Technique Notes

RADIOLOGICAL
TECHNIQUES
Din XJ
CONTENT
1. Contrast Media & Drugs 1

2. General Radiography 15
a) Chest 16
b) Abdomen 25
c) Head & Neck 28
d) Spine 48
e) Upper Limb 58
f) Lower Limb 74
3. Breast Imaging 92
4. Fluoroscopy 105
a) General Principles 105
b) Gastro-Intestinal Tract 106
c) Genito-Urinary Tract 122
d) Head & Neck 130
e) Spine 132
f) Musculoskeletal System 138
5. Angiography 143
a) General Principles 143
b) Cardiovascular System 151
c) Respiratory System 162
d) Gastro-Intestinal Tract 165
e) Genito-Urinary Tract 173
f) Brain 179
6. Ultrasound 186
7. Computed Tomography (CT) 220
8. Magnetic Resonance Imaging (MRI) 235
9. Nuclear Medicine 276
Chapter 1 CONTRAST MEDIA
& DRUGS
1
INTRAVENOUS CONTRAST MEDIA IN CT SCAN

 Initial contrast media developed: Ionic contrast wt ↑ osmolarity (HOCM)
a) Ionic properties:
- Contrast ionizes in solution → Anion & Cation
- Anion: Iodine that causes opacification
Cation: Ion that does not contribute to opacification, but contributes in osmolarity
b) ↑ Osmolarity
- Osmolarity: 1,200 – 2,000 mosmol/kg (5x osmolarity of blood)
- Causes side effects & toxicity
 Efforts to ↓ side effects & toxicity:

a) Ionic contrast media wt ↓osmolarity
- ↑ Iodine per molecule
- ↓ Cation released per molecule
b) Non-ionic contrast media
 Types of contrast media:

a) Ionic
(i) High Osmolar CM Sodium iodide
Diatrizoate (Gastrograffin, Urograffin) Gastrograffin & Urograffin:
Metrizoate (Isopaque) - Seldom used as IV CM, due to its high osmolarity
Iothalamate (Conray) - But widely used as oral & rectal CM
(ii) Low Osmolar CM Ioxaglate (Hexabrix) Dilution: 3%
b) Non-ionic
(i) Iso-Osmolar CM Iotrolan (Isovist)
(Dimers) Iodixanol (Visipaque)
(ii) Low Osmolar CM Iopamidol (Iopamiron, Solutrast)
(Monomers) Iohexo l(Omnipaque)
Iopromide (Ultravist)
Iomeprol (Iomeron)
 Types of contrast media used in HUKM:

Ultravist 300 General CT scan
Omnipaque 350 CT Angiogram
Angiogram
Visipaque 320 Angiogram in patient wt CKD
Din XJ
2
ADVERSED EFFECTS
 Properties of contrast media that cause adverse effects:
a) Osmolarity
b) Ionic charge (ionic CM)
c) Chemical structure
d) Lipophilicity
 Incidence of adverse reaction (non-ionic iodinated CM): Rare (1%)
Mild Majority
Severe – very severe 0.044%
1. Soft tissue toxicity

 Effects: Pain, swelling, erythema, sloughing of skin
 Causes: Extravasation
 Treatment: RICE
a) Compression & elevation of the limb
b) Application of cold packs
c) Mediations: Steroids, NSAIDs, antibiotics
2. Vascular toxicity
a) Venous
Effects Causes
(i) Pain at injection site Perivenous injection
(ii) Immediate limb pain Stasis of CM in vein
(iii) Delayed limb pain Thrombophlebitis (toxic effect on endothelium)
b) Arterial
- Effects: Pain & burning sensation
- Causes: Arterial endothelial damage & vasodilatation
3. Nephrotoxicity (Contrast-induced nephropathy, CIN)

 Effects:
No effect
Transient renal impairment Serum creatinine ↑ within 24hrs
Peak by 2 – 3 days
Returns to baseline by 3 – 7 days
Permanent renal failure
Following renal impairment → ↓ Clearance of drugs excreted by kidneys (Eg. Metformin)
 Predisposing factors:
a) Pre-existing renal impairment (GFR < 30ml/min, Serum creatinine > 130 μmol/L)
b) Pre-existing medical illness: DM, multiple myeloma
c) ↑ Age
d) Dehydration
e) ↑ Dose of CM
f) Use of other nephrotoxic drugs
 Mechanisms:
a) Impaired renal perfusion Adverse cardiovascular toxicity → Peripheral vasodilatation & hypotension
↓ Vascularity of renal vascular bed
Osmotic diuresis
b) Glomerular injury Impaired renal perfusion
Hyperosmolar effects
Chemotoxic effects
c) Tubular injury Impaired renal perfusion
Hyperosmolar effects
Chemotoxic effects
d) Obstructive uropathy Cytoplasmic vacuolation in tubules (following tubular injury)
Precipitation of Tamm-Horsfall protein
Precipitation of Bence-Jones protein (in multiple myeloma)
Din XJ
3
4. Cardiovascular toxicity
Effects Causes
a) Arrhythmia, ↑ vagal activity → Depression of SA node & AV node
Bradycardia, asystole
b) Hypotension HOCM
→ ↑ Serum osmolarity
→ Water influx into vascular compartment (↑ blood volume)
→ ↑ Cardiac output
→ Transient ↑ SBP
→ Reflex peripheral vasodilatation
→ More prolonged ↓ BP
 Injection into right heart → Transitory pulmonary HPT & systemic hypotension
 Injection into left heart → Transient systemic HPT, followed by more prolonged ↓ BP
5. Haematological toxicity
Effects Causes
a) Haemolysis Mixture or RBC wt CM (↑ concentration), in syringe
→ RBC damage
→ Further haemolysis upon re-injection of damaged RBC into blood stream
b) Thrombus formation Mixture of blood wt contrast (more common wt LOCM), in syringe
→ Blood in contact wt foreign material (CM & wall of syringe)
→ Activation of coagulation pathways
→ Further thrombosis upon re-injection of the CM into blood stream
c) RBC aggregation ↑ Concentration of CM
However, disaggregation occurs easily → No significant clinical effect
d) Coagulopathy CM impairs blood clotting & platelet aggregation
CM potentiate the action of heparin
e) Capillary occlusion HOCM
→ Water leaves RBC via osmosis
→ RBC becomes more rigid & less deformable
→ Less easy to pass through capillaries, may cause occlusion
f) Transient eosinophilia Occur 24 – 72 hrs after CM injection
g) Sickle cell crisis Precipitated by CM
6. Neurotoxicity
 Effects: Convulsions (rarely)
 Causes: CM crosses blood brain barrier → Osmolarity & chemotoxic effects
7. Thyroid function
 Effects: Thyrotixicosis (esp in patient wt non-toxic goiter or pre-existing thyrotoxic symptoms)
8. Idiosyncratic reactions
→ Anaphylactoid reactions (Non-IgE mediated)
 Severity:
a) Minor reactions Do not interfere wt examination, but require patient reassurance
b) Intermediate reactions Interfere wt examination, but do not requirement treatment
c) Major reactions Interfere wt examination, require treatment
d) Fatal reactions Very rare (1.1 – 1.2 per million)
 Predisposing factors:
a) Previous contrast reaction → ↑ 6x risk
b) Previous allergic reaction, requiring medical treatment
c) Bronchial asthma → ↑ 6-10x risk
d) Intra-venous injection > Intra-arterial injection
Din XJ
4
 Effects:
a) Skin
(i) Urticaria
(ii) Necrotizing skin lesions More in patient wt CKD
b) CNS
(i) Tingling sensation
(ii) Fever, rigors
c) GIT
(i) Metallic taste
(ii) Nausea, vomiting
(iii) Abdominal pain
(iv) Desire to empty rectum
d) GUT
(i) Perineal burning
(ii) Desire to empty bladder More in female
e) CVS
(i) Flushing(vasodilatation)
(ii) Angioneurotic oedema Usually facial region
(iii) Arrhythmias
(iv) Hypotension Usually transient & mild
May a/w reflex tachycardia OR bradycardia (vagal overactiviety)
f) Respiratory system
(i) Sneezing
(ii) Bronchospasm
(iii) Non-cardiogenic pulmonary oedema
g) Delayed-onset reactions Rashes, headache, parotid gland swelling
(1hr – 1wk after CM injection)
 Mechanisms:
a) Histamine release
(i) Direct CM (more with HOCM)
→ Histamine released from mast cells & basophils
(ii) Indirect CM
(via complement activation) → Activation of complement system
→ Formation of anaphylatoxins
→ Histamine released from mast cells & basophils
- Effects: Urticaria
Metallic taste,
Flushing, angioneurotic oedema, arrhythmias, hypotension
Sneezing, bronchospasm
b) Protein binding (CM are weak protein binders)
(i) Acetylcholinesterase inhibition CM
→ Binds wt acetylcholinesterase
→ Inhibits the action of acetylcholinesterase
→ ↑ Acetylcholine in synapses
→ ↑ Cholinergic effects (Parasympathetic activities)
Effects: Urticaria
Abdominal pain, desire to empty rectum / bladder
Flushing, bradycardia, hypotension
Bronchospasm
(ii) Cellular immunity activation CM
→ Binds wt immune receptors on T-cells
→ Activation of T-cells (cellular immunity)
→ Release of cytokines (interleukins, interferons, TNF)
→ Acute reaction
Din XJ
5
c) Chemotoxicity
(i) Intrinsic chemotixicity of the CM molecules
(ii) Hyperosmolarity
d) Stimulation of autonomic nervous system
CM → Cross blood brain barrier
→ Stimulation of hypothalamus & limbic lobe
→ ↑Autonomic activity
Pre-ganglionic Post-ganglionic
Neurotransmitter Receptors Neurotransmitter Receptors
Sympathetic
a) General Ach Cholinergic NA Adrenergic (α, β)
b) Sweat glands Ach Cholinergic Ach Cholinergic
c) Smooth muscle of Ach Cholinergic Ach Cholinergic
blood vessels
d) Adrenal medulla Ach Cholinergic Release Adrenaline -
(Adrenal medulla) into blood stream
Parasympathetic Ach Cholinergic Ach Cholinergic
(i) Muscarinic (M1-M5)
(ii) Nicotinic (α, β, γ, δ, ε)
PROPHYLAXIS OF ADVERSED EFFECTS

1. Prophylaxis for nephrotoxicity
 Identify patient at risk (with predisposing factors)
a) Pre-existing renal impairment (GFR < 30ml/min, Serum creatinine > 130 μmol/L)
b) Pre-existing medical illness: DM, multiple myeloma
c) ↑ Age
d) Dehydration
e) ↑ Dose of CM
f) Use of other nephrotoxic drugs
 Consider alternative imaging modality, without using CM
 Consider stopping nephrotoxic drugs 1 day before procedure
 Adequate hydration 6hrs before & after procedure
 Use smallest possible dose of CM
 Prophylactic IV or oral N-acetyl cysteine (NAC)
Insufficient evidence to support its benefit
2. Prophylaxis for idiosyncratic reactions
 Identify patient at risk (with predisposing factors)
a) Previous contrast reaction
b) Previous allergic reaction, requiring medical treatment
c) Bronchial asthma
 Consider alternative imaging modality, without using CM
 Use LOCM / IOCM
Use different CM if patient has previous reaction towards a particular contrast
Use smallest possible dose of CM
 Prophylactic oral Prednisolone 40mg, 12hrs &2hrs before examination
Inconclusive evidence to support its benefit
3. Prophylaxis for special conditions
a) Pregnancy Check thyroid function of neonate during 1st week of life
b) Breast feeding Breast feeding can continue normally
c) Thyrotixicosis Risk of thyroid storm
→ IV CM should not be given if patient is thyrotoxic
d) Phaeochromocytoma Risk of adrenergic storm
→ Premedication: α-blocker & β-blocker
e) Sickle cell anaemia Risk of sickle cell crisis
→Use IOCM
Din XJ
6
CONTRAST MEDIA IN FLUOROSCOPY

Barium Sulphate
 Material: Pure barium sulphate, BaSO4 (Barium carbonate, BaCO3 is poisonous)
 Properties of BaSO4:
a) Small particles More stable in suspension
b) In non-ionic suspension medium Would no aggregate into clumps
c) Resulting solution wt pH of 5.3 More stable in gastric acid
 Types of BaSO4 available:
a) E-Z HD - Contains: Simethicone (coating agent), sorbitol (coating agent)
- Advantage: Provides thin coating
- Usage: Barium swallow, barium meal
b) E-Z Paque - Contains: Sorbitol (coating agent)
- Advantage: Partially resistant to flocculation (not suitable if transit time is long)
- Usage: Barium follow-through, small bowel enema
c) Polibar - Usage: Barium enema
d) Baritop - Usage: All parts of GI tract
 Dilution of BaSO4:
Examination Dilution (% w/v) Ingredients
a) Barium swallow 150 600g BaSO4 + 400mls water
b) Barium meal 240 600g BaSO4 + 250mls water
c) Barium follow-through 60 600g BaSO4 + 1L water
d) Small bowel enema 20 300g BaSO4 + 1.5L water
e) Barium enema 60 600g BaSO4 + 1L water
f) Defecating proctogram 60 Oral: 600g BaSO4 + 1L water (Drink 600mls)
Rectal: Remaining 400mls + 100g BaSO4+ 50g potato
Paediatrics:
a) Upper GI study 20 300g BaSO4 + 1.5L water
b) Lower GI study 60 600g BaSO4 + 1L water
(single contrast Ba enema)
 Advantages & disadvantages:

Advantages Disadvantages
a) Cost: Cheap a) Flocculation
b) Excellent coating (compared to water soluble CM) b) Subsequent abdominal CT & US are difficult to interpret
- May require 2wks for satisfactory clearance of barium
c) ↑ mortality if perforation or intravasation
 Complications:
a) Constipation & impaction May require 2wks for satisfactory clearance of barium
b) Aspiration Causes pneumonitis & granuloma formation (which are relatively harmless)
Treatment: Chest physiotherapy
c) Perforation (i) Into peritoneal cavity → Barium peritonitis → Pain & hypovolemic shock
- Mortality rate: 50%
- Those who survive, 30% develop peritoneal adhesion & granulomata
- Treatment: Hydration, steroids, antibiotics
(ii) Into mediastinal cavity → Barium mediastinitis
- Significant mortality rate
d) Intravasation Causes barium pulmonary embolism
Mortality rate: 80%
 Contra-indications:
a) Confirmed / suspected perforation Better alternative: Water soluble CM (Gastrograffin & LOCM)
b) Relatively safe for patient at risk of aspiration Better alternative: LOCM (not gastrograffin)
Din XJ
7
Gastrograffin
 Material: Diatrizoic acid (Diatrizoate)
 Properties: Ionic HOCM (water soluble)
 Indications:
a) Fluoroscopy When barium is contraindicated (confirmed / suspected perforation)
Meconium ileus
b) CT scan As oral & rectal contrast (Dilution 3%)
Contraindications:
a) Patient at risk of aspiration
b) Patient with known allergies to gastrograffin
 Complications:
a) Anaphylactoid reactions
b) Pulmonary oedema if aspirated
c) Dehydration, especially in children (due to its hyperosmolarity)
d) May precipitate hyperchlorhydric gastric acid
LOCM
 Examples: Ultravist, Omnipaque, Iopamero
 Properties: Non-ionic LOCM (water soluble)
 Indications:
a) Fluoroscopy When barium is contraindicated (confirmed / suspected perforation)
When gastrograffin is contraindicated (patient at risk of aspiration)
b) CT scan As IV contrast
Contraindications: Patient with known allergies to LOCM
 Complications: Anaphylactoid reactions
Gases
 Indications: Used in conjunction wt barium to produce ‘double contrast’ effect
 Properties:
a) Produce adequate volume of gas (200 – 400 mls)
b) Do not interfere wt barium coating
c) Do not produce bubble
d) Dissolve rapidly
 Types:
a) CO2 (via carbex granules) - For upper GI studies (oesophagus, stomach, duodenum)
- Carbex granules / powder are administered orally
b) Room air - For lower GI studies (large bowel)
- Room air is administered per rectum, via hand pump attached to the enema tube
Din XJ
8
CONTRAST MEDIA IN MRI

 Mechanism:
a) Shorten T1 relaxation time
CM used in MRI possess unpaired electrons
→ Exert a large magnetic field density
→ Interact wt magnetic moments of protons in tissue
→ Alter the magnetic properties of protons in tissue
→ Shorten T1 relaxation time (Hyperintense T1 images)
b) Shorten T2 relaxation time
Following alteration of magnetic properties of protons in tissue
→ Local changes in magnetic field
→ Rapid photon dephasing
→ Shorten T2 relaxation time (Hypointense T2 images)
 Degree of signal enhancement depends on composition of the tissue
Tissue with more water & fat content → Demonstrate more enhancement
 All CM shorten both T1 & T2 relaxation time
But some predominantly affect T1 (longitudinal relaxation rate) or T2 (transverse relaxation rate)
 Types of contrast media:

a) Ferromagnetic Iron, cobalt, nickel Retain magnetism even when gradient field is removed
→ Causes particle aggregation & interfere cell function
→ Unsafe for clinical use
b) Paramagnetic Gadolinium Possess magnetic moments only when gradient field is applied
c) Superparamagnetic Particles of iron oxide:
(i) Large particles
(ii) Small particles (SPIO) Predominantly shorten T2 relaxation time
(iii) Ultrasmall particles (USPIO) Predominantly shorten T1 relaxation time
 Preparation:
Gadolinium Oral & IV (with gadolinium compounds made soluble by chelation
Particles of iron oxide:
(i) Large particles Oral suspension
(ii) Small particles (SPIO) IV
(iii) Ultrasmall particles (USPIO) IV
 Precaution:
Pregnancy Should not be routinely given
No reports on teratogenic effect
But insufficient evidence to support its safety
Breast feeding Breast feeding can continue normally
Din XJ
9
GADOLINIUM
 Types of CM:
a) Extracellular fluid (ECF) agents - Circulate within vascular system
(i) Gd-diethylenetriaminepenta-acetic acid (DTPA) - Excreted unchanged by kidneys
Dimegluminegadopentetate Magnevist - Do not cross blood brain barrier
(ii) Gadodiamide (Gd-DTPA-bismethylamide) Omniscan
Usage: General
(iii) Gadoteridol (Gd-DO3A) ProHance
b) Liver agents - Gd chelates wt altered excretory pathway
(i) Gd-BOPTA Multihance - Taken up by hepatocytes
(ii) Gd-DTPA Primovist Excreted unchanged by hepatobiliary system
(iii) Manganese-DPDP (Non-gadolinium) Telescan
Usage:
Detect liver lesions with no hepatocytes (liver mets)
Characterize liver lesions wt hepatocytes (HCC)
c) Blood pool agents - Remain longer in vascular system
(i) Gadofosveset trisodium Vasovist
Usage: Vascular imaging
 Dosage of ECF gadolinium agents: 0.1 – 0.2 mmol/kg
 Adverse reactions:
a) Acute adverse reactions
Effects (i) Urticaria
(ii) Nausea, vomiting
(iii) Dizziness, confusion
(iv) Dyspnoea, chest discomfort, palpitation
(v) Anaphylactoid shock
Predisposing factors (i) Previous contrast reaction
(ii) Previous allergic reaction, requiring medical treatment
(iii) Bronchial asthma
b) Delayed adverse reactions
(i) Renal impairment - At standard doses: No significant renal impairment
- At ↑ doses to give equivalent x-ray attenuation: More nephrotoxic than iodine
(ii) Nephrogenic systemic fibrosis (NSF) - ↑ Collagen deposition, in skin & other tissues
- 2 – 3 mths after contrast injection
- Mechanism: Unknown
- Renal impairment is the main trigger
 Prophylaxis of adverse reactions:

a) Acute adverse reaction s
- Identify patient at risk (with predisposing factors)
(i) Previous contrast reaction
(ii) Previous allergic reaction, requiring medical treatment
(iii) Bronchial asthma
- Consider alternative imaging modality, without using CM
- Use different CM if patient has previous reaction towards a particular contrast
Use smallest possible dose of CM
- Prophylactic oral Prednisolone 40mg, 12hrs & 2hrs before examination
Inconclusive evidence to support its benefit
b) Delayed adverse reactions
- Identify patient at risk: Pre-existing renal impairment (GFR < 30ml/min, Serum creatinine > 130 μmol/L)
- Consider alternative imaging modality, without using CM
- Use smallest possible dose of CM
Din XJ
10
IRON OXIDE
 Superparamagnetic CM, consists of particles of iron oxide
 Types of CM:
a) Large particles
b) Small particles (SPIO) Predominantly shorten T2 relaxation time
c) Ultrasmall particles (USPIO) Predominantly shorten T1 relaxation time
 Preparation:
a) Large particles Oral suspension
b) Small particles (SPIO) IV
c) Ultrasmall particles (USPIO) IV
 Mechanism:
a) Small particles (SPIO) Taken up by reticulo-endothelial cells in liver & spleen
→ Hypointense signal in normal liver & spleen, on T2 images
Not taken by lesions wt no reticulo-endothelial cells
→ Retain high signal intensity, on T2
Usage: Detect liver tumour (HCC)
b) Ultrasmall particles (USPIO) Taken up by reticulo-endothelial cells in bone marrow & LN
→ Hyperintense signal, on T1 images
Usage: Imaging of bone marrow & LN
GASTRO-INTESTINAL (ORAL) CONTRAST MEDIA

1. Positive agents
Types a) Fatty oil
b) Gadolinium
Mechanism Shorten T1 relaxation time → Hyperintense signal on T1 images
Disadvantages a) ↑ Bowel motion artifact
b) The effect varies with pulse sequence → Non-uniformity in signal
2. Negative agents
Types a) Ferrite
b) Barium sulphate (60 – 70% w/w)
Mechanism Shorten T2 relaxation time → Hypointense signal on T2 images
Disadvantages a) Image distortion in high concentrations
b) Required dose for ferrite is potentially lethal
→ Chelation needed to ↓ iron absorption
3. Biphasic agents
Types Klean-Prep (contains macrogol, KCl, NaCl, NaSO4, NaHCO3)
Mechanism
Disadvantages
Din XJ
11
CONTRAST MEDIA IN ULTRASOUND

 Mechanism:
IV contrast: Microbubbles of air / nitrogen / fluorocarbon gas, coated within a thin shell of albumin / galactose / lipid
→ ↑ Acoustic impedance btw microbubbles& surrounding bleed / tissue
 Types of CM:
a) Levovist Microbubbles of air, coated within palmitic acid, in galactose solution
b) SonoVue Microbubbles of sulphur hexafluoride, in aqueous suspension
 Usage:
a) Assess macro & microvasculature in different tissue
b) Identify & characterize lesions in liver, spleen, pancreas, kidney, prostate, ovary & breast
c) Assess patency of fallopian tube at HSG
d) Assess VUR at voiding US
e) In echocardiography
 Adverse reactions: Allergic-like reactions
Din XJ
12
DRUGS USED IN RADIOLOGICAL PROCEDURE

Drugs that affect GI motility
1. Hyoscine-N-butyl bromide (Buscopan)
Pharmacology Antimuscarinic agent
→ Inhibit muscarinic receptors (a type of cholinergic receptors), inhibit parasympathetic effects
→ Inhibit smooth muscle contraction / spasms in GIT & GUT
→ Inhibit gastric secretion & intestinal motility
Also inhibit muscarinic receptors in sweat glands, salivary glands, eyes, heart
→ Causes inability to sweat, dry mouth, inability of eyes to accommodate far vision, tachycardia
Dose Adult: IV / IM / SC 20mg
No recommended in children
Indications a) GI studies: Barium meal, barium enema
b) Hysteroslaphingography
c) Mesenteric angiogram
Advantages & Advantages: Disadvantages:
Disadvantages a) Cost – cheap a) Transient blurring of vision
b) Immediate onset of action b) GIT: Dry mouth, acute gastric dilatation, constipation
c) Short duration of action (5-10mins) c) GUT: Urinary retention
d) Transient bradycardia, followed by tachycardia
Contraindications a) Closed angle glaucoma
b) Myasthenia gravis: Circulating antibodies that block cholinergic receptors
c) GIT: Pyloric stenosis, paralytic ileus
d) Prostatomegaly
e) Underlying heart disease
Better alternative Glucagon
Pre-ganglionic Post-ganglionic
Neurotransmitter Receptors Neurotransmitter Receptors
Sympathetic
a) General Ach Cholinergic NA Adrenergic (α, β)
b) Sweat glands Ach Cholinergic Ach Cholinergic
c) Smooth muscle of Ach Cholinergic Ach Cholinergic
blood vessels
d) Adrenal medulla Ach Cholinergic Release Adrenaline -
(Adrenal medulla) into blood stream
Parasympathetic Ach Cholinergic Ach Cholinergic
(i) Muscarinic (M1-M5)
(ii) Nicotinic (α,β,γ,δ,ε)
2. Glucagon
Pharmacology Polypeptide hormone, produced by α-Langerhans cells in pancreas
→ ↑ blood glucose & smooth muscle relaxation in GIT
Dose Barium meal Adult – IV 0.3mg, Paeds – 0.5 – 1 μg/kg
Barium enema Adult – IV 1mg, Paeds – 0.8 – 1.25 μg/kg
Indications a) When buscopan is contraindicated
b) If combine barium meal & follow-through, as it does not interfere wt small bowel transit time
Disadvantages a) More potent than Buscopan a) Cost - Expensive
b) Short duration of action (15mins) b) Relatively slower onset of action
c) Do not interfere small bowel transit time
c) Allergic reaction (as it is a protein)
d) GIT: Nausea, vomiting, abdominal pain
e) HypoK+
Contraindications a) Phaeochromocytoma : Glucagon causes tumour to release cacholamines → Adrenergic crisis, HPT
b) Insulinoma (relative) : Glucagon causes hyperglycemia, followed by reflex hypoglycemia
c) Glucagonoma (relative)
Din XJ
13
3. Metoclopramide (Maxolon)
Pharmacology Anti-dopaminergic agent→ Stimulate gastric emptying & small bowel transit
Dose Oral / IV / IM / rectal 20mg
Indications Barium follow-through
Disadvantages a) Anti-emetic a) Extrapyramidal side effects
b) Rapid onset of action
Contraindications a) Confirmed / suspected bowel obstruction
b) Phaeochromocytoma: Maxolon causes tumour to release cacholamines → Adrenergic crisis, HPT
c) Caution in Parkinson’s disease
d) Caution in patient on antipsychotics
Drugs for bowel preparation

1. Bisacodyl (Dulcolax)
Pharmacology Stimulate enteric nerves → Colonic contractions
Dose 2 tabs ON for 2 days before examination
Indications Bowel preparation
Disadvantages -
Contraindications Confirmed / suspected intestinal obstruction
2. Fleet solution (Fleet phosphor-soda)

Pharmacology Sodium dihydrogen phosphate dehydrate PhEur + Sodium phosphate dodecahydrate Ph Eur
Dose 3 days before examination: Low residual diet
1 day before examination: - Light breakfast, then only clear fluids
- Fleet phospho-soda at 7pm (15hrs before) & 6am (3hrs before)
Dilute 45mls fleet phospho-soda + 150mls water
- Drink lots of clear fluids subsequently
Indications Bowel preparation
Disadvantages -
Contraindications Confirmed / suspected intestinal obstruction
Caution in patient wt renal impairement& heart disease
Drugs used in angiographic procedures

1. Acetylsalicylic acid (Aspirin)
Pharmacology a) Antiplatelet → Inhibit platelet cyclooxygenase
b) Anti-inflammation
c) Analgesia
Dose Tab 75 – 150 mg
Indications Post-stenting
Disadvantages a) CNS: Tinnitus
b) GIT: PUD
c) Renal impairment
d) Reye’s syndrome
Contraindications a) Bleeding disorders
b) Caution in PUD& renal impairment
c) Children < 16yrs
2. Heparin
Pharmacology Anticoagulant
Dose IV bolus: 60 – 100 μ/kg (Small size: 3,000 μ Large size: 5,000 μ)
Prolonged procedure: Add 1,000 μ
Indications Prevention of vascular & pericatheter thrombosis, during endovascular procedure
Disadvantages Bleeding
Reversal IV Protamine Sulphate(1mg for every 100μ remaining heparin, maximum 50mg)
Contraindications a) Bleeding disorder & tendency
b) PUD
Din XJ
14
Analgesia & Sedation

1. Chloral Hydrate
Pharmacology Sedation for paediatrics
Dose Oral suspension 50mg/kg (Max 2g)
Indications Sedation for paediatrics
Disadvantages a) GIT: Vomiting, may affect liver function
b) Respiratory: May worsen rhinitis Sx
2. Benzodiazepin
Pharmacology Diazepam (Valium) Midazolam (Dormicum)
Dose Tab 10mg, 2hrs before procedure Adult: IV 2.5 – 7.5mg (usually 5mg given)
IV 0.3 mg/kg Paeds: Rectal 0.35 – 0.45 mg/kg
Indications a) Sedation
b) Anxiolysis
Disadvantages a) CNS: Headache, drowsiness, dizziness
b) GIT: Nausea, vomiting
c) GUT: Incontinence, urinary retention
d) Respiratory depression
e) Hypotension
Reversal IV Flumazenil 0.3 – 0.8mg
Contraindications a) Myasthenia gravis
b) Acute narrow angle glaucoma
c) Acute alcohol intoxication
d) Caution: elderly, COPD (risk of resp depression), CKD, CCF (risk of cardiac arrest)
3. Opioids
Pharmacology Pethidine Fentanyl
Dose Oral 50 – 150mg, 4hrly Transdermal / Oral / IV / IM:
IV 0.5 – 1 mg/kg 1 – 50 μg/kg (usually 1 – 2 μg/kg used)
Indications Analgesia for moderate to severe pain Analgesia for moderate to severe pain
(50x potent than morphine)
Disadvantages a) CNS: Headache, drowsiness, dizziness a) Respiratory depression
b) GIT: Nausea, vomiting b) Bradycardia
c) Respiratory depression
d) Bradycardia
Reversal IV Naloxone 0.01 mg/kg (0.1 – 0.2mg, Max 0.4mg)
Contraindications Caution in patient wt head injury, renal & liver impairment
4. Lignocaine
Pharmacology Amide derivative of diethylaminoacetic acid (DEAAC)
Dose Infiltration / intrathecal / epidural: 0.3 mg/kg → 200mg (20mls of 1% solution)
Indications Local anaesthesia → Reversible neural blockade
Disadvantages Neurotoxicity: Perioral numbness, tinnitus, dizziness, convulsion
Contraindications a) Hypovolemia
b) Heart block
Din XJ
Chapter 2 GENERAL
RADIOGRAPHY
15
SCRIPT FOR RADIOGRAPHIC EXAMINATION
This is a ……
1. Type of examination
2. Type of projection
3. Indication
4. Contra-indication
5. Technique
a) General - Confirm correct patient, test & indication
- If female of reproductive age, confirm LMP
- Proper exposure
- Remove foreign objects at region of interest
- Gonadal shield
b) IR - IR size
- Grid / non-grid
- Correct annotation: Patient ID, anatomical marker
c) Exposure technique - kV
- mAs
d) Patient position
Respiration
e) Tube position
f) CR
g) Collimation - Apply 4-sided collimation
Din XJ
16
CHEST
A. PA & AP view
PA AP
Indication - Lung pathology

- Trauma: Rib fracture (Ant ribs: PA view, Post ribs: AP view)
- Heart size
IR 35 x 43 cm 35 x 43 cm
Grid Non-grid (to prevent grid cut-off)
Exposure 110 – 120 kV (high kVp)
2 – 3 mAs, short exposure time (100 mA, 0.02 – 0.03sec)
Position
- Erect, front facing IR - Sitting / supine, back facing IR

- Chin raised & rest on IR - MSP ∟ IR, MCP ║ IR
- Ant chest pressed against IR - Full inspiration, suspend
- Both shoulders depressed, rotated forward,
pressed against IR
- Both elbows flexed
- Dorsal of both palms rest on hips
- Female: Breasts moved upward & outward
- MSP ∟ IR, MCP ║ IR
- Full inspiration, suspend
Tube Horizontal beam Sitting (Horizontal), Supine (Vertical), Mobile
FFD: 180cm FFD: 100cm
CR - Midline - Sternal notch
- Level of T7
a) Midpoint btw inferior angle of scapula
b) 18-20cm below C7 vertebra prominens
Collimation - Upper border: Lung apices
- Lower border: Costophrenic angles
- Sides: Lateral skin margins
Din XJ
17
Remarks (i) General

- Patient’s particular
- Anatomical marker
(ii) Exposure / penetration
- T1-T4: Vertebral details are clearly seen
- Below T4: Intervertebral disc spaces are clearly seen, vertebral details are not
- Visible lung markings
(iii) Adequate coverage (Collimation)
- Upper border: Lung apices - Lower border: Costophrenic angles
(iv) Positioning
- No rotation: Symmetrical spinous process to both med end of clavicle
- Chin is sufficiently raised from obscuring lung apices
- Clavicles are in horizontal plane, from obscuring lung apices
- Scapula displaced laterally from lung field
- Humerus abducted away from chest
(v) Full inspiration
- Right anterior 6th rib / posterior 10th rib crosses diaphragm along MCL
(vi) No artifacts
- No motion: Sharp outlines & margins
1. Trachea 1. Contour of Rt brachiocephalic vein

2. Clavicle 2. Contour of subclavian artery
3. Lung apex 3. Subclavian & aortic arches
4. Curve of lung apex 4. Aortic arch
5. Post border btw Rt & Lt lung 5. Azygos vein
6. Rt paratracheal stripe 6. SVC
7. Carina 7. Main pulmonary artery
8. Rt main bronchus 8. Rt pulmonary artery
9. Lt main bronchus 9. Lt pulmonary artery
10. Intermediate bronchus 10. Rt pulmonary artery – Intermediate part
11. Para-aortic stripe 11. Pulmonary artery – Inferior lobar branch
12. Descending aorta 12. Pulmonary valve
13. Azygoesophageal stripe 13. Lt atrium
14. Paraspinal stripe 14. Aortic valve
15. Breast shadow 15. Venous confluence
16. Diaphragm 16. Mitral valve
17. Gastric bubble 17. Rt atrium
18. Insertions of the diaphragm 18. Tricuspid valve
19. Costodiaphragmatic recess 19. Lt ventricle
(costophrenic angle) 20. IVC
21. Rt ventricle
Din XJ
18
DISCUSSION
1. Reason of high kV technique in CXR:
a) Chest has high subject contrast: Difference btw bone / heart / lungs
- ↑ kV allows better penetration of bones, heart & lung bases → Visualization of fine lung markings
- ↑ kV will ↓ dynamic range → Allows visualization of mediastinum & lungs with 1 exposure
b) ↓ mAs (exposure time) → ↓ Motion artifacts
c) ↓ mAs → ↓ Patient dose
2. Difference btw PA erect film & AP film

PA AP
a) Heart size Less magnification More magnification
- Long FFD (180cm): ↓ Beam divergence - Shorter FFD (100cm): ↑ Beam divergence
- Heart nearer to IR - Heart further away from IR
b) C6, C7, T1
- Lamina - Inverted V shape - Flattened
- Disc space - Closed - Open with no distortion
- Spinous process - Well-demonstrated - Not well-demonstrated
- Vert end plates - Not prominent - Prominent d/t tangential to divergent beam
c) Scapula Outside lung field (> lateral) Overlaps with lung field (> medial)
d) Clavicles More vertical More horizontal, higher
e) Ribs Prominent anterior ribs Prominent posterior ribs
More horizontal posterior ribs
f) Stomach gas Seen in fundus
Other advantages of PA view - Allows diaphragm to move down further for full lung expansion
- Prevents engorgement of pulmonary vessels
- Visualization of air-fluid levels
3. Hidden areas
a) Apices - PA: Partially obscured by ribs, clavicles & soft tissues
- Lat: Limited visualization
b) Hilum - PA: Central lesions are superimposed
- Lat: Better visualization
c) Mediastinum (retro-cardiac region) - PA: Central lesions are superimposed
- Lat: Better visualization
d) Diaphragms & costophrenic angles - PA: Lung bases& posterior sulcus are partially obscured by posterior diaphragm
Worse if under-inspiration
e) Bones & costal cartilages - PA: Lung lesions may be obscured
- Expiratory, AP & oblique films may be helpful
Din XJ
19
B. Lateral & Lordotic view

Lateral view (Apical) Lordotic view
Indication - To localize a lesion seen on PA/AP CXR - To assess lung apices (Pancoast tumour, TB)
- To clarify lobar collapse/consolidation → Clavicle projected above lung apices
- To explore a retrosternal or retrocardiac shadow - Medial aspect of 1st 4 ribs
- To confirm the presence of encysted fluid in the oblique
fissure (pseudotumour)
IR 35 x 43 cm 35 x 43 cm
Grid Grid
Exposure 110 – 120 kV (usually + 10kV from PA view) 110 – 120 kV
2 – 3 mAs 2 – 3 mAs
Position
- Erect
- Standing 30cm away from IR, back facing IR
- Side of interest facing IR (typically left):
- Then lean back to IR
Left lung is more obscured in PA view
- Back of head, neck & shoulder against IR
Less magnification of heart in left lateral view
- Chin up - Shoulders rolled forward
- Both arms raised above head - Hands on the hips
- MSP ║ IR, MCP ∟ IR
Tube Horizontal beam Horizontal beam
CR - MCP - MSP
- Level of T7 - Level of T7 (Midway btw sternal notch & xiphoid process)
Collimation - Upper border: Lung apices 4 sides to lung fields
- Sides: Anterior & posterior skin margins
Din XJ
20
Remarks (i) General: Patient’s particular, Anatomical marker - Similar to AP view

(Lateral) (ii) Exposure / penetration - Clavicles projected above lung apices
- Vertebral bodies progressively ↑ translucent caudally - Med ends of clavicles superimpose wt only 1st & 2nd
(iii) Positioning ribs
- No rotation: - Near superimposition of ant & post ribs
a) Nearly superimposed hemidiaphragms
b) Rt & Lt posterior ribs superimposed
c) Neural foramina of thoracic vertebrae are open
- Chin & arms are elevated from obscuring lung apices
- Ant-inf lung & heart shadows are well defined
(v) Full inspiration
(vi) No artifacts
1. Soft tissue of shoulder 11. Lt upper lobe bronchus 20. Mitral valve
2. Trachea 12. Main pulmonary artery 21. Tricuspid valve
3. Scapula 13. Descending aorta 22. Pulmonary veins
4. Sternal angle 14. Pulmonary valve 23. Lt ventricle
5. Aortic arch 15. Pulmonary veins 24. Retrocardiac space
6. Sternal body 16. Aortic valve 25. IVC
7. Aorto-pulmonary window 17. Lower lobe bronchus 26. Gastric bubble
8. Ascending aorta 18. Lt atrium 27. Lt hemidiaphragm
9. Rt upper lobe bronchus 19. Rt ventricle 28. Rt hemidiaphragm
10. Retrosternal space
DISCUSSION
1. Difference btw right & left lateral film
Right lateral Left lateral
a) Heart size ↑ Magnification ↓ Magnification
b) Lung details ↑ Rt lung radiographic detail (Rt lung closer to IR) ↑ Lt lung radiographic detail (Lt lung closer to IR)
c) Hemidiaphragm - Rt hemidiaphragm lower than Lt
- Rt hemidiaphragm meets with Rt posterior ribs
2. Distinguish right & left hemidiaphragm

Right hemidiaphragm Left hemidiaphragm
a) Diaphragm outline Rt hemidiaphragm is visible throughout its length
(anterior to posterior)
b) Heart shadow Merges with anterior part of Lt hemidiaphragm
c) Gastric air bubble Directly below Lt hemidiaphragm
Din XJ
21
C. Lateral decubitus & Dorsal decubitus view

Lateral decubitus view Dorsal decubitus view
Indication - Air-fluid level in pleural cavity Air-fluid level in pleural cavity

- Mobility of mediastinal / pleural mass (for patient unable to stand / sit)
IR 35 x 43 cm 35 x 43 cm
Grid Grid
Exposure 110 – 120 kV 110 – 120 kV (usually + 10kV from PA view)
2 – 3 mAs 2 – 3 mAs
Position
- Supine, side facing vertical IR
- Both arms raised above head
- Lateral recumbent position, back facing IR

a) Air: Up
b) Fluid: Down
- Chin up
- Both arms raised above head
- MSP ║ IR, MCP ∟ IR
Tube Horizontal tube Horizontal tube
FFD 180cm FFD 100cm
CR - MSP - MCP
- Level of T7 (8-10cm below jugular notch) - Level of T7
Collimation 4 sides to lung fields 4 sides to lung fields
Remarks Similar to AP view Similar to lateral view
Din XJ
22
D. Oblique view
Anterior oblique view (Typically !!) Posterior oblique view (LPO & RPO)
HUKM practice posterior oblique !!!
RAO LAO
Indication - Trauma: Rib fracture (Ant ribs: Ant oblique, Post ribs: Post oblique)
- Lung pathology, hilum
- Lateral constophrenic angles
- Cardiac configuration
a) RAO (equivalent to LPO): To assess Lt side
b) LAO (equivalent to RPO): To assessRt side
IR 35 x 43 cm 35 x 43 cm
Grid Grid
Exposure 120 kV 120 kV
2 – 3 mAs 2 – 3 mAs
Position RAO LAO
- Erect,
AP projection (IR posteriorly related)
- Region of interest: Facing IR
- Erect, PA projection (IR anteriorly related)

- Region of interest: Away from IR
- MSP rotated 45o
- Arm near IR: Flexed, hand placed on hip
- Arm away from IR: Raised, hand placed on head
Tube Horizontal beam Horizontal beam
CR Level of T7 Level of T7
Collimation 4 sides to lung fields 4 sides to lung fields
Remarks - Lung field of side of interest is 2x the other side More magnification than anterior oblique
- Visualized heart shadow, trachea, principle bronchi & SCJ
Din XJ
23
Anterior oblique (Right chest)
1. Right lung 11. Infundibulum

2. Left lung 12. Inferior Rt pulmonary vein
3. Aortic arch 13. Inferior Lt pulmonary vein
4. Trachea 14. Left atrium
5. Ascending aorta 15. Right atrium
6. Descending aorta 16. Left ventricle
7. Lt upper lobe pulmonary vein, artery, bronchus 17. IVC
8. Main pulmonary artery 18. Gastric bubble
9. Left pulmonary artery 19. Diaphragm
10. Pulmonary art – Rt inferior lobar branch
Anterior oblique (Left chest)
1. Sternum 11. Lt pulmonary vein

2. Aortic arch 12. Rt pulmonary vein
3. Trachea 13. Descending aorta
4. Ascending aorta 14. Right ventricle
5. Carina 15. Left ventricle
6. Lt pulmonary artery 16. Right lung
7. Rt main bronchus 17. IVC
8. Lt main bronchus 18. Gastric bubble
9. Right atrium 19. Rt hemidiaphragm
10. Rt pulmonary artery 20. Left lung
Din XJ
24
SCRIPT FOR CXR (PA view)

This is a ……
1. Type of examination - Chest radiograph
2. Type of projection - done in PA projection
3. Indication - To look for
a) Lung pathology
b) Rib fracture in trauma cases
c) Assess heart size
4. Contra-indication - No absolute contraindication
5. Technique To perform this examination,
- Proper exposure
- Gonadal shield
b) IR - IR size of 35 x 43 cm
- Gridded cassette
- Correct annotation: Patient ID, anatomical marker
c) Exposure technique - 110 – 120 kV
- 2 – 3 mAs
d) Patient position - Erect, front facing IR
- Chin raised & rest on IR
- Ant chest pressed against IR
- Both shoulders depressed, rotated forward, pressed against IR
- Both elbows flexed
- Dorsal of both palms rest on hips
- Female: Breasts moved upward & outward, compressed against IR
Respiration - Full inspiration, suspend
e) Tube position - Horizontal beam
- FFD: 180cm
f) CR - Midline
- Level of T7
a) Midpoint btw inferior angle of scapula
b) 1 palm below C7
- Upper border: Lung apices
Important things in CXR:

1. All the lines on CXR
a) Anterior & posterior junctional lines
b) Azygo-oesophageal line & Pleuro-oesophageal line, trachea-oesophageal stripe (lateral)
c) Right & left paratracheal stripes, posterior paratracheal stripe (lateral)
d) Right & left paraspinal lines
2. Hilar point & hilar angle
3. Aorto-pulmonary window
4. Mediastinal & cardiac borders
Din XJ
25
ABDOMEN
A. AP (supine) / KUB & PA (prone) view
IR 35 x 43 cm
Grid
Exposure 70 – 80 kV (Intermediate kVp)
30 mAs, short exposure time
Position AP (supine) / KUB PA (Prone)
↓ Gonadal dose (if kidney is not the interest)
- Supine, back facing IR

- Prone, front facing IR
- Arms at sides, away from body - Arms up beside head
- Legs extended, with support under knees - Legs extended, with support under ankles
- MSP centered to midline of IR - MSP centered to midline of IR
- Center of IR at Iliac crest - Center of IR at Iliac crest
- ASIS equidistant from table top - PSIS equidistant from table top
- End of expiration, suspend - End of expiration, suspend
Tube Vertical beam
FFD: 100cm
CR - MSP
- Level of iliac crest
Collimation - Upper border: Diaphragm
- Lower border: Must include symphysis pubis
- Side: Close to skin margin
- KUB (AP): Must include symphysis pubis, Closer side collimation
Remarks (i) Exposure / penetration: (iii) Positioning
- Visible outline of liver, spleen, kidneys, - Spine is straight& in midline
psoas shadows, air-filled stomach, bowel - Ribs & hips are equidistant from spine
- Visible lumbar transvers process & ribs - Symmetrical Iliac wings & ischial spines
(ii) Adequate coverage (Collimation)
- Diaphragm to symphysis pubis
1. Spleen
2. Liver
3. Left kidney
4. Right kidney
5. Subcutaneous fat
6. Abdominal muscles
7. Preperitoneal fat
8. Psoas
9. Iliac crest
10. Ilium
11. Sacrum
12. Obturator internus
13. Urinary bladder
Din XJ
26
B. AP (erect) view
AP (erect)
Indication:
Air under diaphragm
IR 35 x 43 cm, Grid
Exposure 70 – 80 kV
30 mAs, short exposure time
Position
- Erect, back facing IR

- Arms at sides, away from body
- Legs slightly spread
- MSP centered to midline of (erect) IR
- Center of IR at 2 inch above Iliac crest
- End of expiration, suspend
Tube Horizontal beam

FFD: 100cm
CR - MSP
- 5cm above iliac crest
Collimation Closely on sides to skin margin
Remarks (i) Exposure / penetration: Visible both diaphragms, air-filled stomach, bowel
(ii) Positioning
- Spine is straight
- Outer margins of lower ribs are equidistant from spine
- Iliac wings & ischial spines are symmetrical
DISCUSSION
1. Difference btw AP& PA film
AP PA
a) Pelvic brim Rounder, wider Oval & narrow
b) Sacrum & SI joint Wider Narrow
c) Iliac wings Smaller Bigger
d) Obturator foramen Oval Rounder, > vertically orientated
2. Fat in abdominal cavity
Advantages Greater tissue absorption for organ surrounded by fat (eg. Kidneys)
Disadvantages Scatter radiation
3. Differences btw AXR & KUB XR
a) Different indication
b) For KUB, closer side-side collimation, but symphysis pubis must be included inferiorly
c) KUB requires bowel-prep
Din XJ
27
C. Lateral decubitus & Dorsal decubitus view

Lateral decubitus Dorsal decubitus
Indication - Air-fluid level - Air-fluid level

- Abdominal mass
- Aneurysm
IR 35 x 43 cm
Grid (vertical)
Exposure 70 – 80 kV 80 – 85 kV
30 mAs, short exposure time 50 mAs, short exposure time
Position
- Lateral recumbent, back facing (vertical) IR - Supine, side facing (vertical) IR
- Patient on firm surface, to prevent sagging - Arms up beside head

- Arms up beside head - Knees partially flexed
- Knees partially flexed - MCP centered to midline of (vertical) IR
- MSP centered to midline of (vertical) IR - MCP ∟ IR, MSP ║ IR
- MSP ∟ IR, MCP ║ IR - Center of IR at 5cm above Iliac crest
- Center of IR at 5cm above Iliac crest - End of expiration, suspend
FFD: 100cm
CR - MSP - MCP
- 5cm above iliac crest - 5cm above iliac crest
Collimation Closely on sides to skin margin
Remarks (i) Exposure / penetration: (i) Exposure / penetration:
- Slightly ↓ density than supine AXR - Ribs & gas bubble margins are sharp
- Visible both diaphragms, air-filled stomach, bowel - Visible air-filled bowel & soft tissue detail
(ii) Positioning (ii) Positioning
- Spine is straight Superimposition of bilateral ASIS, posterior
- Outer margin of lower ribs are equidistant frm spine borders of iliac wings, posterior ribs
- Iliac wings & ischial spines are symmetrical
Din XJ
28
HEAD & NECK
A. External acoustic meatus (EAM)
B. Glabello-meatal line (GML)

C. Orbito-meatallne (OML) - Radiological baseline
D. Infraorbital-meatal line (IOML) - Anthropological baseline
Auricular line: Perpendicular to IOML, through center of EAM
E. Acantho-meatal line (AML)
F. Mento-meatal line (MML)
G. Glabello-alveolar line (GAL)
H. Gonion
Din XJ
29
A. Skull 1. Lateral D. Optic foramen 1. Parieto-orbital oblique (Rhese method)

2. PA / OF
a) PA 0o E. Jugular foramen
b) PA 15o (Caldwell 15o)
c) PA 20o(Caldwell 20o) F. Zygomatic arches 1. Tangential
d) PA 25-30o 2. AP axial / FO
3. AP axial / FO a) Modified Towne
a) 30o (Towne) 3. SMV
b) 37o
4. SMV G. Mandible 1. PA / OF
* Usual Projection: Lat, Caldwell 20o 2. AP axial / FO
3. Axio-lateral oblique
Sella 1. Lateral
turcica 2. AP axial / FO H. Mastoid &TMJ 1. Axio-lateral oblique (Law)
a) 30o (Towne) 2. Axio-lateral (Schuller)
b) 37o
I. Nasal bones 1. Lateral
B. Facial 1. Lateral 2. Tangential / Supero-inferior
2. PA / OF 3. Parieto-acanthial / OM
a) PA 15o (Caldwell) a) Waters
3. Parieto-acanthial / OM
a) Waters K. Orthopantomogram
b) Modified Waters
C. PNS 1. Lateral
2. PA / OF
a) PA 15o (Caldwell)
3. Parieto-acanthial / OM
a) Waters – Open mouth
4. SMV
Din XJ
30
A. Skull, Facial & PNS XR
1. Lateral view
Skull Sella turcica view Facial & PNS

Indication 1. Skull + sella turcica 2. Facial & PNS
a) Trauma: Fracture a) PNS pathology (Inflammation, tumour)
b) Skeletal survey: Multiple myeloma b) Trauma: Fracture
c) Foreign body (Orbit)
IR 24 x 30 cm
Grid
20 mAs
Position
- Sitting or prone, side of interest facing IR

- Head in true lateral position
- Neck slightly flexed
- IOML ∟ Front edge of IR
- Inter-pupillary line ∟ IR
- MSP ║ IR
- Suspend respiration
Tube Sitting (Horizontal), Prone (Vertical)

FFD 100cm
CR 1. Skull: 5cm superior to EAM
Sella turcica view: 2cm superior & 2cm anterior to EAM
2. Facial & PNS: 2cm posterior to outer canthus
Collimation 1. Skull: Entire cranium
Sella turcica view: More collimation
2. Facial & PNS: Close beam collimation
Remarks 1. Skull
- Sella turcica not rotated
- Superimposition of orbital roof, mastoid region, EAM, TMJ, mandibular rami, zygomatic bone
- Postero-inferior occipital bone & posterior arch of atlas are not superimposed
2. Facial & PNS
- Zygoma in center
- Sella turcica not rotated
- Superimposed orbital roof & mandibular rami
Din XJ
31
1. Parietal bone – Outer table 10. Cribriform plate 19. Maxillary sinus
2. Diploe 11. Anterior clinoid process 20. Opening of EAC
3. Parietal bone – Inner table 12. Posterior clinoid process 21. Coronoid process of mandible
4. Coronal suture 13. Nasal bone 22. Foramen magnum
5. Groove of middle meningeal art 14. Sphenoid sinus 23. Zygomatic process
6. Frontal sinus 15. Zygomatic bone 24. Hard palate
7. Pituitary fossa 16. Clivus 25. Nasopharynx
8. Greater wing of sphenoid 17. Ethmoid sinus 26. Soft palate
9. Lambdoid suture 18. Temporal bone – Petrous part 27. Mandible
1. Floor of ant cranial fossa & orbital roof 7. Pituitary fossa

2. Sphenoid 8. Sphenoid sinus
3. Anterior clinoid process 9. Clivus
4. Tuberculum sellae 10. Petrous ridge
5. Posterior clinoid process 11. Greater wing of sphenoid
6. Dorsum sellae
Din XJ
32
2. PA (Occipito-frontal, OF) view
PA 0o PA 20o (Caldwell 20o)

Indication 1. Skull 2. Facial & PNS
a) Trauma: Fracture a) PNS pathology (Inflammation, tumour)
b) Skeletal survey: Multiple myeloma b) Trauma: Fracture
c) Foreign body (Orbit)
Angle caudally To see ……

0o CR ∟ IR Frontal bone
15o Caldwell
20-25o Superior orbital fissure
25-30o Foramen rotundum
IR 24 x 30 cm
Grid
20 mAs
Position
- Erect or prone, front facing IR

- Neck flexed
- Forehead & nose in contact with IR
- OML ∟ IR
- MSP ∟ IR
- Center of IR to CR
Tube Erect (Horizontal), Prone (Vertical)

FFD 100cm
Angle CR caudally: 0o (CR ∟ IR), 15o (Caldwell 15o), 20o (Caldwell 20o), 25-30o (Waters)
CR Exit at nasion
Collimation 1. Skull: Entire cranium
2. Facial & PNS: Close beam collimation
Remarks - Lateral border of skull & lateral border of orbit are equidistant
- Petrous ridges are symmetrical
- Enough angulation to bring down petrous ridge in relation to orbit
(Caldwell 15o: Lower ⅓ of orbit, 20o: Lower orbital margin)
Din XJ
33
1. Sagittal suture 13. Condylar process of mandible

2. Pacchionian granulations 14. Nasal septum
3. Lambdoid suture 15. Maxillary sinus
4. Frontal sinus 16. Mastoid process
5. Orbital roof 17. Occiput
6. Sphenoid 18. Dens of C2
7. Ethmoid sinus 19. Maxilla
8. Fronto-zygomatic suture 20. Mandibular canal
9. Petrous ridge 21. Angle of mandible
10. Innominate line 22. Mandible
11. IAC 23. Mental protuberance
12. Zygomatic arch
Din XJ
34
3. AP Axial (Fronto-occipital, FO) view
Towne
Indication 1. Skull + sella turcica
Structures to be seen:
Petrous pyramids, foramen magnum, dorsum sellae, posterior clinoid processes, occipital bone,
post part of parietal bones, semicircular canal, IAM, Arch of atlas, arcuate eminence
Angle caudally Tuberculum sellae & anterior clinoid process projected

30o to OML Towne ABOVE foramen magnum
(37o to IOML) (FO30)
37o to OML WITHIN foramen magnum
IR 24 x 30 cm
Grid
20 mAs
Position
- Supine or erect (usually supine)

- Back facing IR
- Depress chin
- OML ∟ IR
- MSP ∟ IR
- Center IR to CR

FFD 100cm
Angle CR caudally: 30o to OML or 37o to IOML (Towne’s view), 37o to OML
CR 5cm above glabella
Collimation Skull: Entire cranium
Sella turcica view: More collimation
Remarks (i) Exposure / penetration:
Visible occipital bone, without excessive density at lateral borders of skull
(ii) Positioning
- Lateral border of skull & lateral border of foramen magnum are equidistant
- Symmetrical petrous pyramids
- Posterior clinoid processes & dorsum sellae are within foramen magnum
Din XJ
35
Reverse Towne’s view (Haas method)

Indication Structures to be seen:
Petrous pyramids, foramen magnum, dorsum sellae, posterior clinoid processes, occipital bone,
post part of parietal bones, semicircular canal, IAM, Arch of atlas, arcuate eminence
IR 24 x 30 cm
Grid
20 mAs
Position - Prone
- Place forehead & nose on table
- OML ∟ IR
- MSP ∟ IR
FFD 100cm
Angle CR 25o cranially
CR Exit at glabella
Remarks Skull is projected without geometric distortion compared wt Towne’s view
1. Lambdoid suture 9. Semicircular canals

2. Occipital protuberances 10. Mastoid air cells
3. Occipital bone 11. IAC
4. Sulcus of transverse sinus 12. Posterior arch of C1
5. Occipital crest 13. Jugular foramen
6. Foramen magnum 14. Dens of C2
7. Petrous bone 15. TMJ
8. Arcuate eminence 16. Condyle of mandible
Din XJ
36
4. Submento-vertical, SMV view

Indication 1. Skull: Trauma Structures to be seen:
(Base of skull & associated foramina) - Petrosae, mastoid process, occipital condyle,
2. PNS odontoid process of axis, atlas, mandible
IR 24 x 30 cm - Maxillary, sphenoid & post ethmoid sinuses,
Grid perpendicular plate of ethmoid
Exposure 70 – 80 kV - Formn ovale, formn spinosum, jugular formn, carotid canals
20 mAs - Bony part of Eustachian tubes, IAM, ossicles, EAM
Position
- Usually supine
- Head extended over the end of table
- Head supported with IR
- IOML ║ IR, IOML ∟ CR
- MSP ∟ IR
Tube Vertical beam

Angle so that IOML ∟ CR
CR Midpoint btw angle of mandible (2cm anterior to EAM)
Remarks (i) Exposure / penetration: Structures of cranial base are clearly seen
(ii) Positioning
- Lateral border of skull & lateral border of mandibular condyles are equidistant
- Symmetrical petrosae
- Superimposed frontal bone & mandibular symphysis
- Mandibular condyles are anterior to petrous pyramids
1. Nasal septum 9. Sphenoid sinus 17. Semicircular canals

2. Zygomatic bone 10. Foramen ovale 18. Anterior arch of C1
3. Posterior wall of maxillary sinus 11. Foramen spinosum 19. Jugular foramen
4. Maxillary sinus 12. Clivus 20. Mastoid air cells
5. Middle cranial fossa, greater wing 13. Foramen lacerum 21. Dens of C2
6. Pterygopalatine fossa 14. Condyle of mandible 22. Foramen magnum
7. Coronoid process 15. Cochlea 23. Cervical spine
8. Pterygoid fossa 16. IAC
Din XJ
37
5. Parieto-acanthial / Occipito-mental, OM / Waters view
Indication Facial & PNS

a) Trauma: Fracture
b) PNS pathology (Inflammation, tumour)
IR 18 – 24 cm
Grid
20 mAs
Position
- Erect, front facing IR

- Neck extended, chin rest on IR
- For PNS: Open mouth
- OML 37o from IR
- MSP ∟ IR

FFD 100cm
CR Exit at acanthion
Collimation Visualized: Orbits, maxillae, zygomatic arches
Remarks - Lateral border of skull & lateral border of orbit are equidistant
- Symmetrical orbits & maxillary sinuses
- Anterior nasal spine is at the center of IR
- Sphenoid sinuses are seen through the open mouth
- Petrous ridges lie immediately inferior to the floor of maxillary sinus
* McGrigor’s Line: Important in assessing facial bones injury (LeFort fracture)
Line 1 Through zygomatico-frontal synchondrosis suture & superior orbital margin
Line 2 Through superior border of zygomatic arch, body of zygoma, inferior orbital margin & over the nose
Line 3 Through inferior border of zygomatic arch, lateral & medial walls of maxillary antra
Din XJ
38
1. Frontal sinus 8. Foramen rotundum 14. Foramen ovale

2. Nasal bone 9. Posterior ethmoid sinus 15. Alveolar process of maxilla
3. Anterior ethmoid sinus 10. Zygomatic bone 16. Condyle of mandible
4. Orbit 11. Maxillary sinus 17. Petrous ridge
5. Nasal septum 12. Alveolar recess of maxilla 18. Tongue
6. Greater wing of sphenoid 13. Sphenoid sinus 19. Mandible
7. Infraorbital foramen
Line 1:
- Look for widening of the zygomatico-frontal sutures
- Fractures of the superior rim of the orbits
- "Black-Eyebrow" sign due to orbital emphysema
- Opacification / air-fluid level in the frontal sinuses
Line 2:
- Look for fractures of the superior aspect of the zygomatic arch
- Fractures of the inferior rim of the orbits
- Soft tissue shadow in the superior maxillary antrum
- Fractures of the nasoethmoid bones and medial orbits
Line 3:
- Look for fractures of the inferior aspect of the zygomatic arch
- Fractures of the lateral maxillary antrum
- Opacification / air-fluid level in the maxillary sinuses
- Fractures of the alveolar ridge
Din XJ
39
B. Optic Canal XR
IR 18 x 24 cm (crosswise)
Grid
Exposure 80 kV
20 mAs
Position - Erect (more common) or prone, front facing IR
- OML raised by 35o
- MSP 55o to IR
Tube Horizontal (Erect), Vertical (Prone)
FFD 100cm
CR Down side orbit
Remarks Optic canal seen end on in the lower ½ adjacent to lateral margin of orbit
1. Frontal sinus 11. Superior orbital fissure

2. Orbital roof 12. Frontal process of zygomatic bone
3. Sphenoid 13. Foramen rotundum
4. Orbit (grey background) 14. Orbital floor
5. Ethmoid sinus 15. Petrous ridge
6. Lateral wall of orbit 16. Nasal septum
7. Lesser wing of sphenoid 17. Zygomatic arch
8. Innominate line 18. Inferior turbinate
9. Orbital plate 19. Maxillary sinus
10. Greater wing of sphenoid 20. Hard palate
C. Jugular Foramen XR
20 mAs
Position - Erect or supine, back facing IR
- OML ║ IR
- MSP ∟ IR
Tube Horizontal (Erect), Vertical (Supine)
FFD 100cm
Angle CR 20o caudally
CR 2.5cm distal to mandibular symphysis
Remarks - Jugular foramen not superimposed with mandible
- Angle of mandible & lateral border of skull are equidistant
Din XJ
40
D. Zygomatic Arches
- Basic views: Tangential (Bilateral or Unilateral), AP axial / OM / Modified Towne, SMV
1. Tangential view
IR 18 x 24 cm
Grid
6 mAs
Position
- Erect, back facing IR

- Neck extended
- MSP ∟ IR
- For unilateral projection: Rotate MSP 15o towards examined side

FFD 100cm
Angle CR ∟ IOML
CR - Bilateral projection: Midway btw zygomatic arches
Unilateral projection: Mid zygomatic arch
- 2.5cm posterior or outer canthus
Remarks Zygomatic arches are symmetrical, no foreshortening, free from overlying structures
Tangential (Bilateral) Tangential (Unilateral)
1. Maxillary sinus 5. Temporo-zygomatic suture

2. Zygomatic recess 6. Coronoid process
3. Zygomatic arch 7. Zygomatic process of temporal bone
4. Temporal fossa
Din XJ
41
2. AP Axial (Fronto-occipital, FO) view – Modified Towne
IR 24 x 30 cm
Grid
20 mAs
Position
- Supine or erect (usually supine)

- Back facing IR
- Depress chin
- OML ∟ IR
- MSP ∟ IR
- Center IR to CR

FFD 100cm
Angle CR caudally: 30o to OML or 37o to IOML
CR Glabella (Modified Towne’s projection)
instead of 5cm above glabella (Normal Towne’s projection)
Remarks Zygomatic arches are symmetrical, no foreshortening, free from overlying structures
Din XJ
42
E. Mandible
- Basic views: PA / OF, AP axial / FO, Axio-lateral oblique
1. PA (Occipito-frontal, OF) view

IR 18 x 24 cm
Grid
20 mAs
Position
- Erect or prone, front facing IR

- Nose & chin contact with IR
- MSP ∟ IR
- Center of IR to CR
Tube Erect (Horizontal), Prone (Vertical)

FFD 100cm
CR CR Angle To see ……
Level of lips 0o (CR ∟ IR) Mandibular body
Midway btw TMJs 30o cranially Rami & condylar process of TMJ
Collimation Entire mandible

Remarks - Symmetrical mandibular body & rami
- Condylar processes of TMJ should be visualized when CR is angled 30o cranially
1. Orbital floor 6. Anterior nasal spine

2. Nasal septum 7. Coronoid process
3. Base of skull 8. Maxilla
4. Maxillary sinus 9. Ramus of mandible
5. Lateral wall of maxilla 10. Angle of mandible
Din XJ
43
2. Axio-lateral oblique
IR 18 x 24 cm
Grid
20 mAs
Position
- Sitting erect or prone

- Head in true lateral position, side of interest facing IR
- Neck extended
- Long axis of mandibular body ║ IR
Tube Sitting erect (Horizontal), Prone (Vertical)

FFD 100cm
Angle 25o cranially
CR Slightly posterior to mandibular angle (away from IR)
Collimation Mandibular body of interest
Remarks Mandible of interest should not superimposed wt opposite mandible
1. TMJ 7. Pulp cavity

2. Condyle of mandible 8. Root canal
3. Coronoid process 9. Apical foramen of the tooth
4. Ramus of mandible 10. Mental foramen
5. Mandibular foramen 11. Mandibular canal
6. Mental protuberance 12. Angle of mandible
Din XJ
44
F. Mastoid & Temporo-mandibular Joint

- Basic views: Axio-lateral oblique & Axio-lateral (Schuller method)
1. Axio-lateral oblique (Close & Open mouth)
IR 18 x 24 cm
Grid
14 mAs
Position
- Sitting erect or prone

- Head in true lateral position,
side of interest facing IR
- Inter-pupillary line ∟ IR
- MSP ║ IR
- Acquire both open & close mouth views
Tube Horizontal
FFD 100cm
Angle CR 25o caudally
CR If mastoid is the interest: Mastoid tip in contact with IR
If TMJ is the interest: TMJ in contact with IR (5cm superior to TMJ away from IR)
Remarks - TMJ anterior to EAM
- Close mouth: Condyle in mandibular fossa
- Open mouth: Condyle inferior to articular tubercle
Din XJ
45
G. Nasal Bone XR
- Basic views: Lateral, Tangential, Parieto-acanthia / OM / Waters
Indication Trauma: Fracture
Exposure 55 kV
3 mAs
Position
- Supine or erect, side of interest facing IR - Prone, chin over IR

- Head in true lateral position - Chin extended fully, rest on sandbag
- Inter-pupillary line ∟ IR - Glabello-alveolar line ∟ IR
- IOML ∟ IR - MSP ∟ IR
- MSP ║ IR
Tube Vertical (Supine), Horizontal (Erect) Vertical beam
FFD 100cm FFD 100cm
CR 1.25cm (½ inch) inferior to nasion
Collimation Nasal bone, nasal spine of maxilla, soft tissue Nasal bone, soft tissue
Remarks Nasal bone in center of IR Minimal superimposition of nasal bone over forehead
Tangential Lateral
1. Fronto-nasal suture 5. Nasal cartilage

2. Ethmoidal groove 6. Maxilla
3. Nasal bone 7. Vestibule of nose
4. Naso-maxillary suture 8. Anterior nasal spine
Din XJ
46
H. Orthopantomogram
Indication - Dental assessment
- To assess lamina dura & periodontal membrane
- TMJ or mandibular pathology
IR Curved non-grid cassette
10 mAs (Long exposure time: 12 – 20sec)
Position - Erect
- Head immobilized wt temporal plates
- Chin rest on chin rest
- Incisors bit the bite block
- Lips closed
- Tongue lifted up to hard palate
X-ray tube & bulky move from side to side (in opposite direction) to a fulcrum
CR Middle detector is in line wt infra-orbital line
1. Styloid process 11. Maxillary sinus 20. Pulp cavity

2. Soft palate 12. Pterygopalatine fossa 21. Dentin
3. Condyle of mandible 13. Pterygoid process 22. Enamel
4. Condylar process 14. Angle of mandible 23. Mental foramen
5. Zygomatic arch 15. Shadow of the tongue 24. Root of the tooth
6. Coronoid process 16. Mandibular canal 25. Incisor
7. Orbital floor 17. Hyoid bone 26. Canine
8. Nasal cavity 18. Apical foramen of the tooth 27. Premolar
9. Hard palate 19. Root canal 28. Molar
10. Alveolar process of maxilla
Din XJ
47
SCRIPT FOR SKULL XR (Lateral view)
This is a ……
1. Type of examination - Skull radiograph
2. Type of projection - done in lateral projection
3. Indication - To look for
4. Contra-indication - No absolute contraindication
5. Technique To perform this examination,
- Proper exposure
- Gonadal shield
b) IR - IR size of
- Gridded cassette
- Annotation: Patient ID, anatomical marker
c) Exposure technique - 60 – 70 kV
- Short mAs
d) Patient position - Erect, IR at the side of patient
- Interpupillary line (IP) ∟ IR
MCP ∟ IR
MSP ║ IR
Respiration - Suspend respiration
e) Tube position - Horizontal beam
- FFD: 100cm
f) CR - 5cm above tragus
Important lines in skull XR:

1. McGrigor’s line
2. McRae’s line
3. Chamberlain’s line
Din XJ
48
SPINE
A. Cervical Spine
1. AP + Open mouth view
AP AP – Open mouth
Indication To assess C3 – C7 To assess C1 – C2

IR 18 x 24 cm
Grid
10 mAs
Position
- Erect or supine - Usually supine

- Head extended (if allowable) - Mouth wide open
- Chin slightly raised - Line from lower incisor to mastoid tip ∟IR
- MSP ∟ Table - MSP ∟ Table
- No swallowing - No swallowing
- Suspend respiration - Suspend respiration
Tube Erect (Horizontal), Supine (Vertical) Vertical beam
FFD 100cm FFD 100cm
Angle 15o cranially
CR - Midline Centre of open mouth
- Upper margin of thyroid cartilage
- Level of C4
Collimation - C3 – T1 - Axis (dens & body)
- Surrounding soft tissue - Lateral masses
- Atlanto-axial & atlanto-occipital joints
Remarks - Visualized C3 – T1 - Visualized atlas, axis, dens
- Spinous process at midline of vertebral bodies - Atlas is symmetrical on axis
- Pedicles are symmetrical - Spinous process of axis is aligned wt MSP
- Intervertebral disc space open - Mandibular rami & lateral masses are equidistant
- Superimposed mandible & BOS over C1C2 - Superimposed upper incisor wt BOS
Din XJ
49
2. Lateral & Swimmer’s view

Lateral Swimmer’s view
Indication To assess C1 – C7 To assess C7 – T1

IR 18 x 24 cm
Grid
10 mAs
Position
- Erect of supine,
- Erect of supine,
- Lateral, shoulder against IR
- Lateral, shoulder against IR
- Arm & shoulder (facing IR) raised,
- Chin slightly raised
elbow flexed & forearm rest on the head
- Shoulder depressed
- Arm & shoulder (away from IR) down
- MCP ∟ IR
- No swallowing
- No swallowing
Tube Erect: Horizontal beam to sideway Erect: Horizontal beam to sideway
Supine: Lateral horizontal beam (from sideway) Supine: Lateral horizontal beam (from sideway)
Vertical IR Vertical IR
FFD 120 – 150 cm FFD 120 – 150 cm
CR - MCP Level of T1 (2.5cm above jugular notch anteriorly)
- Level of C4 (Upper margin of thyroid cartilage)
Collimation - C1 – C7 (minimum), Superior ½ of T1 - C4 – T3 (minimum)
- Surrounding soft tissue - Surrounding soft tissue
Remarks - Visualized spinous process - Visible vertebral bodies & intervertebral disc spaces of
- Intervertebral disc space open C4-T3
- Superimposed Rt & Lt pillars & zygo-apophyseal joints - Humeral head & arm (away from IR) should be distal to
of each cervical vertebra T4 or T5
Din XJ
50
3. Oblique view
- Typically posterior oblique (However, anterior oblique ↓ thyroid dose)
- HUKM practice posterior oblique !!!
LPO RPO
Indication To assess neural foramina
a) RPO (equivalent to LAO): To assess left side (neural foramina)
b) LPO (equivalent to RAO): To assess right side (neural foramina)
IR 18 x 24 cm
Grid
10 mAs
Position
- Right or left posterior oblique
- AP projection (IR posteriorly related)
- MSP rotated 45o
- Chin slightly raised
- Head in lateral position,
looking away from the side being imaged
- No swallowing
* Marker usually placed at the side being
assessed
RPO LAO
Tube Vertical beam
FFD 120 – 150 cm
Posterior oblique: Angle 15o cranially Anterior oblique: Angle 15o caudally
CR - Upper margin of thyroid cartilage

- Level of C4
Collimation - C1 – T1
- Surrounding soft tissue
Remarks Visualized neural foramina& intervertebral disc spaces
Din XJ
51
Cervical spine – AP
1. Foramen magnum
2. Atlanto-dental joint
3. Dens of C2
4. Occipital bone
5. Transverse process
6. Vertebral arch
7. Lateral mass of C1
8. Atlanto-axial joint
9. Spinous process (bifid)
10. Uncovertebral joint
11. Overlapping articular process
12. Uncinate process
13. Pedicle
15.Intervertebral disc space
16. Transverse process of T1
17. Radiolucent band of trachea
18. 1st rib
Cervical spine – Lateral

1. Anterior arch of C1
2. Base of skull
3. Odontoid process
4. Posterior arch of C1
5. Mandible
6. Spinous process
7. Body of C2
8. Anterior superior margin of vertebra
10. Anterior inferior margin of vertebra
11. Superior articular facet
12. Inferior articular facet
13. Superior vertebral end plate
14. Inferior vertebral end plate
15. Intervertebral facet joint
16. Intervertebral disc space
17. Lamina
18. Articular pillar
19. Spinous process
20. Trachea
Cervical spine – Oblique
1. Anterior arch
2. Odontoid process
3. Atlas C1
4. Mandible
5. Body of C2
6. Facet joint
7. Inferior articular process
7. Superior articular process
10. Contralateral pedicle
11. Pedicle
12. Intervertebral foramen
13. Spinous process
14. Ribs
Din XJ
52
B. Thoracic Spine
1. AP & Lateral view
IR 35 x 43 cm, Grid
Exposure 80 – 90 kV, 12 mAs
Upper thorax: Overexposed Anode heel effect method
Lower thorax: Underexposed Wedge filter
Position AP Lateral
- Supine, back facing IR - Lateral recumbent position, side facing IR (below)

- Hips & knees flexed (↓ thoracic curvature) - Support beneath lower back (↓ thoracic curvature)
- MSP ∟ Table - Hips & knees flexed, with support btw knees
- MCP ∟ Table, MSP ║ Table
Tube Vertical beam
FFD 100cm
CR Midline, Level of T7 Long axis of spine, Level of T7
(5cm below sternal angle / 10cm below jugular notch) (5cm below sternal angle / 10cm below jugular notch)
Collimation - C7, T1 – T12, L1 - C7, T1 – T12, L1
- 5cm of mediastinum & post ribs on each side
Remarks - Intervertebral disc spaces open - Visualized intervertebral foramina
- Spinous process in midline of vertebrae - Intervertebral disc spaces open
- Sternoclavicular joints & spine are equidistant - Superimposed posterior ribs
AP Lateral
1. Tubercle of 1st rib 9. Body of vertebra 1. Scapula 10. Inferior vertebral end plate
2. Neck of the rig 10. Inferior vertebral end plate 2. Anterior superior margin 11. Head of the rib
3. 1st rib 11. Transverse process 3. Posterior superior margin 12. Intervertebral disc space
4. Trachea 12. Pedicle 4. Anterior inferior margin 13. Intervertebral foramen
5. Clavicle 13. Spinous process 5. Posterior inferior margin 14. Transverse process
6. Head of the rib 14. Diaphragm 6. Vertebral body 15. Spinous process
7. Paravertebral line 15. Inferior articular process 7. Superior articular process 16. Diaphragm
8. Superior vertebral end plate 16. Superior articular process 8. Inferior articular process 17. Facet joint
9. Superior vertebral end plate
Din XJ
53
2. Oblique view
- Typically posterior oblique
Indication To assess facet joints

a) RPO (equivalent to LAO): To see Lt facet joint & Rt posterior ribs
b) LPO (equivalent to RAO): To see Rt facet joint & Lt posterior ribs
IR 35 x 43 cm
Grid
12 mAs
Position - Lying down, 20o rotation from lateral
- Arm (facing IR / table) up & forward
- Arm (away from IR) down & posterior
Tube Vertical beam
FFD 100cm
CR - Mid-axillary line (on raised side)
- Level of T7 (5cm below sternal angle / 10cm below jugular notch)
Collimation Close collimation
Remarks - Visualized T1-T12
- Visualized zygapophyseal joints (away from IR)
Din XJ
54
C. Lumbar Spine
AP Lateral
IR 35 – 43 cm
Grid
Exposure 80 kV
15 mAs
Position - Supine, back facing IR - Lateral recumbent position,
side facing IR (below)
- Arms at sides or on chest
- Hips & knees flexed (↓ lumbar curvature) - Support beneath lower back (↓ lumbar curvature)
- ASIS equidistant from table top - Hips & knees flexed, with support btw knees
- MSP ∟ Table - Spine║ IR
- End of expiration, suspend - End of expiration, suspend
Tube Vertical beam
FFD 100cm
CR - Midline - Long axis of spine
- Level of iliac crest - Level of iliac crest
Collimation - T12 – S1 (minimum), entire sacrum - T12 – Entire sacrum
- SI joints & psoas muscles
Remarks - Spinous process in midline - Intervertebral joint spaces are open
- Rt & Lt transverse process same length - Superimposed greater sciatic notches & posterior
- SI joint & spinous process are equidistant vertebral bodies
AP Lateral
1. Body of vertebra 8. Inferior articular process 1. Superior vertebral end plate 7. Superior articular process
2. Superior vertebral end plate 9. Transverse process 2. Inferior vertebral end plate 8. Inferior articular process
3. Inferior vertebral end plate 10. Spinous process 3. Intervertebral foramen 9. Iliac crest
4. Intervertebral disc space 11. Pedicle 4. Spinous process 10. Promontory
5. Facet joint 12. Sacroiliac joint 5. Transverse process 11. Sacrum
6. Psoas 13. Sacrum 6. Intervertebral disc space
7. Superior articular process 14. Sacral foramina
Din XJ
55
2. Oblique view
- Typically posterior oblique
Indication To assess pars interarticularis – “Scotty dog” appearance
a) RPO (equivalent to LAO): To see Rt zygapophyseal joints, Rt pars interarticularis
b) LPO (equivalent to RAO): To see Lt zygapophyseal joints, Lt pars interarticularis
IR 35 – 43 cm
Grid
Exposure 80 kV
15 mAs
Position
- Lying down, 45o rotation from lateral

- Support back with sponge
- Arm (facing IR / table) up & forward
- Arm (away from IR) down & posterior
Tube Vertical beam

FFD 100cm
CR - Mid-clavicular line (on raised side)
- Level of L3 (lower costal margin)
Collimation T12 – S1
Remarks - Zygapophyseal joint – Visualized“scotty dog”, At the center of vertebral body
- Over-rotation: Pedicle at posterior of body
- Under-rotation: Pedicle at anterior of body
1. Body of vertebra
3. Ribs
4. Interarticular part
6. Lamina
7. Ipsilateral transverse process
8. Contralateral transverse process
9. Pedicle
10. Superior articular process
11. Intervertebral foramen
12. Inferior articular process
13. Spinous process
Din XJ
56
D. Scoliosis series
IR 35 – 43 cm
Grid
Exposure 80 kV
15 mAs
Position First IR: Second IR:
- Erect - Block placed under foot (convex side of curvature)
- Spine aligned - Gonad shields
- Arms at side
- Lower margin 3-5cm below iliac crest

FFD 100-180cm
CR PA or AP (PA is preferred d/t lower gonad dose)
1. Dens of C2 8. Spinous pricess, L6

2. C7 9. Ilium
3. T2 10. Sacroiliac joint
4. Rib cage 11. Sacrum
5. T12 12. Hip
6. L1 13. Gonad shield
7. Pedicle L3
Din XJ
57
1. Transverse process 12. Posterior inferior iliac spine

2. Iliac wing 13. Greater sciatic notch
3. Spinous process 14. Lateral sacral crest
4. L5 15. Cornu of the sacrum
5. Superior articular process 16. Sacral hiatus
6. Inferior articular process of L5 17. Cornu of the coccyx
7. Sacroiliac joint 18. Ischial spine
8. Sacral ala 19. Hip
9. Sacral foramina 20. Coccyx
10. Posterior superior iliac spine 21. Femoral head
11. Median sacral crest 22. Superior pubic ramus
1. Promontory 10. Superior pubic ramus

2. Iliac crest 11. Symphysis pubis
3. Anterior superior iliac spine 12. Obturator foramen
4. Sacrum 13. Coccyx
5. Anterior inferior iliac spine 14. Inferior pubic ramus
6. Greater sciatic notch 15. Ischial body
7. Hip joint 16. Ischial tuberosity
8. Femoral head 17. Femur
9. Ischial spine
Din XJ
58
UPPER LIMB
Indications:
1. Bones 2. Joints 3. Soft tissue
a) Trauma: Fracture a) Trauma: Dislocation / subluxation a) Foreign bodies
b) Infections b) Arthritic changes b) Fat pad
c) Architectural changes c) Swelling
A. Shoulder - Basic views: AP, Lateral (Scapula Y)

1. AP view
Indication - Trauma: Fracture, dislocation, rotator cuff tear, Bankart lesion, Hill-Sachs defect
- Arhritis, subacromial bursitis, supraspinatus tendinitis, impingement syndrome
IR 24 x 30cm
Grid
Position - Standing or supine
- Back facing IR, upper border of IR at least 5cm above shoulder
- Position of arm
a) External rotation (Typical)
- To see greater tubercle (laterally)
- Lesser tubercle superimposed over humeral head
b) Internal rotation (Lateral view)
- To see lesser tubercle (medially)
- Greater tubercle superimposed over humeral head
c) Neutral position
Tube Standing (Horizontal), Supine (Vertical)

FFD 100cm
CR Coracoid process of scapula
Collimation - Entire clavicle, entire scapula
- Proximal ⅓ of humerus
Remarks - Clavicle in horizontal position
- Supero-lateral of scapula not superimposed with thorax
- Head of humerus should be slightly overlapped wt glenoid cavity, but separate from acromion process
1. Acromion 7. Humeral head 13. Glenoid fossa

2. Clavicle 8. Anatomical neck 14. Glenoid labrum
3. Acromioclavicular joint 9. Greater tubercle of humerus 15. Surgical neck
4. Superior angle of scapula 10. Bicipital groove 16. Lateral margin of scapula
5. Spine of scapula 11. Lesser tubercle of humerus 17. Medial margin of scapula
6. Coracoid process 12. Scapula
Din XJ
59
2. Axial / axillary view

Axial (superior inferior) Axial (inferior superior) - Lawrance
IR 24 x 30cm
Grid
6 mAs
Position
- Sitting, at side of table - Supine

- IR on table top - IR (vertical) pressed against neck & shoulder
- Patient lean towards table, to get closer to IR - Arm abducted & externally rotated
- Arm abducted over IR - Suspend respiration
- Elbow flexed
Tube Vertical beam, FFD 100cm Horizontal beam, FFD 10cm
Angle medially to axilla
- 30-35o if arm abducted 90o
- 20o if arm abducted < 90o
CR Head of humerus Axilla
Collimation - Head of humerus, lesser tubercle
- Glenoid cavity, Acromion process, Coracoid process
Remarks - Superimposed acromion process & superior aspect of glenoid with head of humerus
1. Lesser tubercle of humerus 8. Acromioclavicular joint

2. Humeral head 9. Glenohumeral joint
3. Coracoid process 10. Acromion
4. Clavicle 11. Superior angle of scapula
5. Bicipital groove 12. Neck of scapula
6. Greater tubercle of humerus 13. Humerus
7. Glenoid fossa 14.Scapula
Din XJ
60
3. Anterior Oblique (Scapula Y)

IR 24 x 30cm
Grid
6 mAs
Position
- Erect, front facing IR

- Rotate body 45-60o to IR
→ Body of scapula ∟IR
- Arm extended backward
- Dorsum of hand rest on waist
Tube Horizontal beam Neer’s view: - Similar to Y view

FFD 100cm - But angle 10-15o caudally
CR Head of humerus (midpoint of medial border of the scapula)
Collimation - Entire scapula

- Proximal ⅓ of humerus
Remarks - Scapular body, acromion & coracoid forms a ‘Y’ Ant dislocation: Humeral head inferior to coracoid
- Superimposed humeral head wt Y junction of scapula Post dislocation: Humeral head inferior to acromion
- No superimposition of scapular body over bony thorax
1. Distal clavicle 7. Humeral head

2. Superior angle of scapula 8. Ribs
3. Acromioclavicular joint 9. Lateral margin of scapula
4. Coracoid process 10. Humeral shaft
5. Acromion 11. Inferior angle of scapula
6. Spine of scapula
Din XJ
61
4. Stryker’s view
Indication To demonstrate Hill-Sach deformity
IR 24 x 30cm
6 mAs
Position
- Supine
- Arm extended fully
- Elbow flexed
- Hand rest on the head
Tube Vertical beam

FFD 100cm
Angle 10o cranially
CR 2.5cm above head of humerus
1. Cortex 7. Humeral head

2. Metaphysis 8. Clavicle
3. Surgical neck 9. Suprascapular notch
4. Acromion 10. Spine of scapula
5. Acromioclavicular joint 11. Superior angle of scapula
6. Coracoid process
Din XJ
62
5. Clavicle
AP Axial
Indication Trauma: Fracture

IR 24 x 30cm
Grid
6 mAs
Position
- Standing or supine, back facing IR - Same as AP

- Arm at side
Tube Vertical beam Vertical beam

FFD 100cm FFD 100cm
Angle 15-30o cranially
CR Midpoint of clavicle - Midpoint of clavicle

- Just inferior to the clavicle
Collimation - Entire clavicle - Entire clavicle
- Acromio-clavicular & sterno-clavicular joints - Acromio-clavicular & sterno-clavicular joints
Remarks - Medial end of clavicle next to vertebra - Clavicle projected above the ribs & scapula
- Medial ½ of clavicle superimposed wt thorax - Med portion of clavicle superimposed wt thorax
- Lateral ½ of clavicle above scapula
Din XJ
63
AP
1. Conoid tubercle of clavicle

2. Acromioclavicular joint
3. Acromion
4. Clavicle
5. Superior angle of scapula
6. Proximal clavicle
7. Coracoid process
8. Humeral head
9. Spine of scapula
10. Costo-transverse joint
11. Glenoid fossa
Axial
1. Sternoclavicular joint
2. Clavicle
3. Acromion
4. Acromioclavicular joint
5. Manubrium of sternum
6. Coracoid process
7. Greater tubercle of humerus
8. Bicipital groove
9. Lesser tubercle of humerus
10. Humeral head
Din XJ
64
B. Humerus
1. AP & Lateral
IR 35 x 43cm,
Grid if > 10cm
Exposure 75 kv, 6 mAs
Position AP Lateral
- Erect or supine, AP position - Erect or supine, PA position

- Rotate body towards affected side - Rotate body towards affected side
→ Shoulder & prox humerus in contact wt IR → Shoulder & prox humerus in contact wt IR
- Arm slightly abducted & externally rotated - Arm slightly abducted & internally rotated
- Forearm extended - Elbow slightly flexed
- Epicondyles of elbow equidistant to IR - Epicondyles of elbow ∟ IR
- Suspend respiration - Suspend respiration
Tube Erect (Horizontal), Supine (Vertical)
FFD 100cm
CR Midpoint of humerus
Collimation - Entire humerus
- Shoulder & elbow joints
Remarks - Humeral head minimally superimposed wt glenoid - Superimposed epicondyles
- Visualized greater tubercle (lateral), lateral & medial - Visualized lesser tubercle (medial)
epicondyles
AP Lateral
1. Clavicle 1. Coronoid process
2. Lateral process (Scapula) 2. Glenoid fossa
3. Acromion (Scapula) 3. Clavicle
4. Greater tubercle 4. Lesser tubercle
5. Lesser tubercle (Humerus)
6. Humeral Head 5. AC joint
7. Anatomical neck 6. Humeral head
8. Bicipital groove 7. Acromion
9. Surgical neck 8. Cortex
10. Humerus 9. Humeral shaft
11. Deltoid tuberosity 10. Coronoid fossa
12. Lateral epicondyle 11. Radial head
13. Olecranon process 12. Olecranon fossa
14. Olecranon (Ulna) 13. Radius
15. Medial epicondyle 14. Trochlea
16. Trochlea 15. Capitellum
17. Radial head 16. Ulna
18. Radius 17. Olecranon
19. Ulna 18. Coronoid process
Din XJ
65
C. Elbow
IR 24 x 30 cm (divided into 2), crosswise
Non-grid
Exposure 60 kV,
6 mAs
Position AP Lateral
- Sitting, at side of table

- IR on table top, beneath elbow
- Arm fully extended & externally rotated - Sitting, at side of table
- Palm up - IR on table top, beneath elbow
- Medial & lateral epicondyles are equidistant from IR
- Elbow flexed 90o
- Hand & wrist in true lateral position (Palm ∟ IR)
Tube Vertical beam
FFD 100cm
CR 2.5cm distal to midpoint btw medial & lateral epicondyles Lateral epicondyle of humerus
Collimation - Proximal: Distal ⅓ of humerus
- Distal: Proximal ⅓ of radius & ulna
Remarks - Visualized medial & lateral epicondyles - Superimposed epicondyles
- Superimposed prox ulna wt radial head (6mm) - Superimposed radial head & coronoid process
- Capitulum-radial joint open - Elbow joint open
AP Lateral
1. Humerus 10. Trochlea 1. Humerus 8. Lateral epicondyle
2. Olecranon fossa 11. Humero-radial joint 2. Coronoid fossa 9. Radius
3. Medial epicondyle (Humerus) 12. Humero-ulnar joint 3. Coronoid process 10. Humero-ulnar joint
4. Lateral epicondyle (Humerus) 13. Coronoid process 4. Radial head 11. Olecranon
5. Apex of medial epicondyle 14. Radial head 5. Radial tuberosity 12. Humero-radial joint
6. Olecranon 15. Proximal radioulnar joint 6. Olecranon fossa 13. Ulna
7. Lateral margin of trochlea 16. Radial neck 7. Medial epicondyle
8. Medial margin of trochlea 17. Radius
9. Capitellum 18. Ulna
Din XJ
66
D. Forearm
IR 30 x 35 cm, Non-grid
Exposure 60 kV, 6 mAs
Position AP Lateral

- IR on table top
- IR on table top
- Shoulder dropped → Entire UL on same horizontal plane
- Shoulder dropped → Entire UL on same horizontal plane
- Elbow & hand fully extended
- Elbow flexed 90o
- Palm up
- Rotate wrist & hand into true lateral position
Tube Vertical beam, FFD 100cm
CR Midpoint btw elbow & wrist
Collimation - Entire radius & ulna
- Elbow & proximal wrist joint
Remarks
a) Proximal - Visualized medial & lateral epicondyles - Superimposed humeral epicondyles
- Superimposed proximal radius & ulna - Superimposed radial head & coronoid process
b) Distal - Visualized radial styloid - Visualized ulnar styloid
- Min superimposition of MC base wt rad/ulna - Superimposed distal radius & ulna
AP Lateral
1 – 4 Prox carpal row 1 – 4 Prox carpal row
1. Pisiform 1. Triquetrum
2. Scaphoid 2. Scaphoid
3. Triquetrum 3. Pisiform
4. Lunate 4. Lunate
5. Radial styloid 5. Radiocarpal jt
6. Ulnar styloid 6. Ulnar styloid
7. Radiocarpal jt 7. Ulna
8. Distal radioulnar jt 8. Radius
9. Radius 9. Interosseous
10. Interosseous membrane
membrane 10. Radial neck
11. Ulna 11. Radial head
12. Radial tuberosity 12. Coronoid process
13. Prox radioulnar jt 13. Coronoid fossa
14. Radial neck 14. Trochlea
15. Coronoid process 15. Humerus
16. Radial head 16. Olecranon
17. Humero-ulnar jt 17. Olecranon fossa
18. Humero-radial jt
19. Trochlea
20. Capitellum
21. Olecranon
22. Lateral epicondyle
23. Medial epicondyle
24. Olecranon fossa
25. Humerus
Din XJ
67
E. Wrist
1. Basic views 2. Scaphoid views
a) PA a) PA
b) Lateral b) PA with ulnar deviation
c) Oblique c) PA with radial deviation (Not done in HUKM !!!)
d) Posterior oblique
e) Lateral
Indication Scaphoid fractures

IR 18 x 24 cm, divided into 2
Non-grid
4 mAs
Tube Vertical beam
FFD 100cm
Collimation - Proximal: Distal end of radius/ulna
- Distal: Proximal end of metacarpals
- Sides: Skin margins
a) PA
Position

- IR on table top, beneath palm
- Forearm rest on table (prone)
- Elbow flexed 90o
- Palm down
- Fingers slightly flexed & spread
CR Midpoint btw radial & ulnar styloid process

Remarks - Visualized radial & ulnar styloid process at extreme sides
- Radio-ulnar joint open
b) PA with ulnar deviation: Demonstrate long axis of scaphoid

Position
- Same as PA view
- Hand moved towards ulnar side
- Radial & ulnar styloid processes are
equidistant from IR

Remarks - Visualized scaphoid without superimposition or foreshortening
- Interspace more open on radial side
Din XJ
68
c) PA with radial deviation (Not done in HUKM !!!)

Position
- Same as PA view
- Hand moved towards radial side
- Radial & ulnar styloid processes are
equidistant from IR

Remarks - Visualized scaphoid without superimposition or foreshortening
- Interspace more open on ulnar side
d) Posterior oblique (PA oblique): Demonstrate fractures of proximal pole

Position

- IR on table top
- Forearm rest on table
- Elbow flexed 90o
- Hand supinated 45o
Supported by radiolucent block
- Long axis of scaphoid ∟ IR

Remarks - Visualized scaphoid & ulnar styloid
- Trapezium & trapezoid not superimposed
e) Lateral: Demonstrate alignment

Position

- IR on table top, beneath palm
- Elbow flexed 90o
- Hand in true lateral position, thumb side up
- Superimposed radial & ulnar styloid processes
CR Radial styloid process

Remarks - Superimposed radius & ulna
- Superimposed distal end of scaphoid & pisiform
- Superimposed metacarpals
DISCUSSION
1. In HUKM, only 4 views performed: PA, PA with ulnar deviation, lateral & PA oblique
2. Scaphoid fracture: Waist (65&), Proximal pole (15%), Distal pole (8%), Tubercle (8%), Distal articular (2%)
Din XJ
69
AP Lateral
1. Proximal phalanx 10. Pisiform 1. Proximal phalanx 7. Scaphoid
2. 5th metacarpal 11. Scaphoid 2. Metacarpals 8. Triquetrum
3. Carpo-metacarpal jt 12. Lunate 3. Trapezoid 9. Pisiform
4. Trapezoid 13. Radial styloid 4. Hook of hamate 10. Lunate
5. Trapezium 14. Radiocarpal joint 5. Trapezium 11. Radial styloid
6. Capitate 15. Ulnar styloid 6. Capitate 12. Ulnar styloid
7. Hook of hamate 16. Radioulnar joint
8. Hamate 17. Radius
9. Triquetrum 18. Ulna
1. Metacarpal 8. Lunate
2. Hamate 9. Pisiform
3. Trapezoid 10. Radial styloid
4. Capitate 11. Ulnar styloid
5. Trapezium 12. Radius
6. Scaphoid 13. Ulna
7.Triquetrum
Din XJ
70
Carpal tunnel (Gaynor-Hart Tangential Projection)

Indication Carpal bones, especially pisiform & hamate
IR 18 x 24 cm
Non-grid
4 mAs
Position

- IR on table top
- Hand rest on table, palm down
- Wrist hyperextended (dorsiflexed) as far as possible
Fingers held back wt the other hand
- Hand & wrist internally rotated 10o
Tube Vertical beam

FFD 100cm
Angle 25-30o to long axis of hand
CR Base of 3rd MCP joint
Remarks - Visualized carpal sulcus in arched arrangement

- Pisiform & hamate are separated
1. Pisiform 6. Lunate
2. Trapezium 7. Capitate
3. Hook of hamate 8. Trapezoid
4. Triquetrum 9. Hamate
5. Scaphoid
Din XJ
71
F. Hand
- Basic views: PA & anterior oblique
1. PA & Lateral view

PA Lateral
Indication - Trauma: Fracture, dislocation

- Foreign body
- Arthritis
IR 24 x 30 cm, crosswise (divided into 2)
Non-grid
Exposure 55 – 65 kv
3 mAs
Position
- Sitting, at side of table - Sitting, at side of table

- IR on table top, beneath palm - IR on table top
- Forearm rest on table (prone) - Forearm rest on table
- Elbow flexed 90o - Elbow flexed 90o
- Palm down - Hand & metacarpals into true lateral position,
- Fingers slightly spread thumb side up
Tube Vertical beam
FFD 100cm
CR 3rd MCP joint 2nd MCP joint
- Distal: All digits
Remarks - Equal midshaft concavity on both sides, Superimposed :
for 2nd – 5th metacarpals & phalanges - Distal radius & ulna
- MCP & IP joints open - Metacarpals
- Phalanges
Din XJ
72
2. Posterior oblique
Indication - Base of 5th metacarpal fracture

- RA hands
IR 24 x 30 cm, crosswise (divided into 2), Non-grid
Exposure 55 – 65 kv, 3 mAs
Position - Sitting, at side of table
- IR on table top
- Forearm rest on table
- Elbow flexed 90o
- Forearm internally rotated 45o, supported wt wedge-shaped radiolucent block
- Thumb & fingers spread into fan position
Ball-catcher’s (Norgaard) view:

- Both forearms internally / externally rotated 45o
supported wt wedge-shaped radiolucent block
- Fingers spread& curved (as catching a ball)

CR 3rd MCP joint Ball-catcher’s (Norgaard) view: - Midpoint btw hands
- Level of 5th MCP joint
- Distal: All digits
Remarks - Unequal midshaft concavity on both sides
- Midshaft of 3rd – 5th metacarpals not superimposed
- Head of 2nd – 3rd metacarpals not superimposed
- MCP & IP joints open
1. Distal interphalangeal jt
2. Head of proximal phalanx
3. Prox interphalangeal jt
4. Prox phalanx
5. Base of prox phalanx
6. Metacarpo-phalangeal jt
7. Metacarpal
8. Metacarpal head
9. Sesamoid
10. Metacarpal base
11. Capitate & Hamate
12. Trapezoid
13. Triquetrum
14. Trapezium
15. Lunate
16. Scaphoid
17. Ulnar styloid
18. Radial styloid
19. Distal ulna
20. Distal radius
Din XJ
73
G. Fingers
1. Fingers
PA Lateral Oblique
Position
- Sitting, at side of table - Sitting, at side of table - Sitting, at side of table

- IR on table top - IR on table top - IR on table top
- Forearm rest on table (prone) - Forearm rest on table (prone) - Forearm rest on table (prone)
- Elbow flexed 90o - Elbow flexed 90o - Elbow flexed 90o
- Palm down - Other finger flexed - Hand externally rotated 45o
- Fingers extended & spread - Affected finger in true lat position Supported wt block
- Affected finger ║long axis or IR - Affected finger ║long axis or IR - Fingers extended & spread
- Affected finger ║long axis or IR
CR PIP joint of affected finger
Collimation Affected finger (distal metacarpal – distal phalanx) + associated joints (MCP & IP) + soft tissue
Remarks - Symmetric appearance of shafts
- No superimposition of adjacent fingers
- Joint spaces are open
2. Thumb
PA Lateral Oblique
Position

- Sitting, at side of table - IR on table top - Sitting, at side of table
- IR on table top - IR on table top
- Forearm rest on table (prone) - Elbow flexed 90o - Forearm rest on table (prone)
- Elbow flexed 90o - Hand pronated - Elbow flexed 90o
- Hand internally rotated - Thumb abducted - Hand pronated,
- Thumb in contact wt IR - Hand rotated medially till thumb in Palm in contact wt IR
- Thumb ║long axis of IR true lat position - Thumb abducted
CR 1st MCP joint
Collimation Thumb (distal metacarpal – distal phalanx) + associated joints (MCP & IP) + soft tissue
Remarks - Symmetric appearance of shafts
- No superimposition of adjacent fingers
- Joint spaces are open
Din XJ
74
LOWER LIMB
Indications:
1. Bones a) Trauma: Fracture
b) Infections
c) Architectural changes
2. Joints a) Trauma: Dislocation / subluxation
b) Arthritic changes
3. Soft tissue a) Foreign bodies
b) Fat pad
c) Swelling
A. Pelvis
1. AP view
IR 35 x 43 cm, crosswise
Grid
12 mAs
Position
- Arms at side or across the chest
- Hips slightly abducted & internally rotated (15o)
→ Femoral necks ║ IR
- MSP ∟ IR
Tube Vertical beam

FFD 100cm
CR - Midline
- Level btw ASIS & upper border of symphysis pubis
Collimation Proximal ⅓ femur, acetabulum and adjacent parts of pubis, ischium & ilium
Remarks - Symmetrical iliac alae, obturator foramina & visualized ischial spines
- Femoral head / neck in profile (no foreshortening)
- Visualized greater trochanter (laterally)
- Lesser trochanter should not be projected beyond medial border of femur
- Sacrum & coccyx aligned with symphysis pubis
If externally rotated:
- NOF foreshortened
- Lesser trochanter in profile
Din XJ
75
1. Iliac crest 14. Coccyx

2. Iliac wing 15. Greater trochanter
3. Sacrum 16. Superior pubic ramus
4. Sacroiliac joint 17. Femoral neck
5. Posterior superior iliac spine 18. Acetabular teardrop
6. Posterior inferior iliac spine 19. Pubic symphysis
7. Anterior superior iliac spine 20. Obturator foramen
8. Obturator internus 21. Intertrochanteric crest
9. Acetabular convexity (Promontory) 22. Inferior pubic ramus
10. Urinary bladder 23. Ischial tuberosity
11. Ischial spine 24. Lesser trochanter
12. Fat stripe medial to gluteus minimus 25. Fat stripe medial to iliopsoas
13. Posterior acetabular rim 26. Femur
1. Ilium 7. Femoral epiphysis

2. Perkin’s line 8. Pubic bone
3. Acetabular convexity (Promontory) 9. Ischium
4. Angle of acetabular inclination 10. Shenton’s line
5. Wilberg’s center-to-center angle 11. Femus
6. Hilgenreiner’s line
Din XJ
76
2. Frog leg view
Indication: Complementary view for diagnosis of

a) Osteochondritis capital epiphysis (Perthes’ disease)
b) Developmental dysplasia of hip (DDH)
IR 35 x 43 cm, crosswise
Grid
12 mAs
Position
- Supine
- Both knees flexed 90o, externally rotated 60o
- Both plantar surface of feet together
- MSP ∟ IR
Tube Vertical beam

FFD 100cm
CR - Midline
- 2.5cm above symphysis pubis
Collimation Lateral view of acetabulum, femoral head / neck, proximal ⅓ femur
Remarks - Symmetrical ala of ilium, obturator foramina, ischial spine
- Greater trochanters mostly superimposed over femoral neck
Din XJ
77
3. Sacroiliac Joint
PA AP (Patient unable to prone) Posterior oblique
IR 24 x 30 cm, lengthwise, Grid
Position - Prone, front facing IR - Supine, back facing IR - Supine, back facing IR
- Arms raised above - Arms raised above - Trunk rotated 30o,
- PSIS equidistant to IR - ASIS equidistant to IR rising the affected side,
- MSP center to IR - MSP center to IR Supported with radiolucent pad
- MSP ∟ IR - MSP ∟ IR
Tube Vertical beam Vertical beam Vertical beam
FFD 100cm FFD 100cm FFD 100cm
Angle caudally Angle cranially Angle caudally
Male (15o), Female (20o) Male (15o), Female (20o) Male (15o), Female (20o)
CR - Midline - Midline 2.5cm medial to elevated ASIS
- Level of PSIS - Level btw ASIS & upper border of
symphysis pubis
Remarks - Visualized SIJ & sacrum - Same as PA view - Upside SIJ open
- Spinous process in center of a) LPO: Rt SIJ open
vertebral body b) RPO: Lt SIJ open
- No overlap of iliac wing & sacrum
Anterior oblique view
1. Pedicle of L5 7. Iliac wing

2. Transverse process of L5 8. Lateral part of sacrum
3. Iliac wing 9. Ilium
4. Body of L5 10. Arcuate line
5. Sacroiliac joint 11. Acetabular roof
6. Sacral foramen
Din XJ
78
B. Hip Joint
AP (≈ Pelvis AP view) Lateral
IR 24 x 30 cm, Grid
Position

- Arms at side or across the chest - Supine, back facing IR
o
- Hips slightly abducted & internally rotated (15 ) - Hip flexed & abducted 45o
- Femoral necks ║ IR, MSP ∟ IR - Knee flexed → Lateral aspect of thigh in contact wt IR
CR Femoral pulse (neck) of affected side: 2.5cm inferolaterally from mid-inguinal point (midpoint btw ASIS & sym pubis)
Collimation Proximal ⅓ femur, acetabulum and adjacent parts of pubis, ischium & ilium
Remarks - Femoral head / neck in profile (no foreshortening) - Foreshortening of femoral neck
- Visualized greater trochanter (laterally) - Superimposed greater trochanter over femoral neck
- Lesser trochanter should not be projected beyond
medial border of femur
1. Sacroiliac joint
2. ASIS
3. Sacrum
4. AIIS
5. Intergluteal fat stripe
6. Acetabular roof
7. Acetabular convexity
8. Fat stripe med to glut minimus
9. Ischial spine
10. Ant acetabular rim
11. Acetabular floor
12. Post acetabular rim
13. Fovea of femoral head
14. Femoral head
15. Ilioischial line
16. Kohler’s teardrop figure
17. Greater trochanter
18. Terminal line
19. Femoral neck
20. Superior pubic ramus
21. Intertrochanteric crest
22. Obturator foramen
23. Fat stripe med to iliopsoas
24. Ischial tuberosity
25. Lesser trochanter
26. Femur
Din XJ
79
2. Judet’s & reverse Judet’s view

Judet’s view (anterior oblique) Reverse Judet’s view (posterior oblique)
Indication Suspect acetabular fracture, reverse Judet’s view if patient unable to prone
IR 24 x 30 cm
Grid
12 mAs
Position - Prone, front facing IR - Supine, back facing IR

o
- Trunk rotated 45 , rising the affected side - Trunk rotated 45o, rising the affected side
Supported with radiolucent pad Supported with radiolucent pad
- Center of IR longitudinally wt center of femoral head - Center of IR longitudinally wt center of femoral head

FFD 100cm FFD 100cm
Angle 12o cranially Angle 12o caudally
CR Distal to coccyx Femoral pulse of the affected side
Remarks Visualized anterior acetabular rim
Din XJ
80
C. Femur
AP Lateral
IR 35 x 43 cm
Grid
12 mAs
Position
- Supine, back facing IR - Lateral recumbent position, on affected side

- Leg fully extended - Knee of affected side flexed
- Leg rotated internally 5o - Hip over IR
Tube Vertical
FFD 100cm
CR Midpoint of femur
Collimation - Proximal: Hip joint (May not be able to include both joints all the time)
- Distal: Knee joint
Remarks Visualized whole femur
Din XJ
81
D. Knee
IR 18 x 24 cm 18 x 24 cm
Grid if > 10cm Grid if > 10cm
5 mAs 5 mAs
Position AP Lateral
- Leg fully extended - Knee flexed 20o

- Leg rotated internally 5o - Femoral condyles superimposed
- Patella centralized btw femoral condyles - Epicondyles ∟ IR
- Knee over IR
FFD 100cm FFD 100cm
May need to angle 5o cranially
CR 2.5cm below apex of patella Superior border of medial condyle of tibia
Collimation - Proximal: Distal ⅓ femur
- Distal: Proximal ⅓ tibia / fibula
Remarks - Femoro-tibial joint space is open - Knee seen flexed 20-30o
- Symmetrical femoral, tibial condyles, joint space - Superimposed femoral condyles
- Intercondylar eminence in the center of intercondylar - Patella seen in profile
fossa - Femoro-patellar joint space is open
- Superimposed tibia wt fibular head
AP
1. Femur
2. Patella
3. Lateral femoral epicondyle
4. Medial femoral epicondyle
5. Growth plate
6. Lateral femoral condyle
7. Medial femoral condyle
8. Lateral tibial condyle
9. Medial tibial condyle
10. Medial & lateral tubercles of
intercondylar eminence
11. Epiphyseal plate
12. Fibular head
13. Tibia
14. Fibula
15. cortex
Din XJ
82
Lateral
1. Femur
2. Patella
3. Posterior fat
4. Patellar ligament
5. Infrapatellar fat pad
6. Lateral femoral condyle
7. Tibial plateau
8. Intercondylar eminence
9. Tibial tuberosity
10. Fibular head
11. Fibularneck
12. Tibia
2. AP Standing
Indication:
To assess knee joint spce
IR 18 x 24 cm, Grid
Position
- Standing, weight equally distributed, back facing vertical IR

- Leg fully extended
- Leg rotated internally 5o
- Patella centralized btw femoral condyles
Tube Horizontal beam, FFD 100cm

CR Center of both knees
2.5cm below apex of patella
Collimation - Proximal: Distal ⅓ femur
- Distal: Proximal ⅓ tibia / fibula
Remarks - Femoro-tibial joint space is open
- Symmetrical femoral, tibial condyles, joint space
- Intercondylar eminence in the center of intercondylar fossa
- Superimposed tibia wt fibular head
Din XJ
83
3. Tunnel (intercondylar notch) view

Indication To look for loose body within knee joint
IR 18 x 24 cm
Grid
5 mAs
Position
- Supine
- Affected knee flexed 60o
Supported wt radiolucent pad
- Knee over IR
Tube Vertical beam

FFD 100cm
CR 2.5cm below apex of patella
Collimation 4 sides to area of interest
Remarks - Visualized intercondylar fossa

- Symmetrical femoral condyles
1. Femur 10. Lateral tibial plateau

2. Patella 11. Medial tibial plateau
3. Medial femoral epicondyle 12. Tibial tuberosity
4. Lateral femoral epicondyle 13. Growth plate
5. Intercondylar fossa 14. Fibular head
6. Lateral femoral condyle 15. Fibular neck
7. Medial femoral condyle 16. Tibia
8. Lateral tubercle of intercondylar eminence 17. Interosseous membrane
9. Medial tubercle of intercondylar eminence
Din XJ
84
4. Tangential / Axial / Sunrise / Skyline view

Merchant bilateral method (superior inferior) Inferior superior
Indication - Assess retro-patellar joint (cegenerative ds)

- Assess lateral subluxation of patella
- Vertical fracture of patella
IR 24 x 30 cm
Non-grid
5 mAs
Method a) Hughston method
Position: - Prone, IR under knee

Tube: - Vertical beam
Position: - FFD 120 – 150cm (↓ magnification)
- Lying supine on x-ray table - Angle 15o to long axis of the leg
- Knees flexed 45o (over table edge) CR: Patello-femoral joint
- IR supported horizontally at the level of inferior tibial b) Settegast method
tuberosity border (≈ 30cm from the knee)
Tube:
- Vertical beam
- FFD 120 – 150cm (↓ magnification)
- Angle 60o caudally
CR:
- Midpoint btw patellae (CR ║ long axis of patella)
Position: - Prone, IR under knee
Tube: - Vertical beam
- FFD 120 – 150cm (↓ magnification)
- Angle 15o cranially
CR: Patello-femoral joint
Collimation Patella & patello-femoral joint
Remarks - Too much flexion: Patella tracked over lateral femoral condyle
- In adequate flexion: Tibial tuberosity over shadow retropatelar joint
Din XJ
85
E. Tibia & Fibula

1. AP & Lateral
AP Lateral
IR 35 x 43 cm
Non-grid
6 mAs
Position

- Leg fully extended - Knee of affected side flexed
- Leg rotated internally 5o - Leg over IR
- Medial & lateral epicondyles are equidistant to IR
Tube Vertical
FFD 100cm
CR Midpoint of leg (btw knee & ankle)
Collimation - Proximal: Knee joint

- Distal: Ankle joint
Remarks - Visualized entire tibia / fibula, ankle & knee - Visualized entire tibia / fibula, ankle & knee
- Slight superimposed tibia / fibula at prox & distal end - Tibial tuberosity in profile
- Superimposed tibia / fibula at proximal & distal end
Din XJ
86
F. Ankle
1. AP & Lateral
IR 24 x 30 cm (divided into 2) 24 x 30 cm (divided into 2)
Non-grid Non-grid
6 mAs 6 mAs
Position AP Lateral
- Sitting or supine - Sitting or supine

- Leg extended - Leg extended
- Foot (posterior aspect) above IR - Foot (lateral aspect) above IR, and ║ IR
- Foot in natural position (not true AP position) - Foot dorsiflex to 90o
FFD 100cm FFD 100cm
CR Midway btw malleoli Medial malleolus
Collimation - Proximal: Distal ⅓ tibia / fibula - Proximal: Distal ⅓ tibia / fibula
- Distal: Proximal ½ of metatarsals - Distal: Proximal metatarsals
Remarks - Visualized both malleoli, talus - Visualized talo-tibial joint
- Medial mortise is open, lateral mortise is closed - Tarsal sinus is open
- Superimposed fibula over post ½ of tibia
1. Tibia
2. Fibula
3. Growth plate
4. Fibular notch
5. Ankle
6. Medial malleolus
7. Lateral malleolus
8. Trochlea of talus
9. Subtalar joint
10. Calcaneus
11. Navicular
Din XJ
87
1. Fibula
2. Tibia
3. Achilles tendon
4. Growth plate
5. Ankle
6. Trochlea of talus
7. Medial malleolus
8. Talus
9. Lateral malleolus
10. Talar neck
11. Talar head
12. Talo-navicular joint
13. Posterior process of talus
14. Sinus tarsi
15. Navicular
16. Lateral process of talus
17. Calcaneus
18. Medial cuneiform
19. Post tuberosity of calcaneus
20. Cuboid
21. Base of 5th metatarsal
2. AP Mortise view
IR 24 x 30 cm (divided into 2)
Non-grid
6 mAs
Position
- Sitting or supine
- Leg extended
- Foot (posterior aspect) above IR
- Foot in natural position (not true AP position)
- Limb medially rotated 20o
Tube Vertical beam

FFD 100cm
CR Midway btw malleoli
Collimation - Proximal: Distal ⅓ tibia / fibula
- Distal: Proximal metatarsals
Remarks - Visualized both malleoli, talus
- Ankle mortise is open (both medial & lateral)
Din XJ
88
3. Calcaneus: Plantar-dorsal (Axial) view
IR 24 x 30 cm (divided into 2)
Non-grid
6 mAs
Position
- Sitting or supine
- Leg extended
- Foot (posterior aspect) above IR
- Foot dorsiflexed, held wt a strip of gauze
- Plantar surface ∟ IR
Tube Vertical beam

FFD 100cm
Angle 40o cranially
CR Base of 3rd metatarsal
Collimation - Entire calcaneus visualized

- No rotation of calcaneal tuberosity
- Demonstrated talo-calcaneal joint
Din XJ
89
G. Foot
- Basic views: PA & anterior oblique
1. AP & Oblique view
AP Oblique
IR 24 x 30 cm
Non-grid
2 mAs
Position
- Supine - Supine or sitting

- Knee flexed - Knee flexed
- Plantar of foot over IR - Plantar of foot over IR
- Foot medially rotated → Plantar surface 30-40o to IR
- Support position wt block
FFD 100cm FFD 100cm
Angle 10o posteriorly towards the heel
CR Base of 3rd metatarsal Base of 3rd metatarsal
Collimation Entire foot
Remarks - Talus & calcaneus not clearly seen - Visualiaed

(2cm calcaneus seen without talar overlap) a) Tarso-metatarsal & intertarsal joints
- Equal midshaft concavity on both sides, b) Sinus tarsi
for 2nd – 5th metatarsals & phalanges c) Tuberosity of 5th metatarsal
- Base of 1st& 2nd metatarsals are separated - Better visualization of most tarsal bones
- Superimposed base of 2nd- 5th metatarsals - 3rd – 5th metatarsals are not superimposed
Din XJ
90
1. Distal phalanx (tuft) 12. Metatarso-phalangeal joint 23. Lateral malleolus

2. Distal phalanx of great toe 13. Metatarsal 24. Calcaneus
3. DIP joint of great toe 14. Metatarsal head 25. Tarso-metatarsal (Lisfranc’s) joints
4. DIP joint 15. Medial cuneiform 26. Transverse tarsal (Chopart’s) joint
5. PIP joint 16. Middle cuneiform
6. Distal phalanx 17. Lateral cuneiform Common sesamoids:
7. Middle phalanx 18. Base of 5th metatarsal 27. Os intermetatarseum
8. Head of proximal phalanx 19. Navicular 28. Os vesalianum
9. Proximal phalanx 20. Head of talus 29. Os peroneum
10. Sesamoid 21. Cuboid 30. Secondary cuboid
11. Base of phalanx 22. Medial malleolus 31. Os tibiale externum
32. Os supratalare
2. Lateral view
Position Lateral Standing lateral
- Lateral recumbent position, on the affected side - Standing, weight equally distributed
- Lateral aspect of foot over IR - Medial aspect of foot facing vertical IR
- Plantar surface ∟ ankle
Tube Vertical beam
FFD 100cm
CR Base of 3rd metatarsal
Collimation - Distal end tibia / fibula
- Entire foot & ankle
Remarks - Superimposed metatarsals, except 5th metatarsals (below others)
- Talo-tibial joint open
Din XJ
91
1. MTP joint
2. Tarso-metatarsal joint
3. Medial cuneiform
4. Middle cuneiform
5. Lateral cuneiform
6. Cuneonavicular joint
7. Navicular
8. Talo-calcaneo-navicular joint
9. Tibia
10. Ankle
11. Fibula
12. Talus
13. Posterior process of talus
14. Distal phalanx
15. Middle phalanx
16. Proximal phalanx
17. Sesamoid
18. Metatarsal
19. Base of 5th metatarsal
20. Cuboid
21. Calcaneo-cuboid joint
22. Calcaneus
23. Posterior tuberosity of calcaneus
1. Talus 9. Navicular
2. Lateral melleolus 10. Achilles tendon
3. Lateral process of talus 11. Calcaneus
4. Os trigonum 12. Cuboid
5. Subtalar joint 13. Base of 5th metatarsal
6. Posterior process of talus 14. Posterior tuberosity of calcaneus
7. Sinus tarsi 15. Plantar aponeurosis
8. Sustentaculum tali
Din XJ
Chapter 3 BREAST
IMAGING
92
A. Mammography
Indications 1. Focal signs in women > 35yrs, as triple assessment (clinical, radiological, pathological)
2. Assessment of confirmed breast Ca
- Multi-focal (>1 lesion in the same quadrant)
- Multi-centric (>1 lesion in different quadrant)
- Bilateral disease
3. Breast Ca follow-up
- No more frequent than annually
- Less frequent than biennially
4. Metastatic malignancy of unknown origin
5. Screening for asymptomatic women,
a) with low risk btw 40-49yrs (annually), btw 50-75yrs (annually or biennially)
b) with moderate / high risk of breast Ca, < 40yrs
(i) 1st or 2nd degree relative with breast Ca at the age < 50yrs
(ii) H/o breast or ovarian Ca
(iii) H/o breast atypia on biopsy at the age < 40yrs
c) who underwent radiotherapy for Hodgkin’s disease when < 30yrs
6. Screening for women on HRT
a) Prior to commencement of HRT
b) On HRT >5yrs: Annually / biennial
Not indicated 1. Asymptomatic women, without familial history of breast Ca, aged < 35yrs
2. Investigation for generalized sign/symptom (cyclical mastalgia, non-focal pain, lumpiness)
3. Routine investigation of gynaecomastia
4. To assess integrity of silicone implants
5. Patients wt ataxia-telangiectasia mutated (ATM) gene mutation, wt resultant ↑ sensitivity to radiation exposure
Equipment Mammographic unit with:
a) Dual focus x-ray tube
Focal spot size (mm2) Indication
0.3 General use
0.1 Magnification view
b) Dual filtration: molybdenum / rhodium
c) Choice of rotating target material: molybdenum / rhodium / tungsten
d) Interchangeable buckys
18x24 cm
24x30 cm
e) Automated exposure control (AEC)
f) Carbon fibre table top wt reciprocating / oscillating grid (average rid ratio 5:1)
g) Magnification assembly (magnification factors 1.8 / 2.0)
h) Contact spot compression
Technique - Imaging of both breasts
- Gonad shield (esp in CC view)
- Exposure factors:
kV 25 – 35
mA Focal spot 0.3mm2 100 mA
Focal spot 0.1mm2 40 mA
Exposure time 2 sec
- Compression, resulting in
a) ↓ Breast thickness → ↓ Scatter & noise → ↑ Resolution
b) Uniformity of breast thickness → Even penetration
c) Immobilization of the breast → ↓ Blurring
d) ↓ Radiation dose
- Additional features:
a) Spot compression → To remove overlapping composite tissue
b) Magnification → To provide morphological analysis
- Views:
a) Standard views (i) Medio-lateral oblique (MLO)
(ii) Cranio-caudal (CC)
b) Additional views (i) Extended CC
(ii) Lateral: Medio-lateral / latero-medial
(iii) Axillary tail
Additional views are done when any uncertainties arise on standard views
Din XJ
93
Remarks 1. Medio-lateral oblique (MLO) view
- The only projection that demonstrates all breast tissue on a single image
- Best visualize: Upper outer quadrant, axillary tail, tissue adjacent to chest wall
- Criteria for a good MLO image:
a) Visualized entire breast tissue
b) Symmetrical both sides: A line from nipple to pectoralis muscle, difference in both sides < 1cm
c) Nipple in profile
d) Visible skin pores
e) Pectoralis major muscle extending to / below nipple line, convex anteriorly
f) Fibroglandular tissue > Retroglandular tissue
g) Inframammary fat fold (inframammary angle) is seen
2. Cranio-caudal (CC) view
- Visualize: All medial tissue, majority of lateral tissue excluding axillary tail
- Criteria for a good CC image:
a) Visualized all medial tissue & as much of lateral tissue as possible
b) Symmetrical both sides
c) Nipple in profile
d) Visible skin pores
e) Pectoralis major muscle is seen in ⅓ of the posterior edge of the breast
d) Retroglandular fat is seen
3. Extended cranio-caudal view
- Supplementary for better imaging of lateral tissue, including axillary tail

- Visualize lateral tissue including axillary tail, pectoralis major muscle in lateral part of the breast
Din XJ
94
4. Lateral views (Medio-lateral, ML or Latero-medial, LM)
- Supplementary to localize the exact position of a lesion

- Visualize less breast tissue & pectoral muscle, than MLO view
5. Spot compression
- To differentiate superimposed tissue from real mass
6. Magnification
- Breast placed on platform, at a defined distance from grid holder (air gap technique)
Area of interest compressed
Image field collimated as small as possible
- Use small focal spot, remove grid
Tabar’s forbidden zones (areas tht require special attention)

a) Milky way 3-4 cm wide, parallel to edge of pectoralis muscle
MLO
b) Retro-areolar area
c) No man’s land Retro-glandular space
CC
d) Medial ½ of the breast
Din XJ
95
Findings:
Breast Composition A: Almost entirely fatty
B: Scattered fibroglandular density
C: Heterogenously dense, may obscure masses
D: Extremely dense
Architectural Distortion Distorted parenchymal with no visible mass
Asymmetry Asymmetry, focal, global, developing
Mass Shape Round, oval, irregular
Margin Circumscribed, obscured, microlobulated, indistinct, spiculated
Density Fat, low, equal, high
Calcifications Morphology Typically benign
Suspicious: Amorphous, course heterogenous, fine pleomorphic,
fine linear, fine linear branching
Distribution Diffuse, regional, grouped, linear, segmental
Associated features Skin retraction, nipple retraction, skin thickening, trabecular thickening, axillary adenopathy
A. Breast Composition
BIRADS density Description
A Almost entirely fatty
B Scattered fibroglandular density
C Heterogenously dense, may obscure masses
D Extremely dense
B. Architectural Distortion (Distorted parenchymal with no visible mass)

- Appearance: Thin straight lines, spiculations radiating from a point, focal retraction, distortion at the edges of parenchyma
- Differential diagnosis: Scar tissue, carcinoma
Din XJ
96
C. Asymmetry (Unilateral deposits of fibroglandular tissue not conforming to the definition of a mass)
1. Asymmetry Area of fibroglandular tissue, visible on only 1 projection, mostly d/t superimposed normal breast tissue
2. Focal asymmetry Visible on 2 projections, hence a real finding rather than superposition
3. Global asymmetry Asymmetry over at least ¼ of the breast and is usually a normal variant
4. Developing asymmetry new, larger and more conspicuous than on a previous examination
D. Mass (Space occupying 3D lesion seen in 2 different projections)

1. Shape: Round, oval, irregular
2. Margin: Circumscribed, obscured, microlobulated, indistinct, spiculated
3. Density: Fat, low, equal, high
Din XJ
97
E. Calcifications
1. Morphology
a) Typically benign Skin, vascular, coarse, large rod-like, round / punctate (< 1mm), rim, dystrophic, milk of calcium, suture
* Exception: an isolated group of punctuate calcifications that is new, increasing, linear or segmental in
distribution or adjacent to a known cancer
b) Suspicious Amorphous (4B), course heterogenous (4B), fine pleomorphic (4B),
fine linear (4C), fine linear branching (4C)
2. Distribution
a) Diffuse Distributed randomly throughout the breast
b) Regional Occupying a large portion of breast tissue > 2 cm greatest dimension
c) Grouped (historically cluster) Few calcifications occupying a small portion of breast tissue (≥ 5 calcifications within 1cm)
d) Linear Arranged in a line, which suggests deposits in a duct
e) Segmental Suggests deposits in a duct or ducts and their branches
F. Final Assessment
BIRADS category Management Likelihood of cancer
0 Poor examinations Wait for prior examinations / NA
Need additional imaging Recall for additional imaging
1 Negative Routine screening Essentially 0%
2 Benign Routine screening Essentially 0%
3 Probably benign Short interval follow-up (6 months) > 0% to ≤ 2%
4 Suspicious Tissue diagnosis
4A > 2% to ≤ 10%
4B > 10% to ≤ 50%
4C > 50% to < 95%
5 Highly suggestive of malignancy Tissue diagnosis ≥ 95%
6 Known biopsy proven malignancy Surgical excision when clinical appropriate 100%
Din XJ
98
B. Ultrasound
Indications 1. Focal signs in women < 35yrs, as triple assessment (clinical, radiological, pathological)
2. Adjunct to mammographic screening in women > 35yrs
3. Assessment of confirmed breast Ca
- Assess initial tumour size
- Response to neo-adjuvant therapy
4. Diagnosis / drainage / follow-up of breast abscess
5. Assessment of implant integrity
6. US guided biopsy of breast lesion / LN
7. US guided hook wire localization of breast lesion
Not indicated 1. Screening in any age group

2. Investigation for generalized sign/symptom (cyclical mastalgia, non-focal pain, lumpiness)
3. Routine investigation of gynaecomastia
Equipment Linear transducer 8-18 MHz (↑ frequency)
Technique - Position:
a) Supine For examination of the medial aspect of the breast
b) Oblique / lateral For examination of the lateral aspect of the breast & axilla
- Raised the arm on the side to be examined, placed behind the head
- Views:
a) Upper inner quadrant
b) Upper outer quadrant
c) Lower inner quadrant
d) Lower outer quadrant
e) Retro-areolar region
f) Axillary tail
- Look for LN
Remarks
Skin HypER-echoeic line

Glandular tissue HypER-echoeic
Fat HypO-echoeic
Cooper ligaments HypER-echoeic linear structures
Lactiferous Tubular anechoeic structures
Findings:
Breast Composition Homogeneous – fat, homogeneous – fibroglandular, heterogeneous
Mass Shape Round, oval, irregular
Margin Circumscribed
Not circubscribed (angular, microlobulated, indistinct, speculated)
Orientation Parallel, non-parallel
Echo pattern Anechoic, isoechoic, hypoechoic, hyperechoic,
complex solid/cystic, heterogeneous
Posterior features No features, enhancement, shadowing, combined pattern
Calcifications In mass, outside mass, intraductal
Associated features Architecture distortion, duct changes, skin thickening, skin retraction, oedema,
vascularity, elasticity
* Lymph node measurement in US: Cortical thickness (Not short axis)
Din XJ
99
C. MRI
Indications 1. To look for recurrence, 6mths post-breast conservation surgery, for breast Ca
2. Adjunct to mammographic screening in women with high risk of breast Ca
3. Assessment of confirmed breast Ca: Response to neo-adjuvant therapy
4. To clarify equivocal / suspicious mammographic / US findings
5. Investigation of occult breast Ca (Malignant axillary LN but normal breast triple assessment)
6. Assessment of implant integrity
Contra-Ix CIx for standard MRI & IV contrast media
Contrast IV Gadolinium 0.1-0.2 mmol / kg (except in assessment of implant integrity)
Preparation - IV line
- Prone, head first
- Breasts placed in surface coil
Planes: Coronal
1. Coronal Total slice: 13, SL: 4-6mm
2. Axial Total slice: 13, SL: 4-6mm
3. Axial FLASH Total slice: 11slices x 8times (88), SL: 4-6mm
Sequence:
1. T1 TR: 500ms, TE: 15ms
2. T2 fat sat TR: 2,000ms, TE: 110ms
3. T1 FLASH TR: 100ms, TE: 5ms
Axial
Protocol 1. Pre-contrast
Coronal: T1, T2 fat sat (total slice: 15, SL: 4 – 6mm)
Axial: T1, T2 fat sat
→ 11 T1-axial images containing lesion are then imaged wt dynamic FLASH sequence
IV Gadolinium 0.1-0.2 mmol / kg, followed by IV NS 20mls
(Non-enhanced scanning is adequate for assessment of implant integrity)
2. Dynamic contrast study

Axial: Same 11 T1-axial images are imaged wt identical dynamic FLASH sequence, repeated for 8 times
3. Post-contrast
Coronal: FLASH
Axial: T2, PD
Findings:
Focus < 5mm (Cannot be specified)
Mass Shape Round, oval, lobulated, irregular
Margin Smooth, irregular, spiculated
↑ T1 Lymph node, fat necrosis, hamartoma
↑ T2 fat sat Cyst, lymph node, fibroadenoma, fat necrosis, colloid carcinoma
Enhancement Homogeneous, heterogeneous, rim, septa
Kinetics Type 1, 2, 3
Non mass-like enhancement Distribution Focal (punctate), linear, ductal, segmental, regional, diffuse
Pattern Punctate (focal), homogeneous, heterogeneous, clumped
Din XJ
100
A. Focus (an area of enhancement < 5mm in diameter which is too small to characterize)
- Typically stable on follow-up, considered to be a part of the normal background enhancement pattern in the breast
B. Mass (a 3-dimensional lesion that occupies a space within the breast)

1. Shape: Round, oval, lobulated, irregular
2. Margin: Smooth, irregular, spiculated
3. ↑ T1 (Fat content): Lymph node, fat necrosis, hamartoma
Hamartoma: Fat seen within the lesion on T1
4. ↑ T2 fat sat (Water content): Cyst, lymph node, fibroadenoma, fat necrosis, colloid carcinoma
Din XJ
101
5. Enhancement: Homogeneous, rim, septa
6. Kinetics:
Type 1 Slow initial rise, then continue rise with time 6% malignant
Type 2 Slow / rapid initial rise, then plateau in delayed phase Btw 6% (type 1) & 29-77% (type 3)
Type 3 Rapid initial rise, then drop-off (washout) in delayed phase 29-77% malignant
C. Non mass-like enhancement (an area of enhancement without a detectable 3-dimensional mass)
1. Distribution
a) Focal / punctate Enhancement < 25% of a breast quadrant 25% malignant
b) Linear Linear enhancement but not in ductal orientation 31% malignant
c) Ductal Enhancement in ductal distribution 60% malignant
d) Segmental Multiple ductal enhancement 78% malignant
e) Regional Non- ductal or segmental enhancement, but larger than focal 21% malignant
f) Diffuse Diffuse enhancement Typically benign
2. Pattern: Punctate (focal), homogeneous, heterogeneous, clumped
Din XJ
102
D. Ductography
Indications Investigation for single duct discharge, TRO intraluminal abnormality (eg Papilloma)
Equipment 1. Jabzenski cannula
2. LOCM
Technique - Insert Jabzenski cannula (prefilled wt CM), through a duct orifice on nipple surface
- Inject CM
- Acquire x-ray image
1. Skin & subcutaneous tissue 6. Lactiferous sinus

2. Cooper’s ligament 7. Lactiferous duct
3. Subcutaneous fat tissue 8. Ductules
4. Nipple 9. Lobules
5. Main lactiferous duct 10. Lobe
Din XJ
103
F. Lymphoscintigraphy of Breast
Indications Indication: Contraindication:
For sentinel node mapping 1. Allergy to human albumin products
→ If sentinel node is –ve 2. Complete blockage of lymphatic system
→ Extensive axillary LN clearance can be avoided
Radiopharma 99mTc-colloidal
albumin
May complement with Methylene blue dye (visible to naked eye)
Equipment Gamma camera
Preparation None
Technique - Inject 99mTc-colloidal albumin 5ml, under US guidance

a) Palpable lesion Subdermally
b) Non-palpable lesion Peri-areolar
- Acquire images after 2hrs
- Images:
a) Anterior
b) Lateral (Left or right)
- Mark the skin over the node in both axes to guide surgical incision
- These nodes can also be identified intra-operatively with gamma detecting probe
Aftercare None
Complication Anaphylactic reaction
Din XJ
104
G. Image-guided Breast Biopsy

Indications 1. Diagnostic biopsy for HPE
2. Therapeutic biopsy
a) Small fibroadenoma
b) Parenchymal distortion
c) Impalpable papillary lesions
d) Complex cysts
Equipment Automated biopsy gun (Bard biopsy system) + Biopsy needle 14-16G
Preparation Caution for patient on anticoagulant treatment:

a) Aspirin – No contraindication
b) Clopidogrel (Plavix) – Stop for ≥7 days before biopsy
c) Warfarin – INR < 1.5
Technique - Approaches:
a) Ultrasound guided Linear transducer 8-18 MHz
b) Mammographic guided Imaging of a static object, from 2 known angles, from a known zero point
(Stereotactic technique) → Calculation of X, Y, Z coordinates
- Clean & drape, LA infiltrated
- Insert biopsy needle 14-16G (via automated biopsy gun), under mammo / US guidance
- Obtain ≥ 3 passes of specimen
Aftercare 1. Observe for bleeding / haematoma, may require compression / cold pack
2. Analgesia
3. Avoid heavy lifting on the biopsied side
Complication 1. Bleeding / haematoma

2. Infection
3. Damage to adjacent tissue (pneumothorax)
4. Mild fistula (in lactating breast)
H. Pre-Operative Localization (Hook Wire Localization)

Indications Localization of breast lesion, before breast conservation surgery for breast Ca
→ Followed by post-operative assessment of the specimen, to confirm clear margins
Equipment Localizing (Hook) wire
Preparation Caution for patient on anticoagulant treatment:

a) Aspirin – No contraindication
b) Clopidogrel (Plavix) – Stop for ≥7 days before biopsy
c) Warfarin – INR < 1.5
Technique - Approaches:
a) Ultrasound guided Linear transducer 8-18 MHz
b) Mammographic guided Imaging of a static object, from 2 known angles, from a known zero point
(Stereotactic technique) → Calculation of X, Y, Z coordinates
- Insert localizing (Hook) wire, till its tip within the lesion, under mammo / US guidance
- After wire placement, acquire mammographic / US images, to indicate the position of the tip
- Mark the skin immediately overlying the lesion, measure the depth of target
- Secure the wire on the skin
Aftercare 1. Observe for bleeding / haematoma, may require compression / cold pack
2. Analgesia
3. Avoid heavy lifting / vigorous movement on the biopsied side

2. Infection
Din XJ
Chapter 4 FLUOROSCOPY
105
GENERAL PRINCIPLES
Contrast Media
 Dilution of Barium sulphate:
a) Barium swallow 150 600g BaSO4 + 400mls water
b) Barium meal 240 600g BaSO4 + 250mls water
c) Barium follow-through 60 600g BaSO4 + 1L water
d) Small bowel enema 20 300g BaSO4 + 1.5L water
e) Barium enema 60 600g BaSO4 + 1L water
f) Defecating proctogram 60 Oral: 600g BaSO4 + 1L water (Drink 600mls)
Rectal: Remaining 400mls + 100g BaSO4 + 50g potato
 Paediatrics
a) Upper GI study 20 300g BaSO4 + 1.5L water
b) Lower GI study 60 600g BaSO4 + 1L water
(single contrast Ba enema)
Bowel Preparation
3 days before examination Low residual diet
2 days before examination T. Bisacodyl (Dulcolax) 10mg ON x 2 days
1 day before examination - Light breakfast, then only clear fluids
- Drink lots of clear fluids subsequently
Din XJ
106
GASTRO-INTESTINAL TRACT
A. Barium Swallow
Indications Indications: Contraindications:
1. Dysphagia & odynophagia 1. No absolute
2. Unexplained anemia 2. CIx for contrast media & ionizing radiation
3. Tracheo-oesophageal fistula (Barium / LOCM)
4. Assess the site of perforation (water soluble CM)
Contrast 1. BaSO4 (E-Z HD): 225% w/v
2. Gastrograffin→ If suspect perforation
3. LOCM (Ultravist, omnipaque, iopamero) → If patient at risk of aspiration, trachea-oesophageal fistula
Preparation None, unless combine wt barium meal
Technique - Erect position
- Swallow ample mouthful of barium, followed by gas (for double contrast study), spot films taken
Position Projections Frames/sec
a) Laryngopharynx & upper oesophagus PA & lateral 4
b) Mid oesophagus RAO, to throw the oesophagus of spine 2
c) Lower oesophagus & GE junction PA (for GE junction) & RAO 2
Oesophagealvarices Prone RPO, to distend the varices
- Images taken for all projections must be:
a) Full column Single contrast: Barium-filled
b) Air column Double contrast: Mucosal coating wt barium
c) Air collapse
Tracheo-oesophageal fistula in infants:

- Lateral position
- NG tube inserted till mid oesophagus
- CM (barium / LOCM) syringed in to distend the oesophagus
- Further inject CM while withdrawing NG tube, screened in lateral position (spot films are not taken in paeds)
* Overspill may cause aspiration → Incorrect diagnosis of trachea-oesophageal fistula
Aftercare 1. Bowel motions will be white for few days (may require 2wks for satisfactory clearance of barium)
2. Eat & drink normally to avoid barium impaction
Complication 1. Leakage of barium from an unsuspected perforation
2. Aspiration
Upper oesophagus, Lateral Mid oesophagus, RAO GE junction, RAO
Important indentations:
a) Cervical region b) Thoracic region
- Anterior indentations: Posterior cricoid venous plexus - Aortic arch
- Posterior indentations: Crico-pharyngeus - Left main bronchus
- Left atrium
Din XJ
107
Hypopharynx (AP)
1. Pharynx
2. Lateral glosso-epiglottic fold
3. Vallecula
4. Epiglottis
5. Piriform recess
6. Esophagus
Hypopharynx (Lateral)
1. Uvula
2. C2
3. Tongue
4. Oropharynx
5. Mandible
6. Vallecula
7. Larynx
8. Hyoid bone
9. Piriform recess
10. Larynx – Ventricle
11. Esophagus
12. Trachea
Din XJ
108
1. Uvula A. Paratracheal segment

2. Lateral glosso-epiglottic fold B. Aortic segment
3. Epiglottis C. Bronchial segment
4. Piriform recess D. Interbronchial segment
5. Upper esophageal sphincter E. Retrocardiac segment
6. Esophagus F. Epiphrenic segment
7. Aortic arch
8. Bronchial & aortic segment
1. Distal esophagus
2. Gastro-esophageal angle
3. Abdominal esophagus
4. Esophageal hiatus
5. Cardia
Din XJ
109
B. Barium Meal
Indications 1. Double contrast study: 2. Single contrast study:
To demonstrate mucosal pattern (method of choice) To demonstrate gross pathology (for paeds)
To determine the cause of vomiting in paeds
a) Failed OGDS
b) Dyspepsia, reflux Sx a) Malrotation
c) Upper abdominal mass b) Duodenal stenosis / atresia
d) Partial obstruction c) Pyloric obstruction (only if US inconclusive)
e) Unexplained anemia d) Gastro-oesophageal reflux
f) Weight loss
g) Assess the site of perforation (water soluble CM)
CIx 1. Complete large bowel obstruction
2. CIx for contrast media & ionizing radiation
Contrast 1. Double contrast study: 2. Single contrast study:
a) BaSO4 (E-Z HD): 240% w/v a) BaSO4 (E-Z HD): 30% w/v
b) Effervescent (Carbex) granules No paralytic agent used
→ Produce CO2 for better coating
Preparation NBM for 6hrs

Technique 1. Double contrast study:
- Patient swallows carbex granules
- Drinks Ba in Lt lateral position (to prevent Ba from reaching duodenum too fast & obscure the greater curvature)
- Lies supine & slightly Rt (to bring Ba to GE junction)
Ask patient to cough / swallow water (to promote reflux), screened
If reflux is observed, spot films are taken
- IV smooth muscle relaxant given (Buscopan 20mg / Glucagon 0.3mg if Ba meal combine wt Ba follow-through)
- Patient rolls in a complete circle (for Ba coating of gastric mucosa)
- Spot films taken to demonstrate the stomach:
a) RAO Antrum& greater curvature
b) Supine Antrum& body
c) LAO Lesser curvature
d) Lt lateral, head tilted up 45o Fundus
- From Lt lateral position, patient rolls into prone position(Not from Rt side to prevent Ba flooding the duodenum)
- Spot films taken to demonstrate duodenal cap:
a) Prone c) Supine
b) RAO d) LAO
- Patient in erect position, additional spot films may be taken:
a) Fundus PA
b) Duodenal cap RAO & LAO
c) Lower oesophagus RAO, while swallowing CM
2. Single contrast study:
- Supine position
- Insert feeding tube, till the tip reaches stomach
- Demonstration of:
a) Pyloric obstruction - Ba given to fill the fundus (relatively small volume)
- Child turned into LAO / RAO position
- Screen as Ba passes through pylorus into duodenum
b) Malrotation & - Child returned to supine position
Duodenal atresia - To prevent contrast filling the greater curvature & obscure duodenum:
(i) Insert feeding tube, till the tip at antrum
(ii) Child in right lateral position
(iii) Ba given little-by-little slowly
- Screen as Ba passes around duodeno-jejunal flexure
c) GE reflux - Further Ba given to fill the stomach
- Child is rotated through 180o to elicit GE reflux
2. Aspiration
3. Barium impaction:
a) Conversion of partial large bowel obstruction into a complete obstruction
b) Barium appendicitis
Din XJ
110
1. Fundus 8. Pylorus
2. Abdominal esophagus 9. Stomach body
3. Cardia 10. Angular notch
4. Lesser curvature 11. Greater curvature
5. Duodenum 12. Pyloric antrum
6. Ampulla of Vater 13. Antrum
7. Gastric folds (posterior wall)
1. Ampulla of Vater 4. Duodenum – 2nd part

2. Pylorus 5. Papilla of Vater
3. Pyloric antrum
Din XJ
111
C. Barium Follow-through
Indications Indications: (= Small bowel enema) Contraindications: (= Small bowel enema)
1. Pain 1. Complete bowel obstruction
2. Diarrhoea 2. Suspected perforation
3. Malabsorption 3. CIx for contrast media & ionizing radiation
4. Abdominal mass
5. Partial obstruction
6. Unexplained anemia
Contrast 1. BaSO4 (E-Z Paque): 60% w/v Methods to ↓ transit time:

a) Adult: 300 mls a) Dry crackers, before examination
b) Paeds: 3 – 4 mls/kg b) Tab Maxolon 20mg, before examination
2. Water soluble CM, if barium is contraindictaed c) Cool the BaSO4 with ice packs
3. Effervescent agent d) Add Gastrograffin 10mls
Technique - Prelim: Plain AXR, TRO small bowel obstruction& perforation

- Drink 300mls of barium
- IV Glucagon 0.3mg given (if Ba meal combine wt Ba follow-through)
- Lie on the right side
- Prone PA films taken (prone is to separate loops of small bowel):
1st hour Every 15 – 20 mins
Subsequently Every 20 – 30mins, until colon is reached
- Then, spot films of terminal ileum taken
a) Standard view Supine position, compression pad applied
b) Additional views (i) Obliques
(ii) X-ray tube angled into pelvis
(iii) Patient tilted head down
- To detect diverticula, erect film taken, to demonstrate fluid level
(= Ba meal) 2. Eat & drink normally to avoid barium impaction

(= Ba meal) 2. Aspiration
Din XJ
112
1. Ampulla of Vater 6. Duodenum – 2nd part

2. Pyloric antrum 7. Duodenum – 4th part
3. DJ flexure 8. Duodenum – 3rd part
4. Colon 9. Jejunum
5. Stomach body 10. Ileum
1. Jejunum
2. Junction of ileum & jejunum
3. Ileum
4. Caecum
5. Appendix
Din XJ
113
D. Small Bowel Enema (Enteroclysis)

Indications Indications: (= Ba follow-through) Contraindications: (= Ba follow-through)
1. Pain 1. Complete bowel obstruction
2. Diarrhoea 2. Suspected perforation
3. Malabsorption 3. CIx for contrast media & ionizing radiation
4. Abdominal mass
Disadvantages:
5. Partial obstruction
1. Unpleasant for patient (intubation)
6. Unexplained anemia
2. ↑ Radiation dose
Advantages: 3. More time consuming for radiologist
Better visualization of jejunum,
d/t better distension by direct infusion
Contrast BaSO4 (E-Z Paque): 20% w/v
Catheters 1. Bilboa-Dotter tube + guidewire

2. Silk tube + stylet (Hardly ever used)
Technique - Prelim: Plain AXR, TRO small bowel obstruction& perforation

- Sitting position
- Pharynx is anaesthetized wt lidocaine spray
- Tube is inserted through nose / mouth, via fluoroscopic guidance (lateral screening) to pass through epiglottis
Patient asked to swallow, wt neck flexed
Tube advanced into gastric antrum
- Lie down, tube advanced into duodenum. May adopt following manoeuvres:
a) Lie in left lateral position, to straighten out the stomach
Sit up, to overcome tube coiling in fundus
b) Advance tube while applying clockwise rotational motion
c) Introduce guidewire for Bilboa-Dotta tube
d) IV Maxolon 20mg
- Tube advanced into duodeno-jejunal flexure (ligament of Treitz), wt guidewire tip maintained at pylorus
- Supine position
- Barium is run in, spot films taken, until colon is reached
- Tube is withdrawn, residual fluid in stomach aspirated
- Prone & supine AXR taken
Aftercare May have diarrhea, as large volume of fluid given
Complication 1. Aspiration
2. Perforation, d/t manipulation of guidewire
Din XJ
114
E. Barium Enema
Large bowel pathology 1. Toxic megacolon
2. Pseudomembranous colitis
a) Double contrast study 3. Recent rectal biopsy
To demonstrate mucosal pattern (method of choice) a) Rigid endoscope: Within 5 days
b) Single contrast study b) Flexible endoscope: Within 1 day
To demonstrate gross pathology (for paeds) 4. CIx for contrast media & ionizing radiation
Reduction of intussusception (obsolete) Suboptimal study if:
1. Incomplete bowel preparation
2. Recent barium meal
3. Patient frailty
Contrast 1. BaSO4 (Polibar): 60% w/v
2. Air
Preparation Bowel preparation
Catheter Miller enema tube
Technique - Prelim: Plain AXR, TRO perforation & toxic megacolon, to assess bowel preparation
- Left lateral position
- Miller enema tube inserted into rectum, taped firmly in position
Connected to barium bag
- IV Buscopan 20mg / Glucagon 1mg given
- Barium is infused, intermittent screening to check progression, till barium reaches hepatic flexure
- Barium is run back out, by lowering the infusion bag to the floor
- Air is pumped in, forcing barium towards caecum, producing double contrast effect
- Spot films taken:
a) Rectosigmoid colon Lying: RAO, prone, LPO, left lateral
b) Rectum Erect: Left lateral
c) Splenic flexure Erect: LAO
d) Hepatic flexure Erect: RAO
e) Caecal pole Lying: LAO
- Overcouch films taken:
a) Supine
b) Prone
c) Left lateral decubitus
d) Right lateral decubitus
e) Hampton’s view (to visualize sigmoid colon): Prone, tube angled 45o caudally, centered at 5cm above PSIS
Complication 1. Constipation & impaction 5. Cardiac arrhythmia, d/t rectal distension
2. Bowel perforation 6. Venous intravasation → May cause barium pulmonary embolism (Mortality rate 80%)
3. Intramural barium 7. Side-effects of pharmacological agents used
4. Transient bacteremia
AP – Supine AP – Prone
Din XJ
115
Left lateral decubitus Right lateral decubitus Hampton’s view
1. Splenic flexure
2. Hepatic flexure
3. Ascending colon
4. Transverse colon
5. Descending colon
6. Haustra
7. Ileocaecal valve
8. Caecum
9. Sigmoid colon
10. Appendix
11. Rectum
1. Rectosigmoid junction
2. Sacrum
3. Retrorectal space
4. Transverse rectal fold
5. Femoral head
6. Rectal ampulla
7. Coccyx
8. Anorectal junction
Din XJ
116
Instant Enema
1. To identify level of suspected large bowel obstruction 1. Toxic megacolon
2. To show the extent of mucosal lesions in active 2. Recent rectal biopsy
ulcerative colitis a) Rigid endoscope: Within 5 days
b) Flexible endoscope: Within 1 day
3. Chronic ulcerative colitis (formal Ba enema should be done)
4. Crohn’s colitis (unreliable assessment)
Contrast Water soluble CM (Gastrograffin or LOCM)
Technique - Prelim: Plain AXR, TRO perforation & toxic megacolon

- CM is infused into:
a) An obstructing lesion
b) Dilated bowel loops
c) Caecum
Air is not pumped in (single contrast study)
- Spot films taken as required:
a) Prone
b) Left lateral decubitus
c) Erect
Air Enema
Indications To show the extent of ulcerative colitis
Contrast Air
Technique - Insert Foley catheter (14 – 16 Fr) into rectum, inflate balloon (10 – 20 mls)
- Overcouch prelim film taken: AP Abdomen
- Pump air into catheter lumen
- Overcouch film taken: AP Abdomen
F. Herniography
1. History suggestive of hernia 1. Pregnancy
But inconclusive physical examination 2. Infant
2. Undiagnosed groin pain 3. Intestinal obstruction
Preparation Empty bladder before examination
Technique - Supine position

- Clean & drape
- Infiltrate 5-10mls of lignocaine 1%, at midline below umbilicus
- Introduce spinal needle (18G) into peritoneal cavity
- Inject CM into peritoneal cavity
- Patient coughs or performs Valsalva manoeuvre, spot films taken
a) Prone
b) Erect: AP, obliques, lateral
Aftercare None
Complication 1. Haematoma at injection site

2. Injection into abdominal wall
3. Visceral puncture
4. Vascular puncture
5. Allergy to CM
Din XJ
117
G. Defecating Proctogram
1. Constipation 1. Pregnancy
2. Pelvic floor weakness 2. CIx for contrast media & ionizing radiation
(rectocoele, enterocoele, rectal intussusception)
3. Anorectal incontinence (manometry / anal US preferred)
Contrast Oral 600g BaSO4 + 1L water (Drink 600mls)

Rectal paste Remaining 400mls + 100g BaSO4 + 50g potato
Technique - Drink 600mls of diluted barium 30mins before examination, to opacify the small bowel
Insert Foley catheter into rectum
Barium paste (150 – 200 mls) syringed into rectum
Screen to confirm that barium paste has reached the level of sacral promontory
- Patient sit on commode, in lateral projection
- Video recording / spot films taken, during:
a) Rest
b) Valsalva manoeuvre
c) Pelvic floor contractions
Complication 1. Constipation & impaction

2. Bowel perforation
(= Ba enema) 3. Intramural barium
But vr unlikely 4. Transient bacteremia
5. Cardiac arrhythmia, d/t rectal distension
6. Venous intravasation → May cause barium pulmonary embolism (Mortality rate 80%)
7. Side-effects of pharmacological agents used
Din XJ
118
H. GI STUDY FOLLOWING SURGICAL PROCEDURE

1. Retrograde Ileogram
To demonstrate anatomy of small bowel, 1. No absolute, perforation
in patient wt ileostomy 2. CIx for contrast media & ionizing radiation
Contrast 1. BaSO4 (Baritop): 60% w/v
2. Water soluble CM (if conformed / suspected perforation)
3. Air
Preparation None
Technique - Insert Foley catheter (16 – 22Fr) into ileostomy, inflate balloon (10 – 20 mls) at the lip of ileostomy
- Inject contrast into small bowel
- Spot films taken
Aftercare None
Complication Perforation
2. Colostomy Enema
To demonstrate anatomy of large bowel, 1. No absolute, perforation
proximal to colostomy 2. CIx for contrast media & ionizing radiation
Contrast 1. BaSO4 (Polibar): 60% w/v
2. Air
Technique - Insert Foley catheter (22 – 26Fr) into colostomy, inflate balloon (10 – 20 mls) at the lip of colostomy
Connected to barium bag
- Barium is infused as in barium enema
Aftercare = Barium enema
= Barium enema
3. Distal Loopogram
To demonstrate anatomy of bowel, distal to stoma 1. No absolute, perforation
(usually before reversal of Hartmann) 2. CIx for contrast media & ionizing radiation
Preparation None
Technique - Insert Foley catheter into stoma, inflate balloon (10 – 20 mls) at the lip of stoma
- Inject contrast into bowel
- Spot films taken
Aftercare None
4. Conduitogram
To demonstrate anatomy of ileal conduit, ureters & renal 1. No absolute, perforation
pelvicalyceal systems 2. CIx for contrast media & ionizing radiation
1. Narrowing / obstruction of ileal conduit
2. Narrowing / obstruction at anastomosis
3. Leaking
Preparation None
Technique - Insert Foley catheter (18 – 20Fr) into stoma, inflate balloon (10 – 20 mls) at the lip of stoma
- Inject contrast into ileal conduit
- Spot films taken
Aftercare None
Din XJ
119
I. PAEDIATRICS
1. Upper GI study: Contrast Swallow
Tracheo-oesophageal fistula (Barium / LOCM) 1. No absolute, suspected perforation
Contrast 1. BaSO4 (E-Z HD): 150% w/v

2. LOCM (Ultravist, omnipaque, iopamero) → If patient at risk of aspiration, trachea-oesophageal fistula
Gastrografin is contraindicated
Preparation None, unless combine wt barium meal
Technique - Lateral position

- NG tube inserted till mid oesophagus
- CM (barium / LOCM) syringed in to distend the oesophagus
- Further inject CM while withdrawing NG tube, screened in lateral position (spot films are not taken in paeds)
* Overspill may cause aspiration → Incorrect diagnosis of trachea-oesophageal fistula

2. Aspiration
2. Upper GI study: Contrast Meal (Single contrast study)

Indications To demonstrate gross pathology (for paeds) Contraindications:
To determine the cause of vomiting in paeds 1. No absolute, suspected perforation
1. Malrotation 2. CIx for contrast media & ionizing radiation
2. Duodenal stenosis / atresia
3. Pyloric obstruction (only if US inconclusive)
4. Gastro-oesophageal reflux
Contrast BaSO4 (E-Z HD): 30% w/v

No paralytic agent used

- Insert feeding tube, till the tip reaches stomach
- Demonstration of:
a) Pyloric obstruction - Ba given to fill the fundus (relatively small volume)
- Child turned into LAO / RAO position
- Screen as Ba passes through pylorus into duodenum
b) Malrotation& - Child returned to supine position
Duodenal atresia - To prevent contrast filling the greater curvature & obscure duodenum:
(i) Insert feeding tube, till the tip at antrum
(ii) Child in right lateral position
(iii) Ba given little-by-little slowly
- Screen as Ba passes around duodeno-jejunal flexure
c) GE reflux - Further Ba given to fill the stomach
- Child is rotated through 180o to elicit GE reflux

2. Aspiration
Din XJ
120
3. Lower GI study: Contrast Enema

To investigate for low intestinal obstruction in paeds 1. No absolute, suspected perforation
1. Obstruction in colon 2. CIx for contrast media & ionizing radiation
a) Hirschsprung’s disease
b) Functional immaturity of colon
(small Lt colon syndrome, meconium plug syndrome)
c) Colonic atresia
2. Obstruction in distal ileum
a) Meconium ileus
b) Ileal atresia
Contrast Gastrograffin-150
- Do not provoke large fluid shifts
- Less complication if bowel perforated
- Provide satisfactory images
- Can be therapeutic for meconium ileus

- Insert Foley catheter (16-22Fr) into rectum, taped firmly in position
- Gastrograffin syringed into the entire colon
- If the entire colon is small (<1cm) → Likely meconium ileus / ileal atresia
Microcolon of prematurity & total colonic Hirschsprung’s disease are rare
- Treatment for meconium ileus:
Run gastrograffin into the dilated small bowel → Meconium surrounded by CM → Passed out in 1hr
May be repeated over the succeeding few days, till complete resolution
Complication Perforation (2%)
4. Reduction of Intussusception
1. Intussusception 1. Perforation
2. Peritonitis
Contrast 1. Air & fluoroscopy (Pneumatic reduction) → Less suitable for >4yrs, may miss lead points
2. NS & ultrasound (Saline reduction)
Barium reduction is not practiced d/t complications
Preparation 1. Centers wt paeds surgical & anaest backup

2. Adequate hydration & correct electrolyte imbalance
3. May require sedation / analgesia
Technique 1. Pneumatic reduction 2. Saline reduction

- Prelim: Plain AXR, TRO perforation - US Abd, to confirm diagnosis & identify lead point
- Prone position - Supine position
- Insert Foley catheter (16-22Fr) into rectum, - Insert Foley catheter (16-22Fr) into rectum,
taped firmly in position taped firmly in position, connected to NS bag
- Air pumped in, keep pressure at 80mmHg - NS drained in by raising the NS bag (1m above table)
If fails, ↑ pressure to 120mmHg - Assess progression via US
- Assess progression via fluoroscope Successful: Free flow of NS into distal ileum
Successful: Free flow of air into distal ileum - Duration of attempt: 3mins
- Duration of attempt: 3mins If fails, NS is drained out, child rested for 3mins
If fails, pressure is ↓, child rested for 3mins Then repeat (Total attempts: 3)
Then repeat (Total attempts: 3) - If still irreducible,
- If still irreducible, a) Repeat saline reduction after 6hrs
a) Repeat pneumatic reduction after 6hrs b) Surgical reduction
b) Surgical reduction
Images Pre & post-reduction
Din XJ
121
5. Umbilical Artery Catheter (UAC) & Umbilical Venous Catheter (UVC)

UAC UVC
Indications 1. Access to arterial system: Blood sampling 1. Vascular access

2. Close monitoring: Arterial BP
Technique Umbilical artery Umbilical vein
→ Pass inferiorly, before bending superiorly → Pass directly superiorly
→ Internal & common iliac artery → Left portal vein
→ Abdominal aorta → Ductus venosus
→ Middle / left hepatic vein
Tip position: To avoid branches of aorta
→ IVC
a) High position T6 – T10 Above coeliac
b) Low position L3 – L5 Below IMA Tip position: Junction btw IVC & right atrium (T8 & T9)
Malposition 1. Too deep / not deep enough 1. Too deep:
2. Within branches of aorta a) SVC, right atrium, right ventricle
b) Through patent foramen ovale:
Left atrium, left ventricle, pulmonary vein
2. Wrong turn: Do not enter ductus venosus after Lt PV
Rt PV, main PV, SMV, splenic vein
Sequelae of 1. Arterial blockage → Ischaemia / Infarction 1. Thrombosis along normal / malpositioned catheter
mal position 2. Direct injection of concentrated CM into organ 2. Pericardiac haematoma (perforation of cardiac wall)
(esp. kidneys) 3. Hepatic haematoma (perforation of hepatic vascular wall)
Correct position UAC: Tip at aortic arch UAC: Tip at Lf common iliac UAC: Folded in aorta
UVC: Tip at RA UVC: Tip at LA UVC: Tip at Lt PV UVC: Tip at SMV
Din XJ
122
GENITO-URINARY TRACT
A. Intravenous Urography, IVU (Excretion urography)
1. Haematuria 1. No absolute
2. Renal colic 2. CIx for contrast media & ionizing radiation
3. Recurrent UTI (congenital abN, strictures)
4. Suspected urinary tract pathology (tumour)
Contrast LOCM-300
- Adult dose: 50 – 100ml
- Paeds dose: 1 ml/kg
Preparation Before examination:
1. NBM 4-6 hrs. Dehydration is not necessary to improve image quality
2. Bowel prep is not necessary to improve image quality
3. Ambulation 2hrs prior to examination, to ↓ bowel gas
During examination:
1. IV line, antecubital vein (as flow is ↓ in cephalic vein as it pierces clavipectoral fascia)
Technique 1. Preliminary film
a) Supine AP abdomen, in inspiration b) Additional
- Lower border: Symphysis pubis (i) Supine AP renal areas, in expiration
- CR: Midline, level of iliac crest (ii) 35o posterior oblique views
(iii) Tomography of kidneys at the level of ⅓ AP diameter of patient (≈ 10cm)
Injection of contrast media
2. Immediate film (Nephrogram)
- AP renal areas
- Time: 10 – 14secs after injection (arm-to-kidney time)
- Image: Renal parenchymal (renal tubules) opacified by contrast media
- Usually omitted
May need extra contrast media if there is poor initial opacification
3. 5-min film (Excretory / Pyelogram)
- AP renal areas
- Aim: To assess for symmetrical excretion & hydronephrosis
Distension of pelvicalyceal system:
a) Compression
- Compression band applied ard abdomen
- Balloon at midway btw ASIS (ureters as they cross the pelvic brim)
- Contraindication for compression:
(i) Paediatric patients
(ii) When 5-min film shows well-distended calyces or hydronephrosis
(iii) Abdominal pain / ureteric colic
(iv) Large abdominal mass, aortic aneurysm
(v) Recent abdominal surgery
(vi) Recent renal trauma
(vii) Renal transplant
b) Head down position
c) Prone position (PA abdomen)
4. 10-min film (Compression)
- AP renal areas
- Aim: To show the well-distended pelvicalyceal systems
Release of compression if distension if satisfactory
5. Release film
- Supine AP abdomen
- Aim: To show the whole urinary tract
Empty the bladder
6. Post-micturition film
- Supine AP abdomen OR
Coned view of bladder, 15o caudal angulation, center 5cm above symphysis pubis (Cystogram)
- Aim: To assess bladder emptying & return of the dilated upper tracts to normal
Din XJ
123
Additional films:
- 35o posterior obliques of KUB
- 30o caudal angulation of renal areas (to clear the transverse colon from kidneys)
- Tomography (if there are confusing overlying shadows)
Complication 1. Upper arm / shoulder pain d/t stasis of contrast media
- Treatment: Abduction of the arm
2. General complications of CM
Preliminary film: Immediate film (Nephrogram):
5-min film (Excretory / Pyelogram): 10-min film (Compression)
Release film: Post-micturition film:
Din XJ
124
1. Lt kidney – Superior pole 8. Right kidney

2. 12th rib 9. Lt kidney – Inferior pole
3. Superior calyces 10. Ureter
4. Middle calyces 11. Psoas muscle
5. Renal pelvis 12. Distal ureter
6. Inferior calyces 13. Urinary bladder
7. Left kidney
Din XJ
125
B. Micturating Cystourethrography, MCUG

1. Vesicoureteric reflux 1. Acute UTI
2. Bladder abnormalities 2. CIx for contrast media & ionizing radiation
(vesico-vaginal, recto-vesical fistula, perforation or leak)
3. To assess urethra during micturition
4. Stress incontinence
Contrast LOCM-150 - OR - LOCM-300: Dilution 30% (NS 500mls, syringe out 150mls, replace with 150mls LOCM 300)
Preparation Empty bladder before examination
Technique - Prelim: Coned view of bladder
- Supine position
* Never inject
- Insert Foley catheter (adult) / feeding tube (paeds), into bladder
contrast
manually
- Drip CM into bladder passively, until bladder is full (based on calculated bladder capacity)
- During bladder filling, screen & save images of bladder in:
a) PA To assess VUJ for VUR
b) RAO (right ureter), LAO (left ureter)
c) Lateral, if indicated To look for fistula / perforation / leak / stress incontinence
- Once bladder is full, screen & save images of bladder in:
a) PA To assess VUJ for VUR
b) RAO (right ureter), LAO (left ureter)
c) Lateral, if indicated To look for fistula / perforation / leak / stress incontinence
- Remove catheter (if patient is able to PU), ask patient to PU
a) Adult: Standing position
b) Paeds: Supine position
- During micturition, screen & save images of urethra in:
Lateral or RAO / LOA position To assess posterior urethral valve & whole urethra
- After micturition, screen & save images of the whole urinary tract
PA KUB To look for unnoticed reflux into kidneys
To assess post-micturition residue
- Spot films are taken if abN detected (only screening for paeds, no spot films)
Aftercare 1. Possibility of dysuria Radiation protection in paeds patients:
2. May need antibiotic, if there is evidence of VUR 1. Justification of the examination
Complication 1. Catheter trauma 2. Optimization:
2. Bladder perforation, d/t overfilling by CM a) No grid
3. UTI b) Proper collimation
4. CM-induced cystitis c) Avoid magnification
5. Allergic reaction, d/t intravasation of CM via bladder mucosa d) Intermittent screening
e) Store images (do not capture images)
Bladder capacity:(1 oz = 30 mls)

Oz mls
< 2yrs Age in yrs + 2 (Age in yrs + 2) x 30
≥ 2yrs Age in yrs Age in yrs
+6 ( +6) x 30
2 2
Adult 0.4 age in yrs x 4.5 (0.4 age in yrs x 4.5) x 30
During bladder filling, PA view: VUR During micturition, Oblique view
Din XJ
126
C. Ascending Urethrography (Male patient) – Must always conclude with MCUG

1. Congenital urethral anomalies 1. Acute UTI
2. Urethral tears / stricture / fistula 2. Recent instrumentation
3. Periurethral or prostatic abscess 3. CIx for contrast media & ionizing radiation
Contrast HOCM or LOCM 200-300, 20mls
Preparation None
Technique - Prelim: Coned supine PA of bladder base & urethra
- Supine position
- Insert Foley catheter 8Fr, till balloon lies in fossa navicularis, inflate balloon wt 1-2 mls water
- Inject CM, screen & save images of urethra in:
a) LAO 30o, with right leg abducted & knee flexed
b) RAO 30o, with left leg abducted & knee flexed
- Followed by voiding examination, to demonstrate proximal urethra
- Remove catheter (if patient is able to PU), ask patient to PU
a) Adult: Standing position
b) Paeds: Supine position
* Distended prostatic urethra → Indicates that patient is about to PU
- During micturition, screen & save images of urethra in:
Lateral or RAO / LOA position To assess posterior urethral valve & whole urethra
- After micturition, screen & save images of the whole urinary tract
PA KUB To look for unnoticed reflux into kidneys
To assess post-micturition residue
- Spot films are taken if abN detected (only screening for paeds, no spot films)
Aftercare Possibility of dysuria
Complication 1. Urethral trauma
2. UTI
3. Allergic reaction, d/t intravasation of CM when excessive pressure is applied
During CM injection, oblique view
Din XJ
127
D. Hysterosalpingography, HSG
1. Infertility 1. During menses
2. Recurrent miscarriage (incompetent cervix, congenital abN) 2. Pregnancy
3. Post-sterilization, to confirm obstruction / patency 3. Active pelvic infection (purulent discharge)
before reversal of sterilization PID in preceding 6mths
4. Assess integrity of caesarean uterine scar 4. CIx for contrast media & ionizing radiation
Equipment 1. Vaginal speculum: Cusco bivalve speculum
2. Vulsellum forceps
3. Cannulation:
a) Foley catheter 8Fr
b) Leech-Wilkinson catheter
c) HSG balloon catheter 5Fr or 7Fr
Contrast LOCM-300, 10-20 mls
Preparation HSG usually performed on D10-12 menses (or 2days after bleeding stops), risk of contrast intravasation after D12
Abstain from intercourse, from D1 menses till day of examination
NBM for 6hrs, not necessarily, but practiced in HUKM in fear of contrast intravasation
Technique - Prelim: Coned PA view of pelvis
- Lithotomy position
- Clean & drape
- Insert vaginal speculum, inspect & clean the vagina & cervix
- Prefill the catheter wt CM (to expel air bubbles)
Insert catheter into cervical canal, inflate balloon wt 1-2 mls water (Foley catheter)
Remove instrumentation
- Patient change to supine position, without lifting the back from couch
- Inject CM, screening & spot films taken
a) During filling of uterus - PA
- Early, mid & full
b) During filling of tubes - PA
- Isthmus & ampullary phases
c) Peritoneal spillage - PA
- May need to change to oblique position,
to avoid contamination of CM from the side of spillage
d) Cervical canal - PA
- During removal of catheter
- IV / IM Buscopan or Glucagon may be required to relieve spasm (Opioids can cause spasm)
Aftercare 1. PV bleed for 1-2 days
2. Lower abdominal pain up to 2wks
Complication 1. Pain, due to Predisposing Fc of contrast intravasation:
a) Using vulsellum forceps 1. Timing of procedure near menstruation
b) Insertion of catheter 2. Timing of procedure following curettage
c) Uterine distension 3. Uterine anomalies (uterine ca, infection, fibroid)
d) Tubal distension, proximal to a block 4. Direct trauma to endometrium
e) Peritoneal irritation following spillage of CM, up to 2wks 5. Tubal occlusion causing high pressure
2. Bleeding
3. Transient nausea, vomiting, headache
4. Infection
5. Venous intravasation of CM → Lace-liked pattern within uterine wall
6. Allergic reaction, d/t intravasation of CM
7. Abortion
1. Uterine fundus
2. Ostium of fallopian tube
3. Fallopian tube
4. Uterine cavity
5. Cervical canal
6. Fimbriae
7. Vagina
8. Catheter
Din XJ
128
Venous intravasation Venous intravasation
Arcuate uterus Septate uterus
Bicornuate uterus Unicornuate uterus
Uterine didelphys Air bubbles
Din XJ
129
E. Genitography
Ambiguous external genitalia 1. CIx for contrast media & ionizing radiation
Contrast LOCM-300, 3-4 mls
Preparation None
- Clean & drape
- Examine perineal area, to determine presence of
a) Single wide cloanal opening
b) More than one orifice
- CM injection:
a) Single wide cloanal opening - Insert a soft rubber acorn (prefilled wt contrast) to the opening
- Inject CM 3-4 mls, while screening
b) More than one orifice Perform as in cystography
- Acquire images (from screening, no spot films): AP & lateral views
Din XJ
130
HEAD & NECK

A. Dacryocystography, DCG
1. Epiphora (to demonstrate site & degree of obstruction) None
Equipment 1. Digital subtraction angiographic unit
2. Silver dilator & lacrimal cannula -OR-
Blunt needle 18G wt polythene catheter
Contrast LOCM-300: 0.5-2ml per side
Technique - Apply bupivacaine (Marcaine) 5% eye drops
- Massage the lacrimal sac, to express its content
- Evert the lower eyelid, locate the lower canaliculus at medial end of the lid
(only cannulate the upper canaliculus, when having difficulty wt lower canaliculus)
- Dilate the lower canaliculus wt silver dilator / blunt needle 18G
- Stretch the lower eyelid laterally to straighten the bend in canaliculus (to avoid perforation by cannula)
Insert lacrimal cannula / polythene catheter into lower canaliculus
- Inject CM (0.5-2 mls) & perform digital subtraction run (1 frame/sec)
- May compliment wt CT dacryocystography
Aftercare May require eye patch for 30-60mins
Complication 1. Pain
2. Perforation of canaliculus
3. Infection
Important valves in the naso-lacrimal apparatus:

1. Rosenmuller
2. Krause
3. Taillefer
4. Hasner
Din XJ
131
B. Sialography
1. Symptoms: Pain, swelling 1. Acute infection / inflammation
2. Sialolithiasis, sialadenitis, tumour, metastasis, Sicca (Sjogren) syndrome 2. CIx for contrast media & ionizing radiation
Equipment 1. Digital subtraction angiographic unit
2. Silver dilator & cannula -OR- Blunt needle 18G wt polythene catheter
Contrast LOCM-300: Dilution 50%, up to 2mls
Technique - Remove dentures / any radio-opaque artifacts
- Prelim film:
1. Parotid gland (Stensen) 2. Submandibular gland (Wharton)
a) AP - Head rotated 5o away from site of interest a) Infero- Useful view to show calculi
- Center at midline of lower lip superior
b) Lateral Center at angle of mandible b) Lateral Wt floor of the mouth depressed by a
wooden spatula
c) Lateral - Center at angle of mandible c) Lateral - Center 1cm ant to angle of mandible
oblique - Wt tube angled 20o cephalic oblique - Wt tube angled 20o cephalic
- Apply sialogogue (eg. citric acid, lemon, lime) in the mouth, to promote gland secretion & render the orifice visible
- Locate the orifice of the salivary gland
a) Parotid gland Adjacent to the crown of 2nd upper molar
b) Submandibular gland At the base of frenulum of the tongue
- Dilate the orifice wt silver dilator / blunt needle 18G, insert the cannula / polythene catheter into the duct
- Inject CM (up to 2 mls), stop the injection if there is pain (DO NOT overfill the duct)
- Acquire digital subtraction images
a) Immediate films - Immediately after injection of CM
- Same views as prelim films
b) Delayed (post-secretory) films - 5mins after injection of CM
- Same views as prelim films
- Can examine the duct bilaterally, simultaneously
But not separately, as opacification of 1st duct, will superimpose on the later examined contralateral duct
Complication 1. Pain
2. Damage to the orifice / Perforation of the ducts
3. Infection
Parotid: AP Lateral Lateral oblique
Submandibular: Infero-superior Lateral Lateral oblique
Din XJ
132
SPINE
A. Myelography
Patient is contraindicated / unwilling to undergo MRI 1. Raised ICP
1. Spinal cord pathology 2. Local sepsis
- Spinal stenosis 3. Distorted bony anatomy at puncture site
- Conus medullary syndrome - Severe scoliosis, severe spondysosis, RA
2. Exiting / traversing nerve root pathology - Cervical puncture: Cranio / cervical pathology
- Lumbar puncture: Recent LP
- Nerve root compression
- Cauda-equina compression 4. CIx for contrast media & ionizing radiation
Conventional myelography (rarely done alone)

compliment wt CT myelography
Contrast Intrathecal LOCM (Omnipaque)

- Total dose ≤ 3g Iodine (10mls LOCM-300mg/ml)
- Usually only requires 7-8 mls
Preparation Preferably NBM for 6hrs
May requires sedation
Technique Cervical puncture:
General principles:
- Avoid unless patients has severe lumbar ds for LP, or thoracic spinal stenosis which restrict flow of CM
- Only suitable for cervical myelography, CM is too diluted as it travels to remainder spinal canal
- Prone position
Neck in neutral / slight extension
- Identify puncture site under fluoro guidance (lateral beam): C1/C2 intervertebral space, midline
- Insert spinal needle 20G, at puncture site
- Advance it parallel to long axis of spine, till it enters subarachnoid space:
Btw laminae of C1 & C2, at junction btw middle & posterior ⅓ of spinal canal
If the needle is too far anterior → in contact wt exiting nerve root → Neck / radicular pain
- Remove stilette, observe for free flow of CSF
- Test injection of small volume of CM, to confirm position under fluoro
CM will flow anteriorly away from needle tip, to layer behind vertebral bodies
- Inject required volume of CM
- May need to tilt the table, to ensure CM flow into upper cervical & thoracic spinal canal
- Remove needle
- Spot films taken (cervical myelography):
a) AP with cranial & caudal angulation
b) Rt oblique & Lt oblique with cranial & caudal angulation
c) Lateral view (i) with soft & penetrated views (for full assessment of cervico-thoracic junction)
(ii) wt mild neck flexion (for full visualization of upper cervical cord to foramen magnum)
- Proceed wt CT myelography after 4hrs, to allow CM dilution
Lumbar puncture:
General principles:
- Approach of choice
- Safer, less complications
- Suitable for lumbar / thoracic / cervical / whole spine studies, unless presence of spinal stenosis which restrict flow of CM
Din XJ
133
- Position:
a) Lateral decubitus Preferred approach
b) Prone May be technically difficult, d/t approximation of spinous process
c) Sitting Injected CM will be diluted by CSF accumulated in sacral sac, as it descends
- Lateral decubitus wt moderate spinal flexion
Support the dependent lumbar angle wt a pillow, to keep the spine straight
- Identify puncture site wt manual palpation / fluoro guidance (lateral beam):
L2/L3, L3/L4, L5/S1 intervertebral space (1-2 spinous process above iliac crest), midline (unless canal stenosis)
- Insert spinal needle 22G, at puncture site
- Advance it wt 10-15o cranial angulation, till it enters subarachnoid space / thecal sac
(initial moderate smooth resistance, followed by sudden loss of resistance)
- Remove stilette, observe for free flow of CSF
- Inject required volume of CM (may test inject small volume of CM, to confirm position under fluoro)
- Remove needle
- Turn patient to prone position, spot films taken:
a) Lumbar myelography
(i) AP
(ii) Rt oblique & Lt oblique Usually 25o
(iii) Lateral view - Prone lateral
- Erect lateral, wt mild flexion & extension
(iv) Assessment of thoraco-lumbar - Lateral decubitus wt slight head down position
junction & lower thoracic region - Supine AP
b) Thoracic myelography
- Head-down position wt head supported on a pad (for CM to flow upwards, but not beyond foramen magnum)
- Inject ½ of CM & screen, look for spinal canal stenosis
- If no obstruction, inject the remaining CM
(i) AP
(ii) Rt oblique & Lt oblique
(iii) Lateral view
c) Cervical myelography
(i) AP with cranial & caudal angulation
(ii ) Rt oblique & Lt oblique with cranial & caudal angulation
(iii) Lateral view (i) with soft & penetrated views (for full assessment of cervico-thoracic junction)
(ii) wt mild neck flexion (for full visualization of upper cervical cord to foramen magnum)
- Proceed wt CT myelography after 4hrs, to allow CM dilution
Aftercare Brief observation
Complication 1. Nausea & vomiting (5%)
2. Headache (25%)
3. Arachnoiditis (Rarely happens wt currently used LOCM)
4. Damage to local structures: a) Cervical puncture: Vertebral artery damage
b) Cord puncture
5. Extra-thecal injection of CM
a) Extradural - Outlines the nerve roots beyond the exit foramina
b) Subdural - Happens when only the bevel of spinal needle is within subarachenoid space
- Need to repeat the test at a later date
c) Intramedullary - Slit-like collection of CM within spinal canal
Din XJ
134
Cervical myelogram
AP Lateral Lateral – Extension
Thoracic myelogram
AP Oblique Lateral
Lumbar myelogram
AP Lateral Oblique
Din XJ
135
Thoracic myelogram – AP Thoracic myelogram – Lateral
1. Intervertebral disc 6. Lateral subarachnoid space 1. Dural sac 5. Medullary cone

2. Spinal cord 7. Extradural space 2. Posterior subarachnoid space 6. Cauda equina
3. Dural sac 8. Intramedullary region 3. Spinal cord 7. Intervertebral disc
4. Nerve root sheath 9. Medullary cone 4. Anterior subarachnoid space
5. Intradural space
Lumbar myelogram – AP Lumbar myelogram – Lateral
1. Intervertebral disc 1. Dural sac 5. Iliac crest

2. Cauda equina 2. Cauda equina 6. Epidural fat
3. Spinal root in subarachnoid space 3. Intervertebral disc 7. Sacrum
4. Nerve root sheath 4. Intervertebral foramen 8. Distal end of dural sac
5. Distal end of dural sac
Din XJ
136
Lumbar myelogram – Oblique

1. Dural sac
2. Cauda equina
3. L3 nerve root sheath
4. L3/4 intervertebral disc
5. Distal end of dural sac
Lumbar discogram
B. Lumbar Discography
1. Discogenic pain without radicular signs 1. Local / distant sepsis(risk of infective discitis)
2. To confirm normal disc above/below a proposed 2. No plan for surgical intervention
surgical fusion 3. CIx for contrast media & ionizing radiation
Limited role in thoracic & cervical discogenic pain
Avoid (painful procedure with high risk of complications)
Contrast LOCM: 1ml

Preparation May require anxiolytic agents & prophylactic antibiotics
Technique Aim:
1. Inject CM into nucleus pulposus to demonstrate degenerative & herniation
2. To provoke pain, with patient is being investigated for, then to assess its response to analgesia
- Prelim: AP & lateral lumbosacral spine
- Position:
a) Lateral decubitus Lateral oblique extradural approach (Preferred approach)
b) Prone Posterior approach (needle traverses the spinal canal)
- Lateral decubitus wt moderate spinal flexion

Support the dependent lumbar angle wt a pillow, to keep the spine straight
- Clean & drape (strict aseptic technique!!), LA infiltrated
- Identify puncture site wt manual palpation / fluoro guidance (lateral beam):
Usually a hand-breadth from spinal processes
- Insert the outer discographic needle 21G, at puncture site
- Under fluoro guidance , advance it (at angle of 45-60o) towards posterior aspect of disc, till it reaches annulus fibrosus
- Insert the inner discographic needle 26G, through the 21G needle
- Under fluoro guidance, advance the inner needle into nucleus pulposus
- Inject CM (0.5-1 ml)
- Spot films taken: AP & lateral
a) During examination, at each level examined
b) At the end of procedure, after needle removal
c) Flexion & extension views
- At the symptomatic abnormal disc, inject LA to assess response
Aftercare 1. Overnight admission
2. Analgesia
Complication 1. Infective discitis → May cause permanent disc damage
2. As in lumbar puncture for posterior approach
Din XJ
137
C. Facet Joint Arthrography

1. Back pain of facet joint origin 1. Local sepsis
- Degenerated facet joint may not cause pain 2. CIx for contrast media & ionizing radiation
- Facet joint that causes pain can only be determined by
facet joint injection with LA
- Arthrogram performed is for visualization of needle position,
not for pathological anatomy
Contrast LOCM: 0.1-0.2 ml
Preparation May require anxiolytic agents
Technique - Prone oblique position, with interest side raised
- Identify facet joint, under fluoro guidance
- Insert spinal needle 22G, advance perpendicularly to facet joint, till it reaches the joint
A sudden ‘give’ indicates that capsule is penetrated
- Inject CM to confirm position → Immediate opacification of superior & inferior recess
- Inject Marcaine 0.5% 1ml into facet joint
- Observe response for 24hrs
- Both joints at each level should be studied simultaneously
Should not examine >1 level each session
B. CT-Guided Vertebral Biopsy

1. Vertebral neoplasia / infection 1. Bleeding tendency
2. Disc infection 2. Suspected highly vascular lesion
(aneurysmal bone cyst, renal tumour mets)
3. Local sepsis
Needle Trephine needle (Jamshidi set is recommended)
Preparation May require anxiolytic agents
Technique - Prone position
- Puncture site:
a) Lumbar region 8cm from midline
b) Thoracic region 5cm from midline
- Insert biopsy needle , advance btw 30-45o to sagittal plane, till it reaches the cortex
Right side Aim at 4 o’clock of vertebral body / disc
Left side Aim at 8 o’clock of vertebral body / disc
- Advance the trocar & cannula through the cortex, then remove trocar
- Advance the cannula 1cm further in, then twist the needle firmly to severe the specimen
- Withdraw the cannula back to cortex, angulate & reenter, to obtain at least 2 cores of bone
- Remove the needle, while applying suction by syringe attached
- Push out the specimen by inserting the plunger
Aftercare 1. Overnight admission
2. Analgesia
Complication Pneumothorax / haemothorax (for thoracic approach)
Din XJ
138
MUSCULOSKELETAL SYSTEM (ARTHROGRAPHY)

1. General principles:
- Injection of CM directly into the joint, under US (HUKM) or fluoroscopic (HKL) guidance
- For assessment of articular structures
2. Types of arthrography:
a) Conventional arthrography Rarely done, largely replaced by CT / MR arthrography
b) CT arthrography To assess bone & joint (exp trauma, bone tumour& infection)
c) MR arthrography To assess articular structures (synovium, capsule, labrum, meniscus, ligament), cartilage, muscle, tendon
3. Contrast media used:
a) Conventional arthrography (i) Positive contrast: LOCM
(ii) Negative contrast: Air
b) CT arthrography LOCM
c) MR arthrography (i) Direct arthrography: Intra-articular Gadolinium-DTPA
(ii) Indirect arthrography: IV Gadolinium-DTPA
Indications Diagnostic: Therapeutic:

1. Intra-articular structures (cartilage, labrum, tendon) 1. Pain block
2. Trauma (capsule, meniscus, ligament, tendon injury) - To confirm pain source
3. Loose body - Bupivacaine + Steroids
4. Para-articular mass 2. Distension therapy in adhesive capsulitis (frozen shoulder)
a) Para-articular cyst (popliteal cyst, iliopsoas bursa) 3. Intra-articular chemical therapy
b) Para-articular soft tissue mass a) Hyaluronic acid (OA)
(synovial osteochondromatosis, myositis ossificans) b) Fibrinolytic agents (chronic RA)
5. Prosthesis assessment (loosening, infection) c) Radioactive synovectomy
Contra-Ix 1. Local sepsis
2. CIx for contrast media / ionizing radiation / MRI
Contrast Conventional & CT arthrography MR arthrography
- Agent: LOCM 100-150mg iodine / 100mls - Agent: Diluted gadolinium-DTPA wt NS (1:100)
- Volume: - Cocktail:
Single contrast Double contrast Gadolinium-DTPA 0.1 ml
a) Shoulder 15 ml 15ml + 12ml air LOCM-200 5 ml
b) Elbow 6 ml 0.5ml NS 15 ml
+ 6-12ml air Lignocaine 1% 10 ml
c) Wrist 3 ml * In HUKM, under US guidance, LOCM is not used
d) Hip 8 ml
- Volume:
e) Knee 4 ml 4ml + 40ml air
a) Shoulder 15 ml
f) Ankle 4 ml
b) Elbow 6 ml
c) Wrist 3 ml
d) Hip 8 ml
e) Knee 4 ml
f) Ankle 4 ml
Preparation None
Technique - Patient positioning
- Prelim image
- Insert needle into joint space, under fluoroscopic guidance
- Aspirate for synovial fluid
- Test injection of small volume of CM, to confirm position
a) Correct position CM stream away from needle tip ard the joint (dilution of CM)
b) Incorrect position CM remain in a diffuse cloud ard needle tip
- Inject full volume of CM
For MR arthrography, ensure that air bubbles are expelled as they create artifacts
- Remove the needle, gently manipulate the joint to distribute the CM
- Acquire AP & lateral images
- Proceed wt
a) Conventional / CT within 30mins after injection (as CM is being absorbed)
b) MR Arthrography Immediately
Aftercare Joint pain for 1-2 days
Complication 1. Allergic reaction, d/t CM 5. Trauma to adjacent structures (nerve, vessels)
2. Chemical synovitis 6. Infection
3. Pain 7. Vasovagal reaction
4. Capsular rupture
Din XJ
139
A. Shoulder Arthrography
- Position: Supine
Arm of interest adducted & external rotated, palm facing up
- Identify & mark the injection site under fluoro guidance: 1cm inferior & 1cm lateral, to coracoid process
- Clean & drape
- Puncture injection site wt green needle (21G), infiltrate lignocaine 1%, exchange to syringe wt CM
- Advance needle into joint space, aiming for cortex of humeral head, till it reaches the bone
Right side Aim at 4 o’clock of femoral head
Left side Aim at 8 o’clock of femoral head
- Proceed wt conventional / CT / MRI, within 30mins after injection (as CM is being absorbed)
B. Elbow Arthrography
- Position: Sit next to table

Elbow of interest rests on table, flexed wt lateral aspect facing up
- Identify & mark the injection site under fluoro guidance: Btw radial head & capitellum
- Clean & drape
- Puncture injection site wt blue needle (23G), infiltrate lignocaine 1%, exchange to syringe wt CM
- Advance needle into joint space, vertically down
Din XJ
140
C. Wrist Arthrography
(i) Radio-carpal joint

Forearm of interest rests on table, in prone position
Wrist supported over a wedge, in slight flexion
- Identify & mark the injection site under fluoro guidance: Btw radius & lunate
- Clean & drape
(ii) Mid-carpal joint

Forearm of interest rests on table, in prone position
Wrist supported over a wedge, in slight flexion & ulnar deviation
- Identify & mark the injection site under fluoro guidance: Midpoint of scapho-capitate joint
- Clean & drape
Din XJ
141
D. Hip Arthrography
- Position: Supine
Leg of interest extended & internal rotated
- Identify & mark the injection site under fluoro guidance: Midpoint of intertrochanteric line
- Clean & drape
- Puncture injection site wt spinal needle (20G), infiltrate lignocaine 1%, exchange to syringe wt CM
- Advance needle into joint space, vertical-supero-laterally,
till it reaches femoral neck, immediately below the junction of femoral head & neck laterally
- Acquire images
Adult AP
Lateral
Paeds AP
Frog lateral
Abduction & internal rotation
Maximum abduction
Maximum adduction
Push / pull views to demonstrate instability
E. Knee Arthrography
- Position: Supine (medial or lateral approach)

- Identify & mark the injection site under fluoro guidance: 1-2cm posterior to midpoint of patella
- Clean & drape
- Advance needle into joint space, angle slight anteriorly, till it reaches posterior surface of patella
(Horizontal approach may penetrate the infra-patellar fat pad, causing extra-articular injection)

Din XJ
142
F. Ankle Arthrography
- Position: Lateral
Ankle of interest in plantar-flexion
- Identify & mark the injection site under fluoro guidance: Dorsal (anterior) surface, midpoint of 2 malleoli
- Clean & drape
- Advance needle into anterior joint space
Din XJ
Chapter 5 ANGIOGRAPHY
143
GENERAL PRINCIPLES OF ANGIOGRAPHY

Patient Preparation
1. Major procedure: Admission
Minor procedure: Daycare may be sufficient
2. Explanation & consent
3. Blood Ix:
a) FBC TRO anemia & thrombocytopenia
→ May require transfusion before procedure
b) RP To assess renal function
→ May require NAC / HD before procedure
c) PT / APTT / INR TRO bleeding tendency
→ May require transfusion before procedure
4. NBM for 6hrs
Equipment for puncture

1. Needle
a) Seldinger technique - Outer blunt cannula
(Double-wall puncture) - Central stilette
- Inner needle
b) Modified Seldinger technique Simple needle (without stilette),
(Single-wall puncture) wt lumen wide enough to accommodate the guidewire
2. Guidewire
- Consists of:
a) Central cores - Consists of 2 central cores of straight wire
- 1 central core wire is secured at both ends
- Another 1 is secured at 1 end, but terminates 5cm from the other end (flexible end)
b) Surrounding coiled wire spring - To bind the central cores together
- 2 ends of the guidewire are sealed with solder
c) Coating (i) Polyethylene coating
(ii) Additional Teflon (polytetrafluoroethylene, PTFE) coating
→ ↓ Friction, but ↑ thrombogenicity
(iii) Hydrophilic coating (Glide wire)
→ ↓ Friction, require frequent lubrication wt NS
- Types of guidewire:
Category Examples Guidewire Usage
a) Stiff Amplatz (Blue) Urology procedures
b) Semi-stiff Lunderquist Urology procedures

Biliary procedures
c) Hydrophilic (i) Roadrunner Cerebral angiogram

(Glide wire) (White)
(ii) Terumo (Black)
Din XJ
144
3. Introducer sheath
- To facilitate the manipulation of catheters
- When frequent catheter exchanges is anticipated / required
4. Catheters
- Material: Polyurethane / polyethylene
- Consists of: End hole, side holes, performed curves, Luer lock connector (at the end)
- Types of catheter:
Flush catheters
a) Straight pigtail End holes: 1
Side holes: 10-12
- For arch aortogram
- During removal,
guidewire is inserted to
straighten catheter tip,
to ↓ risk of intimal damage
b) Straight End holes: 1

Side holes: 10
c) Gensini End holes: 1

Side holes: 4
Cerebral catheters
a) Vertebral End holes: 1
Side holes: 0
b) Simmons (Sims) / End holes: 1

Sidewinder Side holes: 0
c) JB 2 End holes: 1
Side holes: 0
Din XJ
145
d) Headhunter End holes: 1

Side holes: 0
e) MANI End holes: 1

Side holes: 0
Cardiac & Coronary catheters

a) Cournand
(Pressure measurement in
cardiac angiogram)
b) Pigtail End holes: 1

Side holes: 6
(Cardiac angiogram)
c) National Institute of End holes: 0

Health, NIH Side holes: 4 or 6
(Cardiac angiogram)
d) Amplatz End holes: 1

Side holes: 0
(Coronary angiogram)
e) Judkins End holes: 1

Side holes: 0 or 2
(Coronary angiogram)
Din XJ
146
Femoral-Visceral catheters
a) Simmons (Sims) / End holes: 1
Sidewinder Side holes: 0
b) Cobra End holes: 1

Side holes: 2
c) J-curve catheters End holes: 1

Side holes: 0
d) Biliary ring catheter End holes: 1

- For biliary drainage Side holes: Multiple
e) Robert’s uterine catheter
Visceral (anterior) catheters – Liver catheters

a) Rosch hepatic
b) Yashiro End holes: 1

Side holes: 0
Din XJ
147
Approach of puncture
1. Relative contraindications:
a) Bleeding tendency
b) Aneurysm / pseudo-aneurysm at puncture site
c) Severe atherosclerosis of artery proximal to punctured artery
d) Local soft tissue infection
e) Ehlers-Danlos syndrome (fragile vessel wall)
f) Severe HPT
2. Techniques of puncture
a) Seldinger technique - Both walls of vessel are punctured (through-and-through)
(Double-wall puncture) - Stilette removed
- Needle withdrawn till its tip within the lumen of vessel
↓ Risk of intimal dissection - Guidewire inserted through needle
- Needle removed
- Introducer sheath / catheter threaded over the guidewire
- Guidewire removed
b) Modified Seldinger technique - Single wall of vessel is punctured, needle tip (18G) within the lumen of vessel
(Single-wall puncture) - Guidewire (J-tip) inserted through needle
- Needle removed
↑ Risk of intimal dissection - Introducer sheath / catheter threaded over the guidewire
- Guidewire removed
3. Sites of puncture
a) Femoral artery - Supine position, clean & drape, LA infiltrated
- Usually right side is chosen (unless contraindicated or failed cannulation)
- Locate puncture site:
(i) Clinically - Locate pulsation of femoral artery, inferior to inguinal ligament
- Femoral art continues as ext iliac art superior to inguinal lig
Haemostasis may be difficult to secure by manual compression
(ii) Fluoro guidance - Locate middle ⅓ of femoral head
(iii) US guidance - Femoral art is lateral to femoral vein, pulsatile, non-compressible
- Make a small incision, puncture via Seldinger / modified Seldinger technique
- Obtain good pulsatile blood flow (to indicate satisfactory puncture)
Causes of poor flow: Femoral vein puncture, arterial stenosis, hypotension
- Insert guidewire through needle, intermittent screening to assess position
Femoral art puncture Femoral vein puncture
- Bright-coloured blood - Dark-coloured blood
- Good pulsatile blood flow - Non-pulsatile blood flow
- Guidewire on the left side (aorta) - Guidewire on the right side (IVC)
- CM flow towards periphery - CM flow towards the heart
- Opacification of art branches by CM - No opacification of branches seen
- Remove needle, when guidewire is within thoracic aorta
- Thread introducer sheath / catheter over the guidewire
- Remove guidewire, when catheter tip is at the desired site
- At the end of procedure, remove introducer sheath / catheter
- Manual compression at puncture site for 5-10 mins
b) Brachial artery ↑ Incidence of complications, avoid unless femoral approach is not possible
- Arm in supination
- Location of puncture:
(i) Locate pulsation of brachial artery
(ii) 10cm above elbow
c) Axillary artery ↑ Incidence of complications, avoid unless femoral/brachial approaches are not possible
- Arm in full abduction
- Location of puncture: Just distal to axillary fold
d) Radial artery
Din XJ
148
Catheter Puncture approach Tip of catheter parked at

Arch / Ascending 1. Pigtail Femoral art 1-3cm above aortic valve
aortogram 2. Gensini
3. NIH
Flush aortogram Pigtail Femoral art Proximal to renal vessels (T12)
Cerebral angio 1. Vertebral Femoral art

a) CCA 2. Simmons (Sims) / Sidewinder CCA – Before branching (C4)
b) ICA 3. Head hunter ICA – C2
c) ECA 4. JB 2 ECA – C4
d) Vertebral artery 5. MANI
Spinal artery
Cardiac angio 1. Cournand Rt heart: Femoral vein

2. Pigtail Lt heart: Femoral art
3. NIH
Coronary angio 1. Judkins Radial / brachial / femoral art Tip of ostium of coronary art
2. Amplatz
Pulmonary angio 1. Pigtail Rt femoral vein 1-3cm above pulmonary valve
2. NIH
Coeliac axis 1. Simmons (Sims) / Sidewinder Femoral art Coeliac axis (T12/L1)
2. Cobra
SMA 1. Simmons (Sims) / Sidewinder Femoral art SMA (L1)
2. Cobra
IMA 1. Simmons (Sims) / Sidewinder Femoral art IMA (L3)
2. Cobra
Renal artery 1. Simmons (Sims) / Sidewinder Femoral art Selective renal art (L1 / L2)
2. Cobra
Iliac artery Pigtail Femoral art
Lower limb artery 1. Pigtail Brachial / axillary / femoral art
2. Simmons (Sims) / Sidewinder (Retrograde vs antegrade)
Contrast media & flow rate

Contrast volume, mls Flow rate, mls/sec PSI Frame rate, f/sec
Arch / Ascending 30 – 40 15 – 20 600 6
aortogram
Flush aortogram 40 – 50 20 – 25 600 6
Cerebral angio 12
CCA 12 6 300 2 (VFR)
ICA 10 5 300 2 (VFR)
ECA 4 2 300 2 (VFR)
Vertebral artery 6 3 300 2 (VFR)
Spinal artery 14 6 300 2 (VFR)
Cardiac angio 40 20
Coronary angio 10 Hand inject
Pulmonary angio 40 20
Coeliac axis 36 6
SMA 42 7 600 6
IMA 10 4 or hand inject
Renal artery 10 5 300 2 (VFR)
Iliac artery 20 10 600 6
Lower limb artery
a) 1 limb 20 5
b) 2 limbs 50 15
Roadmap 10 5 300 -
3D Rotational 18 2.5 300 -
XPER CT 22 1 300 -
Din XJ
149
Aftercare
1. Bed rest for 4-6hrs (femoral art puncture)
2. Monitor puncture site for bleeding / haemorrhage
3. Monitor vital signs
Complications
2. Infections
a) Infection at puncture site
b) Bacteraemia / Sepsis
3. Damage to local structures

a) Femoral nerve palsy, usually transient
b) Brachial plexus injury
4. Haemorrhage / haematoma
- Incidence:
Small haematomas 20%
Large haematomas 4%
Haematoma requiring transfusion / surgery 0.5%
- Risk factors (↑ by):
a) Femoral artery puncture
b) Large catheters
c) Frequent catheter exchanges
d) Use of heparin / anti-thrombolytic agent / antiplatelet
e) Inadequate manual compression on puncture site
5. Pseudo-aneurysm (0.2%)
- Causes: Communication btw arterial lumen, wt a cavity bounded by haematoma
- Risk ↑ by: Puncture below bifurcation of common femoral artery
6. Arterio-venous fistula (0.1%)

- Risk ↑ by: Puncture below bifurcation of common femoral artery (artery & vein lie closely together)
7. Arterial dissection
- Causes: Entry of puncture needle / guidewire / catheter / CM, into subintimal space
- Risk factors (↑ by):
a) Puncture needle / technique - Employ Seldinger technique (Double-wall puncture)
- Avoid using single-wall needle wt long bevel
b) Guidewire - Ensure the flexible end of guidewire is entered 1st, not the other end
c) Catheters - Use catheter wt multiple side holes
- Gentle manipulation of catheters
- Always insert guidewire to straighten the pigtail catheter tip, before removal
d) CM - Small volume of manual test injection of CM, before pump injection
8. Arterial thrombus
- Causes:
a) Stripping of thrombus from catheter wall
b) Thrombus formation following trauma to vessel wall
- Risk factors:
↑ by: ↓ by:
a) Guidewires wt additional Teflon coating a) Heparin-bonded guidewires
b) Polyurethane catheters (rough surface) b) Heparin-bonded catheters
c) Large catheters c) Flushing wt heparinized saline
d) Frequent catheter exchanges
e) Prolonged procedure
f) Inexperience radiologist
Din XJ
150
9. Embolism
a) Peripheral embolism (0.5%)
- Causes:
(i) Stripping of thrombus from catheter wall
(ii) Stripping of thrombus formed following trauma to vessel wall
(iii) Dislodged atheromatous plaques
- Sequelae:
(i) Emboli to small artery → Resolve spontaneously
(ii) Emboli to large artery → May need catheter aspiration thrombectomy / surgical embolectomy
b) Air embolism
- Causes: Improper handling of instruments
- May be fatal in coronary / cerebral arteries
- Risk factors (↓ by):
(i) Ensure all connectors are tight
(ii) Always suck back when syringe is connected to catheter
(iii) Ensure air bubbles are expelled from syringe, before injection
(iv) Keep the syringe vertical, when injecting
c) Cotton fibre embolism
- Causes:
(i) Syringe are filled from a gauze pad
(ii) Guidewire is wiped wt dry gauze
- Risk factors ↓ by: Separate bowls of saline for flushing & wet gauze
10. Instrumental-related
a) Guidewire breakage
- Usually involve the 5cm from the tip (flexible end)
b) Catheter knotting
- More likely during angiography of complex congenital heart disease
- Treatment:
(i) Non-surgical reduction of catheter knots
(ii) Surgical removal
c) Catheter impaction
- Signs of catheter impaction:
(i) Sound of sucking air upon removal of guidewire
(ii) Poor back-bleeding from catheter
(iii) Rapid wash-out of CM after a selective injection
- Sequelae: Ischaemic pain (esp. coronary & mesenteric arteries)
Din XJ
151
CARDIOVASCULAR SYSTEM
HEART
A. Cardiac Angiography / Angiocardiography
1. Congenital heart disease (ASD, VSD, PDA) 1. No absolute, bleeding tendency
prior to therapeutic procedures (transcatheter closure) 2. CIx for IV contrast media & ionizing radiation
2. Congenital anomalies of great vessels
prior to therapeutic procedures
3. Myocardial disease
4. Valvular heart disease
prior to therapeutic procedures (balloon valvuloplasty)
5. Assessment of ventricular function
Diagnostic angiocardiography has been replaced by
echo, CT, MRI & radionuclide ventriculography
Equipment 1. Digital fluoroscopy wt angiography facility
2. Pump injector
3. Catheter:
a) For pressure measurement: Cournand catheer
b) For angiocardiography: Pigtail / NIH catheter
Contrast LOCM-370: 40 mls, 20 mls/sec
Normal blood Ix: FBC, RP, PT/APTT
Technique - Supine position, clean & drape, LA infiltrated
- Puncture site (modified Seldinger technique):
a) Rt heart structures & pulm art Femoral vein / Rt antecubital vein / Rt basilic vein
(Avoid cephalic vein d/t difficult passage at clavi-pectorial fascia)
b) Lt heart structures & aorta Adult: Femoral artery
Paeds: Femoral vein → Patent foramen ovale → Lt heart
- Place tip of catheter into appropriate positions & perform angiographic runs
Contrast: 30-40 mls, 15-20 mls/sec
- Image acquisition at 30 frames/sec
a) 4-chamber / Hepatoclavicular / - Lateral beam ∟ long axis of the heart
40o-cranial 40o-LAO view - Lateral beam angled 40o cranially
to ║ line connecting atrial septum & post ventricular septum
b) Long axial oblique / - Lateral beam ∟ long axis of the heart
Long axial 20o -RAO view - Lateral beam angled 20o cranially
- Remove sheath, compression

Aftercare 1. Bed rest for 4-6hrs (femoral art puncture)
Complication 1. General complications of CM
2. General complications of angiography
Din XJ
152
B. Coronary Arteriography
1. IHD 1. No absolute, bleeding tendency
2. Congenital heart disease, prior to surgery 2. CIx for IV contrast media & ionizing radiation
3. Valvular heart disease, prior to surgery
4. After revascularization procedure
5. Therapeutic percutaneous coronary intervention
(Balloon angioplasty & stenting)
2. Pump injector
3. Catheter: Judkins / Amplatz coronary artery catheter
Contrast LOCM-370: 8-10 mls, hand inject for each projection
- Puncture site (modified Seldinger technique): Radial / brachial / femoral artery
- Place tip of catheter at tip of ostium of coronary art & perform angiographic runs
Contrast: 8-10 mls, hand inject
- Image acquisition at 30 frames/sec
a) RCA 30o RAO, 45oLAO, 45oLAO / 20o cranial
b) LCA 30o RAO, 10o RAO, 60oLAO, 4-chamber view
Complication 1. Arrhythmias
2. Ostial dissection by catheter
Aortogram RCA RCA
LCA LCA LCA
Din XJ
153
ARTERIAL SYSTEM
C. Arch / Ascending Aortography
1. Preliminary to endovascular intervention 1. No absolute, bleeding tendency
2. Aortic lesions (aneurysm, dissection, trauma) 2. CIx for IV contrast media & ionizing radiation
3. Lesions of the major vessels (atheroma)
4. Aortic regurgitation
5. Congenital heart disease (coarctation of aorta)
Diagnostic aortography has been replaced by
echocardiography, CT & MRI
2. Pump injector
3. Catheter: Pigtail / Gensini / NIH
Contrast LOCM-370: 40mls, 20 mls/sec
- Puncture site (modified Seldinger technique): Femoral artery
- Place tip of catheter at 1-3 cm above aortic valve
- Small volume of manual test injection of CM, before pump injection (to ensure catheter tip is not in coronary art)
- Perform angiographic (digital subtraction) runs
- Image acquisition at 20-30 frames/sec, PA & RPO view (to open out aortic arch)
Din XJ
154
D. Arteriograpy of Upper Limb

1. Thoracic outlet syndrome 1. No absolute, bleeding tendency
2. Raynaud’s disease 2. CIx for IV contrast media & ionizing radiation
3. AVM
4. Trauma
Diagnostic arteriography has been replaced by
CTA & MRA
2. Pump injector
3. Catheter: Pigtail or Simmons (Sims) / Sidewinder
Contrast LOCM-370
- Place tip of catheter at selected artery
Left subclavian arteriogram Left axillary arteriogram Left brachial arteriogram Left radial / ulnar arteriogram
Din XJ
155
E. Arteriograpy of Lower Limb

1. Preliminary to endovascular intervention 1. No absolute, bleeding tendency
2. Peripheral vascular disease 2. CIx for IV contrast media & ionizing radiation
3. AVM
4. Trauma
Diagnostic arteriography has been replaced by
CTA & MRA
2. Pump injector
3. Catheter: Pigtail or Simmons (Sims) / Sidewinder
Contrast LOCM-370:
a) 1 limb: 20 mls, 5 mls/sec
b) 2 limbs: 50 mls, 15 mls/sec
- Puncture site:
Approach Catheter Tip of catheter
1 limb a) Antegrade puncture at ipsilateral femoral art Femoral art & below
b) Retrograde puncture at contralateral femoral art Sidewinder Common iliac / ext iliac / femoral
art
2 limbs a) Brachial / axillary art Proximal to
b) Femoral art Pigtail aortic bifurcation
- Perform angiographic (digital subtraction) runs:
1 limb 20 mls, 5 mls/sec
2 limbs 50 mls, 15 mls/sec
Iliac artery Femoral artery Popliteal artery
Posterior tibial, anterior tibial & peroneal arteries Plantar arteries
Din XJ
156
F. Percutaneous Transluminal Angioplasty / Balloon Angioplasty

1. Dilatation of partially stenosed vessels 1. No absolute, bleeding tendency
2. Recanalization of occluded vessels 2. CIx for IV contrast media & ionizing radiation
Preceded by diagnostic angiography
Equipment 1. Digital fluoroscopy wt angiography facility (preferably with road-map function)
2. Pump injector
3. Guidewire: Hydrophilic guidewire may be helpful to pass through tight stenosis
4. Catheter:
a) Angiographic catheter: Straight Polyethylene / Teflon
b) Dilatation catheter: Gruntzig double-lumen balloon dilatation catheter / Van Andel dilatation catheter
Contrast LOCM-370
- Preceding diagnostic angiograms
- Insert guidewire, pass its tip beyond the stenotic segment
- Remove angiographic catheter
- Insert dilatation catheter over the guidewire, across the stenotic segment
Remain the guidewire across the stenotic segment, until the procedure is completed
- Inject Heparin 3,000-5,000u
- Distend the dilatation catheter (~ 7 atmosphere for 1 min)
- Perform post-dilatation angiographic runs (may need to repeat the procedure if residual stenosis remains)
Complication 1. Perforation of artery
2. Embolism of artery distal to the stenotic segment
Catheter-directed Arterial Thrombolysis

Indications Indications: Absolute contraindications: Relative contraindications:
1. Arterial thrombosis 1. Recent stroke (< 2mths) 1. Recent major trauma
2. Arterial embolism 2. Recent head trauma 2. Recent major surgery
3. Recent neurosurgery 3. Brain tumour
Responsive in acute episode (< 24hrs)
4. GI bleed 4. Severe HPT
2. Pump injector
3. Catheter
4. Thrombolytic agents: Recombinant tissue plasminogen activator (rt-PA)
Contrast LOCM-370
- Preceding diagnostic angiograms
- Insert guidewire, pass its tip through the thrombus
- Place catheter tip at proximal end of thrombus
- Remove guidewire
- Inject bolus rt-PA
- Leave catheter in-situ (and secured) for infusion of rt-PA
- Patient returned to ward for close observation (for signs of haemorrhage) & monitoring of clotting factors
- Perform check angiogram via same catheter (after several hrs) to assess progression
- rt-PA infusion continued / discontinued
Aftercare 1. Close observation (for signs of haemorrhage)
2. Monitoring of clotting factors
Complication 1. Bleeding complications (haemorrhagic stroke, upper GI bleed)
Din XJ
157
G. Vascular Embolization
1.To control bleeding 1. No absolute
2. To ↓ / stop blood flow to AVM /aneurysm / fistulae 2. CIx for IV contrast media & ionizing radiation
3. To ↓ / stop blood flow to mass / organs
(tumour embo, uterine fibroid embo, treat priapism)
2. Pump injector
3. Catheter: Should not have side holes which may promote clumping of particles, causing blockage
4. Embolic material:
a) Liquid Alcohol, squid, quick-setting glues, polymer
b) Particulate Gel-foam, polyvinyl alcohol, autologous clot
c) Solid Coils, detachable balloons
* All of above materials are permanent, except gel-foam & autologous clot
Contrast LOCM-370
Technique - Selective catheterization of lesion
- Inject embolic material slowly & intermittently, to prevent reflux of embolic material
Aftercare 1. Observe tissue distal to occluded vessel, for ischaemia
2. Bed rest for 4-6hrs (femoral art puncture)
Complication 1. Misplacement of emboli
2. Propagation of thrombosis
3. Post-embolization syndrome, d/t toxins released by infarcted tissue → Fever, pain, ↑ WBC
Din XJ
158
VENOUS SYSTEM
H. Central Venography: Inferior Vena Cavography
1. Preliminary to transvenous intervention (IVC filter) 1. No absolute, bleeding tendency
2. IVC stenosis / occlusion / infiltration 2. CIx for IV contrast media & ionizing radiation
3. Congenital abN of venous system (Double IVC)
2. Pump injector
3. Catheter
Contrast LOCM-370: 30-40 mls, 15-20 mls/sec
- Puncture site (modified Seldinger technique): Femoral vein (preferably under US guidance)
- Place tip of catheter at proximal to IVC bifurcation & perform angiographic (digital subtraction) runs
- Image acquisition at 2 frames/sec, PA & RPO view (to open out aortic arch)
- Remove catheter / sheath, compression
Aftercare 1. Pressure at venopuncture site
1. Right renal vein

2. Left renal vein
3. IVC
4. Common iliac vein
5. Internal iliac vein
6. External iliac vein
Din XJ
159
I. Central Venography: Superior Vena Cavography

1. Preliminary to transvenous intervention 1. No absolute
2. Central venous stenosis / occlusion 2. CIx for IV contrast media & ionizing radiation
3. Congenital abN of venous system (Lt sided SVC)
Equipment Digital fluoroscopy wt angiography facility (with DSA function)
Contrast LOCM-370: neat, 20mls each arm
- Insert a branulla (20G) or butterfly needle (19G), into median cubital / cephalic / basilic vein at elbow (1 or 2 sides)
- Perform a digital subtraction angiographic run (1 frame/sec):
Hand inject CM 20mls into each arm simultaneously, as fast as possible
Flush in NS at the end of procedure (to chase the CM further in)
- May proceed wt venoplasty if indicated
Aftercare None
Complication 1. Haematoma
1. Internal jugular vein

2. External jugular vein
3. Cephalic vein
4. Subclavian vein
5. Left brachiocephalic vein
6. Inferior thyroid vein
7. Venous angle
8. Right brachiocephalic vein
9. Azygos vein
10. SVC
11. Pulmonary trunk
12. Right pulmonary artery
13. Left pulmonary artery
14. Infundibulum
15. Right atrium
16. Right ventricle
Din XJ
160
J. Peripheral Venography: Upper Limb

1. Venous stenosis / occlusion (DVT) 1. Local sepsis
2. SVC obstruction, follow-up central venography 2. CIx for IV contrast media & ionizing radiation
3. Oedema of unknown origin
4. Congenital abN of venous system
US is preferred, even though venograhy is the gold standard to
diagnose DVT
Equipment Digital fluoroscopy wt angiography facility
Contrast LOCM-370: 70% Dilution, 10mls each arm
- Insert branulla (20G) or butterfly needle (19G), into median cubital vein at elbow (Avoid cephalic vn as it bypass axillary vn)
- Hand inject CM 10mls, spot films taken / perform a digital subtraction angiographic run (1 frame/sec)
- Flush in NS at the end of procedure (↓ Risk of phlebitis)
Aftercare None
Upper Limb Lower Limb
K. Peripheral Venography: Lower Limb

1. Venous stenosis / occlusion (DVT) 1. Local sepsis
2. Vericose veins (to demonstrate incompetent perforators) 2. CIx for IV contrast media & ionizing radiation
3. Oedema of unknown origin
4. Congenital abN of venous system
US is preferred, even though venograhy is the gold standard to
diagnose DVT
Contrast LOCM-370: 70% Dilution
Technique - Supine position, tilted 40o head up (to delay transit time of CM)
- Apply tourniquet just above ankle (to occlude superficial venous system, but this may also occlude ant tibial veins)
- Insert a branulla (20G) or butterfly needle (19G), into vein on the foot dorsum
- Hand inject CM 40mls, spot films taken
- Hand inject another 20mls, while slightly tilting to head-down position (to delay transit time of CM) & performing:
a) Valsalva manoeuvre
b) Manual pressure over femoral vein
- Spot films taken after 2-3 sec after release of manoeuvre
- Position:
a) Calf AP, Rt oblique, Lt oblique
b) Popliteal veins AP
c) Common femoral veins AP
d) Iliac veins AP
- Flush in NS at the end of procedure (↓ Risk of phlebitis)
Aftercare None
2. Pulmonary embolism, d/t dislodged embolus from DVT
Din XJ
161
L. Dialysis Fistulography
Fistulous stenosis / occlusion 1. No absolute
2. CIx for IV contrast media & ionizing radiation
Contrast LOCM-300 (May dilute to 70%)
Technique - Supine position, aseptic technique
- Apply tourniquet onto the examined arm
- Insert branulla 20G into the venous limb of the fistula / graft, wt its tip pointing towards the loop
- Tighten the tourniquet
- Hand inject CM into the fistula & perform a digital subtraction angiographic run
- May proceed wt fistuloplasty if indicated
Aftercare 1. Monitor puncture site for bleeding / haemorrhage
Complication General complications of CM
Din XJ
162
RESPIRATORY SYSTEM
A. Pulmonary Arteriography
1.Pulm embolism & other peripheral abN(AVM), 1. ↑Rt ventricle end-diastolic pressure (> 20mmHg) &
when CTPA is inconclusive ↑Pulm art pressure (> 70mmHg)
2. Pulm embolism, - ↑ Mortality rate to 2-3 %
prior to catheter-directed thrombolysis / embolectomy - Proceed wt selective pulm arteriography if needed
2. Left bundle branch block
Diagnostic pulmonary arteriogram has been replaced - Rt heart catheterization may induce complete heart block
by CTPA 3. Bleeding tendency
2. Pump injector
3. Catheter: Pigtail / NIH catheter
Contrast IV LOCM-370: 30-40 mls, 15-20 mls/sec
- Puncture site (modified Seldinger technique): Right femoral vein
Other options (in the presence of ileo-femoral thrombus): Jugular vein, basilic vein
- Cannulate artery (pigtail / NIH catheter) & perform angiographic (digital subtraction) runs:
a) Pulm arteriogram - Place tip of catheter 1-3 cm above pulm valve
- PA view: To visualize whole lungs
40o caudal-cranial view: To visualize trunk & bifurcation of pulm arteries
b) Selective pulm arteriogram - Place tip of catheter in each main pulm artery
- Rt lung: LPO 10o, Lt lung: RPO 10o
Complication 1. Respiratory distress, major dysrhythmias
Mortality rate: 0.2 – 0.5%
Din XJ
163
Pulmonary arteriogram – AP (Arterial phase)
A. Apical branch
B. Left pulmonary artery
C. Right pulmonary artery
D. SVC
E. Lingular branch
F. Middle lobar branch of pulmonary
artery
G. Inferior lobar branch of pulmonary
artery
H. Pulmonary trunk
I. Right atrium
J. Right ventricle
K. IVC
O - Segmental arteries 1-10
Pulmonary arteriogram – AP (Venous phase)
A. Apico-posterior branch
B. Apical branch
C. Inferior pulmonary vein
D. Superior pulmonary vein
E. Common basal vein
F. Right atrium
G. Left atrium
H. Inferior basal vein
O - Segmental arteries 1-10
Din XJ
164
B. Bronchial Arteriography
Diagnosis & embolic treatment of haemoptysis 1. No absolute, bleeding tendency
(Bronchial arteries embolization, BAE) 2. CIx for IV contrast media & ionizing radiation
2. Pump injector
3. Catheter:
Contrast IV LOCM-370
- Perform an aortogram, for identification of the bronchial arteries (usually at T5 / T6 level)
- Cannulate bronchial arteries (if they arise from it) & perform angiographic (digital subtraction) runs
Embolization of bronchial arteries
Complication 1. Spinal ischamia
If the intercostal artery (which gives out medullary branch of the anterior spinal artery) shares the same origin with
the embolized bronchial artery
C. CT-Guided Lung Biopsy

1. Lung malignancies, For HPE 1. Bleeding tendency
2. Lung metastasis, for HPE 2. Respiratory problems:
3. Lung infection, for C+S a) Significant pulmonary art / venous HPT
b) Contralateral pneumonectomy
Central lesions are preferably biopsied transbronchially
c) Presence of bullae
d) Severe impairment of respiratory function
e) Plan of air travel within 6wks
3. Suspected hydatid disease
4. CIx for ionizing radiation
Contrast None
Preparation Normal blood Ix: FBC & PT/APTT
May need lung function test prior, if indicated
Technique Biopsy needle: Coaxial needle biopsy system, (to ↓ number of passes through pleura) – 18-20 G
Aftercare 1. Monitor for pneumothorax
2. Monitor puncture site for bleeding / haematoma
Complication 1. Haemoptysis(2-5 %) 4. Other very rare complications:
2. Local pulmonary haemorrhage(10%) a) Implantation of malignant cells along needle track
3. Pneumothorax (20%) b) Dissemination of infection
c) Air embolism
5. Death (0.15%)
Din XJ
165
A. Arteriography of Coeliac Axis, Superior Mesenteric & Inferior Mesenteric Artery
1. GI bleed (only demonstrable if bleeding >0.5ml/min) 1. No absolute, bleeding tendency
2. GI ischaemia 2. CIx for IV contrast media & ionizing radiation
3. Tumour embolization
4. Portal venography (CT/MR shows portal system well)
2. Pump injector
3. Catheter: Simmons (Sims) / Sidewinder or Cobra catheter
Contrast IV LOCM 320-370
- May give IV Buscopan 10-20mg to ↓ bowel movement
- Cannulate artery (Sidewinder / cobra catheter) & perform angiographic (digital subtraction) runs:
a) Coeliac axis - T12/ L1 level
- Contrast: 35 mls, 6 mls/sec
- May perform selective run for splenic, dorsal pancreatic, gastroduodenal art
b) SMA - L1 level
c) IMA - L3 level
- Patient in 30o LPO (to open the sigmoid loop)
d) Portal vein - Delayed venous phase of coeliac & SMA
Coeliac trunk (Arterial phase) Coeliac trunk (Venous phase)
SMA (Arterial phase) SMA (Venous phase)
Din XJ
166
Coeliac trunk (Arterial phase)

1. Splenic artery
2. Proper hepatic artery – Left branch
3. Right gastric artery
4. Left gastric artery
5. Proper hepatic artery – Right branch
6. Common hepatic artery
7. Coeliac trunk
8. Gastro-duodenal artery
9. Cystic artery
10. Superior supraduodenal artery
11. Right gastroepiploic artery
12. Superior pancreatico-duodenal artery
13. Inferior pancreatico-duodenal artery
(anastomose wt SMA)
Coeliac trunk (Venous phase)

1. Spleen
2. Splenic vein
3. Portal vein
4. Portal confluence
5. Junction of mesenteric vein
6. Liver
SMA (Arterial phase)

1. Middle colic artery
2. Inferior pancreatico-duodenal artery
3. SMA
4. Right colic artery
5. Jejunal arteries
6. Ileocolic artery
7. Ileal arteries
SMA (Venous phase)

1. Portal vein – Left branch
2. Portal vein – Right branch
3. Portal vein
4. Splenic vein
5. Portal confluence
6. SMV
7. Right colic vein
8. Jejunal veins
9. Ileocolic vein
10. Ileal veins
Din XJ
167
B. Portal Venography
1. Assess patency of portal venous system 1. No absolute
2. Assess patency of porto-systemic anastomosis 2. CIx for IV contrast media & ionizing radiation
3. Demonstrate anatomy of portal system before operation
2. Pump injector
3. Coeliac / SMA approach: Simmons (Sims) / Sidewinder or Cobra catheter
4. Trans-splenic approach: Longdwell needle (20G & 10cm with stilette & outer plastic sheath)
Contrast LOCM-370, 50mls
Technique Approaches for portal venography:
a) Venous phase of coeliac / SMA angiography
b) Trans-splenic approach
c) Transjugular-transhepatic approach
d) Paraumbilical vein catheterization
Venous phase of coeliac / SMA angiography

- Supine position, clean & drape, LA infiltrated
- May give IV Buscopan 10-20mg to ↓ bowel movement
- Cannulate artery (Sidewinder / cobra catheter) & perform angiographic (digital subtraction) runs:
a) Coeliac axis - T12/ L1 level
- May perform selective run for splenic, dorsal pancreatic, gastroduodenal art
b) SMA - L1 level
- Delayed (venous phase) image acquisition to demonstrate portal venous system
Trans-splenic approach
- Supine position
- Identify puncture site: Mid-axillary line, 10th – 11th intercostal space
- LA infiltrated, under US guidance
With patient suspend respiration, insert Longdwell puncture needle,
advance inwards & upwards into spleen, till 3⁄4 of needle inserted
- Remove needle & stilette, leaving the plastic canulla in-situ, patient can breathe shallowly
Observe for blood flowing back, if position is correct
- Small volume of manual test injection of CM, to ensure correct position
- Perform a digital subtraction angiographic run (1 frame/sec):
Hand inject CM 50mls in 5sec
Remove cannula as soon as possible, after CM injection
Complication Trans-splenic approach
1. Extra-capsular injection → Pain
2. Sub-capsular injection
3. Haemorrhage
4. Splenic rupture
5. Perforation of adjacent structures (pleura, colon)
Din XJ
168
BILIARY SYSTEM
A. Endoscopic Retrograde Cholangio-pancreaticography (ERCP)
1. Diagnostic for pt unsuitable for MRCP 1. Upper GI obstruction (oesophagus, pylorus, duodenum)
2. Assessment & therapeutic for 2. Previous gastric surgery, that prevents access to duodenum
(i) Bile duct stones 3. Severe cardiac / respiratory disease
(ii) Biliary strictures 4. CIx for IV contrast media & ionizing radiation
(iii) Ampullary lesions
(iv) Chronic pancreatitis
(v) Post-cholecystectomy
3. Ix for diffuse biliary disease (sclerosing cholangitis)
Contrast 1. Pancreas: LOCM 240-300
2. Bile ducts: LOCM-150 (to prevent obscuration of calculi)
Pre-procedure antibiotic
Technique - Endoscopic & fluoroscopic facility
- Prelim: Prone AP or LAO of upper abdomen, to assess calculi
- Sitting position
Pharynx is anaesthetized wt lidocaine spray
Sedation may be required
Introduce endoscope, till ampulla of Vater
- Prone position
Insert polythene catheter (prefilled wt CM) into ampulla
Small test injection of CM to confirm position
- Inject CM into pancreatic duct (if indicated)
Spot films taken: Prone, LPO, RPO
- Inject CM into biliary tree
Spot films taken:
a) Prone AP, LPO, RPO
b) Supine PA, LAO, RAO
Trendelenburg, to fill intrahepatic ducts
Semi-erect, to fill lower CBD & GB
- Remove endoscope, spot films taken, to assess duct obscured by endoscope
Delayed films, to assess GB & emptying of CBD
Aftercare NBM till pharyngeal sensation returns
Monitor vital signs for 6hrs
Continue antibiotics, if there is biliary / pancreatic obstruction
Complication 1. Injury d/t manipulation of endoscope (oesophagus, ampulla, proximal pancreatic duct, distal CBD)
2. Acute pancreatitis
3. Bacteraemia, septicaemia
4. Aspiration
5. Allergic / idiosyncratic reactions d/t CM
Din XJ
169
B. Intra-operative Cholangiography
Assessment of CBD, during cholecystectomy or bile duct surgery, None
to avoid surgical exploration of CBD (MRCP is preferred prior to surgery)
Contrast HOCM or LOCM-150 (to prevent obscuration of calculi): 20mls
Preparation As for surgery
Technique - Operating theatre wt II
- Cannulate cystic duct, wt catheter prefill wt CM
- Inject CM 5mls, spot film taken
- Inject CM 20mls, to demonstrate flowing of CM into duodenum, spot film taken
May give IV Glucagon / Propantheline / Amyl nitrite, to relieve spasm of sphincter of Oddi
- Le Quesne criteria for normal intra-operative cholangiogram:
a) CBD ≤ 12mm
b) No filling defects
c) The terminal narrow segment of the duct is clearly seen
d) Free flow of CM into duodenum
e) No excess retrograde filling of hepatic ducts
Aftercare As for surgery
Complication As for surgery
C. Post-operative (T-tube) Cholangiography

1. To exclude biliary tract calculi, when None
a) Intra-op cholangiogram was unsatisfactory or not performed
b) MRCP was not performed previously
2. To look for biliary leakage,
- Between D7-D10 post-op, before removal of T-tube
Before Day 7: Presence of oedema
After Day10: Risk of fistula formation
Contrast HOCM or LOCM-150 (to prevent obscuration of calculi): 20mls
Preparation None
Technique - Fluoroscopic room
- Supine position
- Drainage tube clamped, then cleaned
- Insert needle 23G (connected to 20ml syringe prefilled wt CM),
into drainage tube (btw patient & clamp)
- Inject CM while screening
- Spot films taken: PA & oblique
Aftercare None
Complication 1. Biliary sepsis, d/t CM injection under high pressure into the obstructed biliary tract
Din XJ
170
D. Percutaneous Transhepatic Cholangiography (PTC)

1. Diagnostic (rarely) 1. Bleeding tendency
2. Prior to PTBD 2. Biliary sepsis, except to control the infection by drainage
3. To place percutaneous biliary stent
4. To dilate post-op stricture
5. To remove stone
6. To facilitate ERCP
Contrast LOCM-150 (to prevent obscuration of calculi): 20 – 60 mls
Pre-procedure antibiotic: IV Cefeperazone (Cefobid) 1g
Chiba needle: Flexible 21-22G needle, 15 – 20cm long
- Supine position
- Assess puncture site under US guidance
a) Right lobe Intercostal (above 10th rib), along mid-axillary line
b) Left lobe Subcostal, to the left of xiphisternum
- Puncture wt Chiba needle (21-22G) under US guidance
Advance the needle towards liver parenchyma into intrahepatic duct, during suspended respiration
Once reaches liver parenchyma, allow shallow respiration
- Remove stilette, look for bile draining out
Connect needle to a syringe prefilled wt CM, inject CM while screening
Needle in bile duct (correct position) Contrast flows towards hilum
Needle in portal vein / hepatic artery Contrast flows towards periphery of the liver
Needle in hepatic vein Contrast flows cranially towards right atrium
- If needle is not in the duct, withdraw the needle, until its tip 2-3cm from liver capsule, make further passes
- Spot films taken: PA, LAO, RAO
- Subsequently,
a) Remove Chiba needle, if it is a diagnostic PTC
b) Proceed wt intervention procedure
Aftercare Monitor vital signs for 6hrs
Continue antibiotic for 3 days
Complication 1. Injury d/t puncture by Chiba needle
a) Puncture of extrahepatic structures (usually no serious sequelae)
b) Cholangitis
c) Bile leakage → Biliary peritonitis
d) Haemorrhage
e) Subphrenic abscess
f) Intrathoracic injection
2. Biliary sepsis, d/t CM injection under high pressure into the obstructed biliary tract
Din XJ
171
E. Percutaneous Transhepatic Biliary Drainage (PTBD)

Indications Indications: For biliary drainage Contraindications:
Only when intrahepatic ducts are dilated 1. Bleeding tendency
1. To relieve jaundice 2. Biliary sepsis, except to control the infection by drainage
2. To control biliary infection / sepsis
3. Prior to surgery
Indications: For internalization of PTBD
To facilitate internal drainage of bile:
1. Better digestion
2. ↓ Fluid loss
3. ↓ Electrolyte imbalance
Contrast LOCM-150 (to prevent obscuration of calculi): 20 – 60 mls
Pre-procedure antibiotic
Chiba needle: Flexible 21-22G needle, 15 – 20cm long
Catheter: Biliary ring catheter
- Perform a PTC (as described before) – Target the most periphery & posterior duct (most suitable for drainage)
- Followed by:
PTBD:
- Insert glidewire 0.035”, through Chiba needle, till its tip within bile duct
Remove Chiba needle, dilate the tract wt dilator
Insert sheath over glidewire 0.035” (Not practiced in HUKM)
- Insert drainage catheter over glidewire 0.035”, into hepatic ducts before obstruction (external drainage)
- Remove glidewire
- Inject CM to check the position of the catheter
- Secure catheter to the skin wt suture
Internalization of PTBD:
- Methods: Usually performed days-weeks after initial PTBD
a) Internal & external drainage via biliary ring catheter
b) Internal drainage via stent insertion
- Supine position, clean & drape
- Insert glidewire 0.035” through initial PTBD catheter
- Remove PTBD catheter, change with cobra catheter, advance glidewire & cobra catheter across the occluded segment
- Remove glidewire, change with Amplatz wire, advance Amplatz wire & cobra catheter into duodenum
- Remove cobra catheter, insert biliary ring catheter over Amplatz wire, into duodenum
Ensure that sideholes of the catheter, are proximal & distal to the occluded segment
- Remove Amplatz wire
- Inject CM to check the position of the catheter
Aftercare Monitor vital signs for 6hrs
Continue antibiotics for 3 days
Regular flushing of drainage catheter wt NS
Complication 1. Injury d/t puncture by Chiba needle
a) Puncture of extrahepatic structures (usually no serious sequelae)
b) Cholangitis
c) Bile leakage → Biliary peritonitis
d) Haemorrhage
e) Subphrenic abscess
f) Intrathoracic injection
2. Biliary sepsis, d/t CM injection under high pressure into the obstructed biliary tract
Chiba needle:
Din XJ
172
F. Hepatic Arteriography
1. To assess vascular & liver lesions 1. Bleeding tendency
2. Preliminary to hepatic artery embolization 2. CIx for IV contrast media & ionizing radiation
a) Traumatic bleeding, blood-bile fistula
TACE:
b) Benign liver tumour 1. Severe liver / renal impairment
c) Primary liver tumour (TACE) 2. Biliary obstruction
2. Pump injector
3. Catheter: Rosch hepatic / Yashiro catheter
Contrast IV LOCM 320-370
Technique Embolization of hepatic artery branches does not cause infarction, d/t dual supply of liver
→ Important to demonstrate portal vein patency before embolization
- Supine position, clean & drape, LA infiltrated
- Cannulate coeliac axis (Sidewinder / cobra catheter) & perform a portal venography (delayed venous phase) runs:
- After demonstration of portal vein patency, proceed with hepatic arteriography
- Cannulate common hepatic artery (Rosch hepatic / Yashiro catheter) & perform angiographic runs
Trans-arterial chemo-embolization (TACE):

- Inject chemotherapeutic agent (doxorubicin, cisplatin) wt an emulsifying agent, into the hepatic artery
- Followed by an embolic material (gelatin, polyvinyl alcohol, sponge)
Complication 1. General complications of CM TACE:
2. General complications of angiography 1. Liver / renal impairment
2. Cholecystitis
3. Liver abscess
4. Carcinoid crisis
Din XJ
173
A. Percutaneous Nephrostomy Tube Insertion
1. Obstructive uropathy 1. Bleeding tendency
2. Pyonephrosis 2. CIx for contrast media & ionizing radiation
3. Prior to PCNL
Contrast HOCM or LOCM-150 (to prevent obscuration of small lesions)
May need pre-procedure antibiotic
Equipment 1. Puncture needle (18G) / Coaxial needle
(Angio suite 2. Guidewire: Hydrophilic / Stiff Amplaz
wt US) 3. Drainage catheter: Pigtail catheter (8Fr for draining urine, 10-12Fr for draining pus)
Technique - Prone / oblique position with pillow placed under the abdomen, Clean & drape
- Identify puncture site: Posterior axillary line, below 12th rib
- LA infiltrated wt spinal needle, under US guidance
Insert puncture needle, advance towards mid / lower pole of kidney, into pelvicalyceal system
Lower pole of kidney Safer (↓ Risk of puncturing lung / pleura)
Brodel’s avascular line - Avascular plane btw anterior & posterior segmental branches of renal artery
- 1-2cm posterior to convex border of kidney (Mid-lateral border of kidney)
Aspirate urine to confirm position

- Insert guidewire through puncture needle, into pelvicalyceal system
Remove puncture needle, dilate the tract wt Teflon dilators
Insert pigtail catheter, till its tip within pelvicalyceal system, remove guidewire
- Inject CM while screening (Antegrade pyelourethrography, APG), spot films taken (Prone AP)
Aftercare 1. Monitor vital signs

2. Perforation of pelvicalyceal system
3. Sepsis
B. Percutaneous Renal Biopsy (Usually US-guided)

1. Renal mass 1. Bleeding tendency
2. Unexplained renal failure
Preparation Normal blood Ix: FBC, RP, PT/APTT
Equipment Bard gun with Core biopsy needle 22G
Technique - Prone / oblique position with pillow placed under the abdomen, Clean & drape
Insert core biopsy needle 22G, advance towards area of biopsy
- Make ≥ 3 passes to obtain adequate sample
- Inject Gelfoam to obliterate the tract
- Dressing
3. Sepsis
Din XJ
174
C. Antegrade Pyeloureterography, APG

1. Failed RPG 1. Bleeding tendency
a) Demonstrate pelvicalyceal system 2. CIx for contrast media & ionizing radiation
b) Demonstrate nature of obstructive lesion
2. Following nephrostomy tube insertion
Contrast HOCM or LOCM-150 (to prevent obscuration of small lesions)
Technique - Angio suite wt US
- Prone / oblique position, with pillow placed under the abdomen
- Clean & drape
Insert puncture needle, advance towards mid / lower pole of kidney, into pelvicalyceal system
Aspirate urine to confirm position
- Inject CM while screening (Antegrade pyelourethrography, APG), spot films taken
a) Prone AP
b) RPO & LPO
- May proceed wt nephrostomy tube insertion
3. Sepsis
D. Retrograde Pyeloureterography, RPG

1. Demonstrate pelvicalyceal system 1. Acute UTI
2. Demonstrate nature of obstructive lesion 2. CIx for contrast media & ionizing radiation
(Not as 1st line, but following ureteric stent insertion)
Contrast HOCM or LOCM-150 (to prevent obscuration of small lesions): 10 mls

Preparation As for surgery
Technique - Operating theatre with fluoroscopic facility
- Ureteric catheter inserted by surgeon, under GA or spinal anaesthesia
- Prelim: Supine AP Abdomen
- Inject 2-5 mls CM at:
a) Renal pelvis
b) 10cm below renal pelvis Not done if
c) Just above ureteric orifice ureteric catheter has to be left for drainage of obstruction
- Spot films taken, at each level during injection of CM
a) Supine PA
b) RAO & LAO
Aftercare 1. Monitor vital signs (post-anaesthesia)
2. May need antibiotic
Complication 1. Catheter trauma 5. Reflux (more in RPG compared with APG)
a) Mucosal injury a) Pyelotubular – Renal pelvis to collecting ducts (renal parenchyma)
b) Perforation of bladder / ureter / pelvis b) Pyelointerstitial – Renal pelvis to interstitial tissue
2. UTI, CM-induced pyelitis c) Pyelosinus – Renal pelvis to renal sinus
3. Extravasation, d/t overdistension of pelvis d) Pyelovenous
4. Allergic reaction, d/t intravasation of CM e) Pyelolymphatic
Din XJ
175
E. Renal Arteriography
1. Renal artery stenosis, prior to angioplasty / stenting 1. No absolute, bleeding tendency
2. Renal tumour, prior to embolization 2. CIx for IV contrast media & ionizing radiation
3. Renal injury (trauma, iatrogenic), prior to embolization
4. Potential renal transplant donor
Diagnostic renal arteriogram has been replaced by
MRA / CTA
2. Pump injector
3. Catheter:
a) Flush aortogram: Pigtail catheter 4Fr
b) Selective arteriogram: Simmons (Sims) / Sidewinder or Cobra catheter
Contrast 1. Flush aortogram: IV LOCM-300 40-50 mls, 20-25 mls/sec
2. Selective arteriogram: IV LOCM-300 10 mls, 5 mls/sec
- Approach:
a) Flush aortogram
- Start wt flush aortogram,
to assess normal anatomy / variants (accessory renal artery),
as selective renal arteriogram may miss lesion at origin of renal artery
- Place tip of pigtail catheter proximal to renal vessels (T12 level)
- Contrast: 40-50 mls, 20-25 mls/sec
- Perform angiographic (digital subtraction) runs: AP & oblique
b) Selective renal arteriogram
- After flush aortogram, for better assessment of renal vasculature
- Place tip of Sidewinder / Cobra catheter at the selected renal artery (L1 / L2 level)
Flush aortogram Selective renal arteriogram – Right Renal arteriogram

(Arterial phase) (Venous phase)
Din XJ
176
Renal arteriogram (Arterial phase)
1. Splenic artery
2. Arcuate arteries
3. Interlobular arteries
4. Superior segmental artery
5. Segmental arteries – Anterior branch
6. Inferior adrenal artery
7. Segmental arteries – Posterior branch
8. Middle segmental artery
9. Inferior segmental artery
10. Right renal artery
11. Left renal artery
12. Abdominal aorta
Renal arteriogram (Venous phase)
1. Interlobular vein
2. Renal vein – Superior branch
3. Arcuate vein
4. Left renal vein
5. Right renal vein
Din XJ
177
F. Renal Venography
1. Renal vein thrombosis / compression 1. No absolute, bleeding tendency
2. Renal tumour, to detect invasion of renal vein / IVC 2. CIx for IV contrast media & ionizing radiation
3. Potential renal transplant donor, to detect venous abN
4. Congenital anomalies
(congenital renal agenesis, small contracted kidney)
2. Catheter: Simmons (Sims) / Sidewinder or Cobra catheter
- Puncture site (modified Seldinger technique): Femoral vein → IVC → Selective renal vein injection
Aftercare 1. Pressure at venopuncture site
G. Iliac & Uterine Arteriography + Embolization

1.Embolization of bleeding (Post-partum haemorrhage) 1. No absolute, bleeding tendency
2. Embolization of uterine mass (tumour, fibroid) 2. CIx for IV contrast media & ionizing radiation
2. Pump injector
3. Catheter:
a) Distal aorta: Pigtail catheter
b) Iliac artery: Simmons (Sims) / Sidewinder or Cobra catheter 5-7 Fr
4. Embolic material: Polyvinyl alcohol
a) Distal aorta: 40-50 mls, 20-25 mls/sec
b) Iliac artery: 20 mls, 10mls/sec
c) Uterine artery:
- Puncture site (modified Seldinger technique): Femoral artery (contralateral retrograde approach)
- Flush aortography: To identify iliac arteries
Place tip of pigtail catheter at distal aorta
Perform angiographic (digital subtraction) runs
- Iliac arteriography: To identify uterine arteries
Change to cobra catheter, place its tip at 1-2 cm into internal iliac artery
Contrast: 20 mls, 10mls/sec
Perform angiographic (digital subtraction) runs: AP + oblique
- Selective catheterization of uterine artery
Perform angiographic (digital subtraction) runs
Inject embolic material
Perform post-embolization angiographic (digital subtraction) runs
Din XJ
178
Iliac arteries Selective left & right internal iliac arteries
Pre & Post-embolization of right uterine artery
Din XJ
179
BRAIN
A. Cerebral Angiography
1.Cerebral ischaemia 1. No absolute, bleeding tendency
2. ICB (SAH & intraparenchymal bleed) 2. CIx for IV contrast media & ionizing radiation
3. Vascular malformation (AVM, aneurysm, CCF)
4. Pre-op assessment of intracranial tumours
Equipment 1. Digital fluoroscopy wt angiography facility (with road map & DSA functions)
2. Pump injector
3. Puncture needle: 18G
4. Femoral sheath: 4-5 Fr
5. Guidewire: Terumo glidewire 0.035” (150cm)
6. Catheter:
a) Younger patient: Vertebral catheter
b) Older patient: Simmons (Sims) / sidewinder catheter or Headhunter or JB 2 or MANI
(Better torque control to pass through atherosclerotic & torturous vessel)
Contrast LOCM
May require sedation / GA (paeds or uncooperative patients)
- Perform an arch aortogram (to identify the branches of aortic arch), then proceed with selective studies:
Small volume of manual test injection of CM, before pump injection (to ensure catheter tip is not in coronary art)
Catheter tip parked at Contrast volume, mls Flow rate, mls/sec Frame rate, f/sec
a) Arch aortogram 1-3cm above aortic valve 30-40 15-20 6
b) CCA C4 (before bifurcation) 12 6 2-4
c) ICA (if indicated) C2 10 5 2-4
d) ECA (if indicated) C4 4 2 2-4
e) Vertebral art 6 3 2-4
- Image acquisition:
a) Arch aortogram: PA & RPO view (to open out aortic arch)
b) Selective studies:
Projections Basic: AP axial / FO 30o (Towne), lateral
Additional: OM view, oblique views
Phases Early & late: Arterial, capillary, venous
- Extra precautions must be taken to prevent embolic ischaemic event
4. Observe for signs of cerebral ischaemia
Complication 1. Cerebral ischaemia / infarction d/t embolism
a) Dislodged atherosclerotic plaque / arterial thrombus
- Never pass a guidewire / catheter through vessel that has not been visualized by prelim injection of CM
- Gentle manipulation of guidewire / catheter
- Use microcatheter to negotiate through sharp curves
b) Thrombus within catheter
- Flush the catheter regularly wt NS
- Never leave guidewire within a catheter >1min without withdrawal / flushing
- Never insert guidewire into a catheter filled wt CM ( must flush wt NS 1st)
b) Air
- Ensure all connectors are tight
- Always suck back when syringe is connected to catheter
- Ensure air bubbles are expelled from syringe, before injection
- Keep the syringe vertical, when injecting
c) Injected solutions (blood clot, cotton fiber, glove powder)
- Avoid contamination of NS / CM by blood clot, cotton fiber, glove powder
d) Embolic material used for embolization
2. ICB d/t arterial dissection by guidewire / catheter
Din XJ
180
Arch aortogram
CCA – Lateral ECA – Lateral
ICA – AP (Arterial phase) ICA – Lateral (Arterial phase)
Din XJ
181
ICA – AP (Venous phase) ICA – Lateral (Venous phase)
Vertebral artery – AP (Arterial phase) Vertebral artery – Lateral (Arterial phase)
Vertebral artery – AP (Venous phase) Vertebral artery – Lateral (Venous phase)
Din XJ
182
Arch aortogram
1. Thyrocervical trunk 6. Aortic arch 1. ICA 8. Inferior thyroid artery

2. CCA 7. Ascending aorta 2. ECA 9. Thyrocervical trunk
3. Vertebral artery 8. Descending aorta 3. Facial artery 10. Suprascapular artery
4. Subclavian artery 9. Aortic bulb 4. Superior thyroid artery 11. Subclavian artery
5. Brachiocephalic trunk 5. Vertebral artery 12. Brachiocephalic trunk
6. Ascending cervical artery 13. Internal thoracic artery
7. CCA
ICA – AP (Arterial phase) ICA – Lateral (Arterial phase)
1. Callosomarginal art 12. Anterior choroidal art 1. Posterior internal frontal art 12. Posterior temporal art
2. Anterior parietal art 14. MCA – 2nd segment 2. Anterior parietal art 13. Prefrontal arteries
3, 5, 8, 13. Pericallosal art 15. Anterior comm art 3. Paracentral art 14. MCA – 2nd segment
4. Posterior parietal art 16. MCA – 1st segment 4. Posterior parietal art 15. ACA – 2nd segment
6. Frontal polar art 17. Temporal polar art 5. Anterior internal frontal art 16. Anterior choroidal art
7. Precentral sulcal art 18. Frontal orbital art 6. Superior internal parietal art 17. Frontal orbital art
9. Artery of angular gyrus 19. Ophthalmic art 7. Medial internal frontal art 18. Posterior comm art
10. Posterior temporal art 20. ICA 8. Interior internal parietal art 19. Ophthalmic art
11. Prefrontal arteries 9. Frontal polar art 20. ICA
10. Antery of angular gyrus 21. Callosomarginal art
11. Pericallosal art
Din XJ
183
ICA – AP (Venous phase) ICA – Lateral (Venous phase)
1. Parietal vein 8. Frontal veins 1. Superior sagittal sinus 13. Inf anastomotic v (Labbe)
2. Superior sagittal sinus 9. Veins of fossal of Sylvian 2. Parietal vein 14. Veins of fossa of Sylvian
3. Sup anastomotic v (Trolard) 10. Sphenoparietal sinus 3. Sup anastomotic v (Trolard) 15. Confluence of sinuses
4. Great cerebral v (Galen) 11. Transverse sinus 4. Occipital veins 16. Cavernous sinus (anterior)
5. Internal cerebral vein 12. Intercavernous sinus 5. Inferior sagittal sinus 17. Transverse sinus
6. Sup thalamostriate vein 13. Inferior petrosal sinus 6. Internal cerebral vein 18. Superior petrosal sinus
7. Basal vein of Rosenthal 14. Sigmoid sinus 7. Sup thalamostriate veins 19. Cavernous sinus (posterior)
8. Vein of septum pellucidum 20. Sigmoid sinus
9. Straight sinus 21. Inferior petrosal sinus
10. Great cerebral v (Galen) 22. Occipital sinus
11. Ascending frontal veins 23. Pterygoid plexus
12. Basal vein of Rosenthal 24. IJV
Vertebral artery – AP (Arterial phase) Vertebral artery – Lateral (Arterial phase)
1. Med occipital a – Calcarine br 7. Sup cerebellar art 1. Parieto-occipital art 8. Posterior comm art
2. Parieto-occipital art 8. Marginal art 2. Dorsal corpus callosal branch 9. Sup cerebellar art
3. Vermis branch 9. AICA 3. Med occipital a – Calcarine br 10. Basillar art
4. Thalamoperforate arteries 10. Basilar art 4. Choroidal arteries 11. AICA
5. PCA 11. PICA 5. Temporo-occipital art 12. PICA
6. Temporo-occipital art 12. Vertebral art 6. PCA 13. Vertebral arteries
7. Post artery to thalamus
Din XJ
184
Vertebral artery – AP (Venous phase) Vertebral artery – Lateral (Venous phase)
1. Straight sinus 7. Inf v of cerebellar hemisphere 1. Sup v of cerebellar hemisphere 8. Transverse sinus
2. Superior cerebral veins 8. Petrosal vein 2. Great cerebral v (Galen) 9 & 11. Inf v of cerebellar
3. Confluence of sinuses 9. Sigmoid sinus 3. Internal cerebral vein hemisphere
4. Transverse sinus 10. Bulb of jugular vein 4. Straight sinus 10. Cavernous sinus
5. Veins of cerebral hemisphere 11. Inferior petrosal sinus 5. Basal vein of Rosenthal 12. Superior petrosal sinus
6. Inferior vein of the vermis 6. Precentral cerebellar vein 13. Inferior petrosal sinus
7. Confluence of sinuses 14. Sigmoid sinus
Din XJ
185
B. Inferior Petrosal Sinus Sampling, IPSS

Indications Diagnosis of hormonally active pituitary microadenoma, when imaging alone is not sufficient
- Usually ACTH-secreting pituitary microadenoma, which may be inapparent on imaging (50%)
CRH or DDAVP (desmopressin) must be administered in the case of ACTH
- Requires simultaneous blood sampling from both IPS & peripheral vein
ContraIx 1. IHD, orthopnoea
2. Bleeding tendency
Contrast IV LOCM
Catheter: Vertebral / Headhunter / Bernstein
- Puncture site (modified Seldinger technique): Bilateral common femoral vein
Insert femoral sheath 5Fr on each side (At least 1 sheath should be oversized to allow peripheral venous sampling)
- Inject IV Heparin 5,000u (to prevent venous sinus thrombosis)
- Insert guidewire 0.035”, followed by catheter 4Fr, till superior jugular vein
Perform digital venography to demonstrate anatomy of superior jugular vein & IPS
- Catheterize each IPS at 1 time, place the tip at orifice of IPS
Perform digital venography to confirm position
- Simultaneous venous sampling from both IPS & left femoral sheath, at
0 minute
Inject IV CRH 1μg/kg
OR
IV DDAVP 10 μg
5 minute
10 minute
15 minute
- Obtain 10mls of blood from each side, during each sampling
Place 5mls of blood into EDTA tube (for ACTH), another 5mls into plain tube (for cortisol & prolactin)
Immersed the samples in ice
- Remove catheter & sheath, compression
Complication 1. Venous SAH
2. Brainstem ischaemia
3. Cerebral venous thrombosis
4. Pulmonary embolism
Din XJ
Chapter 6 ULTRASOUND
186
HEAD & NECK

A. Thyroid & Parathyroid Gland
Indications 1. Thyroid mass (tumour, retrosternal extension)
2. Cold spot on radionuclide imaging
3. Parathyroid adenoma
Equipment Linear probe, 5 – 7.5 MHz
Technique 1. Thyroid gland
- Position: Supine, neck extended
- Planes:
a) Isthmus Midline, transverse
b) Rt & Lt lobe Paramedian, transverse & longitudinal
- Pivot inferiorly to look for retrosternal extension (may ask patient to swallow saliva to look for inferior edge)
Colour duplex: Assess vascularity
- Appearance: Homogenous echogenicity
- Measurement:
Isthmus < 0.5cm
Thyroid lobe (APxWxCC) < 3 x 2 x 4 cm
Normal thyroid nodule < 0.7cm
2. Parathyroid glands
- Technique: Rt & Lt paramedian, transverse & longitudinal
- Appearance: Normal parathyroid glands are not visualized d/t their small size
Posterior to thyroid gland, hypoechoic to thyroid gland
3. Other structures
a) Neck vessels (carotid artery & IJV)
b) Salivary glands
c) Lymph nodes
Din XJ
187
B. Salivary Glands
Indications 1. Symptoms: Pain, swelling, mouth dryness
2. Mumps
3. AbN radiological findings (XR, CT, sialogram)
Equipment Linear probe, 5 – 7.5 MHz
Technique 1. Parotid gland
- Technique: Parotid region, transverse & longitudinal
- Colour duplex: Assess vascularity
- Appearance: Homogenous echotexture, hypoechoic
Normal duct is not usually visualized unless dilated
2. Submandibular gland
- Technique: Submandibular region
- Appearance: Homogenous echotexture, hypoechoic
Normal duct is not usually visualized unless dilated
3. Sublingual gland
- Planes: Midline submantel, transverse
Inferior to tongue, anterior to submandibular gland
- Appearance: Very small glands, may not be able to visualize
Din XJ
188
A. Stomach
Indications Pyloric stenosis (Paediatrics)
Equipment 5 – 7.5 MHz linear probe
- If stomach is distended, insert NG tube
- Give some dextrose, via mouth or NG tube, to distend the antrum
- Scan pylorus in:
a) Longitudinal plane Olive shape
b) Transverse plane Doughnut shape
- Visualize:
a) Muscle Hypoechoeic
b) Mucosa Hyperechoeic
c) Antral peristalsis
- Measurement
a) Muscle thickness, muscle thickness : wall diameter ratio
b) Canal length
c) Pyloric volume
B. Small Bowel
Indications 1. Obstruction
2. Inflammation
3. Midgut Malrotation / Volvulus
Technique - Obstruction: Dilated small bowel loops
- Inflammation: Thickened bowel wall, ↑ vasculation
- Malrotation: Altered normal relationship of SMA & SMV (Normal: SMV anterior & Rt of SMA)
C. Appendix
Indications Appendicitis & complications
Preparation Preferably NBM 6hrs
Technique - Position: Supine
- Technique: RIF, start with transverse plane, press transducer to displace bowel loops
May look for external iliac vessels as anatomical landmark
- Features:
Features Normal appendix Appendicitis
Appearance Compressible, exhibit peristalsis Non-compressible, lack of peristalsis
Measurement
a) Diameter ≤ 6mm > 6mm
b) Wall thickness < 3mm ≥ 3mm
Associated findings - Appendicolith
Echogenic surrounding fat
Periappendiceal collection
Enlarged nodes
Din XJ
189
D. Liver
Indications 1. Symptoms: RHC pain, jaundice, PUO 5. Surveillance for hepatitis
2. Hepatomegaly 6. Suspected portal HPT
3. Deranged LFT 7. Assessment of portal vein, hepatic artery / veins
4. Liver pathology (fatty liver, hepatitis, tumour) 8. Staging of known extrahepatic malignancy (breast ca)
Equipment Curvilinear probe, 3 – 5 MHz
Technique - Position: Supine or Lt lateral decubitus
- Area: Epigastric, subcostal / Rt intercostals
- Planes: Longitudinal & transverse
- Echogenicity (PLiSK): Pancreas > Liver > Spleen > Kidney
1. Liver (assess size, echogenicity, echotexture, capsular contour)

a) Left lobe
Technique Epigastric region below sternum, transverse & longitudinal
b) Right lobe
Technique Rt parasagittal, longitudinal (see Rt liver lobe & Rt kidney)
Rt intercostal, oblique (see middle & Rt hepatic vein)
Rt subcostal, oblique (see Rt portal vein)
Measurement Rt lobe span < 16cm
- At Rt parasagittal (mid-clavicular line), longitudinal
- From diaphragm – lower liver edge
Din XJ
190
2. Portal vein
Technique Main portal vein: Rt Subcostal & Rt intercostal, oblique
Rt & Lt portal vein: Epigastric & Rt intercostal, transverse
Features Echogenicity of portal vein walls > liver parenchyma
Diameter (main portal vein) ≤ 1.3cm
Doppler Waveform: Continuous forward flow wt respiratory variation (↑on inspiration)
Normal: Hepatopetal flow (Flow towards liver)
Portal HPT: Hepatofugal flow (Flow reversal)
Venous flow: 10 – 20 cm/sec
3. Hepatic vein
Technique Epigastric & Rt intercostal, transverse
Features Echogenicity of hepatic vein walls ≤ liver parenchyma
Diameter (distal to last confluence before IVC) ≤ 0.6cm
Doppler Waveform: Triphasic waveform, d/t reflection from Rt atrial events (same as IVC)
4. Hepatic artery
Technique Traced from celiac axis, transverse
Features Seagull appearance (common hepatic or splenic arteries)
Doppler Forward flow, throughout systolic & diastolic, wt sharp systolic peak
Portal HPT Very mild Loss of respiratory variation

Mild ↓ Peak velocity (< 10 cm/sec)
Moderate Balanced (Mixed forward & reversed flow)
Severe Hepatofugal flow
Complete occlusion No flow
Din XJ
191
E. Gallbladder & Biliary System

Indications 1. Symptoms: RHC pain, jaundice, PUO
2. Gallstone
3. Acute pancreatitis
Technique 1. Gallbladder
Technique Rt subcostal, longitudinal & transverse axis of the GB
Trace from right PV to GB fossa
Features Smooth wall, anechoic content
GB folds are normal
Measurement GB wall ≤ 3mm
2. Intrahepatic ducts
Technique Lt lobe: Epigastric, transverse
Rt lobe: Subcostal / Rt intercostal, oblique
Features of Beaded branching appearance
dilated ducts Diameter >40% of accompanying PV branch
3. Extrahepatic ducts
Technique CBD: Subcostal / Rt intercostal, oblique, anterior to PV
Extends downwards through head of pancreas to ampulla
Features CHD ≤ 4mm
CBD ≤ 6mm (Post-cholecystectomy ≤ 10mm)
Din XJ
192
F. Pancreas
Indications 1. Pancreatic tumour 4. Epigastric pain
2. Pancreatitis & its complications 5. Jaundice
3. Epigastric mass
Technique - Position: Supine, may perform in right / left oblique or erect position
Drinking water may improve the window through the stomach
- Appearance: Homogenous, iso-hyperechoic to liver
- Planes:
Body Epigastric, transverse, anterior to splenic vein
Head & tail Epigastric, angle transversely & obliquely
Tail Lt intercostal, oblique, wt spleen as acoustic window
- Measurement:
AP diameter Head < 35mm Pancreatic duct In the head ≤ 3mm
Neck 10-15mm In the body ≤ 2mm
Tail < 20mm
G. Spleen
Indications 1. Symptoms: PUO 4. Splenic pathology (mass, infarction, haematoma)
2. Splenomegaly 5. Portal HPT, varices
3. Infection/inflammation (abscess)

Technique - Position: Supine or Rt lateral decubitus
- Appearance: Homogenous, inverted-coma appearance
- Technique: Lt intercostal & subcostal, oblique
- Measurement:
a) Adult Length (superior-inferior): ≤ 12cm (Female)
≤ 13cm (Male)
Thickness (medial-lateral): ≤ 7cm
(anterior-posterior): ≤ 5 cm
b) Paeds ≤ 1.25 times the length of left kidney
Din XJ
193
A. KUB
Indications 1. Renal pathology 2. Bladder pathology
a) Renal mass a) Bladder mass
b) Renal parenchymal disease b) Obstructive uropathy
c) Obstructive uropathy c) Neurogenic bladder
d) Assessment of renal graft (Bladder volume before & after micturition)
e) Young HPT 3. Prostate: Ca, BPH
f) UTI: Pyelonephritis, pyelonephrosis, recurrent UTI
g) Haematuria
Preparation May require full bladder
Technique 1. Kidney
- Position: Supine, Rt & Lt lateral decubitus
- Technique: Right kidney: Right loin, longitudinal & transverse
Left kidney: Left loin, longitudinal & transverse
Renal graft: Usually RIF, longitudinal & axial
- Measurement:
a) Bipolar length (BPL) 9 – 12 cm (usually left kidney is larger)
Lt & Rt discrepancy should be ≤ 1.5cm
b) Parenchymal thickness (PT) Usually ≥ 1cm
2. Bladder
- Position: Supine (with full bladder)
- Technique: Suprapubic, transverse & longitudinal
- Measurement:
Wall thickness ≤ 3mm
Volume (0.52 x APxWxCC): Residual urine < 100 cm3
Pre- & post-micturition (< 10% pre-micturition volume)
Din XJ
194
3. Prostate gland
- Technique: Suprapubic angle inferiorly, transverse & longitudinal
- Measurement:
Volume (0.52 x APxWxCC) 5 x 3 x 3 cm (≤ 25 mls)
B. Female Reproductive System

Indications 1. Pelvic pain / mass 5. Fertility related
2. Pregnancy a) Assessment of tubal patency
3. Precocious / delayed puberty b) In assisted fertilization technique
4. Menstrual problems, post-menopausal bleeding
Preparation Transabdominal: Full bladder
Transvaginal: Empty bladder
Technique 1. Uterus
- Technique: Suprapubic, transverse & longitudinal
- Measurement:
Endometrial thickness Pre-menopause: < 15mm
(echogenic area in the centre) Post-menopause: < 5mm
Post-menopause (on HRT): < 6mm
2. Ovaries
- Technique: Suprapubic, transverse & longitudinal, pivot Rt & Lt to look for each ovary
- Measurement:
Ovarian volume < 10 cm3
Simple ovarian cyst diameter < 30 mm
Din XJ
195
C. Scrotum
Indications 1. Symptoms: Pain, swelling Testicular mass 5. Undescended testis
2. Mass: Malignancy, Hydrocoele, Vericocoele 6. Scrotal trauma
3. Infection: Epididymo-orchitis 7. Infertility
4. Acute testicular torsion
Equipment Linear probe, 7.5 – 15 MHz
Technique - Position: Supine, tuck the penis up over the symphysis
1. Testis
- Technique: Each testis, transverse & longitudinal
- Comparison view that includes both testes
- Appearance: Homogenous echogenicity
- Measurement: Testicular volume > 10 cm3
2. Epididymis
- Technique: Each epididymis, transverse & longitudinal
Locate the head in transverse plane, then scan downward to body & tail
- Measurement: Epididymal thickness < 3mm
3. Spermatic cord (arteries, pampiniform plexus, nerves, lymphatics)

- Technique: Transverse & longitudinal. Locate the epididymal head, then scan upward
- Measurement: Vein < 2mm
- If varicocele/hernia is seen, perform Valsalva manoeuver or ask patient to stand
Din XJ
196
OBSTETRIC
A. Fetus
1. Gestational sac & Yolk sac
- Appearance:
Gestational sac - Appears during 4th week (on transvaginal scan)
- Echogenic ring surrounding an anechoic centre, within the endometrial cavity
Yolk sac - Appears during 5th week
- Echogenic ring surrounding an anechoic centre, within the gestational sac
- Measurement: Average gestational sac diameter of 3 dimensions (AP,W,CC)
→ To determine gestational age before fetal pole (crown rump length) can be seen
2. Crown Rump Length (CRL)
- Appearance (fetal pole): A mass of fetal cells within the yold sac, appears during 6th week
- Measurement (crown rump length): Longest fetal diameter, from fetal head – fetal rump
→ To determine gestational age until 12th week (replaced by biparietal diameter)
3. Head Circumference (HC) & Biparietal Diameter (BPD)
- Plane: Transverse (must include cavum septum pellucidum, thallamus & choroid plexus in the lateral ventricles)
- Measurement:
BPD Measure diameter, from outer table (of near calvarium) to inner table (of far calvarium)
→ To determine gestational age from 12th – 20th weeks
HC Measure around the skull outer table
→ To determine gestational age if there is variant head shape
Din XJ
197
4. Abdominal Circumference
- Plane: Transverse (must include portal section from umbilical vein, stomach & true cross section of spine wt 3 ossification centres)
- Measurement: Measure around the abdomen
5. Femur Length
- Plane: Can only be measured when femur is horizontal (beam is perpendicular) and shadows evenly from both ends
- Measurement: Measure the entire femur
6. Fetal Heart Beat
a) Heart beat: Beating heart on B-mode, subtle flicker on M-mode (avoid Doppler during early pregnancy)
b) M-mode heart rate
c) Normal situs: On the left
d) Normal anatomy: 4 chambers & valves, RVOT, LVOT, interventricular septum, 3 great vessels (pulm art, aorta, vene cava)
Din XJ
198
B. Maternal
1. Cervix
- Appearance: Presence of echogenic mucous plaque within,

but should contain no fluid
- Measurement: From internal to external os
Normal cervical length: ≥ 30mm
2. Placenta
- Appearance: Long & thin echogenic tissue (lining the inner uterine surface) wt homogenous echotexture
- Assessment:
Location - Anterior or posterior
- Distance btw placental tip & internal os > 3mm
Myometrial rim Space under the placenta ≥ 3mm
(otherwise suspect placenta percreta / accreta)
3. Amniotic Fluid Index (AFI)
Definition:
Deepest vertical pocket (wt no fetal content) in each quadrant,
then add them up together
Din XJ
199
PAEDIATRICS
A. Cranium
Indications 1. Intracranial pathology
2. Congenital anomalies
3. ICB (germinal matrix haemorrhage, extra-axial haemorrhage)
4. Hydrocephalus
Equipment 1. Sector probe, 4-7 MHz
2. Linear probe, 7.5-10 MHz (to visualize superficial structures)
Approach
1. Anterior fontanelle Standard view

2. Supplementary views
a) Posterior fontanelle Assess posterior fossa
b) Squamous temporal Assess region of COW
c) Mastoid fontanelle Assess cerebellum
Planes:
a) Coronal
Images: Structures seen:
1. Frontal lobes (ant to frontal horns) Frontal lobes, optic ridge
2. Frontal horns of lateral ventricles Frontal horns, cavum septum pellucidum,
corpus callosum, thalami, basal ganglia
3. 3rd ventricle & thalami 3rd ventricle, foramen Monro,
thalami, basal ganglia, brainstem
4. Bodies of lateral ventricles Bodies & temporal horns of lateral ventricles
5. Trigone of lateral ventricles Trigone, choroid plexus,
periventricular white matter blush
6. Occipital lobes Occipital & parietal lobes
Din XJ
200
b) Sagittal
Images: Structures seen:

1. Mid-sagittal 3rd & 4th ventricle, corpus callosum
2. Parasagittal Lateral ventricle, caudate nucleus & thalamus
(15o from midline) (caudothalamic groove)
3. Steep parasagittal Frontal, temporal, parietal cortex, Sylvian fissure
(30o from midline)
Measurement:
a) Ventricular index:
Ratio of distance btw lateral sides of lateral ventricles & biparietal diameter
b) Subarachnoid space:
- Appearance: Anechoic, has vessels crossing
(as opposed to subdural space)
- Measure on coronal plane, wt linear transducer
- Normal: < 3.3mm
Din XJ
201
Cranial vasculature:
a) Arteries (ICA, MCA, COW)
- Technique: Anterior fontanelle, coronal plane
- Measure: PSV, EDV, Resistive index
↓ RI Acute ischaemia
↑ RI Cerebral oedema (ICP > systemic pressure)
b) Veins (Sagittal sinus & vein of Galen)

- Technique: Anterior fontanelle, sagittal & transverse planes
Din XJ
202
B. Thorax
Indications 1. Opaque hemithorax on CXR
2. Guidance for thoracic intervention
Equipment Neonates & infant: Linear probe, 7.5-10 MHz
Children & adolescent: Curvilinear probe, 3 – 5 MHz
Technique - Position: Decubitus, supine, prone
Parts examined Approach
Lung, pleura, ant mediastinum Transternal, parasternal, intercostal
Lung apex, sup mediastinum Suprasternal, supraclavicular
Juxtaphrenic paravertebral lesion Subxiphoid, transdiaphragmatic
- Normal findings:
1. Thymus Well-defined homogenous structure, at ant & sup mediastinum, in transverse plane
2. Hyperechoic: Pleural line, air, diaphragm, periosteum
Hypoechoic: Fluid, blood
3. Pleural line Horizontal echogenic line btw 2 ribs, in longitudinal plane over intercostal space
4. Bat sign - Superior and inferior ribs, their acoustic shades (the wings of the bat)
- Pleural line and the lung underneath (the body of the bat)
5. Lung sliding - Lung sliding against the thoracic wall, concordance wt respiration
(seashore sign) - Seen as seashore sign on M-mode
- Normal artifacts:
1. A lines Echogenic horizontal lines, parallel with the pleural line, d/t reverberation artefact
2. B lines Echogenic vertical lines, arising from pleural line, which move wt lung sliding
3. Mirror image Duplicated image d/t reflection by diaphragm
- Common abnormal signs:

1. Lung point Transitional point btw normal & pathological parenchyma
2. Lung pulse Pulsation of lung wt heartbeat → Immobile lung (Atelectasis)
3. Stratosphere Absence of lung sliding sign, replaced by parallel horizontal lines → Pneumothorax
(Barcode sign)
4. Consolidation "Parenchymal" structure when alveoli are filled with fluid,
d/t reflections of the interfaces between alveoli and interstitial spaces
5. Air bronchograms Straight or irregular hyperechoic lines in consolidated area
- Examination for diaphragmatic paralysis (using M-mode):

Normal Paralyzed hemidiaphragm
Diaphragmatic movement Paradoxical movement
- Inspiration Diaphragm moves towards the probe
- Expiration Diaphragm moves away from the probe
Excursion ≥ 4mm Minimal excursion
Differential excursion < 50% > 50%
btw 2 hemidiaphragm
Din XJ
203
Thymus Pleural line, bat sign, lung sliding
Normal lung wt seashore sign Stratosphere (barcode sign) Lung point
Consolidation Air bronchograms Complex effusion Empyema
Normal diaphragm Paralyzed diaphragm - Paradoxical movement Minimal excursion
Din XJ
204
C. Abdomen
Indication Hypertrophic pyloric stenosis
2. Linear probe, 7.5-10 MHz
Preparation NBM 4hrs (to avoid obscuration by gastric gas)
May feed water before examination (to create good acoustic window)
Technique 1. General abdominal examination
2. Assess for pyloric stenosis
- Area: Epigastric, supine position
May roll baby to right decubitus (to promote fluid towards & gas away from pylorus)
- Planes: Longitudinal & transverse plane of the pylorus
Assessment: Normal Pyloric stenosis
Relation of pylorus to GB Distant away from GB Displaced to lie adjacent to GB
Appearance Muscle: Hypoechoic Hypertrophic muscle
Mucosa: Hyperechoic (hypoechoic)
Pyloric canal Water/milk may pass through Closed
Measurement Special sign:
a) Transverse diameter < 13mm Target sign
b) Longitudinal length < 15-17mm Antral nipple sign
c) Pyloric muscle thickness < 3mm Cervix sign
(single muscular wall on transverse)
- If pylorus is normal → Examine for midgut malrotation / volvulus
Normal
Pyloric stenosis
Din XJ
205
Indication Midgut malrotation → Risk of midgut volvulus & inernal hernias

Preparation Ensure adequate hydration
2. Assess for midgut malrotation
- Position: Supine
- Technique: Midline (from epigastric downward), in transverse plane
Look for 1st (coeliac artery) & 2nd (SMA) branches of aorta
Assessment: Normal Midgut malrotation
1. SMA-SMV relationship SMA – on the Lt SMA – on the Rt
SMV – on the Rt SMV – on the Lt
2. Passage of 3rd part of duodenum In btw aorta & SMA Anterior to both aorta & SMA
3. Position of the caecum Low in abdomen High in abdomen
* Normal position of SMA-SMV & duodenum do not exclude malrotation
3. Assess for midgut volvulus
- Position: Supine
- Technique: Midline (from epigastric downward), in transverse plane
1. Whirlpool sign Clockwise swirling of mesentery & SMV, around the SMA
2. AbN superior a) Reversed SMA-SMV relationship
mesenteric vessels b) Truncated SMA, hyperdynamic pulsating SMA
c) Inapparent SMV
3. AbN bowel a) 3rd part of duodenum passes anterior to both aorta & SMA
b) Dilated duodenum, proximal to obstruction
c) Dilated, fluid-filled, thickened wall of small bowel, distal to obstruction
- Look for signs of perforation (intraperitoneal free fluid)
Normal Malrotation
Reversed SMA-SMV relationship Whirlpool sign
Din XJ
206
Indication Intussusception:
Forward peristalsis causing invagination of more proximal bowel (intussusceptum) into more distal bowel (intussuscipiens)
Preparation Ensure adequate hydration
2. Assess for intussusception
- Position: Supine
- Technique: Start scanning at RIF in transverse plane of the bowel, then move distally along the large bowel
If intussusception is seen, scan in longitudinal plane
Assessment:
a) Signs of intussusception Pseudokidney sign, Target/doughnut sign, Crescent in doughnut sign
b) Parts of intussusception (i) Intussusceptum – The proximal loop which enters into intussuscipiens
(ii) Intussuscipiens – The distal loop which receives intussusceptum
(iii) Apex – The part which advances (most distal part of intussusceptum)
c) Type of intususception (i) Ileocolic (most common)
(ii) Ileoileocolic (2nd most common)
(iii) Ileoileal
(iv) Colocolic
d) Others (i) Vascularity (risk of ischemia & irreducibility if diminished)
(ii) Trapped fluid within intussusception (risk of ischemia & irreducibility)
(iii) Intraperitoneal free fluid (may be d/t inflammation or perforation)
(iv) Lead point: Enlarged nodes, inflammation, neoplasm (but mostly idiopathic)
- Proceed to ultrasound-guided hydrostatic reduction if no contraindication
- During & post-procedure ultrasound
Assessment:
a) Dissection sign Fluid dissecting btw intussusceptum & intussuscipiens
(indicator of failed reduction)
b) Signs of perforation Increase intraperitoneal free fluid → Stop reduction if present
c) Successful reduction Resolution of the soft tissue mass
Free reflux of fluid/gas into small bowel, via ileocaecal valve (fishmouth)
Dissection sign Intraperitoneal free fluid Free reflux of fluid into small bowel
Din XJ
207
C. Hip
Indications 1. Development dysplasia of the hip (DDH)
≤ 6mths US can identify the bony acetabulum & unossified elements
(femoral head, labrum, triradiate cartilage)
After 9-12mths Ossification takes place → Plain radiograph more superior
2. Slipped femoral capital epiphysis (SUFE)
3. Hip effusion (Septic arthritis, haemarthrosis)
Equipment Linear probe, 7.5-10 MHz
Planes 1. Coronal view 2. Transverse flexion view
- Probe parallel to lateral aspect of the hip - Probe perpendicular to lateral aspect of the hip
- To assess hip effusion & DDH (static) - To assess DDH (dynamic)
Technique 1. Hip effusion

- Position: Supine (feet facing examiner) / decubitus, in neutral / flexion position
- Technique: Place transducer parallel to femoral neck → Identify the bulging of the anterior joint capsule
- Measurement:
Distance btw bony femoral neck & joint capsule < 3mm
Distance btw affected & unaffected sides ≤ 2mm
2. Development dysplasia of the hip (DDH)

a) Static (Graf) method → Assess acetabular morphology & geometry, wt a single longitudinal image
- Position: Supine (feet facing examiner) / decubitus, in neutral / flexion position
- Technique: Place transducer over greater trochanter, at right angles to all anatomical planes
Must visualize: Horizontal ilium, round femoral head, well-defined acetabular roof
- Draw 3 lines:
Baseline Along vertical cortex of ilium, through femoral head
Roof line Along acetabular roof, intersecting the baseline
Inclination line Along labrum, across top of femoral head, intersecting baseline & roof line
- Measurement:
d/D ratio % of femoral head coverage by acetabular roof > 50%
α angle Formed by acetabular roof to vertical ilial cortex ≥ 60o
(Btw baseline & roof line)
β angle Formed by vertical ilial cortex to labrum < 55o
(Btw baseline & inclination line)
Din XJ
208
b) Dynamic method → Assess hip stability when stressed, wt transverse images

- Position: Decubitus
- Technique: Place transducer in the postero-lateral position, perpendicular to lateral aspect of the hip
Barlow manoeuver Adduct the thigh, apply pressure on the knee (wt hip & knee flexed)
→ To assess dislocatable of the hip
Ortolani manoeuver Thigh abducted & external rotated (wt hip & knee flexed)
→ To assess reducibility of the hip (after dislocation during Barlow)
3. Slipped femoral capital epiphysis (SUFE)

- To identify mild posterior slip
- Position: Supine (feet facing examiner) / decubitus
- Technique: Place transducer along the femoral neck
Din XJ
209
D. Spine
Indications 1. Suspect spinal abnormalities / neural tube defects
- Midline skin dimple, tufts of hair
- Anorectal anomalies
- Posterior midline mass
2. Trauma
3. Infection / abscess
Technique - Position: Prone / lateral decubitus
- Planes: Longitudinal & transverse
Longitudinal - From mid-thoracic to sacro-coccygeal region, in midline & side-to-side
- Assess:
a) Posterior neural arch: Intact, paired, uniform
b) Level of conus medullaris (Not lower than L3)
- Count from iliac crest (L4) upward
- Count from Lumbo-sacral junction (L5/S1) upward
- Count from 12th rib (T12) downward
c) Filum terminale: Thin (2mm) parallel lines, from conus to end of thecal space (≈ S2 level)
d) Cauda equina: Symmetry, at dependent part of thecal sac, gentle oscillating
movement
Transverse - From mid-thoracic to sacro-coccygeal region, in midline
- Assess:
a) Posterior neural arch: Intact, paired, symmetry, uniform
b) Spinal cord: Central position, shape
c) Cauda equina: Symmetry, at dependent part of thecal sac, gentle oscillating
movement
d) CSF space: Uniform
Din XJ
210
FAST scan (Focused Assessment with Sonography for Trauma)

Indications 1. Blunt trauma Clinical implications (to look for):
2. Penetrating trauma 1. Pericardial fluid
3. Unexplained hypotension 2. Pleural fluid / pneumothorax
4. Trauma in pregnancy 3. Peritoneal / pelvic fluid
Technique
1. Hepato-renal interface (Morrison's pouch)

2. Spleno-renal interface
3. Pelvis
4. Pericardial
5. Pleura (bilateral)
Area Probe placement To assess

1. Hepato-renal interface Rt mid-axillary line, longitudinal - Rt lung, Rt pleural space
(Morrison's pouch) - Morrison’s pouch, Rt subphrenic space,
Rt subhepatic space, Rt paracolic gutter
2. Spleno-renal interface Lt mid-axillary line, longitudinal - Lt lung, Lt pleural space
- Splenorenal space, Lt subphrenic space,
Lt paracolic gutter
3. Pelvis Suprapubic, longitudinal & transverse - Pelvic fluid, pouch of Douglas
- Bladder, prostate, uterus
4. Pericardial - Subcostal/subxiphoid, transverse Pericardial space
- Angle upward to the heart
(4-chamber view)
5. Pleura (bilateral) - Mid-clavicular line, longitudinal Pneumothorax
- Use B-mode & M-mode (Absent sliding sign btw pleura & rib space)
Morrison’s pouch Spleno-renal space Pelvis
4-chamber subxiphoid Pleural (B-mode) Pleural (M-mode)
Din XJ
211
VASCULAR
A. Carotid Doppler
Intracranial blood supplied by 2

extracranial arteries on each side:
a) Internal carotid artery
b) Vertebral artery
(arises from subclavian artery)
Indications CVA, TIA

Remarks - Position: Supine, head slightly extended & turned away from side being examined
- Angle: Always angle to the flow, not the vessel wall (they are not always the same)
Angle < 600 (If >600, error is ↑ exponentially)
- Structures scanned:
a) Common carotid artery (CCA) + Bulb + Bifurcation e) Subclavian artery
b) Internal carotid artery (ICA) If suspicious of subclavian steal syndrome (retrograde VA flow)
c) External carotid artery (ECA) f) Adjacent structures (lymph nodes, thyroid etc)
d) Vertebral artery (VA)
Technique 1. Common carotid artery (CCA)
- Planes: Transverse & longitudinal

- Technique: Start from proximal CCA (base of neck) to distal CCA (bifurcation)
- Look for: Tortuous course, intimal thickening, atherosclerotic plaque, calcification
a) Proximal-Mid CCA Longitudinal B-mode + Colour
b) Distal CCA + Bulb + Bifurcation Longitudinal B-mode + Colour
c) Abnormality Longitudinal + Transverse B-mode
- Measurement:
a) Intimal-media thickness (IMT) - Thickness of tunica intima & tunica media
at distal CCA (innermost 2 layers of arterial wall)
- Normal < 0.08cm
b) Abnormality Calculate percentage stenosis
- Colour duplex: To demonstrate patency
- Doppler: At prox-mid CCA (must angle to the flow!!) & anywhere with pathology (before & after the lesion)
CCA waveform - Combination of both ICA & ECA waveform
- Diastole touch / near baseline
Peak systolic velocity, PSV
- Normal < 125 cm/sec
- 0-49% stenosis 125 – 150 cm/sec
- 50-69% stenosis 150 – 230 cm/sec
- ≥ 70% stenosis > 230 cm/sec
- Total occlusion None
Din XJ
212
2. Internal carotid artery (ICA) & External carotid artery (ECA)
- Planes: Transverse & longitudinal

- Technique: Start from bifurcation to distal ICA & ECA
- Look for: Tortuous course, intimal thickening, atherosclerotic plaque, calcification
a) Proximal-mid ICA & ECA Longitudinal B-mode + Colour
b) Distal ICA & ECA (optional) Longitudinal B-mode + Colour
c) Abnormality Longitudinal + Transverse B-mode
- Measurement: Abnormality
- Doppler:
a) ICA
ICA waveform - Measure at proximal-mid ICA (must angle to the flow!!)
- ↓ Resistance flow → ↑ Diastolic flow (Diastole much ↑ from baseline)
- Sharp systolic peak, gradual slope in late systole
- Good forward in entire diastole
Peak systolic velocity, PSV
- Normal < 125 cm/sec
- 0-49% stenosis 125 – 150 cm/sec
- 50-69% stenosis 150 – 230 cm/sec
- ≥ 70% stenosis > 230 cm/sec
- Total occlusion None
b) ECA
ECA waveform - Measure at proximal-mid ECA (must angle to the flow!!)
- ↑ Resistance flow → ↓ Diastolic flow (Diastole touch / near baseline)
- Sharp systolic peak, followed by a systolic notch (forming “statue of liberty”)
- Minimal flow in diastole (May have retrograde flow)
Residual diameter of diseased vessel

- Percentage of stenosis = 100 x (1 - )
Normal diameter of vessel
- Calculate ratio of PSV of ICA:CCA → Normal < 1.8
ICA vs ECA
ICA ECA
Diameter Usually larger Usually smaller
Location (arises) Usually medial Usually lateral
Branches Usually no branches Usually has small branches (superior thyroid artery)
Wave form Lower resistance Higher resistance
“Temporal tapping” No reverberations Reverberations in the trace corresponding to tapping
* Temporal tapping: Tap gently on temporal artery (anterior to the top of the ear) while sampling ECA with Doppler
Din XJ
213
3. Vertebral arteries (VA)
- Planes: Longitudinal
- Technique: Return to longitudinal plane of CCA, angle the probe postero-laterally, with colour mode
Vertebral artery & vein lie in btw vertebral processes as flashes of colour
- Doppler: To assess the flow
VA waveform - ↓ Resistance flow → ↑ Diastolic flow
- Flow above baseline (not below)
Antegrade Flowing towards the head (normal)
Retrograde Flowing in opposite direction (suggesting subclavian steal syndrome)
4. Subclavian artery (If there is retrograde VA flow)

- Look for stenosis, causing subclavian steal syndrome
- The pathology usually located btw the origins of CCA and vertebral artery
5. Adjacent structures
Din XJ
214
B. Abdominal Aorta & IVC

Indications Abdominal aortic aneurysm
Preparation NBM 6hrs
Technique 1. Abdominal aorta
- Position: Supine
- Technique: Midline (from diaphragm to bifurcation), transverse & longitudinal
- Measurement if there is aneurysm:
1. AP diameter: > 3cm (male), > 2.5cm (female)
2. Distance from renal arteries (must note supra- / infra-renal)
- Doppler waveform: Triphasic waveform
2. IVC
- Position: Supine
- Technique: Rt parasagittal, longitudinal
- Appearance: IVC passes through liver wt caudate lobe anteriorly & posteriorly
IVC dilates wt expiration
- Measurement: AP diameter < 2cm
- Doppler waveform: Triphasic waveform, d/t reflection from Rt atrial events
1st component (S) Forward flow during late diastole (atrial relaxation) & ventricular systole
2nd component (D) Forward flow during early diastolic filling
3rd component (A) Retrograde flow during late diastole (atrial contraction)
Din XJ
215
C. Coeliac Artery & Superior Mesenteric Artery

Preparation Preferably NBM 6hrs (to avoid vessels being obscured or compressed by bowel)
Technique 1. Coeliac artery
- Position: Supine
- Area: Midline (from epigastric downward)
- Planes:
Transverse Look for 1st anterior branch of aorta, which then divides into hepatic & splenic arteries
(forming ‘seagull’ appearance)
Longitudinal Coeliac artery is anterior to aorta & superior to SMA, running inferiorly
Peak systolic velocity, PSV 118 – 200 cm/sec
End diastolic velocity, EDV 30 – 75 cm/sec
2. SMA
- Position: Supine
- Technique: Midline (from epigastric downward), longitudinal (inferior to coeliac artery)
Din XJ
216
D. Renal Doppler
Indications Renal arterial stenosis as a cause of HPT
Preparation Preferably NBM 6hrs (to avoid vessels being obscured or compressed by bowel)
Technique 1. Direct method
a) Abdominal aorta
- Position: Supine
- Area: Midline (from diaphragm downward)
Transverse Scan inferiorly to identify renal arteries (lateral branches of abdominal aorta, after SMA)
Then change to longitudinal plane
Longitudinal At the level of renal arteries, perform colour duplex & Doppler
- Measurement:
Doppler waveform - Triphasic waveform
- ↑ Resistance flow → ↓ Diastolic flow (Diastole touch / near baseline)
b) Main renal arteries

- Position: Supine, may roll patient to decubitus position to avoid bowel gas
* RAs are clearly seen on transverse plane anteriorly, but it is perpendicular to US beam (unsuitable for Doppler)
- In transverse plane, move the prove laterally from midline, then angle medially to visualize the main RA
(to achieve acceptable Doppler angle), perform colour duplex & Doppler
- Measurement:
Doppler waveform - Rapid sharp systolic upstroke
- ↓ Resistance flow → ↑ Diastolic flow
PSV Native kidney: < 180 cm/sec
Renal graft: < 250 cm/sec
Acceleration time (AT) < 70 msec
Resistive index (RI) < 0.7
Renal arterial stenosis – Direct method (significant stenosis of > 70%):

PSV of the main renal artery Native kidney: > 180 cm/sec
Renal graft: > 250 cm/sec
Renal to Aortic Ratio (RAR) > 3.5
Din XJ
217
2. Indirect method
- Position: Supine, may roll patient to decubitus position to avoid bowel gas
- Technique: Right / Left loin, longitudinal
Renal graft: Usually RIF, longitudinal
- In longitudinal plane, perform colour duplex & identify the interlobar / interlobular arteries
Then perform Doppler on the interlobar / interlobular arteries of each of the 3 renal poles
- Measurement:
Doppler waveform - Rapid sharp systolic upstroke
- ↓ Resistance flow → ↑ Diastolic flow
Acceleration time (AT) < 70 msec
Resistive index (RI) < 0.7 (Adult), 0.7–1.0 (< 5yrs)
Renal arterial stenosis – Indirect method (significant stenosis of > 70%):

Doppler waveform Parvus tardus (Small & slow systolic upstroke)
Acceleration time (AT) < 70 msec (more specific if < 120 msec)
Resistive index (RI) < 0.7
Din XJ
218
E. Lower Limb – Deep Veins

Indications 1. DVT
2. Lower limb swelling / pain
3. Known pulmonary embolism
Technique - Position: Preferably supine
- Veins examined:
1. Common femoral vein (CFV) Transverse & longitudinal
2. Superficial femoral vein (SFV) Transverse & longitudinal
3. Popliteal vein (PV) Transverse
4. Posterior tibial vein (optional) Transverse
5. Dorsalis pedis vein (optional) Transverse
- Technique: Examine the deep vein from groin – ankle
1. B-mode a) Focal narrowing, filling defect
b) Compressibility
2. Colour duplex a) Assess patency
3. Doppler a) Waveform
b) Augmentation
Din XJ
219
F. Lower Limb – Superficial Veins

Indications 1. Vericose vein
2. Venous ulcer / eczema
3. Lower limb oedema
Remarks 1. Normal venous flow 2. Abnormal venous flow
a) Caudal → Cephalic a) Reflux flow from cephalic to caudal, through malfunctioning valve
b) Superficial → Deep b) Flow from deep to superficial veins, through incompetent perforating vein
Technique - Position: Supine (for SFJ), prone (for PFJ), standing (for perforators)
- Veins examined:
a) Sapheno-femoral junction (SFJ) Great saphenous vein (GSV) runs from medial malleolus,
up the medial aspect of LL, into CFV via SFJ at the groin
b) Sapheno-popliteal junction (SPJ) Short saphenous vein (SSV) runs up the posterior midline of the calf,
into popliteal vein (PV) via SPJ at the popliteal fossa
c) Perforating veins Join the superficial veins to the deep veins
- Technique:
a) SFJ - Position: Supine
- Identify CFV in transverse plane, look for the site where GSV joins the CFV via SFJ
(forming a ‘Mickey mouse’ sign)
- Change to longitudinal plane, use colour duplex, ask pt to perform Valsalva manoeuver
- If incompetent → Prolonged flow reversal in GSV
Distal SFV - In trasverse/longitudinal plane, use colour duplex, ask pt to perform Valsalva manoeuver
- If incompetent → Prolonged flow reversal in SFV
b) SPJ - Position: Prone (Sometimes not seen)
- Identify PV in popliteal fossa, look for the site where SSV joins the PV via SPJ
(forming a ‘Mickey mouse’ sign)
- If incompetent → Prolonged flow reversal in SSV
Popliteal v - Trasverse plane at popliteal fossa
- If incompetent → Prolonged flow reversal in PV
c) Perforators - Position: Standing (Only perform when SFJ & SPJ are competent)
- In trasverse plane, scan along the GSV & SSV, from malleolus upward
- If incompetent → Dilated perforator (> 3mm) with flow reversal from deep to superficial
Measure its distance from the malleolus
Din XJ
Chapter 7 COMPUTED
TOMOGRAPHY
(CT)
220
GENERAL PRINCIPLES
1. Types of CT scan:
a) Scan-and-view Scan 1 image, view 1 image No overlapping of images
Pb: Partial volumic
b) Sequential Scan few images, view few images Overlapping of images
(scan-and-scan)
c) Spiral / helical Scan with x-ray tube in helical movement Overlapping of images
Acquire 3 images per rotation
2. Techniques for contrast scanning:

a) Delayed scan / Bolus timing - Contrast injection
- Spiral scan after a certain fixed delay of time
- Eg: Neck (45s), Thorax (45s),
Abdomen: Arterial (30s), Porto-venous (60s)
CTA brain (15-18s)
b) Bolus tracking - Place ROI (region of interest) at a certain anatomical site
Eg: CTPA (Pulmonary trunk), CTA Brain (arch of aorta)
- Contrast injection
- Repeated scans at ROI
- Spiral scan after HU reaches a certain fixed value
Triggering HU: 100 – 120 HU
c) Test bolus - Place ROI (region of interest) at a certain anatomical site
- Test bolus wt IV LOCM 15mls, 5mls/sec
- Repeated scans at ROI
- Time to peak enhancement is estimated
- Repeat scans using estimated delay time after contrast injection
- Eg: CTA coronary
3. CT Number:
Tissue HU
Fluid 0
Air - 1,000
Bone +1,000
Fat - 65 to +10
Brain White matter +25
Grey matter +40
Lung - 400 to - 600
Thyroid +70 ± 10
Liver +65 ± 5
Soft Muscle +45 ± 5
tissue Spleen +45 ± 5
Pancreas +40 ± 10
Kidney +30 ± 10
Lymphoma +45 ± 10
Coagulated +80 ± 10
Blood Lysed +55 ± 5
Fluid Plasma +27 ± 2
Exudate > +18 ± 2
Transudate < +18 ± 2
CSF +15
Bone Compact bone > +250
Spongy bone + 130 ± 100
4. Image reconstruction
a) Maximum intensity projection (MIP) Building a volume, by stacking axial slices
→ Displays the volume in a different plane (usually orthogonal)
b) Multiplanar reconstruction (MPR) Building a volume, by stacking individual slices one on top of the other
→ Displays the volume in an alternative manner
Allows viewing of image in any planes (oblique), other than orthogonal planes
c) Surface 3D-rendering A threshold value of radiodensity is chosen, processed wt edge detection algorithms
→ Displays the surfaces in 3D model
Different threshold value allows different colours to represent different components
(bone, muscle, cartilage)
d) Volume 3D-rendering Transparency & colours are used for better representation of the volume
e) Image segmentation Manual or automatic removal of the unwanted structures from volume rendering image
→ Displays structures that were previously concealed (Eg. Brain, vessels)
Din XJ
221
CONTRAST MEDIA
IV Contrast Media
1. Contrast media used: Iodine based (300mg I ml-1)
2. Dose:
a) Normal CT scan
Dose (mls) Rate (mls/sec)
Brain 50 Bolus by hand injection
Orbit 50 Bolus by hand injection
PNS 50 Bolus by hand injection
Neck 70 3
Thorax 70 3
Abdomen 100 3
Liver 4 phase 100 5
Pancreatic protocol 100 5
IVU 100 3
Renal 4 phase 100 5
Adrenal protocol 100 5
NTAP 100-120 3
Paediatrics 1 – 1.5 mls/kg
b) CT Angiogram
Dose (mls) Rate (mls/sec)
Brain 70 5
Perfusion Brain 50mls + 50mls NS 5 mls/sec + 4 mls/sec (NS)
Carotid 100 5
CTPA 70 – 100 5
Thoracic aorta 100 5
Coronary 60 – 80 5
Abdominal aorta 100 5
Renal 100 5
Mesentery 100 5
Lower Limb 120 5
Paediatrics 2 mls/kg
3. Timing:
a) Normal CT scan
Delay (sec) IVU
Brain - - Plain -
Orbit - - Nephrographic 100 – 120
PNS - - Delay bladder 5 mins
Neck 45 Renal 4 phase
Thorax 45 - Plain -
Abdomen / NTAP - Cortico-medullary(Arterial) 30
- Porto-venous 60 - Nephrographic(Venous) 60
Liver 4 phase - Excretory(Delayed) 5 mins
- Plain - Adrenal protocol
- Arterial 30 - Plain
- Porto-venous 60 - Porto-venous
- Delay liver 5mins - Delay
Pancreatic protocol
- Plain -
- Arterial 15
- Porto-venous 35
- Delay pancreas 5 mins
b) CT Angiogram: Bolus tracking
4. Preparation for IV contrast media

a) Fasting ≥ 6hrs (≥ 4hrs for paeds)
b) No allergies or asthma
- Cover wt T. Prednisolone 40mg 12hrs before & 2hrs before examination
c) Normal renal profile (creatinine< 130)
- May require NAC (600mg BD x 2days) or dialysis
Din XJ
222
Oral Contrast Media

1. Contrast media used:
a) Water-soluble contrast
Gasrograffin 3% 1 bottle (120mls of 300mg I ml-1), dilute to 4L
Urograffin 20mls of 150mg ml-1, dilute to 1L
Gastromiro 20mls of 150mg ml-1, dilute to 1L
b) Low density barium suspension
2. Dose:
a) Adult: 750 – 1000 mls, 30 – 60 mins before scanning
b) Paediatrics: Gastrograffin 1%, 3 doses every 30mins
Age Volume (mls)
0 – 6 mths 40
6 – 12 mths 60
1.5 – 3.5 yrs 80
3.5 – 6yrs 120
6 – 10 yrs 170
> 10 yrs 250
Rectal Contrast Media

Contrast media used:
Gastrograffin 3% 1 bottle (120mls of 300mg I ml-1), dilute to 4L
Din XJ
223
BRAIN
1. CT Brain
Indication a) Traumatic head injury (skull fracture, ICB) d) Suspected SOL
b) CVA (ischaemic & haemorrhagic) e) Suspected ↑ ICB (before lumbar puncture)
c) Intracranial infection
Exposure 120kV, 360mAs
Contrast a) Plain
b) Contrast: IV LOCM 50mls (bolus hand injection)
Position - Supine, OML ∟ Table
- Gantry tilted (~15o), Line from orbital roof to ant aspect of foramen magnum ∟ Horizontal plane
Topogram Lateral skull, Slices ║ BOS
Coverage Caudo-cranial: BOS – Vertex (orbits not included)
Technique - Spiral / helical or sequential technique
- Acquired slice thickness: 2.4mm (Detector configuration: 1.2mm x 64 per scan)

- Recon slice thickness (for medweb): 5mm at BOS, 10mm up to vertex
Window Brain soft tissue: 80 WW / 30 WL
Bone setting: 1,500 WW / 500 WL
2. CT Cisternography
Indication Indication: Contraindication: Relative
a) Study of basal cisterns with CM, a) Meningitis
to demonstrate tumours in CP angle & suprasellar cisterns b) ↑ ICP
(This indication has been replaced by MRI)
b) To identify site of CSF leak before closure
Contrast a) Positive contrast: Intrathecal LOCM-240, 10mls
b) Negative contrast: Intrathecal air
Technique - To promote active CSF leakage (if present) before the procedure:
Press the neck, to occlude both jugular veins for 5mins before the study
- Inject intrathecal LOCM (LOCM-240, 10mls), via lumbar puncture
- Tilt the table to head-down position, to ensure good cranial penetration
- CT brain:
a) Prone - Start wt coronal, to maximize leaking
- Axial
b) Supine - Axial, esp when CSF leakage is profuse
- Acquired slice thickness: 1-2mm, small FOV, at area of suspected leakage

Window Brain soft tissue: 80 WW / 30 WL
Complications 1. Infection
2. Lumbar CSF leak
3. Contrast-induced side effects: Headache, meningeal irritation, seizures
Din XJ
224
3. CTA Brain (+ CTV)

Indication CTA - Vascular occlusion (thrombus) CTV - Sinus thrombosis
- Vascular abN (Aneurysm, AVM, fistula)
Contrast - Green line, at antecubital fossa
- IV LOCM 70mls, 5mls/sec
- Gantry tilted (~15o), Line from orbital roof to ant aspect of foramen magnum ∟ Horizontal plane
Coverage Caudo-cranial: BOS – Vertex (must cover COW)
Technique - Spiral / helical technique
- Contrast scanning:
a) Delayed scan - Spiral scan after delay of 15-18sec
b) Bolus tracking - Place ROI at arch of aorta
- Triggering HU: 100 – 120 HU
c) Test bolus - Place ROI at basilar artery
- Test bolus wt IV LOCM 15mls, 5mls/sec
- Repeat scans using estimated delay time after contrast injection
- CTV: Delay at 100sec
- Acquired slice thickness: 1mm (Detector configuration: 0.6mm x 64 per scan)

- Recon to VRT (volume rendering technique): 1mm slice thickness
- Recon to coloured perfusion images → Demonstrate cerebral blood volume & time-to-peak
Window Soft tissue setting: 450 WW / 50 WL
4. CT Perfusion of Brain
Indication Indication: Contraindication:
a) Acute ischaemic stroke (< 9hrs of onset) a) Haemorrhagic stroke
b) Assess the potentially salvageable brain tissue b) Ischaemic stroke
(i) Onset > 9hrs
(perfusion & penumbra)
(ii) Mild stroke (NIHSS <4), Severe (NIHSS >25)
Penumbra: Area surrounding infarcted core where damage is reversible

- IV LOCM 50mls, 5mls/sec + Saline 50mls, 4mls/sec (CTP)
- Another IV LOCM 50mls, 5mls/sec + Saline 50mls, 4mls/sec (CTA)
- Gantry tilted, Line from orbital roof to ant aspect of foramen magnum ∟ Horizontal plane
Coverage
- Protocol:
a) Plain CT brain TRO haemorrhage & large completed infarction
b) CT perfusion - Multiple scans at center of infarct / region of basal ganglia, dynamically for 40sec
- Wait for 5mins for contrast washout, then proceed with CTA
c) CTA brain To look for vascular stenosis & Lt heart thrombus, help in identifying center of infarct

Din XJ
225
HEAD & NECK

1. CT Neck
Indication a) Infection / inflammation
b) Thyroid pathology
c) Neck pathology / tumour
d) Neck vascular pathology / anomaly
Contrast IV LOCM 70mls, 3mls/sec
Position Supine, OML ∟ Table
Topogram Lateral neck
Coverage Cranio-caudal: BOS (at glabella) – Arch of aorta
Technique - Spiral technique
- Scan at 45sec delay
- No swallowing during exposure, don’t have to suspend respiration

- Recon slice thickness (for medweb): 5mm
If looking at thyroid pathology: 3mm at thyroid region
- MPR (multiplanar recon): 1mm slice thickness with 30% overlapping
2. CT Cervical Spine
Indication Trauma
Exposure
Contrast Plain
- Slices ║ Disc space
Topogram Lateral neck
Coverage Cranio-caudal: C1 – T1
- Slices ║ Disc space

Window Bone setting: 1,500 WW / 500 WL
Soft tissue setting (If indicated)
3. HRCT Temporal (IAM)

Indication a) Trauma
b) Infection / inflammation
c) Tumour
d) Investigation for conductive / sensorineural hearing loss
e) Assessment for cochlear implant
Contrast Plain
Position a) Axial: Supine, OML ∟ Table
b) Coronal: Prone, neck extended
Topogram Lateral skull
Slices 20o cranial to OML, passing through EAM
Coverage Caudo-cranial: BOS – Tip of mastoid process
- Use bone algorithm wt high resolution (kernel B70)

Window Bone setting: 1,500 WW / 500 WL
Din XJ
226
4. CT Orbit
Indication a) Trauma
b) Infection / inflammation
c) Tumour
Contrast a) Plain
b) Contrast: SOL & intracranial involvement
- IV LOCM 50mls (bolus hand injection)
Position a) Axial: Supine, OML ∟ Table
Slices ║ Hard palate
b) Coronal: Prone, neck extended
Slices ∟ Hard palate
Coverage a) Axial Caudo-cranial: Orbital floor – Orbital roof
b) Coronal AP: Orbital rim – Clivus

5. CT PNS
Indication a) Congenital anomaly
b) Trauma
c) Infection / inflammation: Sinusitis
d) Tumour
Contrast a) Plain
b) Contrast: SOL & intracranial involvement
- IV LOCM 50mls (bolus hand injection)
Position a) Axial Supine, OML ∟ Table
Slices ║ Hard palate
b) Coronal Prone, neck extended
Slices ∟ Hard palate
Coverage a) Axial Caudo-cranial: Inferior maxillary sinuses – Slightly above frontal sinuses
b) Coronal AP: Anterior nose – Sphenoid sinuses

Bone setting: 1,500 WW / 500 WL (if looking for OMC)
6. CTA Carotid Arteries

Indication a) Vascular anomaly: Aneurysm
b) Assessment for cerebral vascular insufficiency: Acute stroke, TIA, unexplained neuro deficit, headache
c) Following trauma: Facial fracture, cervical fracture, major thoracic injuries
Coverage Caudo-cranial: Below aortic arch – COW
Technique - Place ROI at arch of aorta

Din XJ
227
HEART & THORAX

1. CT Thorax
Indication a) Lung mass
b) Lung metastasis
Contrast IV LOCM 70mls, 3mls/sec
Upper limbs above the head
Topogram AP Chest
Coverage Cranio-caudal: 5cm above shoulder (include lung apices) – Adrenal glands
- Scan at 45sec delay
- Use mediastinal algorithm wt medium resolution (kernel 30)

Lung setting: 1,500 WW / -500 WL
2. HRCT Thorax
Indication a) Diffuse infiltrative lung disease
b) Interstitial lung pathology (Bronchiectasis)
c) Airway stenosis
Contrast Plain
May compliment with prone (to confirm reversible dependent changes)
Topogram AP Chest
Coverage Caudo-cranial: Below diaphragm (include lung bases) – 5cm above shoulder (include lung apices)
- Use bone algorithm wt high resolution (kernel B70-80)

Window Lung setting: 1,500 WW / -500 WL (Normal lung density: -700 to -800 HU)
3. CT Pulmonary Angiogram
Indication Pulmonary embolism, down to subsegmental level
May complement wt CT venogram for lower limbs (to look for DVT)
Contrast Green line, at antecubital fossa
IV LOCM 70 – 100mls, 5mls/sec
Topogram AP Chest
Coverage Cranio-caudal: Lung apices (just above aortic arch) – Lung bases(just above diaphragm)
- Contrast scanning:
a) Delayed scan - Contrast injection
- Spiral scan after delay of 15sec
b) Bolus tracking - Place ROI at pulmonary trunk

PE-specific window: 700 WW / 100 WW
Lung setting: 1,500 WW / -500 WL
Din XJ
228
4. CTA Thoracic Aorta

Indication Assess thoracic aorta (rupture, aneurysm)
IV LOCM 100mls, 5mls/sec
Topogram AP Chest
Coverage Cranio-caudal: Lung apices (just above aortic arch) – Lung bases (just above diaphragm)
Technique - Place ROI at descending aorta, just distal to aortic arch
5. CTA Coronary Artery

Indication a) Assess coronary arterial disease, as alternative to DSA coronary artery
b) Assess congenital anomalies of coronary arteries
c) Assess patency of coronary artery grafts / stents, as alternative to DSA coronary artery
d) Screening for symptomatic patient wt equivocal stress test or atypical chest pain
e) Screening for asymptomatic patient wt high coronary risk
Patient radiation dose for CTA coronary (6-25 mSv) > Conventional catheter angiography (5.6 mSv)
Patient’s criteria a) Heart rate < 65 (Depends on CT machine used)
b) Sinus rhythm
c) Able to hold breath for 15sec
Preparation - NBM 4hrs, Avoid caffeine 12hrs before scanning
- Give medications to ↓ HR:
a) T. Metoprolol 50-100mg the night & 30-60 mins before scanning, max 150mg
b) T. Verapamil 80mg, max 120mg (If metoprolol contraindicated: BA, heart block, ↓ HR, ↓ BP)
- Give T. Lorazepam (Ativan) 0.5mg before scanning, to ↓ anxiety & HR
- Give S/L GTN (if HR > 55, SBP > 100mmHg) on gantry, to dilate coronary arteries
- Practice breathing technique: Inhale, exhale, inhale then hold
Contrast - Green line, at antecubital fossa (preferably right side, to ↓ streak artifacts from left subclavian art)
- IV LOCM (iopamero 370) 60 – 80mls, 5mls/sec
Contrast volume = Scan time (from above arch of aorta – below apex of heart) x 5 mls/sec
Position Supine
Topogram AP Chest
Coverage Cranio-caudal: Above arch of aorta – Below apex of heart
Technique - Place ECG: 2 at midclavicular, 1 at left subcostal
- Choose cardiac CTA coronary protocol-gating system
- Perform scout image (suspend breathing, inhale, exhale, inhale then hold)
- Scan for plain images (important to calculate calcium score): Do not proceed with CTA if Ca score >800
- Contrast injection (Test bolus technique):
- Place ROI at ascending aorta (aortic root)
- Test bolus wt IV LOCM 10mls + saline 50mls
- Repeated scans at ROI (ascending aorta), every 2sec
- Time to peak enhancement is estimated
- Repeat scans using estimated delay time after contrast injection (60 – 80mls) + NS 50mls
- Types of study:
a) Prospective Scan throughout cardiac cycle Images are reconstructed later
Higher patient dose
b) Retrospective Only scan at mid diastollic Limited images taken
Less patient dose
- Recon window: 60% of RR interval
Calcium score: Calculated from volume of calcium in coronary arteries (↑ CAC score → ↑ Risk of coronary event)
Calcium score (CAC score) Implications CV risk
0 No identifiable atherosclerotic plaque Very low
1 – 10 Minimal plaque Low
11 – 100 Mild plaque Moderate
101 – 400 Moderate plaque High
> 400 Extensive plaque Very high
Din XJ
229
ABDOMEN
1. CT Abdomen-Pelvis
Indication a) Abdominal mass c) Intestinal obstruction
b) Tumour staging d) Altered bowel habit in elderly
Contrast a) Oral contrast: 3% Gastrograffin, 250-300mls x 3doses, 30mins before scanning
2% Barium is an alternative
b) Rectal contrast: 3% Gastrograffin, 100mls
c) IV Contrast: IV LOCM 100mls, 3mls/sec
May require tampon for female
Topogram AP Abdomen
Coverage If just abdomen Caudo-cranial: Iliac crest – Dome of diaphragm
If abdomen-pelvis Symphysis pubis – Dome of diaphragm
- Scan at 60sec delay (porto-venous phase), delayed bladder view at 5mins may be required
2. CT Colonography
Indication a) Screening for individual at high risk of colon ca
b) Failed / incomplete colonoscopy
c) Patient’s refusal for colonoscopy
Preparation Full bowel preparation
Exposure 80mA (Low dose technique)
Contrast Rectal contrast: Air or CO2
Position Supine & prone
Topogram AP & PA Abdomen
Coverage Dome of diaphragm – Symphysis pubis
Technique - Patient in left lateral position
- Insert Foley’s catheter / rectal tube into the rectum
- Air or CO2 insufflated, IV Buscopan 20mg or IV Glucagon 1mg given during insufflation
- Scan abdomen in supine & prone position
- Recon
a) 2D MPR images
b) 3D endoluminal (fly through) images
3. CT Abdomen: Liver 4 phase

Indication a) Diagnosis & assessment of liver pathology: Infection, malignancy, metastasis
b) Screening for patient at high risk for HCC
Topogram AP Abdomen
Coverage a) Plain Only liver
b) Arterial phase Only liver
c) Porto-venous phase Liver – Iliac crest
d) Delayed phase Only liver
- Scan for (a) plain study
- Contrast injection (delayed scan / bolus timing)
- Phases:
b) Arterial phase Delay at 30sec
c) Porto-venous phase Delay at 60sec (40sec delay from arterial phase)
d) Delayed phase Delay at 5mins
Din XJ
230
4. CT Abdomen: Pancreatic Protocol

Indication a) Diagnosis & assessment of pancreatic mass: Malignancy, metastasis
b) Pancreatitis & its complications (eg. Necrosis)
c) Obstructive jaundice
Contrast a) Oral water, as negative contrast
- Plain water, 250-300mls x 3doses, 30mins before scanning
- Last dose on gantry, just before scanning
b) IV contrast
- Green line, at antecubital fossa
Topogram AP Abdomen
Coverage a) Plain Only pancreas (T12 – L3)
b) Arterial phase Only pancreas (T12 – L3)
c) Porto-venous phase Dome of diaphragm – Iliac crest
d) Delayed phase Only pancreas (T12 – L3)
- Phases:
b) Arterial phase Delay at 15sec
c) Porto-venous phase Delay at 35sec (20sec delay from arterial phase)
d) Delayed phase Delay at 5mins

5. CT Cholangiography
MR Cholangiography is usually a better option
Indication a) Cholelithiasis
b) Other biliary abnormality: Polyps, congenital abnormalities
c) Traumatic biliary injury
d) Pre-op screening of anatomy
Exposure
Contrast Cholangiographic agent → Opacification of biliary tree
a) IV Meglumineiotroxate 100mls, over 50mins OR
b) IV Iodipamidemeglumine 52% 20mls diluted wt NS 80mls, over 30mins
Topogram AP Abdomen
Coverage
Technique Scan after 30mins contrast injection
6. CT Urogram
Indication a) Investigation for renal colic
b) Assessment of renal calculi / obstructive uropathy
Contrast Plain
Full bladder
Position Supine
Topogram AP Abdomen
Coverage Caudo-cranial: Symphysis pubis (include bladder) – Top of the kidneys

Din XJ
231
7. CT IV Urogram
Indication a) Investigation for renal colic
b) Assessment of renal calculi / obstructive uropathy
c) Assessment of renal parenchymal & collecting system
Contrast - Full bladder
Position Supine
Topogram AP Abdomen
Coverage a) Plain Top of the kidneys – Symphysis pubis (include bladder)
b) Nephrographic Only kidneys
c) Delayed kidney & bladder Top of the kidneys – Symphysis pubis (include bladder)
* No cortico-medullary phase
- Phases:
b) Nephrographic Delay at 100 – 120sec
c) Delayed bladder Delay at 5mins

8. CT Renal 4 phase
Indication Diagnosis of renal mass
Topogram AP Abdomen
Coverage a) Plain Only kidneys
b) Cortico-medullary phase (Arterial) Only kidneys
c) Nephrographic phase (Venous) Doom of diaphragm – Symphysis pubis
d) Excretory phase (Delayed) Upper border of kidneys – Symphysis pubis
- Phases:
b) Cortico-medullary phase (Arterial) Delay at 30sec
c) Nephrographic phase (Venous) Delay at 60sec (Delay 30sec from cortico-medullary phase)
d) Excretory phase (Delayed) Delay at 5mins

Arterial (Cortico-medullary) phase: Venous (Nephrographic) phase: Delayed (Excretory) phase:
Din XJ
232
9. CT Adrenal Protocol
Indication Diagnosis of adrenal mass
Suspicious of pheochromocytoma (must correlate wt HPT, VMA level)
Contrast a) Plain (if suspect pheochromocytoma)
b) Contrast
- Oral water
- IV LOCM 100mls, 5mls/sec (not to be given if suspect pheochromocytoma, as it may precipitate HPT crisis !!)
Topogram AP Abdomen
Coverage Adrenal glands – Bifurcation
- Phases: * No arterial phase
b) Porto-venous phase Delay at 60sec
c) Delayed phase Delay at 10mins

10. CTA Abdominal Aorta

Indication Assess abdominal aorta (rupture, aneurysm)
IV LOCM 100mls, 5mls/sec
Topogram AP Abdomen
Coverage Cranio-caudal: Dome of diaphragm – Symphysis pubis
- Place ROI at abdominal aorta, level of celiac trunk

11. CTA Renal

Indication a) Renal artery: Stenosis, aneurysm, AV fistula, AVM, thrombosis
b) Renal vein: Thrombosis, tumour
c) Delineation of vascular anatomy before laparascopic surgery (Eg. Nephrectomy)
Exposure
Topogram AP Abdomen
Collimation Cranio-caudal: Region of kidneys
- Place ROI at abdominal aorta, level of infrarenal

- Recon to VRT (volume rendering technique): 1mm slice thickness with 30% overlapping
Din XJ
233
12. CTA Mesentery

Indication a) Lower GI bleed
b) Bowel / mesenteric ischaemia
Contrast - No oral / rectal contrast (if indication is bleeding) !
- Green line, at antecubital fossa
Position Supine
Topogram AP Abdomen
Coverage Cranio-caudal: Dome of diaphragm – Symphysis pubis
- Place ROI at abdominal aorta, level of celiac trunk
- If the indication is bleeding:

a) Plain
b) Arterial phase: Bolus tracking
c) Delayed phase: Delay at 5mins

CT Thorax-Abdomen-Pelvis
Indication a) Diagnosis & staging of malignancy
b) Assessment of treatment response
Contrast a) Oral contrast: 3% Gastrograffin, 250-300mls x 3doses, 30mins before scanning
2% Barium is an alternative
b) Rectal contrast: 3% Gastrograffin, 100mls
c) IV Contrast: IV LOCM 100 - 120mls, 3mls/sec
May require tampon for female

Topogram AP Chest &Abdomen
Coverage 5cm above shoulder (include lung apices) – Symphysis pubis
- Scan at 60sec delay (porto-venous phase)
- Delayed bladder view at 5mins may be required

Din XJ
234
MUSCULOSKELETAL
1. CTA Lower Limb
Indication a) Lower limb ischaemia
b) AVM of lower limb
c) Vascular injury following trauma of lower limb
Exposure
Position Supine
Topogram AP LL
Coverage Cranio-caudal: Iliac crest – Tip of toes
- Place ROI at abdominal aorta, level of infrarenal

- Recon to VRT (volume rendering technique): 1mm slice thickness with 30% overlapping
2. CT Venogram Lower Limb

a) Direct CT Venogram
- Direct contrast injection via foot vein
- Not used in clinical practice
b) Indirect CT Venogram
Indication Suspected lower limb DVT in patient wt PE, after CTPA
Not recommended for patient wt suspected lower limb DVT, but without PE (no diagnostic advantage over Doppler US)
Exposure
a) Adult: IV LOCM 70 – 100mls, 5mls/sec
b) Paeds: IV LOCM 2 mls/kg
Position Supine
Topogram AP LL
Coverage Cranio-caudal: Iliac crest – Popliteal fossa
- Delay at 2mins, after completion of CTPA
Din XJ
Chapter 8 MAGNETIC
RESONANCE
IMAGING
(MRI)
235
GENERAL PRINCIPLES
A. T1 & T2 weighted images
TR TE
T1 Short (< 500 ms) Short (< 30 ms)
T2 Long (> 1,500 ms) Long (> 80 ms)
Proton spin density (PD) Long Short
B. Signal intensity
T1-weighted T2-weighted PD-weighted
Hyperintense (Bright)
1 Fat Water, CSF Fat, fluid (joint fluid) 1
2 Marrow 2
3 3
4 Intervertebral disc 4
5 Brain (white matter) Brain (grey matter) 5
6 6
7 Liver, pancreas Spleen 7
8 Brain (grey matter) Muscle, hyaline cartilage 8
9 Kidney 9
10 Spleen 10
11 11
12 Brain (white matter) 12
13 Liver 13
14 CSF Fat 14
15 Water, lung Iron in basal ganglia 15
16 Air, cortical bone, flowing blood Air, bone, flowing blood Fibrocartilage 16
Hypointense (Dark)
C. Clinical applications of common MR sequences

1. T1-w sequences
a) T1-w SE or FSE - Good contrast & spatial resolution, but slow
b) T1-w 2D GRE
- SPGR, T1-TFE, FLASH - Fast, but ↓ contrast & spatial resolution
- In- & out-of-phase imaging - Fat suppression sequence
c) T1-w 3D GRE (3D-FLASH,VIBE,LAVA,THRIVE) - Fastest T1-w sequence → For multiphasic & dynamic studies
d) T1-w IR (MPRAGE & T1-FLAIR) - For neuro-imaging
2. T2-w sequences
a) T2-w SE or FSE - Good contrast & spatial resolution, but slow
SSFSE (HASTE) - Very fast → For cardiac, bowel, fetal imaging
Can acquire ↑TE (heavily T2w) wt thin slice → For MRCP, MRU, MR myelography
b) T2-w 2D GRE (Balanced SSFP) - Very fast wt highest SNR, but ↓ resolution → For cardiac, bowel, fetal imaging
c) T2-w 3D GRE (CISS-3D) - Provide thin slice wt ↑ resolution → For IAC & CP angle pathology
d) T2-w IR: STIR - Fat suppression → For spine (bone marrow), orbital imaging
T2-FLAIR - Fluid attenuation → For neuro-imaging
3. T2*-w sequences Gradient Hemo (MPGR, T2-FFE), SWI → For haemorrhage, calcification
a) T2*-w spoiled GRE (MEDIC) Cartilage sensitive sequences (DESS, MEDIC) → For joint imaging
b) T2*-w steady-state GRE (MPGR, T2-FFE, DESS)
c) T2*-w EPI
Din XJ
236
D. Summary of MR sequences
1. Saturation recovery sequences a) T1-weighted image
b) T2*-weighted image
c) Proton/spin density-weighted image (PD)
2. Spin echo sequences (SE) a) Dual / Double Spin Echo Sequence
a) T1-w image b) Fast / Turbo Spin Echo Sequence (FSE / TSE): HASTE, RARE
b) T2-w image c) Single-shot FSE Sequence (SSFSE)
c) Proton/spin density-w image (PD)
3. Gradient/Field echo sequences (GRE) a) Spoiled/incoherent GRE: SPGR, T1-TFE & T2-TFE, MEDIC, FLASH, VIBE, LAVA, THRIVE
a) T1-w image b) Steady-state free precession (SSFP)
b) T2*-w image (i) Post-excitation refocused steady-state sequences: T1-FFE, FISP, GRASS
c) Proton/spin density-w image (PD) (ii) Pre-excitation refocused steady-state sequences: T2-FFE, Reverse FISP (PSIF)
d) In-phase & Out-of-phase (iii) Fully refocused / Balanced SSFP sequences: Balanced FFE, True FISP, CISS,
(modification of T1-w 2D GRE) DESS, FIESTA
4. Inversion recovery sequences (IR) a) Short tau inversion recovery (STIR)
b) Fluid attenuation inversion recovery (FLAIR)
c) Turbo inversion recovery magnitude (TIRM)
d) Double inversion recovery (DIR)
5. Echo-planar pulse sequences (EPI) EPI GRE & EPI SE
6. Fat suppression sequences a) Frequency-selective fat suppression (CHESS, Fat sat)
b) Short tau inversion recovery (STIR)
c) Out-of-phase imaging
d) Dixon method
e) Water selective excitation
7. Diffusion weighted sequences a) Diffusion weighted image (DWI)
b) Apparent diffusion coefficient (ADC)
c) Diffusion tensor imaging (DTI)
8. Perfusion weighted imaging
9. Susceptibility weighted imaging (SWI) Magnitude, filtered phase, SWI, MIP SWI
10. Flow sensitive sequences a) MR angiography (MRA): (i) Conventional MRI – Black blood (SE) & Bright blood (GRE)
(ii) Non-contrast enhanced MRA – TOF & phase contrast
(iii) Contrast enhanced TOF MRA
b) MR venography (MRV)
c) CSF flow study
11. MR spectroscopy
12. Functional MRI BOLD imaging
Din XJ
237
BRAIN
A. Routine brain
Position - Supine, head first
- Head in head coil, in symmetry position (nose & outer canthus as reference point)
- Centering point: Nasion / Galbella
Scout images - Planes: Axial, sagittal, coronal (3 slices in each plane)
- SL: 8mm, FOV: 230mm2, TR: 7ms, TE: 2.95ms
Planes:
1. Axial - Planes: Parallel to temporal lobe Axial
- Coverage: Vertex – Foramen magnum
- Total slice ≈ 19
- SL: 5mm, FOV: 230mm2
2. Coronal - Planes: Perpendicular to axial plane
(temporal lobe)
- Coverage: From frontal sinus,
to cover the whole brain
Coronal
3. Sagittal - Planes: Parallel to interhemispheric fissure
- Coverage: Right – Left parietal bone
4. T1 MPRAGE - Planes: Acquire sagittal images
(Parallel to interhemispheric fissure)
- Coverage: Right – Left parietal bone
- TR: 1,900ms, TE: 3ms Sagittal
- Post-processing axial, coronal & sagittal
images (SL: 5mm)
5. T2 CISS 3D - Planes: Acquire axial (IAC) images
Parallel to temporal lobe (Coronal image)
Parallel to hard palate (Sagittal image)
- Coverage: Pons & IAC
- SL: 0.5mm, FOV: 200mm2
- TR: 5.78ms, TE: 2.42ms
Sequence
1. T1 TR: 450ms, TE: 9ms - Anatomy scan
2. T2 TR: 5,000ms, TE: 103ms - Pathology scan
3. T2 FLAIR TR: 8,000ms, TE: 106ms, TI: 2,500ms - Better visualization of periventricular lesion & multiple sclerosis
4. T1 med IR TR: 8,600ms, TE: 66ms, TI: 400ms - Detect cortical dysplasia & migrational abN (epilepsy)
4. T2 FLASH - TR: 800ms, TE: 26ms - Detect haemorrhage (Ferritin, hemosiderin) & calcification
GRE (Hemo)
5. DWI / ADC TR: 3,300ms, TE: 97ms - Detect restricted diffusion
4 sets of images: b=0, b=500, b=1,000, ADC
Flow sequence MRA-TOF
1. MRA-TOF - Planes: Parallel to BOS
COW - Coverage: COW & basilar artery
- SL: 0.6mm, FOV: 180mm2
- TR: 24ms, TE: 7ms
Din XJ
238
2. MRV-phase - Plan the coronal plane on sagittal image MRV-phase contrast

contrast - Planes: 10o to midline of the brain
(to reduce the in plane saturation effects)
- Coverage: Left – right temporal lobe
- TR: 70ms, TE: 8ms
B. Common Protocols
Indications Protocol
1. Stroke Axial: T1, T2, T2 FLASH - GRE or SWI, DWI/ADC
Sagittal: T1, T1 MPRAGE
Coronal: T2 FLAIR
MRA-TOF COW & Neck ± Gadolinium
MRV-phase contrast (if infarcts are peripheral or haemorrhagic, TRO venous sinus thrombosis)
2. ICB Axial: T1, T1 (CE), T2, T2 FLASH - GRE or SWI, DWI/ADC
Sagittal: T1, T1 (CE)
Coronal: T1 (CE), T2 FLAIR
MRA-TOF COW ± Gadolinium (if vascular malformation)
MRV-phase contrast (if infarcts are peripheral or haemorrhagic, TRO venous sinus thrombosis)
3. Vasculitis Axial: T1, T1 (CE), T2, T2 FLASH - GRE or SWI, DWI/ADC
Sagittal: T1 MPRAGE
Coronal: T1 (CE)
MRA-TOF COW ± Gadolinium
4. Dementia & Axial: T1, T2, T2 FLASH – GRE, DWI/ADC
neuro-psychiatric problem Coronal: T2 FLAIR,
Sagittal: T1 MPRAGE
MRA-TOF COW
5. Demyelination (MS) Axial: T1 ± T1 (CE), T2, T2 FLAIR
Sagittal: T1, T2, T2 FLAIR
Coronal: ± T1 (CE), T2
Spinal cord
T2 in all 3 planes: Mainstay for demyelinating lesions
FLAIR: To assess periventricular lesions
FLAIR sagittal: Best shows callaso-septal lesions
Spinal cord: TRO cord involvement
6. Epilepsy 1. TRO SOL or cortical dysplasia
2. Assess temporal lobes & hippocampus (esp in partial seizure)
Axial (whole brain): T2
Coronal (whole brain): T2, T2 FLAIR
(only temporal lobes): Medium T1 IR
Sagittal: T1 MPRAGE
T2 FLAIR: to look for small cortical epileptogenic foci & abN signal in the mesial temporal sclerosis
Medium T1 IR: To look for cortical dysplasia & migrational abN
7. Tumour & Infection 1. Differentiate neoplastic from non-neoplastic lesion (Eg. Infection)
2. Grading of tumour
3. Guiding for biopsy or surgery
4. Spinal cord screening TRO drop metastasis
(ependymoma, medulloblastoma, hemangioblastoma, choroid plexus tumour)
Axial: T1, T1 (CE), T2, T2 FLASH - GRE or SWI, DWI / ADC
Coronal: T1 (CE), T2 FLAIR
Sagittal: T1 MPRAGE (CE)
Spectroscopy for mass
Din XJ
239
T1 T2 T2 FLAIR GRE
SWI SWI (Phase image) DWI (b=1,000) ADC

MRA-TOF COW MIP Reconstruction
MRV-phase contrast MIP Reconstruction
Din XJ
240
C. Sella
Indications 1. Pituitary lesions (adenoma, macroadenoma, microadenoma)
2. Endocrine abnormalities (hypopituitarism, prolactinoma, Cushing’s ds)
Planes
1. Axial - Planes: Parallel to temporal lobe
(Whole brain) - Coverage: Vertex – Foramen magnum Sagittal Coronal
2. Sagittal - Planes: Planned on axial image at cavernous sinus
(Pit fossa) Parallel to midline
- Coverage: The whole cavernous sinus
3. Coronal - Planes: Planned on mid-sagittal image
(Pit fossa) Perpendicular to sellar floor (or pituitary stalk)
- Coverage: Orbital apex – Petrous apex
- Total slice ≈ 11 (5 for dynamic study)
Protocol All cases except microadenoma: Pituitary microadenoma:
Axial (whole brain): T1, T1 (CE), T2, T2 FLAIR Axial (whole brain): T1, T1 (CE), T2, T2 FLAIR
Sagittal (pit fossa): T1, T1 (CE), T2, T1 MPRAGE CE) Sagittal (pit fossa): T1, T1 (CE), T2, T1 MPRAGE CE)
Coronal (pit fossa): T1, T1 (CE), T2 Coronal (pit fossa): T1, T1 (CE), T2, T1 (CE) dynamic study
D. CP Angle / Internal Auditory Canal (IAC)

Indications 1. Ear symptoms (hearing loss, tinnitus, dizziness, vertigo)
2. Infection & Inflammation (abscess, mastoiditis, osteomyelitis)
3. Tumour (acoustic neuroma, schwannoma)
4. Assessment for cochlear implant
Scout image - Planes: Axial, sagittal, coronal (3 slices in each plane)
Planes:
1. Axial - Planes: Parallel to temporal lobe Axial (IAC)
(Whole brain) - Coverage: Vertex – Foramen magnum
2. Axial - Planes: Parallel to temporal lobe (Coronal image)
(Post fossa) Parallel to hard palate (Sagittal image)
3. Coronal - Planes: Parallel to lines connecting IAM
Coronal (IAC)
(Post fossa) - Coverage: Pons (anterior ½) & IAC
4. T2 CISS 3D - Planes: Acquire axial (IAC) images
Parallel to temporal lobe (Coronal image)
Parallel to hard palate (Sagittal image)
- SL: 0.5mm, FOV: 200mm2
- TR: 5.78ms, TE: 2.42ms
Protocol Axial (whole brain): T2 CISS 3D: Shows dark cranial nerves (VII & VIII) in the bright CSF
Axial (Post fossa): T1, T1 (CE), T2, T2 CISS 3D IV Gadolinium: TRO labrynthitis & SOL (acoustic neuroma)
Coronal (Post fossa): T2 MRA: TRO vascular loop
Post-gado: T1 axial (Post fossa)
Din XJ
241
E. Trigeminal / Facial Nerve Neuralgia

Indications 1. Facial symptoms (hemifacial spasm, trigeminal neuralgia)
2. Infection & Inflammation
3. Tumour (schwannoma)
Protocol Axial (whole brain): T1, T2, T2 FLAIR, T1 MPRAGE (CE)
Axial (Post fossa): T1, T1 (CE), T2, T2 CISS 3D
Coronal (Post fossa): T1, T1 (CE), T2
Sagittal: T2
MRA-TOF COW
T1 axial T2 axial T1 coronal T2 coronal
T2 CISS 3D axial
Din XJ
242
F. Orbit
Indications 1. Eye symptoms (suspected intra-orbital or visual pathway lesions, diplopia)
2. Infection & Inflammation (orbital cellulitis/abscess, optic neuritis)
3. Tumour (retinoblastoma, orbital pseudotumour)
4. Thyroid eye disease
5. Trauma
Planes
1. Axial - Planes: Parallel to temporal lobe Axial (orbit)
(Whole brain) - Coverage: Vertex – Foramen magnum
2. Axial - Planes: Parallel to optic nerve / temporal lobe
(Orbit) - Coverage: Orbital roof – Orbital floor
3. Coronal - Planes: Perpendicular to optic nerve / temporal lobe
(Orbit) - Coverage: Eye lid – To include cavernous sinus
- SL: 3mm, FOV: 220mm2 Coronal (orbit)
Protocol Axial (whole brain): T1, T1 (CE), T2, T2 FLAIR

Axial (orbit): T1 fat sat, T1 fat sat (CE), T2 fat sat
Coronal (orbit): T1 fat sat, T1 fat sat (CE), T2 fat sat
T1 coronal T2 fat sat coronal T2 fat sat axial
Din XJ
243
HEAD & NECK

A. Neck
Indications 1. Neck infection / abscess
2. Tumour (diagnosis & staging): Intracranial (tumour extension),
nasal & paranasal, NPC, tongue, larynx, salivary gland, lymphoma
3. Disorders of the thyroid, parathyroid & throat
4. Demonstration of cranial nerve and other intracranial disease resulting in head & neck symptoms
- Head in head & neck coil, in symmetry position (nasal bridge & outer canthus as reference point)
- Centering point: Nasion / Galbella
Scout - Planes: Axial, sagittal, coronal (3 slices in each plane)
image - SL: 8mm, FOV: 230mm2, TR: 7ms, TE: 2.95ms
Planes:
1. Axial - Planes: Parallel to hard palate Axial
- Coverage: Just above BOS – Thoracic inlet
2. Coronal - Planes: Perpendicular to axial plane & hard palate

- Coverage: Tip of nose – Soft tissue at back of neck
3. Sagittal - Planes: Parallel to interhemispheric fissure

- Coverage: Right to left parietal bone
Coronal
Sagittal
Sequence:
1. T1 TR: 450ms, TE: 17ms
2. T2 TR: 5,000ms, TE: 110ms
Protocol Axial: T1, T1 fat sat, T1 fat sat (CE), T2 fat sat
Coronal: T1, T1 fat sat, T1 fat sat (CE)
Sagittal: T1 MPRAGE
Din XJ
244
B. Temporo-Mandibular Joint
Indications 1. Pain (TMJ headache, pain in the jaw, ear area, tooth, neck, shoulder)
2. Jaw movement (Irregular movement, difficult movement, clicking sounds during jaw movement)
Preparation - Practice open/close mouth technique wt patient (may need to fashion bite block, to maintain open mouth position)
- Patient has to chew gum intensely for at least 20mins
- Inject IV Gadolinium 0.1 – 0.2 mmol/kg 30mins before scan
- Use TMJ double coil, in symmetry position (nasal bridge & outer canthus as reference point)
Planes
1. Coronal - Scout: Axial image Coronal
- Planes: Across each mandibular condyle
(≈20o off horizontal plane)
2. Sagittal - Scout: Axial image

- Planes: Across each mandibular condyle
(≈70o & 110o off horizontal plane)
Sagittal
Protocol Coronal: T1,

Sagittal: T1 (neutral, open-mouth, close-mouth)
T1 sagittal (close-mouth) T1 sagittal (open-mouth)
Din XJ
245
SPINE
Indications:
1. Cord compression, radiculopathy/myelopathy, cauda equina synd 5. Demyelinating disease (MS), syringomyelia
2. Infection / inflammation 6. Scoliosis (MR whole spine)
3. Tumour, drop metastases of CNS tumour 7. Previous spinal surgery
4. Trauma
Bone marrow - Yellow marrow: Bright on T1, isointense on T2 (contains fat)
- Red marrow: Dark on T1, bright on T2 (contains hematopoietic tissue)
- As a child grow, red marrow converts gradually into yellow marrow
Intervertebral disc - Annulus fibrosus: Dark in all sequence (low mobile proton density)
- Nucleus pulposus: Dark on T1, bright on T2 (high water content)
- Internuclear cleft: Central dark horizontal area in nucleus pulposus on T2 (in adult > 30yrs)
Spinal cord Grey on both T1 & T2
A. Cervical Spine
Position - Supine, head first, arms by each side
- Use head & neck coils, in symmetry position (nasal bridge & outer canthus as reference point)
- Centering point: Thyroid cartilage
Scout image - Planes: Sagittal, axial, coronal (3 slices in each plane)
Planes: Sagittal
1. Sagittal - Scout: Coronal neck & upper chest
- Planes: Straight sagittal (Parallel to spine)
- Coverage:
Superior Craniovertebral junction
Inferior Upper thoracic vertebra
Lateral Transverse process on both sides
2. Axial - Scout: Mid-sagittal & coronal images

- Planes: Perpendicular to coronal
Axial
- Coverage: Include all abN levels
Protocol Sagittal: T1, ± T1 (CE), T2, ± STIR

Axial (selective cut): T1, ± T1 (CE), T2, ± STIR
± IV Gado: T1 sagittal, T1 axial
T1 T2 T2 STIR
Din XJ
246
B. Thoracic Spine
- Use head, neck & spine coils, in symmetry position (mid-sagittal line as reference point)
Scout image - 2 sets of scout images: Cervico-thoracic & Thoraco-lumbar
- Planes: Sagittal, axial, coronal (3 slices in each plane)
Planes:
1. Sagittal - Scout: Coronal cervico-thoracic region (upper thorax) Sagittal
Coronal thoraco-lumbar region (lower thorax)
- Coverage:
Upper thorax:
Superior Craniovertebral junction
Inferior Whole thoracic vertebrae
Lower thorax:
Superior C7/T1 junction
Inferior Sacral vertebra
- Total slice ≈ 19 (each)
2. Axial - Scout: Mid-sagittal & coronal images Axial

- Coverage: Include all abN levels
- SL: 3-5mm, FOV: 200mm2

Din XJ
247
C. Lumbosacral Spine
Scout image - Planes: Sagittal, axial, coronal (3 slices in each plane)
Planes: Sagittal
1. Sagittal - Scout: Coronal thoraco-lumbar region
- Coverage:
Superior T12/L1 junction
Inferior Coccyx vertebra

Can be done as 1 stack or MSMA (parallel to end plate)
- Coverage: Include all abN levels Axial
- SL: 3-5mm, FOV: 200mm2

T1 T2 T2 STIR
Din XJ
248
D. Whole Spine
Scout image - 2 sets of scout images: Cervico-thoracic & Thoraco-lumbar
- Planes: Sagittal, axial, coronal (3 slices in each plane)
Planes: Sagittal
1. Sagittal - Scout: Coronal spine
- Coverage:
1st stack C1 – T6
2nd stack T5 – S4
2. Coronal - Scout: Mid-sagittal & axial images

- Planes: Straight coronal
- Coverage:
Anterior Most anterior vertebral body
Posterior Most posterior spinous process Coronal

- Planes: Parallel to intervertebral discs
(at levels wt abnormalities)
- Coverage:
Superior Lower end plate of vertebra above
Inferior Upper end plate of vertebra below
Axial
Protocol Sagittal: T1, T2, STIR

Coronal: T1, T1 FLASH 3D (GRE), T2 SPACE 3D
Axial (selective cut): T1, T2
± IV Gado: T1 fat sat sagittal, T1 fat sat axial
Din XJ
249
CARDIOVASCULAR SYSTEM
A. MRI Cardiac
Evaluation 1. Anatomy 2. Function
a) Heart a) Myocardial mass, wall motion
b) Great vessels b) Stroke volume, ejection fraction
c) Coronary arteries c) Valvular function
d) Myocardial perfusion & viability
Indications 1. Congenital heart disease (ASD, VSD, TGA, truncus arteriosus)
2. Valvular heart disease
3. Cardiomyopathies (hypertrophic CM, restrictive CM v/s restrictive pericarditis, infiltrative CM)
4. Coronary artery disease
a) Assess ventricular function
b) Assess myocardial perfusion & viability
5. Cardiac mass (myocardial & pericardial)
Preparation - Refrain from stimulus (caffeine) on the examination day
- NBM 4hrs
- IV line
Position - Head first
- Use body coil (dedicated cardiac phase array coil is preferred)
Technique 1. ECG gating
- To acquire images in a particular phase of cardiac cycle in every cardiac cycle
→ To avoid cardiac motion artifact
→ To get ‘motion-free’ images of the heart
- Usually R wave is used to trigger acquisition, after some delay following R wave, in the diastolic phase
2. Respiratory gating:
a) Navigator → Allow free breathing
b) Breath hold technique
Scout image Axial, sagittal & coronal section
Planes 1. 2-chamber view (Vertical long-axis)
Scout Axial image wt the largest oblique diameter of LV

Plane Centre of the plane at centre of mitral valve, the other end at LV apex
To assess LA, LV, mitral valve
2. 4-chamber view (Horizontal long-axis)
Scout 2-chamber view

Plane Draw a line passing LA, LV & mitral valve
To assess All 4 chambers, mitral & tricuspid valves
Din XJ
250
3. Short-axis plane
Scout 2-chamber view

Plane Plane ∟to LV long axis, from base to apex of the heart
To assess Ventricular mass, wall thickness, wall motion, volume & ejection fraction
4. 5-chamber view
Scout Coronal image

Plane Image ║ to line passing through LV apex
To assess All 4 chambers, aortic root (5th chamber), mitral & aortic valves
5. Right ventricular outflow tract, RVOT
Scout Axial image

Plane Plane ║ to main pulmonary artery, passing through RVOT
To assess RVOT obstruction in congenital heart disease (AVSD)
Sequences 1. Dark-blood imaging
- SE sequence (Shows the flowing blood as flow void) → Assess anatomy
- Eg: Breath-hold FSE, Double IR FSE
2. Bright-blood imaging
- GRE sequence (Shows the blood bright) → Assess cardiac function, heart beat & jet turbulence
- Eg: Spoiled GRE (turbo FLASH, SPGR, T1-FFE), Balanced SSFP (True FISP, FIESTA)
3. Flux quantification sequences
- Phase contrast imaging → Shows flux direction & speed (similar to CSF flow study)
4. Inversion recovery sequences (STIR)
- Null signal from blood & other tissue (Improves contrast) → To look for myocardial oedema d/t inflammation
5. Perfusion study
- T1 GRE CE sequence (3mins post contrast) → To look for hypoenhanced area (infarcted myocardium)
6. Viability study
- T1 GRE CE sequence (10mins post contrast) → To look for hyperenhanced area (fibrosis: nonviable myocardium)
d/t delayed washout
Din XJ
251
ABDOMEN
A. Upper Abdomen
Indications Abnormality in the upper abdomen
- Use body coil (upper abdomen: nipple – iliac crest), in symmetry position (mid-sagittal line as reference point)
- Centering point: Lower costal margin
- Give IV Buscopan 10mg / Glucagon 0.25mg
Planes:
1. Axial - Scout: Mid-coronal image Axial
- Planes: Perpendicular to coronal plane
- Coverage: Liver dome – Aortic bifurcation
- SL: 8mm, FOV: 360 – 400mm2
2. Coronal - Scout: Axial image

- Planes: Perpendicular to axial plane
- Coverage: Ant – post abdominal wall
- SL: 3mm, FOV: 380 – 400mm2
Coronal
Protocol Axial: T1, T2

Coronal: T2
Din XJ
252
B. Liver (Modified upper abdomen)

Indications 1. Lesion detection, prior to hepatic resection for liver mets
2. Lesion characterization, following CT / US
Planes: Axial
1. Axial - Scout: Mid-coronal image
- Coverage: Whole liver (superior – inferior)

- Coverage: Whole liver (anterior – posterior)
- Total slice ≈ 25 Coronal
Protocol Axial: T1 in-phase & out-of-phase, T1 fat sat (CE), T2, T2 fat sat, DWI/ADC
Dynamic study:
1. Pre-contrast Baseline
2. Arterial phase Immediate after contrast injection
3. Portal venous phase 45sec after contrast injection
4. Delayed phase 5mins after contrast injection
1. Technique
a) Pulse sequences (i) T1 spoiled GRE (iii) T1 GRE fat-supp volume acquisition
(ii) Magnetization-prepared T1 GRE (iv) T2 FSE / TSE
b) In-phase & out-of-phase - Fat in tissue which contains fat & water → Appears darker (on OP image)
Tissue with only fat or only water → Appears similar (on both IP & OP image)
- Best in assessing fatty liver
c) Fat suppression & STIR - ↓ Motion artifacts from subcutaneous & intra-abdominal fat
- ↑ Dynamic range of the image
- Better delineation of fluid-containing structures
- Improves signal-to-noise & contrast-to-noise ratio of focal liver lesions
d) Very heavily T2w Show water content in bile ducts, cysts & some focal lesions
sequences (i) GRE breath-hold sequences (FISP)
(ii) Breath-hold very FSE (HASTE)
(iii) Non-breath-hold respiratory gated sequences used for MRCP
2. Contrast studies:
a) Gadolinium
(i) T1 spoiled GRE sequences - Arterial phase: Sensitive to liver metastasis, HCC
- Portal phase: Sensitive to hypovascular malignancies
- Equilibrium phase: Sensitive to cholangioCa, slow-flow haemangiomas
(ii) T2 FSE - Sensitive to HCC, neuroendocrine tumours
b) Reticuloendothelial cell agents - Taken up by RE or Kuppfer cells → ↓ T2 intense
(SPIO) - Not taken up by malignant lesions → ↑ T2 intense
c) Hepato-biliary agents: - Taken up by normal hepatocytes & excreted into bile → ↑ T1 Intensity
Gd-BOPTA (Multihance) - Not taken by metastatic lesions → ↓ T1 Intensity
Din XJ
253
T1 T1 fat sat T2
T1 in-phase (normal liver) T1 out-of-phase (normal liver) T1 out-of-phase (fatty liver)
Dynamic study: Pre-contrast
Arterial phase Portal venous phase Delayed (parenchymal) phase
Din XJ
254
C. MR Cholangio-Pancreaticography (MRCP)
Indications 1. Obstructive jaundice
a) Biliary calculus (choledocholithiasis)
b) Malignancy (cholangioCa, pancreatic head Ca)
2. Cystic disease of bile duct (choledochal cyst, choledochocele, Caroli’s disease)
3. Congenital anomalies (low cystic duct insertion, medial cystic duct insertion, parallel course of cystic & hepatic ducts)
4. Chronic pancreatitis
5. Sclerosing cholangitis
6. Prior to ERCP / PTC
7. Post-surgical complications
Contrast No contrast needed
Preparation NBM 4-8hrs → Distend biliary tract, ↓ fluid in gastric antrum & duodenum
Planes: Axial
1. Axial - Scout: Coronal image
- Coverage: Biliary system (diaphragm – C-loop duodenum)

- Coverage: Whole liver (anterior – posterior)
3. Coronal - Scout: Axial image Coronal

T2 3D FSE - Planes: Perpendicular to axial plane
(SPACE) - Coverage: Cover the whole biliary system
(GB, CBD, pancreatic duct)
Protocol Axial: T2, T1 fat sat (for pancreas)

Coronal: T2, T2 3D FSE (SPACE)
- MRCP images are taken in axial, coronal & 3D formats
Coverage: Entire gallbladder, biliary ducts, pancreas
- Heavily T2W sequence → Demonstrate intra-, extra-hepatic & pancreatic ducts
- Combined 2 techniques
a) Single-shot radial slabs in axial & coronal plane
b) Balanced SSFP in axial / coronal plane
Axial T2 Coronal T2 T2 3D FSE
Din XJ
255
D. Pancreas
Indications 1. Pancreatic tumours (adenoCa, cystic neoplasm, islet cell tumour)
2. Same as CT pancreatic protocol * CT is preferred d/t availability & cost
- Use body coil, in symmetry position (mid-sagittal line as reference point)
Planes: Axial
- Coverage: Whole pancreas (superior – inferior)
- SL: 5mm, FOV: 380-400mm2

- Coverage: Whole pancreas (anterior – posterior)
- SL: 6-8mm, FOV: 380-400mm2
Coronal
3. Paracoronal - Scout: Axial image
(Biliary tree & - Planes: Course of pancreatic duct & CBD
pancreatic duct) (0-30o off the horizontal plane)
- Coverage: Whole pancreas (anterior – posterior)
Paracoronal
Protocol Axial: T1 fat sat, T1 fat sat (CE), T2 fat sat

Coronal: T1 fat sat (CE), T2
Paracoronal (KIV): T2 fat sat
1. T1W fat-suppressed GRE
- Normal pancreas: More hyperintense to normal liver
2. T1W spoiled GRE (FLASH)
- Normal pancreas: Isointense to normal liver
3. T1W fat-suppressed (CE) spoiled GRE
- Acquired after 45sec, 90sec & 10mins, following gadolinium administration
- Normal pancreas: Hyperintense to normal liver & adjacent fat on early images, fading on later images
T1 T2 T2 fat sat
Din XJ
256
E. Iron Overload Imaging (T2* Imaging)

Indications - Patient on long-term blood transfusion (Thalassemia)
→ Iron overload (deposition of ferritin & hemosiderin in liver, heart, endocrine organs)
→ Faster decay of transverse magnetization (shorter T2)
- MRI to detect & quantify iron deposition in organs (particularly heart & liver)
a) Compare signal intensity of target organ wt unaffected tissue (muscle), via signal intensity ratio
b) Determine T2 decay pattern or T2* relaxation rates
Protocol Axial: T1, T2, STIR
Sagittal oblique: T1, T2, PD, STIR
Coronal oblique: T1, T2, STIR
- Acquired slice thickness: 4mm
- T2* value is then calculated
T2* heart (Short-axis) T2* liver (Axial)

Normal Normal
Iron overload Iron overload
F. Lower Abdomen & Pelvis

Indications 1. Inflammatory bowel disease
2. Local staging of rectal ca
3. Suspected perianal fistula
Contrast Air within bowel is a natural contrast agent
Additional CM is usually not needed
Technique - To ↓ peristalsis motion artifacts:
a) GRE sequence (instead of SE sequence)
b) IV Buscopan / Glucagon
- To ↓ respiration motion artifacts:
a) Prone position
b) Compression band
Protocol - Sequences (General):
Single-shot FSE & ↓ Motion artifacts
Breathold GRE Relatively poor contrast resolution
Standard FSE Better contrast resolution
May suffer from motion artifacts
1. Local staging of rectal ca
- Supine position
- Sequences:
Sagittal T2W FSE
Axial & coronal T2W FSE
- Supine position
- Sequences:
Axial & coronal T1W FSE fat-sat, T2W FSE fat-sat or STIR, T1W fat-sat (CE)
Din XJ
257
G. MR Enterography (Small bowel)

Indications 1. Inflammatory bowel disease (especially Crohn’s disease)
2. Other bowel pathology:
- Thickening of bowel wall, fibrofatty proliferation
- Abscess, collection
- Strictures, fistula
Contrast Enteric contrast (given orally): Sorbitol 3% / Venofundin (Voluven) 20 ml/kg (1L)
IV: Gadolinium
Preparation 1. NBM for 6hrs
2. IV line
3. Drink oral contrast: 20 ml/kg (1L)
1st dose 10 ml/kg (500ml), 1hr before scan
2nd dose 5 ml/kg (250ml), 30mins before scan
3rd dose 5 ml/kg (250ml), just before scan
Position - Prone/supine (preferably prone), head first, arms by each side

Planes: Axial
- Coverage: Whole abdomen (liver dome – pelvic inlet)

- Coverage: Whole abdomen (anterior – posterior)
Coronal
Protocol
1st scan: Coronal: T2
Pre-buscopan scanning
(Give 1st dose IV Buscopan 10mg / Glucagon 0.25mg)
2nd scan: Axial: T1 fat sat, T2
Post-buscopan scanning Coronal: T1 fat sat, T2
(Give 2nd dose IV Buscopan 10mg / Glucagon 0.25mg, together wt IV Gadolinium)
3rd scan: Axial: DWI/ADC
Post-contrast scanning Coronal: 3D T1 fat sat (VIBE,THRIVE,LAVA), T2
Din XJ
258
H. MR Enteroclysis (Small bowel)

– Same as MR enterography –
Indications * Better bowel distension compared to enterography
Contrast Enteric contrast (given via Bilboa-Dotter tube): Sorbitol 3% / Venofundin (Voluven) 20 ml/kg (1L)
IV: Gadolinium
Preparation 1. NBM for 6hrs
2. Insert IV line
3. Insert Bilboa-Dotter tube till duodeno-jejunal flexure, via fluoroscopy
- Prelim: Plain AXR, TRO small bowel obstruction& perforation
- Sitting position
- Pharynx is anaesthetized wt lidocaine spray
- Tube is inserted through nose / mouth, via fluoroscopic guidance (lateral screening) to pass through epiglottis
Patient asked to swallow, wt neck flexed
Tube advanced into gastric antrum
- Lie down, tube advanced into duodenum. May adopt following manoeuvres:
a) Lie in left lateral position, to straighten out the stomach
Sit up, to overcome tube coiling in fundus
b) Advance tube while applying clockwise rotational motion
c) Introduce guidewire for Bilboa-Dotta tube
d) IV Maxolon 20mg
- Tube advanced into duodeno-jejunal flexure (ligament of Treitz), wt guidewire tip maintained at pylorus
4. Position / scout image / planes: – Same as MR enterography –
Protocol
1st scan: Supine position Coronal FISP
2nd scan: Prone position Connect B-D tube to infusion pump, infuse Klean-prep 80-100 mls/min
Acquire: HASTE, to monitor filling of small bowel to ileocaecal valve
(Give IV Buscopan 10mg / Glucagon 0.25mg)
3rd scan: Post-buscopan scanning Axial & coronal, HASTE & FISP
(Give IV Gadolinium)
4th scan: Post-contrast scanning 3D T1W fat suppressed (Eg. VIBE)
T1 axial T2 axial
T1 coronal T2 coronal
DWI ADC
Din XJ
259
I. Pelvis - Rectum
Indications 1. Local staging of rectal ca
Contrast Air within bowel is a natural contrast agent
Additional CM is usually not needed
- Use body coil (upper border at iliac crest), in symmetry position (mid-sagittal line as reference point)
- Centering point: Centre of the coil
Planes: Axial
1. Axial - Scout: Mid-sagittal image
- Planes: Perpendicular to rectal axis
- Coverage: Iliac crest (sup) – Anus (inf)
2. Sagittal - Scout: Axial image, at level of hip joint

- Planes: Parallel to mid-sagittal plane
- Coverage: Right to left hip joint (mid)
- SL: 3mm, FOV: 350mm2 Sagittal
3. Coronal - Scout: Mid-sagittal image

- Planes: Parallel to rectal axis
- Coverage: Symphysis pubis (ant) – Rectum
(post)
Coronal
Protocol Axial: T1, T1 fat sat (CE), T2, T2 fat sat

Sagittal: T1 fat sat (CE), T2
Coronal: T2
Axial T2 Sagittal T1 fat sat (CE) Coronal T2
Din XJ
260
A. Kidney
Indications 1. Inflammation/infection (Xanthogranulomatous pyelonephritis)
2. Benign lesion (Cyst, angiomyolipoma, oncocytoma)
3. Malignant lesion (RCC, TCC)
Planes: Axial
- Coverage: Whole kidney (superior – inferior)
- SL: 5mm, FOV: 380-400mm2
2. Coronal - Scout: Sagittal & axial image

- Planes: Parallel to renal axis
- Coverage: Whole kidney (anterior – posterior)
- SL: 5mm, FOV: 380-400mm2
Coronal
Protocol Axial: T1, T1 fat sat (CE), T2, T2 fat sat

Coronal: T1 fat sat, T2
T1 T1 fat sat
T2 T2 fat sat
Din XJ
261
B. MR Urography (MRU)
Indications 1. Renal pathology 2. Local staging of bladder ca
a) Renal mass / scarring 3. Potential renal transplant donor (+ MRA renal)
b) Congenital renal anomalies
c) Obstructive uropathy
- Not d/t calculi
- Patient wt poor renal function
d) Screening for von Hippel-Lindau disease
Contrast IV Gadolinium 0.1 mmol/kg
± IV Lasix 0.3 mg/kg (5-10mg in adult)
Preparation - Keep NBM 4hrs prior to procedure
- KIV sedation (children)
- Insert branulla, hydrate wt 1ʘ NS 30mins prior to procedure
- Empty bladder, insert CBD if patient sedated (children)
- Supine, head first, arms above the head, empty bladder

- Use body coil (at the level of the chest)
- Scout views obtained: TRUFI localizer (axial, sagittal, coronal) & T2 HASTE sagittal
Protocol 1. Pre-contrast:
Axial: T2 fat sat HR
Coronal: T1, T1 fat sat, T2 fat sat HR, T2 fat sat 3D
± IV Lasix prior to IV contrast, to distend the collecting system (Omit if there is already obstruction)
2. Post-contrast:
Coronal: T2 FLASH 3D Dynamic
Sagittal: T1 fat sat VIBE Dynamic
3. Delayed (10mins):
Coronal: T1 fat sat VIBE
1. Static (fluid-filled) MRU
- Sequence: Non-contrasted heavily T2-w FSE axial → Convert to 3D-image (MIP & VR)
- Resemble IVU
- To demonstrate fluid-filled structures, especially in poorly functioning kidney or marked hydronephrosis
2. Excretory MRU
- Sequence: T1 GRE pre & post-gado (at 15sec, 1’, 2’, 3’, 5’, 15’, 20’) → Convert to 3D-image (MIP & VR)
- Resemble CTU
- To demonstrate complicated anatomical variants
Dynamic data is used to assess perfusion, filtration, concentration & excretion of kidney
* In-phase & out-of-phase T1 GRE → To identify adrenal lesions / lipid within angiomyolipoma / renal clear cell ca
Static (fluid-filled) MRU Excretory MRU
Din XJ
262
C. MRA Renal
Indications 1. Renal artery anomalies (aneurysm, AVM, dissection, stenosis)
2. Potential renal transplant donor (+ MRU)
Contrast Pump injector: 30mls Gadolinium + 60mls NS
IV Gadolinium 0.1 mmol/kg, 2mls/sec
Preparation - Insert branulla (at least 21G – Pink) at the antecubital fossa
- Supine, head first, arms on each side of the body
- Use body coil
- Use body coil (xiphoid process – ASIS), in symmetry position (mid-sagittal line as reference point)
Kidneys are in the middle of the frame
Both common iliac arteries (down to the bifurcation) are included
Planes:
Coronal - Scout: Axial & sagittal images
- Planes: Parallel to midline along Rt – Lt kidneys
Parallel to abdominal aorta
- Coverage: Both kidneys anterior – posterior
Protocol 1. Pre-contrast renal scan: T2 coronal (at the level of renal hila)
2. MRA-phase contrast renal
Set ROI at abdominal aorta, for contrast bolus tracking
Contrast infusion via pump injector
3. Post-contrast MRA: T1 FLASH-3D axial
MRA-phase contrast Post-contrast T1 FLASH-3D MRA
Din XJ
263
D. Adrenal Glands
Indications Adrenal mass: Adenoma vs Metastasis, suspected pheochromocytoma
Planes: Axial
- SL: 5mm, FOV: 380-400mm2
2. Coronal - Scout: Sagittal & axial image

- SL: 5mm, FOV: 380-400mm2
Coronal
Protocol Axial: T1, T1 GRE in-phase & out-of-phase, T1 (CE), T2

Coronal: T1, T2
* In-phase & out-of-phase sequence → Demonstration of fat content (chemical shift) in the mass
T1 axial T2 axial
T1 coronal T2 coronal
Din XJ
264
E. Pelvis - Male
Indications 1. Prostate gland: Local staging of prostate carcinoma / sarcoma
2. Testis & scrotum: Primary tumour, intra/extra testicular abN, undescended testis
Planes: Axial
- Planes: Perpendicular to prostate gland
- Coverage: Iliac crest – Symphysis pubis

- Total slice ≈ 19 Sagittal

- Planes: Parallel to prostate gland
- Coverage: Symphysis pubis (ant) – Rectum (post)
Coronal
Protocol Axial: T1, T2, T2 HR, STIR, DWI/ADC

Sagittal: T2
Coronal: T2
MR spectroscopy
T1 T2 T2 HD
T2 STIR DWI ADC
Din XJ
265
F. Pelvis - Female
Indications 1. Vagina: Congenital anomalies, tumour
2. Uterus: Congenital anomalies, tumour (leiomyoma, carcinoma, sarcoma, gest trophoblastic tumour), adenomyosis
Cervix: Tumour
3. Ovary: Ovarian torsion, cysts, endometrioma, tumour (carcinoma, teratoma)
Planes: Axial
- Planes: Perpendicular to uterine axis
- Coverage: Iliac crest – Symphysis pubis

Sagittal

- Planes: Parallel to uterine axis
- Coverage: Symphysis pubis (ant) – Rectum (post)
Coronal
Protocol Axial: T1, T1 fat sat, T1 fat sat (CE), T2, T2 HR

Sagittal: T2, T1 fat sat (CE)
Coronal: T2, T2 STIR
T1 axial T2 axial T2 STIR axial
Din XJ
266
MUSCULOSKELETAL SYSTEM
Indications:
1. Injuries (Sport, trauma)
2. Degenerative disorders
3. Infection / inflammation
4. Tumour
Common sequences used in MRI of MSK

Tissue Sequences
Bone T1 T2 fat sat STIR
Cartilage T2 fat sat PD fat sat GRE fat sat
Labrum T1 fat sat T1 SE GRE T2
(Intra-articular gado) (Intra-articular gado)
Meniscus T1 GRE T2 PD fat sat
Tendon / Ligament T1 T2 fat sat GRE T2
Muscle T1 STIR T1 fat sat
Marrow T1 STIR PD fat sat
Synovium T1 T1 fat sat T1 SE
(IV gado) (IV gado)
Contrast media
a) Direct arthrography Intra-articular Gadolinium-DTPA To assess cartilage, capsule, labrum, meniscus, ligament
b) Indirect arthrography IV Gadolinium-DTPA To assess:
(i) Synovial disease (RA)
(ii) Infections
(iii) Tumours
(iv) AVN (Perthe’s disease, scaphoid fracture)
(v) Postop spine (to differentiate disc herniation from scar tissue)
Din XJ
267
A. Shoulder
Indications 1. Injuries (Sport, trauma):
- Shoulder pain/fracture/dislocation
- Muscle (rotator cuff, biceps), labrum, ligament (glenohumeral), bursa (subacromial bursitis)
- Impingement syndrome, coracoclavicular & acromioclavicular separations
4. Tumour
MR Arthrogrm Shoulder joint instability → To assess glenohumeral ligaments & labrum
Position - Supine, head first, arms by each side (in neutral rotation)
- Use shoulder coil, in symmetry position (mid-sagittal line as reference point)
- Centering point: Head of humerus
Scout image - Planes: Axial, coronal (oblique), sagittal (oblique) – 3 slices in each plane
- SL: 6mm, FOV: 280mm2, TR: 6.4ms, TE: 2.6ms
Planes: Axial
1. Axial - Scout: Coronal oblique image
- Planes: Perpendicular to glenoid
- Coverage: Top of AC joint – Axillary recess
2. Cor oblique - Scout: Axial image (SST or glenohumeral jt)

- Planes: Parallel to supraspinatus tendon (SST) OR
Perpendicular to glenoid
- Coverage: Long head of biceps tendon (LHBT)
– Infraspinatus tendon insertion (IST)
Coronal oblique
3. Sag oblique - Scout: Axial image (SST or glenohumeral jt)

- Planes: Perpendicular to SST OR
Parallel to glenoid
- Coverage: Deltoid – Mid scapular blade
4. T2 DESS 3D - Acquire coronal oblique images

Sagittal oblique
- Scout: Axial image (SST or glenohumeral jt)
- Planes: Parallel to SST OR
Perpendicular to glenoid
- Coverage: LHBT – IST
- SL: 0.7mm, FOV: 200mm2
- TR: 18.7ms, TE: 7.35ms, TI: 160ms
Sequence:
1. T1 TR: 400ms, TE: 9ms
2. T2 TR: 2,400ms, TE: 79ms
3. PD TR: 2,400ms, TE: 24ms
4. STIR TR: 2,950ms, TE: 28ms, TI: 160ms
Protocol:
1. Usual MRI Axial: T1, T2, PD, STIR
Coronal oblique: T1, T2, PD, STIR, T2 DESS 3D
Sagittal oblique: T1, T2, PD, STIR
± Post-gado: T1 fat sat for axial, coronal oblique & sagittal oblique
2. MR arthrogrm Axial: T1, T1 fat sat, T2

Coronal oblique: T1, T1 fat sat, T2, PD, STIR, T2 DESS 3D
Sagittal oblique: T1, T1 fat sat
Din XJ
268
B. Elbow
- Fractures (supracondyle, epicondyle, radial head) & dislocation (posterior)
- Lateral epicondylitis (tennis elbow), medial epicondylitis (golfer's elbow)
- AVN of radial head, biceps tendon injury, osteochondral injury, nerve injury
4. Tumour
Scout image - Supine, head first, arms by each side (in neural rotation)
- Use flex small coil, off centre (elbow as close to centre of gantry as possible)
- Centering point: Elbow joint
Position - Planes: Axial, coronal, sagittal (3 slices in each plane)
Planes: Axial
1. Axial - Scout: Coronal image (both epicondyles)
- Planes: Parallel to epicondyles
- Coverage: Lower ⅓ humerus – Upper ⅓ rad/ulna
2. Coronal - Scout: Axial & sagittal (to see humerus)

- Planes: Parallel to humeral axis
- Coverage: Capitellum – Olecranon process
Coronal
3. Sagittal - Scout: Axial & Mid-coronal (to see humerus)
- Planes: Perpendicular to axial & coronal planes
- Coverage: Medial – Lateral epicondyle
Sagittal
Sequence:
1. T1 TR: 450ms, TE: 7ms
2. T2 TR: 3,000ms, TE: 76ms
3. PD TR: 2,000ms, TE: 33ms
Coronal: T1, T2, STIR
Sagittal: T2, PD
± Post-gado: T1 fat sat for axial, coronal oblique & sagittal oblique
Din XJ
269
C. Wrist
- Carpal tunnel syndrome
- Tendon (flexor & extensor tenosynovitis), ligament, Triangular fibrocartilage complex (TFCC)
4. Tumour
Position - Supine, head first, arms by each side (in lateral rotation)
- Use flex small coil, off centre (wrist as close to centre of gantry as possible)
- Centering point: Wrist joint
Scout image - Planes: Axial, coronal, sagittal (3 slices in each plane)
Planes:
1. Axial - Scout: Coronal image (radial & ulnar styloids) Axial
- Planes: Parallel to line joining radial-ulnar styloids
- Coverage: Base of MCBs – Distal radius/ulna
2. Coronal - Scout: Axial (Distal row of carpals) & Mid-sagittal

- Planes: Parallel to line joining palmar extent of carpals
- Coverage: Skin to skin
3. Sagittal - Scout: Axial (Distal row of carpals) & & coronal Coronal
- Planes: Perpendicular to axial & coronal
- Coverage: Base of 1st – 5th MCBs
4. T2 DESS 3D - Acquire coronal images

- Scout: Axial (Distal row of carpals) & Mid-sagittal
- Planes: Parallel to line joining palmar extent of carpals
- Coverage: Skin to skin
- Total slice ≈ 80 Sagittal
- SL: 0.6mm, FOV: 120mm2
- TR: 19.7ms, TE: 8ms
Sequence:
1. T1 TR: 450ms, TE: 7ms
2. T2 TR: 3,000ms, TE: 76ms
3. PD TR: 3,500ms, TE: 24ms
Coronal: T1, T2, PD, STIR, T2 DESS 3D
Sagittal: PD fat sat
± Post-gado: T1 fat sat for axial, coronal & sagittal
Din XJ
270
D. Hip
Indications 1. Injuries (Sport, trauma): Occult fracture, AVN of femoral head
3. Infection / inflammation: Septic arthritis, OM, synovial osteochondromatosis
4. Tumour
Position - Supine, head first, both legs straight (in internal rotation 10o)
- Use body coil (upper border at iliac crest), in symmetry position (both ASIS equidistant from the couch)
- Centering point: Midpoint btw ASIS – Symphysis pubis
Planes:
1. Coronal - Scout: Axial image (both femoral heads) Coronal
- Planes: Parallel to line joining both femoral heads
- Coverage: Symphysis pubis – Sacrum
2. Axial - Scout: Coronal image (both femoral heads)

- Planes: Parallel to line joining both femoral heads
- Coverage: Iliac crest – Proximal femoral shaft
Axial
Sequence:
1. T1 TR: 450ms, TE: 9ms
2. T2 TR: 3,500ms, TE: 91ms
3. PD TR: 3,500ms, TE: 26ms
Protocol Coronal: T1, T2, PD, STIR
Axial: T2 fat sat, PD fat sat
± Post-gado: T1 fat sat for axial & coronal
Din XJ
271
E. Knee
- Marrow (AVN, marrow edema syndromes, stress fractures)
- Muscle and tendon (extensor mechanism abN, strains, tears, tendonitis, tendonopathy)
- Osteochondral & articular cartilage (infractions, osteochondral fractures, osteochondritis)
- Loose bodies (chondral, osteochondral, osseous)
- Meniscus (tears, discoid menisci, cysts)
- Ligament (cruciate, collateral, retinaculum)
- Synovial based disorders (synovitis, bursitis, popliteal cysts)
4. Tumour
Position - Supine, head/feet first, both legs straight (knee in 30o flexion)
- Use knee coil
- Centering point: Patellar apex
Planes:
1. Axial - Scout: Mid-coronal & mid-sagittal images Axial
- Planes: Parallel to line joining inferior surface of
medial-lateral femoral condyles
- Coverage: Just above patella – Patellar tendon insertion
2. Coronal - Scout: Axial (femoral condyles) & sagittal (popliteal vssels)

- Planes: Parallel to line joining medial-lateral femoral
condyles posteriorly
- Coverage: Patella – Popliteal vessels
3. Sagittal - Scout: Axial (femoral condyles) & coronal (fibula)

- Planes: Perpendicular to line joining medial-lateral
femoral condyles posteriorly
- Coverage: Medial femoral condyle – Fibular head
4. T2 DESS 3D - Acquire sagittal images Sagittal

- Scout: Axial (femoral condyles) & coronal (fibula)
- Planes: Perpendicular to line joining medial-lateral
femoral condyles posteriorly
- Coverage: Medial femoral condyle – Fibular head
- SL: 0.6mm, FOV: 160mm2
- TR: 19.7ms, TE: 8ms
Sequence:
1. T1 TR: 450ms, TE: 13ms
2. T2 TR: 3,000ms, TE: 96ms
3. PD TR: 3,000ms, TE: 24ms
Protocol Axial: PD fat sat
Coronal: PD fat sat
Sagittal: T1, T2, PD, T2 DESS 3D
Din XJ
272
F. Ankle
Indications 1. Injuries (Sport, trauma)
4. Tumour
Position - Supine, feet first, both legs straight (ankle in neutral position)
- Use flex small coil, off centre (wrist as close to centre of gantry as possible)
- Centering point: Ankle joint
Planes:
1. Axial - Scout: Mid-sagittal image Axial
- Planes: Parallel to calcaneal axis
- Coverage: Distal tibia – Bottom of calcaneum

- Planes: Perpendicular to calcaneal axis
- Coverage: Base of MTBs – Post end of calcaneum
3. Sagittal - Scout: Axial image (at malleoli)

- Planes: Parallel to talar axis
- Coverage: Medial – Lateral malleoli
Sagittal
Sequence:
1. T1 TR: 600ms, TE: 15ms
2. T2 TR: 3,000ms, TE: 74ms
3. PD TR: 3,000ms, TE: 32ms
Protocol Axial: T2, PD
Coronal: T1, PD fat sat
Sagittal: T1, STIR
Din XJ
273
G. Sacro-iliac Joint
Indications Sacroiliitis
- Use body coil (upper border at iliac crest), in symmetry position (both ASIS equidistant from the couch)
- Centering point: Midpoint btw ASIS – Symphysis pubis
Planes:
1. Axial - Scout: Mid-sagittal (sacrum) Axial
- Planes: Perpendicular to sacrum
- Coverage: Whole sacrum
2. Coronal - Scout: Mid-sagittal (sacrum)

- Planes: Parallel to sacrum
- Coverage: Anterior – posterior sacral spine
Coronal
Sequence:
1. T1 TR: 450ms, TE: 9ms
2. T2 TR: 3,500ms, TE: 76ms
3. PD TR: 3,500ms, TE: 39ms
Protocol Axial: T1, T2, PD
Coronal: T1, T1 fat sat, STIR
T1 axial T2 fat-sat axial T1 coronal STIR coronal
Din XJ
274
H. Brachial Plexus
Indications 1. Injuries (Sport, trauma)
3. Infection / inflammation (acute neuritis)
4. Tumour
- Use head, neck & body coils, in symmetry position (nasal bridge & outer canthus as reference point)
Planes: Axial
1. Axial - Scout: Mid-sagittal & coronal (spine)
- Planes: Perpendicular to cervical spine
- Coverage: C4 – T5 (to cover axilla)
2. Sagittal - Scout: Coronal (neck & upper chest)
- Coverage: C4 – T5, to include both axillae
- SL: 3mm, FOV: 350mm2 Sagittal
3. Coronal - Scout: Mid-sagittal & axial
- Planes: Parallel to cervical spine
- Coverage:
Anterior Clavicle
Posterior Spinous process
Coronal
4. CISS 3D - Acquire coronal images
- Scout: Mid-sagittal & axial
- Planes: Parallel to cervical spine
- Coverage:
Anterior Clavicle
Posterior Spinous process
- TR: 6ms, TE: 3ms
Sequence:
1. T1 TR: 450ms, TE: 8.6ms
2. T2 TR: 6,000ms, TE: 80ms
3. PD TR: 6,000ms, TE: 30ms
Protocol Axial: T2 fat sat, PD fat sat
Sagittal: T1, STIR
Coronal: T1, CISS 3D
T1 axial T2 sagittal T2 STIR coronal
Din XJ
275
WHOLE BODY MRI

Indications Non-invasive screening tht acquires entire body images in coronal plane, only using fast MR pulse sequences
1. Screening in paediatric patients wt small round blue cell tumours (neuroblastoma, Ewing sarcoma, lymphoma,
rhabdomyosarcoma) for metastasis
2. Assess tumour burden & possible malignant transformation, in patients wt neurofibromatosis
Technique - Mainly STIR coronal images
- Slice thickness 3-4mm
- Images are acquired in a few stations
Station Normal size patient Small size Large size
1 Head – Clavicle Head – Clavicle Head – Clavicle
2 Lung apex – Iliac crest Lung apex – Iliac crest Thorax
3 Iliac crest – Mid femur Iliac crest – Knee Abdomen – Iliac crest
4 Mid femur – Proximal tibia Knee – Toes Iliac crest – Mid femur
5 Proximal tibia – Toes Mid femur – Proximal tibia
6 Proximal tibia – Toes
Protocol 1. Small round blue cell tumours: T1 out-of-phase, T2, STIR, ± DWI/ADC
(only coronal) 2. Neurofibromatosis: STIR
Din XJ
Chapter 9 NUCLEAR
MEDICINE
276
GENERAL PRICIPLES
1. Nuclear medicine imaging
- Imaging modalities that detect ɣ-rays (via gamma camera)
- produced by radiopharmaceutical agents, administered into the body
2. Types of imaging technique:

a) Conventional planar imaging with gamma camera
b) Single Photon Emission Computed Tomography (SPECT)
c) Positron Emission Tomography (PET)
Conventional gamma camera SPECT PET
Detect x-ray Detect x-ray Detect x-ray

Produce 2-D images Produce 3-D images Produce 3-D images
Tracer emits x-rays, Tracer emits x-rays, Tracer emits positrons,
tht is measured directly tht is measured directly tht annihilates wt nearby e-,
emitting 2 x-rays in opposite directions,
tht is subsequently measured
Low energy Low energy High energy
Low resolution images Low resolution images High resolution images
Less expensive Less expensive More expensive
CT + SPECT = SPECT CT CT + PET = PET CT
2. Radiopharmaceuticals used in nuclear medicine imaging

a) Thyroid 99mTc-pertechnetate / 123 I-sodium iodide / 131 I-sodium iodide
b) Parathyroid 99mTc-methoxyisobutylisonitrile (MIBI or sestamibi) + 99mTc-pertechnetate
c) Lungs
(i) Ventilation scan 99mTc-technegas
(ii) Perfusion scan 99mTc-macroaggregated albumin particles (MAA)
d) Biliary (Cholescintigraphy) 99mTc-trimethylbromo-iminodiacetic acid (TBIDA) – Hepatic IDA (HIDA)
e) Renal
(i) Dynamic 99mTc-diethylene triaminepentacetic acid (DTPA) / 99mTc-mercaptoacetyltriglycine (MAG-3)
(ii) Static 99mTc-dimercaptosuccinic acid (DMSA)
f) Bone scan 99mTc-methylene diphosphonate (MDP)
Din XJ
277
BRAIN
A. Positron Emission Tomography, PET scan
1. Brain tumour 1. Recent chemotherapy (minimum interval 2-3 wks)
2. Epilepsy 2. Recent radiotherapy (minimum interval 8-12 wks)
3. Dementia 3. Poorly controlled DM (DXT < 8.5 mmolL)
Radiopharma 1. Fluorine-18 fluorodeoxyglucose (18FDG) OR
- Max dose: 400 MBq (10 mSv ED)
2. L-[methyl- 11C] methionine ([11C] MET) OR
3. 3’-deoxy-3’-[18F] fluorothymidine ([18F] FLT)
Ensure good glycemic control
Technique - Administer 18FDG
- Minimize movement & activity to ↓ muscle uptake
- Acquire image at 1hr post-injection
Aftercare Ensure good glycemic control
Complication None
B. Single-Photon Emission Computed Tomography, SPECT

1. Grading of brain tumour 1. No absolute
2. Assess brain tumour after surgery / radiotherapy 2. CIx for ionizing radiation
Radiopharma 201Thalium
- Dose: 100 MBq (25 mSv ED)

Technique Inject IV 201Thalium
Aftercare None
Complication None
C. Radionuclide Cisternography
Indications Indications: Contraindication: Relative
1. Normal pressure hydrocephalus 1. Meningitis
2. VP shunt dysfunction 2. ↑ ICP
3. Occult CSF rhinorrhea / otorrhea 3. CIx for ionizing radiation
4. Porencephalic / leptomeningeal / posterior fossa cysts
Radiopharma 1. 99mTc-DTPA 2. 111Indium-DTPA
- Dose: 4 – 10 mCi - Dose: 250 – 500 μCi
- Easily available, lower radiation, better resolution - Suitable for intermittent CSF leak
- Suitable to detect fast profuse CSF leak
Insert nasal / ear pledgets to improve detection
Technique - Inject intrathecal radionuclide, via lumbar puncture
- Image acquisition: 2hrs, 6hrs, 24hrs after injection
Analysis Adult: Children: More rapid
(Normal findings) 1 – 3 hrs Activity seen in basal cisterns 15 – 30 mins Activity seen in basal cisterns
3 – 6 hrs Sylvian fissure & IHF 12hrs Surround the brain
> 24 hrs Surrounds the brain
No activity normally seen in ventricles
4 hrs post injection: 24 hrs post injection:
Aftercare None
Complication None
Din XJ
278
HEAD & NECK

A. Radionuclide Thyroid Imaging
1. Goitre, including retrosternal extension 1. No absolute
2. Toxic goiter, to assess thyroid uptake before radio-iodine therapy 2. CIx for ionizing radiation
3. Thyroid nodule (benign vs malignant)
4. Thyroiditis
5. To locate ectopic thyroid tissue
6. Neonatal hypothyroidism
Radiopharma 1. 99mTc-pertechnetate OR
- Production: Readily available from 99Molybdenum / 99mTechnetium generator
- 99mTc-pertechnetate trapped in thyroid by active transport mechanism, but not organified
Time of imaging: 20-30 mins
2. 123 I-sodium iodide OR
- Production: Cyclotron, decay by e- capture
- 123 I-sodium iodide trapped in thyroid by active transport mechanism, it is organified
Time of imaging: 3-4 hrs
- Agent of choice, but it is produced by cyclotron (expensive & ↓ availability)
3. 131 I-sodium iodide
- Production: Cyclotron, β- decay
- Usually used for therapeutic purpose, but can also be used for whole body imaging
Time of imaging: 48hrs (after injection), 7 days (after 131 I ablation therapy)
- Higher radiation dose
Uptake may be ↓ by anti-thyroid drugs, iodine-based preparation, iodine-based CM
Equipment 1. Gamma camera
2. Collimator: Pinhole converging / High resolution parallel hole → For magnification purpose
Preparation None
Technique - Administer radiopharmaceuticals
a) 99mTc-pertechnetate IV
b) 123 I-sodium iodide IV or oral
- Image acquisition:
a) 99mTc-pertechnetate - 20 mins after IV injection
- Before imaging, patient must drink water to wash away pertechnetate in saliva
b) 123 I-sodium iodide 3-4 hrs after IV injection OR 24 hrs after oral dose
- Supine position, neck slightly extended
- Gamma camera anterior over the thyroid
Position pinhole collimator to give maximum magnification for the camera FOV (usually 7-10cm from neck)
- Place markers on suprasternal notch, clavicles, edge of neck & any palpable nodules
- During imaging, patient should not swallow or talk
- Images:
a) Anterior
b) RAO & LAO
c) Large FOV image (if retrosternal extension or ectopic thyroid tissue is suspected)
Whole body 131 I imaging is often performed after thyroidectomy & 131 I ablation for thyroid ca, TRO mets
Analysis Radioactive iodine uptake (RAIU) can be calculated (for 123 I & 131I)
Normal uptake at 4hrs 4 – 15%
Normal uptake at 24hrs 10 – 30%
Din XJ
279
B. Radionuclide Parathyroid Imaging / Parathyroid Scintigraphy (MIBI or Sestamibi Scan)

Localization of parathyroid adenomas & 1. Clinical hyperparathyroidism (↑ PTH, ↑ Ca2+, ↓ PO4)
hyperplastic glands, before operation 2. CIx for ionizing radiation
Radiopharma 1. 99mTc-methoxyisobutylisonitrile (MIBI or sestamibi) + 99mTc-pertechnetate OR
- Max dose:
MIBI Typical dose: 500 MBq
Max dose: 900 MBq (11 mSv ED)
99mTc-pertechnetate Max dose: 80 MBq (1 mSv ED)
- Both are trapped by thyroid, but only MIBI accumulates in hyperactive parathyroid tissue
- MIBI washed out of thyroid tissue, faster than parathyroid
- Applications: AbN parathyroid activity can be seen via
a) Computer subtraction of pertechnetate from MIBI images
b) Delayed images of MIBI
2. 99mTc-tetrofosmin (Myoview) + 99mTc-pertechnetate OR
- Similar quality with computer subtraction technique
- Less ideal for delayed imaging
3. 201Tl-thallous chloride + 99mTc-pertechnetate
Uptake may be ↓ by anti-thyroid drugs, iodine-based preparation, iodine-based CM
Equipment 1. Gamma camera
a) Small FOV: For thyroid images
b) Large FOV: For chest images
2. Collimator: Pinhole converging / High resolution parallel hole
Preparation None
Technique - Inject IV 99mTc-pertechnetate, leave the cannula in place for 2nd injection
- Acquire image 20 mins after IV injection
Before imaging, patient must drink water to wash away pertechnetate in saliva
- Supine position, neck slightly extended
- Gamma camera anterior over the thyroid
Position pinhole collimator to give maximum magnification for the camera FOV (usually 7-10cm from neck)
- During imaging, patient should not swallow or talk
- Then, inject IV 99mTc-MIBI
- Acquire image 10 mins after IV injection
- Computer subtraction is performed (subtraction of pertechnetate from MIBI image)
- If a lesion is clearly visible, test is terminated
If the lesion is not obvious, delayed MIBI images are acquired at hourly intervals, up to 4hrs
May compliment wt SPECT, for better localization (3-D)
Analysis 1. Delay technique (Single tracer dual phase) 2. Subtraction technique
Aftercare None
Complication None
Din XJ
280
RESPIRATORY SYSTEM
A. Radionuclide Lung Ventilation / Perfusion Imaging (V/Q Scan)
Indications Indications: Contraindications: Relative
1. Pulm embolism (CTPA is still the gold standard) 1. Rt-to-Lt shunt(Risk of cerebral emboli)
2. Congenital heart / pulm disease → However, perfusion scan can also be used for its assessment
3. Quantification of lung performance, 2. Severe pulm HPT
before/after lung transplant / volume reduction surgery 3. CIx for ionizing radiation
4. Assessment of Rt-to-Lt shunt
Contrast 1. Ventilation scan 2. Perfusion scan

- 99mTc-technegas - 99mTc-macroaggregated albumin particles (MAA)
- Max dose: 40 MBq (0.6 mSv ED) - Max dose: 100 MBq (1 mSv ED)
- Aerosol form, consists of ultrafine Tc-labelled carbon - IV form, consists of very small particles (10-40 µm)
particles (5-20 nm) which occlude small lung vessels
- Once inhaled → Adhered to alveolar walls - After IV injection → Trapped throughout pulm bed
Then exhaled → Trapped by filter in mouthpiece (following distribution of pulm blood flow)
Preparation Practice breathing technique

Technique 1. Ventilation scan
- Performed at the same time as perfusion scan
- Same position as perfusion scan, to obtain identical views
- Patient practices breathing technique with mouthpiece
- Attach mouth piece to air supply, switch on generator
2. Perfusion scan
- Supine / semi-recumbent / sitting position
- Administer IV 99mTc-MAA, over 10sec (fast injection may cause respiratory failure)
- Patient remains in position for 2-3 mins
Images acquired: Anterior, posterior, RPO, LPO (must be identical in both ventilation & perfusion scan)
May require SPECT scan for cases with intermediate probability
Analysis Normal V/Q scan: PE of left main pulmonary art:

- Upper diagram: Normal ventilation - Upper diagram: Normal ventilation
- Lower diagram: Normal perfusion - Lower diagram: Restricted perfusion
Aftercare None
Complication Respiratory failure following MAA injection
Din XJ
281
A. Meckel’s Diverticulum Scan
To detect Meckel’s diverticulum, 1. Recent barium study in 2-3 days
as a cause of GI bleed / obstruction / pain → Ba causes attenuation of gamma photons
2. Recent in-vivo labeled RBC study in few days
→ Pertechnetate may adhere to RBC
Radiopharma 99mTc-pertechnetate → Localizes in normal & ectopic gastric mucosa in diverticulum
- Typical dose: 200 MBq (2.5 mSv ED)
Preparation NBM for 6hrs, unless emergency
May give H2-antagonist (Cimetidine or Ranitidine), to ↑ uptake of 99mTc-pertechnetate by gastric mucosa
Technique - Empty the bladder, to prevent bladder from obscuring diverticulum
- Supine position
- Gamma camera over stomach, abdomen & pelvis
- Administer IV 99mTc-pertechnetate
- Dynamic imaging
Acquire: Posterior & lateral images
Aftercare None
Complication None
B. Radionuclide Imaging of GI Bleeding

GI bleed of unknown origin 1. No active bleed during imaging
2. Slow bleed < 0.5 mls/min
3. Recent barium study in 2-3 days
→ Ba causes attenuation of gamma photons
Radiopharma 1. 99mTc-labelled RBCs, max 400 MBq (4 mSv ED)
a) In-vitro labeling - RBCs pretreated wt stannous agent
(most efficient) - 99mTc-pertechnetate is then added
- 99mTc-labelled RBCs injected into patient
b) In-vivo labeling - Stannous agent & 99mTc-pertechnetate injected directly into patient
(least efficient)
c) In-vivo/vitro method - Labeling occurs in the syringe, as blood withdrawn from patient
(compromised)
2. 99mTc-colloid, max 400 MBq (4 mSv ED)

- Less suitable as colloids are rapidly extracted from circulation &colloids localize in liver / sleen
Preparation Patient has to empty the bladder before each image is taken

- Gamma camera over anterior abdomen & pelvis
- Administer IV 99mTc-labelled RBCs or Stannous agent + 99mTc- pertechnetate
- Dynamic imaging:
2-sec images for 1min
1-min images up to 45mins
1-min images for 15mins,
at 1, 2 , 4, 6, 8 and 24hrs or till bleeding site is detected
Acquire: Oblique& lateral images
Aftercare None
Complication None
Din XJ
282
BILIARY SYSTEM
A. Cholescintigraphy / Hepatobiliary Iminodiacetic Acid (HIDA) Scan
1. Assessment of neonatal jaundice, TRO biliary atresia 1. No absolute
2. Assessment of GB, CBD, sphincter of Oddi 2. CIx for ionizing radiation
3. Assessment of biliary drainage / obstruction
4. Suspected biliary leakage (trauma or surgery)
5. Acute cholecystitis
Radiopharma 1. 99mTc-trimethylbromo-iminodiacetic acid (TBIDA) – Hepatic IDA (HIDA)
- Typical dose: 80 MBq (1 mSv ED)
- After IV injection → Binds wt protein → Enters canaliculi → Excreted without being conjugated
2. 99mTc-pertechnetate → To demonstrate stomach outline
- Dose: 10 MBq (0.13 mSv ED)
Preparation T. Phenobarbitone 5mg/kg/day in 2 divided dose, 3-5 days before procedure (to promote hepatocyte uptake)
NBM for 6hrs
Sedation for infants, investigated for biliary atresia
- Gamma camera over anterior abdomen, wt liver at the top of FOV
- Administer IV HIDA
Dynamic imaging: 1-min images, for 45mins
- When GB is visualized (30-45mins after injection), liquid fatty meal (300mls full cream milk) given to stimulate GB contraction
Dynamic imaging: 1-min images, for 45mins
- If GB & duodenum are not seen, acquire static images at intervals, up to 4-6hrs
- If GB & duodenum still not seen after 4-6hrs (possible biliary atresia) , acquire another image at 24hr
Cholecystokinin (CCK) provocation: To assess GB, CBD, sphincter of Oddi
When GB is well visualized (30-45mins after injection),
Give IV CCK infusion over 2-3mins, to stimulate GB contraction & sphincter of Oddi relaxation
Dynamic imaging: 1-min images, for another 30mins
Morphine provocation: To assess for acute cholecystitis
If GB is not seen by 60mins,
Give IV morphine infusion 0.04 mg/kg over 1min, to stimulate sphincter of Oddi contraction
Dynamic imaging: 1-min images, for another 30mins
If GB is not seen after 90mins → Confirm diagnosis
Analysis Normal HIDA scan: Biliary atresia – No demonstration of biliary excretion
Aftercare None
Complication Adverse effects of CCK & morphine
Din XJ
283
A. Dynamic Renal Scintigraphy / DTPA scan
Indications Indications: Assess renal functional status Contraindications:
1. Renal impairment 1. No absolute
2. Obstructive uropathy 2. CIx for ionizing radiation
3. Renal artery stenosis
4. Reflux nephropathy
5. Renal trauma
6. Assessment of renal transplant
Radiopharma 1. 99mTc-diethylene triaminepentacetic acid (DTPA)
- Typical dose: 150 MBq (1 mSv ED)
DTPA does not bind well to plasma protein → Cleared by glomerular filtration(Can be used to calculate GFR)
Cheap but poorer quality
2. 99mTc-mercaptoacetyltriglycine (MAG-3)
- Typical dose: 100 MBq (0.7 mSv ED)
MAG-3 binds to plasma protein → Cleared by tubular absorption (80%) & glomerular filtration (20%)
Better quality but expensive
Preparation Well hydrated
Empty bladder
- Gamma camera over posterior abdomen
- Administer IV DTPA
Dynamic imaging: 10-15 frames, for 30-40 mins
- If poor excretion is seen in 1 or 2 kidneys, after 10-20 mins, IV Lasix 40mg given
Dynamic imaging: 10-15 frames, for another 15 mins
- At the end of examination, if there is significant retention in kidneys, ask patient to void & walk ard for 1min
Take a further spot image
- All images taken in posterior
Additional techniques: To assess GB, CBD, sphincter of Oddi
a) Pre & post-captopril study
- To diagnose RAS
- Images taken before & 1hr after Captopril (25-50 mg)
b) Indirect micturating cystography
- To diagnose VUR
- After renography, dynamic images taken from 2mins before to 3mins after micturition
Analysis 1. Kidney time activity (renogram) curves
2. Relative function figures
3. Perfusion index
4. Parenchymal & whole kidney transit time
Normal renogram: Left obstructive uropathy:
Aftercare None (unless Lasix or captopril given)

Complication None (unless Lasix or captopril given)
Din XJ
284
B. Static Renal Scintigraphy / DMSA scan

Indications Indications: Assess morphology / scarring / differential renal function Contraindications:
1. Renal impairment 1. No absolute
2. UTI 2. CIx for ionizing radiation
3. Reflux nephropathy
4. Renal mass, to differentiate column of Bertin from true mass
5. Congenital renal anomalies (horseshoe, ectopic)
Radiopharma 99mTc-dimercaptosuccinic acid (DMSA)
- Max dose: 80 MBq (0.7 mSv ED)

DMSA binds to plasma protein → Retain in renal cortex for 2hrs → Cleared by tubular absorption
Preparation None
Technique - Administer IV DMSA
- Acquire images btw 1 – 6hrs (Imaging within 1st hour may detect free 99mTc in urine)
- Images taken in
a) Posterior
b) RPO & LPO
c) Zoomed / pinhole views (Paeds)
May require SPECT scan for to assess scarring
Analysis 1. Relative function
2. Absolute uptake
Cortical defects representing scar tissue
Aftercare None
Complication None
C. Direct Radionuclide Micturating Cystography

VUR (↓ Radiation dose compared to MCUG) 1. Acute UTI
Radiopharma 99mTc-pertechnetate
- Max dose: 25 MBq (0.3 mSv ED)

Preparation Empty bladder
- Insert Foley catheter (adult) / feeding tube (paeds), into bladder
- Infuse bladder with 99mTc-pertechnetate, till full
a) Dilute 99mTc-pertechnetate wt NS 500mls at body temperature, then infuse into bladder
b) Infuse 99mTc-pertechnetate into bladder, followed by NS at body temperature
- Gamma camera over posterior abdomen
- Dynamic imaging:
a) During bladder filling 5-10 sec per frame
b) Full bladder Continue another 30 sec
c) During micturition 5-10 sec per frame
d) After micturition Continue another 2-5 mins
Analysis 1. KUB time activity curves
2. Residual & reflux volume
Aftercare 1. Possibility of dysuria
2. May need antibiotic, if there is evidence of VUR
Complication 1. Catheter trauma
2. Bladder perforation, d/t overfilling by 99mTc-pertechnetate
3. UTI
4. 99mTc-pertechnetate – induced cystitis
5. Allergic reaction, d/t intravasation of 99mTc-pertechnetate via bladder mucosa
Din XJ
285
MUSCULOSKELETAL SYSTEM
A. Bone Scan
1. Staging of cancer 1. No absolute
2. Staging of primary bone tumours 2. CIx for ionizing radiation
3. Bone & joint infection
4. Bone & joint infarction (AVN)
5. Complications of metabolic bone disease
6. Trauma (equivocal on x-ray)
7. Arthropathies (RA)
8. Assessment of multifocal disorders (Paget’s disease)
9. Prosthesis assessment (loosening, infection)
Radiopharma 99mTc-methylene diphosphonate (MDP)
- Typical dose: 500 MBq
Max dose: 600 MBq (3 mSv ED)
SPECT: 800 MBq (5 mSv ED)
- Site of uptake: Areas of active bone formation (osteoblastic) / repair, areas of amorphous CaPO4
- Excreted by kidneys
Preparation Well hydrated
- Patient in position on gamma camera, FOV preferably whole skeleton
- Administer IV 99mTc-methylene diphosphonate
- Encourage patient to drink plenty &PU frequently (to ↓ radiation dose)
PU immediately before imaging (to prevent bladder obscuring sacrum & pelvis)
- Studies:
a) Standard study Static imaging 2-4 hrs after injection
6hrs for patient wt renal impairment
b) 3-phase study (i) Arterial phase: Dynamic imaging for 1min after injection (at area of interest)
(for infection, infarction, → Demonstrate perfusion of an area
1o bone tumour) (ii) Blood-pool phase: Dynamic imaging at 5mins after injection (at same area)
→ Demonstrate blood pool d/t blood stagnation
(iii) Delayed phase: Static imaging 2-4 hrs after injection (as for standard study)
→ Demonstrate the amount of bone turnover
- Images taken:
a) Whole skeleton
b) Anterior view (may take oblique view to separate sternum & spine)
c) Posterior view (to assess posterior ribs, scapula, shoulder)
d) Magnified views (to assess small bones & joints)
May compliment wt SPECT, for better localization (3-D)
Analysis Detection of hot spot:
Normal bone scan Bone metastasis

Aftercare None
Complication None
Din XJ
286
B. Bone Mineral Density Scan: Dual-Energy X-ray Absorptiometry (DXA / DEXA scan)
1. Osteoporosis 1. No absolute
- To diagnose osteoporosis 2. CIx for ionizing radiation
- To assess the risk of fracture 3. Recent contrast study (2 weeks)
- To monitor osteoporosis treatment - Barium studies
2. Conditions related to osteopororsis - CT scan / MRI
a) Lost height - Nuclear medicine
b) Unexpected fracture
c) On medications (steroids)
d) Post-transplant
e) Hormonal problem
- Post-menopausal
- On treatment of prostate ca
- HyperPTH
Preparation - No history of recent contrast study (2 weeks)
- Should not take Ca2+ within 24hrs before the test
Technique - Usual tested bone: Spine (lumbar), hip, forearm
- Uses X-ray to measure the density of Ca2+ & other minerals in a segment of bone
2 beams of low-dose X-ray wt distinct energy peaks, sent through the bones being examined
(1 beam is mainly absorbed by soft tissue, the other mainly by bones)
X-rays that pass through will be read by detector placed behind
- Bone mineral density = Total amount – Soft tissue amount
- Types of devices:
a) Peripheral devices: (Clinic setting)
- Measure density in forearm, wrist, finger, heel
- A small portable machine wt space for forearm / foot to be imaged
b) Central devices: (Hospital setting)
- Measure density in spine & hip
- Consist of a platform for patient to lie on & an overhead mechanical arm over the body
Analysis 1. Area mineral density
- Unit: g cm-1
2. T-score:
- Subject’s bone density compared to healthy young adult of same sex
- Unit: Number of standard deviation, from the average
> -1 Normal
-1 to -2.5 Osteopenia
< -2.5 Osteopororsis
3. Z-score:
- Subject’s bone density compared to someone of same age, sex, ethnic group & weight
- Unit: Number of standard deviation, from the average
<2 Abnormal bone loss d/t sth other than aging
Aftercare None
Din XJ

Technique Notes

Uploaded by

Copyright:

Available Formats

You might also like

Technique Notes

Uploaded by

Document Information

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

Technique Notes

Uploaded by

Copyright:

Available Formats

RADIOLOGICAL

1. Contrast Media & Drugs 1

INTRAVENOUS CONTRAST MEDIA IN CT SCAN

 Efforts to ↓ side effects & toxicity:

 Types of contrast media:

 Types of contrast media used in HUKM:

1. Soft tissue toxicity

3. Nephrotoxicity (Contrast-induced nephropathy, CIN)

PROPHYLAXIS OF ADVERSED EFFECTS

CONTRAST MEDIA IN FLUOROSCOPY

 Advantages & disadvantages:

CONTRAST MEDIA IN MRI

 Types of contrast media:

 Prophylaxis of adverse reactions:

GASTRO-INTESTINAL (ORAL) CONTRAST MEDIA

CONTRAST MEDIA IN ULTRASOUND

 Adverse reactions: Allergic-like reactions

DRUGS USED IN RADIOLOGICAL PROCEDURE

Drugs for bowel preparation

2. Fleet solution (Fleet phosphor-soda)

Drugs used in angiographic procedures

Analgesia & Sedation

SCRIPT FOR RADIOGRAPHIC EXAMINATION

g) Collimation - Apply 4-sided collimation

Indication - Lung pathology

- Erect, front facing IR - Sitting / supine, back facing IR

Remarks (i) General

1. Trachea 1. Contour of Rt brachiocephalic vein

2. Difference btw PA erect film & AP film

B. Lateral & Lordotic view

Remarks (i) General: Patient’s particular, Anatomical marker - Similar to AP view

2. Distinguish right & left hemidiaphragm

C. Lateral decubitus & Dorsal decubitus view

Indication - Air-fluid level in pleural cavity Air-fluid level in pleural cavity

- Lateral recumbent position, back facing IR

- Erect, PA projection (IR anteriorly related)

Anterior oblique (Right chest)

1. Right lung 11. Infundibulum

Anterior oblique (Left chest)

1. Sternum 11. Lt pulmonary vein

SCRIPT FOR CXR (PA view)

Important things in CXR:

- Supine, back facing IR

- Erect, back facing IR

Tube Horizontal beam

C. Lateral decubitus & Dorsal decubitus view

Indication - Air-fluid level - Air-fluid level

- Lateral recumbent, back facing (vertical) IR - Supine, side facing (vertical) IR

- Patient on firm surface, to prevent sagging - Arms up beside head

HEAD & NECK

A. External acoustic meatus (EAM)

B. Glabello-meatal line (GML)

A. Skull 1. Lateral D. Optic foramen 1. Parieto-orbital oblique (Rhese method)

A. Skull, Facial & PNS XR

Skull Sella turcica view Facial & PNS

- Sitting or prone, side of interest facing IR

Tube Sitting (Horizontal), Prone (Vertical)

1. Floor of ant cranial fossa & orbital roof 7. Pituitary fossa

2. PA (Occipito-frontal, OF) view