1.
Introduction to Radiology
Radiology uses imaging to diagnose and treat disease. Modalities include radiography (X■ray),
ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), nuclear medicine
(NM), and interventional radiology (IR). Mastering indication selection, image interpretation, and safety
is essential for medical students.
2. Basic Imaging Physics
X■rays are high■energy photons attenuated by tissues; attenuation depends on density and atomic
number. CT reconstructs cross■sectional images from many X■ray projections; values are in
Hounsfield units (HU). MRI detects signals from hydrogen nuclei in a magnetic field; tissue contrast
depends on T1/T2 relaxation and proton density. Ultrasound uses high■frequency sound; echoes
depend on acoustic impedance. Nuclear medicine images radiotracer distribution (physiology).
3. Radiation Units and Dose
Absorbed dose (Gray, Gy) and effective dose (Sievert, Sv). Typical effective doses: chest X■ray ~0.1
mSv, CT abdomen/pelvis ~8–10 mSv. Apply ALARA (As Low As Reasonably Achievable): justify,
optimize, and limit exposure. Use shielding, dose modulation, and appropriate protocols.
4. Contrast Agents Overview
Iodinated contrast (CT/angiography) enhances vessels and soft tissues; risks: allergy■like reactions,
contrast■associated AKI. Gadolinium agents (MRI) shorten T1; rare risk of nephrogenic systemic
fibrosis in severe renal failure. US contrast (microbubbles) enhances vascularity; good safety profile.
Screen renal function, allergies, and pregnancy; obtain informed consent when appropriate.
5. Managing Contrast Reactions
Mild: urticaria, pruritus—antihistamines ± observation. Moderate: bronchospasm,
hypotension—oxygen, β■agonists, IV fluids. Severe anaphylactoid: airway, epinephrine IM, call code.
Pre■medication protocols may reduce risk in prior reactors, but do not eliminate it.
6. Patient Preparation and Safety
Verify identity, indication, and laterality; check pregnancy status for ionizing studies; remove metal for
MRI; assess eGFR and metformin status for iodinated contrast; obtain consent for invasive procedures.
Maintain sterile technique and standard precautions.
7. Image Viewing Basics (PACS)
Use standardized hanging protocols. For CT/MRI, use appropriate windows: lung (~−600/1500), soft
tissue (~40/400), bone (~400/1500). For radiographs, confirm patient, date/time, projection, and side
marker before interpretation.
8. Chest Radiograph: Systematic Approach
Use ABCDE: Airway (trachea), Breathing (lungs/pleura), Cardiomediastinum (size, contours),
Diaphragm (free air, costophrenic angles), Everything else (bones, devices). Confirm projection (PA vs
AP), rotation, inspiration. Cardiothoracic ratio <0.5 on PA.
9. Chest X■ray Pathologies
Consolidation (air bronchograms), interstitial patterns (reticular, nodular), atelectasis (volume loss,
fissure shift), pleural effusion (meniscus, blunting), pneumothorax (pleural line, absent lung markings),
pulmonary edema (Kerley B lines, bat■wing), ARDS (diffuse opacities with normal heart size).
10. Tubes, Lines & Devices on CXR
Endotracheal tube tip 3–5 cm above carina; enteric tube below diaphragm; central line tip near
cavoatrial junction; chest tube directed to apex for pneumothorax; pacemaker/ICD leads course to right
heart. Always assess devices before parenchyma.
11. CT Chest Essentials
Airways, lungs (nodules, GGO, consolidation), mediastinum (nodes, vessels), pleura, chest wall. Use
lung and mediastinal windows. For PE, use CTPA timed to pulmonary arterial phase; for aorta, CTA
with bolus tracking. Nodule assessment uses size, morphology, and risk factors.
12. Chest CT Patterns
Ground■glass opacity (partial filling, edema, inflammation), crazy paving (GGO + interlobular septal
thickening), tree■in■bud (endobronchial spread), honeycombing (fibrosis), mosaic attenuation (air
trapping/vascular). Correlate with clinical context.
13. Cardiac Imaging Basics
Chest radiograph suggests cardiomegaly; echocardiography is first■line for function and valves.
Cardiac CT evaluates coronaries (calcium score, CTA). Cardiac MRI characterizes cardiomyopathies
and viability (late gadolinium enhancement). Understand gating and motion artifacts.
14. Abdominal Radiograph (AXR)
Indications: obstruction, perforation (erect CXR/AXR for free air), foreign body, constipation. Small
bowel obstruction: central, valvulae conniventes across full width; large bowel: peripheral, haustra do
not traverse fully. Beware limitations—CT is often superior.
15. CT Abdomen/Pelvis: Reading Strategy
Start with overview (phase, contrast), then organs: liver, gallbladder/bile ducts, pancreas, spleen,
adrenals, kidneys/ureters/bladder, bowel, mesentery/lymph nodes, vessels, bones, lung bases. Look
for appendicitis, diverticulitis, pancreatitis, obstruction, perforation, solid organ injury.
16. Liver and Biliary Imaging
US: first■line for RUQ pain and gallstones; CT/MRI for staging masses. Fatty liver: low attenuation on
CT; cirrhosis: nodular contour, enlarged caudate, portal hypertension signs. HCC: arterial enhancement
and washout on portal/delayed phases.
17. Pancreas and Spleen
Acute pancreatitis: enlarged, stranding, peripancreatic fluid; use contrast CT for complications
(necrosis). Chronic pancreatitis: calcifications, ductal changes. Splenic trauma: lacerations, perisplenic
hematoma; grade with AAST; consider non■operative management if stable.
18. Gastrointestinal CT Signs
Appendicitis: dilated >6 mm, wall thickening, periappendiceal fat stranding. Diverticulitis: inflamed
diverticula, pericolic fat stranding, wall thickening. Bowel ischemia: pneumatosis, portal venous gas,
absent enhancement. Perforation: free intraperitoneal air (falciform ligament sign).
19. Genitourinary Imaging
Renal colic: non■contrast CT for stones; US in pregnancy. Hydronephrosis on US with twinkling artifact
on Doppler for stones. Pyelonephritis: striated nephrogram, wedge■shaped perfusion defects.
Testicular torsion: US Doppler shows absent flow; ovarian torsion: enlarged ovary, peripheral follicles.
20. Pelvic Imaging and OB/GYN
Transvaginal US evaluates uterus and adnexa; fibroids are hypoechoic masses; endometriosis often
requires MRI for deep infiltrating disease. Pregnancy: confirm intrauterine sac and yolk sac; evaluate
ectopic with discriminatory hCG level. Placental issues and cervical length on OB US.
21. Musculoskeletal Radiography: ABCS
Alignment, Bone density, Cartilage (joint spaces), Soft tissues. Identify fracture pattern, joint
congruency, and fat pad signs (sail sign at elbow). Compare with prior images and contralateral side
when needed.
22. Fracture and Dislocation Essentials
Describe location, pattern, displacement, angulation, intra■articular extension, and open vs closed.
Common injuries: Colles (distal radius), scaphoid (risk of AVN), ankle malleolar fractures, shoulder
dislocation (anterior most common; look for Hill■Sachs and Bankart lesions).
23. Spine Imaging Basics
Evaluate alignment (cervical/lumbar lordosis), vertebral body heights, disc spaces, facet joints,
prevertebral soft tissues. Red flags: burst fractures, retropulsion, subluxation. MRI for cord
compression, infection, or malignancy.
24. Arthritis Patterns on Imaging
Osteoarthritis: joint space narrowing (often asymmetric), osteophytes, subchondral sclerosis/cysts.
Rheumatoid arthritis: symmetric small■joint involvement, periarticular osteopenia, marginal erosions.
Gout: punched■out erosions with overhanging edges; chondrocalcinosis in CPPD.
25. Ultrasound Fundamentals
Operator■dependent modality with real■time imaging. Anechoic (fluid), hypoechoic (soft tissue),
hyperechoic (fat, calcifications). Use color Doppler for vascularity; recognize artifacts (posterior
acoustic enhancement, shadowing, reverberation).
26. FAST and POCUS in Emergencies
FAST exam: RUQ (Morison’s), LUQ (splenorenal), pelvis (pouch of Douglas), pericardial. Look for free
fluid. Lung US: A■lines (normal), B■lines (edema), lung point for pneumothorax. Guide procedures like
paracentesis and central lines.
27. MRI Sequences and Interpretation
T1: fat bright; T2: fluid bright; FLAIR suppresses CSF; DWI/ADC for restricted diffusion (acute infarct);
GRE/SWI for blood products. Beware artifacts: motion, susceptibility from metal, chemical shift.
28. CT Head: Emergencies
Acute hemorrhage is hyperdense. Epidural: biconvex lens■shaped, arterial, does not cross sutures.
Subdural: crescentic, venous, can cross sutures. SAH: hyperdensity in cisterns/sulci. Large territory
infarct becomes hypodense with loss of gray■white differentiation; DWI detects early ischemia.
29. Stroke Imaging Pathway
Non■contrast CT to rule out hemorrhage, CT angiography for large vessel occlusion, CT perfusion to
assess penumbra/core when thrombectomy considered. MRI DWI/FLAIR mismatch can date infarcts.
Time is brain—coordinate with stroke team.
30. Brain Tumors and Mass Effect
Look for mass, edema (vasogenic), enhancement pattern (ring■enhancing lesions include abscess,
metastasis, GBM). Assess midline shift, effacement of ventricles/sulci, herniation signs (uncal,
tonsillar).
31. Pediatric Radiology Pearls
Dose reduction is critical. Salter■Harris classification for physeal injuries. Croup vs epiglottitis on neck
films (steeple vs thumb sign). Intussusception: target sign on US; air/contrast enema is both diagnostic
and therapeutic.
32. Breast Imaging Basics
Mammography uses low■dose X■rays; screening intervals depend on guidelines. BI■RADS
categories standardize reporting. Ultrasound helpful in dense breasts; MRI for high■risk screening.
Know features of benign vs suspicious masses (shape, margins, density, calcifications).
33. Nuclear Medicine Essentials
Bone scan (Tc■99m MDP) for metastases and occult fractures; thyroid uptake scans; V/Q scans for PE
when CTPA contraindicated; PET■CT for oncologic staging (FDG uptake reflects metabolism, but
inflammation can also be avid). Understand half■life, radiation safety, and patient prep.
34. Interventional Radiology (IR) Overview
Image■guided procedures: biopsies, drainages, vascular access, embolization (GI bleed, postpartum
hemorrhage), TACE/TARE for tumors, venous interventions, dialysis access, pain procedures. Know
consent, anticoagulation management, and post■procedure care.
35. Emergency Radiology Checklist
For trauma, follow ABCs; obtain chest/pelvis X■rays and FAST, then whole■body CT if indicated. In
non■trauma emergencies, prioritize life■threatening diagnoses (PE, aortic dissection, ruptured ectopic,
stroke, bowel perforation) with appropriate imaging pathways.
36. Incidental Findings and Follow■Up
Use structured algorithms (e.g., incidental adrenal nodule size/attenuation, lung nodule Fleischner
guidelines, renal cyst Bosniak classification). Document recommendations clearly with timelines and
modality.
37. Reporting Structure and Communication
Use concise, structured reports: clinical indication, technique, comparison, findings by organ system,
impression with prioritized, actionable conclusions. For critical results, perform closed■loop
communication and document it.
38. Appropriateness Criteria and Choosing Wisely
Select the right test for the right patient using ACR Appropriateness Criteria, minimizing unnecessary
radiation and cost. Consider US first in pediatrics and pregnancy; avoid duplicative studies.
39. Artifacts Across Modalities
Radiograph: motion blur, grid cutoff. CT: beam hardening (streaks), partial volume. MRI:
motion/ghosting, susceptibility, aliasing. US: reverberation, side lobes. Recognizing artifacts prevents
misdiagnosis.
40. Infection Control and Sterility
Clean transducers between patients; high■level disinfection for endocavitary probes. Use sterile
technique for US■guided procedures. Follow institutional policies for contrast extravasation
management.
41. Imaging in Pregnancy
Prefer US/MRI (no ionizing radiation). If CT is necessary, tailor dose and shield when appropriate.
Avoid gadolinium unless benefit outweighs risk; iodinated contrast crosses placenta but is generally
considered safe—use judiciously.
42. Measurements and Practical Calculations
Radiographic heart size, mediastinal width, Cobb angle for scoliosis, ankle■brachial index (with
Doppler), CT attenuation (HU) for lesion characterization (fat ~−100 HU, soft tissue ~40 HU, calcium
>200 HU), and perfusion maps in stroke.
43. Structured Approaches by Complaint
Chest pain → ECG, troponins; consider CXR, CTPA for PE, CTA for dissection, coronary CTA if
low–intermediate risk. Abdominal pain → US first for RUQ/OB■GYN; CT for acute abdomen.
Headache → non■contrast CT for thunderclap; MRI for subacute focal deficits.
44. AI in Radiology (For Students)
AI aids detection (e.g., intracranial hemorrhage, PE triage) and workflow (prioritization). It does not
replace radiologists; always clinically correlate and avoid automation bias. Understand basics of
sensitivity/specificity and calibration.
45. Study Strategy and Resources
Practice systematic reads daily. Review normal anatomy and variants. Correlate imaging with clinical
cases. Keep a log of misses/pearls. Use reputable resources and local protocols; ask for feedback
during rotations.
