Ultrasound Imaging

ƒƒ Very commonly used modality in our hospitals and clinics Production of Ultrasound beam—
based on use of high frequency sound waves to characterize The Piezoelectric EffectQ
tissues in the body
ƒƒ REAL-TIME Imaging modality—Unlike radiographs/ ƒƒ This is the basic mechanism of production of ultrasound
CT/MRI, USG is a real-time modality thus allowing a beam
live telecast of body tissues like the heart, fetal movements, ƒƒ Piezoelectric crystalsQ/PiezoceramicsQ—Crystals having
blood flow in vessels—has great diagnostic utility property of Piezoelectricity
ƒƒ No Radiation exposure—as it is just high frequency sound •• Natural crystals—Quartz
waves, there is no question of any Radiation exposure— •• Artificial crystals—Lead zirconate-titanateQ (PZT)Q
Modality of choice for Obstetric imaging.Q —Most common crystal used in USG machines
ƒƒ Ultrasound Probe –
Basics of Sound Spectrum •• Consists of a Piezoceramic at its tip, fixed between 2
electrodes, and placed on a backing block. A wire is
ƒƒ Sound—is just mechanical energy travelling through matter attached to the probe and brings in the electric current
as a wave. It cannot travel through vacuum ƒƒ Piezoelectric effect: It is the property of such crystals to
ƒƒ The velocity of sound beam in human body is—1540 m/ convert one form of energy into another and vice versa. Thus:
secondsQ
ƒƒ Sound is transmitted in space as a pressure wave consisting

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of –

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•• CompressionQ—High pressure areas
•• RarefactionQ—Low pressure areas
ƒƒ Sound wave frequencies: Based on wave frequencies the
sound spectrum is broadly divided as shown in the image—
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ƒƒ This is how the USG probe works:

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Simply put –
• Less than 20 Hz—InfrasonicQ
Ultrasound Imaging

• 20–20000 Hz—Audible range of soundQ

• > 20000 Hz—Ultrasound spectrumQ
Watch the image carefully. It tells us that anything >20000 Hz
is ultrasound, but the part of the Ultrasound spectrum that is
used in diagnostic imaging is the part above a frequency value of
1 MHzQ

Conceptual Review of Radiology  •  43

 Ultrasound Probe and Frequencies
ƒƒ Probe is the primary device that is placed on the patient's body while doing an USG examination.
ƒƒ It emits ultrasound beam into the patient's body and receives the reflected ultrasound beam– this is used in image generation.
ƒƒ Various types of Ultrasound probes are used as follows:

Frequency (Mhz) Probe name Applications

2–4 Pencil probe Q
• Trans-cranial Doppler (TCD)Q probes

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3.5–5 ConvexQ/CurvilinearQ • Routine abdomen + pelvic ultrasoundQ
probe • Routine obstetric ultrasoundQ
• Obstetric Doppler studiesQ/Renal Doppler studiesQ
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7.5–12 Linear probeQ • Superficial organ imagingQ—Neck/thyroid/breast/

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scrotum/shoulder/tendons etc.
• Peripheral vascular DopplerQ—Upper/lower limb—
arterial/venous Doppler studies

>10 Endoluminal probesQ • Transvaginal sonography (TVS)Q

• Transrectal ultrasound (TRUS)Q
• Transesophageal Echocardiography (TEE)Q
Ultrasound Imaging

• Endoscopic ultrasound (EUS)Q

• Intravascular ultrasoundQ

50 Specialized UBM probes • Ultrasound biomicroscopy (UBM)Q of eye

• Please note that these Frequency values are just approximate values. The actual values may differ from
book-to-book/machine-to-machine and should not create unwarranted confusion/controversy!

44  •  Conceptual Review of Radiology

Principle of USG Image formation—The Pulse-Echo PrincipleQ
ƒƒ A very simple concept is used, that was used in olden days for a technique called as SONAR technique

Sonar Technique Human Ultrasound Imaging

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Common formula is used:

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Velocity (V) = Distance (D)/Time (T)

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so
D=V×T
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Here:
• D = Depth of ocean/Depth at which the organ is located from skin surface
• V = Velocity of sound in water/human body
• T = Time required to travel this distance. Since we can easily measure the time between emission of pulse and reception of echo (by
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ship or by probe), if we used just half of this time we will get T. This is because between emission and reception the sound beam has
travelled the distance D twice, once as a pulse and once while returning as echo.
Thus by using this simple principle and formula we now know at what depth the organ is located from the patient's body surface!!
Important point to note here is that as the Ultrasound beam enters the body tissues, it may be Reflected, refracted, absorbed or
attenuated. Of these fates of the beam it is BEAM REFLECTION—that is used in image generation

Methods of Display of Ultrasound: How the Above Information is Displayed

A—ModeQ • A—AmplitudeQ
• It is a very crude/basic way of representing data
Ultrasound Imaging

• It is just a graph of
ƒƒ Amplitude of returning echoesQ on Y axis
ƒƒ Depth of originQ on X axis
• Was used in SONAR technique
• A-Scan of eyeQ—It is the only current practical application in
human USG imaging

Conceptual Review of Radiology  •  45

 B—ModeQ • B - Brightness modeQ
• Most common method of display of ultrasoundQ
• The amplitude value is given a brightness value on a brightness
scale—and an image is created
• The brightness of every point on this image corresponds to the
amplitude of returning echoes arising from that point in the
body
• High amplitude = High brightness
• Low amplitude = Low brightness

M—ModeQ • M—MotionQ
• Moving structures are described along a single line of the
ultrasound beam
• Rapid sampling of around 1000 times/second—ensures rapid
motion assessment—hence is used in Cardiac and Fetal cardiac
imaging

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B-Mode USG Descriptive Terminology

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Hypoechoic:
• Low amplitude of returning echoes from a tissue results in its
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appearing Dark/Black—Hypoechoic
• Seen in cases of fluid filled structures in the body—like GB/UB/
Cysts/Free fluid etc.
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Look at the hypoechoic appearing simple cyst at lower pole of left

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kidney
Isoechoic
• Intermediate amplitude of returning echoes, results in Gray
appearance—Isoechoic
• Seen in most of the solid organs—Liver/spleen, Muscles
Ultrasound Imaging

Look at the relatively isoechoic appearing Liver parenchyma.

While the GB—being fluid filled is appearing hypoechoic

46  •  Conceptual Review of Radiology

 Hyperechoic:
• High amplitude of returning echoes, results in White
appearance—Hyperechoic
• Seen in Air/Calculi in the body

Look at the hyperechoic appearing calculus at lower pole of left

kidney

Doppler UltrasoundQ Doppler Angle Values

ƒƒ Extended application of Ultrasound—based on the Ideal situationQ Should be 0 degreesQ—but not practically
Doppler effect possible
ƒƒ Used for Vascular imaging—detection of blood flow in Should NEVER beQ 90 degreesQ—as cos90 is ZERO. Hence
blood vessels the above equation will give Fd = Zero—
ƒƒ Doppler EffectQ (Named after the physicist Christian absent flow

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Doppler)—Change in frequency of sound whenever there In Routine practiceQ Should be 60 degreesQ (Practically a value

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is relative motion between the emitter of sound and the between 45 to 60 degrees is considered
reflector of sound. The absolute change in frequency of optimal)
sound that occurs is called as Doppler shift (Fd)Q
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ƒƒ Color DopplerQ:
• Emitter—USG probe •• Subjective methodQ of Doppler interpretation
Routine on body surface— •• The information is color coded based on direction of
DOPPLER
og
B mode STATIONARY
EFFECT—does not flow:
Ultrasound of • Reflector—Liver
occur  Blood towards the probe—Red colorQ
Liver parenchyma -
STATIONARY  Blood away from the probe—Blue colorQ
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•• This Red-Blue allotment is arbitrary, can be

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• Emitter—USG probe
on body surface— reversedQ—hence subjective method
•• Also the color flow can be seen, but the flow cannot be
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STATIONARY
• Reflector—RBCs in measuredQ—hence subjective method.
USG of Carotid carotid arteries— DOPPLER •• Has low sensitivityQ for flow detection. Can miss
arteries MOVING EFFECT— occurs detection of low volume flow
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• Thus there is relative •• Color saturation/Intensity—determined by Velocity of

motion between
blood flowQ
emitter and reflector
of sound.
ƒƒ Power DopplerQ:
•• Subjective methodQ of Doppler interpretation
ƒƒ Doppler EquationQ •• Directional assessment is not doneQ
Fd = 2FoVCosθ
Q
•• The color display is based on amplitude of returning
C echoes
•• Fd = Doppler shiftQ—that absolute change in frequency •• High sensitivityQ—Even low flow volume can be
•• Fo = Transmitting frequencyQ—constant value detected—Advantage over Color Doppler
•• V = velocity of blood flow in vesselsQ •• Color flow is seen, but the flow cannot be measured—
Ultrasound Imaging

•• C = velocity of sound in human body (1540 m/s)Q hence subjective method

ƒƒ Doppler angleQ: ƒƒ Spectral DopplerQ/Pulsed DopplerQ
•• Defined as angle between the ultrasound beam and •• Objective methodQ of Doppler interpretation
plane of blood flow •• The flow information is plotted as a graph of Velocity
•• Used in Doppler equation as Cosine value of that angle (Y axis)Q and Time (X axis)Q

Conceptual Review of Radiology  •  47

 •• Thus accurate velocity measurements like Peak systolic Basic Ultrasound Image Interpretation
velocity (PSV)Q, End diastolic velocity (EDV)Q can be
obtained—Hence Objective method. • Ultrasound image interpretation is a
skill acquired by radiologists over many-
many years of practice.
Acoustic Impedance (Z) Q
• Interpretation of USG spot images in
ƒƒ Physical property of tissue that determines how much isolation is very difficult—because
resistance ultrasound beam faces while travelling through USG is a real-time dynamic modality
that tissue. and changing the probe angulation
ƒƒ ZQ = Tissue densityQ x Sound velocityQ and pressure may change the image
appearance
ƒƒ Since the sound velocity in human body is taken as a
• Hence USG Spot images are almost
constant of 1540 m/sQ (actually it varies very minimally never kept in MD/DNB radiology
from tissue-to-tissue), it is the density of tissue that practical examinations in the Spotter
determines its impedance. section of the examination.
ƒƒ Reflection of ultrasound beam: • But USG spot images (very typical ones)
•• Most important factorQ that determines image have been asked in your NEET/DNB/
formation AIIMS PG Entrance examinations……..!!
•• Reflection—determined by “Difference in Acoustic Hence we must explore this DANGER
impedance between 2 tissues—which will mainly be AREA!
determined by difference in densities between 2 tissues” Let us start with appearance of 3 Basic densities in
•• Greater is the reflection—Greater will be the amplitude the body:
of returning echoes—The corresponding points will

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appear hyperechoic on USG 1. Water/Fluid
•• Hence look at the following interfaces and the • As USG beam passes through the Gel into

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reflection occurring at these interfaces: Fluid containing organ (Cyst/UB), there is
minimal change in density
Interface Density % Reflection of Sound Beam • Hence there is minimal reflection of
Difference
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Liver - Kidney Low 0–1% • Thus the amplitude of returning echoes is
low—appears hypoechoic/dark
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Liver—Muscle Low 1–2% • Hence fluid/water containing structures
Muscle—Fat Intermediate 10–15% will appear hypoechoic/darkQ
Liver—Fat Intermediate 10–15%
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Water - Bone High 60–80%

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Liver - Air High 90–100%

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Ultrasound Gel—Why is it used?

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• US coupling gel is used to help transmit US waves to and from

the transducer.
• Reflection of sound waves occurs at interfaces where there is a
difference in the speed of propagation of sound waves, and, as
Ultrasound waves travel relatively slowly through air, the air-
skin interface has potential to reflect a great deal of the waves 2. Bone/Calculi
we would like to use for imaging. • As USG beam passes through the Gel into
• Placing US coupling gel between the transducer and skin Bone/calculus, there is large change in
greatly reduces this effect, so that maximum Ultrasound beam density
• Hence there is near-total reflection of
Ultrasound Imaging

enters the patient's body.

• System is designed in such a way that both the transducer face ultrasound beam
and the coupling gel have acoustic impedances similar to that • Thus the amplitude of returning echoes is
of skin, thus minimizing reflection from skin surface very high—appears hyperechoic/bright
• USG Coupling Gel consists of: • Hence Bone/Calculi appear hyperechoic/
ƒƒ Polyethylene glycolQ whiteQ
ƒƒ GlycerineQ • Also because there is near total
ƒƒ Phenoxyethanol reflection—the machine cannot generate
ƒƒ Polyacrylamide gel any image beyond that point—seen as a
dense shadowQ behind the bone/calculus

48  •  Conceptual Review of Radiology

 3. Air
• As USG beam passes through the Gel into
Air/Lungs, there is large change in density
• Hence there is large reflection of
ultrasound beam
• Thus the amplitude of returning echoes is
high—appears hyperechoic/bright
• Hence Air/Lungs appear hyperechoic/
whiteQ
• Small amount of USG beam that enters the
lungs gets trapped and undergoes multiple
reflections—resulting in Reverberation/
Comet tail artifacts
Remember that Fat also appears—Hyperechoic/bright as it has
multiple septae/tissue interfaces that reflect a lot of USG beam,
thus causing high amplitude of returning echoes.

So whenever you come across any USG image just try to characterize the appearance as follows:

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Biologic effects on Human body: Ultrasound imaging is Mechanical EffectsQ

remarkably safe for imaging, with no major known adverse ƒƒ The sound wave being comprised of alternate Compression
effects demonstrated in human experiments. However there and Rarefaction create rapid rise and fall in tissue pressures
may be 2 potential hazards associated with it - along the wave path
Thermal EffectsQ ƒƒ Especially in organs that have a lot of air-fluid interfaces
(lungs, bowel), these pressure changes may cause physical
ƒƒ Because Ultrasound is a form of energy, it may be deposited
tissue damage due to rapid oscillations of tissue components.
into the body tissues, resulting in heating of tissues.
ƒƒ This is termed as CavitationQ/Micro-cavitationQ
ƒƒ This is the Ultrasound beam that is attenuated by the
ƒƒ Mechanical index (M.I)Q: Attempts to quantify the
Ultrasound Imaging

tissues that gets deposited in the tissues and causes heating

likelihood of cavitation. Value must always be less than 1.9.
ƒƒ Minimal rise in temperature noted in diagnostic ultrasound
imaging, with greater heating in Doppler applications.
ƒƒ Thermal Index (T.I)Q: Ratio of
Power produced by Probe
Power required to raise tissue temperature by 1° Celcius

Conceptual Review of Radiology  •  49

 Special Applications of Ultrasound:

ElastographyQ • Detection of change in Elasticity of tissues due to presence of a pathology. This change in elasticity is
detected and measured in USG Elastography
• Two types:
ƒƒ Strain elastographyQ—Physical compression is used to check elasticity
ƒƒ Shear wave elastographyQ—High intensity wave is used instead of physical compression
• Applications:
ƒƒ Breast tumorsQ—Benign versus Malignant
ƒƒ Assessing liver fibrosisQ
ƒƒ Liver steatosisQ - NASH
HIFUQ • High Intensity Focused UltrasoundQ—Non-invasive focused thermal ablation technique
• Therapeutic application of ultrasoundQ
• Lethal heat is produced at the focus point—causing thermal ablation of tissue
• Applications:
ƒƒ Uterine fibroid ablationQ
ƒƒ Breast lesion ablationQ
ƒƒ Liver lesion ablation
Harmonic imagingQ • Uses integer multiplesQ of the transmitted ultrasound wave for imaging
• Preferred for hepatobiliary imaging
Contrast enhanced • Involves administration of IV contrast containing “microbubbles”Q
Ultrasound (CE-US)Q • These microbubbles when exposed to rapid compression- rarefaction affect the sound reflection, and

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may result in enhancement of tissues similar to that seen in CT/MR
• Microbubbles measure around 6–8 micrometersQ so do not cause any risk of air embolism

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MRI Basics
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Scope of Discussion
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MRI Physics is well…Bizarre! Many books about MRI physics are called MRI-made-Easy or similar titles, but none of them ever
achieve that. It would be cheating to tell you that MRI is very easy and you could understand most things at your level. I can tell
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you this and make it happen for all modalities, except MRI.
Hence the title here is not MRI Physics but MRI Basics.
Let us have a brief overview of the Basics that we must know about this modality. Let us stress on what has been asked till date
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and will probably be asked at your level.

For those geeks who really want to explore MRI in detail, well… All the Best!!

History of MRI •• He concluded that, based on these differences, it

ƒƒ Q
Felix Bloch —Elucidated Nuclear Magnetic Resonance should be possible to do tissue characterization.
(NMR)Q •• Based on this discovery he produced the first ever
•• In 1946 he proposed in a Nobel Prize winning paper NMR image of a rat tumor in 1974.
some rather new properties for the atomic nucleus. •• In 1977 Damadian and his team constructed the
He stated that the nucleus behaves like a magnet. first super conducting NMR scanner (known as The
He realized that a charged particle, such as a proton, IndomitableQ) and produced the first image of the
spinning around its own axis has a magnetic field, human body, which took almost 5 hours to scan
known as a magnetic momentum. He wrote down his ƒƒ Paul LauterburQ –
findings—in the form of famous Bloch Equations.Q •• Also developed his own imaging machine.
MRI Basics

ƒƒ Raymond DamadianQ— •• He was awarded the Nobel prize in 2003Q for his
•• Discovered that malignant tissue had different NMR contributions for MRI along with Peter MansfieldQ.
parameters than normal tissue.

50  •  Conceptual Review of Radiology

ƒƒ NMR–to–MRI: Structure of Atom
•• The name Nuclear Magnetic Resonance (NMR) ƒƒ We have seen in X-ray discussion that an atom consists of
was changed into Magnetic Resonance Imaging a central nucleus and electrons around it. Inside any atom
(MRI) because it was believed that the word Nuclear there are 3 types of motions occurring continuously –
(commonly associated with bombs) would not find •• Electrons rotating around Nuclei
wide acceptance amongst the public. So apparently
•• Electrons rotating around themselves
NMR seems dangerous, but MRI seems safe!
•• Nucleus (protons) rotating around themselves—Most
important for MRIQ
MRI Magnet ƒƒ This Nuclear spin is called as—Net nuclear magnetic
ƒƒ Most commonly used magnets in our MRI machines are spin—and is a pre-requisite for MRI. This spin gives rise
superconducting magnetsQ to a property of the nucleus called as “Gyro-magnetic
ƒƒ The magnetic field is generated by a current, which runs property”Q
through a loop of wire. The wire is surrounded with a ƒƒ Atoms with a strong nuclear magnetic spin are called as
coolant, such as liquid helium, to reduce the electric MRI active nuclei. The MRI active nucleiQ (and their
resistance of the wire. At 4 Kelvin (-269ºC) electric wire atomic mass numbers) in the body are:
loses its resistance. Once a system is energized, it won’t lose •• Hydrogen–1, Carbon–13, Nitrogen–15, Oxygen–17,
its magnetic field. Fluorine–19, Sodium–23, Phosphorus–31
ƒƒ In few 0.3 T machines a Permanent magnet may be used.
ƒƒ Magnets used in our hospitals range from 0.2 Tesla to 3 Why Human MRI is Based on Hydrogen Nucleus?
TeslaQ.
ƒƒ It is most abundantly present atomQ in the body. 60–70% of
ƒƒ Stronger is the magnet—better is the Image resolutionQ.
body weight is formed by water (H2O)—each molecule has

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ƒƒ Remember that MRI has no Radiation exposureQ as X-rays
2 hydrogen atoms
are not involved.

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ƒƒ Maximum Gyromagnetic ratioQ: In quantum physics there
“Human MRI is based on Gyro-magnetic propertyQ is an entity called “Gyromagnetic Ratio”. It is beyond the
of Hydrogen nucleusQ” scope of this discussion. It is enough to know that this ratio
Let us try and understand this statement is different for each proton, being maximum for hydrogen.
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Basic Steps of MRI Functioning
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• Under the influence of Earth’s magnetic field (weak magnetic field), all
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the Hydrogen nuclei in our body are randomly oriented, thus cancelling
out each other. Our bodies do not have any significant magnetism
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• When placed under a strong external magnetic field (like an MRI magnet)
all the nuclei get aligned along the plane of the external magnetic field
(Bo)
• Majority align parallel to Bo, few align antiparallel.
• After cancelling out a few anti-parallel ones, the human body now
develops a Net Magnetization Vector (NMV)Q along the direction of Bo
MRI Basics

Contd…

Conceptual Review of Radiology  •  51

 • While aligned the nuclei begin to Precess/Wobble along an axis.
• They precess at a particular frequency called as Larmor frequencyQ given
by the equation:
ω = gBoQ
where:
ω is Precessional/Larmor frequencyQ
g is Gyro-magnetic ratioQ
Bo is Magnetic field strengthQ

• Now back to the Net magnetization vector.

• The NMV is also called as Longitudinal magnetizationQ—along the
longitudinal axis of Bo—the external magnetic field

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• An excitation Radio-frequency (RF) pulse is applied at the exact Larmor
frequency of H-nucleus
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• This transfers energy to the NMV and flips it into the Horizontal plane—
Transverse magnetization
• This process is called excitation
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• T1 relaxationQ:
ƒƒ Occurs along Z axis
ƒƒ Is also called as Spin-Lattice
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relaxation
ƒƒ T1 recovery timeQ—is the time
the nucleus takes for 63% of
longitudinal magnetization to
recover
ƒƒ Determines T1 contrastQ
• T2 relaxation/decayQ:
ƒƒ Occurs along X-Y axis
ƒƒ Also called as Spin-Spin relaxation
ƒƒ T2 relaxation timeQ - is the time the
nucleus takes for 63% of transverse
magnetization to be lost
ƒƒ Determines T2 contrast
• Because every tissue has different and
peculiar T1/T2 relaxation properties,
MRI Basics

each tissue will appear different on

T1/T2—MRI thus has excellent soft
tissue contrast resolution
Contd…

52  •  Conceptual Review of Radiology

 Image acquisition

• During T1/T2 relaxation the excess energy acquired from the RF pulse is
being emitted out
• This energy is received by the Receiver coils of the machine at particular
times—and is used for Image formation.
• Thus the MRI image is formed.

• I had warned you MRI is bizarre! Now let us move into relatively easy things in MRI!!

MRI—Descriptive Terminology and Important Sequences

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Since in MRI we detect the intensity of signal arising from the nuclei/protons, the appearance is described as:

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ƒƒ Hypo-intenseQ: Dark
ƒƒ Iso-intenseQ: Intermediate
ƒƒ Hyper-intenseQ: Bright
T1 Weighted sequence (T1W)
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CSF/Water: HypointenseQ (dark) CSF/Water: HyperintenseQ (bright)

Fat: HyperintenseQ (bright) Fat: HypointenseQ (dark)
Gray-White matter appearance (As per their names)
Q
Gray-White matter appearance (Opposite to their names)
• Gray matter—is GrayQ (isointense) • Gray matter—is hyperintenseQ
• White matter—is WhiteQ (hyperintense) • White matter—is hypointenseQ
MRI Basics

Better for depiction of anatomyQ Better for depiction of pathologyQ

Conceptual Review of Radiology  •  53

 The FAT Controversy

Which of the following appears hyperintense (bright) on both

T1W and T2W images?
A. Gallbladder B. CSF
C. Kidney D. Fat
Answer—D. Fat (How????)

Do not panic. There is a reasonable answer to it.

This is a Controversial question - rather because it has been framed incorrectly.
On Conventional MRI SequencesQ:
• T1W: Fat is Bright, Water is Dark.
• T2W: Fat is Dark, Water is Bright.
But Conventional T1/T2 sequences are very time consuming and hence are not used in routine practice.
FAST SPIN ECHO/TURBO SPIN ECHO sequencesQ:
The technique of acquiring images was slightly modified and this is what we use in our daily practice today. These are acquired in a
much shorter time than conventional sequences and hence are preferred. But because the acquisition technique is slightly modified the
appearance of FAT on FAST/TURBO SPIN ECHO SEQUENCES is slightly different.
• That is Fat appears Hyperintense (Bright) on both T1 and T2W images.
To summarize remember:

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• Conventional sequences (Theoretical, not used because time consuming)
ƒƒ T1: Fat - hyperintense,

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ƒƒ T2: Fat - Hypointense.
BUT
• Fast Spin Echo/Turbo Spin Echo (Used in clinical practice)
ƒƒ Fat is HYPERINTENSE on both T1 and T2.
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No more confusion. I think the examiners also need to be reasonable, show some courtesy and set the questions correctly!
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T2W and FLAIR Sequences

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T2 Weighted (T2W) Fluid Attenuated Inversion RecoveryQ (FLAIR)Q

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CSF/Water: Hyperintense CSF/Water: Hypointense—FLUID signal is attenuatedQ—hence the name!

Gray-White matter appearance (Opposite to their names) Gray-White matter appearance (Opposite to their names)
• Gray matter—is hyperintense • Gray matter—is hyperintense
MRI Basics

• White matter—is hypointense • White matter—is hypointense

Better for depiction of pathology Can detect even the smallest of lesions

54  •  Conceptual Review of Radiology

 Flair: Why is it Needed?

• FLAIR is one of the most important sequences in Neuro- • Let us go for a movie in a theatre….
radiology. No brain MRI is complete unless at least 1 FLAIR ƒƒ Buy tickets…enter the theatre….the lights are on….take your
sequence is obtained in any plane. seat…..movie begins…..lights are switched off……STOP! Why
• Life was so easy when - are the lights switched off??
ƒƒ CSF is bright—T2 ƒƒ Because if the ambient light is too high, you will not see the
ƒƒ CSF is dark—T1 image well on the theatre screen, isn’t it? In a dark room/
ƒƒ Why to complicate life by introducing FLAIR?? theatre the contrast of the screen is much better seen!!
• Believe me, the intention of FLAIR is to simplify the job of a • Same applies to MRI!
radiologist. How? • Remember that 99% of abnormalities appear hyperintense/
bright on T2W MRI. Just imagine you want to search for a
small lesion located in the cortex—which is expected to appear
hyperintense. So:

T2W FLAIR

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Lesion Hyperintense (look at the left frontal region) Hyperintense

CSF Background Hyperintense Hypointense
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Lesion Not good Very good. FLAIR increases the conspicuity of the
prominence lesion (like movie screen in a dark theatre hall!!)
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Other Important MRI Sequences

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STIRQ: Short tau Inversion RecoveryQ

• Inversion recovery sequence similar to FLAIR

• FatQ - Signal intensity suppressed
• Great use in Musculoskeletal imagingQ
• Most bone lesions appear hyperintense on STIR
• STIR is excellent to identify Marrow edema
MRI Basics

Contd…

Conceptual Review of Radiology  •  55

 GREQ: Gradient Echo sequencesQ/T2* sequenceQ

• Susceptible to minute magnetic field inhomogeneity.

• BloomingQ/Intense loss of signalQ/Black spots are seen in presence
of:
ƒƒ Blood productsQ or
ƒƒ CalcificationQ
• Known as Blood sensitive sequenceQ

SWIQ: Susceptibility weighted imagingQ

• Similar to GRE
• Better sensitivity than GREQ

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• Known as Blood sensitive sequenceQ

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DWIQ: Diffusion weighted imagingQ
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• Based on diffusion of molecules in tissues due to random

thermal motion
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• Abnormalities described as Restricted diffusion/Facilitated diffusion

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• Restricted diffusion in Brain is seen inQ:

ƒƒ Acute infarct
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ƒƒ Abscess/Empyema
ƒƒ Diffuse axonal injury
ƒƒ Lymphoma
ƒƒ Epidermoid
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ƒƒ ADEM
ƒƒ Carbon monoxide poisoning

PWIQ: Perfusion weighted imagingQ

• Assessment of tissue perfusion

• Involves injection of Gadolinium contrast
Parameters measured include:
1. Mean transit time (MTT)Q or Time to peak (TTP)Q of the decon-
volved tissue residue function (Tmax)
2. Cerebral blood flow (CBF)Q
3. Cerebral blood volume (CBV)Q
Usually used in:
MRI Basics

• Ischemic strokeQ
• Brain/Head and neck TumorsQ

Contd…

56  •  Conceptual Review of Radiology

Fat suppressed images

• May be T1 or T2W
• Used to differentiate fat from other lesions
• Postcontrast MRI images are always Fat-suppressed T1W images

PDQ: Proton Density imagesQ

• Nuclear magnetic resonance of protons (hydrogen ions) forms
the major basis of MRI. Hence it is used such that signal is
weighted to reflect the actual density of protons; an intermediate
sequence sharing some features of both T1 and T2.
• Proton density images were extensively used for brain imaging,
however they have largely been replaced by FLAIR.
• PD however continues to offer excellent signal distinction
between fluid, hyaline cartilage and fibrocartilage - makes it ideal
in the assessment of joints.Q

e
1/
MRI AngiographyQ
• Various types:
ƒƒ Time-of-flight (TOF) MRAQ—Most commonly used. Does not
require injection of any contrast
y,
ƒƒ Contrast enhanced (CE) MRAQ—requires injection of
Gadolinium compounds
og
ƒƒ Phase contrast (PC) MRAQ—Can detect direction and velocity
of flowQ
l

MR VenographyQ
io
ad

• Most commonly used for suspected intracranial venous sinus

thrombosis
R

• Does not require injection of contrast

MR SpectroscopyQ

• Detects chemical composition of tissuesQ

• Produces a spectrumQ rather than images
• May be single/multivoxel typeQ
MRI Basics

Contd…

Conceptual Review of Radiology  •  57

 Magnetic Resonance Cholangiopancreatography (MRCP)Q

• Heavily T2W images suited for demonstration of fluid filled

structures
• Used for demonstration of biliary tree and pancreatic ducts.
Entire biliary tree is visualized.
• Equivalent to ERCP

Blood Oxygen Level Dependent (BOLD) Imaging/Functional MRI • Echo planar imaging (EPI), a fast MR image acquisition technique,
imaging (fMRI) is used to sequentially acquire brain images, every few seconds,
during several minutes. These images are of average quality and
prone to various kinds of artifacts, but their short acquisition
time makes them ideal for fMRI acquisitions
• Functional MRI cannot detect absolute activity in the brain.
It can only detect differences in brain activity between several
conditions. During the fMRI image acquisition, the patient

e
is therefore asked to alternatively perform several tasks or
is stimulated to trigger several processes or emotions. The

1/
combination of these conditions is called an fMRI paradigm.
• The detection of brain areas which are used during a condition is
based on the Blood Oxygenation Level Dependent (BOLD) effect.
y, When neurons are activated, the resulting increased need for
oxygen is overcompensated by a larger increase in perfusion.
As a result, the venous oxyhemoglobin concentration increases
og
and the deoxyhemoglobin concentration decreases. As the latter
has paramagnetic properties, the intensity of the fMRI images
increases in the activated areas. As the conditions are alternated,
the signal in the activated voxels increases and decreases
l
io

according to the paradigm.

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Lesions/Tissues Appearing Hyperintense/Bright •• Epidural catheters/CNS Ventricular catheters

on T1W ImagesQ (Remember as PF2M4) •• Spinal fixation devices
ƒƒ Proteinaceous fluid
•• Feeding tubes
R

ƒƒ Fat
•• Prosthetic heart valves
ƒƒ Slow Flow Lesions/Tissues Appearing HypointenseQ on both
ƒƒ Melanin
T1W and T2W Images
ƒƒ Methemoglobin—in Subacute hemorrhage
ƒƒ Mineralization—copper (Wilson’s), Manganese deposition ƒƒ Air
ƒƒ Contrast Medium—Gadolinium ƒƒ Cortical bone
ƒƒ Ligaments/tendons/dense fibrous tissues
Contraindications for MRIQ: ƒƒ Flow voids
ƒƒ Absolute contraindicationsQ— ƒƒ Hemosiderin
•• Cardiac pacemaker
Faraday CageQ:
•• Metallic foreign body of eye
•• Ferromagnetic hemostatic aneurysm clips in CNS ƒƒ Radiofrequency (RF) shielding of an MR scanner is
ƒƒ Relative contraindicationsQ – mandatory:
•• To prevent extraneous electromagnetic radiation from
MRI Basics

•• Cochlear implants
•• Claustrophobia contaminating/distorting the MR signal
•• Insulin pumps/Nerve stimulators •• To prevent electromagnetic radiation generated by
•• 1st trimester pregnancy the MR scanner from causing interference in nearby
medical devices.

58  •  Conceptual Review of Radiology

ƒƒ The RF-shield must encircle the entire room - walls, floor, ƒƒ The floor is generally made of monolithic copper covered
and ceiling. Such a conductive box used to shield out stray over with a solid flooring material.
electromagnetic interference is also known as a Faraday ƒƒ The interior walls are typically finished with drywall.
cageQ. ƒƒ The ceiling is suspended from the RF shield to allow space
ƒƒ Virtually any type of metal can be used, including aluminum for recessed lighting and mechanicals.
and galvanized steel. However, the most common RF- ƒƒ The door must not allow any RF leakage, being sealed by
enclosure consists of wood panels wrapped with copperQ. a set of electrical contact strips or a continuous metallic
ƒƒ At the range of frequencies used for MRI the skin pneumatic tube. Because of repetitive opening and closing,
conductive depth for copper is very small (on the order RF-seals around the door are frequently damaged and a
of 0.1 mm), meaning that only a thin layer of metallic common source of RF-leakage into the room.
shielding is required. ƒƒ Windows are laminated with blackened copper mesh
between two pieces of glass that connects peripherally with
the RF enclosure walls.

Contrast Media in Radiology

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CLASSIFICATION

1/
Definition of Contrast Medium

To be honest, no exact definition of Contrast medium exists in

y,
literature. Here is my perspective of what a contrast medium is,
and it helps us understand it conceptually.
og
“Contrast medium is any agent used to enhance the appearance
of a structure on a radiological image”
For example:
1. On a routine Chest radiograph, we see the mediastinal soft tissues
l
io

as a midline opacity. But can you see the esophagus separately

in the mediastinum? No. Now ask the patient to swallow some
barium, and as soon as he does, take another chest X-ray. Now
ad

the esophagus would be outlined by the barium contents. Thus

Barium enhances the appearance of esophagus—it is a contrast
medium!
R

2. Similarly on an Abdomen X-ray we cannot see the kidneys/ureters

separately from other soft tissues. Inject some Urograffin and
after same time if we repeat the abdomen radiograph we can see
the renal outline and the ureters filled with white/dense material.
Thus Urograffin (Iodinated compound) has enhanced the renal/
ureteric structures—it is a contrast medium!

Contrast Media in Radiology

X-RAY AND CT CONTRAST MEDIA
Negative versus Positive Contrast Media
Negative Contrast MediaQ Positive Contrast MediaQ
Attenuate/Block less radiationQ than the surrounding soft tissues Attenuate/Block more radiationQ than surrounding soft tissues
Appear Lucent/DarkQ on X-ray/CT image Appear Dense/BrightQ on X-ray/CT image
Contd…

Conceptual Review of Radiology  •  59

 There is an Intussusception seen in the right iliac fossa. But seen how the Barium filled esophagus with a smooth elongated tapering at
fluid within the dilated proximal small bowel loops helps us recognize its distal end—is Achalasia cardiaQ
these bowel loops separately from other soft tissues.

Examples: Examples:
• AirQ—used to distend bowel loops for Double contrast Barium enema • BariumQ/Iodinated contrast mediaQ used in Bowel related
(DCBE)/CT Colonography studies
• WaterQ/MannitolQ—Used to distend bowel loops prior to CT abdomen • Iodinated contrast mediaQ used in IVU/MCU/RGU

e
Barium Contrast Media Barium mealQ For evaluation
of stomach and

1/
ƒƒ Barium sulfate —BaSO4 : Most common barium
Q Q

compound used proximal duodenum

ƒƒ Why is it used?
•• Barium has a High atomic number—56. Hence it is
y,
highly radio-opaque
•• BaSO4—is extremely InertQ. It does not cause any
og
irritation/damage to bowel mucosa. It does not
interfere with normal process of digestion/absorption.
•• It does not itself gets absorbedQ (being water
l

insoluble)—remains in the bowel lumen where we Barium meal follow-through (BMFT)Q For small bowel
io

want it to be. evaluation

•• Is non-toxic
ad

•• Coats the mucosa uniformly thus revealing mucosal

patterns/abnormalities
ƒƒ Where is it used?
R

Used for endoluminal bowel fluoroscopic/spot studies like:

Barium swallowQ For evaluation
of hypopharynx,
esophagus and
gastro-esophageal
junction
Contrast Media in Radiology

Barium enemaQ For large bowel and

Ilio-cecal junction
evaluation

Contd… Contd…

60  •  Conceptual Review of Radiology

 Barium distal loopogramQ For evaluation of the  Prior allergic reactions
distal loop of bowel  Left sided colonic obstructionQ—If it remains
after a colostomy, static in an obstructed colon it may get inspissated
prior to colostomy and hard leading to severe constipation
closure. Iodinated ƒƒ Complications of Barium use:
contrast medium is •• Chemical peritonitis/pleuritis/mediastinitis—as discussed
usually preferred above
•• Airway obstruction—if aspirated in large amount
•• Embolism—Intravasation into blood vessels
•• Inspissation in bowelQ—especially in left sided colonic
obstruction
•• Barium encephalopathyQ—Barium absorbed from
peritoneum may travel into CSF through circulation—
ƒƒ How is it used? causes encephalopathy
•• Used as a BaSO4 suspensionQ—not a solutionQ because
BaSO4 is water insoluble Oily Contrast Media
•• Accurate dilution is achieved either by ƒƒ Were used in olden days when water soluble iodinated
 Weight-by-weight (w/w) suspensionQ
contrast media were not available. Not used today.
 Weight-by-volume (w/v) suspensionQ
ƒƒ They include Iophendylate (Myodil, Pantopaque)Q, a
 Volume-by-volume (v/v) suspensionQ
myelographic agent and Lipiodol Ultra fluide (Ethiodol)Q,
•• High density suspensions—preferred for Fluoroscopic a lymphangiographic agent.
studiesQ

e
ƒƒ A major drawback is the lack of resorptionQ. Complete
•• Low density suspensions—used for CT studiesQ removal through aspiration is usually impossible after a
•• Available commercially as

1/
procedure and the remaining droplets may lead to chronic
 “Microbar” paste
irritationQ and severe arachnoiditisQ
 “Microbar” suspension
ƒƒ The applications of Oily contrast media today include:
 “Microbar” HD—High density, low viscosity
y, •• Lymphography/lymphangiography
suspension •• Transarterial chemoembolization (TACE) of liver tumors
•• Saccharine/Fruit essences/flavors added to make it
og
palatable. Chocolate flavor—causes a lot of allergic Iodinated Contrast Media
reactions—hence not used.
ƒƒ Contraindications for use of Barium: Iodine
l

•• Absolute contraindicationQ: Perforation of ƒƒ Atomic number—53—has excellent radio-opacity, hence

io

bowelQ—as it causes severe inflammation/chemical seen better separately from soft tissues.
peritonitis/pleuritis/mediastinitis—which may be fatal ƒƒ Iodine content of the molecule determines its radiographic
ad

•• Relative contraindications: density. More is Iodine, more is density—whiter/denser it

 Suspected tracheoesophageal fistula/Rectovaginal/ appears—so that it is better differentiated from adjacent
Rectovesical fistula—Iodinated contrast is better soft tissues
R

alternative in such cases ƒƒ Has low toxicity profile in the body

Iodine: Particle Ratio—Another Boring Ratio??

This topic of Contrast media is a very factual topic. We are dealing with classifications, names, lists and hence it is also very volatile/ Contrast Media in Radiology
difficult to remember. To add upon it is a Numerical ratio here that could add to our woes. But what if we understood what it means
conceptually rather than just mugging it up. Let us try!

Number of Iodine atoms

• Iodine/Particle ratio/Contrast agent ratio =
Number of particles per mL solution
Numerator: Number of Iodine atoms—Determines Attenuation
• We have seen above that the Iodine content will determine the radiographic density of the contrast medium
• This is because it is Iodine that is responsible for blocking/attenuating the X-ray beam
• More is Iodine, more is density—whiter/denser it appears—so that it is better differentiated from adjacent soft tissues
• So ideally for a contrast medium, we would want the Iodine content (Numerator) to be as high as possible
Contd…

Conceptual Review of Radiology  •  61

 Denominator: Number of particles per mL—Determines Osmolarity
• If we dissolve a powder in water and create a solution, there may be osmotically active particles per mL of that solution—that will
determine its osmolarity.
• For contrast media, the Ideal osmolarity—is as low as possible. Because the High osmolar contrast agents have an osmolarity of around
5-times that of blood/serum. Hence they will be associated with adverse effects.
• So ideally for a contrast medium, we would want the particles/mL (Denominator) to be as low as possible
Now let us review the Ratio again:
I Iodine (Ideally as high as possible)
= = Ideal Ratio should be AS HIGH AS POSSIBLE
P Particles/mL (Ideally as low as possible)
Hence remember that
An IDEAL I/P ratio—is AS HIGH AS POSSIBLE

Classification of Water-soluble Iodinated ƒƒ I/P ratio = 3: 1Q—is almost similar to the Ionic dimers.
Contrast Media ƒƒ Osmolarity is around twice that of human plasma
ƒƒ Examples:
•• Metrizamide (Amipaque)Q—1st member of this group
to be developed. Is not used now
•• Iohexol (Omnipaque)Q—Commonest and Safest of
the clinically used individual contrast media

e
•• Iopamidol (iopamiro)Q
•• Ioversol (Conray)Q

1/
•• Iopromide (Ultravist)Q

Nonionic Dimers: I/P Ratio = 6: 1Q—Highest and

y,
Best RatioQ
ƒƒ Iso-osmolar groupQ of contrast media—Osmolarity is
og
similar to that of human plasma
ƒƒ Theoretically the Safest contrastQ—but due to cost
constraint not very commonly used
l

Ionic Monomers: I/P ratio = 3: 2Q—Lowest and ƒƒ Highest and Best I/P ratio: 6: 1Q
io

Worst RatioQ ƒƒ Examples:

ƒƒ These are sodium/meglumine salts of Triazoic acid/ •• IotrolQ
ad

Iothalamic acid •• IotrolanQ (Isovist)Q

ƒƒ I/P ratio is 3: 2—not a good ratio •• IodixanolQ/(Visipaque)Q
ƒƒ Examples:
R

•• Diatrizoic acid salts—UrografinQ, GastrografinQ, Toxicity/Adverse Effects of Contrast Media

AngiograffinQ, TrazograffQ, UrovisionQ, UrovideoQ ƒƒ Hyperosmolarity related adverse effectsQ:
•• Iothalamic acid salts—ConrayQ, TriovideoQ •• More with Ionic monomers/dimers
ƒƒ Have very high osmolarity (5–8 times that of human •• Leads to RBC damage Endothelial damage (resulting
plasma) in increased permeability), peripheral vasodilatation.
ƒƒ Ionic contrast media are contraindicated for use in ƒƒ Chemotoxicity related adverse effectsQ:
Contrast Media in Radiology

myelographyQ •• Most likely due to the Cations (Na+,K+)

•• Contrast Induced Nephropathy (CIN)Q—Consid-
Ionic Dimers: I/P ratio = 6: 2Q ered in detail later
ƒƒ Slightly better I/P ratio than ionic monomers ƒƒ Immunological/Allergic adverse effects:
ƒƒ Examples: •• May be either Anaphylactic/Anaphylactoid reactionsQ
•• Salts of Ioxaglic acidQ, Iocarmic acidQ •• May be minor-intermediate-severe in intensity
ƒƒ Ionic contrast media are contra-indicated for use in •• Severe reactions could be life threatening and require
MyelographyQ resuscitation
ƒƒ Idiosyncratic Adverse effects:
Nonionic Monomers: I/P Ratio = 3: 1Q •• Pyrogenic/Febrile reactions due to unsterile injections
ƒƒ Most common group of contrast medium used clinicallyQ •• Vasovagal shock
ƒƒ Safest of the clinically used group of contrast mediaQ •• Hypertensive attacks

62  •  Conceptual Review of Radiology

ƒƒ Low osmolar contrast media have a higher risk of  Ascorbic acid/Vitamin CQ
Thromboembolic phenomenaQ associated with them—  Metformin, though not nephrotoxic, should
HeparinizationQ is required if they are used for angiography be used prudently, because if renal failure does
occur, there is risk of concomitant lactic acidosis.
Contrast Induced Nephropathy (CIN)Q Therefore, metformin should be stopped at the
ƒƒ All iodinated contrast media are nephrotoxic. time of the procedure and resumed 48 hours later
ƒƒ High osmolar are more nephrotoxicQ, low osmolar are less if renal function remains normal.
nephrotoxicQ •• Prognostically, it is a transient process, with renal
ƒƒ Diagnostic criteria: function may reverting to normal within 7-14 days of
•• Impairment of renal function, measured as contrast administration, provided good supportive care
 25% increase in serum creatinine from baselineQ is administered and comorbidities are well managed
or
 0.5 mg/dL (44 µmol/L) increase in absolute serum
creatinine valueQ ULTRASOUND CONTRAST MEDIA
 within 48-72 hoursQ after intravenous contrast
administration (following contrast exposure, Concept
serum creatinine levels peak between 2 and 5 days ƒƒ The appearance of tissues on USG depends upon the extent
and usually return to normal in 14 days) of reflection of ultrasound beam from the tissues. The
ƒƒ Markers of CINQ: reflection in turn depends upon the differences in density/
•• Serum creatinineQ—as described above acoustic impedance at tissue interfaces. A solid tumor (for
•• Estimated GFR (eGFR)Q (estimated GFR [eGFR] <60 example HCC) in a solid organ (liver) will have similar

e
mL/min/1.73 m2)—predictive marker of CIN acoustic impedance and hence may appear isoechoic to the
•• Serum Cystatin C levelsQ liver—may be missed.

1/
•• Plasma neutrophil gelatinase-associated lipocalin ƒƒ USG contrast agents are echoenhancers that boost the
(NGAL), also known as human neutrophil lipocalin, echogenicity of blood.
is an early predictive biomarker ƒƒ These consist of microscopic gas filled bubbles, their surfaces
ƒƒ Pathophysiology: Multiple mechanisms are involved
y, reflecting large amount of USG beams. The backscattering
•• Direct cytotoxic effects on PCT cells effect they create increases the echogenicity of blood.
•• Increase in free radicals
og
ƒƒ When these microbubbles reach the target tissue through
•• Increased resistance to renal flow by precipitating blood they change the echogenicity of that tissue as well.
vasoconstriction
•• Risk factors for CIN: Generations of USG Contrast Agents
l

 Elderly age
io

ƒƒ 1st GenerationQ—Unstablized bubbles. Cannot survive

 Diabetes mellitus
through the pulmonary circulation, hence used for Large
 CKD—Known case of chronic kidney disease
ad

vein and Cardiac studies (intra-cardiac shunt identification)

(estimated GFR [eGFR] <60 mL/min/1.73 m2) ƒƒ 2nd GenerationQ—Longer lasting bubbles coated with
 Metabolic syndrome
shells of Protein, Lipids, Synthetic polymers
 Anemia
ƒƒ 3rd GenerationQ—Encapsulated emulsions/bubbles
R

 Hypovolemia
 Multiple myeloma
Types of USG Contrast Agents
 Hypoalbuminemia
 Renal transplant ƒƒ Tissue specific USG contrast agentsQ:
•• The single most important patient-related risk factor is •• Used for Liver, kidney, pancreas, prostate, ovary
preexisting Chronic Kidney DiseaseQ •• Improve the acoustic differences between normal and
abnormal tissues
•• Patient's with CKD in the setting of diabetes mellitus
•• Bubble rupture creates a characteristic mosaic
Contrast Media in Radiology
have a 4-fold increaseQ in the risk of CIN.
•• Treatment of CIN pattern—Induced acoustic emission
 HemodialysisQ can efficiently remove contrast •• Examples—
from the blood stream  LevovistQ—1st generation agent used for Cardiac/
•• Prevention of CIN: Liver imaging
 Pre-contrast hydration using IV normal salineQ—  SonovistQ, SonozoidQ
is most important step ƒƒ Vascular USG contrast agentQ:
 High dose StatinsQ—Rosuvastatin •• Gas microbubbles less than 5–10 micrometers, so that
 Bicarbonate therapyQ they can pass through pulmonary circulation into the
 N-Acetyl cysteineQ—Has sulfhydryl groups that systemic circulation
act as anti-oxidants and free radical scavengers •• Examples—AlbunexQ, InfosanQ

Conceptual Review of Radiology  •  63

 ƒƒ Recent advances— Liver Specific Contrast Agents
•• SonosalpingographyQ—may be done using contrast ƒƒ Manganese—DPDPQ
agents to assess tubal patency ƒƒ Gd—BOPTAQ
•• Reflux sonographyQ done similar to MCU—for VUR ƒƒ Gd—EOB—DTPAQ
assessment
•• Gastric distension by contrast—resulting in better Nephrogenic Systemic FibrosisQ—Unique
pancreas visualization.
Adverse Effect of MRI Contrast Agents
ƒƒ It is caused by gadolinium exposure used in imaging in
MRI CONTRAST AGENTS patient's who have renal insufficiencyQ
ƒƒ In olden days when a Contrast CT could not be done
in a CRF patient, Contrast MRI using gadolinium was
T1 Relaxation AgentsQ: preferentially used—due to no significant associated renal
ƒƒ Gadolinium compoundsQ: Most commonly used MRI risk
contrast mediumQ ƒƒ With time however it was realized that this is not correct as
•• Paramagnetic substancesQ—Affect the magnetic a unique effect occurred
properties of adjacent molecules ƒƒ Also known as Nephrogenic fibrosing dermopathyQ
•• Act as extracellular contrast agent a cause shortening ƒƒ Subcutaneous edema and firm, indurated, erythematous
of T1 relaxation timeQ—hence appear bright on T1W skin plaques seen. They progress to flexure contractures
MRIQ with restricted movements. Liver/spleen/lungs also affected
•• But fat also appears bright on T1W images, and ƒƒ Pathophysiology:
would cause confusion whether the hyperintense •• Seen in patient's with moderate to end-stage renal

e
(bright) appearance is due to contrast enhancement impairment due to transmetallationQ, which is

1/
or fat. So the post contrast images acquired are always replacement of the gadolinium from the chelate and
Fat-suppressed T1W imagesQ—so anything that is forming a free gadolinium ion, free gadolinium ions
hyperintense is contrast enhancement. may then deposit in different tissues and result in
•• FDA approved agents: inflammation and fibrosis.
y,
 Gd—HP—DO3A—Gadoteridol/ProHance •• Toll-like receptors (TLR)Q, in particular TLR4Q and
 Gd—DTPA—Magnevist TLR7Q, play a role in the development of nephrogenic
og
 Gd—DTPA—BMA—Omniscan systemic fibrosis
ƒƒ Associated gadolinium compounds:
T2 Relaxation AgentsQ •• OmniscanQ/GadodiamideQ—Most commonly impli-
l

ƒƒ Super-paramagnetic-iron-oxide SPIOQ/Ultrasmall—SPIO cated

io

(USPIO)Q— •• MagnevistQ/Gadopentetate dimeglumineQ—2nd most

•• SPIO is a unique MRI contrast medium that undergoes common
ad

selective phagocytosis by reticulo-endothelial system •• OptiMARK/GadoversetamideQ

cellsQ (Kupffer cells)Q ƒƒ Progressive condition with increased morbidity and mortal-
•• Uptake causes hypointense appearance on T2W ity and no definite treatment
R

imagesQ ƒƒ Role of Plasmapheresis—is being experimented

•• Specific for FNH—shows around 60–70% signal loss
on T2W imagesQ
•• Hepatic adenomas show only 15–20% signal loss.
Contrast Media in Radiology

64  •  Conceptual Review of Radiology

 Multiple Choice Questions
X-rays 12. Mammography uses?  (JIPMER May 2016)
A. Continuous spectrum radiation/Bremsstrahlung
1. X-rays were discovered by?
B. Characteristic radiation
A. Ian Donald B. Godfrey Hounsfield
C. Electrons
C. Wilhelm Röntgen D. Marie curie
D. Gamma rays
2. International radiology day is celebrated on?
13. Acute Hematological syndrome occurs at an exposure of?
A. 1st May B. 22nd August
A. 2 Gy B. 10 Gy
C. 8 November
th
D. 1st December
C. 20 Gy D. 50 Gy
3. The main difference between X-rays and Light is?  (AI 2010)
14. SI unit of Radiation exposure is?
A. Energy B. Mass
A. Roentgen B. Rad
C. Speed D. Type of wave
C. Gray D. Coulomb/kg
4. X-rays are produced when?  (AIIMS NOV2002)
15. The ALARA principle applies to what aspect of Radiology?
A. Electron beam strikes nucleus.
A. Contrast media safety
B. Electron beam strikes anode.
B. Radiology quality control and assurance
C. Electron beam reacts with electromagnetic field.
C. Radiation safety
D. Electron beam strikes cathode.

e
D. Workplace ethics and abuse prevention
5. Atomic number of Tungsten?  (JIPMER May 2016)
16. The 10 day rule applies to?

1/
A. 42 B. 181
A. Children
C. 74 D. 82
B. Young females
6. Which of the following X-ray interaction is the most common C. Elderly males
y,
of all X-ray interactions and is responsible for almost all D. Elderly females
scatter radiation?
A. Photo-electric effect B. Compton effect Computed Tomography
og
C. Pair production D. Photodisintegration. 17. The first generation CT scanner developed by Sir Godfrey
7. Photo-electric effect can best be described as? Hounsfield was what type?
A. Interaction between high energy incident photon and the A. Translate-Rotate B. Rotate-Rotate
l
io

inner shell electron. C. Rotate—Fixed D. Electron beam type.

B. Interaction between low energy incident photon and outer 18. Continuous helical acquisition of data in CT scanners, with
shell electron
ad

360 degree continuous rotation of the gantry was possible

C. Interaction between high energy incident photon and because of introduction of?
outer shell electron A. Advanced X-ray tubes B. Slip-ring technology
D. Interaction between a low energy incident photon and the C. Spring technique D. Mobile detectors.
R

inner shell electron

19. CT Number of water and bones respectively? 
8. Contrast of a radiographic image is determined by?  (JIPMER May 2016)
A. kVp B. mAs A. 100 and 0 B. 0 and - 1000
C. Both D. None C. 0 and + 1000 D. + 1000 and - 100
9. Photon transferring a small part of its energy to an electron 20. Walls of CT scanner room are coated with?  (AI 2010)
occurs in? A. Lead
A. Photoelectric effect B. Compton effect
Multiple Choice Questions
B. Glass
C. Pair production D. Photodisintegration C. Tungsten
10. Thermionic emission occurs at? D. Iron
A. Cathode B. Anode 21. Calcification is best detected by?
C. Exit window D. Collimators A. USG B. CT
11. Which of the following statements about “Stochastic effects” C. MRI D. Fluoroscopy
of radiation is true? 22. 128 slice CT scanner is a?
A. Severity of effect is a function of dose A. 1st generation scanner
B. Probability of effect is a function of dose B. 2nd generation scanner
C. It has a threshold C. Multi-detector CT scanner
D. Erythema and cataract are common examples D. Portable CT scanner

Conceptual Review of Radiology  •  65

 23. Which of the following appears hypodense on CT? 37. Mode/Method of display used in ophthalmic ultrasound is?
A. Acute blood B. Bone A. A mode B. B mode
C. Calcification D. CSF C. Doppler mode D. All of above
24. CTDI represents? 38. All of the following appear hypoechoic on USG except?
A. CT Densitometry index B. CT Dose index A. GB B. UB
C. CT Duplication index D. CT Detection index C. Simple cyst D. Calculus
25. Mean Transit Time (MTT) is measured in? 39. Cavitation in tissues is what type of biologic effect of Ultra-
A. CT Angiography B. HRCT sound?
C. Perfusion CT D. CT Densitometry A. Thermal effect B. Mechanical effect
C. Idiosyncratic effect D. Contrast effect
26. Q-CT is used for?
A. Cardiac assessment 40. HIFU is?
B. Interstitial lung disease A. High intensity fluoroscopic ultrasound
C. Bone mineral density measurement B. High intensity focused ultrasound
D. Brain perfusion C. High interval fractionated ultrasound
D. High interference fragmented ultrasound
Ultrasound Imaging 41. Elastography is used in?
27. Harmonic imaging is used in? A. Breast imaging B. Brain imaging
A. USG B. CT C. Doppler studies D. Obstetric studies

e
C. MRCP D. Nuclear imaging
28. In color Doppler the Intensity of red/blue color is determined
MRI Basics

1/
by? 42. FLAIR images in MRI selectively suppress the signal arising
A. Direction if flow B. Amount of flow from?
C. Velocity of flow D. Temperature A. Gray matter B. White matter
y, C. CSF D. Skull vault
29. Piezoelectric effect is used in which modality?
A. X-ray diffraction B. USG 43. Which of the following is contraindication for MRI?
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C. NMR D. DEXA scan A. Presence of cardiac pacemakers
B. Cochlear implants
30. The part of sound spectrum, known as Ultrasound, is one
C. Claustrophobia
above a frequency value of?
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D. All of the above

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A. 20 Hz B. 20,000 Hz
44. Gyromagnetic property of Hydrogen nucleus/proton is used
C. 1 MHz D. 20 MHz
in?
ad

31. The part of sound spectrum, used in diagnostic imaging is the A. USG B. CT
part above a frequency value of? C. MRI D. PET
A. 20 Hz B. 20,000 Hz
45. The magnetic field strength of a MRI magnet is measured in?
C. 1 MHz D. 20 MHz
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A. Hounsfield unit B. Tesla

32. Most commonly used Piezoelectric crystal is? C. MHz D. Gray
A. Quartz B. Cane sugar
46. On T1W MRI image, all of the following appear hypointense
C. Lead zirconate D. Barium zirconate
except?
33. Doppler effect is the change in? A. Cortical bone B. Air
A. Velocity B. Frequency C. Ligaments D. Subacute Hemorrhage
C. Temperature D. Reflection
47. Which of the following appear hyperintense on both T1 and
Multiple Choice Questions

34. In routine clinical practice the Doppler angle should equal to T2W Turbo spin echo sequence images?
or less than? A. GB B. Kidney
A. 0 degrees B. 45 degrees C. Fat D. CSF
C. 60 degrees D. 90 degrees
48. MRI rooms are shielded completely using a continuous sheet
35. Probe used for thyroid ultrasound is? or wire mesh of copper/aluminum known as?
A. Convex probe B. Linear probe A. Maxwell cage B. Faraday cage
C. Endoluminal probe D. Cardiac probe C. Edison cage D. Ohm’s cage
36. Most commonly used method of display of Ultrasound is? 49. Time-of-Flight (TOF) principle is used in?
A. A mode B. B mode A. CT angiography B. MR angiography
C. M mode D. D mode C. MR perfusion D. Digital radiography

66  •  Conceptual Review of Radiology

50. Which of the following does not cause any radiation exposure 64. Absolute contraindication for use of Barium is?
to the body? A. Obstruction B. Hernia
A. X-rays B. CT C. Perforation D. Ascites
C. PET D. MRI 65. Most commonly used Barium compound is?
51. All are true regarding MRI except? A. BaSO4 B. BaPO4
C. BaS D. BaCl
A. Contraindicated in cardiac pacemaker patient's
B. Multiplanar imaging 66. Which of the following has the lowest Iodine—Particle ratio?
C. May not show bony abnormalities A. Ionic monomers B. Ionic dimers
C. Non-ionic monomers D. Non-ionic dimers
D. Maximum radiation exposure
67. USG Contrast media are?
52. Nobel prize for the invention of MRI was awarded to?
A. Gel microbubbles B. Air microbubbles
A. Felix Bloch B. Raymond Damadian C. Nano-colloid particles D. None of above
C. Paul Lauterbur D. Godfrey Hounsfield
68. Most important risk factor for development of CIN is?
53. MRI magnet is a? A. Elderly age B. Pre-existing CKD
A. Ferro-magnet B. Para-magnet C. Diabetes mellitus D. Anemia
C. Simple magnet D. Superconducting-magnet 69. Best preventive strategy for CIN is?
54. Which of the following element in the human body has the A. Precontrast hydration
maximum Gyro-magnetic ratio? B. N-Acetyl cysteine
A. Hydrogen B. Oxygen C. Bicarbonates
D. Statins

e
C. Iron D. Nitrogen
70. Markers of CIN include?
55. Blood sensitive MRI sequence is?

1/
A. Serum Cystatin C
A. DWI B. PWI
B. Serum creatinine
C. SWI D. MRCP C. eGFR
D. All of above
Contrast Media in Radiology
y,
71. Gadolinium is?
56. The Iodine: Particle ratio is maximum for? A. Ferromagnetic
A. Ionic monomers B. Ionic dimers
og
B. Diamagnetic
C. Non-ionic monomers D. Non-ionic dimers C. Paramagnetic
57. Contrast media used in MRI is? D. Supermagnetic
A. Iodine B. Gadolinium
l

72. NSF stands for?

C. Metrizamide D. Omnipaque
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A. Nephrogenic sodium failure

58. The safest of the recent contrast media is? B. Nephrogenic systemic fibrosis
A. Trazograff B. Angiograffin C. Nephrogenic salt failure
ad

C. Iohexol D. Ioversol D. Nephrogenic superficial fibrosis

59. Which of the following indicates radiograph contrast induced 73. Most common contrast agent associated with NSF is?
nephropathy?  (AIIMS Nov 2013) A. Gadopentetate
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A. Increased creatinine levels B. Gadodiamide

B. Decreased urine output C. GadoDTPA
C. Increased bilirubin D. Gadovistate
D. Decreased bilirubin
60. Which of the following contrast agent is preferred in a
patient with decreased renal function to avoid contrast
nephropathy?
A. Acetylcysteine B. Fenoldopam
Answers Multiple Choice Questions
C. Mannitol D. Low osmolar contrast 1. C 12. B 23. D 34. C 45. B 56. D 67. B
2. C 13. A 24. B 35. B 46. D 57. B 68. B
61. Intravenous contrast is not used in?
A. CE-CT B. MRI 3. A 14. D 25. C 36. B 47. C 58. C 69. A
C. IVU D. Myelography 4. B 15. C 26. C 37. D 48. B 59. A 70. D
5. C 16. B 27. A 38. D 49. B 60. D 71. C
62. Heparinization is required to prevent the risk of thrombo-
embolic phenomena when using? 6. B 17. A 28. C 39. B 50. D 61. D 72. B
A. High osmolar contrast B. Low osmolar contrast 7. D 18. B 29. B 40. B 51. D 62. B 73. B
C. Gadolinium D. USG contrast 8. C 19. C 30. B 41. A 52. C 63. D
63. All of the following are negative contrast media except? 9. B 20. A 31. C 42. C 53. D 64. C
A. Air B. Water 10. A 21. B 32. C 43. D 54. A 65. A
C. Mannitol D. Barium 11. B 22. C 33. B 44. C 55. C 66. A

Conceptual Review of Radiology  •  67

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