Basic Radiology, Second Edition - 2nd Edition

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 To the memory of my mother
M.Y.M.C.
To Susan, Stephen, and the memory of my parents and father-in-law
D.J.O
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 Contents
Contributors vii 7. Imaging of Joints 181
Preface ix Paul L. Wasserman and Thomas L. Pope

PART 1. INTRODUCTION
PART 4. ABDOMEN
1. Scope of Diagnostic Imaging 1
8. Plain Film of the Abdomen 211
Michael Y. M. Chen and Christopher T. Whitlow
Michael Y. M. Chen
2. The Physical Basis of
Diagnostic Imaging 15 9. Radiology of the Urinary Tract 233
Robert L. Dixon and Christopher T. Whitlow Jud R. Gash and Jacob Noe

10. Gastrointestinal Tract 255

PART 2. CHEST David J. Ott

3. Imaging of the Heart and 11. Liver, Biliary Tract, and Pancreas 289
Great Vessels 25
Melanie P. Caserta, Fakhra Chaudhry,
James G. Ravenel and Robert E. Bechtold

4. Radiology of the Chest 67

Caroline Chiles and Shannon M. Gulla PART 5. HEAD AND SPINE
12. Brain and Its Coverings 325
5. Radiology of the Breast 129
Michael E. Zapadka, Michelle S. Bradbury,
Rita I. Freimanis and Joseph S. Ayoub
and Daniel W. Williams III

13. Imaging of the Spine 365

PART 3. BONES AND JOINTS
Nandita Guha-Thakurta and Lawrence E. Ginsberg
6. Musculoskeletal Imaging 155
Tamara Miner Haygood and Mohamed M. H. Sayyouh Index 389

v
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 Contributors
Joseph S. Ayoub, MD Lawrence E. Ginsberg, MD
Fellow, Department of Radiology, Baylor College of Medicine, Professor of Radiology and Head and Neck Surgery,
Houston, Texas Department of Radiology, University of Texas,
M. D. Anderson Cancer Center—Houston,
Robert E. Bechtold, MD Texas
Professor, Department of Radiology, Wake Forest University
School of Medicine, Winston-Salem, North Carolina Nandita Guha-Thakurta, MD
Assistant Professor, Diagnostic Radiology, Department of
Michelle S. Bradbury, MD, PhD Radiology University of Texas, M. D. Anderson Cancer
Assistant Attending Radiologist, Molecular Imaging & Center, Houston, Texas
Neuroradiology Sections Department of Radiology,
Memorial Sloan Kettering Cancer Center Shannon M. Gulla, MD
Assistant Professor of Radiology, Weill Medical College Mid-South Imaging and Therapeutics,
of Cornell University, New York, New York Memphis, Tennessee
Melanie P. Caserta, MD
Assistant Professor, Department of Radiology, Wake Forest
Tamara Miner Haygood, MD, PhD
University School of Medicine, Winston-Salem, North Assistant Professor, Department of Diagnostic Radiology,
Carolina University of Texas, M. D. Anderson Cancer Center,
Houston, Texas
Fakhra Chaudhry, MD
Mecklenburg Radiology Associates, Charlotte, Jacob Noe, MD
North Carolina Chief Resident, Department of Radiology,
University of Tennessee at Knoxville, Knoxville,
Michael Y. M. Chen, MD Tennessee
Associate Professor, Department of Radiology, Wake Forest
University School of Medicine, Winston-Salem, North David J. Ott, MD
Carolina Professor, Department of Radiology, Wake Forest
University School of Medicine, Winston-Salem,
Caroline Chiles, MD North Carolina
Professor, Department of Radiology, Wake Forest University
School of Medicine, Winston-Salem, North Carolina Thomas L. Pope, MD
Professor, Department of Radiology and Radiologic Science,
Robert L. Dixon, PhD Medical University of South Carolina, Charleston,
Professor, Department of Radiology, Wake Forest University South Carolina
School of Medicine, Winston-Salem, North Carolina

Rita I. Freimanis, MD James G. Ravenel, MD

Associate Professor, Department of Radiology, Wake Forest Professor, Chief of Thoracic Imaging, Department of
University School of Medicine, Winston-Salem, North Radiology and Radiologic Science, Medical University of
Carolina South Carolina, Charleston, South Carolina

Jud R. Gash, MD Mohamed M. H. Sayyouh, MD

Professor, Department of Radiology, University of Tennessee Assistant Lecturer, Department of Radiology, National
at Knoxville, Knoxville, Tennessee Cancer Institute, Cairo University, Egypt

vii
 viii
䊱 CONTRIBUTORS

Paul L. Wasserman, DO Daniel W. Williams III, MD

Assistant Professor, Department of Radiology, Wake Forest Professor, Department of Radiology, Wake Forest University
University School of Medicine, Winston-Salem, North School of Medicine, Winston-Salem, North Carolina
Carolina
Michael E. Zapadka, DO
Christopher T. Whitlow, MD, PhD Assistant Professor, Department of Radiology, Wake Forest
Fellow, Department of Radiology, Wake Forest University University School of Medicine, Winston-Salem, North
School of Medicine, Winston-Salem, North Carolina Carolina
 Preface
The primary goal of this book was to create a concise text on current radiologic imaging for medical students and residents not
specializing in radiology. After the first two introductory chapters, subsequent chapters employ an organ-system approach.
Imaging techniques pertinent to the organ system, including their appropriate indications and use, are presented. Question-oriented
exercises highlight the most commonly encountered diseases for each organ system.
The first chapter describes the various diagnostic imaging techniques that are available: conventional radiography, nuclear
medicine, ultrasonography, computed tomography (CT), and magnetic resonance (MR) imaging. In recent years, many new
techniques, such as CT angiography, CT colonography, MR angiography, MR cholangiopancreatography, and positron emission
tomography (PET)/CT have emerged with new generations of CT and MR equipment. The second chapter gives an overview of
the physics of radiation and its related biological effects, ultrasound, and magnetic resonance imaging. The remaining chapters
focus on the individual organ systems of the heart, lungs, breast, bones, joints, abdomen, urinary tract, gastrointestinal tract,
liver, biliary system, pancreas, brain, and spine. The chapters have a similar format to provide a consistent presentation. Each
chapter briefly describes recent developments in the radiologic imaging of these organ systems. This is followed by a description
of the normal anatomy and a discussion of the most appropriate and rational imaging techniques for evaluating each organ sys-
tem. Each chapter stresses the proper selection of each imaging examination based on clinical presentation, need for patient
preparation, and potential conflicts between techniques. Finally, all chapters end with questions and imaging exercises to en-
hance and reinforce the principles of each chapter. All exercises include numerous images and specific questions focusing on
common diseases or symptoms. One question per case is used in all exercises, and the case and question numbers are matched
for clarity. A short list of suggested readings and general references is included at the end of each chapter.
We hope that this book will help medical students and residents not specializing in radiology to better comprehend the ba-
sics of each imaging technique. Ideally, this book will also aid them in selecting and requesting the most appropriate imaging
modality for each patient's presenting symptoms. Our further hope is that the interactive exercises presented will familiarize
readers with the more common diseases that current radiologic imaging can best evaluate.
We wish to thank Allen D. Elster, MD, Director of the Division of Radiologic Sciences and Professor and Chairman of the
Department of Radiology of the Wake Forest University School of Medicine, and C. Douglas Maynard, MD, now retired former
Director of Division of Radiologic Sciences and Professor and Chairman of the Department of Radiology of the Wake Forest
University School of Medicine, who have provided us with the supportive environment needed to complete this endeavor. This
book would not have been possible without the able support of Michael Weitz, Karen Edmonson, Laura Libretti, and their fine
associates at Lange Medical Books/McGraw-Hill.

ix
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 Part 1. Introduction
 1

1
Scope of
Diagnostic Imaging

Michael Y. M. Chen, MD
Christopher T. Whitlow, MD, PhD

Conventional Radiography Ultrasonography

Contrast Studies Magnetic Resonance Imaging
Computed Tomography
Nuclear Medicine

For almost half a century following the discovery of x-rays by are now being used clinically, with genetic and molecular
Roentgen in 1895, radiologic imaging was mainly based on marker imaging expected in the future.
plain and contrast-enhanced radiography. Those images This chapter is intended to provide an overview of a vari-
were created by exposing film to an x-ray beam attenuated ety of modalities in diagnostic radiology and basic knowl-
after penetrating the body. The production of x-rays and edge regarding radiologic image-based diagnosis. Specific
radiographic images is described in the next chapter. In the modality settings in each field and diagnostic interpretation
recent half century, diagnostic radiology has undergone for the use of these modalities in evaluating various organ
dramatic changes and developments. Conventional angiog- systems are described in subsequent chapters.
raphy, nuclear medicine, ultrasonography, and computed
tomography (CT) were developed between 1950 and 1970.
Magnetic resonance (MR) imaging, interventional radiology,
CONVENTIONAL RADIOGRAPHY
and positron emission tomography (PET) were developed Conventional radiography refers to plain radiographs that are
later. Conventional radiology, including contrast-enhanced generated when x-ray film is exposed to ionizing radiation
radiography and CT, uses ionizing radiation created from x-ray and developed by photochemical process. During develop-
equipment. Nuclear medicine uses ionizing radiation that is ment, the metallic silver on the x-ray film is precipitated, ren-
emitted from injected or ingested radioactive pharmaceuticals dering the latent image black. The amount of blackening on
in various parts of the body. Ultrasonography and MR imag- the film is proportional to the amount of x-ray radiation ex-
ing modalities use sound waves and magnetism, respectively, posure. Plain radiography relies on natural and physical con-
rather than ionizing radiation. trast based on the density of material through which the
Radiologic subspecialties have been developed based on x-ray radiation must pass. Thus, gas, fat, soft tissue, and bone
organ systems, modalities, and specific fields. Organ-oriented produce black, gray-black, gray, and white radiographic im-
subspecialties of radiology include musculoskeletal, breast, ages, respectively, on film (Figure 1-1).
neurologic, abdominal, thoracic, cardiac, gastrointestinal, and Although other image modalities such as CT, ultra-
genitourinary imaging. Modality-oriented subspecialties com- sonography, and MR imaging are being used with increasing
prise nuclear medicine, interventional, ultrasonography, and frequency to replace plain radiographs, conventional radiog-
MR imaging. Specific field subspecialties include pediatric and raphy remains a major modality in the evaluation of chest,
women’s imaging. Functional and metabolic imaging methods breast, bone, and abdominal diseases.
 2
 PART 1 INTRODUCTION

 Figure 1-1. Standard posteroanterior

chest radiograph demonstrated the striking
contrast between the heart (H) and lungs (L).
A tumor (T) is seen at the left hilum.

Computed radiography (CR) or digital radiography is image intensifier absorbs x-ray photons and produces a
presently replacing conventional screen-film combination quantity of light on the monitor. The brightness of the image
techniques. The most common CR technique, photostimu- is proportional to the number of incident photons received.
lable phosphor computed radiography (PPCR), uses a Fluoroscopy is a major modality used to examine the gas-
phosphor-coated plate to replace the film-screen combina- trointestinal tract. For example, fluoroscopy can be used to
tion. When a cassette containing the phosphor-coated plate follow the course of contrast materials through the gastroin-
is exposed to x-rays, the phosphor stores the absorbed x-ray testinal tract, allowing the evaluation of both structure and
energy. The exposed cassette is then placed in a PPCR function. Spot filming or video recording may be used syn-
reader that uses a laser to stimulate release of electrons, re- chronously with fluoroscopy to optimally demonstrate
sulting in the emission of short-wavelength blue light. The pathology. Fluoroscopy is also used to monitor catheter
brightness of the blue light is dependent on the amount of placement during angiography and to guide interventional
absorbed x-ray photon energy. This luminescence generates procedures. In recent years, digital detectors (such as charge-
an electrical signal that is reconstructed into a gray-scale coupled devices, CCDs) have begun to replace video cameras
image, which may be displayed on a monitor or printed as a on fluoroscopy units.
hard copy. Digital images generated from PPCR are capable Conventional tomography produces an image of one in-
of being transmitted through a picture archiving and com- tended area by blurring structures superimposed on both
munications system (PACS), similar to other digital images sides of a focus plane. This technique, however, has been
acquired from CT or MR facilities. PPCR is better than largely replaced by CT.
plain radiography in linear response to a wide range of x-ray Mammography uses a film-screen combination tech-
exposure. However, PPCR provides less spatial resolution nique to evaluate breast lesions for the early detection of
than plain radiography. Another CR technique that is being breast carcinoma. A mammographic unit is installed with a
developed uses an amorphous selenium-coated plate, which special x-ray tube and a plastic breast-compression device. A
directly converts x-ray photons into electrical charges. standard mammogram obtains views in two projections,
Fluoroscopy uses a fluorescent screen instead of radi- producing craniocaudal (CC) and mediolateral oblique
ographic film to view real-time images generated when an (MLO) images of the breast. Additional images of the breast
x-ray beam penetrates through a certain part of the body. An in other projections, such as mediolateral (ML) views, and
 SCOPE OF DIAGNOSTIC IMAGING CHAPTER 1
 3

using diagnostic techniques such as magnification and/or

spot compression views may also be obtained to further char-
acterize potential pathologic findings. Ultrasonography (US)
is also used in breast imaging as a complementary modality
to further characterize breast pathology. Several image-
guided breast interventional procedures, such as preoperative
needle placement for lesion localization and core needle
biopsy using stereotactic ultrasound or MR guidance,
are widely available.

 Contrast Studies
Contrast materials are used to examine organs that do not
have natural inherent contrast with surrounding tissues.
Contrast media are commonly used to evaluate the gastroin-
testinal tract, the urinary tract, the vascular system, and solid
organs. Contrast media used in MR imaging are described in
the MR modality section.
Barium suspension is still used daily in the examination
of the gastrointestinal tract. Barium suspension is a safe
contrast media that provides high imaging density on
upper gastrointestinal (UGI) series, small-bowel studies, and
evaluation of the colon. Both single-contrast and double-
contrast techniques may be used to evaluate the gastroin-
testinal tract (Figure 1-2). In the single-contrast study,
barium suspension is administered alone. In the double-
contrast study, both barium and air are introduced to de-
lineate the details of the mucosal surface, which facilitates
the identification of superficial lesions in the bowel lumen.
 Figure 1-2. A single-contrast retrograde colonic enema
In the UGI double-contrast study, air is introduced into the
bowel lumen by administering oral effervescent agents. For in the left posterior oblique view demonstrates an annular
double-contrast evaluation of the lower GI tract with bar- lesion representing a cecal carcinoma (arrows). Bilateral
ium enema, air is introduced into the bowel lumen via di- hip prostheses are an incidental observation.
rect inflation with a small pump through a rectal catheter.
Small-bowel contrast studies include peroral, enteroclysis, media are the high osmolar ionic contrast agents (diatrizoate
and retrograde techniques. The peroral small-bowel study and its derivatives). Low osmolar contrast media include
is performed by feeding barium suspension to the patient ionic (meglumine ioxaglate) and nonionic (iohexol, iopami-
and recording the progress of contrast through the small dol, ioversol, iopromide) monomers, as well as nonionic
bowel. Enteroclysis is performed by placing a catheter in dimers (iodixanol). Low osmolar contrast media have an
the proximal jejunum and infusing barium suspension overall lower incidence of adverse reactions, including
through the catheter. Enteroclysis is preferred for evaluat- nephrotoxicity and mortality, than high osmolar ionic agents;
ing focal small-bowel lesions or the cause of small-bowel however, lower osmolar agents are also three to five times
obstructions. Retrograde small-bowel examination is per- more expensive.
formed by retrograde reflux of barium suspension into the The occurrence and severity of adverse reactions after ad-
small bowel during barium enema or via direct injection ministration of iodinated contrast material are unpre-
through an ileostomy. dictable. These reactions are categorized as mild, moderate,
Water-soluble contrast media are commonly used for an- or severe based on degree of symptoms. Mild adverse reac-
giography, interventional procedures, intravenous urogra- tions include nausea, vomiting, and urticaria that do not re-
phy, and enhancement of CT. All water-soluble contrast quire treatment. The incidence of mild adverse reactions may
media are iodinated agents that are classified as high or low be less if using a lower osmolality contrast agent. Moderate
osmolar, ionic or nonionic, and monomeric or dimeric in reactions include symptomatic urticaria, vasovagal events,
chemical nature. The iodine atoms in contrast medium absorb mild bronchospasm, and/or tachycardia that requires treat-
x-rays in proportion to the concentration in the body when ment. Severe and life-threatening reactions, such as severe
radiographed. The most common water-soluble contrast bronchospasm, laryngeal edema, seizure, severe hypotension,
 4
 PART 1 INTRODUCTION

and/or cardiac arrest, are unpredictable and require prompt after fallopian tube spillage appears. A transcervical recanal-
recognition and immediate treatment. ization of obstructed fallopian tube has been introduced to
Contrast-induced nephropathy (CIN) is characterized by improve the fertility rate.
renal dysfunction after intravenous administration of iodi- Angiography is the study of blood vessels following intra-
nated contrast material. There is no standard definition of arterial or intravenous injection of water-soluble contrast
CIN. Findings with CIN include percent increasing serum agents. A series of rapid exposures is made to follow the
creatinine from baseline (such as 20% to 50%) or increasing course of the contrast medium through the examined blood
absolute serum creatinine above baseline (such as 0.5 to vessels. Angiographic images are recorded by standard or dig-
2.0 mg/d) within 24 to 48 hours (or in 3 to 5 days). The inci- ital imaging, and/or stored digitally.
dence of CIN is variable. Patients with renal failure or under- Thoracic aortography is performed when there is suspi-
lying renal diseases are several times more likely to develop cion of traumatic aortic injury, dissection (Figure 1-3), or
CIN than those with normal renal function following the atherosclerotic aneurysm, and to evaluate cerebral and upper
administration of iodinated contrast material. extremity vascular disease. Multidetector CT has largely re-
Water-soluble contrast agents are used in the gastroin- placed conventional aortography as the initial modality to
testinal tract when barium suspension is contraindicated, evaluate aortic trauma (Figure 1-4). Conventional aortogra-
when perforation is suspected, when surgery is likely to fol- phy, however, remains important in specific settings, such as
low imaging, when confirmation of percutaneous catheter planning endovascular stent graft therapy and assessing small
location is necessary, and when gastrointestinal opacifica- branch vessel injuries in stable patients. Abdominal aortogra-
tion is required during abdominal CT evaluation. Unlike phy is used to evaluate vessel origins in vascular occlusive
barium suspension, water-soluble contrast agents are readily disease or prior to selective catheterization. Abdominal
absorbed by the peritoneum if extraluminal extravasation aortography is also used for vascular mapping prior to
occurs, but provide less image density. High osmolar water- aneurysm repair or other intra-abdominal surgery. Coronary
soluble contrast agents may cause severe pulmonary edema angiography is most commonly performed to evaluate coro-
if aspirated. High osmolar contrast agents may also cause nary occlusion. Pulmonary angiography is used in patients
fluid to shift from the intravascular compartment into the who are suspected of having pulmonary embolus, especially
bowel lumen, resulting in hypovolemia and hypotension, in the setting of equivocal results on ventilation-perfusion
which is less likely to occur with low osmolar water-soluble imaging. Inferior venacavography is performed to evaluate
contrast media. for caval occlusion from venous thrombosis, obstruction or
Intravenous urography (IVU) uses ionic or nonionic compression by retroperitoneal lymphadenopathy, or fibro-
water-soluble contrast agents to evaluate the urinary tract. sis. Inferior venacavography is also performed to evaluate the
Renal excretion/concentration of intravenously administered configuration of the inferior vena cava before filter place-
iodinated contrast material opacifies the kidneys, ureters, ment. In recent years, conventional angiography has been
and bladder approximately 10 minutes postinjection. Intra- replaced by CT angiography and MR angiography.
venous urography has been largely replaced over the past Less commonly used contrast studies include myelogra-
decade by unenhanced helical CT evaluation. IVU, however, phy (evaluating disk herniation and spinal cord compres-
remains useful for the evaluation of subtle uroepithelial neo- sion), fistulography (sinus tracts for abscesses and cavities),
plasms and other diseases of the renal collecting system, and sialography (evaluating the salivary glands for ductal ob-
it can provide additional information that complements data struction or tumor), galactography (assessing the breast duc-
from cross-sectional image modalities. Additional contrast- tal system), and oral cholecystography, cholangiography
enhanced imaging examinations of the genitourinary system (evaluating the biliary tree), and lymphangiography (assess-
include cystography, voiding cystourethrography, and retro- ing lymph nodes and lymph channels for malignancies).
grade urethrography to evaluate the bladder and urethra.
Hysterosalpingography is primarily used to evaluate the  Computed Tomography
patency of fallopian tubes and uterine abnormalities in pa-
tients with infertility. Hysterosalpingography is also used for Computed tomography, an axial tomographic technique,
postsurgical evaluation and to define anatomy for reanasto- produces source images that are perpendicular to the long
mosis procedures. axis of the body (Figure 1-5). Attenuation values generated
Hysterosalpingography is performed by inserting a by CT reflect the density and atomic number of various tis-
catheter into the uterus and subsequently injecting water- sues and are usually expressed as relative attenuation coeffi-
soluble contrast medium (some institutions prefer oil-based cients, or Hounsfield units (HUs). By definition, the HUs of
iodine contrast) to delineate the uterine cavity and the patency water and air are zero and –1,000, respectively. The HUs
of the fallopian tubes. A fluoroscopic spot image is taken of soft tissues range from 10 to 50, with fat demonstrating
once contrast medium fills the uterus and fallopian tubes, but negative HU. Bone is at least 1,000 HU. The contrast resolu-
before spillage into the peritoneum. A second image is taken tion of vascular structures, organs, and pathology, such as
 SCOPE OF DIAGNOSTIC IMAGING CHAPTER 1
 5

 Figure 1-3. An aortogram demon-

strated transection (arrow) of the aortic
arch at the aortic isthmus extending
about 4 cm below.

hypervascular neoplasms, can be enhanced following intra- The first helical (spiral) CT scanner was introduced for
venous infusion of water-soluble contrast media. The type, clinical applications in the early 1990s. Helical CT is charac-
volume, and rate of administration as well as the scan delay terized by continuous patient transport through the gantry
time vary with specific study indication and protocol. Addi- while a series of x-ray tube rotations simultaneously acquire
tionally, oral contrast material, namely, water-soluble agents volumetric data. These dynamic acquisitions are typically ob-
or barium suspensions, can be administered for improved tained during a single breath hold of about 20 to 30 seconds.
bowel visualization. Artifacts may be produced by patient Higher spatial resolution can be achieved with narrower col-
motion or high-density foreign bodies, such as surgical clips. limations. The advantages of helical CT technology include
reduced scan times, improved speeds at which the volume of
interest can be adequately imaged, and increased ability to
Variety Scanners
detect small lesions that may otherwise change position in
Conventional CT scanners have traditionally operated in a non-breath-hold studies. In addition, gains in scan speed
step-and-shoot mode, defined by data acquisition and pa- permit less contrast material to be administered for the same
tient positioning phases. During the data acquisition phase, degree of vessel opacification.
the x-ray tube rotates around the patient, who is maintained The evolution of multidetector CT (MDCT) scanners has
in a stationary position. A complete set of projections are ac- resulted from the combination of helical scanning with multi-
quired at a prescribed scanning location prior to the patient slice data acquisition. In this CT system, a multiple-row detec-
positioning phase. During this latter phase, the patient is tor array is employed. Current state-of-the-art models are
transported to the next prescribed scanning location. capable of acquiring 64, 128, or 256 channels of helical data
 6
 PART 1 INTRODUCTION

A B
 Figure 1-4. Axial (A) and sagittal (B) view of CT angiography (CTA) on a patient with a motor vehicle accident
showing aortic transection (arrow) at the level of the ductus arteriosus with a surrounding mediastinal hematoma that
extends superiorly along the aorta.

 Figure 1-5. Contrast-enhanced CT

image of the upper abdomen demon-
strated two low-attenuation areas (M)
confirmed as multiple hepatic metas-
tases from a gastrointestinal stromal
tumor.
 SCOPE OF DIAGNOSTIC IMAGING CHAPTER 1
 7

 Figure 1-6. 3D reformatted image from

CT angiography of brain shows a 16-mm
aneurysm (arrow) arising from the left lateral
aspect of the mid basilar artery.

simultaneously. For a given length of anatomic coverage, during the arterial, venous, and/or equilibrium phases. Ex-
multidetector CT can reduce scan time, permit imaging with quisite anatomic detail of both intraluminal and extralumi-
thinner collimation, or both. The use of thinner collimation nal structures is revealed using this technique, including
(0.4 mm to 2 mm) in conjunction with high-resolution re- detection of intimal calcification and mural thrombosis. CT
construction algorithms yields images of higher spatial reso- angiography has become an important tool for assessment
lution (high-resolution CT), a technique commonly used for of the abdominal and iliac arteries and their branches, the
evaluation of diffuse interstitial lung disease or the detection thoracic aorta, pulmonary arteries, and intracranial and
of pulmonary nodules. Multidetector CT offers additional ad- extracranial carotid circulation (Figure 1-6).
vantages of decreased contrast load, reduced respiratory and
cardiac motion artifact, and enhanced multiplanar recon- CT Colonography
struction capabilities. These innovations have had a signifi-
CT colonography (virtual colonoscopy), introduced in 1994,
cant impact on the development of CT angiography (CTA).
is a relatively new noninvasive method of imaging the colon
Multidetector CT has replaced conventional angiography as a
in which thin-section helical CT data are used to generate
primary modality in patients with acute aortic injuries.
two-dimensional or three-dimensional images of the colon.
This technology has been used primarily in the detection and
CT Angiography characterization of colonic polyps, rivaling the traditional
CT angiography protocols combine high-resolution volu- colonoscopic approach and conventional barium enema
metric helical CT acquisitions with intravenous bolus ad- examinations. These images display the mucosal surface of
ministration of iodinated contrast material. Using an MDCT the colon and internal density of the detected lesions, as well
scanner, images are acquired during a single breath hold, en- as directly demonstrating the bowel wall and extracolonic
suring that data acquisition will commence during times of abdominal/pelvic structures.
peak vascular opacification. This has permitted successful
imaging of entire vascular distributions, in addition to mini-
mizing motion artifact and increasing longitudinal spatial
ULTRASONOGRAPHY
resolution, thus potentially lowering administered contrast Diagnostic ultrasound is a noninvasive imaging technique
doses. The time between the start of contrast injection and that uses high-frequency sound waves greater than 20 kilo-
the commencement of scanning can be tailored in response hertz (kHz). A device known as a transducer is used to emit
to a particular clinical question, permitting image acquisition and to receive sound waves from various tissues in the body.