Learning Radiology Recognizing the Basics, 4th Edition
Visit the link below to download the full version of this book:
https://medipdf.com/product/learning-radiology-recognizing-the-basics-4th-editio
n/
Click Download Now
LEARNING
RADIOLOGY
This page intentionally left blank
LEARNING
RADIOLOGY
Recognizing the Basics
4th Edition
William Herring, MD, FACR
Vice Chairman and Residency Program Director (retired)
Einstein Healthcare Network
Philadelphia, Pennsylvania
LEARNING RADIOLOGY, FOURTH EDITION ISBN: 978-0-323-56729-9
Copyright © 2020 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each product
to be administered, to verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products, instructions,
or ideas contained in the material herein.
Previous editions copyrighted 2016, 2012, and 2007.
International Standard Book Number: 978-0-323-56729-9
Content Strategist: Marybeth Thiel
Senior Content Development Specialist: Ann Ruzycka Anderson
Publishing Services Manager: Catherine Albright Jackson
Senior Project Manager: Claire Kramer
Design Direction: Bridget Hoette
Printed in China.
Last digit is the print number: 9 8 7 6 5 4 3 2 1
1600 John F. Kennedy Blvd.
Ste 1600
Philadelphia, PA 19103-2899
To my wife Patricia,
and our family
vi CHAPTER
CONTRIBUTORS
Debra Copit, MD Trevor Lewis, MD Jeffrey L. Weinstein, MD
Former Director of Women’s Imaging Resident in Diagnostic and Interventional Section of Interventional Radiology
Einstein Healthcare Network Radiology Beth Israel Deaconess Medical Center
Philadelphia, Pennsylvania Beth Israel Deaconess Medical Center/ Program Director, Vascular and
Harvard Medical School Interventional Radiology Fellowship and
Daniel J. Kowal, MD Boston, Massachusetts Residency Programs
Chief and Medical Director of Ultrasound Instructor in Radiology
Baystate Health Peter Wang, MD Harvard Medical School
Assistant Professor Section Head of Body CT and MRI Boston, Massachusetts
University of Massachusetts Medical Assistant Residency Program Director
School–Baystate Einstein Healthcare Network
Springfield, Massachusetts Philadelphia, Pennsylvania
vi
Preface vii
P R E FA C E
This fourth edition of Learning Radiology: Recognizing the Please pay particular attention to the wealth of additional
Basics features numerous changes and additions while adhering and complementary material available online to registered users
to its core design of presenting key, fundamental material in a of the textbook starting, of course, with full-access to the entire
concise, uncomplicated format. text and all of its photos.
Three completely new chapters have been added to this Online, you will also find two dozen interactive quizzes that
edition. Almost all the photos in the text have been fine tuned reinforce essential elements found throughout the text; an inter-
to highlight the findings. Key sections have been reorganized active anatomy section that helps you learn key, normal, radio-
to strengthen teaching in the vital, cross-sectional modalities graphic structures; and another two dozen clinical cases to
of computed tomography, magnetic resonance imaging, and challenge and sharpen your imaging skills.
ultrasound. There is also an online-only chapter on Nuclear Medicine
The three new chapters will expand your understanding of and an in-depth algorithm for diagnosing adult heart disease
the growing use of ultrasound, enable you to appreciate the role using conventional radiography that should be very helpful.
of image-guided interventions in clinical care, and introduce There are online glossaries and an appendix that links to lists
you to mammographic imaging. of the most appropriate imaging study to order for each of a
Scattered throughout relevant chapters in the text are mini myriad of clinical situations. This information should prove
“clinical-scenarios” that invite you to examine how image-guided indispensable on clinical rounds.
interventions might be helpful in solving everyday clinical prob- We have always believed that this text and its online extras
lems. The solutions to these clinical challenges are revisited in allow you to rapidly begin recognizing abnormalities and making
the new chapter on interventional radiology. diagnoses that will impress your mentors and peers and astonish
Trauma has been reorganized into three consecutive chapters, your friends and relatives. With this new edition, you hold the
bringing together related material to cover this critical topic in potential to be even more astounding.
a cohesive manner. Prepare to amaze.
vii
viii Acknowledgments
AC K N OW L E D G M E N T S
I am again grateful to the many thousands of you whom I have never met but who first found
a website called LearningRadiology helpful and made it so popular that it played a role leading
from the first edition of this text to what is now its fourth edition.
For his help and suggestions, I would like to thank Stacy White, MD, one of my former radiol-
ogy residents, who made invaluable suggestions about how this edition could be improved and
then helped in improving it. Peter Wang, MD, contributed two chapters on ultrasound, augment-
ing and expanding the material from the last edition. Daniel Kowal, MD, again did a wonderful
job in simplifying the complexities of MRI for the chapter he wrote. Debra Copit, MD, FACR,
contributed a terrific, new chapter on mammography. Jeffrey Weinstein, MD, an attending physi-
cian at Beth Israel Deaconess Medical Center along with resident Trevor Lewis, MD, also at Beth
Israel Deaconess, added an important new chapter on image-guided interventions in medicine.
I want to thank Brooke Devenney Cakir, MD, Mindy Horrow, MD, FACR, and Huyen Tran,
MD, for their assistance in this edition.
I certainly want to recognize and again thank Jim Merritt from Elsevier for his long-term
support and Ann Anderson, Claire Kramer, and Marybeth Thiel from Elsevier for their
assistance.
I also wanted to acknowledge the hundreds of radiology residents and medical students who,
over the years, provided me with an audience of motivated learners without whom a teacher
would have no one to teach.
Finally, I want to thank my wonderful wife, Pat, who has encouraged me throughout the
project, and my family.
viii
1 Recognizing Anything: An Introduction to Imaging Causes of Pleural Effusions, 60
Modalities, 1 Types of Pleural Effusions, 60
Many Shades of Gray, 1 Side-Specificity of Pleural Effusions, 61
Conventional Radiography (Plain Films), 2 Recognizing the Different Appearances of Pleural
The Five Basic Densities, 2 Effusions, 61
Computed Tomography, 3
9 Recognizing Pneumonia, 70
Ultrasound, 4
General Considerations, 70
Magnetic Resonance Imaging, 4
General Characteristics of Pneumonia, 70
Fluoroscopy, 5
Patterns of Pneumonia, 71
Nuclear Medicine, 6
Lobar Pneumonia, 71
Conventions Used in This Book, 7
Segmental Pneumonia (Bronchopneumonia), 72
2 Recognizing a Technically Adequate Chest Interstitial Pneumonia, 72
Radiograph, 8 Round Pneumonia, 72
Evaluating the Chest Radiograph for Technical Cavitary Pneumonia, 72
Adequacy, 8 Aspiration, 73
Penetration, 8 Localizing Pneumonia, 4
Inspiration, 8 How Pneumonia Resolves, 76
Rotation, 10
Magnification, 10 10 Recognizing the Correct Placement of Lines and Tubes
Angulation, 12 and Their Potential Complications: Critical Care
Radiology, 77
3 Recognizing Normal Pulmonary Anatomy, 14 Endotracheal and Tracheostomy Tubes, 77
The Normal Frontal Chest Radiograph, 14 Intravascular Catheters, 79
The Normal Lateral Chest Radiograph, 15 Peripherally Inserted Central Catheters: PICC, 81
Normal CT Anatomy of the Chest, 20 Multiple Lumen Catheters: "Quinton Catheters:'
4 Recognizing Normal Cardiac Anatomy, 25 Hemodialysis Catheters, 82
Evaluating the Heart on Chest Radiographs, 25 Pleural Drainage Tubes (Chest Tubes, Thoracotomy
General Principles, 26 Tubes), 83
Evaluating the Heart on Cardiac CT, 26 Cardiac Devices: Pacemaker, Automatic Implantable
Uses of Cardiac CT, 30 Cardiac Defibrillator (AICD), Intra-aortic Balloon
Cardiac MRI, 33 Pump (IABP), 84
Automatic Implantable Cardiac Defibrillators
5 Recognizing Airspace Versus Interstitial Lung Disease, 37 (AICD), 85
Classifying Parenchymal Lung Disease, 3:;;' Intra-aortic Counterpulsation Balloon Pump (IABP or
Characteristics of Airspace Disease, 31 IACB), 85
Some Causes of Airspace Disease, 38 GI Tubes and Lines: Nasogastric Tubes, Feeding Tubes, 86
Characteristics of Interstitial Lung Disease, 40
Some Causes of Interstitial Lung Disease, 41 11 Recognizing Other Diseases of the Chest, 90
Mediastinal Masses, 90
6 Recognizing the Causes of an Opacified Hemithorax, 47 Anterior Mediastinum, 91
Atelectasis of the Entire Lung, 47 Middle Mediastinal Masses, 93
Massive Pleural Effusion, 48 Posterior Mediastinal Masses, 94
Pneumonia of an Entire Lung, 50 Solitary Nodule/Mass in the Lung, 95
Postpneumonectomy, 50 Bronchogenic Carcinoma, 98
7 Recognizing Atelectasis, 52 Metastatic Neoplasms in the Lung, 101
What Is Atelectasis? 52 Pulmonary Thromboembolic Disease (PE), 101
Signs of Atelectasis, 52 Chronic Obstructive Pulmonary Disease, 102
Types of Atelectasis, 55 Bullae, Cysts, and Cavities, 104
How Atelectasis Resolves, 58 Bronchiectasis, 106
8 Recognizing a Pleural Effusion, 60 12 Recognizing Adult Heart Disease, 108
Normal Anatomy and Physiology of the Pleural Space, 60 Recognizing an Enlarged Cardiac Silhouette, 108
Modalities for Detecting Pleural Effusions, 60 Recognizing Common Cardiac Diseases, llO
ix
CONTENTS
13 Recognizing the Normal Abdomen and Pelvis: Types of Ultrasound, 191
Conventional Radiographs, 123 Adverse Effects or Safety Issues, 191
Recognizing the Normal Abdomen: What to Look Medical Uses of Ultrasonography, 191
For,123 Female Pelvic Organs, 197
Acute Abdominal Series: The Views and What They Pregnancy, 203
Show, 126 Abdominal Hernias, 206
Recognizing the Normal Abdomen: Extraluminal Appendicitis, 206
Air, 129 Ascites, 206
Recognizing the Normal Abdomen: Calcifications, 129 Musculoskeletal System, 206
Recognizing the Normal Abdomen: Organomegaly, 130 Contrast-Enhanced Ultrasound, 207
14 Recognizing the Normal Abdomen and Pelvis on 20 Vascular, Pediatric, and Point-of-Care Ultrasound, 209
Computed Tomography, 134 Peter Wang
Introduction to Abdominal and Pelvic CT, 134 Vascular Ultrasound, 209
Intravenous Contrast in CT Scanning, 134 Arterial Stenosis, 210
Oral Contrast in CT Scanning, 134 Pseudoaneurysm, 211
Abdominal CT: General Considerations, 137 Deep Vein Thrombosis (DVT), 212
Abdominal CT: By Organ, 137 Pediatrics, 212
Point-of-Care Ultrasound, 216
15 Recognizing Bowel Obstruction and lleus, 141
Abnormal Gas Patterns, 141 21 Magnetic Resonance Imaging: Understanding the
Laws of the Gut, 141 Principles and Recognizing the Basics, 220
Functional Ileus: Localized-Sentinel Loops, 142 Daniel J. Kowal
Functional Ileus: Generalized Adynamic Ileus, 143 How MRI Worl<s, 220
Mechanical Obstruction: Small Bowel Obstruction, 144 Hardware Tnat Makes Up an MRI Scanner, 220
Mechanical Obstruction: Large Bowel Obstruction What Happens Once Scanning Begins, 221
(LBO), 148 How Can You Identify a Tl -Weighted or T2-Weighted
Volvulus of the Colon, 150 Image? 221
Intestinal Pseudoobstruction (Ogilvie Syndrome), 150 MRI Contrast: General Considerations, 224
MRI Safety Issues, 226
16 Recognizing Extraluminal Gas in the Abdomen, 153
Diagnostic Applications of MRI, 227
Signs of Free Intraperitoneal Air, 153
Signs of Extraperitoneal Air (Retroperitoneal Air), 157 22 Recognizing Nontraumatic Abnormalities of the
Signs of Air in the Bowel Wall, 157 Appendicular Skeleton Including Arthritis, 229
Signs of Air in the Biliary System, 159 Conventional Radiography, CT, and MRI in Bone
17 Recognizing Abnormal Calcifications and Thei Imaging, 229
Causes, 161 Normal Bone and Joint Anatomy, 230
Patterns of Calcification, 161 Diseases That Affect Bone Density, 230
Location of Calcification, 167 Diseases That Increase Bone Density, 232
Diseases That Decrease Bone Density, 235
18 Recognizing Gastrointestinal, Hepato biliary, and Urinary Diseases of the Joints: An Approach to Arthritis, 240
Tract Abnormalities, 168
Barium Studies of the Gastrointestinal Tract, 168 23 Recognizing Nontraumatic Abnormalities of
Esophagus, 168 the Spine, 250
Stomach and Duodenum, 170 The Normal Spine, 250
Small and Large Bowel, 170 Normal MRI Appearance of the Spine, 252
Large Bowel, 172 Back Pain, 252
Pancreas, 178 24 Recognizing Trauma to the Bony Skeleton, 262
Hepatobiliary Abnormalities, 179 Recognizing an Acute Fracture, 262
Biliary System, 184 Recognizing Dislocations and Subluxations, 264
Urinary Tract, 184 Describing Fractures, 264
Pelvis, 186 Avulsion Fractures, 268
Urinary Bladder, 186 Salter-Harris Fractures: Epiphyseal Plate Fractures in
Adenopathy, 186 Children, 268
19 Ultrasonography: Understanding the Principles and Its Child Abuse, 268
Uses in Abdominal and Pelvic Imaging, 189 Stress Fractures, 269
Peter Wang Common Fracture Eponyms, 269
How it Works, 189 Some Subtle Fractures or Dislocations, 270
CONTENTS
Fracture Healing, 274 Pulmonary Embolism: Thrombolysis, 341
SpinalTrauma,276 Pulmonary Embolism: Inferior Vena Caval (IVC) Filter
Pathologic Fractures, 278 Placement, 342
Pulmonary Nodule: Image-Guided Biopsy, 343
25 Recognizing the Imaging Findings of Trauma to
Hepatic/Renal/Pulmonary Tumor: Thermal
the Chest, 281
Ablation, 344
Chest Trauma, 281 Portal Hypertension: Transjugular Intrahepatic
Chest Wall Trauma, 281 Portosystemic Shunt (TIPS), 345
Pleural Abnormalities: Pneumothorax, 282 Abscess: Percutaneous Abscess Aspiration and Drain
Imaging Modalities Used to Diagnose a Placement, 346
Pneumothorax, 283 Gastrointestinal (GI) Bleeding: Arteriography and
Trauma-Related Parenchymal Lung Abnormalities, 288 Embolization, 348
Aortic Trauma, 291 Obstructive Uropathy: Percutaneous Nephrostomy
26 Recognizing the Imaging Findings of Trauma to the (PCN)/Nephroureterostomy (PCNU), 349
Abdomen and Pelvis, 294 Aortic Aneurysm: Endovascular Aneurysm Repair
Abdominal Trauma, 294 (EVAR),350
Pelvic Trauma, 296 Uterine Fibroids: Uterine Fibroid Embolization
Less Common Abdominal Injuries, 298 (UFE), 351
Acute Ischemic Stro e: Mechanical Thrombectomy, 353
27 Recognizing Some Common Causes of lntracranial
Pathology, 300 30 Recognizing the Findings in Breast Imaging, 355
Normal Anatomy, 300 Debra Copit
MRI and the Brain, 302 Breast Imaging-:_Modhlities: Overview, 355
Head Trauma, 304 Mammography: Screening Versus Diagnostic, 356
Intracranial Hemorrhage, 306 Fundamental Mammography Findings, 359
Diffuse Axonal Injury, 310 Ultrasound, 362
Increased Intracranial Pressure, 310 Magnetic Resonance Imaging, 363
Stroke, 311 Management of Breast Abnormalities, 364
Ruptured Aneurysms, 314 pedal Considerations, 365
Hydrocephalus, 316
Cerebral Atrophy, 318 Bibliography, 369
Brain Tumors, 318 Chapter 1 Quiz Answers, 371
Other Diseases, 321 Online-Only Appendixes
Terminology, 322 A. Self-Assessment Quizzes
28 Recognizing Pediatric Diseases, 324 B. Normal Imaging Anatomy Quizzes
Diseases Discussed in This Chapter, 324 C. Unknown Cases
Newborn Respiratory Distress, 324 D. The ABCs of Heart Disease
Childhood Lung Disease, 327 E. Radiation Dose and Safety
Soft Tissues of the Neck, 329 F. What to Order When
Ingested Foreign Bodies, 331 G. Chapters 1 and 18 Glossaries (General Terminology
Other Diseases, 332 and GI Imaging Terminology)
Salter-Harris Fractures: Epiphyseal Plate Fractures in H. Nuclear Medicine: Understanding the Principles and
Children, 332 Recognizing the Basics
Child Abuse, 335
Necrotizing Enterocolitis (NEC), 335
Esophageal Atresia With/Without Tracheoesophageal
Fistula (TEF), 336
29 Using Image-Guided Interventions in Diagnosis and
Treatment: lnterventional Radiology, 339
Jeffrey L. Weinstein, and Trevor Lewis
Arterial Access and Arteriography, 339
Central Venous Access: Image-Guided Venous
Access, 340
This page intentionally left blank
Video Contents xiii
VIDEO CONTENTS
Chapter 1: Recognizing Anything: An Introduction to Imaging Twisted vascular pedicle in testicular torsion
Modalities Sonohysterography
Spinning gantry of CT scanner Cine of normal, viable fetus
Virtual bronchoscopy Inguinal hernia containing bowel and fluid that is more
Color Doppler scan of carotid artery prominent during cough
Normal swallowing function captured by fluoroscopy Contrast-enhanced ultrasound of the kidney
Fluoroscopy used for angiography demonstrating an enhancing renal mass
Spinning PET scan
Chapter 20: Vascular, Pediatric, and Point-of-Care Ultrasound
Chapter 3: Recognizing Normal Pulmonary Anatomy Color Doppler carotid with waveform
Maximum intensity projections of pulmonary Pseudoaneurysm arising from the brachial artery after
vasculature catheterization
Normal sliding motion of the pleura
Chapter 4: Recognizing Normal Cardiac Anatomy
Absence of sliding motion of the pleura due to a
Catheter angiogram of right coronary artery
pneumothorax
MRI, four-chamber view of the heart
Pneumothorax
Chapter 12: Recognizing Adult Heart Disease Pericardial effusion
3D CT coronary angiogram Elevated central venous pressure
Chapter 18: Recognizing Gastrointestinal, Hepatobiliary, and Chapter 24: Recognizing Trauma to the Bony Skeleton
Urinary Tract Abnormalities Chance fracture: T10
Video swallow, aspiration
Chapter 25: Recognizing the Imaging Findings of Trauma to
Tertiary esophageal waves
the Chest
Lipoma seen on CT colonography
Fractures of pelvis and ribs
Hemangioma of the liver
Chapter 19: Ultrasonography: Understanding the Principles
and Its Uses in Abdominal and Pelvic Imaging
Duplex color sonography of the carotid artery
Doppler effect (audio only)
xiii
This page intentionally left blank
Recognizing Anything
An Introduction to Imaging Modalities
This chapter provides a brief introduction to the major imaging very thin, many films in thousands of patients' folders
modalities. Accompanying most of the modalities is a Case Quiz took up a great deal of space ( eFig. 1. 1)
that uses that modality. A number 2 pencil is not necessary for • The other drawback was that the radiographic films could
the quiz. The answers to the quizzes are at the very end of this physically be in only one place at a time, which was not
book. If you do not know the answers to any of the quizzes, that necessarily where they might be needed to help in the care
is perfectly fine because you are about to learn about each of of the patient.
these imaging modalities, how to approach imaging studies, and • Eventually digital ra8iography came into being, in which
much more as you complete this text. the photographic film was replaced by a photosensitive cas-
sette or plate hat could be processed by an electronic reader,
and that image could be stored in a digital format. This
MANY SHADES OF GRAV electronic processing no longer required a darkroom to develop
• In 1895, Wilhelm Rontgen (or Roentgen), working in a the film or a large room to store the films. Countless images
darkened laboratory in Wurzburg, Germany, noticed that could be stored in the space of one, spinning, hard disk on
a screen painted with a fluorescent material and located a a comRuter server. Even more importantly, the images could
few feet away in the same room as a cathode ray tube he be vi!';}Ved by anyone with the right to do so, anywhere in the
had energized and made lightproof, started to glow (fluo- world, at any time.
resce). After repeating the experiment, he recognized that the • f he studies were maintained on computer servers on which
screen was responding to the nearby production of a form the images could be archived for posterity, from which they
of energy transmitted invisibly through the room. He named could be communicated to others and in which they could
the new rays "x-rays" using the mathematical sym o '\x:'' be stored. This system is called a PACS system, for picture
for something unknown. It did not take long before almost archiving, communications and storage system.
everyone was taking x-rays of almost everytliing imaginable • With PACS systems, images from all modalities can be stored
(Fig. 1.1 ). and retrieved, including conventional radiographs (CR), CT
• Like today, conventional radiographic · ages (usually short-
ened to x-rays) were produced by a combination of ionizing
radiation and light striking a photosensitive surface which,
in turn, produces a latent image that is subsequently processed
to become visible. For about a hundred years after the dis-
covery of x-rays, radiographic images survived their birth as
a burst of ionizing radiation by resting comfortably on a piece
of film.
• At first, the processing of film was carried out in a darkroom
containing trays with various chemicals, and the films were
then, literally, hung up to dry.
• When an immediate reading was requested, the films were
interpreted while still dripping with chemicals and the
term wet reading for a "stat" interpretation was born.
• Films were then viewed on lighted view boxes (almost always
backward or upside down if the film placement was being
done as part of a movie or television show). In a few places,
Fig. 1.1 Wilhelm Roentgen Discovers X-Rays. Wilhelm Roentgen in
film is the medium still used, but it is much less common
his laboratory in Germany is shown in this photograph from 1895, the
because it has some major drawbacks. year in which (on November 8), he discovered a new, invisible source
• It required a great deal of physical storage space for the of electromagnetic radiation he called x-rays. For his discovery, he was
ever-growing number of films. Even though each film was awarded the very first Nobel Prize for Physics in 1901.
1
CHAPTER 1 Recognizing Anything 1.e1
eFig. 1.1 Film File Room. When medical images were stored on film,
they occupied a tremendous amount of space for each facility. This is
one aisle containing several thousand patient films among many dozens
of similar aisles in a cavernous room that was needed to store all of
the images. Now all these images can be stored in the relatively small
space taken up by computer servers and are viewable, with permission,
from any location.
