Image revision Chest and Abdomen

RADY 4034, 4035 Clinical Practice 4 Med Imaging

Presented by Greg Brown FSMRT
Lecturer in Medical imaging
April 2017

• Educating Professionals • Creating and Applying Knowledge • Engaging our Communities

Images credited, or under creative commons are not copyright, while the
presentation and content are.
Chest and Abdomen Imaging

Radiographs CT MRI

• Technique
• Image evaluation
• Pathology
• Artefacts

Questions
Intended to aid your engagement, and evidence you
participation in the session.
 RIPE
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Rotation
Inspiration
Projection
Exposure
Date
Patient ID
Markers
Correct exam / views

Image credit: https://geekymedics.com/chest-x-ray-

interpretation-a-methodical-approach
 RIPE
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ROTATION
PA chest, check that the
sternal ends of the
clavicles are equidistant
from the spinous process

Question 1
Why is the lack of
rotation so important?

https://geekymedics.com/chest-x-ray-interpretation-a-methodical-approach/
base images,modified. accessed 4 April 2017.
 RIPE
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INSPIRATION
Look for
5 – 6 anterior ribs,
9th or 10th rib visible
posterior
All lateral rib edges,
6 Ant Both costo-phrenic angles
Root of fourth rib on the
medial clavicle
11

Question 2
Describe the abnormality

Image credit Asci, L 2016 (1)

.
 RIPE
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Projection
• Scapulae projected clear
of lungs by the divergent
beam
• Clavicles near horizontal
• Intervertebral disc spaces
visible to at least T5
• Side marker visible and
correct
• Field free of artefacts
• Collimation marks
• Lung markings visible

Image credit Asci, L 2016 (1)

.
 RIPE
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Exposure
• Left hemi-diaphragm
visible to the heart
• Spine visible through the
heart
• The required penetration of the
mediastinum can be variable.
Some radiologists want to see
clearly to T5 with outlines visible
beyond.
Many prefer complete penetration
without loosing lung field
markings

Question 3
What exposure parameter controls
penetration and flattens image
contrast?
Image credit Chadrasekhar A.J. 2006.
.
 RIPE
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Question 4
Critique this image with
RIPE

Image credit Ward, D. 2016 geekymedics.com

.
 A repeat view is NOT always necessary
but
Use every image to drive your skill development

• Aim to get a perfect image

• Evaluate each image honestly
• Identify imperfections
• Options to correct faults
• Unleash your growing professional skills to work
for consistent optimal performance.
 CXR interpretation - ABCDE
• Airway
 Trachea: deviation, compression narrowing
 Corina: angle of bifurcation of main bronchi
 Right wider and more vertical than left
 Hilum: enlarged? Visible nodes? Asymmetric ?
• Breathing
 Lungs: lung markings radiate to edge. Lobar divisions
 Pleura: covering of lungs not normally visible. Air of fluid?
• Cardiac
 Heart size < 50% (on non rotated PA)
 Well defined heart borders. If not ? Lung consolidation
 CXR interpretation - ABCDE
• Diaphragm
 Right: higher than left, Indistinguishable from liver.
 Left: stomach and bowel appear below the diaphragm
 Gas: gas under diaphragm – alert radiologist
 Costo-phrenic angles Sharp and clear if blunt -> fluid
collection, or over inflation. Medial diaphragm attachments
• Everything else
 Mediastinal contours – Aorta
 Bones – sclerosis, fractures, erosion
 Soft tissue – odd lumps, implants, interstitial air
 Objects – tubes (trace them) heart valves, pacemakers ECG
dots,
 Artefacts - wet hair, rocks, glass, pens, piercings, coins
(where?)
 ABCDE
Airways
The more vertical Right
bronchus is a common
location for inhaled
objects.

Image credit Patel , J.J. emrems.com 2014

.
 ABCDE
Everything else
Artefacts: do they
obscure? Do they reflect
poor preparations

Question 5
Identify all the additions to
the patient, tubes etc.

Image credit: Khimani,A et al. Case Rep Pulmonology 2013 doi 10.1155/2013/364195
.
 Image Cadogan M. 2011
https://lifeinthefastlane.com/table/radiology-database/
Image” Nadalo, L.A. Medscape.com

Rib # Lt 4,5,6,?7 metal from Question 6

trolley obscuring ribs, costo- Inhaled or swallowed or ?
phrenic angle

Image credit: Khimani,A et al. Case Rep Pulmonology 2013 doi 10.1155/2013/364195
.
 Replace this panel with image of your choice a) Describe the
abnormality
b) Name the pathology
c) Note any non-patient
items?
d) What could it be?
e) How could it be
handled better?

Image credit Ward, D. 2016 geekymedics.com

.
 CT Chest
Increasingly common for
identifying mass lesions

IV iodinated contrast may

be used.
Chest spirals can be
acquired during contrast
transit to liver

Image credit Gaillard, F. Radiopaedia.org, rID: 7390

.
 Mentor asks,
“what do you see?”
CP 4 Hint….
Don’t answer
“nothing” or “I don’t
know what it is”

Observations
Modality, body part ?
Gender ?
Image windowing ?
Lesions ?
Image credit Gaillard, F. Radiopaedia.org, rID: 7390
Pathology?
.
CT Bone metastases

Blastic lesion high Lytic lesion decreased density,

density, non expansive. expansive. Mets of other multiple
In male = Ca Prostate primaries
metastases
.
Image credit Gaillard, F. Radiopaedia.org, rID: 7390
CT Aortic dissections
Image credit Gaillard, F. Radiopaedia.org, rID: 12384 & 9068

Aortic dissection Two lumens. Type A: Type B: Descending Aorta.

isolated to Ascending Aorta.Show Find lowest extent, identify
involvement of the coronary A. or origins of abdominal vessels,
Aortic valve to direct surgery
. true or false lumen
MR Aortic dissections
Case courtesy of Dr Roberto Schubert, Radiopaedia.org, rID: 13810

Oblique Maximum Intensity

Projection, Contrast
enhanced MR angiogram,
reconstructed from Coronal
slices.

High signal shows the

lumens.

Always accompanied by black

blood MR for aneurysms
morphology

.
MR Aortic dissections
Fig 4. Evangelista A. et al Circulation. 2003;108:583-589

Circulation. 2003;108:583-589

Sag obl. black blood (A) and white blood MRI (B) no
injected contrast material
.
MR Flow contrasts & quantification
• A. Sag Oblique
white blood
• B. Black blood
axial
• C. white blood
axial
• D. Phase contrast

Images: Cardiovascular Magnetic Resonance, Sydney, Australia).

A. CE MRA.
B phase calculated flow lines,
C/E Phase flow quantification in Asc. Aorta, true and false lumen.
D/F Phase flow quantification in abdominal aorta showing true and
false lumens
https://www.researchgate.net/profile/Arno_Roest/publication/260430221/figure/fig6/AS:297173083279390@144786299265
9/FIGURE-6-4D-flow-visualization-of-a-type-A-aortic-dissection-in-a-50-year-old-male.png
Refresher of abdominal locations

Quadrants Regions
 Abdominal X-ray
• Erect
 Have patient upright 5 to 15 minutes prior to show free gas
 Perform this view first
 Coverage as for supine
• Supine
• Cover diaphragm to ischial tuberosities, both flanks
• Make psoas muscles and flank line visible.
• Decubitus
 Alternated to erect view. Right Side UP, Use marker on the
upper side and annotate image
• KUB
• Subregion of abdomen, coverage of the kidneys down to lowest
extent of urinary tract
 Free gas

Left Lateral decubitus. Gas seen above

Liver. Often looked for, rarely found

Image: Fuller M.J. Wikiradiograpghy.com 2009

 • Gas-fluid levels
obstructed small
bowel.
• Note the multiple
transverse loops
& the multiple
folded
texture.Helps
distinguish SBO
from large bowel.
• Horizontal beam is
more important than
a vertical patient
• More common than
intraperitoneal gas

Image: Fuller M.J. Wikiradiograpghy.com 2011

 Renal calculi.
Presentation (renal
colic) is extreme,
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often requiring opiate
pain relief.
? Real or drug
seeking

Sensitivity
Ultrasound 20%
X-ray 45-60%
CT 95 %

http://www.aafp.org/afp/2001/0401/p1329.html
Image : Radiologymasterclass.com
http://www.radiologymasterclass.co.uk/tutorials/abdo/abdomen_x-
ray_calcium/calcium_introduction
Liver tumours
Need to distinguish
• Primary or secondary
• Benign or malignant
• Number of lesions (to decide surgical or non surgical
treatment
• Vascular supply and liver segment (surgical plan)
Modalities
• Ultrasound
• CT
• MRI
Contrast phases
• Pre contrast
• Often not used in CT, always in MRI
• Early Arterial phase (20 - 40 sec)
• first pass hepatic artery
• Portal venous phase (1.5 min)
• Maximal enhancement of the liver parenchyma
• Equilibrium phase (3-4 min)
• Contrast washing out of the liver, assess speed of
washout in lesions
• Delayed phase (10 – 20 minutes)
• Used in MRI with hepatic excretion agent
(Primovist) to give specific enhancement of hepatic
tissue
Contrast phases

CT acquires two phases usually. (late arterial and late

portal venous)
Limited by radiation concerns

MRI acquires 5 phases of contrast enhancement plus

other contrast types.
Arteriography
Diffusion
T2 (fluid weighting)
Fat / water percentage, iron levels
 unenhanced late arterial

portal venous equilibrium

CT Haemangioma. Common benign liver lesion. No therapy.

Highly vascular, delayed washout
Adapted from http://www.radiologyassistant.nl/en/p446f010d8f420/liver-masses-i-characterization.html
unenhanced late arterial CT HCC
• Hepatpo-cellular
carcinoma
Replace this panel with image of your choice
• Liver primary tumour
associated with fatty
liver disease,
(alcoholic & non
alcoholic)
• Capsule is
characteristic. Less
dense in unenhanced
CT, tumour blush in
arterial, with washout
& some later
equilibrium specimin enhancement of
capsule
 CT HCC
• Hepatpo-cellular
carcinoma
Replace this panel with image of your choice
• Liver primary tumour
associated with fatty
liver disease,
(alcoholic & non
alcoholic)
• Capsule is
characteristic. Less
dense in unenhanced
CT, tumour blush in
arterial, with washout
& some later
equilibrium specimin enhancement of
capsule
 MRI HCC with
central scar

T2 weighted
Coronal MRI

Fatsat T1
weighted axial
Case courtesy of Dr Natalie Yang,
Radiopaedia.org, rID: 7011 MRI
 HCC MRI
T1 fatsat images post
contrast

equilibrium post contrast

Delayed post
contrast
Case courtesy of Dr Natalie Yang,
Radiopaedia.org, rID: 7011
 MRCP
Imaging the biliary tree , gall bladder and pancreatic
ducts using the natural fluids present.
Strong T2 contrast weighting, with fat suppression.
 MR Enterography
Small bowel imaging.
Fill small bowel with sugar doped water. Bright on T2
(lumenography), dark on T1. IV contrast to enhance bowel
wall
 MR Liver Iron Measurement
Quantitative methods MR R2 or R2* signal decay roughly
proportional to liver iron concentration. Also used in heart.
 MR Liver Iron Measurement
L iv e r R 2 *

250

200

150
S ig

100

50 Liver R2* 304 Hz

10.2 mg/g iron **
0
0 .0 0 0 0 .0 0 5 0 .0 1 0 0 .0 1 5 0 .0 2 0

sec Normal is 0.9 mg/g

** Custom calibration Brown G. thesis , in progress

Associated material
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