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Acknowledgments

At University College Dublin, Cliona Skelly, Emma Tobin, Antonella Puggioni, Eloisa Terzo, Sarah Acton,
Frances O’Leary, Catherine D’Helft, and Joan Dalton were generous with their patience, time, and efforts.

Invaluable help was also provided by Manuel Pinilla, Jan Butler, Aidan Kelly, Terry McCreery, and John
Kealy.

In the United States, thanks to colleagues at Iowa State University and the University of ­Pennsylvania.
We particularly thank Dr. Clifford R. Berry, Dr. Scott Tidwell, Dr. Eric Ferrell and, most especially, Dr. Susan
Randell at Affiliated Veterinary Specialists, Florida.

We also acknowledge the continued patience, encouragement, and support of Joan Kealy and all the
Kealy family.

Finally, our sincere thanks to all who helped with the past editions and to Tony Winkel and ­Carrie Stetz
and the staff at ­Elsevier who shepherded this work to completion.

ix
C H A P T E R

one

The Radiograph

Competent radiologic practice presupposes the avail- affect the film and produce the image. Some of the inci-
ability of good-quality radiographs. Familiarity dent radiation is absorbed within the body, and some
with the basic principles underlying the production is scattered. Scattered radiation reaching the film is
of radiographs is a prerequisite for the radiologist. undesirable because it causes fogging and blurring, or
Accurate positioning of the animal under investiga- “unsharpness.” Fogging gives a radiograph a cloudy
tion, correct exposure factors, the use of grids and or hazy appearance. Structure margins are indistinct.
other ancillary aids, and good processing technique Grids are used to reduce scatter. As rule they should
all influence the quality of a radiograph. The use of be used when the part under examination exceeds
a technique chart is essential for consistent results. 10 cm in thickness.
Consistency is important, particularly when studies Fast film/screen combinations reduce exposure
have to be repeated over time to assess the progress times and minimize movement blur. A radiograph
of a particular case. If the radiographs in such studies shows not only the outline of an organ within the
are not comparable, errors of interpretation are likely body but also other body structures superimposed on
to occur. Radiographs may be of poor quality because it and on one another.
of improper positioning, improper exposure tech- Not all structures allow x-rays to pass through
nique, or poor darkroom technique. It is hazardous to them in the same way. Dense substances, such as bone,
attempt to interpret such radiographs. inhibit the passage of radiation, whereas substances
Radiographic technique is discussed in this book that are less dense, such as gases, allow the rays to
only insofar as is necessary for a proper understand- pass through them virtually unchanged. In between
ing of points of interpretation. The necessary detailed there are substances, such as the soft tissues, that per-
information on technique can be found in any of the mit more radiation to reach the film than is permitted
several works devoted to this topic. by bone but not as much as is permitted by gases. It is
A radiograph is a composite shadow of structures this differential absorption of x-rays that enables one
and objects in the path of an x-ray beam recorded on structure to be distinguished from another. Fluoros-
film. Because a radiograph is, in essence, a ­shadowgraph, copy is imaging of structures in real time using x-rays
the geometric rules applicable to the formation of shad- and an image intensifier. There is an increased haz-
ows are also valid for radiographs. Thus, the nearer ard with this technique. It should not replace conven-
the object under examination is to the film, the sharper tional radiography.
will be its outline. Distance of an object from the film
causes magnification of the resulting shadow and DENSITY AND OPACITY
some distortion and blurring. The nearer the object is A radiograph is an image made up of shadows of dif-
to the source of radiation, the greater will be the degree ferent opacities. Subject density is the weight per given
of magnification. The area being studied, therefore, volume of a body tissue or other object. Bone is more
should be placed as near to the film as possible and dense than muscle, and muscle is more dense than fat.
at a standard acceptable distance from the source of The denser an object is, the more it inhibits the passage
radiation, usually 100 cm (36 to 40 inches). Because the of radiation. Radiographic opacity is a measure of the
radiograph (being a shadowgraph) outlines an object capacity of a tissue or structure to block x-rays. Where
in only two planes, at least two views, made at right x-rays readily reach the film, the film appears black
angles to one another (orthogonal views), are required after processing. If the x-rays are prevented from
to demonstrate the object in a three-dimensional repre- reaching part of the film, the unaffected area will
sentation. Shadows are cast not only of the outline of appear white on the processed film. Between these
the body, but also of structures within it (Figure 1-1). two extremes, various combinations of light, dark,
The radiograph is not a simple shadowgraph: some and gray areas are produced. Radiographic opacity
of the x-rays pass directly through the body being therefore depends on subject density; the greater the
examined. These are the useful rays because they subject density, the less radiation reaches the film.
1
2 Chapter 1 n The Radiograph

B
Figure 1-1 The necessity for two views. A, Four objects have been radiographed in an end-on position. From this view alone, insuf-
ficient information is available to enable a comprehensive description to be given of any item. B, A second view, made at right angles
to the first one, shows the items, from left to right, to be a key, a coin, a teacher’s pointer, and a mechanical pencil.

Increased opacity denotes a whiter shadow on ­subject density. A radiolucent defect is an abnormal area
the radiograph than would normally be expected. of decreased radiographic opacity and hence of sub-
The term thus refers to increased subject density as ject density within a structure.
reflected on the radiograph. Decreased opacity denotes Five radiographic opacities can be recognized:
a darker shadow on the radiograph than would nor- • Metal
mally be anticipated. The decreased subject density • Bone or mineral
allows more radiation to reach the film, causing a • Fluid or soft tissue
greater degree of blackening. • Gas (air)
All objects inhibit, to some extent, the passage of • Fat
radiation. Structures that absorb little of the incident Metallic substances are very dense, and they inhibit
radiation are said to be radiolucent. X-rays readily pass the passage of virtually all incident radiation. Areas
through them, and they appear dark on a radiograph. of film covered by such material appear white (radi-
Structures that inhibit the passage of most of the inci- opaque) on a radiograph.
dent radiation are said to be radiopaque. Bone is not as dense as a metallic substance. It
Increased radiolucency represents decreased sub- allows little radiation to pass through it compared
ject density; increased radiopacity represents increased with other body tissues. Areas of film that have
 Chapter 1 n The Radiograph 3

been covered by bone appear almost white on a ­ therwise be seen; for example, perirenal fat may out-
o
radiograph. line the kidneys by providing a contrasting opacity to
Fluid inhibits the passage of more of the incident the kidney tissues.
radiation than gas but not as much as bone does. A fluid Gases, including air, allow x-rays to pass freely
opacity lies between the whiteness of a bone opacity and through them. Areas of film covered by gas-­containing
the blackness of a gas opacity. Fluid opacities appear organs, such as the lungs, appear dark (radiolucent)
gray on a radiograph. Because soft tissues consist, for the on a radiograph.
most part, of fluid, soft tissue opacity and fluid opacity Bone, fluid, fat, and gas occur normally within the
appear similar. All fluid ­opacities appear the same. It is body and are said to have biologic densities. Metal-
not possible, consequently, to distinguish radiographi- lic densities are introduced into the body as ­contrast
cally among blood, chyle, transudates, and exudates. media (explained later in this chapter), surgical
Fat opacity falls between fluid and gas opacities. implants, or foreign bodies (Figure 1-2, A to C).
Fat may help to outline structures that would not

B
Figure 1-2 Radiographic opacities. A, A gas (air) shadow surrounds, from left to right, metallic, bone or mineral, soft tissue, and fat
opacities. B, A lateral view of a stifle joint demonstrates the five radiographic opacities. The L marker is a metallic opacity. The femur,
patella, fabellae, and tibia have bone (or mineral) opacity. The muscles have soft tissue opacity. Fat opacity (arrows) is seen within the
femorotibial joint caudal to the patellar ligament and between the muscle planes. Gas (air) opacity surrounds the limb.
4 Chapter 1 n The Radiograph

F M

D
Figure 1-2, cont’d C, A right lateral recumbent abdominal radiograph of a dog with an abdominal swelling showing the five radio-
graphic opacities. The bladder (white square) contains fluid. The spleen (white oval) is soft tissue opacity. Fluid and soft tissue are similar
in radiographic opacity. The bony skeleton has a mineral opacity (arrow M) and the right marker (R) is metallic; gas is present in the
stomach (arrow A) and the intestines. The caudal abdomen is occupied by a large mass that is a fat opacity (arrow F). Recognition of
radiographic opacities in this instance allows the differentiation of a fluid mass from a fat mass. This was a large intraabdominal lipoma.
D, This right lateral recumbent abdominal radiograph of a clinically normal dog shows both the right kidney (arrowheads) and the left
kidney (arrows). The left kidney appears larger and is therefore further away from the film/detector and is closer to the x-ray tube. The
left kidney appears larger than the right because of magnification. Comparison of the renal silhouettes should only be made on a ventro-
dorsal projection, when both kidneys are at an equal distance from the tabletop. Spondylosis is also evident but is an incidental finding.
 Chapter 1 n The Radiograph 5

CONTRAST RADIOLOGIC CHANGES

Contrast means difference. The subject densities of As well as demonstrating the varying opacities of bod-
various tissues result in different radiographic opaci- ies under examination, the x-ray beam also delineates
ties, known as radiographic contrast. A structure can their outlines or shapes. The edges of a bone permit
be ­distinguished on a radiograph only if it contrasts determination of its size and shape, and the varying
with its surroundings; that is, a structure is seen opacities of the cortex and medulla will be visible.
when it has a different radiographic opacity from A radiograph, then, is an image consisting of the outlines
what ­surrounds it. Structures lying in contact with of structures and their varying opacities. It therefore can
one another cannot be distinguished as separate enti- be said that as far as abnormalities are concerned, five
ties if they have the same radiographic opacity. If a observations of significance can be made from the study
structure is surrounded by a radiopaque material, it of a radiograph. One can detect changes in:
will appear relatively radiolucent; if it is surrounded • Size
by a radiolucent material, it will appear relatively • Shape
radiopaque. • Number
Radiographic contrast manifests itself as varying • Position
degrees of blackening of the film. Apart from varying • Opacity
subject densities, contrast also depends on the inher- A pathologic condition in an organ can sometimes
ent contrast capability of the film; scattered radiation be deduced from the fact that it displaces an adjacent
reduces contrast. A low kilovoltage/high milliamper- organ. Changes in opacity include changes in radio-
age technique produces a radiograph showing a high graphic detail. For example, changes in trabecular
degree of contrast. A high kilovoltage/low milliam- pattern within a bone may be the first radiographic
perage technique produces a radiograph of low con- evidence of a disease process.
trast but with a wide range. The former technique is
most suitable for areas of low contrast, such as the STANDARD VIEWS
abdomen. For changes in outline, position, and opacity to be appre-
ciated, it is essential that the radiologist be familiar
FACTORS AFFECTING IMAGE QUALITY with the radiologic appearance of normal structures—
Many factors can affect the quality of a radiographic that is, radiologic anatomy. If one is unfamiliar with
image: the normal appearance, one cannot appreciate aber-
• Motion: movement of the subject or the film will rations from it. Because almost any structure can be
cause blurring. rotated through 360 degrees, it would be virtually
• Film properties: fast film results in a less sharp image. impossible to become familiar with all the possible
This is related to the size of the silver halide crystals projections that could be produced from any given
in the film emulsion. organ. Consequently, standard views of each part of
• Film/screen combinations: faster film/screen com- the body are used. These usually consist of two views
binations give a less sharp image than slower made at right angles to one another so that a three-
­combinations. dimensional impression is gained of the structure
• Object/film distance: the nearer an object is to the under study.
film, the sharper its outline will be. Agreed terms are used to describe the standard
• Grids: grids improve film quality when thicker projections. The terminology used in this book is that
parts are under examination. suggested by the Nomenclature Committee of the
• Processing: processing faults affect image quality; American College of Veterinary Radiology. The commit-
underdevelopment results in a pale image and tee recommended that veterinary anatomic directional
overdevelopment results in a dark, flat image. terms should be those listed in the Nomina Anatomica
• Artifacts: adventitious marks on a film, such as Veterinaria. Radiographic projections are described by
scratches, dirt marks, or marks from dirty or dam- the direction in which the central ray of the primary
aged cassettes; may interfere with interpretation. beam penetrates the body part of interest—from the
• Distortion: distortion of an image can be caused by point of entrance to the point of exit. The subject area
improper positioning of the patient or the radiation of interest should be as close to the film or detector as
source. Standard positioning is a prerequisite of possible. Structures within the body that are further
good film quality. away from the film are magnified (Figure 1-2, D).
Border Effacement (Silhouette Sign) Definitions
Border effacement is when two objects of the same The meanings to be ascribed to the different direc-
radiopacity are in contact and their individual mar- tional terms are as discussed in the following sections
gins cannot be distinguished from one another. Con- (Figure 1-3).
versely, an object of a different radiopacity, such as Dorsal—Dorsal means the upper aspect of the head,
air or fat, interposed between them will provide neck, trunk, tail, and cranial (anterior) aspects of
contrast, and individual margins can then be identi- the limbs from the antebrachiocarpal (radiocarpal)
fied. This latter effect has sometimes been called a and tarsocrural (tibiotarsal) articulations distally
negative silhouette. It is seen commonly in thoracic (downward). Dorsal also means toward the back or
­radiographs. vertebrae.
6 Chapter 1 n The Radiograph

al
str
Ro
al
Dors Cranial
Caudal
Ventral

Dorsal

Ventral

Caudal
Cranial

Cranial
Caudal

Tarsocrural
Antebrachiocarpal
joint
joint Dorsal
Dorsal Plantar

Palmar
Figure 1-3 Directional terms.

Ventral—Ventral means the lower aspect of the head, beam enters the body through the right side and exits
neck, trunk, and tail. Ventral also means toward the through the left side. This is generally termed a left lat-
lower aspect of the animal. eral recumbent (LLR) view. A ventrodorsal (VD) view
Cranial—Cranial is a directional term that describes means that the x-ray beam enters the body ventrally
parts of the neck, trunk, and tail positioned toward and exits dorsally to reach the film. A dorsoventral
the head from any given point. Cranial also describes (DV) view indicates the opposite. Mediolateral means
those aspects of the limb above the antebrachiocarpal the x-ray beam enters a limb from the medial side and
and tarsocrural joints that face toward the head. exits on the lateral side. Most so-called lateral radio-
Rostral—Rostral describes parts of the head positioned graphs of the limbs are taken in a mediolateral direc-
toward the nares from any given point on the head. tion. In a lateromedial view, the x-ray beam enters a
Caudal—Caudal is a directional term that describes parts limb from the lateral side and exits on the medial side.
of the head, neck, and trunk positioned toward the Fluid level refers to an interface between fluid and
tail from any given point. Caudal also describes those gas. A fluid level is usually seen on a standing lateral
aspects of the limbs above the antebrachiocarpal and radiograph using a horizontal beam when there is a
tarsocrural articulations that face toward the tail. mixture of fluid and gas within a viscus. The fluid line
Palmar—The term palmar is used instead of caudal is always horizontal. A standing lateral view is a lateral
when describing the forelimb from the antebrachio- view made with the animal in the standing position
carpal articulation distally. and with the x-ray beam directed horizontally. A fluid
Plantar—The term plantar is used instead of caudal level may also be seen on a decubitus view using a
when describing the hindlimb from the tarsocrural horizontal beam. The term decubitus is used when a
articulation distally. horizontal beam is used with the animal in a recum-
Proximal—Proximal describes nearness to the point of bent position. It is always necessary to use a horizon-
origin of a structure. tal beam to demonstrate a fluid level.
Distal—Distal describes remoteness (farther away) Appropriate safety measures should be adopted
from the point of origin of a structure. irrespective of beam direction, and special care is
Superior and Inferior—The terms superior and inferior are needed when horizontal beams are in use.
used to describe the upper and lower dental arcades.
Recumbent—Recumbent means the animal is lying TECHNIQUE
down when the radiograph is made. Most radio- Standard views are views taken at right angles to one
graphs of the dog and cat are made with the animal another and usually are made in the routine examina-
in the recumbent position, and this position should tion of a part of the body. The most common are the
be presumed unless the contrary is stated. The term dorsoventral, ventrodorsal, lateral, mediolateral, cra-
decubitus is used when a horizontal beam is used. niocaudal, dorsopalmar, and dorsoplantar. An oblique
view is made at an angle somewhere between the stan-
BEAM DIRECTION dard views. In the case of oblique views, in addition to
The direction of the x-ray beam is described from its stating the anatomic points of entry and exit of the x-ray
point of entry into the body to its point of exit. For beam, the angle of obliquity may be given. This infor-
example, a right-left lateral recumbent view means mation enables studies to be repeated with accuracy.
that the animal is lying on its left side, and the x-ray Thus L50D-RVO is read as left 50 degrees ­dorsal-right
 Chapter 1 n The Radiograph 7

VIEWING THE RADIOGRAPH

Box 1-1. Common Radiographic Abbreviations Radiographs should be viewed under optimal condi-
tions. A room with subdued lighting is best. The radio-
Le Left
Rt Right graph is placed on a viewing box, or illuminator, which
D Dorsal has fluorescent lighting. This device provides an even
V Ventral light intensity over the entire film. Any other method
C Cranial of viewing is unsatisfactory. For anatomic reasons, the
Cd Caudal
R Rostral
entire radiograph does not transmit an even intensity of
RLR Right lateral recumbent light. Thin parts of the body will appear darker on the
LLR Left lateral recumbent radiograph than will thicker parts. It is useful to have
M Medial a bright light available to give added illumination to
L Lateral the darker parts. The standard viewing box is designed
Pr Proximal
Di Distal to illuminate the largest radiographs in common use.
Pa Palmar When smaller films are viewed, light coming from the
Pl Plantar viewing screen around the film may cause troublesome
O Oblique glare. Masks are available to adapt illuminators to dif-
ferent sizes of film. Masks can be homemade from dark
cardboard or other suitable material. Viewers with
ventral oblique. It means that an oblique study was varying masking devices are also available. Direct
made with the beam entering the body on the left side light falling on the illuminator makes viewing diffi-
dorsally at an angle of 50 degrees toward the back and cult. The use of a magnifying glass is sometimes help-
exiting on the right side ventrally. Lesion-oriented stud- ful in detecting fine radiographic detail, particularly
ies are sometimes used with tangential (skyline) or non- in the study of bone structure. Increasing the distance
standard views. A lesion-oriented oblique view is one between the viewer and the radiograph is often helpful
that profiles a lesion. in recognizing diffuse borders or subtle changes.
VD and DV radiographs are, by convention, placed
Abbreviations on the illuminator with the left side of the animal’s
Common radiographic abbreviations include those body to the radiologist’s right; this positioning is
listed in Box 1-1. used throughout this text. Lateral views should be
displayed with the animal’s head facing toward the
CONTRAST MEDIA viewer’s left. Always placing radiographs on the illu-
Contrast media are frequently used as diagnostic aids. minator in the same way facilitates ready recognition
A contrast medium is a substance introduced into the of anatomic structures.
body to outline a structure or structures not normally
seen or poorly seen on plain radiographs. Systematic Approach
Radiographic contrast agents may be either posi- The radiologist should adopt a systematic approach to
tive or negative. Negative contrast agents are gases; the viewing of radiographs. This approach will ensure
the most commonly used gases are air, carbon dioxide, that all the radiograph—not just the area in which a
and nitrous oxide. These agents are used in imaging the lesion is believed to exist—is examined on each occa-
urinary bladder and proximal or distal gastrointestinal sion. Significant changes may be demonstrated away
tract. Negative contrast studies of the pericardial and from the area of immediate interest, and these may
peritoneal spaces have been described but have now well be overlooked if the radiograph is not system-
been superseded by ultrasound. Positive radiographic atically examined. It is especially important that the
contrast agents may be particulate suspensions or water viewer acquire a habit of making sure that all struc-
soluble. Barium sulfate is the contrast agent used in tures that should be present are indeed there.
suspensions, and a paste is used to evaluate the gastro- It is good radiographic practice to have the areas of
intestinal tract. It is not suitable for use in body cavities interest located at the center of the film. At this location
or joints because it will provoke an intense granuloma- there is the least distortion of the image, and structures
tous reaction. Water-soluble positive contrast agents on either side can be seen. Because the center of the
are divided into two classes, nonionic and ionic, based radiograph tends to attract the eye initially, it is proba-
on whether the molecules dissociate when in solution. bly good practice to examine the periphery of the radio-
Ionic contrast agents are hyperosmolar compared with graph first and systematically progress to the center.
plasma, whereas the nonionic agents have an osmolar- Each structure encountered should be noted for position
ity closer to that of plasma. These agents can be injected and normality or abnormality. The center of the radio-
intravenously or introduced into almost any body cav- graph is examined last. If an obvious lesion at the center
ity to improve contrast and detect a lesion. Only the of a radiograph is examined first, there is a tendency to
nonionic agents may be injected into the subarachnoid give only a cursory examination to the rest of the film,
space to outline the spinal cord in myelography. particularly if the lesion seen is consistent with a tenta-
A filling defect is a space-occupying mass within a hol- tive diagnosis. Any method of viewing that ensures a
low organ (see Chapter 2, p.154). Contrast medium fails to full examination of the entire radiograph is acceptable.
fill the organ fully at the site of the mass (defect). A plain Some radiologists prefer to examine radiographs
radiograph is one made without any contrast agent. “cold,” that is, without any knowledge of the clinical
8 Chapter 1 n The Radiograph

picture. After a preliminary examination, the radio- Digital radiography (DR) involves translating x-ray
graph is then evaluated in the light of the clinical and energy into an electric signal that is in turn ­converted
other findings. Preconceived notions about a case may to digital data (numbers). The process may be direct,
militate against an objective assessment of a radiograph. indirect, or hybrid. In direct DR, the x-ray energy is con-
Beginners tend to commit two kinds of errors. Either verted directly into an electrical signal. In indirect DR,
they miss something that should have been seen, or the x-ray energy is first converted to light by using a
they “overread” the radiograph. Indeed, these errors phosphorescent plate; the light is then converted to an
are not always confined to beginners. Overreading a electrical pulse. The data are recorded on a plate, which
radiograph means drawing conclusions from it that is connected to a computer, and the x-ray image is avail-
are not warranted on the basis of objective evidence. able for viewing almost immediately after exposure. It
This is most likely to happen if one has been involved can then be stored or printed out. Hybrid radiographic
in the clinical assessment of the case and already processes record the output of the phosphorescent plate
reached a tentative diagnosis. A definite tendency with a system similar to that found in a digital camera.
exists for one to see what one expects or wants to see. CR and DR systems have a number of advan-
Good film reading involves several stages. The first tages compared with film screen systems. The ­linear
step is to identify all the structures on the radiograph, response of digital systems to the x-ray exposure
noting features that appear to be abnormal. The sec- means that these systems are relatively forgiving of
ond step consists of elaborating a list of possible expla- errors in radiographic technique. However, the quality
nations for the abnormalities seen. The third step is to of DR images depends on software processing to pro-
correlate the radiographic findings with the clinical duce a degree of contrast that is familiar to the reader.
signs and with the results provided by other ancillary DR and CR images are stored on a computer hard
diagnostic tests. The final step is to produce a list of drive and should be saved as DICOM (Digital Imag-
possible diagnoses, arranged in order of probability, ing and Communication in Medicine) files. Some
taking all the factors into consideration—that is, a list form of backup device is recommended, ideally at
of differential diagnoses. another location. The images may be quite large files,
The best radiologic practice combines knowledge of but they can be easily transmitted to a remote loca-
normal radiographic anatomy with an understanding tion for review by a radiologist or other specialist.
of physiologic, pathologic, and pathophysiologic pro- These images may be manipulated in multiple ways,
cesses; consideration of the clinical picture and the results including adjusting brightness and contrast, applying
of other diagnostic procedures; and an element of expe- sharpening filters, inverting the image, and magnify-
rience. It must be appreciated that the body responds to ing part or all of the image.
disease processes in a limited number of ways. Different
diseases may produce similar radiologic changes. The Viewing the Digital Image
same disease does not always manifest itself in the same CR and DR images may be printed on film but are
way. One disease process may be superimposed on more commonly reviewed on a computer. Ideally, a
another. The use of radiologic signs, provided that the gray-scale monitor with 2- or 3-megapixel resolution
processes that lie beneath them are understood, greatly should be used when reviewing images. However,
facilitates radiographic interpretation. such monitors are quite expensive, and a high-quality
The more radiologic signs that are seen to support a color monitor with at least 2-megapixel resolution is
diagnosis, the more probable that diagnosis becomes. an acceptable alternative in most clinics.
Instant diagnoses, based on the recognition of one or
two specific signs or on the basis that one has seen a COMPUTED TOMOGRAPHY
condition before, are discouraged. The ability to read Computed tomography (CT) is an imaging method that
radiographs thoroughly and accurately comes only uses the principles of tomography. Tomography is the
with practice and attention to detail. The formula- demonstration of a slice through the body displayed
tion of a list of differential diagnoses, placed in order without interference from structures lying above or
of probability, is the function of the radiologist, who below the level under examination. CT uses x-rays gen-
must be prepared to reconcile his or her observations erated by a high-output x-ray tube. The tube is mounted
with the other evidence available. on a gantry opposite a series of detectors. The tube
Computed radiography (CR) and digital radiog- and the detectors rotate in unison around the subject
raphy produce radiographic images without the use under examination. A fan-shaped beam of x-rays passes
of intensifying screens and film. In the case of CR, a through the body at a predetermined level. The pattern
photo-stimulable phosphor plate contained within a of x-rays that reaches the detectors is recorded—a projec-
cassette is used in an identical manner as a conven- tion. The entire gantry assembly is then rotated slightly,
tional film screen cassette, placed either in a Potter- and the procedure is repeated, generating a new projec-
Bucky tray or on the table top. The photo-stimulable tion. A series of such projections is obtained, completely
phosphor plate records the x-ray exposure as a pattern encompassing the body under examination. A computer
of trapped excited electrons. The plate is read by a laser uses complex mathematical formulas to create an image
that causes the trapped electrons to emit light as they from the series of projections. This image represents a
return to a lower energy level. The emitted light is con- slice of the body at the level under examination.
verted to an electrical signal, which in turn is converted The advantage of CT is its ability to distinguish dif-
to digital data that are sent to a computer for display. ferent types of soft tissue, such as brain white and gray
 Chapter 1 n The Radiograph 9

­ atter or liver and gallbladder. CT achieves this degree

m A radio signal pulse at the same frequency as the spin
of contrast by being able to measure very fine differ- of the protons will knock them out of their equilibrium
ences in the ability of tissues to stop x-rays passing state. As the protons return to their original state, they
through them. CT images are digital, and a computer release energy in the form of a radio signal, effectively
is used for viewing. The gray scale can be adjusted to an echo of the original pulse used to disturb the pro-
highlight specific features such as bone or soft tissue tons. This signal is collected by a scanner, processed,
(windowing). In CT imaging, tissues and structures are and displayed. Smaller gradient magnetic fields are
described in terms of attenuation, which is a measure used to localize signals from specific blocks of tissue.
of the capacity of a tissue to stop x-rays. Attenuation is Whereas CT offers good soft tissue detail, the con-
equivalent to radiopacity in radiography. The appear- trast seen with MRI is superb. Different sequences of
ance of a tissue is defined in relation to some reference radiopulses can be used to emphasize different tissue
tissue or its expected normal appearance. Thus isoatten- characteristics. Manipulation of the parameters such as
uating means having the same attenuation and would the timing and duration of the radiopulse and the inter-
be displayed as the same shade of gray. If the tissue val before an echo is recorded is used to highlight tis-
attenuates or stops the x-rays less than the reference sue features. MRI has superb contrast resolution in soft
tissue or less than expected, it is described as hypoat- tissues and is very sensitive to changes such as edema
tenuating and is portrayed as a darker shade of gray. and hemorrhage. Signal intensity is used to describe
The term hyperattenuating is used to describe tissues the appearance of tissues in MRI, just as attenuation is
with more attenuation than expected. These terms are in CT imaging. It is a relative measure of the radio sig-
relative rather than absolute, and the reference tissue nal generated by tissues in response to the stimulating
or structure is usually stated. Superimposed structures radio energy pulse. If something is termed isointense, it
are eliminated. Iodinated contrast agents such as those has the same appearance as some reference tissue—for
used for myelography or excretory urography may be example, a mass might be isointense to the gray matter
used by intravenous injection. Lesions with abnormal of the brain. Hypointense means less signal and appears
circulation may show marked contrast enhancement darker, whereas hyperintense means more signal and a
after such injections. In viewing CT images, brightness brighter appearance. As in CT, these terms are relative
and contrast are adjusted to highlight specific struc- and must be defined in relation to the expected nor-
tures. CT can resolve far greater contrast than can be mal appearance, reference tissue, or appearance before
displayed on a monitor or appreciated by the human the use of contrast. Bones, ligaments, and tendons
eye. Therefore the gray scale of the image is adjusted appear quite dark on all image sequences because they
to assign useful grays to tissues with varying levels of have very little water content and therefore very little
attenuation, referred to as the window. A lung window hydrogen to generate a signal. Nonetheless, MRI can
will show detail within the lungs, but almost all other provide useful data about these structures.
structures appear white with little detail. A bone window Like CT, MRI uses contrast agents that enhance
will display detail of skeletal structures such as cortex lesion visibility. However, in the case of MRI, the
and trabeculae, whereas soft tissues appear gray with agents are based on gadolinium, which alters the local
little detail and lungs appear quite black. A soft tissue magnetic field and changes signal intensity. Lesions
window shows good contrast and detail within soft tis- that accumulate gadolinium appear bright (hyperin-
sue structures such as the liver. Hepatic veins can be tense) with some sequences. MRI is capable of distin-
distinguished from the gallbladder and other soft tis- guishing or resolving objects of approximately 1 mm
sues, whereas bone appears white and lungs dark. in size, which is termed spatial resolution. This is simi-
CT may be used to image almost any body part. lar to CT but compares poorly to radiographic sys-
Among the more common applications are diseases tems, which can resolve objects of 0.1 mm in size. MRI
of the nasal cavity, sinuses, and ears. It may also be has excellent contrast, showing different soft tissues
used to evaluate the spine, brain, joints, lungs, medi- as distinct shades of gray, which creates the impres-
astinum, pleural cavity, and abdominal masses (see sion of much finer detail.
Figure 2-1, I to L; Figure 3-6, M to O; and Figures 5-9, Unlike CT, which is limited to images in the plane
D to F, and 5-10, O). of the gantry, images can be obtained in any plane, so
slices can be varied infinitely to highlight lesions. MRI
Magnetic Resonance Imaging applications include imaging disease of the central
Unlike CT, no ionizing radiation is used in mag- nervous system, nasal cavity and sinuses, joints, and
netic resonance imaging (MRI). MRI uses hydrogen the abdomen (see Figure 5-32, D and E).
atoms to generate an image. Hydrogen is universally The physics of MRI is very complex, and the reader
­distributed in the body, principally in water mole- is referred to more specialized works on this subject.
cules. Hydrogen atoms are essentially spinning pro-
tons and have an electrical charge. Each atom acts as Nuclear Medicine (Scintigraphy)
a tiny bar magnet. Under normal circumstances, these Scintigraphy is a branch of nuclear medicine. It is an
tiny magnets are arranged randomly. MRI uses rela- imaging technique in which radionuclides (radioactive
tively strong magnetic fields, ranging from 0.05 to 3.0 elements emitting gamma rays) are administered to a
tesla in clinical use. In a strong magnetic field, a small subject. The radionuclides are attached to chemicals to
majority of the protons will be forced to point in the form radiopharmaceuticals that accumulate in the tis-
direction of the field while spinning at a specific rate. sue of interest. Most radiopharmaceuticals are ­analogues
10 Chapter 1 n The Radiograph

of physiologic substances or biologic organic molecules. an ­electrical impulse is applied to the crystal, the
Their presence, and their concentration, can be detected piezoelectric effect results in the crystal becoming
by gamma-ray detection equipment—usually a gamma deformed. It then vibrates, and ultrasound waves are
ray camera. The gamma rays are converted by the cam- generated. The crystal acts both as an emitter (1% of
era into signals from which a computer produces a the time), sending ultrasound waves into the body,
digital format that is used to construct an image of the and as a receiver (99% of the time), receiving return-
area under examination. Nuclear medicine images are ing echoes. When it receives ultrasound echoes, it
described in terms of uptake of the radiopharmaceu- produces electrical impulses proportionate to the
tical. The degree of uptake is subjectively assessed in strength of the returning echoes. These impulses are
some techniques, while in others quantitative analysis displayed as various shades of gray on the monitor.
is performed. In this way normal and abnormal tissues The stronger the returning echo, the brighter the point
can be identified by the selective accumulation of the is on the screen image. The time between emission
radioactive substances within them (see Figure 2-10, P and the return of the reflected echoes depends on the
through W, and Figure 4-30, Z1). distance traveled. The ultrasound machine calculates
the position of the source of reflection of the returning
ULTRASOUND echoes and displays it at a specific site on the moni-
Ultrasound denotes high-frequency sound waves tor. The image is constantly updated, which permits a
inaudible to the human ear. Audible sound frequency dynamic display. A centimeter scale enables the oper-
is of the order of 50 to 20,000 kilohertz (1 kHz = ator to appreciate the relative depth of structures on
1000 cycles per second). In diagnostic ultrasound, a the image.
pulse of ultrasound waves is directed into the body. It The instrument in which the crystal is mounted is
traverses the tissues until it reaches a reflecting surface called a transducer or probe. Its body contact surface
from which it is reflected back to the transmitter, which is called a footprint. Diagnostic ultrasound machines
also acts as a receiver. The returning signal is called may have crystals mounted in a transducer in a vari-
an echo. The returning echoes reach a computer that ety of ways, either as a single crystal or as multiple
processes the signals and displays them on a screen crystals in various formats. Transducer crystals are
as a two-dimensional (2-D) representation. Diagnostic usually made to vibrate at a predetermined frequency
ultrasound frequencies range from 2 to 15 megahertz (dedicated). Some transducers have several differ-
(1 MHz = 1 million cycles per second). Use of this ent crystals mounted in them (multipurpose) or per-
noninvasive, flexible, and relatively safe technique is mit variation of the electrical impulse to the crystal
becoming widespread in practice. Consequently, inva- ­(multifrequency).
sive radiographic procedures such as cardiac angiog- An oscillating crystal may be made to sweep over
raphy and other contrast studies, such as those of the an area by mechanical or electronic means to produce
urinary tract, have been to some extent superseded. a fan-shaped beam (sector) of ultrasound waves.
Interpretation of ultrasonograms requires an Electronic firing of a sequence or array of aligned sta-
understanding of the principles of ultrasound and its tionary crystals produces a longitudinal or square-
interaction with tissue. In addition, one must be famil- shaped beam (linear array). These designs permit
iar with the ultrasound machine and the transducer, a beam of sound to be produced and swept across
as well as their capabilities and the artifacts that can the surface of the transducer and from there into
be generated. Otherwise, problems with misinterpre- the tissues. More sophisticated transducers vary the
tation or overinterpretation will arise. The ultrasonog- method of electronic format or transducer shape. For
rapher must develop a standard imaging protocol and the various advantages and disadvantages of these
an appreciation of three-dimensional anatomy. The transducer types and details of ultrasound physics
ultrasonogram is essentially an image of a thin slice of in general, the reader is referred to more specialized
tissue. The orientation of the transducer and the plane texts.
of section within the body cavity or organ of interest
are standardized, as is the nomenclature for various Interaction of Ultrasound With Tissue
organ studies. The emitted ultrasound beam is produced in small
Radiographic and ultrasonographic ­examinations bursts. The velocity of sound in tissues varies, being
are complementary. Thoracic radiographs may ­indicate slow in gas (air), fast in soft tissue, and fastest in bone.
simply cardiac enlargement, whereas echocardio­ The calculated speed of ultrasound through body soft
graphy (ultrasound of the heart) permits assessment tissues is approximately 1540 m/sec.
of the various cardiac components and an accurate The density of various body tissues has a profound
evaluation and quantification of the cardiac disease effect on ultrasound transmission. If a tissue is homo-
problem. The presence of fluid on radiographs often geneous, no sound is reflected. It is the interaction of
renders organs invisible, whereas fluid may enhance ultrasound waves with different tissue structures and
the ultrasonographic appearance of structures. interfaces that allows some echoes to be reflected back
to the transducer. The rest of the ultrasound beam
Ultrasound Production may pass through the tissue and be variably reflected.
Ultrasound waves are generated by the piezoelec- Where there are interfaces of varying tissue densities,
tric effect in a suitable medium, such as a specially there is a difference in ultrasound transmission result-
manufactured crystal made of lead zirconate. When ing in attenuation (weakening) of the beam.
 Chapter 1 n The Radiograph 11

As the ultrasound beam and returning echoes the image becomes too bright. The power of the ultra-
travel through tissue, there is some attenuation. The sound beam should therefore be set to maximum or
attenuation depends on the transducer frequency and as high as possible to obtain a good image by ensur-
on the tissue. Lower frequency (2.0 to 3.5 MHz) sound ing strong returning echoes. If it is too low, the image
waves travel further into tissue, but the image reso- quality is reduced because the returning echoes are
lution or definition they produce is relatively poor. too weak. Ultrasound pulses and echoes are very
Conversely, higher frequency (7.5 to 10 MHz) sound weak, and high-power settings are not usually a prob-
waves become attenuated in tissue more quickly, but lem. However, if the image becomes too bright, the
resolution of the resulting image is much better. So gain should be reduced.
there is a trade-off between tissue depth and image The gain control of the machine amplifies the
resolution and quality (Figure 1-4, A and B). Therefore returning echoes so that the signal is strong enough to
careful selection of transducer frequency is required, produce an image. If the gain is set too high, it gener-
depending on the structure under examination. For ates random or spurious echoes and the image is too
example, a 7.5-MHz transducer may be excellent for bright. If the gain is set too low, the image becomes too
renal sonography of a cat but may not be adequate to dark (Figure 1-4, C and D).
evaluate the heart of a Great Dane. The strength of the ultrasound beam decreases as
For all but human fetal applications, the perceived it travels deeper into the tissues. Therefore the signal
wisdom is to run the transducer at full power and from deeper structures is weaker. This will result in an
reduce the gain control of the ultrasound machine if image that gets darker as depth increases. ­Ultrasound

A B

C D
Figure 1-4 A and B show two sonograms of the liver and stomach of a small dog. A, Using a 5-MHz transducer, the stomach in the
near field is visible but the detail is poor. B, Using an 8-MHz transducer, the layers of the stomach are more clearly seen because of the
improved resolution and image quality. C and D show the effect of gain on the ultrasound image. C, This image of the cranial abdomen
shows the liver but the gain setting is too high. The image is too bright, which will mask details of the tissues. D, This is the same area
of the cranial abdomen as in C, but using the correct gain settings. This has improved the tissue detail and image contrast.
Continued
12 Chapter 1 n The Radiograph

F
Figure 1-4, cont’d E and F show incorrect (E) and correct (F) gain settings for examination of the cranial abdomen in this dog.
F, A correct TGC setting; the TGC sliders are set for a decreased gain in the near field and increased gain in the deeper tissues.

machines have a control setting that should be beam. Total reflection means no ultrasound transmis-
adjusted to compensate for this effect: the time gain sion beyond the interface; this phenomenon is termed
compensation (TGC). TGC allows control of the gain acoustic shadowing. As an example, gas in the colon
at different depths and should be manipulated so that masks structures beyond it (Figure 1-4, G to I).
the image is homogeneous in appearance. The TGC The transmission of sound through a structure
control normally consists of multiple parallel slider of low attenuation, such as one filled with fluid,
controls or knobs (Figure 1-4, E and F). results in stronger returning echoes from beyond
The characteristic of sound transmission in a tissue the ­structure. This phenomenon is termed acoustic
type is termed its acoustic impedance. It is defined by enhancement. An example is the gallbladder/liver
the following equation: interface (Figure 1-5).
Transducers have an optimal imaging zone along
Acoustic impedance (Z) = Velocity (v) × Tissue density (P) the beam length. This area is termed the focal zone, and
it varies with the crystal frequency. Some machines
Because the sound velocity in most soft tissues is have an electronic focusing device that moves the
relatively constant, the differences in tissue density focal zone closer to or farther from the transducer
of the various body tissues are an estimate of their surface. It is important when imaging tissues to try to
acoustic impedance. The differences in the acoustic optimize the focal zone of the transducer over the area
impedance of tissues vary the intensity of returning of interest. This endeavor may also be managed by
echoes. Because most soft tissues have minimal dif- varying the imaging orientation or planes. Structures
ferences in acoustic impedance, most of the sound that lie close to the skin and transducer surface often
beam is transmitted through them, and only some is lie outside the optimal focal zone of the transducer.
reflected. This transmission and partial reflection of The use of a fluid offset, or standoff, is often advan-
echoes is what contributes to the final image. Com- tageous under such circumstances. A standoff is an
pared with soft tissue, the sound velocity decreases in ­echolucent material that may be part of the transducer
gas-filled ­structures; therefore gas has a lower acous- or may be a detachable component. It is placed on the
tic impedance. Bone has a high acoustic impedance skin, and it moves the ultrasound source away from
and transmits sound at a higher velocity than soft tis- the skin, thus bringing skin surface structures into the
sue. Consequently, in areas where gas, soft tissues, or focal zone of the transducer. If it is detachable, it must
bone are located in the ultrasound beam pathway, the be closely applied to the transducer. Coupling gel is
marked differences between the acoustic impedance applied between the transducer and the standoff and
in these areas result in almost total reflection of the between the standoff and the skin.
 Chapter 1 n The Radiograph 13

A
G

GB

H
B
Figure 1-5 Acoustic enhancement. A, In the diagram the ultra-
sound beam traveling along the path B traverses the gallblad-
der (GB). The gallbladder attenuates the beam less than the
surrounding liver. The echoes emitted distally from the gall-
bladder along path B will be stronger than the ones following
path A through the liver. This artifact usually occurs deep to
fluid-filled structures such as cysts. B, The anechoic fluid-filled
gallbladder (GB) does not attenuate sound at the same rate as
the adjacent liver tissue (L). The liver area beyond the gallblad-
der appears more echogenic (arrows) as a result of the reduced
attenuation of sound through the gallbladder. This is termed
acoustic enhancement. (A, Courtesy Dr. M. Pinilla.)

Mode of Display
The returning echoes can be displayed in a variety of
I ways on the ultrasound machine. The echoes are dis-
played as voltage spikes on a linear trace. The inten-
Figure 1-4, cont’d G and H, Acoustic shadowing. The diagram
and image are of a urolith in the bladder. Echogenic structures
sity of each echo is indicated by a variation in the
cause almost complete reflection of the ultrasound beam. The amplitude of the spike plotted against a depth scale.
area deep to these structures appears dark because of the lack This is termed the A-mode (amplitude), and its use is
of echoes. (G, Courtesy Dr. M. Pinilla.) I, A sagittal abdominal restricted to specialized ophthalmology examinations
scan of a pregnant bitch. The mineralized ribs and spine of (Figure 1-6).
the fetus are identified as a ­hyperechoic interrupted arc. Some The most common display is the brightness, or
sound travels ­between the skeletal structures producing hy-
poechoic stripes (AS, arrows), which are acoustic shadows. Cr,
B-mode, presentation. Modern machines ­permit
Cranial; R, rib; AS, acoustic shadow; H, heart; L, lung.
14 Chapter 1 n The Radiograph

RV

IVS

LV

Figure 1-7 2-D image. A cross-sectional view of the left ventricle

at the level of the papillary muscles (arrows) from the right side
Figure 1-6 A sonogram of a normal eye using a 15-MHz ocu-
of the thorax. LV, Left ventricle; RV, right ventricle; IVS, inter-
lar transducer. The 2-D image is in the near field. The cornea
ventricular septum.
is to the left (arrow). The lens is in the center of the image
(arrow), and the back of the globe (arrow) is on the right of
the image. The undulating horizontal line along the bot-
tom of the image is the A-mode, or amplitude display. This sweeps across the monitor and allows the motion
is used only in specialist ophthalmology practices. (Courtesy of the structures to be studied in the form of a line
Dr. N. Mitchell.) tracing or map. This mode permits more accurate
measurements than 2-D B-mode studies. M-mode is
particularly useful for cardiac evaluation (Figure 1-8).
­ ariation in the computer updating frequency, or
v As with radiographic studies, at least two ultrason­
frame rate. Frame rate, or the number of images ographic imaging planes of the structure of interest
acquired per second, is determined by multiple fac- are required—usually in the sagittal (longitudinal)
tors. Frame rate determines the temporal resolution— and transverse planes. The dorsal plane is the term
that is, the capacity to identify individual events that used when the transducer imaging plane is along the
occur at different times. With a greater depth of view, long axis of the animal’s body, with the transducer
the time required for a pulse to travel out and an echo placed on the lateral aspect of the animal. However,
to return increases and frame rate is decreased. The depending on the area being examined, the terminol-
more pulses or scan lines used to construct an image, ogy and plane of orientation will vary. This subject
the lower the frame rate. Conversely, a shallow depth is discussed in more detail in the relevant sections.
of view and fewer scan lines allow a higher frame rate. A permanent record of the sonogram may be obtained
Finally, the capacity of the machine to analyze and by using a thermal imager producing prints, or the
process data limits the frame rate. In current equip- sonograms may be saved in a digital format for a com-
ment, the last factor accounts for the much higher puter. ­Multiformat cameras are available that produce
frame rates that can be achieved now compared with a hard copy format using x-ray film.
what was possible some years ago.
Faster updating, or frame rates of the images, Doppler
is necessary for cardiac work when structures are Doppler ultrasonography is used to identify blood
moving quickly. Better-quality images are obtained flow and velocity and to calculate pressure gradients
from relatively static structures such as muscles and across cardiac valves. The Doppler principle is based
tendons by using a lower frame rate. The returning on the fact that the frequency of sound changes as it
echoes are digitized and converted into various inten- approaches or travels away from a moving object.
sities of brightness in two dimensions on a gray-scale For ­example, an ambulance siren has a higher pitch
format and are displayed on a monitor. Strong echo ­traveling toward the listener and a lower pitch as it
returns are very bright, and poor echoes are gray or moves away. When ultrasound waves of a known
black. The returning image is continuously updated frequency encounter blood cells moving toward
by the computer to give a 2-D image that is a dynamic, the transducer, the reflected sound waves have an
or real-time, image. The continuous computer update increase in frequency. As they move away, the fre-
allows motion to be appreciated. A scale on the moni- quency is reduced. The change in frequency is termed
tor indicates the depth of the tissue under examina- the Doppler shift and depends on the blood flow veloc-
tion (Figure 1-7). ity. It depends on the frequency of sound used, the
Another form of display is the M-mode, or motion blood flow velocity, the speed of sound in the tis-
mode. Returning B-mode echoes from a specific area sues, and the angle of incidence of the sound beam.
are plotted against time to form a tracing. This ­tracing The angle of incidence should be as close to zero as