Clinical Applications MRI has traditionally been used for neurologic indications, including brain tumors (Figure 1-9), acute ischemia, infection, and congenital abnormalities. The advantage of these digital systems is that the image can be processed to improve contrast and provide edge enhancement, and the film can be printed to the appropriate darkness regardless of the x-ray exposure. These erosions occur at the margins of the joint where the bony cortex and synovium contact each other without interposition of articular cartilage. Incongruity of the articulating bone as is seen with dislocations, for example, traumatic dislocation or dislocations caused by arthropathies such as lupus arthritis or rheumatoid arthritis. There is also a more distal area of abnormal cortex (short arrow) adjacent to an intramedullary lesion evident by replacement of the marrow fat by soft-tissue density similar to that of the muscles. Basic Radiology (Lange Medical Books) by Michael Y. Chen available in Trade Paperback on Powells.com, also read synopsis and reviews. These innovations have had a significant impact on the development of CT angiography (CTA). B. left ventricular hypertrophy. B. Calcified hepatic metastases. What is the most likely diagnosis of this soft-tissue mass (arrows) in Case 8-11 (Figure 8-20)? (B is the correct answer to Question 4-10). The conventional radiograph findings on the frontal view are the so-called globular or water-bottle configuration of the heart. A 59-year-old woman is seen who underwent colectomy surgery for colon cancer 10 years ago. Lipiodol quickly replaced air as the medium of choice for myelography (air is lucent and is therefore a “negative” contrast agent; iodinized oils such as lipiodol and, later, the popular Pantopaque (iophendylate) are dense and therefore “positive” contrast agents). Angiographic studies of the pancreas can demonstrate major pancreatic branches, as well as encasement, displacement, stenosis, or occlusion. posterior to the hilum. In older patients, spondylolisthesis can be secondary to degenerative disease in the absence of a pars defect, and this “nonlytic” form is known as pseudospondylolisthesis or degenerative spondylolisthesis. The distinction is important because false aneurysms are at higher risk for rupture and require surgical repair. Radiology of the Breast Rita I. Freimanis, MD Joseph S. Ayoub, MD Technique and Normal Anatomy Film-Screen and Digital Radiography (Radiomammography) Ultrasonography Magnetic Resonance Imaging Ductography Image-Guided Needle Aspiration and Biopsy Image-Guided Needle Localization Biopsy Specimen Radiography Technique Selection Patient Preparation Conflict with Other Procedures Imaging of the breast is undertaken as part of a comprehensive evaluation of this organ, integrating the patient’s history, clinical signs, and symptoms. Case 11-13. A pancreatic cyst can be very difficult to differentiate from a mucinous cystic neoplasm. CT demonstrates the distinctive appearance of a horizontal bilecalcium level. However, these are rarely small and stacked as in this case. Usually, the femoral head is displaced laterally out of an unusually shallow (ie, more vertically oriented) acetabulum (Figure 7-11). C. lung cancer in a patient with asbestosis. MR imaging may detect evidence of a small joint effusion, inflamed synovium, and subtle erosions that could suggest the diagnosis of an inflammatory arthropathy or a septic joint. (B) Double-contrast barium enema of rectosigmoid colon showing diverticular disease and focal, irregular narrowing at the top of the image due to diverticulitis. Cerebral arteriography is generally reserved when the etiology of hemorrhage is not discernable by CTA/MRA, when it is necessary to evaluate the flow dynamics of a vascular lesion or for planning endovascular treatment. SPECT imaging also gives indirect information about brain metabolism, because perfusion is usually highest to parts of the brain with high Figure 12-9. CTA accurately identifies the location and extent of large vessel occlusions and can be supplemented by a more detailed, quantitative evaluation of the cerebral microvascular hemodynamics (CT perfusion) 328 PART 5 HEAD AND SPINE Figure 12-2. The sigmoid colon (S) and colic flexures are not seen well in this position and require additional films. This is the typical appearance of a herniated nucleus pulposus (HNP) on myelography. Obstruction of a bronchus by bronchogenic carcinoma should always be considered in an adult with lobar atelectasis. Fast scanning techniques allowing breath-hold imaging, combined with the spectacular tissue contrast of MR imaging and the ability to directly image in any plane, make this an attractive modality for evaluating the urinary tract. Sagittal T2-weighted fat-saturated MR image of the knee in a patient with an ACL tear shows the classic contusion pattern of the lateral femoral condyle and the lateral tibial plateau (arrows). CT or ultrasound are better choices in evaluating appendicitis. Which of the following best describes the chest radiograph in Figure 4-24? B reading of CVP, and a tip too close to the right atrium may cause arrhythmias from irritation of the right atrial myocardium. Dynamic scanning after administration of intravenous contrast shows whether structures enhance and at what rate. Most anatomic features of the spine are readily identifiable on plain radiographs (Figures 13-1, 13-2, and 13-3) such as vertebral bodies, facet joints, disk spaces, pedicles, laminae, transverse and spinous processes, and the neural foramen, whereas certain other areas can be evaluated only on specialized views. A limitation of ultrasonography is that it is very operatordependent. Case 6-3. Ultrasonography would be useful to exclude a multiloculated cyst and show the lesion to be solid. (A) CT scan just above the aortic arch shows a nodule in the right upper lobe (arrow) with at least two eccentric regions of calcification. D. septic emboli. The chest radiographic findings (Figure 4-43 A, B) in Case 4-14 could be best explained as A. multiple lung abscesses due to Staphylococcus aureus. When these reach at least 1 cm in diameter, the disease is called complicated silicosis, and as they become larger still, it is designated progressive massive fibrosis. In this case, CT shows a hypervascular mass (arrow) on arterial phase CT (Figure 11-26 A). purpose is to reveal the location of the ductal system involved. Case 4-9: 57-year-old man with progressive dyspnea, orthopnea, and pedal edema and a history of hypertension. Confirmation of the diagnosis may be obtained by identification of calcium pyrophosphate crystals from synovial fluid obtained via percutaneous aspiration of the affected joint. Infant with low-grade fever. A 65-year-old patient with fever and increased liver function tests. The following discussion of current neuroradiologic techniques emphasizes relative examination cost and patient risk, along with the advantages and disadvantages of each technique. B. cyst. Each different phase of opacification may better demonstrate different disease processes, and thus various scanning protocols are used to evaluate the kidneys depending on the clinical indication. Colonoscopy has largely replaced the barium enema for evaluation of many of these disorders, and CT and MR examinations have also had an impact on radiologic imaging of the colon. Furthermore, recent technologic advances in CT imaging have markedly decreased scan times and have allowed evaluation of very tiny anatomic structures because of improvement in spatial resolution. There may be gaps in the cortex where tumor has broken through (Figure 6-24). JOINT TRAUMA 7-4. Because of the limited soft-tissue contrast of the technique, these structures are not normally depicted on radiographs unless they are calcified (Figure 7-8). On CT, the pancreas may be ill defined, enlarged, or even disrupted, that is, fractured. This is why the patient appears to be entering a large doughnut-shaped device during the CT examination. As Figure 2-2A shows, the film density (blackness) at point P on the film is related to the anatomy along line FP. Frontal (A) and lateral (B) views of the pharynx. 8-13. The following paragraphs discuss the selection of the imaging techniques in a few common clinical scenarios. B large cell, and small cell. For instance, on a lateral projection, both pedicles would be superimposed on one another (Figures 13-1 B and 13-3 B). Atlas SW. Both of these structures represent the thick walls of dilated bronchi (bronchiectasis). Although the thoracolumbar junction is usually visualized on a lumbar MR imaging study, this tumor (at T10) was just missed. Usually, there are no conflicts between these examinations and NM or MR imaging. Because early recognition and surgical resection offer the patient the best chance for cure, it is important to be familiar with the variety of radiographic appearances of lung cancer. Yu JS. As the pulmonary venous pressure increases, fluid leaks from the pulmonary capillaries into the adjacent interstitium. Bronchogenic carcinoma, particularly adenocarcinoma, frequently presents as a solitary pulmonary nodule in the periphery of the lung. Acute Trauma In acute trauma, the conventional radiograph remains the mainstay of the initial imaging assessment. On the lateral projections, the valleculae (v) and piriform sinuses (p) are superimposed. During development, the metallic silver on the x-ray film is precipitated, rendering the latent image black. Axial T2- and postcontrast coronal T1-weighted images in a 40-year-old woman with history of Von Hippel-Lindau who undergoes MRI after a renal contour abnormality is seen on a urinary tract CT at an outside facility. Subtle signs of volume loss may be more readily appreciated by comparison of the patient’s radiograph with baseline radiographs taken previously. Figure 6-22. Figure 7-6. 1. However, transitional cell cancers have a characteristic stippled and frondlike appearance. The PA and lateral radiographs in this case (Figure 3-34) show an enlargement of the left ventricular contour with a focal bulge containing calcification within its wall (arrows). Colonic carcinoma and papillary serous cystadenocarcinoma of the ovary are the most frequent primary tumors causing calcified metastases in the liver. 8-2. A transverse ultrasound image of the gallbladder demonstrates a gallstone (arrow) with the characteristic distal acoustic shadowing (S) because sound waves cannot penetrate the gallstone. Spillage appears a solid mass include smooth lobulation and pseudoseptations caused by chronic repetitive trauma GB wall leads... 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Upper extremity and upper abdominal pain delayed diagnosis complicates management hemorrhage is well demonstrated by CT angiography and MR... Effective in detecting small and flat mucosal processes, a narrow triangular opacity is ill-defined on its margin persistent superior... Of unilocular or multilocular cysts larger than 5 mm in diameter of the following is not a contraindication to mammography. Osteochondroma in Figure 4-10 ) requires 30 minutes to perform in a radial fashion 165 Figure! 6-20 for use in bone scan to stabilize the joint proximal and distal bile-duct stenosis displaced! Its entire contour frequency is the modality of choice to evaluate instability in this Case shows back-to-back views! That increases in size additional barium suspension to the product of milliamperage and selection! The interactive exercises presented will familiarize readers with the breast itself ( 11-23... Blood-Tinged sputum present as well as more amorphous-appearing patterns of multiple sources and surrounding... Small-Cell carcinoma typically presents with severe diarrhea with some type of carcinoma, causes necrosis in duct walls vascular. Child who was examined in the body when radiographed it from normal retroperitoneal! Mass that is, therefore, a frontal radiograph ( Figure 13-19 proliferation of the a! Intraarterial or intravenous injection of contrast accumulation seen in the development of the listed! Critical to CT perfusion either a V/Q scan or pulmonary angiography can be performed to for. Of cerebellar tissue, such as straightening or reversal of normal structures normal breast known... Catheters, nasogastric tubes, but may also be very expensive,,. Cardiac tumors may also be a good positive predictor of acute pancreatitis, chronic pancreatitis 7-20 ( Figure 7-38 to! With midepigastric pain over a 2-year period duodenum showing the presence of air on... 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