Diagnostic Imaging

Diagnostic imaging refers to the use of those techniques Applications

for looking inside the body in a noninvasive manner
to aid a diagnosis. It is integral in reaching a diagnosis Radiographs are especially good at looking at bones
of an extremely large number of conditions in equine and so of particular use for orthopaedic cases and for
veterinary medicine. looking at structures of the head, including the teeth
and sinuses. We can occasionally use radiographs for
The aim of article is to give an introduction into soft tissue pathology, e.g. confirming the presence of
these various modalities, how they work, their main lung masses.
advantages and disadvantages and some examples of
cases in which they have been useful.
Disadvantages
RADIOGRAPHY Safety: X-rays are a form of ionizing radiation
meaning they can alter the atoms in the body leading
X-rays were discovered by a German physicist
to unnatural chemical reaction inside cells, which
Wilhelm Röntgen in 1895 and were quickly adapted
may cause the cell to die or to become cancerous.
for use in human medicine. A radiograph is obtained
Lead is very good at absorbing x-rays so lead gowns,
by placing an area of a patient in front of an x-ray
gloves and thyroid protectors are worn by operators to
detector (an x-ray plate) and then firing a short pulse
shield the most sensitive areas of the body.
of x-rays through the patient and onto the plate.
Sensitivity: It is not possible to detect small changes in
Bones contain a high amount of calcium, which
bone density therefore changes may be undetectable
due to its atomic properties, is good at absorbing, or
early in a disease process. This is of particular
attenuating, x-rays. The soft tissues contain atoms that
relevance with stress fractures in racehorses. These
are not as good as absorbing x-rays, so more x-rays
small, hair-line fractures are often initially impossible
pass through without being absorbed.
to see radiographically but have the potential to
Traditionally x-ray sensitive film was used as the propagate into complete catastrophic fractures. If
detector. When a beam of x-rays is shone through there is suspicion but radiographs are negative, the
a patient onto a detector, areas where there is no horse is often put on strict box rest, or cross-tied,
structures that stop the x-rays, e.g. not the patient, the for 10-14 days before re-radiographing. During this
film turned black. If no x-rays hit the detector, e.g. period the bone will re-model in response to the
behind very dense bone, the film turned white. fracture (the fracture line actually gets wider over this
period as part of the bones natural healing process)
Any density in between these two extremes turned a and there may be enough change in bone density for
grey, tone contrast depends on the relative density of it to be visible on the radiograph. The other option in
tissues in between the x-ray generator and the detector these cases is for a nuclear scintigraphy.

Fig. 1: Diagram showing how a radiograph is formed

Case slides 1 & 2

U LT R A S O N O G R A P H Y Advantages
Ultrasonography relies on the use of high frequency • Portable
sound waves. Images are produced by using an • Safe - no ionizing radiation.
ultrasound transducer (probe) to send out pulses of
• Quick - there is no processing delay with
ultrasounds. The waves are then reflected back from
images being acquired in real time meaning.
tissues under examination dependent or their density,
Therefore can be used during certain
and an image is produced by a computer.
procedures, e.g. for guiding in needle
placement for blocking or medication of
Uses
structures.
• Orthopaedics - for examining soft tissue
structures such as tendons, ligaments, and Disadvantages
muscles.
• Penetration - all the waves are reflected back
• Also extremely useful for looking at the surface
from air, bone and other dense materials, so
of bones and joints.
no image is formed the other side of these
• Stud medicine - to examine the ovaries and structures. Ultrasound cannot therefore be
uterus in a non-invasive manner to provide used for looking into bone or into normal
information of ovarian follicular development, lung tissue.
ovulation and ovarian pathology. It also allows
• Requires skill - its accuracy is very dependent
for early and accurate pregnancy diagnosis,
on the expertise, experience and knowledge of
monitoring the development of the early
the individual operator.
embryo, sexing of the fetus as well as detection
of pathology.

Case slide 3 Case slide 4: Ilial Wings

GAMMA SCINTIGRAPHY Applications
( “ B O N E S CA N ” ) • Cases where it is difficult to locate the origin of
a lameness - particularly when it is non-specific
Gamma scintigraphy uses gamma rays emitted from
or involves multiple limbs.
radioactive substances to detect and evaluate bone
disease that involves an increased rate of bone • Back and pelvis injuries - the large amount of
turnover. Gamma waves are identical to x-rays overlying soft tissue structures restricts or limits
except for their source. In equine scintigraphy the the use of other modalities, as in the pelvis.
vast majority of scintigraphic imaging is done using • Stress fractures - can be detected with
the pharmaceutical methylene diphosphonate scintigraphy within hours but may not be
(MDP), “labeled” with Technetium 99m (99mTc), visible radiographically for 14 days.
a radioactive compound which emits gamma rays. • Confirming the significance of pathology
When this radiopharmaceutical (99mTc-MDP) is detected using radiography; radiographs cannot
injected into a horses’ vein it will be distributed tell us how recent or active an area of bony
around the body. MDP binds to specific molecules pathology is.
that are highly prevalent at areas of bone with a
high turnover and thus these areas emit gamma
Advantages
rays which can be detected using a gamma camera.
The camera sends information regarding amount of • Highly sensitivity for areas of bone with
radiation detected back to a computer that formulates increased turnover.
a 2D image of relative radioactivity for interpretation. • Entire skeleton can be imaged relatively easily
Abnormal areas of bone, those which are actively and quickly.
remodeling, will show up as “hot spots” on the 2D
images, the greatest activity being associated with
Disadvantages
fractures, infection and tumor.
• Poor for morphological changes
• Non-specific (fracture vs. infection vs.
tumor); pattern recognition is important in
interpretation as hot spots look similar for
many conditions.
• Some significant lesions may not produce a
change visible on the images
• Safety - Unlike radiography, it is the horse
that is the source of radiation and thus some
exposure to radiation is unavoidable in order
to acquire the images. Horses emit radiation
for some time following injection and are
consequently put into “isolation” until the
radiation they are emitting is below a certain
Fig 2: A Schematic Representation of Nuclear Scintigraphy level, usually about 24hours from injection.
The radiopharmaceutical is excreted in the
urine and special care has taken with the
contaminated bedding.

Case slide 5
C R O S S S E C T I O NA L I M AG I N G COMPUTED TOMOGRAPHY
M O DA L I T I E S Computed tomography (CT) is an x-ray imaging
Cross sectional imaging refers to imaging based on technique that uses computer-processed x-rays to
cross-sections (“slices”) of the body and includes produce slices of a patient. An English engineer Sir
both MRI and CT. These modalities are relatively Godfrey Hounsfield first developed the technology
recent additions to equine veterinary work but their in the 1970s providing a novel way for the indirect
availability and use for aiding diagnosis and surgical visualisation of organs.
planning is becoming more wide-spread due to their
Relatively recently systems have been adapted to
vast benefits.
allow to the scanning of horses under standing
One of the main advantages of cross-sectional imaging sedation, permitting CT scans of the head and cranial
is that it avoids superimposition of structures. It also neck whilst negating the risks and costs involved with
enables the construction of slices in any desired a general anaesthetic (GA). This development has led
image plane; in the case of CT this is often done to CT becoming more accessible for equine veterinary
retrospectively. Another gain is the improved spatial use, although the scanner at Rossdales is one of only
resolution. 7 systems in the UK capable of scanning horses under
standing sedation. Standing CT in adult horses is
limited to the head, neck and limbs; the amount of
each depending on the individual system.

Basic Physics: An x-ray tube is spun around the patient

firing multiple exposures to be measured by a detector
opposite. The x-rays are attenuated (absorbed) to
varying amounts by different tissues. The varying
attenuation values of tissues, measured in Hounsfield
units, enables the construction of a slice. Slices are
then reconstructed into a volume by a computer that
can then be used to construct planar images in any
direction, called mulitplanar reconstruction.

Fig 4
Fig 3a & 3b: Why Cross-Sectional Imaging Works

As with plain radiography, CT is best suited for

evaluation of osseous structures where it affords
excellent spacial resolution but it also has superior
contrast resolution to radiographs in evaluating
soft tissues.
 Applications and Advantages of GA CT
• Fractures - the information that CT affords in
comparison to radiography is vast enabling
accurate assessment of morphology of
complicated fractures and location of bone
fragments.
• Keratomas and other space occupying lesions
- CT enables accurate surgical planning for
removal.
• Foals - especially for certain cases of septic
arthritis, lung disease and rib fractures.

Fig 5

Applications and Advantages of Standing CT

• Cases with sinus and/or dental disease.
Radiography is limited in assessing for disease
of the head due to superimposition of the
complicated anatomy, poor spacial resolution
and lack of contrast for soft tissues. CT has
been crucial in the advancement of our
knowledge and understanding of sinus and
dental diseases, which are common in horses.
• Cases of head trauma where the morphology
and extent of complicated fractures can be
difficult to discern.
• Neurological cases and headshakers.
• Excellent surgical planning

Standing CT: Disadvantages

• Movement - much greater compared to an
anesthetised patient, decreasing image quality
• Risk of injury to the horse or personnel
or damage to the machine. Having an
experienced and relatively constant team will
reduce some of this risk. Case slides 6a & 6b
• Limited to head and top of the neck, the further
the horses’ head is in the gantry, the greater the
risk of damage or injury.
• It can take a long time to get the horse in the
correct plane of sedation to persuade them to
put their entire head through the gantry, and in
some it is not possible at all.
• Expensive
M AG N E T I C R E S O NA N C E Applications
I M AG I N G The equine MR scanner is capable of scanning up to
the knee and hock in horses. However, the two main
Magnetic resonance imaging (MRI) uses radio waves
areas we routinely scan on a daily basis at Rossdales
and magnetic fields to produce images. The patient
are feet and fetlocks. MRI has revolutionised our
is placed in magnet and hydrogen atoms in water
understanding of foot pathology and demonstrated
molecules in the tissues line up with the magnetic
the presence of numerous previously unrecognised or
field and “resonate”. The magnetic field is then
poorly understood conditions of the limbs.
altered using a radiofrequency (RF) coil fitted around
the patient, changing the resonance of the atoms.
Advantages
This is detected using the RF coil and the data is fed
back into the computer to formulate an image. The • Contrast for soft tissue - MRI has extremely
physics behind how and why this is achieved is vastly good contrast for soft tissues but it also can
complex and requires a degree in quantum physics to give us an enormous amount of information
fully understand! regarding about bone compared with other
modalities.
• Safe –there is no ionizing radiation

Disadvantages
• Expense
• Expertise - both to read the images but also to
acquire them.
• Time and patience - the horse needs to stand
completely still until the scan is complete. To
complete a scan of one foot takes around an hour
to acquire. Consequently some horses are not
suitable candidates for MRI - e.g. young horses

Fig 6

The first human MR scanner was produced in 1977

by Damadian, Goldsmith and Minkoff. MRI was first
used in veterinary medicine in the 1990s with the
use of human machines scanning heavily sedated or
anesthetised patients. However the potential value of
the technique for equine use wasn’t recognised until
the development of a scanner capable of scanning
standing equine patients.

The first human MR scanner was produced in 1977

by Damadian, Goldsmith and Minkoff. MRI was first
used in veterinary medicine in the 1990s with the
use of human machines scanning heavily sedated or
anesthetised patients. However the potential value of
the technique for equine use wasn’t recognised until
the development of a scanner capable of scanning
standing equine patients).

The standing MR system is what is known as a “low

field” scanner, meaning the strength of the magnet
is less than 1 tesla (T). Most MR scanners in human
hospitals are between 1.5-3 T. The images from the
equine scanner do not have the clarity as those
acquired using high field scanners but still are able
to give us exquisite anatomical and physiological
information of both soft tissues and bone. Case slides 7 & 8