast images of the
gastrointestinal tract and with water soluble iodinated contrast media for
135
double contrast investigations of joints. New technologies, such as com

puted tomography, magnetic resonance tomography and the use of con
trast media in these techniques, have almost completely eliminated the
use of gas in encephalography and myelography.
The use of gas as a contrast medium in the gastrointestinal tract has
no other adverse effects than those induced by the volume of the gas.
Gas emboli may occur from unintentional intravascular injection of
gas. The danger of injecting gas decreases with smaller gas volumes and
higher water solubility of the injected gas. Carbon dioxide has the high
est water solubility and there is an increased interest in using carbon diox
ide in for example femoral arteriography because the digital subtraction
technique may produce images of workable quality. An advantage is of
course the low price of the gas. Gas may only be used in areas that the
examiner considers will tolerate a transient reduction or transient inter
ruption of blood flow.
CONTRAST MEDIA IN MAGNETIC RESONANCE

IMAGING (MRI)
In the early years of clinical MRI it was believed that the natural con
trast between different soft tissues would exclude the need for contrast
media. It was soon found (just as in computed tomography) that the sig
nal differences between the different tissues, i.e. the contrast resolution
in the MR-image, could be profoundly improved by different contrast
media. It was not until the first MRI contrast medium (Gd-DTPA, based
on the paramagnetic gadolinium ion inside the chelate DTPA) became
commercially available that MRI became equal to or better than com
puterized tomography in certain applications.
Mechanisms behind MR contrast media

For information on the Tl- and T2-weighted images in MRI, we refer
the reader to the chapters on "Radiophysics” and on ’’Modalities".
The signal intensity from a small volume unit (a voxel) in a patient un
dergoing MRI depends on several factors. Among the machine-related
factors are the strength of the magnetic field and gradient coils, the se
quences of proton-exciting radio waves from the transmitting antenna
and the timing for signal registration in the receiving antenna. Among
patient factors are the proton spin density inside a voxel and the T 1- and
T2-relaxation times of the protons inside those voxels. It is known that
136
Figure 6. MR Proton
Influence o f paramagnetic Signal density T1 T2
Strong i i High I i Short Long

and ferromagnetic contrast
media on the intensity o f the
MR-signal.
Paramagnetic Superparamagnetic
contrast media contrast media
Weak Low Long Short
some substances may influence the relaxation times of protons in their

vicinity. The MR contrast medium inside a voxel can influence the pro
ton relaxations times T l and T2 or the proton density inside that voxel.
Depending on different magnetic properties, the MR contrast media are
divided into paramagnetic and super-paramagnetic media.
Paramagnetic contrast media

Atoms with one or several unpaired electrons have paramagnetic prop
erties. The most common MRI contrast media are paramagnetic metal
ions with a large magnetic moment. Examples of such ions are gadolin
ium, chromium, manganese, nickel and iron. Gadolinium compounds
have hitherto enjoyed the largest clinical use. The large arrows in Fig. 6
illustrate that the MR signals from a voxel become stronger with higher
proton density, shorter Tl-time and longer T2-time. The small arrows in
Fig. 6 illustrate how a paramagnetic contrast medium, in clinical doses,
may increase the signal intensity through a shortening of Tl-time, while
the super-paramagnetic contrast media mainly decrease the MR-signal
through a shortening of T2-time. The contrast medium effect of the
gadolinium ions is a reduction in T l- and T2-relaxation times. In low
doses it is mainly a Tl-effect which increases the signal intensity, illus
trated in Fig. 6. In high doses it is more a T2-effect with a reduction of
the signal.
Superparamagnetic contrast media

Superparamagnetic iron oxide is used as contrast medium. Its dominat
ing effect is a reduction of T2-relaxation time. With an increasing dose
there is a reduction of signal intensity (Fig. 6).
137
Depending on the above mentioned mechanisms the Tl-weighted im

ages are mainly influenced by paramagnetic contrast media, while T2-
weighted images are mainly influenced by superparamagnetic contrast
media (Figure 6).
Water soluble extracellular contrast media

The first registered contrast medium is a gadolinium chelate, gadopen-
tatedimeglumine (MagnevistR). Chelate means "claw” and describes how
the gadolinium ion (Gd3+) with three positive "unit charges" is trapped
in a negatively charged chelate (claw or cage) consisting of the dimeg-
lumine salt of diethylene-triamine-penta-acetic-acid (DTPA), which has
5 negatively charged carboxyl groups (5 "unit charges"). The Gd-DTPA
ion has 2 negative "charges" (+3 -5 —2) and is accompanied by 2 posi
tively charged meglumine ions for electroneutrality. The benefit gained
by enclosing the Gd-ion in DTPA is that the Gd-DTPA ion has a ten
times lower toxicity than the free or non-chelated Gd-ions. This DTPA
detoxi-fying effect on the Gd-ion toxicity causes slight shielding of the
magnetic field of the 7 unpaired electrons of the Gd-ion with some de
crease of its effects on protons in the body. The pharmacokinetic prop
erties of Gd-DTPA resemble those of the intravenous water soluble io
dine contrast media. It has a high water solubility, a small binding affin
ity for proteins and a low intracellular penetration. It is distributed almost
exclusively in the extra-cellular space and excreted by the glomeruli. At
normal glomerular filtration rate its plasma half-life is 90 minutes and
over 75% of the dose is excreted via the kidneys in 3 hours.
Gd-DTPA, like the iodine contrast media, does not cross the normal
blood brain barrier when injected intravascularly. When there is a blood
brain barrier damage, e.g. in patients with cerebral tumors or vascular le
sions, Gd-DTPA leaks out into the interstitial fluid of the CNS (within
the tumor or vascular lesion). The higher the Gd concentration gets in a
tissue (compartment) the shorter the Tl-tim e in that tissue. The Gd-
DTPA concentration may be different in normal brain parenchyma,
edema and tumor tissue and this increases the ability to differentiate be
tween these structures.
The clinically recommended doses vary between 0.1 and 0.2 mmol/kg
body weight. Sometimes a feeling of warmth and headache can occur (1 -
2%). Gd-DTPA (Magnevist) is extremely safe and has in clinical doses
an even lower frequency of pseudoallergic reactions than the non-ionic
138
iodine contrast media.

New Gd contrast media for the extracellular space are being devel
oped and some have been introduced into clinical practise. Some exam
ples follow: Gd-DTPA is a linear ionic Gd-chelate, while Gd-DOTA is
a cyclic ionic chelate. Gd-DTPA-BMA (Omniscan) and Gd-HP-D03A
(Prohance) are neutral or nonionic linear and cyclic chelates, respec
tively. Their clinical use has just started and their exact roles will be de
fined in the future.
Macromolecular Gd-chelates (Albumin-Gd-DTPA, Dextran-Gd-
DTPA, Polylysin-Gd-DTPA) and paramagnetic liposomes have been
tried as blood pool agents. The liposomes are taken up by the reticu
loendothelial cells (RES) and may be used as media to image the retic
uloendothelial system, for instance, Kupffer cells. Water soluble para
magnetic contrast media with lipophilic components in the chelate host
are taken up by the liver and have been designed as contrast media for
the liver parenchyma. Some examples of these are: Mn-DPDP, Gd-
BOPTA, and Gd-EOB-DTPA.
Oral contrast media

Just as in computerized tomography the oral contrast media are used
mainly in abdominal imaging, in order to differentiate between intestine
and surrounding normal and pathological tissues. Demarcation of the
small intestine is particularly important in abdominal diagnosis.
Magnetite, Fe30 4 is a contrast medium which has been used in the gas
trointestinal tract. This is a superparamagnetic contrast medium with its
main effect on the T2 relaxation and it works as a negative contrast
medium. This means that it decreases the signal intensity. Other nega
tive contrast media in the gastrointestinal tract are gases and perfluor
compounds which in principle do not contain any hydrogen atoms and
therefore do not give any signal.
Contrast media for ultrasound

In ultrasound, sound waves with a frequency of 3-15 MHz are used.
These sound waves are generated by the piezoelectric crystal in the ul
trasound transducer. Ultrasound energy penetrates different tissues and
is attenuated both by reflection and absorption. In contrast to the
roentgenogram which is created by X-rays transmitted by different struc
tures of the body, the ultrasound image is created by ultrasound energy
139
reflected by different structures of the body: "echoes”.

The extent to which sound is reflected by a tissue depends on the
acoustic impedance of the tissue or the tissue components. The larger the
difference in acoustic impedance between two tissue types, the larger the
reflection of the ultrasound from the interface between those two tissues.
Except for air, fat and bone, the natural differences in acoustic im
pedance between different soft tissues in the body are small. The differ
ences that exist between different tissues with regard to reflectivity o f ul
trasound depend on the different amounts of components such as colla
gen, fat and fibro-elastic tissue. Presently, contrast media are developed
which increase the differences in the amount of ultrasound energy re
flected by different structures of the body. An ultrasound contrast
medium can thus be described as an echogenic substance which is in
troduced into a vessel or organ system in order to induce an increased
echogenicity - increased ability to reflect ultrasound energy. Such me
dia may be injected intravenously and examples are - suspensions of
solid particles, emulsions of fluid droplets, micro bubbles of pure gas,
gas bubbles encapsulated in various structures or liquids that release mi
cro bubbles. Like other contrast media, ultrasound media should have
low toxicity and fast excretion.
Examples of ultrasound contrast media, in different stages of devel
opment and/or clinical introduction, are:
- Suspensions in water of solid particles of, for instance, an ethylester
of the biliary medium iodipamide, which, in blood, functions as as a
blood pool agent and increases the reflectivity of blood and which,
after being phagocytosed in the liver, increases the echogenicity (re
flectivity) of the liver.
- Droplets of perfluorocarbon compounds, oily liquid media, which
similarly first act as a blood pool medium and then as a liver
parenchyma medium.
- Micro bubbles of gas encapsulated in albumin (Albunex).
- Micro bubbles of gas encapsulated by galactose (Echovist) or en
trapped in galactose/fatty acids (Levovist).
- Liquid which is injected into the blood and then inside the blood re
leases micro bubbles of gas (EchoGen).
While Echovist is trapped in the lungs and therefore used only for car
diac diagnosis and for the large veins, several of the other ultrasound me
140
dia pass through the lung capillaries and other capillaries and can there
fore be used for a larger number of organs.
The usefulness of an ultrasound medium is that it may incrase the con
trast resolution between normal and diseased tissue and may improve the
identification of deep lying vessels and help in identifying tumors or tu
mor vessels. Other possible advantages are the improved visualization of
stenotic arterial segments, e.g. renal arteries and the increased ability to
detect areas of infarction or ischemia. The possibility of tissue character
ization might also increase with different ultrasound contrast media.
141
Chapter 8
Interventional radiology
Christoph Zollikofer
Practically all interventional procedures are based on Seldinger’s historic

invention of the percutaneous technique for inserting catheters into blood
vessels in 1953. Using this principle percutaneous access to many organ
systems was developed in the mid 1950s to the 1960s. After a slow start
and much scepticism from the clinicians, the performance of percuta
neous procedures gained momentum and had a tremendous surge dur
ing the 1970s and 1980s, thanks to rapid developments in material, sci
ence and biotechnology. The expansion of these ’’minimally invasive
therapies” has been further helped by the development of high resolu
tion image intensifies, digital subtraction angiography and rapid ad
vances in ultrasound (US) and computed tomography (CT).
RECANALIZATION PROCEDURES FOR

ARTERIAL STENOSIS AND OCCLUSIONS
Balloon angioplasty
The first percutaneous transluminal treatment of peripheral atheroscle
rotic disease was performed by Charles Dotter on January 16th, 1964
with the aid of coaxial Teflon-catheters. Only after Andreas Gruntzig de
signed the non-compliant balloon catheter in 1973 did percutaneous
transluminal angioplasty (PTA) become widespread. Today balloon di
lation of iliac stenosis as well as stenosis and short occlusions of the
femoro-popliteal arteries is a standard procedure, particularly for patients
presenting in Fontain' stage two who are generally non-surgical candi
dates.
The 5 year patency rates for iliac artery PTA are in the range of 90 to
95 % and 60 to 70% for the femoro-popliteal area. These results are com
parable to the traditional surgical methods but usually with a lower mor-
143
Figure 1.
Patient with restpain in left leg.
A + B) Angiogram shows severe femoropopliteal stenoses partially calcified and only
one patent artery to the calf and fo o t (fibular artery) (arrows).
C) After PTA improved lumen but residual stenoses
particularly in the mid-popliteal artery from calcified plaques. Clinical im
provement to Fontaine stage Ha.
D + E) Angiogram one year later shows again severe femoropopliteal stenoses with
now short occlusion o f the proximal fibular artery (arrow).
Patient is again in clinical stage III.
F + G) After repeat PTA and recanalisation o f the fibular artery there is an adequate
lumen and the patient's symptoms converted to clinical stage I la.
144
INTERVENTIONAL RADIOLOGY
bidity. Furthermore in most cases angioplasty can be easily repeated if

recurrent stenosis occurs (Fig. 1).
In order to remove rather than displace, remodel or crack atheroma
tous material and for the purpose of recanalisation of occluded arteries,
laser angioplasty and atherectomy catheters have been introduced. Laser
technology is still a long way away from routine clinical use as it has
rather disappointing longterm results. Atherectomy devices such as the
Simpson catheter may be useful in certain indications, such as the treat
ment of localised or eccentric stenosis and for removing intimal flaps af
ter PTA. The Simpson atherectomy device has not been accepted as an
alternative to simple balloon angioplasty as it does not improve long
term results.
Mechanical recanalisation and aspiration

thrombembolectomy
Various mechanical recanalisation devices have been developed to help
recanalisation in those cases where conventional guidewire techniques
including hydrophilic wires have failed. Particularly in patients with a
limb at risk it may be important to recanalise long segment occlusions
of more than 10 cm.
Power driven rotating or pulsating devices are used to create a chan
nel through an area of occlusion which then accepts the guidewire over
which an angioplasty balloon can be introduced to finish the dilation pro
cedure.
Figure 2.
Patient with atrial fibrillation expe
rienced acute ischemia with rest-
pain in right foot.
A) Right femoral arteriogram shows

embolic occlusion o f popliteal
artery involving also the tibio
fibular arteries.
B) After percutaneous aspiration
embolectomy with an 8- and 5F
aspiration catheter complete
restoration o f the arterial lumen
o f the popliteal and tibiofibular
arteries is re-established without
using any thrombolytic drugs.
145
For fresh and subacute occlusions of an embolic and/or thrombotic na

ture in the femoro-popliteal region aspiration catheters with a non-ta-
pered tip made from thin-walled material with a large inner diameter and
an outer diameter of 5 to 9F are used to aspirate the occluding clot. The
main advantage of this technique is twofold: first the reduction of the
dosage or even the complete avoidance of fibrinolytic drugs and second
a considerable shorter procedure time (Fig. 2).
Thrombolysis
Thromboembolic occlusions may also be treated by fibrinolytic agents.
Local fibrinolysis using Urokinase or rt-PA today is the preferred
method. The lytic agents are infused directly into the clot via a selec
tively placed catheter. Even older clots may be lysed after weeks and
months as long as the clot organisation has not been completed. Therefore
local fibrinolysis is often used in combination with PTA and/or clot as
piration (Fig. 3).
Stents
Vascular stents have been designed to improve patency rates o f PTA es
pecially after recanalisation of long occlusions or insufficient PTA, re
coiling lesions and dissections. These stents are made from stainless
steel, Tantalum or Nitinol wire filaments or tubing and are introduced
with a percutaneous introducing system of 7 to 9F. There are self-ex
pandable and balloon expandable stents in use (Fig. 4).
Figure 3.
Patient with subacute severe right
lower leg ischemia.
A) Right femoral arteriogram shows
occlusion o f the popliteal artery
involving all 3 tibio-fibular ar
teries. Collaterals fill the fibular
and posterior tibial artery in the
mid-calf.
B) After clot aspiration from the
popliteal artery, local thrombol
ysis with 280,000 units o f uroki
nase and additional PTA o f the
tibio-fibular arteries, complete
recanalisation o f all 3 c a lf arter
ies has been achieved.
146
Figure 4.
Most widely used endovascular stents.
A + B) Balloon expandable Palmaz and Strecker stent.
С + D) Self-expandable Wallstent and Gianturco double-stent partially and totally
released (the Gianturco stent is used mainly in the venous system).
Figure 5. 76-year old male patient with lib claudication in left leg.
A) Pelvic arteriogram shows chronic occlusion o f left external iliac artery with collat
eral filling o f common fem oral artery.
B) After recanalization using conventional guidewire technique and placement o f a
12 mm Wallstent good patency o f the left external iliac artery is re-established.
147
While excellent results have been achieved in the iliac arteries (Fig.
5) no significant improvement has been gained in the femoro-popliteal
region because o f reobstruction by intimal hyperplasia developing within
the stents. So called covered stents are currently being tested as internal
grafts hoping to decrease the rate of or even completely avoid intimal
hyperplasia.
VENOUS INTERVENTIONS
Dilatation and stent placements fo r venous strictures are increasingly
used for malignant and benign stenoses. For most venous narrowings,
particularly those caused by tumor compression or fibrosing processes
(superior and inferior vena cava syndrome), postoperative scarring or af
ter recanalisation of thrombotic occlusions, PTA alone is usually insuf
ficient and additional stenting has proved to give excellent long-term re
sults (Fig. 6). In these conditions stenting is the method of choice. For
outflow stenoses of hemodialysis fistula PTA remains the first approach
with stenting reserved for recurrences or recoiling lesions.
Figure 6. Patient with superior V. cava syndrome from mediastinal metastases due to
bronchogenic carcinoma.
A) Bilateral arm phlebography shows severe stenoses o f upper superior V. cava and
also some narrowing o f the right brachiocephalic vein. Note numerous collaterals
and drainage via the azygous vein (arrows).
B) Follow-up phlebography 13 months after implantation o f a 16 mm Wallstent reach
ing from the right brachiocephalic vein to the superior V. cava. There is good ante
grade drainage to right atrium. Note that the left brachiocephalic vein remains
patent and empties through the mesh o f the Wallstent. The patient survived without
signs o f venous obstruction for 18 months.
148
Figure 7.
Patient with recurrent pulmonary emboli
in spite o f anticoagulation.
A) V. cavagram to measure the diameter
o f the V. cava and mark the level o f
the renal veins (arrows).
B) V. cavagram following percutaneous
placement o f titanium Greenfield filter
shows good filter position. Arrows
mark inflow o f renal veins.
Obliteration o f spermatic veins for symptomatic varicoceles and in

fertility today is a standard alternative to surgical ligation. After selec
tive catheterisation of the testicular vein embolization may be achieved
with coils, detachable balloons or sclerosing agents on an outpatient ba
sis.
Inferior vena cava filters were introduced in the late 60s and early 70s
as a protection from recurrent pulmonary emboli despite anticoagulation
or for patients with contraindications to anticoagulation. Various types
of filters for percutaneous introduction have been developed over the last
few years and some of these have proved a relatively safe and effective
means of preventing pulmonary embolism. Great care should be taken
during patient selection and the choice of the filter device should be based
on the operator's experience (Fig. 7).
Retrieval o f lost foreign bodies, mainly severed central venous
catheters from the superior vena cava can be performed by a percuta
neous transvenous approach. Retrieval from the vena cava, the right heart
and even the pulmonary arteries by way of wires, snares and loops or
hook-shaped catheters has a high success rate. These foreign bodies
should be retrieved as early as possible before fixation by overgrowth of
endothelium has occurred.
149
EMBOLIZATION PROCEDURES
Embolization with particulate matter was introduced in 1930 by Brooks
for the treatment of a traumatic carotico-cavemous fistula with muscle
fragments. Embolization therapy was later greatly influenced by the land
mark paper by Nusbaum and Baum in 1963 who were able to demon
strate that bleeding rates as low as 0.5 ml per minute could be detected
angiographically. This report was soon followed by transcatheter man
agement, first using selective infusion of Vasopressin. Shortly thereafter
in 1972 Roesch, Dotter and Brown reported control of acute gastric he
morrhage by embolization of the gastroepiploic artery using autologous
clot. In the early 70s various embolic materials such as Gelfoam,
polyvinyl alcohol (Ivalon), the tissue adhesive Isobutyl Cyanoacrylate
(Bucrylate) and detachable balloons were developed which, together
with improvements in catheter technology, caused a tremendous upsurge
of interest in embolizsation procedures (Fig. 47 chapter 15). In the mid
70s Gianturco and Wallace developed steel coils which today are one of
the most widely used embolic materials. In 1981 Ellman et al. introduced
absolute ethanol for tissue ablation and used it for infarction of kidneys.
New technologies using minicatheters and microcoils have further fa
cilitated the management of peripheral and neurovascular lesions.
Embolization for bleeding

Gastrointestinal bleeding can be effectively treated with interventional
methods once the bleeding source has been demonstrated angiographi
cally. Transcatheter treatment for GI bleeding includes pharmacologic
agents for vasoconstriction such as Vasopressin (Pitressin) and embolic
materials. Vasopressin is particularly indicated in acute gastritis and
stress ulcers. With infusion into the left gastric artery bleeding may be
stopped in up to 80% of cases. Peptic ulcers of the stomach and duode
num and diverticular disease of the colon can be successfully treated with
selective intraarterial infusion of Pitressin also. Alternatively GI bleed
ing can be arrested by embolotherapy with various temporarily or per
manently occluding materials. Bleeding from lesions such as ulcers, ero
sions, diverticula, spontaneous leaks and traumatic tears requires em
bolization with temporarily occluding materials to get the patient through
the acute episode which will permit vessel recanalization later so that
perforation or stricture of bowel as well as organ function loss is min
imised. Only if the bleeding site can be stopped right at its origin in the
150
Figure 8. 23-year old HIV-positive female patient with acute lower Gl-bleeding.
A) Arteriogram o f the superior mesenteric artery shows massive extravasation o f
contrast material in proximal jejunum from the second jejunal artery branch.
B) After placement o f 3 microcoils close to the bleeding site using coaxial super-
selective catheter technique the bleeding has stopped. There was an unevent
fu l recovery and the bleeding was found to be due to intestinal lymphoma.
periphery can small particles or microcoils be used (Fig. 8). Bleeding re
sulting from tumors, arteriovenous malformations and esophageal
varices requires materials for permanent embolization such as Ivalon,
coils, or tissue glues and ethanol.
For bleeding after trauma adequate angiographic assessment includ
ing CT for abdominal and pelvic injuries is necessary for optimal treat
ment in serious vascular trauma. Proper surgical care should not be de
layed in the unstable patient in whom major vascular or organ injury is
suspected. Embolization procedures should be considered particularly in
conditions where surgical hemostasis is difficult such as in the thigh, the
buttocks, the pelvis and the retroperitoneum. The catheter should be
placed as selectively as possible for embolization to spare as much
healthy tissue as possible. Steel coils are commonly used since they pro
duce a fast and permanent occlusion. Alternatively, agents such as
Gelfoam and Ivalon can be used.
Traumatic bleeding of organs such as kidney and liver often results
from iatrogenic injuries secondary to punctures and biopsies which may
result in AV-fistulas or false aneurysms. Such symptomatic lesions can
be treated successfully by transcatheter embolization in a high percent-
151
Figure 9. Patient with kidney transplant and hematuria following biopsy

o f the transplanted kidney.
A) Selective angiogram o f transplant kidney shows peripheral A VF
(small arrow) with early filling o f the renal vein (large arrow). Note
catheter induced spasm near origin o f transplant renal artery (open
arrow).
B) After placement o f two microcoils (arrow) into the distal renal artery
branch close to the A VF the arteriogram shows occlusion o f the A VF.
Most o f the lower peripheral renal artery supply has been saved.
age using particulate matter especially coils and Ivalon, detachable bal
loons and tissue adhesives (Fig. 9). The choice between conservative man
agement, transcatheter treatment and surgery in patients with non-iatro-
genic trauma to abdominal organs is based on the clinical status. Laceration
of organs with significant bleeding usually requires surgical revision.
Bleeding from arteriovenous malformations is treated with emboliza
tion as the primary method of choice. Correct selection of the appropri
ate embolization material (coils, detachable balloons, Ivalon, Bucrylate,
ethanol) is mandatory to occlude the nidus of the lesion and not just the
peripheral feeding arteries which would lead to rapid recurrence via col
laterals.
Organ ablation and tumour embolization

Organ ablation by embolization for hypersplenism or renovascular hy
pertension in endstage kidney disease may be a valuable alternative to
surgery. Total embolization of the spleen in one step however should be
avoided because of the possible fatal complications from splenic ab
152
Figure 10. Palliative embolization o f right kidney in

80-year old patient with renal cell carcinoma.
A) Selective renal angiogram shows typical tumor vas
culature o f renal cell carcinoma involving the upper
pole o f kidney with dilated tortuous capsular artery
(arrows).
B) After embolization with Ethibloc a cast o f the ves
sels filled with the Ethibloc mixed with Lipiodol is
seen. To secure permanent occlusion coils were
placed into the capsular artery and into the two
main branches o f the renal artery.
C) On injection o f contrast only filling o f a short stump
o f the right renal artery remains.
scesses or splenic rupture etc. Therefore only partial embolization of the

spleen or embolization in multiple sessions have been advocated together
with a meticulous aseptic technique and antibiotic therapy.
Tumor embolization may by carried out for acute bleeding from tu
mor vessels (bronchogenic carcinoma, renal tumors), to reduce the blood
supply to the tumor before surgery (renal cell carcinoma) or to treat pri
mary and secondary tumor manifestations (Fig. 10). Various protocols
for embolization using Gelfoam, Ivalon, liquid polymers and ethanol to
treat hepatocellular carcinoma and metastatic disease from colo-rectal
and neuro-endocrine tumors have been developed. Chemo-embolisation,
originally introduced in Japan, is being increasingly used in the U.S. and
Europe to treat primary and secondary liver tumors as well as renal car
cinoma. This technique uses a simultaneous combination of intraarterial
153
chemotherapy and peripheral embolizsation. Mitomycin C,

Doxorubicin, 5-fluorouracil and Cisplatin have been used together with
Gelfoam or Ivalon.
In pelvic malignancies embolisation serves mainly to treat bleeding
by embolization of visceral branches o f the hypogastric artery.
Superselective catheterisation which confines the embolization to the
vessels feeding the tumor is desirable.
Most complications encountered after organ embolization are grouped
and known as the post-embolization syndrome. Fever and pain are the
most prominent symptoms seen in almost every patient and usually last
ing for two to seven days. Nausea and vomiting are seen in approximately
50% of the patients with embolization of the liver. Other possible com
plications are due to overspill or displacement of embolic material with
damage to non-target areas.
Neuroembolization
Embolization procedures in the brain, head and neck and spinal cord have
gained great importance since the first report of an embolization of a trau
matic carotico-cavemous fistula by Brooks in 1930. With the develop
ment of detachable balloons and flow directed catheters for superselec
tive catheterisation endovascular embolization of intra- and extracranial
AV-malformations, angiomas and fistulas has become the primary
method of treatment. Furthermore cerebral aneurysms not suited to sur
gical clipping may be treated with detachable balloons and certain tu
mors (meningiomas, glomus tumors, angiofibromas) may be embolized
pre-operatively with Bucrylate or Ivalon particles.
BILE DUCT INTERVENTIONS
Percutaneous transhepatic cholangiography (PTC) and

drainage procedures
The transhepatic approach for diagnostic visualization of the bile ducts
was originally described by Burkhardt and Muller in 1921 with injection
of contrast media into the gallbladder through a needle introduced
through the liver. This technique was modified in 1937 by Huard et al.
who injected Lipiodol directly into the bile ducts. It was only after Carter
and Leger reported their experiences using water-soluble contrast mate
rial that this technique became more widely used. The method was fur
154
ther improved and popularised by Okuda et al. in 1974 by using a thin

flexible needle of 0.7 mm outer diameter. This fine-needle eliminated the
need for immediate operation following the procedure.
The main indication for PTC is obstructive jaundice which is primar
ily diagnosed by ultrasound and CT. Although these two latter methods
are sensitive methods of distinguishing obstructive from non-obstructive
jaundice, demonstration of small lesions or partial obstructions and bil
iary tree anatomy is beyond their capabilities. In addition, 10 to 20% of
patients with obstructing lesions such as common duct stones, strictures
and tumors will not have dilated ducts demonstrable by ultrasound or
CT. In these cases cholangiography by percutaneous or endoscopic
routes is invaluable. For diagnostic purposes PTC has partly been re
placed by endoscopic retrograde cholangiography (ERC). However, if
ERC fails or in patients who are candidates for biliary drainage, espe
cially with high obstructions, PTC is still the first step for opacifying the
bile ducts and demonstrating the exact site of obstruction be it by tumor,
stones or inflammation. Further indications are bile leakages after
surgery or trauma which may also be treated with catheter drainage. In
1966, Seldinger reported his experience with transhepatic cholangiog
raphy by a right intercostal approach using a sheathed needle which al
lowed external drainage of the biliary system following cholangiogra
phy. The technique was further developed and refined using specialised
guidewires and catheters which allow complete obstructions to be
crossed and combined internal/external drains with antegrade flow
through the catheter into the duodenum to be deployed.
The main indication for percutaneous biliary decompression and
drainage is the non-surgical palliation of malignant biliary obstruction.
Whenever possible, definitive drainage should be established by inter
nal drainage with an endoprosthesis. Because of the significantly lower
mortality rate the traditional treatment o f surgical biliary-enteric anas
tomoses should be replaced by percutaneous or retrograde endoscopic
placement of an endoprosthesis. Instead o f conventional 8 to 14F plas
tic stents expandable metal prostheses of 10 mm diameter are increas
ingly used for palliation of malignant jaundice (Fig. 11). For obstruction
of the common bile duct these prostheses can often be placed endo-
scopically (Fig. 12). For hilar lesions or lesions requiring drainage of
multiple ducts a percutaneous approach from a right lateral and/or ante
rior epigastric approach is preferred. Using these methods internal
155
Figure 11. 70-year old patient with acute obstructive jaundice due to carcinoma o f the
pancreas treated with primary Wallstent drainage.
A) Percutaneous transhepatic drainage shows occlusion o f distal common bile duct
with dilation o f proximal intra- and extrahepatic ducts. A catheter has been passed
into the duodenum.
B) Balloon dilation o f stricture o f common bile duct.
C) After placement o f a 10 mm Wallstent with the distal end protruding through the
papilla there was good drainage and normalisation o f serum bilirubin level.
drainage is possible in over 90% with long-term primary patency rang

ing from 75-80%.
Percutaneous biliary drainage and balloon dilation of benign biliary
duct strictures, surgical anastomoses or sclerosing cholangitis are an im
portant alternative in these often very difficult situations which have lim
ited surgical options apart from liver transplantation. Long-term drainage
with plastic tubes is often required particularly for intrahepatic strictures.
Expandable metallic prostheses should only be used for extrahepatic le
sions or anastomotic strictures, but only as a last resort if multiple bal
loon dilations have failed. Percutaneous interventions for biliary calculi
have been rendered much less common with the advanced techniques of
retrograde endoscopic papillotomy and stone retrieval.
156
Figure 12.
76-year old patient with
obstructive jaundice sec
ondary to suspected pan
creatic carcinoma.
Л)
ERC shows high-grade
stenosis in common he
patic and proximal com
mon bileduct with dilation
o f intrahepatic ducts.
B)
After endoscopic retro
grade placement o f 10
mm Wallstent the stent
has only partly expanded.
C)
Retrograde balloon dilation o f
the stent.
D)
After balloon dilation the stent is
now well expanded and provides
good drainage.
GALLBLADDER INTERVENTIONS
Interventions of the gallbladder have significantly lost importance since

the recent surge of interest in laparoscopic cholecystectomy. The percu
taneous technique of gallbladder ablation developed by Burhenne and
Coleman has not yet proved to be a valid alternative. Percutaneous chole-
cystostomy currently seems the only percutaneous therapy for the gall
bladder which is an established alternative to surgical procedures in poor
risk patients presenting with acute cholecystitis, gallbladder empyema
or cholangitis.
157
GASTROINTESTINAL INTERVENTIONS
Percutaneous gastroenterostomy
In patients who are in need of long-term nutritional therapy for swal
lowing disorders or tumor obstruction of the esophagus percutaneous
placement of a feeding tube into the stomach or jejunum under fluoro
scopic control is a low risk procedure. The main advantage over endo
scopic gastrostomy is that the radiologic procedure is feasible even in
patients with complete obstruction of the upper gastrointestinal tract. In
contrast to a surgical approach percutaneous placement of a feeding tube
is particularly useful for patients in poor physical condition.
Jejunal feeding may be accomplished via a percutaneous gastrostomy
by manipulating the feeding tube into the jejunum. In patients after to
tal gastrectomy or with extensive tumor infiltration of the stomach, the
feeding tube can be placed directly into the jejunum.
Dilatation and stenting of oesophageal and enteric

strictures
Since the early 80s guidewire guided balloon dilatation catheters have
been used to treat enteric strictures under fluoroscopy. Although oe
sophageal lesions have been most frequently treated, symptomatic stric
tures in the pylorus, colon and stenosed surgical anastomoses also have
been dilated. Using over the wire balloon techniques benign oesophageal
strictures can be safely dilated with a lower risk of complication (perfo
ration) compared to the bougienage method. Very tight stenoses can be
negotiated using hydrophilic guidewires and angiographic catheters. For
anastomotic strictures balloon dilation is often the only non-operative
technique because the lesions cannot be reached by conventional bou
gies. Usually these anastomotic strictures respond very well to balloon
dilation. In the oesophagus at sites of oesophagogastric, oesophagojeju-
nal or esophagocolonic anastomoses, the same techniques are used as for
primary oesophageal lesions.
For inoperable malignant tumors of the oesophagus or anastomotic re
currences after partial or total gastrectomy balloon dilation does not of
fer a durable palliation. Metallic endoprostheses, mainly of the self-ex
panding types or Nitinol stents, have been tried in an attempt to improve
the results of dilation. Initial results have been quite encouraging al
though tumor ingrowth into the stent may occur quite rapidly. To pre-
158
Figure 13.
Patient with recurrent carcinoma o f the the
esophagus.
A) Barium swallow shows marked irregular
stenosis o f the mid-esophagus with
proximal dilatation.
B) After placement o f two overlapping
25 mm coated Wall-stents there is rapid
passage o f Barium through a normalized
esophageal lumen.
vent tumor invasion into the stented area covered stents are currently be
ing tested (Fig. 13).
ABSCESS DRAINAGE
Drainage of abdominal and retroperitoneal abscesses

Since the introduction of ultrasound-guided abscess drainage in 1974 by
Holm et al. and CT-guided drainage in 1976 by Haaga et al. abdominal
abscess drainage has become an established radiological method. With
a significantly lower mortality rate compared to surgical drainage
80-85 % of abscesses can be treated exclusively by percutaneous catheter
drainage. Whether ultrasound or CT-guidance for catheter insertion is
selected depends mainly on the expertise of the performing radiologist
with each modality. In addition however, overlying structures such as
bone (ribs) or gas-filled bowel may limit the use of ultrasonic guidance.
Depending on the size and anatomic location (i.e. the route of access), a
Trocar or Seldinger technique is used. Most commonly catheters of
8-12F are sufficient, however larger catheters may be necessary to drain
purulent and necrotic material (Fig. 14). The aspirated fluid or pus is al
ways sent for Gram-stain and culture. Exact catheter placement may be
controlled by repeated CT or careful injection of contrast material under
fluoroscopy. Sterile fluid collections and non-infected cysts such as pan
creatic pseudocysts are evacuated through the needle without leaving
159
Figure 14. Patient with retroperitoneal abscess and fever following endoscopic papil
lotomy fo r biliary calculi.
A + B) CT at two different levels in lower abdomen shows fluid collection containing
air in right retroperitoneum (arrows).
С + D) Two days after CT guided drainage with three Pigtail-catheters the flu id col
lection has markedly diminished. The temperatures have subsided. Arrows
mark two o f the draining catheters.
160
Figure 15. Patient with hydronephrosis and fever secondary to metastatic obstruction
o f right ureter.
A) Percutaneous antegrade pyelogram with Chiba-needle shows dilated renal pelvis
with obstruction o f the right ureter at the level o f L4.
B) A Pigtail catheter has been inserted fo r drainage.
C) After passing the ureteral obstruction with a guidewire and balloon dilation o f the
ureter a double Pigtail catheter has been placed fo r permanent internal drainage.
drainage catheters in place.
Percutaneous drainage of thoracic fluid collections

In contrast to abdominal abscess drainage, percutaneous treatment of tho
racic fluid collections has received less attention with the exception of
drainage of pleural and pericardial effusions. Empyema, lung abscess
and mediastinal fluid collections are successfully treated with catheter
drainage if they do not respond well to antibiotic therapy. The basic tech
niques for catheter placement are again the Trocar or Seldinger method
with ultrasound or CT guidance. The main potential complications are
pneumothorax or bleeding.
URORADIOLOGIC INTERVENTIONS
Drainage procedures of the kidney

Antegrade pyelography followed by percutaneous catheter drainage is
the method of choice in supravesical urinary obstruction and py
onephrosis if retrograde cystoscopic drainage via the bladder and ureter
161
Figure 16.
Patient with iatrogenic distal ureteral fistula after
colon surgery.
A) There is massive extravasation o f the contrast
material from the severed supravesical ureter.
B) After re-establishing ureteral continuity via a
percutaneous approach with a steerable
guidewire and catheter stenting there is still
some contrast extravasation (arrow).
C) After prolonged percutaneous stenting with an
internal/external catheter over 10 months the
nephrostogram shows a healed and patent distal
ureter after stent removal.
is not possible. Percutaneous nephrostomy has been refined remarkably

since the original description by Goodwin and Casey in 1955 with tech
nical success rates of about 98 % and a complicationrate of less than 0.5%.
With ultrasound and/or fluoroscopic guidane percutaneous nephrostomy
offers a rapid and safe means of relieving hydronephroses or pyogenic
obstructions under local anesthesia. Even very sick patients may be treated
in order to improve the clinical status for later curative or palliative ther
apy (Fig. 15). More often percutaneous nephrostomy now serves as the
initial step in a variety of percutaneous procedures such as antegrade di
lation and stenting of the ureter, endourologic stone removal as an adjunct
162
to extracorporeal shock wave lithotripsy (ESWL), percutaneous pyelo-

and litholysis and treatment of ureteral fistulas etc. (Fig. 16).
Procedures in the ureters and the urethra

Ureteral stenting is indicated for obstruction whether it be benign stric
ture, malignant encasement or intraluminal blockage and edema (Figs.
15 + 16). Ureteral balloon dilations are performed for postsurgical and
anastomotic strictures with good results. Excellent indications for bal
loon dilation are strictures after ureterotomy, ureterovesical and
ureteroileal anastomoses. Patients with recent, benign, cicatricial, trau
matic strictures may also benefit from this procedure. In patients with
kidney transplants only the anastomotic strictures respond well to bal
loon dilation. Inflammatory, densely fibrotic strictures and ischemic
strictures do not respond to dilation. Congenital pyeloureteral strictures
usually do not respond well to dilation in the long term.
Dilation of the prostatic part of the urethra in benign prostatic hyper
plasia was developed in the early 80s at the University of Minnesota. In
spite of the overall success rate of 60 to 70% at two years, the technique
is not yet widely used and longer follow-up periods are needed to prove
that balloon dilation is a valid alternative to transurethral resection of the
prostate (TURP). Implantation of removable and non-removable metal
lic stents has been tried but the exact role of stents in the management
of benign prostatic hyperplasia has not been defined.
The treatment of benign urethral strictures secondary to trauma or in
flammation by balloon dilation has not proved to be superior to conven
tional dilation techniques. Metal stents have been tried successfully by
Dick and colleagues but again more long term follow-up is needed to
prove its efficacy.
Fallopian tube recanalization

Over the last few years a new technique for hysterosalpingography us
ing a special vacuum cup-type device (hysterocath) has been developed
by Thurmond and Rosch. This special instrument allows intubation of
the proximal tubal ostium of the uterus using a coaxial catheter system.
If injection of contrast material through a 5.5F catheter positioned in the
tubal ostium shows obstruction of the proximal fallopian tube this may
be recanalized using a guidewire and/or a coaxial 3F catheter (Fig. 17).
The technical success rate for recanalizsation of a proximal obstruction
163
Figure 17.
Patient referred fo r fallopian tube
investigation because o f infertility.
A) Hysterogram shows proxim al
occlusion o f right fallopian
tube.
B) Recanalization o f the occluded
fallopian tube with coaxial
catheter system. Contrast mater
ial injection through the catheter
shows patency.
C) Follow-up hysterogram now
shows normal apprearance o f
the right tubal ostium and p a
tency o f the fallopian tube with
normal intra-abdominal distri
bution o f contrast material.
164
of the fallopian tube is up to 95% followed by an intrauterine pregnancy

rate within the first 7 months of 33%. Fluoroscopic transvaginal fallop
ian tube catheterisation in patients with proximal tubal obstruction has
proved a valuable alternative to surgery and should be the first interven
tion before the more invasive and more expensive microsurgery.
INTERVENTIONAL TECHNIQUES FOR PAIN

RELIEF
Percutaneous lysis of neural structures

Malignant tumors situated in the upper abdomen originating from the
pancreas, stomach and duodenum, proximal small intestine, liver and bil
iary system or from compressing lymph nodes or the dilated urinary sys
tem may generate intolerable upper abdominal pain. If opiate medica
tion or radiation therapy is unsatisfactory percutaneous neurolysis of the
celiac plexus and the splanchnic nervs can be of great help. A celiac
plexus block has also been advocated for treatment of the abdominal pain
in Crohn's disease, visceral neuropathy and diabetic reticulopathy. Using
CT guidance the region of the celiac plexus is infiltrated with absolute
ethanol. Usually an anterior approach is optimal for needle placement.
For splanchnic neurolysis a posterior percutaneous approach under CT
guidance is commonly used. Usually pain related to tumor invasion re
sponds best to neurolysis with a significant reduction of pain in about 73
to 87% of the treated patients.
For treatment of vasospastic disorders percutaneous sympathectomy
using phenol has been advocated instead of surgical sympathectomy. For
vasospastic disorders of the upper limbs or occlusive arteriopathy phe
nol may be injected paravertebrally at the level of T3 in the region of the
sympathetic chain under CT guidance. Similarly percutaneous blockage
of the lumbar sympathetic chain may be achieved in advanced athero
sclerotic disease of the lower limbs. Done again under CT guidance a 22
gauge Chiba needle is inserted at the L2 and L4 levels and neurolysis is
induced by slow injection of phenol after verification of proper place
ment of the needle by a careful injection of 1 cc of contrast material. A
positive effect can be expected in about 50 to 75% of patients.
Percutaneous neurolysis carries a significantly lower risk compared to
surgical procedures.
165
Chapter 9
The brain
Kjell Bergstrom and Giuseppe Scotti
During the past two decades neuroradiology has developed enormously.

This development began in 1972 when the Englishman Godfrey
Hounsfield constructed the first scanner for clinical computed tomogra
phy (CT). CT influenced and quickly changed the course of neuroradi-
ological investigation. With the advent of other computerised examina
tion techniques, nuclear medicine techniques and magnetic resonance
imaging (MRI), neuroradiological diagnosis underwent further rapid
change. The sensitivity and specificity o f imaging modalities and their
ability to localise disease have all improved markedly. These develop
ments have in turn led to improved therapeutic choice and monitoring
capability. Apart from these diagnostic developments, methods of treat
ment using percutaneous catheter techniques have been introduced. This
type of treatment, interventional neuroradiology, is expanding rapidly
and in many areas is replacing surgical treatment.
Modem neuroradiological diagnosis o f disorders of the brain is dom
inated by CT and MRI. In addition, nuclear medicine techniques are de
veloping rapidly. The coming of these methods has rendered pneu
moencephalography redundant. However, there is still a place for an
giography, but the indications for it have changed and have also
decreased markedly. Plain x-ray examination of the skull is performed
less often than previously and the indications for it, apart from trauma,
are much reduced.
167
MODALITIES FOR EXAMINATION OF THE

CRANIUM AND THE BRAIN
Skull radiography
Radiographic examination of the skull has significantly diminished af
ter the introduction and diffusion of CT and MRI. There are, however,
many conditions that can be diagnosed by skull radiography directly or
indirectly. Intracerebral calcifications can be normal as in the pineal
gland and in the choroid plexus or pathologic as in infectious diseases,
e.g. toxoplasmosis, cytomegalic inclusion disease and cysticercosis.
Tumour calcifications are most frequently identified in oligoden
drogliomas, meningiomas and craniopharyngeomas. Lateral displace
ment of the calcified pineal gland has been used as a sign of intracra
nial mass effect. Decalcification of the sella turcica can be a general
sign of increased intracranial pressure. Enlargement of the sella turcica
indicates a pituitary adenoma.
Osteolytic lesions occur in many diseases, both benign and malignant.
Epidermoid, eosinophilic granuloma, multiple myeloma and metastases
are some examples. Sclerotic lesions can represent meningiomas, os
teomas, fibrous dysplasia, Paget’s disease or metastases from prostatic
carcinoma.
Skull fractures are usually of linear type. In depressed skull fractures
tangential films are essential for determination of the degree of depres
sion. A pineal shift indicates an intracranial mass effect and is a signifi
cant finding.
Computed tomography
When computed tomography was first presented to the scientific com
munity in April 1972, the acquisition of two slices in the axial plane re
quired more than 4 minutes, the matrix size was 64x64, and it was nec
essary to place a water bag around the head to allow the evaluation of
subtle density differences within the head by the computer.
Nevertheless, it was immediately clear that a revolutionary diagnos
tic tool had become available to neuroradiologists; pneumoencephalog
raphy and ventriculography rapidly became extinct.
Nowadays, modem spiral CT acquires serial images of the whole head
in less than one minute and the resolution has increased up to matrix size
of 1024x1024. Three dimensional reconstructions (3D) may be obtained
168
THE BRAIN
routinely and almost instantaneously. CT angiography has become a re

ality following intravenous injection of contrast.
The basic physical principle of CT, however, has not changed: this
technique is based on x-ray absorption and the capability to measure and
localise different absorption coefficients exhibited by tissues with dif
ferent atomic numbers.
In the MRI era, CT remains essential in the neuroradiological work
up of almost all disease entities mainly because of its speed and acces
sibility. Patients can easily be monitored and even uncooperative patients
may be examined.
In trauma cases CT is the first modality; in all patients with sudden,
severe neurological deficit a CT scan provides the first most useful an
swers on the presence or absence of a surgically treatable condition.
MRI follows only if a more subtle evaluation of parenchymal abnor
malities, a better topographical definition, or further attempts at gross
pathological tissue characterisation are required. In a modem neurora
diological department, a high quality CT system is a minimum require
ment, possibly with a second less sophisticated unit mainly for trauma,
emergency cases and follow-up.
Magnetic resonance imaging

Magnetic resonance imaging has been used in neuroradiology for more
than ten years. The method has come to be used widely during the past
few years and its value in diagnostic neuroradiology is significant. MRI
is superior to CT in the assessment of lesions in the white substance of
the brain. In addition, it is the examination of choice in posterior fossa
lesions, as well as in the examination o f those lesions situated near the
mid-line or the base of the skull. The main disadvantage of the method
is the difficulty in visualizing fresh blood and calcification. For diag
nostic neuroradiology access to both CT and MRI is essential. The brain's
normal anatomy as shown by MRI is illustrated in Fig. 1.
It is important to be aware of the fact that MRI is mainly a morpho
logical technique despite the fact that it is often claimed that the tech
nique has great potential in the characterisation of tissues. This type of
analysis has been found to be difficult and the technique's possibilities
in this sphere are limited. This means that MRI still does not distinguish
itself markedly from CT. As a purely morphological method is has, how
ever, certain advantages over CT and provides extremely good analysis
169
Figure 1. The brain's normal anatomy as shown by M RI in the transverse plane at the
level o f the lateral ventricles (a) and in the sagittal plane in the mid-line (b). Note the
high contrast between grey and white matter. Structures such as the basal ganglia, in
ternal capsule, corpus callosum, guadrigeminalplate are clearly shown.
of anatomical detail in all three planes. Other advantages of MRI include

high tissue contrast without the use of additional contrast media and also
the absence of artefacts caused by bone and air. If the patient is unable
to lie still, serious movement artefacts result. Aneurysm clips made of
magnetic material represent an absolute contraindication to examination
by MRI.
The grey matter of the brain contains 10-15% more water than the
white matter while the white matter contains relatively more lipids. This
difference in content contributes to the high contrast difference demon
strated by MRI between grey and white matter. Compared to white mat
ter, grey matter has longer, and CSF much longer, relaxation times both
with Tl and T2. Because pathological processes in the central nervous
system in the main exhibit increased water content (oedema) and because
MRI is more sensitive than CT in the demonstration of water content in
crease, MRI has high sensitivity. However, specificity is still a problem.
Measurement of the relaxation times on Tl and T2 has not increased
specificity to any great degree because there is significant overlapping
of values thus obtained in different types of pathological processes. For
example, it can still be difficult to differentiate between benign and ma
lignant tumours and between tumours and inflammation. The paramag
netic contrast medium Gadolinium-DTPA can improve specificity but
170
THE BRAIN
gives more or less the same type of information as contrast medium-en

hanced CT.
Within the central nervous system, magnetic resonance spectroscopy
(MRS) has still not established itself clinically. The reasons are several,
including difficulties in precisely locating the lesion, poor signal-scatter
ratios and low sensitivity.
Angiography
The basic principle of angiography has not changed since 1927 when Egas
Moniz, a Portuguese neurosurgeon, first presented it by performing di
rect puncture of the carotid artery in the neck. Angiography, however, is
nowadays performed almost universally via the femoral artery and the se
lective catheterization and injection of the arteries of interest. The images
are electronically acquired with digital systems and subsequently pho
tographed onto x-ray film (Digital Subtraction Angiography, DSA).
The technique o f femoral puncture was first described by Seldinger in
the 1950s; an introducer is nowadays usually placed in the right femoral
artery and a preshaped catheter, usually 5 French, is directed under flu
oroscopic control in the supraaortic vessels.
Angiography remains necessary in many conditions but it is usually
preceded by CT and/or MR.
Angiography must always be performed in the case of subarachnoid
hemorrhage, or when an AVM must be defined in all its aspects (feed
ing arteries, nidus, draining veins) before surgery or interventional pro
cedures can be performed. Angiography is frequently needed in the pre
operative evaluation of tumours, particularly meningiomas, in case of ar
teritis or when the vessels in the neck must be demonstrated before
surgery or angioplasty for atherosclerotic disease.
Magnetic resonance angiography (MRA) will probably further reduce
the need for catheter angiography; it seems, however, that this technique
will always remain in the neuroradiological armamentarium, particularly
because of the growth of intravascular interventional techniques, whose
indications are expanding to include the treatment of subarachnoid
aneurysms.
Nuclear medicine methods

Nuclear medicine techniques using isotopes give primarily functional in
formation and, because spatial resolution is not nearly as good as with
171
Figure 2.
Cerebral blood flow with SPECT
in the investigation o f epilepsy.
Hypoperfusion in the left temporal
lobe (arrow).
CT and MRI, morphological information is limited. They are capable,

however, of identifying the region of interest. The value of isotope meth
ods as compared with CT and MRI varies depending on the type of le
sion being examined. There are examples of lesions which can only be
visualized with these functional methods. O f course, there are also ex
amples of the opposite. Isotope techniques are becoming increasingly
important as a result of the development of tracing molecules and other
technical advances.
SPECT (single photon emission computed tomography) examinations
are performed with a gamma camera. The radiopharmaceuticals are
lipophilic and because of this pass the intact blood-brain barrier, and are
extracted from the blood into the brain substance in proportion to blood
flow in the region (rCBF). Blood flow is considered to be related to meta
bolic activity. Both hypo- and hyperperfusion can be demonstrated.
Clinically SPECT is used in the localization of epileptic foci (Fig. 2), in the
assessment of ischaemic conditions and in the investigation of dementia.
Basic static brain scintigraphy, in which 99m Technetium sodium
pertechnetate (half-life six hours) is injected into a peripheral vein, has
become less important. The technique depends on the fact that many in
tracerebral lesions cause a defect in the blood-brain barrier through which
172
THE BRAIN
Figure 3.
PET with 18FDG (glucose analogue)
in a patient with partial complex
epilepsy. Reduced radioactive uptake
indicating reduced glucose metabo
lism in the region o f the epileptic fo
cus in the left temporal lobe (arrow).
the radiopharmaceutical passes into the lesion, and is then detected with
the gamma camera. The scintigram exhibits poor resolution, low speci
ficity and varying sensitivity.
PET (positron emission tomography) is a complex form and extension
of the classical tracing molecule technique. The technique depends on
special synthesis techniques in which different substances are labelled
with short lived positron-emitting radionuclides, for example n C with a
half-life of 20 minutes, which are produced in a cyclotron. A very large
number of substances can be labelled, such as amino acids, carbohy
drates, signal substances and drugs. After injection of the preparation
into the patient, its distributon in time and space is examined with the
help of the positron camera. Other short-lived positron-emitting ra
dionuclides are 150 (half-life 2 minutes), 13N (10 minutes) and 18F (110
minutes). The method gives regional quantitative functional and bio
chemical information. This information can be difficult or impossible to
obtain in any other way. Blood volume, blood flow, metabolism, recep
tor and enzyme kinetics and pH can all be studied with PET. The tech
nique improves the diagnosis and monitoring of treatment in a number
of large groups of illness, for example tumours, infarctions, epilepsy (Fig.
3), skull injuries, psychiatric, movement and metabolic disorders. PET
is capable of contributing enormously in the diagnosis and characterisa
tion of central nervous system disorders. It is capable of shedding light
on pathophysiology and is used in the development of new treatment
173
methods. The method is still to a large extent used for research purposes
but is increasingly being used clinically.
As far as the availability of isotope techniques goes, SPECT is used
widely while the use of PET is limited to rather few hospitals worldwide.
PET is a markedly more expansive technique than SPECT but is of great
interest because of the potential which derives from the enormous vari
ety of tracer molecules and quantification possibilities.
MODALITIES FOR EXAMINATION OF THE

SELLAR REGION
CT and MRI allow good demonstration and analysis of pathological
processes in the region of the sella. The relative positions of the anatom
ical structures within this region allow optimal visualization in the coro
nal plane. However, the sagittal plane has certain advantages. The ex
amination should include visualization of the region of the hypothala
mus and also the part of the sphenoid sinus nearest the sella. With MRI,
greater contrast differences between the tissues are achieved than with
CT and in addition artefacts caused by the base of the skull, the sinuses
and tooth fillings are avoided. Another advantage of MRI is that it is mul-
tiplanar. One of the disadvantages of MRI as opposed to CT is that cal
cifications are not shown or are difficult to assess and this is also true of
bone lesions. In summary, MRI is regarded as the examination of choice
in this region. The posterior lobe has a higher signal intensity than the
anterior lobe on Tl-weighted images.
The need for computed cisternography has decreased with the techni
cal development of CT and MRI which allow improved geometrical res
olution. Plane X-ray examination of the sella region and tomography
have become more or less obsolete.
Anatomy
The sella turcica is bordered superiorly by diaphragma sellae and later
ally by the cavernous sinus. Above the sella turcica is the chiasmatic cis-
tema and this contains the upper part of the infundibulum, the optic
nerves and chiasm, the supraclinioid parts of the carotid siphons and the
circle of Willis. The normal height of the pituitary gland is 3-8 mm and
its width 10-17 mm. The upper surface is normally flat or somewhat con
cave, seldom convex. A convex upper surface occurs, however, more of-
174
THE BRAIN
Figure 4.
Normal pituitary gland.
a) MRI in the sagittal plane.
Above the pituitary gland the
stalk o f the pituitary gland can
be seen (horizontal arrow) as
can the optic chiasm (vertical
arrow).
b) CT in the coronal plane through
the pituitary gland. Inferiorly
the base o f the sella and the
sphenoid sinus are seen, superi
orly the stalk o f the pituitary
gland and on each side o f this is
the anterior clinoidprocesses
(vertical arrow) and in addition
the cavernous sinus (star). The
contrast medium-filled left
carotid siphon can also be seen
(horizontal arrow).
ten in young patients or pregnant women but symmetry is preserved, al

though the height can increase to 9-10 mm. Slight asymmetry, less than
1.5 mm, of the bottom o f the sella is relatively common. The correlation
between the size o f the pituitary gland and the volume of the sella is poor.
The normal anatomy of the sellar region is shown in Fig. 4.
MODALITIES FOR EXAMINATION OF THE ORBIT

Radiological diagnosis of orbital lesions has changed and become more
accurate since the advent of CT and MRI. Instead of demonstrating in
direct changes by examination of the skeleton and orbital phlebography,
it has become possible with the new modalities to demonstrate, define
the extent of and characterize the lesion. A major reason for this is the
large difference in attenuation (about 100 HU) and signal between the
orbital fat and for example the optic nerve. CT and MRI are highly reli
able in the demonstration of expanding lesions within the orbit. The abil-
175
ity to differentiate between different types of lesions is, however, rela

tively difficult because pathology is so variable in this area. CT remains
the method of choice and is particularly prefered for the demonstration
of calcification, bony detail and foreign bodies. Potential advantages of
MRI as opposed to CT are, apart from the avoidance of the use o f ion
izing radiation, that MRI is multiplanar and that it is capable o f analysing
the apex region, especially if there is access to fat-suppressing sequences
in combination with contrast injection. The inner structure o f certain le
sions, for example haemangiomas, is demonstrated much more satisfac
torily with MRI. Intraoccular melanomas have been shown to have char
acteristic signal qualities.
Depending on the choice of technique with CT, the dose to the lens
varies enormously (between 50 and 150 mGy). Because of the naturally
good contrast conditions in the orbit, contrast medium injection does not
generally need to be used to demonstrate a lesion. The value of contrast
enhancement is limited in the differentiation of lesions. However, exam
ination with contrast should always be performed when there is a suspi
cion of a lesion in the region of the optic chiasm or when invasion of the
skull cavity is suspected. Other indications for the use of contrast medium
are suspicion of a varix or arterio-venous malformation (AVM) and to
differentiate between optic glioma and meningioma in the optic sheath.
In the diagnosis of tumours, plain X-ray examination has become ob
solete. Angiography is seldom indicated but if it is performed for eval
uation of vascularity it should be performed with injection of contrast
medium into both the internal and external carotid artery. A relative in
dication for orbital phlebography is orbital varices.
Anatomy
The wall of the orbit is composed of seven different bones. The superior
orbital fissure is situated between ala magna and ala parva and through
this passes the superior ophthalmic vein in addition to the third, the
fourth, the first division of the fifth and the sixth cranial nerves. Through
the inferial orbital fissure, between the maxilla and ala magna, passes the
inferior ophthalmic vein. Through the optic nerve canal passes the nerve,
which is surrounded by a thin fluid-filled cavity, and the ophthalmic
artery. The four straight eye muscles form a muscle cone with the bulb
of the eye as the base and the apex region as the tip. In addition, there
are two oblique eye muscles as well as musculus levator palpebrae. The
176
THE BRAIN
Figure 5.
Normal CT scan o f the orbit (a)
through the optic nerve and the
straight medial and temporal eye
muscles and (b) through the lower
straight eye muscles (arrow) and
the lenses o f the eye.
lacrimal gland is situated in the upper antero-lateral part of the orbit.

Some important anatomical structures are shown in Fig. 5.
PATHOLOGY
Cerebrovascular lesions
CT, MRI and angiogrpahy are the three main methods used in the diag
nosis of ischaemic and haemorrhagic lesions of vascular origin. CT is
the most important method because it is capable of distinguishing be
tween infarction and fresh intracerebral haemorrhage. Clinically these
conditions are collectively referred to as stroke. It is difficult to distin
guish between infarction and fresh bleeding using MRI and the role of
MRI in this area of neuroradiology is still not entirely clear. The impor
tance of MRI, however, is likely to increase. Angiography gives specific
information about the anatomy of the vessels prior to surgical procedures
for aneurysm or stenosis.
Infarction
Infarction can be classified as large infarction, lacunar infarction and sub-
cortical atherosclertic encephalopathy (Binswanger's disease). Other
177
Figure 6.
Schematic CT scan o f different types o f
infarction. Within the right cerebral
hemisphere, infarction corresponding to
the regions supplied by the middle cere
bral and posterior cerebral arteries,
respectively, as well as central lacunar
infarcts within the basal ganglia. In the
left cerebral hemisphere, central infarc
tion (caput nucleus caudatus), as well as
infarction in the border zone between
the area o f supply o f the middle cerebral
and posterior cerebral arteries (water
shed infarction).
Figure 7.
CT scan o f a large right-sided middle
cerebral artery infarction.
types of infarction occur at the junction between areas supplied by dif

ferent vessels (so called watershed infarctions). In addition, infarction
occurs secondary to vein or sinus thrombosis. Infarction can also display
a haemorrhagic component. Fig. 6 shows schematically the different
types of common infarction.
CT can demonstrate an infarct after approximately six hours but some
infarcts are not visible on CT for one or sometimes two days.
Occasionally, as a very early sign of infarction, the thromboembolus it
self can be seen in the vessel as a hyperdense structure. Areas of infarc-
178
THE BRAIN
tion can be seen earlier with MRI than with CT. The larger infarcts are
confined to specific vessel areas and of these infarction confined to the
area supplied by middle cerebral artery is the most common (Fig. 7). This
type of infarction involves both white and grey matter. Initially, CT
shows a diffuse hypodensity and MRI hyperintensity with T2-weighted
images. These changes occur because of oedema. During the subsequent
3-5 days the oedema becomes more obvious and the infarct's borders
more clearly defined. At this stage, the area of infarction reaches its max
imum size and its effect on surrounding structures is at its greatest. The
part of the ventricular system nearest to the infarction is compressed. A
large infarct can give rise to considerable swelling and result in dis
placement of mid-line structures and herniation. The swelling begins to
reduce after approximately one week and disappears after 2-3 weeks. At
a certain stage the area of infarct can be more or less isodense with the
surrounding structures. Later the area of infarction becomes clearly de
fined and atrophic changes appear. Clinically, there is no reason in most
cases to monitor the development of the infarction with CT. The first ex
amination is usually diagnostic in combination with history and exami
nation. An infarct can develop haemorrhagic components some days af
ter onset and these can be recognized as hyperdense areas within the in
farction at CT (Fig. 8).
Figure 8.
Infarction o f the left occipital lobe
with haemorrhagic components.
179
Figure 9.
Lacunar infarction in the left thala
mus (arrow).
Injection of contrast medium is only used when it is difficult to dif

ferentiate between infarction and other lesions. At infarction, damage to
the blood-brain barrier is seen and this is most obvious after 2-3 weeks
and can remain for a long time.
Lacunar infarctions are small (less than 15 mm) and usually situated
in the area of the internal capsule. Infarctions as small as 5 mm in di
ameter can be demonstrated (Fig. 9). It can, however, take more than a
week before they are detected. In the brain stem they are difficult or im
possible to demonstrate with CT and in this region the use o f MRI can
be helpful.
In Binswanger's syndrome (Fig. 10) a diffuse hypodensity is seen in
the white matter within the centrum semiovale, mainly periventricularly.
This hypodensity can be accompanied by lacunar infarctions. The
changes are usually bilateral but can be asymmetrical and are best shown
with MRI using T2-weighted images.
The appearances of cerebellar infarction may resemble those o f tu
mour of low attenuation. Considerable swelling can occur with com
pression of the 4th ventricle and development of hydrocephalus.
Infarcts arising as a result of thrombosis within the superior sagittal
sinus are usually situated parasagittally. These can also be haemorrhagic.
At CT, the thrombus itself can sometimes be demonstrated in the early
stages as a lesion of high attenuation and the diagnosis can be confirmed
180
THE BRAIN
Figure 10.
CT scan o f Binswanger's disease with
diffuse hypodensity in the white matter
and widening o f the lateral ventricles.
by injection of contrast medium. However, to be absolutely certain an

giography needs to be performed. Experience with MRI and MR an
giography suggests that these methods will replace CT and conventional
angiography in the diagnosis of thrombosis.
Intracerebral haematoma
Spontaneous intracerebral haematoma can occur in hypertension or at
rupture of arterial, mycotic or arteriovenous aneurysms. Haemorrhage
can also occur in infarction and in tumours or metastases.
A fresh haemorrhage is hyperdense and well-defined at CT (Fig. 11).
During the first days a hypodense zone o f oedema appears around the
haematoma. Large haemorrhages affect the ventricular system and can
break through into the CSF contained within. Haematomas as small as a
few mm. in diameter can be demonstrated.
The density of the haematoma decreases gradually from the periphery
to the centre. Depending on its size it takes from 2-4 weeks before the
hyperdense component has disappeared. After two months the
haematoma is hypodense and resembles, as far as density is concerned,
an old infarct.
At MRI, the haematoma increases gradually in signal intensity because
the haemoglobin assumes changed paramagnetic qualities in the process
of changing to methaemoglobin. The haemoglobin molecules break-
181
Figure 11.
CT scan o f a fresh haemorrhage in the
left putamen.
down and the effect this has on signal intensity is shown in Table 1. When
conversion to haemosiderin is complete the signal intensity becomes low.
It is important to note that fresh bleeding can be overlooked at MRI.
Table 1. Breakdown o f the haemoglobin molecule and resultant effects

on the signal at M RI
Stage Product Effect on signal
acute oxyhaemoglobin insignificant

subacute deoxyhaemoglobin slight shortening o f T2
methaemoglobin shortening o f T 1
chronic haemosiderin shortening o f T2
Haematoma following rupture of an arterio-venous malformation is

usually confined to the lobe in which the malformation is situated (Fig.
12). The possibility to diagnose such a malformation at CT depends on
its size. The tortuous vessels have a characteristic appearance especially
after injection of contrast medium and an impression of afferent and ef
ferent vessels can be perceived. At MRI, vessel malformations display
low intensity because of the blood flow within (signal void). For more
detailed information of arterial supply and venous drainage of malfor
mations angiography must be performed (Fig. 13). This information can
182
THE BRAIN
Figure 12.
Haematoma (arrowj in association
with arteriovenous malformation in
the left occipital lobe (see Fig. 13).
The haemorrhage has broken through
into the ventricular system.
Figure 13.
AP angiogram o f arterio-venous mal
formation in the left occipital lobe (ar
row).
also be obtained with MR angiography.

Rupture of an arterial aneurysm can, as well as causing subarachnoid
haemorrhage (Fig. 14) cause an intracerebral haematoma. This latter
haemorrhage, if it does occur, gives information about the vessel from
which the bleeding has occured. Even the distribution of blood in the
subarachnoid space often gives an indication of the vessel involved.
183
Figure 14.
CT scan o f subarachnoid haemor
rhage with blood in the basal cisterns
and Sylvian fissures bilateraly and
the interhemispheric sulcus.
Figure 15.
Lateral angiogram in a patient with
subarachnoid bleeding (see Fig. 14).
Aneurysm o f the pericallosal artery>
(arrow).
The commonest locations for aneurysms are the anterior communi

cating artery and the middle cerebral artery. In 20% of cases more than
one aneurysm is evident. The accuracy of CT in cases of subarachonid
haemorrhage depends on the size of the haemorrhage and the time o f on
set. In certain cases it is impossible to demonstrate the haemorrhage with
CT. In these cases lumbar puncture is necesary to confirm the diagnosis.
MRI is a poor method for detecting blood in the subarachnoid space.
Larger aneurysms can be demonstrated with CT after injection of con
trast or with MRI which displays low signal, or varying signal intensity
if the aneurysm is partly thrombosed. Further information about the rel
evant anatomy can be obtained at angiography (Fig. 15) and in general
all intracerebral vessel areas need to be examined in order to detect the
184
THE BRAIN
Figure 16.
Depressed fracture (arrow) in the left squama
ossis temporalis.
a/ plain x-ray o f the skull
b/ CT scan with measuring points
presence or otherwise of additional aneurysms. The investigation should

be performed immediately after the onset of bleeding because vessel
spasm can occur after 2-3 days and this can last for approximately one
week. If surgery is delayed the risk of a further episode of bleeding is in
creased.
Other vascular lesions

Dissection within the carotid or vertebral artery is an often overlooked
cause of stroke. Dissection can occur spontaneously or as a consequence
of trauma to the neck. The intra-mural haemorrhage and also the re
maining vessel lumen can be visualized both with CT and MRI and if
further information is required, angiography must be performed.
Cavernous haemangioma is best diagnosed at MRI and is seen as a
small lesion containing haemorrhages of different ages. Calcium content
is shown best with CT. A true cavernous haemangioma displays no in
creased vascularity at angiography but different combinations occur in
the spectrum between cavernous haemangioma and arterio-venous mal-
185
Figure 17.
Schematic CT scan o f the most common skull
and brain injuries at trauma
1. Linearfrature
2. Depressed fracture
3. Foreign body o f metal density
4. Pneumocranium andpneumocephalus
5. Contusion haematoma with oedema
6. Acute subdural haematoma
7. Chronic subdural haematoma with re
bleeding
8. Extradural haematoma
formation.
Venous angioma is regarded as an insignificant anatomical variation
with a collection of small veins joining to form a single large vein. In
general the appearances are characteristic both at CT and MRI.
Trauma
CT is the most important radiological examination technique in the emer
gency management of head injuries. The equipment is widely available
and the examination is quick, has high sensitivity for fresh bleeding and
can reveal oedema. It can also indicate the presence of increased in
tracranial pressure which manifests itself in the form of compressed cis
terns, sulci and ventricles. CT is well suited to the diagnosis of certain
fractures especially depressed fractures (Fig. 16) and fractures o f the
skull base. It is also useful in the examination of multiple injuries. Fig.
17 shows in schematic form the commonest traumatic lesions. During
examination o f the skull and brain, an examination of the cervical spine
can be performed and this is important in unconscious patients.
Assessment of the brain stem and the posterior fossa is made difficult by
beam-hardening artefacts from the dense surrounding bone. If clinically
indicated, examination by CT can easily be repeated as required. CT has
markedly improved the potential to treat and care for patients with head
injury.
MRI is not nearly so important as CT in the emergency assessment of
patients with head injury. This is because of certain diagnostic and prac
tical problems. At MRI there are difficulties in detecting fresh bleeding
186
THE BRAIN
Figure 18.
Linear fracture through squama os-
sis temporalis (arrows).
and a traumatic subarachnoid haemorrhage can go undetected. The ac

quisition time is longer than at CT and this leads to greater problems with
movement artefacts. In addition, the MR scanner lends itself less well
than its CT counterpart to the examination of head injury patients re
quiring life-support equipment. MRI has, however, certain advantages
in the examination of patients in the subacute stage and at later follow-
up because of its greater sensitivity in the detection of old bleeding,
oedema and other fluid collections. MRI is better suited than CT, both
in the acute and in later stages, in the important diagnosis of so called
shearing injuries between the grey and white matter. These manifest
themselves in the form of small focal changes between grey and white
matter and deep axon injuries, both of which can go undetected at CT if
they do not have a bleeding component.
To sum up, MRI has a limited role in the emergency examination of
head injury patients and CT is the method of choice. In the later stages
MRI is superior to CT in providing information of clinical value.
The importance of plain X-rays of the skull in the assessment of frac
tures has decreased markedly. In general, it can be said that the presence
or otherwise of a fracture is less important than intracranial complica
tions resulting from the trauma, in particular bleeding. In addition, with
a suitable window setting at CT, precise assessment of both the vault and
the base of the skull can be performed. Demonstration of depressed frac
tures and fractures of the skull base, as well as assessment of the pres
ence of air in fractures involving the sinuses and mastoid air cell system
is possible. However, an ordinary linear fracture (Fig. 18) is impossible
to detect at CT if it runs more or less parallel to the plane of the slice. In
this way certain parts of a comminuted fracture can be overlooked.
Intracranial air and foreign bodies can be diagnosed both with plain x-
187
Figure 19.
Multiple contusion haematomas with
surrounding oedema. Compression
and displacement o f the lateral ven
tricles.
ray of the skull and CT, but CT is more sensitive especially if small
amounts of air are involved or if the foreign body is of low density. Plain
radiographs o f the skull can indirectly demonstrate haemorrhage by
showing displacement of a calcified pineal body though the examination
can be negative if the bleeding is bilateral or situated basally or in the
posterior fossa. This is also true when determining the mid-line with ul
trasound (echo- encephalography). Unwanted artefacts can make the
exmination with ultrasound even more difficult. It should be made clear
that both plain X-ray of the skull and echo encephalography can be neg
ative in the presence of serious intracranial complications.
Contusion injuries
Focal traumatic intracerebral lesions are made up of contusion with
oedema, with or without a bleeding component, or of a pure haematoma.
The injuries are often multiple (Fig. 19) and the sites of predilection are
the anterior parts of the frontal and temporal lobes. The oedema is some
times diffuse. Traumatic haematomas can generally be distinguished
from spontaneous haematomas by the fact that they are usually more ir
regular in outline and in addition that they involve the cortex. They are
seldom localized to the basal ganglia and are often multiple. At CT,
oedema displays low attenuation and at MRI with T1-weighted images
188
THE BRAIN
Figure 20.
Large acute left-sided subdural
haematoma with a small portion along
the falx (arrow). Left lateral ventricle se
verely compressed and displaced beneath
the falx.
low signal and with T2-weighted images high signal. Fresh bleeding dis
plays high attenuation at CT, up to between 50-80 HU, and this decreases
post-haemorrhage by 2-3 HU per day. At MRI fresh bleeding is, as has
previously been mentioned, difficult to detect. With T2-weighted im
ages, contusion bleeding is demonstrated as an area of low signal within
the high signal area of oedema. When the bleeding reaches the subacute
stage with formation of methaemoglobin the lesion can, however, be
demonstrated well at MRI because of its high signal intensity.
A haematoma can occur some days after trauma and explain sudden
worsening of the clinical picture. This is an indication for a repeat CT
exmamination. Similarly a delayed intracerebral haematoma can arise
after surgery for an extracerebral haematoma which, through compres
sion of the hemisphere, prevented development of an intracerebral
haematoma.
Shearing injuries resulting in multiple small haematomas or areas of
oedema but must be regarded as potentially serious. In the demonstra
tion of traumatic subarachnoid haemorrhage the same rules apply as for
a similar spontaneous haemorrhage. Intraventricular bleeding can also
occur at trauma.
189
Figure 21.
Right-sided isodense subdural
haematoma. The surface o f the brain
cawju$l be seen (arrows).
Subdural haematoma
Acute subdural haematomas arise through venous bleeding and there is
often a co-existing contusion injury. The haematoma is seen between the
skull and the surface of the brain and does not deform the latter (Fig. 20).
As usual, the collection of blood is hyperdense at CT and the attenuation
of the lesion decreases with time. In the subacute stage (after 1-3 weeks)
the haematoma is more or less isodense and can therefore give rise to di
agnostic difficulties. Visualization of the lesion can be facilitated by in
jection of contrast medium because a thin membrane takes up contrast
to a greater or lesser degree which forms between the haematoma and
the surface of the brain. In addition, compression and displacement of
the ipsilateral lateral ventricle should lead to the suspicion that the cause
is an isodense subdural haematoma (Fig. 21). Assessment of the config
uration of the ventricular system is especially important in bilateral iso
dense subdural haematomas because displacement of the mid-line struc
tures may not occur.
After approximately 3 weeks the haematoma becomes hypodense and
the condition is then called chronic subdural haematoma. The
haematoma at this stage has varying density because of re-bleeding on
one or several occasions, but the hypodensity always dominates (Fig.
22). The shape can become biconvex with formation of multiple mem
branes.
190
THE BRAIN
Figure 22.
Right-sided chronic subdural
haematoma with form ation o f mem
branes which show up clearly after in
jection o f contrast medium. Re-bleed-
ing visible within the haematoma.
Figure 23.
Frontal extradural haematoma on the
left side.
MRI has higher sensitivity for small subdudral haematomas than does
CT once the acute stage has passed.
Extradural haematoma
Extradural haematomas usually arise through rupture of meningeal ar
teries, usually the middle meningeal artery, but can arise from venous
bleeding. Usually a co-existing fracture of the skull is present. The
191
haematoma has a biconvex shape (Fig. 23) and usually respects the su
tures because the dura in these areas is especially well attached to the
skull. However, the haematoma can detach venous sinuses. Shunting can
occur from the haematoma to diploic veins and this can explain the vary
ing pathophysiology of epidural haematomas. The haematoma’s density
at CT and signal intensity at MRI are similar to those seen with acute
subdural haematoma.
Sequelae following skull trauma

Sequelae following skull trauma include CSF fistula with rhinorrhoea
caused by a fracture in combination with laceration of the dura and the
arachnoid. Another complication is a fistula between the carotid siphon
and the cavernous sinus. Hydrocephalus is another posttraumatic com
plication.
Tumours
The term ’’brain tumour” usually includes all neoplastic growths origi
nating from the skull, the meninges, cranial nerves, pituitary, brain
parenchyma, embryological remnants, metastases and lymphomas.
Many classifications have been proposed mainly based on histological
criteria, taking into consideration the cell of origin and the degree of ma
lignancy; periodical revision of these criteria by neuropathologists, adds
complexity to the histological classification.
For the purposes of this chapter we will adopt a main basic topo
graphical subdivision within which the histological subtypes will be con
sidered:
supratentorial tumours
extraaxial
intraaxial
infratentorial tumours
extraaxial
intraaxial
Pituitary and parasellar tumours are treated in a specific chapter.
Different histological subtypes occur more frequently in the paediatric
age (infratentorial tumours, medulloblastomas, spongioblastomas,
ependymomas), while others are more frequent in adults and in the supra
tentorial compartament (meningiomas, gliomas).
192
THE BRAIN
The main aim of the neuroradiological diagnosis is first to identify and

recognise the tumour, then to locate it precisely, define its gross macro
scopic structure (solid, cystic, necrotic, calcified, etc) and recognize its
relationships with the surrounding structures (mass effect, hydro
cephalus). To achieve this task the three main diagnosic modalities, CT,
MRI and angiography may be necessary.
MRI is the most informative modality due to its multiplanar capabil
ities that provide superb topographic details as well as its multiparamet-
ric specificity (T l, T2, Proton Density Weighted Images) that provides
maximum contrast resolution; CT, however, better demonstrates calci
fication, providing relevant information on age and gross characteristics
of the tumour.
Angiography is nowadays very rarely necessary for diagnostic purposes;

it is performed only when knowledge o f the type and degree of vascu
larization is relevant for planning surgery or when a preoperative em-
bolisation may be envisaged, for example meningiomas.
Supratentorial, extraaxial tumours

They are mainly represented by meningiomas, craniopharyngiomas, epi
dermoids, chordomas, neurinomas.
Only meningiomas will be discussed in this chapter, since the other
histological types occur mainly at the level of the skull base and in the
sellar region where they will be dealt with.
M eningiomas
Meningiomas are the most common, non glial, primitive intracranial tu
mours; their prevalence among operated tumours is around 13-19%. They
may occur at any age but have a peak incidence around 45 years of age;
60% occur in females. One% are multiple, usually in neurofibromatosis.
The most common locations are: falx and parasagittal (25%), convex
ity (20%), sphenoid (20%) olfactory groove (10%) suprasellar (10%),
posterior fossa (10%), middle fossa (3%) and intraventricular (2%).
Neuropathology
The cells of origin of meningiomas are arachnoidal meningothelial; dural
fibroblasts and pial cells may also participate in the formation of the
meningioma. Macroscopically, they are usually well circumscribed, ho-
193
mogenous, with a capsule; sometimes they are necrotic, contain cystic

components or areas of calcification.
They are usually subdivided from a histological point of view into five
groups; syncitial, transitional, fibrotic, angioblastic and malignant.
Clinical presentation
Meningiomas may present with seizures, progressive focal neurological
signs in relation to the location of the tumour and signs of raised in
tracranial pressure.
Neurological signs may appear very late, when tumours have reached
a very large size.
Neuroradiological diagnosis
Plain films of the skull may be diagnostic when they show focal hyper-
ostotic changes of the skull or calcification, associated or not with signs
of raised intracranial pressure (erosion of the floor of the sella turcica).
CT is almost invariably able to demonstrate the presence of the menin
gioma if the examination is performed using intravenous contrast en
hancement.
Since meningiomas are usually isodense to the cerebral cortex, small
meningiomas located in critical topographical positions such as the floor
of the middle fossa, may be missed if only axial slices without contrast
injection are acquired.
About 20% o f meningiomas contain areas of calcification and may
then range from slightly to markedly hyperdense (Fig. 24, 25). Rarely
meningiomas contain necrotic, cystic or fatty components. Almost in
variably meningiomas enhance intensely and homogeneously following
intravenous injection of iodinated contrast. Surrounding oedema may be
absent or very marked, without definite relationship to tumour size.
On MRI (Fig. 24, 25) meningiomas tend to be isointense to cortex and
hypointense to white matter in T1-weighted images; in T2-weighted im
ages meningiomas are again isointense to slightly or markedly hyperin
tense.
Enhancement with Gadolinium (Gd) is usually very marked and ho
mogeneous. MRI has the advantage over CT of being able to provide im
ages in different planes; coronal images are very useful in demonstrat
ing critical areas such as the middle fossa or the upper convexity; MRI
shows much better than CT the relationship of the tumour with vascular
194
THE BRAIN
Figure 24. Large, calcified fa lx meningoma

a, b) CT without and with contrast injection. Markedly hyperdense (calcific) anterior
midline space occuping lesion, with enhancement.
c) MRI, T2-weighted image, axial. Inhomogenous mass with very low signal (cal
cifications) surrounded by some hyperintensity (oedema) o f the left frontal lobe.
d) MRI, Tl-weighted image, coronal slice following Gd injection. Enhancement o f
the parenchymatous part o f the meningiomas.
195
Figure 25. Right pterional meningioma

a, b) MRI, TI-weighted image, in the coronal plane, without and with i.v. injection o f
Gd. Large, slightly hypo-isointense mass, displacing the frontal lobe, with
marked inhomogeneous enhancement,
c, d) Right external and internal carotid angiography, arterial phase. Hypertrophy o f
the middle meningeal arteries that provides blood supply to the tumour. Some
supply is also provided by branches o f the middle cerebral arteries.
structures, the carotid siphon, venous sinuses, their compression or ob

struction and all topographical relationships useful for surgical planning.
MRI is the modality of choice but CT is definitely diagnostic in the ma
jority of cases.
Neither with CT nor MRI, despite certain characteristic features, is it
possible to distinguish the different histological subtypes of menin
giomas.
196
THE BRAIN
Once the extraaxial location is recognized, the differential diagnosis

includes metastases and neurinomas.
Angiography (Fig. 25) is performed preoperatively not for diagnostic
purposes but to evaluate the type and degree of vascularization, and with
a view to possible preoperative embolisation.
Intraventricular meningiomas are a rare entity; they occur mainly
within the lateral ventricles, at the level of the glomus of the choroid
plexus in the trigone. They may mimic an intraaxial thalamic tumour and
must be suspected any time a tumour growth is within the trigone, with
sequestration and dilatation of the temporal horn, limited or no oedema
of the surrounding parenchyma.
Supratentorial intraaxial tumours
Gliomas
Primary cerebral gliomas represent about 50% of all intracranial tu
mours; they include
1. astroglial tumours; the precursor cell type is the astrocyte
2. oligodendroglial tumours, originating from the oligodendroglia
3. ependymomas, originating from the ependymal cells
4. glioblastoma multiforme, highly malignant glial tumour without a
clearly defined cell of origin
Not infrequently mixed cell types are encountered. From a clinical point
of view the most common presentation is that of progressive focal neu
rological deficits related to the localisation of the tumour; motor, sen
sory, visual fields, language, memory, behaviour etc. Signs of raised in
tracranial pressure or seizures are not infrequently the presenting sign.
Astrocytoma
In adults they represent 25-35% of all supratentorial gliomas, they may
arise anywhere in the cerebral hemispheres; histologically low grade
gliomas are subdivided into three differrent types: fibrillary, protoplas
matic and gemistocytic.
At CT (Fig. 26) they appear as homogenous areas of hypodensity with
relatively well defined margins, they rarely present with perifocal
oedema. Contrast enhancement is rarely found.
197
*
\
Figure 26. fronto-temporo-insular astrocytoma.

a, b) CT without and with contrast injection. The
tumour is hypodense and shows no enhancement. The two arrows point to the
middle cerebral artery branches within the sylvian fissure.
c) MRI, Tl-weighted, coronal image. The tumour is hypointense, with well defined
margins slightly hyperintense. The arrowheads indicate, by comparison, the ele
vated right sylvian fissure.
d) MRI, T2-weighted image. The tumour is markedly hyperintense.
e, j) Right carotid angiogram. Elevation and displacement o f the middle cerebral artery,
produced by the temporal component o f the tumour. No abnormal vessels are seen.
198
THE BRAIN
At MRI, the tumour tissue is usally slightly hypointense in T 1 and def

initely hyperintense in T2 (Fig. 26); the lesion usually appears homoge
neous with well defined margins; enhancement may be present in nodu
lar or diffuse form. Calcification is present in about 20% of astrocytomas
and is better recognized with CT.
Differential diagnosis is relatively easy and includes other neoplastic
lesions such as metastasis, other gliomas and lymphomas, cerebral ab
scesses, cerebritis and ischemic lesions.
Angiography, when performed, usually only shows vessel displace
ment due to mass effect and no tumour vascularization.
Glioblastoma and anaplastic astrocytoma

Glioblastoma is a highly malignant tumour with a mean survival of
months and represents about 15-20% o f all intracranial tumours.
The gross pathological appearance of this tumour is that of an infil
trating lesion, with areas of necrosis and haemorrhage, neovasculariza
tion and surrounding oedema.
The CT appearance is very variable in relation to the macroscopic
anatomy of the tumour; basically the density is inhomogeneous, with hy-
podense and hyperdense areas mixed togheter, irregular margins, sur
rounding oedema and marked inhomogenous enhancement.
At MRI (Fig 27) a wide heterogeneicity of pictures is encountered, due
to the possible presence of haemorrhage, necrosis and solid components.
The tumour is usually hypointense in T l with possible changes associ
ated with the paramagnetic effects of blood and hyperintense in T2 with
the same haemorrhagic changes. Enhancement is usually marked and in
homogenous. Angiography, when performed, shows neovascularization
with pathologic vessels and early draining veins.
Oligodendroglioma
Oligodendrogliomas represent about 5% of all glial tumours, they orig
inate from the oligodendroglia, are highly cellular, infiltrating, with rel
atively well defined margins and high incidence of calcifications (about
75%) (Fig. 28). At CT and MRI their appearance is not specific and does
not differ much from the other glial tumours apart from the much higher
199
Figure 27.
Glioblastoma multiforme
a) MRI, T1-weighted image. Large
frontal tumour, inhomogeneous with
hypointense area and scattered hy
perintensities due to haemorrhage
within the tumour. The arrows indi
cate the middle cerebral artery,
b, c) MRI, axial and coronal TI-weighted
image following Gd-injection.
Marked inhomogenous irregular en
hancement o f the most peripheral
part o f the tumour,
d, e) Right carotid angiography, early and
late phase. Displacement o f vessels
due to mass effect, neovasculariza
tion and early draining veins.
b с
d e
200
THE BRAIN
incidence of calcification, which is better demonstrated on CT.
Other tum ours

Other rare supratentorial intraaxial tumours are subependymomas,
choroid plexus papillomas, colloid cysts, ganglioglioma and gangliocy-
toma, tumours originating from the pineal germ cell, lymphomas and
metastasis.
Extraaxial infratentorial tumuors

These are tumours located under the tentorium, outside the brain stem
and the cerebellum. Symptoms may be due to dysfunction of the nervous
structures of the brain stem and cerebellum and to signs of raised in-
tracrainal pressure due to hydrocephalus.
N euroradiological diagnosis
Plain radiographs are not now necessary although they may show signs
of raised intracranial pressure, rarely a direct sign of calcification within
the tumour or focal bony changes in the posterior fossa may be found.
Figure 28.
Left frontal olidogendroglioma
a) Plain film o f the skull, lateral projection. Arrows indicate scattered opacities due to
calcification.
b) CT: calcification in the left frontal lobe within an isodense space occyping lesion
compressing the left frontal horn.
201
Figure 29. Infratentorial meningioma

a, b, c, d) MRI, sagittal Tl, axial T2, sagittal and coronal Tl-weighted images with
Gd. The tumour is isointense, but is well seen after Gd-injection, due to the
marked enhancement.
CT, without and with intravenous injection of contrast is able to de

tect the majority of lesions except small intracanalicular neurinomas.
MRI has the superiority of superb spatial resolutuion with multiplanar
sections and better tissue discrimination.
Angiography is rarely needed, mainly in vascular tumours (haeman-
gioblastomas).
202
THE BRAIN
Classification
Meningiomas
The most frequent sites for infratentorial meningiomas are: the petrous
bone, clivus, foramen magnum, tentorium; extremely rare is an intra-
ventricular meningioma of the fourth ventricle.
CT and MR appearance of posterior fossa meningiomas does not dif
fer from that of supratentorial lesions (Fig. 29).
Neurinomas
They represent about 8% of intracranial tumours. The most frequent in
fratentorial neurinoma is that of the 8th nerve; much more rare are those
of the 7th, most frequently found in patients with neurofibromatosis type
2, and those of the 12th, 9th and 10th cranial nerves.
The CT and MRI appearances are not different from those of the supra
tentorial tumours. They usually enhance markedly but may have intra-
tumoural cystic components (Fig. 30).
For the tumours of the 8th nerve, plain films of the skull may still be
useful to detect enlargement and erosion of the acoustic canal. Much
more important is the possibility to detect, with high resolution MRI and
use of paramagnetic contrast media, small intracanalicular tumours, be
fore any bone change or growth within the cerebellopontine angle is ob
served.
Epidermoids and dermoids

Epidermoids, or less properly ’’epidermoid cysts” and dermoids are be
nign congenital tumours of developmental origin. Some terminiological
confusion exists because some authors improperly call these tumours
cholesteatomas. They originate from ectopic ectodermic cells; the most
frequent sites are the subarachnoid space at the level of the clivus, the
CP angle, the perimesencephalic cistern. Rarely epidermoids and der
moids may be intraventricular.
On CT (Fig. 31) they appear usually isodense with CSF, do not en
hance and displace, without infiltrating, the surrounding structures.
On MRI (Fig. 31) they have a signal close to that of CSF both in T1
and in T2-weighted images. Dermoids may have more complex signals,
including T1 shorteming and T2 shortening due to the presence of para
magnetic substances.
203
Figure 30.
Large right acoustic neurinoma
a, b) MRI, Tl and T2-weighted images.
The tumour is isointense in Tl and
inhomogeneously hyperintense in
T2.
c) MRI, Tl-weighted image following
Gd-injection. M arked inhomoge-
neous enhancement o f the lesion.
Lipomas
Lipomas are benign tumours of maldevelopmental origin. They are usu
ally incidental asymptomatic findings. The most common site is the
quadrigeminal and perimesencephalic cistern.
At CT they appear hypodense, with the density of fat; sometimes they
contain calcification.
On MRI they are hyperintense in T l and iso-hypointense in T2.
Chordomas
These tumours originate from remnants of the embryonic notochord.
They usually arise from the clivus at the level of the spheno-occopital
synchondrosis; more rarely from the petrous bone. They produce de-
204
THE BRAIN
Figure 31.
Epidermoid in the left cerebellopontine
angle
a) CT: hypodense space occupying
structure in the left CP angle, dis
placing the pons and cerebellum,
b, c) MRI, Tl and T2-weighted image.
The lesion has a signal very close to
that o f CSF.
struction of bone and on CT appear hypodense with hyperdense inclu

sions representing fragments of destroyed bone.
On MRI they are hypointense in T l, hyperintense in T2, and usually
show marked enhancement following Gd-injection.
Other more rare extraaxial tumours of the posterior fossa are choroid
plexus papillomas, glomus jugulare tumours and metastases.
Intraaxial infratentorial tumours

As for extraaxial tumours, intraaxial infratentorial tumours may present with
focal signs due to impairment of nervous strutures of the posterior fossa,
brain stem and cerebellum, or with signs of supratentorial hydrocephalus.
205
As a general rule, posterior fossa intraaxial tumours in chldren are usu

ally primary tumours (brain stem gliomas, cerebellar medulloblastomas or
astrocytomas) while in adults most commonly they are secondary tumours
(metastases mainly from lung tumours in male, breast tumours in female).
Classification
Astrocytoma
Cerebellar astrocytoma accounts for 6-10% of all cerebral tumours and
is the most common infratentorial tumour in children. It is a slow grow
ing infiltrating tumour, with significant cystic components in about 60%
of cases, mainly localized in the cerebellar hemispheres in 75 % of cases.
It is more common in the first decade with a peak around the fourth year.
206
THE BRAIN
It usually appears as a well defined round lesion with regular margins,

the most common histologic variety is the pilocytic one.
On CT the solid components (Fig. 32) of the tumour are isodense and
the cystic parts are hypodense. Marked enhancement of the solid com
ponent is usually observed, enhancement may occur at the level of the
capsule of the cyst. Calcification is found in about 10-20% of cases. MRI
(Fig. 32) clearly shows the nodular component, usually isohypointense
in Tl and slightly hyperintense in T2. The cyst may be isointense in Tl
due to the high protein content and hyperintense in T2. Marked en
hancement following Gd injection is usually observed at the level of the
parenchymal component.
Medulloblastoma
Medulloblastoma is a highly malignant tumour, originating from pri
mary, non differentiated neuroectodermic cells located at the level of the
roof of the fourth ventricle. The most common location is midline, within
the cerebellar vermis, with anterior growth within the fourth ventricle.
On CT (Fig. 33) the tumour presents as a solid, homogenous mass,
usually isodense or slightly hyperdense, with marked enhancement fol
lowing contrast injection. Calcification and cysts are only rarely present.
On MRI the tumour is most commonly isointense both in T l and T2
and enhances markedly following Gd injection.
Ependymoma
It originates from ependymal cells lining the ventricular cavity; it is usu
ally solid, with an attachment to the floor of the fourth ventricle.
Tumoural cysts are very rare but areas of calcification are not infrequently
found. The tumour tends to grow and spread through the foramina of
Luschka and Magendie.
CT and MR appearances are non-specific and differential diagnosis
includes medulloblastomas and choroid plexus papilloma.
Haemangioblastoma
Haemangioblastoma originates from endothelial cells and is most com
monly located in the cerebellar hemisphere or in the medulla. In about
10% of the patients the tumours are multiple, occuring in von Hippel-
Lindau disease.
The most common macroscopic presentation is that of a cyst with a
small vascular mural nodule. Large nodular vascular tumours without an
207
Figure 33. Medulloblastoma o f the vermis

a) CT without contrast. The tumour is isodense, minimally hyperdense.
b, c, d) MRI, Tl, T2 and Tl with Gd images. The tumour is isointense and shows
marked inhomogenous irregular enhancement.
associated cyst are, however, not uncommon.

The CT appearance is non-specific while MRI (Fig. 34) is able to
demonstrate the flow void appearance of sufficiently large vessels. This,
together with multipicity, may be a useful indicator in differential diag
nosis with other cystic tumours with mural nodules (astrocytoma).
Angiography (Fig. 34) is mandatory for final diagnosis: a marked cap
illary blush within the nodule is usually observed, together with drain
ing veins and feeding arteries.
208
THE BRAIN
Figure 34. Haemangioblastoma

a) MRI, midline sagittal Tl-weighted image following Gd-injection. Marked inhomo
geneous enhancement o f a midline nodule, behind the medulla.
b) Vertebral angiography. Two nodules are well seen, one fed by the posterior inferior
cerebellar artery and the other in the cerebellar hemisphere, fe d by branches o f the
superior cerebellar artery.
Brain stem tumours

Astrocytoma or spongioblastoma are the usual histological types of brain
stem gliomas. The pons is the area most frequently involved. They are
slowly growing tumours that produce a progessive enlargement o f the
brain stem and compression of the fourth ventricle: hydrocephalus oc
curs only in the advanced phase of the disease. Anterior exophytic growth
may encase the basilar artery.
On CT brain stem gliomas usually appear as hypodense lesions, with
out defined margins, and exhibit minimal or no enhancement. Sometimes,
however, the tumours have a more nodular appearance with enhancement
at the level of the nodule.
The MR appearance is specific only because of the location, type of
spread and deformity of the brain stem. The tumour is hypointense in Tl
and hyperintense inT2. Enhancement is foundmainly in the nodular forms.
The differential diagnosis of the nodular form includes metastases,
granulomas, cavernous haemangiomas, etc.
209
Figure 35. Right frontal abscess

a) CT with contrast: fa in t ring enhancement o f the abscess capsule around the hypo-
density o f the necrotic lesion
b) MRI, Tl-weighted image (Wl), axial slice: the abscess is hypointense with a slightly
hyperintense capsule
c) MRI, T2W1: the abscess is hyperintense, with an isointense capsule and is sur
rounded by hyperintense oedema o f the white matter o f the frontal lobe
d) MRI, T1WI, follow ing Gadolinium injection: marked enhanement o f the capsule.
210
THE BRAIN
Infection
Infection and inflammation of the brain may be caused by all the known
pathologic agents: bacteria, viruses, fungi, parasites, etc.
The reaction o f the brain is, however, peculiar, due to the presence of
the blood-brain barrier and specific immunological processes.
From a clinical point of view infections of the brain may manifest with
specific neurological signs related to the location of the lesion and indi
rect signs of infection such as fever, malaise and meningeal signs.
Bacterial infections
The brain manifestations of bacterial infection are:
a. abscesses
b. meningitis
c. empyemas (subdural or epidural)
When a pyogenic organism, usually staphylococcus, succeeds in local

ising within the brain parenchyma, a cerebritis occurs. The lesion is
poorly defined, usually hypodense at CT and on MRI it is hypointense
in Tl and hyperintense in T2.
If the process is not eradicated by antibiotic therapy, the central area
of the cerebritic lesion becomes necrotic and is surrounded by a capsule
of collagen tissue, forming the abscess.
On CT (Fig. 35) the abscess usually appears as a round or ovoid le
sion, hypodense, with an isodense capsule that enhances following con
trast. The capsule is usually thin and regular. There is usually abundant
surrounding oedema.
MRI (Fig. 35): the capsule of the abscess is not infrequently hyperin
tense in T l, probably due to paramagnetic effects of free radicals; the
center of the abscess is either hypo- or isointense. On T2 the abscess is
usually hyperintense. The capsule enhances markedly following gadolin
ium injection.
Meningitis
Both CT and MRI may show leptomeningeal enhancement and associ
ated cortical or brain involvement.
211
Figure 36.
Bilateral herpes simplex en
cephalitis
a) CT without contrast: hypodense
areas with scattered haemor-
rhagic hyperdensities bilater
ally, at the level o f the insular
cortex.
b) MRI, T2W1, bilateral hyperin
tensities at the level o f the insu
lar cortex; the haemorrhagic
component is hypointense, due
to the presence o f extracellular
deoxyhaemoglobin.
Empyema
Empyemas are characterised by presence of purulent material in the
subdural or epidural space. In the majority of cases they represent an
extension of an infectious process of the paranasal cavities. Both CT
and MRI may demonstrate collections that have density and signal
characteristics that may not be too different than those of chronic sub
dural haematomas.
212
THE BRAIN
Figure 37.
Tuberculosis
MRI, T1W1, follow ing Gadolinium.
Multiple small granulomas scattered
within the brain parenchyma are seen
(miliary tuberculosis).
Viral infections
These may produce minimal changes at CT and be better seen at MRI
with non-specific T2 hyperintensity both involving the cortex and the
white matter.
Herpes simplex encephalitis may have haemorrhagic components
demonstrated by CT (Fig. 36) and occurs usually bilaterally in specific
locations such as the temporal lobe, the hippocampus and the insula.
MRI (Fig. 36) clearly shows not only the T l hypointensity and the T2
hyperintensity of the lesion but also the paramagnetic effect of the haem
orrhagic component. Contrast enhancement is usually not necessary.
Microbacteria and fungi produce abscesses and granulomas with or
without meningeal involvement; both CT and MRI are sensitive in
demonstrating the lesions, particularly following contrast injection.
Tuberculosis in the miliary form only may be appreciated following con
trast injection (Fig. 37).
Parasitic infections
The most common parasitic infections are cysticercosis and echinococ
cosis.
In cysticercosis, both intraparenchymal and meningeal cysts are found
which at different stages may include calcified nodules; CT clearly
demonstrates the calcification; frequent meningeal enhancement is en
countered.
213
Figure 38.
Definite M S
a, b) CT without contrast. A
few small fo c i o f hy-
pointensity are barely
seen.
c, d) CTfollowing intra
venous injection o f iodi
nated contrast. A t least
three nodular enhanc
ing fo c i within the white
matter are seen.
Among the parasitic brain infections, toxoplasmosis is today the most

frequent, due to its high incidence in AIDS patients. Multiple nodules
are found both in the basal ganglia and in the cerebral hemisphere. They
tend to enhance and the differential diagnosis with multinodular lym
phomas is frequently difficult.
AIDS has given rise an increase of all parasitic infections. Brain abnor
malities directly related to AIDS are atrophy and subtle changes of sig
nal intensity o f the white matter.
Otherwise, the picture is that of parasitic, fungal or viral opportunis
tic infections.
Demyelinating diseases
Demyelination is produced by many different agents from infection to
radiation therapy, toxic effect of drugs, autoimmune processes, is-
chaemia, etc. The term demyelination is then used to indicate a condi
tion in which normally formed myelin is later destroyed: dysmyelination
214
THE BRAIN
is used to indicate a condition in which, usually due to genetic causes,

myelin never forms properly.
The clinical presentation of demyelinating and dysmyelinating dis
eases is very different: dysmyelination usually manifests earlier, with
progressive signs.
Demyelination is either clinically related to the underlying disease (vas
culitis, viral infections) or, as in the case of the most common demyeli
nating condition, multiple sclerosis, the course may be as a series of re
lapses and remissions of neurological signs or it may be progressive.
The role of neuroradiological diagnosis in multiple sclerosis has sig
nificantly changed with the advent of CT in 1972, and subsequently with
MRI in the early eighties.
Before CT the neuroradiologist was involved only in the differential
diagnostic process, to rule out by means of angiography or pneumoen
cephalography tumours, vasular ischaemic lesions or any other disease
affecting the brain and the spinal cord.
With CT the brain parenchyma is directly imaged: white matter is
slightly hypodense with respect to the slightly hyperdense gray matter.
Foci of demyelination may be recognized as hypodense areas against the
already hypodense background of the white matter.
MRI has proven to be far superior to CT in the diagnosis of white mat
ter lesions, due to its sensitivity to white matter changes that appear as
hyperintense areas against the relatively isointense background of the
white matter on PD and T2-weighted images.
Gadolinium injection shows the disruption of the blood-brain barrier
when present and has proven to be of great value in better diagnosing
MS and understanding its clinical evolution.
Multiple sclerosis
CT is usually positive in about 50% of MS patients non-selected for type
or phase of the disease. Plaques are visible as foci of hypodensity (Fig.
38), mainly in the supratentorial periventricular white matter. Small
plaques, particularly in the corpus callosum, in the subcortical areas, in
the brain stem and posterior fossa are in general not easily recognized.
There is no way to distinguish recent from old plaques when they co
exist in the same patient.
MRI is definitely superior to CT: much smaller plaques can be detected
and critical areas such as the corpus callosum and the brain stem are eas
215
ily investigated employing sagittal or coronal sections.

The positivity of MRI is around 90% in patients non-selected for type
or phase of the disease; the positivity rises up to 100% in cases o f defi
nite MS. MRI is more sensitive than laboratory tests like evoked poten
tials or CSF oligoclonal bands in patients with definite MS.
Plaques tend to be periventricular, frequently have an oval shape with
a radial distribution along medullary veins, and the major axis oriented
perpendicular to the lateral wall of the ventricle.
The most common locations are in the deep white matter of the cere
bral hemispheres (Fig. 39); the cerebral or cerebellar peduncles, brain
stem (Fig. 40, 41), medial longitudinal fasciculus and corpus callosum
are also frequently involved. As with CT, it is not possible with routine
SE sequences to differentiate new from old plaques.
Gadolinium injection provides the only way to differentiate recent
from old plaques; recent plaques show a focal hyperintensity on Tl.
Sometimes Gd allows identification of hyperacute plaques that have not
yet produced a signal change in T l or T2. Gd is in fact able to demon
strate the disruption of the blood brain barrier before the formation of
the inflammatory infiltrate and subsequent formation of oedema.
Gd enhancement may have different appearances; ring enhancement
probably reflects reactivation of an old plaque while a nodular homoge
neous enahancement indicates a recent plaque.
The demonstration in the same patient at the first clinical presentation
of acute enhancing plaques together with chronic non-enhancing plaques
confirms that MS is not a monophasic disease and provides useful crite
ria for differential diagnosis with other diseases affecting the white mat
ter such as Acute Disseminated Encephalomyelitis (ADEM).
Some authors have performed Gd enhanced scans every two weeks
and have demonstrated a high subclinical activity in the formation of
plaques. The knowledge of this phenomenon has provided a useful in
dication for clinical models in therapeutic trials.
Optic neuritis
MRI is particularly useful in patients that present with a first episode of
optic neuritis; not infrequently asymptomatic plaques may be seen in the
brain parenchyma. They may either be contemporary to the episode of
optic neuritis or indicate previous episodes.
216
THE BRAIN
Figure 39. Definite M S

a) MRI, axial T2-weighted image. Plaques are mainly periventricular, oval shaped
with a major transverse axis, hyperintense with respect to normal parenchyma.
There is no way in this patient with a relapse to tell which is the active plaque.
b) Following Gd injection a ring-like enhancement aorund a plaque in the left centrum
semiovale is seen.
Figure 40. Figure 41.

Plaque in the pons, along the left fifth Plaque in the midbrain. T2-weighted im
nerve, in a patient with trigeminal age: the plaque is in the left cerebral p e
neuralgia. duncle.
217
Figure 42.
Spinal cord plaque. T2-weighted sagittal
image. Large focus o f increased signal
at C2-C3, with mild cord widening.
The same is true for other clinical presentations; many more plaques,
frequently inactive, are found in patients at the first clinially recognized
episode of MS.
Spinal cord M S (Myelitis)

Plaques in the spinal cord are less easily seen than in the brain since MRI
is less sensitive in demonstrating small lesions in the cord than in the
brain.
Cervical plaques, particularly when they are sufficiently large and pro
duce some swelling of the cord, may be detected (Fig. 42).
218
THE BRAIN
The positive yield is much lower for the thoracic cord. A commonly
used protocol in a patient suspected of having cord localization of MS,
is to scan the brain in search for asymptomatic plaques. If this test is pos
itive, the diagnosis is easily made; a negative brain MRI, however, does
not rule out a diagnosis of MS.
The higher frequency of dectecion of spinal cord MS plaques in the
cervical region probably reflects the better resolution of MRI for the topo
graphical region rather than a significantly higher frequency of ocur-
rrence of plaques in the cervical cord.
Differential diagnosis
Diagnosis of MS is a clinical diagnosis that must be supported by clini
cal history, age of the patient, other laboratory data such as evoked po
tentials and CSF oligoclonal bands.
The MR appearance of a plaque is per se non specific. In the presence
of multiple, diffuse white matter focal lesions, other disease entities such
as vasculitis, radiation damage and subcortical atherosclerotic en
cephalopathy (Binswanger's disease) must be taken into consideration.
Acute disseminated encephalomyelitis (ADEM) has a very similar ap
pearance but knowledge of a previous viral infectious episode or vacci
nation and the monophasic aspect of the demyelinating foci will lead to
the diagnosis.
Pseudotumoural plaques
In some rare cases, plaques may be very large and simulate the diagno
sis of a tumor both clinically and morphologically (Fig. 43). Short term
follow-up, close clinical observation, MR spectroscopy will lead to the
correct diagnosis.
Diseases of the orbit
Intraorbital expanding lesions

With tumours or inflammatory lesions within the orbit the patient can
have exophthalmus, poor vision, pain or double vision. Despite the large
variation in pathology the symptomatology is fairly similar for all lesions
in this area.
Retrobulbar tumours can be classified into intraconal and extraconal
depending on whether or not they are situated witin or outside the mus-
219
cle cone. It is important to note that overlapping can occur. Intraconal:

optic glioma, optic meningioma, cavernous and capillary haemangioma,
haemangiopericytoma, lymphangioma and neurofibroma. Extraconal:
lacrimal gland tumour (pleomorphic adenoma, adenoid cystic cancer),
dermoid, lymphoma, pseudotumour, rhabdomyosarcoma and metastases.
Of intrabulbar tumours, retinoblastoma and malignant melanoma
should be mentioned. Retinoblastoma usually occurs during the first two
years of life as a calcified lesion in the posterior part of the bulb. Another
cause of calcifiction in the area of the papilla is drusen which is a cal
cium-containing lesion of the papilla and is often familial. Malignant
220
THE BRAIN
Figure 44.
Cavernous haemangioma within
the left orbit.
melanoma has a pathognomonic signal quality at MRI, relatively high

signal with Tl-weighted images and relatively low signal with Tl-
weighted images.
Thickening o f the optic complex can be caused by several conditions;
optic glioma, optic meningioma, optic neuritis, lymphoma, leukaemia,
sacroidosis, thyrotoxicosis, oedema with raised intracranial pressure and
high subarachnoid space.
Optic glioma is often seen in childhood and has an increased incidence
in patients with neurofibromatosis. The commonest configuration is
fusiform but it can be exophytic or tubular. The tumour is usually ho
mogeneous. However, on CT, varying contrast enhancement of differ
ent parts of the tumour is commonly seen. Large tumours can exhibit
cyst formation. The tumour may have a significant intracranial compo
nent and this is best shown by MRI.
Meningioma of the optic sheath usally occurs in adults but can be seen
in young patients suffering from neurofibromatosis. In contrast to optic
glioma which respects the dura the meningioma invades the dura and this
may appear irregular. Meningiomas often contain calcification in con
trast to optic gliomas. A tubular shape is commonest but fusiform and
exophytic tumours occur. A characteristic but not pathognomonic, find
ing at intravenous injection of contrast medium is that the sheath menin
gioma exhibits higher attenuation than the optic nerve.
Cavernous haemangiomas is the commonest orbital tumour in adults
(Fig. 44). They have a round or oval shape and smooth borders. If contrast
medium is administered at CT, the attenuation increases from negative to
approximately isodense with the eye muscles. In capillary haemangioma,
which occurs in children, MRI may reveal a discrete vacularity.
221
Figure 45.
Marked muscle thickening in
dysthyroid myopathy with com
pression o f the optic nerves in the
apex regions.
Lacrimal gland tumours occur in the upper lateral quadrant o f the or
bit. Both benign (pleomorphic adenoma) and malignant forms (adenoid
cystic cancer) occur. The latter invades bone.
Dermoids are well defined and often situated anteriorly in the upper
half of the orbit. The cystic part is in general hypodense at CT but this
is not always the case and depends on the dermoid's content. Similar
varying signal intensity is seen at MRI. Erosion is not uncommon in the
upper lateral part of the orbit. A coexisting fluid level (fat and fluid) is
pathognomonic.
Lymphoma is most common in older people and can occur as a pri
mary tumour of the orbit or may be secondary to a systemic illness.
Usually lymphomas are diffuse, infiltrating, retrobulbar lesions which
are iso- or hyperdense at CT. Bone erosion is common.
Pseudotumour is a chronic non-specific inflammation of unknown ae
tiology. It may appear similar to lymphoma. It is a diffuse expanding le
sion which, in its extreme form, can stretch from the apex anteriorly to
the bulb. The sclera is often thickened as are individual muscles.
Rhabdomyosarcoma is the commonest malignant orbital tumour in
children. It usually occurs extraconally but can also occur intraconally.
At CT it displays medium density without contrast medium. It is impor
tant that the diagnosis is made and treatment started as soon as possible
because of the tumour's aggressive behaviour.
Metastasis is commonest from breast, lung, kidney, and colon cancer.
Of these metastases, those from breast and lung tuours occur most com
monly. The metastases display very varying morphological patterns.
Muscle thickening is commonest in hyperthyroidism (dysthyroid my
opathy (Fig. 45) and can occur before, during and after the hyperthyroid
stage. If only individual muscles are thickened, the muscles most
222
THE BRAIN
Figure 46.
Large intra- and suprasellar pitu
itary adenoma. M RI in the coronal
plane (a) and the sagittal plane (b).
The optic chiasm (arrow) is
displaced upwards.
commnly affected are the medial and inferior rectus. Isolated thickening
of the inferior rectus muscle must not be misdiagnosed as tumour.
Inflammation, in the form of orbital or periorbital cellulitis, can occur
as a result of underlying sinusitis or following trauma with a foreign
body. The inflammatory lesion can display varying appearances with ex
tra- and intraconal involvement. It may develop into an abscess.
Mucocele can invade the orbit and become inflamed.
Trauma
CT is excellent for the mapping of traumatic lesions, haematoma, frac
tures, retrobulbar air (indicating fracture of the wall of the orbit), bulb
laceration and foreign bodies. It should be noted that splinter fragments
can display varying attenuation depending on the type of wood and on
the water content.
223
Pathology in the region of the sella

In general, sellar lesions present with endocrinological or neurological
symptoms. Approximately 60% of the patients display the symptoms
and signs o f pituitary malfunction. Suprasellar involvement often gives
rise to visual field defects through pressure on the optic chiasm but can
also cause symptoms attributable to hypothalamus dysfunction. The
commonest lesions in the sellar region are pituitary adenoma, cranio
pharyngioma, suprasellar meningioma and empty sella. Less common
lesions are: optic glioma, hypothalamus glioma, large aneurysms, metas-
tases, cancer of the sphenoid sinus, arachnoid cysts, chordoma, germi-
noma, sarcoidosis and lymphoma. The huge variety of pathology in this
region is due to the numerous anatomical structures.
Pituitary adenomas are found in the anterior lobe of the pituitary gland
and can be expanding or invasive. Small adenomas, less than 10 mm (of
ten referred to as microadenomas), do not affect the surrounding struc
tures. Those adenomas which do not produce hormones are often those
which reach the largest size and their presence is usually first detected
when their continued expansion gives rise to symptoms of compression
on surrounding structures. Sixty per cent o f pituitary adenomas are pro
lactin-producing tumours, so called prolactinomas which cause amen-
orrhoea, galactorrhoea and impotence. More uncommon are those which
produce ACTH and cause Cushing's syndrome, and are in general small
and those which produce growth hormone, cause acromegaly and the
majority are small.
Large adenomas are well shown both at CT and MRI and display both
an intra- and suprasellar component. The mass effect on suprasellar struc
tures, such as the optic chiasm (Fig. 46) is demonstrated better with MRI
than with CT. Because flowing blood gives no signal at MRI the carotid
siphon's position in relation to the tumour is easy to determine. Invasive
growth in the cavernous sinus is better shown by MRI than by CT. The
tumour can grow around the carotid siphon but does not compromise the
lumen. Degenerative changes are commonest in large tumours and man
ifest themselves in the form of necrosis, cyst formation, bleeding (which
is also seen after drug treatment) as well as volume reduction. Fresh
bleeding is easier to detect with CT whereas MRI is superior in the de
tection of older bleeding. With bleeding or infarction which gives rise to
rapid expansion, pituitary apoplexy and serious compression of the op
tic chiasm requiring emergency operation can occur.
224
THE BRAIN
Small adenomas are seen on CT as small focal hypodensities (Fig. 47)

and by MRI as low signal lesions, in both cases soon after intravenous
injection of contrast medium. Slice thickness should be approximately
2 mm. Eccentric position of the stalk of the pituitary gland and asym
metry of its upper surface can facilitate diagnosis.
Craniopharyngiomas are derived from the remnants of Rathke's cleft.
They are usually situated superior to the sella but 20% of them have an
intrasellar component. The cystic and solid proportions of these tumours
are variable and calcification within the tumour is common (Fig. 48).
Calcium-containing tumours allow easy diagnosis with CT while di-
agosis with this method can be difficult if the tumour is more or less cys
tic. At MRI, T2-weighted images allow the cyst to be distinguished from
CSF by its higher signal but on Tl-weighted images the cyst can display
high or low signal depending on its content.
Suprasellar meningiomas are in general easy to diagnose at CT be
cause of their marked contrast uptake and commonly demonstrable hy
perostosis. On MRI meningiomas generally have a signal which is sim
ilar to that of grey matter which in turn means that they are difficult to
differentiate from their surroundings. Gadolinium-DTP A raises signal
intensity on Tl-weighted images and facilitates diagnosis.
Empty sella is the term employed when the chiasmatic cistern pro
lapses into the sella turcica which in its turn leads to the sella becoming
partly or almost wholly filled with CSF. This phenomenon and the re
maining pituitary tissue can be demonstrated with both CT and MRI.
225
Figure 48.
Transverse CT scan o f a cranio
pharyngioma. Solid central contrast-
enhancing component (arrow)
surounded by cystic component with
wall calcifications.
Other expanding lesions include: optic gliomas which are wholly con
fined to the optic chiasm can be impoossible to differentiate from hypo
thalamus glioma, sarcoidosis, germinoma and lymphoma. This is true
using both CT and MRI. In general, these tumours display positive con
trast enhancement. Hamartomas in the tuber cinereum are isodense and
no signal increase is obtained on injection of contrast medium. Large
suprasellar aneurysms are important to consider as an alternative diag
nosis to tumour. MRI gives the diagnosis of non-thrombosed aneurysm
easily because of the lack of signal (so called signal void of flowing
blood). Arachnoid cysts can occur in the suprasellar region and their at
tenuation at CT and signal at MRI can mimic those obtained with CSF.
The stalk of the pituitary gland cannot be defined.
INTERVENTIONAL NEURORADIOLOGY
Interventional neuroradiology is the treatment of CNS lesions by catheter
techniques. The procedures are technically demanding and a compre
hensive knowledge of the different types of catheters and embolization
materials is required. The commonest procedures are occlusion of arte-
rio-venous fistula with detachable balloons, for example occlusion of fis
tula between the carotid siphon and the cavernous sinus (Fig. 49), and
partial or total embolization of arterio-venous malformations (Fig. 50),
226
THE BRAIN
Figure 49.
Lateral angiogram showing a fis
tula between the carotid siphon
and the cavernous sinus.
a) Cavernous sinus filled with con
trast medium (arrow) and
drainage via the superior oph
thalmic vein and the inferior
petrosal sinus.
b) The fistula has been occluded
with a balloon (arrow) de
tached from a special catheter.
intracerebral or dural, with small particles or special glue. Another non

operative treatment method for arterio-venous malformations is radio
therapy in the form of stereotactic gamma or proton therapy. Preoperative
embolization of meningioma is performed only occasionally. Techniques
for obliteration of arterial aneurysms and dilatation at vessel spasm are
developing rapidly.
227
Figure 50. AP angiogram (a) o f temporal arteriovenous malformation (horizontal

arrow) with draining vein (vertical arrow). After super-selective catheterization and
injection o f glue the angiogram appears normal (b).
228
Chapter 10
The head and neck
Sven G. Larsson and Anthony A. Mancuso
MODALITIES
The facial skeleton and the soft tissues of the head and neck area have a
varied and complex anatomy. Imaging of this area therefore has to be
tailored with regards to the organ to be examined and the individual clin
ical setting. Conventional plain radiographs are today used mainly to as
sess the facial skeleton and the paranasal sinuses. Computed tomogra
phy and magnetic resonance imaging both lend themselves to cross-sec
tional imaging of the head and neck area and both have proven to be
useful adjuncts for the evaluation of tumors and infections in this area.
Because of the complex anatomy and the varied pathology each
anatomical region will be considered separately with regards to exami
nation technique, anatomy and pathology.
TEMPORAL BONE
Technique
High resolution computed tomography using thin 1-2 mm sections in
both the axial and coronal projections is the preferred imaging method
to examine the temporal bone.
Anatomy
The hearing and balance organs are imbedded in the pyramid of the tem
poral bone. These complex organ systems develop from all embryologi-
cal layers. The inner ear is derived from the otocyst of the ectodermal plate,
and is fully developed at birth. The labyrinth can therefore easily be seen
on plain films of the newborn skull. The external ear canal and the middle
ear are derived from the first and second branchial arch apparatus.
229
Figure 1. Normal transverse cross

sectional anatomy o f the temporal
bone at consecutive levels fro m bottom
to top.
A) Junction between the hypotympa-
nun and the mesotympanun at the
level o f the round window niche (2).
The tensor tympani muscle can be
seen extending towards the handle
o f the malleus (6) and the tympanic
membrane.
B) A t the level o f the basal turn o f the
cochlea (3) form ing the promontory>
which is part o f the medial wall o f
the mesotympanum.
C) A t the level o f the internal auditory
meatus (17) and the oval window
(15). The suprastructures o f the
stapes can be seen (8).
D) Epitympanon (20) housing the head
o f the malleus (6) and the incus (7).
The horizontal portion o f the facial
nerve canal is passing underneath
the lateral semicircular canal.
E) Epitympanon (20) at the level o f the lateral semicircular canal (18) and the aditus
ad antrum (22).
F) Cross section o f the two limbs o f the superior semicircular canal (18) at the level o f
the tegmen tympani.
1. Facial nerve canal 2. Round window
3. Cochlea 4. Cochlear aqueduct
5. Hypotympanon 6. Malleus
7. Incus 8. Stapes
9. Pyramidal eminence 10. Mesotympanon
11. Jugular bulb 12. Sinus tympani
13. Posterior semicircular canal 14. Vestibular aqueduct
15. Oval window 16. Vestibule
17. Internal auditory canal 18. Lateral semicircular canal
19. Antrum 20. Epitympanon
21. Geniculate ganglion 22. Aditus
23. Superior semicircular canal 24. Subarcuate canal
The normal anatomy of the middle and inner ear is depicted in Fig. 1.
The vestibule is the central part o f the labyrinth and communicates
with the basal turn of the cochlea and is in contact with the middle ear
through the oval window. Posteriorly, the vestibule is in contact with the
three semicircular canals which are situated in perpendicular planes to
230
THE HEAD AND NECK
each other. The posterior semicircular canal runs parallel to the poste
rior surface of the pyramid. The superior semicircular canal is perpen
dicular to the long axis of the pyramid and its most superior portion cre
ates the arcuate eminence seen on the upper surface of the pyramid. The
lateral or horizontal semicircular canal indents the medial portion of the
middle ear cleft above the oval window niche. The bony coverings of the
cochlea have two and half turns and its central axis has an oblique an
terolateral orientation. The cochlear aqueduct originating from the basal
turn of the cochlea connects the perilymphatic space with the subarach
noid space in the posterior fossa. The endolymphatic duct courses
through the vestibular aqueduct into a sac which lies along the dura on
the posterior surface of the pyramid. The lamina cribrosa separates the
vestibule from the internal auditory canal. The facial nerve runs in the
anterior cranial portion of the internal auditory canal above the cochlear
nerve, while the two vestibular nerves occupy the posterior half sepa
rated by the crista falciformis along the posterior wall of the canal.
The facial nerve enters the otic capsule and traverses the middle ear
on its way to the stylomastoid foramen. The first part being the
labyrinthine portion runs anteriorly lateral to the vestibule and just above
the cochlea to the geniculate ganglion. Here the nerve swings back at the
first genu and the tympanic portion runs underneath the lateral semicir
cular canal having a thin bony covering above the oval window. Reaching
the posterior wall of the middle ear the nerve makes a ninety degree turn
downward at the posterior (second) genu and the mastoid portion of the
nerve runs down to the stylomastoid foramen before branching out in the
parotid gland. The ossicular chain in the middle ear cleft connects the
tympanic membrane with the oval window. The handle of the malleus is
secured up against the tympanic membrane and the head articulates pos
teriorly with the body of the incus. The long process of the incus con
nects with the stapes through the incudostapedial joint. Many small lig
aments suspend the ossicular chain along with the tensor tympani and
the stapedius muscles which attaches to the handle of the malleus and
the stapes respectively.
The middle ear forms together with the antrum and the mastoid cells
a complex aircell system. The mesotympanum is the part of the middle
ear that can be visualized through the tympanic membrane. Its medial
border is the promontory which is the lateral bony covering of the basal
turn of the cochlea. Hidden from direct inspection is the attic or epitym-
231
Figure 2.
Congenital inner ear malformation -
computed tomography
Coronal section through the middle
ear at the level o f the oval window
niche. Isolated malformation with a
dilated lateral semicircular canal (ar
row). The second portion o f the facial
nerve canal runs in a normal fashion
underneath the lateral semicircular
canal (crossed arrow).
panum in which the head of the malleus and the body of the incus can
be found. The roof of the epitympanum is the tegmen tympani which
separates the middle ear from the middle cranial fossa. The epitympa
num communicates with antrum and the mastoid aircells through the adi-
tus ad antrum. The hypotympanum is located below the lower limbic
margin of the tympanic membrane and the promontory. It connects with
the eustachian tube through the prototympanum.
Pathology
Congenital malformations
The inner ear is fully developed in the 23rd week of pregnancy. Inner
ear malformations are often bilateral when they occur. A blunt and di
lated horizontal semicircular canal is the most common malformation
(Fig. 2). If it is isolated it will often not be associated with any symp
toms. The cochlea which normally has two and a half turns can have ar
rested its development and will then have fewer turns. Depending on the
severity it will have a sac like appearance being the so called Mondini
malformation. The neurogenic hearing loss will depend on its severity.
Computed tomography can depict the inner ear in detail and it is possi
ble to assess the number of turns the cochlea as well as the semicircular
canals along with the other canals o f the inner ear.
The external and middle ear are derivatives of the branchial appara
tus. This often leads to unilateral but combined malformations. Atresia
of the external ear canal is often associated with malformed ossicles in
232
THE HEAD AND NECK
Figure 3.
Atresia o f the external ear canal Я
- computed tomography
Transverse section through the
epitympanun. Normally developed in- I
ner ear structures and mastoid air- шЁЬь
cells while malformed ossicles are \ш ЩШШйЩЙ
fused with the wall o f the middle ear
cleft (arrow). W j U Я
'В '
Ир *
i 4 A
a small middle earcleft (Fig. 3).

Dysostosis mandibulo-facialis (Treacher-Collins syndrome), which is
autosomal dominant inherited malformation, is the most common con
genital ear malformation. The malformation is characterized by a hy
poplastic mandible and maxilla leading to a low sitting outer ear and an
atretic canal with malformed ossicles in a malformed middle ear.
Computed tomography is the primary method for evaluating external
ear atresia in order to assess if the atretic plate is bony or cartilaginous
and if there is a normal middle ear cleft with normal ossicles.
Inflammatory lesions
Acute otitis m edia

Acute infections of the middle ear most commonly occur in children and
often in connection with an infection o f the upper respiratory tract when
bacteria can reach the middle ear through the eustachian tube. Imaging
studies are of little value in uncomplicated acute cases. If the suspicion
arises that the infection is progressing to a serious mastoiditis with threat
ening brain abscess computed tomography should be undertaken.
Chronic otitis m edia

Recurring acute middle ear infections or an inadequately treated acute
infection can lead to chronic otitis media. Adults having chronic changes
often had recurring ear infections as children.Computed tomography
shows poorly developed opacified mastoid aircells having thick and scle
rotic walls. The middle ear cleft is also often atelectatic and opacified.
233
Figure 4.
Chronic otitis - computed tomogra-
phy
epitympanun. The mastoid aircells
are opacified having thickened scle
rotic septae. A suspicious
cholesteatoma is seen in the aditus
with erosion o f the short process o f
the incus (arrow).
Figure 5.
Cholesteatoma - computed tomogra-
phy
Coronal section through the anterior
portion o f the middle ear cleft. A
small cholesteatoma interposed be
tween the head o f the malleus (white
arrow) and the eroded scutum (black
arrow).
Part of the ossicular chain can also be deminerlized or missing. The in
ner ear structures including the bony coverings of the lateral semicircu
lar canal are intact (Fig. 4).
Cholesteatoma
Keratin producing squamous epithelium that becomes enclosed in a cav
ity like the middle ear cleft will produce a cholestetoma. Primary
cholestetoma arise from abberant epithelial rests, most commonly oc-
curing in the epitympanun or the petrous apex. An acquired, or secondary,
cholesteatoma arises in a retraction pocket of the tympanic membrane
extending up into the attic and epitympanun or through a marginal per
foration. Cholesteatoma expands in all directions like a ball of tissue. An
acquired cholesteatoma can be seen on computed tomography as a
rounded soft tissue collection in the epitympanun in between the lateral
wall and the ossicles. The scutum being the upper margin of the tym-
234
THE HEAD AND NECK
Figure 6.
Labyrinth fistula - computed tomogra-
phy
Coronal section through middle ear at
the level o f the oval window (black ar
row). A large cholesteatoma fills in the
middle ear and has eroded the bone
covering the lateral semicircular canal
(white arrow). The ossicles have been
eroded.
panic ring will become eroded and blunted as will the medially displaced
malleus and incus (Fig. 5). Continued expansion can lead to a labyrinth
fistula with vertigo due to erosion of the bony covering of the lateral
semicircular canal (Fig. 6). Acquired cholesteatoma is often found to
gether with other chronic ear changes and diagnosis can therefore be dif
ficult at times even by computed tomography (Fig. 4). A cholesteatoma
should always be suspected if signs of expansion and erosion are found
in patients with chronic middle ear changes.
Fractures
The ear is the most commonly affected sensory organ in severe head
trauma. The fracture extension will depend on the type and direction of
the trauma force as well of the development and pneumatisation of the
temporal bone. The fractures can be classified according to their orien
tation along the long axis of the pyramid in longitudinal and transverse
fractures. Longitudinal fractures are the most common and can be seen
with blunt trauma to the forehead. These fractures run along the long axis
of the pyramid through the middle ear out into the roof of the external
auditory canal often leading to hematotympanun. Transverse fractures
are perpendicular to the the long axis can occur in trauma to the back of
the head, as well as, the forehead. These fractures often start at the rim
of the foramen magnum crossing the internal auditory canal or the
labyrinth. Damage to the seventh and eight cranial nerves can therefore
occur while the middle ear may not be affected.
Computed tomography makes it possible to immediately detect these
fractures if thin section high resolution tomograms are added to the reg-
235
Figure 7.
Facial schwannoma
Transverse section through the upper
portion o f the epitympanun. The
labyrinthine portion o f the fa cia l nerve
canal is expanded (black arrow) and an
expansile lesion is present at the level o f
the geniculate ganglion (open arrow).
ular head exam in the emergent phase. If a longitudinal fracture is found

the patency o f the ossicular chain should be evaluated along with any
potential communications between the subarachnoid space and the mid
dle ear that can lead to a cerebrospinal fluid leak. In transverse fractures
it is the relationship of the labyrinthine portion of the facial nerve to the
fracture that is important.
Tumors
Facial nerve schwannoma can occur anywhere along the nerve from the
posterior fossa down into the parotid gland. The symptoms depends on
the location of the tumor and paralysis can be a late symptom. The
schwannoma grows in a spindle fashion along the nerve enlarging the
facial nerve canal if situated within the temporal bone. Computed to
mography will therefore display an expanded facial nerve canal (Fig. 7).
Magnetic resonance imaging using Gadolinium enhancement will dis
play the schwannoma as a high signal lesion along the enlarged portion
of the nerve. Facial schwannomas within the internal auditory canal or
the cerebellopontine angle cannot be differentiated from those originat
ing from the acoustic nerve.
Paraganglioma or so called glomus tumors can occur anywhere where
paraganglionic tissue is present including the temporal bone. These most
often benign, but locally expansile tumors are named after their origin.
Glomus jugulare tumors are found in adjacent to the jugular bulb, glo
mus tympanicum over the promontory in the middle ear (Fig. 8 a) and
236
THE HEAD AND NECK
Figure 8. Glomus tympanicum - computertomography

a) Coronal section through the middle ear at the level o f the oval window. A soft tissue
mass fills in the middle ear at the level o f the promontory (arrow).
b) Selective external carotid angiogram shows a contrast blush corresponding to the
soft tissue mass in the middle ear (arrow).
glomus vagale along the auricular branch of the vagus nerve. The origin
of larger tumors can be difficult to assess. Tumors growing in the mid
dle ear can be seen as a bluish mass behind the ear drum and will cause
tinnitus as well as conductive hearing loss. High resolution computed to
mography of the temporal bone and contrast enhanced computed to
mography of the posterior fossa, alternatively magnetic resonance imag
ing with Gadolinium enhancement can demonstrate the tumors.
Paraganliomas are highly vascularized and carotid angiography can help
in making the diagnosis (Fig. 8). The vascular supply is often from the
ascending pharyngeal and occipital arteries, both being branches of the
external carotid artery.
Malignant tumors affecting the external ear canal and the middle ear
are relatively rare. Squamous cell carcinoma is the most common ma
lignancy in this area and often hide in changes of chronic otitis which
can delay the discovery. Like squamous cell carcinoma in other areas of
the facial skeleton these tumors will also cause destruction of the bor
dering skeleton early in their course. The tumors may grow down into
the temporomandibular joint and the parotid bed leading to facial paral
ysis. Malignant (necrotising) external otitis, which is an infectious
process often caused by psuedomonas aueriginosa and seen in elderly
237
diabetics, can sometimes be difficult to differentiate from a true malig

nancy. Radionuclide studies, the pattern of disease as seen on CT and the
clinical setting usually make the differential diagnosis straight forward.
THE NOSE, PARANASAL SINUSES AND THE

FACIAL SKELETON
Technique
Both conventional and cross sectional imaging is an important comple
ment to the clinical examination of the the nose, paranasal sinuses and
the facial skeleton in malformations, as well as, conditions relating to,
trauma, infections or tumors. Conventional plain radiographs of the
paranasal sinuses can be used to verify or rule out involvement o f the si
nuses in both allergic and infectious conditions. Large destructive lesions
associated with an underlying malignancy can also be detected. Plain
films are also indicated in the primary evaluation of facial trauma.
The complex anatomy of the facial skeleton nessecitates the use of up
to four projections to completely depict the paranasal sinuses. The four
views are the frontal or Caldwell view, the semiaxial or Waters view,
and the lateral and the axial view (Fig. 9). The examination should be
done with the patient sitting up in order to be able to demonstrate air-
fluid levels in the paranasal sinuses.
Tomography using panorama technique, so called orthopantomogram
or Panorex views, can be used for an overview of the jaw and the teeth.
Temporomandibular joints, the maxilla and the pterygoid plates can also
be studied by this technique.For close up study of the teeth and their roots
regular dental radiographs are needed.
Computed tomography, and more recently magnetic resonance imag
ing, have become invaluable tools for the assessment of malignancies.
Both methods can also be used to assess both traumatic and infectious
conditions in this area. MRI is the primary study for internal derange
ments of the temporomandibular joints.
Anatomy
The ethmoid aircells are present at birth. The maxillary sinuses develop
thereafter from small outbuddings in the nose underneath the middle
turbinate. The frontal sinuses start to develop at approximate two years
of age and the sphenoid sinuses at 3-4 years. The paranasal sinuses are
238
THE HEAD AND NECK
Figure 9.
Normal sinus series
a) Frontal projection (Caldwell view).
Frontal sinuses and the ethmoid air-
cells are visualized while the petrous
bones hides the maxillary antra.
b) Semi-axial projection (Water's view).
Both maxillary antra are well depicted
and the orbital floor with the infraor
bital canal (black arrow) is separated
from the orbital rim (open arrow). The
sphenoid compartments can be seen
through the open mouth (white arrow).
c) Lateral projection. A well developed
sphenoid sinus can be seen extending
back under the pituitary fossa. The
posterior walls o f the frontal and the
maxillary sinuses can also be outlined
(arrows).
d) Axial projection. The posterio-lateral
walls o f the maxillary antra form a
smooth s-shaped curve (black arrow)
while the lateral walls o f the orbits
form a straight line (open arrow). The
depth and posterior wall o f frontal si
nuses can also be visualized (asterisk).
not fully developed until the early teens.

The lateral walls of the ethmoid air cells are formed by the lamina pa-
pyracea and medially by the base of the upper and middle turbinates and
the lateral wall of the nose. The ethmoids drain through 2-3 openings
underneath the middle turbinate and thereby dividing the aircells into the
239
anterior, middle and posterior compartments; the posterior cells drain

into the sphenoethmoidal recess.
The openings of the maxillary antra or sinuses can also be found un
derneath the middle turbinates. Fully developed the antra will extend out
towards the zygomatic process of the maxilla, down into the alveolar
ridge, and superiorly up against the ethmoids and the orbital floor with
the inferior orbital nerve canal.
The frontal sinuses can form multiple lobulated recesses in the frontal
bone. Each frontal sinuses therefor has a unique shape which can be used
for identification purposes. These sinuses empty into the nose through
the frontonasal duct anteriorly in the nose close to the anterior ethmoids.
Both the frontal sinuses and the anterior ethmoids can extend into the or
bital roofs.
The sphenoid sinuses originate above and behind the middle turbinate
and fully developed can reach back to the clivus. Sometimes large lat
eral recesses will develop in underneath the foramen rotundum.
Pathology
Choanal atresia
Congenital malformations of the nasal cavity will lead to various forms
of atresia of the posterior choanal openings and can be both uni- or bi
lateral. Bilateral atresia will lead to life threatening breathing problems
particularly when feeding. Unilateral atresia can sometimes be missed
during childhood and be discovered later due to complaints of chronic,
one-sided nasal congestion. The diagnosis can be made in the neonatal
period by passing a feeding tube into the nose. Computed tomography
using 2-3 mm slices can be used to confirm the diagnosis particularly if
surgical intervention is contemplated. The exam is done preferably after
suctioning the obstructed side clean. Computed tomography can display
the thickness and shape of the nasal septum and the vomer and assess
wether the atresia is bony or membranous (Fig. 10).
Acute sinusitis
The normal mucosal membrane cannot be separated from the underly
ing periosteum and bone on the plain radiograph. The mucosa will be
come visible first when it has become thickened by inflammation and
can then be seen outlining the bony margins of the paranasal sinuses. The
240
THE HEAD AND NECK
Figure 10.
Choanal atresia
Transverse section through the nasal
cavities with bone window settings. A
membrane is seen blocking the poste
rior choanal opening on the right side
(arrow).
Figure 11.
Acute sinusitis
Water's view demonstrating mucope-
riosteal thickening in both maxillary
antra (white arrow) and on the left
side an air-fluid level can also be seen
(open arrow).
Figure 12.
Ethmoiditis with preseptal cellulitis
and early subperiosteal orbital ab
scess - computed tomography
Transverse section through the eth
moid aircells. The anterior and mid
dle ethmoids are opacified and begin
ning subperiosteal collection is also
seen (arrow). Note also the swollen
eylid (preseptal soft tissues).
241
Figure 13.
Mucous retention cysts
Water's view shows bilateral
smoothly outlined retetion cysts in
otherwise normally aerated maxil
lary sinuses (arrows).
inflamed mucosa will lead to impairment of the drainage causing stag

nation of mucous and fluid in the sinuses. Airfluid levels can therefore
be seen in the maxillary antra and sometimes also in the frontal, as well
as, the sphenoid sinuses (Fig. 11). Mucosal thickening and fluid within
the small ethmoid aircells will be seen as clouding of these sinuses on
plain radiographs. Infectious processes in the paranasal sinuses can
spread to the orbits or intracranially (Fig 12). Recurring unilateral max
illary sinusitis should lead to further assessment of the neighboring teeth.
In allergic sinusitis all paranasal sinuses tends to be involved of vary
ing degree, while airfluid levels are less common. There can also be co
existing nasal polyposis.
Mucous retention cysts

The drainage of a solitary mucous gland can become obstructed leading
to the formation of a mucous retention cyst. These cyst are often dis
covered by accident since they usually do not cause any symptoms. On
the plain radiograph they can be seen as a smoothly outlined soft tissue
density without any surrounding mucosal thickening (Fig 13).
Mucoceles
When a sinus becomes permanently blocked, for example due to a pre
vious fracture, chronic infection or nasal polyposis it will lead to muco
cele formation. An isolated mucocele occurs most commonly in the
frontal followed by the ethmoid and sphenoid sinuses. They form less
242
THE HEAD AND NECK
Figure 14.
Mucocele - computed tomography
frontal sinuses. The right compart
ment is opacified and expanded.
Erosion o f the posterior wall is also
noted (arrows).
often in the maxillary antra. The collection of normal desquamated ep

ithelium in the blocked sinus will make the walls of the sinus become
thinned as the sinus is taking on a more rounded expanded contour. With
time a mucocele can erode the bony wall and empty into the orbit or in-
tracranially (Fig. 14). In chronically allergic patient mucoceles occur
commonly in the maxillo-ethmoidal complex because of nasal polyps
obstructing the middle meatus.
Nasal polyps
Benign nasal polyps can be seen in allergic nasal conditions, but can also
be of infectious origin. Nasal polyposis often involves both nasal cavi
ties in a symmetric fashion leading to expansion of the nose and in turn
leading to nasal obstruction and chronic sinusitis.
Inverting papilloma traces its name to the histologic appearance with
squamous epithelium inverted in the polyps. This process is often uni
lateral originating from the lateral margin o f the nasal cavity. As the pa
pilloma grows it will lead to expansion of the involved nasal cavity and
unilateral sinus obstruction. Inverting papilloma have a potential to be
come malignant and then behave in the same destructive way as any squa
mous cell carcinoma (Fig. 15); the incidence of associated malignancy
is estimated at 10-15% of cases.
Choanal polyps are solitary nasal polyps having more of the charac
teristics of a mucous retention cyst than a nasal polyp. They form near
the ostium of the maxillary antrum and therefore hang out into the pos
terior choanal area, as well as, dumbbelling into the maxillary antrum.
Similar sphenochoanal polyps may extend out of the sphenoid sinus os-
teium.
243
Figure 15. Inverting papilloma

Transverse section through the nasal
cavity. A spindle-shaped tumor fills in
the nasal cavity. The tumor extends into
the pterygopalatine fossa (arrow) and
the posterior and medial wall o f the
maxillary sinus is destroyed being sus
picious fo r a malignant component
within the polypoid tumor.
Figure 16.
Squamous cell carcinoma
Trarnsverse section through the sphe
noid sinus. A tumor fills in the sinus
with spread into the middle cranial
fossa (black arrows) and the inferior
orbital fissure (open arrow).
Malignant tumors
Squamous cell carcinoma, the most common cancer form in the paranasal
sinuses, destroys the affected bony margins early in the disease process.
In other malignancies like lymphoma and adenocarcinoma the tumor will
first fill and expand the involved sinus and bone destruction may not be
present. Localised bone destruction, being an important sign of a possi
ble underlying malignancy in an opacified sinus, is difficult to detect on
plain radiographs and computed tomography is needed to confirm such
findings and to outline the tumor better (Fig. 16).
Fractures
The facial skeleton is built around the maxilla. Depending on the area of
impact and the direction of the force, predictable fractures will occur in
the facial skeleton.
Nasal fractures often being detected by clinical examination can be
confirmed by plain radiographs of the nose and computed tomography
is seldom needed.
244
THE HEAD AND NECK
Figure 17.
Tri-pod fracture
a) Water’s view. A fracture system is
seen extending through the inferior
orbital rim and flo o r continuing
down through the maxilla (white
arrows). The frontozygomatic su
ture is also separated (open ar
row).
b) Axial view. Fracture with depres
sion o f the zygomatic arch on the
same side (arrow).
The tripod fracture is the most common type of fracture in the rest of
the facial skeleton. This fracture is unilateral and separates the lateral part
of the maxilla. The fracture runs through the anterior wall of the maxil
lary antrum and the orbital rim at the level of the infraorbital foramen ex
tending along the orbital floor and the lateral wall of the sinus. The frac
ture also separates the maxilla from the frontal bone at the frontozygo
matic suture, as well as, fracturing the zygomatic arch. Plain radiographs
using modified sinus views, including an axial view with exposure fac
tors set to show the zygomatic arches, are often sufficient for diagnoses
(Fig. 17). If open reduction and fixation of the orbital rim and floor is con
templated computed tomography in the coronal plane will better show the
malalignment and possible loose fragments of the orbital floor.
Blow-out fractures of the orbit are caused by blunt direct trauma to
one orbit. The orbital rim will remain undamaged while the force of the
trauma will lead to a fracture of the more fragile orbital floor. The frac
ture fragment will become depressed leading to enophthalmus and dou
ble vision. Part of the orbital content including the inferior rectus mus
cle can also become trapped. Blow-out fractures of the lamina papyracea
can also occur particularly if the maxillary antrum is hypoplastic. This
type is however of less clinical concern.
245
Facial fractures due to severe midface trauma are classified according

to the system of Le Fort. The Le Fort I fracture separates the alveolar
process of the maxilla from the rest of the face. The Le fort II fracture
extends from the nasal bridge down trough the maxilla separating a cen
tral pyramid like fragment from the face. The most complex fracture is
the one of the Le Fort III type separating the whole facial skeleton from
the skullbase. This fracture extends from the nasal bridge through both
orbits and the frontozygomatic sutures and down through the base of the
pterygoid plates also fracturing both zygomatic arches. Complex frac
tures of the midface can lead to leakage o f cerebrospinal fluid, pneumo-
cephalus and possible meningitis.
Fractures o f the mandible are often bilateral because o f the closed ring
the mandible forms with the skull base. A fracture through the angle or
foramen mentale area of the mandible is combined with a fracture
through the neck on the contralateral side. Neighboring teeth roots can
also become fractured. Orthopantomography combined with plain radi
ographs of the mandible including axial views of the condyles is usually
sufficient to diagnose these fractures. In more subtle fractures close up
dental radiographs may be needed.
NASOPHARYNX
Technique
The nasopharynx, the nasal cavities and the paranasal sinuses are in close
contact with the skullbase, the parapharyngeal space and the infratempo
ral fossa. All these areas should therefore be assessed when examining
nasopharyngeal lesions by cross-sectional imaging. Superficial lesions of
the nasopharyngeal mucosa are best evaluated by direct inspection while
computed tomography or magnetic resonance imaging is needed to de
pict deep tumor extension and possible skullbase involvement.
Anatomy
The nasopharynx communicate forward with the posterior choanal open
ings of the nasal cavities and downward with the oropharynx. The roof
and posterior margins of the nasopharynx is formed by the sphenoid bone
and the clivus and the insertion of the prevertebral muscles into the skull
base. The lateral margins are made up by the pharyngeal constrictors and
the torus tubarius in the center of which the opening of the eustachian
246
THE HEAD AND NECK
Figure 18. Normal nasopharyngeal

anatomy - computed tomography
Transverse section through the na
sopharynx at the level o f the mandibu
lar condyle (k). The lateral pterygoid
muscle (m) runs from the lateral ptery
goid plate (black arrow) to the insertion
along the medial aspects o f the
mandibular neck. Air is seen in the eu-
stachian tube close to the opening in
torus tubarius (open arrow). Thefossa
o f Rosenmiiller is partly collapsed
(arrowhead). (a=intemal carotid
artery; v=intemal jugular vein;
s=styloid process)
tube can be found. The nasopharyngeal mucosa is rich in lymphoid tis

sue. The nasopharynx is surrounded and formed by the strong pharyn-
gobasilar fascia. The fascia is only penetrated by the eustachian tubes
and the levator veli palatine muscles and is a tight barrier between the
superficial and deep structures of the nasopharynx (Fig. 18). Behind the
torus tubarius the fossa of Rosenmiiller is found being a deep recess be
yond which the internal carotid artery can be found.
Pathology
Benign lesions
Adenoid hyperplasia commonly found in childhood can remain up into
the late teens. The benign adenoidal pad has a characteristic appearance
on computed tomography and magnetic resonance imaging and it should
not be mistaken for a malignant tumor. The adenoidal pad has a typical
lobulated surface. On contrast enhanced computed tomography images
the pad is seen superficial to the pharyngobasilar fascia which is outlined
by the enhancing lamina propria. On magnetic resonance imaging the
high signal lymphoid tissue is seen superficial to the low signal fascia.
Congenital remnants high in the nasopharynx can give rise to a mid
line cyst, the so called Thomwald cyst. This cyst is is discovered in the
young adult and on cross sectional imaging it can be seen as a smooth
well demarcated midline cyst.
Juvenile angiofibroma occurs in teenage boys and is characterized by
uncontrollable nosebleeds. This benign but expansile and highly vascu
247
larized tumor originates from the lateral wall of the nasopharynx close
to the pterygopalatine fossa. The tumor will expand the fossa as it grows
both out into the nasopharynx and into the nasal cavity, as well as, out
into the infratemporal fossa. From the pterygopalatine fossa the tumor
can grow up through the infraorbital fissure into the orbit and continue
intracranially through the superior orbital fissure. On computed tomog
raphy the tumor shows intense homogenous contrast enhancement and
on magnetic resonance imaging the tumor will show characteristic flow
voids both findings compatible with a highly vascularized tumor. This
together with the location and the expansion of the pterygopalatine fossa
contributes to the diagnosis of a juvenile angiofibroma.
Malignant tumors
Squamous cell carcinoma accounts for more than 90% of all malignant
tumors of the nasopharynx. The tumor often originating laterally fills out
the fossa of Rosenmuller and will cause obstruction of the eustachian tube.
Serous otitis and a metastatic neck mass are the most common presenting
symptoms of a nasopharyngeal carcinoma. The nasopharynx should there
fore be included in the imaging study for the work-up of these symptoms.
Contrary to benign adenoid tissue, squamous cell carcinoma will pene
trate the pharyngobasilar fascia early in the course reaching the parapha
ryngeal space and the skull base. Metastatic lymph nodes are often found
in the posterior triangle posterior to the sternocleidomastoid muscle.
Lymphoma found in the nasopharynx is often of the non-Hodgkin type
and coexisting bilateral lymphadenopathy can therefore often be found
in the neck as well as below the diaphragm. The lymphoma can be of
considerable size and direct extension up into the skullbase is often along
the neurovascular bundles.
Rhabdomysosarcoma is the most common malignant nasopharyngeal
tumor in children. These tumors are often of considerable size when they
are detected and the exact origin can be difficult to discern.
Computed tomography with intravenous contrast is often sufficient to
diagnose and evaluate the extent of any nasopharyngeal tumor. Magnetic
resonance imaging is the primary tool, however, because it shows the
overall extent relative to the skull base, cavernous sinus and brain better
than CT in most cases. Coronal non-contrast CT is required in selected
cases to exclude subtle skull base invasion.
248
THE HEAD AND NECK
ORAL CAVITY AND THE OROPHARYNX
Technique
The oropharynx including the base of the tongue and the floor of the
mouth, is despite its relationship to the mouth difficult to evaluate clin
ically. Computed tomography has therefore become an important com
plement to the clinical examination when assessing solid lesions of this
region. Ultrasound can be used to confirm cystic lesions of the floor of
the mouth and the neighboring neck.
Anatomy
The hard and soft palate forms the upper boundary of the oropharynx
while the hypopharynx and the supraglottic airway forms the lower
boundary. The three pharyngeal constrictors forming the palatoglossal
arches makes up the lateral and posterior margins of the oropharynx. The
palatine tonsils are found between the palatoglossal and palatopharyn
geal arches (anterior and posterior tonsillar pillars).
The bulk o f the tongue is formed by paired intrinsic and extrinsic
tongue muscles. The interdigitating intrinsic muscles consist of longitu
dinal as well as oblique and transverse muscles. The three extrinsic
tongue muscles anchor the tongue to the surrounding structures and help
move the tongue. These three muscles are the genioglossus, the hyo-
glossus and the styloglossus muscles. The genioglossus muscles take
their origin from the midline genial tubercles on the inside of the
mandible. The hyoglossus muscles originates from the lateral margins
of the hyoid bone while the styloglossus muscles descend from the sty
loid processes and joins the hyoglossus muscles forming the lateral bor
ders of the base of the tongue (Fig. 19a).The circumvallate papillae is the
dividing landmark between the oral free portion and the base of the tongue.
The tongue base is rich in lymphoid tissue forming the lingual tonsil.
The floor of the mouth is also made up of three paired muscles. The
converging mylohyoid muscles forms the supporting floor meeting in a
midline raphe. These muscles take their origin along the broad mylohy
oid line on the inside of the mandible. The geniohyoid muscles run in the
midline on the oral side of the mylohyoid muscles. The anterior bellies
of the digastric muscles run parallel just off the midline superficial to the
mylohyoid muscles inserting on the inside of the mandible (Fig. 19b).
249
Figure 19.
Normal oropharyngeal anatomy
— computed tomography
a) Transverse section through the base
o f the tongue. The paired genioglos-
sus muscles can be seen on both
sides o f the fibrous lingual septum
(crossed arrow).
b) Coronal section through the floow o f
the mouth. The mylohyoid muscles
(mh) coming from the inside o f the
mandible (crossed arrow) converge
in the midline.
(m=mandible; mh=mylohyoiod mus

cle; hg=hyoglossus muscle; dg=an-
terior belly o f the digastric muscle;
sm=submandibular gland; a=inter
nal carotid artery; v=internal jugu
lar vein)
Pathology
Benign lesions
Congenital cysts can be found in the midline of the tongue base and the
floor of the mouth as well as further down in the neck. The thyroid gland
migrates down from the foramen caecum of the tongue. Along this route
ductal remnants can form a thyroglossal cyst. These are often discovered
after a upper respiratory infection in childhood. The cyst is always mid
line in location spreading the midline muscles apart. The cyst often has
contact with the body of the hyoid bone and computed tomography can
show this relationship. This is of importance since surgical removal
should include the cyst together with the body of the hyoid bone and the
ductal remnant up to the foramen caecum in order to avoid any recur
rence. Both epidermoid and dermoid cyst can occur in the midline.
250
THE HEAD AND NECK
Figure 20.
Epidermoid cyst
Transverse section through the floor
o f the mouth. A large cyst with mixed
content that is layering out can be
seen in the midline.
Figure 21.
Base o f tongue thyroid
Transverse section at the level o f the
hyoid bone (h). A round, well demar
cated hyperdense tumor compatible
with thyroid tissue is seen in the
floor o f the mouth in fro n t o f the hy
oid bone (arrows).
Epidermoids lined by squamous epithelium are filled by fluid, while der

moid cyst can can have a more fatty content (Fig. 20).
Residual thyroid tissue in the tongue base will give rise to a lingual
thyroid. In 70% of these patients this represent a failure of thyroid mi
gration and the lingual thyroid being the only thyroid tissue. Before at
tempting any removal of a lingual thyroid a thyroid scan should be done
to map all thyroid tissue. Like the thyroglossul duct cyst the lingual thy
roid can be found in the midline of the tongue base. Because of the nat
ural iodine content the glandular tissue can be visualized on computed
tomography without contrast enhancement (Fig 21).
251
Figure 22.
Carcinoma o f the base o f the tongue
Transverse section through the tongue
base. A large inhomogenously enhanc
ing tumor is seen on the left side deep
in the tongue crossing the midline
(black arrow). Bilateral lymph node
metastases can also be seen in front o f
the carotid sheaths (white arrows).
Malignant tumors
Squamous cell carcinoma accounts for more than 90% o f the malignan
cies of the oropharynx. Malignant lesions originating from the lips, buc
cal mucosa, alveolar ridge, floor o f the mouth and the oral free portion
of the tongue can usually be detected and assessed by direct inspection
and palpation. Plain radiographs or computed tomography can give ad
ditional information regarding any bone invasion. Carcinoma originat
ing in the base of the tongue or the tonsillar area are much more difficult
to detect and evaluate clinically. Therefore tumors originating out of
these two areas have neck metastases in a high percentage when they are
discovered. Computed tomography or magnetic resonance imaging can
detect tumors in the base of the tongue and the tonsil at an earlier stage
and give a better assessment of the size and extent of the primary tumor
as well as detect any coexisting metastatic lymphadenopathy (Fig. 22).
SALIVARY GLANDS
Technique
Conventional radiographs can be used to localize radiopaque salivary
stones. These are most common in the submandibular gland and duct.
Sialography can visualize the ductal system of the parotid or sub
mandibular glands and detect any obstruction by radiolucent stones or
tumor as well as demonstrate inflammatory changes. Isotope studies us
ing Technetium 99m pertechnetate are today used only for studying sali
vary gland function.
252
THE HEAD AND NECK
Computed tomography or magnetic resonance imaging can be used to

assess salivary gland tumors particularly those located in the deep por
tion of the parotid gland as well as assess their relationship to the skull-
base and the facial nerve. Ultrasound can be used to differentiate between
solid and cystic lesions which sometimes can be difficult by the other
imaging modalities.
Anatomy
The three large paired salivary glands are responsible for the major pro
duction of saliva. Accessory salivary tissue is found throughout the mu
cosal membranes of the mouth and the oropharynx and the rest of the up
per aerodigestive tract.
The parotid salivary glands are found inferior to the preauricular area
wrapping around the posterior aspect of the ramus of the mandible. The
gland rest posteriorly on the sternocleidomastoid and the posterior belly
of the digastric muscles. The facial nerve exits the stylomastoid foramen
and enters the gland where it branches. This leads to surgical implica
tions and the gland is therefore divided into a superficial and deep por
tion. The superficial portion is lateral to the mandible resting against the
masseter muscle. The deep portion extends behind the mandible in front
of the styloid process. This portion therefore reaches the parapharyngeal
space. Scattered lymph nodes can be found throughout the gland.
The submandibular gland is the size of a walnut wrapping around the
posterior margin of the mylohyoid muscle and sits between the mandible
and the hyoglossus muscle towards the sublingual space. The sub
mandibular duct runs towards the papilla surrounded by the sublingual
salivary glands.
Pathology
Sialolithiasis
Intermittent swelling of any of the major salivary glands, often related
to food intake, is seen in obstruction of the major duct by a calculus.
Calculi are most common in the ductal system of the submandibular
glands and are frequently calcified. Chronic recurring episodes of cal
culi and obstruction can lead to chronic changes with strictures.
Sialography is used to outline the ductal system and verify a obstruction
caused by a calculus.
253
Figure 23.
Sialoectasis
Sialogram o f the parotid gland; lateral
projection. In the glandular
parenchyma pools o f contrast can be
seen. The aceesory paroid gland is also
affected (arrow).
Obstruction of a sublingual gland can give rise to a retention cyst called

a ranula. A ranula can be seen as a blueish submucosal swelling in the
floor of the mouth. As a ranula grows and ruptures it can can dissect be
yond the sublingual space and into the submandibular space becoming
what is called a diving ranula.
Infections
Acute bacterial infections often only needs clinical assessment before
treatment. In recurring infections sialography should be performed to de
tect any underlying cause like stones or strictures or to demonstrate
chronic ductal changes with caliber variations. The sialogram should be
done after the infection has been brought under control.
Systemic diseases
Symmetrically enlarged parotid glands can be seen in sarcoid and after
heavy metal poisoning. Enlarged glands are also found in diabetics and
alcoholics. Lymphnode enlargement can occur in the parotid glands in
tuberculosis, lymphoma and in HIV positive patients. In the latter lym-
phoepithelial cysts can be found in the glands preceding any other symp
toms of AIDS. Ultrasound as well as computed tomography and mag
netic resonance imaging can be used to assess all forms o f diffuse sali
vary gland enlargement. In Sjogren’s syndrome the salivary gland tissue
is replaced by periductal lymphocyte infiltrates. The salivary gland
changes leading to mouth dryness are accompanied by a symptom com
plex consisting of keratoconjuntivitis sicca and arthritis. The sialogram
will demonstrate characteristic sialoectasis in the parotid glands (Fig. 23).
254
THE HEAD AND NECK
Figure 24.
Malignant tumor o f the parotid gland
-computed tomography
parotid glands. A well demarcated ex
pansion is seen in the deep portion o f
the parotid gland (black arrows). The
retromandibular blood vessels are
displaced laterally (white arrow).
Tumors
Salivary gland tumors are relatively rare. About 80% of the tumors oc
cur in the parotid glands. Among these parotid tumors another 80% are
benign while in the submandibular glands 40-50% of the tumors are be
nign. Solid masses in the salivary glands can be assessed by ultrasound,
computed tomography or magnetic resonance. Benign parotid tumors are
most often round and well demarcated being either cystic or solid. They
are commonly found in the superficial lobe.Ultrasound can be used to
assess superficial parotid tumors while computed tomography or mag
netic resonance imaging can be used to demonstrate involvement of the
deep lobe. A poorly delineated tumor in the deep lobe with accompany
ing facial nerve paralysis is highly suggestive of a malignant lesion (Fig.
24). Fine needle aspiration cytology possibly by ultrasound guidance can
be used to give the final diagnosis.
LARYNX
Technique
Computed tomography using short exposure times and 2-3 mm slices is
recommended to successfully demonstrate the details of the glottic and
supraglottic larynx. Magnetic resonance imaging has still certain limita
tions but has the possibility to depict the larynx in the coronal projection
which may better demonstrates tumor extension, relative to the laryn
geal ventricle.
255
Figure 25.
Normal anatomy o f the neck and larynx
— computed tomography
a) Transverse section through the up
per part o f the hypopharynx and the
pharyngo epiglottic fo ld (arrow).
b) Transverse section through the
larygeal inlet and the aryeaeppiglot-
tic fold (arrow). The preepiglottic
space (pe) filled by loose areolar
fatty tissue is seen in fro n t o f the
a
epiglottis.
c) Transverse section through the vocal
cords. The vocal cords (sb) extend
from the anterior commissure (open
arrow) back towards the aryethnoid
and cricoid cartilages (arrow).
d) Transverse section at the level o f the
thyroid gland. Intense contrast en
hancement is seen in the normal thy
roid gland (th) which wraps around
the trachea and extends back in be
tween the neck vessels and the
oesophagus (oe).
(a=common carotid artery;
oe=oesophagus; p e =preepiglottic
space; sb=vocal cords; sp=pyriform
sinus; st= sternocleidomastoid
muscle; v=internal jugular vein)
256
THE HEAD AND NECK
Anatomy
The ring-shaped cricoid cartilage is the foundation of the laryngeal skele
ton supporting the thyroid and the arytenoid cartilages. The paired lam
ina of the thyroid cartilage protect the laryngeal airway. The vocal cords
take their origin from the vocal processes of the arytenoids which artic
ulate with the cricoid lamina posteriorly. The vocal cords converge and
insert in the midline on the inside of the thyroid cartilage above the thy
roid notch. The racket shaped epiglottis, which folds back to protects the
airway during swallowing, is connected to the inside of the thyroid car
tilage just above the anterior commissure of the true vocal cords. The
preepiglottic space is filled in by fatty areolar tissue in between the thy
roid lamina and the epiglottis. Above the true vocal cords the laryngeal
ventricles are formed by the overlying folds of the false vocal cords. The
laryngeal skeleton is interconnected and connected to the surrounding
structures by several ligaments and muscles. The hypopharynx runs
down behind the larynx and the pyriform sinuses forms lateral gutters
medial to the posterior thyroid lamina (Fig. 25 a-c).
Pathology
Benign lesions
Laryngoceles are sac like out pouching originating from the saccule in
the roof of the laryngeal ventricle. Saccular cysts and laryngoceles can
be both congenital and acquired, the latter sometimes being found in
trumpet players. If the airfilled sac stays on the inside of the thyroid lam
ina it forms an internal laryngocele which will expand the false vocal
cord obscuring the glottis. If the laryngocele penetrates the thyrohyoid
membrane it becomes an external laryngocele which can be seen inter
mittently as a soft neck mass. Laryngoceles have a characteristic ap
pearance and since they are often airfilled they can easily be demon
strated by computed tomography.
Malignant tumors
Squamous cell carcinoma accounts for more than 95 % of all malignant
laryngeal tumors, most commonly originating out of the true vocal cords.
Hoarseness is therefore often a presenting symptom in laryngeal cancer.
Hypopharyngeal carcinoma occurring in the pyriform sinuses will be
cause of the close relationship to the larynx have similar symptoms from
257
Figure 26.
Ca o f the larynx - computed tomogra-
phy
Transverse section at the level o f the
vocal cords. An infiltrating tumor is
seen along the right vocal cord filling
in the posterior commissure and de
stroying parts o f the cricoid carilage
(arrow).
the upper airway along with complaints of dysphagia. Computed to

mography and magnetic resonance imaging can be used as an adjunct to
the clinical inspection since a better demonstration of the deep extension
into the paralaryngeal, the preepiglottic and subglottic spaces is possi
ble (Fig. 26). The irregular calcification of the laryngeal skeleton still
makes assessment for cartilage invasion difficult even by these methods.
Other soft tissue tumors can also originate from the supporting soft tis
sue structures of the larynx. Chondroma and chondrosarcoma can arise
from the laryngeal skeleton and then most commonly the cricoid cartilage.
NECK
Technique
Both computed tomography and magnetic resonance imaging can be
used to a great advantage to demonstrate all structures of the neck.
Intravenous contrast is needed to better demonstrate tumor extension and
to separate the neck vessels from lymph nodes on computed tomogra
phy. Magnetic resonance imaging can image the neck in any plane and
does not necessitate the use of intravenous contrast.
Anatomy
The soft tissues between the base of the skull and the mandible down to
the thoracic aperture along the cervical spine forms the neck. The neck
can be divide into three compartments, the anterior visceral compartment
containing the larynx and the hypopharynx in the upper half and the tra
chea, oesophagus, the thyroid and the parathyroid glands in the lower
half. The neurovascular bundles together with the sternocleidomastoid
muscles are found lateral to the visceral compartment. The cervical spine
258
THE HEAD AND NECK
Figure 27.
Second branchial cleft cyst
A large cystic expansion is seen in
front o f the sternocleidomastoid
muscle with an extension in towards
the hypopharynx.
along with the supporting muscles make up the posterior third compart
ment (Fig. 25 a-d).
Pathology
Branchial cyst are of congenital origin and originate out o f pharyngeal
pouches in connection to the branchial clefts. The most common is the
second branchial cleft cyst found in front o f the sternocleidomastoid mus
cle below the level of the hyoid bone (Fig.27). The cyst can be connected
to the skin or the pharynx through a fistulous tract. The cyst often become
symptomatic in adolescence after they have become infected. The first
branchial cleft can also give rise to a cyst in the preauricualr area.
Computed tomography and magnetic resonance imaging will easily
demonstrate these lesions in typical location having cystic characteristics.
A thyroglossal duct cyst can also be found in the midneck. The cyst is
then situated just off the midline on the outside of the one of the thyroid
lamina.
Cystic hygroma is the most common congenital lesion of the neck of
ten originating in the supraclavicular fossa and extending down into the
mediastinum as well as up into the neck. A hygroma consists of dilated
malformed lymphatic vessels and infiltrate diffusely between the mus
cle bundles of the neck also extending posterior to the sternocleidomas
toid muscle. Large tumors will also lead to compression and narrowing
of the upper airway.
259
Lymphadenopathy in the neck often reflects an underlying malig

nancy. Computed tomography and magnetic resonance imaging can ver
ify these enlarged lymph nodes and also demonstrate lymphadenopathy
in areas difficult to assess by clinical examination as well as demonstrate
the primary. Squamous cell carcinomas originating in the nasopharynx,
tonsil, base o f the tongue or the pyriform sinuses are the most common
reasons for lymphadenopathy which can be clinically of unknown ori
gin. Lymph nodes having a short axis diameter of more than 1 -1.5 cm
are to be considered enlarged (Fig 22). Metastatic lymph nodes often
have an enhancing rim around a more necrotic center on contrast en
hanced computed tomography. Metastases can also be seen as local de
fects in the periphery of homogeneously enhancing nodes. Tuberculosis
can also have similar appearing lymphadenopathy. Lymphoma in the
neck is often of the non-Hodgkin variety and more often present with
homogenous lymph nodes in large numbers and of varying sizes.
Parapharyngeal tumors
Parapharyngeal tumors are detected as a bulging asymmetry o f the lat
eral pharyngeal wall or as a mass behind angle of the mandible.
Computed tomography or magnetic resonance imaging can delineate the
parapharyngeal space and detect smaller tumors which are difficult to
assess clinically and often suggest the origin of most of these tumors
which is of importance for the surgical approach.
The lateral border of the parapharyngeal spaces made up of the
mandible, the parotid gland and further down of the sternocleidomastoid
muscle while the lateral pharyngeal wall makes up the medial border.
The styloid process divides the space into an anterior and a posterior
compartment. In the anterior compartment one finds tumors originating
out of the deep portion of the parotid gland or from an accessory sali
vary gland. The majority of these tumors are benign mixed tumors al
though malignant parotid tumors are also possible. Tumors in the poste
rior compartment along the neurovascular bundle will displace the sty
loid process and musculature arising from the styloid process anteriorly.
The two most common tumors along the neurovascular bundle are
schwannomas and paragangliomas. Schwannomas are most often asso
ciated with the vagal nerve extending up towards the jugular foramen
while paragangliomas originate out of the ganglion nodosum of the va
gus nerve (glomus vagale). Both these tumors enhance on computed to-
260
THE HEAD AND NECK
Figure 28. Glomus vagale - magnetic resonance imaging and angiography

a) Magnetic resonance Tl weighted spin echo image in the tranverse plane demon
strates a large parapharyngeal tumor bulging into the oropharynx (black arrow)
and dislocating the internal carotid artery anterior (open arrow). The tumor is well
separated from the surrounding structures.
b) Selective external carotid angiogram shows a prominent ascending pharyngeal
artery supplying the highly vascularized tumor (arrow).
mography and can be difficult differentiate. External carotid angiogra

phy can separate the highly vascular paranganglioma from the poorly
vascular schwannoma (Fig. 28 a-b). Magnetic resonance imaging can
often also separate these two tumor types by showing a characteristic
pattern of vascular flow phenomena in the paragangliomas.
THYROID AND PARATHYROID GLANDS
Technique
Nuclear medicine studies using iodine isotopes is used to study the size,
location and function of the thyroid gland, as well as, demonstrate in-
traglandular lesions. Ultrasound has higher diagnostic yield than com
puted tomography to demonstrate and characterize small adenomas in
both the thyroid and the parathyroid glands. Ultrasound can also differ
entiate between cyst and solid tumors seen as cold nodules on isotope
studies. Intrathoracic extension of thyroid tumors or goiter is better
261
demonstrated by computed tomography or magnetic resonance imaging.
Anatomy
Because of its high iodine content the normal thyroid gland can be seen
as hyperdense tissue easily separated from the surrounding structures
even without contrast enhancement. The triangle shaped lobes on both
sides of the trachea are connected anteriorly by the isthmus. The inter
nal jugular veins and the common carotid arteries are found adjacent to
the thyroid lobes (Fig 25 d). The four parathyroid glands can normally
not be visualized by cross sectional imaging. The glands are located in
association with each pole of the thyroid lobes in the angle between the
common carotid artery and the oesophagus.
Pathology
It is not possible to differentiate between benign thyroid adenomas and
malignant nodules with any imaging method. Ultrasound and nuclear
medicine studies are still the most useful to evaluate an enlarged thyroid
gland. In hyperparathyroidism ultrasound is the primary method to lo
calise a parathyroid expansion. If the ultrasound and radionuclide ex
amination of the neck is negative computed tomography or magnetic res
onance imaging can be used to assess for adenomas in the upper medi
astinum. In previously operated cases with persistent or recurring
hyperparathyroidism ultrasound, radionuclide and cross sectional imag
ing can be supplemented by selective venous sampling and digital sub
traction angiography. Two studies should be positive to confidently iden
tify recurrent adenoma or hyperplasia unless one positive study appears
absolutely definitive.
262
Chapter 11
Dental radiology
Lars Hollender and Karl-Ake Omnell
Dental radiology has evolved from being concerned only with the teeth
and their surrounding bone to include the entire oral and maxillofacial com
plex and associated structures of the head and neck. A profound knowl
edge of dentistry is essential for the oral and maxillofacial radiologist, since
the pathological processes found within the jaws are commonly related to
the dentition. In this chapter, examination and diagnosis of pathological
conditions within the teeth and jaw bones will be discussed.
MODALITIES
The most common imaging modalities in dentistry are panoramic and
intraoral radiography. Panoramic radiography (Figs. 1, 2) is frequently
used to supplement other radiographic examinations. It yields a view of
the dentition and surrounding bone, and of adjacent facial structures and
cranial base. Intraoral radiographs can either be periapical and bitewing
radiographs or occlusal radiographs. The latter are placed in the occlusal
plane. Occlusal radiographs are used for increased coverage and for lo
calization of objects, such as impacted teeth and foreign bodies (Fig. 14).
A complete intraoral survey of the permanent dentition consists of
14-16 periapical films and four bitewing films of the posterior teeth. A
bitewing radiograph displays the crowns of the maxillary, as well as the
mandibular teeth and the marginal alveolar bone. In most cases a
panoramic radiograph (Fig. 2) and two bitewing films are adequate for
examination of the primary dentition. Periapical radiographs are taken
as needed. Although several systems for dental digital radiography are
available, conventional radiography is still predominant.
Other classical projections commonly used in the diagnosis of patho
logical processes within the jaws are projections such as cephalometric,
Waters, Towne, Caldwell, and submentovertex. Tomography has to a
263
Figure 1. Panoramic radiograph o f an adult patient. Left maxillary third molar is

impacted (arrow). 1. Zygomatic arch. 2. Pterygomaxillary fissure. 3. Maxillary zygo
matic process. 4. Infraorbital margin. 5. Maxillary sinus. 6. Hard palate. 7. Soft
palate. 8. Ghost image o f opposite mandibular ramus. 9. Inferior concha. 10. Nasal
septum. 11. Tongue. 12. Styloid process. 13. Submandibular fossa.
Figure 2. Panoramic radiograph o f a 5-year-old child.

1. Cervical spine. 2. Adenoid hyperplasia. 3. Pharyngeal space. 4. Prevertebral soft tis
sues. 5. Maxillary sinus. 6. Mandibular foramen. 7. Mandibular canal. 8. Cranial base.
large extent been replaced by computed tomography (CT) and magnetic

resonance imaging (MRI). Both CT and MRI, as applied to the jaws,
have a limitation, however, since dental materials may cause disturbing
artifacts. It should be emphasized that tomography is still valuable in
some areas of oral and maxillofacial radiology by virtue of its compara
ble diagnostic yield, lower radiation doses, and significantly lower costs
264
DENTAL RADIOLOGY
Figure 3. Left mandibular mo

lars showing normal anatomy.
The root development o f the
third molar is incomplete. The
enamel capping the crowns is
more radiopaque than the
dentin due to its higher mineral
content. The pulp chambers, as
well as the root pulps are fully
discernible. The roots are sepa
rated from the lamina dura
(arrow) o f the tooth socket by
the periodontal ligament
(double arrows), which appears
as a radiolucent line.
than CT and MRI.

Isotope scans are employed to examine the jaw bones in a number of
disease processes. For instance, in metastatic disease and osteomyelitis,
they disclose affected areas earlier than plain radiography. Ultrasound is
being used increasingly to examine soft tissues adjacent to the jaws. It
is also applied to depict changes in the outer contour or the jaw bones.
In lesions within the jaws it is common to combine panoramic or other

extraoral radiographs with intraoral radiographs, to achieve the neces
sary three-dimensional information about extent, borders and relation
ships to other structures or lesions. The intraoral radiographs are more
likely to depict finer structures than extraoral radiographs, tomograms,
and CT or MR images. Sometimes the detailed information of an intra
oral radiograph is crucial for the differential diagnosis of a jaw lesion.
ANATOMY
Adults
The teeth consist of dentin, which is capped by enamel over the crown
and by cementum over the root. Due to the difference in the degree of
mineralization between the enamel and the dentin, the dentino-enamel
junction is discernible radiographically (Fig. 3). Since the cementum is
very thin and its mineral content is approximately the same as that of the
dentin, cementum and dentin are radiographically indistinguishable. The
center of the tooth is occupied by the pulp, which contains the nerves
265
Figure 4.
Incisive foramen is visible as a
rounded radiolucency (arrows) be
tween the apices o f the central in
cisors. The anterior nasal spine, and Figure 5.
part o f the nasal fossa, appear above The superior foramina o f the incisive
the teeth. Loss o f alveolar bone due canal are seen on both sides o f the
to periodontal disease. nasal septum.
and vessels that support the dental tissues. It has a wider coronal part,
the pulp chamber, and a more narrow root portion, the root pulp.
The wall o f the alveolar tooth socket forms a thin layer o f dense bone,
the lamina dura, that parallels the root surface but is separated from the
root by the periodontal ligament. The ligament is represented by a thin,
radiolucent line. Normally, the radiopaque lamina dura is continuous
around the root and with the crest of the alveolar ridge. General absence
of lamina dura may be a sign o f systemic bone loss such as occurs
in for example hyperparathyroidism, Cushing's syndrome, leukemia,
myeloma, osteomalacia caused by adult celiac disease (sprue), chronic
glomerular and tubular dysfunction, and scleroderma.
The maxilla
In the maxilla, the alveolar bone has a uniform trabecular appearance
with small marrow spaces exept for the tuberosity region. The incisive
foramen is located anteriorly in the midline of the palate. In radiographs
of the central incisors it appears between their apices (Fig. 4). It varies
in size, shape, and visibility. In radiographs of the lateral incisors, and
in some instances the cuspids, the image of the incisive foramen may be
superimposed on the images of the central insisors, mimicking a peri-
266
DENTAL RADIOLOGY
Figure 6. The inferior border o f

the maxillary sinus projects as a
downward, convex, radiopaque
line (arrow). The floor o f the
nasal fossa is represented by a
thin horizontal radiopaque line
(double arrows). The maxillary
zygomatic process, which is aer
ated, forms a radiopaque U
(triple arrows) from which the
zygomatic bone extends posteri
orly (open arrow). The radiolu-
cent band (double open arrows)
is caused by grooves in the lat
eral sinus wall containing the
posterior superior alveolar
nerves and vessels.
Figure 7. The maxillary sinus is

extensively pneumatized follow
ing early tooth extraction, the
complex pattern o f radiolucent
bands (arrows) illustrates the
branching o f the posterior supe
rior alveolar nerves and vessels.
The coronoid process is also
visible (1).
apical lesion. If the central incisors are radiographed with an excessive
vertical angulation of the x-ray beam, the superior foramina of the inci
sive canal can become visible on both sides of the nasal septum (Fig. 5).
The anatomy of the maxillary sinus is described elsewhere. Certain as
pects of the antral anatomy will be considered here as they pertain to in
traoral periapical radiographs. Before 4-5 years of age, the maxillary si
nus does not appear in these radiographs. In the adolescent and in the
adult, the sinus usually extends from the premolar area to the tuberosity.
The inferior border is defined by a thin, downward, mostly convex, ra
diopaque line (Fig. 6). The floor of the nasal fossa may appear as a hor
izontal, radiopaque line superior to the sinus border. Frequently, narrow,
curved radiolucent bands running a posteroanterior course are seen
within the image of the maxillary sinus. They are caused by grooves in
the lateral sinus wall containing the posterior superior alveolar nerves
and vessels that are supporting the maxillary teeth and their surrounding
tissues (Figs. 6, 7). Early removal o f the molars usually results in ex-
267
Figure 8. The mandibular canal (arrow) extends from the mandibular foram en (I) to
the mental foram en (2). The two radiopaque objects on the left side o f the maxilla are
caused by excessive root filling material fo rced through the root canals into the sinus.
pansion of the maxillary sinus in the alveolar process (Fig. 7).

The maxillary zygomatic process extends laterally from the surface of
the maxilla in the region of the first and second molars. In the periapical
radiograph it frequently gives rise to a U-shaped radiopacity (Fig. 6).
Posterior to the zygomatic process, the zygomatic bone appears as a ra
diopaque structure. The coronoid process of the mandible may show in
the posterior part of the periapical radiograph of the maxillary molars
(Fig. 7).
The mandible
In the mandible, the trabecular pattern varies much more than in the max
illa. Overall, there is a coarser trabecular network with much larger mar
row spaces. In some instances, particularly in the posterior regions, there
are areas where the trabecular pattern may be missing.
The mandibular canal, which contains the inferior alveolar nerve and
vessels, runs anteriorly from the mandibular foramen which lies on the
medial aspect of the mandibular ramus (Fig. 8). In most individuals, it
is radiographically visible as a radiolucent band defined by thin ra
diopaque lines running as far as, or slightly anterior to, the premolar re
gion. Here, the mental nerve and vessels emerge from the mandibular
canal through the bucally located mental foramen, which is discernible
268
DENTAL RADIOLOGY
Figure 9.
a) Periapically, at the second preomolar, a wei
defined radiolucency (arrow) mimics a gran
uloma.
b) Vertical change in projection relative to the
radiograph in a). The radiolucency (double
arrows), caused by the mental foramen, is
now located below the apex o f the second
premolar.
in about 50% of periapical radiographs. The image of the mental fora

men may be superimposed upon the apex of one of the premolars, mim
icking a periapical lesion (Fig. 9).
Frequently the borders of the mandibular canal are not discernible. The
distance between the canal and the apices of the posterior teeth varies.
At times the canal runs very close to the roots of the third molar. In or
der to prevent injury to nerves and vessels, this relationship should be
determined before extraction of the third molars is attempted. Expansile
benign lesions of the mandible frequently cause a displacement of the
mandibular canal. Local widening of the canal may be caused by neural
tissue tumours. Increased width over longer distances, combined with
lack of definition and widening of the mandibular foramen, occurs when
malignant tumors are spreading via the perineural lymphatic tissues.
The submandibular gland fossa is found on the lingual aspect of the
mandible in the molar region below the mylohyoid ridge (Fig. 1). The
fossa exhibits a considerable variation in length, height and depth.
Sometimes it appears as a well-defined radiolucency which can be mis
taken for an osteolytic lesion.
Children
The radiographic anatomy of the jaws in children differs markedly from
that in adults. The younger the children, the greater the difference. In
young children, bone trabeculae are obscured by the germs of the per-
269
Figure 10. Posterior part o f the left maxillary

alveolar process from a young child. The tooth
germs o f the permanent teeth obscure the bone Figure 11.
structure. The follicle surrounding the
crown o f the maxillary right
cuspid is wide, mimicking a
dentigerous cyst.
Figure 12.
The radiolucent area (arrow)
derives from the incompletely
formed apex and should not be
mistaken fo r a periapical lesion.
manent teeth and their follicles (Fig. 10), which limits the diagnosis of
bone disease. The rounded tooth follicle is defined by a cortical lining.
At an early stage of tooth formation, before mineralization of the crown
has begun, the uniformly radiolucent image of the tooth follicle may
mimic an osteolytic lesion. The follicles of the mandibular third molars
are most likely to cause such mistakes. When the crowns are mineral
ized, a radiolucent area remains between the cortical border of the folli
cle and the tooth enamel. The width of this area also varies under nor
mal circumstances. Around certain teeth, such as the maxillary cuspids
the follicle prior to eruption may have a considerable width, mimicking
a follicular cyst (Fig. 11). When tooth formation is nearly complete the
270
DENTAL RADIOLOGY
Figure 13.
A small invagination o f dentin (arrow) and enamel
(arrows) in the right maxillary lateral incisor. Due
to infection o f the pulp and the periapical bone, af
ter eruption o f the incisor, the root formation
ceased and a large radicular cyst developed.
apical tip of the root canal is shaped like an inverted V. The radiolucent
area between the mineralized portion of the forming apex and the ra
diopaque line caused by the lamina dura, should not be mistaken for a
pathological lesion (Fig. 12).
PATHOLOGY
Diseases occurring in other parts of the skeleton also appear in the jaws,
but the most common lesions are associated with the teeth or derived
from dental tissues. Different pathological entities may have similar ra
diographic features. On the other hand, the very same pathological en
tity can have a varied radiographic appearance. Many lesions cannot be
diagnosed solely through imaging.
Malformations
Malformations of the jaws and teeth may be confined to the j aws or may
occur as part of a syndrome causing morphological and functional im
pairment of the facial region, the entire skull, and other body organs.
Tooth anomalies can involve single teeth or the entire dentition. In the
latter case, the permanent dentition is more frequently involved than the
primary.
Dens invaginatus (Fig. 13) is the descriptive name of a common tooth
anomaly caused by an invagination o f the enamel organ. In its advanced
forms, it affects the size, shape, as well as the structure, of the perma
nent teeth. It may occur in any tooth, but is most commonly found in the
271
Figure 14. Supernumerary tooth in inverted

position.
Figure 15. Mandibular incisors in a patient with

dentinogenesis imperfecta. The pulps are obliter
ated, the roots are short, and the incisal enamel is
worn by attrition.
maxillary lateral incisors. Frequently, it is impossible to discover the in

vagination at a clinical examination. The only sign may be a palatal pit.
Mineralization defects in the invaginated hard tissues provide routes of
infection of the pulp and the periapical bone.
Increased numbers of teeth, hyperodontia, or supernumerary teeth
(Figs. 14, 16) are predominant in the anterior maxillary part o f the per
manent dentition. Supernumerary teeth are prevalent in certain syn
dromes, such as cleidocranial dysplasia (cleidocranial dysostosis),
Gardner's syndrome, and orofaciodigital syndrome (mandibulofacial
dysostosis, Treacher Collins' syndrome). A decreased number of teeth,
hypodontia, is unusual in the primary dentition, but is rather common in
the permanent dentition. Total absence of teeth, anodontia, is rare; it is
one of the expressions of ectodermal dysplasia.
Among structural changes are amelogenesis imperfecta (hereditary hy
poplasia of enamel) and dentinogenesis imperfecta (hereditary opales
cent dentin). Dentinogenesis imperfecta occurs either as a solitary phe
nomenon (Fig. 15), or in conjunction with osteogenesis imperfecta.
Hyperplasia of the maxillary tuberosities, hyperplasia of the coronoid
processes, and congenital hypoplasia of the mandible (micrognathia) are
among malformations that are confined to the jaws. The most common
272
Figure 16.
a) Young patient with
bilateral cleft lip
and palate (arrow).
A supernumerary
unerupted incisor is
located between the
right mandibular
first premolar and
the cuspid.
b) Intraoral radi
ographs o f the
clefts in the alveo
lar process.
Figure 17.
a) So called latent or
static cyst (arrow),
which is considered
to be a developmen
tal defect on the lin
gual aspect o f the
mandible.
b) Same defect two
years later. An in
crease in size is evi
dent.
malformations that extend beyond the jaws include congenital unilateral

hypo- and hyperplasia of the face, progressive facial hemiatrophy, clei
docranial dysplasia, craniofacial dysostosis (for example: Apert,
Crouzon and Pfeiffer syndromes), and orofaciodigital syndrome.
Facial clefts predominantly affect the maxilla. Cleft lip and palate are
by far the most common. They may be solitary or combined with mal
formations in multiple organs. The clefts can be either uni- or bilateral.
Palatal clefts may be incomplete or complete, in which case they run
through the soft and hard palates and the alveolar ridge anteriorly, usu
ally in the region of the lateral incisor (Fig. 16). The lateral incisor is fre
quently malformed or missing. Although there are racial differences in
the prevalence of cleft lip and palate, approximately one in 800 infants
is bom with either cleft lip or cleft palate.
The so called latent or static cyst, also referred to as idiopathic bone
cavity or Stafne cyst, is a malformation, which consists o f an excavation
on the lingual aspect of the mandible. It is typically located in the angu
lar region below the mandibular canal. Radiographically it resembles a
cystic lesion with varying size and border characteristics (Fig. 17). It usu
ally develops after the first to second decade but appearance after the age
of 30 has also been observed. When the lesions have been explored sur
gically, either an empty cavity or a cavity containing salivary gland tis
sue has been found.
Inflammatory changes in and around the teeth

The most prevalent oral diseases, caries and periodontal diseases, are
caused by infection, which gives rise to inflammatory changes in and
around the teeth.
Caries
Caries is the predominant cause o f pain in the jaws. In the premolar and
molar regions, carious lesions may be difficult to detect clinically. This
holds true in particular for proximal, some occlusal, and deeply situated
root caries. Radiographic examination is therefore o f importance.
Proximal and occlusal caries (Fig. 18) commonly show a narrow dem
ineralized entrance in the enamel. When the lesion reaches the dentino-
enamel junction, it spreads along the junction, undermining the enamel.
Root caries (Fig. 18) has a much wider entrance that is frequently con
cealed by the gingiva. In an adult population, the most common type of
274
DENTAL RADIOLOGY
Figure 18.
a) Bitewing radiograph o f the
posterior teeth with multiple
carious lesions (arrows). In
the enamel the lesions are nar
row, whereas in the dentin
they are spreading along the
dentino-enamel junction.
b) Large carious lesion in the
third molar underneath an al
most intact occlusal enamel.
c) Recurrent root caries under an
amalgam restoration.
caries is recurrent (secondary) caries at the cervical margins of proximal

restorations.
Pulpitis
Inflammation of the dental pulp is a common sequelae of caries. Pulpitis
seldom causes radiographic signs. It may, however, be associated with
periapical widening of the periodontal ligament.
275
Figure 19.
a) Periapically, at the first premolar, an ill-de
fined osteolytic lesion (arrows) caused by an
acute or a chronic abscess.
b) Left maxillary lateral incisor with a well-de-
fined osteolytic lesion periapically, typical o f a granuloma. The borders o f the
lesion are sclerotic.
Periapical osteitis
If untreated, pulpitis results in necrosis of the pulp tissue and an acute
periapical abscess. The abscess can either become chronic, or more com
monly, develop into a periapical granuloma, which is formed in response
to the infection. The only sign of an acute abscess may be a widening of
the periodontal ligament space. Usually, however, both an acute and a
chronic abscess are represented by a discontinuity of the lamina dura and
an ill-defined rounded osteolytic lesion (Fig. 19). Periapical granulomas
have well-defined borders, frequently surrounded by bone sclerosis (Fig.
19). If a periapical granuloma becomes reinfected, the borders break
down and it will take the shape of an abscess. The periodontal ligament
contains epithelial cell rests, which may proliferate and form a lining
around the granuloma, leading to radicular cyst formation.
Osteomyelitis
Odontogenic infection via a root canal, a periodontal pocket or an ex
traction wound is the most common local cause of osteomyelitis of the
jaws. Rarely, a fracture serves as in infection route. Haematogenous
spread of an infective agent from another part of the body also occurs.
A distinct type of osteomyelitis, osteoradionecrosis, occurs after thera
peutic irradiation of oral and neck malignancies.
276
DENTAL RADIOLOGY
Figure 20.
An ill-defined periapical and
interdental osteolytic lesion
in the mandibular anterior
region three weeks after on
set o f clinical symptoms o f
osteomyelitis.
Figure 21.
Chronic suppurative osteomyelitis
with three sequestra (arrows).
Osteolytic as well as sclerotic areas
are present.
Osteomyelitis is more common in the mandible than in the maxilla. In

the mandible, it occurs predominantly in the posterior parts, the ramus
included, whereas in the maxilla, it is more frequent in the anterior than
in the posterior parts. In the acute phase, osteolysis is not visible radi
ographically until one or two weeks after the onset of clinical symptoms
which are: pain, fever, local lymphadenopathy, increased white blood
cell count, and teeth sensitive to percussion. Numbness of the lower lip
is another common sign of mandibular osteomyelitis.
The initial radiographic changes are blurring and thinning of the tra
beculae and subsequent enlargement of the bone marrow spaces. Without
treatment, large volumes of the bone tissue can rapidly become involved,
causing loosening of the teeth (Fig. 20).
If acute osteomyelitis becomes chronic, it is frequently possible to dis
tinguish between chronic suppurative osteomyelitis (Fig. 21) and chronic
sclerosing osteomyelitis (Fig. 22), both of which have ill-defined bor
ders. In the suppurative form, radiolucent areas alternate with sclerotic,
giving the bone a "moth-eaten” appearance. This is further enhanced
when sequestra develop. In chronic sclerosing osteomyelitis, radiolucent
areas occur, but there is a predominance of radiopaque changes due to
the formation of sclerotic bone. The bone is often enlarged through pe
riosteal bone formation (Figs. 22,23). Overtime, the distribution of scle-
277
Figure 22.
Chronic sclerosing os
teomyelitis o f right mandible
with some osteolytic areas.
Ramus is enlarged.
b
Figure 23.
a) Right mandibular molars in a young patient. The alveolar bone is unevenly scle
rotic; chronic sclerosing osteomyelitis.
b) Occlusal view o f the same patient. Periosteal bone formation (arrow) on the buccal
side o f the mandible.
rotic and radiolucent areas varies, indicating disease activity.
Periodontal diseases
In periodontal disease, gingival pockets develop through a complex in
teraction between bacterial plaque formed on the tooth surfaces and the
host. Untreated, it may result in a considerable loss of the bone that sup
ports the teeth. The course of disease is episodic, i.e. bursts of disease
activity alternate with periods of stability. Consequently, in the same
dentition, at any given time,there may be disease active as well as dis
ease inactive sites. Radiographs (Figs. 4,24) do not yield information on
disease activity, but on the total bone loss over time. Idiopathic juvenile
periodontal disease affects children and young adults. It is characterized
by aggressive bone destruction around the permanent first molars and in
cisors, leaving the rest of the periodontal bone intact (Fig. 25).
278
DENTAL RADIOLOGY
Figure 24.
Generalized periodontal dis
ease. The marginal bone loss is
substantial and includes de
struction o f bone in the furca
tion areas o f multirooted teeth
(arrows).
Figure 25.
a) Extensive alveolar bone loss at the mandibular
first molars associated with juvenile periodontal
disease (arrows).
b) Maxillary incisors o f the same patient with alve
olar bone loss around the left central incisor, not
visible in the panoramic radiograph.
Cysts
The majority of cysts of the jaws are odontogenic. The most common
are radicular and dentigerous cysts, less common are keratocysts, lateral
periodontal, botryoid, and non-odontogenic developmental cysts.
Cysts present well-defined radiolucent lesions, usually with a thin cor
tical lining (Figs. 26, 28). If the cyst is infected, the lining may be dif
fuse or more sclerotic. Also, if the hydraulic pressure within the cyst de
creases bone formation may give rise to sclerotic walls. Large cysts ex
pand and thin the cortical borders of the jaws. Occasionally the cortex
may lose its integrity in discrete areas (Fig. 27). Large cysts may also
cause an image suggestive of multilocularity, although the lesion is
merely lobulated. In the lower jaw the mandibular canal may be displaced
by an expanding cyst (Fig. 26). In the upper jaw expansion may occur
into the maxillary sinus and the nasal cavity where the thin layer of bone
covering the cyst forms an upward convex bony border (Fig. 27). An ex
panding cyst may cause divergence of the roots of adjacent teeth. Root
resorption is sometimes seen, particularly in conjunction with infected
cysts. Radicular or periapical cysts are associated with non-vital teeth.
279
Figure 26.
Large radicular cyst in the
mandible displacing the
mandibular canal inferiorly
(arrows) and thinning the infe
rior cortex.
Figure 27. Transversal (a) and frontal (b) CT i ages o f a large dentigerous cyst ex
panding into the maxillary sinus. Note loss o f cortical lining (arrow).
Figure 28.
Dentigerous cyst o f a mandibular third molar.
A residual cyst is a radicular cyst, which remains or recurs after removal

of the tooth associated with the cyst (Fig. 29). It shows the same char
acteristics as the radicular cyst. Dentigerous cysts emanate from the cer
vical parts of impacted teeth and the crowns, but not the roots, are in
cluded in the cysts (Fig. 28). This is an important differential diagnostic
sign. The affected tooth may be displaced by the cyst. The most com
mon sites for dentigerous cysts are the lower third molar region and the
upper cuspid region.
280
DENTAL RADIOLOGY
Figure 29.
Residual cyst in the mandibular premolar region.
Keratocysts differ
from other odontogenic cysts in regard to their origin and way of growth
but radiographically they are in many instances indistinguishable. They
can appear unilocular or multilocular and their borders are not consis
tently evenly and thinly corticated (Fig. 30), areas of sclerosis can be
seen. Root resorption is more frequently caused by keratocysts than by
other odontogenic cysts. Keratocysts may be associated with impacted
teeth and also with congenitally missing teeth when they are called pri
mordial cysts. They show a high recurrence rate. In patients with multi
ple keratocysts the nevoid-basal cell carcinoma (Gorlin's) syndrome
should be suspected. The lateral periodontal cyst (Fig. 31) is named af
ter its location on the lateral aspect of a root. It has some histologic fea
tures that distinguishes it from other odontogenic cysts. Clinically and
radiographically it cannot be differentiated from a keratocyst with the
same location.
Non-odontogenic cysts occur at sites where parts of the facial skele
ton fuse during development. Most common among the developmental
cysts are the midline and incisive canal cysts (Fig. 32). They are similar
in appearance and may very well be the same pathological entity. A
rounded, well-defined unilocular radiolucenty in the midline that exceeds
approximately 6 mm in width suggests the presence of such a cyst. In in
traoral radiographs the superimposition of the anterior inferior borders
of the nasal cavity and the anterior nasal spine may give this cyst a heart-
shaped image.
281
Figure 30.
Large keratocyst in the right
posterior mandible:
a) Prior to surgery
b) Two years after surgery
c) Four years after surgery, a
recurrence is seen in the su
perior parts o f the ramus
(arrows).
Figure 31.
Lateral periodontal cyst with a
lobulated appearance between
and lingual to the mandibular
left cuspid and premolar.
The so called traumatic or simple bone cyst is an obscure lesion, which

mostly occurs in the lower jaw (Fig. 33). Anteriorly, it usually presents
as a rounded well-defined radiolucency; whereas posteriorly it expands
between the teeth causing a scalloped appearance. Toward the base of
the mandible it tends to have less distinct borders. In about 30% the cor-
282
DENTAL RADIOLOGY
Figure 32.
Developmental cyst o f the incisive canal. Note the
superimposition o f the anterior nasal spine region
(arrows).
Figure 33.
Traumatic bone cyst in the
mandibular premolar region.
Note the intact lamina dura and
the poor definition inferiorly.
tex is expanded. Surgical reports have frequently described the traumatic

bone cyst as an empty cavity lined with a thin "endosteum". These cysts
may heal spontaneously. On the other hand, recurrencies have been re
ported after surgery. A tentative diagnosis can usually be made when the
lamina dura of adjacent roots is intact.
Tumours and tumorous conditions
Benign
The majority of benign tumours of the jaws are odontogenic. Odontogenic
tumours can be divided into ectodermal, mesodermal, and mixed ecto-
and mesodermal. Ameloblastoma, adenomatoid odontogenic tumor, cal
cifying epithelial odontogenic tumour, compound and complex odon
toma, ameloblastic odontoma, ameloblastic fibroma, odontogenic myx
oma, and benign cementoblastoma are considered odontogenic tumours.
Ameloblastoma is a locally aggressive tumour often associated with a
clinically missing tooth. Approximately 80% of ameloblastomas occur
in the posterior part of the mandible. They are radiolucent and vary in
283
what could be a dentigerous cyst,

b) Occlusal cross-sectional radiograph demonstrates the expansion o f the lesion and
displacement o f the mandibular canal (arrows).
shape and size, although the multilocular appearance with a marked vari
ation in size between the loculi is typical (Fig. 34). The ameloblastoma
has a high recurrence rate if not removed with sufficient margins. The
so called unicystic ameloblastoma radiographically appears like a
dentigerous cyst since it apparently develops in the wall of a dentiger
ous cyst (Fig. 35). The adenomatoid odontogenic tumour is seen in the
anterior regions mimicking a dentigerous cyst, except that parts of the
root are encompassed in the lesion. When hard tissue appearing like "dri
ven snow” occurs within the radiolucency this tumour should be easily
diagnosed. The calcifying epithelial odontogenic tumour resembles the
ameloblastoma radiographically but occasionally scattered areas of scle
rotic foci indicate the possibility of this rare tumour.
The odontogenic tumours forming hard tissues are more easily diag
nosed. The compound odontoma consists of a varying number of tooth
like formations, whereas the complex odontoma contains the tissues of
284
DENTAL RADIOLOGY
Figure 36.
Compound odontoma in the mandibular incisor region with
multiple tooth-like structures.
Figure 37.
Complex odontoma in the left maxilla.
The first permanent molar is missing.
Figure 38.
Odontogenic myxoma in the
right maxilla with straight
bony trabeculation and
poorly defined borders.
a tooth in a much less organized arrangement producing a more homo

geneous radiopacity than the compound odontoma (Figs. 36, 37).
Compound odontomas are usually seen in the anterior regions. They are
occasionally associated with a clinically missing tooth, whereas com
plex odontomas are mostly found in the posterior regions, typically in
combination with unerupted or missing teeth. The odontogenic myxoma
has a varying radiographic appearance. It occurs most commonly in the
posterior regions. Typically, it is a less well delineated multilocular le
sion with more straight bony septa than, for instance, the ameloblastoma
(Fig. 38). Odontogenic myxomas are frequently associated with a miss
ing tooth.
Fibroosseous lesions and tumours include ossifying and cementifying
fibromas (Fig. 39), as well as periapical cemental dysplasia, florid os
seous dysplasia, and fibrous dysplasia. Differential diagnosis would in-
285
Figure 39.
Ossifying fibroma in the left
mandible with divergence o f
teeth and erosion o f the infe
rior cortex (arrows).
Figure 40.
Periapical cemental dysplasia at mandibular in
cisors (arrows). Some lesions contain hard tissue
(open arrows).
elude Paget's disease, osteopetrosis, sclerosing osteomyelitis, and scle

rosing osteogenic sarcoma. These lesions can be anything from radiolu
cent to completely radiopaque depending on the stage of development
at which the examination is undertaken. Intraoral radiographs are valu
able because they depict the finer structures of diagnostic importance,
such as a radiolucent capsule in cases of ossifying or cementifying fi
bromas. The distinction between periapical cemental dysplasia and florid
osseous dysplasia is not clear-cut (Fig. 40). Periapical cemental dyspla
sia occurs most commonly anteriorly in the mandible, often at multiple
teeth. It is more prevalent in women than in men, with a typical age range
at the time of diagnosis of between 30-^0 years. The lesions are initially
radiolucent, when they can be mistaken for inflammatory lesions. The
periodontal ligament is widened and there is a loss of lamina dura. The
borders are well defined and in places slightly sclerotic. At a later stage
a cementum like tissue is formed centrally in the lesions. In the final, ma
ture stage, the lesions are radiopaque and surrounded by thin radiolucent
286
DENTAL RADIOLOGY
Figure 41.
Monostotic fibrous dysplasia o f the
right maxilla with ground glass ap
pearance.
Figure 42.
Osteosclerosis posterior to mandibular second
molar following extraction o f a third molar.
Histologically, the diagnosis was "dense bone
formation ".
capsules. Periapical cemental dysplasia should not be confused with hy-

percementosis, which is a deposition of cementum on the root surface.
All three types of fibrous dysplasia can be found within the jaws. A
typical site for the most common variety, monostotic fibrous dysplasia,
is the posterior maxilla where it can encroach upon the maxillary sinus
and expand the alveolar process (Fig. 41). The typical ground glass or
stippled appearance of the bone is pathognomonic for fibrous dysplasia.
Histologically, the bone in fibrous dysplasia resembles the primary bone
laid down initially when fractures heal and after bone surgery. A num
ber of lesions, originally diagnosed as fibrous dysplasia, have been shown
to be chronic sclerosing osteomyelitis with reactive bone formation. In
fibroosseous lesions bone scintigrams will demonstrate increased activ
ity, which should be taken into account if screening for metastatic dis
ease is performed.
Osteomas and exostoses are masses on the outer surfaces o f bones.
Dense bony structures within the jaws without apparent relation to an in
flammatory process are usually referred to as bone islands, idiopathic os
teosclerosis, enostosis, focal sclerosis, fibrous dysplasia, or reactive bone
formation. These lesions have a varying size and radiographic appear
ance and sometimes they suggest a tumorous condition (Fig. 42). Once
established, they seem to change very little over time and are clinically
287
Figure 43.
Giant cell granuloma in the mandible
with faint bony septa within the lesion
(arrows).
Figure 44.
Soft tissue calcifications
(phleboliths) in a cavernous
hemangioma o f the neck
(arrows).
symptomless. Occasionally, osteosclerosis is associated with root re

sorption.
The giant cell granuloma is commonly found in the mandibular pos
terior regions. It is an expansile tumour, which can displace and resorb
adjacent teeth. It often presents with some delicate wispy bony septa
within a radiolucency (Fig. 43). The aneurysmal bone cyst is also ex
pansile and shows faint bony septa within the lesion. Periapical and oc
clusal cross-sectional radiographs are helpful in the differential diagnosis
of these lesions. Typically, these lesions are found in young individuals.
Giant cell tumours ("brown tumours") in conjunction with hyperparathy
roidism have the same radiographic appearance but they are found in
adults. Haemangiomas occur both in the jaw bones and in the adjacent soft
tissues. Soft tissue calcifications (phleboliths), typical of cavernous hae
mangiomas, are serendipitous findings in radiographs of the jaws (Fig.
44). The radiographic presentation of intraosseous haemangiomas varies
but the occurrence of straight trabeculae separated by larger spaces than
in normal bone is fairly typcial for these lesions (Fig. 45).
288
DENTAL RADIOLOGY
Figure 45.
Intraosseous hemangioma in the right maxillary
incisor region (arrows) with straight septa and
lack o f normal trabeculation.
Figure 46.
Invading carcinoma o f the floor
o f the mouth eroding the
mandible on the right side creat
ing a broad-based rounded
defect.
Figure 47.
Mucoepidermoid carcinoma in posterior mandible
with partly distinct borders and resorption o f the
roots o f the first and second molars (arrows). The
lesion resembles a cyst.
Malignant
Malignant tumours comprise those that invade the jaws from the periph
ery, those arising primarily within the jaws, and those which are metas
tases from distant primary tumours. The most prevalent malignant tumour
is the invading squamous cell carcinoma which presents as a broad-based
erosive change with variable definition of the borders (Fig. 46).
Squamous and mucoepidermoid carcinomas, osteogenic sarcomas,
lymphomas, and myelomas are among the primary malignancies of the
jaws. Squamous and mucoepidermoid carcinomas may appear radi
ographically similar to a cyst since these tumours may arise within a den
tal cyst (Fig. 47). Osteogenic sarcomas, sclerosing osteogenic sarcoma
289
Figure 48.
Sclerosing osteogenic sarcoma o f the anterior
maxilla.
Figure 49.
Osteogenic sarcoma o f the left maxilla. Root re
sorption o f first molar (arrow).
and chondrosarcomas are seen at older ages in the jaws than in the long
bones (Figs. 48, 49). Adjacent teeth may show a widening of the peri
odontal ligament, which is then suggestive of a sarcoma. Primary myeloma
(Fig. 50), multiple myeloma, and malignant lymphomas of the jaws are
rare. In multiple myeloma the jaws are involved in less than 50%.
Metastatic tumours produce a variable radiographic image (Figs. 51,52).
Typical is an irregular radiolucency with mostly ill-defined borders and
a moth-eaten appearance, occasionally with sclerotic areas. The most
common tumours that metastasize to the jaws are breast, lung, kidney,
prostate, and colon adenocarciomas and the most frequent site is the pos
terior mandible.
TEMPOROMANDIBULAR JOINT
Throughout life the TMJ is subject to remodeling, the most important
reason being its functional relationship with the dentition. Functional
stress may, however, be so severe that it leads to a pathological response,
resulting in a break down of the joint tissues analogous to that found
when other joints are overloaded. In addition to these alterations, rang
ing from physiological remodeling to degenerative osteoarthrosis, the
290
DENTAL RADIOLOGY
Figure 50.
Myeloma o f the posterior mandible
with punched out appearance.
Figure 51.
Metastatic breast carcinoma to
the mandible. Irregular ill-
defined osteolytic and sclerotic
areas. Several teeth endodonti-
cally treated since symptoms and
radiographic findings were
thought to be caused by periapi
cal inflammatory lesions.
Figure 52.
Metastatic Ewing sarcoma to the right mandible.
a) Panoramic radiographs obtained three months
apart
b) CT, and
c) MRI o f a patient with numbness o f the lower lip.
Pathological changes can only be seen in the MR
image as a low signal intensity o f the marrow
spaces on the right side (arrows).
Figure 53.
Oblique transcranial radiograph o f the TMJ. The contours
o f the lateral parts o f the joint are seen (arrows). The
medial parts o f the condyle are superimposed on the
condylar process (open arrow). The medial parts o f the
fossa and articular eminence are not depicted.
Figure 55.
Panoramic radiograph show
ing degenerative changes o f
the left condyle and eminence
(arrows).
Figure 56.
MR images o f the TMJ:
a) Tl-weighted sagittal section demonstrating
disc at partial opening.
b) Frontal section displaying capsule and disc
c) T2-weighted sagittal section showing high
signal intensity o f the synovial and
retrodiscal spaces.
292
DENTAL RADIOLOGY
TMJ can be affected by trauma and the same diseases as the other syn
ovial joints, such as septic arthritis and various tumours.
The TMJ has three main components enclosed by a capsule; the tem
poral with the glenoid fossa and the articular eminence, the mandibular
comprising the condyle, and, interposed between these components, the
disc. The glenoid fossa is a depression in the cranial base, posteriorly
separated from the external auditory meatus and the middle ear by the
tympanic plate and parts of the petrous portion of the temporal bone. The
anterior aspect of the glenoid fossa forms the posterior slope of the ar
ticular eminence. The mandibular condyle is shaped like a half cylinder,
convex in both lateromedial and anteroposterior directions. When the
teeth are held together in central occlusion, the condyle is situated in the
glenoid fossa. Projected on a horizontal plane its long axis forms an av
erage angle of 25° with the frontal plane. Seen in the sagittal plane the
normal disc is biconcave. It consists of collagen fibers condensed to a fi
brous cartilage. Posteriorly the disc attaches to the posterior ligament and
anteriorly to the capsule and the superior belly of the lateral pterygoid
muscle. The capsule attaches to the tympanic plate, neck of condyle, cra
nial base and the disc. The movements of the mandible upon opening,
closing, protrusion, and latero- and mediotrusion, are governed by a com
plex interaction between the masticatory muscles.
Earlier, radiographic examinations o f the TMJ were mainly focused
on determining the topographical relationship of its osseous components
and on its morphology and structure. Today, the soft tissue components,
disc and capsule, have come into focus as a result of an increasing aware
ness of the high prevalence of internal derangement of the joint.
Remodeling and degenerative changes of the osseous components of
the joint can be studied by means of plain films, tomography, CT, and
MRI. The oblique transcanial radiograph produces a limited and distorted
view (Fig. 53). The panoramic radiograph can demonstrate marked
changes in shape and structure, in particular in the condyle (Fig. 55).
Sagittal tomography is an even better technique for examination of struc
tural changes and condylar position (Fig. 54). For internal derangement,
such as anterior and lateromedial disc displacement, with and without
reduction, and deformation of the disc, single- and double contrast
arthrography and MRI, are the methods of choice. Many consider MRI
to provide the gold standard for examination of internal derangement.
The depiction of the disc and distinguishing it from the posterior attach-
293
Figure 57.
Fibrous scar follow ing surgery including extraction o f max
illary lateral incisor. Note sclerotic borders o f the through
and through defects (arrows).
Figure 58.
Recurrence o f a keratocyst:
a) Prior to initial removal.
b) Recurrence three years later.
One year after surgery, ap
parent healing had taken
place.
ment can, however, be difficult. Even MR images can in this respect be

ambiguous, i.e. if the posterior attachment has become fibrous and yields
a low signal intensity similar to that of the disc. One advantage o f arthrog
raphy is that fluoroscopic studies can be made during function, facilitat
ing the identification of the disc and posterior attachment and the differ
ential diagnosis between disc displacement with and without reduction.
MRI can provide similar information if a series of stationary positions
of the lower jaw during opening is combined into a motion sequence. In
294
DENTAL RADIOLOGY
the future, dynamic MRI will in all likelihood allow real time studies of
the joint function. MRI provides other important information about the
tissues in and around the TMJ (Fig. 56). Clinical evaluation in combi
nation with a less sophisticated examination procedure may, however,
produce similar diagnostic results.
POSTOPERATIVE CHANGES
After fractures, removal of teeth, cysts and tumors, healing takes place
with varying speed and results. Normally, new bone formation can be
seen in three to six months. However, in radiographs taken after extra-
tion of teeth the alveoli may appear "empty" several years after extrac
tion. This may be attributed to loss of functional stimulus whereby the
primary bone remains instead of being replaced with regularly organized
bone. Often, the surgical entrance to a lesion leaves a fibrous scar and a
defect in the cortical plate, especially if there is a through and through
defect. A fibrous scar is usually seen as a distinct radiolucency lined by
a broad sclerotic zone with radiolucent radiating striations (Fig. 57). It
can be mistaken for recurrences. However, initially a recurring cyst or
benign tumor usually presents as a small spherical radiolucency with thin
cortical borders which can appear as soon as one year after surgery. It
may, however, take several years until a recurrence becomes evident ra-
diographically. This is in particular true for some keratocysts (Fig. 58).
295
Chapter 12
The spine
Stig Holtas, Maximilian F. Reiser and Axel Stabler
ANATOMY AND DEVELOPMENT

The spine enables humans to stand erect and to walk. Three important
functions are provided by the spine: protection for the spinal canal,
weight bearing, and motion. The spinal canal protects the spinal cord
from damage and provides security for the control of the brain over the
body. The function of weight bearing is provided by the vertebral bod
ies, which therefore increase in size downwards. The intervertebral discs,
the facet joints and at the cervical spine, the uncovertebral joints supply
mobility to the spine. The mobility is greatest at the cervical spine thus
allowing fast movements of the head towards the direction of interest
and it is least at the thoracic spine where the ribs decrease mobility and
increase stability, thus protecting the lungs and the heart.
In newborns, only kyphosis of the thoracic spine is present. The cer
vical lordosis forms when the baby learns to hold the head while lumbal
lordosis results from straightening the legs. Slight scoliosis convex to the
right can be normal in the upper thoracic spine.
Development
The development of the spine includes evolution of the vertebral column
and of the spinal cord. Stages in formation of the cord are neurolation
for the main cranial portions and retrogressive differentiation for the cau
dal parts and myelination. The vertebral column develops by membrane
formation, chondrification and ossification.
In all vertebrates first a notochord develops when cells grow from the
Hensen's node between the ectoderm and endoderm in a cranial direc
tion. The notochord induces the formation of the neural plate in the ecto
derm. Folding of the neural plate creates a neural groove. Further dorsal
297
closure forms a neural tube which separates from the ectoderm and mi
grates into the center of the body. Early segmentation of the laterally lo
cated mesoderm develops the somites which appear as para-axial protu
berances. The caudal end of the neuroaxis develops by canalisation and
caudal regression, forming the filum terminale and ventriculus terminalis
which later becomes the conus medullaris.
At the end of the third fetal month, the cord extends throughout the
whole length of the vertebral canal. The relatively faster growth of the
vertebral spine causes the conus medullaris to ascend. It is located at the
L2-3 level at birth and by 3 months of age at the adult level o f L 1-2.
For the first segmentation, the mesoderm cells on both sides of the no
tochord orientate themselves as symmetrical aggregations called somites
separated by the intersegmental (metameric) arteries. On the 24th day
resegmentation of the membranous segments into cartilaginous verte
brae with chondrification centers on both sides of the notochord occurs.
The notochord is an elastic column preventing compression o f the soft
vertebral blastemes of the embryo, which runs through the developing
discs and vertebral bodies. At this time, segmentation o f the notochord
occurs.
The uniform tube of the notochord degenerates to a mucoid streak op
posite the vertebral bodies and expands at the disc levels to form the nu
cleus pulposus later. If the notochord fails to reexpand completely, small
defects in the middle to the dorsal third of the endplates may be visible
in the adult. These must be differentiated from Schmorl's nodes which
are true herniations of cartilage into the endplates.
Ossification starts at the end o f the second month of gestation in the
lower thoracic area. At the previous location of the notochord ventral
and dorsal to the mucoid streak, two ossification centers develop, rapidly
fusing to a single ossification center. Paired perichondral ossification
centers appear at this time in both of the neural arches. Therefore, x-rays
will visualize three ossification centers in each vertebra. The atlas and
the axis show a different type of ossification. It is generally accepted that
the lost body of the atlas forms the odontoid process. The atlas develops
two lateral ossification centers in the neural arches, while the axis has
two ossification centers, one at the base and one butterfly-shaped for the
odontoid process.
Between 8 to 15 years of age, ossification of the ring apophysis oc
curs. The ring apophysis is a cartilaginous ring in the periphery of the
298
THE SPINE
vertebral endplates and anchors the annulus fibrosus to the vertebrae.

Additional secondary ossification centers appear in the transverse
processes, the mamillary processes, the spinous processes and the tips
of the articular processes of the apophyseal joints.
Vertebrae
Humans have 24 vertebrae, 7 cervical like all other mammals, but fewer
vertebrae in the thoracic and lumbar spine reflecting the tendency to re
build the ribs, which becomes evident in the different lengths of the 12th
rib. Except for the atlas, which has lost its vertebral body, and the axis
with its cephalad directed dens (odontoid process), the vertebrae exhibit
a uniform appearance, consisting o f a vertebral body and a neural arch
formed by the pedicles and the laminae. The superior and inferior artic
ular processes create the apophyseal joints on each side.
In the cervical spine, the relatively small vertebral bodies have a
squared appearance when looked at from above. The uncinate processes,
which are developed from parts o f the neural arches, are exclusively
found in the cervical spine. They are orientated in a cephalad direction
and prevent the vertebral body from sliding sidewards, therefore allow
ing the apophyseal joints to be orientated in a coronal plane. The spin
ous processes are directed caudally with a bifurcated bump at the sec
ond to sixth cervical vertebrae. The spinous process of the seventh ver
tebra lacks bifurcation, is most prominent and can be easily palpated.
The transverse processes are formed in their anterior part by the rudi
mentary ribs creating the anterior tubercle. Each transverse process forms
a foramen containing the vertebral artery. The thoracic vertebral bodies
articulate at the level of the end-plates and at the transverse processes
with the ribs. The lumbar vertebrae exhibit a kidney-like appearance.
The fifth lumbar vertebra is slightly sickle-shaped and is higher in its
ventral portion. The reinforced superior articular processes have a small
bump, the mamillary process.
Apophyseal joints
The apophyseal joints (facet joints) are formed by the superior and infe
rior articular processes of adjacent vertebrae and form the dorso-lateral
part of the neural foramina. In the cervical spine, they are arranged par
allel with an angulation of 45° from the coronal plane to the axial plane.
In the thoracic spine, the facets rotate externally and more vertically to
299
be nearly in the sagittal plane in the upper lumbar spine. In the lower
lumbar spine, the facets rotate again inwards to form an angle of about
45° on transverse sections and the plane is orientated between coronal
and sagittal. Especially in the cervical spine, where loading forces to the
upper and lower parts of the facets are applied by forced extension and
flexion, meniscoid synovial folds are found in the upper and lower parts
of the apophyseal joints.
Discs
Each disc from C2 to the lumbosacral region has both a nucleus pulpo-
sus in its center, developing from the remnants of the notochord and an
annulus fibrosus, composed from reversed helical fibers in the outer parts.
In children the discs are vascularized, while from the age of 5 years they
are free of vessels.
Aging is normal in discs. In young adults degeneration starts with the
development of mucoid degenerations leading to circular fissures in the
annulus fibrosus. These fissures may communicate and progress to ra
dial fissures. Reaching the very peripheral and vascularized parts of the
annulus, a secondary vascularisation of the disc can be induced.
Vascularised fibrous granulation tissue grows into the disc in an attempt
to repair the tears. However, this repair will usually not be successful.
Degeneration will progress with dehydration of the nucleus and loss of
disc height. Vascularization o f the disc can be visualized with
Gadopentate-enhanced MRI. The discs show mostly linear increases in
signal parallel to the end-plates. A decrease in disc height results in a
loss of stability and initiates spondylosis.
In the cervical spine of children up to 8 years of age, the uncinate
processes are still not erect and no fissures are present at the uncoverte-
bral junctions. In the second decade of life under the influence o f motion
fissures in the lateral parts of the cervical annulus fibrosus develop and
uncovertebral joints are formed. The tears progress medially and can dis
sect the whole cervical disc in a transverse direction.
Ligaments
The vertebral bodies are connected by the annulus fibrosus as well as the
anterior and posterior longitudinal ligament. In caudad direction the an
terior longitudinal ligament becomes broader and stronger. The deep lay
ers bridge adjacent vertebrae without connection to the annulus fibrosus,
300
THE SPINE
the superficial layers cross 4-5 vertebra. The posterior longitudinal lig
ament is smaler and weaker than the anterior longitudinal ligament. In
the cervical spine it is broader than in the thoracic and lumbar spine,
where only a small part of the dorsal annulus is covered. In the thoracic
and lumbar spine the posterior longitudinal ligament is connected mainly
to the discs and bridges the dorsal surfaces of the vertebral bodies. The
neural arches are connected by the symmetrical ligamenta flava between
the laminae and by the interspinous ligaments between the spinous
processes.
TRAUMA
Spinal trauma is a disease of the young, and covers a wide range from
minor injury, not needing radiological evaluation, to the quadriplegic pa
tient, in whom an extensive radiological evaluation is required. The ra
diological evaluation is extremely important for correct treatment. It is
not only necessary to describe the various fractures and dislocations, but
also to evaluate the stability. It is also important to avoid false positive
diagnosis, since this might lead to unnecessary painful traction and sta
bilization of the spine. False positive diagnosis is more often seen in the
upper cervical spine because of anatomical variants, whereas false neg
ative interpretation is more common in the lower cervical spine because
of the problems with good visualization of this part, due to overprojec
tion of the shoulders. New modalities, such as MRI, have allowed a bet
ter visualization of the soft tissues, which is important for prognosis and
in some cases also for treatment.
Modalities
Plain films
The most important examination is plain film radiography in most cases
of spinal trauma, for several reasons. This modality is available in any
hospital and can be performed easily even without moving the patient
from his stretcher or bed. It is also the modality giving best information
about dislocations, which sometimes might be difficult to appreciate on
axial CT-slices. Important structures, such as the facets in the cervical
spine, are shown well on plain films, while the findings on axial CT-
slices can be confusing because of unfavorable slice direction for visu
alization o f these structures. Another advantage of plain films is that ex-
301
Figure 1.
Flexion injury with rupture o f
ligaments. In acute stage, examination
in extension (a) and flexion (b) reveals
an almost normal finding. Five months
later sliding with gibbus formation has
occurred (c). This case illustrates that
examination in provocation should not
be performed too early, because muscle
spasm will prevent sliding.
302
THE SPINE
amination can easily be performed in provocation, which allows evalu

ation of stability. Without provocation instability might be overlooked
if there is an isolated rupture of the ligaments and no dislocation in neu
tral position. Plain films in flexion and extension should be obtained ap
proximately two weeks after the trauma. If the examination is performed
too early, it might be a false negative because the pain causing protec
tive muscle spasm will prevent sliding (Fig. 1). Examination in flexion
and extension should always be obtained in patients with severe trauma
to the cervical spine, in whom conventional examination without provo
cation has not shown instability. In flexion there is normally a sliding
amounting to a couple of millimeters of the superior vertebral body in
relation to the inferior. This sliding occurs in the normal case in a stair
case pattern in the whole cervical spine and disappears in extension. This
can be rather marked,especially in young girls with weak muscles (Fig. 2).
In pathological cases there is a local displacement which is more pro
nounced than at normal levels and the distance between the spinous
processes is wider at the level o f trauma than at others. A situation which
might cause problems is local displacement secondary to degenerative
Figure 2. Normal mobility o f cervical spine. Note staircase sliding at several levels in
flexion (a). In extension sliding disappears (b).
303
disease. If these patients are

examined without old films
available their displacement
might be misinterpreted as
caused by a ligamentous tear.
A careful evaluation of the in-
tervertebral joints and the
disks, and examination in
provocation, should, how
ever, disclose the correct eti
ology (Fig. 3). Plain films
also visualize the preverte-
bral soft tissues. Prevertebral
hematoma, causing increased
soft tissues, is a sign of rup
ture of the anterior longitudi
nal ligament. As a rule, un
stable injuries have a prever
tebral hematoma, whereas it
is unusual for this to be found
in stable lesions.
The minimum requirement
for a plain film examination
in the acute stage is frontal, Figure 3. Anterior subluxation o f C4, caused
lateral, and oblique views by intervertebral arthrosis. No trauma.
with 45° tube angulation. A
good rule is to start with the lateral view, which usually gives informa
tion about the degree of injury and dislocations. This view should cover
the area down to at least the level of T l, which sometimes can be diffi
cult, but can be achieved by gently pulling the arms downwards during
exposure to avoid overprojection of the shoulders. Sometimes it is im
possible to visualize the lower cervical spine on lateral views, but in al
most all cases important dislocations can be seen on oblique views, in
which it is easy to image the lower cervical spine and upper thoracic
spine (Fig. 4). In patients with marked kyphosis in the thoracic spine and
lordosis in the cervical spine, it is an advantage to angulate the x-ray tube
approximately 10° in the caudal direction for best visualization of the
lower cervical - upper thoracic area. It is also valuable to obtain a frontal
304
THE SPINE
Figure 4. Bilateral interfacetal dislocation. Initial examination interpreted as normal.

On the lateral view (a), the shoulders are overprojected on the lower cervical spine.
On an oblique view (b), a severe luxation can be seen. On a lateral view with gentle
pulling o f the arms, bilateral inferfacetal dislocation is shown. M RI shows severe
dislocation and transsection o f the cord (d).
305
view of the odontoid process in the open-mouth-projection. These views

will almost always give enough information for the acute treatment of
patients with cervical spine trauma. Later there might be a need for spe
cial views. Conventional tomography, especially for evaluation of odon
toid fractures and fractures of the facets are often valuable. In the eval
uation o f thoracic and lumbar spine injury it is usually sufficient to take
only frontal and lateral views.
Computed tomography (CT)

CT gives valuable additional information to plain films and is of special
value for identification of fractures, particularly of the neural arch, and in
patients with burst fractures in whom there is a suspicion o f bone frag
ments in the spinal canal. In patients with suspected Jefferson fracture of
С 1, CT gives the best information about the degree of injury including lig
amentous tears and fracture dislocations (Fig. 5). CT-slices should be thin
and parallel to the neural arch for best the information. A slice direction
parallel to the disk sometimes results in slightly oblique views through the
neural arches which are difficult to interpret. If thin slices have been ob
tained, reformatting gives valuable information about dislocations.
Magnetic resonance imaging (MRI)

In patients with spinal trauma and neurological deficit which cannot be
explained by the findings on plain films, MRI gives valuable additional
information about the soft tissues. In the majority of patients with neu-
Figure 5. Jefferson fracture. Frontal tomogram shows lateral displacement o f lateral

masses o f C l in relation to C2 (a). CT shows bilateral fractures both in the anterior
and posterior arches. There is also a small fragment close to the odontoid process
indicating ligamental tear (b).
306
THE SPINE
Ир ^ ш
1
Wl
jjj§P
Щv л Л?Ц v ф
' ; -хШ1
1<;
W1^
шИт
К
щ
-^
, % Щ
: У
%Шк
1УЛ
Яш
НЕ 'Щ
Figure 6. Flexion tear-drop fracture. A small triangular fragment is seen at the lower
anterior border o f C5 (a). No dislocation. M RI reveals a contusion o f the cord (b). The
patient is paraplegic with reduced strength in his arms. During the trauma there has
been a severe dislocation which has returned to normal.
rological symptoms a cord contusion can be disclosed by MRI (Fig. 6),

but more importantly it rules out a traumatic disk herniation (Fig. 7) or
epidural hematoma (Fig. 8) which requires an operation. The degree of
cord contusion might also be helpful for establishing prognosis. This is,
however, not yet fully evaluated. Significant traumatic disk herniation
and epidural hematomas as the main causes of neurological symptoms
are rare but extremely important to rule out since they can be treated and
the presence of these lesions might also change the surgical approach.
MRI is also valuable in the post-traumatic stage, especially for evalua
tion of possible cyst formation in patients with increasing neurological
symptoms. Although fixation material might disturb imaging, a proper
selection of sequence- and frequency-encoding direction usually allows
visualization of most or all the cord.
307
Figure 7. Traumatic disk herniation. Plain film s show signs o f ligamental tear shown
as sliding in the intervertebral joint (arrow) and widening o f the disk space (a).
Posterior fixation is planned. However, M RI reveals a traumatic disk herniation
(arrow) with compression o f the cord (b). The surgical approach is therefore changed
to an anterior approach with removal o f the disk herniation follow ed by fixation later.
Figure 8.
Whiplash trauma in patients with
anchylosing spondylitis. Displacement is
seen at C6-C7 level and there is a
posterior epidural hematoma compressing
the cord.
308
THE SPINE
Pathology
Anatomical considerations
The construction of the spine is very specialized to allow both mobility
and stability, which reduces the risk o f trauma to the nervous soft tis
sues. The stability is achieved by the bony elements, intervertebral disks,
ligaments and muscles. The stability is better in the thoracic and lumbar
spine than in the cervical spine, which has more mobility. In the thoracic
region, the ribs also make the spine more stable. It is unusual to see sig
nificant dislocations in this area, which are sustained only in major
trauma. In the lumbar spine traumatic dislocations causing neurological
deficits are similarly unusual. In the cervical spine, on the other hand,
weaker construction and greater mobility allow compression injury of
the cord and nerves, following relatively moderate trauma. The width of
the spinal canal is very important with regard to the potential conse
quences o f dislocation. The ratio between the sagittal measurement of
the spinal canal and the vertebral body is usually approximately 1 in the
middle cervical spine. This ratio should not be lower than 0.8. The width
of the canal is much larger in the C l - C2-area than lower down in the
cervical spine. A rather pronounced dislocation can therefore be seen in
the Cl - C2-area without neurological symptoms. There is a consider
able individual variation in the width o f the cervical spinal canal.
Important for correct diagnosis in spinal trauma is knowledge of the
common anomalies which are often found in the upper cervical spine. A
frequent variant is a defect in the arch of Cl, which should not be mis
interpreted as a fracture. In congenital variants the bone edges are usu
ally rounded and cortical bone is seen in all areas, which is not the case
in patients with fractures. Another area in which anomalies are frequent
is the odontoid process. The odontoid process is formed from several
dermatomes and sometimes there will be a non-union and a formation
of an os odontoideum. This might be misinterpreted as a fracture but, as
in other anomalies, the margins are rounded and sclerotic.
Cervical spine
Trauma in the cervical spine can be divided according to the type of
trauma in flexion injuries, extension injuries and injuries caused by ax
ial or vertical force. There is also a group in which the force is unclear
or varied.
309
F lexion injuries
Subluxation
This injury is most often seen in the lower cervical spine where there is
a rupture of the posterior ligaments, causing the vertebra above the
trauma to slide in the forward direction. The distance between the spin
ous processes is increased and there is a dislocation in the intervertebral
joints o f varying degree. In this type of injury the radiological finding is
sometimes very subtle and the situation seems to be stable. After some
time, when the muscle defense diminishes, a sliding above the lesion
might be seen, causing an angulation (Fig. 1). In uncertain cases exam
ination in flexion and extension is mandatory to rule out a tear of the lig
aments. This examination should be performed approximately two weeks
after the trauma.
Bilateral interfacetal dislocation

This type of injury is caused by stronger force than in anterior sublux
ation but is otherwise of the same type. In the worst situation there is a
locked position between the facets at the injured level (Fig. 4). Sometimes
there is a fracture of the facet in this type of trauma, which is important
to disclose because it influences the stability after the initial treatment.
This injury is unstable because there is a tear of all ligaments and the
disk. Many of the patients are tetraplegic if they have a narrow canal. In
some cases the locked position is only seen on one side.
Wedge fracture
The wedge fracture is seen in the lower cervical spine and is stable.
Usually there is a compression o f the upper endplate of the vertebra with
preserved posterior border. It is important that a burst fracture, which
might have a fragment in the canal, is not misinterpreted as a wedge frac
ture. In uncertain cases CT should be performed.
Fracture o f the spinous process

Another example of a flexion fracture which is stable is the isolated frac
ture of the spinous process.
Flexion tear-drop fracture

In this type of fracture the force has been vertical with the spine in flex
ion. This leads to an avulsion of a triangular fragment from the ventral
310
THE SPINE
lower border o f the vertebra. This is actually the only part of the verte
bra which remains in normal position. During the trauma the posterior
part is pushed backwards, creating a severe gibbus and severe trauma to
the cord. Thereafter the posterior elements return to almost normal po
sition (Fig. 6). In 50% of the patients there is a tetraplegia after such a
trauma. The spine is totally unstable.
Extension injuries
Hyperextension injury without fracture
In these cases the injury is caused by a forceful extension of the cervi
cal spine, causing a rupture of the anterior longitudinal ligament and the
distance between the vertebral bodies is increased anteriorly. When the
injury occurs the dislocation is pronounced, causing a severe compres
sion of the spinal cord, causing tetraplegia. After the trauma the bony
component returns to essentially normal position, and the only thing
found at examination is a somewhat wide disk space anteriorly. Typical
for this injury is a very pronounced prevertebral hematoma. The situation
is unstable in extension. Accompanying facial trauma is also typical.
Hyperextension fracture
In this injury the force also causes a hyperextension, but there is also a
vertical component. The injury causes fracture in the base of the pedicle
and posterior elements on one side, causing the facet to rotate forwards.
This leads to a horizontal position of the facet, which is typically seen
on the frontal view (Fig. 9). The vertebral body is dislocated in the an
terior direction. On the other side, which is usually without fracture, a
subluxation is found in the intervertebral joint. There is also an injury to
the anterior longitudinal ligament and therefore a prevertebral hema
toma. The injury is unstable.
Hang-man fracture
In this fracture there is a strong extension of the cervical spine, causing
fractures on the pars interarticularis on C2 (Fig. 10). Occasionally, there
are fractures in the massa lateralis or further posterior in the lamina. The
fractures affect both sides, but are not necessarily symmetrical. The de
gree of instability varies. The injury is often without neurological deficits,
depending on the width of this part of the cervical spine.
311
Figure 9.
Hyperextension fracture. Lateral and frontal plain films show rotation o f the facet
(arrow) on the left side (a + b). MRI shows the rotation o f the fa cet more clearly (c).
312
THE SPINE
Extension tear-drop fracture

In this type of injury, a fracture with avulsion of a small trian-gular frag
ment from the anterior lower part of C2 is found. This fracture is unsta
ble in extension, because the anterior longitudinal ligament is tom but
stable in flexion, because the posterior ligaments are intact, as well as
the facets. Frequently, a prevertebral hematoma is found. Usually there
are no neurological symptoms.
Isolated fracture o f the posterior atlas

In hyperextension, Cl is sometimes compressed between C2 and the oc
cipital bone, causing an isolated fracture of the neural arch. This is a stable
fracture without neurological symptoms. The injury must, however, be dif
ferentiated from the Jefferson fracture, which is most easily done by CT.
Injuries caused by vertical fo r c e

Burst fracture
Vertical force affecting the cervical spine in neutral position can cause
burst fractures in the vertebral bodies of the lower cervical spine. The
313
Figure 11.
Burst fracture several years ago.
MRI shows sequelae after laceration
o f the cord. The lower cord is
atrophic.
vertebral body will burst in several fragments, and one or several of these
can be pushed posteriorly into the canal (Fig. 11). The intervertebral
joints and the ligaments are usually intact and the injury is thus stable.
CT is often necessary to show the degree of encroachment upon the spinal
canal. Traction can reduce the narrowing of the canal.
Jefferson fracture
Axial force sometimes causes a burst fracture of the atlas, caused by
downward force from the occipital condyles towards the atlas. In the typ
ical case there are fractures of the arch, both anteriorly and posteriorly.
The lateral mass is displaced laterally on both sides and the transverse
ligament is ruptured. Sometimes a small fragment is found, indicating
rupture of the transverse ligament. The injury is unstable when the trans
verse ligament is ruptured. On plain films there is a typical finding with
lateral displacement of the lateral mass on the atlas. However, all frac
314
THE SPINE
tures might be difficult to visualize without tomography. CT is the best

modality for evaluation of all fractures (Fig. 5).
M iscellaneous
Odontoid fractures
Odontoid fractures can be caused both by flexion and extension. There are
two main types - one in which the fracture affects the odontoid process,
and another where the fracture runs through the base of the odontoid process
downwards in the vertebral body of C2. The first type is more unstable and
has a greater tendency to pseudarthrosis. Often the patient has moderate
symptoms, and it is not unusual that the fractures are discovered a week
after the trauma, when the patient is examined because of remaining pain.
Thoracic and lumbar spine injuries

Most injuries are found between the T12- and L2-levels, which is ex
plained by the fact that this is the area where the spine turns from a rigid
upper part to a mobile lower part. This is also where the thoracic kypho
sis turns into the lumbar lordosis. Isolated dislocations without fracture,
which can be seen in the cervical spine, are extremely unusual in the tho
racolumbar area. Fractures in this area can be divided into fractures af
fecting the vertebral body, fractures of the transverse process, posterior
ligaments, transverse shear injuries and fracture dislocations.
Fractures o f the vertebral body

The most common fracture is the compression fracture of the anterior
part of the vertebral body. It is usually caused by a pure hyperflexion in
jury. The posterior elements of the vertebra are not injured and the frac
ture is thus stable. In some cases there is a rupture of the ligaments and
anterior sliding of the vertebra above the compressed level. When the
force is axial, a burst fracture can be found. In this situation a fragment
is sometimes pushed backwards towards the spinal canal, causing com
pression of the cauda equina or conus. CT is extremely valuable in this
situation, because it shows the degree of compression, which is some
times difficult to evaluate on plain films (Fig. 12).
Fractures in the posterior elem ents and transverse processes

Fractures through pedicles, laminae and facets are unusual as isolated in
juries, but are sometimes seen in connection with fractures to the verte-
315
Figure 12. Compression fracture o fL 2 (a). CT reveals a fragment in the spinal canal
with compression o f the cauda equina (b). After stabilization with a Harrington device,
the dislocation o f the fragment has diminished considerably (c).
bral body and are important in the evaluation of stability. Fractures of

the transverse processes are more common as isolated injuries, but are
usually associated with direct focal force.
Transverse shear injury

Transverse shear injuries are uncommon and are most commonly seen
in the upper lumbar spine. A special type is the Chance fracture in which
there is a horizontal fracture through the vertebral body, pedicles and
laminae. This is an unusual injury which can be seen in traffic accidents
in which a lap-seat-belt has been used (Fig. 13).
316
THE SPINE
Fracture dislocations
Fractures with dislocations are usually caused by a combination of flex
ion and rotation forces. Often there are compression fractures as well as
fractures through the posterior elements. These injuries are most often
found in the lumbar spine.
DEGENERATIVE DISEASE
Degenerative disease of the spine is a major health problem in the
Western World. It is of considerable economical importance, since back
pain and sciatica caused by degenerative disease lead to numerous con
sultations and prevent the patient from working for long periods.
Furthermore, the patients are often middle-aged and therefore belong to
one of the most important groups of workers. The diagnostic work is of
ten difficult because in many patients there is a poor correlation between
radiological findings and clinical symptoms. Thus, it is not unusual that
a patient has advanced degenerative changes with large osteophytic spurs
in the spine without symptoms, while others have severe symptoms with
rather discrete radiological findings. The discrepancy between clinical
317
symptoms and findings is especially pronounced in the cervical region.

Another complicating element is the combination of psychosocial fac
tors and low back pain. Therefore, it is of extreme importance that the
radiologist liaises closely with the clinicians, preferably during dedicated
clinico-radiological conferences. There are a number of different modal
ities and techniques that can be used for diagnosis and the choice be
tween these is based on several factors, such as availability, cost and ex
perience of the radiologist with the method. Furthermore, the situation
is also changing due to the rapid spread, technical development and im
proved film quality of MRI, which certainly will influence working prac
tice in the future.
Modalities
Plain film s
Although plain films do not give information about the soft tissue, each
evaluation should start with this modality which gives a good overview
and shows anomalies, which are important for determining the level at
which surgery should be undertaken. Plain films also show the degree of
spondylosis, scoliosis and different dislocations. Such images guide the
choice o f modality for further soft tissue evaluation.
Myelography
Myelography has been used for many decades for evaluation o f low-back
pain and most radiologists are familiar with the method. The advantages
of the method are that it gives a good overview, shows intradural mor
phology with a very high spatial resolution and is not as sensitive for pa
tient motion as MRI. Furthermore, it has the capability o f showing spinal
block and provocation can easily be performed. This is of special im
portance in patients with spinal stenosis. In patients with intradural cyst
formation and inflammatory adhesions, myelography is usually superior
to CT and also to MR in the majority of cases. Myelography is of spe
cial value in patients with spinal stenosis, and even more when the spinal
stenosis is combined with scoliosis. In patients with cervical root symp
toms, in whom MRI has failed to give an explanation of the patient's
symptoms, myelography and CT-myelography are also valuable. The
disadvantages of myelography are that the method is invasive and that
the area beyond the root-sleeve is not visualized. When there is a free
318
THE SPINE
choice of modality in well-equipped centers, myelography is nowadays

seldom used routinely and is used only in selected patients.

Today almost every major hospital in the Western World is equipped
with a CT-scanner and most radiologists have considerable experience
in the diagnosis of lumbar disease with this modality. CT is very valu
able for the evaluation of degenerative disease in the spine for many rea
sons: the method is non-invasive, it is quick, it provides excellent visu
alization o f bone in the axial projection and it shows the root-canals and
paraspinal area. It is usually easy to make a diagnosis of disc herniation,
as well as to detect bony elements narrowing the spinal canal, recesses
and/or root-canals. CT is therefore especially useful for the diagnosis of
the different causes of spinal stenosis. The draw-backs are that for prac
tical reasons only a limited number of disk levels are routinely covered
at most institutions, and only direct axial views can be obtained.
Projections other than the axial view can be obtained by using thin slices
and reformatting. However, if a large area is to be visualized, there will
be significant irradiation of the patient. Another, and probably more im
portant drawback is that the content of the dural sac is not visualized, un
less contrast has been injected into the subarachnoid space, and there
fore intradural pathology, such as a tumor, might be missed.

MRI is the latest modality for morphological evaluation of the lumbar
spine. The method has been available already for more than ten years,
but the images obtained before the introduction of surface coils were of
poor quality. There is a dramatic technical development still going on in
this field, and the quality is steadily improving. Furthermore, MRI is now
rapidly becoming more available in general hospitals, and the modality
must therefore be evaluated against others in the diagnostic work-up in
patients with degenerative disease of the spine. The advantages of the
method are that it is non-invasive, it gives a good overview from the
sacrum to the conus, all slice orientations can be obtained, and the content
of the dural sac, root-canals and paraspinal area are visualized (Fig. 14).
MRI also provides good information about the bone marrow. Cortical
bone is not as well visualized as with CT, but with improving quality this
difference has been diminished. Another drawback of the method is that
319
Figure 14. M RI and CT o f patient with a huge central disc herniation at the L 5-SI level
a) Tl-weighted image shows a disc herniation and also a normal conus ending at the
Ll-L2-level.
b) T2-weighted image shows the border o f the disc better and degeneration o f the L5-S1-
disk. Other discs have an essentially normal nucleus pulposus.
c) Axial Tl-weighted image shows central position o f the disc herniation.
d) Corresponding CT-examination.
In a case like this any modality would show the disc herniation but the advantage o f MRI
compared to CT is that it also shows other levels and the content o f the dural sac.
320
THE SPINE
it is rather time-consuming, but this is changing due to technical devel

opment allowing high resolution examinations with modem scanners in
a few minutes. Several investigations have shown that MRI provides equal
or better information than myelography or CT in the diagnosis of degen
erative disease in the lumbar spine. With modem MR-scanners this will
probably shift further in favour of MRI. A standard evaluation of the lum
bar spine should include Tl-weighted sagittal images covering the area
from the conus down to the sacrum, from neural foramen to neural fora
men. Axial views should always be obtained at the levels of interest. This
is especially important in the evaluation of the lateral part of the spinal
canal which is difficult to evaluate on sagittal views. T2-weighted images
with standard spin-echo-technique are time-consuming and usually not re
quired, but can be helpful when the disk is difficult to delineate and when
a more thorough evaluation of the disk content is necessary, as for instance
in a suspected infection. Using newer techniques, fast spin echo T2-
weighted images can be obtained in a much shorter time, and this tech
nique might be the standard for evaluation in the near future. The speci
ficity of MRI is high since not only pathology in the spinal canal is dis
closed, but also pathology in adjacent organs, such as the aorta, which
might mimic disease originating in the spine (Fig. 15). MRI is therefore
superior to other methods, especially in cases with unclear symptoms.
However, in patients with a typical history and location of the symptoms
to one level and one side, CT is usually sufficient for diagnosis. If all modal
ities are available the following strategy for evaluation of patients with
low-back pain and sciatica is suggested: Routine patient: 1/ plain films, 2/
MRI. Patient with advanced spinal stenosis or severe scoliosis: 1/ plain
films, 2/ myelography, 3/ CT at selected levels, after myelography.
Discography
Discography is necessary in the evaluation of patients intended for
chemonucleolysis and might be helpful in the evaluation before percu
taneous discectomy. The method has also been used for the evaluation
of patients presenting diagnostic difficulty and in selecting the proper
level in cases with multiple pathology. However, there are different opin
ions on the value of the method in this respect. Some authors have tried
to correlate the induced pain with the therapeutical result. In a recent
large study, the value of the method in this respect was found to be low.
321
Figure 15.
An aneurysm o f the aorta which has
ruptured into the psoas muscle found in
a patient sent fo r routine M RI o f the
spine with suspicion o f disc herniation,
a) Sagittal view shows the neck o f
the aneurysm
b + c) Complementary coronal view
shows the fu ll extent o f the
aneurysm.
322
THE SPINE
Diagnostic lumbar nerve-rootblock

Another method for evaluation of patients with normal findings on MR,
CT or myelography, or multiple pathological levels, is diagnostic nerve-
root block. In this method, a small amount of carbocain is injected in close
relation to the nerve under investigation. The neurological state before
and after nerve-block is carefully recorded. The method is easy to per
form and has been shown to be of value in the determination of the level
of pathology and in the evaluation of patients with uncertain findings.
Pathology
Lumbar spine
Anatom ical considerations

The spinal cord usually ends at the LI - L2-level and puncture of the
subarachnoid space should not be performed above the L2 - L3-level.
The nerve-roots have a more cranio-caudal course in the lower lumbar
spine than in the upper, and the root-sleeves of the lower lumbar nerves
are larger and longer than those in the upper lumbar spine. Common nor
mal variants are root-sleeve cysts and conjoined nerve-roots. This can
cause diagnostic problems using CT or MRI, because they can be mis
interpreted as disk herniation (Fig. 16). The epidural space is thickest at
the L 5-S 1 level and tissue which contains numerous vessels is normally
seen as a symmetrical soft tissue mass in close relation to the L5 - Sl-
disk. It is important not to misinterpret this as a disk herniation. On MRI
and CT images the dural sac is surrounded by fat, which is of great help
for diagnosis. Also the nerve-roots in the root-canals are surrounded by
fat in the normal patient. An important area to identify is the lateral re
cess where the nerve-root is turning in the lateral direction and then passes
under the pedicle into the root-canal. The ligamentum flavum and the in-
tervertebral joints can usually easily be identified on both CT and MRI.
Disc herniation
A bulging disc is a common finding and is often seen in combination
with reduction of the height of a disc. In bulging discs there is a general
expansion of the disc beyond the margins of the adjacent vertebral end-
plates. Bulging discs, not necessarily related to symptoms, are very com
mon in the middleaged population and there is a considerable risk that
323
Figure 16.
a) CT shows right-sided
disc herniation with
compression o f the
L5-root.
b) Myelography shows
disc herniation with
compressed L5-root
and root-sleeve.
c) CT at L5-S1 level
shows increased soft
tissue in fro n t o f
dural sac on left side
which could be
misinterpreted fo r a
disk herniation.
d) Myelography shows a
big root-sleeve and
conjoined nerve-
roots (arrow).
324
THE SPINE
bulging discs are misin

terpreted as disc hernia
tions. In disk hernia
tions, which affect the
L4-L5 or L 5 -S 1 discs in
90%, there is a focal ex
tension of different size
of the disk outside the
vertebral body. In inter
national literature this is
called "focal disc bulge"
or "protrusion". These
terms are used inter
changeably and usually Figure 17. Schematic illustration o f a bulging disc
represent different de and various types o f disc herniation. The thick dark
grees of the same condi grey line represents the posterior longitudinal
ligament.
tion, protrusion being
a) Normal
the larger disc hernia b) Bulging disk
tion. Common to both is c) Focal bulge or protrusion. The nucleus material
that the nucleus material remains within the outermost fibres o f the
annulus fibrosus.
remains within the con d) Prolapse or extrusion. The nucleus material has
fines of the outermost fi penetrated the annulus fibrosus but is contained
bres of the anulus fibro in fro n t o f the posterior longitudinal ligament.
e) Sequester or free fragment.
sus which is focally
weakened. In "prolapse"
or "extruded disk" the nucleus material has penetrated the annulus fi
brosus but is contained in front of the posterior longitudinal ligament.
With the present imaging modalities it is often impossible to differenti
ate between these types of disc herniation. In sequestration or free frag
ment the disc material is no longer contiguous with the intervertebral disk
and usually it has penetrated the posterior longitudinal ligament (Fig. 17).
This is important for the choice o f surgical technique. Most disk herni
ations are found in the posterolateral direction (Fig. 18), because the pos
terior longitudinal ligament is weakest in this part. Disk herniations are
divided into central, posterolateral, lateral (foraminal) (Fig. 19), and lat
eral (extraforaminal). The latter group is also called "far lateral" disk her
niation. Sequesters or free fragment can migrate both in the upward and
downward direction and can sometimes be found at considerable dis-
325
Figure 18.
CT examination showing posterolateral disk
herniation at L4-L5-level on the right side
causing compression o f the L5-root.
Figure 19. CT and M RI o f patient with lateral

(foraminal) disc herniation at L2-L3-level.
a) CT. Disc herniation is seen in right root-
canal, compressing the L2-nerve. Note
normal low attenuation fa t on left side.
Tl-weighted sagittal M RI shows disc
herniation in root-canal, replacing nor
mal fat. Compare with the level below,
c) Axial Tl-weighted view, showing disk herniation in right root-canal and high sig
nal fa t in left. Note intermediate signal from cauda equina in posterior dural sac
and low signal in CSF-containing anterior dural sac.
326
THE SPINE
tance from the disc of origin. Intradural disc herniations are very rare. A
firm attachment between the dura and posterior longitudinal ligament
due to inflammatory adhesion is thought to play an important role in in
tradural disc herniation. A sudden increase in disc pressure can then push
the disc material through the dura into an intradural position.
In the radiological report it is important not only to describe the disc
herniation but also its influence on nerve-roots and the dural sac. The
general rule is that the common posterolateral disc herniation compresses
the nerve-root which exits in the neural foramen below the interverte-
bral disc, i.e. a L4-L5 disc herniation will compress the L5-root. In lat
eral disc herniation, the root in the root-canal will be compressed and in
this situation a L4-L5 disc herniation will compress the L4-root. It is not
uncommon for disc herniation to disappear on conservative treatment
(Fig. 20). Imaging following surgery should be interpreted with caution
since there is a poor correlation between findings on imaging and clini
cal outcome. All of the three modalities, myelography, CT and MRI, can
be used for the diagnosis of a disc herniation with the advantages and
disadvantages previously described. On CT, disc herniation will have a
high attenuation (Fig. 14 d, 16 a, 18, 19 a) relative to the dural sac, and
on Tl-weighted MRI, the signal intensity will be increased in relation to
the subarachnoid space (Fig. 14 a + c, 19 a + c, 20 a), and on T2-weighted
images decreased (Fig. 14 b).
Figure 20. Tl-weighted axial MR-image, showing huge right-sided posterolateral disc
herniation and compression o f the SI-nerve (a). Following conservative treatment, the
disk herniation has almost disappeared six months later (b). Note that epidural fa t is
now seen in front o f the dural sac on left side, but there is still some compression o f
the epidural fa t on right side.
327
A special problem is the differentiation between recurrent disc herni

ation and postoperative scar. Scar tissue is more vascularized than disk
material, and therefore it is possible to differentiate these two tissues by
using intravenous contrast media. This can be done by using CT, but is
more efficient using contrast enhanced MRI with gadolinium-contain-
ing compounds. Using this technique, contrast enhancement will usually
be seen early after injection (approximately 5 minutes) in scar tissue but
not in disc herniations (Fig. 21). However, in disc herniations there is
not uncommonly a rim enhancement caused by surrounding granulation
tissue. The differentiation between hernia and scar is very important since
reoperation on scar tissue is associated with poor results, while reoper
ation of disc herniation often leads to cure.
Figure 21. Tl-weighted MRI before contrast (a) shows tissue adjacent to the L4-L5-
disk which cannot be defined. After contrast (b), the scar tissue enhances and a recur
rent disk herniation is seen. There is also enhancement o f the reactive changes in the
vertebral bodies adjacent to the disk.
328
THE SPINE
Figure 22.
Myelography without (a)
and with (b) provocation
shows narrowing o f the
canal at two levels. CT
after myelography (c)
shows spinal stenosis
caused by bulging disk and
hypertrophy o f the facets.
Spinal stenosis
Spinal stenosis can be divided into central or lateral, and there is often a
combination of both types. In spinal stenosis, pain can be induced by ac
tivity or in special positions. Typically, the pain disappears at rest or in
certain positions. Spinal stenosis can be congenital and is always seen in
some conditions, such as achondroplasia. In acquired spinal stenosis the
spinal canal is narrowed in the sagittal direction by bony spurs on the
vertebral bodies, bulging discs, thick ligaments, and new bone forma
tion adjacent to intervertebral joints. An anteroposterior diameter of less
than 10 mm is usually associated with the symptoms. In lateral spinal
stenosis facet hypertrophy, vertebral body bony spurs, and bulging disks
narrow the lateral recess and the root-canal. The narrowing of the spinal
canal can be estimated by measuring the cross-sectional area of the dural
sac. It has been shown that there is a critical cross sectional area of about
75 mm2 at the L3-level. Below this measurement patients are almost al
ways symptomatic. In the diagnosis of spinal stenosis, a combination of
myelography and CT is very efficient (Fig. 22), because these methods
visualize the bony changes so well. MRI can be used, but is more diffi
cult to interpret.
M iscellaneous
Spondylolisthesis is readily identified on plain films, and the most com
mon types are degenerative and isthmic or spondylolytic spondylolis
thesis. Isthmic spondylolisthesis results from a defect in the pars inter-
articularis. Plain films are usually sufficient for the management of these
Figure 23.
T1-weigh ted MRI
shows spondylolis
thesis. On lateral
views, the deforma
tion o f the root-
canal is seen as is
compression o f the
nerve (arrow).
Compare normal
root-canal at level
above.
330
THE SPINE
Figure 24.
Vacuum phenomenon with collection
o f gas in disk herniation. Gas collec
tion in this circumstance is pathog
nomonic o f disc herniation.
patients, but MRI might be helpful in showing pedicular kinking and nar
rowing of the root-canal which is causing nerve-compression (Fig. 23).
Degenerative disease in the intervertebral joints is a frequent finding
in combination with spinal stenosis and disc degeneration but can occa
sionally be the single cause of nerve-root compression in the lateral re
cess or root-canal.
Gas collections in intervertebral disks are commonly demonstrated with
CT. The cause is excessive mobility, causing a vacuum phenomenon,
leading to an accumulation of nitrogen. Gas collection in the canal in the
extradural space can occasionally be seen in disk herniations (Fig. 24).
Cervical spine
Anatom ical considerations

In the cervical region the nerve-roots are directed laterally and do not
have the descending pattern seen in the lumbar region. On myelography
the root-sleeves are easily identified and also subtle compression can be
disclosed. Normally, the cord is somewhat thicker in the cervical region
than in the thoracic, which should not be interpreted as a tumor. On MRI
both the bony components as well as the soft tissues of the spinal canal
can be visualized. The root-sleeves should always be identified and in
high quality MRI both the dorsal and ventral root can be identified. The
root-canals are easily identified on MRI because of fat content. The spinal
331
cord has an oval shape with the long axis in the horizontal direction on
axial views. On high quality images the H-shaped gray matter of the
spinal cord can be identified.
D isc herniation
Isolated soft disc herniations, which are seen in young and middleaged
adults are relatively uncommon in the cervical spine. However, the ma
jority of disc herniations are found in combination with degenerative os-
teophytic spurs with narrowing of the spinal canal as well as the root-
canals. As in the lumbar spine the disc herniations are usually postero-
332
THE SPINE
lateral raising the possibility of nerve-root compression. Large postero

lateral and central disk herniations sometimes cause compression of the
cord (Fig. 25). In the cervical spine free fragments are unusual. MRI is
usually sufficient for diagnosis, however, minor nerve-root compres
sions might be difficult to see on MRI. In cases where there is a dis
crepancy between clinical symptoms and findings on MRI, cervical
myelography, preferably in combination with CT, should be performed.
It is often difficult to separate compression caused by bony spurs from
disk herniation on MRI. In this situation plain films are usually helpful
for analysis of the bony components.
Spinal stenosis
Bony spurs causing narrowing o f the spinal canal and root-canals are
very common in the middle-aged and in the elderly. There is often a poor
correlation between these degenerative changes and clinical symptoms,
except in the most advanced cases. The most frequent location of ad
vanced degenerative disease is seen at the C5-C6 and C6-C7 levels,
where mobility is most pronounced. Osteophytic spurs from the verte
bral bodies encroach upon the central spinal canal and osteophytes from
Figure 26.
T2-weighted MRI in a patient with mild spinal
stenosis in the cervical region. A T2-weighted
image is usually the best sequence fo r showing
spinal stenosis.
333
the unco vertebral joints and intervertebral joints encroach upon the root-
canals (Fig. 26). MRI or myelography in combination with CT can be
used for diagnosis. The previously mentioned difficulty in distinguish
ing between bony spurs and calcified hard disk herniations is from the
practical point of view, of minor importance. The clinical information
needed is knowledge of the presence of a cord or nerve-root compres
sion, at what level it is found, and whether there are single or multiple
affected levels. All of this information is important for the choice of sur
gical procedure, i.e. laminectomy, facetectomy or anterior approach.
M iscellaneous
Ossification of posterior longitudinal ligament (OPLL) is a well recog
nized cause of cervical canal stenosis and myelopathy. Its cause is un
known. Although ossification can be seen on plain films, CT-myelogra-
phy is valuable for diagnosis and more precise information (Fig. 27).
OPLL might be difficult to observe on MRI, especi-ally if only T l-
weighted images are used, in which case the calcified ligament might
mimic normal CSF.
Figure 27. Plain film (a) and CT-myelography (b) showing ossification o f posterior
longitudinal ligament. On CT-myelography a slight compression o f the cord is noted.
334
THE SPINE
Thoracic spine
Degenerative changes are less frequent in the thoracic spine than in other
parts because of better stability in this region due to mechanical support
from the ribs. Thoracic disc herniations are uncommon, with a reported
Figure 28.
Tl-weighted M RI (a) and
myelography (b) show a thoracic
disc herniation, however, detailed
information is not obtained. The
lesion is better visualized on CT-
myelography which shows a huge
calcified herniation with
compression o f the cord (c).
incidence o f approximately 1/1 000 000/year. Recent investigations have

shown that this figure is probably too low. The diagnosis o f thoracic disc
herniation is often difficult, because the symptoms are often vague and
usually don't indicate the level. All imaging modalities have limited use
fulness in this region due to anatomical factors and disturbance from mo
tion in adjacent organs, such as heart and lungs. However, with modem
MR-scanners, an adequate image quality can usually be achieved. In
other cases a combination of myelography for identification of level and
CT for detailed information is recommended (Fig. 28). Thoracic disk
herniations are often calcified.
INFLAMMATORY DISEASE
Most patients with inflammatory diseases of the spine present with pain.
Depending on the site and extent of the pathological process, neurolog
ical deficits and other symptoms may be found. Spondylitis can be caused
by various organisms like bacteria, tuberculous bacilli, fungi and para
sites. Moreover, aseptic spondylitis may be found in ankylosing
spondylitis and rheumatoid arthritis. Erosive osteochondritis is a special
type of aseptic spondylitis mimicking septic spondylitis in MRI, but ma
jor bone destruction and signs of infection are missing. Aseptic, de
structive spondylarthropathy is related to (32-microglobulin-associated
amyloid deposits in patients with chronic renal failure and has to be dif
ferentiated from septic spondylitis as well.
The correct diagnosis of septic spondylitis is mandatory to allow
proper antibiotic and/or surgical treatment. Any delay bears the risk of
a severe complication, especially para- and tetraplegia. Epidural exten
sion of abscesses, gibbus formation and sequestration of bony elements,
as well as granulation and scar tissue may cause encroachment of the
spinal cord. In rare instances ascending meningitis and meningoen
cephalitis can originate from pyogenic vertebral osteomyelitis.
Ankylosing spondylitis or erosive osteochondritis bear no risk of neuro
logical complications whereas (32-microglobulin amyloid deposits in
dialysis-associated, destructive spondylarthropathy can cause cord com
pression with neurologic deficits.
336
THE SPINE
Modalities
Plain films
For diagnosis, differential diagnosis and follow-up of inflammatory dis
eases of the spine, analysis of the endplates plays a key role. Erosions,
destructions, subchondral or regional sclerosis and osteopenia as well as
gibbus formation are clearly visualized on plain films. Healing and pro
gression, respectively, can also be monitored by plain film radiography,
which is indispensible for diagnosis and follow-up. In the early phase of
septic spondylitis, plain films are frequently negative and at the time of
onset of clinical symptoms only 25% of the patients show unambiguous
destructions of the endplates. The aseptic types of spondylitis, on the
other hand, are characterized by a chronic course and changes at the dis
covertebral junction are usually present, when patients complain of clin
ical symptoms.
Frequently reduction of the disc height is an early sign of septic
spondylitis, even if erosions of the end plates are missing. In the lumbar
spine, for example, a gradual increase o f disc height is found from LI to
L5 and the L5/S1 disc is smaller. Segmental thinning of the disc space
is found in spondylitis and can be easily assessed on the plain film.
Bone scintigraphy
The sensitivity of 99m-technetium bone scintigraphy is high (more than
90%) for the detection of osteomyelitis, discitis and aseptic spine dis
eases. However, bone scans are nonspecific and are also positive in neo
plastic and degenerative spine disorders, postoperatively and after post-
traumatic or osteoporotic fractures. With Indium-labeled leucocyte
scintigraphy, specificity is improved which may be helpful in the few
cases when organisms play a role in the pathogenesis. With scintigraphic
methods, precise assessment of extent and localization o f inflammatory
spine processes is not possible and the involvement of bony elements by
infection cannot be differentiated from soft tissue infection.

For the specific diagnosis of spondylitis, CT is less useful than plain film
radiography. Early destructive changes at the end plates, an important
sign of spondylitis, may be missed by axial scanning due to partial vol
ume averaging. Destruction of the vertebral bodies on CT are often am
337
biguous and tumors as well as infection may be responsible. Destruction

within a vertebral body and geographic lesions with sclerotic margins
are readily depicted by CT. CT is extremely useful for the assessment or
exclusion o f paravertebral and epidural abscess extension which cannot
be detected on conventional films. With i.v. contrast enhancement, ex-
traosseous abscesses are better detected by demonstrating their enhanc
ing rims. Even with i.v. contrast, however, epidural involvement may be
missed on CT due to beam hardening artefacts especially in the cervico-
thoracic region requiring intrathecal contrast enhancement for more com
plete evaluation.
Percutaneous biopsy can be performed under CT guidance allowing
precise localization of the suspected foci and planning o f the best line of
approach. Drainage of paraspinal fluid collections and abscesses can be
performed under CT-guidance as well.

Multiplanar imaging capabilities and high sensitivity for soft tissue and
bone marrow lesions make MRI the modality of choice for the diagno
sis of inflammatory spine disorders. Pathological alterations of the disc
space are demonstrated by MRI as well. Frequently, characteristic pat
terns of disc space, bone marrow and paravertebral lesions allow the spe
cific diagnosis of spinal infections. Therefore, in many institutions MRI
has replaced CT in the evaluation of inflammatory spine diseases.
In pyogenic spondylitis, ankylosing spondylitis and some types of de
generative disc disease, a uniform pattern of signal changes within the
bone marrow is found in MRI. Low signal intensity on short TR, short
ТЕ sequences (Tl-weighted) and high signal on long TR, long ТЕ se
quences (T2-weighted) is found. Bony sclerosis is detected on suscepti
bility sensitive GE-sequences with high sensitivity. In our institution, op
posed phase GRE sequences have proved very useful. On opposed phase
GRE sequences, normal red bone marrow exhibits low signal intensity
by subtraction of the water and fat component. On opposed phase GRE
sequences bone marrow edema is characterized by high signal intensity
whereas in even minor bony sclerosis low signal is found. Inversion re
covery sequences with short inversion time (STIR) and T2-weighted se
quences with selective fat suppression pulses are the most sensitive se
quences for the detection of bone marrow edema and inflammatory le
sions within the bone marrow.
338
THE SPINE
Contrast enhancement is demonstrated to good advantage on opposed

sequences like GRE sequences, e.g. with ТЕ = 17 ms at 1.0 T or opposed
Tl-weighted sequences with an asymmetric 180° refocussing pulse. On
"in phase” T 1-weighted SE-sequences the conspicuity of marrow lesions
is decreased after contrast enhancement. Recent reports indicate, that
contrast-enhanced MRI examinations and frequency-selective fat satu
ration techniques are superior to every other imaging protocol for the de
tection of inflammatory spine disorders.
Pathology
Pyogenic spondylitis
In pyogenic spondylitis, hematogenous spread of bacteria and other mi
croorganisms within the bone marrow of the vertebral bodies is the most
common portal of infection. Direct inoculation is less frequent than other
causes, whereas postoperative infection is the most important. However,
disc or vertebral puncture can also be responsible for inoculation of
pathogenetic organisms. A dense paravertebral net of valveless venous
collaterals exist which communicates with the inferior vena cava and the
pelvic veins (Batson’s venous plexus). This enables organisms and ma
lignant cells to invade the vertebral bone marrow retrogradely.
Nevertheless, it is now generally accepted that the arterial route is the
most important for hematogenous osteomyelitis of the spine entering the
vertebral body through the central dorsal nutrient foramen. From the ver
tebral bodies, the discs are affected by direct invasion of the organisms.
In degenerative disc disease, secondary vascularization of the disc is pos
sible. Granulation tissue may penetrate radial tears of the annulus fibro-
sus, which contributes to the stabilization of the disc. In rare instances,
hematogenous spread of infection direct to the discs is therefore also pos
sible in adults. In children and young adolescents up to the age of 5 years
the disc is still vascularized providing a hematogenous route by which
the organisms can be carried directly to the disc.
Pyogenic infections of the spine affect patients most frequently in the
fifth and sixth decades of life. The offending organisms can be cultured
from blood samples, needle or open biopsies in about half of the cases.
The most common organism is Staphylococcus aureus (80-90%), but
other organisms like Streptococcus, Salmonella, or Klebsiella are found
as well.
339
Figure 29.
Postoperative pyogenic spondylitis
(staphylococcus aureus). On con
ventional film s in the anterior part
o f the disk space fa in t early de
struction o f the endplates o f L5 and
the sacrum are visible (a).
In Tl-weighted images (550/15 ms)
M RI shows bone marrow edema
adjacent to the disc space L5/S1
(b). Following Gadopentate injec
tion increase o f signal intensity in
Tl-weighted image is visible in the
disk and bone marrow edema (c).
Gd-DTPA enhancement gives high
contrast in frequency-selective fa t
suppressed Tl-weighted images
(601 ms/15ms, d). Bone marrow
edema shows high signal intensity
in T2-weighted Turbo-SE image
(500/90 ms, e).
On plain films, ill-defined destruction can be detected after 2 to 3 weeks

(Fig. 29). In most of the cases, intramedullary foci are located in the an
terior and subchondral portion of the vertebral bodies, in which high vas
cularity exists. From the intramedullary focus infection penetrates early
to the disc. In this very early phase of pyogenic spondylitis, an increase
of disc height may be found in rare instances. A typical sign of early
spondylitis is a reduction of the height of the disc which may be the sin
gle radiological sign of spondylitis. From the disc spaces infection pen
etrates the adjacent end plates of the vertebral bodies and extends into
the bone marrow. Irregular destructions of the end plates are visualized
on radiographs and tomograms. Depending on the host's resistance (im-
340
THE SPINE
munological competence) and the virulence of the organisms, the de

structions can progress to vertebral collapse and/or gibbus formation.
Weeks or 2-3 months after the onset of symptoms, bony sclerosis indi
cating attempted healing of spondylitis is radiographically depicted.
Sclerosis, ebumation, severe narrowing of the disc space or even bony
ankylosis, as well as osteophytosis are found in healed spondylitis.
However, radiographic findings may be ambiguous and complete heal
ing can only be diagnosed, when long term follow-up examinations in
dicate no further changes.
In pyogenic spondylitis on Tl-weighted images MRI shows low sig
nal intensity within the marrow o f the vertebrae adjacent to the involved
disc (Fig. 29). Disc space narrowing is a common finding and the signal
intensity of the disc is low; thus contrast between the disc and adjacent
vertebral bodies is reduced or lost. In the early phase of infection within
a normal, non-degenerated disc, swelling and increase o f disc space, may
be found in rare instances. On follow-up examinations and frequently on
initial examination, a considerable loss of the height of the disc space is
found which progresses rapidly. Granulation tissue and abscesses may
extend into the subligamentous and epidural space. Moreover, erosions
of the cortical endplates are visualized. Infrequently, only one vertebra
or more than two are affected.
On T2-weighted and STIR-images, abnormally high signal intensity
is detected in the bone marrow o f the affected vertebrae and definite sig
nal increase is found following Gadopentate injection (Fig. 29). In the
disc space, high intensity fluid collections are frequently found. The "in
tranuclear cleft", which is present in about 30% of normal discs, can no
longer be identified. The shape o f the disc is irregular and extension of
the high signal intensity disc within the bone marrow of the adjacent ver
tebral body may be found. Opposed Tl-weighted sequences and fre
quency selective fat saturation techniques support the use of paramag
netic contrast media and are definitely useful in assessing the extension
of epidural involvement or abscesses and show involvement of the spinal
canal and soft tissues (Fig. 29).
Healing of spondylitis following surgical or conservative treatment is
associated with long standing signal alterations in MRI, even if there is
no clincial evidence of persistent infection. After several months, high
signal intensity marrow is found in the vertebral bodies on Tl-weighted
images which is higher in signal intensity than the uninvolved vertebrae,
341
presumably due to conversion of haematopoietic marrow to fatty m ar

row. High signal intensity on T2-weighted and contrast enhanced exam
ination decreases and the soft tissue and epidural involvement resolves.
Tuberculous spondylitis
Tuberculous spondylitis is characterized by a chronic course of clinical
symptoms and radiological changes. Spondylitis has become the most
frequent manifestation of osteoarticular tuberculosis and it is often as
sociated with tuberculosis of other organs, especially of the lung. Low
grade fever, nocturnal sweating and moderate elevation o f the erythro
cyte sedimentation rate are found.
Widespread osteopenia of the bones involved by osteoarticular tuber
culosis and of the adjacent skeletal elements has been descibed as typi
cal for tuberculosis in many textbooks. However, this is not a constant
finding and differentiation between pyogenic and tuberculous spondyli
tis is frequently not possible based upon radiological findings.
After i.v. administration of Gadopentate, intraosseous abscesses with
ring-like, peripheral enhancement are frequently found. The disc space
can be preserved for prolonged periods. The cortical endplates are fo-
cally destroyed. In the thoracic vertebral column, destruction of the an
terior aspects of two adjacent vertebrae results in gibbus formation. In
the lumbar spine axial compression may be found due to axial forces of
weight bearing. Large abscesses are frequently found in the pre- and par
avertebral region, which may extend into the psoas muscle, under the
longitudinal ligaments and along the pleura-lined spaces o f the thorax.
Tuberculous abscesses may spread over long distances, especially when
originating from the lumbar vertebrae and fistulae may appear within
the groin, above the iliac crest, at the medial side o f the thigh and within
the popliteal fossa. Extension and localization of tuberculous abscesses
are readily assessed by coronal and sagittal MRI. Involvement of the
posterior elements of the vertebrae and of the suboccipital area are very
unlikely in pyogenic spondylitis, but can be found in tuberculous
spondylitis.
Fungal spondylitis
Candida and Aspergillus are saprophytic fungi which may cause spinal
infection in immunocompromised patients. Candida and aspergillus
spondylitis cause morphological findings similar to pyogenic spondylitis.
342
THE SPINE
If more than one area in the spine is involved, however, aspergillus in
fection should be taken into consideration. There is only little contrast
enhancement within the disc, but anterior and posterior bulging of the
disc with protrusion of the annulus fibrosus and enhancement of the an
terior and posterior longitudinal ligament and of the subligamentous
space are frequently detected.
Blastomycosis, Cryptococcosis and Coccidioidomycosis are endemic
in South Africa, South America and the United States, but rarely en
countered in Europe. Definite diagnosis of granulomatous fungal infec
tions requires culture of the organism or microscopic proof.
"Inflammatory" Disc Degeneration

Pyogenic spondylitis has to be differentiated from acute, erosive degen
erative disc disease with edema of the vertebral bone marrow adjacent
to the endplate. This disorder simulates the signal patterns of infectious
spondylitis, named by Modic as Type I reaction (Fig. 30). The underly
ing mechanism is rapid disc degeneration without the creation of ade
quate spondylophytes. The rapid loss o f segmental stabilitiy, which can
occur spontaneously, after surgery with removal of the disc material or
after chemonucleolysis, causes transient disc vascularization and bone
marrow edema (see chapter on spinal anatomy). The vascularized gran
ulation tissue within the disc, as well as bone marrow edema exhibit
Gadopentate enhancement (Figs. 30, 31). Bone marrow edema and disc
vascularization may be found together or only one of these features may
be present. No epidural or paravertebral abscess is found. Gas within the
disc space on CT is a frequent finding and it is strongly suggestive of
erosive degenerative disc disease (Fig. 31). No major destruction of the
vertebrae is found in this entity, but with time, dense sclerosis will de
velop known as spondylosclerosis hemispherica.
Dialysis-associated, destructive spondylarthropathy

Bone destruction due to (32-microglobulin (p2-M)-related amyloid de
position increase in frequency with long-term haemodialysis. (5,-mi-
croglobulin-associated amyloidosis plays an etiological role in carpal-
tunnel syndrome, subchondral bone cysts, pathological fractures and de
structive, erosive, non-infectious spondyloarthropathy. Destructive,
erosive, non-infectious spondyloarthropathy in patients on chronic
haemodialysis was first described by Kuntz (1984). The cervical spine,
343
Figure 31. Erosive degenerative disk disease. Conventional film s show erosions with
out destruction, bony sclerosis had developed at the L5/S1 level (a). On CT, at the
same level, a gas collection is shown (b). Tl-weighted MR image (530/15 ms) indicate
erosions o f the endplates at the L3/4, L4/5 and L5/S1 level with associated fatty bone
marrow degeneration (Type II reaction according to Modic) (c). Vascularized granu
lation tissue inside the disk exhibit a marked Gadopentate enhancement (d).
344
THE SPINE
especially the atlanto-axial region and the lower cervical spine are most
frequently involved, however, the lumbar and thoracic spine are also
commonly affected. In patients with end stage renal disease, |32-M ac
cumulates and serum concentrations are elevated. (32-M is usually ex
creted by the kidneys and dialysis membranes eliminate it inadequately.
Eventually, triggered by crystals, (32-M related amyloid is deposited in
the disc space and in the ligaments. After narrowing o f the disc space,
the endplates are eroded and pseudocystic hemations into the trabecular
bone of the vertebrae with sclerotic margins are found. Amyloid infil-
Figure 32. /32-microglobulin related

amyloid deposits in destructive,
noninfectious spondylarthropathy. Patient
fo r 21 years on haemodialysis. Conventional
ap tomogram shows destruction o f the body
o f the axis, dens fracture and lateral
dislocation o f the lateral masses o f the atlas
(a). The lytic process originates from /32-
microglobulin associated amyloid deposits.
In Tl-weighted MR image only a hy-
pointense mass in the atlanto-axial region
and a dens fracture are visible (b). The
amyloid deposits light up in opposed phase
GE images (500/17ms/90°) (c).
Figure 33.
Ankylosing spondylitis.
Complete ossification o f the ventral annulus
fibrosus and the apophyseal joints. During
a skiing accident a fracture passing
through the С6/C 7 disk space, the lamina
С 7 and the spinous process o f С6 had
occurred.
trates in the dens axis increase the risk of dens fracture (Fig. 32).
Amyloid deposits in the transverse or posterior longitudinal ligament or
in the ligamenta flava can encroach upon the epidural space and
myelopathy may result.
Ankylosing spondylitis
Ankylosing spondylitis is a chronic inflammatory disorder of unknown
origin affecting predominantly the spine and the sacroiliac joints. The
frequency of ankylosing spondylitis (about 1%) in men is much higher
than in women and there is a definite assocation with the histocompati
bility antigen HLA-B27. The clinical onset of the disease is insidious and
usually betwen 15-35 years o f age. The patient complains of stiffness
and low back pain.
Sacroiliac joint abnormalities and spinal ligament calcification and os
sification are characteristic of ankylosing spondylitis. Marginal syn
desmophytes are orientated vertically and may extend up the entire length
346
THE SPINE
Figure 34.
Ankylosing spondylitis. Ventral subligamental
osteitis creates new bone formation at the
anterior vertebral border resulting in squaring
o f the vertebral body.
Osseous bridging at the ventral annulus
fibrosus is also seen.
Figure 35.
Tl-weighted MR image
(570/15 ms) pre- and post
contrast in ankylosing
spondylitis with an
Anderson lesion at the
T11/T12 level. Parallel to
the endplates all discs
exhibit Gadopentate en
hancement (b). Erosive,
destructive changes with
widening o f the disk space
and bone marrow edema in
the region o f the Anderson
lesion is present.
of the spine. Eventually, osseous ankylosis of the apophyseal joints and

of the intervertebral disc spaces (bamboo spine) is found (Fig. 33).
347
Erosions of the vertebral margins heal by proliferation of sclerotic

bone, which stands out in marked contrast to the rest o f the vertebral
body (shiny comer). Healed erosions and deposition o f new bone be
neath the inflamed longitudinal ligaments (osteitis) contribute to squar
ing o f the vertebral bodies (Fig. 34).
On MRI, widespread bone marrow edema and inflammatory changes
of the disc space is found (Fig. 35). The disc spaces are narrowed and
marked reactive sclerosis is present. Occasionally, localized discoverte-
bral erosions and destructions are seen, in some cases ending in a disc
pseudarthrosis (Andersson lesion), resembling infective discitis (Fig. 35).
Following minor trauma, fractures through the porotic bones just beneath
the endplates or through the discs may occur, and may result in spinal
pseudarthrosis.
SPINAL TUMORS
Apart from metastases spinal tumors are rare. The radiological evalua
tion of spinal tumors has undergone a dramatic change during the last
decade after the introduction o f MRI. This has led to a new approach to
therapy at some hospitals because of the significantly improved infor
mation about the intrinsic architecture of the tumor that can be obtained
preoperatively. Improved surgical technique and equipment has also in
creased the demand for more information about the nature and spread of
the tumor.
Modalities
Plain film s
Every examination should start with plain films. In some patients this
might even be sufficient, for instance if metastases are found, further
evaluation may be unnecessary. In other patients plain films are needed
for determination of the affected level before surgery. Although scal
loping of a vertebral body or thinning of a pedicle, caused by pressure
from the tumor, might be seen in some patients, plain films are normal
in the majority of patients with intraspinal tumors.
Isotope studies
Isotope studies are valuable, especially for screening of metastases.
However, it is important to be aware of that the method is unspecific,
348
THE SPINE
gives poor anatomical information and sometimes yields false negative

results in patients with osteolytic metastasis, myeloma and lymphoma.
Myelography
Myelography has been used for many decades for the diagnosis of spinal
tumors but has several significant limitations. In patients with spinal
block only the lower tumor border is visualized if the contrast has been
introduced in the lumbar region. Myelography gives information only
about the contour of the cord but does not give information about its com
position and the area beyond the root-sleeves is not visualized. In pa
tients with cord compression, the lumbar puncture frequently worsens
the patient’s neurological deficits. Therefore, myelography should be
avoided if MRI is available. However, in some situations myelography
is valuable, i.e. in cases with subarachnoid spread of small tumor nod
ules, for instance from a medulloblastoma in the posterior fossa. The high
spatial resolution sometimes allows diagnosis of such small tumor nod
ules on nerve-roots and on the surface of the cord, which are not always
visualized on MRI. If a tumor has been found on myelography and there
is a suspicion of spread outside the spinal canal, CT should also be per
formed. In cases with myelographic block, CT can sometimes visualize
also the cord above the myelographic block. CT following myelography
is also valuable in differentiating between a tumor and syringohy-
dromyelia. In syringohydromyelia diffusion of contrast will visualize the
cyst. CT examination in such cases should be performed approximately
six hours after myelography to allow for this diffusion.

CT without contrast in the subarachnoid space is a poor method for the
diagnosis of spinal tumors, because the cord is not regularly visualized.
As previously described, the method is, however, of great value in com
bination with myelography.

MRI is the method of choice for spinal tumors. The advantage of this
modality is that all components of the area are visualized, i.e. the cord
and its content, the subarachnoid space, the epidural space, the paraspinal
region, and the bone and bone-marrow. In patients with multiple tumors
causing spinal block, MRI will succeed where myelography fails to show
349
the area between tumors. MRI can separate cystic from solid tumor com
ponents. This is of great importance in the preoperative evaluation of in-
tramedullary tumors. Contrast enhancement with a gadolinium-contain
ing contrast medium facilitates the diagnostic work-up and should al
ways be used in patients with intramedullary tumors and is often helpful
in intradural extramedullary tumors. In patients with metastases to the
vertebral bodies, contrast enhancement usually does not give any further
information and can even obscure tumors.
Pathology
Anatomical considerations
The spinal cord, which usually ends at the L1-L2 level in adults, has a
fusiform cervical enlargement caused by the supply to the large spinal
nerves, supplying the upper limbs, and a lumbar enlargement corre
sponding to the innervation of the lower limbs. These enlargements
should not be misinterpreted as tumors. From the conus medullaris, the
cord continues downwards in the filum terminale, reaching down to the
sacrum. Parallel to the filum terminale, the peripheral nerves descend
downwards in the cauda equina. It is important to be aware of that there
is a considerable difference between vertebral level and segmental level
in the spinal cord, which becomes more pronounced in the caudal di
rection. In a peripheral injury with compression of the cauda equina, the
patient will develop a flaccid paresis, often combined with pain. When
there is a compression of the spinal cord, there will be a spastic paresis
since the upper motor neuron is affected, while the peripheral neuron is
intact. In cord compression from outside, the long fibres to the legs will
first be affected. When the compression is increased, the clinical level
will ascend and eventually correlate with the level o f compression. If a
patient has signs of incomplete cord damage, the injury should thus be
looked for at the clinical level or higher. This difference between cen
tral and peripheral injury is of great practical importance in determining
the affected level. Paresis of the legs and bladder with spasticity can thus
not be explained by a lumbar disk herniation, and the lesion must be
looked for at the level of the cord. In a patient with such symptoms, it is
not correct to perform CT of the lumbar spine to search for a disk her
niation. Patients with signs of cord compression must be examined within
24 hours to avoid permanent damage to the cord.
350
THE SPINE
Spinal tumors are divided into in

tramedullary, intradural extramedul-
lary and extradural tumors. Most tu
mors are found in one of these com
partments, but some tumors, such as
for instance neurinomas, might be
seen in several compartments.
Intramedullary tumors
Intramedullary tumors are uncommon
with an incidence of less than 10
cases/million/year. Ependymomas and
astrocytomas constitute more than
90% of intramedullary tumors. On
imaging it is often difficult to differ
entiate between the two types. Usually
there is a fusiform enlargement o f the
cord and frequently a cystic compo Figure 36.
nent is found both in the cranial and Tl-weighted M RI showing cervical
astrocytoma with central solid tumor
caudal direction of the solid central tu and surrounding cystic components.
mor (Fig. 36). In rare cases, somewhat
more often in astrocytomas, the tumor is completely cystic. In such cases
the tumor might be difficult to separate from a syringohydromyelia. It is
important to visualize cysts and solid components, because treatment
with ultrasound should be directed towards the solid component.
Ependymomas are more frequent than astrocytomas in the lower spine,
especially in the filum terminale. Astrocytomas are more frequent in the
cervical and thoracic cord. Another difference is that ependymomas are
more frequent in elderly patients. Tumors other than ependymomas and
astrocytomas, are unusual in the spinal cord. A few spinal tumors are he-
mangioblastomas. This tumor is most frequent in the cerebellum, but can
occasionally be found in the spinal cord and is characterized by a small
solid richly vascularized tumor nodule, usually surrounded by a cystic
component.
Intramedullary metastases can occasionally be found, usually in asso
ciation with a known primary tumor. Intracranial medulloblastomas,
ependymoma, and germinomas frequently cause tumor spread in the sub
arachnoid space, which can cause tumor nodules on the surface of the
351
Figure 37.
Tl-weighted M RIfollowing gadolinium-DTPA
injection. Slightly enhancing tumor nodules are
seen on the surface o f the spinal cord (arrows).
The patient has an intracranial medulloblastoma.
Figure 38.
Myelography and Tl-weighted M RI
o f patient with syringohydromyelia.
Myelography only shows an expan
sion o f the cord, while MRI shows
the cyst.
spinal cord (Fig. 37), nerve roots and, in some rare cases, to the central
canal of the cord. Embryonal tumors are most frequently seen in the conus
region and are often accompanied by dysraphism. Syringohydromyelia
is not a tumor but might be misinterpreted as a neoplastic lesion beca-
sue it causes an enlargement o f the spinal cord. The lesion consists of a
cyst filled with CSF. Theoretically, hydromyelia is a cystic enlargement
of the central canal, lined with endothelium, while syringomyelia is an
eccentric or central cord cavity, lined by glial cells. However, in
practice it is often difficult to separate them and therefore the term
352
THE SPINE
Figure 39.
MRI showing cervical ependymoma.
a) Tl-weighted image shows fusiform
enlargement with central low signal.
b) T2-weighted image shows high signal
from tumor and also surrounding
edema which cannot be separated.
c) Tl-weighted image following
gadolinium-DTP A injection shows
enhancement o f the tumor but not o f
the surrounding edema.
’’syringohydromyelia" is sometimes used (Fig. 38). Syringomyelia is fre

quently associated with congenital malformations, especially the Chiari
2-malformation.
Plain films are most often normal in intramedullary tumors, but o c
casionally increased distance between the pedicles, thinning of the pedi
cles or scalloping of the vertebral body are seen. At myelography a
353
fusiform widening of the cord is found, sometimes in combination with

myelographic block. For differentiation of tumor and syringohy-
dromyelia, CT should be performed approximately six hours after myel
ography, as previously described.
MRI is superior to all other methods in the diagnosis of intramedullary
tumors, and a minimum requirement is Tl - and T2-weighted images in
the sagittal projection, followed by Tl-weighted images after intra
venous contrast enhancement with a gadolinium-containing contrast
medium. This is extremely important, because solid tumor components
usually enhance. Occasionally these components are seen without con
trast, but if they are surrounded by cysts containing protein, their differ
entiation may be very difficult. Edema is often difficult to separate from
tumor components without contrast enhancement (Fig. 39). In heman-
gioblastoma contrast enhancement is essential for the visualization of the
vascularized tumor nodule. Embryological tumors often have a charac
teristic appearance on MRI because of fat content and calcifications.
Hemorrhage in intramedullary tumors, which is especially common in
malignant melanoma metastases, is visualized as an area of increased
signal on Tl-weighted images.
Intradural extramedullary tumors

Intradural extramedullary tumors are more frequent than intramedullary
tumors but are still relatively rare. The dominating tumors are menin
gioma and neurinoma with an approximately even distribution between
the two types. The tumors are usually rounded and displace and com
press the spinal cord. Meningiomas are almost always completely in
tradural and are more frequent in the thoracic spine. Meningiomas are
more frequent in middle-aged and elderly and more common in women
than in men. Neurinomas are evenly distributed in the spinal canal, are
found at all ages, and have an even sex distribution. The tumor is usu
ally found on the dorsal root, and therefore the spinal cord is displaced
in the anterior and lateral direction. Sometimes there is an extradural
component which can continue in the root-canal as a dumb-bell tumor
(Fig. 40). In neurofibromatosis there are often multiple neurinomas at
many levels in the spinal canal. These patients also have an increased in
cidence of spinal meningioma and in some patients bone dysplasia and
meningoceles are found which should not be misinterpreted as tumors.
Other tumors are uncommon in this compartment. Occasionally,
354
THE SPINE
Figure 40.
Cervical neurinoma.
a)
Tl-weighted image before contrast shows
tumor with signal isointense with cord, with
central low signal area indicating necrosis.
b ,c d )
Tl-weighted images after contrast show
marked enhancement, displacement o f cord
and growth in the neural foramen.
Figure 41.
Enlarged neuralforamen due to dumb-bell neurinoma.
Figure 42.
Myelography shows lower border o f neurinoma causing
myelographic block.
Figure 43.
Tl-weighted M RI shows
meningioma in the an
terior spinal canal with
broad attachment to the
dura. The cord is com
pressed and displaced
posteriorly. The signal
pattern is similar to the
cord.
Figure 44.
Myelography and Tl-weighted
M RI o f neurinoma in the dural
sac at the level o f sacrum. Myelo
graphy shows only the upper
pole o f the tumor, while MRI
shows the complete tumor
(arrows). The low signal in the
center o f the tumor indicates
necrosis, which is a frequent
finding in large neurinomas.
metastatic spread is seen from intracranial medulloblastoma, ependy

moma and germinoma, as previously described.
Plain films occasionally show enlargement of a neural foramen, indi
cating a dumb-bell neurinoma (Fig. 41). Otherwise, plain films are usu
ally normal. Myelography easily visualizes both meningioma and neuri
noma, but should always be combined with CT for visualization of pos
sible extradural tumor component. The typical finding is a rounded
contour, representing the border of a tumor (Fig. 42), an enlarged sub
arachnoid space, and displaced cord. In cases with myelographic block,
356
THE SPINE
a b с
Figure 45. Intradural paraganglioma. This tumor is extremely rare in this location
and has the appearance o f a meningioma.
a) Tl-weighted image shows tumor which cannot be separated from cord.
b) Following intravenous gadolinium-DTPA injection, tumor and cord can be sepa
rated.
c) T2-weighted image.
CT frequently is capable of visualizing the upper border of a tumor, since

some contrast usually passes the blocked area, even if it is not visualized
on myelography. In cases with suspected spread of intracranial tumor
with small tumor nodules, myelography is an excellent method because
of the high spatial resolution. Otherwise, MRI is the main method for di
agnosis. On T 1-weighted images both meningioma and neurinoma have
a signal pattern like the spinal cord but are usually easy to detect, since
they have a high contrast relative to the low signal CSF (Fig. 43, 44).
Neurinoma usually has a high signal on T2-weighted images - higher
than meningioma, which has a more fibrous tissue, giving lower signal.
Both types of tumor usually enhance, following injection of a gadolin-
ium-containing contrast medium, which makes the tumors easy to detect
and differentiate from the cord. Contrast enhancement is especially valu
able when small tumors are looked for, as for instance in the subarach
noid spread of a medulloblastoma and also for differentiation of tumor
from cord (Fig. 45).
357
Figure 46. M RI o f paraspinal lymphoma.

a) Sagittal Tl-weighted image shows invasion o f a tumor o f the bone marrow and
growth in the neural foramen at two levels (arrows).
b) Axial Tl-weighted view shows paraspinal tumor component (arrows) replacing the
normal fat, and growth through the neural foramen.
358
THE SPINE
Extradural tumors
The most common spinal tumors are extradural, and among these verte
bral metastases are the largest single group. The most frequent primary
tumors are breast- and lung cancer and cancer of the prostatic gland. In
some rare cases extradural tumors are found only in the extradural space
without connection to the bone. This is especially common in lymphoma
which has a tendency to spread from a paraspinal location through the
neural foramen into the epidural space (Fig. 46). In the pediatric age-
group, neuroblastoma has a similar growth pattern. Primary bone tumors
are unusual. Hemangiomas are usually asymptomatic and have a char-
acteriztic appearance on plain films with thickened bony trabeculae, lead
ing to a palisade pattern. Chordomas are unusual and are most often found
in the sacrum (Fig. 47). Tumors involving the bone-marrow, such as
myeloma and lymphoma, are frequently localized to the spine and are
sometimes associated with neurological symptoms caused by compres
sion of nervous tissue. As previously mentioned, neurinoma sometimes
has an extradural spread, which is indicated by a widening of the inter-
vertebral foramen.
Plain films will usually reveal the malignant extradural tumors because
of bone destruction. Plain films are, however, not sufficient when the pa-
Figure 48.
Metastasis from sarcoma in the thigh. The
tumor displaces and compresses the cord. Note
that there is also metastasis in the vertebral
body further down.
359
tient has neurological symptoms, because it is important also to visual

ize the degree of involvement of nervous structures, paravertebral
growth, etc. Bone scintigraphy is excellent for the screening of metas
tases in patients without neurological symptoms. Myelography has been
used for many decades for the evaluation of cord compression in patients
with metastasis. It is usually easy to visualize the level o f compression,
but when there is a block it is difficult to show the whole extent of a tu
mor and also whether there are multiple tumors or not. As for other spinal
tumors, MRI, if available, is the method of choice. Usually Tl-weighted
images are sufficient because this sequence will visualize the level of
compression and degree of paraspinal growth. It is also easy to visual
ize metastases at multiple levels (Fig. 48). Tumor growth in the bone-
marrow is easily visualized because the fat, normally giving a high sig
nal on T 1-weighted images, will be replaced by low signal caused by the
invasion of malignant cells. T2-weighted images are usually not neces
sary and the metastases are often less well visualized on this sequence.
Contrast enhancement is usually not necessary and will actually obscure
the tumors growing in the fatty bone-marrow, because the enhancing tu
mor will then get a signal similar to fat on Tl-weighted images, unless
fat suppression techniques have been used. MRI is very sensitive for de
tecting the infiltration of bone-marrow, and this is particularly important
in those tumors, such as lymphomas, which have a permeative growth
pattern in bone. (They often escape detection on plain films and also
when CT is used.) Isotope studies can also be negative in such cases.
CONGENITAL SPINAL MALFORMATIONS

The vast majority of congenital anomalies of the spine represent mani
festations of spinal dysraphism which refers to a failure of incomplete
midline fusion of mesenchymal, osseous, and nervous tissue.
Spinal dysraphic abnormalities are described as open (not covered by
skin) and closed (covered or occult) lesions and are divided into differ
ent groups depending on the presence of a back mass. The anomalies
with back masses and uncovered protrusion of all or part of the intraspinal
contents include myelocele, myelomeningocele and meningocele. They
are called spina bifida aperta and are usually clinical obvious at birth.
Occult spinal dysraphism includes skin-covered masses such as subcu
taneous lipoma, skin-covered meningoceles or myelocystoceles and the
group of spinal dysraphism without an associated mass. This group en
360
THE SPINE
compasses dorsal dermal sinus, spinal lipoma, tethered cord (tight filum
terminale syndrome), fibrolipoma of the filum terminale, diastemato-
myelia, and anterior sacral meningocele.
Spinal dysraphism is typically associated with midline cutaneous le
sions such as a hairy tuft, dimple or hemangioma. Moreover, scoliosis,
clubfoot and neurological deficits are frequently found in malformations
of the spine and spinal cord.
Modalities
Plain film s
For the assessment of bony abnormalities of the spine, anteroposterior
and lateral films are adequate in most cases. With CT and MRI superior
soft tissue contrast is achieved and no superimposition of other anatom
ical structures is found. Sagittal, coronal and oblique reformats, as well
as 3-D surface rendering of CT data sets allow for visualisation of fine
anatomical details and may be preferred to conventional tomography.

For precise evaluation of bony structures and subtle anatomical details,
CT is superior to other imaging modalities. In diastematomyelia, CT with
2-D reformats and 3-D rendering is indispensible. Delayed post-myel
ography CT is able to demonstrate communications of a syringohy
dromyelia or cystic structures with the subarachnoid space. MRI has re
placed myelography in most instances.
Ultrasound (US)
In the newborn, US can be used to good advantage in order to visualize
the spinal canal, the spinal cord and the thecal sac. Spinal dysraphism,
especially when associated with cystic components, can be detected or
excluded by ultrasound. In children older than 1 year and adults, how
ever, no appropriate acoustic windows are available for ultrasound ex
amination of the spine.

For the evaluation of spine anomalies, MRI is extremely useful. Due to
its multiplanar capabilities, the lack of ionizing radiation and its supe
361
rior soft tissue contrast, MRI allows for the delineation o f the spinal cord,
the subarachnoid space, the vertebral bodies and the intervertebral discs
and can be employed in infants and children without harmful effects.
For MRI of infants and children, however, sedation or even general
anesthesia is required. For the assessment of spinal malformations, ax
ial and sagittal Tl-weighted images are adequate and the administration
of contrast media is not necessary. High-resolution technique and a slice
thickness o f 2 or 3 mm should be employed.
Figure 49. Lower thoracic and upper lumbar spine, ap (a) and lateral (b).
Left and dorsal hemivertebra o f T il, partial block vertebra T11/T12 with fusion o f the
spinous processes.
362
THE SPINE
Figure 50.
Block vertebra C5/6 without spondylosis at
this segment and incomplete development o f
the disk. Degenerative hypermobility in the
two segments above in the dorsiflexion film.
Pathology
Osseous spinal abnormalities
Anom alies o f the vertebral body

Disturbance in the formation of the somites results in lateral hemiverte
bra or anterior agenesis with posterior hemivertebra (Fig. 49). Lateral
hemivertebrae are usually accompanied by angulated scoliosis. Butterfly
vertebrae are broadened and constricted centrally. Non-segmentation
will form block vertebra (Fig. 50). The discs are rudimentary or absent
and at the disc level a waist-like constriction indicates the lack of full de
velopment of endplates. Block vertebrae can either be congenital or a re
sult of juvenile spondylitis.
Both neural arches and pedicles originate from separate chondrifica-
tion centers to form the spinal canal. The cartilaginous closure of the dor
sal arches starts from the 3rd month of gestation in the mid thoracic spine
to progress step-like down- and upwards. Failure of dorsal closure causes
spinal dysraphism which is discussed later. Pedicular absence or hy-
363
poplasia may be asymptomatic. Failure of segmentation results in the fu

sion of adjacent laminae or pedicles forming vertebral bars.
K lippel-F eil syndrome

The Klippel-Feil syndrome descibes a segmentation disorder of the cer
vical and upper thoracic spine with fusion of multiple vertebrae, in co
existence with a short neck and low hair line. Association with Sprengel's
deformity (elevated scapula), omovertebral bone, cervical ribs, and
kyphoscoliosis is common. The omovertebral bone bridges the scapula
and spinous processes and is composed of osseous, cartilaginous or fi
brous tissue.
C raniocervical junction abnorm alities

Craniocervical junction abnormalites include agenesis o f the odontoid
process, os odontoideum, ossiculum terminale and assimilation of the at
las. The os odontoideum occurs along with a hypoplasic dens axis and
carries a risk of anterior, posterior and lateral atlanto-axial instability
(Fig. 51). It is rare for cases of craniocervical junction abnormalities to
result in cervical myelopathy.
Sacral agenesis
Sacral agenesis frequently occurs in children of diabetic mothers.
Concurrent malformation of the genitourinary tract, alimentary tract,
agenesis of the lumbar spine and dysplasia of the pelvis and legs is com-
364
THE SPINE
Figure 52.
Spina bifida occulta at L5. Persisting
ossification centers at the tips o f the
inferior articular processes o f the
apophyseal joints o f L2.
mon. Imaging has to evaluate the

urinary tract and to rule out other
dysraphic conditions.
Spinal dysraphism
Osseous abnormalities associated
with spinal dysraphism include in
complete fusion of the posterior
elements of the vertebra, termed
spina bifida, in occasion with for
mation of hemivertebra, butterfly
vertebra and block vertebra. Spina
bifida occulta has come to mean a
mild non-union of the laminae,
usually at the L5 and SI level, a
common finding without clinical
importance (Fig. 52).
Spina bifida aperta
M yelocele and m yelom eningocele

In this disorder, the neural tissue fails to form a tube and develops as a
flat plate, termed a placode, herniating through a bony defect. Usually
the lumbar spine is involved. The placode is exposed to the air and the
skin ends at the edge of the placode. The nerve roots arise from the ven
tral surface of the placode. In myelomeningocele, a CSF filled space is
found anteriorly to the placode. The placode and leptomeninges protrude
dorsally (Fig. 53). In myelocele, no distension of the subarachnoid space
is found. Hemimyelocele is a special type of myelomeningocele with di-
astematomyelia and it is present in about 10% of myelomeningoceles.
365
Myeloceles and myelomeningoceles are usually operated upon within

the first 24 hours of life. Postoperative complications after repair of
myelomeningocele may be a tethering of the cord and placode by scar
ring or cord compression by a lipoma, a dermoid or a epidermoid tumor.
Following surgery of myelomengingocele syringohydromyelia and sco
liosis can develp in childhood.
In all patients with myelomeningoceles, Chiari II malformation is
found. Chiari II malformation is characterized by downward herniation
of the hindbrain through the foramen magnum. The posterior fossa is too
small. The brainstem together with the fourth ventricle, the tonsils and
vermis is stretched inferiorly and is located behind the cervical cord. This
inferiorly displaced cervico-medullary junction forms a characterstic
kink. Frequently, dysplasia o f the corpus callosum, hydrocephalus and
hydromyelia are associated findings in Chiari II malformation.
Occult spinal dysraphism
D orsal derm al sinus

A dorsal dermal sinus is a midline epithelium-lined tube which extends
from the surface of the skin to a varying degree inferiorly. The ectoderm
of the skin can be connected with the ectoderm of the spinal cord.
Frequently, a dimple or small ostium is seen on the skin associated with
hairs, hemangioma or hyperpigmentation. Complications are meningitis
and subcutaneous or intraspinal abscess. Approximately 50% of dorsal
dermal sinuses end within a dermoid or epidermoid cyst.
Spinal lipom a
Three types of spinal lipomas can be differentiated: intradural lipomas,
lipomyelomeningoceles and fibrolipoma o f the filum terminale. In in
tradural lipomas, the dura is intact, and they can lie in any part of the
spine. These subpial-juxtamedullary lesions fill the dorsal cleft between
the central canal and the pia. When located in a low position spinal lipo
mas may tether the conus medullaris.
Lipomyelomeningoceles present as a skin-covered fatty, slightly
firm back mass. They account for 50% of cases o f occult spinal dys
raphism. The cord is usually tethered to a large fatty mass extending
from the subcutaneous region through a bony spina bifida into the
spinal canal. Lipomas exhibit high signal intensity on Tl-weighted MR
366
THE SPINE
images and negative density values on CT.
Tethered cord
In tethered cord syndrome, a short, more than 2 mm thick filum termi
nale holds the conus medullaris in a low position. Patients may be asymp
tomatic or become symptomatic at any age, usually when the spine grows
too long for the fixed cord. Frequently, tethered cord syndrome is asso
ciated with mild forms of osseous spina bifida without spina bifida aperta.
In about one third of cases a lipoma or fibrolipoma of the filum termi-
nalae is found (Fig. 54). Lipomyelomeningoceles are typically associ
ated with a tight filum terminale syndrome.
Myelocystocele is an occult spinal dysraphism with herniation of an
ependyma-lined cyst from a syringohydromyelia through a spina bifida de
fect into the subcutaneous tissue. Anterior sacral meningoceles are CSF filled
meningoceles extending through an anterior sacral defect into the pelvis.
D iastem atom yelia

Diastematomyelia is a form of split notochord syndrome with sagittal di-
vison of the spinal cord into two pia-lined hemicords. In complete clefts
with formation of two dural sacs, a fibrous, cartilaginous or osseous spur
is present in half of the cases. The doubling of the cord can occur in the
thoracic or lumbar spine. The spinal column is nearly always grossly ab-
367
Figure 55.
Cervical A VM.
a) Tl-weighted image shows tortuous vessels in
the cervical cord and marked atrophy o f the
cord.
b) The T2-weighted image shows enlarged
draining veins.
c) Angiography shows fin e details o f the arterial
supply and venous drainage o f the A VM.
normal. Hemivertebrae, butterfly vertebrae, block vertebrae and in al

most all cases, spina bifida, are present. Cutaneous naevi overlying the
site of diastematomyelia, tethering of the cord, hydromyelia, and club
foot deformity are frequently found in children with diastematomyelia.
368
THE SPINE
SPINAL ARTERIOVENOUS MALFORMATIONS

Spinal arteriovenous malformations (AVM) can be divided into dural
and intramedullary types. The most common type is the dural arteriove
nous fistula which is found on the outside of the dura or along a root-
sleeve, most common in the thoracic or lumbar region. The fistula is
drained intrathecally by perimedullary veins. This disease most fre
quently affects elderly men and causes a slowly progressive myelopathy
which is thought to be caused by increased pressure in the medullary
veins. Intramedullary arteriovenous malformations are predominantly
seen in younger individuals and most often in the cervical or thoracic re
gion. They are usually discovered by acute neurological symptoms
caused by an intramedullary bleeding. Spinal AVMs can usually be di
agnosed by myelography, because enlarged tortuous vessels are found
in the subarachnoid space. On MRI intramedullary components can be
visualized and when there are large AVMs, vessels are seen in the sub
arachnoid space (Fig. 55). In dural AVMs, MRI is, however, unreliable
and sometimes falsely negative. It should also be mentioned that flow
artifacts often create a pattern which might mimic vessels, especially on
fast spin-echo T2-weighted sequences. For definite diagnosis angiogra
phy is, however, necessary. This examination is also a prerequisite for
therapy. The blood supply to the spinal cord is complicated and catheter
ization of a large number of vessels is required. Following angiography
these diseases can successfully be treated by embolization.
INTERVENTIONAL PROCEDURES
Spinal AVM
Dural fistulas and intramedullary AVMs are preferably treated by en-
dovascular methods. Following thorough angiographic mapping of the
lesion, the feeders are superselectively catheterized. In dural fistulas
occlusion is usually achieved by injecting glue (bucrylate). In the ideal
case, the glue should reach the proximal portion of the venous system.
By this treatment, the pressure in the venous system is reduced permit
ting improved venous drainage from the cord. Usually the progressive
myelopathy caused by the increased venous pressure can be arrested and
in some favourable patients the symptoms might diminish. In in
tramedullary AVMs, occlusion is normally achieved by injecting small
particles following superselective catheterization of the feeders. In some
369
cases this is combined with injection of glue. The risk of bleeding is

thereby reduced and in cases with impairment of the venous drainage
from the normal cord, the pressure can be lowered.
Percutaneous discectomy
Patients with contained disc herniations are candidates for treatment by
percutaneous discectomy. In this technique, disc material is removed
through a thin needle inserted by a dorsolateral approach. A careful pre
operative investigation, preferably by high resolution MRI, is necessary
to rule out free fragments, which are a contraindication for this proce
dure. The advantages of the technique are the following: it is minimally
invasive and reduces the need for hospital admission and sick-leave. It
is especially efficient for treatment of far lateral disk herniations, which
are difficult to reach by conventional surgery. The formation of scar tisue
is avoided, and if the procedure is unsuccessful, conventional surgery
can be performed as a second step. The frequency of successful proce
dures is lower compared with conventional surgery, but still acceptable
results are achieved in the majority of patients and there are few com
plications.
Chemonucleolysis
This method of treatment o f disc herniations has been used for thirty
years. The treatment consists of injection of chymopain through a nee
dle introduced by posterolateral approach into the disc. The enzyme
breaks down the content of the nucleus pulposus which becomes reduced
in volume and the pressure in the disc diminishes. Only contained disc
herniations can be treated and at some centers discography is routinely
performed to disclose possible leakage of the contrast material outside
the disc. The indications are the same as for percutaneous nucleotomy.
The main drawback of the method is that some patients develop allergic
reactions towards the enzyme.
370
Chapter 13
Musculoskeletal radiology
Niels Egund, Kjell Jonsson, Holger Pettersson and

Donald Resnick.
Radiography has been used in the assessment of bone disease for over
100 years, and today approximately 40% of all examinations performed
in a general department of radiology relate to the musculoskeletal sys
tem. The two most prominent indications for radiographic examination
are trauma and degenerative joint disease. Until approximately 20 years
ago, radiologic examination o f the musculoskeletal system was limited
to plain film radiography, and this method still provides highly impor
tant information. However, during the last two decades, musculoskele
tal radiology has undergone a revolution as a result of the introduction
and refinement of new diagnostic imaging methods, such as ultrasonog
raphy, scintigraphy, computed tomography, and magnetic resonance
imaging.
The radiographic features of the growing skeleton differ widely from
those of adolescents and adults. This chapter is mainly confined to condi
tions of adults; the pediatric skeletal radiology is described in chapter 14.
MODALITIES
The initial assessment of a bone lesion begins with plain film radiogra
phy using specific views to evaluate particular problems. A certain
amount of image detail is necessary to see and diagnose the presence of
a fracture, and therefore different screen-film combinations are used de
pending on the size and the depth of the bone to be examined. For small
bones and in young children the best combination is single emulsion films
(mammography screens) with a resolution of more than 10 line pairs/mm.
Digital radiography has been used to replace conventional film tech
nique (Chapter 5), but it has a limited spatial resolution of 3 to
371
Figure 1.
The significance o f bone scintigraphy,
a) Anteroposterior (AP) radiograph o f a
36-year-old man with pain o f three
week's duration in the knee. In the ab-
sence o f history o f a previous fibular
fracture, the cortical thickening o f the
fibula was considered significant,
b) Bone scintigraphy shows increased
uptake at the site o f the head o f the
fibula (arrow) with a normal appear
ance at the site o f the cortical thicken
ing (the patient later recalled a previ
ous ankle injury). (B = accumulation
o f isotope in the urinary bladder) d
с and d)
Transaxial Tl-weighted and T2-weighted (d) MR images o f the proximal portion o f
the tibia and the fibula. The region o f low (c) and high (d) signal intensity repre
sents a stress fracture (arrows).
372
MUSCULOSKELETAL RADIOLOGY
Figure 2. Comparison
between CT and MRI in
osteosarcoma o f the
distal portion o f the fe-
a) Transaxial CT scan
through the distal
end o f the right and
left thigh. A large ex
panding lesion, rep
resenting an os a
teosarcoma o f the
fem oral metaphysis, displaces
the medial vastus o f the quadri
ceps muscle (Vm) and contains
fragments o f bone with high
density. Edema, o f low density,
surrounds the femur and the ex
panding lesion (arrows).
b) T2-weighted transaxial MRI
section at the same level as in
(a). The bone fragments within
the soft tissue lesion that are
shown in (a) are not visualized
with MRI. The tumor within the
bone marrow is seen clearly.
The surrounding edema (ar
rows) has a high signal intensity b
on this T2-weighted image.
5 lines/mm. Moreover, its diagnostic accuracy in the assessment of sub

tle fractures of small bones as well as bone quality still is uncertain.
Conventional tomography (Chapter 4) is used to evaluate structures or
objects obscured by overlapping shadows on the plain radiograph and
commonly is employed for routine radiography of the sacroiliac joint,
the sternum, and the adjacent joints. It also is used to identify fragments
of comminuted fractures.
Bone scintigraphy using Technetium-99m-methylene diphosphonate
plays an important role in the identification and localization of bone le
sions, particularly when the entire skeleton needs to be surveyed.
Abnormal osseous uptake of the bone-seeking isotopes occurs as a re
sult of increased osteoblast activity; therefore, certain osteolytic
processes (e.g., osteolytic metastases and plasma cell myelomas) may
not be detected. A normal bone scan generally excludes a serious con
dition when a sclerotic lesion is present on plain films (Fig. 1).
373
Figure 3. Comparison o fT l- and T2-weighted images o f hip jo in t effusion.

a) Tl-weighted coronal section o f the hip o f a 12-year-old boy with osteogenesis im
perfecta 3 days after trauma to the hip joint. A fracture o f the acetabulum is pre
sent. The intracapsular hemorrhage has low signal intensity (arrowheads).
b) T2-weighted MR image. The intracapsular effusion (arrowheads) has high signal
intensity, f = fat.
Computed tomography (CT) provides excellent visualization in the

transverse, or transaxial, plane. Conventional tomography has, to a large
extent, been replaced by CT. CT commonly is used as a routine supple
ment to plain film examination of injuries and lesions of the spine, pelvis,
wrist, ankle, and foot as well as in the assessment of bone and soft tis
sue tumors (Fig. 2).
The widespread availability of magnetic resonance imaging (MRI) in
recent years has had a great impact on musculoskeletal radiology.
Although it cannot image cortical bone directly, MRI provides better de
finition of soft tissue and bone marrow than any other imaging technique
currently available. Muscle, fat, fluid, tendons or ligaments, and carti
lage can be distinguished from one another (Fig. 3). In the assessment
of traumatic, tumor-like, and inflammatory lesions of the skeleton and
the soft tissue, a fat suppression MRI sequence (e.g., short tau inversion
recovery or STIR) used in conjunction with a Tl-weighted sequence af
ter the intravenous administration of a gadolinium compound is ex
tremely useful (Fig. 4).
Ultrasonography typically is used to evaluate the soft tissue of the
musculoskeletal system. This readily available, inexpensive, and rapidly
374
Figure 4.
The diagnostic value o f gadolinium
contrast medium studies in MRI.
a) T2-weighted gradient echo MR im-
age o f the left hip in a 6-year-old
girl with Legg-Calve-Perthes dis
ease. The region o f osteonecrosis o f
the epiphysis is o f low signal inten
sity in comparison to the epiphysis
in Figure 3 b. The pouch at the me
dial aspect o f the femoral neck
(white arrow) contains a joint effu
sion or synovitis,
b and c)
Tl-weighted images before (b), and
after (c) intravenous injection o f
gadolinium contrast medium.
Contrast enhancement is indicative o f synovitis rather than flu id (white arrow).
Contrast enhancement in the periphery o f the epiphysis (black arrows) indicates
vascularization o f the tissue.
performed study also can be used in infants and children. The indications
for sonographic examination are expanding and include the following:
Assessment of joint instability (e.g., developmental dysplasia of the
hip.
Joint effusion (Fig. 5).
Injuries to joints, tendons, and ligaments.
Detection of foreign bodies in the soft tissue, especially pieces of glass
and wood not detectable on routine radiography
Guidance in fine needle aspiration and biopsy
Figure 5. Comparison between normal and abnormal hip jo in t sonography.

a) Normal anatomy at longitudinal scanning along the fem oral head and neck. Co =
fem oral neck, Ca =femoral head. Open arrow = the echo from the ventral aspect o f
the capsule.
b) The opposite hip with joint effusion, distention o f the capsule (open arrow), and
transient synovitis.
Arthrography today in most cases has been replaced by MRI, but sev
eral major indications for arthrography still exist, including the assess
ment of the shoulder, hip (Fig. 6), knee, and wrist. CT arthrography with
double contrast technique (air and positive water soluble contrast mate
rial) (Fig. 7) remains useful in the detection of intraarticular bodies or
labrum tears of the shoulder.
MEASUREMENTS
Knowledge of anatomic of distances and angles in the skeleton is nec
essary and most important in pediatric radiology and traumatology.
Tables detailing the normal maturation of the skeleton should be made
available in any department of radiology.
Although measuring distances and angles is a classic radiographic dis
cipline, the precise examination technique required to obtain adequate
measurements is less well known. When measuring the distance between
points A and В (Fig. 8), as in determining the length of the lower ex
tremities, two conditions must be fulfilled:
(1) both points should be in the same plane and equidistant from the
film plane, and (2) the x-ray magnification factor must be known.
376
Figure 6.
Arthrography o f the right hip joint
using 4 ml o f water soluble con
trast medium.
a) AP view
b) Lauenstein projection. Note the
extension o f the joint capsule
along the fem oral neck. The
joint space is delineated clearly
(open arrow), as is the acetabu
lar limbus (arrow).
Figure 7.
Double contrast CT arthrography
o f the patellofemoral joint using
50 cc o f air and 1 ml o f water sol
uble contrast medium. As com
pared to Figure 15 the border o f
the patellar cartilage is clearly
defined (arrowheads). The reti
naculum has torn after a lateral
patellar dislocation (arrow).
Figure 8. Magnification o f an object and

measurement o f distances on radiography.
The length o f the object О is measured us Figure 9. Measurement o f rotational
ing two separate exposures (R-a and R-b) displacement.
o f the same film. Both exposures are p er When two fragm ents (a and b) with
pendicular to О and to the film (orthoradi defined surfaces are displaced around
ographic technique). The length o f 0 is a vertical axis (o), the displacement
equal to the distance that the x-ray table can be measured by two exposures,
was moved between the exposures R-a and each o f which is tangential to the sur
R-b. A t a single exposure from R l a magni faces. The angle o f the direction o f
fication o f the object О will occur, a l - bl. beams between the two exposures rep
I f the distance between the tube R l to the resents the displacement expressed in
object О and the distance between R l and degrees.
the film plane (F) is known, the magnifica
tion can be calculated.
Figure 10. Three-dimensional biplanar measurements o f the anteversion angle o f the

fem oral neck. I f a dry femur is placed on a plate and examined in a transaxial view from
the fem oral condyles to the head, the femoral neck will be noted to have an anterior an
gle in relation to the plane o f the plate (the plane consisting o f the dorsal aspect o f the
two fem oral condyles). This an
gle is defined as the anteversion
angle (OH). The angle is calcu
latedfrom two perpendicular
views o f the proximal end o f the
fem ur and one lateral view o f
the fem oral condyles. By mea
suring the distances a and b, re
spectively, from the central axis
o f the fem oral diaphysis (o) to
the center o f the femoral head
(h) in both projections, the an
teversion angle a f is calculated
or measured directly on a
drawing.
378
Such measurements are performed with accuracy using orthoradi

ographic technique (Fig. 8). A prerequisite for direct measurement of an
gles is that both arms of the angle be positioned in the same plane par
allel to the film plane. This condition rarely is fulfilled in the assessment
of displaced fractures of long bones, and in such cases the correct angle
is measured by three-dimensional biplane technique. The size of the mea
sured angles is independent of magnification. Rotational displacement
around longitudinal axes (e.g., fractures of long bones) can be measured
directly if two points of any anatomic surface are defined in each frag
ment (Fig. 9). If two such anatomic landmarks are not available in one
of the fragments (e.g., in a fracture of the femoral shaft or in hip joint re
placement), a biplane technique as demonstrated in Fig. 10 can be used.
A CT examination provides a series of images. Each image corre
sponds to a volume in a three-dimensional coordinate system in which
each anatomic structure in the different slices can be defined by X, Y,
Z coordinates. By simple geometric calculations angles and distances
between the different landmarks can be measured with high accuracy
(Fig. 11).
ANATOMY
In this chapter, it is not possible to present a detailed analysis the nor
mal anatomy of the entire musculoskeletal system as it appears in dif
ferent imaging methods. Rather, several figures display a few anatomic
structures, including the shoulder (Fig. 12), the hand (Fig. 13), the hip
Figure 11. CT in the mea

surement o f angles and dis
tances.
Four transaxial CT sections
o f the knee and lower leg are
displayed. In each section
anatomic landmarks (e.g., a
and b) are defined with X
and Y coordinates when us
ing the region o f interest.
The Z coordinate is repre
sented by the distance be
tween the different slices. By
simple calculations ana
tomic angles and distances
in all planes are determined
with high accuracy.
379
Figure 12.
Normal anatomy o f the shoulder,
a) A P radiograph, b) Tl-weighted
coronal MR image, c) Tl-
weighted transaxial MR image
A = acromion, В = biceps tendon,
Cl = clavicle, Cg = scapula with
the glenoid cavity, D = deltoid
muscle, H = humeral head,
I = infraspinatus tendon and mus
cle, P = coracoid process,
Sc = subscapularis tendon and
muscle, Sm = supraspinatus mus
cle, arrows = glenoid labrum.
(Fig. 14), and the knee (Fig. 15). These figures should be used for com
parison with other figures in the chapter that demonstrate other abnor
mal conditions.
PATHOLOGIC CONDITIONS
Physical injury
Physical abuse to bone and soft tissue represents the most common in
dication for radiologic examination of the musculoskeletal system.
However, radiography does not constitute the most important part in the
evaluation of trauma. The initial stage in the care of the injured patient
should be to obtain a detailed history and to perform a careful physical
examination, including determination of the mechanism of the injury,
380
b
hamulus ossis
hamati
hamatum
trapezoideum
trapezium
triquetrum
capitatum
scaphoideum
lunatum
pisiforme
d
Figure 13. Normal anatomy o f the hand.
a) PA radiograph, b) lateral radiograph. The
joint surface o f the distal end o f the radius is
angulated volarly 10 to 15 degrees, v = volar,
d = dorsal.
c) Anatomic drawing o f the bones o f the carpus.
d) Coronal CT section o f the carpus and wrist.
e) Tl-weighted coronal MR image o f the wrist.
381
Figure 14.
Normal anatomy o f the hip.
a) AP radiograph o f the left hip
b) Transaxial CT section o f left hip
с and d)
T l- (c) and T2-weighted (d) coronal MR
images o f the adult hip.
e) Tl-weighted coronal MR-image o f the
right hip o f a child
A = acetabulum, Af= fem oral artery,
С = fem oral head, E = epiphysis,
G = gluteal muscle, M = metaphysis,
T = greater trochanter, V = fem oral vein,
open arrows = hip joint capsule, white
arrows = cartilage.
382
Figure 15. Normal anatomy o f the knee joint,

a) AP radiograph, b) lateral view, c) transaxial
view o f the patellar joint, d) transaxial CT sec
tion, e) Tl-weighted transaxial MR image, f)
Tl-weighted sagittal MR image.
А V = popliteal arteiy and vein, Bx = posterior cruciate ligament, E = intercondylar
eminence, F = fibula, Fx = anterior cruciate ligament, Lp = patellar ligament, P =
patella, Q = quadriceps tendon, white arrows = cartilage, open arrows = joint capsule.
383
whenever possible. A radiographic examination should never be con

sidered a substitute for the history and the physical examination; serious
injuries commonly exist in the absence of radiographic findings. It is
mandatory that significant data provided by the history and the physical
examination be included on the request for radiographic examination if
a relevant and sufficient examination is to be obtained. In any case, the
radiologist also should assess the injury by performing his or her own
physical examination.
The initial radiographic examination should include well-known stan

dard views, which are used because they have been found to demonstrate
most abnormalities. To do less than this will compromise the evaluation.
Under no circumstances should radiographs in a single plane only be
considered adequate. Radiographs in two planes at right angles to each
other are the minimum, although additional oblique views often are nec
essary. The imaging assessment of the injury may require information
obtained from methods other than conventional radiographs, such as
sonography, CT, MRI, or bone scintigraphy, which commonly demon
strate the extent of the injury within the soft tissue or bone marrow.
Successful treatment starts with accurate diagnosis. The physician
should be familiar with the common pathogeneses of injury. Certain ac
tivities result in specific forms of injury, following a typical pattern com
monly related to the age of the patient, the type of trauma, and its loca
tion. Insufficient knowledge of the mechanism and circumstances of in
jury is the most common reason for misinterpretation of radiographs after
trauma. For this reason, emphasis in this chapter is placed on the general
principles governing the analysis of the most common fractures and dis
locations and on those injuries that, when overlooked, may result in se
rious complications.
Terminology
A fracture, in its most simple definition, is a break in the continuity of
bone, cartilage, or both, with associated soft tissue injury. It should be
stressed that in many injuries the therapeutic implications of the soft tis
sue lesion may be more important than the associated break of bone.
A closed fracture indicates that the skin is intact. An open fracture is
characterized by disruption of the skin, which allows communication be
tween the fracture and the outside environment.
384
Figure 16. Types o f shaft fractures.

a = bowing fracture, b = torus fracture, с = impaction fracture,
d = complete fracture with two fragments, e = comminuted fracture with three frag
ments.
A complete fracture occurs when the entire circumference (tubular

bone) or both cortical surfaces (flat bone) have been disrupted (Fig. 16).
A complete fracture may consist of two fragments (Fig. 16 d); however,
if more than two fragments are present, the fracture is termed a com
minuted fracture (Fig. 16 e). Incomplete fractures occur in the elastic
bones of children and young adults and are classified into various types,
including traumatic bowing (Fig. 16 a), torus fractures (Fig. 16 b), and
infractions (greenstick fractures) (Fig. 16 c) (see also Chapter 14).
A transchondral fracture represents an injury to the joint. The frag
ments may consist of cartilage alone or both of cartilage and bone and
are termed chondral and osteochondral fractures, respectively.
Osteochondritis dissecans may be the result of such a lesion (Fig. 17).
Bone scintigraphy is an important examination for detection these le
sions, and CT and MRI are needed to visualize their full extent.
Osteochondral fractures are seen most commonly in connection with lig
amentous lesions of joints (e.g., injury of the femoral condyles in ante
rior cruciate ligament tears of the knee).
Bone bruise o f the bone marrow is a term that has been introduced as
a result of MRI findings in patients who have had an injury. It is con
sidered to represent edema or bleeding secondary to traumatic trabecu
lar lesions. A bone bruise is seen most commonly in cases of bone con
tusion and in early stages of stress fractures (Fig. 70).
385
Figure 17.
Osteochondral injury o f the dome o f the talus.
a) A P radiograph o f the left ankle 2 years after a fracture o f the medial malleolus. A
defect with a fragment in the medial aspect o f the talus (arrow) is seen.
b) Coronal CT section o f the ankle joint. The defect o f the talus is visualized clearly,
as is the migrating osteochondral fragment. С = calcaneus, L = lateral malleolus,
Та = talus, Ti = tibia, open arrow = metal artifact caused by the head o f the screw
An impaction fracture results when one fragment o f bone is driven

into an apposing fragment. Two specific types of impaction fractures are
recognized. A compression fracture most commonly involves the verte
bral bodies. A depression fracture results when impacted forces occur
between one hard bone surface and an apposing softer surface, typically
represented by a fracture of the lateral tibial condyle after a valgus force
is applied to the knee (Fig. 44).
An avulsion fracture occurs when an osseous fragment is pulled from
the parent bone by a tendon or a ligament (Fig. 18). On the radiographs
this type of fracture appears as a small thin cortical fragment close to
the joint. In the assessment of an avulsion fracture, the effect of liga
mentous disruption on joint stability must be considered. In the inter
vertebral joints of the spine, the carpometacarpal joints o f the hand, the
ankle, and the articulations in the foot, a single fragment in one radi-
386
Figure 18.
Avulsion fracture o f the medial malleolus
(white arrow).
A fracture o f the distal end o f the fibula is ob
served (open arrow). The avulsion fracture and
the widening o f the joint space medially indi
cate a serious ankle injury (supination-external
rotation injury stage IV).
Figure 19.
Lipohemarthrosis o f the hip joint.
Transaxial CT section o f the right
hip after trauma. The radiographic
examination was normal. The joint
capsule (arrowheads) is displaced
from the fem oral head. A fat-blood
level is present (arrows). The fa t
(of lower density) is located above
the blood.
ographic view may represent complete joint disruption (e.g., fracture-

dislocation) (see later).
A joint effusion containing blood and fat occurring after trauma is
termed a lipohemarthrosis and is reliable evidence of an intraarticular
fracture, the fat being released from the marrow. Radiographic exami
nation using horizontal beam technique may demonstrate a fat-blood
fluid level after injury to the joint and may represent the only sign of bone
injury. Most commonly, this finding is seen in radiographs of a knee or
shoulder, but it also may be noted in those of other articulations, including
the elbow and hip (Fig. 19).
387
\
a
\ b
Figure 20. Reporting o f fractures (see text).
Radiographic report
n
с d
An accurate and concise radiographic report is an important responsi

bility of the radiologist, yet one that commonly is ignored. A radiographic
report that includes such terms as "satisfactory" or "unsatisfactory" in
describing the position is of no value, as this decision is better left to the
orthopedic surgeon. The report should accurately describe the charac
teristics of the injury and its type and stage, using precise and accepted
terminology.
Location and appearance

The distance of the fracture from a defined landmark (e.g., a joint space),
the course of the fracture (transverse, oblique, or spiral), and the num
ber and displacement of fracture fragments are noted in the report.
D isplacem ent (Fig. 20 a)

The radiographic report also describes the position of the fracture (i.e.,
the extent of the dislocation, expressed as a percentage o f bone width as
seen on two perpendicular views; Fig. 20 a); shortening or compression,
measured precisely in centimeters or millimeters (Fig. 20 b); and angu
lar displacement, reported in degrees, on frontal views (Fig. 20 c), on
lateral views, and with internal or external rotation along the long axis
of the bone (Fig. 20 d).
By convention, the displacement of the distal fragment is described in
relation to the proximal one.
388
Figure 21. Fracture o f the distal end o f the radius (Colies fractures).
a) PA view, b) lateral view. The angulation occurs in a dorsal direction, v = volarly,
d = dorsally.
Injuries o f the upper extremity

Fractures of the distal portion of the forearm and the wrist are the most
common injuries of the entire skeletal system and among the injuries that
are overlooked most frequently. These injuries are well suited to illus
trate the general principles that govern the analysis of fractures and dis
locations as a whole.
Forearm
The distal end of the radius is expanded and has a slightly concave sur
face that articulates with the carpal bones (Fig. 13). In the lateral view,
the distal surface of the radius is angulated 10 to 15 degrees in a palmar
or volar direction (Fig. 13 b). A fracture of the distal portion of the ra
dius most often reveals posterior angulation with impaction of its dorsal
surface, a pattern commonly termed a Collesfracture (Fig. 21). Although
cortical disruption may not be seen in the frontal and lateral radiographs,
the absence of palmar angulation of the joint surface is indicative of a
radial fracture with dorsal impaction. The fracture often is comminuted,
with articular involvement. In 60% of the cases there is an associated
fracture of the styloid process of the ulna.
Injury to the distal portion of the radius in children may involve the
physis, most commonly is a Salter-Harris type II injury (Chapter 14), and
389
Figure 22. Epiphysiolysis o f the distal end o f the radius with displacement in a dorsal
direction, Salter-Harris type II injury (see Chapter 14). Two years after the injury
there is premature closure o f the physis and severe deformity.
may lead to displacement of the epiphysis (Fig. 22). In the child, bone
displacement and angulation commonly occur in a dorsal direction.
A fracture of the distal end of the radius also may appear with volar
angulation of the distal fragment. This fracture is the opposite of a Colies
fracture and therefore, often is referred to as a reverse Colies fracture or
Smith type fracture (Fig. 23). A striking similarity is seen in the appear
ance of a Colies and a Smith type fracture on the posteroanterior (PA)
view of the wrist. The precise diagnosis is made on the lateral view, which
clearly demonstrates that in cases of a Smith type fracture, the distal frag
ment is displaced anteriorly with palmar angulation of the radial articu
lar surface. The Colles fracture and the Smith type fracture both are
treated with closed reduction of the displacement even when commin
uted and when intraarticular extension is present.
390
Figure 23.
Fracture o f the distal end o f the radius
o f Smith type with displacement volar ly
(v).
Figure 24.
Intraarticular fracture o f the distal end
o f the radius, fracture-dislocation,
Barton type. The volar lip o f the distal
portion o f the radius is displaced in the
proximal direction, together with the
carpus.
Figure 25.
CT o f Barton type fracture-dislocation.
Sagittal CT section through the base o f
the third metacarpal bone (m), the cap
itate (c), the lunate (I), and the distal
end o f the radius (r). The fracture is in-
traarticular with displacement o f the
volar lip.
The Barton fracture represents a classic example of a fracture-dislo-

cation. In 1838 Barton described a fracture of the rim of the distal radial
joint surface in the coronal plane with the volar lip of the distal end of
the radius being displaced proximally together with the carpal bones
(Figs. 24, 25). Fractures involving the volar rim are more common than
those involving the dorsal rim (original Barton fracture). Open reduction
with fixation of the larger fragments is required in this type of fracture-
dislocation. The Barton fracture may be associated with a Smith type
fracture, which may lead to some diagnostic confusion, and conventional
tomography or sagittal CT images may be helpful to confirm the pres
ence of disruption of the radiocarpal joint (Fig. 25).
H and
The Bennett fracture is an oblique fracture of the base of the first
metacarpal bone. The metacarpal bone is pulled dorsally and radially by
the abductor pollicis longus tendon. The fracture extends into the first
392
Figure 26.
Bennett injury (intraarticular fracture-dis-
location o f the first carpometacarpal
joint). Note displacement o f the dorsal
fragment in a proximal direction (arrow).
Figure 27.
Intraarticular fracture-dislocation in the
fifth carpometacarpal joint: ”reverse
Bennett fracture".
393
Figure 28. Fracture-dislocation o f the fourth andfifth carpometacarpal joints.

a) AP view o f the carpus reveals a small fragment between the base o f the third and
fourth metacarpal bones (arrow).
b) The lateral view reveals a dorsal fracture, which initially was overlooked (arrow).
c) Sagittal CT section demonstrates fracture-dislocation o f the fifth carpometacarpal
joint with a fracture o f the dorsal lip o f the hamate displaced in a proximal direc
tion. m = fifth metacarpal, t = triquetrum, I = lunate, и = ulna, h = hamate
d) pin fixation after open reduction o f the injury.
394
carpometacarpal joint, isolating a fragment consisting of the volar lip of

the base of the first metacarpal bone. This volar fragment remains in place
(Fig. 26). The Bennett fracture requires surgical reduction with pin fix
ation. Conversely, a transverse fracture at the base of the first metacarpal
bone is relatively benign and without joint instability, but it may be com
minuted with intraarticular extension (Rolando fracture). Fracture-dis-
locations may be seen in any carpometacarpal joint. In the fifth car
pometacarpal joint the injury commonly is termed the reverse Bennett
injury (Fig. 27). Fracture-dislocations of other carpometacarpal joints
are relatively rare but important to diagnose (Fig. 28). These injuries are
overlooked easily because many bones are superimposed in the lateral
view. Physical examination is extremely important and even the small
est bone fragment seen in any of the views may indicate a fracture-dis-
location. Conventional tomography and CT are valuable for visualizing
the injury and associated bone displacement (Fig. 28). Displacement of
the metacarpal bones occurs in the dorsal and proximal direction and re
quires pin fixation after reduction.
Carpus
Disruption of ligaments between the carpal bones may result in dis
placement and instability between the carpal bones, most commonly be
tween the scaphoid and the lunate. To assess these lesions, knowledge
of normal anatomy in the frontal as well as the lateral view is necessary.
Carpal instability commonly is visualized only at dynamic examination
during which documentation is afforded by video recording or fluo
roscopy during active or passive movement of the wrist.
Scaphoid
The most commonly fractured carpal bone is the scaphoid. Generally
such fractures occur between the ages of 15 and 40 years; they are rare
in childhood and after the age of 60 years. Approximately 70% of the
fractures of the scaphoid occur in the waist (Fig. 29). The clinical sign
of a scaphoid fracture is tenderness in the anatomic snuffbox. At radi
ography the fracture line may be so fine that it is obscured, and several
views with varying degrees of angulation may be required before the
fracture is identified.
In some cases the fracture simply is not apparent on the initial exam
ination despite strong clinical suspicion. In this situation the wrist is
395
Figure 29. Fracture o f the scaphoid.

Oldfracture through the scaphoid with
delayed union. The density o f the proxi
mal fragment is increased relative to the
distal fragm ent and remaining carpal
bones. The increased density may indicate
osteonecrosis o f the proximal fragment.
Tl-weighted coronal MR image o f the
wrist demonstrates normal bone marrow
signal intensity o f the proximal fragment
but decreased signal intensity o f the fra c
ture and the distal fragment.
Tl-weighted image after intravenous in
jection o f gadolinium contrast agent.
There is enhancement o f the fracture area
and the distal fragment, indicating vital bone. This was confirmed at surgery, during
which the fracture was found to have healed with fibrous union.
placed in a cast or plaster splint and re-examined in 7 to 10 days. If strong

clinical suspicion still exists, a bone scan or MRI will exclude or con
firm the presence of an occult fracture or a bone contusion. Should the
patient be lost to follow-up, delayed union or nonunion of a scaphoid
fracture may occur with or without osteonecrosis of the proximal frag
ment (Fig. 28).
Fractures of the remaining carpal bones are relatively rare.
Phalanges and m etacarpal bones

Fractures of the phalanges are more common than those o f the metacarpal
bones, and fractures of the distal phalanges account for more than half
of all fractures of the hand. Phalangeal fractures commonly are com-
396
Figure 30.
A boxer’s fracture o f the fifth metacarpal bone
with delayed union.
minuted and work-related. A characteristic injury of the fifth and some

times the fourth metacarpal bone is the boxer’s fracture resulting from a
blow struck with the fist. The distal fragment characteristically is angu-
lated volarly. Reduction of the fracture fragment may be difficult, and
healing may be delayed (Fig. 30).
M etacarpophalangeal jo in ts and interphalangeal jo in ts

In the assessment of ligamentous injuries of the joints of the fingers, di
agnosis of a ligament tear usually is accomplished clinically. The initial
radiographic examination is normal except in those cases in which a small
avulsed triangular fragment appears at the site of the insertion of the col
lateral ligament. A typical lesion, termed the "gamekeeper's thumb", is
an injury to the ulnar collateral ligament of the metacarpophalangeal joint
of the thumb. The lesion is particularly common in skiers.
Radius and ulna

Fractures of the shafts of the bones of the forearm are quite common, of
ten caused by a fall on the outstretched hand resulting in a compression
force along the longitudinal axes of the bone. The fractures also may be
caused by a direct blow to the forearm. These forces usually result in a
fracture of both bones, and the diagnosis usually is obvious both clini
cally and radiographically. Two views of the forearm are required to con-
397
Figure 31. Galeazzi injury with Figure 32. Monteggia injury with iso
isolated fracture o f the radius lated fracture o f the ulna and dorsal
and displacement o f the distal angulation associated with ventral
radioulnar joint (arrow). dislocation o f the radial head.
firm the diagnosis; however, care should be taken to include both the el
bow and the carpal bones in the examination so any associated disloca
tion or fracture will not be overlooked. Fractures of the shaft of both
bones of the forearm rarely are merely angulated, either ventrally or dor-
sally. Almost always, some degree of rotation of the distal fragment is
seen. To maintain a normal range of supination and pronation it is im
portant that the degree and nature of the rotational displacement be de
termined radiographically after fracture reduction and fixation.
A fracture of a single bone of the forearm is less common. As a general
rule, an isolated fracture of either the ulna or the radius indicates a high
probability of displacement o f the other bone at the elbow or the wrist.
The definition o f the Monteggia lesion includes radial head displace
ment in any direction associated with a fracture of the ulnar shaft. The
fracture of the ulna is located in the proximal third in 89% of the cases,
in the middle third in 10% of cases, and in the distal third in 1% of cases.
The direction of the displacement of the radial head and the angulation
of the ulnar fracture are characteristic. Most common (65%) is an ante
rior dislocation of the radial head associated with fracture of the ulnar
398
diaphysis at any level, with anterior angulation at the fracture site (Fig.
32). Less common (18%) is a posterior dislocation of the radial head as
sociated with fracture of the ulnar diaphysis with posterior angulation at
the fracture site. In children the ulnar component of the Monteggia le
sion often is a greenstick fracture or, on occasion, a bowing type of in
jury. Most commonly, treatment requires open reduction of the fractures.
A direct blow may result in isolated fracture of one bone particularly
the ulna, without either fracture or dislocation of the other. Isolated frac
tures o f the radius usually occur at the junction of the middle and distal
thirds of the bone and almost invariably are associated with dislocation
of the distal radioulnar joint with disruption of the triangular fibrocarti-
lage (Fig. 31). Treatment almost invariaby requires open reduction. It is
important to look for evidence o f redislocation on follow-up radiographic
examinations of the Monteggia lesion and, in particular, the Galeazzi
fracture.
E lbow
The elbow articulation is composed of three distinct joints, the humero-
ulnar, the humeroradial, and the radioulnar, all contained within one sin
gle synovium-lined cavity, the capsule of the elbow joint. The capsule
comprises two distinct layers, the inner (synovial) layer and the outer (fi
brous) layer. Fat interposed between these two layers, both anteriorly
and posteriorly, is termed the anterior and posterior fa t pads. The initial
examination of the traumatized elbow includes anteroposterior (AP) and
lateral views. In many cases the injury is obvious (Fig. 34), but fractures
with minor degrees of displacement or subtle injuries may be difficult to
see. Therefore, analysis of radiographs of the injured elbow should in
clude a search for the fa t pad sign (Fig. 33). An intraarticular fracture
may allow blood and marrow contents to collect within and to expand
the joint (lipohemarthrosis). If a positive fat pad sign is not present in a
child or adult, significant intraarticular injury is unlikely. However, the
fat pad sign is not specific for trauma; any cause of a joint effusion or
synovitis may give rise to this sign.
The most common injuries of the elbow in adults ar qfractures o f the
radial head and neck (50%),fractures o f the olecranon (20%), disloca
tions and fracture-dislocations o f the elbow (15%), and supracondylar
fractures o f the humerus (10%). Approximately one half of all fractures
of the radial head and neck are undisplaced, and oblique views frequently
399
Figure 33.
Traumatic hemarthrosis o f the el
bow jo in t, the fa t pad sign A fr a c
ture o f the radial head, Salter-
Harris type II (white arrow), is
seen. A jo in t effusion displaces the
ventral as well as the dorsal fa t p a d
(white arrowhead). A normal ossifi
cation center o f the olecranon is
present.
Figure 34.
Displaced supracondylar fracture
o f the humerus in a child.
Figure 35.
Fracture o f the surgical neck o f the humerus
(black arrow) with moderate displacement.
Soft tissue calcification is present about the
greater tuberosity (white arow).
are necessary to disclose them. Fractures of the olecranon usually are ob
vious and readily demonstrated at radiography in the lateral projection.
Most fractures of the olecranon are displaced and require open reduction
and fixation. The elbow is the third most common site of joint disloca
tion in adults, the shoulder and interphalangeal joints of the fingers be
ing the two most frequent. The elbow is the most common site of dislo
cation in children. Soft tissue lesions commonly are the most important
sequelae of these injuries.
In children the supracondylar fractures are by far the most frequent
(60 %), and fractures of the radial head and neck are rare, most commonly
seen as a Salter-Harris type II injury (Fig. 33). Many supracondylar frac
tures are barely visible and recognized only by joint effusion and char
acteristic posterior angulation o f the distal fragment. After open or closed
reduction, it is important to determine external or internal rotation of the
distal fragment (Fig. 9).
H um erus
Fractures of the humeral shaft are common. The shaft of the humerus,
with its wide range of motion and relatively unprotected position, is ex
posed to a variety of stresses that may result in injury. With displaced
fractures, associated injuries of nerves, particularly the radial nerve, are
common. Fractures o f the proximal portion o f the humerus (Fig. 35)
401
most often result from the moderate trauma sustained in a fall from the
standing position, landing on the outstretched hand. The prevalence o f
fracture is two to three times greater in women than in men, and this frac
ture is associated with an increased prevalence of other fractures, par
ticularly of the distal end of the radius and proximal portion of the fe
mur, in patients with osteoporosis. The fractures through the surgical
neck may consist of two fragments but commonly are comminuted, with
significant displacement and multiple fragments involving the joint sur
face. In the presence of severe comminution, CT is helpful in determin
ing displacement and rotation of fracture fragments and their relation to
the glenoid fossa. During the post-injury period, the humeral head may
be displaced inferiorly to such an extent that the joint surface becomes
incongruent giving a false appearance of traumatically induced inferior
subluxation or dislocation. The displacement may be related to the joint
effusion and, in some cases, the weight of the cast.
G lenohum eral jo in t
The glenohumeral joint is the most commonly dislocated joint in the
body, accounting for over 50% of all dislocations. Such dislocations are
uncommon in children. Glenohumeral dislocations are classified as an
terior, posterior, inferior, or superior. Approximately 40% of anterior
dislocations are recurrent. Although posterior dislocations account for
only 3 % of all dislocations, they are troublesome because of the ease and
frequency with which the diagnosis is missed on the initial evaluation.
Posterior dislocations may be bilateral and commonly are associated with
seizures and drug abuse.
In 95% of dislocations of the glenohumeral joint, the humeral head is
displaced anteriorly. The diagnosis of anterior dislocation usually is ob
vious on physical examination. Radiographic examination is confirma
tory, and the dislocation is best demonstrated using the axial or semiax-
ial view. The dislocated humeral head most often rests in the subcora
coid position. Three different complications may be seen: avulsion
fracture of the greater tuberosity (15%); compression fracture of the
humeral head (Hill-Sach’s defect) (60%); avulsion fracture of the ante
rior rim of the glenoid (10%) or, alternatively, a lesion of the anterior
portion of the glenoid labrum, (Bankart lesion), either of which may re
sult in joint instability and recurrent dislocation.
402
Figure 36.
Partial tear o f the supraspina-
tus tendon.
Tl-weighted coronal MR
image shows increased signal
intensity o f the supraspinatus
tendon (arrow) and reduced
signal intensity in the subdel
toid fa t (arrowheads). T2-
weighted MR images con
firmed the presence o f the
tear.
The bone lesions are best demonstrated by CT and the soft tissue le
sion of the anterior labrum by CT arthrography, MRI, or sonography
(Fig. 12).
The rotator cuff in the subacromial space contains four tendons, the
subscapular, supraspinatus, infraspinatus and teres minor tendons.
Anterior dislocations occurring in persons over the age of 45 years fre
quently are complicated by tears of the rotator cuff, but such tears more
commonly are the result of degenerative and inflammatory conditions
(Fig. 36). Diagnosis of a total tear of one of these tendons is based on
the clinical examination and commonly is confirmed at arthrography,
sonography or MRI. Partial tears of the rotator cuff most commonly in
volve the anterior portion of the supraspinatus tendon and their visual
ization by imaging techniques remains a challenge.
Acrom ioclavicular jo in t
Displacements of the acromioclavicular joint are visualized on the frontal
projection of the shoulder with proximal displacement of the lateral por
tion of the clavicle relative to the acromion. Demonstration of acromio
clavicular joint instability by passive traction of the upper extremity has
little clinical significance today.
Clavicle
The clavicle is a very frequent site of fracture. Most fractures of the clav
icle are complete and displaced, but they may appear as either a green-
403
II III IV
Figure 37. The Garden classification offractures o f the fem oral neck.
Figure 38. Types o f intertrochanteric fractures o f the proximal end o f the femur, clas
sified according to the number and localization o f fragments.
stick or a bowing injury as well.
Scapula
Fractures of the scapula commonly are associated with other fractures.
Usually they result from a direct blow to the shoulder, as in a motor ve
hicle accident. CT plays a role in the assessment of complex injuries to
the scapula by establishing the relationship of major fragments.
Injuries o f the lower extremity
P elvis, hip, and fe m u r

Fractures of the femoral neck (Fig. 37) and the intertrochanteric region
(Fig. 38) begin to appear after the age of 45 years, and the frequency then
increases progressively with increasing age, especially in women, re
flecting the effects of osteoporosis. Fractures of the proximal end of the
femur constitute a major public health issue because of their frequency,
morbidity, mortality, and cost. Most fractures are displaced; however,
even undisplaced fractures of the femoral neck should not create diag-
404
Figure 40.
Displaced fractures o f
the pubic rami associ
ated with fracture o f the
left portion o f the
sacrum (arrows).
nostic problems. The demonstration by sonography or CT of a lipohe-

marthrosis (Fig. 19) is indicative of an intracapsular fracture. In the ab
sence of joint effusion a fracture of the femoral neck is unlikely. If an ef
fusion is present, extension and internal rotation of the hip will lead to
elevation of intracapsular pressure and result in severe pain. The pain
and increased intraarticular pressure are diminished by flexion and ex
ternal rotation of the hip or by joint aspiration. Displaced as well as undis
placed fractures require surgical procedures (Fig. 39).
405
Figure 41.
Hip jo in t dislocation.
a) AP radiograph o f the left hip af
ter a motor vehicle accident. A
large fragment appears at the
medial aspect o f the neck. The
position o f the femoral head,
relative to the acetabulum, sim
ulates loss o f joint space.
b) CT examination confirms the
presence o f dislocation
After an injury to the hip joint, a fracture of the acetabulum or the pu
bic rami must be excluded. Therefore, the radiographic examination
should include views of the entire pelvis including both hips and sacroil
iac joints.
Fractures of the acetabulum commonly are subtle and may require
oblique views for diagnosis. Lipohemarthrosis with increased intracap
sular pressure commonly is seen after fractures of the acetabulum.
Fracture of the pubic rami may result in disruption of the entire pelvic
ring. Indeed, fractures of the pubic rami are associated almost invariably
with other fractures of the pelvic ring, especially a vertical fracture of
the sacrum adjacent to the sacroiliac joint (Fig. 40). These secondary
sacral fractures often are inapparent on the radiographs but are confirmed
at scintigraphy, CT, or MRI.
406
Figure 42.
Osteonecrosis o f the femoral head af
ter fracture o f the neck. Almost noth
ing remains o f the head, and the nail
is penetrating the acetabulum.
Dislocations andfracture-dislocations of the hip are relatively rare in

juries, resulting from severe trauma, most commonly motor vehicle ac
cidents (Fig. 41). CT is essential in the management of these injuries.
Osteonecrosis o f the fem oral head after displaced fractures of the
femoral neck and hip dislocations occurs with a frequency
of more than 20%. Ischemia of the femoral head can be demonstrated
shortly after injury by means of bone scan, but radiographic changes
rarely are seen within the first year after the injury (Fig. 42).
Subtrochanteric fractures commonly are considered a subgroup of the
intertrochanteric fractures, occurring in the elderly as a result of falls or
metastatic disease and in the young as a result of severe trauma. Fracture
of the femoral shaft in the young adult is the result of severe violence
and in the elderly person generally is related to metastatic disease. Such
fractures also occur in children, in whom growth disturbance may fol
low the injury. Spontaneous correction of angular and rotational defor
mity may take place in young children but not in adolescents and adults.
Rotational displacement after femoral shaft fractures is determined by
measurement of the femoral neck anteversion by CT (Fig. 10).
407
Figure 43.
Classification o f
supracondylar
fractures o f the
femur.
a) transverse,
b) unicondylar,
and
c) intercondylar.
K nee
Supracondylar fractures (Fig. 43) are most common in elderly women
and are associated with other diseases, such as osteoporosis, os
teoarthrosis, rheumatoid arthritis, or neurologic disorders.
Tibial plateau fractures more commonly involve the lateral plateau
(15%) and are caused by a valgus force to the knee. The femoral condyles
generally are stronger than the tibial plateaus. It is important to deter
mine the presence and depth of depression of the fracture fragments, a
factor that has surgical implications. The extent of the displacment may
not be immediately obvious on standard radiographs (Fig. 44). If the
fractures are comminuted, surgical reconstruction may be difficult and
the development of secondary osteoarthrosis is not uncommon.
Fractures o f the patella occur by direct blows or indirectly from ten
sion forces generated by the quadriceps muscle. The most common frac
ture is transverse and, if displaced, requires open reduction and fixation.
Dislocation o f the patella is a common injury. Lateral dislocations pre
dominate. The dislocation results from an abrupt femorotibial rotation oc
curring during running or dancing with the knee in flexion and with ex
ternal rotation of the tibia. Recurrent dislocation may occur because of
weakening or tears in the medial retinaculum (Fig. 7) or as a result of
anatomic factors, including dysplasia of the femoral condyles or of the
patella, high position of the patella (patella alta) in its relation to the femoral
condyles, or joint laxity, allowing abnormal femorotibial rotation.
During analysis of routine radiographs, which includes assessment of
the transaxial view, it is important for the radiologist to realize that dis
location frequently is associated with chondral or osteochondral frac-
408
Figure 44. Fracture o f the lateral tibial condyle after a fa ll from a height.
a) The radiograph shows displacement offragments o f a lateral condyle, but the sever
ity o f displacement cannot be assessed.
b) Tl-weighted sagittal MRI scan o f the lateral femoral and tibial condyle. Advanced
displacement o f osteochondral fragm ent (white arrows) is present. The tibiofibular
joint is indicated (black arrow).
Figure 45.
Tear o f the anterior cruciate liga
ment.
Tl-weighted sagittal MR image. The
posterior cruciate ligament (white
arrow) is well demonstrated, but
only a small portion o f the anterior
cruciate ligament is visible.
tures. These arise either from the medial facet of the patella, or from the
lateral edge of the femoral condyle, or from both locations. Numerous
operations are proposed to prevent recurrent patellar dislocation, but
many of these result in a high frequency of secondary osteoarthrosis.
Recurrent dislocation is rare after the age of 30 years.
409
Figure 46. Sagittal instability after complete tear o f the anterior cruciate ligament.
a) Standing lateral view o f the knee joint without load to the joint.
b) With weightbearing, displacement o f 12 mm occurs.
Disruption o f the anterior cruciate ligament is a common injury, which

is associated with sport activities. The diagnosis o f a complete tear is
made on clinical examination. Arthroscopy or MRI is confirmatory (Fig.
45). Complete tears, as well as partial tears, may require surgical re
construction. Functional instability of the knee joint is a predisposing
factor for osteoarthrosis and commonly is demonstrated in the routine
lateral view of the knee joint if performed with the knee weightbearing
(Fig. 46).
Tears o f the menisci represent the most common internal lesion of the
knee joint. The diagnosis o f meniscal tear depends on clinical examina
tion and arthroscopy (at which time fine repair can be performed).
Arthrography is a reliable technique to demonstrate and localize menis
cal lesions, but, in large part, it has been replaced by arthroscopy or MRI,
or both (Fig. 47).
Tibia and fibula

It is important that radiographic evaluation of all fractures of the dia-
physes, tibia, and fibula allows visualization of the entire length of the
bones, the knee, and the ankle joint. Fractures of the tibia frequently are
associated with fractures of the fibula, often located at a point remote
410
Figure 47.
Tear o f the medial meniscus.
T2-weighted sagittal MR image o f the
medial portion o f the femur and tibia
using gradient echo technique. There
is a normal low signal intensity in the
anterior horn o f the medial meniscus
(black arrow). In the posterior horn
o f the meniscus a tear is seen (white
arrow). V = joint effusion, В = Baker
cyst.
Figure 48. Fracture o f the lower leg and ankle o f a child.

a) The radiograph demonstrates a spiral fracture extending distally through the physis
and the epiphysis with slight displacement.
b) Tl-weighted coronal MR image o f the ankle demonstrates the extension o f the
lesion within the physis and epiphysis o f the distal tibia as well as the distalfibula.
from the site of the tibial fracture, and the fractures commonly occur in
association with injury of the ankle joint. Indirect forces result in spiral
or oblique fractures of the tibial shaft, and often the fibula remains intact
(Fig. 48). High energy forces may result in comminuted fractures of the
tibia, usually including the fibula. The distal half of the tibia is the most
411
Figure 49.
Staging o f supination-external
rotation injury o f the ankle ac
cording to Lauge Hansen.
common site of delayed union or nonunion in the entire skeleton, and

these complications are increased in frequency if an open fracture is com
plicated by infection. Isolated fractures of the fibula most commonly are
associated with an injury to the ankle or a direct blow.
A n kle
The ankle is the most commonly injured joint in the body. Most ankle
injuries occur in a fall with the foot planted or fixed to the ground as the
leg either angulates or rotates about it. On the basis of mechanism of in
jury, four categories can be distinguished by characteristic fibular frac
tures, the Lauge Hansen classification:
(1) Supination-external rotation (70%)
(2) Supination-adduction (rare)
(3) Pronation-extemal rotation (20%), and
(4) Pronation-dorsiflexion (rare)
Each type of injury occurs in a predictable sequence, and therefore the
presence of a characteristic fracture indicates the presence of specific lig
amentous injuries, even if such injuries are not obvious on the radiograph.
Supination-External Rotation (SER) (Figs. 49, 50)

Stage 1 (SER-1): Rupture of the inferior anterior tibio-fibular
ligament
Stage 2 (SER-2): Stage 1 plus oblique spiral fracture of the
lateral malleolus
Stage 3 (SER-3): Stages 1 and 2 plus fracture of the posterior
lip of the distal end of the tibia or a tear of
the posterior tibiofibular ligament
412
Figure 50.
Supination-external rotation injury o f the ankle
stage IV.
a and b)
AP (a) and lateral (b) radiographs demonstrate
a fracture o f the distal end o f the fibula and the
medial malleolus as well as an avulsion fracture
o f the posterior lip o f the tibia (arrowheads),
c) Postoperative radiograph after fracture reduc
tion and fixation o f this stage IV injury.
Figure 51.
Staging o f pronation-external rota
tion injury o f the ankle according to
Lauge Hansen.
413
Figure 52.
Pronation-external rotation injury, stage I V o f
the ankle.
AP (a) and lateral (b) radiographs reveal a
fracture o f the fibula at a high level and a sm all
avulsion fracture o f the posterior lip o f the tibia
(arrow). According to the staging, the injury in
cludes complete tear o f the deltoid ligament o f
the medial malleolus.
Stage 4 (SER-4): Stages 1 to 3 plus transverse or oblique fracture

of the medial malleolus or a tear of the deltoid
ligament
Pronation-Extemal Rotation (PER) (Figs. 51, 52):
Stage 1 (PER-1): Transverse fracture of the medial malleolus or
tear o f the deltoid ligament
Stage 2 (PER-2): Stage 1 plus tear of the inferior anterior tibio
fibular and interosseous ligaments
Stage 3 (PER-3): Stages 1 and 2 plus tear of the interosseous
membrane to the level of a spiral fracture of the
fibula 7 to 8 cm or more proximal to the tip of
the lateral malleolus
Stage 4 (PER-4): Stages 1 to 3 plus avulsion fracture of the
posterior lip of the tibia or a tear of the posterior
tibiofibular ligament
This system indicates that stages 3 and 4 injuries cannot be excluded ra
diographically in the absence of a fracture of the posterior lip of the tibia
and medial malleolus, respectively.
The supination-adduction or pronation-dorsiflexion injuries are sel
dom seen and, therefore, a detailed stage classification is not given.
414
Figure 53.
Osteochondral fracture o f the dome o f
the talus, osteochondritis dissecans.
T2-weighted coronal, gradient echo
MR image o f an ankle in a young
woman one month after injury to the
ankle. The cartilage has high signal
intensity. The osteochondral lesion ap
pears at the medial aspect o f the dome
o f the talus (arrow). The lesion is cov
ered by cartilage.
If an isolated fracture of the medial malleolus is present or the patient

has clinical evidence of a deltoid ligament lesion but no fracture is seen
in the distal end of the fibula, radiographs of the entire lower leg are re
quired to rule out fracture of the proximal portion of the fibula as part of
a pronation-extemal rotation injury.
Ankle injuries may be associated with different degrees of displace
ment with or without widening between the talus and the malleolus.
Severe displacement should be reduced in the emergency room prior to
examination in the radiology department, and assessment of any vascu
lar lesion is mandatory to prevent delay in treatment.
Most orthopedic surgeons agree that stages 3 and 4 ankle injuries are
unstable and require internal fixation of the fracture site and that the lig
amentous injury should be identified and sutured at the same time (Fig.
50). Ankle lesions in children are relatively rare. Involvement of the ph-
ysis, especially Salter-Harris types III or V (Fig. 48), is associated with
a high rate of premature closure of the growth plate.
F oot
Injury to the tarsus requires a number of specific radiographic views to
assess complete fractures or avulsion fractures. CT is useful and easily
performed in different planes, especially for evaluation of the talus and
the calcaneus (Fig. 17). Ankle injuries may be associated with osteo
chondral fractures of the dome of the talus, resulting in osteochondritis
415
Figure 54.
Displaced fracture-dislocation
o f the first through fourth ta rso
metatarsal joints, the Lisfranc
jo in t (arrows), and avulsion
fractures between the base o f
second and third metatarsal
bones (short arrow).
dissecans, which can be depicted by CT or MRI (Figs. 17, 53).

Fracture-dislocation o f the tarsometatarsal jo in t, commonly
referred to as the Lisfranc dislocation, is an important injury, not to be
ignored or missed. When the components are displaced, the injury is
rarely overlooked (Fig. 54). If the bones are displaced slightly or are
undisplaced, the lesion may be misinterpreted as a "simple" abnormal
distorsion of the foot. The result of conservative treatment may be poor.
Subtle findings indicating the true nature of the injury include the fol
lowing:
(1) one or more avulsion fractures of the bases of the metatarsal bones
(Fig. 55), (2) widening between the bases o f the first and second
metatarsal bones (Fig. 55), (3) one or more fractures through the bases
of the second, third, or fourth metatarsal bones or (4) fracture or avul
sion fracture of the lateral aspect of the cuboid bone (Fig. 55 d).
When one or more of these lesions are present, the diagnosis of afrac
ture-dislocation o f the Lisfranc joint is justified. CT in the longitudinal
plane will demonstrate the true nature of the injury, revealing multiple
avulsion fractures about the tarsometatarsal joints that are inapparent on
plain radiographs (Fig. 55 d). Open reduction with pin fixation is the
treatment of choice.
Transverse fractures o f the proximal portion o f the fifth metatarsal
bone are relatively common. Two distinct types occur: one is an avul
sion fracture of the tip of the tuberosity, where the peroneus brevis ten
don is attached. The other transverse fracture of the proximal shaft of the
416
Figure 55. Fracture-dislocation o f the Lisfranc joint after fa ll during jogging,

a and b) AP (a) and oblique (b) radiographs show small avulsion fractures between
the bases o f the metatarsal bones (arrows) and a slight increase in distance
between the bases o f the first and second metatarsal bones,
с and d) CT sections o f the tarsometatarsal joints confirm the extension o f the injury
throughout the Lisfranc joint (ventral arrows) with multiple avulsion frac
tures, including one at the lateral aspect o f the cuboid (horizontally oriented
white arrow in d).
fifth metatarsal bone commonly is referred to as the Jones fracture. In

children the longitudinally oriented apophysis found at the lateral mar
gin of the base of the fifth metatarsal bone may be mistaken for an avul
sion fracture.
The remaining fractures of the shaft and neck of the metatarsal bones
and phalanges usually are the result of heavy objects falling on the foot
and rarely give rise to diagnostic difficulties.
417
Figure 56.
Stress fracture (march fracture) o f the second
metatarsal bone. The radiograph demonstrates p e
riosteal thickening and a small fracture line at the
medial aspect o f the bone. The patient had had
symptoms fo r six months, but relief ofpain oc
curred after one month at rest.
Figure 57.
Stress fracture o f the
tibia o f a child.
a) The radiograph
demonstrates periosteal
proliferation at the lat
eral aspect o f the tibia.
b) Note increased uptake
at bone scintigraphy.
Although the lesion
could represent a benign
tumor (osteoid osteoma)
or osteomyelitis, the pa
tient had pain only dur
ing physical activity,
which confirmed the di
agnosis o f a fatigue fra c
ture.
a b
Stress fractures
Two types of stress fracture can be recognized: a fatigue fracture, re
sulting from the application of abnormal stress or torque to a bone with
a normal elastic resistance, and an insufficiencyfracture, occurring when
normal stress is placed on a bone with deficient elastic resistance.
Pain with pain relief at rest or with reduced physical activity is typi
cal of fatigue fractures. The most common fatigue fracture is that of the
418
Figure 58.
Periosteal proliferation o f the distal end o f the
tibia and fibula in chronic venous insufficiency.
metatarsal shafts, often called the march fracture (Fig. 56). Stress frac
tures of the shafts of the long bones usually show periosteal proliferation
(Fig. 57) and, sometimes, a horizontally oriented linear defect. Bone scan
demonstrates increased radionuclide uptake and MRI, using fat suppres
sion sequences, shows extensive abnormalities within the bone marrow.
The differential diagnosis of the imaging findings of stress fractures
include tumors (Fig. 88) and osteomyelitis. In adition, hypertrophic os
teoarthropathy and venous insufficiency may lead to periosteal prolifer
ation (Fig. 58).
Stress fractures about the knee and hip are described in relation to os
teoarthrosis.
Osteochondritis dissecans
Osteochondritis dissecans generally is believed to represent a sequela of
osteochondral fractures caused by shearing, rotatory, or tangentially
aligned impaction forces (Figs. 17, 53). The most typical location is in
the medial or lateral femoral condyles (Fig. 59). Osteocartilaginous frag-
419
Figure 59. Osteochondritis dissecans o f

the lateral fem oral condyle.
a) The AP radiograph o f the knee reveals
a typical osteochondral lesion with a
defect containing a fragment, located
centrally in the femoral condyle.
b) Sonography with sagittal sectioning o f
the posterior aspect o f the lateral
femoral condyle demonstrates the nor
mal cartilage o f the condyle (arrow
heads) and a defect not covered by car
tilage (arrow).
F = femoral condyle, T = tibial condyle
ments may be partially or completely detached, but often they are cov
ered with cartilage and may be visualized by sonography or MRI (Fig.
59). Other locations of osteochondritis dissecans are the patella, the talus
(Figs. 17, 53), and the capitulum of the humerus.
420
Figure 60. Osteoarthrosis and arthritis.

Schematic drawing contrasting the typical anatomic changes in
osteoarthrosis (a) and inflammatory join t disease (arthritis) (b).
a) Local joint space narrowing, marginal osteophytosis, subchon
dral sclerosis, and cysts in the weightbearing or pressure area.
Secondary synovitis is evident.
b) Synovitis, eroding both the articular cartilage and the adjacent
bone (bare areas and subchondral bone) is observed.
Degenerative disease in peripheral joints

Although terminology for degenerative arthritis that is accepted world
wide has not yet been established, degenerative joint disease is the best
general phrase to describe degenerative changes in any type of articula
tion (i.e., synovial, cartilaginous, or fibrous). The terms osteoarthritis
and osteoarthrosis are reserved for degenerative disease of synovium-
lined joints. Because in most of the affected articulations inflammatory
changes are not pronounced, the suffix -osis appears more appropriate
than -itis and therefore the term osteoarthrosis is used throughout this
chapter.
Osteoarthrosis is defined as a non-inflammatory, localized degenera
tion of hyaline cartilage (Fig. 60). In comparison, rheumatoid arthritis is
a disorder of the synovial membrane (i.e. synovitis) with secondary de
struction of the articular cartilage (Fig. 60).
Etiology and pathogenesis o f osteoarthrosis

The causes o f this common articular disease are diverse. Both systemic
factors (such as genetics, advancing age, nutritional and metabolic sta
tus, and physical activity) and local factors (such as trauma and preex-
421
Figure 61.
Subchondral lesion after jo in t in
stability.
Tl-weighted sagittal MR image
o f a fem oral condyle in a 19-
year-old woman, 9 months after
complete tear o f the anterior cru
ciate ligament (same patient as
in Fig. 46). At open surgery the
cartilaginous surface appeared
normal, but at palpation the car
tilage covering the defect was
depressed.
isting articular disease or deformity) are important. Traditionally, de

generative alterations have been thought to begin in the articular carti
lage with disruption of the cartilage matrix and degradation of the chon
drocytes. However, an alternative theory emphasizes the initial role of
subchondral bone abnormalities in the pathogenesis of osteoarthrosis.
According to this theory, stress overload produces microfractures of the
trabeculae in the subchondral region; repair of these fractures subse
quently leads to stiffness of the bone, exposing the overlying cartilage
to increasing force and secondary degeneration.
Joint instability occurring after ligamentous tears plays an important
role in the development o f osteoarthrosis. In the knee joint after com
plete tear of the anterior cruciate ligament, the first signs of osteoarthro
sis may appear in the subchondral bone of the femoral condyles as vi
sualized by MRI (Fig. 61). These lesions consist of fibrovascular inva
sion of the bone marrow and osteonecrosis, and they may heal if the
instability is reduced before further deterioration takes place.
In general, the progression of osteoarthrosis is slow, but joint insta
bility in some joints (e.g. the tarsometatarsal) may lead to advanced os
teoarthrosis in only a few months.
422
Figure 62. The natural course o f osteoarthrosis o f a knee joint.

a) Weightbearing radiograph reveals medial joint space loss, subchondral sclerosis,
marginal osteophytes (open arrows), and varus displacement as measured from the
hip-knee-talus line (black lines).
b) Weightbearing radiograph o f the same patient four years later shows increasing
varus deformation, lateral instability, femorotibial subluxation, and involvement o f
the lateral compartment (black arrow).
Imaging o f osteoarthrosis: general aspects
Conventional radiography
The radiographic definition of osteoarthrosis is confined to the demon
stration of a localized reduction of the joint space (Fig. 62).
One of the characteristic radiographic alterations of osteoarthrosis is
the development of osteophytes at the margins of the joint (Fig. 62).
Osteophytes, however, are not synonymous with osteoarthrosis and may
be seen in other conditions without loss of cartilage. After cartilage loss,
the subchondral bone reveals varying degrees of sclerosis (Fig. 62), and
subchondral cyst formation is an important and prominent finding in os
teoarthrosis (as well as in other articular disorders) (Fig. 60).
The routine radiographic examination must employ correct technique.
Three conditions should be fulfilled (Fig. 63).
1. The direction of beam must be tangential to the subchondral bone
423
Figure 63. Radiographic examination in osteoarthrosis: technique.

a) Normal joint. The beams from the tube (R) are tangential to the subchondral bone
and the joint space (L) is correctly delineated on the film (F).
b) Normal joint. The direction o f beam is not tangential and jo in t space will appear
reduced.
c) Cartilaginous defect o f apposing joint surfaces. The direction o f the beam is cor
rect, being tangential to the subchondral bone. The total extent o f joint space loss
will then be reflected on the film.
d) Only the depth on the lower lesion o f the cartilage will appear on the film.
e) Apposing joint surfaces are resting on cartilage o f normal height, and the joint
space will appear normal. This situation commonly occurs at weightbearing exami
nation o f a knee joint in extension.
2. The joint must be placed in such a position (e.g., flexion-extension)

that the central beam is tangential to the most severely involved parts
of the cartilaginous lesions
3. Stress views (e.g., weightbearing) are mandatory when examining
some joints, most importantly the knee joint (Fig. 65).
B one scan and M RI

Bone scam play an important role in the evaluation of osteoarthrosis in
those cases in which the joint space appears normal on routine radio
graphs. Characteristically, a focal increased uptake at the site of the
subchondral lesion and a slight, diffuse inreased uptake as a result of
424
b
Figure 64. Medial osteoarthrosis o f the
knee joint.
a) Weightbearing radiograph shows
moderate joint space loss.
b) Scintigraphy demonstrates a localized
lesion o f the medial tibial condyle and
an slightly increased uptake generally
within the knee joint.
c) Tl-weighted coronal MR image
demonstrates a localized cartilaginous
lesion and a large subchondral abnor
mality o f the tibial condyle corre
sponding to increased uptake at
scintigraphy, which were visible on
the radiograph.
synovitis are seen (Fig. 64). The intensity of the uptake varies.
MRI has some limitations in the demonstration of early cartilaginous
lesions but clearly allows visualization of some subchondral lesions not
visible at arthroscopy (Figs. 61, 64, 66). There is some lack of correla
tion between the extent of joint degeneration as seen with routine radi
ography and the severity of symptoms, but this correlation is better for
scintigraphy and MRI.
425
Figure 65.
Weightbearing examination o f the knee
joint, technique.
The lower leg is placed with 5 to 10 de
grees o f inclination relative to the film
plane. In this position the central beam
will be tangential to the tibial condylar
plane. In addition, the knee is examined
in 10 to 15 degrees o f flexion.
a
b
Figure 66. Osteoarthrosis o f the hip joint.

a) AP radiograph o f the right hip shows slight
reduction o f the proximal joint space and
subchondral sclerosis.
b) Scintigraphy demonstrates localized in
creased uptake at the proximal joint space
and slightly increased uptake generally in the
joint due to secondary synovitis.
c) Tl-weighted coronal MR image o f the hip
shows a localized subchondral lesion (arrow)
but only slight reduction o f the cartilage
height. These subchondral lesions often are
not seen in T2-weighted images.
с
426
Figure 67.
Examination technique for os
teoarthrosis o f the hip joint.
Oblique lateral radiograph,
obtained in a standing posi
tion, shows total loss o f the
posterior joint space in the left
hip (arrow). In the anteropos
terior view the joint space ap
peared normal.
Radiology o f osteoarthrosis in specific joints
Hip
Osteoarthrosis of the hip commonly is bilateral. The most common lo
cation of joint space loss is the superior aspect of the articulation (75%)
(Fig. 66). Less typically, joint space narrowing occurs medially. To vi
sualize any associated anterior and posterior joint space loss, both AP
and oblique views are required (Fig. 67). The commonly used Lauenstein
projection has no place in the diagnosis of degeneration of the hip joint
(Fig. 63 d).
Treatment is almost confined to total hip replacement (Fig. 10). The
position of acetabular and femoral components of the prostheses can be
assessed on the postoperative radiographs (Fig. 10). Less than optimal
position may result in mechanical loosening.
Knee
The knee joint is a common site of osteoarthrosis, with a female pre
dominance (Figs. 62, 64). Either the medial (90%) or, rarely, the lateral
joint space is affected. When diffuse joint space narrowing involves both
the medial and lateral femorotibial compartments, rheumatoid arthritis
should be considered. Osteoarthrosis of the patellofemoral compartment
usually is combined with abnormalities of the femorotibial compart
ments but may be seen as an isolated finding.
427
Figure 68. The effect o f a high tibial osteotomy in osteorthrosis o f a knee joint.
a) The varus deformity is corrected by cutting a wedge laterally in the proximal p o r
tion o f the tibia.
b) After surgery the femorotibial load is located at the lateral compartment, and (if
subluxation is reduced) at the normal cartilage o f the central portion o f the medial
compartment (white arrow). A jo in t space may appear (open arrow).
Films obtained during weightbearing or varus and valgus stress are

necessary in early stages of osteoarthrosis o f the knee joint. Ideally, the
weightbearing radiographs should be obtained with a patient standing
only on the involved leg in 15 to 20 degrees o f knee flexion (Fig. 65).
Additional exposures using other degrees of knee flexion may be neces
sary to demonstrate the loss of joint space, especially in the lateral com
partment. With the knee in extension, early joint space loss may not be
seen (Fig. 63). The weightbearing technique also allows more accurate
delineation of subluxation, varus or valgus angulation, and lateral insta
bility (Fig. 62).
The treatment of osteoarthrosis of the knee joint includes joint re
placement of one, two, or three compartments and, less commonly, high
tibial osteotomy. With osteotomy, the femorotibial alignment in the
frontal view is restored (or overcorrected) and when successful, sublux
ation and lateral instability will disappear (Fig. 68). Regeneration of car
tilaginous erosions may occur.
A nkle and fo o t
In the absence of previous significant trauma, osteoarthrosis of the an
kle is infrequent, but when it occurs, symptoms may be disabling. If joint
428
Figure 69.
Osteoarthrosis o f the first car
pometacarpal joint with oblitera
tion o f the joint space (white ar
row) and osteophytes (black ar
row).
space loss is inapparent on the routine AP and lateral views, films ob
tained during valgus and varus stress should be used as a supplement.
Scintigraphy and MRI also may play an important role in the assessment
of the ankle joint. Significant degenerative changes may develop at the
first tarsometatarsal joint.
Upper extremity
Shoulder pain is common and usually results from degenerative disease
of the cervical spine, rotator cuff disease, or calcified tendinitis (Fig. 35).
Osteoarthrosis affects the glenohumeral joint, but severe involvement is
rare in the absence of a history of physical injury.
Osteoarthrosis o f the elbow joint is uncommon. It usually follows ac
cidental or occupational trauma (particularly in miners and drillers).
Involvement of thefirst carpometacarpaljoint is not uncommon and can
lead to prominent clinical abnormalities. It is best demonstrated in stress
views of the thumb (Fig. 69). Such involvement commonly is bilateral
and combined with degeneration in the scaphoid-trapezoid joint.
Osteoarthrosis of the distal interphalangeal and proximal
interphalangeal joints of the hand is extremely common, particularly in
the middle-aged postmenopausal women. Clinically detectable bony en
largements about the distal interphalangeal joints are designated
Heberden's nodes. Symptoms are not prominent and cause little disabil
ity.
429
Figure 70.
Stress fracture o f the medial tibial
condyle.
50-year-old man, who appeared
with spontaneous pain medially in
the knee. Weightbearing radi
ograph was normal.
a) Scintigraphy demonstrates in
tensive uptake in the medial
tibial condyle, suggesting a
stress fracture.
b) Tl-weighted coronal MR im
age confirms the presence o f a
stress fracture.
Differential diagnoses
Osteoarthrosis is associated with a localized loss of joint space. The ap
pearance of diffuse joint space loss usually indicates another disease
process, such as rheumatoid arthritis or septic arthritis. Seronegative
spondyloarthropathies (e.g., ankylosing spondylitis, psoriatic arthritis,
and reactive arthritis) are most common in younger patients. A charac
teristic appearance of hip involvement in ankylosing spondylitis is bony
proliferation at the lateral junction of the head and neck of the femur.
If there is clinical suspicion of osteoarthrosis in the hip, knee or ankle
joints but the conventional radiographs are normal, the following dif
ferential diagnoses should be considered:
430
Figure 71.
Bilateral idiopathic osteonecrosis o f
the femoral head in a 25-year-old
man.
a and b) Tl-weighted coronal MR
images o f the right and left hips, re
spectively. On the right, there is
lower signal intensity within the os-
teonecrotic portions o f the femoral
head, with segmental collapse o f the
proximal joint surface and a moder
ate joint effusion. On the left, there
is relatively high signal intensity
within the region o f osteonecrosis,
representing fa t degeneration.
(1) osteoarthrosis (i.e., insufficient examination technique) (Fig. 63), (2)

stress fracture (Figs. 70, 109), or (3) osteonecrosis (early).
Bone scans and MRI play an important diagnostic role in this situa
tion. About the knee, spontaneous osteonecrosis is most common in the
medial femoral condyle and stress fractures are most frequent in the me
dial tibial condyle (Fig. 70). With stress fractures of the femoral neck,
bone scan and MRI will demonstrate the lesion, most commonly located
in the medial aspect of the neck.
431
Osteonecrosis
Ischemic necrosis o f bone is a condition that is secondary to diminished
or disrupted blood supply, often subchondral bone, leading to cell death
and tissue breakdown. An identical process occurring in the diaphysis o r
metaphysis of a bone sometimes is called a bone infarct. The pathogen
esis o f ischemic necrosis of bone is incompletely understood. The defi
cient blood supply may be secondary to occlusion of arteries, veins, or
sinusoidal vessels. Whatever the cause, many believe that a vascular in
cident may lead to bone marrow edema or hemorrhage, resulting in in
creased intraosseous pressure, ischemia, and necrosis.
Causes of osteonecrosis include: (1) trauma, (2) systemic disease, (3)
steroids, (4) arthritis (increased intracapsular pressure), and (5) idio
pathic.
The hip is the most common site of traumatically induced ischemic
necrosis, which may be caused by a fracture of the femoral neck or a hip
dislocation (Fig. 42). Posttraumatic necrosis also may be seen in the
scaphoid, the lunate, and the dome of the talus. Legg-Calve-Perthes dis
ease in a child (Fig. 4) and the idiopathic necrosis o f the adult hip (Fig.
71) are additional examples of osteonecrosis. Atraumatic osteonecrosis
is bilateral in 50 to 80% of the patients.
Bone infarction is a common finding in the diaphysis and metaphysis
of long bones, most frequently in patients reciving corticosteroids and
in those with sickle cell anemia. These infarctions appear as irregular re
gions of marrow calcifications.
Plain film findings of osteonecrosis in an epiphysis occur late in the
course of the disease. Early signs are "cystlike" lesions or the "sub
chondral crescent sign". In addition, segmental collapse of the subchon
dral bone may be seen.
Bone scan is a most sensitive method to demonstrate osteonecrosis of
the femoral head in the immediate posttraumatic period or when a joint
effusion is present. MRI also can demonstrate the osteonecrosis at an
early stage (Fig. 71), and sequences obtained after intravenous adminis
tration of a gadolinium compound play an important role in the assess
ment of revascularization (Fig. 4).
Synovial inflammatory disease

A group of inflammatory diseases of connective tissue may cause bone
and joint changes. These diseases, for discussion purposes, may be di-
432
Figure 72.
Principal anatomy o f the synovial joint.
The inside o f the joint capsule is covered by a synovial
membrane. At the fold between the joint capsule and
bone, the synovial membrane is in direct contact with
bone, which is not covered with cartilage, the so-
called "bare" areas (arrows).
vided into those associated with seropositivity for rheumatoid factor (i.e.,
rheumatoid arthritis) and those that are seronegative for rheumatoid fac
tor (e.g., seronegative spondyloarthropathies (ankylosing spondylitis,
psoriatic arthritis, Reiter’s syndrome, and other types of reactive arthri
tis). All produce significant abnormalities in synovial joints.
General anatomy of the synovial joint

To understand the development of inflammatory joint changes, one must
be familiar with the general anatomy of the synovial joint. It consists of
two bone ends covered with articular cartilage. The joint is surrounded
by a joint capsule, which is lined internally with a synovial membrane.
At the edge between the joint capsule and bone a small area of the bone
is bare (i.e., the synovial membrane has direct contact with bone with
out overlying cartilage) (Fig. 72).
Rheumatoid arthritis
Rheumatoid arthritis (RA) is a common type of arthritis. Its precise cause
is unknown, but immunologic tissue damage is evident. No specific di
agnostic test for RA exists. The diagnosis must be certified on the basis
of clinical, laboratory, and radiologic criteria. Autoantibodies, the so-
called rheumatoid factor, can be found in 75% of patients with RA.
433
Figure 73. Schematic development o f joint changes in RA.

a) Normal joint
b) Synovial proliferation and pericapsular edema
c) The inflammatory synovial tissue (pannus) has covered the surface o f the hyaline
cartilage and have caused erosions o f the cartilage.
d and e)
Progressive destruction o f joint cartilage and underlying bone,
f) A t the end-stage, fibrous ankylosis may occur.
Radiographic pattern o f jo in t changes

At the early stage of RA, synovial proliferation occurs, which causes dis
tention of the joint capsule and edema in the surrounding soft tissues (Fig.
73). This inflammation leads to hyperemia about the joint which is fol
lowed by periarticular osteoporosis. With continued synovial proliferation,
bone erosions develop, particularly in the bare areas where the synovial
membrane has direct contact with bone. These erosions have a character
istic distribution and appearance, especially in the fingers and toes (Fig.
74). The articular cartilage also is destroyed, leading to reduction of joint
space. Finally, segments of the subcortical bone are destroyed and even
tually a fibrous or bony ankylosis may ensue. Paralleling the changes in
the joint are alterations in the ligaments and tendons. Such changes, corn-
434
Figure 74.
Rheumatoid arthritis.
Typical erosions adjacent to the
metacarpophalangeal joints
(arrows). Erosions also are present
adjacent to the proximal interpha
langeal joints. Note the soft tissue
swelling adjacent to these joints.
Figure 75.
Ulnar drift.
Advanced RA with ulnar subluxation
at the metacarpophalangeal joints
("ulnar drift"). The erosions o f the
metacarpal heads are relatively small
in comparison to the extensive de
rangement o f the joints.
bined with muscle inbalance cause subluxation of the joints. One exam
ple of this is ulnar deviation at the metacarpophalangeal joints (Fig. 75).
D istribution o f joint changes

RA usually develops symmetrically. Portions of joints that normally com
municate with each other are affected simultaneously, for instance in the
various compartments of the wrist, midfoot, and knee. Adjacent joints that
normally are separate may develop communication because of soft tissue
destruction (and then they too are affected) e.g., the distal radioulnar joint).
435
Figure 76.
RA in the fo o t with erosions in m etatarso
phalangeal joints and in the interpha-
langeal jo in t o f the great toe (arrows).
Figure 77.
RA in the left hip joint.
General cartilage destruction and cyst
like changes are seen adjacent to the hip
joint (arrow). Compare to the localized
cartilage destruction in osteoarthritis
(Fig 67).
In the wrist and hands, the radiocarpal, distal radioulnar, metacar

pophalangeal, and proximal interphalangeal (PIP) joints are affected,
whereas the distal interphalangeal (DIP) joints are involved infre
quently.
In the feet, involvement predominates in the metatarsophalangeal
joint and the interphalangeal joint of the great toe (Fig. 76). The PIP and
DIP joints rarely are involved. O f the large joints, the knees are affected
predominantly (Fig. 77), and the hips, ankles, elbows and glenohumeral
joints are affected less commonly. The temporomandibular joints are
involved frequently. In the spine the cervical region is involved most
436
Figure 78.
RA with involvement o f the retrocalcaneal
bursa, which is filled with fluid. An erosion is
present in the calcaneus adjacent to the bursa
(arrow).
typically (see Chapter 10).
Changes in ligaments a n d bursae

Synovial membranes also are present in the bursae and tendon sheaths.
Inflammation in these regions leads to soft tissue swelling and bone ero
sion (e.g., at the dorsal aspect of the calcaneus near the retrocalcaneal
bursa) (Fig. 78). Laxity and rupture of ligaments cause subluxations and
dislocations (Fig. 75). In the wrist, the ligament between the lunate and
scaphoid bones often is eroded, resulting in scapholunate dissociation
(i.e., the distance between the lunate and the scaphoid increases).
Destruction of the supraspinatus tendon also may be evident; the deltoid
muscle pulls the humerus in a cranial direction, with diminution of the
distance between the humeral head and the acromion.
Seronegative spondyloarthropathies
These seronegative disorders consist of psoriatic arthropathy, ankylos
ing spondylitis, Reiter's syndrome, and reactive arthritis. The radiologic
pattern of peripheral joint involvement in these disorders differs from
that in RA. Less prominent periarticular osteoporoses and bony prolif
eration adjacent to sites of erosions are typical (Fig. 79). Ultimately, bony
ankylosis is common. In Reiter's disease the feet are involved more of
ten than the hands. In psoriatic arthropathy, the DIP joints or all the joints
of one ray in the hand may be affected. Bone proliferation at the muscle
and tendon insertions (i.e., enthesitis) often can be seen in the seroneg-
437
Figure 79.
Psoriatic arthropathy in the inter
phalangeal joint o f the thumb. In
addition to erosions, there also is
new bone formation (arrows) that
is characteristic o f seronegative
spondyloarthropathy. Soft tissue
swelling is present adjacent to the
joint.
ative arthritides. In ankylosing spondylitis, the sacroiliac joints are af

fected symmetrically, whereas in psoriasis and Reiter's syndrome in
volvement may be asymmetric.
D ifferential diagnosis
In both RA and the seronegative arthritides, cartilage destruction usually
is diffuse, affecting all areas of a joint. In osteoarthrosis, often only the
weightbearing part of the joint is affected and osteophytes are seen. In
gout, the hands and feet are involved, most often the first metatarsopha
langeal joint but also other joints, sometimes without involvement of the
great toe. The joint space may be normal or reduced in width, and mar
ginal bony erosions with a characteristic appearance are seen. Bone pro
liferation leads to overhanging edges about the eroded area. Lobulated
soft tissue swelling may be evident adjacent to the bone erosion (Fig. 80).
Juvenile arthritis
Juvenile chronic arthritis (JCA) consists of a heterogeneous group of
joint diseases affecting children. Seropositive arthritis simulating adult-
438
Figure 80.
Gout in the first metatarsophalangeal
joint. Soft tissue swelling (tophus) adja
cent to the joint and erosions (arrows,
arrowhead). The joint cartilage in the in
terphalangeal joint is preserved.
Figure 81.
Juvenile chronic arthritis. Thickening o f
the proximal and middle phalanges o f the
second to fifth fingers due to periostitis is
seen. Irregularity o f the carpal bones and
general osteoporosis also are present.
type RA may affect children. This type is seen in 5 to 10% of all chil
dren with juvenile arthritis. The largest group, approximately 70%, con
sists of those with seronegative chronic arthritis. The disease usually
starts before the age of 5 years. Most frequently the joints are involved
symmetrically as in seropositive arthritis. Initially, the radiologic findings
439
Figure 82.
Chondrocalcinosis
with calcification
in the medial and
lateral menisci
(arrow).
are identical (i.e., soft tissue swelling and osteoporosis). Because of hy
peremia the epiphyses show increased growth and appear large in rela
tion to the diaphyses. In the hip joint, coxa valga deformity, hypoplasia
of the iliac bones, and acetabular protrusion may be evident. Joint space
reduction and erosions are late manifestations. In the hand, periosteal re
action of the phalanges is identified (Fig. 81). The carpal bones often ap
pear irregular (Fig. 81). In the cervical spine, erosions are seen in the
apophyseal joints and bony ankylosis may develop (Chapter 10).
Premature closure of the physes is common, causing shortening of stature.
In certain types of juvenile arthritis, the joint findings are monoarticular.
Radiologically it may be difficult to differentiate between JCA and he
mophilia, especially if only a single joint is evaluated. Multiple epiphy
seal dysplasia also may cause deformity and joint abnormalities that sim
ulate those of JCA.
O ther arthritides
Pyrophosphate synovitis (i.e., deposition of calcium pyrophosphate di
hydrate [CPPD] crystals), is relatively common, especially in middle-
aged and older patients. CPPD crystals are deposited in fibrous or hya
line cartilage (chondrocalcinosis) or in both (Fig. 82). Common sites of
chondrocalcinosis are the pubic symphysis, knees, and wrists. As a rule,
periarticular osteoporosis is not present, but reduction of the joint space
is seen. Soft tissue swelling may be present during acute attacks of arthri
tis. Degenerative-like changes in certain joints, such as the metacar
pophalangeal, radiocarpal, and patellofemoral articulations, suggest the
440
Figure 83.
Soft tissue calcifications
in SLE with typical local
ization in the lower arm
and at the back o f the
elbow.
Figure 84.
Acro-osteolysis (arrowhead).
diagnosis of CPPD crystal deposition disease.

Systemic lupus erythematosus (SLE) is an immunologic disease of
connective tissue, often leading to polyarthritis. The synovitis may oc
cur bilaterally and symmetrically with the same distribution as in RA.
Soft tissue swelling and periarticular osteoporosis are seen, but joint
space reduction and erosions are rare. Soft tissue involvement often
causes subluxation, and periarticular or diffuse soft tissue calcifications
may be evident (Fig. 83). Acro-osteolysis occurs in SLE but is more char
acteristic of scleroderma (Fig. 84). In rheumatic fever, migrating poly
arthritis may occur, especially in the large joints. Nonerosive arthropa
thy of the hands (Jaccoud's arthropathy) also may be seen.
Infections of bone and joints

A bacterial infection of bone is called osteomyelitis or osteitis and that
of a joint, septic arthritis. Both may be caused by bacterial spread via
the blood stream (i.e., hematogenous spread) or by direct implantation
441
Figure 85.
Osteomyelitis, Brodie's abscess: conven
tional tomography.
There is a large defect in the distal p a rt o f
the tibia with involvement o f the metaph
ysis, physis, and epiphysis.
o f bacteria, such as in open fractures or at surgery.
O steom yelitis
In areas of the world where antibiotics are easily available, osteomyelitis
is rare, but the disease still is encountered commonly in many other
places. The infection often is caused by staphylococcus, but sometimes
also by streptococcus (including Streptococcus pneumoniae), E. coli,
Klebsiella, Haemophilus influenzae, and My cobacterium tuberculosis. It
is important to recover fluid or tissue from the site of inflammation, ei
ther by open surgery or by percutaneous techniques. Treatment with an
tibiotics should be begun after recovery of tissue or fluid, not before. On
the basis of the course of the disease, osteomyelitis may be separated into
acute, subacute, and chronic stages.
Acute osteomyelitis often is seen in children, localized in the meta-
physes. The clinical symptoms and signs are pain, swelling, tenderness,
fever, elevated sedimentation rate, and leukocytosis. Conventional radi
ographic examination initially may be negative, but after a few days or
1 to 2 weeks, irregular osteolytic regions are seen, together with a pe
riosteal reaction. In the early stages of osteomyelitis, diagnosis is better
accomplished with scintigraphy and MRI.
In subacute osteomyelitis, an osteolytic area may be seen in the meta-
physes close to the physis, termed a Brodie’s abscess (Fig. 85).
Surrounding bone sclerosis is typical, and channel-like radiolucent
442
Figure 86.
Chronic osteomyelitis with differ
ential diagnostic features o f a tu
mor.
Frontal (a) and lateral (b) views
reveal a sclerotic area with small
radiolucent regions. At CT exami
nation (c), cortical violation is
seen (arrow). Biopsy showed os
teomyelitis.
regions are virtually diagnostic o f infection.

Chronic osteomyelitis often is the result of previous open comminuted
fracture or surgery, or both. Chronic osteomyelitis occurring after pre
vious fracture or osteosynthesis is one of the most difficult conditions to
treat in orthopedic surgery. It often causes the formation of sinus tracts
leading to the skin surface. A sequestrum (an avascular fragment of bone)
almost always is diagnostic of chronic osteomyelitis.
Garre osteomyelitis is difficult to treat and sometimes is difficult to
differentiate from malignancy. It is characterized by extensive periosteal
new bone formation with cortical thickening, and a positive bacterial cul
ture rarely is obtained (Fig. 86). The differential diagnoses include os
teoid osteoma, stress fracture, and osteosarcoma.
443
Figure 87.
Tuberculous arthritis o f the ankle.
The CT examination reveals wide
spread destruction. There is in
creased density in the distal portion
o f the tibia (Ti) and talus (Ta) com
pared with the calcaneus (C), repre
senting infection and edema in the
spongy bone tissue.
S eptic arthritis
Hematogenous infection may lead to septic arthritis in any joint, but it
is most common in the hip and in the sacroiliac joints. In any joint, sep
tic arthritis may be caused by trauma from an open wound, surgery, or
adjacent osteomyelitis. Septic arthritis occurring in superficial joints gen
erally is easy to diagnose because of joint swelling due to intraarticular
pus or synovitis or both (Fig. 87). Septic arthritis in deep joints, such as
the hip and sacroiliac joints, and in the spine is more difficult to diag
nose.
Septic arthritis o f the hip

Septic arthritis of the hip joint can occur in children as well as in adults,
and it causes severe pain in the acute state because of the increased pres
sure in the joint. This increased pressure may cause circulatory deficiency
in the femoral head, leading to osteonecrosis. The clinical signs of in
creased intracapsular pressure in the hip joint should be well known to
radiologists and other clinicians alike: the patient tries to reduce the pres
sure in the hip joint by lying down with the leg flexed, abducted, and ro
tated externally. Extension and internal rotation of the hip aggravate the
pain.
In the acute stage, the conventional radiographic examination may be
normal. After one week the joint cartilage is reduced and broad erosions
in the femoral neck may be observed. Subsequently, the hip joint may
444
Figure 88. Septic arthritis: ultrasonography and CT.

a) Ultrasonography o f a hip jo in t shows increased distance between the outside o f the
capsule (white arrow) and the fem oral neck (open arrow). It is not possible to judge
i f this is due to an aseptic effusion (coxitis simplex), pus, or synovial swelling.
b) CT shows an inflammatory thickening o f the joint capsule (arrow) without fluid in
the joint.
be totally destroyed.
Synovitis in the hip joint leads to joint fluid that can be detected with
ultrasonography, but it is not possible to differentiate among aseptic fluid,
pus, and hypertrophic synovitis (Fig. 88 a). Fluid also can be identified
with CT (Fig. 88 b) and MRI. In a patient with fluid or synovitis in the
hip joint and with extensive pain and signs of infection, immediate di
agnostic aspiration should be accomplished and, if the result is positive,
the joint should be drained and the patient should be treated with antibi
otic therapy.
When not treated promptly, septic arthritis may lead to total destruc
tion of the hip joint and osteonecrosis (Fig. 89). Many adult patients with
septic arthritis of the hip have RA, osteoarthritis, or malignant disease
or drug or alcohol abuse.
Septic arthritis of the hip joint may be missed for the following rea
sons:
1. Clinical and radiologic examination of the hip joint is incomplete.
2. Lack of knowledge about conditions leading to a joint effusion, in
cluding
A. Nonseptic arthritis, which rarely causes a sizeable joint effusion.
445
Figure 89. Septic arthritis in the hip joint with osteonecrosis in a drug addict.
Radiograph (a) and MR image (b) show a completely destroyed hip joint. After intra
venous injection o f gadolinium contrast medium (b), a linear region o f increased sig
nal intensity is seen, indicating an inflamed synovial membrane (arrows). Increased
signal intensity also is seen in the bone. The joint contains pus andfluid.
B. Osteoarthritis, which also causes small amount of joint effusion,

if any is produced at all.
C. Osteonecrosis.
D. Stress fractures.
E. Malignancy.
3. Lack of knowledge of typical scintigraphic patterns:
A. Osteoarthritis (limited localized uptake of radionuclide)
B. Arthritis (general, extensive increase in radionuclide uptake on
both sides of the joint space.
C. Malignancy (locally increased uptake on one side of the joint
space)
D. Insufficiency fracture and osteonecrosis (localized uptake of the
radionuclide)
D iscitis and spondylitis

These conditions are described in Chapter 12.
Tumors and tumor-like conditions

Bone tumors may cause nonspecific changes, but an analysis of these
changes is very important for the further assessment of the patient. Soft
446
Figure 90.
Localized osteolytic destruction in distal portion o f the fem ur and
permeative destruction pattern more proximally (arrows).
(Metastases from renal cell carcinoma.)
Figure 91.
Permeative destruction pattern (black ar
rows).
Note destruction o f the cortical bone medially
(arrowheads) and the onion-peel periosteal
reaction laterally (white arrow).
(Aneurysmal bone cyst in early stage.)
tissue tumors may grow to a considerable size before a clinical diagno

sis is established.
R eactive patterns o f bone

The reactive patterns of bone that develop in response to benign and ma
lignant tumors may be similar, and these may simulate those of other
conditions, such as inflammation, metabolic diseases, and trauma. The
reactive patterns can be divided into (1) bone destruction (osteolysis),
447
Figure 92.
Sclerotic bone reaction around a local
ized region o f destruction (nonossifying
fibroma).
Figure 93.
Neoplastic bone with high density and irregular
architecture. Also note the perpendicular p e
riosteal reaction. (Osteosarcoma o f the femur,
radiograph o f specimen.)
448
Figure 94.
Periosteal reaction as a single layer (black
arrow) and onion-peel pattern (white ar
row). (Osteoblastoma o f ulna.)
(2) reactive bone formation (osteosclerosis), and (3) periosteal reaction

(periostitis).
Bone destruction can occur as a localized osteolytic region (Fig. 90),
which is seen not only in benign tumors but also with metastatic disease.
Bone destruction also can appear as numerous small cavities, 1 to 5 mm
(Figs. 90, 91), a pattern that may be seen in more aggressive tumors. In
any single tumor, different types of destruction may be present at the
same time.
Bone reaction may be localized about the periphery of a tumor (Fig.
92), or it may be seen as diffuse sclerosis throughout the bone. Neoplastic
bone (i.e., bone produced by the tumor itself) often has an irregular ap
pearance (Fig. 93).
With slowly growing tumor, as well as osteomyelitis, a periosteal re
action may be seen as a thin calcified layer (Fig. 94). If the tumor grows
more rapidly and with varying speeds, several such layers are superim
posed on each other in an onion-peel pattern (Fig. 94). In rapidly grow
ing aggressive tumors, a perpendicular periosteal reaction may be seen
with calcified thin streaks, which may be oriented perpendicular to the
surface of the bone. This last pattern of periostitis relates to elevation of
449
the periosteal membrane due to rapid tumor growth, ingrowth o f c o n

nective tissue and small blood vessels, and mineralization o f bone
(Fig. 93).
Principles fo r radiologic evaluation o f tu m o r

Modem treatment of bone and soft tissue tumors is based on extremity-
preserving surgery in combination with radiotherapy and chemotherapy.
This means that the orthopedic surgeon must remove the tumor with
enough margin to avoid recurrence but at the same time leave as much
normal tissue as possible to preserve maximum function of the extrem
ity. From a radiologic point of view the factors most important to eval
uate are the local aggressiveness of the tumor, the specific diagnosis, and
the local tumor extension.
L o ca l aggressiveness
Aggressiveness relates to how rapidly a tumor grows. Generally a rela
tionship exists between the aggressiveness o f a tumor and the grade o f
malignancy so that a fast growing destructive tumor tends to have a higher
degree of malignancy than a slowly growing benign tumor. This rela
tionship is not absolute, and individual cases often reveal exceptions.
Thus, some benign tumors have an aggressive growth pattern, such as
aneurysmal bone cysts, and some malignant tumors can grow very slowly
over long periods with minimal amount of bone destruction.
Aggressiveness in a bone tumor is best evaluated on the conventional
radiographic examination. Tumors can be categorized as having charac
teristics of slow, intermediate, or rapid growth.
A slowly growing tumor often causes a well-defined zone of osteolytic
destruction surrounded by a sclerotic rim (Fig. 92). When present, a pe
riosteal reaction, often occurring as a single layer, is seen.
A tumor of intermediate growth potential may cause a well-defined
osteolytic region of destruction. The transition zone between the lesion
and the normal bone is narrow and well defined. A sclerotic rim may or
may not be present. The cortical bone may be destroyed or expanded. If
there is a periosteal reaction it usually is seen as one layer or multiple
layers with an onion peel-appearance (Fig. 91).
An aggressive tumor, rapidly growing, shows poorly defined destruc
tion with a broad transition zone between it and normal bone. No scle
rotic rim surrounds the tumor. The cortical bone often is destroyed with
450
Figure 95. POST

Bone scintigraphy for evaluation ofpossi
ble metastases. Increased uptake is ob
served in an osteosarcoma in the distal end
o f the femur, and a metastasis is seen in the
proximal portion o f the humerus (arrow
head). (Same patient as in Figure 96.)
a soft tissue mass outside the bone. The periosteal reaction may have an
onion-peel appearance, or perpendicular striations may be evident (Fig.
93).
The aggressiveness of a soft tissue mass cannot be evaluated radio-
logically. Deep soft tissue tumors (under the deep fascia) must be con
sidered aggressive until proved otherwise.
D iagnosis
A single specific diagnosis may be difficult from a radiologic, pathologic
and clinical point of view. The radiologist must consider a number of pa
rameters in the diagnostic approach:
- The aggressiveness of the tumor
- The multiplicity of the tumor
- The localization of the tumor
- The specific radiologic pattern
- The age of the patient and associated laboratory results and other clin
ical findings
451
A newly recognized tumor may be solitary or multiple. Multiple lesions

may indicate the presence of a multicentric tumor, such as histiocytosis
X, or a primary malignant tumor that already has metastasized. Bone
scintigraphy (Fig. 95) may be useful as both bone and soft tissue tum ors
frequently cause increased uptake of the radionuclide.
Tumor localization also is important. Bone tumors can occur anywhere
in the skeleton, but many tumors predominate in specific locations. M ost
primary bone tumors occur in the long bones, but certain types prefer flat
bones, small bones, or vertebrae. Osteomas often are seen in the skull,
hemangiomas in the skull and vertebral bodies, chordomas at the base
o f the skull and sacrum, and enchondromas in the tubular bones o f the
hand. Localization in an involved bone also can be of diagnostic help.
In the long tubular bones, most tumors are seen at sites where the growth
is most extensive (i.e., in the proximal portion of the humerus, the dis
tal end of the femur, and the proximal end of tibia). Several exceptions
exist, however. Chondroblastomas often occur in the epiphysis before
the physis is closed, and giant cell tumors originate in the metaphyses
and quickly extend into the epiphysis.
In many cases the patterns of bone destruction, bone reaction, and pe
riosteal reaction are nonspecific. Certain tumor types show a specific ra
diologic pattern, however. Osteosarcoma often forms neoplastic bone,
which is seen as irregular, dense areas within the bone or amorphous
dense masses in the soft tissues (Fig. 96). In chondromatous tumors (en-
chondroma and chondrosarcoma), calcifications often are seen as punc
tate or ringlike regions (Fig. 97).
Certain types of soft tissue tumors can be diagnosed with a high de
gree of certainty with CT and MRI (e.g., lipoma) (Fig. 98), but in most
cases the radiologic appearance of soft tissue tumors is not specific. CT
and MRI, on the other hand, contribute to the evaluation of tumor mass,
providing information regarding vascularity and necrotic areas within
the tumor (Fig. 99).
L ocal tumor extension

The local extension of a tumor must be assessed carefully preoperatively.
Previously this was accomplished with several imaging methods, such
as conventional radiography, scintigraphy, and angiography. The addi
tion of CT led to an improvement in the evaluation of tumor location and
extension. Today MRI is the best method to evaluate tumor location and
452
Figure 96.
Osteosarcoma with irregular dense neo
plastic bone in the distal portion o f the fe
mur and amorphous neoplastic bone
masses in the soft tissues.
Figure 97.
Chondrosarcoma with ring-shaped thin
calcifications in the tibia (arrow) and a
minimal endosteal destruction (arrow
heads).
the only method generally needed in addition to conventional radiog

raphy. With MRI the tumor location in bone and tumor extension into
soft tissues or joints can be diagnosed (Fig. 100). Concerning soft tis
sue tumors, MRI can determine the position of a tumor, the structure
from which it emanates, and the involvement of surrounding structures
(Fig. 99).
453
Figure 98.
Lipoma.
a) CT, b) MRI. With both C T
and MRI, the diagnosis is es
tablished without biopsy. The
low attenuation o f the tumor
on the CT examination and the
increased signal intensity in
the tumor with MRI are typi
cal.
Figure 99. Local extension and tissue characteristics o f a soft tissue tumor: MRI.
a and b) T l- and T2-weighted images. The localization o f the tumor in relation to sur
rounding muscles, vessels and nerves can be evaluated. In the T2-weighted image (b)
areas with high signal intensity correspond to necrosis and liquid degeneration.
(Malignant fibrous histiocytoma.)
The skeletal reaction to a pathologic stimulus is nonspecific, and diag
nostic considerations may include other pathologic conditions, such as
infections and inflammatory, metabolic, traumatic, and anomalous le
sions. In some cases, it may be impossible to differentate radiologically
between a malignant tumor and osteomyelitis, and other clinical findings
454
Figure 100.
Local tumor extension: MRI.
The localization o f the tumor in the f e
mur and the violation o f the cortical
bone with soft tissue extension (arrows)
can be seen. (Osteosarcoma.)
or even an open biopsy often is required to reach a specific diagnosis.

Stress fractures have been described earlier in this chapter. When they
occur unilaterally with a diffuse sclerotic reaction it may be impossible
to separate this condition from a tumor on the basis of conventional ra
diographic findings. Clinical history, scintigraphy, and other imaging
data often are required for definite diagnosis.
Ossification anomalies can simulate a tumor radiologically, but, in

most cases, such anomalies occur in specific areas and in specific age
groups.
Sinography and fistulography

Musculoskeletal infections with development of sinus tracts or fistulas
are not uncommon. It is essential for the surgeon to know the relation
ship of the sinus tract or fistula to vital structures, such as nerves and ves
sels but also to joints, bones, and, in some cases, endoprostheses. Contrast
medium is injected through a thin catheter or cone-shaped needle intro
duced into the sinus tract or fistula, and contrast opacification is observed
455
Figure 101. Sinography in a patient with chronic osteomyelitis.

a) It is not possible with conventional technique to determine the relationship o f the si
nus tract system to bone, vessels, or nerves.
b) This relationship is clearly shown with CT, however.
under fluoroscopy. Precise asssessment of the exact anatomic location

of the sinus tracts or fistulas may require CT (Fig. 101).
Diagnostic biopsy
Biopsy of pathologic lesions in bone or soft tissue is an important diag
nostic procedure. Biopsy may be done as a fine needle aspiration or with
larger (trephine) needles (1 to 5 mm in diameter) during fluoroscopic,
ultrasonographic, or CT guidance. CT-guided biopsy is important in cer
tain regions of the skeleton, especially in the upper part of the thoracic
spine, where it is difficult to assess the region with fluoroscopy. Even
small lesions may be biopsied in this way (Fig. 102).
Angiography
A major indication for angiography is localization of sites of vascular
damage and embolization of sites of bleeding, especially in the pelvis
and with certain vascular malformations in the soft tissue.
Arthrography
This interventional method was described previously in this chapter.
456
Figure 102.
CT-guided biopsy o f infective
spondylitis.
The patient is examined in the
prone position. The most infor
mative CT section through the
area o f destruction is chosen.
Guided by the CT image, the
needle is directed towards the
area o f destruction and the
corect position is verified with
additional CT scans.
457
Chapter 14
Pediatric musculoskeletal radiology
Andrew K. Poznanski
In this chapter we will consider the radiologic manifestations of some

musculoskeletal disorders in children. Infection, and tumors in children
will be described in other chapters.
GENERAL PRINCIPLES
Radiographic technique used in children must be chosen so as to decrease
the chance of motion during exposure. The shortest possible exposures
should therefore be used. To permit the shortest exposures, high output
generators with rapidly functioning automatic exposure devices and
grids should be used. If exposures are too short for the speed of the mov
ing grid, grid lines may appear. Immobilization devices are very useful
in pediatric radiology as they help to maintain correct positioning and
minimize motion.
Sedation may need to be used for computed tomography (CT), nuclear
medicine, and magnetic resonance imaging (MRI), particularly in chil
dren under 5 years of age. MRI generally requires more sedation than
CT and nuclear medicine.
With CT of small children not only axial but also coronal and sagittal
views can be obtained of almost every bone. One simply positions the
child so that the plane desired is in the plane of the gantry. This can be
done by either angling the child or the gantry or both. Almost all pro
jections are possible if the child is small enough. For example, in infants
direct sagittal views of the entire spine can be done simply by placing
the infant supine in the plane of the gantry.
In MRI any plane can be obtained without changing the position of the
child. The smallest coil possible should be used to maximize image
quality. For MRI of the hip, one can use a head coil in most children un
der five years of age and an extremity coil can be used in infants. For
459
Figure 1. Small carpus in JRA and a normal wrist fo r comparison.

a) 2.5-year-old girl with severe clinical manifestations o f JRA. Note that the space be
tween the metacarpals and the distal radius appear smaller than in the normal wrist
o f a girl o f about the same age as the patient. This indicates carpal destruction or
lack o f growth.
b) Normal girl 2.9 years o f age.
imaging the knee in small children a wrist coil will produce excellent
images. Gradient echo images with a small flip angle (about 20°) are of
ten very useful in musculoskeletal MRI of children since with this tech
nique cartilage has a high signal and is clearly separated from other tis
sues. The use of a small flip angle helps to separate cartilage from fluid.
The advantage of MRI in evaluating the skeleton of children is that it al
lows visualization of the bone ends which are still cartilaginous. Cartilage
cannot be seen directly with other modalities as it cannot be separated
from other soft tissues. In such situations secondary signs such as rela
tive position or distance between two ossified portions are used to imply
changes in cartilage. When these signs are equivocal MRI is very use
ful. An example of the use of such secondary signs is to evaluate the
carpal bones. The carpal bones are not visible on hand radiographs at
birth; yet, the proportions and shapes of their cartilaginous models are
very similar to those of the adult. Determination of their overall size can
be obtained by measuring the distance between the radial growth plate
460
PEDIATRIC MUSCULOSKELETAL RADIOLOGY
Figure 2.
Asymmetry o f ischiopubic
synchondrosis. The left
synchondrosis is larger
than the right. This is a
normal variant.
and the base of the third metacarpal and comparing it to normal stan
dards. Alternately one can simply compare the radiograph in question to
that of a child of similar age or to a bone age book (Fig. 1).
THE NORMAL PEDIATRIC SKELETON

In evaluation of children's bones it is extremely useful to look carefully
at the growth plate (physis), the metaphysis and the epiphysis (ossifica
tion center). In many pediatric diseases useful diagnostic clues are seen
in these areas because they are areas of rapid growth. One must look
carefully at the width and regularity of the growth plate, the shape and
density the ossification centers, the presence of lucent or dense lines in
the metaphyses, and the degree of modelling of the shaft. One must be
aware of the normal variations in these structures. For example, some
ossification centers such as the tarsal navicular often begin to ossify in
many small fragments and may be sclerotic. This may involve only one
foot and should not be confused with disease. Other common normal
variants, which can often be mistaken for disease, include the prominent
ischiopubic synchondrosis, which can be wide and irregular, sometimes
even unilaterally (Fig. 2) and bowing of the legs in infants. The normal
physiologic bowing should be differentiated from various diseases that
cause bowing. It usually progresses to knock knee deformity which even
tually straightens spontaneously. There are many other such possibili
ties. The reader is referred to textbooks such as Keats Normal Variants
or Kohler's Borderland o f Normal Pathology for further reading. As in
any radiological diagnosis it is essential that the normal variation be
known before pathological abnormalities can be detected. Because of the
461
Figure 3.
Multiple growth lines in a 3-year-old
boy. This boy has received several
courses o f chemotherapy fo r leukemia.
The growth lines are evidence o f arrest
and restart o f growth.
added factor of growth more of these normal variants are seen in chil
dren than adults.
There are a number of lines that are visible in the metaphysis. Small
sclerotic lines in the metaphysis which are parallel to the growth plate
may be seen normally. These have been called Park lines or growth lines
and they simply represent an episode when growth has restarted after it
was arrested. The growth lines are more common when a child under
goes major stresses such as may occur following serious disease. The
lines are often multiple in children undergoing chemotherapy where
many arrests and restarts of growth occur with each treatment (Fig. 3).
Also, multiple growth lines associated with marked retardation of skele
tal maturation can be seen in children with psychological deprivation
(psychosocial dwarfs). The lines are a useful marker of growth of the end
of a bone. For example, if a growth line does not form in a bone end on
one side and forms on the other it indicates that growth has stopped on
the side where no growth line is seen. A growth line further away from
the physis on one side than the other indicates excess growth which could
be due to hyperemia such as may occur in joint disease. Similarly, if af
ter a fracture the growth line is not parallel to the growth plate this is an
462
Figure 4.
Ankle several years after
trauma. The growth lines in
the distal tibia are not parallel
to the growth plate. The
middle part o f the growth line
is very close growth plate,
while both medially and
laterally it is further away.
This indicates a partial fusion
in the middle portion.
Figure 5. Normal zone o f provisional calcification and lead lines.

a) Normal dense zone ofprovisional calcification in the metaphyses o f the femur, tibia
and to a lesser degree the fibula. This is simply a manifestation o f active growth.
b) Child with lead poisoning. The zones o f provisional calcification are somewhat
wider and somewhat denser than in the normal child. The fibular zone ofprovi
sional calcification is much denser than in the normal.
463
Figure 6.
Lucent metaphyseal bands in a
premature infant o f fifteen days o f
age, with broncho-pulmonary dys
plasia.
indication that growth is greater in one part of the growth plate and sub
sequent deformity will occur (Fig. 4).
A dense line at the metaphysis immediately adjacent to the growth
plate is a normal finding in growing children. It is the zone of provisional
ossification. This line can be dense and should not be mistaken for a lead
line (Fig. 5 a). Dense metaphyseal lines caused by lead intoxication are
usually more circumscribed and appear somewhat more dense than the
normal zone of provisional calcification (Fig. 5 b). It is often difficult to
differentiate the lead lines from normal. The lead lines often appear in
areas where the normal zones of provisional calcification are usually not
visible such as in the proximal fibular metaphysis or in the iliac crest.
However, their presence even in those areas does not prove that they are
lead lines as sometimes in rapidly growing children they be seen in these
regions as well. The only way to be certain on radiographs that these
lines are related to lead poisoning is if the lines move away from the
metaphysis and there is a space between the distal metaphysis and the
dense line.
464
Figure 7.
Lucent bands at the time o f birth in
CVM. Similar bands can be seen in
other TORCH infections.
Lucent bands (Fig. 6) at the ends of the bones are usually a sign of
growth disturbance and poor ossification. If they are seen in the neonate
at birth it usually means some growth disturbance occurred in utero such
as may be caused by cytomegalovirus (CMV) (Fig. 7) or rubella. In
rubella and to a lesser degree in CMV linear striations in the metaphysis
parallel to the diaphysis may be seen. In syphilis lucent bands may also
be seen or there may be more destructive changes (Fig. 8) often affect
ing the medial side of distal femoral and proximal tibial metaphyses.
Postnatally metaphyseal lucent bands are very common in infants with
severe distress and are particularly common in hyaline membrane dis
ease and bronchopulmonary dysplasia (Fig. 6). They are of little diag
nostic significance in this age group. In children over two years of age,
however, lucent metaphyseal bands are usually the hallmark of leukemia
(Fig. 9). The leukemic lines can be seen even in children who have a nor
mal peripheral blood smear and when they are noted in multiple bones
a bone marrow biopsy is indicated. They may be the presenting radi
ographic sign of leukemia in a child examined for joint pain.
Occasionally rickets that has been treated can have a similar metaphy-
465
Figure 8.
Syphilis in the
neonate. The lu
cent bands have a
more destructive
appearance than
in CMV, often the
lucent defects in
the fem ora and
tibias are seen
particularily on
the medial side.
Figure 9.
Leukemic line. Lucent metaphyseal
band in a child who complained o f
pain in the legs. When seen in chil
dren over two years o f age these lu
cent bands i f bilateral are usually
indicative o f leukemia.
seal lucent bands. Lucent bands affecting only one bone or limb can be
due to local disease or immobilization.
SKELETAL MATURATION
The process of increasing ossification of the ends of bone with eventual
closure of the growth plates is termed skeletal maturation. Various meth
466
ods are available to determine skeletal maturation. The most practical is

the use of various atlases. The hand atlas of Greulich and Pyle is suit
able for most children over two years of age. Alternatively a scoring
method may be used such as the TW2 method. In infants and children
under two years of age there is relatively little change in maturation with
time in the hand standards. Additional use of the foot and knee atlases is
of value in such situations. There are some racial differences in matura
tion; although, these are relatively small. Nutrition plays an important
part in affecting maturation and growth. Generally speaking malnutri
tion, either due to lack of food or secondary to chronic disease, affects
growth more than maturation. This results in a short adult stature at ma
turity since growth is more affected than skeletal maturation, and growth
therefore ceases relatively prematurely in relation to attained size. It is
the interaction between growth and maturation that determines the final
stature. Skeletal maturation is also affected by various hormones, par
ticularly sex and thyroid hormones. Hypothyroidism severely retards
skeletal maturation as does absence of growth hormone. Absence of sex
hormones in older children causes a delay in maturation since epiphy
seal closure is dependent on their presence. Absence of sex hormones
has little effect in early childhood since they have little effect on onset
of ossification. Excess thyroid hormone and premature sex hormone se
cretion as may occur in precocious puberty cause marked advancement
of skeletal maturation. Skeletal maturation may be disharmonic, where
not all the centers follow the same sequence as the normal standard.
Disharmony is common in many congenital malformation syndromes
and when maturation is markedly retarded or advanced. Some dishar
mony of maturation may occur in normal children. Individual growth
plates may close prematurely in congenital disorders and may affect spe
cific bones. An example of this is the premature closure of the 3rd, 4th,
and 5th metacarpal head growth plates resulting in the shortening of these
bones in pseudohypoparathyroidism and in Turner syndrome.
SKELETAL TRAUMA
Although children may have the same types of fractures as adults, they
also have a number of injuries which are unique to them. The cause of
those differences is the presence in children of the cartilaginous growth
plate (physis) that is the weakest part of the bone. Also, the bones in chil
dren are somewhat softer and more elastic than those of adults and pro-
467
1 2 3
Figure 10. Classicification o f growth plate injuries.

Types 1-5 are those o f Salter and Harris, while types 6 and 7 have been added by
Ogden.
duce types of diaphyseal fractures which do not occur in adults. A ma

jor difference in fractures in children, as opposed to adults, is the occur
rence of growth disturbances, particularly following some physeal frac
tures.
Physeal and epiphyseal injuries

Because the ligaments in children are relatively strong around the joints,
as compared to the strength of the cartilaginous growth plate, many in
juries, which in an adult would cause ligamentous injuries, will cause a
fracture through the growth plate. The physis is involved in 6-18% of
limb fratures in children. Eighty percent of physeal fractures occur be
tween 10 and 16 years o f age. Many, but not all, physeal fractures go
through the hypertrophic zone of the physis. The cartilage in this zone
consists of large cells and contains relatively less matrix than resting car
tilage and is, therefore, weaker. In some cases physeal fractures extend
into the other parts of the growth plate or into the metaphysis on a mi
croscopic level. Physeal fractures may extend grossly into the metaph
ysis or epiphysis.
Except in the hip, the blood supply of the metaphysis and epiphysis is
separate so that fractures through the growth plate usually do not inter-
468
Figure 11.
Salter 1fracture o f
the proximal
humeral epiphysis.
Note the angulation
o f the right epiph
ysis as compared to
the normal left.
fere with the vascular supply to the epiphysis or the metaphysis. Healing
is usually good in these fractures. However, in some cases growth dis
turbances do occur. Salter and Harris devised a classification of growth
plate injuries based on their location. This system has been expanded by
Ogden who added several categories and subdivided the original group
(Fig. 10).
Type 1 fractures
Type 1 fractures pass only through the growth plate (Fig. 11). They
account for approximately 5 % o f growth plate fractures. Often, these
fractures may invole a very small part of the metaphysis that is not
visible radiographically. Diagnosis may be difficult if no displace
ment is seen. There is usually a somewhat greater separation at the
fractured growth plate than on the opposite side or there is angula
tion at the growth plate. In the neonate, these fractures are very dif
ficult to diagnose, particularly if the epiphysis is not yet ossified.
They may only be manifest after a few days when periosteal eleva
tion becomes evident (Fig. 12). The prognosis on these types of frac
tures is very good.
Type 1 fractures may occur in children with neurological impairment
such as in myelodysplasia. These children may still walk on these frac
tures and this results in considerable widening and irregularity at the frac
ture site. This appearance can sometimes be confused with osteomyelitis
(Fig. 13). A similar appearance can occur in the upper extremity - par
ticularly in the distal radius in young adults who keep on doing their sport
469
Figure 12.
Salter 1 fra ctu re
o f the left fe m o ra l
neck in 4-day-old
infant.
Initially this was
confused with a
dislocation o f the
hip. The callous
formation about
the fem oral shaft
was evidence o f
fracture which
was confirmed with
ultrasound and
showed the
fem oral head to be well seated in the acetabulum. Poznanski AK: in Resnick D,
Pettersson H (ed.) Skeletal Radiology: NICER Series on Diagnostic Imaging. Coconut
Creek, Florida: Merit Communications, 1992, p. 270.
Figure 13.
Nonimmobilized
fracture o f a distal
tibial growth plate
in a child with
myelodysplasia
who can walk.
There is widening
and irregularity o f
the growth plate
which is due to in
ability to heal be
cause o f motion.
This is a charac
teristic appearance
o f a fracture that
has not been immobilized in a child who has no sensation in the extremity. Clinically,
these types o f injuries must be separated from osteomyelitis as they present with
swelling and redness o f the extremity. The appearance, however, is very characteristic
o f a nonhealing Salter fracture and should be treated as such. An additional clue is the
tilting o f the talus which causes increased stress on the growth plate. Poznanski AK: in
Resnick D, Pettersson H (ed.) Skeletal Radiology: NICER Series on Diagnostic
Imaging. Coconut Creek, Florida. Merit Communications, 1992, p. 264.
470
Figure 14.
Salter 2 fracture o f the distal f e
mur.
The fracture goes through the lat
eral part o f the growth plate and
extends into the metaphysis.
after a growth plate injury. Also distraction injuries in young gymnasts

may cause similar lesions.
Type 2 fractures
These fractures go through the growth plate and then extend into the
metaphysis (Fig. 14). The metaphyseal fragment may be small or quite
large. This is by far the most common type of fracture accounting for 75
% of all growth plate injuries. The distal radial epiphysis is one of the
more common sites of this fracture. The prognosis o f this fracture is gen
erally good particularly in the radius. However, when it occurs in the
knee or elsewhere in the lower extremity premature growth plate closure
may occasionally occur.
Type 3 fracture
This fracture is relatively uncommon, accounting for 8 % of growth plate
injuries. Type 3 fractures go through the epiphysis into the physis but do
not involve the metaphysis. Some of these fractures are undisplaced and
may be difficult to see on radiographs. They may be missed unless mul-
471
Figure 15. Salter 4 fracture o f the Figure 16. Deformity o f the ankle secondary
proximal phalanx o f the great toe. to growth disturbance following previous
The fracture goes across the growth Salter 4 fracture o f the distal tibia.
plate and involves the metaphysis and
the epiphysis.
tiple projections including oblique views are obtained. If displacement

occurs it must be carefully reduced since lack of reduction will cause an
irregularity along the articular surface and may result in arthritis. With
good alignment, prognosis is otherwise good as growth arrest is rela
tively rare. Ogden has subclassified this type into two parts. One in which
the physeal component of the fracture extends only to involve one seg
ment of the broken epiphysis. In the other type it extends all the way
through the physis resulting in two separate epiphyseal fragments.
Type 4 fracture
In type 4 the fractures extend from the metaphysis into the epiphysis
while traversing the physis (Fig. 15). This type most commonly occurs
in the elbow and in the distal tibia. The incidence of these fractures ac-
472
Figure 17.
Follow-up o f Salter
5 fracture o f the left
knee.
Initially no abnor
mality was seen.
With time, there was
closure o f the
growth plate o f the
distal fem ur with
shorterning o f the
fem ur and a cone-
shaped deformity o f
the epiphysis.
count for 12% of growth plate injuries. Type 4 fractures are the ones
most commonly associated with growth arrest and angular deformity
(Fig. 16). It is, therefore, very important in these fractures to obtain proper
alignment and fixation, as this will minimize the incidence of growth ar
rest and deformity. Ogden has subclassified type 4 into several sub
groups.
Type 5 fracture
This is the rarest of the Salter Harris fractures, accounting for less than
1% of growth plate injuries. These fractures are compressions of the
growth plate and may involve either the whole growth plate or one side
of it. They are very difficult to diagnose at the time of the initial injury.
They may only be noted on follow-up. There may be a closure of the
growth plate resulting in shortening, cone-shaped deformity or consid
erable angular deformity (Fig. 17).
Type 6 fracture
This is a type described by Ogden and is an injury to the peripheral zone
of Ranvier at the edge of the physis (Fig. 10). This fracture eventually
may form an osseous bridge at the edge of the physis causing angular
deformity in that area.
Type 7fracture
This is really not a growth plate fracture as it involves only the epiph
ysis. The fracture goes through the cartilage of the epiphysis or through
473
Figure 18.
Bowing fracture in a 5-year-old boy.
a) Note the bowing o f the radius a n d
ulna.
b) Follow-up study 4 weeks later:
There is periosteal elevation on
the radius confirming the bow ing
fracture. Poznanski AK: in
Resnick D, Pettersson H (eds)
Skeletal Radiology: NICER Series
on Diagnostic Imaging. Coconut
Creek, Florida: Merit
Communications, 1992, p. 252.
a b
the epiphyseal ossification center (Fig. 10).
Triplane fracture
In the ankle an additional growth plate fracture may be seen. It is the tri
plane fracture in which there is a combination of several of the types. It
is seen only in the ankle and only as the growth plate starts to close.
Imaging of growth plate injuries

Most growth plate injuries can be seen well with conventional radi
ographs. However, multiple views are often necessary for better evalu
ation. In some cases, particularly when the ends of the bones are mainly
composed of cartilage such as in the elbow, magnetic resonance imag
ing is of considerable value. Computed tomography or MR are also im
portant in evaluating type 3 and 4 fractures to determine whether the
alignment is proper.
474
Figure 19.
Greenstick fracture o f the ulna.
There is a break in one cortex while the other cor
tex shows no break. There is also some bowing o f
the radius which was more bowed than the opposite
side. It is not unusual to have a bowing fracture o f
one o f the forearm bones with a greenstick fracture
o f the other. Poznanski AK: in Resnick D,
Pettersson H (eds): Skeletal Radiology: NICER
Series on Diagnostic Imaging. Coconut Creek,
Florida: Merit Communications, 1992, p. 254.
Diaphyseal fractures
Fractures of the diaphysis are relatively common in children. Toddlers

are prone to have oblique fractures, particularly at the tibia, when they
are just beginning to walk. These may not be identified on conventional
radiographic views, although the chance of detection is increased if
oblique views are obtained. If there is question of such fracture, follow-
up films after casting will show presence of periosteal elevation. If di
agnosis needs to be made immediately a bone scan is of value.
Bowing fractures o f the diaphysis

These occur from multiple microfractures along a bone leading to a
bowed appearance without evidence of an actual fracture (Fig. 18). This
fracture is due to the fact that the children's bones are more elastic than
the adult and will bend a small amount. It is most common in the fore
arm. Comparison with the opposite extremity may be needed to deter
mine if the bowing is abnormal or a normal variant. A bone scan may be
475
Figure 20. Torus fracture in 3-year-old child.

a) There is a buckle along the ulnar side o f the distal radius.
b) Follow-up view 6 weeks after injury. There is a linear area o f density across the ra
dius which is evidence that the fracture was across the entire bone. Some periosteal
changes are also seen.
Poznanski AK: in Resnick D, Pettersson H (eds): Skeletal Radiology: NICER Series on
Diagnostic Imaging. Coconut Creek, Florida: Merit Communications, 1992, p. 253.
used for diagnosis or follow-up radiograph several weeks later will show
periosteal elevation confirming the fracture.
Torus and greenstick fractures

Another manifestation of the relative greater elasticity of children's bones
is the greenstick fracture. Here there is a fracture of only one cortex and
bending or a buckling of the cortex on the opposite side of the bone (Fig.
19). A torus fracture (buckle fracture) is simply a buckling of the cortex
(Fig. 20 a). Torus fractures may be subtle and the fracture may not be
initially apparent. On follow-up, a linear area of sclerosis is seen since
these buckle fractures actually go across the entire bone (Fig. 20 b).
Healing of diaphyseal fractures

Children's fractures generally heal better and faster than those of adults.
How rapidly the fracture heals is dependent upon the age of a child and
the bone involved. In the infant and newborn some callous may be seen
476
Figure 21.
Abundant callous following a fracture in an
infant with myelomeningocele. Note the
marked callous formation about the fra c
ture. These fractures heal very well.
Poznanski AK: in Resnick D, Pettersson H
(eds): Skeletal Radiology on Diagnostic
Imaging. Coconut Creek, Florida: Merit
Communications, 1992, p. 263.
in a mattter of days while in a teenager it may take several weeks. Callous

is particularly prominent in children with neurological deficits, such as
myelodysplastics (Fig. 21). In infants and young children remodelling is
excellent and even if the bones are left in an angular position or over
riding position, they often remodel to normal within a relatively short
time. Nonunion is relatively rare in children’s fractures. Overgrowth of
fractured bones can occur in children when there is complete apposition
and alignment due to hyperemia. This is particularly true in the femur.
Because of this the femora are often casted with some overriding of the
fracture fragments.
Avulsion fractures
These fractures are really a form of growth plate fractures and represent
an avulsion of an apophysis (Fig. 22). The most common location for
these is the pelvis. In the pelvis the most common location is at the is
chial attachment of the hamstring muscles. Initially, what is seen is an
area of irregularity (Fig. 22 a). On follow-up there may be extra calcifi
cation that may have the appearance of an extra bone (Fig. 22 b).
477
Figure 22.
a) Irregularity o f the right
ischium due to an avul
sion fracture in yo u n g
soccer player.
b) Old avulsion fra ctu re o f
the ischium. A large os
sification area is sepa
rated from the main
a portion o f the ischium.
This girl had a previous
history o f pain in this
region after sports in
jury.
Poznanski AK: in Resnick
D, Pettersson H (eds):
Skeletal Radiology:
NICER Series on
Diagnostic Imaging.
Coconut Creek, Florida:
Merit Communications,
1992, p. 257.
Stress fractures
These occur in children as in adults. A location of stress fractures seen
mainly in children is in the tarsal bones, particularly the cuboid and the
calcaneus. These are seen in toddlers who may stop walking or who may
present with a limp. Initially, notching may be seen radiographically and
only later there may be evidence of a sclerotic line in the bone. The bone
scan shows an area of increased activity.
Pathological fractures
Pathological fractures can occur in children as in adults. In children they
may be associated with severe osteopenia in chronic conditions such as
in Crohn’s disease or juvenile rheumatoid arthritis. They may be seen in
the neonate who has been very sick in intensive care. Osteogenesis im
perfecta is associated with fracture both in the neonatal form and later in
milder forms. It is sometimes difficult to separate osteogenesis imper
fecta in the toddler from the battered child syndrome. In arthrogryposis
and other contracture syndromes unsuspected fratures may be seen pos
sibly related to attempts to straighten the limbs. Growth plate fractures
478
Figure 23.
Frostbite.
This child has se
vere frostbite defor
mity on the right
and milder involve
ment on the left.
There is closure o f
several growth
plates in the pha
langes and
metacarpals in both
hands. There is loss
o f the middle and
distal phalanges o f
the right index fin
ger secondary to necrosis. The latter finding is more the type offrostbite damage that
can occur in adults. Closure o f the growth plates with shortening o f the hand bones is
a finding specific to children. The short distal and middle phalanges bilaterally and the
short right metacarpals are due to damage o f their growth plates. The thumbs are rel
atively less affected than the other fingers.
Diagnostic Imaging. Coconut Creek, Florida: Merit Communications, 1992, p. 265.
may occur in neurogenic disorders. Another situation where growth plate

fractures can occur is in renal osteodystrophy.
Physical agents causing trauma

Cold injury, bums and electrical injury all can cause closure of growth
plates with resultant alterations in the length and angulation of the hand
bones (Fig. 23). In frostbite the thumbs are often spared as they have a
better vascular supply than do the other fingers. The thumbs are also more
protected as they are often clasped within the hand when the child is ex
posed to cold.
Child abuse
Abused children can have a variety of different fractures. The charac
teristic fracture is the comer fracture where all that may be seen is a break
of a small comer of metaphysis (Fig. 24). Actually, these fractures go
through the entire distal portion of the metaphysis. They are often very
difficult to identify initially (Fig. 24 a), but subsequently periosteal
changes may occur which make their diagnosis easier (Fig. 24 b). The
bone scan is also positive in these fractures. These comer fractures are
479
Figure 24.
a) Child abuse with corner fracture in 4-month-old who presented with swelling o f the
leg. There is a very small ossification fragment along the anterior part o f the distal
tibial metaphysis which is barely apparent. The bone scan taken at the same time
showed considerable increased activity in the entire tibia and child abuse was sus
pected. This was confirmed with clinical history and further radiographs.
b) Subsequent film 12 days later. There is considerable healing at the fracture site with
periosteal changes. The fracture now has become very obvious.
Diagnostic Imaging. Coconut Creek, Florida: Merit Communications, 1992, p 272.
not the only fractures that are seen in child abuse. Any diaphyseal or phy
seal fracture may occur in this population. Child abuse should be sus
pected if there is a presence of multiple metaphyseal fractures, posterior
rib fractures or fractures showing different degrees of healing suggest
ing that they ocurred at different times. Suspicion is also aroused if a
child has skull fractures and bilateral fractures or a severe epiphyseal in
jury which does not fit with the type of trauma that has occurred.
Generally, in the presence of suspected child abuse one should obtain a
complete skeletal survey. The bone scintigram should also be obtained
as it is much more sensitive than radiographs for the detection of poste
rior rib fractures which are so characteristic of child abuse. Although ra
diological evidence is very important in the diagnosis of child abuse it
480
Figure 25.
Developmental dysplasia o f
the hip in the neonate.
a) Plain radiographs. The ac-
etabulae are not particu
larly steep. There is a
somewhat poor develop
ment o f their upper lip.
b) Hilgenreiner line is drawn
through the Y cartilage on
the radiograph in A. The
acetabular angles also
drawn measure 30° bilater
ally which is within normal
limits fo r a neonate,
c) MRI (with gradient echo
sequence) in coronal plane.
Note the lateral and some
what superior displacement
o f the femoral heads. The
cartilage appears light grey
in this sequence. There is
some fluid in the hip joint
(appears white). The ossi
fied bones appear black.
M RI is not usually used in
the diagnosis o f DDH but it
b
nicely illustrates the
pathology.
481
is not the only information needed. Social history is also very im portant.
Other possible causes of multiple fractures such as osteogenesis im per
fecta must be considered. Radiologically one o f the more helpful signs
which defines osteogenesis imperfecta is the presence of m ultiple
wormian bones in the skull. However, even that is not an absolute sep
aration as some cases of osteogenesis imperfecta are not associated w ith
wormian bones and in some normal children wormian bones can occur.
DEVELOPMENTAL PROBLEMS
Developmental dysplasia of the hips (DDH)

Developmental dysplasia of the hip (DDH) was formerly known as con
genital dislocation o f the hip (CDH) but since it sometimes may occur
postnatally, the term developmental dysplasia had been now been ac
cepted by most pediatric orthopedic surgeons. The condition is more
common in girls than in boys and usually presents in the neonate. It can
usually be diagnosed by clinical examination using the Ortolani and the
Barlow maneuvers. The radiographic findings in the neonate may be very
subtle since the proximal femoral head is usually not ossified until three
to four months of age (Fig. 25 a).
The plain film of the pelvis in many cases, however, is suggestive; the
acetabular angle is usually greater than normal often with a poor supe
rior lip. The mean normal angle in neonates is 28°. The 2 S.D. range is
18° - 37°. After three months the + 2 S.D. upper limit is 30°. The proxi
mal femoral hip metaphysis may also be displaced laterally and superi
orly (Fig. 25 c). When a Hilgenreiner line (Fig. 25 b) is drawn through
the Y cartilage, displacement of the femoral metaphysis can be measured
in relationship to this line. The useful view is the AP with the legs in neu
tral position. It is in this projection that dislocation tends to occur, while
the frog leg view tends to relocate the hips in the acetabulum. A normal,
plain radiograph, however, does not rule out DDH (Fig. 26 a). The op
timal radiologic approach to evaluate possible DDH is ultrasonography
with examination of the hip in the coronal plane. The static method as
described by Graf examines the acetabular angle with ultrasound in this
projection. The neonatal femoral head is usually clearly visualized on ul
trasound examination as it contains many small signals within it. These
are due to small vessels within the cartilaginous femoral head. A dy
namic study can also be done to determine if the head is dislocatable.
482
Figure 26.
Developmental dys
plasia o f the hip
missed in infancy.
a) Radiograph at 1
day o f age. There
is a poor forma
tion o f the right
acetabulum as
compared to the
left with a some
what steeper ac
etabular angle
and a less well
developed lip.
b) The child re
turned at 9
months o f age
and having re
ceived no treat
ment. There is
now frank dislo
cation, lack o f
development o f
the right femoral
head and a
pseudoacetabu
lum, above the
true acetabulum.
After several months another sign of DDH is a delay in ossification of

the femoral head (Fig. 26 b). This is more easily detected if the disease
is unilateral. When the infant begins to stand a pseudoacetabulum may
form (Fig. 26 b). Although MRI clearly shows the femoral heads rela
tion to the acetabulum (Fig. 26 c), it is rarely used as the initial method
of diagnosis of DDH since the clinical examination is usually sufficient.
If there is a questionable clinical exam ultrasound and/or radiographs can
be used.
There is some controversy on the value of ultrasound screening of chil
dren for DDH. Screening is probably not worthwhile in the general pop
ulation because of the expense, the relatively low incidence of DDH and
the fact that DDH can often be diagnosed clinically. It may be of value
in the high risk infant such as in infants whose mothers had previous such
483
babies, when there is breech presentation, or when there is other fam ily
history of DDH. In these populations there is a much higher incidence
of DDH and, therefore, ultrasound screening may be worthwhile.
When diagnosed early in infancy DDH is usually easily treatable w ith
some type of splinting and the success of reduction can be m onitored
with ultrasound. In children in whom DDH is first detected after six
months or a year of age, reduction becomes more difficult. In these cases
CT is of value to determine whether the femoral head has indeed been
replaced following closed reduction. It is very difficult to determine
whether the head had been reduced on radiographs of the child in plas
ter. In one comparison study we showed that correct evaluation by ex
perienced pediatric radiologists and orthopedists of whether the femoral
head was reduced was only 50%. CT on the other hand, clearly shows
the position of the femoral head in relationship to the acetabulum. It also
shows many of the reasons why the femoral head may be displaced such
as the presence of a prominent pulvinar (fibrofatty tissue) or an indenta
tion by the iliopsoas muscle upon the hip capsule. CT for postoperative
evaluations should be done using very low mAs and, therefore, decreased
radiation dose. We use 50 mAs. MRI outlines the soft tissues and carti
lage much better than CT but its use is somewhat limited in the hip since
many MRI gantries are small and most infants in a frog leg cast will not
fit in them. Femoral anteversion and acetabular torsion can be determined
with both CT and MRI.
Dislocation of the hip occurs secondarily in many contracture syn
dromes and in children with myelodysplasia or other neurologic prob
lems (Fig. 27). These dislocations can occur later in childhood. In chil
dren with cerebral palsy dislocation usually occurs late and acetabular
changes may be less apparent. They may have coxa valga which tends
to promote dislocation of the hip (Fig. 27). The role o f the radiologic ex
amination in these cases is to see how well the femoral head is covered
by the acetabulum. If there is still question of adequate coverage of the
femoral head on radiographs of young children, MRI is useful since the
actual cartilaginous portions of the acetabulum and femoral head are well
visualized. In neonates with contracture syndromes an additional useful
plain radiologic sign is the presence of pseudoacetabuli. Their presence
in the neonate indicates a contracture syndrome because in otherwise
normal children with DDH pseudoacetabuli occur only secondarily to
weight bearing.
484
Figure 27.
Child with cerebral
palsy with lateral
dislocation o f the
left hip. The left ac
etabulum is poorly
formed; however,
the femoral heads
are not too dissimi
lar in size. They
usually are much
smaller on the af
fected side in DDH.
Foot deformities
Foot deformities may be due to congenital anomalies, may be secondary
to position in utero, or they may be due to contractures or neuromuscu
lar problems. The most common foot deformity that needs to be cor
rected is the club foot deformity (talipes equinovarus) (Fig. 28).
However, there are many other foot deformities. In evaluation of foot
deformities one should use weight bearing or simulated weight bearing
views. The axes of the talus and calcaneus in both the AP and lateral pro
jections must be determined. The angle between these bones as well as
the relation of their axes to the axis of the first metatarsal and other
metatarsals must be determined. In normal children in the AP projection
the axis of the talus should pass through the first metatarsal and the axis
of the calcaneus through the fourth. In varus deformities of the foot such
as in the club foot, the axis of the talus passes lateral to the first metatarsal.
The calcaneus may be lateral to all the metatarsals (Fig. 28). In club foot
deformity the calcaneus and talus become parallel to each other, partic
ularly in the lateral position. There is also plantar flexion of the foot (equi-
nus deformity). In valgus deformity of the foot the axis of the talus lies
medial to the first metatarsal. A common form of valgus deformity is as
sociated with a vertical or oblique talus (Fig. 29). In this case the angle
between the talus and the calcaneus is increased in the lateral projection
with the talus pointing downwards. In severe cases there is dislocation
between the talus and the tarsal navicular. In young infants, however,
this cannot be visualized as the tarsal navicular is usually not ossified at
birth. MRI shows some promise in defining the relationship between all
485
Figure 28. Clubfoot. Both views were obtained with weight bearing.
a) In the AP view the axes o f the talus and o f the calcaneus are almost parallel and
their axes project considerably lateral to their normal position.
b) In the lateral view they are also somewhat parallel and the fo o t stays somewhat
plantar flexed even with weight bearing.
of these bones since those that are not ossified or partially ossified can
be visualized.
Packing deformity
Occasionally children are bom with a bowed tibia and fibula caused by
a relatively tight uterus and pressure of one extremity on another (Fig.
30). This bowing usually straightens out postnatally. The condition must
be separated from bowing due to congenital pseudoarthrosis or secondary
to neurofibromatosis (Fig. 31). In neurofibromatosis the bowing is usu
ally anterior while in packing deformity it is frequently from side to side.
Bilateral bowing may also be due to a variety of congenital disorders and
syndromes such as the campomelic syndrome.
486
Figure 29.
Vertical talus and
rocker bottom foot.
The talus is vertical
in relation to the
foot and is subluxed
in relation to the
navicular.
Figure 30.
Faulty fetal packing. This type o f bowing
o f the leg results from pressure on the limb
in utero and usually straightens with time.
The bowing is usually from side to side
rather than anterior or posterior.
487
Figure 31.
Tibial bowing in neurofibromatosis in 10-year-
old girl There is a suggestion o f an old
pseudoarthrosis. In neurofibromatosis the bow
ing is usually in an anterior direction; however,
it is not specific fo r neurofibromatosis.
Coxa vara and coxa valga

Coxa vara is when the angle between the femoral neck and the femoral
shaft is decreased, while coxa valga is when it is increased. The normal
angle after five years measures 122-149°.
Coxa vara may be congenital or acquired. The acquired form may oc
cur in any situation where the bones are soft such as in rickets or osteo
genesis imperfecta. It may occur secondarily to fractures, may be asso
ciated with a number o f congenital malformation syndromes, or in as
sociation with a congenital short femur. Coxa valga is frequently
secondary to lack of weight bearing and is seen in paralysis or various
neuromuscular syndromes.
CONGENITAL ANOMALIES
There are many congenital anomalies possible in the skeleton. Any bone
can be malformed. In the hand alone there are a large number of anom
alies some of which are associated with other malformations and some
which are not. Defects o f bones in the extremities can be transverse or
longitudinal. Longitudinal defects have also been called hemimelia im-
488
plying absence of half of a limb. Longitudinal defects is a better term,

since often only a small longitudinal portion may be missing. The de
fects can also be terminal such as absence of fingers or of the hand or in
tercalary meaning in the middle part of a limb such as phocomelia. A
good example of a longitudinal defect is radial hypoplasia or absence.
The spectrum of involvement may range from absence of the radius and
the first and second metacarpals to where only the thumb may be absent
or hypoplastic. The radial defects are associated with many other anom
alies or syndromes. Radial defects are associated with an increased in
cidence of congenital heart disease, vertebral anomalies, imperforate
anus, esophageal atresia, renal anomalies, and many others. Ulnar effects
are less commonly associated with other anomalies.
In the hand or foot there maybe failure of differentiation of parts such
as syndactyly which is fusion of adjacent digits or symphalangism which
is fusion of parts of the same digits or tarsal and carpal coalition.
Duplications ranging from polydactyly to double limb or dicheiria may
occur. Other abnormalities include overgrowth conditions such as mega-
lodactyly, circular constrictions (Streeter bands), and contractures.
Deviation of the digits are called clinodactyly when they are in the plane
of the hand and camptodactyly when they are perpendicular to it.
Syndactyly
Syndactyly is fusion of adjacent digits. It may be osseus or cutaneous. It
may also be seen in otherwise normal individuals. Some forms of syn
dactyly are familial. A number of syndromes are associated with syn
dactyly. An example is the Apert syndrome where there is also coronal
suture synostosis, facial abnormalities as well as a mitten-like hand and
a sock-like foot with osseous and cutaneous syndactyly (Fig. 32).
Polydactyly
Polydactyly is an abnormality of the hand or foot in which there are extra
digits or extra portions of digits such as phalanges or metacarpals. If the
extra digits are on the radial side of the hand or medial one of the foot
the polydactyly is called preaxial. When they are on the ulnar side of the
hand or lateral part of the foot they are called postaxial. Polydactyly may
be seen as an isolated finding, either sporadic or familial. Postaxial
polydactyly of the hand is a common normal variant particularly in
individuals of African origin in whom it is inherited as autosomal
489
Figure 32. Apert Syndrome. This is a syndrome o f coronal suture synostosis associ
ated with a mitten-like hand and sock-like foot.
a) Hand. There is cutaneous syndactyly and osseous syndactyly o f the distal pha
langes. There is fusion o f the proximal and middle phalanges (symphalangism). The
thumb is broad, laterally deviated, and has a triangular proximal phalanx.
b) Foot. Cutaneous syndactyly is present. There is partial duplication o f the first
metatarsal and there is an extra proximal phalanx (polydactyly). The great toe is
short and wide.
dominant. It is also seen in a variety of congenital malformation syn

dromes and sometimes in association with syndactyly.
Proximal focal femoral deficiency

There is a congenital shortening of the femur often with associated coxa
vara (Fig. 33). It is also sometimes associated with hypoplasia of the
fibula or part of the tibia. The purpose of imaging in these cases is to de
termine whether the femoral head is well formed, whether it articulates
with the acetabulum and whether it is continuous with the femoral shaft.
The best approach to evaluation of this abnormality is with MRI which
allows the clear delineation of the anatomy (Fig. 33 b). Gradient echo
imaging is optimal for this evaluation as the cartilaginous portion of the
bones are thus best seen.
490
Figure 33.
Proximal focal femoral deficiency (PFFD).
a) The left femur is short and there is a large
gap between the proximal left fem oral epi
physis and the remainder o f the femur. The
upper end o f the left femoral shaft lies
above the femoral head and is smaller than
the right.
b) MR with gradient echo sequence. The carti
lage is white, the bone is black. There is
continuity between the fem oral head and
shaft by the still unossified cartilaginous
femoral neck. The greater trochanter is
also still composed o f cartilage.
Tarsal coalition
Tarsal coalition is one of the causes of pain in the foot in older children. It
may present as a spastic flat foot. The most common isolated foot coali
tions are the calcaneonavicular and the talocalcaneal. The calcaneonavic
ular coalition is very easily seen on oblique views of the foot (Fig. 34 a).
Talocalcaneal coalitions are more difficult to identify on plain film as
one has to obtain an image with the axis of the x-ray beam exactly through
the talocalcaneal joint which is often difficult. A much easier method for
detecting talocalcaneal coalition is to use coronal CT (Fig. 34 b). The fu
sion of the middle facet of the calcaneus with the talus is usually clearly
delineated in this projection. Often in children the coalitions are not com
plete, but one sees narrowing and irregularity of the affected joints. This
narrowing has the same significance as an osseous coalition and may
491
Figure 34. Tarsal coalition.

a) Calcaneonavicular coalition in a 12-year-old boy who had pain in the fo o t on walk
ing. There is an irregular space between the calcaneus and talus without complete
bony fusion. In unaffected children these bones are further apart. This fusion is o f
ten incomplete in children and is best seen in this oblique view o f the foot.
b) CT o f talocalcaneal coalition in a 7-year-old boy. There is an irregular jo in t at the
middle facet. This type o f coalition is difficult to detect with radiography and is best
visualized with CT. The images were obtained with the child's foot in a tennis shoe
which facilitates immobilizing the foot.
need to be treated surgically. A plain film sign of coalition in the lateral

view is a beak on the superior distal portion of the talus. If the coalition
involves the more distal tarsals this almost invariably indicates associa
tion with a congenital malformation syndrome. The talocalcaneal and
calcaneonavicular coalitions may be isolated or syndrome associated.
THE BONE DYSPLASIAS

These are systemic disorders affecting bone and often are associated with
dwarfism. Although there is a large number of these, many of them are
relatively common. They are much more common than many conditions
that are well recognized by radiologists - for example, malignant bone
tumors. The prevalence of achondroplasia is 37-64 per million,
thanatophoric dysplasia 28-60 per million, achondrogenesis 23-28 per
million, osteogenesis imperfecta 36-64 per million, as compared to all
492
malignant tumors in which it is 5.3 per million. The incidence of all the
bone dysplasias is 244-322 per million. The radiologic diagnosis of these
conditions has real importance since in many of them the radiological
diagnosis is the final word. In many of the bone dysplasias there are no
other specific biochemical or other tests. Even when such tests are avail
able in some disorders, such as the mucopolysaccharidoses, the radio
logical appearance points to which test should be done to confirm the di
agnosis. The importance o f correct diagnosis is also to determine prog
nosis and genetic counseling. For example, a condition such as
achondroplasia usually has a good prognosis so an affected achon-
droplastic neonate who may have severe respiratory distress should be
actively treated. On the other hand, the neonate with thanatophoric dys
plasia need not since there is no chance of survival. Also, it is important
to know what other associated anomalies may be present. For example,
in chondroectodermal dysplasia there may be congenital heart disease
and in spondyloepiphyseal dysplasia there may be congenital myopia
with retinal detachment.
Prenatal radiologic evaluation of bone dysplasia is usually done with
ultrasound. Unfortunately, specific diagnosis is often difficult to deter
mine unless one knows that an affected infant was previously bom to the
mother. Occasionally, radiography may be of value particularly in eval
uation of osteogenesis imperfecta. For such studies it is worthwhile to
sedate the infant by giving the mother 10-15 mg o f morphine intramus
cularly before radiography.
Approach to the bone dysplasias

For optimal evaluation of the bone dysplasias a complete bone survey
should be done including the limbs, skull, spine, hands and feet.
Although sometimes a diagnosis can be suggested from specific radi
ographs, the chance for error decreases if the entire skeleton is exam
ined. To be able to diagnose these conditions one needs to know some
of the cardinal radiographic signs. The appearance of the diaphysis, the
metaphysis, physis and epiphysis are important both in terms of their
shape and configuration. The bone length of various bones is also im
portant. Is the shortening rhizomelic (humeri and femora), mesomelic
(tibia and fibula or radius and ulna), or acromelic (hands and feet)? The
shape, size, and density of the vertebrae are also important. Not all the
described findings for a dysplasia may be present in an individual. (A
493
Figure 35. Achondroplasia.

a) Pelvis o f a 6-month-old
achondroplastic infant. Note
the square appearing pelvic
wings with fla t acetabular
angles and a sharp sacrosci-
atic notch. This appearance
is very characteristic o f
achondroplasia.
b) Normal pelvis. There is a
normal lower iliac segment
in the pelvis which gives the
pelvic wing an appearance o f
a paddle with a handle. The
pelvis in achondroplasia has
the appearance o f a paddle
without a handle since it
lacks the lower iliac seg
ment.
c) Lack o f widening o f the dis
tance between the pedicles as
one descends in the lumbar
spine. This is common in
achondroplasia.
494
three legged dog is still a dog!)

A few of the more common bone dysplasias will be described briefly
here. The reader is advised to refer to texts on the subjects for more com
plete information.
Achondroplasia
This is the most common short limbed bone dysplasia. The affected in
fants have a depressed nasal bridge and a prominent forehead with some
what rhizomelic short limbs. The radiographic appearance is often char
acteristic. The pelvis has square wide iliac wings with flat acetabular an
gles (Fig. 35 a). The appearance has been likened to that of a paddle
without a handle and is due to the lack of the normal lower iliac segment
(Fig. 35 b). There is lack o f the normal widening of the interpedicular
distance as one descends down the lumbar spine (Fig. 35 c). There is also
narrowing of the AP diameter of the spine. Clinically, the narrow spinal
canal may become significant in adult life when even, small, hypertrophic
spurs may impinge upon the spinal cord. Although the cerebral ventri
cles are often dilated this is usually not a significant hydrocephalus.
Achondroplasia is inherited as autosomal dominant. If two achon-
droplastic parents have a child they have a one in four chance of having
one that receives the achondroplastic gene from each of the parents re
sulting in homozygous achondroplasia which is usually fatal in infancy
or early childhood. The radiologic appearance of the homozygous form
is much more severe than ordinary (heterozygous) achondroplasia and
can be distinguished from it radiologically.
Thanatophoric dysplasia
The term thanatophoric means death-dealing and indeed affected infants
are still-born or usually die a few days after birth. Characteristically the in
fants have a long trunk and very short curved limbs. The most character
istic radiological findings are very flat ossification centers of the vertebral
bodies that are most easily recognized in the lateral view (Fig. 36 a). Usually
central indentations are present and there are large spaces between the
ossified centers. The femora and other bones are very short and usually
curved (Fig. 36 b). Although thanatophoric dysplasia was previously
confused with achondroplasia it is easily distinguishable. It is a very dif
ferent entity and it is not related genetically. It is probably inherited as
an autosomal dominant.
495
Figure 36. Thanatophoric dysplasia.

a) Lateral view. The vertebrae appear very flat with large spaces between them.
Histologically the vertebrae are actually not fla t but have veryflat ossification cen
ters. The limbs are very short.
b) The femora are very short and curved. The pelvis is somewhat similar to that in
achondroplasia, but is much more everely involved. The trunk is long.
Achondrogenesis
This other relatively common group of fatal neonatal dysplasias is achon

drogenesis. Characteristic of this group is lack of ossification of the ver
tebral bodies with a relatively short trunk (Fig. 37). There are several
forms of achondrogenesis, some with long, others with short limbs. Most
are inherited as autosomal recessive.
There are many other fatal neonatal conditions including several with
very short ribs and polydactyly.
496
Figure 37.
Achondrogenesis. Lateral view.
The trunk is short and the ab
domen is protuberant in con
tradistinction to the long trunk o f
thanatophoric dysplasia. There is
very poor ossification o f the ver
tebral bodies, but somewhat bet
ter ossification o f the posterior
elements.
Figure 38.
Chondrodysplasia punctata.
There are multiple punctate cal
cifications in the wrist and elbow
regions. The skin appears mot
tled, which is due to the severe
ichthyotic changes in the skin.
497
Chondrodysplasia punctata
This is a heterogeneous group of conditions associated with small punc
tate calcifications in the epiphyses that are present at birth (Fig. 38). The
two major types are the x-linked dominant form (Conradi-Hunerman
type) and the rhizomelic form which is inherited as autosomal recessive.
The later form is a peroxisomal disorder and is often associated with mi-
grational disorders of the brain. The presence of the puncta in the carti
lage is usually associated with abnormality of growth and development.
The punctata usually disappear after a few years of life so that in older
children the diagnosis can only be made by the presence of resulting de
formity which may be nonspecific. A close clinical and radiologic mimic
of chondrodysplasia punctata is seen in infants of mothers who have re
ceived the anticoagulant warfarin. Another mimic is the Zellweger
Syndrome (cerebrohepatorenal syndrome) which is another peroxisomal
disorder. A distinctive finding of the Zellweger syndrome is the common
location of the puncta in the patellae. Punctata may also be seen in a va
riety of other forms of chondrodysplasia punctata as well as other dis
eases including trisomy 18 and 21 and fetal alcohol syndrome. In many
of these other disorders the puncta involve only the tarsal bones.
Diastrophic dysplasia
This condition is characterized by dwarfism associated with club feet and
a normal facial appearance. Sometimes ear swellings are present at birth
which result in ear deformity later in life. At birth the knee ossification
centers are very retarded. When they ossify they are flattened and irreg
ular. Later in life this results in severe arthritis. The thumb is very short
with a short often round first metacarpal (Fig. 39 a). Also peculiar lon
gitudinal epiphyses are often seen in the phalanges of the hand. One of
the major complications of diastrophic dysplasia is acute kyphosis in the
midcervical spine which may result in cord compression (Fig. 39 b). This
dysplasia is inherited as autosomal recessive.
Chondroectodermal dysplasia (Ellis van Creveld

syndrome)
This is a dysplasia which is characterized by short limbed dwarfism, poly-
dactyly, and nail and tooth abnormalities. It is inherited as autosomal re
cessive. Congenital heart disease is present in over half of the cases. A
large atrial septal defect or a single atrium are the most common cardiac
498
Figure 39.
Diastrophic dysplasia.
a) Hand in a newborn in
fant. Note the veiy short
яВВивНК' - 1 round first metacarpal
fW and a thumb that points
away from the hand in a
hitch-hiker position.
| < % [§> : . . ' ' .'-V :
There is also an abnor
Ш ШШШШк mal proximal phalanx o f
the middle finger. This is
due to an unossified lon
gitudinal epiphysis. The
carpal ossification cen
ters are somewhat early
which is common in this
condition.
b) Severe kyphosis in same
neonate as in a. This se
vere angulation is seen
in about 15 % o f infants
with diastrophic dyspla
sia and it can cause
spinal cord compression.
anomalies. There is postaxial polydactyly of the hand. The distal pha

langes of the hand are hypoplastic and there are cone shaped epiphyses
in the middle phalanges (Fig. 40). Several carpals are often fused.There
may be a hypoplastic thoracic cage.
Asphyxiating thoracic dysplasia - Jeune syndrome

The main manifestation of this condition is a small thorax which results
in respiratory distress. The condition may vary from very severe to quite
mild. The infants with the mild cases survive but may develop renal fail
ure in later childhood due to microcystic renal disease (nephronopthisis).
In the neonate this disorder may be difficult to differentiate from chon-
droectodermal dysplasia since occasionally polydactyly may be present.
499
Figure 40.
Chondroectodermal dysplasia
(Ellis-van Creveld syndrom e) in a
6-year-old girl. The tubular bones
are short. There is deform ity o f
the fifth metacarpal, and a resid
ual o f a sixth finger that was p r e
viously present. There is fu sio n o f
the capitate and hamate a nd an
additional carpal bone. The distal
phalanges are quite characteris
tic with very unusual long thin
epiphyses, particularly in the sec
ond andfifth digits. There are
also short middle and proxim al
phalanges with characteristics
cone epiphyses.
Spondyloepiphyseal dysplasia
congenita
These infants have a flat face and a short trunk. Some have a cleft palate,
club feet, and myopia. The most characteristic appearance radiographi-
cally is a marked delay in ossification of the pubis, talus, and calcaneus.
In the spine there is flattening or hypoplasia of the vertebral bodies.
Hypophosphatasia
This is a condition of variable severity. In the severe infantile form the
whole skeleton is very poorly ossified with marked cupping of the ends
of the bones with poor ossification of the skull. The cupped ends of the
bones can be detected on prenatal ultrasound. In older children spotty lu-
cencies and lucent defects are present in the metaphyses of long bones
which sometimes may be confused with rickets (Fig. 41). Serum alka
line phosphatase is very low and there is increased excretion of phos-
phoethanolamine in the urine.
500
Figure 41.
Hypophosphatasia. Ill defined lu-
cencies are seen in the distal
femoral and proximal tibial meta-
physes. In the distal radius these
have a more punched out appear
ance. Although hypophosphatasia
can sometimes be confused with
rickets, differentiation usually is
not difficult as in rickets the meta
physeal lucency and irregularity is
similar across the whole growth
plate.
Figure 42.
Metaphyseal chondrodysplasia (Jansen type).
Extensive dense calcification is seen in all meta
physeal regions. This appearance is pathogno
monic o f this rare disorder.
Metaphyseal chondrodysplasias
There are several metaphyseal chondrodysplasias that are characterized
by irregularity of the metaphyses with some similarity to rickets. The
most characteristic of these is the Jansen form which at birth has the ap
pearance of rickets. In early childhood dense, irregular calcifications oc
cur in the ends of the bones which are pathognomonic of this condition
501
Figure 43.
Metaphyseal chondrodysplasia (M uK usick
type). There is metaphyseal irregularity with
some areas o f lucency and sclerosis. This is a
disorder often associated with severe im m une
deficiency.
(Fig. 42). In the adult the bones are short thick with bulbous ends. A re-
cessively inherited form of this disease, the McKusick form, is impor
tant to recognize because it is associated with immune defects. Both T
cell and В cell defects may occur. The characteristic radiological ap
pearance is of rickets-like changes in the ends of the bones. They differ
from rickets in that there are areas of focal sclerosis in the metaphyses
(Fig. 43) and that there is shortening of the long bones.
Osteogenesis imperfecta (OI)

This is a group of diseases that were previously clinically divided into
four forms. Actually they represent a large number of different abnor
malities mostly involving type I collagen. Many different often single
amino acid substitutions at various positions in the collagen I chain have
been found. The severe neonatal form of OI itself has a wide spectrum;
sometimes presenting with marked shortening and widening of the long
bones in an accordion pattern (Fig. 44) while in others there are very thin
bones which are bowed or broken. At birth fresh fractures may or may
not be present but, instead, healing fractures may be evident in the long
502
Figure 44.
Osteogenesis imperfecta type II.
Severe neonatal form. This infant
had the appearance o f a short
limb dwarf. There is marked tele
scoping o f bones particularly the
femora. Multiple healing fractures
are seen. Some bones are bowed.
bones or ribs. Skull ossification is very poor at birth and sometime the
skull bones are barely visible. Multiple wormian bones (sutural bones)
are commonly seen although they are usually seen better later in child
hood. In milder forms of OI the fractures may not occur until the child
is several years old. Prognosis in the neonatal form depends on the num
ber of fractures. Blue sclera are seen in many forms. Most of the forms
of OI are inherited as autosomal dominant. Sometimes the less severe
forms of OI may be mistaken for child abuse. Skull radiographs are of
value in such cases since if wormian bones are present the diagnosis of
OI is more likely.
Osteopetrosis
This is a condition of increased bone density which has been seen in in
fants, children, and adults. In infants the bone may be very dense and the
marrow space very small resulting in lack of bone marrow and hence
anemia and leukopenia. In the infant lucent bands may be seen at the
metaphyseal ends. Considerable bony sclerosis is also present in older
individuals frequently with bands of sclerosis and lucency perpendicu-
503
Figure 45.
Multiple exostoses. The ex o sto se s
point away from the grow th p la te .
They are seen at most o f the b o n e
ends.
lar to the bony shaft. The bones are often brittle and fractures are not un
common. There are many other sclerotic bone dysplasias. Another char
acteristic one is pyknodysostosis in which there is associated acro-osteo-
lysis and hypoplasia of the acromial ends o f the clavicles.
Cleidocranial dysplasia
This is a disorder with absence or a hypoplasia o f the clavicles, delayed
ossification of the pubis and often posterior defects in ossification o f the
spine. The children who are affected may be able to place their shoul
ders together anteriorly. In the hand, abnormal, thick epiphyses are seen
in the distal phalanges. Inheritance is autosomal dominant.
Multiple hereditary exostoses (МНЕ)

Exostoses seen in МНЕ are bony projections covered in childhood by a
cartilaginous cap. They are present in the metaphyses of bones and point
away from the growth plate (Fig. 45). They can result in growth distur
bances if they are close to the growth plate. The disturbances are partic
ularly severe in the ulna where they can cause severe shortening and de-
504
Figure 46.
Enchondromatosis (Maffucci type). This
type is associated with hemangiomas.
a) Multiple lucent defects involve many o f
the bones o f both hands. M ostly the dia-
physes are affected. On the left there are
many areas o f widening o f the soft tis
sues.
b) Arteriogram o f the left hand. There is an
extensive increase in vascularity in the
region o f the soft tissue swellings indi
cating the presence o f hemangiomas.
formity of the radius as well. The metacarpals or phalanges may also be

affected with resulting shortening or deformity. In the hand the exostoses
may be difficult to see since they are small. In the pelvis there is a coxa
valga deformity with thick, irregular femoral necks. The exostoses may
press on nerves or vessels. Adjacent bones may be deformed by an ex
ostosis in a nearby bone. The incidence of malignancy is now consid
ered to be about 1% in this disorder. Multiple hereditary exostosis is in
herited as autosomal dominant.
505
Figure 47.
Neurofibromatosis with pseudoarthrosis o f the tibia
andfibula. The defect in the tibia and fibula is one o f
the manifestation o f this disease. It is not due to
neurofibromatosis tissue in the gap but is due to
mesenchymal abnormality.
Multiple enchondromatosis
(Oilier and Maffucci syndrome)
There are two types of this disease; Oilier disease which is the more com
mon type and Maffucci syndrome which is the association of multiple
enchondromatosis with hemangiomas (Fig. 46). Although Oilier disease
is usually asymmetrical it is rarely unilateral. Growth disturbances may
result from enchondromas near a growth plate. There is an increased risk
of malignancy present in both forms of the disease. The risk of malig
nancy, however, is much greater in Maffucci syndrome where not only
bone neoplasms occur, but cerebellar, cerebral, and soft tissue malignant
vascular tumors may be seen.
Neurofibromatosis (NF)
This is a condition with many different manifestations in the skeleton as
well as other parts of the body. There are two forms of the disease (NF 1
and NF2) each due to a different gene abnormality. NF1 is the one as
sociated with most skeletal anomalies. In the newborn, there may be bow
ing of the tibia and fibula, sometimes with pseudoarthrosis (Fig. 47).
506
Figure 48.
Larsen Syndrome. This is a syn
drome o f multiple dislocations
and flat face. There is a double
ossification o f the calcaneus.
This is a very rare isolated nor
mal anomaly. When present in
association with dislocations,
particularly o f the knees, it is
very characteristics o f the Larsen
Syndrome.
These defects represent mesodermal abnormalities and are not due to lo
cal neurofibromas. They are very difficult to treat. There may be local
ized enlargement of any body part associated with large fusiform neu
rofibromas in the soft tissues. These are well visualized on MRI and are
often associated with thickening of nerves. When the hip is affected there
is often a coxa valga deformity, as well as a deformity of the pelvis. In
the thoracolumbar spine a sharply angulated scoliosis may be present
while in the cervical spine there may be a sharp kyphosis and/or there
may be enlargement of the neural foramina. Defects in the occipital part
of the skull are occasionally seen. There may be absence of the lesser
wing of the sphenoid. These defects are also not due to destruction by
neurofibroma but are due to a mesodermal defect. Spinal cord tumors
and optic nerve glioma may be seen. The neural changes are best shown
with MRI. Abnormal signal abnormalities present in the brain in neu
rofibromatosis are common but have not been adequately explained.
Arterial lesions may also be present with narrowing of the renal or other
arteries.
Larsen syndrome
This is a syndrome of multiple dislocations. Additional characteristic ra
diological findings in the young infant include double ossification of the
calcaneus (Fig. 48) and short, broad metacarpals. Sharp kyphosis in the
mid cervical spine may be seen. It may compress the cervical cord and
cause quadriplegia or death. In older children there may be considerable
irregularity in shape and location of the carpals, and there may be mul
tiple extra carpals.
507
Figure 49.
Holt Oram Syndrome with triphalangeal
thumb, which appears finger-like. This is
a syndrome o f atrial or ventricular se p ta l
defects associated with hand abnorm ali
ties ranging from a triphalangeal thum b
to an absent thumb.
Holt Oram syndrome

This is a syndrome o f atrial or ventricular septal defects, or a conduction
defect of the heart associated with a variety of radial abnormalities which
range from triphalangeal thumb (Fig. 49) to an absent thumb or pho-
comelia. The triphalangeal thumb is rarely seen in other conditions and
when present with the above heart defects Holt Oram syndrome should
be suspected. The condition is inherited as autosomal dominant. It needs
to be differentiated from the VATER association (Vertebral anomalies,
imperforate Anus, Tracheoesophageal fistula, Esophageal atresia, Radial
defect) which is a nongenetic association of anomalies. Many other
anomalies can occur with those in the VATER association including
heart disease as well as renal and other bone anomalies.
Gaucher disease
This is a disease caused by a deficit of glucocerebroside hydrolase re
sulting in storage of glucosylceramide within the lysosomal bodies o f
macrophages and other reticuloendothelial cells. This causes alterations
in the bone marrow, enlargement of the spleen, and a modeling abnor
mality with an Erlenmeyer flask appearance of the lower femora (Fig.
50 a). Aseptic necrosis of the proximal femoral epiphysis or of the
508
Figure 50.
Gaucher Disease.
a) 8-year-old girl. There is an Erlenmeyer
flask deformity o f the distal femur. This is
a manifestation o f Gaucher disease in
children.
b) Same girl at 6 years o f age. There are
multiple areas o f lucency and sclerosis in
the femoral heads, which represent asep
tic necrosis. There is also a fracture o f
the femoral neck with sclerosis around it.
This fracture was incidentally discovered
and was not clinically suspected. This
type o f fracture is very characteristic o f
Gaucher disease.
femoral neck with sclerosis and sometimes fractures may be seen (Fig.
50 b). The necrosis also often involves the diaphysis. The spleen is
markedly enlarged. Vertebra plana may be seen. MRI is of value to de
termine the extent of the various changes that can occur in the bone mar
row of these children before they are apparent on radiography. They may
include aseptic necrosis, fresh hemorrhage or infarcts.
The mucopolysaccharidoses (MPS)

These are disorders of mucopolysaccharide metabolism with excretion
of mucopolysaccharides in the urine. Although there are at least eight
509
Figure 51.
Mucopolysaccharidosis type IH (Hurler disease)
a) Characteristic appearance o f the pelvis with a
pinched in appearance o f the lower iliac areas.
Compare this to the normal pelvis in Figure 35 b.
The acetabula are poorly form ed and there is coxa
valga deformity.
b) There is poor modeling o f the metacarpals which ap
pear wide. The proximal ends o f the metacarpals are
pointed.
c) The ribs appear thick, particularly away from the
spine while near to the spine they are o f normal cal
iber.
d) Minimal anterior beaking o f thoracic lumbar verte
brae.
510
Figure 52.
Joint effusion demon
strated with ultra
sound. On the left
there is a large
sonolucent space in
front o f the left
femoral neck which
represents a hip effu
sion. While on the
right the structures
appear normal.
defined clinical types there are many more enzyme abnormalities asso
ciated with them. They all have similar radiologic changes but with con
siderable variation in severity. Some have distinctive changes of their
own. The most common finding to all is in the pelvis with thinning of
the lower iliac segment (Fig. 51 a). Other findings include relatively thick
coarse bones and some pointing at the proximal ends of the metacarpals
(Fig. 51 b). The ribs are often wide away from the spine and relatively
thin near it (Fig. 51 c). The classic MPS changes are seen in the Hurler
form (MPS IH) (Fig. 51). In other forms they may be milder such as in
the San Filippo form (MPS III). In MPS IV (Morquio syndrome) flat ver
tebral bodies are seen throughout the spine while in the other forms of
MPS only beaking in the thoracolumbar region may be seen (Fig. 51 d).
Clinical and radiologic diagnosis to determine the specific type is useful
as it decreases the number of tests that need be done to characterize the
disorder.
OTHER MUSCULOSKELETAL DISORDERS
Hip effusion
It is important to detect hip effusions in children as increased intracap
sular pressure can affect the vascular supply to the femoral head as it is
intracapsular. Permanent damage to the femoral head can occur very
quickly. Plain radiographs are not very useful to detect effusion unless
there is displacement of the femoral head. The best diagnostic radiologic
method is ultrasound (Fig. 52). If this is not available, radiographs ob
tained during traction of the hip are of value. If there is a vacuum phe-
511
Figure 53.
Normal vacuum phenomenon with trac
tion. A 1.5-year-old toddler with a limp.
The radiograph was obtained while the
leg was pulled. The presence o f vacuum
almost completely rules out a jo in t effu
sion.
Figure 54. Child with a limp.

a) Before traction.
b) After traction. The joint space is several millimeters wider than before which is in
dicative o f effusion. Hip aspiration confirmed the effusion.
512
Figure 55.
Legg-Calve-Perthes
disease in the left
hip and normal vari
ant o f ossification in
the right.
a) The left femoral
epiphysis appears
normal while the
right is frag
mented.
b) Bone scan. The
left femoral head
appears cold
which is diagnos
tic o f LCP while
the right is nor
mal. Subsequently
the left femoral
head became
fragmented and
had an appear
ance similar to
that seen in
Figure 56 a.
nomenon (Fig. 53) it is very unlikely that fluid is present. If there is sep
aration and no vacuum (Fig. 54) this is diagnostic of fluid. If there is no
separation the finding is not diagnostic and traction can be repeated. The
failure of traction to be diagnostic is due to lack of relaxation and occurs
in about 25% of cases.
Legg-Calve-Perthes disease (LCP)

This is an idiopathic avascular necrosis of the hip which occurs in young
children. It presents with pain in the hip or with a limp. The initial radi
ographic findings may be very subtle or absent (Fig. 55 a). The earliest
radiologic sign may be an abnormal bone scan with lack of localization
of isotope in the entire femoral head (Fig. 55 b). This is a different pat
tern than seen in other aseptic necroses where there may be increased ac-
513
Figure 56.
Legg- Calve-Perthes
disease (LCP).
a) Radiograph in
fro g leg position.
There is m arked
fragm entation o f
the left fe m o ra l
head and appar
ent increased
width o f the jo in t
space.
b) M RI with gradient
echo sequence.
The cartilage o f
the left fem o ra l
head is flattened
and thickened as
compared to the
right. There is
fragmentation and
flattening o f the
ossified portion
(black). There is
some flu id within
the hip jo in t
(brighter white)
and there is sepa
ration o f the left
femoral head
away from the ac
etabulum.
tivity in the femoral head. Pin hole imaging should be used so as to ob
tain the necessary resolution. MRI can also detect LCP before radi
ographs are abnormal. Loss of the normal fatty signal within the bone
marrow on Tl weighted images is an early MRI sign of LCP. Bone
scintigraphy is probably more sensitive than MRI for early detection
since the femoral head appears totally cold on the bone scintigram while
the MRI changes may be spotty. Usually, when the child first presents,
radiographic changes are already present. The first radiographic sign is
separation of the femoral head ossification center from the tear-drop edge
of the acetabulum. This is due to swelling of the cartilage and/or syn
ovitis. Eventually there is a subcortical fracture, fragmentation, sclero
sis, and flattening of the femoral head (Fig. 56 a). These are relatively
514
Figure 57.
Multiple epiphyseal dysplasia (MED) in a
10-year-old girl
a) There is fragmentation o f both femoral
heads. This may be difficult separate from
LCP disease. When bilateral fragmenta
tion is seen in the hips, radiographs o f the
knees and hands should be obtained to
differentiate LCP from MED.
b) Knee o f the same girl. The epiphyses o f
the tibia and femur are fla t and irregular
which confirmed the diagnoses o f MED.
In the lateral view there was evidence o f
a double ossification center o f the patella.
There was irregularity o f the carpals on
the hand radiograph that was also ob
tained.
late manifestations of the disease although they are often the radiologic
findings at the time of onset of symptoms. The course of the disease lasts
over several years. There may be eventual reformation of the femoral
head or there may be residual deformity. During the time of the disease
the femoral head is very soft and is prone to indentations. Therapies in
clude splinting, varus osteotomy of the femur or pelvic osteotomy; all of
which help to place the femoral head inside the acetabulum. MRI may
be useful to determine containment of the hip since this is an important
feature in decisions regarding the management approach as it permits vi
515
sualization of the cartilaginous portion of the femoral head (Fig. 56 b).

Another approach to determine femoral head coverage is to use arthrog
raphy. This has the advantage that the hip can be manipulated and the
coverage of the femoral head can be determined in various projections.
Legg-Calve-Perthes may be a bilateral condition. Whenever bilateral
changes are seen the possibility of multiple epiphyseal dysplasia (MED)
should be considered as it can mimic LCP disease (Fig 57). Radiographs
of the hands and AP and lateral radiographs of the knees are o f value to
determine whether there is any flattening of the epiphyses (Fig. 57 b) or
if the carpus has decreased in size. These are all signs of MED. A dou
ble ossification center of the patella with one center in front of the other
in the lateral view is a useful sign of MED. In MED the prognosis is
worse than in LCP as these patients often develop severe hip and knee
arthritis as young adults.
Another condition in which an aseptic necrosis similar to LCP may be
seen is the trichorhinophalangeal syndrome. This is an autosomal dom
inant disorder which is associated with slowly growing hair and prema
ture baldness in boys as well as a bulbous, pear-shaped nose and defor
mities of the fingers. Gaucher disease (Fig. 50) and sickle cell disease
may also result in aseptic necrosis. Steroids can cause aseptic necrosis
of the hip but the appearance is usually different and the course quite dif-
fererent than in LCP. In steroid necrosis fluid in the hip joint is seen as
an initial sign. In contrast to LCP there is increased activity of the femoral
head on the bone scintigram.
Slipped capital femoral epiphyses (SCFE)

This is a relatively common cause of limp in teenagers particularly in
those who are overweight. It is basically a slow fracture through the
growth plate of the proximal femur with remodeling as the slip pro
gresses. The plain radiographs are usually diagnostic, particularly on the
frog leg views (Fig. 58 b) since the slip is usually from front to back. On
the AP view the findings are more subtle (Fig. 58 a). A line drawn along
the superior margin o f the femoral neck normally should intersect the
femoral head. In SCFE it usually does not. Additional signs on the AP
view are relative widening and poor definition of the growth plate (Fig.
58 a) and deformity or bending of the femoral neck. SCFE can be caused
by too much force on the growth plate such as may occur with increased
weight of the child or from the forces of active sports. Alternatively the
516
Figure 58.
Slipped capital femoral epiphysis
(SCFE)
a) In the neutral position the slip is not
seen. There is, however, a wider
growth plate in the left hip than on
the right which is suggestive o f
SCFE. The findings in SCFE can be
very subtle in the neutral position
view. The diagnosis can be missed
unless a frog-leg view is obtained.
b) Frog-leg view. The slipped capital
epiphysis on the left is clearly seen.
The reason it is best seen in this view
is that the slip is mainly from front to
back, rather than side to side.
growth plate may be too weak for the normal forces placed upon it, such
as in children who have rickets, renal osteodystrophy (Fig. 59), hy
pothyroidism, or following previous radiation therapy to the hip region.
One of the serious complications of treatment of SCFE is chondrolysis
which is an arthritis with narrowing and irregularity of the hip joint (Fig.
60). Aseptic necrosis of the femoral head may also occur, although, if
no attempt is made to reduce the slip the incidence of aseptic necrosis is
very low.
517
Figure 59.
Slipped capital
fem oral epiphyses in
15-year-old boy with
renal osteodystrophy.
The growth p la tes a re
wide and the m eta
physeal m argins are
irregular. There are
also fu zzy m argins o f
the ischia which is
evidence o f hper-
parathyroidism.
Figure 60.
Chondrolysis o f the
right hip fo llo w in g
pinning o f bilateral
SCFE. The right hip
joint is narrow and
irregular.
Osteochondritis Dissecans
In this disorder small fragments of bone separate from the articular sur
face. It is seen in many joints but particularly in the distal femoral epi
physis, the dome of the talus and the proximal femoral epiphysis.
Osteochondritis dissecans may be acquired from trauma, steroids, or
other conditions and there is also a congenital familial form. Although
osteochondritis dissecans is readily diagnosable in adults it is difficult to
diagnose in the knees of children because of the common normal vari
ant of irregular ossification of the distal femoral epiphysis (Fig. 61).
These epiphyseal irregularities and abnormal centers are commonly seen
in a large percentage of normal children, more commonly in young chil
dren. They usually do not represent a loose fragment in a very young
child but represents uneven ossification of the epiphysis. Magnetic res
onance imaging can be of value to prove that these are well within the
518
Figure 61.
10-year-old boy with pain in the
knees. An apparent fragm ent is
seen in the lateral condyle. There
was a question whether this repre
sented a normal variant or osteo
chondritis dissecans. On the plain
films alone it is very difficult to
make this distinction in children,
because normal ossification vari
ants can mimic the disease. MRI,
however, confirmed that in this
case the defect was simply a nor
mal variant.
cartilage of the epiphysis.
Joint disease
Juvenile rheumatoid arthritis (JRA) is the most common joint disease in
children. The term juvenile chronic arthritis has been used in countries
other than the USA for the same condition. Radiological signs are usu
ally secondary in very young children since the bone ends are covered
by a thick layer of cartilage and erosion of cartilage may not be detected
until maturity. One of the roles of radiology is to determine whether the
clinical signs are due to JRA or due to some mimic of joint disease.
Radiologic studies are also of value to determine the activity of the dis
ease and to determine whether it is improving or getting worse.
Radiologic evaluation is often more objective than the clinical exam and
is a good way to monitor the efficacy of therapy. JRA can occur in very
young children one or two year of age who are often not very good his
torians and cannot localize pain well.
Inflammatory changes in JRA can be detected by the presence of
growth disturbances secondary to the associated hyperemia. These may
519
Figure 62.
Juvenile Rheumatoid Arthritis in a 15-
year-old girl with long standing disease.
Note the markedly broadened distal ends
o f the proximal phalanges. This is evi
dence o f hyperemia and is often the only
sign o f JRA in the hand. In this p articu
lar child, however, joint changes are
also evident at the metacarpal p h a
langeal joints. There are also irregulari
ties o f the carpals indicating jo in t in
volvement.
Figure 63.
Juvenile rheumatoid arthritis in a 2.5-
year-old girl.
Note the extensive periosteal changes
particularly in the fourth metacarpal and
in all the proximal phalanges. The p e
riosteal changes in the proximal pha
langes may result in broadening o f these
bones. The carpals and metacarpal
carpal joints appear irregular.
520
be the only radiographic signs present. A common location of hyperemic

change is the distal portion of proximal phalanges, which often have a
bulbous configuration (Fig. 62). The condyles o f the femur or patella or
any other bone end may also be enlarged. Initially the bones may be too
long from the hyperemia. Eventually they may become too small as pre
mature closure of the growth plates stops further growth. Periosteal ele
vation may occur in young children (Fig. 63). The best method for eval
uating synovitis is with MRI and enhancement following intravenous in
jection of gadolinium compounds. In this way one can separate fluid from
synovitis. This is otherwise very difficult to do radiographically. With
MRI, meniscal deformity and hypoplasia, which are common in JRA,
may be detected. Bone scintigraphy has a smaller role in joint disease as
correlation with disease is not very good. Loss o f cartilage is best eval
uated by MRI. Loss of cartilage can be implied in the hand by showing
a decrease in the space between the growth plate of the distal radius and
the third metacarpal (Fig 1 a). A measurement o f this space can then be
compared to the length of the second metacarpal or the width of the base
of the metacarpals and give a measure of carpal loss. Bone erosion oc
curs later and is seen particularly in older children. Various joint dislo
cations may occur. Ulnar dislocation of the wrist is common particularly
when associated with short ulna. The cervical spine is occasionally in
volved in JRA with subluxation at Cj-C2. Eventual fusion of the poste
rior elements of cervical vertebrae may occur. Temporomandibularjoints
can also be involved in JRA with associated hypoplasia of the mandible
and deformity of the mandibular condyle. MRI with gadolinium can
show active synovitis and meniscal damage in the temporomandibular
joints.
In evaluating children with joint symptoms it is very important to rule
out the many mimics of joint disease. Eight to ten percent of children
presenting with joint symptoms have leukemia rather than arthritis. The
presence of lucent metaphyseal bands (Fig. 9) is a useful sign of leukemia.
Destructive changes also may be seen. Carpal-tarsal osteolysis can in its
early stages mimic JRA both clinically and radiographically. It is a hered
itary condition which is usually inherited as autosomal dominant.
Initially carpal and tarsal bones are destroyed with soft tissue swelling.
Eventually the destruction becomes much more severe and even the base
of the metacarpals may be destroyed. Often it is only when the destruc
tion becomes great that one can separate it from JRA. The name carpal-
521
Figure 64.
Dermatomyositis with extensive calcifi
cation in a 12.5-year-old girl.
Fortunately, with modern therapy we
now rarely see the disease in this fo rm .
tarsal osteolysis is somewhat of a misnomer since elbows and other joints

may also be affected.
There are many other mimics of joint disease in children including var
ious other collagen disorders, Gaucher disease, fibrodysplasia ossificans
progressiva, osteomyelitis, neuroblastoma, trauma, etc. When unilateral
joint disease is present particularly in the hip or knee the possibility of
tuberculosis should always be considered.
Juvenile dermatomyositis (JDMS)

In long standing JDMS calcification can be seen in soft tissue (Fig. 64)
and there may be considerable bony demineralization. In early disease ra
diographs are normal. MRI has been very useful to localize active myosi
tis in early or late disease as often the muscle involvement is patchy. It is
best demonstrated on MRI using a T2 weighted fat suppressed sequence.
The affected muscle has a very high signal. Without MRI for localization
normal muscle may be biopsied since involvment is often not universal.
MRI is also useful in following the results of therapy.
522
Figure 65. Fibrodysplasia ossificans progressiva.

a) There is extensive calcification and ossification in the soft tissues around the shoul
ders and chest wall.
b) Foot o f the same girl as in A. The great toe is short with a valgus deformity. The
first proximal phalanx is fu se d to the first metatarsal. The appearance o f the foot is
characteristic o f this disorder and is evident long before the onset o f calcification.
Fibrodysplasia ossificans progressiva
This is a syndrome in which ossification occurs in the tendons and fascia

of muscles with eventual, total immobilization of the patient (Fig. 65 a).
The condition usually starts in childhood around the shoulder girdle with
swelling and pain. It does not show any initial radiographic findings in
the affected area. Early changes can be detected with MRI. A radio-
graphic finding that is present since birth, well before the ouset of symp
toms which is not related to the ossification, is a foot abnormality with
a pathognomonic appearance. The great toe is very short with a valgus
deformity and sometimes with absence of the proximal phalanx or fusion
of it to the first metatarsal (Fig. 65 b). The foot abnormality precedes the
ossifications in the soft tissues.
523
Figure 66.
Fractures in infant with severe osteoporo
sis associated with prematurity and
bronchopulmonary dysplasia. This infant
was three months o f age and developed
fractures while in the hospital. There is
callous and periosteal elevation about the
fractures.
METABOLIC BONE DISEASE

Bone loss in children can be due to osteoporosis, rickets, which is the
pediatric form o f osteomalacia, and hyperparathyroidism.
Osteoporosis
Simple observation of the density of plain radiographs is a very inaccu
rate method of quantitating bone loss in children. The apparent density
of bone on radiographs is very dependent upon technical factors such as
film screen characteristics, KV used, fog from scatter, and part thickness.
A useful method of evaluating bone loss in children is measurement of
cortical thickness of bones. In the neonate the humerus can be measured
and compared to normal standards. In the hand the cortical measures of
the second metacarpal are also useful. Osteoporosis in children occurs
as in adults with resorption at the endosteal surface. There is usually no
bone loss on the outside of the bone. When the outside diameter of the
bone is small this is a manifestation of lack of growth which suggests
the disease process causing it is of long standing. Dual energy x-ray ab-
sorptionmetry (DXA) shows some promise as a tool for measuring bone
524
Figure 67. a and b Rickets. There is irregularity o f the metaphyses particularly in the
distal femur radius and ulna with widening o f the growth plates. This is a characteris
tic appearance o f rickets. The evidence o f rickets is proportional to the growth rate at
the bone ends. Thus, it is greater in the distal fem ur than in the proximal tibia.
mass in children.
Many pediatric conditions are associated with osteoporosis including
juvenile rheumatoid arthritis, Crohn disease, other chronic diseases, and
nutritional problems. In the neonate with severe pulmonary problems
there may be extremely severe osteoporosis. The bones may be so thin
that they fracture during usual handling (Fig. 66).
Rickets
Rickets has a very characteristic radiographic appearance which is seen
only when the growth plates are open. After closure of the growth plates
the disease is called osteomalacia. In rickets, there is widening of the
growth plates with irregularity and fraying of their metaphyseal board
ers (Fig. 67). There is often cupping of the anterior rib ends. The bones
may have a very washed out appearance with very thin, fuzzy cortex (Fig.
68). Intracortical striations may be seen. Most forms of rickets have a
very similar appearance except for vitamin D resistant rickets (hy-
pophosphotemic rickets) where in older children there are thick, short,
bowed bones (Fig. 69). The changes in rickets are most severe where
525
Figure 68. Severe Rickets

a) At ten-months o f age note the marked separation between the distal fe m u r and prox
imal tibia with marked irregularity and fuzziness o f the metaphysis. Overall miner
alization is very poor.
b) Six months later after therapy the epiphyses have appeared and now there is some
sclerosis o f the distal metaphysis. The space between the ossified metaphyses o f the
femur and tibia has decreased due to their increased ossification with healing.
bone growth is the greatest. Therefore, the knees, ankles, and wrist are
the best sites for evaluating possible rickets and monitoring therapy. The
changes also are most marked when growth is rapid. Thus, in some
chronic rickets, such as vitamin D resistant rickets, they may appear to
increase in adolescence. In some forms of rickets there may be associ
ated secondary hyperparathyroidism. This is particularly common in vi
tamin D dependent rickets, a familial condition due to lack o f the sec
ond hydroxylation of vitamin D in the kidney. It is never seen in vitamin
D resistant rickets. The bones affected by rickets may be bowed and frac
tured. During healing of rickets the zone of provisional calcification of
ten calcifies first and there may be lucent bands in the metaphyses.
Periosteal elevation may also be seen during the healing process
Fig. 68 b).
526
Figure 69.
Vitamin D resistant rickets (hypophos-
phatemic rickets). There is shortening
and bowing o f the bones which appear
somewhat thickened. This appearance is
not seen in other form s o f rickets. The
rachitic changes are not severe.
There are many conditions that mimic rickets. These include copper
deficiency in infancy, hypophosphatasia, hyperparathyroidism both pri
mary and secondary, Shwachman syndrome, several forms of metaphy
seal chondrodysplasia as well as other disorders. In many of these dis
orders the appearance of the metaphyses although similar to rickets, usu
ally can be distinguished from it on radiographs.
Renal osteodystrophy
This may be difficult to separate radiologically from rickets unless the
hyperparathyroidism is severe, which is uncommon in ordinary rickets.
The best sign of hyperparathyroidism in older children as well as in adults
is subperiosteal resorption along the radial side of the middle phalanges.
It is best seen on radiographs obtained with high detail such as on mam
mography film. In infants and very young children resorption is often
better seen in the medial part of the upper tibia, the medial proximal
humerus, and medial femoral neck. Brown tumors may be seen and frac
tures are common. The ends of the ribs may be cupped. Diagnosis is pos
sible on a chest radiograph by looking at the humeri, clavicles, and ribs.
Slipped capital femoral epiphyses (Fig. 59) and similar changes in the
shoulder joint may occur. The "slips" are really Salter I fractures and are
527
usually symptomatic.
PERIOSTEAL ELEVATION IN CHILDHOOD AND

CORTICAL THICKENING
Periosteal elevation may be physiologic in rapidly growing infants - this
type of periosteal elevation is characteristically uniform, not very thick
and involves the femora, tibias, and humeri but rarely other bones. There
are many pathologic causes including healing rickets (Fig. 68 b), Caffey
disease, prostaglandin therapy, leukemia, tumors, infection, vitamin A
poisoning and trauma.
Caffey disease
This is an idiopathic disorder of bone which is associated with tender
ness and swelling along the bones. There is considerable cortical thick
ening or periosteal elevation. The mandible is frequently but not always
involved. Both flat bones and tubular bones can be affected. The condi
tion usually occurs within the first six months of life. It is often seen at
birth or even in utero. There may be elevated levels of prostaglandin pre
sent. The infant’s symptoms may be relieved by prostaglandin antago
nists. The condition is usually self limiting and is treated by conserva
tive means.
Prostaglandin therapy
Periosteal elevation may occur from administration of prostaglandins to
keep the ductus arteriosus open in infants with severe cyanotic heart dis
ease prior to definitive therapy such as heart transplants. The periosteal
change in the bone can be extensive not unlike those seen in Caffey dis
ease, particularly if the treatment is prolonged.
FROSTBITE IN CHILDREN
The manifestations of frostbite that are different in children in adults are
growth disturbances due to growth plate damage. The first affected ar
eas are the distal phalanges of the hand or foot the resultant closure of
the affected growth plates and resultant deformity and shortening of these
bones. A characteristic pattern may be seen in the hand with the distal
phalanges of the fingers affected but with sparing of the distal phalanx
of the thumb. This is due to the fact that the thumb has better circulation
and it is often clasped within the hand. Other phalanges and even
528
metacarpals may be affected in severe cases. Bums can similarly cause

growth plate closure.
LANGERHANS CELL HISTIOCYTOSIS

Previously known as histiocytosis X, Langerhans cell histiocytosis in
cludes the entities known as eosinophilic granuloma, Hand-Shuller-
Christian disease, and Letterer-Siwe disease. This condition has variable
manifestations. In the skeleton there are areas of bone destruction usu
ally with sharply defined lucent lesions without a cortical rim. However,
a variety of other manifestations may be present (Fig. 70). During heal
ing sclerotic areas may be present. In the pelvis there may be sclerotic
changes mimicking Ewings. Langerhans cell histiocytosis should be con
sidered in the differential diagnosis of all bone tumors and in almost any
type of bone destruction in the skeleton. Flattening of vertebrae bodies
sometimes with disk-like vertebra plana may be seen. In the skull the le
sions are usually sharply defined round or geographic (Fig. 70 b).
Occasional target like lucencies may be seen in the skull due to dififer-
529
Figure 71.
Myofibromatosis (congenital fibromatosis) in a
5-month-old boy. There are sharply circum
scribed lytic defects in the fibula. Other similar
lesions were present in other parts o f the skele
ton. These lucencies are similar to what may
be seen in histiocytosis X, but they occur at a
very early age; often at birth.
ent degrees of destruction in the outer and inner tables. The lesions of
Langerhans cell histiocytosis may clear up spontaneously leaving no vis
ible residual.
MYOFIBROMATOSIS
This is also known as congenital fibromatosis. This condition which af
fects bone in the neonate with sharply defined lucent lesions and some
times soft tissue tumors as well (Fig. 71). It is the most likely diagnosis
in the neonate with sharply defined lucencies. Langerhans cell histiocy
tosis does not usually appear at this age. The lesions usually disappear
spontaneously unless there is visceral involvement.
SICKLE CELL DISEASE IN CHILDHOOD

In toddlers one of the important findings of sickle cell disease is the so
called hand-foot syndrome which presents as swelling and pain in the
fingers and toes. It represents areas of infarction within the metacarpals,
metatarsals, or phalanges. There may be periosteal elevation and focal
areas of destruction usually involving several but not all digits. Generally
530
in the United States only the tubular bones of the hands and feet are af
fected. In Africa involvement of other bones may also occur. The im
portant differential if only one or two bones are affected is the possibil
ity of osteomyelitis, which also can occur in these children. The hand-
foot syndrome is difficult to separate from osteomyelitis. Bone marrow
scans and bone scintigraphy have been used to try to differentiate os
teomyelitis from infarcts of the hand foot syndrome but this effort is of
ten unsuccessful. The areas of infraction may damage growth plates caus
ing growth alteration resulting in coned epiphyses and short metacarpals
or other bones.
Other skeletal manifestations of sickle cell disease occur in older chil
dren. These include asceptic necrosis of the hips and spine changes. In
the spine there may be a squared off indentation of the end plates which
represents a growth disturbance.
531
Chapter 15
Pediatric radiology
Donald R. Kirks and Sven Laurin
Pediatric radiology is the application of diagnostic radiology to the un

derstanding, prevention, diagnosis, treatment, and follow-up of diseases
of infants and children. The history of pediatric radiology is based on the
emergence of pediatrics and radiology as medical specialties, the growth
of these two parent specialties, their fusion into pediatric radiology, and
the explosive growth of pediatric radiology as a subspecialty of diag
nostic imaging. It must be emphasized that pediatric radiology is a unique
subspecialty of diagnostic radiology with specific knowledge and ex
pertise required. The child and its parents need special care, examina
tion methods must be adapted to the pediatric patient, and radiologic find
ings as well as disease entities are frequently different in infants and chil
dren from adults.
In the past, radiologists have simply attempted to improve the accu
racy of various imaging techniques. They have only been interested in
the ability of a specific diagnostic modality to detect patients with dis
ease (sensitivity) and to exclude patients without disease (specificity).
However, the many imaging modalities as well as increasingly limited
medical resources available require problem-oriented decisions to de
termine which techniques should be used or omitted in any given clini
cal situation. Radiation exposure, delay in diagnosis and therapy, and
costs must be minimized. We must be aware of what we are doing to the
pediatric patient (risk) as well as what we are doing/or the child (bene
fit). The radiologic procedure must be tailored to the specific clinical
problem; this problem-oriented approach is based on history, physical
examination, laboratory data, clinical diagnostic considerations, and po
tential yield of various imaging techniques. Throughout this chapter, we
will point out our approach to problem-oriented pediatric radiology.
533
The purpose of this chapter is to provide an overview of imaging of

the respiratory system, cardiovascular system, gastrointestinal tract, and
genitourinary tract of infants and children. The constraints of an overview
prevent detailed discussion of radiological and imaging techniques.
Pediatric neuroimaging and imaging of the musculoskeletal system of
children are discussed in other chapters.
PEDIATRIC TECHNIQUES
Children are imaged with the same radiographic equipment as adults.
Clinical exposure times require a modem multipulse generator.
Conventional radiographic examinations (plain films, fluoroscopy) still
comprise 80-85% of all pediatric studies; the remainder is made up of
ultrasound (8-12%), CT (3-5%), MRI (2-4%), nuclear medicine
(2-4 %) and vascular/interventional procedures (0.5-1 %).
Angiographic examination of children has limited indications; most
studies are for diagnosis and potential interventional therapy of cardiac
and vascular malformations. Computed tomography (CT) is used to in
vestigate neurologic disease, pediatric oncologic abnormalities, and
acute cerebral or abdominal trauma. Magnetic resonance imaging (MRI)
is used to investigate neurological abnormalities, pediatric oncologic dis
ease, cardiovascular abnormalities, and complex musculoskeletal dis
ease.
Special emphasis is given to reduction of radiation dose in radiologic
examinations of children. Indications for examination must be well
founded. Radiation protection is critical; lead shielding of the gonads is
used whenever possible. The fundamental principle is that radiation of
the pediatric patient should be minimized. Exposure is reduced by se
lecting studies based on a detailed history, performing only indicated
studies, using non-ionizing radiation examinations (sonography, MRI)
whenever possible, limiting the radiation dose of an examination, and
shielding the gonads when feasible.
Examination of the gastrointestinal tract, kidneys, and liver in children
up to 3 months of age requires no preparation. In older children, the same
preparations should be used as for adults.
Conventional radiographic examinations and ultrasound (US) are per
formed without sedation or general anesthesia. Nuclear medicine (NM),
CT, and MRI usually require sedation or general anesthesia in children
below 7 years of age. However, even 3-year-old children who are coop-
534
PEDIATRIC RADIOLOGY
Figure 1.
Normal chest radiograph.
1-year-old male with cough.
The heart, mediastinum and
lungs are normal.
erative and have had previous, non-painful radiologic examinations can

sometimes be examined by these modalities without sedation.
Interventional procedures, which are frequently painful, should always
be performed with heavy sedation or general anesthesia. It is frequently
helpful to allow parents to be present during radiological examinations,
if they wish. However, parents should not be permitted in the angio
graphic suite during complex diagnostic and interventional procedures.
RESPIRATORY SYSTEM
Modalities
Chest radiography remains the ’’foundation” examination for the evalu
ation of any thoracic abnormality. Both AP or PA and lateral views of
the chest should be obtained for accuracy of interpretation. Evaluation
of the upper airway requires AP and lateral radiographs. Abnormalities
identified by conventional chest radiographs may require additional plain
films for clarification. Potential supplementary chest radiography in
cludes oblique views, high-kilovoltage techniques, inspiration-expira-
tion films, and lateral decubitus views. Other modalities which may be
helpful for evaluation of abnormalities of the respiratory system include
fluoroscopy, esophagography, angiography, bronchography, US, CT,
and MRI.
Chest radiographs comprise up to 1/3 of all X-ray examinations in chil
dren. Conventional X-ray technology demonstrates most respiratory
tract disease. All children, who can stand, should be examined in a chest
unit. Special equipment, where the patient is restrained, are used as lit
tle as possible. Supine radiographs are appropriate in younger infants or
535
for portable examinations. Frontal and lateral views with good position
ing, deep inspiration, and adequate exposure is critical (Fig. 1).
Neonatal chest X-ray examinations are performed for respiratory prob
lems. Many o f these children are treated in incubators and with breathing
assistance. They must be examined in the intensive care unit with portable
X-ray equipment. To avoid heat loss, exposures are made with the patient
in the incubator. Electric cables and electrodes are not removed from the
patient. However, an electrode situated so that it will obscure the carina
or trachea should be permanently moved since it can obscure location of
an endotracheal tube. It is important that the frontal film is not oblique.
Only AP films are required for follow-up examination of the newborn;
lateral films are helpful for initial diagnostic evaluation or clarification of
unexplained abnormalities on the AP radiograph.
Airway abnormalities
Choanal Atresia
Choanal atresia is a congenital obstruction of the posterior nasopharynx
that can be membranous or bony, unilateral or bilateral, complete or in
complete. Choanal atresia is the most common congenital anomaly of
the nasal cavity. Since the newborn is an obligate nose breather, bilat
eral choanal atresia causes severe respiratory distress, especially during
feeding. The diagnosis is suspected clinically by failure to pass an en
teric tube via the nasal route. The diagnosis can be verified by injecting
water-soluble, non-ionic contrast into the nasal cavity (Fig. 2 a). CT is
also able to confirm the diagnosis by demonstrating the anatomic ab
normality (Fig. 2 b).
Tracheomalacia
Tracheomalacia is a weakness in the wall of the trachea, either local or
generalized, causing collapse during breathing. It may be due to intrinsic
weakness of the tracheomembranous cartilage but more commonly is a re
sult of extrinsic factors. The diagnosis is verified by fluoroscopy. Contrast
in the esophagus aids in the diagnostic evaluation. Some of the secondary
vascular causes of tracheomalacia include innominate artery compression,
double aortic arch, right aortic arch with anomalous left subclavian artery,
and pulmonary sling. Initial diagnostic study should be a contrast exami
nation of the esophagus in both frontal and lateral projections.
536
PEDIATRIC RADIOLOGY
Figure 2.
Choanal atresia,
a) Bilateral choanal
atresia. Newborn
male with respira
tory distress during
feeding. Water-sol
uble contrast mate
rialfills the nasal
cavity (arrow) but
does not enter the
pharynx,
b) Unilateral choanal
atresia. 7 year-old-
male with nasal
congestion. Axial
CT section demonstrates bony plate
(arrow) on the left. [From Kirks DR.
Practical Pediatric Imaging:
Diagnostic Radiology o f Infants and
Children. 2nd Ed. Boston: Little,
Brown and Company, 1991. With per
mission o f editor and publisher.]
Croup and Epiglottitis

Croup is a common cause of upper-airway obstruction in temperate zones
and is almost invariably due to viral infection. Although the entire air
way (laryngotracheobronchitis) is infected, the critical area of airway
narrowing is located 1cm below the larynx. Croup is a disease of infants
and young children, with the age range being between 6 months and 3
years; the peak age for occurrence is approximately 12 months. The child
presents with a mild barky cough and intermittent respiratory stridor. AP
radiographs show loss of the normal lateral convexities ("shoulders") of
the subglottic trachea (Fig. 3 a). Lateral radiographs demonstrate hy-
popharyngeal overdistention during inspiration, normal epiglottis and
aryepiglottic folds, loss of definition of the tracheal lumen just below the
level of the vocal cords, and narrowing of the subglottic portion o f the
trachea (Fig. 3 b).
537
Figure 3. Croup.
2-year-old fem ale with inspiratory stridor.
a) AP view o f the upper airway shows subglottic
narrowing well below the level o f the pyriform
sinuses, producing a steeple appearance (arrows). [From Kirks.]
b) Lateral view o f the upper airway shows mild subglottic tracheal narrowing (arrow).
Figure 4. Epiglottitis.
2-year-old male with inspiratory stridor and
drooling. Lateral view o f the upper airway shows
moderate enlargement o f the epiglottis with
marked thickening o f the aryepiglottic folds.
[From Kirks.]
Epiglottitis is less common but much more dangerous than croup. It

affects older children than does croup, with the peak incidence between
3 and 6 years of age. The usual bacterial etiology is Hemophilus in
fluenzae. A patient with acute epiglottitis is in mortal danger; no physi
cal or radiologic examination should be performed that may further com
promise the airway. The lateral radiograph shows marked enlargement
of the epiglottis and thickening of the aryepiglottic folds (Fig. 4). The
development of an effective vaccine has decreased the incidence of both
538
PEDIATRIC RADIOLOGY
Figure 5. Wet lung disease.

a) Term 2-hour-old fem ale with increased respiratory rate but no cyanosis or fever.
The heart is at the upper limits o f normal in its transverse diameter. There is
increase in vascularity with hazy margins and patchy interstitial and acinar opaci
ties that obscure the heart margins. Note the right pleural effusion.
b) Follow-up chest radiograph at 24 hours o f age. The heart and vascularity are now
normal. Pleural fluid no longer identified.
epiglottitis and H. influenzae pneumonia.
Respiratory distress in the newborn

Respiratory difficulties occur in up to 3 % of all newborn infants. At least
half of all newborn infants weighing 2kg or less will have some respira
tory distress. Infants weighing 1kg or less have a 95% incidence o f res
piratory difficulties.
Medical Disease
Wet-Iung disease
Wet-lung disease (pulmonary adaption syndrome; transient tachypnea
of the newborn), due to delay in normal clearing of lung fluid, is one of
the most common causes of respiratory distress in the newborn.
Typically, infants with wet-lung disease are full-term. There is an in
creased frequency with cesarean section, prematurity, or maternal seda
tion. Tachypnea develops during the first few hours of life but pH and
pC 0 2 are normal. Chest radiographs demonstrate the pathophysiologic
abnormalities due to a delayed resorption of fluid. The findings include
indistinct pulmonary vessels indicating vascular congestion, fluid in the
fissures, bilateral pleural effusions, and patchy parenchymal opacities
(Fig. 5 a). The changes are usually symmetric and the general aeration
539
Figure 6. Respiratory distress syn

drome.
a) Severe RDS. There is diffuse opacity
with marked underaeration o f both
lungs.
b) M ild RDS. There are bilateral reticu-
logranular densities. The general
aeration o f the lungs is only slightly
decreased.
of the lungs is normal. In severe cases, it may be difficult, if not impos

sible, to distinguish wet-lung disease from neonatal pneumonia or meco
nium aspiration. The clinical appearance as well as the chest radiograph
are usually normal by 24-48 hours (Fig. 5 b). In fact, the chest radiograph
usually shows marked improvement by 12 hours of age.
Respiratory distress syndrome

Respiratory distress syndrome (RDS), also called hyaline membrane dis
ease or idiopathic respiratory distress syndrome, is due to a deficiency
of surfactant. Deficiency of this lipoprotein decreases alveolar surface
tension and causes acinar atelectasis. The diffuse collapse of alveoli is
associated with interstitial edema, damage to alveolar epithelium, un
even expansion, and generalized lung underaeration. The disease is most
common in premature infants but can occasionally occur in full-term
newborns.
540
PEDIATRIC RADIOLOGY
Figure 7.
Pulmonary hemorrhage.
2-day-old premature male with
RDS. Sudden clinical deterioration
with blood suctioned from the
trachea. Chest radiograph shows
severe bilateral parenchymal
opacities with decreased general
aeration.
The chest radiograph in severe cases demonstrates nearly airless lung;

only air in bronchi ("air bronchograms") are seen (Fig. 6 a). In mild cases,
there are fine reticulogranular densities in both lungs (Fig. 6 b). These
radiographic findings are due to the superimposition of multiple acinar
nodules caused by atelectatic alveoli contrasting against adjacent en
larged bronchi and air-containing parenchyma.
The primary factor predisposing to RDS is prematurity. Dyspnea is
manifest by inspiratory retraction, tachypnea, nasal flaring, expiratory
grunting, and progressive cyanosis. The lungs in patients with RDS are
stiff with decreased compliance. Due to strongly negative intrapleural
pressures associated with labored breathing, the esophagus is frequently
air-filled. Radiologic examination is essential to characterize the disease
and exclude other causes of respiratory distress. Newborns with RDS are
treated by respirators; this increases inspiratory pressure and maintains
end-expiratory pressure. During the first week of life, there is a contin
ued increase in surfactant production. This permits the alveoli to expand.
RDS may also be treated by the tracheal instillation of exogenous sur
factant.
RDS is frequently complicated by iatrogenic effects of artificial ven
tilation. Air-block complications include pulmonary interstitial emphy
sema, pneumomediastinum, and pneumothorax. Differential diagnostic
considerations in newborns with RDS are wet-lung disease, meconium
aspiration, and neonatal pneumonia. Without clinical correlation and se
quential radiographs, it is extremely difficult to distinguish RDS from
wet-lung disease or neonatal pneumonia.
541
Figure 8.
Meconium aspiration.
Full-term male with respiratory
distress requiring ventilator
therapy. There are patchy
pulmonary parenchymal opaci
ties with associated regions o f
atelectasis. Note the marked
hyperaeration.
Pulmonary haemorrhage
Pulmonary hemorrhage is usually a complication of RDS or neonatal
pneumonia. Clinically, blood is present in the trachea. After a sudden de
terioration, the chest radiograph shows a diffuse increase in lung density
bilaterally with air bronchograms. In fact, the lungs can look completely
airless (Fig. 7).
Meconium aspiration
Severe in utero hypoxemia or asphyxia may cause fetal defecation and
gasping; this leads to aspiration of meconium in amniotic fluid into the
tracheobronchial tree below the level of the vocal cords. Meconium as
piration causes both mechanical obstruction of the larger airways and an
inflammatory reaction peripherally in the bronchioles. Ventilation dis
turbance is greater in meconium aspiration than in wet-lung disease.
There are patchy, bilateral, asymmetric areas of opacity. There is as
sociated hyperinflation of the lungs with flattening of the domes of the
hemidiaphragms (Fig. 8). Air-block complications occur in approxi
mately 25% of patients with proven meconium aspiration. Differential
diagnostic considerations include RDS, neonatal pneumonia, wet-lung
disease, and pulmonary hemorrhage.
Neonatal pneum onia

Neonatal pneumonia may be acquired in utero, during delivery, or after
birth. Etiologic organisms include viruses, bacteria, protozoans, and fungi.
542
PEDIATRIC RADIOLOGY
Figure 9.
Bronchopulmonary dysplasia.
This 5-week-old fem ale required
ventilator therapy at birth fo r RDS.
Circular lucencies and curvilinear
densities produce a honeycomb
appearance o f the lungs; this is
Stage IV BPD.
Hemolytic streptococcal infection is a common neonatal acquired

pneumonia; the radiologic appearance may be identical to that of RDS,
with reticulogranular densities frequently associated with pleural fluid
or fluid in the fissures. Organisms causing neonatal pneumonia acquired
through the ascending route or during delivery are normal inhabitants of
the vaginal flora. With the exception of P-hemolytic streptococcal pneu
monia, most neonatal pneumonias are characterized by patchy, asym
metric pulmonary opacities with associated hyperaeration.
Brochopulmonary dysplasia
Bronchopulmonary dysplasia (BPD) is a common and significant com
plication of newborns that have undergone ventilator therapy, usually for
RDS. BPD is a distinct pulmonary disease affecting all the tissues of the
developing lung related to prolonged oxygen and/or respiratory therapy.
During the course of the disease, mucosal necrosis, interstitial edema,
and interstitial fibrosis develop. Initially, there is alveolar exudation and
inflammatory reaction with decreased lung aeration. After 10-20 days of
age, there is the development of a bubbly radiologic appearance of the
lung; this is due to local areas of hyperventilation intermixed with areas
of atelectasis and interstitial thickening. Stage IV BPD develops after
one month of age; a honeycomb appearance of the lung is due to fibro
sis. BPD can heal spontaneously, but in most cases the changes are
chronic. Advanced cases with hyperaeration and severe chronic lung dis
ease (Fig. 9) may lead to cor pulmonae and even death.
543
Figure 10.
Diaphragmatic hernia.
The stomach (identified by enteric tube)
and small bowel are in the left chest;
mass effect displaces the mediastinum
from left to right and causes compres
sive atelectasis o f the right lung.
Surgical Disease
D iaphragm atic hernia

Bochdalek hernia is due to a defect in the posterior pleuroperitoneal fora
men. The left pleuroperitoneal foramen is most commonly involved; ini
tial radiographic appearance may be that o f a large intrathoracic soft-tis-
sue density mass. After several hours, multiple loops of air-filled bowel
are identified in the chest (Fig. 10). There is almost always ipsilateral
lung hypoplasia; large diaphragmatic hernias will also cause contralat
eral lung hypoplasia.
Clinically, the abdomen is scaphoid and the thorax is asymmetric. If
the bowel loops are fluid-filled, placement of an enteric tube and/or in
jection of a small amount of air will confirm the diagnosis. The progno
sis of patients with diaphragmatic hernia is dependent on the degree of
associated lung hypoplasia.
Cystic lung disease

Cystic intrathoracic masses in the newborn include cystic adenomatoid
malformation, lobar emphysema, sequestration, and bronchogenic cyst.
Congenital Lobar Emphysema

Congenital lobar emphysema is a condition characterized by progressive
overdistention o f a pulmonary lobe or, rarely, multiple lobes. Location,
in decreasing frequency, of lobar emphysema is left upper lobe, right
544
PEDIATRIC RADIOLOGY
Figure 11.
Cystic adenomatoid malforma
tion.
Neonate with mild respiratory
distress. Clinically, the abdomen
is normal. There are cystic and
solid components o f the mass in
the left chest; the cystic adeno
matoid malformation displaces
the heart and mediastinum to the
right. The left hemidiaphragm is
well visualized.
middle lobe, and right upper lobe.

During the first few days of life, lung fluid may be trapped in the in
volved lobe, producing a soft-tissue mass. Subsequently, the classic ra
diologic appearance o f an emphysematous lobe with diffuse radiolu
cency develops. Treatment for lobar emphysema is surgical resection;
the prognosis is excellent.
Cystic Adenomatoid Malformation

Cystic adenomatoid malformation (CAM) is a developmental, hamar-
tomatous malformation of the lung. Radiographically, there is a soft-tis-
sue mass in the chest which usually displaces heart and mediastinal struc
tures. This chest mass may be solid or cystic; the cysts may be small or
large. As opposed to diaphragmatic hernia, the bowel gas pattern is nor
mal and the diaphragm is intact (Fig. 11).
A ir-Ыоск com plications

Mild forms of air-block phenomena occur in 2% of all newborns. This
usually results in minimal respiratory symptoms. Resorption of gas oc
curs without difficulty.
The incidence of air-block complications increases by as much as 10%
with mechanical ventilation. If there is alveolar rupture, air may local
ize and coalesce in the parenchyma to produce a pulmonary pseudocyst.
More frequently, air accumulates in the perivascular spaces to produce
pulmonary interstitial emphysema (PIE). The radiologic features are
characteristic with multiple, tortuous linear lucencies radiating out from
545
Figure 12.
Air-Ыоск complications.
a) Tension pneumothorax.
There is increased volume o f
the left hemithorax with
associated lucency. Both
lateral and anteromedial
pleural air collections
identified. The multiple linear
lucencies in the left lung are
pulmonary interstitial
emphysema.
b) Pneumomediastinum. The
thymus is elevated and air is
seen along the upper left
a mediastinum (arrow).
c) Pneumopericardium. Air
completely surrounds the
heart with no cranial
extension above the level o f
the great vessels. Note the
associated left
pneumothorax.
546
PEDIATRIC RADIOLOGY
the hilar regions (Fig. 12 a).

Spontaneous pneumomediastinum is not uncommon in a newborn;
most of these are small and clinically insignificant. A moderate-sized
pneumomediastinum produces a radiolucent line that outlines the heart
border and elevates the thymus (Fig. 12 b). Air can also dissect into the
neck and into the abdominal cavity.
A large pneumothorax can be identified by transillumination of the
chest in premature infants; chest X-ray remains the best method of di
agnosis, particularly in larger and more mature infants. Chest radiogra
phy is also important in following up air-block complications.
Pneumothorax in the newborn should be considered a tension pneu
mothorax. Tension is manifest by an increase in volume of the hemitho-
rax with associated contralateral shift of the heart and mediastinum, de
pression of the diaphragm, and widening o f the intercostal spaces (Fig.
12 a). Tension pneumothorax is life-threatening and requires immediate
tube drainage.
It may be difficult to distinguish a medial pneumothorax from pneu
momediastinum or pneumopericardium. With pneumopericardium, air
completely outlines the heart on both AP and lateral views (Fig. 12 c).
Pulmonary infection
Respiratory tract infection is the most common illness that occurs in hu
mans. Viruses are the major cause of pulmonary infection in children,
particularly in patients less than 5 years of age. Bacteria become an in
creasing important cause of pneumonia in children who are 5 years of
age or older, have other diseases, and are hospitalized.
Pulmonary infection involves the peripheral air spaces, interstitium,
or conducting airways. Infection may primarily involve the peripheral
air-exchanging lung (consolidative pneumonia), the conducting airways
and adjacent air spaces (bronchopneumonia), or the conducting airways
alone (airways infection). Acute pulmonary infection in childhood can
be divided into three pathologic types: those that primarily involve the
acini or peripheral air spaces, those that primarily involve the airways,
and those that involve both the airways and peripheral air spaces.
Although this radiological localization is useful, it lacks specificity and
requires correlation with both clinical information and laboratory data.
Air space disease (acinar disease) is characterized by lobar, segmental,
or subsegmental coalescent opacities with discrete or irregular markings
547
Figure 13.
Viral airways disease.
a) 2-year-old male with viral
bronchiolitis. The lungs
are mildly hyperaerated,
and there is a diffuse in
crease in linear markings
in the parahilar regions
with associated peri
bronchial cuffing (arrows).
b) Microscopic lung section
o f a patient who died o f
adenovirus pneumonia.
The alveoli (A) are nor
mally aerated and contain
no inflammatory exudate.
A There is marked inflamma
% tory exudate within a bron
chiole (B) with associated
V* * ;■
Ф
',i• % : -
4? A bronchiolar necrosis (ar
ШХи
rows) and peribronchial

*
" r
ГО
’- s .
t
interstitial extension o f the

4
• 'V -
У' ; inflammatory process (I).
%
,
1 кД
..
' .
i t Ц
[From Kirks.]
: / V ’ ‘V
A I* 1
w.
v’. :‘ ..................A ' .
and frequently air bronchograms. This pattern is present when infection

involves the peripheral segment o f lung, and it reflects local extension of
inflammatory exudate into adjacent air spaces. This type of consolidative
pneumonia is typically due to bacterial infection. However, viral inflam
matory disease can occasionally cause this radiological appearance.
Airways disease causes bronchial wall thickening (peribronchial cuff
ing) beyond the inner 1/3 of the lung. Parahilar linear markings and ring
shadows with the anatomic configuration and location of bronchi are
identified. Streaky opacities frequently radiate from the hilar regions
(parahilar opacities). Generalized hyperaeration with lung hyperlucency,
flattened diaphragms, and increased lung volumes are also manifesta
tions of airways disease. Irregular aeration with areas of hyperaeration
and atelectasis is usually present. These findings are frequently bilateral
and usually symmetrical; this radiological appearance is typical of in
fection involving the airways.
548
PEDIATRIC RADIOLOGY
Pulmonary infection may produce a mixture of the above patterns with

characteristics of both air space and airways disease. This type of bron
chopneumonia is most frequently due to viral organisms but can also be
seen in bacterial infection.
Viral pneum onia

Common etiologies of viral airways disease are respiratory syncytial
virus, adenovirus, influenza and parainfluenzae. Viral infections usually
cause bronchiolitis, bronchitis, or bronchopneumonia. Typical findings
are hyperaeration, peribronchial cuffing, and increase in parahilar linear
markings (Fig. 13 a). Characteristically, there are no areas of focal lung
opacity since the infection involves the airways and not the airspaces
(Fig. 13 b).
Bacterial pn eu m on ia
Common etiologies of pediatric bacterial pulmonary infection are
Streptococcus pneumoniae, Staphylococcus aureus, Streptococcus pyo
genes, Hemophilus influenzae, and tuberculosis.
Bacterial infections usually cause bronchopneumonia or consolidative
(segmental, subsegmental) pneumonia. The chest X-ray typically shows
segmental or subsegmental parenchymal opacity (Fig. 14 a, b); there may
or may not be associated atelectasis. This radiological appearance is due
to the fact that inflammation involves primarily the airspaces (Fig. 14 b,
c), as opposed to viral infection which primarily involves the airways.
Acute pneumonia in children may produce a spherical or rounded den
sity on chest radiographs. This round pneumonia should not be confused
with an intrathoracic neoplasm. Such round pneumonias are almost al
ways bacterial in etiology, and most are pneumococcal in origin. The pa
tient should be treated with appropriate antibiotics.
There is an increasing frequency of tuberculosis in the pediatric pop
ulation. Initial pulmonary inflammatory exudate produces localized air
space disease that may involve any lobe. Regional lymph node enlarge
ment and pleural effusion are frequently also present.
Thoracic tumours
Chest masses in infants and children are uncommon but not rare abnor
malities. Radiology plays a critical role in the detection, diagnosis, pre
operative evaluation, treatment planning, and follow-up of pediatric tho-
549
Figure 14. Bacterial pneumonia.

a) AP chest radiograph o f an 8-year-old male with cough and fever shows segmental
consolidation in the left upper lobe.
b) Lateral view confirms left upper lobe consolidation (arrows).
c) Histologic section o f patient with bacterial pneumonia. Alveoli (A) are completely
filled with organisms and inflammatory exudate.
[From Kirks.]
racic tumors. The symptomatology is highly variable, depending on the

patient age, size and location of the thoracic mass, and any compromise
of adjacent anatomic structures.
Chest masses in the pediatric patient may be located in the chest wall,
lung, or mediastinum. They may arise in a variety of tissues and organs.
Pathologic abnormalities may be congenital, inflammatory, neoplastic,
traumatic, or vascular in etiology. A normal variant, as well as normal
variability in organ size and configuration may mimic thoracic masses.
These pseudotumors, such as prominent thymus (Fig. 15), can be con
fusing to the unwary.
The role of radiology in pediatric chest masses should be not only to
confirm the presence of an abnormality but also to characterize it. Current
550
PEDIATRIC RADIOLOGY
Figure 15.
Normal thymus.
a) Prominent left lobe o f thymus.
The wavy contour is due to the
soft thymus being indented by
the anterior ribs.
b) Prominent right lobe o f thymus.
The right lobe o f the thymus
mimics a mediastinal mass.
Fluoroscopy verified that the
mass was anterior in location
and relatively flat. The child
was asymptomatic. A follow-up
film 3 years later was normal.
pulmonary imaging techniques allow precise determination of charac

teristics, extent, and associated abnormalities of a pediatric thoracic tu
mor. In addition to the chest radiograph, which remains the "foundation"
examination for evaluation, this diagnostic approach may require sup
plementary plain films, fluoroscopy, sonography, nuclear scintigraphy,
CT, or MRI.
Chest wall m asses

Tumors of the chest wall are the rarest of all thoracic masses in infants
and children. Bone destruction, not just bone erosion or rib splaying, in
dicates that the mass arises from the chest wall. Cross-sectional imaging
(US, CT, MRI) are frequently helpful in determining whether a chest
wall mass is soft tissue, bony, or extrapleural intrathoracic in location.
Soft-tissue masses of the thorax may arise from cutaneous or subcu
taneous tissues. Benign tumors are more common than malignant neo
plasms. Clinical examination is extremely helpful in characterizing the
lesion and its extent. Tangential radiography or fluoroscopy may be help-
551
fill; CT or MRI precisely characterize the internal features and extent o f

the soft-tissue mass.
Chest wall masses may arise from the soft-tissues, extrapleural-in-
trathoracic region, or bony thorax. Soft-tissue tumors are usually benign.
The most common include lymphangioma, cystic hygroma, lipoma, and
hemangioma. Extrapleural-intrathoracic tumors are most commonly ma
lignant; rhabdomyosarcoma is the most common mass arising in this lo
cation. Bony thoracic tumors may be part of a generalized bone disease
(neurofibromatosis; histiocytosis; multiple exostoses) or a primary skele
tal mass. Benign primary skeletal tumors include fibrous dysplasia, bony
exostosis, and enchondroma. Malignant bony thoracic tumors may be ei
ther metastatic (neuroblastoma; leukemia) or primary. The most common
primary skeletal malignant tumor of childhood is Ewing sarcoma and re
lated round-cell tumors (Askin tumor; primitive neuroectodermal tumor).
M ediastinal m asses
Mediastinal masses in infants and children may be located in the ante
rior, middle, or posterior compartments. The posterior mediastinum is
behind a line drawn tangential to the ventral margins of the vertebral bod
ies. The anterior mediastinum is in front of a line drawn from the most
cephalad portion of the manubrium to the diaphragm and paralleling the
previously described posterior line. The middle mediastinum is between
the anterior and posterior compartments; this places the trachea and
esophagus in the middle of the middle mediastinum. These 3 mediasti
nal compartments may be extrapolated from the lateral chest radiograph
to CT or MR images.
Anterior m ediastinum
Approximately 30% of pediatric mediastinal tumors are located in the
anterior compartment. They usually arise from either the thymus or
lymph nodes. The radiologic differential diagnosis includes the four
"Ts": Teratoma (germ-cell tumor), Thymic tumor, Thyroid tumor, and
"Terrible” lymphoma/leukemia. Since tumors of the thymus and thyroid
gland are unusual in infants and children, the primary differential diag
nostic considerations of a pediatric anterior mediastinal mass are germ
cell tumor and lymphoma (Fig. 16).
552
PEDIATRIC RADIOLOGY
Figure 16.
Hodgkin disease.
12-year-old female with cough and
shortness o f breath. There is a
lobular mediastinal mass that
extends to the left. CT verified the
presence o f a mass involving the
anterior and middle mediastinum.
M iddle m ediastinum
Approximately 30% of pediatric mediastinal tumors are located in the
middle compartment. Although the diagnostic considerations are exten
sive, the primary differential diagnosis is remembered by the letters AB.
The masses usually arise from lymph nod (Adenopathy) or primitive
foregut (Bronchopulmonary foregut malformation). Common abnor
malities include infectious adenopathy (bacterial, granulomatous), neo
plastic adenopathy (lymphoma/leukemia, metastatic disease), and bron
chopulmonary foregut malformations (bronchogenic cyst, enteric dupli
cation, enteric cyst, sequestration). The esophagus is the "roadmap" of
the mediastinum; it serves as an important anatomic landmark. The
esophagus may be displaced by or communicate with a mediastinal mass.
Moreover, a mediastinal mass is occasionally esophageal in origin (ex:
hiatus hernia) so that the esophagogram may be diagnostic.
Posterior m ediastinum
Approximately 40% of pediatric mediastinal tumors are in the posterior
compartment. As many as 95 % of these pediatric posterior mediastinal
masses are neurogenic in origin. These tumors are usually derived from
sympathetic ganglion cells; there is a spectrum of such tumors from the
most malignant neuroblastoma to ganglioneuroblastoma to benign gan
glioneuroma. Posterior mediastinal masses have a propensity for ex
tradural extension (Fig. 17).
553
Figure 17.
Apical neuroblastoma.
4-year-old male with left Horner
syndrome.
a) Cone-down view o f chest radio
graph shows a left apical soft-
tissue mass (m).
b) CT myelogram demonstrates
extradural extension o f the left
apical mass (m) encroaching on
the subarachnoid space and
displacing the spinal cord (c).
[From Kirks.]
Figure 18. Bronchopulmonary sequestration.

10-year-old male with recurrent right lower '----------------
lobe pneumonia.
a) PA chest radiograph shows opacity in the right lower lobe.
b) Lateralfilm confirms this is in the posterior basilar segment o f the right lower lobe.
Thoracic aortography demonstrated a systemic vessel arising from the aorta and
supplying the sequestration.
Lung tumors
Lung tumors in infants and children may involve the pleura or
parenchyma. Metastatic lesions are the most common lung tumors in
554
PEDIATRIC RADIOLOGY
children. Most primary parenchymal tumors in children are benign. In

contrast to the adult, primary malignant tumors in children are rare. Most
common pleural masses in children are metastatic disease. Pleural metas
tases are usually small, round-cell tumors; common etiologies are lym
phoma/leukemia, neuroblastoma, Ewing sarcoma, and PNET.
Malignancies which commonly metastasize to lung include Wilms tu
mor and osteogenic sarcoma. Common benign primary lung tumors are
sequestration (Fig. 18) and parenchymal bronchogenic cyst.
Integrated im aging
As previously noted, the chest radiograph remains the "foundation” ex
amination for evaluation of pediatric chest masses. PA and lateral chest
radiographs permit localization of a chest mass to the chest wall (oblique
views may be required), mediastinum, or lung parenchyma. However,
accurate characterization, as well as precise location and extent of the
mass, requires CT or MRI.
Because of the long examination time and expense of MRI, CT cur
rently remains the modality of choice for evaluating bony chest-wall
masses, anterior mediastinal masses, middle mediastinal masses, and
pulmonary parenchymal lesions. MRI is the method of choice for eval
uating soft-tissue masses of the chest wall and posterior mediastinal
masses; the latter is due to a propensity for extradural tumor extension.
Chest trauma
Lower-airway fo reig n bodies

Foreign bodies of the lower airway are a serious clinical problem in chil
dren, and radiology plays an important role in diagnosis. Patients with
aspirated foreign bodies range in age from 6 months to 15 years, with
the peak incidence in children of 1-2 years. Three-fifths of foreign bod
ies are located in the right bronchial tree, 1/3 in the left bronchial tree,
and the remainder in the larynx, trachea, or both bronchi. Only 10% of
lower-airway foreign bodies are opaque. Radiological findings include
hyperinflation of the lungs, atelectasis, consolidation, and air trapping.
Since normal inspiratory chest radiographs may be seen in children
with aspirated foreign bodies, at least one supplementary diagnostic ma-
neuvre (expiration film, fluoroscopy, decubitus view) should always be
performed if this diagnosis is suspected (Fig. 19). The possibility of a
555
Figure 19.
Airway foreign body.
2-year-old male with cough and fever.
a) Inspiration view shows lucency o f
the left lung and hyperaeration o f
the left hemithorax.
b) Expiration view confirms air trap
ping on the left; the mediastinum
shifts to the right. A t bronchoscopy,
a peanut was found in the left main-
stern bronchus.
foreign body in the lower airway must be considered in any child less
than 3 years of age with clinically suspected or radiographically con
firmed pneumonia. The radiologist must be alert to direct or indirect signs
of air trapping in a pediatric patient with possible pneumonia.
Pneumomediastinum or pneumothorax may be associated with foreign
body aspiration. The presence of pneumonia associated with either of
these air-block complications in a child less than 3 years o f age should
suggest the possibility of foreign body in the lower airway.
N ear-drowning
Near-drowning is a form of aspiration. The extent and severity of radi
ographic findings relate to the amount of water ingested rather than the
type of water ingested. Moreover, many of the radiological findings of
near-drowning are due to hypoxic lung injury.
The chest radiograph usually shows patchy parahilar acinar densities
of pulmonary edema with a normal-sized heart. Clinical assessment and
556
PEDIATRIC RADIOLOGY
serial blood gas determinations are much more important than chest ra
diographs for following the clinical course and assessing the prognosis
of the patient.
CARDIOVASCULAR SYSTEM
Imaging plays a critical role in the diagnosis and appropriate therapy of
cardiovascular disease in the pediatric patient. The incidence of cardio
vascular malformations in children is less than 1%. In pediatric patients
requiring surgery or treatment, diagnosis is based on invasive techniques
in 60% and non-invasive methods, primarily echocardiography, in 40%.
Modalities
Diagnostic evaluation of general abnormalities of the heart and great ves
sels is based on accurate clinical, laboratory, and radiologic observations.
Pertinent clinical information includes age, sex, onset of symptoms, pres
ence of cyanosis, type of symptoms, blood pressure, presence or absence
of peripheral pulses, and type of murmur. Important laboratory data in
cludes hemoglobin, hematocrit, electrolytes, blood urea nitrogen, crea
tinine, calcium, and glucose. The electrocardiogram provides informa
tion about specific chamber size, electrophysiologic activity, conduction,
and cardiac axis. Echocardiography demonstrates anatomy and dynamic
function. The chest radiograph remains a valuable and readily available
imaging modality. Although the chest radiograph is a static image of the
heart and lungs, it provides important physiologic as well as anatomic
information. Nuclear scintigraphy allows imaging and quantification of
certain pulmonary vascular abnormalities, shunts, and myocardial dys
functions. Cardiac catheterization provides information regarding pres
sure and oxygenation within select chambers and great vessels.
Angiocardiography demonstrates the anatomy as well as function of in
dividual cardiac chambers and great vessels. Magnetic resonance imag
ing demonstrates cardiac anatomy without the use of ionizing radiation.
Pulmonary vascularity, as assessed from the chest radiograph, forms
the basis for the classification of congenital heart disease. It must be re
membered that an increase in pulmonary vessel size is not seen until a
left-to-right shunt is at least 2:1. Decreased pulmonary vascularity is
more unusual in patients with congenital cardiovascular malformations
than normal pulmonary blood flow or increased vascularity; decreased
pulmonary vascularity is associated with congenital cyanosis.
557
Congenital heart disease

Congenital heart disease (CHD) is classified by the presence or absence
of cyanosis with the radiologic appearance of the pulmonary vascular
ity. This functional classification forms the basis for differential diag
nosis of CHD in children.
A cyanotic CHD with norm al or increased pu lm on ary b lo o d

flo w
Ventricular septal defect (VSD)

Ventricular septal defect (VSD) is second only to bicuspid aortic valve
in frequency among congenital cardiovascular anomalies. VSD may be
an isolated anomaly or part of a more complex malformation. V SDs may
involve the membranous or perimembranous portion of the septum
(70-80%), the muscular septum (10%), conal region (5%), or posterior
septum (5-10% ) as part of atrioventricular canal defects.
The hemodynamics of VSD are determined by the size o f the defect
and the pressure difference between the right and left ventricle. In pa
tients with small or moderate VSDs, there is shunting of blood from the
high-pressure left ventricle to the low-pressure right ventricle and low
resistance lungs. Large shunts can produce pulmonary arteriolar changes
that increase pulmonary vascular resistance. This may produce fixed pul
monary hypertension (Eisenmenger physiology) with clinical cyanosis.
The chest radiograph in a patient with a small VSD (less than 2:1 or
50% shunt) is normal. It must be remembered that a normal chest radi
ograph in no way excludes a small left-to-right shunt. In patients with
moderate to large VSDs, there is cardiac enlargement, increase in the
main pulmonary artery segment, and an increase in pulmonary vascu
larity (Fig. 20). Due to volume overload, the left atrium is usually en
larged; this is best seen on the lateral view with posterior displacement
of the left mainstem bronchus and/or impression on the barium-filled
esophagus.
Atrial septal defect

Atrial septal defect (ASD) is relatively common, often occurs as an iso
lated lesion, and is more common in females. Due to a defect in the atrial
septum, blood passes from the left atrium to the right atrium and into the
right heart and pulmonary vascular bed. The left atrium is not enlarged
558
PEDIATRIC RADIOLOGY
Figure 20.
Ventricular septal defect.
a) The heart is moderately enlarged
and there is shunt vascularity. The
distinct vessel margins indicate no
interstitial edema. Cardiac
catheterization showed a large
shunt (2.5:1) at the ventricular
level.
b) There is posterior displacement o f
the esophagus (arrows) by left
atrial enlargement.
a
since blood is immediately shunted left-to-right across the ASD.

In patients with small ASDs and in patients of a young age, the heart
size and pulmonary blood flow are usually normal. In older children with
moderate-sized ASDs, the chest radiograph is highly suggestive o f the
diagnosis. Pulmonary vascularity is increased and of the shunt type.
There is right heart enlargement, a normal left atrium, and a normal-sized
aorta (Fig. 21).
In all patients with suspected ASD, the upper lobe pulmonary veins
and upper mediastinum should be carefully evaluated. There may be
anomalous right upper pulmonary venous drainage into the right atrium
with associated sinus venosus ASD. There is also association between
partial anomalous pulmonary venous connection in the left upper medi
astinum with an ostium secundum ASD.
559
Figure 21.
Atrial septal defect.
a) There is shunt vascularity. The
heart is enlarged in its transverse
diameter and there is prominence o f
the main pulmonary artery segment.
b) Retrosternal density is due to right
ventricular enlargement. There is
no evidence o f left atrial
enlargement.
Patent ductus arteriosus (PDA)

During fetal life, the ductus arteriosus shunts blood from the pulmonary
artery to the aorta; this allows blood to bypass the non-aerated lungs.
Functional closure usually occurs by 24 hours of age. Prematurity and
hypoxia can maintain patency of the ductus arteriosus. PDA produces a
left-to-right shunt with a characteristic machinery murmur.
There are two distinct groups of patients with PDA. The majority are
older children with a murmur. Most patients have a small PDA with a
completely normal chest radiograph. Moderate to large PDAs show in
creased vascularity of the shunt type. The vessels and chambers through
which blood circulates are enlarged. Therefore, there is enlargement of
560
PEDIATRIC RADIOLOGY
the main pulmonary artery, pulmonary vessels, left atrium, left ventri
cle, and transverse portion of the aortic arch.
In premature infants, the diagnosis of PDA is best confirmed by ser
ial films. There is frequently underlying pulmonary disease. Slight in
crease in cardiac size and hazy, ill-defined pulmonary densities due to
pulmonary edema in a premature infant suggest a PDA. Doppler sonog
raphy is important in diagnosing a PDA in infants. Angiographic stud
ies are rarely performed. Premature infants usually require surgical clo
sure of the PDA.
Atrioventricular can al defect (A VC)

Atrioventricular cardiac defect (AVC) (atrioventricular communis, en
docardial cushion defect) is due to abnormalities of growth and fusion
of the endocardial cushions. This causes a defect in the formation o f the
upper ventricular septum, the lower portion of the atrial septum, and the
septal leaflets of both mitral and tricuspid valves. The spectrum of AVC
includes ostium primum defect and atrioventricular canal defects.
Physiologically, there are shunts at both the atrial and ventricular level
as well as frequently insufficiency of both mitral and tricuspid valves.
With an ostium primum defect, the heart may be normal to only slightly
enlarged and the pulmonary vascularity is minimally increased. With the
complete AVC, the heart is moderately to markedly enlarged. The right
atrium is frequently enlarged. The pulmonary artery is prominent and the
pulmonary vascularity is increased. The left atrium is normal to markedly
enlarged. There is frequently heart failure in the newborn period.
Patients with trisomy 21 (Down syndrome) account for 40% of all pa
tients with the complete type of AVC; conversely, 33% of patients with
Down syndrome have AVC.
Coarctation o f the aorta

Coarctation is a congenital narrowing of the aorta. The localized or jux-
taductal type is most common; the area of coarctation is located just be
yond the origin of the left subclavian artery at the level of the ductus ar
teriosus and is short as well as discrete. The diffuse type is also known
as infantile or preductal type; there is a long segment of narrowed aorta
that extends from just distal to the brachiocephalic artery to the level of
the ductus arteriosus.
561
Figure 22.
Coarctation o f the aorta.
Coned-down view shows inferior
rib notching (arrows) due to bony
erosion by enlarged intercostal
arteries.
Figure 23.
Discrete coarctation o f the aorta.
Sagittal MRI demonstrates aortic
narrowing just distal to the origin o f the
left subclavian artery.
Figure 24.
Tetralogy o f Fallot.
A neonate with cyanosis.
The heart is not enlarged in its
transverse diameter. There is eleva
tion o f the cardiac apex, concavity
o f the main pulmonary artery seg
ment, and a right aortic arch. The
pulmonary vascularity is decreased.
Intracardiac defects, most commonly VSD, are present in 50% of pa

tients with the diffuse type of coarctation. PDA is almost always present
with this type of lesion. The diffuse type of coarctation usually presents
in the neonate or young infant with congestive heart failure and bound
ing pulses in the upper extremities.
562
PEDIATRIC RADIOLOGY
The localized type of coarctation is usually diagnosed during late child

hood; these patients are frequently asymptomatic. On physical exami
nation, the patients may have upper extremity hypertension. The heart is
usually not enlarged in its transverse diameter. However, there is fre
quently rounding of the left ventricular contour on the AP film as well
as left ventricular enlargement on the lateral view. There is dilatation of
the aorta and a notch in the descending aorta may be identified. Rib notch
ing may be present due to pressure erosion caused by dilated intercostal
arteries (Fig. 22). The pulmonary vascularity is normal unless left ven
tricular failure has developed. MRI has replaced cardiac catheterization
and angiocardiography in older patients with coarctation. The exact size
and extent of the coarctation is demonstrated, and the degree of collat
eral circulation is assessed (Fig. 23).
Aortic stenosis an d valvular pulm onary stenosis

Most children and adolescents with aortic stenosis are asymptomatic.
Congenital valvular pulmonary stenosis is a common abnormality that
may be found as an isolated lesion or in combination with other abnor
malities. These patients are frequently also asymptomatic despite the
presence of a loud systolic murmur.
Considerable aortic valvular stenosis may be present with a normal
appearing chest radiograph. The lateral film frequently demonstrates left
ventricular enlargement. There may be dilatation of the ascending aorta
on the AP view due to poststenotic dilatation. Dilatation of the ascend
ing aorta is not present in subvalvular or supravalvular aortic stenosis.
The chest radiograph in mild valvular pulmonic stenosis is completely
normal. With moderate and severe pulmonic stenosis, there is dilatation
of the main pulmonary artery due to the high velocity of blood ejected
through the small pulmonary valve orifice. This dilatation may extend
to the left pulmonary artery.
Cyanotic CHD with decreased pu lm on ary blood flow
Tetralogy o f Fallot
The four components of tetralogy of Fallot are right ventricular outflow
tract obstruction, sub-aortic large ventricular septal defect, overriding of
the aorta, and right ventricular hypertrophy. Cyanosis is usually present.
563
X-ray features are those of a normal-sized heart with abnormal shape.

The vascular pedicle is narrow and there is uplifting of the ventricular
apex due to rotation of the heart secondary to right ventricular enlarge
ment. There is concavity in the region of the main pulmonary artery seg
ment. This leads to a characteristic boot-shaped heart (Fig. 24). The pul
monary vascularity is usually decreased. A right-sided aortic arch is pre
sent in 25 % of patients with classic tetralogy of Fallot and 50% of patients
with tetralogy with pulmonary atresia (pseudotruncus arteriosus).
Echocardiography is diagnostic. Angiography is frequently performed
prior to surgery. MRI is becoming increasingly important in demon
strating the main, right, and left pulmonary arteries.
Tetralogy of Fallot is frequently corrected in two surgical stages.
Initially, a shunt is created between the aorta and the pulmonary circu
lation. At 1-2 years of age, definitive correction is performed. This in
cludes closing the VSD, removing infundibular muscle causing ob
struction, and inserting a patch or conduit to increase flow from the right
ventricle to the main pulmonary artery. Several cardiovascular surgical
centers are performing definitive repair in the neonatal period.
Tricuspid atresia
Because of agenesis (atresia) of the tricuspid valve, there is no commu
nication between the right atrium and right ventricle. There is an oblig
atory right-to-left shunt at the atrial level through an ASD or patent fora
men ovale and usually associated hypoplasia of the right ventricle as well
as a VSD or PDA. There may be normally related great vessels or asso
ciated transposition. Chest radiography demonstrates a normal or small
heart with decreased pulmonary blood flow. There is convexity of the
left cardiac border with an elevated apex and concave main pulmonary
artery segment. The right heart border may be straight (Fig. 25 a).
Angiocardiography demonstrated the pathologic anatomy (Fig. 25 b).
Ebstein anom aly

In this anomaly, there is redundancy of tricuspid valve tissue and ad
herence of this valve tissue to the right ventricular wall. This causes a
functional obstruction to the emptying mechanism of the right atrium, as
well as tricuspid regurgitation. An interatrial communication (either
patent foramen ovale or ASD) is almost always present. Radiographic
findings depend on the severity of the anomaly. Infants with Ebstein
564
PEDIATRIC RADIOLOGY
Figure 25.
Tricuspid atresia.
a) 2-day-old male with cyanosis.
The heart is mildly enlarged in
its transverse diameter. There
is convexity o f the lower left
cardiac border with an ele
vated apex and concave main
pulmonary artery segment.
There is slight flattening o f the
lower right heart border.
b) 1-month-old female with a
cyanosis. The catheter could
not be passed through the tri
cuspid valve. Injection o f con
trast material into the right
atrium (RA) shows opacifica
tion o f the left atrium (LA) and
left ventricle (LV). There is a
triangular lucency (arrow) to
the left o f the tricuspid valve in
the position normally occupied
by the inflow portion o f the
right ventricle.
[From Kirks.]
Figure 26.
Transposition o f the great vessels.
Newborn male with profound
cyanosis.
The heart is not enlarged. The
heart is more oval than normal.
Pulmonary vascularity is normal.
565
anomaly present with severe cyanosis and may have decreased pul
monary vascularity and massive cardiomegaly due to right atrial en
largement. Older patients, with milder malformations, have a mildly en
larged heart with a "box-like" appearance. This abnormal cardiac shape
is due to right atrial enlargement; there is usually some decrease in pul
monary vascularity.
Cyanotic CHD with increased pu lm onary blood flo w
Transposition o f great vessels (TGV)

Complete transposition of the great vessels is the most common con
genital heart disease presenting with cyanosis during the first 24 hours
of life. The lesion may be isolated or part of a more complex anomaly.
In TGV, the aorta and pulmonary arteries are transposed. The as
cending aorta and coronary arteries arise from the right ventricle while
the pulmonary artery arises from the left ventricle. As a result of the ab
normality in arterial relations, there are two parallel circuits. Desaturated
systemic venous blood enters the right atrium, passes into the right ven
tricle, and is ejected into the aorta. There must be a left-to-right shunt for
survival; possible communications between the two circulations include
a patent foramen ovale, ASD, VSD, PDA, systemic collateral arteries,
or any combination of these. Due to physiologic pulmonary arterial hy
pertension, the pulmonary blood flow is usually normal at birth (Fig. 26).
As the pulmonary vascular resistance decreases, the pulmonary blood
flow becomes increased. If there is a small shunt between the two circu
lations or if there is associated pulmonary stenosis, the pulmonary vas
cularity is normal or decreased.
The radiographic findings of TGV include (1) the superior medi
astinum is narrow due to absence of thymic tissue and abnormal rela
tionship of the great vessels. (2) There is an absence of visualization of
the malpositioned aortic arch on the left and a concavity in the region of
the main artery segment since both the aorta and main pulmonary artery
are rightward in position. (3) Frequently, there is asymmetry of pul
monary arterial blood flow. As noted above, the pulmonary arterial flow
may be diminished if there is associated subpulmonic or pulmonic steno
sis, normal in the first few days of life or if the size of a left-to-right
shunt(s) is small, or increased if there is significant intracardiac shunt
ing. A Rashkind balloon atrial septostomy now permits survival until de-
566
PEDIATRIC RADIOLOGY
Figure 27.
Atrial balloon septostomy.
a) Balloon is inflated in the left atrium.
b) Balloon pulled through the foramen
ovale.
с) The deformed balloon is in the inferior
vena cava.
finitive repair can be performed. A balloon catheter is placed across the

atrial septum, and the balloon is inflated. Once position is verified, the
balloon is rapidly withdrawn across the atrial septum, rupturing and en
larging the interatrial communication (Fig. 27). This interatrial commu
nication permits better mixing of blood with decrease in clinical cyanosis.
At several cardiac surgical centers in the world, primary surgical repair
(arterial switch procedure) is performed in the newborn period.
Other congenital lesions included as part of the transposition complex
include double outlet right ventricle, Taussig-Bing complex, and cor
rected transposition of the great vessels.
567
Truncus arteriosus
Truncus arteriosus (ТА) is due to failure of division of the primitive com
mon truncus arteriosus into aorta and pulmonary artery. One large ves
sel (truncus) originates from the heart to supply the coronary circulation,
systemic circulation, and pulmonary circulation. There is an associated
VSD, which is high in position and large in size.
ТА is an admixture lesion. There is right-to-left shunting across the
VSD and high flow from the truncus into the pulmonary arteries; the
pressure in the two ventricles is similar. Cyanosis and heart failure oc
cur early in infancy. Peripheral pulses are bounding, and the pulse pres
sure is wide because of aortic run-off.
Cardiomegaly is frequently present at birth; as pulmonary vascular re
sistance decreases (after the 2nd or 3rd day of life), there is a marked in
crease in pulmonary arterial blood flow. The truncus or ascending aorta
is usually prominent. A right-sided arch is identified in one-third of pa
tients and, in conjunction with increased pulmonary vascularity and car
diomegaly, is highly suggestive of the diagnosis.
Total anom alous pulm onary venous return

Total anomalous pulmonary venous return (TAPVR) is due to an error
of embryologic development. It occurs when the common pulmonary
vein fails to develop or is obliterated so that pulmonary veins connect
with other venous structures.
TAPVR may be divided into 4 main groups according to the site or
sites of connection: supracardiac, cardiac, infracardiac, and mixed.
The radiographic appearance of TAPVR varies according to the site
of abnormal venous drainage as well as the presence or absence of ob
struction of anomalous vein. In supracardiac TAPVR, the dilated left ver
tical vein, right superior vena cava, and right atrium give the appearance
of a ’’snowman”. On lateral chest radiographs there may be a pretracheal
density due to superimposition of the left vertical vein on the superior
vena cava.
In TAPVR at the cardiac level, the pulmonary venous blood flows into
the coronary sinus and right atrium. The radiologic findings simulate a
large left-to-right shunt at the atrial level.
The infracardiac type of TAPVR (obstructed) demonstrates a normal
sized heart with severe pulmonary edema. Kerley В lines are usually pre
sent due to pulmonary venous hypertension. This serious cardiovascu
568
PEDIATRIC RADIOLOGY
lar anomaly may be confused with pulmonary parenchymal abnormali

ties such as wet-lung disease or neonatal pneumonia.
Cardiomegaly without cardiac malformation

These congenital and acquired heart diseases are characterized by car
diomegaly and pulmonary venous hypertension. Lesions distal to the mi
tral valve usually have cardiomegaly because of left ventricular failure
or dysfunction. Cardiac enlargement is out of proportion to the promi
nence of the pulmonary vascularity. Although there is interstitial edema
due to pulmonary venous hypertension, there is no shunt vascularity.
Infiltrative disease
Endocardial fibroelastosis may occur as a primary disease or may be
secondary to left ventricular obstruction. There is marked deposition of
collagen and elastin within the endocardium of the left ventricle; this
causes restricted left ventricular contractility and subsequent mitral in
sufficiency. Chest radiography demonstrates cardiac enlargement with
significant enlargement on lateral film of the left ventricle and left atrium.
Glycogen storage disease leads to deposition of glycogen in the skele
tal muscles and myocardium. There is massive thickening of the ven
tricular septum and walls resulting in cardiomyopathy. Chest radiogra
phy shows striking cardiac enlargement; this cardiomegaly is out o f pro
portion to the prominence of the pulmonary vascularity. As a child
becomes older, there is increasing left atrial enlargement that compresses
the left lower lobe bronchus and may cause collapse.
Coronary artery abnorm alities

In patients with anomalous origin o f the left coronary artery, the left
coronary artery arises from the pulmonary artery. This is a rare anomaly
that usually presents in young children with tachypnea and sweating. The
EKG shows changes of myocardial ischemia or infarction. The chest ra
diograph may be entirely normal. However, if the patient has had an in
farct, marked cardiomegaly is present. Left ventricular enlargement and
left atrial enlargement, secondary to mitral insufficiency, may be present.
Coronary artery fistula

is characterized by a communication between a dilated coronary artery and
an intracardiac chamber. The etiology is probably due to persistence of
569
Figure 28.
Double aortic arch.
a) Lateral esophagogram shows a posterior im
pression on the esophagus (arrow) and marked
tracheal narrowing (arrow).
b) Axial MRI. The right (R) and left (L) limbs o f
the double arch are seen encircling the trachea
and esophagus.
c) Coronal MRI demonstrates that the right (R)
and left (L) limbs o f the double arch jo in poste
riorly. The right arch (R) is higher and larger.
[From Kirks.]
normal fetal vascular communications. Most fistulas from the coronary

arteries enter either the right atrium or right ventricle. This results in sig
nificant left-to-right shunting. Clinically, a murmur may suggest a PDA.
Echocardiography is extremely useful for the diagnosis of these lesions.
Acquired heart disease

Acquired heart disease is much less common in children than in adults.
Etiologies include arrhythmia, anemia, fluid overload, Kawasaki disease,
and acute rheumatic fever. Depending on the severity of the cardiac in
sult, the heart may be normal in size, or enlarged. Congestive heart fail
ure may develop.
Vascular rings
A vascular ring is an anomaly in which there is complete encirclement
of the trachea and esophagus by the aortic arch and its vascular deriva-
570
PEDIATRIC RADIOLOGY
tives. If a vascular ring is not complete, there are rarely symptoms. If a

vascular ring is present, symptoms may be due to tracheal compression
or esophageal compression. The most common asymptomatic vascular
rings are left aortic arch with aberrant right subclavian artery or innom
inate artery compression. The most common symptomatic vascular rings
are double aortic arch, right aortic arch with aberrant left subclavian
artery and aortic diverticulum, and pulmonary sling.
The diagnosis of vascular rings traditionally has been based on chest
radiography and esophagography. MRI now allows precise anatomic di
agnosis without invasive studies. Angiography is rarely required.
Double aortic arch

Double aortic arch is the most common type of vascular ring. Although
the anomaly usually exists in isolation, it can be associated with con
genital heart disease. The ascending aorta rises anterior to the trachea
and divides into an anterior and posterior branch; these branches then
join posteriorly to form a common descending aorta. The right arch is
usually larger, more posterior, and higher than the left aortic arch; it
passes posterior to the trachea and the esophagus (Fig. 28).
Pulmonary sling
Anomalous origin of the left pulmonary artery may be a part of a more
complex anomaly, or it may be an isolated finding. The left pulmonary
artery is aberrant and arises from the right pulmonary artery. It crosses
over the proximal portion of the right main stem bronchus or trachea and
then proceeds posteriorly to the left behind the trachea in front of the
esophagus. Plain radiographs of the chest usually show abnormal aera
tion of the lungs, low position of the left hilum, and anterior bowing of
the lower trachea or right main-stem bronchus. An esophagogram shows
anterior bowing of the trachea and a ventral impression on the esopha
gus by the aberrant vessel (Fig. 29). MRI accurately assesses the vascu
lar anomaly as well as the degree and extent of any associated tracheal
abnormality.
GASTROINTESTINAL TRACT
Diseases of the abdomen and gastrointestinal (GI) tract may be unique
in infants in children: they may be found only in the pediatric age group
(congenital anomalies, necrotizing enterocolitis); and they have radio-
571
Figure 29.
Pulmonary sling.
There is a characteristic soft-tissue mass
(arrows) between the trachea and the
esophagus. This is the oberrant left
pulmonary artery seen on-end.
logic or imaging features unique to the child when compared with the
adult (hiatus hernia, abdominal masses).
Modalities
Conventional plain films are still important in the diagnosis of gastroin
testinal disease; they should be obtained prior to contrast studies or other
imaging modalities. There are general guidelines for the use of gas
trointestinal contrast media. Most GI examinations are performed with
barium sulfate. If there is a risk of aspiration or perforation, a water-sol
uble, non-ionic contrast medium should be used. Water-soluble contrast
is also preferred if obstruction is suspected. Hyperosmolar contrast
medium is extremely dangerous and should only be used as a possible
therepeutic enema for patients with meconium ileus.
Ultrasonography has become increasingly important in the evaluation
of pediatric gastrointestinal disease. US allows systematic evaluation of
all abdominal and pelvic organs. CT and MRI have more limited applica
tions. Abdominal angiography is rarely performed in infants and children.
572
PEDIATRIC RADIOLOGY
Problem-oriented pediatric GI radiology
Vomiting
Vomiting is a common phenomenon in neonates and young infants.
Contrast examination is performed in severe cases and may demonstrate
gastrointestinal reflux, hiatus hernia, and partial or complete obstruction
of the more distal bowel. Barium is the contrast medium of choice; if
symptoms are severe or there is a known risk of aspiration, water-solu
ble, non-ionic contrast may be used. Nuclear medicine can assess inter
mittent episodes of gastrointestinal reflux; US assesses other abnormal
ities of the abdomen.
Abdominal pain
Non-specific abdominal pain in children frequently has non-organic
causes. Radiological evaluation is indicated with long-standing, severe,
or intermittent symptoms. Abdominal radiography may demonstrate a
stone in the urinary tract or severe constipation. US can demonstrate mal-
rotation, hydronephrosis, or cholelithiasis. Severe, intermittent pain
should be evaluated during an episode.
Some common, organic causes of abdominal pain in children include
malrotation with volvulus, cholelithiasis, intussusception, and hy
dronephrosis. Imaging of these abnormalities will be discussed later in
this chapter.
Oesophagus
Oesophageal atresia/Tracheoesophageal fistula

Oesophageal atresia (EA) and tracheoesophageal fistula (TEF) is a com
plex of congenital anomalies characterized by failure of formation of the
tubular oesophagus or an abnormal communication between the oe
sophagus and trachea. It occurs approximately 1 in 5000 births. The com
plex includes pure EA without a fistula; EA with a fistula that may be
proximal, distal, or proximal and distal; and a TEF without oesophageal
atresia. The most common abnormality (85 %) is EA with a distal fistula;
the blind-ending upper pouch is distended by air and fluid (Fig. 30).
Contrast examination may be performed to verify the diagnosis of
EA and demonstrate or exclude a fistula within the upper segment of
the oesophagus and the trachea. Water-soluble, non-ionic iso-osmolar
573
Figure 30.
Esophageal atresia and distal
tracheoesophagealfistula.
Enteric tube coils in upper esophageal pouch
(arrows). Gas is seen in stomach and small
bowel.
[From Kirks.]
Figure 31.
Tracheoesophagealfistula.
3-week-old male with cough during feeding.
Fistula (arrow) is identified passing obliquely
upward from the esophagus (E) to the trachea
(T).
[From K irks]
contrast media should be used. A small amount of contrast is injected

through a tube; the contrast is removed as soon as the diagnosis is made.
This type of pouch injection is always performed with fluoroscopy. In
2 % of patients with EA/TEF, there is a right aortic arch; surgery should
be performed through a left thoracotomy. Therefore, the position of
the aortic arch should always be determined preoperatively by chest
574
PEDIATRIC RADIOLOGY
radiography or US.
Coexisting anomalies may involve the cardiovascular, skeletal, gas
trointestinal, genitourinary, central nervous, and other systems. If EA is
present without a fistula, no gas is seen in the stomach. In these cases,
the atretic segment may be quite long; end-to-end anastomosis may be
difficult or impossible.
An isolated TEF may cause coughing and choking during feeding, re
current pneumonia, failure to thrive, and gaseous abdominal distention.
The fistula may be extremely difficult to visualize. If a tube examination
is performed, the tip of the tube is withdrawn from the distal oesophagus
to the proximal oesophagus with syringe injections of contrast material
at every 1-2 cm of the entire esophagus. The fistula will be identified pass
ing obliquely upward from the oesophagus to the trachea (Fig. 31).
Hiatus hernia/Gastroesophageal reflux

A hiatus hernia (HH) is present if the gastroesophageal junction herni
ates through the diaphragmatic hiatus into the chest. Gastroesophageal
reflux (GER), the retrograde flow of gastric contents into the oesopha
gus is always abnormal. Reflux is more clinically significant if it is spon
taneous, reproducible, and severe.
Although nuclear scintigraphy and US may be used to assess the gas
troesophageal junction, initial radiologic evaluation in any infant with sus
pected HH or GER should be a UGI series for careful assessment of oe
sophageal peristalsis, anatomy of the gastroesophageal junction, presence
or absence of reflux, and anatomy of the stomach in its outflow. A contrast
study can demonstrate concomitant aspiration. It is always important to
exclude obstruction of the stomach or pylorus in patients with vomiting.
It should be remembered that oesophagitis is an endoscopic, not an X-
ray diagnosis. However, the sequela of oesophagitis, such as ulceration or
stricture, are readily demonstrated by contrast examination. Radiologic
findings of HH include high location of the gastroesophageal junction, gas
tric mucosal folds above the hiatus, wide hiatus with wide oesophagus
above it, and large part of the stomach above the diaphragm in the chest.
Oesophageal foreign body

Children between the ages of 6 months and 3 years frequently put for
eign objects in their mouths and may sometimes swallow them. Most
foreign bodies that are swallowed pass through the GI tract without corn-
575
Figure 32.
Esophageal duplication.
Soft-tissue mass (arrows) inciden
tally noted at cardiac catheteriza
tion for pulmonary valvular steno
sis. CT confirmed a cystic mass in
the middle mediastinum.
plication. Occasionally, a foreign body lodges in the oesophagus and re

quires removal. Oesophageal foreign bodies may lodge at the thoracic
inlet (75%), thoracic oesophagus at the level of the carina (20%), or dis
tal oesophagus at the gastroesophageal junction (5%).
Radiopaque foreign bodies (some metal, glass, mineral) are seen on
conventional radiographs; contrast examination is required to demon
strate nonopaque (plastic toys, vegetable material, food particles) for
eign bodies. Oesophageal foreign bodies may be removed at endoscopy
or by catheter with fluoroscopic control. After removal of the foreign
body, a contrast examination should be performed to exclude any
esophageal abnormality.
Oesophageal duplication
Oesophageal duplication is one of the causes of a mediastinal mass
(Fig. 32). It usually does not extrinsically compress the oesophagus but
displaces it. Rarely, there is communication between the duplication and
the normal oesophageal lumen. CT or MRI demonstrate a cystic mass of
the middle mediastinum.
Stomach and duodenum
Peptic ulcer disease

Peptic ulcer disease is much less common in children than in adults. Only
2-3 cases of duodenal ulcer per year are seen in a children's hospital; gas-
576
PEDIATRIC RADIOLOGY
trie ulcers in children are even less frequent. Etiology of peptic ulcer dis
ease in children is unknown, but it is thought to be related to increased
acid production in response to stimulation, to abnormal mucosal protec
tive barriers, and to emotional stress.
The criteria for radiologic diagnosis of gastric ulcer and duodenal ul
cer in children are identical to those in the adult. Complications, such as
perforation, gastric outlet obstruction, or fistula, are also rarer in children
than adults.
Hypertrophic pyloric stenosis

Hypertrophic pyloric stenosis (HPS) is the most common disease of in
fancy in the United States requiring surgical therapy. Males are affected
4 times as frequently as females. Symptoms of HPS occur most fre
quently during the second to sixth weeks o f life, with a peak incidence
at 3 weeks of age. The most frequent symptom is nonbilious vomiting,
beginning as simple regurgitation and progressing to projectile vomit
ing. Other findings may include weight loss, dehydration, and metabolic
alkalosis.
HPS may be diagnosed by clinical examination, UGI series, or US.
The diagnosis is based on the demonstration of a thickened pyloric mus
cle producing a mass. HPS by UGI series shows a long and thin pyloric
lumen with muscle hypertrophy producing an impression on the gastric
antrum and duodenal bulb (Fig. 33 a). The UGI is best performed after
placement of an enteric tube into the stomach; this allows the injection
of small amounts of barium. At the end of the UGI, any remaining con
trast medium should be removed.
Muscle hypertrophy is well demonstrated by US. The findings o f HPS
are those of a soft-tissue mass of hypertrophied muscle that surrounds
the pylorus; this muscle thickening increases the overall diameter of the
pylorus, thickens the pyloric wall, and elongates the pyloric canal (Fig.
33 b). Specific findings of HPS include a pyloric diameter of more than
8mm, pyloric canal length of more than 13mm, and pyloric muscle thick
ness of more than 3mm.
Duodenal atresia/Duodenal stenosis

Duodenal atresia and stenosis are common causes of bowel obstruction
in the neonate. There is complete obliteration of the duodenal lumen with
atresia but only a partial or incomplete obstruction of the duodenal lu-
577
Figure 33.
Hypertrophic pyloric stenosis.
a) UGI examination. The pylorus (*) is
elongated with extrinsic compression
producing a double and triple
channel sign. There is extrinsic
impression on the gastric antrum
(arrowheads) and duodenal bulb
(arrowheads).
b) Ultrasound examination.
Longitudinal oblique sonography
shows that the pyloric muscle is
elongated (19.8mm) and thickened
(7mm).
Figure 34.
Duodenal atresia.
Supine radiograph demonstrates gas in
the stomach and markedly dilated duo
denal bulb.
men with stenosis. Duodenal atresia is approximately 15 times as com

mon as duodenal stenosis or annular pancreas with duodenal stenosis.
Most intrinsic congenital obstructions are thought to represent an
alteration of normal development caused by some insult during early
gestation.
578
PEDIATRIC RADIOLOGY
Abdominal radiography in duodenal atresia is usually diagnostic. Gas

is present in the stomach and dilated duodenal bulb ("double bubble"),
but there is no air in the distal gastrointestinal tract (Fig. 34). If the ab
dominal radiograph shows partial duodenal obstruction, a small amount
of barium (3-5ml) is injected into the stomach.
Small bowel
Small bowel atresia and stenosis

Small bowel atresia and stenosis are important causes of neonatal in
testinal obstruction. Atresia is a complete occlusion of the intestinal lu
men; it accounts for 95% of cases. Stenosis, an incomplete intraluminal
occlusion, is much less frequent. Small bowel atresia and stenosis are
due to an in utero vascular accident.
The diagnosis of obstruction is usually apparent on plain films of the
abdomen. If obstruction is present in the jejunum, a few gas-filled loops
of small bowel are present, with the remainder of the abdomen being gas-
less. Further radiologic studies are usually not necessary. A small amount
of air may be injected for confirmation of complete or partial jejunal ob
struction. The diagnosis of distal ileal atresia by plain films is more dif
ficult. It may be difficult or impossible to distinguish dilated distal small
bowel from colon. A contrast enema is frequently indicated to establish
the precise diagnosis. Water-soluble, nonionic contrast material is pre
ferred. The enema distinguishes between small and large bowel disten
tion, determines the presence or absence of microcolon, and locates the
position of the cecum in regard to possible abnormalities of intestinal ro
tation and fixation. Contrast opacifies a small colon, indicating that di
lated loops are small bowel and complete obstruction is present.
Intestinal duplication
Duplications are enteric cysts. A duplication is a spherical or tubular
structure that has an internal lining of intestinal epithelium, has smooth
muscle in its wall, and is adherent to some portion of the intestinal tract.
Duplications of the small bowel have a mesenteric location. Multiple du
plications may occur anywhere from tongue to anus, most are located in
the terminal ileum near the ileocecal valve. Other common sites of du
plication include distal esophagus, stomach, and duodenum.
579
Figure 35.
Gastric duplication cyst.
a) Left upper quadrant mass (M) extrinsically
compresses the stomach (arrowheads).
b) Longitudinal sonography confirms that the
mass (M) is cystic. The muscular rim sign
is due to echogenic mucosa and mucus
(white arrows) with adjacent sonolucent
muscularis mucosa (black arrows).
[From Kirks.]
Plain films usually show

a soft-tissue mass within
the abdomen (Fig. 35 a).
Sonography may demon
strate either anechoic cys
tic mass, or mixed echo
genic mass due to hemor
rhage and inspisated
material within the dupli
cation. The muscular rim
sign is highly suggestive of
an enteric duplication; US demonstrates an inner echogenic line of in
testinal mucosa interfacing with mucus and is surrounded by a hypoechoic
rim of muscularis mucosa in the wall of the duplication cyst (Fig. 35 b).
Contrast examinations confirm that the mass is intraperitoneal in loca
tion and extrinsically affects bowel.
Malrotation with midgut volvulus

Malrotation includes a wide spectrum of anomalies of intestinal rotation
and fixation. During normal development, the midgut rotates 270° coun
terclockwise about the superior mesenteric artery; the small bowel
mesentery is attached from the left upper quadrant (duodenojejunal junc-
580
PEDIATRIC RADIOLOGY
Figure 36.
Malrotation with midgut volvulus.
The duodenojejunal junction (curved
arrow) overlies the spine and is
inferior to the duodenal bulb. There
is also an abnormal, spiral course
(curved arrow) o f the duodenum.
tion) to the right lower quadrant. In malrotation, a narrow mesenteric at

tachment may lead to midgut volvulus or peritoneal bands (Ladd bands)
may partially obstruct the bowel.
US may show an abnormal relationship between the superior mesen
teric artery and vein; however, it may also be completely normal in pa
tients with malrotation. UGI demonstrates that the duodenojejunal junc
tion is not in its normal location to the left of the spine at the level of the
bulb (Fig. 36). There may be a spiral course of the duodenum due to
volvulus and the proximal small bowel may be on the right. Barium en
ema may be completely normal in malrotation with midgut volvulus and
cannot be used to exclude the diagnosis. However, in most cases o f mal
rotation, the cecum is high and not located in its normal position over-
lying the right iliac wing.
The treatment of malrotation with volvulus is a surgical emergency
because of potential bowel necrosis. The accepted surgical procedure
(Ladd operation) includes reduction of volvulus, resection of nonviable
bowel, transsection of abdominal peritoneal bands, exclusion of possi
ble associated abnormalities, and placement of small bowel in the right
abdomen with the colon on the left. The mesentery of the small bowel is
spread smoothly from right to left with a broad attachment that elimi
nates the potential for recurrent volvulus.
581
Figure 37.
Necrotizing enterocolitis.
Air is seen in the wall o f the descend
ing colon (arrows). There is also a
suggestion o f air in the portal venous
system.
Necrotizing enterocolitis
Necrotizing enterocolitis (NEC) is a disease most frequently seen in pre
mature infants. The etiology is multifactorial: prematurity, hypoxia,
stress, ischemia, early feeding, congenital heart disease, and infection.
Indirect and direct bowel injury cause loss of the mucosal protective bar
rier with subsequent bacterial overgrowth leading to NEC.
Radiographic findings in NEC include focal bowel distention in the
right lower quadrant, ileus, intramural gas, bowel-wall thickening, and
portal vein gas (Fig. 37). The only absolute radiologic indication for
surgical intervention is pneumoperitoneum due to bowel perforation.
The cross-table, horizontal-beam radiograph is the most sensitive indi
cator of pneumoperitoneum. US may demonstrate air in the bowel wall
air in the portal venous system, and free gas or fluid in the peritoneal
cavity.
Mortality in NEC is high, especially in infants of very low birth weight.
Repeat physical examination and serial abdominal radiographs are im
portant in following neonates with NEC. Indications for surgical inter
vention include perforation and clinical deterioration with shock, peri
tonitis, persistent metabolic acidosis and disseminated intravascular co
agulation. Surgical treatment includes resection of necrotic bowel with
ileostomy or colostomy. Strictures may occur following NEC; contrast
studies of the excluded bowel segment are always performed prior to re
establishment of bowel continuity to exclude the possible development
582
PEDIATRIC RADIOLOGY
of a stricture. Strictures due to NEC may be treated by surgical resection

or balloon dilatation.
Problems with meconium

There are at least four common problems with meconium that should be
distinguished and not confused: meconium peritonitis, meconium ileus,
meconium ileus equivalent, and meconium-plug syndrome. Meconium
peritonitis is due to antenatal perforation o f the GI tract. It may be due
to meconium ileus but is not always associated with cystic fibrosis. For
practical purposes, meconium ileus and meconium ileus equivalent oc
cur only in patients with cystic fibrosis. Meconium-plug syndrome is one
of several causes o f functional colonic obstruction in the newborn.
Meconium-plug syndrome may be the presenting syndrome of
Hirschsprung disease; it is rarely due to cystic fibrosis.
Acquired small-bowel obstruction (SBO)

One of the aims of this section is to remind the reader of the differential
diagnosis of acquired small-bowel obstruction in children. This aim is
spelled AIIMM; the letters stand for the most common causes of ac
quired small-bowel obstruction in children: Adhesions from previous
surgery; Appendicitis, frequently with abscess formation (See Fig. 41);
Incarcerated inguinal hernia; Intussusception; Malrotation with volvu
lus, ladd bands, or both; and Miscellaneous (Meckel diverticulum, du
plication, ingested foreign body). Intussusception is the most frequent
cause of mechanical obstruction of infants and children.
Colon
Anorectal malformation
Anorectal malformation (imperforate anus) includes a group of related
anomalies of the termination of the hindgut. In most patients, there is
communication of the hindgut with the perineum, genital tract, or uri
nary system. The precise diagnosis and proper surgery are critical for
preventing serious genitourinary or gastrointestinal tract damage. These
patients need specialized treatment and should be referred to tertiary
medical centers.
Frequency of anorectal malformations is approximately 1 in 5000 live
births, with males affected usually more frequently than females. Careful
583
Figure 38.
Hirschsprung disease.
3-day-oldfem ale with failure to pass
meconium.
a) AP supine abdominal radiograph.
Gaseous distention o f both small
bowel and colon.
b) Barium enema. There is a
discrepancy in caliber between the
maximal diameter o f the rectum
(lower arrows) and the maximal
diameter o f the sigmoid colon
(upper arrows). The narrowed
rectum is aganglionic.
physical examination of the

newborn with anorectal malfor
mation almost always estab
lishes the diagnosis and level of
hindgut termination. There are
frequently other visceral and
skeletal anomalies in patients
with anorectal malformations.
These include abnormalities of
the spine (sacral anomalies),
urinary tract (neurogenic blad
der), GI tract (atresia, TEF) and
cardiovascular system (CHD).
Hirschsprung disease
Hirschsprung disease is a func
tional colonic obstruction due to
an absence of ganglion cells in
the distal segment of bowel; the distal colon is most commonly affected.
The frequency is approximately 1/5000 births. Most patients (80%) with
Hirschsprung disease present in the first 6 weeks of life with obstruction
or intermittent diarrhea and constipation. Symptoms usually date from
birth. There is an increased frequency in patients with Down syndrome.
584
PEDIATRIC RADIOLOGY
Abdominal radiographs show dilatation of bowel proximal to the agan-

glionic segment with associated air-fluid levels (Fig. 38 a). The radio
logic diagnosis of Hirschsprung disease requires a barium enema with
meticulous technique; contrast enemas are performed and contrast is in
jected slowly through a catheter. The critical film for identifying a tran
sition zone is a lateral film during slow injection. The transition from
narrowed aganglionic colon to dilated normal bowel is clearly demon
strated (Fig. 38 b). Delayed films at 24 hours may be helpful. Patients
with Hirschsprung disease show little evacuation at 24 hours; there is a
lack of bolus movement of barium toward the left colon and rectum.
Since children with Hirschsprung disease are at risk for the development
of toxic colitis, diagnostic evaluation should be performed as soon as
possible. The barium enema is highly accurate for the diagnosis of
Hirschsprung disease, even in the newborn; the diagnosis is confirmed
by rectal biopsy before surgical repair.
Intussusception
Intussusception is an invagination of a segment of intestine into adjacent
bowel. More than 95% of intussusceptions in children are ileocolic or
ileoileocolic and have no pathologic lead point; these idiopathic cases
are probably due to hypertrophy of lymphoid tissue in the terminal ileum.
Pathologic lead points that may cause intussusception include Meckel
diverticulum, lymphosarcoma, and polyp. Most patients with idiopathic
intussusception are between 3 months and 2 years of age. Signs and
symptoms include pain, vomiting, blood per rectum, and a palpable ab
dominal mass.
Plain film findings include normal bowel gas pattern, loss of the sub-
hepatic angle, intraluminal soft-tissue mass, and mechanical small-bowel
obstruction. Intussusception may also be diagnosed by US; a soft-tissue
mass with concentric layers of echogenicity produces a target sign on
transverse images or a pseudokidney sign on longitudinal images.
The only absolute contraindications to contrast enema and attempted
reduction of intussusception are pneumoperitoneum and clinical peri
tonitis. Hydrostatic or pneumatic reduction are successful in 75-85% of
cases (Fig. 39). During hydrostatic reduction, the rule of 3s is used: 3 at
tempts; 3 minutes of intermittent fluoroscopy for each attempt; bag
placed 3-4 feet above the tabletop. Mean pressures during air insuffla
tion should not exceed 120 mmHg at rest.
585
Figure 39.
Intussusception.
Hydrostatic reduction o f intussusception.
The intussusceptum (*) is identified in the right
transverse colon. Subsequently, the intussus
ception was readily reduced.
Figure 40.
Sonography o f appendicitis.
16-year-old male with right
lower quadrant and pelvic pain.
a) Transverse and
b) Longitudinal sonographic
sections demonstrate dilated
appendiceal lumen (L),
thickened appendiceal wall
(W), and appendicolith
(arrow) with distal acoustic
shadowing.
[From Kirks.]
Appendicitis
Acute appendicitis is the most frequent condition requiring abdominal
surgery in children. Disease is rare in young infants but becomes more
frequent during each year of childhood. In older children, the clinical
586
PEDIATRIC RADIOLOGY
findings are usually suggestive of the diagnosis. However, in young chil

dren with appendicitis, there is an increased frequency of perforation and
decreased specificity o f physical findings. Imaging is performed only if
the clinical presentation is confusing.
Plain films of the abdomen may be completely normal in patients with
acute appendicitis. An appendicolith is present in up to 2% of cases.
There are frequently signs of right lower quadrant inflammatory disease
on plain films of the abdomen. These inflammatory changes include air-
fluid levels in the terminal ileum and cecum, thickening of the cecal wall,
soft-tissue mass effect on the cecum, loss of the obturator intemus fat
plane in the pelvis, and fluid between the cecum and properitoneal fat
line. A common manifestation of perforated appendicitis is small-bowel
obstruction.
Sensitivity and specificity of US for the diagnosis of appendicitis in
children is between 80 and 90%. Graded compression in patients with
US shows a noncompressible appendix, an overall diameter of more than
6mm, thickening of the appendiceal wall, dilatation of the appendiceal
lumen, and, occasionally, an appendicolith (Fig. 40). CT is the imaging
modality of choice for evaluating patients with complicated appendici
tis and possible abdominal abscess formation (Fig. 41).
Liver and biliary disease
Choledochal cyst
Choledocal cyst is a localized dilatation of the biliary ductal system.
There are two broad groups of patients. The first group is neonates with
choledocal cyst which is caused by stenosis or atresia of a portion of the
biliary tree and is related to biliary atresia. A second group is diagnosed
later in life and is frequently associated with anomalous relationship of
the terminations of the common bile duct and pancreatic duct.
US and hepatobiliary nuclear scintigraphy confirm the diagnosis of
choledocal cyst. US shows a cystic mass in the porta hepatis with possi
ble dilatation of bile ducts emptying into this cystic mass. Functional he
patobiliary nuclear scintigraphy shows normal extraction of tracer by the
liver accumulation and stasis within the choledocal cyst, and absent or
decreased bowel excretion.
587
Figure 41.
Pelvic abscess due to appendicitis.
a) AP supine film shows dilated small bowel
consistent with mechanical obstruction.
b) CT section shows large pelvic abscess (A)
containingfluid and air that impresses on
the bladder (B). Note thickening o f wall o f
sigmoid colon (S) adjacent to the abscess
collection.
[From Kirks.]
Biliary atresia/Neonatal hepatitis

Some jaundice is physiologic during the newborn period. However, if
neonatal jaundice is marked or persistent, the possibility o f biliary atre
sia, neonatal hepatitis, or choledocal cyst should be considered.
The initial imaging procedure in patients with neonatal jaundice is US
to exclude choledocal cyst or dilatation of the extrahepatic biliary system.
US of the hepatic parenchyma and intrahepatic bile ducts in both hepati
tis and biliary atresia in the neonate is usually normal. Hepatobiliary
scintigraphy, with phenobarbital enhancement, permits accurate differen
tiation of biliary atresia from neonatal hepatitis. In infants less than 3
months of age with biliary atresia, the hepatic extraction of tracer is good
but there is no excretion into the GI tract. In neonatal hepatitis, there is
588
PEDIATRIC RADIOLOGY
poor extraction of tracer by the liver with demonstration of some tracer

activity within the GI tract; operative cholangiography will demonstrate
a small but patent bile duct system.
There is a spectrum from neonatal hepatitis to biliary atresia which ex
plains intermediate cases as well as the known progression from hepati
tis to post-natal occlusion of bile ducts. Liver biopsy is also helpful in
the important distinction between biliary atresia and neonatal hepatitis.
Portal hypertension
Portal hypertension is caused by increased resistance to portal venous
blood flow. Portal hypertension in children may be due to extrahepatic
obstruction, intrahepatic obstruction, hepatic venous hypertension, or
hyperkinetic hypertension. The frequency of extrahepatic portal ob
struction is considerably higher in children than adults; moreover, ex
trahepatic obstruction due to portal vein thrombosis (cavernous trans
formation of the portal vein) is a more frequent cause of portal hyper
tension in children than is intrahepatic obstruction due to cirrhosis.
Duplex US with Doppler, and color-flow Doppler analysis is extremely
useful for assessing patients with portal hypertension. The size of the
portal vein and direction of portal venous flow can be determined; por
tosystemic collateral circulation is identified. The earliest signs o f por
tal hypertension are abnormal Doppler flow with subsequent reversal of
flow. Severe portal hypertension causes thickening of the lesser omen
tum due to varices. MRI may also be extremely useful in evaluating pa
tients with portal hypertension and end-stage liver disease. Angiography
is able to determine portal venous obstruction and active GI bleeding as
well as evaluating vascular hemodynamics. However, increased appli
cations of Doppler sonography and MRI have decreased the need for an
giography in pediatric patients with portal hypertension.
Gallbladder disease
Gallstones in children are uncommon but not rare; they occur more fre
quently than acute cholecystitis. Although cholelithiasis can occur in pa
tients with hemolytic anemias, most cases in infants and children are still
idiopathic. US is the imaging modality of choice for diagnosis of gall
stones; hepatobiliary scintigraphy may aid in the diagnosis of acute
cholecystitis. It should be remembered that gallstones in neonates may
spontaneously resolve; sequential US is able to determine if tumefactive
589
Figure 42.
Splenic fracture and
hematoma.
14-year-old male involved in
sledding accident. There is a
fracture o f the upper pole o f
the spleen (S) with a
perisplenic hematoma (H).
[From Kirks.]
sludge in neonates resolves or progresses to gallstones.
Blunt abdominal trauma

Not every child with abdominal injury should undergo radiologic or
imaging evaluation. Children who have had severe blunt abdominal
trauma and are clinically unstable require immediate surgery. Pediatric
patients with trivial trauma who are clinically stable require nothing more
than careful clinical evaluation and observation. It is in the third group
of pediatric patients (known severe blunt trauma and clinically stable)
that CT has proved critical for therapy and management.
It should be stressed that up to 20% of children with blunt abdominal
trauma have multi-organ injury. CT accurately images the liver, spleen
(Fig. 42), kidneys, pancreas, peritoneal cavity, mesentery, and bowel. It
is able to demonstrate vascular integrity of an organ without being de
pendent on specific function for organ visualization. CT can also detect
free intraperitoneal air as well as the amount of intraperitoneal blood.
GENITOURINARY TRACT
Radiology plays an important role in the evaluation of abnormalities of
the genitourinary tract in infants and children. There are a number of
modalities, both noninvasive and invasive techniques for evaluating the
adrenal glands, kidneys, ureters, bladder, urethra, gonads, and genitalia.
Modalities
Ultrasound
Ultrasound (US) is a particularly useful imaging modality for the pedi
atric patient as it does not utilize radiation and is diagnostically accurate.
590
PEDIATRIC RADIOLOGY
Figure 43.
Normal neonatal renal
sonography.
7-day-old infant. The renal
contours are irregular due
to fetal lobulation. The
medullary pyramids are
hypoechoic and prominent.
These normal, triangular
pyramids should not be
confused with cysts or
hydronephrosis.
The renal parenchyma is well demonstrated by US. Dilatation of the re

nal pelvis is readily apparent. The bladder should be evaluated when dis
tended; a dilated distal ureter is well seen at its entrance into the blad
der. US is extremely operator dependent; another drawback is the lack
of information regarding renal function. The renal papillae in the neona
tal period are prominent and hypoechoic (Fig. 43); their triangular shape
differentiates them from cystic disease of the kidney or hydronephrosis.
Excretory urography
Excretory urography (intravenous pyelography) is performed after in
jecting 2-3 ml/kg body weight of water-soluble contrast media intra
venously. Most pediatric radiologists prefer to use non-ionic contrast ma
terial; there is less pain with injection and if extravasation occurs, pain
and tissue damage are significantly less than with ionic contrast media. A
preliminary film is always obtained. A coned-down AP film of the kid
neys is obtained approximately 1-2 minutes after injection (Fig. 44 a); a
prone PA film is then obtained at 7-10 minutes to show both kidneys and
bladder (Fig. 44 b).Cleansing enema may be needed to improve the qual
ity of the examination. Fasting and fluid restriction should be avoided.
Voiding cystourethrography
Voiding cystourethrography (VCUG) demonstrates the anatomy of the
bladder and urethra as well as the presence or absence of vesicoureteral
reflux (VUR). The urethra is catheterized and dilute contrast media is in
stilled into the bladder. Because gonadal radiation dosage is relatively
high, fluoroscopy should be brief and intermittent. Spot films are ob
tained of the bladder with low-volume filling and after complete filling.
591
Figure 44.
Normal excretory urogram.
a) 1-minute film. There is good
visualization o f the contours o f
the renal parenchyma (arrow
heads). Some contrast already
present in the pelvicalyceal
systems.
b) 10-minute film. The stomach is
distended by carbonated bever
age. The kidneys, renal pelves,
and proximal ureters are well
visualized.
Both oblique projections visualize the region of the ureterovesical junc

tions for any reflux or abnormality. During voiding, the male urethra is
visualized in the oblique projection whereas the female urethra is visu
alized in the lateral or oblique projection. The bladder should again be
evaluated in the supine position at the end stage of voiding. The absence
of vesicoureteral reflux should be documented with spot films of the kid
neys at the end of the study. If reflux is present, the level and amount of
associated distention should be documented.
Nuclear medicine
Isotope cystography correlates well with conventional VCUG for as
sessing the presence and degree of vesicoureteral reflux (VUR). The low
cost and low radiation dose make it an ideal method for studies in fe
males with urinary tract infection and for follow-up studies in patients
with known VUR. Conventional VCUG is still preferred as the initial
imaging procedure in males and in females with suspected anatomic ab
normalities.
592
PEDIATRIC RADIOLOGY
Renal scintigraphy is able to assess a variety of physiologic parame

ters: differential renal function, renal plasma flow, glomerular filtration
and renal clearance. Renal cortical scanning agents are particularly use
ful in studying renal morphology; they can localize small amounts of re
nal parenchyma, diagnose acute pyelonephritis, and identify malposi-
tioned kidneys.
CT
CT is most frequently performed after initial investigation of the kid
neys by US or excretory urography. Intravenous sedation may be re
quired up to 7 years of age. Intravenous contrast injection is mandatory.
CT is particularly helpful in the evaluation of retroperitoneal tumors
(Wilms, neuroblastoma, rhabdomyosarcoma) and evaluating patients
with renal trauma.
M RI
Since MRI uses no ionizing radiation, it is particularly well suited for
pediatric imaging. Images may be obtained in the axial, sagittal, coro
nal, and other orthogonal planes. Because of sensitivity to any motion,
children frequently require intravenous sedation or general anesthesia.
MRI is helpful in evaluating large abdominal masses since the coronal
and sagittal planes gives a global view of the abnormality (See Fig. 54).
MRI has also been exceedingly valuable in the evaluation of neuroblas
toma. The inability of MRI to detect calcification is outweighed by its
ability to image in orthogonal planes, assess extradural tumor extension,
and determine bone marrow involvement.
Angiography
With the emergence o f less invasive imaging modalities, there has been
a dramatic change in the indications for pediatric angiography. The most
common clinical indication for renal angiography is evaluation of reno
vascular hypertension. Transluminal angioplasty is able to treat renal
artery stenosis.
CT is the initial method of evaluating renal trauma in children.
However, renal angiography may be indicated to further evaluate a re
nal vascular pedicle injury, false aneurysm, or arteriovenous fistula.
593
Renal abnormalities
Congenital
Renal ectopia and horseshoe kidney

Renal ectopia is an abnormal position of a kidney. It may be due to fail
ure of complete ascent of the kidney from its primitive location at the
S I-2 level or to excessive cranial migration beyond its normal location.
Crossed renal ectopia is a condition in which the affected kidney is lo
cated entirely or primarily on the opposite side of the abdomen. The ec
topic kidney lies below the normal contralateral kidney, and the two or
gans are almost always fused.
Renal fusion is the union of two kidneys. Horseshoe kidney is the most
common type of renal fusion. There is fusion of the lower pole of the
two kidneys across the midline by an isthmus, which usually lies ante
rior to the aorta and inferior vena cava. The diagnosis may be made by
excretory urography or US. Complications associated with horseshoe
kidney include hydronephrosis and renal stones. There is also an in
creased incidence of Wilms tumor, renovascular hypertension, and ade
nocarcinoma in patients with horseshoe kidney.
Renal cystic disease

Cystic disease of the kidneys is a complex topic. Classifications are usu
ally based on proposed etiology, pathology, anatomic location, or radi
ologic features.
Polycystic kidney disease

Infantile polycystic kidney disease (IPCKD) is a spectrum of abnormal
ities that includes both microcystic and macrocystic renal disease with
variable degrees of hepatic fibrosis. IPCKD is inherited as an autosomal
recessive trait. Patients present in the first several months of life with pal
pable kidneys and variable degrees of renal failure. There is renal en
largement with diffuse increased echogenicity of the kidneys by US.
Juvenile polycystic disease of kidney and liver (renal tubular ectasia
with congenital hepatic fibrosis) is also inherited as an autosomal reces
sive trait; patients usually develop symptoms after 10 years of age. There
is hepatosplenomegaly and portal hypertension. Fewer than 10% o f re
nal tubules are dilated and hyperplastic; there is gross hepatic fibrosis.
594
PEDIATRIC RADIOLOGY
Figure 45.
Multicystic dysplastic kidney.
Longitudinal sonography
demonstrates multiple cysts o f
varying sizes in the kidney.
There is no renal pelvis
identified. The multiple cysts
do not intercommunicate and
there is no identifiable renal
parenchyma.
Adult polycystic kidney disease (APCKD) is an autosomal dominant

trait with variable penetrance. It is felt to be a separate entity from
IPCKD. The cysts are of variable size and involve both renal cortex and
medulla; hepatic cysts occur in approximately 1/3 of patients, but there
is usually no periportal fibrosis. APCKD usually presents in early adult
hood with hypertension, hematuria, or renal failure.
Multicystic dysplastic kidney

Multicystic dysplastic kidney (MCDK) is the second most common ab
dominal mass in the neonate. The central embryonic event in the for
mation of MCDK is ureteropelvic atresia during the metanephric stage
of intrauterine development.
US demonstrates multiple cysts of varying size; the largest of these
cysts is not central and does not represent a dilated renal pelvis (Fig. 45).
Renal scintigraphy confirms markedly decreased perfusion and absent
or markedly decreased renal function. Because many of the cysts de
crease in size, MCDK may completely involute; patients are usually
treated conservatively. Surgical removal is only indicated if the cysts
markedly enlarge or if hypertension develops.
Simple renal cyst

Prior to the use of US, simple renal cysts were rarely diagnosed in chil
dren. A simple renal cyst is unilocular, solitary, and contains a single
layer of flattened epithelium with a fibrous wall. There is no communi
cation between the cyst cavity and the renal collecting system. Although
percutaneous needle puncture may be performed, sequential US is sug-
595
Figure 46.
Hydronephrosis due to UPJ obstruction.
Excretory urography shows that there is
almost complete obstruction at the left
ureteropelvic junction. The right kidney and
bladder are normal.
gested as the method of choice for follow-up.
M ultilocular cyst
A multilocular renal cyst (multilocular cystic nephroma) is a unilateral
and solitary benign lesion of the kidney. US shows multiple cysts with
intervening thin and linear septa. Foci of nephroblastomatosis or Wilms
tumor may be found in the walls of multilocular cysts; such masses usu
ally have thickened as well as irregular septa and should be considered
a well-differentiated Wilms tumor of the kidney. The usual treatment for
multilocular renal cyst is nephrectomy.
Ureteropelvic junction obstruction

Congenital ureteropelvic junction (UPJ) obstruction is the most common
congenital obstruction of the urinary tract. There is an intrinsic narrow
ing of the UPJ that causes hydronephrosis (Fig.46).
596
PEDIATRIC RADIOLOGY
Figure 47.
Primary megaureter.
Excretory urography demonstrates
a dilated right ureter to a level ju st
above the bladder. The right renal
pelvis and ureter are markedly
dilated.
If the obstruction is mild, intermittent hydronephrosis may only be

manifest with diuresis.
Sonography of UPJ obstruction shows a large cystic mass within the
kidney. There are multiple hypoechoic cystic spaces, with the largest be
ing medial in location and representing the dilated renal pelvis. The cysts
intercommunicate, and one can usually identify infundibulae and calyces
as well as surrounding renal parenchyma. There is no evidence of ureteral
dilatation; the bladder is normal. All patients with suspected UPJ obstruc
tion should have a voiding cystourethrogram to exclude reflux. Moreover,
some patients may have UPJ obstruction associated with reflux.
Excretory urography shows delayed excretion of contrast medium,
which is diluted by retained urine within the large renal pelvis. Nuclear
scintigraphy with DTPA shows a photon-deficient area due to the dilated
renal collecting system; there is central migration of isotope into the re
nal pelvis on delayed images. If renal function is markedly decreased,
scintigraphy will be helpful in identifying the amount of functioning re
nal parenchyma.
Primary megaureter is a functional obstruction of the distal ureter. It
may be isolated (Fig. 47) or associated with reflux and other urinary tract
abnormalities.
597
Figure 48. Ectopic ureter. 2-year-oldfe

male with urinary tract infection.
a) Transverse sonography o f the bladder
demonstrates a dilated right ureter
(arrows).
b) Excretory urography. There is a duplex
system on the right. The upper pole
moiety (arrow) is dilated and poorly
functioning.
c) Voiding cystourethrography. There is
reflux into the dilated ureter (lower
arrows) and dilated upper pole moi
ety (upper arrows).
Ectopic ureter
Failure of the ureter to separate from the wolfian duct results in the
ureteral orifice being carried to some point distal to its normal location.
The result is ureteral ectopia, which is 3-4 times more frequent in fe
males than in males. In females, this anomaly is usually present with an
associated duplex system, so that the ureter draining the upper pole moi
ety terminates ectopically. The ectopic orifice in the female empties into
the urethra, vestibule, or vagina (Fig. 48 a). Rarely, it may empty in the
uterus, cervix, or rectum. In males, ectopic ureters less likely involve du
plex systems. Ectopic ureteral openings may be in the posterior urethra,
ejaculatory ducts, seminal vesicle, vas deferens, or rectum. A common
598
PEDIATRIC RADIOLOGY
Figure 49.
Ectopic ureterocele.
Excretory urography shows a large
ureterocele (arrowheads) in the
bladder. There is a duplex collecting
system o f the left kidney. The right
ureter and lower pole moiety o f the
right kidney are displaced laterally.
The upper pole moiety o f the right
kidney (*) is non-functioning.
clinical presentation in females is urinary incontinence or dribbling; since

the ectopic opening lies proximal to the external sphincter in males, there
usually is not incontinence.
Excretory urography may suggest the diagnosis by directly visualiz
ing the termination of the ectopic ureter, verifying the presence of a non
functioning upper pole renal moiety, or demonstrating a nonfunctioning
kidney (Fig. 48 b). A cyclic VCUG may be helpful in filling ectopic
ureters that drain into the urethra (Fig. 48 c).
Ectopic ureterocele
A ureterocele is a cyst-like protrusion into the bladder lumen of a dilated
distal portion of an ectopic ureter. It is almost invariably associated with
duplication, obstruction of the ureter, and drainage of the upper pole re
nal moiety. An ectopic ureterocele is larger and more inferior than a sim
ple ureterocele, is usually unilateral, and is far more common (4:1) in fe
males than in males.
The sonographic appearance of the ectopic ureterocele is characteris
tic. There is a dilated upper renal collecting system which connects with
a dilated, tortuous ureter. A round thin-walled, intravesical ureterocele is
seen within the bladder. Excretory urography shows a mass in the upper
pole of the affected kidney due to the dilated, hydronephrotic upper pole
moiety as well as a lucent filling defect in the bladder due to the ectopic
ureterocele filled with urine within the contrast-filled bladder (Fig. 49).
599
VCUG may not demonstrate an ectopic ureterocele, as contrast mater

ial is highly radiopaque and filling may flatten the ureterocele or even evert
it if it is not tense. When VCUG is performed for suspected ectopic urete
rocele, it is important to use dilute contrast material in very small amounts.
Fluoroscopy should be performed in varying degrees of obliquity.
Urinary tract infection

Urinary tract infection (UTI) is the most common abnormality o f the uri
nary tract in children and the second most common infection in the pe
diatric age group, exceeded only by upper respiratory tract infection. Not
only is UTI exceedingly common in children it is also potentially dan
gerous. This danger is due to difficulties and delays in diagnosis, high
relapse rate following treatment, and potential for renal damage leading
to chronic renal disease.
There is increasing evidence that first-time UTI in both males and fe
males should be evaluated. The purpose of this imaging evaluation is to
diagnose congenital physiologic abnormalities, identify renal damage,
provide a baseline for subsequent evaluation of renal growth, and estab
lish the prognosis.
The traditional imaging approach has been VCUG (Fig. 50) followed
by excretory urography. More recently there is a trend toward utilizing
nuclear cystograms to replace radiographic VCUG, particularly in fe
males or for follow-up examinations, and US for evaluation o f the up
per urinary tract.
There is increasing utilization o f cortical scintigraphic agents (DMSA,
glucoheptonate) to evaluate the kidneys for renal scarring and acute
pyelonephritis. These techniques are more sensitive than US or excre
tory urography for the detection of subtle scars and changes of acute
pyelonephritis.
Lower urinary tract abnormalities
Neurogenic bladder
Spinal dysraphism is the most common cause of neurogenic bladder in
children. Other causes include trauma, childhood viral diseases, and pre
vious pelvic surgery. The basic pathophysiology of neurogenic bladder
is functional abnormality of the sphincter mechanism o f the urethra.
There is disordered contractility of the detrusor muscle with subsequent
600
PEDIATRIC RADIOLOGY
Figure 50.
Vesicoureteral reflux.
Voiding cystography shows marked
left vesicoureteral reflux (Grade III)
and moderate (Grade II) right reflux.
inadequate bladder emptying

and retention of urine within the
bladder.
A neurogenic bladder may be
small, normal, or large in vol
ume. Usually, the bladder is
small with a thick vesical wall
and many cellules, sacules, and
even diverticula. There is in
competence of the bladder base
at rest and poor relaxation of the
external sphincter during at
tempted voiding. US examina
tion demonstrates a thick-walled
bladder and any associated up
per urinary tract dilatation.
Posterior urethral valves

Posterior urethral valves are the most common cause of urethral ob
struction in the male infant, child, or adolescent. Diagnosis should be
made as early as possible in order to prevent renal damage. If the mar
gins of the normal mucosal folds (plicae collicularis) fuse anteriorly, ob
structing posterior urethral valves are formed.
US may confirm the presence of bilateral hydronephrosis and ureterec-
tasis. Examination of the pelvis shows dilated ureters and a thick-walled
dilated bladder. Careful examination of the posterior urethra using the
distended bladder as a window may demonstrate dilatation that is ac
centuated by manual compression. However, VCUG remains the method
of choice for confirming the diagnosis (Fig. 51). The bladder is frequently
thickened and markedly trabeculated. There may be vesicoureteral re
flux, which is usually unilateral, and even extravasation of contrast ma
terial or urine into the peritoneal cavity from the kidney or bladder, pro-
601
Figure 51.
Posterior urethral valves.
Newborn male with bilateral
hydronephrosis detected on
prenatal sonography. Voiding
cystourethrography demon
strates rounded obstruction due
to posterior urethral valves
(arrow), markedly dilated
posterior urethra (U), small and
thick-walled bladder (B), and
reflux into the utricle (*) as well
as tortuous ureters.
ducing urinary ascites. The urethra should be examined in the steep

oblique or lateral projection during voiding. There is frequently sec
ondary thickening of the bladder neck and wall of the bladder. The pos
terior urethra is dilated with the obstructing posterior urethral valve pro
ducing a "spinnaker sail" appearance (Fig. 51).
Exstrophy o f the bladder

Exstrophy is a failure of closure of the anterior wall of the bladder. With
exstrophy of the bladder, there is widening of the symphysis pubis due
to outward rotation of the iliac bones, outward rotation of the pubic bones,
and lateral displacement of the iliac bones (Fig. 52). There are usually
no malformations of the upper urinary tracts. Initial renal US should be
performed as a baseline at 1-2 weeks of age. There is usually slight di
latation of the distal ureters which should not be interpreted as a sign of
significant obstruction.
Genitourinary tumors
Wilms tumor
Wilms tumor (nephroblastoma) is a triphasic, embryonic neoplasm that
contains epithelial, blastemal, and stromal elements. It is similar in over
all incidence to neuroblastoma and accounts for approximately 8 % of all
pediatric malignant tumors. Wilms tumor is the most common solid ab-
602
PEDIATRIC RADIOLOGY
Figure 52.
Exstrophy o f bladder.
AP view o f the pelvis during excretory uro
graphy. There is marked widening o f the
symphysis pubis. The kidneys are normal. Due
to surgical reconstruction, the bladder is small
in capacity.
dominal mass as well as the most common renal malignancy o f child

hood.
The peak incidence of Wilms tumor is between 30 months and 3 years
of age; 78% of all cases are detected between 1 and 5 years of age. The
most common clinical presentation is that o f an asymptomatic abdomi
nal mass. Other infrequent clinical presentations include abdominal pain,
fever, anorexia, hematuria, and hypertension.
Wilms tumor is bulky and replaces most of the involved kidney; the
tumor arises in the renal parenchyma and displaces as well as distorts the
pelvicalyceal system. The tumor is usually solid with a prominent
pseudocapsule that separates it from normal renal parenchyma. Wilms
tumor may infiltrate the capsule or invade the renal vein and inferior vena
cava; there are frequently local metastases to retroperitoneal lymph
nodes. There may be local extension of tumor, venous extension, lym
phatic metastases, or urothelial spread. The two major pathological tu
mor types are favorable histology (no anaplasia, nonsarcomatous) and
unfavorable histology (anaplasia, sarcomatous).
The screening modality of choice in pediatric patients with a palpable
abdominal mass is US. Wilms tumor is an intrarenal, echogenic mass
(Fig. 53 a); tumor echogenicity is usually equal to or slightly greater than
that of adjacent liver and more homogeneous than the echogenicity of
neuroblastoma. There may be hypoechoic areas within the tumor that
603
Figure 53.
Wilms tumor.
I-year-old fem ale with left
abdominal mass.
a) US. Longitudinal ultrasono
graphy shows a large,
echogenic mass (M) within
the left kidney.
b) CT. Left renal mass (M)
distorts the normal kidney
(arrow). Low attenuation
areas within the tumor mass
are due to necrosis. The right
kidney and inferior vena
cava are normal.
c) Abdominal radiograph after
CT. There is a large,
intrarenal mass (M) that
stretches and distorts the
calyces.
[From Kirks.]
604
PEDIATRIC RADIOLOGY
represent hemorrhage, necrosis, or dilated calyces. It is critical to eval

uate the renal vein and inferior vena cava for possible tumor thrombus.
CT confirms the presence of an intrarenal mass, determines local extent
of Wilms tumor, visualizes vascular structures, identifies nodal involve
ment, evaluates presence or absence of liver metastases, and images the
opposite kidney (Fig. 53 b, c). Calcification is identified by CT in ap
proximately 15% of cases. Chest CT is also performed, since pulmonary
metastases are present in over 10% of patients at the time of initial di
agnosis. MRI accurately assesses the renal origin of Wilms tumor as well
as its margins and local extension. Orthogonal plane imaging of MRI is
useful for detecting spread of tumor to adjacent structures.
Neuroblastoma
Neuroblastoma is the most common extracranial solid malignant tumor
in children; it is the third most common pediatric malignancy, surpassed
in incidence only by acute leukemia and primary brain tumors.
Neuroblastoma is the second most common abdominal malignancy in
the older infant and child, occurring with an almost equal frequency as
Wilms tumor. Neuroblastoma is a malignant tumor of primitive neurob
lasts that may arise anywhere within the sympathetic ganglion chain or
adrenal medulla.
Fifty percent of patients are less than 2 years of age, 75% of patients
are less than 4 years of age, and fewer than 10% of neuroblastomas are in
children over age 10. Neuroblastoma usually remains clinically silent un
til it invades or compresses adjacent structures, metastasizes, or produces
unusual paraneoplastic syndromes. At least 70% of patients will have dis
seminated disease at the time of diagnosis, and many presenting symp
toms and signs are secondary to metastases. Common sites of metastatic
disease are skeleton, bone marrow, liver, lymph nodes, and skin.
Neuroblastoma and its more differentiated forms, ganglioneuroblas-
toma and ganglioneuroma, arise from primitive sympathic neuroblasts
of the embryonic neural crest. Microscopically, the tumor consists o f
small, round cells. Neuroblastoma is composed entirely of undifferenti
ated sympathoblasts; ganglioneuroblastoma contains undifferentiated
neuroblasts and mature ganglion cells; ganglioneuroma is a benign tu
mor containing mature ganglion cells. Two-thirds of neuroblastomas are
located in the abdomen; approximately 2/3 of these abdominal tumors
arise in the adrenal gland.
605
Figure 54. Unresectable Stage IV

neuroblastoma. 3-year-old male
with palpable abdominal mass.
a) US. There is a large, inhomoge
neous, echogenic mass (M)
above the right kidney.
b) Contrast-enhanced CT. The
large retroperitoneal mass dis
places the right kidney (RK) lat
erally and inferiorly.
Neuroblastoma extends across
the midline posterior to the aorta
(A). Note that the aorta (A), su
perior mesenteric artery (a), su
perior mesenteric vein (v), infe
rior vena cava (I), right renal
artery (arrows), and left renal
artery (arrowheads) are com
pletely surrounded and encased
by tumor mass. The tumor is not
resectable.
c) Coronal proton-density MRI.
The large neuroblastoma (large
arrows) displaces the right kid
ney (RK) laterally and inferiorly
b and crosses the midline. The
tumor mass surrounds the aorta (A), right renal artery (small arrows), and left
renal artery (arrowheads),
d) Sagittal proton-density MRI. The large neuroblastoma (arrows) surrounds and
encases the aorta (A), celiac axis (c), and superior mesenteric artery (s). L=liver.
[From Kirks.]
с d
606
PEDIATRIC RADIOLOGY
During the past decade, CT has become the imaging modality of choice
for patients with neuroblastoma. Currently, MRI is playing an increas
ingly important role in determining the relationship of tumor to vascu
lar structures, detecting bone marrow involvement, diagnosing ex
tradural tumor extension, and improving preoperative staging.
Neuroblastoma can usually be distinguished from Wilms tumor by US
because of its extrarenal location (Fig. 54 a). Moreover, the echogenic
ity of neuroblastoma is more inhomogeneous than Wilms tumor due to
increased cellularity, hemorrhage, necrosis, or dystrophic calcification.
CT is superior to sonography for defining morphologic details of neu
roblastoma and precisely assessing extent of disease. Neuroblastoma is
commonly suprarenal or paravertebral in location. It is usually inhomo
geneous due to tumor necrosis and contains calcification by CT in ap
proximately 85% of patients. Neuroblastoma commonly extends across
the midline behind the aorta and surrounds intra-abdominal vessels (Fig.
54 b). The advantages of MR over CT and sonography are as follows:
(1) Multiple planes o f imaging which is useful for assessing adjacent or
gan invasion (Fig. 54 c); (2) Exclusion or detection of extradural tumor
extension, without requiring intrathecal contrast injection; (3)
Identification of bone marrow metastases which is useful for staging; and
(4) Better delineation of intra-abdominal vessel displacement or en
casement (Fig. 54 d).
Neonatal adrenal hemorrhage

Adrenal hemorrhage is a relatively common abnormality of neonates that
may present as an asymptomatic mass. Symptoms and signs may include
anemia and jaundice. The etiology of renal hemorrhage is unknown, but
birth trauma, stress, anoxia, dehydration, and systemic disease have been
implicated. Surgical intervention is usually unnecessary unless there is
secondary infection with adrenal abscess formation. On initial US,
adrenal hemorrhage may appear as a solid lesion (Fig. 55 a), which sub
sequently liquefies and then shows the classic anechoic appearance of a
hematoma. The mass may again become echogenic as clot and subse
quently calcification develop. Sequential US shows a decrease in size of
the mass with eventual disappearance or calcification over several
months (Fig. 55 b-d).
The primary differential diagnostic considerations in a neonate with a
suprarenal mass are adrenal hemorrhage and neuroblastoma. US almost
607
Figure 55.
Neonatal adrenal hemorrhage.
Newborn with anemia, jaundice, a n d
a questionable right abdominal mass.
a) 1 day o f age. Longitudinal sonog
raphy demonstrates an inhomoge-
neous, solid mass (arrows) above
the right kidney (k).
b) 1 week (left) and 2 weeks (right) o f
age. Sequential sonography
a demonstrates an adrenal
hematoma above the right kidney
(k) that becomes smaller and more
hypoechoic with time.
c) 1 month o f age. The adrenal hem
orrhage (arrows) above the right
kidney (k) is now smaller and ane-
choic.
d) 5 months o f age. There is an
b echogenic focus (H) above the
right kidney (k). Plain film s
demonstrated suprarenal calcifica
tion.
[From Kirks.]
608
PEDIATRIC RADIOLOGY
always is able to distinguish between neuroblastoma (echogenic and vas

cular) and neonatal adrenal hemorrhage (anechoic and avascular).
Moreover, because congenital adrenal neuroblastoma has an excellent
prognosis, serial US is an acceptable way to differentiate the exceedingly
rare case in which history, physical examination, and sonography are not
diagnostic. If immediate differentiation is imperative, MRI may confirm
adrenal hemorrhage.
ACKNOWLEDGEMENTS
Some material in this chapter is modified from information in the text
book, Practical Pediatric Imaging: Diagnostic Radiology o f Infants and
Children, edited by Donald A. Kirks with permission of the editor, au
thors, and publisher. As indicated in the figure legends, some illustra
tions are also from this textbook.
609
Chapter 16
Pediatric neuroradiology
Olof Flodmark and Derek Harwood-Nash
There is little difference in neuroradiological examination of children

and adolescencts as compared to that of adults. The main reason to rec
ognize pediatric neuroradiology as a specific entity is the significant dif
ference in the panorama of diseases. Hence, the radiologist must possess
good knowledge o f the specific pathology that can be encountered in the
central nervous system of the neonate, infant and adolescent. Such
knowledge is a necessary prerequisite for the ability to practice good pe
diatric neuroradiology. The radiologist must also remain sensitive to the
legitimate needs o f the parents of sick and handicapped children, to be
given as specific diagnosis as is possible, even if no treatment is avail
able.
Clinical examination of the central nervous system is difficult to per
form in children, particularly in the newborn. Various types of neurora
diological investigation have come to play an increasing role in the as
sessment of children during the last decade. This is particularly true in
the newborn with cerebral pathology. The most common indications for
neuroradiological investigation of children are the evaluation of psycho
motor handicap, epilepsy, cerebral inflammation and when a malignancy
is suspected. Tumours of the brain are, next to leukaemia, the most com
mon form of malignancy in children. However, the types of brain tumors
found in children are quite different from those found in adult patients
in reference to both cell type and localization. Although brain tumors are
considered common in children, the actual number is small compared to
that of adult patients with this disease. A large number of investigations
are carried out on the suspicion of hydrocephalus and as follow-up ex
aminations after shunting. Although cerebrovascular disease is the most
common indication for neuroradiological investigation in adult patients,
this disease is less common in children. The large group of perinatal cere-
611
bral diseases represents a common cause for investigation, unique to the

pediatric population.
Spinal tumors and degenerative diseases of the spine are uncommon
in children and the main indication for neuroradiological investigation
of the spine and its contents in infant and adolescent is the suspicion o f
a congenital malformation. This situation has a major impact on the
choice o f imaging modality and on the mode of investigation.
The essence of pediatric neuroradiology is found in choosing the cor
rect imaging modality and the optimal way of performing the investiga
tion. Hence, it is impossible to exclude the presence of a malformed brain
on a CT or MR investigation in which the images are degraded by mo
tion. Neuroradiological investigation of a child is an uncommon event
in most radiology departments and the general radiologist will have lim
ited experience. However, lack of experience can partly be counter-bal
anced by careful planning of the examination and by using optimal tech
niques. The greatest risk for error in interpreting a pediatric neuroradio
logical investigation lies in incorrectly calling an examination normal
rather than assigning the incorrect pathological diagnosis. Thus it might
be assumed, that radiological methods including a review o f previous
films, are unable to provide the correct diagnosis and that further radio
logical efforts would be considered futile. Neuroradiological investiga
tions of children are usually performed either by adult neuroradiologists
or pediatric radiologists and only rarely is a pediatric neuroradiologist
available. However, it is always wise to have films reviewed by col
leagues more experienced and knowledgeable in the special cerebral and
spinal pathology that can be found in children - pediatric neuroradiolo
gists.
It may be true that many diagnoses overlooked by less experienced ra
diologists may have less or no impact for future treatment of the child
but this is poor defence for less than optimal radiology. One should never
underestimate the psychological impact of a correct diagnosis even if no
treatment is available. The correct diagnosis on a malformation of the
brain can have a significant impact of the parents ability to accept that
their child is handicapped. Furthermore, correct diagnosis of a malfor
mation can alleviate much anxiety and worry that certain events in the
perinatal period could be associated with the handicap of the child.
A discussion of common clinical problems rather than a systematic re
view of a variety of pathological entities is therefore appropriate.
612
PEDIATRIC NEURORADIOLOGY
MODALITIES
The choice of a certain imaging modality is not only influenced by the
age of the patient and the indication for the study, but also by the avail
ability of certain techniques as well as the individual skill and knowl
edge of the radiologist. The sensitivity and specificity of a certain imag
ing modality are also important when choosing the mode of investiga
tion as there is a significant difference between confirming a suspected
diagnosis and excluding a possible but less likely diagnosis. In the latter
case, the sensitivity and specificity must be very high. The potential dam
aging effect of ionizing radiation means that all radiological investiga
tion in children must be well indicated and carried out using correct tech
nique. However, fear of radiation must never lead to acceptance of a re
duced diagnostic accuracy. This is a particularly important consideration
if neurosonographic examination of the brain and particularly the spine
is the only examination that is carried out.
Neurosonographic examination of the brain has become very impor
tant as the method has obvious advantages. The equipment is relatively
cheap and therefore generally available. The portable equipment allows
for the examination to be carried out crib-side and in the isolette.
However, this imaging modality has important limitations. The need for
an acoustic window, the anterior fontanel, means that neurosonographic
examination can only be carried out in small children. The cerebral con
vexities, as well as the posterior fossa structures are difficult to examine
with ultrasound and the quality of the examination is very much depen
dent on the skill and experience of the sonologist and his or her specific
knowledge of the pathology that can be expected. Even if the use of rou
tine projections is adequate, a neurosonographic examination is very dif
ficult to review and its value as a tool to exclude a possible diagnosis is
seriously curtailed.
Computed tomography (CT) is the imaging modality most often used
in the examination of the brain in children. Motion artifacts must be
avoided and the patient must therefore remain immobile during the en
tire examination. An unacceptable increase in the radiation dose will fol
low when many CT-slices have to be repeated due to motion artifacts.
Sedation can be carried out in many ways and the sedative can be ad
ministered by mouth, rectally, intramuscular or intravenously. Routines
for sedation must be developed in close coopration with pediatricians
and anesthesiologists. All efforts must be made to examine the child in
613
supine position and placed straight in the gantry. Evaluation of asym

metries between the two cerebral hemispheres becomes very difficult if
the patient’s head is not straight in the gantry. Excellent spatial resolu
tion is necessary in order to properly evaluate the anatomical structures
and to detect possible malformations. The thickness of the CT-slices
should therefore not exceed 5 mm. Although the radiation from the CT-
scanner is well collimated, a significant dose may be delivered to the area
examined. The lens of the eye is sensitive to radiation and efforts should
therefore be made not to include this structure without good reason.
The need for repeat examination following injection o f contrast ma
terial is much less in children than in adults. Processes associated with
a break-down of the blood-brain barrier are much less common in chil
dren. It is much more important to be able to correctly evaluate the de
tailed structures of the brain, the anatomy and the symmetry. It is the re
sponsibility of the radiologist to determine the need to use contrast ma
terial. An examination should always start with images without contrast
unless the examination is carried out to look for intracranial metastases
in a child with known primary tumor. However, this is uncommon in the
pediatric patient. Contrast material is rarely indicated in CT examina
tions during the neonatal period. It is uncommon for images obtained
following administration of contrast material provide to additional and
useful information should the pre-contrast scans be entirely normal. It is
uncommon that a repeat examination following contrast injection will
clarify uncertain findings on a pre-contrast scan. The use of thinner slices
or examination carried out in an alternative projection, such as true coro
nal images, are usually much more informative. The main rule is to re
peat the examination following a contrast injection when tumor or AVM
is included as differential diagnoses. However, this rule can be broken
should these diagnostic possibilities appear unlikely based on available
clinical information. This is contrary to the situation in adults. It is quite
obvious that contrast material should be used whenever needed, how
ever the merits of using contrast should be carefully analyzed by the ra
diologist in each individual case. When used, contrast should be admin
istered in a dose of 3 ml/kg body weight and non-ionic contrast materi
als should be used. The imaging should be carried out immediately
following a bolus injection.
Magnetic resonance imaging (MRI) is technically very complicated
and therefore more difficult to utilize in the examination o f children. The
614
development of the brain including the myelination process has major

impact on the appearance of the images during the first two years of life.
Familiarity with this process is necessary in order to correctly interpret
images. This adds a certain degree of uncertainty to the interpretation of
the images but the increased sensitivity and the superb delineation of
anatomical structures will lead to the increased use of MRI in pediatric
neuroradiology. MRI has a particularly major impact in the detection and
correct identification of cerebral malformations and certain forms of in-
traspinal pathology.
The majority o f all myelographic studies carried out in children are
done in one of two indications; the suspicion of congenital malforma
tion or intraspinal tumor. The technique does not vary much with the in
dication and includes both conventional radiography and subsequent CT
scanning. Myelography is best carried out under general anesthesia in
children younger than 10 years.
Angiography of cerebral and spinal vessels are rare procedures in chil
dren. The indications are limited to detailed evaluation of arterio-venous
malformations or other rare vascular disease. This procedure should only
be performed by neuroradiologists.
COMMON CLINICAL PROBLEMS
Epilepsy
Epilepsy in childhood is most commonly due to structural changes in the
brain that cannot be detected by any neuroradiological method. Most
children with epilepsy will make a full recovery before adulthood.
Malformations and destructive lesions of the brain can sometimes be as
sociated with epilepsy and diagnostic efforts are often concentrated on
identifying these patients with the help of neuroradiology. Tumors of the
brain are uncommon as the cause for epilepsy in childhood. It is neither
practically possible, nor desirable to study all children with epilepsy us
ing neuroradiological imaging methods. It is the task of the pediatric neu
rologist or pediatrician with specific expertise in neurology to select the
patient who shold be investigated using neuroradiology. It is important
to recognize that a request for a neuroradiological investigation shall
never replace a referral of the patient with epilepsy to a specialist in pe
diatric neurology. The most commonly used criteria in selecting children
suitable for CT examination of the brain are the following:
615
- epilepsy with psycho-motor defects in a child below one year of age,

particularly infantile spasm
- epilepsy with a changed seizure pattern
- epilepsy with focal EEG-changes, particularly with focal slowing
- epilepsy with seizures resistant to medical therapy and in which
surgery is contemplated
- status epilepticus
- post-traumatic epilepsy
It is usually stated that the CT scanning can detect pathology in about

40 % o f patients with infantile spasm. The diagnoses encountered in
clude such diseases as phakomatoses, cerebral malformations or de
structive brain damage that may have occurred in utero or perinatally. If
possible, this investigation should be delayed until the child has reached
the age o f six months, in order to maximize the diagnostic yield. It is eas
ier to assess the structure of the brain at the age of six months and mal
formations are then easier to detect or exclude. Rare cases o f a tumor
causing epilepsy are found particularly in children with a changing pat
tern of epilepsy and in those with focal EEG-changes. The neuroradio-
logical work-up is extensive, should surgery be contemplated as treat
ment for epilepsy. It will include MR-imaging, positron emission to
mography and specialized neurophysiological methods (Fig. 1). Positive
findings are uncommon in patients with status epilepticus but the find
ing of a normal CT scan is quite helpful and important in the immediate
care for the child that is unconscious following status epilepticus.
Children developing seizures hours or days following a head trauma
should be urgently investigated with a CT-scan, even if such a procedure
was performed and found to be negative at the time of admission fol
lowing the trauma. The possibility for delayed intracranial hemorrhage
is significant in the short range, while development of leptomeningeal
cysts is a distinct possibility in the long range.
616
b
Figure 1.
This five-year-old boy has epilepsy with
focal EEG-changes generated from the
right cerebral hemisphere.
a) This CT-image through the parietal
lobes shows a focal area in the right
parietal region where the cortex has
an abnormal appearance with thicker
than usual cortical mantel (arrows).
There is a widened sulcus superficial
to this abnormality.
b) The corresponding MR proton-
weighted image shows the white mat
ter in the right-sided centrum semio-
vale to lack the extensions normally с
found into each gyrus.
c) This heavily T2-weighted image in the coronal plane shows no abnormal signal
characteristics but the rather simplistic pattern o f white and gray matter in the right
parietal lobe as compared to the left side. These images show a focal abnormality
o f neuronal migration following which the cortical structures have been malformed.
Abnormal head circumference -

hydrocephalus or atrophy
The head circumference and growth rate is dependent on the intracranial
content as long as the sutures are open. Increased intracranial volume
may be due to increased amount of fluid or increased amount of normal
or abnormal brain tissue and will result in increased head circumference
in small children. By the same mechanism, a decreased size of the brain
will give rise to a small head.
617
The strict definition of hydrocephalus is increased amount of fluid in

the cranial cavity. The meaning of the word has gradually changed and
the contemporary definition is that of abnormal hydrodynamics influ
encing the cerebro-spinal fluid circulation and causing increased in
tracranial pressure. Dilatation of the ventricles and sometimes the ex
tracerebral subarachnoid spaces is secondary to the increased pressure
and the increased amounts of fluid will cause an increase in the head cir
cumference. On the other hand, destructive damage to the brain will not
only cause loss of brain tissue but also a decrease in further growth of
the brain. The consequence will be a small head, microcephaly. Loss of
brain tisssue, atrophy, may also cause an incresaed size of the intracra
nial CSF-spaces but this increase in size is secondary to a decreased size
of the brain. The degree of atrophy in a normo-cephalic adult can be di
rectly assessed by comparing the size of the brain to the size of the skull.
Decreased skull growth in a child, that is a consequence of a brain dam
age with tissue loss, will tend to hide even extensive loss of brain tissue
as the size of the skull is adapted to the size of the brain and the degree
of atrophy can then no longer be assessed simply by comparing the size
of the brain to size of the skull. For this reason, the degree of atrophy in
a child is often underestimated.
Wide CSF-spaces are very common before the age of 18 months.
However, this finding does not necessarily indicate neither hydro
cephalus nor atrophy. The finding of wide CSF-spaces cannot and must
not be interpreted without knowledge about the head circumference, head
growth and clinical symptoms. This situation must be recognized by the
radiologist who must never make the diagnosis of atrophy without be
ing absolutely convinced of the presence of loss of brain tissue, as in a
child with wide CSF-spaces and reduced head growth or microcephaly.
Similarly one should never make the diagnosis of hydrocephalus unless
head growth is accelerated or head size significantly increased.
Ventriculomegaly is common and may be present in many other clinical
situations than hydrocephalus. A combination of atrophy and hydro
cephalus may therefore be very difficult or even impossible to evaluate
using neuroradiology. Hence, every request for a neuroradiological in
vestigation in children must include information about history, size and
growth of the head, as well as a clincial evaluation of the intracranial
pressure.
618
Clinical suspicion of increased intracranial pressure is a clear indi

cation for neuroradiological investigation. The task of the radiologist is
first to confirm presence of hydrocephalus and then to assess the cause
of this condition. Increased intracranial pressure can usually be radio-
logically confirmed but it may sometimes be impossible to diagnose in
creased intracranial pressure by neuroradiological methods alone. The
investigation must be carried as far as possible and may include both CT
and MRI before and after contrast injection, if the cause for hydro
cephalus or ventriculomegaly is unknown. The diagnosis of aqueductal
stenosis, previously a diagnosis by exclusion, has been common in the
past. With the capability of MRI to much more precisely detect the cause
for hydrocephalus, aqueductal stenosis is now a rare diagnosis. If the rea
son for the hydrocephalus in an infant is known, i.e. intracranial hemor
rhage or meningitis, a neurosonographic examinaton may be quite suf
ficient to establish the size of the ventricular system. No further neuro
radiological investigation is then indicated.
Assessment of shunt patency and function becomes necessary when a
patient with hydrocephalus has been treated with a ventriculo-peritoneal
shunt. Direct verification that the intracranial pressure has been normal
ized is often difficult. However, neuroradiology can be of assistance by
assessing indirect signs such as the size of the ventricles. Although as
sessment of the ventricular size is the most simple method, the ideal size
of the ventricles varies from patient to patient and the assessment is there
fore very difficult without access to a base-line examination carried out
when the patient is clinically well and without any clinical signs of ei
ther under- or over-function of the shunt. Routine examinations of the
brain are not indicated.
Delayed psycho-motor development

Delayed psycho-motor development is in most cases thought to be due
to brain damage that occurred in utero or during the perinatal period.
Although few of the conditions that may cause psycho-motor delay are
treatable, the indication for neuroradiological investigation is obvious.
Establishing a correct diagnosis has great impact for the parents of the
child and might relieve feelings of guilt and assist in genetic counseling.
The finding of a congenital malformation of the brain has important con
sequences in medico-legal situations when quality of obstetrical care may
be in question. The importance of neuroradiological investigation is
619
Figure 2.
This boy had a larger than normal head
at two years o f age. He had a marked
delay in his psycho-motor development.
The CT image shows a generalized mal
formation o f the brain, called holopros-
encephaly. In this malformation there is
an abnormality o f the cleavage into tnw
cerebral hemispheres which may be only
partial. Note the absent interhemispheric
fissure and the bridging o f white and
gray matter between the two cerebral
hemispheres anteriorly (arrows). The
lateral ventricles are fu sed into a
monoventricle communicating posteri
orly with a midline parietal cyst.
Absence o f falx cerebri is secondary>to
absence o f the interhemispheric fissure
anteriorly.
much less in the normo-cephalic mentally retarded child without motor

handicap.
The neuroradiological investigation of children with non-progressive
psycho-motor handicap, cerebral palsy, should include CT or MRI with
out contrast and is best carried out after the child has reached the age of
at least eighteen months. The radiologist should be particularly obser
vant towards loss of brain tissue that may cause asymmetries between
the cerebral hemispheres and abnormal structure of the brain that may
indicate abnormal neuronal migration or other congenital malformations,
when investigating a child on the indication of cerebral palsy (Fig. 2).
Phakomatoses, such as tuberous sclerosis or destructive damages after
intra-uterine infection, may also be seen as well as brain tissue loss caused
by ischemic brain damage in the pre-, peri- or postnatal period.
Metabolic diseases should be suspected in children with progressive
symptoms of brain dysfunction. This damage may be widespread and in
volve both white and grey matter. It can be seen by CT but it is much
better assessed using MRI. These diseases can produce complicated pat
terns of decreased attenuation on CT or changes in signal on MRI.
Although typical patterns can be recognized in specific diseases, assess
ment in the individual case of these findings is often difficult and the
findings are quite frequently non-specific.
620
Headaches
Headache is a common symptom in children and adolescents but it is an
uncommon symptom of intracranial pathology and as such occurs almost
exclusively in situations with increased intracranial pressure. CT or MRI
without contrast injection can, with certainty, exclude the presence of a
mass lesion as the reason for the headaches. However, CT or MRI both
with or without contrast can never exclude the presence of the rare
aneurysm or a small arterio-venous malformation that has not bled.
However, headaches occur in this situation when the aneurysm or AVM
has ruptured and the fresh subarachnoid hemorrhage can then be diag
nosed using CT without contrast. A large AVM with a significant arte
rio-venous shunt may cause headaches, even without rupture, but such
a large arterio-venous malformation is also obvious on a CT scan with
out contrast. As with epilepsy, a request for a neuroradiological investi
gation, CT or MRI, must never replace the referral of a child with
headaches to a specialist in pediatric neurology. A normal result is the
expected finding on CT or MRI in a child with headaches. As a normal
result may be very important as support in the further care of the child
with headaches, the request for neuroradiology in a child with headaches
should come from a physician trained in pediatric neurology.
Severe, often a unilateral headache in a child who has experienced a
recent head trauma should lead to an urgent investigation on the suspi
cion of an epidural hematoma.
Cerebral infection
Suspected or ongoing meningitis is a common reason to request a neu
roradiological examination. However, it is reasonable to suggest that in
dication for imaging is present only when the detection of pathology will
lead to change of therapy. Hence, investigations done with the sole pur
pose of confirming the strong clinical suspicion that a complication such
as an infarct has happened, is of rather limited value. Apart from infarc
tion, subdural effusions and contrast enhancement in the leptomeninges
are common findings. In addition, every child suffering from bacterial
meningitis has to a certain degree a disturbed CSF-circulation, recog
nized as slight increase in the size of the ventricular system and subara-
chonid spaces (Fig. 3). The medical treatment given to the child should
not be influenced by these findings on CT or MRI as the causal rela
tionship between the clinical findings and these radiological findings are
621
a b
Figure 3. This 4-months-old girl had

been diagnosed with a H. influenzae
meningitis a week prior to this CT scan.
Early seizures provided the indication
for this study.
a) Note the extensive area o f decreased
brain tissue attenuation correspond
ing to an infarct in the areas sup
plied by the left middle cerebral
artery (arrows) in this pre-contrast
image. Two small subdural effusions
are seen adjacent to the anterior
portion o f the interhemispheric fis
sure (arrowheads).
b) No break down o f the blood-brain
barrier is noted in the infarct follow
ing contrast enhancement but dense
enhancement is seen in the leptomeninges over both frontal lobes (arrows). This en
hancement is due to meningeal inflammation secondary to infection and does not
indicate an empyema,
c) An extensive area with loss o f brain tissue, atrophy, corresponding to the infarct in
a) and b) is seen in this image obtained fo u r months later.
at best weak or even non-existing. Hence, prolonged fever and early con
vulsions represent rather doubtful indications for imaging. The possibil
ity that an abscess can present as a complication to a hematogenous
spread meningitis is unlikely. However, neonatal meningitis caused by
various gram-negative bacteria may frequently be complicated with the
formation of brain abscesses. Severe neurological depression and un-
622
consciousness as presenting symptoms during meningitis does indicate

early and extensive brain damage and the CT scan done at the time of,
or soon after, admission may provide important prognostic information,
as evidence of widespread ischemic brain damage early in the disease
process carries a poor prognosis. Late onset of convulsions or persistent
seizures later than two weeks after presentation of the disease, represent
good indications for neuroradiological investigation with CT, as sub
dural effusions may have become secondarily infected and developed
into an infected subdural empyema. It is therefore quite clear from the
discussion above, that routine imaging is not indicated in children with
meningitis, but that each case must be evaluated and the indications for
imaging assessed individually.
The clinical symptoms are often dramatic in smaller children who suf
fer encephalitis. Nevertheless, neuroradiological findings are often rather
unimpressive. Neither CT nor MRI seem to have a great potential in the
early diagnosis of the disease. The diagnosis is usually confirmed clini
cally long before neuroradiological findings may be present. The clini
cal course is similarly quite dramatic in patients with postinfectious en
cephalitis, acute disseminated encephalo-myelitis (ADEM), and there
are usually good reasons to suspect an intracranial or intraspinal mass
lesion. CT scanning of the brain is capable of excluding an intracranial
mass lesion, while MRI may show, even during the early stages of the
disease, the demyelinating plaque either in the brain or in the spinal cord.
The clinical picture is often typical with alarming neurological symp
toms approximately ten days to two weeks following an uncomplicated
upper respiratory infection or after an immunization. Acute onset of
transverse myelitis is the presenting symptom should the demyelinating
plaque be located in the spinal cord. These patients must be investigated
on an urgent basis, 24 hours a day, in order to exclude an intraspinal ab
scess or hemorrhage amenble to surgical intervention. MRI is clearly the
procedure of choice in transverse myelitis as it can not only exclude a
mass lesion but also clearly demonstrate the demyelinating plaque, if
present.
Stroke in childhood
Acute onset of hemiplegia or other neurological deficits, represent a se
rious disease in a child. The first aim of the investigations is to differen
tiate between a hemorrhagic or an ischemic lesion as the cause for the
623
patient's symptoms. A hemorrhage may be caused by an arterio-venous

malformation or by a tumor. Further investigation with cerebral angiog
raphy is indicated, should an AVM be suspected. An immediate an
giogram is indicated if urgent surgery is needed. Otherwise, such an
giograms should be delayed and performed two or three months after the
acute episode. The hematoma may compress the arterio-venous malfor
mation which then escape may detection altogether. Hence, an an
giogram performed in the acute stage of the disease can fail to show all
components of the AVM or fail to show any trace of the AVM. Whether
or not the angiogram is normal, it must be repeated when the hematoma
has been reabsorbed and prior to elective treatment.
The indication for angiographic evaluation in the ischemic injury is
controversial. An urgent angiogram is only indicated if the findings can
lead to an altered therapy. Alterations in the child's coagulation system
may cause an infarction but can also increase the risk for complications
during an angiogram. Although treatment of childhood stroke usually is
conservative, an angiogram can demonstrate an injury in the cervical ves
sels that may be amenable to surgery if the stroke has a causal relation
ship with neck trauma.
Neonatal cerebral disease

Neuroradiological investigation aimed at identifying intracranial hem
orrhage or pathology amenable to surgery during the neonatal period is
of assistance in the immediate care for the neonate. In addition, neuro
radiological investigation can assist in the early assessment of long term
prognosis in terms of possible future psycho-motor handicap.
Cerebral damage in the form of ischemic or hemorrhagic lesions
caused by cerebral vascular disease can occur during late pregnancy, in
the perinatal or neonatal period. The lesions may be located in white mat
ter (periventricular leukomalacia) or grey matter. Hemorrhage or is
chemic damage to the white matter is thought to occur almost exclusively
in the immature brain while damage to the grey matter is more common
after 34 weeks of gestation and in the child bom at term. The patho-
physiolsogy of these injuries is intimately related to the changes in vas
cular physiology in the developing brain. The vascular architecture of
the brain in a 30 weeks fetus is profoundly different from that of a full
term neonate. Consequently, the pathology of brain damage before and
after 34 weeks gestation is quite different, even though the mechanism
624
of injury may be the same. Hence, different types of injury can be re
lated to the stage of brain development at the time of injury and should
not be related to the time of the delivery. The pathology in the neonatal
brain injury is quite different in the mature and immature brain, respec
tively. This fact has an important impact on the indications for investi
gation and choice of imaging modality; the modality used for neurora
diological investigation should depend mainly on the maturity of the
neonate.
Neuroradiological investigation in the prematurely bom neonate is
best carried out using neurosonography. Significant hemorrhage is eas
ily identified while evidence of parenchymal damage may be rather sub
tle and often impossible to show with either neurosonography, CT or
MRI. It is important to identify intraventricular hemorrhage, as large he
morrhages are almost always associated with damage to parenchyma and
hence future handicap. Intracerebral hemorrhages are uncommon in
neonates more mature than 34 weeks gestational age. Ischemic damage
to parenchyma is in these children often located in cortical or subcorti-
cal brain tissue. Extensive ischemic brain damage can give rise to gen
eralized cerebral edema, a condition that almost always can be demon
strated by CT, while the interpretation of findings of edema on neu
rosonography may be more difficult. Hence, CT scanning should be the
method of choice in neuroradiological investigation of mature newborns
with clinical evidence of brain injury. The cerebral edema developing as
a consequence to ischemic damage is known to peak at about 72 hours
following the injury. Therefore, the CT should if possible be carried out
during the third day of life, assuming an injury at the time of delivery.
A CT scan performed at this time can provide important information use
ful in assessing the long term prognosis, albeit only in terms of severe
handicap. It is clear from the discussion above that a request for neuro
radiological investigation of a neonate must include information about
the maturity of the neonate to allow the radiologist to choose the appro
priate mode of investigation.
Congenital malformations of the spine

Congenital malformations of the spine include both mesodermal (mus
cular or skeletal) and neuro-ectodermal (neurogenic) structures. The mal
formations typically occur in combination with varying degrees of in
volvement. However, malformations can occur in each of these structues
625
independent of the other. Abnormal segmentation of the spine can be as

sociated with neurogenic malformations but can also be isolated.
The neuroradiological investigation in a patient with suspected spinal
malformation should aim first at confirming or excluding the possibility
of neurogenic malformation. If a malformation is found, further investi
gation should concentrate on demonstrating all components of the mal
formation. This very important knowledge allows the neurosurgeon to
plan reconstructive surgery. Plain films of the spine, sometimes includ
ing conventional tomography, may be very important for the orthopedic
surgeon but are of little value in assessing a possible association with
neurogenic malformations. This evaluation must focus on the content of
the spinal canal by direct visualization of the subarachnoid space and it’s
content. Spinal ultrasound can provide useful information during the
neonatal period but this mode of investigation does not allow confident
exclusion of a suspected malformation. Myelography followed by CT is
capable of providing all necessary information. MR imaging of the spine
is also capable of showing all components of a malformation. However,
a complete MR examination of the spine is a rather time-consuming pro
cedure and, although non-invasive, quite often requires heavy sedation
or general anesthesia. Modem MR scanners, and with the use of mod
em imaging sequences, are capable of showing most components of these
malformations but some types of malformations, e.g. diastematomyelia
and dermoid tumors, can be very difficult to detect, despite the use of
excellent MR technique. It is often so that both MRI and myelography
followed by CT, are required not only to describe all aspects of a mal
formation but also, in other patients, to completely exclude the possibil
ity of a congenital malformation of neural tissue.
626
Chapter 17
Breast imaging
Ingvar Andersson and Baldur F. Sigfusson
MODALITIES
Breast imaging has developed mainly during the last three decades
(Fig. 1). In the fifties and sixties breast imaging was not part o f the rou
tine diagnostic armamentarium of most x-ray departments possibly with
Figure 1.
a) Radiographic equipment used by one o f the pioneers o f mammography, Dr Raul
Leborgne, Montevideo, in the 1940s.
b) Modern mammography unit featuring high frequency generator, bi-metal anode,
magnification capability, power assisted compression device, automatic exposure
control, and Виску. The X-ray tube and examination table are mounted on an arm
which can be rotated around a horizontal axis. This makes it easy to obtain images
in different projections without moving the patient who can be seated or standing
during the examination.
627
one exception - galactography (ductography). Today, mammography is

among the most frequent x-ray examinations performed. This develop
ment has parallelled a continuous increase in the incidence of breast can
cer, especially in the industrialized countries. Nationwide mammo-
graphic screening programs for breast cancer have been introduced in
several countries.
Although mammography is the dominating breast imaging modality,
ultrasound is rather extensively used as a complimentary modality.
Magnetic resonance imaging has shown promising results, although its
role remains to be defined. Transillumination of the breast (light scan
ning) has been claimed by some authors to be as accurate as mammog
raphy in the diagnosis of breast cancer. In a Swedish multicenter study,
however, light scanning turned out to be far less sensitive and specific
than mammography, especially in the diagnosis of non-palpable carci
nomas.
Thermography of the breast was used in many centers in the sixties
and seventies, but the results were disappointing, and its use has largely
been abandoned.
Mammography
Soft tissue radiography like mammography implies imaging of tissues
with relatively small differences in absorption characteristics, mainly fat
and fibroglandular tissue. To achieve a high subject contrast, appropri
ate radiation quality is critical. Factors influencing radiation quality are
tube target material, added filtration and kV setting.
In the late sixties the molybdenum tube was introduced by Charles
Gros together with a dedicated mammography unit. Molybdenum target
tubes with beryllium windows and molybdenum filters operated at kV
settings of about 25 to 28 produce a relatively monochromatic radiation
providing a high subject contrast. Tungsten tubes with special filtration
as well as bi-metal tubes made of molybdenum and rhodium are also cur
rently being used by some manufacturers of mammography units.
A major step forward in the technology of soft tissue radiology was
taken in the seventies by introducing intensifying screens, usually made
of rare earth phosphors, such as gadolinium or lanthanum. Combining
such a screen with high contrast film of relatively high speed the radia
tion dose could be reduced by a factor of 50 compared with direct ex
posure films.
628
BREAST IMAGING
Figure 2.
Characteristic
curves illustrating
films with high and
low contrast.
Density
Log R elative Exposure
Film contrast is defined as the slope of the characteristic curve (Fig. 2);
the steeper the curve, the higher the contrast. In addition to the inherent
properties of the film, the processing conditions are critical. Ideally, a
processor dedicated to mammography should be used, although this is
not always possible. The processing should be monitored with daily sen-
sitometry (see below). Most mammography units today come with a rec
iprocating grid which reduces scattered radiation and thus improves con
trast. The trade-off is a doubling of the radiation dose which is consid
ered acceptable.
Another technique to improve image quality is magnification. By us
ing a small focal spot (about 0,1 mm focal spot size) and an air gap sev
eral effects are obtained. The scatter is reduced by the air gap, the ef
fective noise in the recording system is reduced, and the magnified im
age is easier to view. A magnification of 1,7 to 2,0 is usually used. Again,
the trade-off is a higher dose.
Ultrasound (US)
Ultrasound examination of the breast helps to clarify problematic lesions
that have been detected on physical examination or mammography. For
this type of focused examination a hand-held 7,5 MHz transducer is gen
erally used. The operator should have a thorough knowledge of US as
well as mammography and breast pathology. Ultrasound is o f value in
the following situations:
629
Figure 3.
35-year old woman with a 2 cm
palpable mass at the 12 o'clock
position in the right breast.
a) On mammography very
dense breast parenchyma
was demonstrated without
clearly definable tumor cor
responding to the physical
finding.
b) On ultrasound examination a
1,9 by 1,4 cm hypoechoic le
sion with irregular border is
seen.
- In the evaluation of a well circumscribed nodule on the mammogram.

The differentiation between a cystic and a solid lesion is usually easy
and accurate. However, some cysts may be moderately echogenic and
therefore difficult to identify as cysts. Some circumscribed carcinomas
may be of very low echogenicity, and sometimes even show some echo
enhancement and thus simulate cysts. When a lesion has been demon
strated to be solid, the differentiation between benign and malignant is
often impossible.
- US is also valuable in the evaluation of any discrepancy between phys
ical findings and mammography. Thus, in the presence of a physical find
ing with a negative mammogram, especially in the dense breast, US can
often demonstrate the presence or absence of a focal lesion (Fig. 3).
Similarly, in the presence of an unclear density on the mammogram US
630
BREAST IMAGING
can often confirm or dispel a suspicion of a focal lesion.

- US is useful when analysing lesions which cannot be demonstrated by
mammography for anatomic reasons. One example is a juxtathoracic tu
mor, another is lymph nodes high in the axilla.
-U S guided fine-needle aspiration biopsy (FNAB) is often a quick and
accurate procedure. One advantage over x-ray guidance is that the punc
ture can be performed under direct visual control. Either a centrally per
forated transducer or a freehand technique may be used. The procedure
is facilitated if an assistant operates the syringe which is connected to
the needle by a flexible tube. The examiner thus operates the transducer
with one hand and the needle with the other. US guided FNAB has been
shown to be as accurate as x-ray guided FNAB.
- US can also be used to perform preoperative wire localization of non-
palpable breast lesions.
- US is superior to mammography in the evaluation of silicone breast
implants, especially regarding rupture and leakage, and also in the guid
ance of FNAB of palpable and non-palpable lesions adjacent to an im
plant. Breast Doppler US has shown some promising results but should
still be considered experimental.
There are several limitations to the US examination of the breast. It is
quite operator dependent. The sonographic contrast between tumors and
fatty tissue is poor. Furthermore, lesions presenting as small calcifica
tions without a mass cannot be demonstrated. Thus, e.g. pure intraduc
tal carcinoma without focal tumor can usually not be seen.

MRI of the breast has been demonstrated to be of value in certain situa
tions, provided the correct technique and dedicated surface coils are used.
Several investigations have shown that dynamic studies of the enhance
ment pattern after intravenous administration of contrast medium pro
vide important differential diagnostic information. Malignant tumors al
most always enhance faster and more intensely than benign tumors (Fig.
4). Cellular fibroadenomas, some types of proliferative mastopathy and
inflammatory lesions as well as postoperative scar tissue during the first
six months after operation may show an enhancement pattern similar to
carcinoma. On the other hand, MR has been shown to be of value in the
postoperative breast after about six months, especially in patients with
silicone implants which are often difficult to evaluate mammographi-
631
Figure 4.
48-year old woman who had
fe lt a mass in her left breast.
a) MR examination with a T l
weighted 3 D gradient echo
sequence (FLASH, Siemens)
shows a low signal area
centrally in the breast.
b) After injection o f intra
venous contrast medium
(Gadolinium-DTDA, 0,1
mmol/kg body weight) a
substantial signal enhance
ment is seen. On histopatho
logic examination an inva
sive carcinoma was found
(Courtesy o f Dr Beata
Bone, Huddinge Hospital,
Stockholm).
cally. MR of the breast is limited by its complexity and cost. This may
change in the future with small dedicated breast MR machines.
Digital mammography
Experience is accumulating regarding the use of storage phosphor based
digital mammography. Although the spatial resolution is somewhat in
ferior to conventional screen film mammography this is compensated for
by a higher contrast. Important factors are image algorithms and post
processing of the images. Although there are still limitations in the char
acterization of small calcifications, digital techniques will be important
in the future. Actually, there are already commercially avalable aquip-
632
BREAST IMAGING
ments for stereotactic biopsy, using digital technology (CCD camera)

providing near real time image display.
INTERVENTIONAL PROCEDURES
Fine-needle aspiration biopsy (FNAB)

FNAB is a valuable modality which is used to evaluate breast
lesions, palpable as well as non-palpable. In many institutions fine nee
dle aspiration biopsy is part of the routine work-up of all breast lesions
that need further characterization over and above that obtained by phys
ical examination and mammography. With proper use of FNAB the num
ber of surgical biopsies for benign lesions can be reduced. Furthermore,
a definitive diagnosis can be made preoperatively in most patients with
carcinoma. Thus, different treatment options can be discussed with the
patient, and surgery can in most cases be performed as a one-stage rather
than a two-stage procedure.
Certain principles must be adhered to. The results of cytology should
always be considered together with those of mammography and, in the
case of a palpable lesion, the physical findings. If representative mater
ial is not obtained, the cytology should be disregarded. Needless to say,
the cyto-pathologists must be familiar with breast cytology especially re
garding small and borderline lesions. Ideally, the results of the various
modalities should be discussed in rm^tidisciplinary conferences between
radiologists, cytopathologists, surgeons, and oncologists.
X-ray guided FNAB

Non-palpable breast lesions can be localized using a 3-dimensional
stereotactic technique or a 2-dimensional co-ordinate grid technique. As
was discussed above, US can also be used to guide FNAB. Also, for pal
pable lesions sometimes an X-ray- or US-guided FNAB is used, if the
tumor is much smaller than the physical finding or if it is not clear whether
the physical finding corresponds to the mammographic finding.
The stereotactic localization technique implies that the position of the
lesion is calculated from two-dimensional x-ray pictures of the lesion
with a projection difference of approximately 30 degrees (Fig. 5). From
these two pictures the x-, y- and z-coordinates of the lesion can be cal
culated, as well as the necessary adjustments of the needle-holder. A 21
or 22 gauge needle is generally used together with a 10 ml syringe in a
633
Figure 5. 68-year old asymptomatic woman.

Screening mammogram reveals several small nodules in the left breast. The figure
shows two stereoscopic views o f one o f the nodules. Also illustrated are the position o f
the needle in relation to the nodule, the aperture in the compression plate as well as
the reference lines in the form o f an inverted T. The aspirate contained benign epithe
lial cells. Microscopic examination o f the surgical specimen showed multiple papillo
mas without evidence o f malignancy.
special holder. Usually, 2 to 5 separate aspirations are made from dif

ferent areas of the lesion. The aspiration technique is critical: the target
tissue must be fixed and the amplitude of the needle strokes sufficient.
It is important to be aware of the pitfalls and limitations of FNAB.
Sampling error due to improper position of the needle may occur. This
in turn may be due to needle deviation caused by the bevelled tip of the
needle or due to the fact that the lesion is difficult to delineate in both of
the two stereotactic views. It is important to verify the position of the
needle by taking pictures of the needle in position immediately prior to
aspiration. Further reasons for sampling error may be abundant fibrosis
in the lesion or necrosis. A lesion may be complex, some parts being be
nign, others malignant.
Suboptimal smearing technique is another reason for diagnostic error.
Smears should be prepared according to the rules given by the labora
tory to which they are sent.
The co-ordinate grid technique is another way of performing x-ray
guided FNAB. The aperture in the compression plate is lined by a coor
dinate grid and only one film is exposed. The x- and у-coordinates of the
lesion are easily defined on the film, and the point of interest is then
marked on the surface of the breast. The depth of the lesion has to be es
timated from previous mammograms. After introduction of the needle,
a film should be exposed to verify the needle position and to provide the
634
BREAST IMAGING
Figure 6.
Specimen radiograph showing a
cluster o f calcifications which has
been removed with a wide margin.
A hook wire was used to localize
the cluster. Also, in the specimen
the cluster has been marked with a
needle. Microscopic examination o f
the specimen revealed a non-inva-
sive intraductal carcinoma o f
comedo-type.
necessary adjustments for subsequent punctures. With this technique one

should be aware of the problem of beam divergence resulting in a pro
jection error in all points outside the area of the central ray. A co-ordi-
nate grid technique is a simple way of localising a lesion and the results
are satisfactory, provided the examiner is familiar with the technique.
Preoperative localization of non-palpable lesions

X-ray, as well as ultrasound guidance can also be used for preoperative
localization of non-palpable lesions. A hook wire is usually introduced
through a needle. Depending on the surgeon's preference different ap
proaches can be used. For lesions in the upper quadrant of the breast we
usually use the craniocandal approach. If the lesion is in the lower quad
rants, a medial or lateral approach is generally preferred. A mammogram
showing the exact position of the localizing device in relation to the le
sion should always be obtained and be available to the surgeon.
Instead of placing a metal wire, carbon powder can be injected.
If the lesion is located superficially a lead marker can be placed on the
skin over the lesion. After obtaining a new mammogram to confirm the
correct position of the lead marker, the location of the lesion can then be
marked on the overlying skin.
A specimen radiogram should always be taken to verify that the lesion
has been removed (Fig. 6). If necessary, the lesion can be marked with
a needle to guide the pathologist.
635
Galactography
Galactography is the radiographic imaging of the duct system of the
breast using contrast medium injected through a duct opening on the nip
ple. The main indication for galactography is bloody nipple discharge
and possibly also serous nipple discharge. Bloody nipple discharge is as
sociated with malignancy in about 20% of cases, serous nipple discharge
in a far lower percentage. Other types of nipple discharge, such as blue,
green, yellow and brown discharge are practically always associated with
fibrocystic or other benign changes.
Technique
The discharging duct opening on the nipple must be clearly identified.
For this purpose headmounted magnifying glasses may be together with
a bright light. If there is a significant discharge, the opening is usually
dilated and easier to find and cannulate. A blunt, bent needle or a plas
tic catheter can be used. Any type of water soluble contrast medium is
appropriate. Usually a small amount, 0,1-1,0 ml is injected. It is impor
tant to stop the injection when the resistance increases or when the pa
tient experiences pain or tension in the breast. The needle or catheter can
be left in place while taking a craniocaudal and lateral view, or, it can be
withdrawn. The use of magnification technique is to be preferred. Usually
enough contrast material will stay in the duct system during moderate
compression. The duct opening can also be sealed by applying a small
amount of collodium to the nipple.
Findings
In the presence of a significant discharge the duct system is usually di
lated. A solitary, polyplike contrast defect is a common finding, almost
always representing an intraductal papilloma (Fig. 7). Sometimes ex
tensive intraductal filling defects with more or less complete obliteration
of ducts are found. Differentiation between papillomatosis and intra
ductal carcinoma is not possible in such cases (Fig. 8). In some patients
with bloody nipple discharge duct ectasia is the only finding.
In the presence of intraductal filling defects it is often wise to repeat
the galactography to exclude false positive results due to air bubbles or
debris in the ducts. Cannulation and injection of contrast medium is re
peated after expressing as much as possible of the contrast medium from
the previous injection.
636
BREAST IMAGING
Figure 7.
67-year old patient with a discharge
from the left nipple. The discharge
had been serous but turned bloody a
few days before the current exami
nation. Cytology o f the discharge
showed only red blood cells. The
galactogram shows two filling de
fects, the larger one measuring 4x8
mm (arrow). The duct is dilated. On
microscopy an intraductal papil
loma (benign) was found.
Figure 8.
36-year old woman with a 13-year
history o f non-bloody discharge
from the left nipple. Cytologic exam
ination o f the discharge showed red
blood cells and no malignant cells.
On galactography several filling de
fects were demonstrated (arrows) in
a dilated duct system. Microscopy o f
the resected specimen showed
multiple papillomas.
Again, after completion of the examination as much as possible of the

contrast medium should be expressed.
To guide the surgeon, a mixture of contrast medium and blue dye is
injected with the technique described above. Pictures should be taken to
confirm that the proper duct has been injected.
637
Figure 9.
76-year old woman
who was referred be
cause o f a 2,0 cm p a l
pable mass in the lat
eral aspect o f the left
breast. Mammography
confirmed this finding
and in addition showed
another suspicious tu
mor in a different quad
rant. Microscopic ex
amination o f the surgi
cal specimen showed 2
separate carcinomas
and one metastatic
node in the axilla.
Indications
Mammography remains the gold standard among the imaging modali
ties of the breast due to its overall accuracy, relative simplicity and low
cost. Every woman from the age of 30 with a significant breast problem
should have a mammogram. Mammography should be performed even
in the presence of a physical finding that appears benign. A tumor which
feels smooth and mobile may represent a carcinoma. Furthermore, a non
specific thickening may be the only physical finding in a patient with car
cinoma. Women between 25 and 30 should have a mammogram only if
there is a clear clinical suspicion of malignancy. In our opinion, women
below the age of 25 should only exceptionally be referred for mam
mography due to the extremely low risk of carcinoma and the, albeit
somewhat hypothetical, risk of radiogenic carcinoma. FNAB is often suf
ficient in the young woman.
Mammography should be undertaken even in the presence of a clear
clinical diagnosis of breast carcinoma. A mammogram will help to clar
ify the exact position of the tumor, the extension of tumor outside the
palpable mass and the presence of multiple foci of carcinoma (Fig. 9) as
well as the status of the contralateral breast. This information is critical
for proper planning of the treatment.
638
BREAST IMAGING
Figure 10.
74-year old woman with a pace
maker. The breast tissue is well vi
sualized.
There are no absolute contraindications to mammography. Patients

with a pacemaker can be examined, provided due caution is observed
when compression is applied to the breast (Fig. 10). Also patients with
silicone and other types of prostheses can be examined without problems
(see below).
Pregnant women can undergo mammography. The scattered radiation
of mammography is of low energy and will be absorbed in the skin. Thus,
the fetus will not be exposed to any radiation. For psychological reasons
it is wise to put a lead apron on the patient, also it is very important to
give proper information to the patient before the examination, so that the
patient can make the final decision herself. During the last two months
of pregnancy and even more so during lactation, the breasts are usually
very dense, resulting in a relatively low sensitivity for carcinoma.
Examination technique
Proper examination technique in mammography is of critical impor
tance. Positioning and compression are vital components of the tech-
639
a
Figure 11.
a) Patient positioned fo r the oblique view.
The tube should be angled between 45
and 60 degrees depending on the habitus
o f the patient.
b) Oblique view o f the left breast. The pec b
toral muscle should be visible down to the
midplane o f the breast. Ideally, the muscle should have a convex border, indicating
that the patient has relaxed the muscle which is important fo r proper positioning.
The inframammary fold and abdominal skin should be included.
nique (Fig. 11). Not only the technologist but also the radiologist should
have a thorough knowledge of the principles of the examination technique.
Continuous cricital evaluation of the mammograms regarding adequacy
of positioning and compression is necessary to maintain a high quality.
Faulty positioning may result in a missed diagnosis of carcinoma.
For the positioning it is important to be aware of the anatomy of the
breast and especially the different mobility of various parts of the breast.
Basically, the lateral and lower portions of the breast are mobile, while
the superior and medial portions are relatively more fixed. Also, the cas
sette holder of the mammography unit is fixed while the compression
plate is mobile. These circumstances should be taken advantage of when
performing the mammography. Thus, the mobile part of the breast should
be moved by the technologist's hands towards the cassette holder in or
der to minimize the amount of tissue that is excluded, when the com
pression is applied.
Even with good technique it is not possible to include all breast tissue
on any single view (Fig. 12). On the oblique view the medial juxtatho-
640
BREAST IMAGING
Figure 12.
Asymptomatic 5 7-year old woman
undergoing screening examination,
a) Craniocaudal b) oblique view.
On both views two calcifications
are seen (arrow). The distance from
the calcifications to the posterior
edge o f the film is 2 cm in the cran
iocaudal view, while in the oblique
view the corresponding distance is
7 cm, illustrating that the superior,
juxtathoracic portion o f the breast
is not imaged in the craniocaudal
racic portion of the breast tends not to be included. Similarly, on the

straight lateral view the most lateral juxtathoracic portion tends to be
missed. On the craniocaudal view the most superior portion of the breast
tends not to be imaged. Also, on the craniocaudal view either a lateral or
a medial juxtathoracic portion is omitted depending on how the patient
is rotated.
For examination of the symptomatic patient, either two (craniocaudal
and oblique) or three (craniocaudal, oblique and lateral) views should be
obtained (Fig. 13). For screening purposes either one (the oblique) or
two (craniocaudal and oblique) views should be obtained. Most centers
641
Figure 13.
The standard projections o f mam
mography. The most common ex
tension o f the glandular tissue is
indicated. The arrows show the
beam direction: I. oblique, 2.
craniocaudal, 3. lateral projec
tion.
today use two views, at least as a baseline examination. After a baseline

two-view study we obtain two views on dense breasts in subsequent ex
aminations, while in predominantly fatty breasts only one view, the
oblique, is obtained.
Patients with silicone prosthesis should have the regular views and in
addition so called Eklund views. This means that the tissue anterior to
the prosthesis is compressed separately while displacing the prosthesis
towards the chest wall.
It cannot be emphasized enough that the examination of the sympto
matic patient has to be tailored to the individual patient. Additional views,
such as coned down views with localized compression to spread the struc
tures apart, and magnification views should be obtained as necessary, of
ten in combination. Slightly angled views (plus and minus 5 to 10 de
grees) are often useful in the investigation of a small unclear density seen
in one projection only. If caused by superimposition, the slightly angled
views will usually "resolve" the density. Once the presence of a lesion
has been confirmed, further characterization can often be accomplished
by using either magnification or coned down views or a combination of
both. Good viewing conditions for mammography include proper light
boxes, access to a bright light, a magnifying lens or a special viewer.
Correlation with clinical findings is often useful and indeed necessary,
if there is any discrepancy between the radiologic findings and the phys
ical findings cited by the referring physician. A small lead marker on the
skin overlying the physical finding is often useful. Even with good mam-
mographic technique, 5 to 10 per cent of carcinomas with positive phys-
642
BREAST IMAGING
Figure 14.
Asymptomatic 33-year old
woman with a fam ily history o f
breast cancer. Very dense breast
parenchyma. Compare the pre
dominantly fatty breast in figure
l i b . The radiographic demon
stration o f a tumor is more diffi
cult in a dense than in a fatty
breast.
ical findings (albeit not always characteristic for carcinoma) cannot be

demonstrated on mammography. This may be due to dense breast
parenchyma, the growth pattern of the tumor or a combination of these
factors. Thus, a suspicious physical finding with a negative mammogram
needs further investigation.
Anatomic considerations
The radiographic appearance of the female breast shows greater varia
tions than that of any other organ of the body. This is due to a consider
able variation in the proportion of fibroglandular, dense tissue in relation
to fat tissue, which is relatively radiolucent (Fig. 14). This variation is
related to several factors, age being one of the most important. Generally
speaking, premenopausal women have more fibroglandular tissue than
postmenopausal women. During pregnancy and lactation there is a sub
stantial increase in the density of the breast due to proliferation of the
glandular tissue. Hormone replacement therapy in the menopause may
also increase the density of the breast (Fig. 15). The change is usually
generalized, but may be focal.
643
Figure 15. 58-year old, asymptomatic woman.

a) Oblique view o f the right breast, b) Same view two years later. The dense tissue
component has increased substantially in b). The findings were identical in the left
breast. The patient was put on hormone replacement therapy six months prior to the
examination in b).
Other factors related to the density of the breast are age at first preg
nancy and a history of breast cancer. Women with an early first preg-
nancy tend to have more fatty breasts than women with a late first preg
nancy or no pregnancy at all. Women with a history of breast cancer tend
to have denser breasts than women without a cancer history. The den
sity of the breast may also be related to other risk factors for breast can
cer. It is also the single most important factor in determining the sensi
tivity of mammography. Thus, on average, mammography is somewhat
less sensitive in younger than in older women, and also in high-risk
women compared to low-risk women. It is important to realize that these
are statistical relationships only. In practice, there are many exceptions.
Thus, many younger women have predominantly fatty breasts, and older
644
BREAST IMAGING
Figure 16.
48-year old woman with tender, nodular
breasts. On the mammogram multiple tumors
o f varying size are seen. The tumors seem to
be well circumscribed although the margin
cannot be followed all around in most o f the
lesions, presumably due to superimposition.
The patient had had repeated aspirations o f
benign cysts. Radiographic diagnosis:
Fibrocystic changes.
women may have dense breasts. The radiologist’s report should include
a statement of the density of the breast parenchyma to give the referring
physician an idea of the sensitivity of the procedure.
Another important reason for the extensive normal variation of the
anatomy of the breast is the common occurrence of fibrocystic changes.
This is a not well-defined proliferative process in the breast parenchyma
with a diffuse borderline between the normal and pathological. From a
radiographic point of view the result is increased density of the breast
parenchyma, often with the appearance of well-defined nodules repre
senting cysts. It is important to realize that not only microscopically but
also radiographically the borderline between normal and pathological is
not well-defined. The radiologist should hesistate before diagnosing fi
brocystic disease. We do not make this diagnosis unless there is a nodu
lar breast parenchyma on physical examination combined with a dense
breast parenchyma and cyst-like lesions on the mammogram (Fig. 16).
Due to its frequency it may also be wise to use the term fibrocystic
changes rather than disease.
On a properly positioned oblique view one can usually identify one or
several lymph nodes in the lower axillary region. Lymph nodes may be
seen anywhere in the breast, although by far most frequently in the up
per outer quadrant, along the lateral thoracic artery and veins. Normal
645
Figure 17.
58-year old woman who underwent conserva
tive surgery o f the right breast fo r invasive
breast carcinoma.
a) Oblique view o f the normal left breast in
cluding several normal lymph nodes in the
lower axilla, one o f which is indicated by
an arrow.
b) The routine examination o f the left breast
two years later showing the same lymph
node (arrow) which has increased in size
and density. Furthermore, the area o f fat
infiltration in the hilum seen in a) has dis
appeared. Surgical biopsy confirmed the
presence o f metastasis from the contralat
eral breast carcinoma.
c) 60-year old, asymptomatic woman with
multiple pathologic lymph nodes seen on
the oblique view o f the left breast. Similar
lymph nodes were seen on the right side.
The patient had a history o f rheumatoid
arthritis and no evidence o f breast carci
noma or other malignant disease.
lymph nodes are kidney-shaped, with fat in the hilum. Pathologic lymph
nodes are usually rounded without fat in the hilum and often of relatively
higher density (Fig. 17). Size per se is no indicator of abnormality.
Normal lymph nodes may be several centimeters in size, when they con
tain much fatty tissue. Normal lymph nodes, smaller than 1 cm in dia-
646
BREAST IMAGING
Figure 18.
67-year old woman with a palpable mass in
the right lower axilla. The oblique view o f
the right breast shows a tumor with an ir
regular, spiculated border. Microscopy o f
the surgical specimen showed a primary
breast carcinoma. No lymph node metasta
sis.
mater, may be rounded without fat in the hilum. The radiographic ap
pearance of pathologic lymph nodes is the same whether the process rep
resents metastasis, lymphoma, or inflammation. A common cause of
pathologic lymph nodes in the axilla is rheumatoid arthritis.
On a correctly positioned oblique view the pectoral muscle should be
seen posteriorly at least down to the midplane of the breast. The muscle
may be more or less striated due to fat infiltration. The breast parenchyma
has a variable superior margin of extension and may reach high up to
wards the axilla and lateral to the pectoral muscle. Breast parenchyma
may occur isolated in the axillary region and even simulate a malignant
tumor on the mammogram. In the presence of a non-specific density in
the axillary region, it is important to perform a physical examination and
to evaluate the results with the mammogram. In the presence of ancil
lary normal breast tissue the patient often gives a history of premenstrual
swelling and tension in the axillary portion of the breast. On rare occa
sions even an extra nipple can be seen in this area. An important conse
quence of this anatomic variation is that primary breast cancer can oc
cur in the lower part of the axilla (Fig. 18).
647
Figure 19.
a) A 72-year old woman with a
palpable mass in the lateral
portion o f the left breast.
Mammography shows a 3 cm
lobulated tumor, mainly well
circumscribed but with areas o f
indistinct border and a couple
o f thin extensions into the sur
rounding fa tty tissue. The den
sity o f the tumor is relatively
high.
Microscopic diagnosis: Mucinous

carcinoma.
b) 62-year old woman who had

felt a mass in her left breast.
The mammogram shows a
spiculated tumor with a diame
ter o f approximately 2 cm.
Microscopy o f the surgical speci

men showed invasive ductal carci
noma.
Principles of mammographic differential diagnosis

It is useful to analyze breast lesions in terms of a few general categories,
which often occur in different combinations:
1. Tumor, including so-called asymmetrical density
2. Architectural distortion
3. Calcification
4. Oedema
Tumor
There are two main categories of mass lesions according to their mar
ginal characteristics: Circumscribed and not circumscribed (Fig. 19). A
well-circumscribed lesion carries a high probability of representing a be
nign tumor, while a mass with an irregular margin is usually malignant.
Actually, the likelihood that a spiculated tumor represents a carcinoma
648
BREAST IMAGING
Figure 20.
39-year old patient who was referred be
cause o f a tumor in her right lung which
turned out to be a hamartoma. She was
asymptomatic from the breasts. The left
mammogram shows an 8.0 cm lesion o f
variable density, surrounded by a cap
sule-like structure (arrows). On palpa
tion, a soft, lens-like structure was felt.
Radiographic diagnosis:
Fibroadenolipoma (hamartoma).
is over 90% provided postoperative changes can be excluded.

Most well circumscribed tumors represent a benign lesion like a sim
ple cyst, fibroadenoma, lymph node, sebaceous cyst, papilloma, or
hematoma. There are, however, exceptions in that carcinoma may pre
sent as a circumscribed mass. Also rare tumors like sarcoma and lym
phoma usually present in this way.
Often the radiographic differentiation between benign and malignant
circumscribed masses is difficult or impossible. Ultrasound is then use
ful in the differentiation between a solid and a cystic mass. However,
once a mass has been shown to be solid, further differentiation is usu
ally impossible by ultrasound.
In addition to the marginal characteristics of a tumor other radiographic
features are sometimes helpful. The density is of some interest in that
relatively low density of the tumor in relation to normal parenchyma is
in favour of a benign lesion, while a relatively high density increases the
probability of malignancy. It is important to stress that there are many
exceptions: some carcinomas may be of relatively low density, and some
cysts may be of high density. Mixed lesions with areas of fat density are
practically always benign. Three types of lesions may contain a varying
amount of fat: hamartoma (fibroadenolipoma) (Fig. 20), fat necrosis, and
649
Figure 21.
Asymptomatic 56-year old woman. The
oblique view o f the right breast shows
several small rounded nodules along the
lateral thoracic artery and vein. This is a
typical location fo r lymph nodes.
galactocele. Hamartomas may also be homogeneously dense.

The presence of a halo strongly favours a benign lesion. A halo is a
thin, radiolucent band around the tumor. Usually the halo cannot be seen
all around the tumor. It should be noted that a halo may be seen around
circumscribed malignant tumors on rare occasions. It has been debated
whether a halo represents a so-called Mach band. However, from a prac
tical standpoint the sign is useful.
The location of a circumscribed tumor may speak in favor of a benign
lesion. This applies to a well-circumscribed nodule in the upper outer
quadrant, especially if located close to the vessels which, as mentioned
before, is a typical location for lymph nodes. The region of the infra
mammary fold is the typical location of a sebaceous cyst. If this is sus
pected, tangential views should be obtained to demonstrate its close re
lationship to the skin.
Another important parameter is multiplicity. If multiple well-circum
scribed nodules or tumors are seen in the breast, they probably represent
benign structures like cysts or possibly fibroadenomas (Fig. 16), or, if
located in the upper outer quadrant, possibly lymph nodes (Fig. 21). One
exception is metastatic disease which may present as multiple circum-
650
BREAST IMAGING
Figure 22. 52-year old woman with a palpable mass in her left breast.
a) On the lateral view (horizontal beam) a corresponding lobulated well marginated
tumor is seen. In two places sedimentation o f calcium is seen.
b) After almost complete aspiration o f the cyst fluid and injection o f air, intracystic tu
mor can be ruled out on the pneumocystogram.
scribed nodules in the breast. A solitary circumscribed mass, especially

in an older woman, carries a higher probability of malignancy.
In the presence of a solid, well-circumscribed mass in which malig
nancy cannot be ruled out radiographically, further investigation has to
be performed. In this situation we use fine-needle aspiration biopsy. If
the lesion is cystic the fluid may be aspirated and a pneumocystogram
performed by replacing the fluid with air (Fig. 22) to exclude intracys
tic tumor. If there is no suspicion of intra-cystic tumor and if the cyst
fluid is not bloody, cytologic examination of the fluid is unnecessary.
Most cysts do not recur after pneumocystography.
A tumor with an irregular border, especially if spiculated, carries a
much higher probability of malignancy as mentioned above. There are,
however, a few differential diagnostic possibilities. By far the most im
portant is postoperative changes. Usually, a surgical scar presents as an
area of architectural distortion, but sometimes a scar may present as a tu
mor with surrounding spicules. This is especially true if there has been
a complication like hematoma, seroma or abscess, perhaps further com
plicated by fat necrosis. Information on previous surgery should always
be available to the radiologist. Blunt trauma to the breast may result in sim
ilar changes (Fig. 23). A word of caution: Occasionally, a patient with
breast cancer will associate the tumor with a recent trauma. It is important
651
Figure 23. 60-year old woman with a palpable mass in the subareolar region o f the
left breast after blunt trauma to the breast.
a) Six months after the trauma there is a 3 cm ill-defined, spiculated density. Cytology
showed giant cells and other evidence o f a post-traumatic lesion.
b) Two years later the lesion has shrunk with the development o f calcifications.
Radiographic diagnosis: Post-traumatic lesion, probably with fa t necrosis.
Figure 24.
Asymptomatic 58-year old woman. The
mammogram shows a small, ill-defined
density with retraction o f surrounding
structures (center o f image). On cytology
there was no suspicion o f malignancy.
Microscopy o f the surgical specimen re
vealed a 3 mm radial scar.
for the referring physician and the radiologist not to be mislead by such
a history.
Mastitis or abscess may present radiographically as a mass with an ir
regular border. It should be noted that mastitis is not always associated
with obvious inflammatory signs clinically due to low-grade inflamma
tion. Ultrasound and flne-needle aspiration biopsy usually provide valu
able differential diagnostic information. The diagnosis of inflammation
or abscess may also be obtainede^^uyantibus, i.e. by treatingjh e patient
with antibiotics and repeating the mammogram after 3 to 4 weeks. A
652
BREAST IMAGING
Figure 25.
84-year old woman with a palpable
mass in the left breast. The oblique view
shows a spiculated tumor with retrac
tion o f the pectoral muscle as well as o f
the skin which is thickened (arrow). On
histopathological examination o f the
mastectomy specimen a 2,6 cm invasive
carcinoma was found. There was no tu
mor invasion in the skin or the pectoral
muscle.
mastitis will usually regress substantially in this period of time.

In rare cases certain forms of fibrocystic disease may present as a spic
ulated lesion, as may also the so-called radial scar (Fig. 24) which will
be described later.
In summary, lesions with an irregular and spiculated margin imply a
high probability of carcinoma. A recommendation of surgical biopsy is,
therefore, practically always appropriate.
There is some correlation between the mammographic appearance of
carcinoma and the microscopic type. The irregular, spiculated border of
many carcinomas is caused by reactive fibrosis. This type of carcinoma
is hard on palpation and on the cut surface grey-yellow streaks repre
senting elastin are often seen. The fibrotic reaction may extend far be
yond the tumor itself, with thickening of connective tissue in the so-called
Cooper's ligaments which are anchored to the skin (Fig. 25). Similarly,
the periductal tissue in the subareolar region may be involved by reac
tive fibrosis. The fibrotic tissue characteristically undergoes shortening
(retraction) with dimpling of the overlying skin and retraction of the nip
ple. This is the basis for important radiographic as well as clinical symp
toms. Cancer with reactive fibrosis usually feels larger than its actual
size. It should be noted that periductal fibrosis and nipple retraction can
be seen with benign disease such as duct ectasia. In such cases the nip
ple retraction is most often bilateral and has almost always been noted
by the patient for many years.
653
In contrast, the circumscribed type of carcinoma usually has much less

reactive fibrosis, none or little elastin, no tubules and usually larger cells.
The circumscribed type of ductal carcinoma is sometimes called ductal
carcinoma of comedo-type. There is evidence that this type of breast can
cer has a graver prognosis than ductal carcinoma productive of fibrosis.
Altogether, the ductal carcinoma with productive fibrosis and ductal car
cinoma of comedo-type comprise 70-80% of all breast carcinomas. The
less frequent special types of carcinoma like medullary with lymphoid
stromal infiltration and mucinous carcinoma usually present as well-cir
cumscribed tumors, while lobular invasive carcinoma usually has a spic
ulated appearance.
Asymmetrical density
This is a common problem in mammography. The vast majority of asym
metrical densities simply represent areas of asymmetrical normal glan
dular tissue or fibrocystic changes. If in doubt, the radiologist should ob
tain special views including magnification and coned down views to bet
ter demonstrate morphologic detail. Physical examination and
correlation of physical findings and history with the mammogram are of
ten useful. Hormone replacement therapy may sometimes explain a new
asymmetrical density. A history of recent trauma may similarly explain
a new asymmetrical density which thus may represent contusion of breast
tissue. In the presence of a bloody discharge the asymmetrical density
may represent an intraductal carcinoma.
There is reason to be cautious, if an area of asymmetrical density is
new or has any characteristics which may imply malignancy, like calci
fications, spiculation or architectural distortion, furthermore, if the pa
tient has a bloody discharge or finally, if there is a suspicious finding on
physical examination in the area of the asymmetrical density. It should
be re-emphasized that an area of asymmetrical density in the absence of
any tumor characteristics rarely represents carcinoma.
Architectural distortion
Architectural distortion may be defined as a disruption of the normal ar
chitecture of the breast without a dominating mass. This may be seen in
malignant as well as benign disease. The most common explanation of
architectural distortion is postoperative scarring. As was pointed out
above, information on previous surgery should always be available to
654
BREAST IMAGING
Figure 26. 75-year old woman who sought advice because o f a palpable mass in the
left breast.
a) The oblique view o f the left breast shows an area o f architectural distorsion (ar
rows) and an area o f non-specific density.
b) The normal right breast for comparison.
On histopathological examination o f the left breast a 2,1 by 0,8 cm tumor was found
corresponding to the area o f architectural distorsion seen in a). The microscopic diag
nosis was invasive and non-invasive lobular carcinoma.
the radiologist. In addition to postoperative scarring there are two main

differential diagnostic possibilities: carcinoma, and radial scar.
One particular microscopic type of carcinoma, invasive lobular carci
noma, sometimes presents as an area of architectural distortion without
an evident tumor mass (Fig. 26). This may be explained by its propen
sity to grow multifocally and in single rows diffusely infiltrating the nor
mal breast tissue. There may also be a varying degree of reactive fibro
sis. US is often useful in these cases, demonstrating a hypoechogenic le
sion, sometimes with multiple foci of shadowing.
A radial scar (infiltrating epitheliosis) is a benign lesion which is usu
ally small and virtually always non-palpable. A radial scar has a stellate
configuration with a fibrotic center containing elastin deposits and tubu
lar structures and surrounded by a corona of retracted ducts and lobules,
655
Figure 27.
a) 76-year old asymptomatic p a
tient. On the mammogram a
coarse calcification is demon
strated in the subareolar re
gion, relatively characteristic
fo r a fibroadenoma. There is
no soft tissue mass, which m ay
be due to hyaline degenera
tion o f the fibroadenoma, a
common finding in elderly
women.
b) 69-year old asymptomatic
woman. On the mammogram,
a mixture o f needle-like, glob
ular and tubular calcifications
are seen, characteristic fo r
duct ectasia (plasma cell mas
titis).
often containing epithelial proliferations and sometimes even intraduc

tal carcinoma. Sometimes the center of the lesion is relatively radiolu-
cent, but basically, the lesion is not characteristic enough to allow a be
nign diagnosis (Fig. 24). Further, according to some pathologists, radial
scars are potential precursors of carcinoma.
In summary, a surgical biopsy should always be recommended in the
presence of architectural distortion, provided postoperative changes can
be excluded.
Calcifications
This is a very common finding at mammography. The vast majority of
calcifications are benign, and many of the benign calcifications can
easily be classified as such. On the other hand, calcifications are some
times the only radiographic sign of malignancy. This is especially true
for early, non-invasive carcinoma, which is usually non-palpable.
Calcifications are the main radiologic finding in 20 to 30 per cent of
656
BREAST IMAGING
a
Figure 28. 44-year old woman with premenstrual tenderness in the breasts.
a) On the craniocaudal view smudges o f calcification are seen.
b) On the lateral view (horizontal beam) linear and curvilinear calcifications are seen,
representing sedimentation o f calcium in small cysts ("tea cups").
Radiographic diagnosis: Microcystic disease.
Figure 29. 60-year old

asymptomatic woman.
Incidental finding o f a 2.4 cm
well-marginated lesion with
fat attenuation. The "capsule"
is partly calcified. This ap
pearance is characteristic for
an oil cyst which occurs after
fat necrosis. The lesion was
palpable. The patient had a
history o f trauma to the
breast from a safety belt five
years prior to the current ex
amination.
carcinomas detected on screening.

Characteristic, benign calcifications are often seen in fibroadenoma
(popcorn like), ductectasia (needle like) (Fig. 27), microcystic disease
(teacups) (Fig. 28), and sometimes in sclerosing adenosis. Various glob
ular calcifications are also easily identified as benign (Fig. 29).
Sometimes, however, calcifications in these benign diseases may be dif
ficult to categorize correctly. This is especially true for the early stages
of calcifications in fibroadenoma, fat necrosis, and fibrocystic disease
and, sometimes in arteriosclerosis.
657
Figure 30.
73-year old woman with eczema on
the right nipple. Physical examination
o f the breast was otherwise
unremarkable. The magnification
view (x 1,8) o f the lateral portion o f
the right breast shows a 4 cm area o f
dense parenchyma containing
numerous calcifications which vary in
size, form and density. In some places
there is a suggestion o f ductal
arrangement. X-ray guided FNAB
showed malignant cells.
Microscopy o f the mastectomy

specimen showed intraductal
noninvasive carcinoma o f comedo
type with Paget's disease o f the nipple. The axilla was free from metastases.
Calcifications should be analyzed as regards morphology (size, form

and density), distribution (scattered or clustered), and arrangement (lin
ear, lobular).
Benign calcifications tend to be scattered and rounded with a relatively
uniform size and density. Malignant calcifications tend to vary in size,
shape and density (Fig. 30). Lobular calcifications are usually arranged
in rounded groups, while calcifications of ductal origin tend to be
arranged in groups with an irregular outline. Linear or branching con
figuration of the calcifications is an important indicator of a ductal ori
gin.
The most characteristic type of malignant calcifications are those as
sociated with intraductal carcinoma (ductal carcinoma in situ - DCIS),
which is usually subdivided into the comedo- and non-comedo types.
The most typical calcifications are seen with the comedo-type in which
dystrophic calcifications are formed in necrotic material in the center of
dilated ducts. Other growth patterns of DCIS such as cribriform or mi-
cropapillary, are usually associated with less characteristic calcifications
or no calcifications at all.
Basically, invasive disease cannot be ruled out on the basis of a mam
mogram. The greater the extent of the calcifications, the higher the prob
ability of microinvasion, even in the absence of a soft tissue mass. In the
presence of a soft tissue mass or retraction, invasive disease must be sus
pected (Figs. 31, 32). Also, the extent of the disease is often greater than
658
BREAST IMAGING
Figure 31. 64-year old, asymptomatic

woman undergoing screening mammog
raphy. Physical examination was unre
markable. The magnification view (x 1,8)
shows irregular calcifications in an area
with architectural distorsion (retrac
tion). Evident ductal arrangement o f
some o f the calcifications. On the basis
o f the mammogram invasive carcinoma
combined with DCIS was suspected.
FNAB revealed atypical cells, suspicious
for carcinoma.
Microscopy o f the surgical specimen
showed a 1.0 cm invasive carcinoma
with extensive intraductal component o f
mixed comedo and cribriform type.
Three metastatic nodes in the axilla.
Figure 32. 63-year old woman with

a palpable mass in the left breast.
The magnification view (x 1.8)
shows a 2.2 cm mainly well mar
gin ated mass with extensive calcifi
cations in as well as outside the tu
mor. Evident ductal arrangement in
several areas. FNAB showed can
cer cells.Microscopic examination
o f the surgical specimen revealed
an invasive carcinoma with exten
sive intraductal component involv
ing ducts adjacent to the tumor and
into the nipple. No metastases in
the axilla.
the extent of the calcifications. This is especially true for the non-comedo
types of DCIS.
It should be mentioned that lobular carcinoma in situ (LCIS) is not a
radiographic diagnosis. LCIS occasionally found in biopsies performed
for clustered calcifications is usually an incidental finding, the calcifica
tions representing fibrocystic or other benign disease.
With experience it is possible to make rough estimates of the proba
bility of carcinoma for broad categories of calcifications. Table 1 shows
an example of a classification of calcifications into four risk groups, based
on 213 biopsies of clustered calcifications.
As a rough rule, we consider clusters of five or more irregular calcifi
cations as suspicious for carcinoma. It should be understood that five is
659
Table 1. Radiographic appearance o f clustered calcifications and risk

o f malignancy
Risk group Radiographic characteristics Proportion of biopsies

of calcifications with breast carcinoma *
N%
1. a) rounded
b) "cloudy"
c) "tea cups" 0/54 0
2. as in risk group 1, but with some
irregular calcifications 13/75 17
3. a) irregular, few
b) possible ductal arrangement 22/58 38
4. a) irregular, abundant
b) definitive ductal arrangement 25/26 96
Modified after Sigfusson, Andersson et al. 1983
*) 10 cases of LCIS which were incidental findings in areas adjacent to benign calcifi
cations were excluded, 3 in risk group 1, 5 in group 2, and 2 in group 3.
not a magic number. More important is the morphology and arrangement

of calcifications. A ductal or branching configuration of the calcifications
substantially increases the probability of carcinoma. Magnification
views should virtually always be obtained to allow the study of mor
phologic detail. It should also be understood that the size of the cluster
is of no diagnostic significance. A cluster of malignant calcifications may
be a few millimeters in diameter or the calcifications may involve more
than one quadrant. In our institutions, FNAB is included in the further
work-up of patients with clustered calcifications. Borderline clusters with
negative cytology are usually followed at intervals of six and twelve
months. For more suspicious calcifications with a higher degree of sus
picion a surgical biopsy is recommended irrespective of the result of cy
tology. In the presence of a definitive cytologic diagnosis of carcinoma
a segmental resection is usually performed, if the calcifications are lim
ited to one quadrant.
Oedema
Radiographically, oedema of the breast is characterized by an increased
trabecular pattern in the subcutaneous tissue, skin thickening and gen-
660
BREAST IMAGING
Figure 33. 88-year old woman with a clinical diagnosis o f mastitis or

abscess in the lateral portion o f the right breast. The craniocaudal pro
jection shows increased density, skin thickening and a trabecular pat
tern in the subcutaneous tissue in the lateral portion o f the breast (left
portion o f the image). FNAB was negative for malignancy. Complete
resolution after treatment with antibiotics.
Final diagnosis: Mastitis with oedema o f the breast.
erally increased density in the breast (Fig. 33). The pathophysiologic ba
sis for these changes is veno-lymphatic obstruction which may be caused
by angiolymphatic growth of cancer in the breast, inflammation of the
breast (mastitis), obstruction of the lymphatic drainage in the axilla from
metastatic disease, postirradiation reaction, or obstruction of the drain
ing veins including the superior vena cava. This means that oedema of
the breast can be seen with a variety of benign and malignant diseases.
In practice the most common cause of oedema of the breast is previ
ous breast irradiation. Postirradiation oedema is usually most pro
nounced after 6-12 months, and it tends to regress gradually thereafter.
Sometimes oedema is the only radiographic sign of carcinoma of the
breast, but often the malignant tumor or calcifications are also evident.
Usually there are enlarged lymph nodes in the axilla. Some, but not all
of these patients present as so-called inflammatory carcinoma, which,
however, is a clinical diagnosis and should usually not be made on the
basis of radiograms. On the other hand, mammography is more sensitive
than clinical examination in detecting oedema.
Any disease causing generalized oedema of the body such as cardiac
failure or hypoalbuminemia due to liver failure can cause oedema of the
breast. Although such oedema is usually bilateral, it may be unilateral,
661
Figure 34. 67-year old woman who underwent screening examination,

a) A somewhat spiculated 0.5 by 0.6 cm tumor was detected in the upper outer quad
rant o f the left breast (arrow), highly suspicious for malignancy. The patient refused
further investigation and treatment. She returned almost three years later with a pal
pable mass in the upper outer quadrant o f the left breast. Repeat mammogram (b)
shows that the tumor has grown substantially, now measuring 2.5 x 2.0 cm.
Microscopic examination o f the mastectomy specimen showed invasive carcinoma o f
the comedo-type and 14 metastatic nodes in the axilla, all with periglandular growth.
if the patient is bedridden and lying on one side.

Rarely, a malignant process in the mediastinum may cause venous ob
struction with oedema of one or both breasts as a result.
In the presence of oedema of the breast without obvious reason, it is
wise to perform a physical examination and obtain a clinical history
which will often give a clue to the correct diagnosis.
SCREENING FOR BREAST CANCER
General background
It is well known that mammography can detect breast carcinoma before
it is palpable and sometimes even in a preinvasive stage (Fig. 34).
Furthermore, it has been demonstrated in several controlled trials that
662
BREAST IMAGING
screening with mammography can reduce breast cancer mortality. In ad

dition, breast saving surgery can be performed in a higher proportion of
cases and the need for systemic therapy can be reduced. However, sev
eral prerequisites must be fulfilled for screening to be successful.
Obviously, the attendance among invited women must be high. A high
quality in all steps of the imaging procedure and film reading is neces
sary as well as professional management of women with positive find
ings on the screening mammogram. A high rate of false positive find
ings will create undue anxiety and costs. Thus, a high specificity is im
portant. The detection of some very slow growing carcinomas, which,
in the absence of screening would not have presented during the wom
an's lifetime is unavoidable. Women who participate in a screening pro
gram also have to experience an excess of breast cancer years due to lead
time and length bias, which will be explained later. A negative screen
ing examination may be falsely reassuring. This, in turn may delay the
diagnosis o f a carcinoma appearing in the interval between screenings.
Women who participate in screening programs should be instructed to
perform monthly breast self-examination and to seek advice if there is a
change in the breast.
Breast cancer is not a uniform disease, but rather a spectrum of dis
eases ranging from quite innocent to very malignant. Furthermore, in the
screening situation there are mechanisms which tend to bias the sample
of cancer that is detected at screening.
The length bias refers to the fact that slow growing tumors are more
likely to be detected at screening than fast growing. Fast growing tumors
tend to appear in the intervals between screenings, so-called interval can
cers. The detection bias refers to the fact that some cancers have an ap
pearance which is more easy to detect radiographically or to identify as
malignant, while others are more difficult to detect. The self selection
bias refers to the fact that those women who are invited but do not at
tend a screening program have, in most studies, turned out to have a
greater than average risk of dying from breast cancer. This seems to be
due to the fact that once the non-attenders seek advice for their breast
cancer they have a more unfavourable staging.
The lead time bias refers to the period of time with which the diagno
sis is advanced through screening. Thus, survival may erroneously seem
prolonged. Therefore, survival cannot be used to measure the effect of
screening unless the lead time is controlled for, which is difficult.
663
Accordingly, in all controlled trials of the effect of breast cancer screen

ing, mortality has been used as a measure of the effect. Furthermore, all
breast cancer deaths in the invited group, including cases detected in the
intervals between screenings and among non-attenders, must be com
pared with the number of breast cancer deaths in the control group due
to the biases mentioned above.
Review of trials
The effect of breast cancer screening has been estimated in several ran
domized trials, including one study with geographical controls (the UK
Trial) and in three case control studies. The age groups invited, the size
of the study populations as well as screening interval and screening
modalities are given in Table 2.
Table 2. Controlled trials o f breast cancer screening
Study Age No. invited/ Interval Modality

group controls (months) M = mammography
P = physical
examination
HIP , New York, USA 40-64 31.000/31.000 12 M+P

Malmoe, Sweden 45-69 21.000/21.000 21 M
Two counties, Sweden 40-74 77.000/56.000 24-33 M
UK trial, England 45-64 46.000/127.000 12-24 M+P
Edinburgh, Scotland 45-64 23.000/23.000 12-24 M+P
Stockholm, Sweden 40-64 40.000/20.000 28 M
Gothenburg, Sweden 40-59 22.000/30.000 18 M
Canada 40-59 45.000/45.000 12 M + P*
*) only 50-59
The detection rate of breast cancer at the first screening was usually be
tween 5 and 8 cases per 1000 women (Fig. 35) and in subsequent screen
ing rounds between 2 and 4, depending on the screening interval. The
detection rate in the first screening exceeded the control group incidence
by a factor of about 2 in the younger age group (< 50 years) and by a fac
tor of about 4 in the older age group. The lower relative detection rate
among younger women is due to a lower sensitivity o f mammography
in this age group and possibly also a detection bias and faster growth
rate. The number of advanced cancers (stage II and over) was reduced
among women invited to screening, an effect that was usually seen after
664
BREAST IMAGING
Figure 35.
Schematic representation Of Screening 100
7. . mammography
a mammographic screening ▼
program (prevalence 4 .5 o/0 Complete mammogram,
round). I Physical examination
~2% Fine needle aspiration biopsy
Surgical biopsy < 1% - 0.2 % Follow-up

mammogram
Breast 0.5-0.8 % 0.2-0.4 % Benign lesions

carcinoma
about three years of screening. The relative reduction has in most stud
ies been in the order of 20 to 30%. The positive predictive value of a rec
ommendation of surgical biopsy has been between 40 and 80%.
Currently, it is about 75% in most high quality screening studies, mean
ing that 3 out of 4 surgical biopsies are malignant. FNAB is used rou
tinely in most studies and has increased the predictive value of a rec
ommendation for surgical biopsy.
In the combined Swedish randomized trials a 24% reduction of breast
cancer mortality has been achieved. This result was statistically signifi
cant. In younger women (40 to 49 years) the reduction was only 13%
(not statistically significant), while in the age group 50 years and over
the corresponding reduction was 29% (statistically significant). In ab
solute terms the cumulative breast cancer mortality after 12 years was
3,9 per 1000 person years in the invited group and 5,1 in the control group
(all ages invited). Similar results have been achieved in the UK trial.
Most experts conclude that screening women between the age of ap
proximately 50 to 70 years is cost effective, while the issue of screening
40 to 49 year old women is still under debate.
Radiation dose
The carcinogenic risk of the radiation exposure at mammography has at
tracted attention, especially in the context of screening asymptomatic
women. Our knowledge has increased substantially since a relationship
between breast cancer and x-irradiation was first demonstrated in the six
ties. The radiologist working with mammography should be aware of the
state of knowledge in this field. The female breast is sensitive to the car
cinogenic effects of ionizing radiation. The dose response relationship
665
is relatively well known at high doses (one hundred to several hundred

cGy (rads)). In the low dose range (up to several cGy), data are insuffi
cient for determining the shape of the dose response curve. It is gener
ally agreed that a linear extrapolation from the high dose range would
represent the highest possible risk. Other functions, such as linear qua
dratic or pure quadratic which would imply a lower risk per cGy than the
linear model have been discussed. Using the linear model the risk of
breast cancer induction has been calculated to be in the order of 6 to 7
cases per million women irradiated per cGy and per year after a latency
period of about ten years, and continuing for the rest o f the women's life.
It is clear that the carcinogenic effect of ionizing radiation is age-re-
lated. In epidemiological studies of women exposed to high doses of ion
izing radiation an excess number of breast cancers has been observed
mainly in women who were below the age of 30 to 40 at the time of ir
radiation. Recent data indicate that exposure already in infancy and child
hood increases the incidence of breast cancer, while earlier studies indi
cated that the greatest risk would be from exposure between 10 and 20
years of age with virtually no risk before that age. Furthermore, there is
a latency period of 5 to 10 years between the radiation and the appear
ance of any excess cancer. Dose fractionation probably does not reduce
the risk. Thus, the effect of low doses seems to be additive.
The mean absorbed dose in the breast gland per mammographic film
is in the order of 0.1 cGy for the average breast. Comparing with the
background radiation in for example Sweden, the effective dose equiv
alent of one mammographic exposure is only 30% of the background ra
diation during one year. Although the risk of inducing breast cancer with
mammography is exceedingly small, it should be taken into account in
two situations:
1) When screening large populations of asymptomatic women. As was
pointed out above, the age of the women to be screened would be an
important determinant of risk.
2) When examining symptomatic patients under the age of 30. As a gen
eral rule, every symptomatic woman aged 30 and over should have
a mammogram. In the age group 25 to 30, mammography should be
performed only if there is a clinical suspicion of malignancy. Under
the age of 25 mammography should be performed only exception
ally.
666
BREAST IMAGING
Figure 36.
a) and b). Two mammograms o f the same breast obtained in two different institutions
(and in two different countries) in a short time interval. Both examinations were per
formed using identical mammography film. There is a substantial difference in image
contrast, image a) being clearly substandard. Imaging and processing parameters for
image a) are unknown but there is reason to believe that the main reason fo r the low
contrast was a processor problem. The patient had a 5 cm spiculated carcinoma. The
consequences in terms o f reduced sensitivity fo r the detection o f early carcinoma o f an
image quality like the one illustrated in a) are obvious.
It is generally agreed that the potential risk of mammography is far out

weighed by the potential benefits. However, it is important to optimize
the mammographic imaging system and to monitor the imaging process
by a proper quality control program in order to keep the radiation dose
as low as possible.
Quality control
Several factors influence the accuracy of mammography, e.g., technical
factors related to the x-ray machine and processing (Fig. 36), the exam
ination technique and the radiologist's performance. Accordingly, there
are several components of a quality assurance program.
All personnel involved should have proper training. The x-ray equip
ment must meet certain criteria. Medical outcome measures should be
monitored. Data should be available to calculate the sensitivity, speci
ficity and predictive values of the procedures used. Continuous correla
tion of radiographic findings with pathology is an essential component
of a quality assurance program. In addition to its value for follow-up and
training, such a correlation provides a reference base for policies on the
management of different categories of lesions, e.g. calcifications and cir
667
cumscribed masses.
The goal in mammography is to consistently produce high quality
mammograms with minimal radiation exposure to the patient. To main
tain a high image quality regular tests have to be carried out. The per
formance of the processor should be monitored by daily sensitometry.
Usually, a 21 -step sensitometer is used, producing densities ranging from
gross fog to maximum density. After processing, the steps are measured
in a densitometer. A minimum daily check should include speed, con
trast and gross fog.
Another test that should be performed daily or at least weekly, is a
phantom exposure which will provide an over-all check of the imaging
system by measuring density, contrast resolution, kV and phototimer op
eration.
Several parameters relating to the x-ray machine such as beam qual
ity, function of the automatic exposure device, tube current, absorbed
dose, and focal spot size should be measured by a physicist semiannu
ally or annually. If a darkroom is used, the darkroom should be checked
at regular intervals for light leaks.
In some countries an accreditation program has been implemented to
guarantee a high and consistent mammographic quality.
668
Index
P-blocker 1173 acinar atelectasis 540

P-hemolytic streptococcal - disease 547
pneumonia 543 -nodule 541
|32-microglobulin amyloid acoustic impedance 27,65
deposition 336,343 acquired cholesteatoma 235
1,25-dihydroxyvitamin D3 1128 - cystic disease 1142
1311 cholesterol adrenal imaging 1124 - heart disease 570
i3iI or 123l MIBG adrenal imaging 1124 - immune deficiencysyndrome
131I-19-iodocholesterol 1211 (AIDS)2
,31I-Hippuran 1122 - small-bowel obstruction (SBO) 583
3D reconstruction 810 - spinal stenosis 330
5-fluorouracil 154 - valvular disease 793
57Cr-EDTA 1122 acrania 1226
99m-Tc-HIDA 1046,1053 acro-osteolysis 441,504
99mTc Glucoheptonate 1122 acromelic 493
99mTc DMSA 1122 acromioclavicular joint
99mTc sestamibi 785 instability 403
99mTc DTP A 1122 ACTH 1209
99mTc MAG 1122 actinomycosis 736,966
A/D converters104 acute aortic insufficiency 797
A-mode 67,68 - arterial occlusion 825
abdominal aorta 820 - bowel ischaemia 1105
- circumference (AC) 1220 -cholecystitis 1051
- trauma 1107 - disseminated encephalo-
abortingtwin 1223 myelitis (ADEM) 216,217, 623
abscess 622,652,1072,1195 - ischaemia of the bowel 983
abscess drainage 159 - ischaemic colitis 1003
absent thumb 508 - osteomyelitis 442
absorbed dose 31 - otitis media 233
AC (abdominal circumference) 1220 -pyelonephritis 1150
acalculous cholecystitis 1052,1328 - rheumatic fever 570
accordeon pattern 502 - sinusitis 240
acetabular protrusion 440 - tubular necrosis 1156
achalasia 902 - viral pericarditis 802
achondrogenesis 492,496 acyanotic CHD 558
achondroplasia330,492,493,495,1227 Addison's disease 1209
XVII
ADEM (acute disseminated alpha particle 28,61

encephalomyelitis) 216,217, 623 - radiation 17
adenovirus 734 alpha-heavy chain disease 974
adenocarcinoma 244, 720, 974 aluminium filter 37
adenoid hyperplasia 247 alveolar cell tumor 720
adenoma 1006, 1032 - echinococcosis 1270
adenomatoid odontogenic tumor283, 284 - hydatid disease 1269, 1270
adenomyomatosis 1053 - opacity 737
adenomyosis 1202 ameloblastic odontoma 283
adenopathy 553 ameloblastoma 283
adenovirus 549 amelogenesis imperfecta 272
aditus 230 American trypanosomiasis 1272
adrenal adenoma 1213 amniotic fluid 1230
- atrophy 1210 - fluid index (AFI) 1220, 1231
- cortical adenoma 1208 - fluid volume 1220
- cortical carcinoma 1208, 1213 amoebiasis 1239
- cyst 1215 amoebiasis of the bowel 1239
- gland 1207 - chest 1245
- haemorrhage 607 - liver 1242
- hyperplasia 1208 amoebic hepatic abscess 1242
adrenogenital syndrome 1209 - hepatitis 1242
adult polycystic kidney disease - liver absces 1245
(APCKD) 595, 1140, 1155 - lung abscess 1245
adult respiratory distress syndrome amoeboma 1241
(ARDS) 743, 738, 758, 770, amplitude mode 68
adynamic ileus 1105 amyloid 345
AFI (amniotic fluid index) 1220, 1231 amyloid deposits 336, 346
aganglionic segment 585 amyloidosis 747., 1156, 1210
aganglionic colon 585 anaerobic infection 730
agaragar 131 analogue/digital transformation 103
AIDS (acquired immune deficiency analogue detectors 47
syndrome) 214, 754, 920, 1156 - image 101
AIDS-related cholangitis 1328,1329 - techniques 47
- complex (ARC) 1322,1323 anaphylactoid (anaphylactic) shock 130
- infections 966 anaphylactoid reaction 127, 129
- Kaposi's sarcoma 1329 anaphylatoxins 128
- lymphoma (ARL) 1321, 1323 anaplastic astrocytoma 199
AIIMM 583 Ancylostoma duodenale 1281
ainhum 1296, 1297 ancylostomiasis 1281
air bronchogram 541, 542, 726, 726, 747 Anderson lesion 348
- embolism 813 anemia 503, 607
- trapping 713 aneurysm 621,693,800,836
airways infection 547 aneurysm of the aortic arch 707
akinesis 799 - ascending aorta 707
ala magna 176 aneurysmal bone cyst 288, 450
- parva 176 angina pectoris 799
ALARA (As Low As Reasonably angiocardiography 557,563,781
Achievable) 33 angiodysplasia 861, 1021, 1022
alcohol abuse 445 angiography 171
alcoholism 728 angiomyolipoma 1145
alevolar consolidation 724 angiotensin II 1132
allergoid (allergic) reactiori 127, 129 angiotensin-converting enzyme 1131
XVIII
INDEX
angular displacement 388 Apert syndrome 489

ankle injury 412 aphthoid ulcer 959, 963
ankylosing spondylitis apical segment 685
336, 338, 346,430,433, 437, 751 apico-posterior segment 685
ankylosis 341 apophyseal joints 299, 347
Ann Arbor staging system 882, 883 appendicitis 586,1093
annihilation 64 appendicolith 587
annulus fibrosus 300 aqueductal stenosis 619
anodontia 272 arachnoid cyst 226
anorectal evacuation disorder 1014 artificial ventilation 541
- malformation 583 ARC (AIDS-related complex) 1322, 1323
antegrade pyelography 161 architectural distortion 654,655
antenatal screening 1220 ARDS (adult respiratory distress
anterior communicating artery 184 syndrome) 738, 743, 758, 770
- diaphragmatic hernia 707 argon-laser 856
- dislocation 402 ARL (AIDS-related
- fat pads 399 lymphoma) 1321,1323
- hernia 697 Armillifer armillatus 1301
-junction line 688 arterial embolization 825,1073
- longitudinal - occlusive disease 824
ligament 300,301,304,311 - switch procedure 567
- mediastinal masses 705 - thrombosis 825
- mediastinum 552 arteriovenous malformation
- sacral meningocele 361a (AVM) 152, 171, 369, 624, 843, 1021
- segment 685 - fistula 864
- tibial artery 820 arteriosclerosis 657,1130
- tibial vein 822 arteritis 829, 831
anteroposterior radiograph 671 arthritis 432,446
antiparallel protons 74 arthrography 376
antler sign 739 aryepiglottic folds 538
antrum 230 arytenoid cartilage 257
aortic aneurysm 837, 1106, 1173 asbestosis 744
- arch 819 ascariasis 1276,1278
- arteritis 1291 Ascaris lumbricoides 1276
- syndrome 832 ascaris infestation 968
- balloon pump 768 ascending phlebography 813
- dissection 677 - thoracic aorta 819
- diverticulum 571 ascites 1086
- insufficiency 797 ASD (atrial septal
- rupture 759, 760 defect) 558, 559, 564, 566
- stenosis 563, 792, 796 aseptic necrosis 516, 531
- valve 787 - spondyliltis 336
- valvular disease 796 Asian Oceanian Society o f
- valvular insufficiency 791 Radiology (AOSR) 15
- valvular stenosis 563, 837 Askin tumor 552
aortitis 829 Aspergillus 342,736,1319
aortocoronary by-pass 765 aspergillus spondylitis 342
aortopulmonary window 688, 721 asphyxiating thoracic dysplasia 499
AOSR (Asian Oceanian Society aspiration 728
of Radiology) 15 aspiration pneumonia 769
APCKD (adult polycystic kidney - technique 634
disease) 595,1140,1155 - thromboembolectomy 145
XIX
asthma 710 Barkla, Charles C. 5

astrocytoma 197,206,351 Barlow maneuver 482
astroglial tumours 197 Barrett's oesophagus 907,916
asymmetrical density 654 - mucosa 904
atelectasis 716, 719, 725, 699, 768 Barton fracture 392
atherectomy catheter 145,857 Basic Radiological System (BRS) 14
atheromatous plaque 826, 829 basilic vein 824
atherosclerosis 801,826,1130 bat-wing 740
atherosclerotic aneurysm 841 Batson's venous plexus 339
atlas 299 BD (biparietal diameter) 1220
atom 19 Becquerel (Bq) 29
atresia o f the external ear canal 232 Behcet's disease 964
atrial myxoma 793 benign calcification 657
- septal defect (ASD) 558 - cementoblastoma 283
atrioventriculare communis 561 - cystic leiomyoma 1202
atrioventricular canal defect (AVC) 561 - lymphoid hyperplasia
atrophy 617,618 (BLH) 946, 976
attenuation 24, 66 benign prostate hyperplasia (BPH) 1192
attenuation number 58 Bennett fracture 392
audio display 70 beta radiation 17
auricle 787 - particles 61
autoantibodies 433 beta-minus particle 28
AV-fistula 813 beta-plus particle 28
AVC (atrioventricular canal defect) 561 bifid rib 682
AVF (congenital arteriovenous bilateral multicystic kidney 1226
fistula) 843 Bilbao-Dotter tube 956
AVM (arterio-venous malformation) bilharzia 1177,1246
152, 171,369, 624, 843, 1021 bilharziomas 1256
avulsion fracture 386, 402, 477 biliary atresia 588
axial imaging 18 - duct disease 1055
axillary artery 820 - imaging 1031
- v e in 824 - obstruction 155
azygoslobe 684 biligraphy 1044
- node 688 Billroth II stomach resection 1097
-v e in 823 Binswanger's disease 177,180,219
В cell 502 Biparietal diameter (BD) 1220
В symptom 882 biphasic barium meal 927
B-mode 67 biplane technique 379
Bacillus fusiformis 1293 Bisacodyl 987
backwash ileitis 963, 997 bladder calcification 1252
bacterial endocarditis 794 - calculi 1178
- infection in HIV 1319 - hernia 1179
- pneumonia 549, 754 - tumors 1182
balloon angioplasty 143 blastomycosis 343,736,1210
- catheter 853 BLH (benign lymphoid
- dilatation 853 hyperplasia) 946, 976
- expandable stents 146 block vertebra 365, 368
bamboo spine 347 blood flow 173
Bankart lesion 402 - flukes 1246
barium platinocyanide screen 5 - volume 173
- sulphate 131,956 blood-brain barrier 123
- contrast media 131 bloody discharge 654
XX
INDEX
blow-out fracture 245 bronchial anomaly 674

blue sclerae 503 - arteriography 772
- light 49 - cancer 700
blunt abdominal - embolization 772
trauma 590,950,1107, 1158 - erythematous plaque 1321
Bochdalek hernia 544, 697 - wall thickening 548
Boerhaave's syndrome 923, 924 bronchiectasis 674,714
bolus formation 894 bronchiole 686,711
bone bruise 385 bronchiolotis 549
- destruction 447, 449 bronchitis 549
- dysplasia 492 bronchogenic cyst 553, 707
-erosion 437,521 bronchography 674,711,716
- infarct 432 bronchopneumonia 549,725
- marrow 338 bronchopulmonary dysplasia
- marrow disease 880 (BPD) 465,543
- reaction 449 - foregut malformation 553
- scan 63, 424, 475 bronchoscopy 674
- scintigraphy 373 brown tumor 288, 527
bony ankylosis 437 BRS (Basic Radiological System) 14, 96
- exostosis 552 Brugiamalayi 1299,1301
- sclerosis 338, 503 Brunner's gland hyperplasia 946, 950
- spurs 333 bubbly bulb 970
boot-shaped heart 564 buckle fracture 476
botryoid cyst 279 bucrylate 150,369,863
bowel bladder 1185 Budd-Chiari syndrome 867,1031
- ischaemia 1108 Buerger's disease 829, 831
-obstruction 1095 bulbar palsy 896
bowel-wall thickening 582 bulging disc 323, 330
bowing fracture 475 bull's eye 941
bowler hat sign 993 bum injury 479
BPD (bronchopulmonary burst fracture 306,313
dysplasia) 465,543 buscopan 900
BPH (benign prostate hyperplasia) 1192 butterfly vertebrae 363, 365, 368
Bq (Becquerel) 29 Caffey disease 528
brachial artery 820 calcaneonavicular coalition 491
brachiocephalic vein 824 calcification 452, 656, 731, 732, 747, 804
brachiocephalic vessel 687 calcified ligament 334
bradykinin 128 - lymph nodes 873
brain abscess 211 - pineal body 188
- damage 623 - pleural plaque 702
- stem 205 calcifying epithelial odontogenic
- tumour 209 tumour 283
- tumour 611 calcium ipodate 1042
branchial cleft cyst 259 Caldwell projection 238, 263
branchial cyst 259 CAM (cystic adenomatoid
breast cancer 644, 648 malformation) 545
- cancer mortality 665 campomelic syndrome 486
-D oppler US 631 Campylobacter 968
-irradiation 661 campy lobacter infection 1001
- self-examination 663 Candida albicans 1319
breech presentation 484 Candida oesophagitis 913, 920
Brodie's abscess 442 - spondylitis 342
XXI
Capillaria philippiniensis 1283 cercaria 1246

capillary hemangioma 220, 843 cerebellar astrocytoma 206
- malformaton 843 - diameter (TCD) 1220
captopril 1132,1133 - infarction 180
captopril-enalpril renogram 1131 - medulloblastoma 206
captopril renography 1124 cerebellum 205
carboxy-methyl-cellulose 131 cerebral candidiasis 1313
carcinoid 971, 1012 - HIV infection 1309
carcinoma 65, 648 - infarction 177
cardiac catheterization 557, 563 - infection 621
- failure 698 - malformation 616
- injury 757 - masses 1311
cardiac tamponade 800 - non-Hodgkin's lymphoma 1312
cardiogenic congestion 739 - palsy 484, 620
cardiogenic edema 739 cerebritis 211
cardiomegaly 568,569,1290 cerebro-hepato-renal syndrome
cardiomyopathy 801 (Zellweger) 498, 1228
cardiophrenic fat pad 697 cerebro-spinal fluid circulation 618
cardiovascular malformation 557 cerebrovascular lesions 177
caries 274 cervical cancer 1200
Caroli's disease 1056 - plaque 218
carotid siphons 174 - rib 364, 682
carpal coalition 489 - spine trauma 306
- fracture 395 CFI (colour flow imaging) 71, 1218
- instability 395 Chaga's disease 904, 1272
carpal-tarsal osteolysis 521 chagoma 1272
carpometacarpal joints 395 Chance fracture 316
cartilaginous growth plate 467 characteristic curve 49
cathecolamines 1132 characteristic X-radiation 20
cathode ray tube (CRT) 62 CHD (congenital heart diseasee) 558
cauda equina 350 chemo-embolisation 153
caustic oesophagitis 921 chemonucleolysis 343, 370
caval filter 846 chemotherapy 154, 450, 462, 732
cavemosometry 1198 chemotoxicity 120
cavernous haemangioma chest radiograph 669
209, 220, 843, 1032 chest wall 681,693
cavography 817 - injury 755
CD (Crohn's disease) -m ass 551
478, 525, 933, 946, 958, 964, 966, 994, Chiari II malformation 366, 1228
996, 999, 1001, 1241 chiasm 174
CDH (congenital chiasmatic cistema 174
dislocation of the hip ) 482 Chiba needle 1045
CDI (colour doppler imaging) 1218 child abuse 479, 480
CDR (computed digital radiography)1218 childhood stroke 624
celiac plexus block 165 chlamydia 1001
celiac trunk 820 Chlamydia trachomatis 1286
cellular fibroadenomas 631 choanal atresia 240, 536
cemental dysplasia 285, 287 - polyps 243
cementum 265 cholangiography 1044
central incisors 266 cholangitis 1328
cephalic vein 824 cholecystitis 1051, 1091
cephalometric projection 263 cholecystographic contrast media 133
XXII
INDEX
choledochal cyst cleft palate 500

587, 588, 1056, 1226, 1228 cleidocranial dysplasia 272, 274
cholelithiasis 573,589 clemastin 130
cholesteatoma 234 clinodactyly 489
cholesterol embolism 825 clonorchiasis 1283
cholesterolosis 1053 Clonorchis sinensis 1283
chondral fracture 408 closed fracture 384
chondrification 297, 298, 363 Clostridium difficile 1093
chondroblastoma 452 club foot 485, 498, 500
chondrocalcinosis 440 cluster of malignant calcifications 660
chondrodysplasia punctata 498 CM V colitis 1327
chondroectodermal dysplasia 493,498 CMV (cytomegalovirus)
chondrolysis 517 465,920,967,1315
chondromatous tumors 452 CMV oesophagitis 920
chondrosarcoma 290, 452 congenital hepatic fibrosis 594
chordal rupture 794 CO^ insufflation 1098
chordoma 204, 359 coagulative systems 128
choriocarcinoma 1224 coalition 491
choroid plexus papilloma 201 coarctation of the aorta 561, 563, 694
- plexus cyst 1230 cobblestoning 959
chronic aortic insufficiency 798 Coccidioides immitis 1319
- arterial occlusive disease 825 coccidioidomycosis 343
- bronchitis 711,713 cochlea 230
-cholecystitis 1053, 1100 cochlear aqueduct 230
- cystitis 1177 coeliac angiography 1020
- glomerulonephritis 1155 - disease 950, 969
- ischaemia of the bowel 984 coherence scattering 23
- lung diseases 728 cold injury 479
- nephrosclerosis 1155 colitis 1093
- osteomyelitis 443 collagen disorder 522
- otitis media 233 - vascular disease 750, 751, 801
-pancreatitis 1069, 1092 collar-stud ulcer 996
- pyelonephritis 1151 Colles fracture 389
- renal failure 933 collimator 62
- rickets 526 colloid intravascular contrast media 135
- sclerosing osteomyelitis 277 colloid cysts 201
- suppurative osteomyelitis 277 colonic adenoma 1008
chylothorax 698 - cleansing enema 987
chylous exudate 698 - diverticula 989
Ci (Curie) 29 - epithelial polyp 1006
cine CT 60, 775 -haemorrhage 1022
- angiography 773 -volvulus 1101
- fluorography 53 colonoscopy 1006
circle of Willis 174 colorectal carcinoma
circular constrictions 489 (CRC) 888, 1005, 1008
circumflex artery 787 colour-Doppler 818
circumvallate papillae 249 colour-flow Doppler 589
cirrhosis 1034 colour flow imaging (CFI) 71, 1218
cisplatin 154 colour Doppler imaging (CDI) 1218
cisternography 174 colpocystourethrography 1179
clavicle 403 column of Bertin 1144
cleft lip 1226 columnar-lined oesophagus 916
XXIII
comedo-type 654, 658 coronary angiography 781, 798, 799

comminuted fracture 187, 385 coronary artery abnormalities 569
common iliac artery 820 - fistula 569
- carotid artery 819 corrected transposition of the
communicating vein 821, 822 great vessels 567
communication network 112 corrosive gastritis 933
compensatory emphysema 713, 764 cortical necrosis 1156
complement systems 128 costocervical tmnk 820
complete fracture 385 costochondral osteochondritis 695
complex odontoma 283 costophrenic angle 684, 698, 700, 72
compound odontoma 283, 285 coxa valga 440, 484, 488, 505
compression fracture 386,388,402 coxa vara 488, 490
Compton scattering 23, 24, 40 CPPD crystal deposition disease 441
computed digital radiography craniocervical junction abnormalities 364
(CDR) 1218 craniofacial dysostosis 274
computed tomography (CT) 18,54 craniopharyngioma 224, 225
computerized axial imaging 18 CRC
congenital anomalies 488 (colorectal cancer) 888, 1005, 1008
- arteriovenous fistula (AVF) 843 CREST syndrome 901,094
- AV-malformation 861 cribriform 658
- cyst 250 cricoid lamina 257
- dislocation of the hip (CDH) 482 - cartilage 257
- fibromatosis 530 cricopharyngeal bar 893
- heart disease (CHD) 489, 558 - prominence 897
- lobar emphysema 544, 713 - webs 898
- pseudoarthrosis 486 crista supraventricularis 786
- short femur 488 CRL (crown rump length) 1220
- spinal malformations 360 Crohn's disease (CD)
- ureteropelvic junction 596 478, 525, 933, 946, 964,966,
congestive heart failure 802 994, 996, 999, 1001, 1241
Conn's syndrome 1209 Crookes William 6
Conradi-Hunerman 498 Crookes tube 5
consolidative pneumonia 547 croup 537
constipation 1017 crown 265
containment of the hip 515 crown rump length (CRL) 1220
continuous wave mode (CW) 70 CRT (cathode ray tube) 62
contracture 489 cryptococcal disease 1313
contracture syndromes 484 cryptococcal meningitis 1315
contrast 43 cryptococcosis 343, 736
contrast media kinetics 122 Cryptococcus neoformans 1319
- media for roentgen rays 116 Cryptosporidium 967
- resolution 55, 106 CSF fistula 192
contusion injuries 188 - oligoclonal bands 219
- o f lung tissue 757 - spaces 618
conus medullaris 350 CT (computed tomography) 18
conventional tomography 18 CT angiography 59, 1029
Cooper's ligament 653 - arthrography 376
copper 37 - myelography 318
copper deficiency 527 - number 58
cord 298 -portography 1029,1037
corkscrew oesohagus 904 cubital fossa 824
comer fracture 479 Curie (Ci) 29
XXIV
INDEX
Cushsing's syndrome 224,1208 demyelinating diseases 214

cutaneous паеvi 368 demyelination 215
-am oebiasis 1245 dens 299
-leishm aniasis 1293 dens invaginatus 271
CW (Continuous Wave Mode) 70 dense breast 630,645
cyanosis 563,568 density 49
cyanotic CHD with decreased dentigerous cyst 279, 280
pulmonary blood flow 563 dentin 265
- CHD with increased dentino-enamel junction 265
pulmonary blood flow 566 dentinogenesis imperfecta 272
cylindrical bronchiectasis 715 depression fracture 186,386
cyst 1072 dermatomyositis 751
cystic adenomatoid malformation dermoid 203, 220, 222, 250, 705, 802
(CAM) 545 descending aorta 819
-bronchiectasis 715 desmoplastic reaction 1173
- degeneration o f the adventitia 835 destructive spondylarthropathy 336, 343
-fibrosis 583 -brain damage 616
-h ygrom a 259,552 detection rate of breast cancer 664
- lung disease 544 - bias 663
-teratom a 1232 developmental dysplasia
cysticercosis 213,1304,1305 of the hips (DDH) 482
cystitis 1177,1252 diabetes mellitus 728,1156
cystograpahy 1116,1178 diagnostic ultrasound 64
cystoides coli 1005 - peritoneal lavage (DPL) 951
cysts of the jaw 279 diaphragm 691
cytomegalovirus diaphragm injury 761
(CMV) 465,920,967,1315 diaphragmatic hernia 544
-oesophagitis 1326 diaphyseal fracture 468,475
D/A converters 104 diastematomyelia 361,365,367,386
D. medinensis 1302 diastolic closure rate (DCR) 796
DALY (Disability-adjusted diastrophic dysplasia 498
life years) 87,88 dicheiria 489
darkness level 108 Die Presse 10
DCBE (double contrast diethylene-triamine-penta-acetic-acid
barium enema) 986 (DTPA) 136,138
DCBM (double-contrast diffuse generalized pulmonary
barium meal) 925,926,933 disease 736
DCIS (ductal carcinoma in situ) 658 - oesohageal spasm 904
DCR (diastolic closure rate) 796 - pulmonary fibrosis 743
DDH (developmental dysplasia digital fluorography 54
of the hips) 482,483,484 - fluoroscopy 54
decay constant 30 -im age 101
decompensated aortic stenosis 791 digital image plates 104
deep femoral artery 820 - mammography 632
- femoral vein 822 - matrix 53
-p alm ar arch 821 - subtraction device 39
-p lan tar vein 821 - projection radiograph 56
- vein thrombosis (DVT) 845,1233 -radiography 53,371
degenerative disease 317 - radiological unit 111
-jo in t disease 421 - subtraction angiography
- disc disease 338 (DSA) 54, 108, 171, 817
deglutition 896 dilated cardiomyopathy 791
XXV
dimer 118 - outlet right ventricle 567

dimple 361 Down's syndrome 584, 1226
diphenhydramine 129 doxorubicin 154
dipyridamole 853 DPL (diagnostic peritoneal lavage) 951
direct fluoroscopy 51 dracunculiasis 1302
- pyelography 1115 drill catheter 857
- radiography 48 dromedary hump 1144
- splenoportography 1075, 1078 drooping lily sign 1159
dirofilariasis 1302 drowning 741
disability-adjusted life years (DALY) 87 drug abuse 445
disc 300 drug-induced oesophagitis 921
disc height 340 DSA (Digital Subtraction
- herniation 323, 325, 327, 332, 333 Angiography) 54, 108, 171, 817
- pseudoarthrosis 348 DTP A (diethylene-triamine
- space 338 penta-acetic-acid) 136, 138
- space narrowing 341 dual energy x-ray absorptiometry
discography 321,370 (DXA) 524
dislocation of the elbow 399 duct ectasia 653
- o f the hip 407 - of Santorini 1067
- of the patella 408 - of Wirsung 1067
displacement 388,415 ductal carcinoma 654
disruption o f the anterior ductal carcinoma in situ (DCIS) 658
cruciate ligament 409 ductectasia 657
dissecting aneurysm 829, 836, 838, 839 ductography 628
dissection o f the intima 813 ductus arteriosus 560
disseminated intravascular Dukes classification 1009
coagulation 770 dumb-bell neurinoma 356
distal interphalangeal (DIP) joint 436 duodenal atresia 577
diuresis renography 1124,1173 - carcinoid tumour 953
diverticula 898, 993, 1175 - disease 944
diverticular disease 989 - diverticula 952
diverticulitis 990, 991.993 - haematoma 951
diverticulosis 990 - laceration 950
Doppler 589 - lymphoma 953
Doppler angle 70 - neoplasm 953
- echocardiography 782, 797 - nodular filling defect 946
- effect 69 - perforation 950, 951
- frequency shift 70 - stenosis 577
- pressure measurement 809 - ulceration 577, 948
- sonography 69 duodenography 1061
- transducer 69 duodenojenunal junction 580
- ultrasound 64 duplex ultrasound scanning 818
dorsal dermal sinus 361,366 - scanning 71,817
dorsalis pedis artery 820 duplication of the renal
dose rate 32 collecting system 1159
dose equivalent 31 DVT (deep vein thrombosis;) 845, 1233
double aortic arch 536,571 dwarfism 498
- bubble 579 DXA (dual energy x-ray
- contrast barium enema (DCBE) 986 absorptiometry) 524
- meal (DCBM) 1925, 926, 933 dynamic contrast study 1068
double halo 958 dysentery 1285
- limb 489 dysfunction of swallowing 896
XXVI
INDEX
dyskinesis 799 emission computed tomography 63

dysmyelination 214 emphysema 711
dysostosis mandibulo-facialis 233 emphysematous bullae 680, 703
dyspepsia 928 - cyst 703
dysphagia 892, 893, 898, 930 empty sella 224, 225
dysraphism 352 empyema 212, 701, 702, 728
dysthyroid myopathy 222 enalpril 1132,1133
E. coli 442, 728 encapsulated fluid 700
E. coli infection 1001 encephalitis 623
E. granulosus 1260 enchondroma 451,452,552
E. histolytica 1239 end plate 340
E. multilocularis 1260 endo-anal sonography 1018
E. oligarthrus 1260 endocardial cushion defect 561
E. vogeli 1260 - fibroelastosis 569
EAR (European Association endocrine tumour 1066, 1072
of Radiology) 15 endoderm 297
early gastric cancer (EGC) 938 endoluminal ultrasound 988
Ebstein anomaly 564 endometrial carcinoma 1202
ebumation 341 - chocolate cyst 1232
ECG gated spin echo imaging 775 endometriosis 1012,1205
ECG gating 680 endomyocardial fibrosis 801
echinococcosis 1260 endoscopic gastrostomy 158
echo time (ТЕ) 80,1085 - retrograde cholangiography
echo-encephalography 188 (ERC) 155,1045
echocardiography - cholangiopancreatography
557, 564, 680, 781,793,838 (ERCP) 1061, 1064, 1065
eclampsia 1233 - ultrasound (EUS)906, 909, 910, 928
ectoderm 297 endoscopy 892
ectopic islet-cell tumour 953 endosonography 1018
-pregnancy 1222, 1223 energy 20
- ureter 598 Entamoeba histolytica 736,1239
- ureterocele 599 enteric cyst 553,579
EGC (early gastric cancer) 938 - duplication 553
Ehlers-Danlos syndrome 836 - neo-bladder 1185
Eisenmenger physiology 558 - stricture dilatation 1024
ejection fraction 791 - tube 1025
Eklund views 642 enteritis 1093
electrical injury 479 enterocele 1018
electrocardiogram 557 enteroclysis 955,956, 961
electrocardiographic (ECG) gating 680 enthesitis 437
electromagnetic (em-) radiation 20 entrapment syndrome 835
electron shells 20 enzyme kinetics 173
electron 19, 28 eosinophilia 1281,1304
Ellis van Creveld syndrome 498 eosinophilic enteritis 964
embolism 681 - gastritis 933
embolization 150,1041,1109 - granuloma 529
embolization of plaque 813 ependymoma 197, 207, 351,356
- procedures 861 epidermoid 203
- therapy 150 epidermoid cyst 250
embolotherapy 1021 epididymitis 1195
embryonal tumors 352 epidural hematoma 621
EMI-scanner 54 epidural space 323
XXVII
epiglottis 537, 538 extracorporeal shock wave lithotripsy

epilepsy 615, 621 (ESWL) 163
epinephrine 129, 130 extradural haematoma 191
epiphrenic diverticula 922 - tumors 359
epiphyseal injury 468 extrarenal haematoma 1159
epiphysis 461,468,469 extrauterine pregnancy (EUP) 1107
epithelial proliferation 656 extremity-preserving surgery 450
epitympanon 230 extruded disk 325
equinous deformity 485 facet joints 299
ERC (endoscopic retrograde facetectomy 334
cholangiography 155,1045 facial cleft 274
ERCP (endoscopic retrograde facial hemiatropathy 274
cholangiopancreatography - nerve schwannoma 236
1061, 1064, 1065 - skeleton fractures 244
Erlenmeyer flask 508 Fallopian tube recanalization 163
erosion 434, 440 false aneurysm 836
erosive degenerative disc disease 343 - diverticula 922
- gastritis 932 familial adenomatous
- osteochondritis 336 polyposis (FAP) 942, 953, 1008
erythema nodosum 748 fast screens 50
erythrocytcylinduria 1174 fat necrosis 649, 657
erythrocytes 128 - pad sign 399
Escherichia coli 442, 728 fatigue fracture 418
ESWL (extracorporeal shock fatty marrow 342
wave lithotripsy) 163 - infiltration 1039
ethanol 151 FDG-glucose 881
ethibloc 863 female genital organs 1198
ethmoid air cells 239 femoral vein 821
EUP (extrauterine pregnancy) 1107 - head coverage 516
European Association femorotibial rotation 408
of Radiology (EAR) 15 femur length 1220
EUS fetal abnormality 1221, 1225
(endoscopic ultrasound)909, 910, 928 - adrenal haemorrhage 1227
eustachian tube 247 - urine 1230
evacuation proctography 1015 fibre optics 856
Ewing sarcoma 529, 552, 555 fibreoptic-endoscopy 1108
excited electrons 104 fibrinolysis 805, 846, 858
exit dose 33 fibrinolytic systems 128
Exner 10 fibroadenolipoma 649
exostoses 287 fibroadenoma 649, 657
expiratory frontal view 671 fibrocystic changes 645
exstrophy of the bladder 602 - disease 645, 653, 657
extension 301 fibrodysplasia ossificans
extension injury 311 progressiva 522, 523
- tear-drop fracture 313 fibroglandular tissue 643
- iliac artery 820 fibrolipoma 361
extension iliac vein 822 - of the filum terminale 366
- herniation 1095 fibromuscular hyperplasia 1131
extra nipple 647 - dysplasia 833
- digits 489 fibrosing alveolitis 743
extraadrenal pheochromocytoma 1211 fibrosis 732, 804, 960
extraaxial infratentorial tumours 201 fibrotic reaction 653
XXVIII
INDEX
- stricture 960 fracture-dislocation 392,395

fibrous dysplasia 285,552 fracture-dislocation of the elbow 399
fibula 409 - h ip 407
field size 34 - Lisfranc joint 416
filariasis 698, 1299 - tarsometatarsal j oint 416
film contrast 629 fragmentation of the femoral head 514
filtration 37 frequency 20
filum terminale 350 frequency spectrum 83
- syndrome 361 frontal sinus 238
fine needle aspiration biopsy (FNAB) Frostberg's sign 1061
456,631,633,651,1025,1037,1073 frostbite 479,528
fistula 455, 702, 962 FTG-glucose PET Scanning 886
flattening of the femoral head 514 full spectral display 70
flexion 301 functional luteal cyst 1232
flexion injury 310 fungal disease in HIV 1319
- tear-drop fracture 310 - pneumonia 736
fluid overload 570 - spondylitis 342
fluorogram 52 funnel-shaped sternum 693
fluorography 52 fusion anomaly 1136
fluoroscopy 18, 671, 672 GA (gestational age) 1221
FNAB (fine-needle aspiration biopsy) gadolinium compounds 137
456, 631, 633, 651, 1025, 1037, 1073 galactocele 650
focal disc bulge 325 galactography 628,636
-hyperplasia 1032 Galeazzi fracture 399
- neurological signs 194 gallbladder carcinoma 1054
- nodular hyperplasia 1032 - disease 589
focus 36 Gallium 67 scanning 63, 881, 884
folds of Kerkring 1097 gallstone 589, 1044
follow-through examination 954 gallstone disease 1048
Fontaine classification 824 -ile u s 1100
foot deformity 485 gamekeeper's thumb 397
foramen magnum 366 gamma 49
- ovale 821 gamma camera 28, 61
- of Luschka 207 -photons 61
- of Magendie 207 - quantum 22, 29
forearm 389 - radiation 17, 20, 29
fossa of Rosenmiiller 247, 248 -ra y s 61
fracture 384 gammascintigraphy 1046
fracture of the acetabulum 406 gangliocytoma 201
- femoral neck 404 ganglioglioma 201
- femoral shaft 407 ganglion cells 584, 605
- fibula 409 ganglioneuroblastoma 605
- intertrochanteric region 404 ganglioneuroma 605
- olecranon 399, 401 gangrenous cholecystitis 1091
- patella 408 Gardner's syndrome 272, 953, 1008
- pubic rami 406 Garre osteomyelitis 443
- radial head and neck 399 gasless abdomen 997
- rib 755 gastric atrophy 933
- sternum 756 gastric carcinoma 938
- tibia 409 - diverticula 936
fracture in transverse processes 315 - lymphoma 943
fracture of the vertebral body 315 -retention 1097
XXIX
- rotation 929 glucoerebroside hydrolase 508

- u lc e r 577,933,937,938 glucosylceramide 508
gastritis 932 gluteal artery 820
gastro-oesophageal reflux glycogen storage disease 569
(GOR) disease 575, 893, 898, 911 goitre 707
gastrocnemius vein 821,822 Goodpastures syndrome 1156
gastrografin 925,1104 Goodspeed A.W. 8
gastrointestinal bleeding 1108, 1109 GOR (gastro-oesophageal reflux)
- haemorrhage 1019 575, 893, 898,911,916
- reflux 573 Gorlin's syndrome 281
gastro-oesohageal reflux 901 Graf 482
Gaucher disease 508,516, 522 graft-versus-host disease (GVHD) 964
gauss 73 gram negative pneumonia 728
gay bowel syndrome 1327 - infections 728
Gd-BOPTA 139 granulation tissue 339
Gd-DOTA 139 granulation 336
Gd-DTPA 136, 138 granuloma 209
Gd-DTPA-BMA 139 granulomatous colitis 999
Gd-EOB-DTPA 139 GRE sequences 338
Gd-HP-D03A 139 great saphenous vein 821
GE-sequences 338 green light 49
gelatin sponge 1021 greenstick fracture 385,476
gelfoam 150, 151,863, 1021 Greulich and Pyle 467
general anesthesia 534 grey matter 170
generations of CT scanners 55 grid 40
genetic counseling 493 gross needle biopsy 1190
geniculate ganglion 230 growth disturbance 465, 468
genioglossus muscle 249 - lines 462
geniohyoid muscle 249 -plate 461,468
genital hernia 1180 - injury 474
geographic lesions 338 -ra te 617
germ-cell tumor 552 Grtintzig, Andreas 804
germinal tumor 707 guided fine-needle biopsy 1040
germinoma 356 guinea worm infection 1302
gestational age (GA) 1221 GVHD (graft-versus-host disease) 964
giant cell granuloma 288 haemangioblastoma 202, 207, 354
- tumour 288, 452 haemangioma 361, 452, 552, 1032
Giardia Iambiia 1280 haemangiopericytoma 220
giardiasis 966, 1280 haematological effects 123
gibbus formation 336,337, 341 haematoma 649
glenohumeral dislocation 402 haematotympanon 235
glioblastoma 199 haematopoietic marrow 342
glioblastoma multiforme 197 haematuria 1174
glioma 197 haemobilia 1073
glomerular filtrate 1127 haemochromatosis 1210
- filtration rate 1122 haemodialysis 831,864
glomerulonephritis 1156 haemoglobin 182
glomus jugulare tumors 236 haemoperitoneum 951
- tumours 236 haemophilia 440,1156
- tympanicum 236 Haemophilus influenzae
- vagale 237, 260 442, 538, 549, 728
glucagon 900 haemopneumothorax 757
XXX
INDEX
haemoptysis 675, 772 higher energy shell 19

haemorrhage 624 hilar enlargement 709
haemorrhagic effusion 698 Hilgenreiner line 482
- lesion 623 Hill-Sach's defect 402
- necrotic pancreatitis 1068 hilum 688
- pancreatitis 1067 hindbrain 366
- pleural fluid 703 hindgut 583
haemosiderin 182 hip effusion 511
haemothorax 755,757 Hippel-Lindau syndroem 1211
hairy tuft 361 Hirschsprung disease 584
half-life 30 HIS ("Hospital Information System") 110
halo 650 histamine 128
hamartoma 226, 649, 942, 1145, 1214 histiocytosis X 452, 529, 552
Hamman-Rich disease 743 Histoplasma capsulatum 736, 1319
Hand-Schtiller-Christian disease 529 histoplasmosis 747, 966, 1210
hang-man fracture 311 Hittorf J.W. 6
hard palate 249 Hittorf vacuum tube 5
head circumference (HC) 617, 1220 HIV infection 920
head and neck tumors 888 - leukoencephalopathy 1314
headache 621 - myelopathy 1316
healing of diaphyseal fracture 476 - polyneuropathy 1316
heart failure 568 HLA-B27 346
- surgery 765 Hodgkin's disease
heart volume 789 874,882, 884, 1215,1323
Heliobacter pylori 929, 968 Holt Oram syndrome 508
helminthoma 1282, 1283 honeycomb lung 743
hemiazygous vein 823 hookworm infestation 968,1281
hemimelia 488 hormone replacement therapy 643
hemimyelocele 365 horseshoe kidney 594
hemiplegia 623 Hospital Information System (HIS) 110
hemivertebra 365, 368 hot balloon 856
Hensen's mode 297 hot tip 856
heparin treatment 845 Hounsfield unit (HU) 58
Heparin 865 HPS (hypertrophic pyloric stenosis) 577
hepatic venography 1031 humeral shaft fracture 401
- bleeding 1041 Hurler form (MPS IH) 511
hepatitis В 1034 hyaline membrane disease 465
hepatobiliary scinitgraphy 588 hydatid cyst 1262
hepatocellular carcinoma 1034 hydatid disease 1260,1262,1266
hepatoma 1034 hydatidiform mole 1224
hepatosplenomegaly 594 hydranencephaly 1226
herpes simplex encephalitis 213 hydrocele 1195,1196
- oesophagitis 920 hydrocephalus 192, 611, 617, 618
herpes virus 734 hydrocortisone 130
herpes zoster 734 hydrogen nuclei 73
Herz (HZ) 20 hydromyelia 352,368
heterotopic gastric mucosa 946 hydronephrosis 573, 596, 1150
hiatus hernia (HH) hydrosalpinx 1206
573, 575, 696, 893, 916, 918, 929 hyoscine butylbromide 900, 925
HIDA 928 hyperaeration 549
high resolution CT 675,714 hypercementosis 287
high-energy photons 25 hyperemia 434, 440, 462, 519
XXXI
hyperextension 311 - manipulation 106

hyperextension fracture 311 - quality 42
- injury 311 -subtraction 108
hyperinflation 542,713 imaging geometry 41
hyperodontia 272 - plates 53
hyperoxaluria 1155 immobilization device 459
hyperparathyroidism 262, 526, 527, 831 immunoblastic sarcoma 1323
hyperplasia of the coronoid impaction fracture 386
processes 272 imperforate anus 489, 583
hyperplasia of the face 274 impotence 1197
- maxillary tuberosities 272 incisive foramen 266
hyperplastic cholecystosis 1053 incomplete abortion 1223
hypertension 791, 1131 -fracture 385
hyperthyroidism 222 incontinence 1018
hypertrophic cardiomyopathy 792 increased intracranial pressure 619
- gastritis 933 - intracapsular pressure 432, 444
hypertrophic pyloric stenosis (HPS) 577 incus 230
- synovitis 445 indirect splenoportography 1075, 1078
hypoalbuminemia 661 indium-labeled leukocyte
hypodontia 272 scintigraphy 337
hypoglossus muscle 249 infantile polycystic kidney disease
hypokinesis 799 (PCKD) 594
hypopharyngeal carcinoma 257 infarct 799
- diverticulum 898 infarction 621, 1210
hypopharynx 249,257 infection 528
hypophosphatasia 500,527 infectious adenopathy 553
hypophosphatemic rickets 525 - gastric lesion 1326
hypoplasia of the face 274 - oesohagitis 920
- fibula 490 infective discitis 348
- iliac bones 440 inferial orbital fissure 176
hypoplastic left heart 1226 inferior mesenteric artery 820
hypothalamus dysfunction 224 - ophthalmic vein 176
hypothyroidism 467,517,1017 - vena cava 823,824
hypotonic drug 900 infertility 1206
hypotympanon 230 infiltrating epitheliosis 655
hysterosalpingography 1117,1206 inflammation 447,647
Hz (Herz) 20 inflammatory aneurysm 839
1-123 SAP (serum amyloid P - bowel disease (IBD) 994
component) 1031 - carcinoma 661
IBD (inflammatory bowel disease) 994 - disc degeneration 343
ICRP (International Commission on - spine process 337
Radiological Protection) 97 influenza 549
idiopathic arteritis 1291 influenza А, В, С 734
- bone cavity 274 infraction 531
- endomyocardial fibrosis 1290 infrared radiation 20
- respiratory distress syndrome 540 - imaging 17
ileocolic intussusception 1109 - photon 25
ileus 582 infratentorial tumours 192
iliolumbar artery 820 infundibulum 174
image compression 111 inguinal ligament 822
- communication 112 inhalation of gases 742
- intensifier 39, 52 initial hematuria 1174
XXXII
INDEX
inner ear malformation 232 - volume 617

innominate artery compression 536 intraductal carcinoma 636, 656, 658
instability 301 intradural extramedullary tumors 354
insufficiency fracture 418, 446 - lipomas 366
intensifying screens 49 intramedullary metastases 351
interactions of electrons 22, 24 - tumours 351
- photons 22 intramural bleeding 1097
- radiation 19 -g as 582
- ultrasound 26 - haematoma 951
interactions of X-rays 21 intranuclear cleft 341
Interamerican College of Radiology 15 intraoral radiography 263
intercostal artery 820 intraorbital expanding lesions 219
interfacetal dislocation 310 intraosseous phlebography 816
interlobar pleural fluid 680 intraparenchymal haematoma 1037
intermediate growth 450 intraperitoneal seeding 974
internal auditory canal 230 intrarenal haematoma 1159
- herniation 1095 - haemorrhage 1158
- iliac artery 820 intrathoracic stomach 930
-jug u lar vein 824 intravenous cholangiography 1044, 1055
- mammary artery 820 - urography (IVU) 1111
- pudendal artery 820 intraventricular bleeding 189
International Commission on - haemorrhage 625
Radiological Protection (ICRP) 97 - meningiomas 197
International Lung Cancer intravesical ureterocele 599
TNM Staging System 886 intussusception 573, 585, 1098, 1099
International Society of Radiology invagination 1095
(ISR) 15 invasive lobular carcinoma 655
interosseous artery 820 inverted 3-sign 1061
interpedicular distance 495 ion-imbalance 120
intersegmental arteries 298 ionic contrast media 119
interstitial edema 540, 543 ionization chamber 31
- fibrosis 543 ischaemia of the small intestine 983
- opacity 737 ischaemic brain damage 625
intervertebral disc spaces 347 - cardiomyopathy 791
-jo in ts 323 - heart disease 799
intestinal duplication 579 - lesion 623
intimal hyperplasia 866 - necrosis of bone 432
intra-abdominal injury 1108 ischiopubic synchondrosis 461
intra-peritoneal gas 1087 islet-cell hyperplasia 949
intra-uterine infection 620 isometric phlebography 816
intraarterial stents 861 isotope cystography 592
intraaxial infratentorial tumours 205 isotope imaging 17
intrabulbar tumours 220 - scanning 784
intracapsular bleeding 1078 ISR (International Society
intracerebral calcifications 168 of Radiology) 15
- haemorrhage 625 ivalon 150, 151,863
- haematoma 181 IVP (intravenous urography) 1111
intracortical striations 525 IVU (intravenous urography) 1111
intracranial air 187 J-guidewire 811
- haemorrhage 619 Jaccoud's arthropathy 441
- medulloblastoma 356 Jansen form 501
- pressure 186 jaundice 607
XXXIII
JCA (juvenile chonic arthritis) 438 - papyracea 245

JDMS (juvenile dermatomyositis) 522 laminectomy 334
Jefferson fracture 306, 314 Langerhans cell histiocytosis 529
jejunal diverticulosis 969, 977 lanthanide screens 49
Jeune syndrome 499 laparoscopic cholecystectomy 157, 1045
joint capsule 433 large bowel ileus 1097
- disease 519 - volvulus 1101
- effusion 387 large cell carcinoma 720
- instability 422 Larmor equation 74
- laxity 408 Larmor frequency 74
- space reduction 440 Larsen syndrome 507
JRA (juvenile rheumatoid arthritis) 519 laryngeal movement 894
jugular bulb 230 laryngocele 257
juvenile angiofibroma 247 laryngotracheobronchitis 537
- arthritis 438 larynx 255,257
- chronic arthritis (JCA) 438 laser angioplasty 145,853,856
- dermatomyositis (JDMS) 522 lateral decubitus view 671
- polycystic disease of kidney - disc herniation 327
and liver 594 - hemivertebra 363
-p o ly p 1008 - periodontal cyst 279
- rheumatoid arthritis (JRA) 478, 519 - pharyngeal protrusion 899
Kaposi's sarcoma - pouches of Retzius 1085
(KS) 976, 1300, 1316, 1320, 1324 - recess 323, 330
karyotyping 1225 - segment 685
Katayama syndrome 1248,1255 - semicircular canal 230
Kawasaki disease 570 - spinal stenosis facet
Keats 461 hypertrophy 330
keratocyst 279, 281, 295 Lauge Hansen classification 412
Kerley A lines 739 LCIS (lobular carcinoma in situ) 659
Kerley В lines 568, 686, 739 LCP (Legg-Calve-Perthes
kerma 31 disease) 513,514,516
kidney-ureter-bladder survey Le Fort fracture 246
(KUB) 1111 lead grid 34,40
Killian's dehiscence 898 - lines 464
kinin systems 128 - time bias 663
klebsiella 339, 442, 754 leather bottle stomach 939
Klebsiella pneumoniae 728 Lecher 10
Klippel-Feil syndrome 364 left anterior descending artery (LAD) 787
Klippel-Treaunay syndrome815, 844, 852 - atrial enlargement 792
Kohler 461 - atrium 785, 787
KS (Kaposi's sarcoma) - auricle 795
976, 1300, 1316, 1320, 1324 - common carotid artery 820
KUB (kidney-ureter-bladder survey) 1111 - iliac artery 820
Kundt, August 3 - coronary artery 787
kyhposcoliosis 364.693 - subclavian artery 820
lacrimal gland 177 - ventricle 785, 787
lacrimal gland tumour 220 Left ventricular enlargement 791
lacunar infarction 177, 180 - failure 768
LAD (left anterior descending artery) 787 left-to-right shunt 709
Ladd bands 581 Legg-Calve-Perthes disease
Ladd operation 581 (LCP) 513,514,516
lamina dura 266 leiomyosarcoma 974, 1202
XXXIV
INDEX
Leishmaniasis 1303 low-energy photons 25

Lenard P. 5, 6 lower airway foreign body 555
length bias 663 - gastrointestinal haemorrhage 1021
Lennep 1 - oesophageal reflux 901
leprosy granulomas 1297 lucent band 503
leprosy 1297 - metaphyseal bands 465, 521
Leriche syndrome 827 lumbar artery 820
lethal dwarfism 1226 -lordosis 315
Letterer-Siwe disease 529 - nerve-rootblock 323
leukaemia - vein 823
221,555,521,528,552,611,880 - vertebra 691
leukemic lines 465 lung 685
leukocytes 128 lung abscess 728
leukopenia 503 -biopsy 771
ligamentous injury 397, 468 - cancer 720
-te a r 304 - infection 723
ligamentum flavum 301,323 - injury 757
light scanning 628 - transplantation 714
light photon 25 - tumour 554
line pair 44 (LIP) 1321

linear fractures 187 lymph node 645, 649
- opacity 745 - flow 875
- ulcer 914 lymphadenopathy 260
- striations 465 lymphadenopathy syndrome 1329
lingual thyroid 251 lymphangiography 874
lingular segment 685 lymphangioma 220, 552
LIP (lymphocytic interstitial lymphangitic carcinoma 722
pneumonitis) 1321 lymphatic malformation 843
lipiodol ultrafluid 132 lymphatic obstruction 687
lipohemarthrosis 405 lymphocytes 128
lipoma 204,366,452,552, 1011 lymphogranuloma venereum 1286
lipomyelomeningocele 366 lymphography 132
Lisfranc dislocation 416 lymphoma
liver cirrhosis 1040 201,220, 221,222, 244, 248, 289,
- failure 661 555, 647, 677, 707, 880, 972, 1329
- fluke 1283 lymphosarcoma 585
Loa loa 1299 M. leprae 1297
lobar pneumonia 725 M. avium-intracellulare 1319
lobectomy 764 M. kansasii 1319
lobular carcinoma in situ (LCIS) 659 M-mode 68
- calcification 658 M-mode 67
local aggressiveness 450 Mach band 650
- tumor extension 452 MacLeod's syndrome 713
localised dissecting aneurysm 839 macrocystic renal disease 594
loculi 700 macronodular hyperplasia 1208
long saphenous vein 821 Maffucci syndrome 506
longitudinal defects 489 magnetic field 73
- epiphyses 498 - examination 25
loop of Henle 1128 - field gradient 80
lordotic view 671 - imaging 17
low energy shell 19 - resonance 76
XXXV
Magnetic Resonance medial retinaculum 408

Angiography (MRA) 82, 171, 818 - segment 685
Magnetic Resonance Imaging (MRI) 72 mediastinal biopsy 771
Magnetic Resonance - bleeding 755
Spectroscopy (MRS) 83 - fibrosis 708
magnification technique 636 - injury 759
major interlobar fissure 684 - lesion 705
malabsorption 969 - mass 552, 680, 693
malaria 1303, 1304 mediastinitis 708
male genital organs 1191 mediastinum 687
malformations of the jaws 271 Mediterranean lymphoma 974
malformations of the teeth 271 medullary sponge kidney 1142
malignancy 446 medulloblastoma 207,357
malignant calcification 658 megacolon 1094
- disease 445 megalodactyly 489
- external otitis 237 megaureter 597
-lym phom a 882,1215 meliodosis 1289
- melanoma 220 membrane formation 297
- mesothelioma 746 MEN (multiple endocrine
malleus 230 neoplasia) syndrome 1211
Mallory-Weiss laceration 924 Menetrier's disease 933
malrotation 573,580 meningeal cysts 213
mammography 628, 630, 638 meningioma 193,203,354,357
mandible 249 meningitis 211,336,619, 621,623, 1315
mandibular canal 268 meningocele 360
- condyle 293 meningoencephalitis 336
mandibulofacial dysostosis 272 mental nerve 268
march fracture 419 mesenteric angina 984
Marfan syndrome 836 - venous thrombosis 984
massa lateralis 311 mesoblastic nephroma 1226
mast cells 128 mesoderm 298
mastitis 652,661 mesodermal abnormalities 507
maxilla 266 - defect 507
maxillary antra 240 mesomelic 493
- cuspid 270 mesothelioma 703,802
-sin u s 238 mesotympanon 230
maxillary zygomatic process 268 metabolic bone disease 524
MCDK (multicystic dysplastic - disease 447
kidney) 595 metabolism 173
McKusick form 502 metacarpal bones 396
meandering artery 843 metameric arteries 298
measurements 376 metaphyseal chondrodysplasia 501, 527
mechanical bowel obstruction 1095 - lines 464
-recanalisation 145 metaphysis 461, 468, 469
Meckel diverticulum 583, 585, 978, 979 metastasis 201, 206, 209, 220, 222, 289,
meconium 583 359, 647, 707, 722, 1012
meconium aspiration 540, 541, 542 metastatic nodal disease 885
- ileus equivalent 583 - disease 555, 650
- peritonitis 583 metatarsophalangeal joint 436
meconium-plug syndrome 583 metoclopramide 956,958
MED (multiple epiphyseal Mexican-hat sign 993
dysplasia) 440, 516 МНЕ (multiple hereditary exostoses) 504
XXXVI
INDEX
microcephaly 1226 mucosal necrosis 543

microcoils 151 - polyp 942
microcystic disease 657 mucous retention cysts 242
microcystic renal disease 499, 594 multicentric tumors 452
microfracture 422 multicystic kidney 1227
micrognathia 272 - dysplastic kidney (MCDK) 595
microinvasion 658 multilocular cystic nephroma 596
middle cerebral artery 179,184 - renal cyst 596
middle lobe 686 multiplanar imaging 338
middle mediastinum mass 707 multiple enchondromatosis 506
midgut volvulus 580,581 - endocrine neoplasia (MEN)
migrating polyarthritis 441 syndrome 1211
miliary tuberculosis 1302 - epiphyseal dysplasia
minor interlobar fissure 684 (MED) 440,516
missed abortion 1223 - exostoses 552
mitomycin С 154 - hereditary exostoses (МНЕ) 504
mitral orifice 787 -m yelom a 1156
- stenosis 793, 795 -sclerosis 215
-v a lv e 787 Murphy's sign 1091
- disease 792, 793, 795 muscle thickening 222
- prolapse 794 musculus levator palpebrae 176
Mn-DPDP 139 Mycobacterium
molar pregnancy 1222 tuberculosis 442, 730, 1316, 1318
molars 267 Mycobacterium avium intracellularae 967
molybdenum 29 Mycoplasma pneumoniae 733, 735
molybdenum tube 628 mycotic aneurysm 838
Mondini malformation 232 myelination 297
monochromatic gamma quantum 28 myelitis 218
monochromatic quantum 20 myelocele 360,365
radiation 22 myelocystocele 360,367
monoclonal antibody imaging 888 myelodysplasia 469,484
monomer 118 myelographic block 349, 356
Monteggia lesion 398, 399 myelography 318, 349
Morgagni hernia 697, 707 myelolipoma 1214
Morquio syndrome (MPS IV) 511 myeloma 289,880
moulage sign 969 myelomeningocele 360,365
MPS IV 511 mylohyoid muscle 249
MPS III (San Filippo form) 511 myocardial infarction 799, 802
MPS IH (Hurler form) 511 myofibromatosis 530
MPS (mucopolysaccharidoses) 493, 509 myopia 500
MR signal 75, 76 myxoma 801
MRA (magnetic resonance Monkeberg's medial sclerosis 831
angiography) 82,171,818 nasal fossa 267
MRI contrast media 136 - fracture 244
MRI (Magnetic Resonance Imaging) 72 - polyps 243
MRS (Magnetic Resonance - regurgitation 894
Spectroscopy) 83 nasopharynx 246
mucinous adenocarcinoma 1160 near-drowning 556
mucoceles 242 NEC (necrotizing enterocolitis) 582
mucoepidermoid carcinoma 289 Necator americanus 1281
mucoid degenerations 300 neck 258
mucopolysaccharidoses (MPS) 493, 509 necrotic pancreatitis 1067
XXXVII
necrotizing enterocolitis (NEC) 582 non-ionic contrast media 119

- external otitis 237 non-obstructive jaundice 155
negative contrast media 116, 135 non-odontogenic
NEMD (non-specific oesophageal developmental cyst 279, 281
motility disorder) 901, 904 non-renal retroperitoneal abscess 1190
neodynium yag-laser 856 non-specific oesophageal motility
neonatal adrenal hemorrhage 607 disorder (NEMD) 901,904
- hepatitis 588 - duodenitis 948
- meningitis 62 non-steroidal anti-inflammatory
-p neum onia 540,541,542 drugs (NSAIDs) 964
neoplastic adenopathy 553 non-tropical sprue 969
nephroblastoma 602 nonunion 477
nephrocalcinosis 1155 notochord 204, 297, 298
nephrographic phase 1111 NSAIDs (non-steroidal
nephronopthisis 499 anti-inflammatory drugs) 964
nephrostomy 1188 nuchal thickening 1230
nerve compression 331 nuclear medicine imaging 17
nerve-root compression 333 - cystogram 600
nerve-roots 327 - magnetic resonance (NMR) 17
net magnetic moment 74 nucleus 19
neural foramen 327 nucleus pulposus 300
- arch 299, 306 nutcracker oesophagus 904
- groove 297 nylon 854
neurinoma 203, 354, 357, 359 oblique eye muscles 176
neuroaxis 298 - talus 485
neuroblastoma 359,522,552,555, 605,607 -v iew 671
neuroblasts 605 obstetric ultrasound 1217
neuroembolization 154 obstructive hydronephrosis 1160
neurofibroma 220,507 -jaundice 155
neurofibromatosis (NF) obturator artery 820
354, 506,486, 552, 694, 1131, 1211 occipito-frontal diameter (OFD) 1220
neurogenic bladder 600,1178 occlusal caries 274
neurolation 297 occult spinal dysraphism 366
neurosonograhpic examination 613 odontogenic infection 276
neurosonography 625 - myxoma 283, 285
nevoid-basal cell carcinoma 281 - tumours 283
NF (neurofibromatosis) - fracture 315
354,486, 506, 552, 694, 1131, 1211 odontoid process 306
NHL (non-Hodgkin's lymphoma) - process 284, 299, 306
882, 884, 972, 1215, 1323 odynophagia 921
nipple retraction 653 oedema 660, 1003
Nitinol 146 oedematous pancreatitis 1068
NMR (nuclear magnetic resonance) 17 oesophageal atresia 489, 573
nocardial brain infection 1313 - bolus obstruction 910
nocardiosis 736 - carcinoma 907
nodular opacity 738 - diverticula 922
non-bacterial pneumonia 733 - duplication 576
non-cardiogenic congestion 741 - dysmotility 911
- edema 741 - foreign body 575
non-ectopic ureterocele 1160 - injury 913
non-Hodgkin lymphoma (NHL) - intramural pseudodiverticulosis 918
882, 884, 1215,972, 1323 - manometry 900
XXXVIII
INDEX
- motility disorders 901 osseous ankylosis 347

- perforation 923 - spina bifida 367
- rupture 759 - spinal abnormalities 363
- stricture 906 ossiculum terminale 364
- transit studies 900 ossification 297, 298
- varices 925 ossification anomalies 455
-w eb 916 - center 298, 461
oesophagitis in AIDS 1326 ossification of posterior longitudinal
oesophagitis 913,918 ligament (OPLL) 334
oesophago-gastro-duodenoscopy osteitis 441
(OGD) 891 osteoarthritis 421, 445, 456
oesophago-tracheal fistula 925 osteoarthrosis 421, 423, 430
oesphageal stenting 158 osteoarthrosis of the ankle 428
OFD (occipito-frontal diameter) 1220 - distal interphalangeal joint 429
OGD (oesophago-gastro- - elbow 429
duodenoscopy 891 - first metacarpal joint 429
Ogden 469 -h ip 427
01 (osteogenesis imperfecta) -knee 427, 428
478, 482, 488, 492, 502 - patellofemoral compartment 427
oligodendroglial tumours 197 -proximal interphalangeal joint 429
oligodendroglioma 199 osteoblast activity 373
oligohydramnios 1230, 1231 osteocartilaginous fragment 419
Oilier syndrome 506 osteochondral fracture 408
omovertebral bone 364 osteochondritis
onchocerca volvulus 1299 dissecans 415,419, 420, 518
oncocytoma 1146 osteogenesis imperfecta
onion-peel appearance 449, 450, 451 (OI) 478, 482, 488, 492, 502
opaficied sinus 244 osteogenic sarcoma 289
open fracture 384 osteoid osteoma 443
open-mouth projection 306 osteolysis 447
ophthalmic artery 176 osteolytic destruction 450
OPLL (ossification of posterior - lesions 168
longitudinal ligament) 334 - metastases 373
opposed phase GRE sequences 338 osteoma 287,452
optic chiasm 224 osteomalacia 525
-g lio m a 220,221,226,507 osteomyelitis 276, 277, 441, 442,449,
- meningioma 220, 221 454,469,522,531
- neuritis 216, 221 osteonecrosis 432, 445, 446
- nerves 174 osteonecrosis of the femoral head 407
- nerve canal 176 osteopenia 337,478
optical cables 112 osteopetrosis 286, 503
orchitis 1195 osteophytes 317, 333,423
organ ablation 152 osteoporosis 524
organ dose 33 osteoradionecrosis 276
orofaciodigital syndrome 272, 274 osteosarcoma 443,452
oropharyngeal swallowing 893 osteosclerosis 449
- dysphagia 896 ostium primum defect 561
oropharynx 246, 249 ostium secundum ASD 559
Ortolani maneuver 482 oval window 230
os odontoideum 364 ovarian cyst 1227
osmolality 120 ovarian malignancy 1232
osmotoxicity 120 ovarian tumor 1203, 1204, 1232
XXXIX
ovarian vein 823 paravertebral lesions 338

overgrowth 477 parietal pleura 683
overpenetrated film 671 Park lines 462
overriding of the aorta 563 Parkes-Weber syndrome 844
oxygen 130 parotid salivary gland 253
P. westermani 1287 particle radiation 20
packing deformity 486 PAT (percutaneous aspiration
PACS (Picture Archiving and thromb-embolectomy) 858
Communications Systems) 104, 110 patella alta 408
Paget's disease 286 patent ductus arteriosus (PDA) 560, 566
pair production 23 - foramen ovale 564, 566
palatal dysfunction 894 Paterson-Kelly syndrome 898
palatine tonsils 249 pathological fracture 478
palatoglossal arch 249 patient dose 30
palatoparhyngeal arch 249 PCKD (polycystic kidney disease) 594
Palmaz stent 861 PCNL (percutaneous
pampiniform plexus 823 nephrolithotomy) 1116
Pancoast tumor 721 PCP (pneumocystis carinii
pancreas annulare 1067 pneumonia) 736, 1316, 1317
- divisum 1067 PD (Pulsed Doppler Mode) 70, 71
pancreatic angiography 1065 PDA (patent ductus arteriosus) 560, 566
- island 1067 pear-shaped bladder 1177
- tumours 1070 pectin 131
pancreatitis 1051, 1064, 1091 pedicles 299
pancuronium bromide 1228 pelvic vein 823
panoramic radiography 263 pelvimetry 1234
panorex view 238 penetrating trauma 1108
papillary muscle rupture 794 peptic ulcer disease 576
- necrosis 1153 percutaneous abscess drainage 1024, 1190
- stenosis 1328 - aspiration thromb-embolectomy
papilloma 649 (PAT) 858
papillomatosis 636 - biopsy 1190
papillotomy 1059 - catheter drainage of the kidney 161
Papova JC virus 1315 - cholecystostomy 157
para-oesophageal hernia 929 - discectomy 370
paracardiac mass 680 - gastroenterostomy 158
paraganglioma 236, 237, 260, 1211 - gastrostomy 1025
paragonimiasis 1287 - litholysis 163
parahilar opacities 548 - nephrolithotomy (PCNL) 1116
parainfluenza 549 - nephrostomy 162, 1188
parallel protons 74 - neurolysis 165
paralytic ileus 1105 - porto-systemic shunting
paramagnetic contrast media 137, 341 (TIPPS) 1041
paranasal sinus 238 - pyelolysis 163
parapharyngeal tumors 260 - stricture dilatation 1190
parasellar tumours 192 - sympathectomy 165
parasitic brain infections 214 - transcatheter embolization
paraspinal fluid abscess 338 of the renal artery 1187
- fluid collection 338 - thrombolysis 1187
parathyroid gland 261 - transhepatic cholangiography
paratyphoid infection 1284 (PTC) 154, 1045
parauterine mass 1232 - portography (РТР) 1031, 1066
XL
INDEX
-translum inal angioplasty (PTA) 143 phakomatoses 616, 620

- balloon angioplasty 853 phalangeal fractures 396
- coronary angioplasty - bones 396
(PTC A) 804 pharyngeal bar 897
- renal angioplasty - constrictors 249
(PTRA) 1186,1187 - foreign body 899
perforated ulcer 1094 pharyngocele 899
perforating vein 821 pheochromocytoma 1212
peri-ampullary duodenal carcinoma 953 phlebolith 844
perianeurysmal fibrosis 1173 phlegmasia cerulea dolens 849
periapical cyst 279 phocomelia 489, 508
- osteitis 276 phosphoethanolamine 500
- granuloma 276 photoelectric absorption 23
periarteritis nodosa 1156 photographic emulsion 48
peribronchial cuffing 548, 549 photomultiplier tubes 62
pericardial cyst 697, 707, 802 photon 19, 20
- disease 802 phrenic paresis 695
- drainage 806 Phrygian cap 1048
- fat pad 707 physeal fracture 468
- fluid 802 - injury 468
- tumor 802 physis 461,462,467
pericarditis 803,804 picket-fence pattern 983
pericardium 788 picture element 101
pericolic inflammation 992 picture archiving and communi
periductal fibrosis 653 cations systems (PACS) 104, 110
perimesencephalic cistern 203 PIE (pulmonary interstitial
perinephric space 1207 emphysema) 541,545
periodontal disease 278 piezoelectrical crystals 65
- ligament 266 Pigtail 812
periosteal pin hole imaging 514
elevation 475, 521, 526, 528, 530 pineal germ cell 201
- reaction 449, 451 pipe-stem colon 996
- membrane 450 pituitary microadenoma 1208
periostitis 449 - adenoma 224
peripheral embolisation 154, 813 - tumour 192
peripheral neuron 350 pixel 53,81, 101,57
peritoneal bands 581 placenta praevia 1231
peritonitis 1093 placode 365
perivascular fibrosis 829 plain film radiography 371
periventricular leukomalacia 624 plaques 216
peroneal artery 820 plasma cell myelomas 373
- vein 822 platelet activating factor 128
peroperative cholangiography 1045, 1055 platelets 128
peroral cholceystography 1042, 1047, pleueral metastases 555
1051 pleura 683
perpendicular periosteal reaction 449 pleural adhesion 732
perpendicular striations 451 - cavity 683
persistent corpus luteum cyst 1226 - effusion 539, 680
PET (Positron Emission -fluid 700,746,771
Tomography) 63, 64, 173, 881 - lesion 698
PET-camera 28 - plaque 745
Peutz-Jegher syndrome 942, 976, 1008 - transudate 698
XLI
- thickening 699, 702, 732 - fossa 205

plicae collicularis 601 -hemivertebra 363
Plummer-Vinson syndrome 898 - hernia 697
PML (progressive multifocal - longitudinal ligament 300,301, 325
leukoencephalopathy) 1315 - mediastinal mass 707
PNET 555 - rib fracture 480
pneumatosis coli 1005, 1088 - segment 685
pneumococcal pneumonia 726 - semicircular canal 230
pneumocolon 1098 - tibial artery 820
pneumoconiosis 744 - vein 822
pneumocystis carinii - urethral valve 601,1226
pneumonia (PCP) 736,1316,1317 posteroanterior radiograph 671
pneumocystogram 651 postinfectious encephalitis 623
pneumomediastinum postirradiation oedema 661
541,547, 556, 759, 761 - reaction 661
pneumonectomy 763 postoperative
pneumonia 723,770 cholangiography 1046,1055
pneumopericardium 547,759 - scarring 654
pneumoperitoneum 585, 1087 postthrombotic syndrome 850
pneumothorax 541, 547, 556, 582, 694, PRC reaction 889
703,704, 732, 757, 761,772, pre-diverticular disease 990
polyarteritis nodosa 751 precession 73
polychromatic radiation 22 precocious puberty 467
polycystic kidney disease 594 prednisolone 130
-d isea se 1033 preeclampsia 1233
polydactyly 489,496 premature closure o f the physes 440
polyethylene 854 presby-oesophagus 904
polyethylene-teraphthalate 854 prevertebral hematoma 304, 311
polyhydramnios 1230, 1231 primary adenocarcinoma 963
polyp 585,993 -aldosteronism 1209
polyposis syndrome 1008 - CNS lymphoma 1309
Polytechnic of Zurich 2 -lym phom a 1316
Polyurethane 854 - lung cancer 886
popliteal artery 820 - oesophageal peristalsis 901
- v e in 821,822 primitive neuroectodermal tumor 552
porcelain gallbladder 1053 progressive subacute HIV
porocephalosis 1301 encephalitis 1314
portal hypertension 589, 594 - multifocal
portal vein thrombosis 589 leukoencephalopathy (PML) 1315
positive contrast media 116 prolapse 325, 1018
positively charged electron 28 proliferative mastopathy 631
positron 28 prominent pulvinar 484
positron emission - colonic lymphoid follicle 1012
tomography (PET) 63, 64, 173, 881 - thymus 550
positron-emitting radionuclides 173 pronation-dorsiflexion 412
post-embolization syndrome 154 pronation-extemal rotation 412
post-myelography 361 prostaglandin 128,1132
post-traumatic epilepsy 616 prostaglandin therapy 528
postaxial polydactyly 489 prostate cancer 889,1193
posterior atlas 313 prostatic abscess 1192
- dislocation 402 prostatitis 1191,1192
- fat pads 399 proton density 75, 77
XLII
INDEX
proton density (PD) weighted imagesi 79 - haemorrhage 542

protons 73 - hydatid cyst 1266
protozoal pneumonia 736 - hypertension 558, 793, 794
protrusion 325 - infarction 722,723
provisional ossification 464 - infection 547
proximal caries 274 - insufficiency 794
- focal femoral deficiency 490 - interstitial emphysema
- interphalangeal (PIP) joint 436 (PIE) 541,545
pseudo-achalasia 904 - ligament 683
pseudo-allergic reaction 127 - orifice 786
pseudo-anaphylactic reaction 127 - perfusion studies 63
pseudoacetabulum 483,484 - pseudocyst 545
pseudoaneurysm 813 - sling 536,571
pseudobulbar palsy 896 - tuberculosis 693
pseudocyst 1072 -v ein 785
pseudohypoparathyroidism 467 - venous hypertension 569, 794
pseudomembrane 914 pulmonic valve 786
Pseudomonas aeruginosa 237, 728, 754 pulp chamber 266
Pseudomonas pseudomallei 1289 pulpitis 274
pseudopolyposis 996 pulse-spray method 859
pseudotumor 220, 550, 1144 pulsed Doppler mode (PD) 70,71
pseudotumoural plaques 219 pulsion diverticula 922
psoriatic arthropathy 437 pulsless disease 832
- arthritis 430, 433 punched-out ulceration 959
psycho-motor development 619 punctate erosion 914
- delay 619 pyelitis 1162
psychological deprivation 462 pyknodysostosis 504
psychosocial dwarfs 462 pyogenic spondylitis
PTA (percutaneous transluminal 336, 339, 340, 341,342
angioplasty) 143 pyonephritis 1163
PTC (percutaneous transhepatic pyramidal eminence 230
cholangiography) 154, 1045 pyriform sinus 257
PTC A (percutaneous transluminal pyrophosphate synovitis 440
coronary angioplasty) 804 quality control 667
PTP (percutaneous transhepatic quantum 19, 25
portography) 1031, 1066 RA (rheumatoid arthritis)
PTRA (percutaneous transluminal 421,430, 433,525,647
renal angioplasty) 1186, 1187 radial absence 489
pull-through method 868 - artery 820
pulmonary adaptation syndrome 539 - hypoplasia 489
- amoebiasis 1245 - scar 653, 655
- angiography 674 radiation enteropathy 986
- arterial disease 677 - induced oesohagitis 922
- arterial pressure 124 - nephritis 1156
- arterial stenosis 709 - protection 30, 33, 534
- arteriovenous malformation 677 radicular cyst 279
- calcification 731 radio frequency (rf-) radiation 26
- congestion 738, 739, 765, 769 - frequency interference pattern 26
- edema 738, 739, 769, 797 - waves 20
- embolism radiographic report 388
63, 680, 722, 723, 769, 846 radiography 18
- fibrosis 744, 750 radioisotope scanning 63
XLIII
radioisotopes 28 -dysplasia 1137

radiological measurements 110 - ectopia 594
- information system (RIS) 110 - failure 742
Radiological Society of North - fusion 594
America (RSNA) 15 - lymhoma 1149
radionuclide imaging 60 - tubular ectasia 594
radionuclides 60 - osteodystrophy 517, 52 7
radiopharmaceuticals 28, 60, 172 - retroperitoneal abscess 1190
radiotherapy 450 - scintigraphy 593
raised intracranial pressure 194 - transplantation 1156
Rashkind ballon atrial septostomy 566 -tuberculosis 1152
ratio 120 - vein 824
Raynaud phenomenon 829, 835, 836 -sam pling 1188
Raynaud's disease 835 -throm bosis 1136
Raynaud's syndrome 835 Rendu-Osler-Weber disease 844
RCA (right coronary artery) 787, 788 renin
rCBF 172 renovascular hypertension 1131, 1132
RDS (respiratory distress repetition time (TR) 79
syndrome) 540, 542 residual cyst 280
reactive arthritis 430, 433, 437 - thyroid tissue 251
- bone formation 449 -urine 1178
- fibrosis 654, 655 resolution 43
-p attern s of bone 447 resonance frequency 73
real-time scanners 69 respiratory syncytial virus 549
receptor kinetics 173 - distress syndrome (RDS) 540, 542
rectocele 1018 reticular opacity 737
recurrent incontinence 1180 reticulo-endothalial system 880
recurrent pneumonia 720 reticulonodular opacity 738, 745
reflux 911,918 retinoblastoma 220
reflux nephropathy 1151 retrieval of lost foreign bodies 149
- oesophagitis 902, 950 retrobulbar tumours 219
regional sclerosis 337 retrocalcaneal bursa 437
regurgitation 898 retrograde phlebography 815
Reiter's syndrome 433, 437 retrogressive differentiatioan 297
remodelling 477 retroperitoneal adenopathy 1149
Remscheid 1 -emphysema 1088
renal abscess 1150 - fat 697
- adenoma 1145 -fibrosis 851,1173
-agenesis 1136,1226 - fluid 951
- anomaly 489 -tum or 1173
- arteriography 1118 retrosternal goitre 705
- arteriovenous fistula 1135 reverse Colies fracture 390
-a rte ry 820 rhabdomyosarcoma 220, 222, 248, 552
- artery aneurysm 1134 rheumatic fever 441,794
- artery percutaneous - heart disease 793
angioplasty 1186 rheumatoid arthritis
- artery stenosis 1130 (RA) 421,430,433,525,647
- atrophy 1168 - disease 751
- biopsy 1135 rhino virus 734
- cell carcinoma 1146 rhinorrhoea 192
- contusion 1158 rhizomelic 493,498
- cystic disease 594 rib notching 563, 694
XLIV
INDEX
- fracture 694 sapphire tip 856

rickets 465,517,525 sarcoidosis 221,747,748,750
right aortic arch 536 SBE (small bowel enema) 955, 956
- atrial enlargement 793 SBO (small-bowel obstruction) 583, 980
- atrium 785 scanogram 56
- coronary artery (RCA) 787, 788 scaphoid fracture 395
- subclavian artery 819 scaphoid-trapezoid joint 429
-v entricle 785,786 scapholunate dissociation 437
- ventricular enlargement 793 scapula 403
- hypertrophy 563 scar tissue 328, 336
right-sided aortic arch 564, 688 scattered radiation 40
ring ulcer 964 SCFE (slipped capital
- apophysis 298 femoral epiphyses) 516,517
RIS (Radiological Schatzki ring 892, 893, 916
Information System) 110 schistosomal cirrhosis 1257
Roentgen, Wilhelm Conrad 1 schistosomiasis 1246
Rokitansky-Aschoff sinus 1053 Schwachman syndrome 527
Rolando fracture 395 schwannoma 260
root caries 274 scintillation crystal 61
root-canal 330,331 scleroderma 747, 1156
root-sleeve 318,331 sclerosing adenosis 657
Rotacs system 857 - agents 863
rotating device 857 - cholangitis 1056
rotator cuff 403 - osteogenic sarcoma 286
round window 230 - osteomyelitis 286
- pneumonia 549 sclerosis 341,423
roundworm infestation 968 sclerosis of the femoral head 514
RSNA (Radiological Society sclerotic lines 462
of North America) 15 -rim 450
rt-PA 853,859 scoliosis 318
Ruhmkorff induction coil 5 scout view 56
Ruhmkorff H.D. 6 screen-film combination 39
rupture of the diaphragm 755, 761 screening 51
S. haematobium 1246, 1247, 1249, 1252 screening for breast cancer 662
S. intercalatum 1247 scrotal enlargement 1195
S.japonicum 1247, 1254 sebaceous cyst 649
S. mansoni 1247, 1254 secondary achalasia 904
S. mekongi 1247 - lobule 686
S. stercoralis 1279 - oesophageal peristalsis 901
saccular cyst 257 - peritonitis 1091
sacral agenesis 364 sedation 534,613
sactosalpinx 1206 seizures 194
sagittal measurement 309 Seldinger technique 811
salivary gland tumors 255 self selection bias 663
salivary glands 252 self-expandable stents 146
salmonella 339,968 sella turcica 174
salmonella colitis 1001 seminoma 1195
-infection 1284 sensitivity 170,613
-o steitis 1286 sepsis 742
Salter and Harris classification 469 septic arthritis 430, 441, 444, 445
sampling error 634 septic spondylitis 336
San Filippo form (MPS III) 511 sequester 325
XLV
sequestration 336,553 - maturation 466,467

sequestrum 443 - trauma 467
serial changers 50 skin dose 33
serofibrinous exudate 698 skip lesion 961,94
seronegative chronic arthritis 438 skull radiography 168
- spondyloarthropathy 430, 433, 437 - fracture 168,480
seropositive arthritis 438 SLE (systemic lupus
serotonin 128 erythematosus) 441, 1156
serum alkaline phosphatase 500 slice of thicknes 59
- amyloid P compound sliding hernia 929
(1-123 SAP) 1031 slipped capital femoral epiphyses
shearing injuries 189 (SCFE) 516, 527
shigella dysentery 1001 small bowel adhesion 981
shiny comer 348 - atresia 579
shivers oesophagus 912 - enema (SBE) 955, 956
short saphenous vein 821 - ileus 1097, 1100
- inversion time (STIR) 338 - lymphoma 972
- ribs 496 - meal 955
shortening 388 - neoplasm 970
shunt function 619 - obstruction (SBO) 583,980
-p ate n cy 619 - stenosis 579
sialoectasis 254 - tuberculosis 962
sialography 254 - series 955
sialolithiasis 253 small cell carcinoma 720
sickle cell disease 516, 530, 531, 1156 smearing technique 634
sigmoidoscopy 1006 Smith type fracture 390, 392
signal to noise ratio 43 smooth muscle tumour 974
silent abdomen 1105 social history 482
silicate crystals 747 sodium ipodate 1042
silicone dioxide 747 soft palate 249
- prosthesis 642 somites 298, 363
- spheres 863 sorbitol 131,958
- implant 631 South American blastomycosis 966
silicosis 744,747 spatial resolution 55, 58, 105
silver bromide 48 specificity 170,613
simple bone cyst 282 specific radiologic pattern 452
-c y st 649,1139 specimen radiogram 635
- renal cyst 595 SPECT (single photon emission
- ureterocele 1160 computed tomo-
Simpson catheter 145 graphy) 63,64, 172, 881
Simpson-atherectomy catheter 857 spermatocele 1195,1196
single umbilical artery (SUA) 1230 sphenoid sinus 238
- contrast barium enema 986 sphincterotomy 1059
- photon emission computed spiculated border 653
tomography (SPECT)63, 64, 172, 881 -tum or 648
sinography 455 spina bifida 368, 1226, 1229
sinus 962 - aperta 365, 367, 370
sinus tympani 230 - occulta 365
- venosus 559 spinal arteriovenous malformations 369
- tract 455 - canal 297
Sjogren's syndrome 254, 751 - cord MS 218
skeletal hydatid disease 1267 - cord tumor 507
XLVI
INDEX
- dysraphism 360, 365, 600 stricture 916

- infections 338 stroke 623
- ligament calcification 346 strongyloidiasis 966, 1279
- ligament ossisfication 346 styloglossus muscle 249
-lip o m a 361, 366 SUA (single umbilical artery) 1230
-sten o sis 318,319,330,,333 subacute osteomyelitis 442
- trauma 301 subarachnoid spread 349
- tumours 348 - haemorrhage 171
spinnaker sail 602 subarcuate canal 230
spinous process 301 subcapsular haematoma 1037
spiral CT 59 subchondral cyst formation 423
splanchnic neurolysis 165 subclavian vein 824
splenic infarction 1076 - artery 820
- rupture 1078 - vessel 688
splenomegaly 1074, 1076, 1304 subcortical atherosclerotic
splinter fragments 223 encephalopathy 177,219
split notochord syndrome 367 - fracture of the femoral head 514
spondylitis 336, 240, 707 subcutaneous emphysema 761, 1088
spondyloepiphyseal dysplasia 493, 500 - lipoma 360
spondylolisthesis 330 subdural haematoma 190
spondylosclerosis hemispherica 343 - effusion 621
spongioblastoma 209 subependydomas 201
spontaneous transmural perforation 923 subependymal lesion 1315
spot filming 52 sublingual salivary gland 253
Sprengel's deformity 364 subluxation 310
squamous cell carcinoma 237, 244, 248, submandibular gland 253
252,289,720, 1160 submentovertex projection 263
stacked coin appearance 952 submucosal haemorrhage 1003
Stafne cyst 274 -tum or 941
standard views 384 subpial-juxtamedullary lesions 366
Stanford classification 838 subtrochanteric fracture 407
stapes 230 subvalvular aneurysms 1291
staphylococcal pneumonia 727 superficial femoral artery 820
Staphylococcus 442 - femoral vein 822
Staphylococcus aureus 339, 549, 727 - palmar arch 821
static brain scintigraphy 172 superior gluteal artery 820
status epilepticus 616 - mesenteric artery 820
steel coils 151 - mesenteric artery syndrome 952
stenosis 829 - ophtalmic vein 176
stents 146 - orbital fissure 176
stereotactic localization 633 - sagittal sinus 180
STIR (short inversion time) 338 - semicircular canal 230
strangulation 1095,1100 - sulcus tumor 677, 721
strawberry gallbladder 1053 - vena cava 684, 687, 785
Strecker stent 861 - vena caval syndrome 677
Streeter bands 489 supernumerary teeth 272
Streptococcus 339,342 superparamagnetic contrast media 137
Streptococcus pneumoniae 549, 726 supination-adduction 412
- pyogenes 549 supination-external rotation 412
streptokinase 805 supracondylar fracture 399, 401,408
stress fracture supraglottic airway 249
418,419, 443,446, 455,478 suprarenal vein 824
XLVII
suprasellar aneurysms 226 ТЕ (echo time) 80,1085

- meningioma 224, 225 tear-drop bladder 1177
supratentorial extraaxial tumours 193 tears of the menisci 409
- hydrocephalus 205 technetium 29
- intraaxial tumours 197 technetium 99m 785, 881
- tumours 192 technetium-99m-methylene
surgical biopsy 656 diphosphonate 373
- neck fracture 402 technetium-labelled red cells 1019
Swan-Ganz catheter 767 TEF (tracheoesophageal fistula) 573
swimmer's itch 1246 teflon catheters 143
sympathoblasts 605 teleradiology 113
symphalangism 489 temporomandibular joint
syncytial virus 734 (TMJ) 290, 293,436
syndactyly 489 tension pneumothorax 547, 755, 757
syndesmophytes 346 teratoma 552
synovial membrane 433 terminal hematuria 1174
synovial proliferation 434 tertiary oesophageal contraction 901
synovitis 425, 445, 521 Tesla (T) 73
syphilis 465 testicular cancer 1195
syringohydromyelia 349, 351, 352, 367 -rupture 1195
syringomyelia 352 -torsion 1197
systemic adenosis 751 -traum a 1197
- collateral arteries 566 -tum or 1195
- disease 432 - vein 823
- lupus erythromatosus tethered cord 361, 367
(SLE) 441,1156 tetralogy of Fallot 563, 564
- malignant lymphoma 1316 tetraplegia 311
- sclerosis 904, 978, 969 TGV (transposition o f great vessels) 566
-vasculitis 751 thallium 201TI 785
T (Tesla) 73 thanatophoric dysplasia 492, 495
T cell 502 thermography 17,628
T. saginata 1304 thoracentesis 700
T. solium 1304, 1305 thoracic aortic aneurysm 837
Tl relaxation 78 - disease 677
Tl-weighted images 79 - drain 763
Tl-weighting 77 - kyphosis 315
T2 relaxation 77 - venous disease 677
T2-weighted images 79 - outlet syndrome 833
T2-weighting 77 thoracic trauma 698
ТА (truncus arteriosus) 568 - tumours 549
taeniasis 1304 thoracoepigastric vein 824
Takayasu's arteritis 832,1131,1291 thoracoplasty 693,732
talipes equinovarus 485 thoracotomy 675
talocalcaneal coalition 491 threatened abortion 1222
Tantalum 146 three-dimensional biplane technique 379
tapeworm 968, 1304 thrombectomy 845
TAPVR (total anomalous pulmonary thromboangitis obliterans 831
venous return) 568 thrombolysis 146,858
tarsal coalition 489, 491 thromboxane A2 128
tarsus 415 thumbprinting pattern 983,994,1003
Tausig-Bing complex 567 thymic tumor 552
TCD (cerebellar diameter) 1220 thyreocervical trunk 820
XLVIII
INDEX
thyroglossal duct cyst 251,259 transition zone 450

thyroid adenoma 262 transitional cell carcinoma 1160
- cartilage 257 transluminal angioplasty 1186
- gland 261 transmitted radiation 60
-tu m o r 552 transmitter sensor 17
thyrotoxicosis 221 transplanted kidney 1125
tibia 409 transposition of great vessels (TGV) 566
tibial plateau fracture 408 transrectal ultrasonograhy 1192, 1193
tibioperonteal trunk 820 transurethral resection
Tietze syndrome 695 of the prostate (TURP) 163
TIPPS (percutaneous - biopsy 184
porto-systemic shunting) 1041 transurethral ultrasonography 1184
tissue plasminogen activator (TPA) 805 transvaginal ultrasound
- glues 151 (TVUS) 1205, 1218
- contrast 38 transvenous pacemaker electrode 768
TMJ (temporomandibular transverse shear injury 316
joint) 290, 293, 436 trauma 447,754
toddler 478 traumatic arterial perfusion disorder 836
tomography 51,671,673 -bleeding 151
tongue movement 894 -bowing 385
tooth anomalies 271 - subarachnoid haemorrhage 189
- follicle 270 Treacher Collins syndrome 233, 272
- formation 270 trematodes 1246
torsed ovary 1203 trephine needle 456
torsion 1195 trichorhinophalangeal syndrome 516
torus fracture 385,476 tricuspid atresia 564
total contrast 39 - insufficiency 793, 794
- linear attenuation coefficient 55 - stenosis 793
- anomalous pulmonary - valve 786
venous return (TAPVR) 568 tricuspid valvular defect 796
Towne projection 263 triphalangeal thumb 508
toxic colitis 1094 triplane fracture 474
- dilatation 1094 tripod fractures 245
toxicity 117 trisomy 18 1226,1228
toxicology 119 tropical eosinophilic lung 1301
toxolasmosis 214, 1311 -splenomegaly 1303
toxoplasmic abscess 1311 - sprue 969
- granuloma 1311 -ulcer 1293
Toxoplasma gondii 736 true aneurysm 836
TPA (tissue plasminogen activator) 805 - diverticula 922
TR (repetition time) 79 - vocal cords 257
tracheo-bronchial angle 684,688 truncus arteriosus (ТА) 568
- rupture 759 Trypanosoma cruzi 904,1272
tracheoesophageal fistula (TEF) 573 tuberculoma 732
tracheomalacia 536 tuberculosis 549, 730, 732,
tracheomembranous cartilage 536 736, 965, 1313, 1318
traditional fluoroscopy 51 tuberculous abscess 342
- tomography 51 -cerebritis 1313
transabdominal ultrasound 988, 1103 - lymphadenopathy 732
transchondral fracture 385 -meningitis 1315
transient tachypnea of the newborn 539 - oesophagitis 920
transillumination 628 - pleurisy 702
XLIX
- spondylitis 342 urodynamic evaluation 1178

tuberous sclerosis 620 urokinase 146, 805, 853, 858
tubular adenoma 1006 US (Ultrasonography) 64, 65
- ectasia 1142 uterine anomaly 1201
tubulovillous adenoma 1007 uterine fibromyoma 1232
tumour 624 UTI (urinary tract infection) 600
tumour embolization 152 vacuum phenomenon 511
- calcification 168 valgus deformity of the foot 485
tungsten 19 Valsalva manoeuvre 815
tungsten tube 628 valvular aplasia 852
Turner syndrome 467 - pulmonary stenosis 563
TURP (transurethral resection valvuloplasty 806
of the prostate) 163 vanishing tumor 701
TVUS (transvaginal ultrasound) 1218 varicella 734
typhoid 968 varicella virus 734
typhoid infection 1284 varicocele 1195, 1196
UC (ulcerative colitis) 994 varicose venous disease 850
ulcerative colitis vascular anomaly 842
(UC) 994,995, 1001, 1241 - compression syndrome 833
ulcerative jejunoileitis 970 - congestion 539
ulnar artery 820 - lesion 415
- dislocation of the wrist 521 - malformation 842
ultra fast CT 775, 793 -rings 570
ultrafiltrate 1127 vasoactive substances 128
ultrasonography (US) 64, 65 vasomotor nephropathy 1156
ultrasound examination 17 vasopressin 150, 1021
ultrasound contrast media 139 vasovagal reactions 129
ultraviolet light 20 VATER association 508
uncinate process 299, 300 VCUG (voiding cystourethrography) 591
uncovertebral joints 334 vena cava filters 149
unilateral headache 621 venae comitantes 822, 824
unilateral emphysema 713 veno-lymphatic obstruction 661
University of Wurzburg 4 venography 813
upper extremity venography 816 venous angioma 186
- gastrointestinal haemorrhage 1020 venous arch 821
- motor neuron 350 - dysplasia 852
urachus 1177 - insufficiency 850
uremia 802 - malformation 843
ureteral balloon dilatation 163 - valve 821
- ectopia 598 ventilation scintigraphy 681
- obstruction 1150, 1152 ventricular septum 785
- occlusion 1191 - outflow tract obstruction 563
- stenting 163 - septum rupture 800
ureteritis 1162 - septal defect (VSD) 558, 566
urethral catheterization 1181 ventriculography 799
- stricture 1181,1190 ventriculomegaly 618
- trauma 1181 vertebra plana 509, 529
- tumors 1181 vertebral anomalies 489
urethrography 1116 - artery 820
urinary ascites 602 -body 299
urinary calculi 1165,1166 vertical force 313
urinary tract infection (UTI) 600 - talus 485
L
INDEX
vesicoureteral reflux (VUR) 591, 601 wet-lung disease 539, 541, 542
vestibular aqueduct 230 Whipple's disease 968, 969
vestibule 230 WHIS (WHO Imaging System) 14, 96
video urodynamics 1178 WHIS-Manual 98
videophlebography 816 WHIS-RAD 96
vigorous achalasia 902, 904 white matter 170
villous adenoma 1006 WHO "Manual of Radiographic
viral pneumonia 549, 733 Technique" 94
Virchows triad 846 WHO Imaging Systems (WHIS) 14, 96
visceral pleura 684 WHO Basic Radiological System 96
visible light 20 WHO (World Health Organization) 85
visual display 70 WHO-BRS 96
vitamin A poisoning 528 WHO-designed x-ray unit 95
- В 12 deficiency 977 Wilms' tumor 596, 602, 605
- D dependent rickets 526 window width 108
- D hypovitaminosis 831 wolfian duct 598
- D resistant rickets 525 workstations 113
vocal cord 257 World Health Organization (WHO) 85
voiding reflex 1129 worm-shaped polyposis 999
voiding cystourethrograhy (VCUG) 591 wormian bones 503
volume scanning 810 Wuchereria bancrofti 1299
volvulus 573,1101 Wurzburg University 3
vomiting 573 Wurzburg Physical Medical Society 9
von Hippel-Lindau disease 1033 X radiation 17
voxel size 58 X-ray guided FNAB 633
voxel 57,81 X-ray examination 17
VSD (ventrcular septal defect) 558, 566 X-ray spectrum 24
VUR (vesicoureteral reflux) 591, 601 X-ray 20
Waldeyer's ring 884 X-ray generator 36
Wallstent 861 X-ray tube 36
wash-in defect 795 xanthogranulomatous pyelonephritis 1152
water solubility 119 xenon-133 681
water siphon test 913 Xenonchloride-excimer-laser 856
Waters view 238 Y cartilage 482
Waters projection 263 Yersinia enterocolitica 959,966, 1001
watershed infarctions 178 Zellweger syndrome (cerebro-
wavelength 20 hepatorenal syndrome) 498,1228
wedge fracture 310 Zenker's diverticulum 893, 898
Wegener's granulomatosis 751,1156 Zollinger-Ellison syndrome933, 948, 949

A Global TextBook of Radiology I

Uploaded by

Copyright:

Available Formats

You might also like

A Global TextBook of Radiology I

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

A Global TextBook of Radiology I

Uploaded by

Copyright:

Available Formats

The NICER C e n ten n ia l

University of Lund Sab NYCOMED

The NICER Institute

Reprinted papers are available from The NICER Institute

Sudarshan K. Aggarwal, India

This book is partly based on a Scandinavian Textbook of Radiology

Editors of the Scandinavian Textbook:

Chapter 1 W.C. Roentgen and the discovery of X-rays.............. 1

Chapter 12 The spine..................................................................... 297

Chapter 18 The lungs and mediastinum...................................... 669

David J. Allison, BSc, MD, Marie-France Beilin, MD

Olle Ekberg, MD Derek Harwood-Nash, MB,

Hassen A. Gharbi, MD Stig Holtas, MD

Philippe Grenier, MD Kjell Jonsson, MD

Frode Laerum, MD Con Metreweii, MB, BChir,

Holger Pettersson, MD Giuseppe Scotti, MD

Lund, January 1995

W.C. Roentgen and the discovery

In today's competitive academic climate, W.C. Roentgen would proba­

While in Zurich, Roentgen studied mechanical engineering, seriously

A new kind of rays

In his original communication Roentgen reported the experimental set­

visible at a distance o f 2 m from the apparatus ...”

In the communication Roentgen acknowledges the achievements of sev­

The moment of discovery

It was late afternoon on Friday, November 8th, 1895, W.C. Roentgen

exposure the first radiograph of a human being was obtained showing

Spreading the news

Figure 7. щ —3- -----------------------

page o f the handwritten manuscript. - 4/

On January 13th, 1896, Roentgen presented his work to Emperor

The period following the discovery

The ready availability of radiographical services is accepted as a normal

veloping countries the available radiological equipment and knowledge

prevailing realities in order to respond to the local needs. The level of

Medical imaging plays a central part in the diagnostic examination of

All of these methods except ultrasound are based on electromagnetic

without taking account of their other advantages.

X-ray imaging methods can be grouped in the following way:

Imaging methods can also be grouped according to whether a volume of

vices, the biological consequences of radiation, and radiation protection,

INTERACTIONS OF RADIATION WITH MATTER

Matter and radiation

Fig. 1 shows the orbits or shells K, L, M etc. of tungsten. These shells

emission of characteristic X-radiation, when simultaneously an electron

Radiation is divided into two principal components:

It is accepted in modem physics that a photon can behave as a particle

Interactions of X-rays and gamma rays with matter

Figure 4. Probabilities fo r photoelectric absorption and Compton scattering, (these

nomena described in the figure are simultaneously possible with differ­

In Compton scattering a photon scatters (changes its direction) with a

Attenuation follows the exponential function 1 = 1 exp"^ x , where

Interactions of electron; X-ray spectrum from X-ray tube

Figure 5. Braking radiation is generated in the anode o f an x-ray tube. In medical

action. This phenomenon means that when a negatively charged electron

Interactions in a magnetic field

Attenuation occurs everywhere

Figure 6. Ultrasound is reflected at all boundary surfaces according to the coefficient

In today's competitive academic climate, W.C. Roentgen would proba

In his original communication Roentgen reported the experimental set

In the communication Roentgen acknowledges the achievements of sev

nomena described in the figure are simultaneously possible with differ

minishes continuously in the cone of tissues in the direction of the mo

The non-stochastic effect of radiation has a definite threshold (nor

is rather well known; physically measurable quantities: contrast, resolu

tem as illustrated in Fig. 5 (3rd generation). A thin, collimated, fan

The ultrasound being transmitted from the transducer is pulsed. An ul

by ECG monitors). The M-mode curves provide very detailed informa

a large range of depths si

also proportional to the number of pro

is an amplitude versus frequency display showing the different frequen