DIAGNOSTIC IMAGING

MODALITIES
Outline
• Introduction
• X-Rays
• Fluoroscopy
• GI
• GU
• CT
• MR
• Innovative Modalities
Modalities Available in
Radiology
• Plain Film / X-Ray/Mammography
• Fluoroscopy
• Ultrasound
• CT
• MRI
• Nuclear Medicine/Molecular Imaging
• Angiography/Interventional
Relative Cost of Imaging Studies
Relative Availability of Diagnostic
Imaging
Teaching
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Suburban
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Plain Fluoro Angio-
Film U/S CT NM MRI interven-
tional
X-Rays
• Discovered in 1895 and still used today
• Most widely performed imaging exam
• X Rays are emitted and detected in cassette
• Cassette can generate either a film or a digital
image
• Films are kept ‘on file’ or in a digital archive
Most Useful Applications for
Plain X-Rays
• Chest
• Musculoskeletal
• Abdomen: limited usefulness
Plain X-Rays
Pros Cons
• Widely available • Ionizing Radiation
• Inexpensive • Relatively insensitive
• Doesn’t require • Requires patient
advanced technologist cooperation
knowledge
• Can be performed
quickly
• Portable
Fluoroscopy
• Fluoroscopy is a type of medical imaging that
shows a continuous X-ray image on a monitor,
much like an X-ray movie. During a fluoroscopy
procedure, an X-ray beam is passed through the
body. The image is transmitted to a monitor so the
movement of a body part or of an instrument or
contrast agent (“X-ray dye”) through the body can
be seen in detail.
Fluoroscopy
• Utilizes X-Rays
• Real-time imaging
• Utilizes image intensifier
• Involves use of contrast agents
Main Uses of Fluoroscopy
• Barium X-rays and enemas (to view the gastrointestinal tract)
• Catheter insertion and manipulation (to direct the movement
of a catheter through blood vessels, bile ducts or the urinary
system)
• Placement of devices within the body, such as stents (to
open narrowed or blocked blood vessels)
• Angiography (to visualize blood vessels and organs)
• Orthopedic surgery (to guide joint replacements and
treatment of fractures)
• Genitourinary Imaging
• Other
• Intraoperative
• Foreign body removal
• Musculoskeletal
Fluoroscopy
Pros Cons

• Widely Available • Requires

• Inexpensive ingestion/injection of
contrast
• Functional and
Anatomic • Patient cooperation
• No sedation required • Time consuming
Gastrointestional Fluoroscopy
• Esophogram/Barium Swallow
• Modified Barium Swallow/Dysphgiagram
• Upper GI
• Small Bowel Series
• Enteroclysis
• Contrast Enema
• Defecography
Single Contrast vs
Double Contrast
• Single Contrast
• Generally uses just thin Barium
• Distends lumen with high density material
• Easier for patient/less mucosal detail
• Double Contrast/Air Contrast
• Thick barium coats lumen
• Effervescent tablets ingested to distend lumen with air
• Produces ‘see-through’ images with greater mucosal
detail
• Greater sensitivity for small lesions, polyps, ulcers
 Single Contrast vs Double Contrast

Single Contrast Double Contrast

Barium Enema Barium Enema
Contrast Materials for GI Exams
• Barium Sulfate
• Thick: used in double contrast studies
• Thin: used in single and double contrast exams
• Paste: mod Ba swallow and defogography
• Gastrograffin
• Full stregnth: rarely used
• Dilute
 Barium vs Gastrograffin

Barium Swallow Study Gastrograffin Swallow Study

Barium Sulfate
• Most widely used
• Better images than gastrograffin
• ‘Chalky taste’
• Peritonitis may develop if perforation
• If delayed transit, may form concretions in colon
Gastrografin
Gastrografin is an X-ray contrast medium that acts
like an X-ray dye when X-rays of the gastrointestinal
tract are being taken.
It is provided as a solution for drinking or diluted for
use as an enema. Gastrografin has a sweet taste.
All X-ray contrast mediums, including Gastrografin,
contain iodine.
Gastrografin
• Water soluble
• Poor mucosal coating
• Basically used for R/O obstruction
• Won’t cause peritonitis if perforation
• May cause severe chemical pneumonitis if
aspirated
• Osmotic pressure draws fluid into bowel lumen
• Progressive distention in small bowel obstruction
• ‘Therapeutic’ enema in constipation
Patient Factors in GI Fluoroscopy
• Ability to ingest contrast
• In order to get high quality images, a relatively large
volume of contrast needs to be ingested fairly quickly
• Mobility
• Multiple positions required for GI exams, particularly
double contrast exams.
• Limited mobility = less diagnostic images
• Weight
• Tables have weight limits
• Requires maximal radiographic technique and exposure
is often suboptimal
Esophogram or Barium Swallow
• Evaluates pharynx and esophagus
• Limited evaluation of stomach
• Double or Single Contrast
• Mucosal contour and Motility
Modified Barium Swallow
• AKA Dysphagiagram and at Carle “cookie swallow”
• Performed with Speech Pathologist
• Barium administered in various bolus consistencies
ranging from liquid to solid
• Evaluates swallowing mechanism
• Evaluates for aspiration
• Performed on videotape
Modified Barium Swallow
Upper GI Exam
• Evaluates esophagus, stomach and duodenum
• Double or Single Contrast
• Can be combined with small bowel series
• Largely replaced by endoscopy and cross-sectional
imaging
• Fairly insensitive
Small Bowel Series
• Patient drinks 2 cups of thin Ba
• Overhead films obtained at routine intervals
• The Ba column is followed through until it reaches
the colon
• Transit time, mucosal contour, bowel loop
distribution are evaluated.
• Insensitive for small masses
Small Bowel Series
Small Bowel Enteroclysis
• “Double Contrast Small Bowel Series
• NGT placed at duodenal-jejunal junction
• Ba injected followed by methylcellulose
• See-through appearance to small bowel
• Greater sensitivity for small masses and mucosal
lesions
• Patient discomfort related to NGT and diarrhea
Contrast Enemas
• Barium or Gastrograffin
• Double contrast or single contrast
• Generally less sensitive than endoscopy
• Requires bowel prep to assess for mucosal lesions
• Requires some element of patient cooperation
 Contrast Enemas

Single Contrast Double Contrast

Barium Enema Barium Enema
Defecogram
• Barium paste is inserted into rectum
• Patient is asked to defecate under fluoroscopy
• Ano-rectal and pelvic floor dynamics can be
assessed
• Rectocele, intussusception, pelvic floor relaxation,
stress incontinence
Genitourinary Fluoroscopy
• Cystogram
• Voiding cystourethrogram
• Retrograde urethrogram
• Hysterosalpingogram
Cystogram

• Usually in adult patients

• Looking for tear or intraluminal mass
• Catheter placed and bladder filled with contrast to
capacity: usually 300-500 ml.
• Spot films obtained when full
• Post void film: usually overhead
 Cystogram

Cystogram with Intraperitoneal Rupture

Voiding Cystourethrogram
VCUG
• Usually in children with history of UTI
• Searching for vesicoureteral reflux
• In males, evaluate for urethral abnormalities:
posterior urethral valves
• Same as cystogram except when full patient voids
under fluoro with spot films
Retrograde Urethrogram
RUG
• Male patients
• Pelvic Trauma
• Post-infectious: STD- looking for stricture
• Different techniques
• Meatus occluded and contrast injected into urethra
under fluoro
Retrograde Urethrogram
RUG
Hysterosalpingogram (HSG)
• Used to evaluate endometrial canal and fallopian
tubes
• Infertility and uterine anomalies
• Dye injected into cervical os under fluoro
• Injection continued with goal to opacify the
fallopian tubes and spill contrast into peritoneum
Musculoskeletal Fluoroscopy
• Fracture/Dislocation reduction
• Hardware placement in the OR
• Flexion/Extension views of c-spine
• Arthrography
• May be performed in conjunction with MRI or CT
 Techniques Relevant to
MSK Radiology
• Radiography (routine and specialized views)
• CT
• MRI
• US
• Densitometry
• Interventional procedures (arthrography,
percutaneous biopsy/vertebroplasty)
 MSK Radiology

Vertebroplasty MRI—Sagittal Knee

T1 Weighted
CT SCAN
CT scan, also known as computed tomography scan,
and formerly known as a computerized axial
tomography scan or CAT scan, makes use of
computer-processed combinations of many X-
ray measurements taken from different angles to
produce cross-sectional (tomographic) images
(virtual "slices") of specific areas of a scanned
object, allowing the user to see inside the object
without cutting.
 Computed Tomography (CT)
• Cross Sectional imaging modality
• Mobile X-ray tube that rotates around a patient
• Slices of X-ray transmission data reconstructed to generate image
• Data displayed in multiple window settings (lungs parenchyma,
bone, etc.)
• Density measurements/Hounsfield Units analyze chemical
component of tissue
• HU: -150-0 = fat, 0 = water, 0-20 = serous fluid, 45-75 = blood,
100-1000 = bone/calcium
 CT Contrast Agents
• Intravenous contrast---iodinated
Differentiate blood vessels vs. vascular internal organs
• Enteric contrast---barium
Differentiate bowel vs. intra-abdominal fluid/masses
• Rectal contrast
• Retrograde urinary bladder contrast
 CT Applications
• Neuro-imaging
-Acute head trauma, acute intracranial hemorrhage
-Low sensitivity for early ischemic stroke,
intracranial metastatic disease, white matter
degenerative disease
• Head and Neck imaging
-Soft tissue of neck, paranasal sinuses, temporal bone
imaging, orbital wall imaging
 CT Applications
• Body Imaging
-Chest, Abdomen, Pelvis (with enteric and IV contrast)
• Pulmonary nodules, Renal Calculi (without contrast)
• Acute appendicitis (with enteric and IV contrast)
• Specialized protocols:
-Liver masses, pancreatic tissue, renal masses, adrenal
masses
 CT Applications
• Acute Abdomen
-decrease rate of false laparotomy procedures
• Trauma Spine Imaging (cervical, thoracic, lumbar)
• Other osseous structures (pelvis, extremities)
• Vascular Imaging
-CT angiography--- i.e. coronary arteries
 CT
Axial, with oral contrast in stomach
CT PET PET/CT
 The Power of CT

CTA
CT Cardiac Imaging
(CT Angiography)
Magnetic Resonance Imaging (MRI)
• Multi-planar scanning
• Without ionizing radiation
• Images generated using powerful magnets and
pulsed radio waves passing through the body
• Data from Pt’s body used to generate image
• Field strength of magnets 0.3-3.0 Tesla
 MR Contrast Agents
• Intravenous contrast---Gadolinium chelate-based
contrast agents
• Gadolinium is a paramagnetic lanthanide that is
toxic as a free metal
• Contrast to evaluate BBB, intracranial edema and
hemorrhage
• Novel agents being developed as tagged
Monoclonal antibodies for Molecular Imaging
 MR Applications
• Neuro-imaging
-Excellent tool due to high soft tissue contrast
resolution
-Abundant water content of CNS allows for imaging
soft intracranial tissue
• Head and Neck imaging
-Multi-planar capability allows for monitoring extent of
disease
-Differentiating subtle soft tissue boundaries of head and neck
 MRI
Axial, T2-Weighted
 MR Applications
• Body Imaging
-Thorax: mediastinal, hilar, chest wall abnormalities
• Limited lung imaging due to artifacts
• New advances in breast imaging
• Potentials for cardiac MRI with coronary MR
angiography
 MRI
Breast Imaging
 MR Applications
• MSK Imaging
- High sensitivity for neoplastic,
inflammatory, and traumatic conditions of
bone and soft tissue
- T1-weighted---fluid collections and
abnormalities in fatty marrow
- T2-weighted---lesions in both marrow and
soft tissue
 MRI
Sagittal, T1-Weighted
 Innovative Modalities
• Constantly evolving face of radiology
• New contrast agents for CT and MR
• Molecular Imaging
- Imaging molecular events---enzymatic
activity, receptor binding, cellular events
• Interventional Radiology and Interventional
Neuroradiology